Friday, June 22, 2018

Safe summer travel tips for doctors and patients

As children finish school and the summer vacation season gets underway, regular or occasional readers of American Family Physician should know about all of the free resources available for prevention and management of medical conditions in travelers, the best of which are included in our Travel Medicine collection. Brush up on key components of the pretravel consultation for international travelers, including vaccination updates and malaria prophylaxis. Patients who plan to play in the water can be provided with recommendations for preventing recreational waterborne illnesses and tips for avoiding neurologic complications of scuba diving or surfing-related injuries. And anyone can learn to recognize and prevent heat-related illness.

Depending on the vacation destination, clinicians may need to counsel patients on risk factors and symptoms of altitude illness (which includes acute mountain sickness and less commonly, cerebral and pulmonary edema) or emerging vector-borne diseases such as West Nile virus, Dengue, Chikungunya, and, of course, Zika virus. A 2015 editorial reviewed advice for protection against mosquitoes and ticks that carry these and other diseases (such as Lyme disease, which doesn't always present with a classic "bull's eye" rash).

And whether your own summer plans include going on a medical humanitarian mission or just relaxing at your favorite fishing hole, AFP has you covered. Clinicians who plan to spend time near any body of water - including the backyard swimming pool - should consider familiarizing themselves with the essentials of prevention and treatment of drowning.

You can access patient education handouts on all of these activities and more from AFP and FamilyDoctor.org at home or on the go. Stay safe, and have fun!

**

A slightly different version of this post originally appeared on the AFP Community Blog.

Thursday, June 14, 2018

Should divided guideline panels publish minority views?

When I give presentations on the guideline development process of the U.S. Preventive Services Task Force, a question I'm often asked is how many votes of the 16-member panel are needed to approve a recommendation statement. The answer is a two-thirds majority, with a minimum of 10 votes in favor in case of absences or conflict-of-interest recusals. In reality, though, during the four years I attended Task Force meetings, I can't recall a statement passing without overwhelming (15-1 or 14-2) or, more commonly, unanimous support. The feeling among members seemed to be that the lack of a strong consensus on a recommendation suggested that there was something missing about the way they were approaching the evidence.

The Supreme Court of the United States always provides justices in the minority the option to write a dissenting opinion for the record, whose legal reasoning sometimes informs future decisions. In contrast, minority opinions rarely accompany medical guidelines. In an unusual case, after the JNC 8 committee published its guideline for management of high blood pressure in adults, five former panel members who disagreed with the guideline's target systolic blood pressure of 150 mm Hg in persons aged 60 years or older formally published their minority view. Even then, this dissenting report appeared some time later, in a different journal than the original guideline.

In a 2016 article in Mayo Clinic Proceedings, Dr. Daniel Musher, a professor of medicine and infectious diseases at Baylor College of Medicine, made the case for regularly publishing dissenting opinions in medical guidelines. He cited his experience as a member of the Advisory Committee on Immunization Practices (ACIP) working group that recommended the use of 13-valent pneumococcal conjugate vaccine (PCV13) in adults 65 years and older, despite his strong disagreement. As is standard process for the ACIP and most guideline panels, he did not have the opportunity to voice his dissenting opinion and rationale in the text of the guideline. His view did not see publication until more than 18 months later, after the new recommendation had been largely implemented into clinical practice. Dr. Musher wrote:

The perceived problems with publishing dissenting opinions are that this practice would (1) cause confusion within the medical community and (2) diminish the force of the recommendations. Regarding the former, the current situation, in which dissent is not included but in which subsequent articles dispute the formal recommendations or different professional societies publish divergent guidelines, is amply confusing—witness the differing guidelines for screening for breast, lung, or prostate cancer. It defies reason to believe that every member of the American Cancer Society's committee thought that breast cancer screening should begin at age 40 years, whereas all who participated in the US Preventive Services Task Force agreed that screening should wait until age 50 years. Inclusion of dissenting opinions in the final version of published guidelines may well have reduced polarization and confusion by bringing dissent into the recommendation process.


I can't testify to the presence or absence of internal discord on the panels that produced the 2015 ACS or 2016 USPSTF guidelines on breast cancer screening, but my best recollection of the July 2008 meeting where the USPSTF first voted to recommend routine mammography starting at age 50 is that, contrary to Dr. Musher's suggestion, there was no minority view. When there is one, I agree with him and the Slow Medicine bloggers that making a forum available to describe conflicts that occurred within the guideline narrative (including all of the various options that were considered and later discarded) could reduce the intensity of second-guessing and better inform clinicians about the guideline's nuances and potential limitations. Now that I have had experience as a voting member of guideline panels on atrial fibrillation and cerumen impaction, though, I wonder if the explication of dissents belongs in the guideline itself, rather than as a separate stand-alone perspective.

Would the airing of minority views within medical guidelines provide useful perspectives for patients, clinicians, or policymakers, or are conflicting guidelines from different organizations already confusing enough as it is?

**

A slightly different version of this post first appeared on Common Sense Family Doctor on June 24, 2016.

Friday, June 8, 2018

Health Systems Science - population health by another name?

In my book review of this textbook in the June 2018 issue of Family Medicine, I took the opportunity to comment not only on the strengths and weaknesses of the text, but the broader movement to incorporate population health concepts into medical education. Here are some excerpts:

Since Abraham Flexner published his report on the state of American and Canadian medical education in 1910, the pillars of medical education have been the basic and clinical sciences. Although in the past century both pillars have experienced dramatic changes, this educational structure has remained the same. Increasingly, however, medical educators have recognized that mastery of the basic and clinical sciences alone is insufficient preparation for clinical practice. In the early 20th century, there were no health maintenance organizations, continuous quality improvement processes, clinical informatics, or population health management—all concepts that are essential for today’s physicians to know.

In 2013, the American Medical Association formed the Accelerating Change in Medical Education Consortium, a group of 11 medical schools tasked with developing innovative curricula to encompass the additional knowledge, attitudes, and skills necessary to prepare students and residents for 21st-century practice. Although my home institution was not part of the consortium, as director of a required first-year course in health disparities and health policy, and as advisor for our population health scholarly track, I have followed its work with great interest. In a series of papers in
Academic Medicine, consortium leaders proposed adding a third pillar of medical education called “health systems science. ...

A concluding chapter suggests structural reforms to make it easier to integrate this content into medical education, such as preferentially admitting students with well-developed teamwork skills, teaching with simulation and in community-based settings, and involving students in real-life practice improvement and health care delivery transformation.

Whether or not this collection of topics truly constitutes a new “science” rather than a blending of existing fields is debatable, but it is certain that in the future, more physicians will be caring for populations within health systems rather than individual patients one at a time.

Monday, June 4, 2018

Curiosity and family medicine

I have never been invited to give a commencement address. The closest I came was my own high school graduation, when I was the unofficial valedictorian. Since my school did not have a tradition of the highest-ranked student addressing the class on graduation day, though, I didn't get the chance. Our commencement speaker, a television news anchor and former graduate, delivered a great speech that I still remember more vividly than the addresses by bigger names at my college, medical school, and public health graduation ceremonies.

Obviously, I have not had the good fortune of hearing Dr. Atul Gawande speak at a commencement. (Atul, if you're reading this, Georgetown University School of Medicine would be delighted to have you address a future graduating class.) Instead, three days ago he delivered a profoundly insightful address at UCLA that has been going viral on social media. It's worth reading in its entirety, but the point he drove home is that in a time when discrimination and unequal treatment have become as socially acceptable in some circles as in the pre-American Civil Rights era, it remains the sacred calling of medicine to recognize that all lives have equal worth, and that doctors and patients share a "common core of humanity":

Without being open to their humanity, it is impossible to provide good care to people—to insure, for instance, that you’ve given them enough anesthetic before doing a procedure. To see their humanity, you must put yourself in their shoes. That requires a willingness to ask people what it’s like in those shoes. It requires curiosity about others and the world beyond your boarding zone.

Curiosity. If medicine were only about the science of the human body in health and disease, I would never have become a family doctor. Fortunately, that isn't so; in fact, after years of practice I often feel that the science has become incidental to doctoring. Yes, the knowledge base for medicine is always expanding, but as I tell students, regardless of what field of medicine you choose, the technical aspects eventually become routine. Even emergency and family physicians, who encounter the largest variety of symptoms and diagnoses, get acclimated to bread-and-butter encounters: back pain, chest pain, respiratory infections, the management of common chronic conditions under or out of control.

What keeps my work meaningful is learning about the details of my patients' lives that aren't strictly medical. As Dr. Faith Fitzgerald wrote in a classic article nearly two decades ago:

What does curiosity have to do with the humanistic practice of medicine? ... I believe that it is curiosity that converts strangers (the objects of analysis) into people we can empathize with. To participate in the feelings and ideas of one’s patients—to empathize—one must be curious enough to know the patients: their characters, cultures, spiritual and physical responses, hopes, past, and social surrounds. Truly curious people go beyond science into art, history, literature, and language as part of the practice of medicine.

Then, as now, pressures to be efficient in evaluating patients threatened to suppress natural curiosity. Dr. Fitzgerald bemoaned an educational system that produces medical students who were too un-curious to ask a patient how he had been bitten in the groin by a snake ("How could one not ask?"), or to question the "BKA (below-knee amputation) times two" description in the chart of a patient who obviously had legs. Finally, she mentioned one patient who had been deemed by the housestaff to be the "dullest" (least interesting) on the service: an old woman who (upon further inquiry) turned out to have survived the sinking of the Titanic.

2018 graduates, I wish that more of you were entering family medicine, but regardless of the medical specialty you've chosen, don't ever stop being curious - especially about the most "difficult" patients and the ones you least understand. It is that skill, more than any other, that will sustain you in your work and that separates the merely competent doctors from the truly great ones.

Monday, May 28, 2018

Requiem for the National Guideline Clearinghouse

Absent a last-minute, lifesaving intervention, after 20 years of reviewing and summarizing clinical practice guidelines in a continuously updated database, the Agency for Healthcare Research and Quality's National Guideline Clearinghouse (NGC) will go offline on July 16th. Prior to its untimely death due to budget cuts, the NGC not only served as a one-of-a-kind online resource for clinicians, researchers, and educators, but raised the bar on guideline development, recently introducing the National Guideline Clearinghouse Extent Adherence to Trustworthy Standards (NEATS) assessment tool to evaluate how well guidelines meet the National Academy of Medicine's (formerly Institute of Medicine) standards for trustworthiness.

To be sure, some will not mourn the deaths of the NGC and its companion online resource, the National Quality Measures Clearinghouse (NQMC). Front-line clinicians have viewed guidelines with increasing suspicion as recommendations with tenuous links to patient-oriented outcomes that matter (e.g., lower hemoglobin A1c targets) have been unwisely converted into formal performance measures that are linked to physician compensation. The Performance Measurement Committee of the American College of Physicians recently evaluated the validity of 86 primary care-relevant measures included in the 2017 Medicare Merit-based Incentive Payment System (MIPS) Quality Payment Program and found that only 37% were valid, 35% were invalid (the majority due to insufficient supporting evidence), and 28% had uncertain validity.

It is also clear that the universe of medical quality, especially in primary care, is not and cannot be restricted to adherence to recommendations in evidence-based guidelines. Dr. Richard Young and colleagues have previously critiqued the application of traditional quality improvement processes to the "complex adaptive systems" of primary care practices and proposed some reasonable alternatives for assessing quality:

Our priorities for primary care quality management include patient-centered reporting; quality goals not based on rigid targets; metrics that capture avoidance of excessive testing or treatment; attributes of primary care associated with better outcomes and lower costs; less emphasis on patient satisfaction scores; patient-centered outcomes, such as days of avoidable disability; and peer-led qualitative reviews of patterns of care, practice infrastructure, and intrapractice relationships.

That being said, the premature ends of the NGC and NQMC will make it more difficult for clinicians to identify good clinical practice guidelines and are unlikely to slow the momentum of the "paying for value" movement, which aims to reward clinicians for their outcomes of care rather than the volume of services they provide. Killing these resources to save a few hundred thousand dollars per year is a penny-wise, pound-foolish decision, and your health and mine will be poorer for it.

Thursday, May 17, 2018

Few family physicians are delivering babies, and few women are having VBACs. What's stopping them?

In 2017, fewer than one in five members of the American Academy of Family Physicians (AAFP) reported providing obstetric care. In a previous Graham Center Policy One-Pager, Dr. Tyler Barreto and colleagues reported that between 2009 and 2016, the percentage of family physicians practicing high-volume obstetrics (more than 50 deliveries per year) fell from 2.1% to 1.1%. A subsequent study in Family Medicine by Dr. Sebastian Tong and colleagues found that 51% of recent family medicine residency graduates intended to provide prenatal care, and 23% intended to deliver babies; however, less than 10% were delivering after 1 to 10 years in practice.

In a recent policy brief in the Journal of the American Board of Family Medicine, Dr. Barreto and colleagues analyzed data from the 2016 Family Medicine National Graduate Survey to identify barriers faced by residency graduates who stated interest in delivering babies but did not do so in practice. Almost 60% of respondents cited the lack of opportunity to do deliveries in the practice they joined and lifestyle considerations as the most important factors. Fewer than 10% felt that inadequate training or reimbursement were major issues.

Although these recent studies did not specifically focus on family physicians who perform surgical deliveries, prior research has established that Cesarean delivery outcomes are comparable whether performed by family physicians or obstetrician-gynecologists. To support women who choose to attempt labor and vaginal birth after Cesarean delivery (VBAC), the AAFP published a 2015 guideline that was largely based on an Agency for Healthcare Research and Quality review of the benefits and harms of VBAC versus elective repeat Cesarean. I summarized the key findings of this review in American Family Physician's "Tips From Other Journals":

The risk of uterine rupture was statistically higher in women undergoing a trial of labor (0.47 percent) compared with women undergoing an elective repeat cesarean delivery (0.026 percent). Fourteen to 33 percent of women who experienced a uterine rupture underwent a hysterectomy. Maternal mortality was rare, but higher in women undergoing an elective repeat cesarean delivery (13.4 deaths per 100,000 deliveries) than in those undergoing a trial of labor (3.8 per 100,000). In contrast, trial of labor was associated with higher perinatal mortality (1.3 deaths per 1,000 deliveries) than elective repeat cesarean delivery (0.5 per 1,000). ... The evidence suggests that most of the differences in maternal and perinatal outcomes between these delivery options are statistically, but not clinically, significant.

Access to VBAC remains limited or nonexistent in many parts of the U.S., and debates continue about its safety for mothers and babies. This month in CMAJ, Dr. Carmen Young and colleagues analyzed a Canadian hospital database containing information on women with a single prior Cesarean between 2003 and 2015 and a second singleton birth at 37 to 43 weeks gestation. They found that rates of the composite outcomes "severe maternal morbidity and mortality" and "serious neonatal morbidity and mortality" were significantly higher after attempted VBAC compared to elective repeat Cesarean. However, absolute differences in these outcomes were low, with NNTs of 184 and 141, respectively.

This new study may give some hospitals and maternity care providers pause about continuing to support women who desire VBAC, and, together with the dwindling numbers of family physicians providing delivery services, could push the overall U.S. Cesarean rate of 32% higher in future years.

**

This post originally appeared on the AFP Community Blog.