Thursday, November 7, 2019

Family physicians caring for fewer children: reversing the trend

"How did you choose family medicine?" I've lost count of the number of times I've been asked this question by a medical student. The truth is, I entered medical school thinking that I would become a general pediatrician and focus my energies on keeping children healthy. It was only after I realized how much I also enjoyed adult medicine and well-woman care that I decided to enter the only specialty that would allow me to provide continuous, relationship-centered primary care to patients from their first until their last day of life.

In 2005, a Robert Graham Center report, whose key findings later appeared as a Policy One-Pager in American Family Physician, sounded an alarm. The authors reported that the share of children who saw family physicians for primary care had declined from one in four to one in six since the early 1990s. A subsequent article in Family Practice Management (now FPM) explored some reasons for the decline: expansion of the pediatrician workforce; fewer family physicians providing prenatal, newborn, and pediatric inpatient care; and a lack of awareness among the public and the media about the broad scope of family medicine training. The FPM article recommended several strategies for individual family physicians to increase their opportunities to recruit children to their practices:

- Build relationships with Ob/Gyns and pediatricians in your community.
- Heighten your visibility in the hospital.
- Get to know the nurses in labor and delivery and the nursery.
- Don't rely solely on word-of-mouth marketing.
- Talk with patients whose children might be outgrowing their pediatrician's office about transferring.
- Create a kid-friendly environment.
- Make sure your hours and appointment access are sensitive to the needs of young families in your community.

Nearly 15 years later, according to the American Academy of Family Physicians member census, 80 percent of family physicians are still caring for adolescents, while 74 percent see infants and younger children. But a recent population-based analysis of an all-payer claims database in Vermont suggested that family physicians' share of children's health care has continued to erode. Between 2009 and 2016, children residing in Vermont were 5% less likely to be attributed to a family physician practice, a trend that included urban and rural areas. Older children, girls, and children with Medicaid were somewhat more likely than others to see family physicians.

Caring for children benefits family physicians and their patients. In an article in the September/October issue of FPM, Drs. Sumana Reddy and Jaydeep Mahasamudram observed that "the satisfaction that comes from taking care of children shouldn't be underestimated in a time of increasing physician burnout." Not only can family physicians smooth young patients' transitions from child to adult care, but by caring for parents and grandparents, they gain perspectives on inter-generational social interactions that pediatricians don't. One example: "As family physicians, we can see all of the ill members together, we can care for both the newborn and the breastfeeding mother with postpartum depression, and we can understand the teenager's mood disorder because we know the parents have been dealing with severe stressors even if the teen doesn't disclose this."

So how can family physicians counter national trends and provide care to more children? In addition to the strategies already mentioned, Drs. Reddy and Mahasamudram suggested taking advantage of opportunities to refresh one's knowledge on child-specific issues (e.g., Kawasaki disease); asking local internists and obstetricians for referrals; volunteering to give community talks on child health topics; and becoming more familiar with Current Procedural Terminology (CPT) codes for visits with young patients, especially those for vaccine administration.

Incidentally, my personal doctor is a family physician, and my wife and children all see a longtime family physician colleague of mine for primary care. Although primary care should stick together to provide a counterweight to the subspecialist-oriented U.S. health system, I also think that it's important for the future of our specialty that patients don't perceive family physicians to simply be another flavor of general internists.

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

Thursday, October 31, 2019

Heading to the 2019 FMEC Annual Meeting

The Family Medicine Education Consortium (FMEC) is a major family medicine organization in the Northeast U.S. that serves as a "catalyst, convener, [and] incubator" for initiatives and programs in medical education, primary care, and community health. I first presented at their annual meeting in 2006, when it was still known as the Society of Teachers of Family Medicine Northeast Region meeting. I continued to attend regularly through 2011, when I, my wife, and our then-three children (one in utero) were involved in a major traffic accident on the Massachusetts Turnpike that ended up totaling our car and damaging six other vehicles. My older son sustained a scalp laceration from shattered window glass, and the rest of us were psychologically traumatized for varying lengths of time. Whether because I from then on associated this meeting with the accident or it was just easier to be the parent who stayed home with the kids while my wife traveled, I haven't been to an FMEC Annual meeting since, other than in 2014 when it was held in nearby northern Virginia.

That changes tomorrow at the FMEC's 2019 Annual Meeting.

Although I originally meant to deliver only a single presentation on a research paper I've been fortunate enough to work on with colleagues at Georgetown, Virginia Commonwealth University, Thibodaux Regional Medical Center in Louisiana, and the Lown Institute, somehow I've ended up having four. In addition to discussing our estimate of annual serious harms from overuse of screening colonoscopy in the U.S. (which number in the thousands to tens of thousands), I'm joining my wife and our family doctor to give a short lecture/discussion on when the doctor's child has a rare disease - in this case, Henoch-Schonlein Purpura, which afflicted our younger son last year around Christmas but fortunately resolved without any complications.

I was also invited by FMEC CEO Larry Bauer to co-lead a seminar on gun violence as a public health issue, a topic I've written about previously on this blog and in American Family Physician, but about which I'm certainly no expert. When I asked Larry why he thought I was best suited to present the evidence on this emotionally charged issue, he said that he was looking for someone who is respected across the political spectrum and perceived as being fair to all points of view. Larry, I promise I'll do my best.

Finally, Dr. Andrea Anderson, a longtime friend and DC-area colleague, asked me to join her in an Advocacy 101 workshop, where I will present tips on using blogs and social media to achieve one's advocacy goals. We will be joined by Dr. Joe Gravel, who will review the new Accreditation Council for Graduate Medical Education (ACGME) milestones for advocacy in family medicine training.

So it promises to be a whirlwind couple of days in Lancaster, Pennsylvania, the town where I grew from a freshly minted M.D. into a full-fledged family physician, and of course, where I met the love of my life. I'm looking forward to coming back.

Monday, October 21, 2019

To prevent pregnancy deaths, clinical care is just the beginning

According to the Centers for Disease Control and Prevention (CDC), about 700 U.S. women die from pregnancy-related complications every year. The U.S. maternal mortality rate has increased over the past 30 years and is much higher than rates in other high-income countries, and 60 percent of maternal deaths were potentially preventable through medical care. Around one-third of deaths occur during pregnancy, one-third during delivery or the first week postpartum, and one-third from one week to one year postpartum.  In an article in the October 15 issue of American Family Physician, Dr. Heather Paladine and colleagues discussed an overall approach to the "fourth trimester" (the first 12 weeks postpartum) and optimal strategies for prevention and prompt detection of some of the most frequent causes of postpartum deaths identified by the CDC: hemorrhage, hypertensive disorders, thromboembolic disorders, and infections. They also reviewed other common issues with health implications for the mother and newborn, such as thyroiditis, depression, urinary incontinence, constipation, weight retention, and breastfeeding problems.

In an accompanying editorial on "What Family Physicians Can Do to Reduce Maternal Mortality," Drs. Katy Kozhimannil and Andrea Westby encouraged clinicians to look beyond clinical risks to also address social determinants of health. These factors, which include "housing instability, food insecurity, community violence, firearms access, financial insecurity, and social isolation," are likely responsible for the large and persistent racial and ethnic disparities in pregnancy-related deaths. For example, the CDC reported that black and American Indian/Alaska Native women aged 30 years and older are four to five times as likely to die as a result of pregnancy complications than white women in the same age group.

Outside of the clinic, Drs. Kozhimannil and Westby suggested several strategies for family physicians to support pregnant patients in their communities: advocating for continuous health insurance coverage for the more than half of women who have public insurance at the time of delivery; supporting increased access to postpartum doulas and community health workers; continuing to provide obstetric services at rural hospitals; and reflecting on "one's own privilege and role in perpetuating or disrupting systems of oppression" that remain obstacles to attaining health equity.

For its part, the American Academy of Family Physicians (AAFP) took aim at the maternal mortality crisis by convening a Maternal Mortality Task Force in April and June to recommend evidence-based methods to decrease maternal morbidity and mortality, reduce implicit bias and disparities, and collaborate with other key stakeholders to stop the accelerating loss of rural obstetrical services. In its report to the 2019 Congress of Delegates (access restricted to AAFP members), the Task Force made a series of recommendations for improving maternal care quality and data collection; retaining family physicians and other clinicians who deliver babies in rural communities; and working with departments and residency programs in family medicine to develop sustainable maternity care workforce goals.

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This post first appeared on the AFP Community Blog.

Wednesday, October 9, 2019

Should dietary guidelines suggest that people eat less meat?

There is a widespread consensus among nutrition and environmental scientists that reducing dietary meat intake, particularly red and processed meats, is not only beneficial for personal health, but also benefits the planet by reducing deforestation, freshwater consumption, and greenhouse gas emissions associated with cattle farming. As my colleague Caroline Wellbery, MD wrote in a 2016 editorial: "According to the 2015–2020 [U.S.] dietary guidelines, moderate to strong evidence demonstrates that healthy dietary patterns that are higher in fruits, whole grains, legumes, nuts, and seeds, and lower in animal-based foods are associated with more favorable environmental outcomes."

Although the effects of individual dietary counseling in patients without cardiovascular risk factors are limited, the Dietary Guidelines for Americans, which are updated every 5 years, have been influential in changing eating patterns. A recent analysis of cross-sectional data from the National Health and Nutrition Examination Survey found small but significant decreases in consumption of refined grains and added sugar and increased consumption of plant proteins, nuts, and polyunsaturated fats from 1999 to 2016. Bigger changes could be on the horizon, if the efforts of entrepreneurs profiled in a recent article in The New Yorker to bioengineer and distribute plant-based hamburger patties and other products that are indistinguishable from real meat prove to be successful.

The next iteration of the Dietary Guidelines will need to consider new evidence that beneficial health effects of eating less meat may not be as large or as certain as previously thought. In a clinical guideline published last week in the Annals of Internal Medicine, an international panel from the Nutritional Recommendations and Accessible Evidence Summaries Based on Systematic Reviews (NutriRECS) consortium made the somewhat shocking suggestion that adults can continue their current (over)consumption of red and processed meats without major health consequences. Four linked systematic reviews found low-quality evidence of small to no benefits on cardiometabolic and cancer outcomes from consuming less red and processed meat in cohort studies and in randomized trials, and a review of health-related values and preferences suggested that "omnivores are attached to [eating] meat and are unwilling to change this behavior when faced with potentially undesirable health effects." Importantly, none of the guideline authors or systematic reviewers received any financial support from the meat industry, though the lead author previously received funding from the International Life Sciences Institute, an industry trade group.

Critical responses from the medical and public health community have been swift and plentiful. Some experts challenged the guideline panel's assessment of the magnitude of beneficial health effects of eating less meat as "very small." For example, meta-analyses estimated that after about 11 years, dietary patterns with 3 fewer servings of red meat per week are associated with absolute risk differences of 6 fewer cardiovascular-related deaths (number needed to treat = 167) and 14 fewer persons developing diabetes (NNT = 71) out of every 1000 persons. To an individual, these differences seem small, but if true, they compare favorably with the NNTs of established clinical preventive services such as colorectal cancer screenings and therapy for osteoporosis. Others faulted the guideline for excluding benefits to animal welfare and the environment from lower population-wide meat consumption. Goals and guidelines for what constitutes a healthy diet will continue to evolve, but this one has provided much food for thought.

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This post first appeared on the AFP Community Blog.

Monday, September 30, 2019

Screening for autism spectrum disorder: the jury is still out

In 2007, the American Academy of Pediatrics (AAP) first recommended using a standardized autism-specific tool to screen all children for autism spectrum disorder at the 18- and 24-month well-child visits. In a recent national survey, most pediatricians reported following this guidance, but I suspect that screening rates are considerably lower among family physicians. In my practice, I don't use an autism-specific screening instrument unless either I or the child's parent or guardian have behavioral concerns, in which case it's no longer screening, but evaluation.

Why not? In 2016, the U.S. Preventive Services Task Force concluded that "current evidence is insufficient to assess the balance of benefits and harms of of screening for autism spectrum disorder (ASD) in young children for whom no concerns of ASD have been raised by their parents or a clinician." The Task Force observed that most ASD treatment studies included children who were considerably older than those identified through screening, and that no controlled studies have looked at the comparative clinical outcomes of screening-identified children with ASD, which is what a guideline writer would definitely want to know before recommending universal screening, even if the AAP didn't think so.

Dr. Doug Campos-Outcalt, a longtime colleague who has served as the American Academy of Family Physicians' liaison to the USPSTF, wrote in American Family Physician that four critical questions needed to be answered before screening for ASD would be "ready for prime time":

1. What are the sensitivity and false-positive rate of the best screening test for ASDs available in an average clinical setting?

2. How much earlier can screening tests detect ASDs compared with an astute clinician who asks a few key questions about, and acts on, parental concerns regarding a child's communication and interactions?

3. What are the potential harms of testing?

4. Does earlier detection by screening result in meaningful and long-lasting improvements compared with detection through routine care?

Although the answers to the second and fourth questions are arguably the most important, until last week there was little evidence to answer the first and third, either. If the recommended screening test, the Modified Checklist for Autism in Toddlers, Revised, with Follow-Up (M-CHAT-R/F), can't reliably detect most children who will eventually develop symptoms of ASD in later life, or there are so many false positives that the harms of parent anxiety and unnecessary diagnostic evaluations would outweigh the benefits, then universal screening is unlikely to work. Unfortunately, the first large study (n=26,000) of near-universal screening for ASD in 31 primary care clinics affiliated with Children's Hospital of Philadelphia just provided disappointing results on both of these fronts. Using an older version of the M-CHAT, the sensitivity of screening was only 38.8%, and only 14.6% of children who screened positive ultimately received an ASD diagnosis, with even lower positive predictive value in children residing in lower-income households.

The authors pointed out that nearly 60% of children with initial positive screens did not return for a follow-up interview that might have reduced false positives and improved predictive value, and that children with positive screens who were diagnosed with ASD were more likely to receive interventions at a younger age, potentially improving outcomes. But the former simply shows how a two-stage screening test performs in real life, rather than in a controlled research setting. As for the latter, outside of anecdotes from screening advocates, we still have no conclusive evidence that long-term outcomes turn out better in these children. The bottom line? For universal screening for ASD in toddlers, the jury is still out.

Monday, September 23, 2019

Using life expectancy and prognosis to support shared decision-making

Due to competing causes of death (e.g., heart disease, stroke, dementia), the benefits of most screening tests decline with increasing age; for example, screening for breast and colorectal cancers is not recommended in persons with a life expectancy of less than 10 years. However, estimating how much time an individual has left to live and incorporating that estimate into shared decision-making with patients is challenging. As a result, a 2014 U.S. population-based survey found that 31% to 55% of participants with a greater than 75% risk of death in the next 9 years were still receiving breast, colorectal, or prostate cancer screenings.

There are many reasons why physicians provide so many unnecessary and potentially harmful screening tests to older persons with limited life expectancies. In an editorial in the September 1 issue of American Family Physician, Dr. Emma Wallace and Norah Murphy observed that "barriers to discussing life expectancy include uncertainty in prognostic estimates, limited time to broach this sensitive topic, and concerns about upsetting the patient or getting negative reactions."

A systematic review of the prognostic value of the "Surprise Question" approach (which asks clinicians, "would you be surprised if this patient died in the next 12 months?") found that the answer has varying degrees of accuracy at identifying patients in their last year of life. The QMortality tool, in contrast, generates a more precise estimate of one-year mortality in persons age 65 to 99 years utilizing multiple clinical and demographic variables, and was found to have good predictive accuracy in 500,000 family practice patients in England.

Some patients may feel uncomfortable about stopping nonbeneficial screening tests even if they are objectively unlikely to benefit from them. In a mailed survey of patients age 50 years or older in the Veterans Affairs health system, nearly 30 percent reported being "not at all comfortable" with discontinuing screening colonoscopy in a hypothetical patient scenario where a colorectal cancer-specific risk calculator predicted a low likelihood of benefit. To help physicians sensitively incorporate prognostic information into discussions about continuing or discontinuing screening, the University of California San Francisco's ePrognosis website provides risk calculators and video examples demonstrating key communication skills.

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This post first appeared on the AFP Community Blog.