The best of the best Common Sense posts of 2014

As I look forward to another New Year, here are the top 10 favorite posts that I wrote for Common Sense Family Doctor in 2014. Best wishes to all for a great start to 2015!

1) Family physicians are natural health system leaders (5/26/14)

Compared to all others, students entering family medicine were statistically more likely to recommend generic over brand-name medications and favor initial lifestyle change counseling to starting medication for a mild chronic condition.

2) The demise of the small practice has been greatly exaggerated (9/22/14)

In addition to providing superior service, solo physicians or small groups can create their own economies of scale by pooling resources and collaborating with other practices in areas such electronic health record systems and quality improvement.

3) Movings and dislocations in life and medicine (2/9/14)

Will newly formed alliances of clinicians and hospitals succeed in organizing themselves to provide accountable care that improves population health outcomes? In other words, is this seemingly inexorable movement toward a brave new health system forward progress, or a temporary dislocation?

4) Nurturing the next generation of diverse family physicians (7/21/14)

The good news is that family physicians are diversifying; the bad news is that Black and Latino physicians still have a long way to go to "catch up" to their numbers in the population. America's need for the next generation of diverse family physicians has never been greater.

5) Don't do stupid sh*t in cancer screening (8/25/14)

Think twice before reflexively doing things to elderly patients that can't possibly help and, therefore, can only hurt. And keep in mind that electronic clinical decision support should never, ever substitute for a physician's brain.

6) Why are doctors still prescribing bed rest in pregnancy? (9/8/14)

71 percent of maternity care providers would recommend bed rest to patients with arrested preterm labor, and 87 percent would advise bed rest for patients with preterm premature rupture of membranes at 26 weeks gestation, even though most of them did not believe it would make make any difference in the outcome.

7) The problem of pain (8/13/14)

Like many doctors, I have complicated feelings about prescribing for chronic pain. On one hand, I recognize that relieving pain has been a core responsibility of the medical profession for ages. On the other hand, deaths and emergency room visits from overdoses of prescription painkillers have skyrocketed over the past 25 years.

8) For homeless patients, housing is preventive health care (11/9/14)

I have come to realize that some of my patients will not be able to fully address their chronic health issues until they have roofs over their heads and the stability and security that comes with having a place to call home.

9) There are many ways of "knowing cancer" (6/5/14)

All of us involved in confronting cancer in all its forms - specialist and primary care clinicians, advocates, patients, family and loved ones - know cancer in different ways, and none should be held up as inherently superior to any other.

10) Of impersonal statements and meaningless use (2/26/14)

Perhaps these electronic exercises collectively known as meaningful use will someday improve care and outcomes. Until then, I know it's only a matter of time before I read a personal essay from an earnest medical school applicant who once aspired to be a professional coder but decided he could have his nonsensical documentation requirements and treat patients, too.

What should doctors do at well-child visits?

As a family physician who provides care to children, and as a father of four ranging in age from 7 months to 8 years, I have a professional and personal interest in the content of well-child visits beyond childhood immunizations. Not only can health maintenance and counseling vary from practice to practice, previous reviews have found large gaps in the evidence to support preventive services recommended by government health agencies and medical groups. Also, clinicians who compare the Bright Futures / American Academy of Pediatrics "Recommendations for Preventive Pediatric Health Care" to the clinical recommendations for children published by the American Academy of Family Physicians (AAFP) will find that groups sometimes disagree about which services should be offered at well-child visits.

To provide perspective on how the AAFP evaluates evidence regarding the net benefit of individual preventive services in children, I recently wrote an editorial in American Family Physician that reviewed the guideline process and discussed why there is insufficient evidence to recommend screening children for autism spectrum disorders, high blood pressure, and cholesterol levels. (Note to readers: although I am a member of the Commission on the Health of the Public and Science and verified that this editorial reflects current AAFP recommendations, it should not be considered an official statement of the AAFP.) Here is the bottom line:

Time is a precious clinical resource. Clinicians who spend time delivering unproven or ineffective interventions at health maintenance visits risk “crowding out” effective services. For example, a national survey of family and internal medicine physicians regarding adult well-male examination practices found that physicians spent an average of five minutes discussing prostate-specific antigen screening, but one minute or less each on nutrition and smoking cessation counseling. Similarly, family physicians have limited time at well-child visits and therefore should prioritize preventive services that have strong evidence of net benefit.

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This post first appeared on the AFP Community Blog.

Immigration policies and health care

I am a child of immigrants. My parents migrated from Taiwan to the United States in the 1950s and 1960s, my father as a graduate student and my mother as a toddler, at that time the youngest member of a family of seven. Both eventually became naturalized citizens.

The ship my mother's family took from China to the U.S.

It is much more difficult to immigrate legally to the U.S. today. Current policies overwhelmingly emphasize family re-unification, reserving two-thirds of "green cards" to persons who already have relatives residing in the U.S. Millions of highly skilled potential immigrants like my parents and grandparents - my father eventually programmed the Hubble Space Telescope, and my mother's father was a neurologist whose biography appeared in the 9th edition of Who's Who in the World - now compete for a comparatively small number of resident permits. Most must wait for years; many lose hope and return their talents to their native countries. As former Florida governor Jeb Bush wrote about the U.S.-Mexican border crisis earlier this year, "A chief reason so many people are entering through the back door, so to speak, is that the front door is shut."

My mother's family in 1950. The baby is my mother.

The recent deluge of unaccompanied minors from Honduras, El Salvador, and Guatemala through this "back door" has substantial physical and mental health needs. But Drs. Douglas Bishop and Rina Ramirez observe in American Family Physician that the legal status of these children, which can vary from state to state, complicates efforts to provide them with adequate medical care:

Those of us on the front lines of community medicine continue to struggle daily with the challenges that this vastly complex and heterogeneous population brings, and we look forward to others sharing best practices to care for and foster resiliency in these children. For now, physicians caring for unaccompanied minors need to begin developing office protocols and medical evaluations that fit with state laws and financial realities while working to engage these children and keep them out of the shadows.

Meanwhile, some undocumented residents who migrated to the U.S. before their 17th birthdays prior to June 15, 2012, better known as "Dreamers," have been completing college and applying to graduate schools. In a commentary in Academic Medicine, Drs. Mark Kuczewski and Linda Brubaker explained why Loyola University Chicago Stritch School of Medicine decided to welcome applications from academically qualified Dreamers and encourages other schools to establish similar admissions policies:

The ethical obligation to train the best potential workforce pulled from all of the best candidates intersects with the social justice value that requires medical schools to form physicians who have the capacity and skills, including cultural awareness and competence, to provide all patients with high-quality, compassionate care. ... Dreamer students represent a very valuable resource in achieving the diversity necessary to meet the health care needs of contemporary U.S. society.

Neither a porous southern border nor a too-narrow pathway to legal residency will benefit the U.S. in the long run. At least 10 million undocumented persons already live in the U.S., often doing jobs that citizens don't want, from child care to cleaning homes to construction. The idea that our country could somehow deport all of them is more of a fantasy than President Abraham Lincoln's early Civil War notion of resettling all 4 million African American slaves in a foreign land instead of granting them citizenship.

Me and my sister with my father's parents in the early 1980s.

Immigration policy is complicated, no doubt, and one might ask what fixing it has to do with medicine. Here are a few ways maintaining the immigration status quo harms health and health care in the U.S. There are millions more people to care for, and few options for them to access care in continuous, cost-effective ways. Loyola University Chicago aside, the best and brightest undocumented immigrants who arrived in the U.S. as children face huge obstacles to becoming part of the diverse health care workforce that America desperately needs. And the "front door" of U.S. immigration remains, for all practical purposes, firmly closed to foreign-born persons with aspirations similar to those my own parents had half a century ago.

False alarms and unrealistic expectations in preventive care

Shortly after we moved to Washington, DC ten years ago, my wife and I purchased a basic home security system, the kind with a programmable keypad, multiple door alarms and a motion sensor. The alarm has sounded about a dozen times since then. None of these times was a burglary actually in progress. On several particularly windy days, one of us forgot to lock the back door after leaving, and it blew open. Two or three other times, departing early for work, I accidentally hit "Away" on the keypad (arming the motion detector at the foot of the stairs) rather than "Stay," causing the klaxon to sound when my unsuspecting son or visiting mother-in-law came down the stairs later in the morning. We've also set off the fire alarm a few times while cooking. Although our security system cost little to purchase, we've spent well over $4000 in monitoring fees, a sum that could easily surpass the value of what we might lose in an actual burglary.

There are, of course, intangible benefits to having a home security system - peace of mind being the most important. But our peace of mind has been achieved at the substantial cost of temporarily diverting multiple municipal police and fire units, disturbing our neighbors, receiving inconvenient cellular phone calls from the monitoring company, and briefly traumatizing my 5 year-old son on his way to breakfast. All things considered, it's hard to argue that the benefits of this preventive measure have outweighed its cumulative harms.

I think about my home security system every time I'm asked to do a physical examination on an apparently healthy young adult. Although the periodic health examination is an established tradition in medicine, and probably builds trust and strengthens the doctor-patient relationship in preparation for future health crises, studies have shown that it doesn't help people live longer, or even better. The same may be said for many of the tests physicians routinely offer at these examinations - including blood pressure measurement (no benefit from treating mild hypertension) and diabetes screening (no benefit from nontargeted screening).

No doubt these routine examinations and tests (if normal), like my home security system, give patients peace of mind. And if patients had clear-eyed expectations of the small potential benefits of screening and preventive treatments, I would have no problem with continuing to do them. Unfortunately, a 2012 study in the Annals of Family Medicine showed that patients greatly overestimate the benefits of preventive interventions that primary care physicians commonly provide: breast cancer screening, colorectal cancer screening, and medications to prevent hip fractures and cardiovascular disease. In most cases, patients' "minimum acceptable benefit" (the lowest level of benefit that in their mind was required to justify the preventive intervention) far exceeded the actual benefit of the service established in randomized trials. Further, this study considered only the benefits of these services, and not the false alarms, which occur in more than 60 percent of women receiving annual mammography after 10 years.

Not only do inflated expectations of the benefits of preventive tests and treatments needlessly complicate shared decision making, they contribute to an environment where proposals to restrict screening tests of marginal benefit (such as the prostate-specific antigen test for prostate cancer) inevitably cause a political uproar. In the words of family physician and former U.S. Preventive Services Task Force member Steven Woolf:

If people are widely convinced that a screening test or drug is beneficial, confronting these beliefs can, if anything, engender suspicions about one's veracity and motives. Whether the messenger is one's physician, a health plan, or a government task force, attempts to set more realistic expectations about benefits, risks, and scientific validity are often taken as insensitivity to suffering, discrimination, or a pretext for cutting costs, rationing health care, or threatening personal autonomy. ... It is an increasingly difficult environment for the American public to receive, let alone absorb, undistorted scientific information from reputable bodies.

Unrealistic expectations therefore persist, surviving not only on misinformation but also by serving other purposes. For example, false beliefs meet the psychological needs of patients for hope and safety, as well as for action, agency, and a sense of control. They enable clinicians to feel they are making a difference; even physicians who know better order unnecessary tests to please their patients. False expectations fuel market demand for products, industries, and health delivery systems and can be fomented by misleading advertising. Confronting these expectations can not only dash hopes but potentially threaten profits, shareholders, clinical practices, industries, legislation, and political careers.

I recently had a testy social media exchange with an obstetrician-gynecologist who disagreed with my view that since cervical cancer screening is needed only every 3 to 5 years, and ovarian cancer screening is useless and potentially harmful, there is no good reason to do annual pelvic examinations in women at low risk for sexually transmitted diseases. However, a recent survey of U.S. gynecologists found that overwhelming numbers (including, presumably, this particular Ob/Gyn) continue to do these examinations despite the absence of proven health benefits. In my view, the only clear benefit (aside from "peace of mind") is financial - doctors can charge more for physicals that include a pelvic examination, payers will pay for them without question, and medical offices then have an easier time keeping their doors open.

Preventive health care has positive effects if offered to appropriately selected and informed patients. But the massive structure of "routine" preventive care, built upon a rotten foundation of false alarms and unrealistic expectations, only serves to increase harms and health care costs. It should be a New Year's resolution of conscientious physicians and policymakers everywhere to help people understand the difference.

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This post first appeared on Common Sense Family Doctor on December 22, 2012.

Job Posting: 2015-16 Robert L. Phillips, Jr. Health Policy Fellowship

The Department of Family Medicine at Georgetown University School of Medicine is currently recruiting qualified applicants for its one-year fellowship in Primary Care Health Policy. This is a unique, full-time program that combines experiences in scholarly research, faculty development, clinical practice, and coursework at the McCourt School of Public Policy. Fellows have the opportunity to interact with local and federal policymakers in Washington, D.C. and conduct health services research projects with experienced mentors at the Robert Graham Center for Policy Studies in Family Medicine and Primary Care. They will join a dynamic group of faculty (including me) at one of the flagship departments for urban family medicine on the East Coast. Past Robert L. Phillips, Jr. Health Policy Fellows hold leadership positions in federal health agencies, community health organizations, and academic institutions. Applicants should be graduates of an accredited residency program in Family Medicine or Internal Medicine or expect to graduate in 2015. Please contact me at Kenneth.Lin@georgetown.edu for more information.

The best recent posts you may have missed

Every few months, I post a list of my top 5 favorite posts since the preceding "best of" list on this blog, for those of you who have only recently started reading Common Sense Family Doctor or don't read it regularly. Here are my favorites from September, October, and November:

1) The demise of the small practice has been greatly exaggerated (9/22/14)

In addition to providing superior service, solo physicians or small groups can create their own economies of scale by pooling resources and collaborating with other practices in areas such electronic health record systems and quality improvement.

2) For homeless patients, housing is preventive health care (11/9/14)

I have come to realize that some of my patients will not be able to fully address their chronic health issues until they have roofs over their heads and the stability and security that comes with having a place to call home.

3) Birth control pills over-the-counter: debate evidence, not politics (11/6/14)

Over-the-counter birth control need not be an evidence-free debate. Regardless of where you stand on this issue personally or politically, it's time to stop with the slogans and inform the discussion with science.

4) Why are doctors still prescribing bed rest in pregnancy? (9/8/14)

71 percent of maternity care providers would recommend bed rest to patients with arrested preterm labor, and 87 percent would advise bed rest for patients with preterm premature rupture of membranes at 26 weeks gestation, even though most of them did not believe it would make make any difference in the outcome.

5) The natural history of symptoms in primary care (11/2/14)

At least one-third of common physical symptoms evaluated in primary care are "medically unexplained," meaning that they are never connected to a disease-based diagnosis after an appropriate history, physical examination, and testing.

If you have a personal favorite that isn't on this list, please let me know. Thank you for reading!

Right-sizing the care of patients with serious illness: it's about time

Concerned about the overuse of ineffective or harmful practices in older patients with serious illnesses, the High Value Task Force of the American College of Physicians (ACP) recently published a synthesis of best practices on patient-centered communication about serious illness care goals. Although these conversations can sometimes be uncomfortable for clinicians or patients, the authors offered several reasons that they should occur early and often:

An understanding of patients’ care goals in the context of a serious illness is an essential element of high-quality care, allowing clinicians to align the care provided with what is most important to the patient. Early discussions about goals of care are associated with better quality of life, reduced use of nonbeneficial medical care near death, enhanced goal-consistent care, positive family outcomes, and reduced costs. Existing evidence does not support the commonly held belief that communication about end-of-life issues increases patient distress.

What clinical situations should trigger discussions about end-of-life preferences? The authors recommended making time for a conversation in the setting of worsening symptoms or frequent hospitalizations in patients with COPD, congestive heart failure, and end-stage renal disease; in all patients with non-small cell lung cancer, pancreatic cancer, and glioblastoma; in patients older than 70 years with acute myelogenous leukemia; in patients receiving third-line chemotherapy; and in hospitalized patients older than 80 years. The ePrognosis website offers useful tools for clinicians to estimate prognoses in older persons with serious illnesses.

According to the ACP, key elements to address in these conversations include understanding of prognosis; decision making and information preferences; prognostic disclosure; patient goals; patient fears; acceptable function; trade-offs; and family involvement. Additional guidance for discussing end-of-life care and eliciting patient preferences has been published in American Family Physician and Family Practice Management.

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This post first appeared on the AFP Community Blog.