Nurturing the next generation of diverse family physicians

Since joining my current practice in 2012, I've noticed that I care for a disproportionate number of immigrants of Chinese and other Asian descent compared to my colleagues. Although both of my parents were born in Taiwan, I don't speak Mandarin or have special expertise on medical conditions common in Asian Americans. Nonetheless, Asian patients seem more comfortable with me anyway. Similarly, U.S. health workforce analyses show that underrepresented minority physicians (Black, Latino, and Native American) are more likely to provide primary care to medically underserved populations.

A Robert Graham Center Policy One-Pager examined the racial diversity of family medicine resident physicians from 1990 through 2012. It compared the proportion of residents of a particular race with the proportion of the U.S. population of the same race. The White and Native American resident to population ratio was close to 1:1, but Blacks and Latinos were present in family medicine residency programs at only 50 to 75 percent of their proportions in the population. (Asian residents have always been overrepresented compared to the population, with a current ratio of 5.1 to 1.) 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. This means that many Blacks and Latinos will receive primary care from physicians of different races, which isn't automatically a bad thing. But it begs the question of why this situation exists in the first place.

Too many Black and Latino Americans grow up in desperately poor and crime-ridden neighborhoods with substandard public schools, and for decades resources have been poured into programs designed to give these students opportunities for educational success, from Head Start to Fairfax, Virginia's Young Scholars. It's still a rough and treacherous road, as Ron Suskind illustrated in the bestseller A Hope in the Unseen, about Cedric Jennings, an African American from Washington, DC who overcame a heartbreaking upbringing (his father was repeatedly incarcerated for dealing drugs and he and his mother were evicted from multiple homes for falling behind on rent payments) and dysfunctional schools to be admitted to Brown University. But if communities can give these kids enough K-12 support to get them accepted to four-year colleges, then a good number of them should go on to become doctors, right?

It's not that simple. In the New York Times Magazine article "Who Gets to Graduate?," Paul Tough delved deeply into the problem of college dropouts at the University of Texas at Austin, a respected public university that offers automatic admission to any Texas resident who graduates in the top 7 percent of his or her high school class. He followed Vanessa Brewer, an African American woman raised in a single-parent home who aspired to become a nurse anesthetist. Vanessa experienced a crisis of confidence after failing her first statistics test, and wondered: "Am I supposed to be here? Am I good enough?" Wrote Tough:

There are thousands of students like Vanessa at the University of Texas, and millions like her throughout the country — high-achieving students from low-income families who want desperately to earn a four-year degree but who run into trouble along the way. Many are derailed before they ever set foot on a campus, tripped up by complicated financial-aid forms or held back by the powerful tug of family obligations. ... Many are overwhelmed by expenses or take on too many loans. And some do what Vanessa was on the verge of doing: They get to a good college and encounter what should be a minor obstacle, and they freak out. They don’t want to ask for help, or they don’t know how. Things spiral, and before they know it, they’re back at home, resentful, demoralized and in debt.

The bottom line on national statistics on college graduation rates is that "rich kids graduate; poor and working-class kids don't." And surprisingly, graduation rates have little relationship to natural ability and much more to do with confidence, rooted in one's socioeconomic background.

A case in point: I failed my first anatomy exam in medical school. It felt terrible to see my score near the bottom of the class, but as the son of a pharmacist and a computer scientist with two Master's degrees, and the grandson of a neurologist and related to a long line of doctors, I pulled myself together and eventually earned a passing grade. Had this sort of setback happened to a student who was the first in his family to finish college, it could easily have led to that student leaving medical school entirely.

A U.T. program called the University Leadership Network (ULN) not only confirmed that a lack of confidence related to humble upbringing puts students at the highest risk of dropping out, but successfully tested an brief online intervention that measurably improved their odds of completing at least 12 credits during their first semester and staying on track to graduate in four years. Tough summarized ULN's straightforward strategy: "Select the students who are least likely to do well, but in all your communications with them, convey the idea that you have selected them for this special program not because you fear they will fail, but because you are confident they can succeed." The payoff for replicating this program at universities across the nation, Tough suggested, could be immense:

Beyond the economic opportunities for the students themselves, there is the broader cost of letting so many promising students drop out, of losing so much valuable human capital. ... Most well-off students now do very well in college, and most middle- and low-income students struggle to complete a degree. ... These two trends are clearly intertwined. And it is hard to imagine that the nation can regain its global competitiveness, or improve its level of economic mobility, without reversing them. ... A big part of the solution lies at colleges like the University of Texas at Austin, selective but not superelite, that are able to take large numbers of highly motivated working-class teenagers and give them the tools they need to become successful professionals. The U.T. experiment reminds us that that process isn’t easy; it never has been. But it also reminds us that it is possible.

Becoming a family physician isn't easy. But America's need for the next generation of diverse family physicians has never been greater, and Tough's article convinced me that nurturing them is possible.

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This post first appeared on Common Sense Family Doctor on July 21, 2014.

Opioid overprescribing: we have met the enemy, and he is us

My last Medscape video commentary of 2015 discusses the draft Centers for Disease Control and Prevention guideline for primary care clinicians who prescribe opioids for patients with chronic non-cancer pain. Twice as many people died from overdoses of prescription opioids than from heroin overdoses in 2014, and although some have wanted to blame the problem on a small number of high-volume prescribers operating "pill mills," family physicians - myself included - bear some responsibility for overprescribing these medications and must be part of the solution.

I would like to take this opportunity to thank Laurie Scudder and her team at Medscape Family Medicine for inviting me to tape these monthly physician-oriented pieces, giving me complete freedom to choose the topics, and for adhering to the highest standard of professionalism throughout the process.

Here is a complete list of my commentaries this year:

1. Lung Cancer: To Screen or Not to Screen (1/16/15)

2. Transforming Primary Care One House Call at a Time (3/31/15)

3. Can Patients Understand the Concept of Overdiagnosis? (4/7/15)

4. Screening Mammography Guidelines: The Change Clinicians Should Know (5/29/15)

5. Conflicts of Interest and Guidelines: Is Bias A Worry? (7/27/15)

6. Primary Care Training: Follow the Money (8/7/15)

7. "Death Panels": Moving Beyond the Rhetoric (9/10/15)

8. Breast Cancer Screening: The Evidence Is Piling Up (10/26/15)

9. Putting SPRINT in Focus for Primary Care (11/16/15)

10. Opioid Abuse: A Primary Care-Created Problem? (12/22/15)

Pharma industry free speech is anything but free

Last month, the American Medical Association (AMA) called for a ban on direct-to-consumer (DTC) advertising of prescription drugs and medical devices, arguing that this type of advertising drives the nation's escalating drug bill by creating demand for new, expensive medications that are often no more effective than older ones. Since the first televised prescription drug ad aired in the U.S. in 1983, pharmaceutical companies have spent billions of dollars on DTC advertising, including $4.8 billion in 2014. The ads are worth every penny. According to Kantar Media, 76% of Americans have seen at least one DTC ad on television in the past 12 months, and 1 of 3 who viewed these ads took some action as a result.

The AMA's call comes at a time of increasing public concern about the potentially harmful impact of loosening restrictions on marketing and promotion of off-label use of drugs. Although the U.S. Food and Drug Administration (FDA) has historically prohibited this practice, earlier this year a federal District Court judge blocked the FDA from enforcing restrictions on promoting a prescription fish oil product for an unapproved indication. The judge determined that if the FDA refused permission to distribute the promotional materials, it would violate the company's First Amendment right to freedom of speech.

Although recent Supreme Court decisions have established that for some purposes, corporations have the same rights as people, there are real dangers to allowing the pharmaceutical industry to claim anything they want about their products to physicians or consumers under the guise of free speech. A Canadian cohort study published in JAMA Internal Medicine found that off-label drug use was 44 percent more likely to be associated with adverse drug events than on-label use, a difference driven almost entirely by the prescription of drugs without strong supporting scientific evidence (about 80 percent of all off-label prescriptions). The top five drugs used off-label were quinine, gabapentin, quetipine, amitriptyline, and risperidone.

A 2014 American Family Physician editorial by Drs. April Fitzgerald and Patrick O'Malley discussed how family physicians can "stay on track when prescribing off-label." The authors noted that the toughest calls occur when evidence suggests potential benefits but the harms are not well described:

The ethics surrounding off-label use become more complicated when considering medications with less clear-cut positive or negative risk-benefit ratios. This is the gray area where physicians individually weigh the translational gaps in evidence between effectiveness, available research, and the complexities of real-world clinical practice. Particular scrutiny is suggested when using off-label medications with red flags, such as new medications, medications with known serious adverse effects, or high-cost medications, or when considering novel off-label use.

Pharmaceutical free speech is actually anything but free. By directly encouraging patients to request new medications from physicians, and by promoting drugs for unapproved uses, the industry will not only continue to increase national spending on prescription drugs, but expose even more patients to an unacceptable risk of iatrogenic harm.

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This post first appeared on the AFP Community Blog.

Announcing the American Family Physician podcast

After several months of development and fine-tuning, the American Family Physician podcast went live today on the journal website and on iTunes, with six 15- to 20-minute episodes representing two pilots and 4 episodes covering content from the Nov. 1, Nov. 15, Dec. 1, and Dec. 15 issues. Although I'm not personally a big podcast listener, I can't say enough about how awesome this podcast is. For AFP readers with physical and virtual stacks of past journals that they often don't get around to reading, listening to this podcast during a workout or on the commute to work is the next best thing.

I am glad to have had the chance to meet some of the University of Arizona College of Medicine, Phoenix family medicine residents who star in the podcast at the Society of Teachers of Family Medicine Conference on Practice Improvement in Dallas earlier this month. As residency program director Steve Brown and AFP editor Jay Siwek wrote in an introductory editorial, "we are proud to share AFP in a new way" and "hope you will tune in"!

My favorite public health and health care books of 2015

This year has seen the publication of so many outstanding books about public health and health care that my top 10 list, which follows below in alphabetical order, doesn't even include Atul Gawande's fabulous Being Mortal (which earns an honorable mention, having been published at the end of 2014).

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1. America's Bitter Pill: Money, Politics, Backroom Deals, and the Fight to Fix Our Broken Healthcare System, by Steven Brill

An expansion of his 2013 Time Magazine article that first got my attention for blowing the whistle on hospitals' outrageous charges for health care services levied on those who can least afford them, Brill's book takes a dim view of the political sausage-making that produced the "Affordable" Care Act and proposes a viable national health insurance alternative that doesn't tread well-worn liberal or conservative paths.

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2. Black Man in a White Coat: A Doctor's Reflections on Race and Medicine, by Damon Tweedy

An African-American psychiatrist draws on his often discouraging personal experiences as a scholarship-supported medical student and resident at a Southern university in the 1990s to reflect on larger intersections of race and medicine. Why are fewer black men graduating from medical school today than in 1978? Why do patients of color consistently receive inferior medical care? The answers (and possible solutions) are complex, but thoughtfully addressed in this revealing memoir.

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3. The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine's Computer Age, by Robert Wachter

In a smattering of previous blog posts, I've cautiously endorsed electronic health records as "medical progress, not panacea," worried about the new types of medical errors that they can cause, and compared laborious data entry tasks to more traditional scut work. Dr. Robert Wachter, an academic hospitalist and healthcare quality leader who was named the most influential physician executive in the U.S. by Modern Healthcare magazine in 2015, does these topics, and more, justice.

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4. Ending Medical Reversal: Improving Outcomes, Saving Lives, by Vinayak Prasad and Adam Cifu

From my book review on November 11th: "In a recent research letter, Dr. Prasad and a colleague reported that news articles about new cancer drugs employed superlatives such as 'breakthrough,' 'miracle,' 'game changer,' 'groundbreaking,' and 'revolutionary' with ridiculous frequency, since more than half of the drugs discussed had not received FDA approval for any indication and several were supported by no human data whatsoever. I believe that this practice largely reflects lazy or uninformed health journalism. So when I describe Ending Medical Reversal as revolutionary, I don't use the term lightly. Go out and read it - right now."

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5. Epic Measures: One Doctor. Seven Billion Patients, by Jeremy N. Smith

From my book review on July 1st: "What I loved about this book ... is that it made sitting in an office cubicle performing complex statistical analyses [about the comparative magnitude of global health problems] seem almost as cool as practicing front-line medicine in remote areas of the world."

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6. Health, Medicine, and Justice: Designing a Fair and Equitable Healthcare System, by Joshua Freeman

A fellow family physician blogger who has been at it even longer than me, Dr. Josh Freeman makes a passionate case for transforming U.S. health care into a system that is affordable and accessible to all, arguing that assuring social justice and eliminating health disparities ought to be a moral imperative.

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7. Learning from the Wounded: The Civil War and the Rise of Modern Medical Science, by Shauna Devine

In 2005 and 2013, I taught an eight-week elective to first-year Georgetown medical students called "Civil War Medicine in the Modern Age." The big idea was that there are lessons to be learned from the imperfect application of medical and public health principles during the Civil War that are still relevant to physicians today. If Devine's staggeringly authoritative work had been in print then, I would have made it the course textbook.

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8. Less Medicine, More Health: 7 Assumptions That Drive Too Much Medical Care, by H. Gilbert Welch

A few years ago, I wrote a glowing review of Dr. Welch's previous book, Overdiagnosed, which led to an invitation to participate in a panel discussion at the Boston University School of Public Health, where he was the keynote speaker. Like that book, Less Medicine, More Health takes tricky concepts such as overdiagnosis and overtreatment and makes them easily understandable to the general public - and many physicians who continue to believe that there are no downsides to screening tests.

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9. Saving Gotham: A Billionaire Mayor, Activist Doctors, and the Fight for Eight Million Lives, by Tom Farley

I became an admirer of then-New York City Health Commissioner Tom Farley in 2012 when he convinced the Bloomberg administration to attempt to limit the size of sugary beverage containers in restaurants (a valiant effort that ultimately failed due to lawsuits brought by the soda industry). In this perfectly paced memoir, Dr. Farley describes the trailblazing public health initiatives launched by himself and his predecessor (current CDC director Tom Frieden) to attack smoking, obesity, and diabetes in the Big Apple in the first two decades of the 21st century.

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10. Understanding Value-Based Health Care, by Christopher Moriates, Vineet Arora, and Neel Shah

This is another text that I wish I'd had when teaching medical students how to practice cost-conscious medicine. A meticulously organized synthesis of evidence and experience, Understanding Value-Based Health Care is a must-read for all health care trainees and practicing professionals who want to do the right thing by their patients without bankrupting the system.

The top ten Common Sense posts of 2013 (yes, you read that right)

You know how Facebook periodically offers you a #TBT photo of a memory that you posted two or more years ago? Well, while I continue working on another top 10 list (of my favorite population health and health care books of 2015), here are links to and excerpts from the ten posts that received the most page views in 2013.

1. PSA testing: excerpts from a roundtable discussion  (January 5)

Even if people don’t follow the U.S. Preventive Services Task Force recommendations and discontinue prostate screening, I hope that we will have improved the quality of discussions patients are supposed to be having with their physicians about what their risk is, what outcomes they value, and what they are willing to endure to make sure that they don’t develop late stage prostate cancer.

2. Why don't clinicians discuss cancer screening harms? (November 3)

More than 90 percent of primary care clinicians aren't telling patients that there are downsides to undergoing routine mammograms, colonoscopies, and Pap smears. Why not? Is it because they aren't familiar enough with the data to accurately describe these harms? Or is it because they fear that patients who receive information about cancer screening harms will choose to decline these tests?

3. Guest Post: Why the Direct Primary Care Model would benefit poor patients (September 6)

With direct pay models, actual health care costs can be kept much lower and made much more affordable. Also, since direct pay models typically care for smaller patient panels, patients have more time with their primary care team to address the myriad of life issues that affect their health.

4. Concerns about calcium supplements (February 8)

Is it time to abandon routine calcium supplementation in healthy adults? If not, what additional evidence do we need?

5. Breast cancer and the Angelina Jolie effect (May 15)

Will the Angelina Jolie effect turn out to be a spike in the rates of women being tested for the mutations in their BRCA genes? If so, it's likely that many more women will be harmed than helped. BRCA mutations are rare, affecting 2 to 3 per 1000 women. The vast majority of women who develop breast cancer do not carry these mutations and will not benefit from testing.

6. Should you be screened for lung cancer? Maybe not, and here's why (July 29)

For lower-risk patients, for whom the potential lifesaving benefits of CT scans are very small, the downsides of the screening test become considerably more important. Screening tests have harms just like any other medical procedure, and it's important for your doctor to thoroughly review those harms with you if you are considering screening.

7. Screening-illiterate physicians may do more harm than good (July 13)

The Institute of Medicine has identified low levels of health literacy as a major obstacle to ensuring optimal health and quality of care. But how can physicians expect our patients to make informed decisions regarding screening tests when large numbers of us are functionally illiterate regarding basic screening concepts?

8. The future of medicine is low-tech and high-touch (May 8)

Yes, robots and smartphones can and will play vital roles in the future of medicine. But if we really want sick patients to have the best chance to get better - and healthy patients to avoid getting sick in the first place - then we should do everything in our power to support low-tech and high-touch interventions too.

9. Unintended consequences of "pregnancy prevention" (February 5)

Defining pregnancy as a disease to be prevented is not just a matter of semantics. An overly interventionist approach to pregnancy is largely responsible for the current U.S. rate of one in 3 babies being born by Cesarean section, and predictions that it may soon approach 50 percent.

10. $10 billion per year to train the wrong physicians (June 18)

Where physician production is concerned, you get what you pay for. Medicare pays a disproportionate amount of its nearly $10 billion per year in subsidies to institutions that produce mostly subspecialists, at the expense of training sorely needed family physicians and other generalists whose presence has been shown time and again to deliver better health outcomes.

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This list first appeared on Common Sense Family Doctor on December 26, 2013.