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.

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 August, September and October:

1) Why precision medicine threatens population health (9/1/15)

2) Community health workers can complement primary care (9/11/15)

3) Liberty and health reform in America (10/2/15)

4) Right Care Action Week and Choosing un-Wisely (10/24/15)

5) Do sofosbuvir restrictions harm or protect the vulnerable? (8/19/15)

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

Two perspectives on the PSA screening pendulum

Two research studies published earlier this week in JAMA presented compelling evidence that the 2012 U.S. Preventive Services Task Force recommendation statement that discouraged prostate specific antigen (PSA)-based screening for prostate cancer has had a significant impact on clinical practice. In one study, researchers from the American Cancer Society used data from the Surveillance, Epidemiology, and End Results registries to document an 18% relative decrease (from 37.8% to 30.8%) from 2010 to 2013 in the percentage of men age 50 years and older who reported PSA screening in the previous 12 months. In another study, a separate team of investigators found a similar decline in the prevalence of PSA screening reported in the National Health Interview Survey in men age 50 to 74 years.

For me, and for other proponents of the view that PSA screening is not effective in reducing mortality from prostate cancer and instead leads to substantial psychological and physical harms, this reversal in practice is good news. In an editorial published in the October 15th issue of American Family Physician, Dr. Vinay Prasad argued that family physicians who reduce or discontinue their use of the PSA test for screening are on solid ground:

When it comes to PSA screening, the pendulum has swung. Not only has our understanding of the benefits and harms shifted, as reflected by a continual change in guidelines away from testing, but the burden to justify screening has also swung. For decades, critics of PSA testing have shown the many unintended repercussions of the test, cautioning that our initial widespread adoption was not justified. Moving forward, it must be the proponents of screening who shoulder the burden of proof. Their task will be to show in a future randomized study whether any PSA screening algorithm can improve survival or quality of life compared with what is now the standard of care—no routine screening. Before primary care physicians consider reintroducing the PSA test, they must have proof that it improves outcomes.

In another editorial that accompanied the JAMA studies, Dr. David Penson also described the shift in practice as a "pendulum," but took the position that until a better screening test is developed, "the PSA test can be deployed more effectively (or strategically), maximizing benefit while minimizing harm." If PSA screening does in fact save some lives, Dr. Penson argued, then extending screening intervals and focusing on men who are more likely to develop "high-risk" prostate cancer could be a better approach than not screening at all:

Certainly, physicians have been overly aggressive in their approach to prostate cancer screening and treatment during the past 2 decades, but the pendulum may be swinging back the other way. It is time to accept that prostate cancer screening is not an “all-or-none” proposition and to accelerate development of personalized screening strategies that are tailored to a man’s individual risk and preferences. By doing this, it should be possible to reach some consensus around this vexing problem and ultimately help men by stopping the swinging pendulum somewhere in the middle.

As it turns out, I've met both Dr. Prasad and Dr. Penson. Both men are outstanding researchers and compassionate physicians. Each believes strongly that his position on PSA screening is correct, and it's entirely possible that both could be right to some degree. If you are a clinician who cares for older men, where do you stand on the pendulum of PSA screening? If you are a man over 50 or a loved one, which approach to this test would you prefer?

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

How care teams can support shared decision making in primary care (2 of 2)

Yesterday, I delivered the keynote speech at the Team Care Challenge, sponsored by the Patient-Centered Primary Care Collaborative, Medstro, and the American Resident Project. This is the second of two posts containing the text of my talk. Part 1 is posted here.

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Let’s take each of these clinical scenarios I brought up one by one. I prescribe medications for high blood pressure all the time, I’m familiar with the current treatment guidelines, and I have a pretty good grasp of the most common side effects. But I would wager that most clinical pharmacists know at least as much as I do about these drugs, if not more. Rather than relegating these team members to the role of dispensing prescriptions, why not co-locate them in large primary care practices, or use FaceTime or Skype for real-time consultations? Based on the eligibility criteria for the SPRINT study, my office could create screening protocols for medical assistants or licensed practical nurses to identify eligible patients at the time of check-in, just as they already pre-review immunization records to see who might need shots that day.

How about the question of when a woman should start screening mammograms? In this situation, competing guidelines make getting to the answer even more complex. But we should keep in mind that the starting and stopping ages in breast cancer screening guidelines were set by guideline developers who applied their own preferences and values to the balance of benefits and harms. We can do better than “what most women would want” – we should find out what the patient in front of us wants. The primary care team could create an agreed-on protocol in which a woman of a certain age could automatically be given a print or electronic decision aid at the time of a health maintenance visit. Medical assistants could ask initial questions about their preferences and concerns and document these in the chart so that when it was time to have the discussion and make a decision, the patient and clinician would already be on the same page.

Advance care planning is perhaps the most emotionally and logistically challenging scenario. Medicare says that we can have these discussions with the patient at a stand-alone visit, a wellness visit, or a visit for management of chronic medical issues. In this situation I envision the primary care team playing a vital behind-the-scenes role. My team members can remind me that I’ve never had this sort of discussion with Mr. Jones or Mrs. Smith, and give me an extra nudge if Mr. Jones or Mrs. Smith is over 65 or has one or more of several life-limiting health conditions. Or perhaps the patient’s advanced directive is several years old and it’s time to revisit it to make sure it still aligns with his or her wishes. To support shared decision making, my team can make sure that I have a blank copy of an advanced directive on hand, and that helpful videos and other educational resources are already open on the desktop computer in the examination room. This way I can focus completely on the patient rather than fumbling around for missing materials or forms.

Now what I’ve just told you is the way I wish things were rather than the way they really are in my practice, and in most primary care practices, even those that, like mine, have achieved certification as a “patient-centered medical home.” Don’t get me wrong, I am all for the PCMH, but I view it as a set of minimum requirements rather than aspirational goals.

And unfortunately, much of what I’ve described would be thwarted by our current, antiquated payment system that only assigns value (and dollars) to the things that doctors do. Who’s going to pay for the clinical pharmacist to spend all day in the outpatient setting providing medication counseling? Who’s going to pay for the extra medical assistant the practice must hire now that there’s have a lot more to do than checking patients in and taking their vital signs? Who’s going to pay for the home blood pressure monitor and the extra time the practice spends text messaging or on phone calls needed to intensify blood pressure treatment in patients who choose to do so?

This is where all of you come in – and by “all of you,” I mean the students and trainees in the audience just as much as the practicing clinicians. Attending this conference means that you already have a vision of the possibilities of team-based primary care that is far more expansive than mine was when I was in training. It will be up to your generation to advocate for changes in health care payment and practice organization that empower primary care teams to reach their full potential to support routine shared decision making. The direct primary care movement may be one answer. Insurers paying practices for health outcomes, rather than numbers of encounters or specific providers of services, is another.

There are countless creative ways we can put patients back at the center of care where they belong, and the ideas from today’s terrific presentations represent only the tip of the iceberg. All of these transformative ideas have this principle in common: they will work best when carried out by high-functioning care teams.

Thank you again for allowing me to speak to you today.

How care teams can support shared decision making in primary care (1 of 2)

Earlier this afternoon, I delivered the keynote speech at the Team Care Challenge, sponsored by the Patient-Centered Primary Care Collaborative, Medstro, and the American Resident Project. This is the first of two posts containing the text of my talk. Part 2 is posted here.

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Good afternoon. Thank you for inviting me here today to speak to you about primary care teams. I was really inspired by all of today’s presentations, and I’m glad that I am not one of the judges, because it would have been a very tough choice!

You have all probably heard something about the White House’s Precision Medicine Initiative. I have expressed skepticism about this initiative because I think that focusing on differences in our genomes will divert attention and funding from social determinants of health that are far more powerful predictors of illness and wellness. The term “precision medicine” is often used interchangeably with “personalized medicine.” That’s too bad, since I would argue that family physicians and other primary care clinicians have been providing personalized medicine long before genomic medicine existed, approaching our patients as individuals with unique backgrounds, values, and preferences that can and should affect the care we provide. One powerful approach to providing this type of personalized care is shared decision-making.

What I’d like to talk about today is how care teams can support patients and health professionals in making shared decisions.

So what have been the big health news stories with implications for the practice of primary care over the past year? For me, three come immediately to mind.

#1. End-of-life counseling. Five years after the phony political uproar over “death panels” that were never included in any health reform legislation, Medicare will finally pay doctors to counsel patients about advance care planning and end-of-life options. This is welcome news.

#2. Breast cancer screening. After decades of insisting that all women at average risk undergo mammograms every year starting at age 40, the American Cancer Society relaxed its guidelines. They now agree with the U.S. Preventive Services Task Force that mammography should be optional for women in their early 40s and that every two years is a more beneficial interval for screening in women older than 55.

#3. Lower blood pressure goals. The NIH-sponsored SPRINT study showed that lower blood pressure goals may be better in some patients over 50 who are at high risk for cardiovascular events. Over a little more than 3 years of follow-up, about 60 people needed to be treated to a systolic BP of 120 to prevent one cardiovascular event or stroke compared to the traditional target of 140. On the flip side, more intensive treatment was associated with one more episode of severe hypotension, one case of syncope, and two more episodes of acute kidney injury for every 100 people.

The one thing that these stories all have in common is that they envision an increased role for shared decision making in primary care.

Some patients will want to receive few aggressive interventions at the end of life, some will want more.

Some women will be fine with waiting until age 45 or 50 to get their first mammogram, some will still want to start at 40.

For some patients, reducing their risk of heart attack or stroke will be worth the price of taking one extra medication and the associated adverse effects. For some patients, it won’t be.

It will be the primary care team’s job to guide patients in making these difficult health decisions.

I will admit to you right now that I’m no expert on shared decision making, and I consider myself to be mediocre at best in engaging patients in this process. Despite the many lectures I’ve given about why patients should think about foregoing PSA screening or mammograms due to the well-documented harms that can result from both tests, I still struggle to explain the relative pros and cons of competing choices and help my own patients pick one or the other. In part, this is because making shared decisions is naturally difficult. But I’ve started thinking that it may be harder than it needs to be because I’m usually trying to do it alone.

So how could a primary care team support shared decision making? A 2012 article in Family Practice Management identified six key characteristics of effective practice teams. These were: shared goals, clearly defined roles, shared knowledge and skills, effective and timely communication, mutual respect, and an optimistic can-do attitude. Effective primary care teams delegate responsibilities so that each staff member does only what he or she is uniquely trained to do, rather than wasting time and energy on tasks that can be performed more efficiently by other team members.

Book Review: "Ending Medical Reversal" is revolutionary

The take-home message of the first lecture of my first clinical clerkship (Obstetrics and Gynecology) was that we should prescribe supplemental estrogen to all postmenopausal women to prevent cardiovascular disease. That lecture happened in 1999. Less than three years later, the Women's Health Initiative trial was stopped earlier than planned because it had already become clear to the data safety monitoring committee that estrogen therapy actually increased the risk of cardiovascular events, as well as strokes, breast cancer and pulmonary emboli.

If we couldn't protect older women's hearts, at least we could protect their bones by encouraging them to take vitamin D and calcium supplements starting in mid-life. "Don't wait until they develop osteoporosis, fall, and fracture their hips," I recall one of my mentors saying. By extension, no need to wait for the randomized trial, either. But in 2006, the Women's Health Initiative reported that calcium and vitamin D supplementation not only had zero effect on hip fracture rates, it increased the formation of kidney stones. Two years ago, the U.S. Preventive Services Task Force recommended against supplementation for the primary prevention of fractures. Finally, a pair of meta-analyses published in the BMJ earlier this year concluded that dietary calcium intake is not associated with fracture risk in community-dwelling adults and that increases in bone mineral density from calcium supplements are small and clinically insignificant.

In my relatively short career as a family physician, these two high-profile episodes represent a tiny fraction of what Drs. Vinay Prasad and Adam Cifu term "medical reversals" in their new book, Ending Medical Reversal: Improving Outcomes, Saving Lives. They provide other humbling examples, many of which I've blogged about over the years: mammography in women younger than 50, PSA screening, vertebroplasty for spinal fractures, coronary artery stenting for stable angina, and gown-and-glove precautions to prevent the spread of drug-resistant bacteria. In 2013, Prasad and Cifu collaborated with others on a review that found an astounding 40 percent of studies published during a 10-year period in the New England Journal of Medicine overturned an existing medical practice.

What can patients, physicians, and other health professionals do to make medical reversal less frequent and protect patients from useless or harmful tests and therapies? Prasad and Cifu don't advocate tinkering with the normal (and healthy) back-and-forth of the scientific process. However, they point out that in most clinical settings it makes sense to require a higher burden of proof before accepting the usefulness of a new treatment because "unlike pure science, medicine directly affects the lives of human beings." (For example, Prasad and a colleague determined that more than half of all cancer drugs approved by the FDA between 2008 and 2012, and 86% of those approved on the basis of a surrogate end point such as "tumor response rate," had either unknown effects or were later shown to have no effect on overall survival. Not good news for patients who were treated with those drugs.) And as I've argued before, the bar should be set even higher for screening tests and preventive medications offered to apparently healthy people who can only experience harm in the short term.

Prasad and Cifu make several excellent recommendations for reforms in how we apply the results of medical science. First, police sources of flawed data: industry-sponsored clinical trials, conflicted guideline developers, off-label marketing, hype about newer treatments always being better than established ones. Next, rethink the foundations of medical education: teach empiricism and evidence-based medicine (what works to help ill patients) before teaching basic science and mechanisms of disease (how therapies are understood to work). Third, value replication as much as discovery, and thoughtful narrative reviews as much as observational studies in decisions about academic promotion or tenure. Finally, make participation in randomized trials the default choice so that the majority of clinical questions, large or small, can be rapidly answered with experimental evidence.

In a recent research letter in JAMA Oncology, 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.

Compared to some pills, cognitive behavior therapy is a bargain

Family physicians commonly treat patients with depression, anxiety disorders, attention-deficit/hyperactivity disorder (ADHD), sleep disorders, and other psychiatric conditions. Although some patients respond to medication, prescribing has significant downsides. Antidepressants can increase suicide risk, and a study that once declared medications to be superior to behavioral therapy for ADHD is now receiving a second look. In contrast, an article by Drs. Scott Coffey, Anne Banducci, and Christine Vinci in the November 1st issue of American Family Physician reported that cognitive behavior therapy (CBT) effectively relieves symptoms of all of these conditions, plus those from post-traumatic stress disorder, autism, obsessive-compulsive and tic disorders, personality disorders, and eating disorders. The article answered several common questions about CBT, including how it works:

The aim of CBT is to help patients adopt more adaptive patterns of thinking and behavior to improve function and quality of life. Treatment goals are selected collaboratively with patients to determine whether progress is being made. CBT involves three core strategies applied alone or in combination, depending on the patients' needs: (1) identifying and challenging problematic thoughts and beliefs, with the goal of helping patients develop more realistic and adaptive thoughts and beliefs, (2) scheduling pleasant activities to increase environmental reinforcement, and (3) extended exposure to unpleasant thoughts, situations, or physiologic sensations to decrease avoidance and arousal associated with anxiety-eliciting stimuli.

Finding a qualified therapist many be a challenge in some communities, and CBT usually doesn't come cheaply. However, CBT for most conditions is time-limited: one session per week for 8 to 12 weeks. At $150 to 200 per session, the typical cost for a treatment course would be between $1200 and $2400.

In comparison, a one-month supply of the newer antidepressants levomilnacipran, vortioxetine, and vilazodone (which are labeled only for treatment of major depressive disorder in adults, and are often prescribed indefinitely) cost $286, $254, and $149, respectively. So a newer antidepressant could cost as much or more than a course of CBT in as little as 4 to 8 months.

But in the weird economics of health care, CBT is a relative bargain only because it actually involves skilled professionals talking to patients, something that our medical system consistently undervalues. If CBT could somehow be packaged into a pill and patented instead, it would likely cost a lot more, given its versatility and enormous potential market share. It might become the next big blockbuster drug, like newer antiviral treatments for hepatitis C that cost between $84,000 and $156,000 for a 12-week course of treatment, or $1000 or more for a single pill. Or, since CBT has been around since the 1960s, perhaps a better benchmark would be the infamous recent example of the 62 year-old drug pyrimethamine (Daraprim), whose manufacturer raised the per-tablet price from $13.50 to $750, literally overnight.

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

The most-tweeted quote from my AHCJ presentation was

"Experts" and laypersons view new medical evidence through the lens of their own biases.

That being said, it's important for patients to consider their physicians' biases in the context of their overall health. A man's urologist may be bound and determined to do everything he or she can to prevent death from prostate cancer (including annual PSA tests), but since 3% of men actually die from prostate cancer, 97% will die of something else. Family physicians and general internists who agree with the U.S. Preventive Services Task Force that the harms of PSA-based screening outweigh the benefits for most men are biased toward preventing statistically much more probable causes of premature death.

Thanks to NPR's Scott Hensley and the Association of Health Care Journalists for inviting me to speak at their Workshop in Evidence-Based Medicine today.

Right Care Action Week and Choosing un-Wisely

This week, American Family Physician joined clinicians, patients and organizations all over the country in supporting the Lown Institute's RightCare Action Week (#RCAW), which aims to re-focus the U.S. health system on care that is "effective, affordable, needed and wanted by well-informed patients, and especially, free of clinical decisions that are made with financial or business considerations." This goal is more far-reaching than the three year-old Choosing Wisely campaign objective of encouraging conversations between physicians and patients about potentially unnecessary care. As my colleague and fellow editor Dr. Jennifer Middleton mentioned last week, AFP has developed several resources to help family physicians implement Choosing Wisely in their practices. On the patient side, Consumer Reports has worked with more than 20 physician groups to create and distribute educational content about specific items in the campaign.

Are these efforts to reduce unnecessary care making a measurable difference? JAMA Internal Medicine recently published a study of national insurance claims data by Dr. Alan Rosenberg and colleagues that analyzed trends among seven of the earliest Choosing Wisely "don't do" recommendations from 2010 through 2013. Although there were statistically significant declines in CT and MRI for uncomplicated headaches and cardiac testing in patients without heart conditions, use of two other inappropriate services increased (NSAID prescriptions in patients with hypertension, heart failure, or chronic kidney disease; and primary HPV testing in women younger than age 30). Since the study didn't include data from 2014 or 2015, the results could either mean that the campaign isn't working or that it was just too early to tell.

Family physicians and patients should keep in mind that even care that is recommended by evidence-based guidelines and incentivized by pay-for-performance programs can be harmful if provided to patients without regard to their individual circumstances. In an Annals of Internal Medicine essay titled "The Tyranny of Guidelines," Dr. George Sarosi described the six-year saga of Mr. O, an independent octogenarian with mild hypertension and diabetes who suffered a hip fracture and subsequent stroke as the unfortunate end result of a "relentless downhill medical care spiral fueled by interventions ... to tightly control both the blood sugar and the blood pressure."

The pitfall in this case wasn't the guidelines themselves as much as the one-size-fits-all way they were applied by "the system" to the patient. Dr. Sarosi concluded, "We need a system that rewards the physician who understands the limitations of guidelines." Indeed, a Right Care system would reward physicians who prevent patients from receiving too much medicine.

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This post first appeared on the AFP Community Blog.

Some common sense on breast cancer screening

Yesterday, the American Cancer Society updated its guidelines on screening mammography for women at average risk, moving closer to the U.S. Preventive Services Task Force guidelines by recommending that most women start screening at age 45 (rather than 40) and be screened every other year (instead of annually) starting at age 55. The ACS also cast doubt on the effectiveness of the clinical breast examination in women who are already undergoing mammography screening. Although I don't agree with every aspect of the new guideline, it has the potential to make breast cancer screening more effective by preserving the benefits and reducing the harms.

A common critique I've heard about the ACS and USPSTF guidelines is that they will "confuse" women who have gotten used to the traditional routine of having annual mammograms starting at age 40. I don't disagree with this; incorporating new scientific evidence into medical practice is always confusing at first. But explaining the implications of new guidelines to individual patients is my job as a family physician - and it's your physician's job, too! I went on NPR's All Things Considered to offer my take on what the new guidelines mean for women. You can listen to the whole segment or read excerpts from the transcript below.

AUDIE CORNISH (HOST): So we heard in our report that the American Cancer Society still wants every woman to talk to her doctor to figure out what makes the most sense. How do you interpret all this?

LIN: What you've just said is probably the best way to describe it, that women should be talking to their doctors about mammography. It shouldn't be automatic. It shouldn't be reflexive. It shouldn't be like the experience of many of my friends who are in their early 40s and they show up at their doctor's and they get a slip and they say, "go get your mammogram." We instead should be raising the topic saying, look, we have this test. It could prevent you from either dying or having a serious illness from breast cancer. But it's not perfect. It has many harms as well, including false positives, diagnosis of a breast cancer that may not ultimately be true cancer but something that we might have to act on. So it's best viewed as an invitation to both patients and physicians to have that conversation if they haven't been having it before.

CORNISH: There have been several studies that have shown that doctors really don't talk all that much about the risks of cancer screenings. They don't give numbers for how many people actually do benefit from the screenings. Do you think these guidelines will change that?

LIN: I hope they do. Now in defense of those doctors, it is a challenging conversation. There are a lot of numbers. There's a lot of uncertainty about some of the numbers. I think that it can be helpful to present patients with either a handout or some sort of visual aid where you can show what the numbers really are for the benefits and the harms. And it's something that I've been doing, but I think a lot of doctors haven't been doing that and I'm hoping the new guidelines encourage them to because I think it's difficult to have this conversation without something to look at to visually illustrate those numbers.

CORNISH: If your doctor doesn't initiate this discussion, what kinds of questions should you ask? I mean, this kind of relies on women thinking of their own family history, race or whatever and somehow divining risk factors. What should patients be thinking about?

LIN: The guideline that the ACS released was a guideline for average risk women who are defined as not having one of the breast cancer genes or not having a family history where you have several family members with breast cancer or a single member at a young age. So the rest of women are kind of lumped into this average risk category. And certainly there are things that may not be accounted for in risk assessment tools that may be important to someone. So I think a patient should go to their doctor and say, look, this is how I feel about mammography. This is my experience with cancer, my family history. Perhaps they don't like having to go for repeated tests. You know, I'm worried about false positives. I think they should also ask their doctor, well, you know, what are downsides to this test? That's really the first question. Doctors always volunteer the upsides, but I think you have to ask specifically what are the downsides. And hopefully that will spark a conversation if your doctor seems otherwise inclined to gloss over it.

CORNISH: What do you say to women who today are are frustrated, maybe even angry or upset, women who have had annual mammograms for many years who've gone ahead with procedures that turned out to be unnecessary? Was that a waste?

LIN: Unfortunately in science this is kind of the way that things progress. We do the best we can with the information we have at a given time. The same thing sort of happened for prostate cancer screening in men. It used to be something that you started at age 50, you do it every year, and now organizations that say you don't do it at all, or if you do it, you have to be aware of the downsides. I understand it can be frustrating to patients. But the greater error is to cling to an old guideline and say, well, we're going to dig in our heels and keep starting at age 40 and doing it every year and ignore the new guideline, because that would be a worse mistake. We have to operate with the knowledge that we have. And I think the ACS has very comprehensively summarized what we know about mammography at the present time and their guidelines reflect that knowledge.

Healthiness is Awesome

I've mentioned my four children occasionally in this blog, usually when referring to the circumstances of their births or the financial costs of my wife's pregnancies. Like most boys his age, my 9 year-old son Isaac spends a good chunk of his free time absorbed with Legos. He also plays golf and several other seasonal outdoor sports, and he's terrifically creative. Isaac submitted this video to the DC Growing Healthy Schools Art Contest, and even if it doesn't win, I hope that you are impressed as I was.

How can tech help Family Medicine for America's Health?

A randomized trial published last month in JAMA found that sending lifestyle change text messages to patients with coronary artery disease improved smoking cessation rates, increased physical activity, and reduced other cardiovascular risk factors. After only 6 months, the texted group had lower low-density lipoprotein, systolic blood pressure, and body mass index measurements than the usual care group. This was an impressive finding, but an unsettling one, since I had just finished reading an American College of Physicians position paper on the use of telemedicine in primary care settings. Taken together, these publications suggest that virtual care technologies, broadly defined, could make many in-person clinical encounters unnecessary. That's good for patient convenience, but potentially threatens one of the best parts about practicing family medicine: seeing patients in person.

Health information technology (IT), as embodied in electronic medical record systems that have replaced paper charts in most family practices, has thus far been a mixed blessing for our specialty. But what about tech beyond traditional health IT? The technology "tactic team" of Family Medicine for America's Health published a special article in Family Medicine that described strategies for family physicians to utilize an array of evolving technologies to strengthen therapeutic relationships and improve outcomes:

1) Smartphone apps and wearable devices that capture data about patients' health habits and give feedback to influence their behavior

2) Point-of-care musculoskeletal ultrasound

3) Web-based communication for "virtual" hospital rounding and specialist consultations

4) Web-based videos to provide patient and professional education

Although all of these initiatives have great potential to benefit patients, many are being developed in silos without leadership or input from family physicians. Therefore, the paper's authors proposed that Family Medicine for America's Health work to integrate these overlapping efforts into "a united front improving health IT and other technologies for the specialty."

Key opportunities for family physicians "to capitalize on our collective strengths" in the near future include partnering with developers to create health IT tools that improve clinical outcomes (rather than merely serving administrative or billing functions); supporting primary care-centric data models; participating in the development of primary care quality measures; and collaborating with patient and consumer organizations locally and nationally to identify and promote patient- and family-centered technology solutions that complement the vital functions of family medicine.

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This post first appeared on the AFP Community Blog.

Liberty and health reform in America

Since 2007, I've participated in about a dozen American Civil War battlefield tours sponsored by the Smithsonian Associates. Even though a handful of Chinese Americans fought on both sides of the Civil War, none of my ancestors did, and friends and family are often perplexed by my endless fascination with this conflict. In Civil War museums and sites thronged by overwhelmingly white tourists, I'm even more of an oddity than the rare African American. This realization got me wondering why so few African Americans are passionate about the history of the war that freed so many of their ancestors from slavery. To Atlantic columnist and fellow Civil War buff Ta-Nehisi Coates, this antipathy stems from the efforts of white Americans over the past 150 years to write them out of the story:

For my community, the message has long been clear: the Civil War is a story for white people—acted out by white people, on white people’s terms—in which blacks feature strictly as stock characters and props. We are invited to listen, but never to truly join the narrative, for to speak as the slave would, to say that we are as happy for the Civil War as most Americans are for the Revolutionary War, is to rupture the narrative. Having been tendered such a conditional invitation, we have elected—as most sane people would—to decline.

As the campaigns gear up for the Presidential election of 2016, economic and racial divisions seem to be resurfacing, with the perennial Republican versus Democratic contest being portrayed in the media as a battle between the "rich" and the "poor," or white citizens versus those of every other color. But these stereotypes ignore the inconvenient facts that plenty of low-income white people who bear no racial grudges and a few minority voters in heavily Democratic states and the District of Columbia dependably vote Republican.

In his most recent book, subtitled "Why the Civil War Still Matters," historian James McPherson shed some light on this present-day paradox by explaining that liberty meant two different things to Southern and Northern leaders in 1861. To white Democrats in the pre-Civil War South (slaveholders or not - and the vast majority were not), liberty meant "freedom from" interference by a distant federal government. Historical figures such as Confederate general Robert E. Lee traced their cause back to the Virginian Founding Fathers and slaveholders George Washington and Thomas Jefferson, whose Revolutionary War was fought to break away from a distant British ruler whose arbitrary actions offended colonial sensibilities.

On the other hand, the Republican Party in the North viewed liberty as "freedom to," arguing that it's hard to achieve anything noteworthy when one is penniless, starving, or a slave. Even though the North won the Civil War, achieving full citizenship for African Americans took nearly a century after passage of the the Fifteenth Amendment to the U.S. Constitution. Only after the hard-won passage of the 1965 Voting Rights Act, which prohibited poll taxes and gave the federal government the power to end various discriminatory practices that prevented most Black citizens in Southern states from registering to vote, did African Americans finally gain freedom to participate in the political process.

The more recent history of how and why African Americans turned away from the party of Lincoln to embrace the party of their former oppressors is too long to recount here, but these differing views of personal liberty - "freedom from" versus "freedom to" - go a long way toward explaining the two political parties' diametrically opposed views of the Affordable Care Act. For the most part, Republican governors have resisted health insurance exchanges and rejected Medicaid expansions because they and their constituents have perceived these provisions of the law as encroachments on freedom by the Washington bureaucracy, while Democratic governors have recognized that it's hard to have freedom to achieve personal success if one is too ill, or too worried about the financial implications of unexpected illness or injury, to plan confidently for the future.

So you heard it here first: not only can you find the roots of modern medicine in the American Civil War, but the roots of our national health policy debate, too.

Guest Post: The next generation of primary care quality measures

- Steve Martin, MD

Nov. 2015 update: Care That Matters published a position paper on quality measurement and health care in PLOS Medicine.

Everybody talks about the weather ... but nobody does anything about it." 

Charles Dudley Warner (1887)

Unlike the weather, there is something that can -- and must -- be done about quality measures. Soon. Here's what's over the next hill:

The Centers for Medicare & Medicaid Services (CMS) is moving towards linking 30% of Medicare reimbursements to the “quality or value” of providers’ services by the end of 2016 and 50% by the end of 2018 through alternative payment models. More recently, CMS announced a goal of tying 85% of traditional fee-for-service payments to quality or value by 2016 and 90% by 2018. Earlier this year, the Medicare Payment Advisory Commission cautioned that “provider-level measurement activities are accelerating without regard to the costs or benefits of an ever-increasing number of measures.”

Where will these measures come from? To realize this vision, America’s Health Insurance Plans (AHIP) and its member plans’ Chief Medical Officers convened leaders from The Centers for Medicare and Medicaid Services (CMS) and the National Quality Forum (NQF), as well as national physician organizations, to form The Core Quality Measures Collaborative in 2014.

This looks to us like the usual policy makers -- not practicing primary care clinicians or patients. That has to change.

Be sure to register now and join is on Thursday October 29th from 1-5 pm at a pre-conference of the Family Medicine Education Consortium (FMEC) on The Next Generation of Primary Care Quality Measures. We'll be joined by representatives of Community Catalyst, the RightCare Alliance, and Dynamed. Dynamed is completing a review of the evidence of current BCBS Alternative Quality Contract metrics and we will share the results at this gathering.

Care that Matters, a group of primary care trainees, clinicians, and faculty, is leading this effort. We'd welcome your joining us. Please see the beginnings of our website here and contact us to join in this work.

In the meantime, please be sure to sign on for RightCare Action Week, to be held this October 18-24. What is RightCare Action Week? Our healthcare system has strayed from its mission: Healthcare that is effective, affordable, needed and wanted by well-informed patients, and especially, free of clinical decisions that are made with financial or business considerations in mind. From Oct. 18 to 24, 2015, people like you across the country will take action to show patients that we have not forgotten what good medical care is. Actions can be as simple as taking a deeper social history or doing a house call.

To recap, please:

1. Join us for The Next Generation of Primary Care Quality Measures on Thursday, October 29th

2. Join Care that Matters for work on metrics that matter

3. Sign on for RightCare Action Week to be held October 18-24

The Next Generation of Primary Care Quality Measures
Held in conjunction with the 2015 FMEC Annual Meeting
DoubleTree by Hilton and CoCo Key WaterPark
Boston North Shore
50 Ferncroft Road, Danvers MA 01923

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 May, June and July:

1) The good news, at last, in prostate cancer screening (6/19/15)

2) Countering a too-neat narrative on screening mammography (7/16/15)

3) For medical schools, mission statements matter (6/11/15)

4) The paradox of health and screening for prediabetes (7/31/15)

5) Overuse of health care: can -ologists help themselves? (5/18/15)

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

Community health workers can complement primary care

In late 2011, I attended an academic meeting where the subject of community health workers came up in a discussion. Earlier that year I had read about Vermont's ambitious blueprint for medical homes integrated with community health teams, so I volunteered that we needed fewer specialists and more trained laypersons with ties to their communities to implement prevention strategies. Another physician objected that while community health workers might work well in lower-income countries like India, we didn't need to deploy them in America, where people already know from their doctors that they should eat healthy foods, watch their weight, exercise, and not smoke and don't need others nagging them about it.

But should community health workers be viewed merely as extensions of medical institutions when large proportions of the population will not visit a doctor in a given year? An alternative model, wrote Health Affairs editor Alan Weil,

views CHWs as part of the communities in which they work. The roles of community health workers are defined by the community and CHWs through a process of community engagement. CHWs are valued for their contribution to community health, not for the savings they generate for health plans or providers. CHWs are embedded in the community, not in a clinician’s office or hospital. Advocacy is required to effect a transfer of resources out of clinical care into the community.

On the other hand, a New England Journal of Medicine commentary observed that the absence of connections between community health workers and family physicians can leave them working at cross-purposes:

CHW services are commonly delivered by community-based organizations that are not integrated with the health care system — for example, church-based programs offering blood-pressure screening and education. Without formal linkages to clinical providers, these programs face many of the same limitations — and may produce the same disappointing results — as stand-alone disease-management programs. CHWs cannot work with clinicians to address potential health challenges in real time, and clinicians can't shift nonclinical tasks to more cost-effective CHWs. Indeed, clinicians often don't recognize the value of CHWs because they don't work with them.

How can we bridge this gap? A recent review in the Annals of Family Medicine provided a list of structure, process, and outcome factors to consider for patient-centered medical homes to partner with peer supporters (a.k.a. community health workers).

For complex patients with multiple health conditions, care coordination is a key role where community health workers could potentially be more successful and cost-effective than expensive projects led by registered nurses or physicians. Reviewing the past decade of Medicare demonstration projects, researchers from the Robert Graham Center drew five lessons for future coordinated care models:

(1) Minimize expenses by sharing resources and avoiding cost ineffective interventions
(2) Concentrate on high utilizers
(3) Foster relationships with both providers and patients
(4) Track patients across the medical neighborhood in real time
(5) Extend rather than duplicate the efforts of primary care practices

Although optimal integration between the roles of community health workers and primary care teams is easier to describe than to achieve, moving both groups toward the common goal of communities of solution will be essential to protecting the health of the whole population.

Why precision medicine threatens population health

Scientific guidelines produced by the American Heart Association tend to spill lots of ink on recommending complex and/or expensive tests, drugs, and procedures for patients who already have heart problems. Even when the topic is ostensibly cardiovascular prevention, as in the current AHA-endorsed cholesterol management guideline, the end result may be prescribing statins to many millions (or even billions) of additional adults. So it was a pleasant surprise to me earlier this summer when the AHA released the insightful consensus statement "Social Determinants of Risk and Outcomes for Cardiovascular Disease." In the introduction, the authors wrote:

There is increasing awareness that the benefits of advances in prevention and treatment [of cardiovascular disease] have not been shared equally across economic, racial, and ethnic groups in the United States. Overall population health cannot improve if parts of the population do not benefit from improvements in prevention and treatment. ... The premise underlying this scientific statement is that, at present, the most significant opportunities for reducing death and disability from CVD in the United States lie with addressing the social determinants of cardiovascular outcomes.

In other words, addressing social determinants of health and health disparities across the U.S. - population health interventions - are likely to have far greater benefits than providing any conceivable number of individual cardiac stress tests, cholesterol-reducing drugs, or coronary artery stents. Bravo to the AHA for acknowledging a reality that may unsettle many of its members whose incomes depend on the latter! Unfortunately, we know much less than we need to about measuring and changing social determinants of health. But the simplicity of focusing on traditional cardiac risk factors rather than nebulous concepts such as "socioeconomic position" may be leading physicians down the wrong path, as David Loxterkamp observed in a 2013 BMJ essay:

A patient recently slumped into my office clutching a paper from his employer. On it were empty boxes for me to enter blood pressure, weight, waistline circumference, cholesterol, and fasting blood sugar readings. We reviewed recent results. Only his glucose level was slightly raised, so we spent the majority of our 20 minutes talking about diet, exercise, and targets for weight loss. None of this concerned him, he revealed on his way out the door, as much as the tension in his marriage and the difficulties he and his wife were having with their autistic son.

Dr. Loxtercamp went on to argue that the primary care clinician's central role is "facilitating change," not only positive changes such as smoking cessation and healthy lifestyles, but also coming to terms with adverse changes such as divorces, illness and deaths of friends or family members, or other traumatic life experiences.

What they [patients] need from us is reassurance, commonsense advice, coordination of community resources, and knowledge of their family values. This was once our vital function, but no longer. We are on a merry-go-round, too, and now see a greater value in access and efficiency than continuity of care. ... Patients are not (only) data fields for the doctor to harvest, objects to be imaged, or problems to be solved. They are also our neighbors asking for help, using posture, gait, gesture, and facial expression to indicate where and how to proceed. Let’s first acknowledge them beneath their symptom complex and accept the story of their illness in their own words.

An obsessive focus on measurement is not the only or even the foremost threat to medicine's role in improving population health. In a recent NEJM commentary, Ronald Bayer and Sandro Galea expressed concern that the Precision Medicine Initiative may prove to be a damaging and costly distraction from the most burdensome U.S. health problems:

“What is needed now” is quite different ... if one is concerned about why the United States has sunk to the bottom of the list of comparable countries in terms of disease experience and life expectancy, or if one is troubled by the steep social gradient that characterizes who becomes sick and who dies. The burgeoning precision-medicine agenda is largely silent on these issues, focusing instead on detecting and curing disease at the individual level. ... The challenge we face to improve population health does not involve the frontiers of science and molecular biology. It entails development of the vision and willingness to address certain persistent social realities, and it requires an unstinting focus on the factors that matter most to the production of population health.

I think their concern is justified. Population health interventions may never prove to be as sexy as precision medicine. Even outstanding narratives about the statistical basis of health policy can't captivate human interest as powerfully as the girl in the well. That doesn't mean that our public investments in health should not or cannot be prioritized by what will provide the most good for the greatest number of people.