Overcoming HPV vaccine hesitancy

Human papillomavirus (HPV) vaccines, which prevent infection with HPV genotypes that cause cervical, anal, vaginal, and penile cancers, are hardly new. The quadrivalent and bivalent HPV vaccines were reviewed in American Family Physician in 2007 and 2010, respectively, and a 9-valent vaccine was approved by the U.S. Food and Drug Administration in 2014. Although long-term studies have yet to demonstrate that HPV vaccines reduce cancer rates, a recent systematic review found that introduction of the quadrivalent vaccine in 9 countries (including the U.S.) was associated with a 90% reduction in infections from the targeted genotypes and similar reductions in genital warts and high-grade cervical abnormalities. Women who receive HPV vaccine are at considerably lower risk for undergoing colposcopy and associated invasive diagnostic or therapeutic procedures.

The Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices (ACIP) recommends that all boys and girls receive the 3-dose HPV vaccine series at age 11 to 12. However, CDC data from 2014 show that only 40% of girls and 21% of boys had completed the series by age 17. (These percentages increased slightly in 2015.) In contrast, 80% of 13 to 17 year-olds had received meningococcal vaccine, and 88% had received TdaP (tetanus, diphtheria, and acellular pertussis) vaccine, which provide protection against serious, but comparably rare, infections. Earlier this year, all 69 National Cancer Institute-designated Cancer Centers released a consensus statement expressing concern about persistently low HPV vaccination rates in the U.S. compared to other countries, which they labeled a "serious public health threat."

A 2015 AFP editorial by Drs. Herbert Muncie, Jr. and Alan Lebato examined parental and physician impediments to HPV vaccination. Parents often express concerns about vaccine safety and worry that their children may be more likely to start having sex after receiving the vaccine. Family physicians can reassure parents on both of these questions:

Parental safety concerns about the HPV vaccine increased from 4.5% in 2008 to 16% in 2010, although the reported adverse effects have been minor (e.g., injection site reactions, syncope, dizziness, nausea, headache). Studies have shown that adolescents who receive the HPV vaccine do not initiate sexual activity earlier, nor is their risk of acquiring an STI increased.

In other cases, physicians have been the primary obstacles to vaccination: they are sometimes reluctant to bring up the topic of sex, they believe the vaccine is unnecessary because Pap smears will detect early cervical cancer, or they present the vaccine as "optional" or don't offer it at all. Drs. Muncie and Lebato suggested several effective strategies for improving HPV vaccination rates:

Instead of discussing the vaccine as a means of STI prevention, physicians can present it as a way to prevent cervical cancer in women and oropharyngeal cancer in men. They can mention that immunologic response is greater in younger adolescents, so earlier immunization is prudent. Physicians should encourage HPV vaccine administration at the same time that other adolescent vaccines are given. They should review immunization status at every visit, and administer the HPV vaccine at any time—including during sick visits.

An editorial in AFP's July 15th issue by Drs. Jamie Loehr and Margot Savoy provided additional tips for physicians on addressing and overcoming vaccine hesitancy in general. More immunization resources, including the latest childhood and adult immunization schedules from the ACIP, are available in AFP's Immunizations Topic Collection.

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This post first appeared on the AFP Community Blog.

A family medicine perspective on cholesterol screening in children

The publication of the U.S. Preventive Services Task Force's updated guidance on screening for lipid disorders in children and adolescents has re-ignited an ongoing debate about the effectiveness (or lack thereof) of pediatric guidelines recommending universal screening for high cholesterol. As it did when it last reviewed this topic in 2007, the USPSTF concluded that there remains insufficient evidence to assess the balance of benefits and harms of this preventive service. Published reactions to this statement were mixed. Labeling lipid screening in children "low-value care," Dr. Thomas Newman and colleagues argued that any potential benefits of screening would likely be outweighed by harms and costs:

Recent analyses suggest possible benefit of statin treatment among selected adults whose 10-year risk of cardiovascular disease (CVD) events is less than the 7.5% value recommended by the American College of Cardiology and American Heart Association, ... although this remains controversial. No models suggest treatment at CVD risk levels anywhere near those seen in children. Because the absolute risk of CVD events in childhood is close to zero, screening and treatment in childhood will likely to lead to costs and harms without quantifiable benefit.

On the other hand, Dr. Stephen Daniels countered that requiring improvements in clinical outcomes such as cardiovascular events to recommend cholesterol screening was inconsistent with the USPSTF's previous recommendation to screen for obesity in children, which focused primarily on evidence for weight reduction:

In its analysis, the USPSTF noted that obesity is a common and serious health problem with long-term adverse consequences for which behavioral change therapy is available and successful. Why should we screen for obesity but have insufficient information to reach a conclusion for screening for heterozygous FH [familial hypercholesterolemia] when there seem to be important parallels in these clinical entities?

Both Dr. Newman and Dr. Daniels raise good points, and although Dr. Newman is himself a pediatrician, their opposing views represent the different perspectives of internists (adult physicians) and pediatricians. Much preventive decision-making in adults, from breast cancer to cardiovascular risk reduction, is driven by 5 to 10-year time frames. To the internist, if a child with high cholesterol at age 13 has a virtually zero risk of having a heart attack by age 23, why bother to screen? To the pediatrician, screening is justified because many childhood conditions have lifelong consequences, and it doesn't make sense to turn a blind eye when an intervention is available. Not every overweight child is destined to become an obese adult, but many will. Kids who don't know they have high cholesterol levels are probably less likely to behave in ways that lower those levels (even though good nutrition and physical activity should be emphasized at all well-child visits), and may end up with two-plus additional decades of atherosclerotic damage by the time they are diagnosed as thirty-something adults.

As a family physician who cares for patients across the entire lifespan, from newborns to nonagenarians (and centenarians, when I eventually see one in the office or hospital), I am sympathetic to both perspectives. I don't screen the vast majority of my child and adolescent patients for high cholesterol, and I do not prescribe cholesterol-lowering medications to children. My threshold for testing a child's cholesterol levels is based on my assessment that an abnormal result would alter my approach or the behavior of my patient and/or his or her parents. For example: the overweight child whose parents aren't particularly motivated by body mass index but who might be moved by a blood test. Or the normal-weight adolescent whose diet consists mostly of fast food and doesn't do any physical activity more vigorous than texting. I am all for debating the evidence, while recognizing that medicine remains an art.

Immigration and health care

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

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

It is much more difficult to immigrate legally to the U.S. today. Current policies overwhelmingly emphasize family re-unification, reserving two-thirds of "green cards" to persons who already have relatives residing in the U.S. Millions of highly skilled potential immigrants like my parents and grandparents - my father eventually programmed the Hubble Space Telescope, and my mother's father was a neurologist whose biography appeared in the 9th edition of Who's Who in the World - now compete for a comparatively small number of resident permits. Most must wait for years; many lose hope and return their talents to their native countries. As former Florida governor and Presidential candidate Jeb Bush wrote in 2014 about the U.S.-Mexican border crisis, "A chief reason so many people are entering through the back door, so to speak, is that the front door is shut."

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

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

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

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

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

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

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

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

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This post first appeared on Common Sense Family Doctor on December 23, 2014.

Do firearm counseling or legal restrictions reduce injuries and deaths?

An online reader of an American Family Physician article on prevention of unintentional childhood injury wondered why the article did not mention counseling about firearm safety. It was a fair question, since in the U.S. more than 7,000 youth under the age of 20 are hospitalized each year for injuries from firearms, and three-quarters of such injuries in children younger than 10 are unintentional (in contrast, most firearm injuries in adolescents are from assaults). According to a subsequent AFP editorial, studies suggest that counseling about safe gun practices such as storing firearms unloaded in locked containers and separately from ammunition may increase the use of such practices.

A national poll conducted last year found that two-thirds of non-firearm owners, and a majority of firearm owners, agreed that health care provider discussions about firearms are at least sometimes appropriate. Outside of Florida, there are no state legal restrictions on physicians' ability to ask patients about firearms, even the Florida statute (which was struck down by a U.S. District Court for violating the First Amendment and remains suspended pending a decision by the 11th Circuit Court of Appeals) contains exceptions. The authors of a perspective paper in the Annals of Internal Medicine recommend that physicians consider asking patients about firearm access when they are at acute risk of violence to self or others; have one or more individual level risk factors (e.g., a history of violence, substance abuse, serious mental illness); or belong to a demographic group at increased risk for violence or unintentional injury (older white men, young African American men, and children).

Although recent high-profile mass shootings have drawn attention to gun violence as a public health problem in the U.S., these represent only 1 in 50 gun homicides in the U.S., most of which are not committed with assault weapons. A recent New York Times analysis of two crowd-sourced databases of 358 shootings with 4 or more casualties found that most occurred in poor neighborhoods, and most victims were African American men in their twenties:

They [the databases] chronicle how easily lives are shattered when a firearm is readily available - in a waistband, a glove compartment, a mailbox or garbage can that serves as a gang's gun locker. They document the mayhem spawned by the most banal of offenses: a push in a bar, a Facebook taunt, the wrong choice of music at a house party. They tally scores of unfortunates in the wrong place at the wrong time: an 11 month-old clinging to his mother's hip, shot as she prepared to load him into a car; a 77 year-old church deacon, killed by a stray bullet while watching television on his couch.

Gun violence has been called an "epidemic" based on the disproportionate numbers of firearm homicide deaths in the U.S. compared to other nations, but also because it spreads much like a sexually transmitted disease within networks of people, where the victim one time becomes the assailant the next. Unfortunately, it isn't clear if legal restrictions (e.g., background checks, waiting periods, concealed carry laws, bans on certain types of firearms) can reduce injuries and deaths. A 2005 review by the Task Force on Community Preventive Services found insufficient evidence to determine the effectiveness of any law in preventing violence, and it doesn't appear eager to take up the topic again. Even though the Centers for Disease Control and Prevention is no longer forbidden from researching gun violence, it hasn't received any Congressional funding for such studies. So U.S. policymakers are left with extrapolating from observational studies, many done in other countries. These studies suggest that implementing multiple firearm restrictions simultaneously (as Australia did in 1996) is associated with reductions in deaths; that laws requiring background checks reduce intimate partner homicides; and that laws requiring safer storage of firearms reduce unintentional deaths in children.

Of course, meaningful firearm legislation in the U.S. remains politically impossible, especially when a Presidential nominee openly calls for "Second Amendment people" to assassinate his opponent should she be elected. Which brings me back to physician counseling. We can start by counseling Donald Trump's doctor to tell him to bow out of the race for the good of the Republican Party and the country, and go back to being a harmless reality show star.

Family physicians are natural health system leaders

The subtitle of a 2014 JAMA editorial on accountable care caught my attention: "The paradox of primary care physician leadership." The authors observed that although a typical family physician's or general internist's patient panel accounts for about $10 million in annual health care spending (of which only $500,000 is primary care revenue), primary care physicians have been "underused" as role players in health system reform. They further suggested that claiming leadership positions in accountable care organizations could be "a powerful opportunity [for family physicians] to retain their autonomy and make a positive difference for their patients - as well as their practices' bottom lines."

The editorial’s urging that family physicians take on more leadership in health care brought to mind the American Academy of Family Physicians’ ongoing initiative Family Medicine for America's Health, an effort to define family medicine’s role in the current health care system. One of the key questions considered by this initiative is "What are the core attributes of family medicine today?" Dr. Robert L. Phillips, Jr., and colleagues from seven U.S. family medicine organizations answered the question in a special article on the future role of the family physician in the Annals of Family Medicine:

Family physicians are personal doctors for people of all ages and health conditions. They are a reliable first contact for health concerns and directly address most health care needs. Through enduring partnerships, family physicians help patients prevent, understand, and manage illness, navigate the health system and set health goals. Family physicians and their staff adapt their care to the unique needs of their patients and communities. They use data to monitor and manage their patient population, and they use best science to prioritize services most likely to benefit health. They are ideal leaders of health care systems and partners for public health.

This forward-looking definition of family physicians as natural health system leaders contrasts the "foil definition" that the researchers envisioned family physicians fitting if they were to accept passive roles and allow themselves to be acted on by the various forces changing American health care:

The role of the US family physician is to provide episodic outpatient care in 15-minute blocks with coincidental continuity and a reducing scope of care. The family physician surrenders care coordination to care management functions divorced from practices, and works in small, ill-defined teams whose members have little training and few in-depth relationships with the physician and patients. The family physician serves as the agent of a larger system whose role is to feed patients to subspecialty services and hospital beds. The family physician is not responsible for patient-panel management, community health, or collaboration with public health.

But are tomorrow's family physicians prepared to be leaders instead of followers?

A research study published in Family Medicine explored relationships between specialty plans and clinical decision making in a national survey of 4,656 senior medical students. Students were asked to choose between management options in patient vignettes that exemplified principles of health reform: evidence-based care, cost-conscious care, and patient-centered care. Compared to all others, students entering family medicine were statistically more likely to recommend generic over brand-name medications and favor initial lifestyle-change counseling to starting medication for a mild chronic condition. Future family physicians were also more likely to prefer U.S. Preventive Services Task Force recommendations on preventive care to those from disease-oriented or patient advocacy groups, although this finding was not statistically significant.

This study’s take-home message is that future family physicians are well positioned to take the lead in implementing health system reforms that improve value and patient-oriented outcomes. Primary care physician leadership is not a paradox; on the contrary, it’s hard to imagine health reform succeeding in the long term without family doctors at the helm.

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A version of this post was first published on the AFP Community Blog and then appeared in Progress Notes on July 24, 2014.

Reflections on my summer publications

When I haven't been blogging, editing, teaching, or seeing patients this summer, I have experienced the satisfaction of having reports of a couple of my longer-term projects appear in medical journals. In contrast to a blog post, which can be conceived, written, and published in a few hours (although the thought process often takes much longer), the timeline from submission to publication in a journal is usually several months at a minimum.

For example, in the spring of 2014, after having helped to develop a search tool for primary care-relevant Choosing Wisely recommendations, I wondered what proportion of these recommendations were based on evidence of patient-oriented outcomes, as opposed to expert consensus. I convinced a collaborator, a family physician at Fort Belvoir Community Hospital, to help me apply the Strength of Recommendation Taxonomy (SORT) to 224 different recommendations that had been generated by various medical specialty societies. It took many hours of working on our own and several conference calls to complete this project, which we presented at the Preventing Overdiagnosis conference at the National Institutes of Health last September. We then wrote the paper and submitted it to what we thought was an appropriate journal, but the editors of the journal (which will remain nameless) disagreed, rejecting it without even sending it for peer review. So we resubmitted it to the Journal of the American Board of Family Medicine, which accepted it after peer review and revision and finally published it in their July/August issue. Here is the bottom line:

We found that a majority of primary care–relevant Choosing Wisely recommendations are based on expert consensus or disease-oriented evidence. In light of other factors that drive unnecessary medical interventions, such as patient satisfaction and fee-for-service reimbursement, this may make it more difficult to convince clinicians to change established practices. Further research is warranted to strengthen the evidence base supporting these recommendations in order to improve their acceptance and implementation into primary care.

Not long afterward, the journal Family Medicine published a book review that I wrote about Dr. Robert Taylor's enjoyable and useful What Every Medical Writer Needs to Know. I love reading good books about the process of writing, medical or otherwise, and recommended it highly:

Although students and novice writers may want to purchase a more traditional and/or less expensive book on the craft, I recommend What Every Medical Writer Needs to Know as a valuable resource not only for “serious” medical authors who write for a living but for family physicians and clinicians who write occasionally for publication and would enjoy learning more about the inspiring history of the profession.

After it was published, a residency mentor, whom I credit for giving me my start in medical writing, e-mailed me to say that he had decided to purchase a copy of the book based on my review!

Although blogging has advantages over traditional medical publications (perhaps my favorite being that I get to be the writer and the editor), I am glad that I invested the time to be published in these family medicine journals.