My favorite public health and health care books of 2016

I took a different approach to this year's top 10 list: rather than selecting only books published in this calendar year, as I did in 2015, I decided to make eligible any book that I read this year, regardless of when it was published. Books are listed in alphabetical order rather than order of preference/enjoyment: they were all compelling reads in their own ways.

Merry Christmas, Happy Holidays, and Happy New Year to all!

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1. Adventures of a Female Medical Detective: In Pursuit of Smallpox and AIDS, by Mary Guinan with Anne D. Mather

2. Dying and Living in the Neighborhood: A Street-Level View of America's Health Care Promise, by Prabhjot Singh

3. The Gene: An Intimate History, by Siddhartha Mukherjee

4. In A Different Key: The Story of Autism, by Jon Donvan and Karen Zucker

5. League of Denial: the NFL, Concussions, and the Battle for Truth, by Mark Fainaru-Wada and Steve Fainaru

6. Pandemic: Tracking Contagions, from Cholera to Ebola and Beyond, by Sonia Shah

7. The Practical Playbook: Public Health and Primary Care Together, by J. Lloyd Michener and co-editors

8. Pulse - Voices from the Heart of Medicine: Editor's Picks: A Third Anthology, by Paul Gross and co-editors

9. Religion As a Social Determinant of Public Health - by Ellen Idler, editor

10. Twelve Patients: Life and Death at Bellevue Hospital, by Eric Manheimer

Yes, health policy agendas can be bipartisan

Between the party-line Democratic votes to pass the Affordable Care Act in 2010 and the very likely party-line Republican votes to repeal critical parts of it in early 2017, a bipartisan group of state health policy leaders (Reforming States Group) recently released a letter to the incoming Administration that proposes a modest federal-state policy agenda designed to advance the Triple Aim.

Three members of the group summarized their proposals in a Perspective article in the New England Journal of Medicine that began with language that was music to my public health-trained ears:

State leaders understand that as a society we are spending our health care dollars in the wrong ways for the wrong things — emphasizing treatment over prevention and medical care over social services. ... High-cost, high-need patients swamp Medicaid programs; prisons have become de facto treatment systems for substance use disorders; today’s neglected children are tomorrow’s state responsibilities; low- and middle-income families struggle with rising health care payments; and the demands of an aging population increasingly tax families, health care systems, and communities.

The four key components of their agenda are as follows:

1) Support state efforts for broad reforms of health care payment and delivery.

2) Support state efforts to address causes and improve management of chronic illness.

3) Support state use of data to inform policy.

4) Strengthen the state-federal partnership on health to assure the greatest impact from federal investments.

Limited as it is, this bipartisan policy consensus has a chance to gain traction as a "long-term agenda for governing" because intentionally "avoids focusing on any single health care issue currently grabbing headlines." Improving population health is, after all, a long-term proposition that requires vision rarely seen in national politics these days. For example, buried in the acclaim heaped upon the recently enacted 21st Century Cures Act was that well over half of it was paid for by gutting the Prevention and Public Health Fund, which had already sustained substantial cuts in previous years to offset more visible or politically advantageous budget priorities.

In an era of increasing federal government paralysis, perhaps state leaders can find a way forward on priorities for health reform. Before Obamacare, there was Romneycare. There are still too many people in this country who can't access essential social services or medical care (even if they have health insurance). Too many people who have health insurance but delay dental care they can't afford and suffer permanently debilitating consequences. If President-Elect Trump wants to "make America great again," he can start by recognizing that we are far too great a nation to continue to allow these things to happen.

How can medical educators support students' well-being?

Even twenty years later, I remember well the pervasive despair that engulfed me for much of my first two years of medical school. Even with a personal support system that included my family and several former college roommates and friends who lived in the same city, I struggled to find my bearings, academically and emotionally. Now that I spend much of my time teaching first-year medical students, I have wondered if the learning environment that I and other faculty provide contributes negatively or positively to their well-being.

A recent systematic review in JAMA examined the self-reported prevalence of depression, depressive symptoms, and suicidal ideation in medical students from 43 countries who were surveyed from 1982 to 2015. Longitudinal studies showed that students' mental health worsened significantly after starting medical school, with a median absolute increase in symptoms of 13.5%. On average, 27 percent of students reported depression or depressive symptoms, but only 16 percent of those students sought formal treatment. In contrast to my own experience, which was feeling much happier once I began third-year clerkships, there was no significant difference in depression prevalence between the preclinical and clinical years. Most alarmingly, 11 percent of students in these studies reported having suicidal thoughts during medical school.

A second systematic review examined associations between learning environment interventions and medical student well-being. The evidence base was limited: only 3 of 28 included studies were randomized trials, and most studies were conducted at a single site. Interventions that appeared to be effective in improving students' well-being included pass/fail grading systems, increased time with patients during the preclinical years, mental health programs, wellness programs including mind-body stress reduction skills, and formal advising/mentoring programs. In an accompanying editorial, Dr. Stuart Slavin observed that the educational culture of some medical schools is often an obstacle to implementing these kinds of reforms:

When signals of problems involving student mental health arise, the reaction in medical education has commonly been failure to recognize that the main problem is often with the environment, not the student. The response has often been limited, such as advising students to eat well, exercise, do yoga, meditate, and participate in narrative medicine activities. These approaches ... may distract educators from recognizing that the learning environment is at the core of the problem, and more must be done to improve it.

To be sure, maximizing student well-being is not the only or even the most important goal of medical education. But just as it is possible to create positive practice environments that protect clinicians from burnout, educators can prepare students to practice medicine competently in learning environments that are least likely to harm their mental health.

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This post first appeared on the AFP Community Blog.

Imitation may be a form of flattery, but plagiarism hurts

I don't envy Dr. Michael Dansinger, whose scientific paper on the effects of commercial diets on surrogate markers of cardiovascular disease, originally submitted to the Annals of Internal Medicine, was stolen by one of the paper's external peer reviewers and published as the reviewer's own research in another medical journal. But unlike others whose work has been plagiarized, he had the satisfaction of not only seeing the plagiarized article retracted with an apology, but being able to publicly call out the plagiarist in a letter published yesterday in the Annals. As further explained in an accompanying editorial from editor Christine Laine, the plagiarist, Italian researcher Carmine Finelli, invented an imaginary cohort of European patients to replace those in Dansinger's U.S. study and recruited seven co-authors to play supporting roles in this scientific charade: "They allowed their names to be used, apparently without contributing anything of value - not even verification of the study's existence."

When I tweeted a link to Dansinger's letter early yesterday evening, some followers responded with incredulity that Finelli (whose scientific stature was high enough that he was invited to review for such a prestigious journal) thought he could possibly get away with such a brazen act without having it ruin his career. But plagiarism in the medical literature is unfortunately quite common, and as the popular blog Retraction Watch illustrates, often goes undetected for years.

Although ripping off an entire study, as in this case, is relatively rare, more frequently authors will plagiarize only parts of articles and/or make perfunctory efforts to reword stolen paragraphs to obscure their original source. This actually happened to me in 2010, when the entire introduction to my previously published review of screening for prostate cancer ended up in a ghostwritten primary care supplement sponsored by the American Urological Association (which, ironically, has strongly disputed the findings of my review).

One of my miscellaneous duties as a medical editor for American Family Physician has been investigating accusations of plagiarism. In one year, my investigations led three different articles to be retracted from their respective journals for plagiarizing all or part of reviews published in AFP. Unfortunately, I found that many journal editors (especially those operated by predatory publishers) were not nearly as enthusiastic as Dr. Laine about getting authors to admit any wrongdoing. And in more than one case, after I contacted the plagiarist's academic institution, it was unclear to me whether he or she would be subject to any disciplinary action.

Nineteenth-century English cleric Charles Caleb Colton is generally acknowledged as the source of the quotation "Imitation is the sincerest form of flattery." But I agree with the unnamed author of this 2011 blog post that plagiarism is neither imitation nor flattery:

The reason I am against this notion of plagiarism as flattery is that it is used as a reason to discourage the aggrieved author from taking action or being less stern with the action they take. While it is one thing to try to provide comfort to someone who is upset, I routinely read on forums that the victim should just “drop it” as they should feel “flattered” by the use and “let it go”.

Strangely, this is one of only a few situations where we tell the victims of an act that they should feel flattered. We don’t tell people who had their car stolen to be grateful the thief thought they had a nice car or someone who was mugged that they looked like a wealthy person. ... Plagiarists aren’t misguided critics or failed creators who are giving tacit approval of a work as they plagiarize. The victims of plagiarism are chosen the same way as any other victims are chosen.

Kudos to Dr. Laine for publishing Dr. Dansinger's broadside against plagiarists everywhere, and putting intellectual thieves on notice that they can and will be called to account for their crimes.

Signed Out Of Prison But Not Signed Up For Insurance, Inmates Fall Prey To Ills

- Jay Hancock, Kaiser Health News and Beth Schwartzapfel, The Marshall Project

INDIANAPOLIS — Before he went to prison, Ernest killed his 2-year-old daughter in the grip of a psychotic delusion. When the Indiana Department of Correction released him in 2015, he was terrified something awful might happen again.

He had to see a doctor. He had only a month’s worth of pills to control his delusions and mania. He was desperate for insurance coverage.

But the state failed to enroll him in Medicaid, although under the Affordable Care Act Indiana had expanded the health insurance program, making most ex-inmates eligible. Left to navigate an unwieldy bureaucracy on his own, he came within days of running out of the pills that ground him in reality.

“I have a serious mental disorder, which is what caused me to commit my crime in the first place,” said Ernest, who asked reporters to use only his middle name to protect his privacy. “Somebody should have been pretty concerned.”

The health law was expected to connect Ernest and almost all other ex-prisoners for the first time to Medicaid coverage for the poor, cutting expensive visits to the emergency room, improving their prospects of rejoining society and reducing the risk of spreading communicable diseases that flourish in prisons.

But Ernest’s experience is repeated millions of times across the country, an examination by The Marshall Project and Kaiser Health News shows.

Most of the state prison systems in the 31 states that expanded Medicaid have either not created large-scale enrollment programs or operate spotty programs that leave large numbers of exiting inmates — many of whom are chronically ill — without insurance.

Local jails processing millions of prisoners a year, many severely mentally ill, are doing an even poorer job of getting health coverage for ex-inmates, by many accounts. Jail enrollment is especially challenging because the average stay is less than a month and prisoners are often released unexpectedly.

Ex-inmates with the worst chances of getting insurance and care are in 19 states that did not expand Medicaid. Only a small number qualify for coverage. Enrollment efforts by prisons and jails are almost nonexistent.

Nationwide, 16 state prison systems have no formal procedure to enroll prisoners in Medicaid as they reenter the community, according to a survey by The Marshall Project. Nine states have only small programs in select facilities or for limited groups of prisoners, like those with disabilities. These 25 states collectively release some 375,000 inmates each year.

Failure to link emerging inmates to health insurance is a missed opportunity to improve health and save money by cutting recidivism as well as visits to the hospital emergency room, advocates say. Studies have showed Medicaid access in Florida and Washington cut return trips to jail among the mentally ill by 16 percent.

“I hate to say it — it’s a captive audience. You have somebody there! You know they’re going to be released in a few weeks,” said Monica McCurdy, who as head of a clinic for Project HOME in Philadelphia constantly sees homeless, recently released prisoners without Medicaid coverage. “Why not do the handoff that’s needed to prevent this person winding up in the ER? It defies common sense.”

Health Risks Soar After Prison Release

Before the Affordable Care Act, state Medicaid programs covered mainly children, pregnant women and disabled adults, which included only a small number of ex-offenders. That’s still generally the case in the 19 states that didn’t expand Medicaid.

President-elect Donald Trump has vowed to repeal the health act and replace it with something else, leaving the law’s Medicaid expansion and eligibility for ex-prisoners in doubt. Rep. Tom Price, Trump’s pick to head the Departmetn of Health and Human Services — which oversees Medicaid — has been one of Obamacare’s most vociferous critics in Congress.

But some analysts expect parts of the law to survive, perhaps including Medicaid expansion managed more directly by states than by Washington.

Even some Republicans have supported the idea, suggesting that revoking Medicaid coverage from millions of new recipients would be difficult. Republican Gov. John Kasich expanded Medicaid in Ohio in part for ex-inmates, he has said, “to get them their medication so they could lead a decent life.”

Other parts of the health law received more attention, but advocates saw giving Medicaid coverage to ex-inmates as one of its most transformative aspects. Illness for illness, inmates are the sickest people in the country.

They have far higher rates of HIV, hepatitis and tuberculosis than the general population. They’re also more likely to have high blood pressure, diabetes and asthma. More than half are mentally ill, according to the Bureau of Justice Statistics, with up to a quarter meeting criteria for psychosis. Between half and three-quarters have an addiction problem.

Prisons and jails have their own doctors, but their responsibility to provide care stops upon an inmate’s departure. Inmates generally aren’t eligible for Medicaid while imprisoned.

No time is more critical than the days immediately after release. One study showed that in the first two weeks, ex-prisoners die at a dozen times the rate of the general population. Heart disease, drug overdose, homicide and suicide are the main causes.

But even in states that expanded Medicaid, the most vulnerable and sometimes dangerous ex-inmates are often left on their own.

Ernest went to prison for shooting and killing his daughter amid a psychotic religious delusion. Re-enacting the biblical story of the sacrifice of Isaac, he thought God would intervene to save the girl. News reports from the time say police found him naked, carrying the child’s lifeless body through the streets of an Indianapolis suburb.

Indiana expanded Medicaid under the health law in February 2015 and set up a system to enroll all eligible prisoners upon release. Yet when Ernest got out in August 2015, he was not enrolled in Medicaid, let alone connected to doctors.

Prison officials say they applied for Medicaid on Ernest’s behalf, but Medicaid records show he applied when he got home. It’s not clear where the system failed.

“It is important that the offenders have some accountability in the process,” said Douglas Garrison, a spokesperson for the Indiana Department of Correction. “The IDOC has worked diligently to ensure released offenders are receiving coverage.”

Ernest’s letters to Medicaid and a clinic before he got out didn’t help. He had to start the application process from scratch after he got home, making increasingly frantic calls and scrambling to find his birth certificate and other paperwork as his supply of lithium and perphenazine, an antipsychotic, dwindled.

“Somebody who’s committed a violent felony because of a mental illness is getting out of prison, and we don’t have anything set up yet?” he said.

Failure to sign up ex-inmates for health care is a common occurrence in states that expanded Medicaid under the health law, even in places such as Indiana where agencies have provided enrollment assistance.

No Enrollment For Thousands Of Chronically Ill

Two-thirds of the 9,000 chronically ill prisoners released each year by Philadelphia’s jails aren’t getting enrolled as they leave, said Bruce Herdman, medical director for the jails. The city lacks even the $2 million necessary to supply a month’s worth of medication for released inmates with prescriptions, he said.

“They give you like two weeks’ supply of medication,” said Ricky Platt, 49, who left the Philadelphia jail in 2015, quickly ran out of Zoloft antidepressants and became homeless. “They don’t give you any resource of where to go or get a doctor and get your prescription filled or anything.”

Emergency doctors at Thomas Jefferson University Hospital in Philadelphia often see released inmates with kidney failure who are at risk of dying if they don’t receive dialysis almost immediately, said Dr. Priya Mammen, one of the hospital’s emergency physicians.

“We’re kind of the go-to spot for many people, but particularly for people who have been released from prison,” she said. “Either in the first week we see them or when their prescriptions run out.”

Kara Salim, 26, got out of the Marion County, Indiana, jail in 2015 with a history of domestic-violence charges, bipolar disorder and alcoholism — and without Medicaid coverage. As a result, she couldn’t afford the fees for court-ordered therapy.

Without therapy she wasn’t allowed to see a psychiatrist for her medications. Without medication she spiraled downward, eventually threatening suicide at a court hearing. When court officers tried to bring her to a psychiatric hospital, she erupted, kicking and scratching them and landing back in jail, with new felony charges: battery against a public safety officer.

“I wish I could tell you she’s the exception,” said Sarah Barham, an addiction counselor with Centerstone, an Indiana nonprofit.

Medicaid enrollment requires resources that many prison systems and local jails — often overcrowded and operating in crisis mode for years — lack or have been reluctant to commit.

“Most of the county sheriffs don’t have the proper staff they need to even run the jails,” said Bill Wilson of the Indiana Sheriffs’ Association. Many jails are making an effort, but in some places “pulling the resources out to enroll an inmate in Medicaid is not something the sheriff’s able to do.”

In Minnesota, only those eligible for special release planning programs are offered assistance in applying; as a result, fewer than 1,000 of the 6,800 prisoners the state released last year applied for Medicaid, according to corrections officials there. Minnesota is one of seven states — Alaska, Hawaii, Arizona, Montana, Louisiana and Illinois are the others — that expanded Medicaid but have not implemented a large-scale enrollment program.

In many states, even prerelease registration requires a follow-up visit to a local Medicaid or welfare office to “activate” the coverage on release. Obtaining a phone, paying for minutes and navigating bus lines to state offices can be daunting for newly released inmates who often struggle with basic needs such as food and shelter.

Indiana officials applied for Medicaid on behalf of more than 7,000 state prisoners from March through September — nearly 90 percent of those released. (Many of the others were released to other states or deported, officials said.) Yet only a little more than half called to activate their coverage when they got home, according to state data. The state said in recent weeks it eliminated the requirement to activate coverage with a call.

Released prisoners also often need to reestablish identification by applying for Social Security cards and birth certificates. That can take weeks or months. Sometimes there’s another step: enrolling in one of the private, managed care networks that many states hire to administer Medicaid benefits.

In the chaotic days and weeks after release, red tape can mean the difference between joining Medicaid or remaining cut off from community caregivers.

William Santee, 46, released from Pennsylvania state prison this year, has diabetes, high cholesterol and high blood pressure. He learned about Medicaid enrollment requirements and the need to visit a welfare office from workers at a homeless shelter.

The prison “didn’t tell me about where to go or anything like that,” he said. “They don’t consider that their responsibility.” Waiting in line and completing the welfare-office paperwork took five hours.

Getting The Details Right

Almost as critical as successful enrollment is choosing a Medicaid plan that covers medicines and services ex-inmates need. Jail and prison workers are rarely equipped to wade through such details.

“That’s a huge issue for us,” said Susan Jo Thomas of Covering Kids and Families, a nonprofit that helps enroll people in Medicaid in Indiana. “You finally get a person to the place where they are ready … to go into detox, but if they have aligned with an insurance company that doesn’t cover the medicine that program uses, then you have a problem.”

In some extreme cases bureaucratic rules clash, leaving ex-prisoners stranded between agencies. In Indiana and several other states, corrections departments consider prisoners in work release programs, who report to jobs during the day, to be free. That means they’re not eligible for care from the prison system.

Medicaid, on the other hand considers them still incarcerated. So they can’t enroll in community health coverage, either.

“We got all excited when Obamacare came out, because everybody’s going to be covered,” said Peggy Urtz, who runs an Iowa work release facility for women. Instead, she said, the women “are going to ERs when they’re ill and racking up medical bills. We have good providers, well experienced in working with women, and they can’t go to them because they don’t have insurance.”

A few states and localities reap praise for innovative and comprehensive attempts to enroll emerging prisoners in Medicaid.

Ohio recently finished phasing in Medicaid registration at all state prisons and is one of the few states giving inmates a managed-care insurance card as they leave, said John McCarthy, that state’s Medicaid director. Chicago’s huge Cook County jail puts prisoners on the Medicaid books as they enter, rather than before they leave, to sidestep the common problem in jails of unpredictable release dates.

More often the process looks like what was happening one recent Friday in Indiana’s Marion County jail, where Lt. Debbie Sullivan was trying to rouse sleepy women to sign up for health insurance.

The document she distributed was three pages long, authorizing a Medicaid application on inmates’ behalf. It asked for names, addresses, birth dates and Social Security numbers. The handwritten information would later be entered into computers — a recipe for transposed digits and misspelled names.

“The program remains a work in progress,” said Katie Carlson, a spokeswoman for the Marion County Sheriff’s Office, which runs the jail. “It has proven a daunting task to enroll, track and provide meaningful information on both Medicaid and health care.”

Experts say such sessions require a half hour or more to get the details right and answer questions about picking the right plan and following up with doctors and insurance officials after release.

Sullivan’s knowledge of the women’s next steps was minimal. In response to questions, she simply told them to contact their local social service office when they get out. She walked out of the block with about 30 signed applications. It was over in 15 minutes.

“Thank you ladies!” she called on her way out, as the heavy steel door slammed behind her.

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This post was originally published on Kaiser Health News (KHN), a national health policy news service and an editorially independent program of the Henry J. Kaiser Family Foundation. This article is published in partnership with The Marshall Project, a nonprofit news organization covering the U.S. criminal justice system, NPR, and Side Effects Public Media, a news collaborative covering public health.

The USPSTF weighs in on statins for primary CVD prevention

In other blog posts, I have discussed the 2013 American College of Cardiology/American Heart Association cholesterol treatment guideline, offered additional perspectives on its 7.5% 10-year CVD event risk threshold for starting a statin, and noted that existing cardiovascular risk calculators tend to overestimate risk by significant margins. The ACC/AHA guideline's expansion of the proportion of adults recommended for statin therapy has remained controversial. The American Academy of Family Physicians partially endorsed the guideline with qualifications (disclosure: I am a member of the AAFP Commission that made this recommendation), and a 2014 guideline from the U.S. Departments of Veterans Affairs and Defense recommended higher thresholds for considering (6%) or starting (12%) statins.

Last month, the U.S. Preventive Services Task Force weighed in with a new recommendation statement on the use of statins for primary prevention of cardiovascular events. The recommendations are similar to those from the ACC/AHA; the USPSTF recommends initiating low- to moderate-dose statins in adults aged 40 to 75 years with at least one CVD risk factor (dyslipidemia, diabetes, hypertension, or smoking) and a calculated 10-year CVD event risk of 10% or greater ("B" recommendation). They recommend shared decision making and selective statin prescribing for similar adults with a 7.5% to 10% CVD risk ("C" recommendation).

The USPSTF's higher risk thresholds for statin therapy may compensate for uncertainty regarding the accuracy of CVD risk calculators, and the "C" recommendation recognizes that in persons at lower risk, the benefits of statins are less likely to outweigh the harms, which include liver enzyme abnormalities and muscle toxicity and a small increased risk of new-onset type 2 diabetes.

Although a prior USPSTF statement had recommended screening for lipid disorders in adults as early as 20 years of age, a new systematic review found no direct evidence on the benefits and harms of screening for or treatment of dyslipidemia in adults aged 21 to 39 years. So when should family physicians check cholesterol levels in an asymptomatic adult, if statins don't become a treatment option until age 40? This is an area to exercise clinical judgment on an individual basis, keeping in mind that healthy lifestyle counseling is more likely to be beneficial in adults with CVD risk factors than in adults without known risks.

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This post first appeared on the AFP Community Blog.

Give thanks for small primary care practices

When I was in high school, a national hardware retailer opened a new franchise down the street from the mom-and-pop hardware store that had served my neighborhood for many years. Since the new store had the advantage of larger volumes and lower costs, it seemed to be only a matter of time before it drove its smaller competitor out of business, the way that big bookstore chains and fast-food restaurants had already vanquished theirs.

But a funny thing happened on the way to the inevitable. By the time I left for college, the new hardware store had folded, and the mom-and-pop operation had moved into their former building. How did this small business manage to retain its customers and win new ones without prior loyalties? The answer was quality of service. I remember visiting both stores when a classmate and I were working on a physics project. At the mom-and-pop store, the owner himself happily held forth for several minutes on the advantages and disadvantages of various types of epoxy adhesive. At the national hardware chain, the staff consisted mostly of kids my age who didn't know much more about glue than I did.

Six years ago, an editorial authored by White House officials in the Annals of Internal Medicine blithely predicted that small primary care practices would eventually be absorbed by "vertically integrated organizations" as a result of health reforms. The editorial prompted the American Academy of Family Physicians to send the White House a letter defending the ability of solo and small group practices to provide high-quality primary care. Despite the migration of recent family medicine residency graduates into employed positions, researchers from the Robert Graham Center estimated that up to 45% of active primary care physicians in 2010 practiced at sites with five or fewer physicians.

The limited resources of small practices seem to put them at a disadvantage relative to integrated health systems and Accountable Care Organizations. Small practices have less capital to invest in acquiring and implementing technology such as patient portals, and fewer resources (dollars and personnel) to devote to quality improvement activities, such as reducing preventable hospital admission rates. Nonetheless, like the small hardware store of my youth, some small practices are not only surviving, but thriving in the new health care environment. Dr. Alex Krist and colleagues reported in the Annals of Family Medicine in 2014 that eight small primary care practices in northern Virginia used proactive implementation strategies to achieve patient use rates of an interactive preventive health record similar to those of large integrated systems such as Kaiser Permanente and Group Health Cooperative. An analysis of Medicare data published in Health Affairs found that among primary care practices with 19 or fewer physicians, a smaller practice size was associated with a lower rate of potentially preventable hospital admissions.

In addition to providing superior service, solo physicians or small groups can create their own economies of scale by pooling resources and collaborating with other practices in areas such electronic health record systems and quality improvement. For example, Dr. Jennifer Brull reported how her practice and four others in north-central Kansas succeeded in improving hypertension control rates in an article and video in Family Practice Management.

These examples illustrate that the demise of the small primary care practice has been greatly exaggerated. Whether small practices can continue to flourish in the era of health care consolidation and questionable quality metrics remains an open question, but I do know this: the small hardware store in my home town is still thriving, a quarter century later.

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This post first appeared on Common Sense Family Doctor on September 22, 2014. Happy Thanksgiving, everyone!

Repeal Obamacare; sustain the Affordable Care Act

On the Election Day that made Donald Trump the next President of the United States, I traveled to Lancaster, Pennsylvania to give a lecture. Long a conservative political stronghold, Lancaster County was dotted with "Make America Great Again" campaign signs, forecasting Trump's comfortable 47,000 vote margin there, which ended up being more than two-thirds of his 68,000 victory margin in Pennsylvania, one of the states that effectively decided the election. Ironically, Lancaster is where I trained to become a family physician from 2001 through 2004, and it is the place where I first recognized that the health care system our country had then was not up to the task of caring for all the people. Lancaster, which started me on my path toward advocating for reforms that ended up in the Affordable Care Act, voted overwhelmingly for a candidate who has promised to repeal it.

Let me admit that I've never had particularly warm feelings toward President Obama. I think his foreign policy has been a mess. The trillions of dollars in debt that the U.S. has run up over his term will hurt my generation and future generations, and if Republicans should be faulted for their fantasy that the federal budget can be balanced exclusively through spending cuts, Obama has sustained the Democratic fairy tale that raising taxes on "millionaires and billionaires" is all that is necessary to pay the skyrocketing bills. On multiple occasions during my time in government, the President had no qualms about squashing science and scientists for political convenience. And for all of his rhetorical gifts when preaching to the choir, he's been one of the least effective persuaders-in-chief to have held the office.

And so, naturally, I oppose Obamacare. I oppose a government takeover of health care that included morally repugnant death panels staffed by faceless bureaucrats who decide whose grandparents live or die and make it impossible for clinicians to provide compassionate end-of-life care. I oppose the provision in Obamacare that said that in order for some of the 50 million uninsured Americans to obtain health insurance, an equal or greater number must forfeit their existing plans or be laid off from their jobs. I oppose the discarding of personal responsibility for one's health in Obamacare. I oppose Obamacare's expansion of the nanny-state that regulates the most private aspects of people's lives.

It's a good thing that Obamacare, constructed on a foundation of health reform scare stories, doesn't exist and never will.

Instead, the Affordable Care Act (which I support) is based on a similar politically conservative law in Massachusetts that was signed by a Republican governor and openly supported by the administration of George W. Bush. It achieved the bulk of health insurance expansion by leveling the playing field for self-employed persons and employees of small businesses who, until now, didn't have a fraction of the premium negotiating power of large corporations that pool risk and provide benefits regardless of health status. The ACA discouraged irresponsible health care "free riders" and provided support for people of modest means to purchase private health insurance in regulated open marketplaces. It told insurers that in exchange for millions of new customers, they could no longer discriminate against the old and sick. Finally, the ACA rewarded physicians and hospitals for care quality and good outcomes, rather than paying for pricey tests and procedures that may not improve health.

The ACA has flaws. It didn't narrow the income disparity between different types of physicians or encourage more medical students to choose careers in primary care. It didn't prevent pharmaceutical companies from arbitrarily jacking up prices on old but essential drugs. Its provisions to discourage overuse of unnecessary medical services were limited and inadequate to the scope of the problem. But it's worth noting that all of these problems all predated the law. We don't have enough family physicians and other primary care clinicians, drugs in the U.S. cost more than anywhere else in the world, and overdiagnosis and overtreatment have been rampant for years. That the ACA took on these issues at all was a small victory.

It's interesting to consider the counterfactual exercise of what might have happened if Mitt Romney had captured the 2008 Republican Presidential nomination and then narrowly defeated Hillary Clinton, the odds-on favorite for the Democratic nomination in that year. No doubt affordable health care would have been an important focus of that hypothetical contest, with Romney successfully linking Clinton to her husband's failed 1994 reform plan that makes right-wing objections to the ACA look insignificant by comparison. Once elected, a President Romney would have felt compelled to advance national health reform, and would have naturally modeled his proposals on his Massachusetts plan. We might have ended up with a conservative law that looked much like the Affordable Care Act, only this time criticized by the left for being too administratively complex and not generous enough in providing coverage for all.

A farfetched scenario, you say? Perhaps. But it underlines the need for thoughtful Republicans to look past their leaders' overheated rhetoric about repealing Obamacare and focus on strengthening and sustaining the ACA, starting now.

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A slightly different version of this post first appeared on Common Sense Family Doctor on September 30, 2013.

When treating addiction, the words we use matter

In a JAMA editorial last month, Director of National Drug Control Policy Michael Botticelli and former DHHS Assistant Secretary for Health Howard Koh wrote that it was time to change the language health professionals and researchers use to refer to patients who suffer from addictions. This isn't simply an exercise in political correctness. Stigmatizing terms that "describe [patients] solely through the lens of their addiction or their implied personal failings" have been shown to negatively influence mental health clinicians' attitudes: someone described as a "substance abuser" was considered less treatable and more likely to be blamed for his or her condition than a "person with a substance use disorder." Similarly, they recommended describing someone with a history of having abused substances as "in recovery" rather than "clean." Botticelli knows his subject perhaps better than any previous U.S. "drug czar" (another term he prefers to not use), being in recovery himself from alcoholism.

I've written before about the failure of our criminal approach to drug misuse and the problems that misuse of legal pain medications have created for patients who suffer from chronic pain. Abetted by pharmaceutical companies whose sales representatives convinced many doctors that opioids were safe and non-addictive, the medical profession handed out powerful drugs like OxyContin as freely as Halloween candy, with devastating consequences.

Those consequences were more devastating in some communities than others. For almost every imaginable medical condition, members of racial and ethnic minorities receive less care and have poorer health outcomes, and addiction is not an exception. An article titled "Deconstructing Addiction" in NYU Physician began by describing two men in their 20s who sought treatment for heroin addictions and severe mood swings. One was diagnosed with bipolar disorder and prescribed antipsychotic medications and supervised methadone treatment. The other received an antidepressant and buprenorphine. Why were their medical plans so different? The first man was "a Latino living in a poor section of Brooklyn," while the second was a "middle-class white man from suburban Queens." Helena Hansen, an NYU psychiatrist and medical anthropologist, has worked to unravel the complex web of social and political forces that created these care disparities:

Methadone, she learned, was initially presented to the public as a tool for lowering crime in black and Latino communities. Accordingly, methadone clinics were mostly located in those areas. ... By the start of the new millenium, media reports warned of an epidemic of OxyContin addiction sweeping suburban and rural America. Buprenorphine maintenance, Dr. Hansen found, was aimed expressly at this new, overwhelmingly white cohort of substance abusers. ... When buprenorphine came on the market, ads portrayed the typical user as a white, middle-class dad who'd become addicted to painkillers after a back injury and wanted to return to coaching the son's baseball team. Even now, many buprenorphine providers accept only private insurance or out-of-pocket payments - unlike methadone clinics, which rely mostly on Medicaid reimbursements.

Although this two-tiered approach to treatment was not intended to create inequality, Hansen emphasized, it rapidly became incorporated into the structure of medicine and perpetuated stereotypes about white versus nonwhite patients with substance use disorders:

For addicted people in private care, most of whom are white, therapy is designed to minimize stigma and get the patient back to work or college; buprenorphine is used as a means toward these ends. Addicted people in public care - which covers most poor and nonwhite patients - are administered methadone under stringent supervision, steered into perceiving themselves as permanently disabled, and prescribed psychotropic medications that may further compromise their health.

On a related note, I've given some serious thought recently to going through the certification process to prescribe buprenorphine. Few family physicians currently possess a Drug Abuse Treatment Act (DATA) waiver to do so, not because the process is particularly onerous (eight hours of mandated education, half live and half online), but because most feel poorly trained and equipped to manage the psychosocial needs of these patients. I can't get a psychiatrist to see my few patients with mental illness that I consider beyond my capabilities unless they can pay cash; my heart sinks when I ponder how to arrange necessary care and social services for patients with substance use disorders. Working for a health system connected to a tertiary medical center, living in a city where the doctor to population ratio is one of the highest in the country, I rarely view myself as the health care option of last resort for anyone. But the need for accessible addiction treatment is great, and it isn't being met.

Underperforming big ideas in diabetes and breast cancer

Management of type 2 diabetes and screening for breast cancer make up a large portion of most family physicians' practices, including my own. Care and prevention for these patients is based on straightforward underlying theories of disease causation and behavior. Patients with type 2 diabetes have high blood glucose levels; treatment involves normalizing blood glucose through lifestyle modification and medication. Small, nonpalpable breast cancers eventually become large, symptomatic tumors. Smaller tumors are more likely to be curable, so undergoing regular screening mammography is preferable to not doing so.

But what if these underlying theories are wrong?

In a recent editorial in JAMA, Drs. Michael Joyner, Nigel Paneth, and John Ioannidis explored how the "big idea" or narrative that investments in genetics and information technology will lead to a revolution in health care has captured a large share of biomedical research funding and journal publications. They then illustrated how this big idea has "underperformed," as central assumptions of precision/personalized medicine have not been borne out in studies and tens of billions of dollars invested into electronic health records since 2009 have not made patient care measurably better or patient data more accessible to researchers.

Is tight glycemic control for patients with type 2 diabetes mellitus an underperforming clinical big idea? In an analysis in Circulation: Cardiovascular Quality and Outcomes, Drs. Rene Rodriguez-Gutierrez and Victor Montori compared clinical policy statements and practice guidelines for patients with type 2 diabetes between 2006 and 2015 with evidence from randomized controlled trials. Despite little or no evidence that tight glycemic control (hemoglobin A1c less than 6.5 or 7.0%) improves microvascular or macrovascular outcomes compared to less strict hemoglobin A1c goals, the majority of guidelines continued to endorse tight control for one or both of those outcomes. (In contrast, American Family Physician editorials and articles have asserted that "Physicians should not let well-intentioned but misguided concern for glucose levels distract them from attending to other interventions that more profoundly affect mortality [in patients with type 2 diabetes]: smoking cessation, blood pressure control, metformin therapy, and lipid reduction.")

And do small breast tumors detected by mammograms become large, lethal ones? Sometimes, but not as often as most patients and physicians think, according to an observational study in the New England Journal of Medicine that concluded: "Women [with tumors detected on mammography] were more likely to have breast cancer that was overdiagnosed than to have earlier detection of a tumor that was destined to become large." This study also concluded that most of the reduction in breast cancer mortality over the past 40 years could be attributed to improved systemic therapy rather than earlier tumor detection. In an editorial on counseling women about breast cancer screening, Dr. Mark Ebell and I discussed the benefits and harms of mammography in younger women and noted that for every additional breast cancer death prevented by starting at age 40, two women will be overdiagnosed with (and overtreated for) breast tumors that never would have become clinically apparent.

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This post first appeared on the AFP Community Blog.

The missing piece in diabetes prevention

Some of my posts, like this one on problems with proliferating systematic reviews, have very brief gestational periods. I read something that stirs my thinking on a topic, I am inspired, and I write about it in one sitting. Others can take longer, such as this post about direct primary care entering the mainstream of medicine, which came together after a few months of reading and speaking with others about the topic. And sometimes I have a topic in mind to write on but just can't decide where it fits best: this blog, the AFP Community Blog, my Medscape commentary series, or a "professional" publication such as a medical journal.

What I had in mind was a sequel of sorts to last summer's post about the folly of screening for prediabetes, which I believed was more likely to cause harm by labeling more people as being diseased than it was to motivate them to take action to prevent diabetes. As the American Medical Association and the Centers for Disease Control and Prevention stepped up their efforts to identify people "at risk" for prediabetes (and an analysis published in JAMA Internal Medicine calculated that 60% of U.S. adults under age 60, and 80% of adults age 60 or older, would fall into this category), I wanted to say more about this over-medicalized approach to diabetes prevention and what a better alternative could look like. Several times I started writing, but couldn't quite decide where the post was leading.

My thoughts finally gelled in a Medscape commentary published earlier this week, where I pointed out three problems with preventing diabetes by screening for prediabetes:

1) The evidence suggests that this approach doesn't help people live longer (mortality) or better (quality of life).

2) Screening (especially with the CDC's tool) will lead to lots of overdiagnosis.

3) By ignoring social determinants of health, such as poverty and inequality, that resist lifestyle changes, this strategy may worsen health disparities.

Here is what I concluded:

Changing unhealthy environments can be a far more effective and long-lasting intervention than one-on-one clinical counseling. In the late 1990s, the US Department of Housing and Urban Development randomly assigned 4500 women with children in high-poverty urban areas to no housing vouchers, unrestricted traditional vouchers, or vouchers that could only be redeemed for housing in low-poverty areas. Ten to 15 years later, the group receiving traditional vouchers was no healthier than the control group, but the group receiving low-poverty vouchers had significantly lower body mass index and glycated hemoglobin levels.

Although the Medicare DPP as proposed should improve the health of many of our patients, in order to prevent diabetes without worsening health disparities, family physicians also require resources to address social determinants of health. To this end, the American Academy of Family Physicians recently published a position paper describing strategies for collaborating effectively with public health partners to lead the prevention of chronic diseases in our communities.

How family physicians can reduce diagnostic errors

Due to our broad scope of practice, family physicians are likely the most vulnerable of all physicians (with the possible exception of emergency medicine physicians) to diagnostic errors. Patients of all ages and different co-morbidities come in with undifferentiated complaints that could be attributed to multiple organ systems. In an editorial in the September 15th issue of American Family Physician, Drs. John Ely and Mark Graber reviewed underlying reasons for incorrect diagnoses:

Most diagnostic errors are caused by the physician's cognitive biases and failed heuristics (mental shortcuts), such as anchoring bias (overly relying on the initial information received or initial diagnosis considered), context errors, or premature closure of the diagnostic process. More than 40 of these biases have been described, but most lead to a single pathway in which the physician fails to generate an adequate differential diagnosis or to even consider the correct diagnosis as a possibility. The single most common reason for a diagnostic error is simply, “I just didn't think of it."

In a previous Curbside Consultation, Dr. Caroline Wellbery explored some of these cognitive biases in greater detail. For example, availability bias "refers to the ease with which a particular answer comes to mind," and can lead physicians toward making diagnoses based on other recent patients with similar presenting symptoms. Premature closure may occur when a framing/anchoring bias causes a physician to view the patient through a familiar lens and dismiss evidence that is not consistent with that frame. Similarly, confirmation bias may lead physicians to overemphasize test findings that support their preliminary diagnoses. Dr. Allan Detsky brought some of these dry concepts to life in a recent narrative in JAMA where he compared difficult diagnoses to the plastic snakes that he used to scare away ducks from the dock at his family's vacation home:

When faced with a difficult and ongoing diagnostic dilemma, refocus on the key assumptions that have driven the strategy to search for the "snakes." Start by dividing the findings into those that are based on facts and those that are based on inferences derived from those facts. Design an experiment to see if those inferences are indeed true, like holding the snakes under the water to see what they will look like on the bottom of the lake.

In their AFP editorial, Drs. Ely and Graber suggested three approaches to reduce diagnostic errors in primary care: 1) Involve the patient as a partner in the diagnostic process; 2) Get second opinions from colleagues or consultants who have not been previously involved in the patient's care; 3) Use a diagnostic checklist to make sure that all appropriate differential diagnoses have been considered. On a health system level, the National Academies of Medicine published a report on "Improving Diagnosis in Health Care" last year, and the Society to Improve Diagnosis in Medicine is leading a coalition of professional organizations, including the American Academy of Family Physicians, to devise and implement strategies to prevent diagnostic errors across all specialties and healthcare settings.

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This post first appeared on the AFP Community Blog.

What can Rwanda teach the U.S. about primary care?

The relative underinvestment of resources in primary care in the U.S. has a great deal to do with the fact that we spend far more on health services than anywhere else in the world, but rank near the back of the pack in health metrics such as life expectancy, infant mortality, and disability compared to other high-income countries. Although inequality, lack of insurance coverage, and shrinking public health budgets are also part of the problem, I'd argue that diverting dollars from redundant multi-million dollar proton beam facilities to provide a patient-centered medical home for every American would have positive effects on population health.

Even though I feel that the U.S. has a lot to learn from other countries about building infrastructure to support high-quality primary care, it was still hard for me to get my head around the premise of an Atlantic headline that caught my eye a few years ago: "Rwanda's Historic Health Recovery: What the U.S. Might Learn." Like most Americans who have never traveled there, I suspect, my impressions of Rwanda have been strongly influenced by popular dramatizations of the 1994 genocide such as the movie "Hotel Rwanda" and Immaculee Ilibagiza's memoir Left to Tell. I had a difficult time imagining how any semblance of a functioning health system could have emerged even two decades later, much less a system that would have something to teach the U.S. But a 2013 BMJ article by Paul Farmer and colleagues documented impressive gains in Rwandan life expectancy, led by declines in morbidity and mortality from tuberculosis, HIV, and malaria that resulted not only from investments in lifesaving drugs but in preventive and primary care. 93% of Rwandan girls have received the complete HPV vaccine series to prevent cervical cancer, compared to only 33% of eligible U.S. girls in 2012.

Here's the thing, though: the foot soldiers in the Rwandan primary care revolution aren't doctors. In fact, there were only 625 practicing physicians in the entire country in 2011. (According to a report published in the same year, Washington, DC alone has about 3,000.) How, then, has Rwanda been able to staff its network of community health cancers and reach out to its eleven million people, many of whom are so poor that they can't afford the national health insurance premium of $2 per person? They do it primarily by relying on community health workers, trusted local residents who receive a minimum of basic medical training and are then integrated into more comprehensive primary care teams. As described further in a BMC Health Services Research article by the group Partners in Health:

Each district is served by a network of community health workers (CHWs) — three per village — offering health education, basic preventive and curative services, and family planning. CHWs are supported by local health centers, which serve approximately 20,000 people and are staffed by nurses, most of whom have a secondary school education level. Health centers provide vaccinations, reproductive and child health services, acute care, and diagnosis and treatment of HIV, tuberculosis, and malaria. District hospitals, staffed in part by 10-15 generalist physicians, provide more advanced care, including basic surgical services, such as cesarean sections.

Image courtesy of BMC Health Services Research.

The lesson to take home isn't that the U.S. can get away with training fewer primary care physicians than it already does. Indeed, Rwanda has every intention of training more doctors with assistance from other countries, including the U.S. What's important is the pyramidal structure of their health system, with primary care at the base and more specialized care at the apex. If you took the U.S. physician workforce, which consists of about 70% specialists and 30% generalists, and mapped it to a similar structure, it would look more like this (apologies for my poor graphical skills):

At the top, you have the super sub-specialists, who are experts on a single narrow spectrum of diseases confined to one organ system (e.g., hepatologists). Lower down are the ordinary specialists, such as gastroenterologists, cardiologists, and pulmonologists, whose expertise is limited to a single organ system and age group (e.g., adults). Still lower are generalists whose scope of practice is limited by age group. Finally, at the bottom, are the family physicians, the only type of physician whose scope is not limited by age, gender, or organ system.

The problem with this upside-down pyramid is that it's inherently unstable. In Washington, DC, it's sometimes easier for a patient with musculoskeletal low back pain to get an appointment with a spine surgeon or for a patient with panic attacks see a cardiologist than it is to find a family physician. You can get a same-day MRI for any number of problems that probably don't require any imaging at all. Such a health system is inefficient and wasteful at best, harmful at worst, and destined to get the extremely poor results it does. To improve population health in the U.S., we need to flip the pyramid so that primary care services are the base for all other health care structures.

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This post first appeared on Common Sense Family Doctor on December 2, 2013.

Does a rising tide of health outcomes lift all boats?

Politicians who favor reducing taxes and other financial policies that predominantly benefit "the rich" have argued that wealthy people have an outsized influence on the general health of the economy, and that their prosperity will benefit lower earners by directly or indirectly creating new or higher-paying jobs. A more pithy expression for this sentiment that President Kennedy first made famous is: "a rising tide lifts all boats." I don't have the expertise to comment on the veracity of this statement in an economic sense, but a recent study in Preventing Chronic Disease by Dr. David Kindig and colleagues asked an analogous question: can states simultaneously improve health outcomes and reduce health outcome disparities?

The study authors used age-adjusted mortality data from a Centers for Disease Control and Prevention database to compare the annual percent change in combined black and non-Hispanic white mortality by state with the annual change in black-white mortality disparities in those states from 1999 through 2013. Overall, in states where sufficient mortality data was available for analysis, combined-race mortality fell by a mean of 1.1% and the black-white disparity fell by a mean of 3.6% per year. However, there was no relationship between combined mortality and racial disparity reductions across states. A few states (Georgia, Maryland, Massachusetts) experienced above average improvements on both measures, but others (Oklahoma) were below average on both, and most states experienced relatively greater improvement on one measure than on the other.

Figure courtesy of CDC.

The implications of these findings are that strategies to improve health across all populations (the "rising tide") may be different from those aimed at eliminating racial health disparities ("all boats"). They also provide a baseline for what state health departments may reasonably expect when setting health improvement and disparity reduction goals in future years.

Guest Post: Hotspotting meets patients where they are

- Kimberly McGuinness, MS, ANP-C

I walked out of my office just in time to watch D.M. pass out, falling backwards off of the scale, narrowly missing my medical assistant. He had come to his primary care visit drunk and hypoglycemic again. I made changes to his medications and insulin, referred him to specialists and had him see our nurse and behaviorist, whom he could only see once because he would not be able to afford her copayment. At each subsequent visit, he was able to repeat all of our prescribed changes back to my nurse and me before he left the office to return to his life and world. He would then return for primary care follow-up after even more ER visits and hospital admissions and without having made any progress. We continued this trend for weeks and months until one day his death certificate arrived on my desk. I failed this patient. We failed this patient. Our system failed this patient.

At the time, I was practicing at a Philadelphia-based federally qualified health center (FQHC) providing primary care for the sickest of the sick. I am an Adult Nurse Practitioner and, when I started to work at the FQHC, I was fresh out of graduate school with a decade’s worth of registered nursing experience. As time went on, I was expected to see more and more of these complex patients, many of whom didn’t speak English, and often waited too long to seek care. As I pushed back on rising productivity expectations, administrators told me that if we went bankrupt and closed our doors, then no one else was going to help these patients. So I became a hamster on the wheel. I might have been keeping our clinic open, but I was not making a difference in the well-being of these patients. I would see one patient, make adjustments to medications, and they would return (maybe) without any discernible improvements to their health. This work was not fulfilling to me. When I walked in the door on Friday evenings, I’d say hello to my husband and then burst into tears – the release of tension from a frustrating week at work. And Monday I would go get back on the hamster wheel.

Then I learned about the Hotspotting Fellowship run by Dr. Jeff Brenner’s Camden Coalition of Healthcare Providers (The Coalition) and the Crozer-Keystone Family Medicine Residency Program in Springfield, Pennsylvania. Dr. Brenner developed a community-based care coordination model that provides quality care for high utilizers of emergency rooms and hospitals through a team-based approach – with the intent of keeping them out of emergency rooms and hospitals. Without a doubt, I knew this was the way that we need to practice medicine.

I got the fellowship, which is now coming to a close. Had I met D.M. during this program, I would have attempted to get to know who he really was and where he came from. I would have asked, “What happened to you?” and not “What is wrong with you?” I would have surrounded D.M. with a team to address the social and psychological issues that might be hindering his medical care and to work toward empowering him to take responsibility for his own care. He would be placed at the center of this care, and we would assist by breaking down barriers and providing him with solid relationships to help build his trust in the health system.

Over the last year, I have learned how to pool data and manage a super-utilizer intervention. I have been welcomed into C-suite meetings and negotiations with insurance companies in order to learn how to develop a successful hotspotting program for their beneficiaries. I have attended state legislative sessions to enact policies designed to break down the silos that intensify the need for a team-based approach. I have had the opportunity to travel to conferences around the country to present the data that we have been working on and to learn from and absorb the knowledge of others who are pushing the boundaries of our current practices.

But most importantly, I have spent my days working in interprofessional teams, providing high-touch, high-intensity care for these high-priority patients in their homes (or wherever they call home). Now when a patient like D.M. walks into my office, I take a step back from the pressing issue, like uncontrolled diabetes, to look at him as a whole. Together with the patient, we try to get to the root of the issue – no refrigerator to keep insulin because the patient is homeless, for example – because that is likely the cause of the uncontrolled diabetes. Having the opportunity to visit the patient on his turf and to deploy a pharmacist or social worker to assist with needs that arise – this feels like real medicine.

The faculty and team at Crozer and the employees of the Camden Coalition have provided me with unbelievable opportunities. They have opened my eyes to the infinite possibilities that are available to aid patients in healing and growing. And for the first time in my practice, I have started to meet patients where they are, not where I am or where my studies tell me they should be. For the first time in my career, I am practicing commonsense medicine and I am watching patients flourish.

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Kimberly McGuinness is an adult nurse practitioner who is completing a year-long Super-Utilizer and Hotspotting Fellowship run by the Camden Coalition of Healthcare Providers and the Crozer-Keystone Family Medicine Residency Program. She hopes to continue to work with the underserved, breaking down silos and redesigning primary care. This post was first published on Progress Notes.

In praise of individual health mandates

Five years ago, my family was involved in a scary traffic accident en route to the Family Medicine Education Consortium's North East Region meeting. I was in the left-hand eastbound lane of the Massachusetts Turnpike when a westbound tractor trailer collided with a truck, causing the truck to cross over the grass median a few cars ahead of us. I hit the brakes and swerved to avoid the truck, but its momentum carried it forward into the left side of our car. Strapped into child safety seats in the back, both of my children were struck by shards of window glass. My five year-old son, who had been sitting behind me, eventually required twelve stitches to close a scalp laceration. Miraculously, none of the occupants of the other six damaged vehicles, including the truck driver, sustained any injuries.

Family physicians like me, and physicians in general, like to believe that the interventions we provide patients make a big difference in their eventual health outcomes. In a few cases, they do. But for most people, events largely outside of the scope of medical practice determine one's quality and length of life, and public health legislation is more likely to save lives than the advice of well-meaning health professionals. My colleagues can counsel parents about car seat safety until they're blue in the face, but state laws requiring that young children be belted into car safety seats are what made the difference for my son between a scalp laceration and a life-threatening injury.

The often-derided individual health insurance mandate that is a prominent feature the Affordable Care Act is often compared by supporters to car insurance. If governments can require drivers to be financially responsible for their cars, the argument goes, why can't they require people to be financially responsible for their health-related expenses? The hole in this argument, of course, is that people aren't required to own cars the way that they "own" their bodies. But even the millions of children too young to drive and adults who choose not to are required to use seat belts or safety seats whenever they are passengers.

That, to me, seems to be the more apt comparison. As insurance against unexpected accidents and injuries, laws requiring seat belts and child safety seats are, essentially, individual health mandates. And it's well past time that all Americans buckled up.

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This post first appeared on Common Sense Family Doctor on November 1, 2011.

Drowning in a sea of redundant or flawed systematic reviews

As a medical officer for the U.S. Preventive Services Task Force from 2006 through 2010, I authored or co-authored several systematic reviews of the effectiveness of screening tests. Lately I have been wanting to assemble a team of colleagues to perform a systematic review of a research question that, to my knowledge, has not been satisfactorily answered for at least a decade (when there was insufficient evidence to answer it), but have been putting it off because I don't have the time. Doing a high-quality systematic review can require countless hours of work, which as a physician / medical teacher / editor / blogger I have been unable to find in my schedule.

Clearly many others do find the time, though. In the current issue of The Milbank Quarterly, my one-time collaborator John Ioannidis, a prolific dean of evidence-based medicine who is best known for his 2005 paper "Why Most Published Research Findings Are False," takes on the problem of "The Mass Production of Redundant, Misleading, and Conflicted Systematic Reviews and Meta-analyses." Ioannidis discusses the implications of an astounding 2700% increase in the number of systematic reviews appearing in the indexed medical literature between 1991 and 2014, a period during which the number of PubMed-indexed items only increased by 150%. He argues that this massive increase is not explained by the need to "catch up" with older published literature; rather, only a small percentage of studies are being included in these reviews, and so many systematic reviews are cataloging the same bodies of evidence that "it is possible that nowadays there are more systematic reviews of randomized trials being published than new randomized trials."

For example, between 2008 and 2012, 11 meta-analyses appeared on statins for the prevention of atrial fibrillation after cardiac surgery. The second of these reported a sizeable and statistically significant benefit, and the next 9 had similar findings. Case closed? Apparently not, since 10 more meta-analyses of the same topic were published between 2013 and 2015! In some cases, excessive production of systematic reviews seems to have a marketing, rather than knowledge-advancing, purpose. Redundancy as stealth marketing is particularly pronounced for certain drugs, such as antidepressants, where financially conflicted authors produced 80% of the 185 meta-analyses published between 2007 and 2014.

Finally, Ioannidis points out that reviews may be original and methodologically well-done but still clinically useless because they are purposely not published; they pool studies of outdated genetic approaches (candidate gene studies with small sample sizes and fragmented reporting, a favorite of Chinese reviewers); or they don't find enough consistent evidence to draw conclusions. In all, he estimates that only 3% of currently produced meta-analyses are "decent and clinically useful," meaning, of course, that the other 97% are not.

There are many possible solutions to this problem, including stricter standards for publication of reviews; altering current incentives for biomedical researchers to "publish or perish"; and establishing single, authoritative, publicly accessible systematic reviews that can serve as living documents to be updated periodically by teams of researchers (think Wikipedia for systematic reviews). After reading Ioannidis's article, I have decided that if and when I do find time to work on a systematic review again, I will do everything in my power to make it one of the 3% that are worth doing.

9/11

On the morning of September 11, 2001, I was a family medicine intern making rounds at a teaching hospital in Pennsylvania. As I started writing a progress note on one of my patients, my senior resident emerged from the next room with tears streaming down her face. I couldn't imagine what had gone wrong. Had we just lost someone? Could I have possibly missed the distinctive overhead page for the Code Blue team?

It was worse than that - much worse. "It's horrible," she managed to say. "Absolutely horrible. I feel so bad for their families." I stepped into the room and saw both televisions airing live footage of the wreckage of the twin towers of the World Trade Center, where not one, but two commercial airliners had just crashed.

The rest of the day was a blur. It was nearly impossible to concentrate on the day-to-day routine of patient care when all I could think about were the thousands of lives claimed in the space of a few minutes. Later in the day I learned that a third plane had hit the Pentagon, and a fourth had crashed into a field about 150 miles west of my home. "This means war," one of my attendings stated flatly.

I had recently graduated from medical school in New York City, and after going home from the hospital, I tried calling former classmates who had chosen residency programs there. But the phone lines were jammed all night. It wasn't until the next day that I heard from a friend about how an army of physicians and medical students had mobilized at NYU's Bellevue Hospital, waiting for a massive influx of injured patients who never came.

In the 15 years that have passed since that awful day, I completed my residency, got married to a wonderful woman, began my career as a family physician, and had four beautiful children who are, thankfully, still too young to fully comprehend what kinds of warped beliefs would possess people to deliberately fly airliners into buildings full of their fellow human beings. Eventually, I know I will have to explain to them the events of 9/11. And tell them, too, about the healing that time, faith, hope, and love can bring about after even the most grievous of wounds.

To all the victims of 9/11, living and dead, may peace be with you, today and evermore.

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A slightly different version of this post first appeared on Common Sense Family Doctor on September 10, 2011.

The politicization of an epidemic: Zika virus and microcephaly

Every day for the past several months, Politico Pulse Check host Dan Diamond has posted a "Zika Virus update" on his Twitter account stating the number of days since the White House requested emergency funding to combat the epidemic (currently 211), how much Congress has appropriated in response ($0), and the number of Zika cases in the U.S. and its territories (currently >16,000). That there has been no funding response even as the virus continues to spread within the continental U.S. is testimony not only to longstanding Congressional gridlock, but to the politically charged nature of a sexually transmitted disease that can cause deformed babies, and therefore raise the issue of abortion. The Senate will vote today on a Republican-controlled bill that is identical to one that failed in late June due to Democratic objections over legislative "riders" stripping funds from the Affordable Care Act and Planned Parenthood. This vote has as much chance of succeeding as the earlier one did: zero. Both parties know this; they're just going through the motions. As a result, no new federal funding will be made available for disease surveillance or prevention, including the development of a vaccine.

As readers know, I get outraged whenever politics trumps science, especially when patients will suffer the consequences. But this story doesn't stop with the U.S. Congress. A potentially devastating piece of misinformation is circulating online that despite months of public health warnings, infection with the Zika virus is not responsible for Brazil's epidemic of microcephalic and otherwise brain-damaged babies. Instead, the story claims, the real culprit is the insecticide pyriproxyfen, which is manufactured by a Japanese affiliate of the widely reviled American biotech and agriculture company Monsanto. Supporters of this claim cite out of context a preliminary report published in the New England Journal of Medicine in June showed an extremely low rate of microcephaly in Colombia; of 12,000 women who were reported to be infected with Zika, none had given birth to a microcephalic baby. This finding is contrasted to Brazil, where pyriproxyfen was used to treat drinking water to kill mosquito larvae.

The key omission here is that most of the women in the Columbian study were still pregnant at the time the study was published. In fact, the only thing that the study's authors felt confident enough to conclude about the data was that Zika infection during the third trimester of pregnancy did not seem to be associated with microcephalic newborns, a finding that made sense given what is known about critical stages of fetal neurologic development. It was subsequently confirmed by a study of Brazilian and French Polynesian live births that reported "a strong association between the risk of microcephaly and [Zika] infection risk in the first trimester and a negligible association in the second and third trimesters." This study estimated that Zika infection raises the risk of having a baby with microcephaly from 2 in 10,000 (0.02%) to between 1 and 13%.

So what is keeping the pyriproxyfen hypothesis alive, a full six months after officials from the World Health Organization first shot it down? You guessed it: politics. Pro-life groups who worry about physicians advising Zika-infected pregnant women to abort their babies are apparently seizing on this misinformation to further muddy the waters of counseling, even though one could argue based on real data that the vast majority of Zika-infected babies will be fine anyway. Environmental groups, on the other hand, can't resist another opportunity to attack Monsanto.

How could this misinformation harm patients? Less insecticide in the air and water means fewer opportunities to control the mosquitoes that transmit Zika virus. Women who are even a little bit confused about the real cause of these birth defects might neglect to take mosquito-avoidance precautions or disregard the CDC's travel advisories. (And absent Congressional action, the CDC is rapidly running out of funding to deliver appropriate public health messages.) I am pro-life, I oppose abortion and capital punishment, and I believe that protecting the environment is a moral imperative. But I also believe in science. A public health crisis of brain-damaged babies is bad enough. Making it worse by twisting the facts to serve one's politics is nothing less than despicable.