Once a Cesarean ... now, a vaginal delivery

A 2015 essay in the "Narrative Matters" section of Health Affairs by physician and health policy researcher Carla Keirns highlighted the challenges that even a highly educated, well-informed patient faces in achieving the desired outcome of a vaginal childbirth, especially if her pregnancy is classified as high risk. Dr. Keirns, whose pregnancy was complicated by "advanced maternal age" (there's that term again) and gestational diabetes, narrowly avoided a Cesarean delivery by obstetricians who often seemed to be "watching the clock" more than assessing her individual circumstances. She observed how the "Cesarean culture" of medical practice overshadows the ideal of shared decision-making about delivery preference:

I was naked and uncomfortable, had invasive lines in place, and hadn’t slept or eaten in three days. If a doctor I trusted, instead of one I didn’t know, had suggested a cesarean forty-eight hours into my labor induction, I might have agreed. If they had told me that my baby’s life or health was in jeopardy, I would have consented to anything. The vision of the empowered consumer, or even the autonomous patient, is laughable under these circumstances.

Once a woman has had one Cesarean delivery, she faces considerable pressure from the medical system to choose repeat Cesarean deliveries in subsequent pregnancies. A 2014 article in The Atlantic explained why the dictum "once a Cesarean, always a Cesarean" increasingly holds true despite good evidence that planned VBAC is safe for, and desired by, most women. After the American College of Obsetricians and Gynecologists (ACOG) published guidelines in 1996 (later challenged by the AAFP) recommending that in-house surgical teams be "immediately available" during planned VBAC, many hospitals stopped allowing women to attempt labor after a Cesarean. Even though ACOG now acknowledges that there is no evidence that hospitals with fewer resources have worse maternal or neonatal outcomes from planned VBAC, these restrictive institutional policies have remained in place.

After our first child was born by Cesarean section, my wife, who is also a family physician, proceeded to have three consecutive uncomplicated vaginal deliveries after the age of 35. To change the culture of medicine to support this kind of outcome, and to reduce the overall frequency of Cesarean deliveries, patients, physicians, and hospitals must advocate for aligning medical protocols with the best evidence and putting mothers and babies back at the center of care.

**

A slightly different version of this post appeared in Common Sense Family Doctor on February 5, 2015.

Three reasons for optimism in health policy

For clinicians like me who worry about how health policy changes may harm our patients, there have been plenty of reasons for pessimism this fall. Congressional re-authorization of the highly effective, popular, bipartisan Children's Health Insurance Program (CHIP), whose funding expired on September 30, was derailed by yet another "repeal Obamacare" attempt that failed to muster 50 of 52 Republican votes (or any Democratic votes) in the Senate. Dr. Tom Price, the now-former Secretary of Health and Human Services, was dismissed after billing taxpayers nearly $1 million for travel on private and military jets between obscure destinations with few commercial options such as ... Washington, DC to Philadelphia. (I was happy to see him go.) And building on his Administration's record of partisan actions on science policy, President Trump has confused just about everybody on whether he will ultimately support a bipartisan agreement to pass legislation stabilizing the Affordable Care Act's health insurance marketplaces in exchange for making it easier for states to obtain waivers to develop their own programs.

So why am I feeling optimistic, instead? Two weeks ago, I attended the 25th anniversary celebration of the Alliance for Health Policy, "a nonpartisan forum for learning and dialogue among policymakers and other leaders working to address the country’s most pressing health and health care issues." (Thanks to my friends at Health Is Primary for the invite.) This is one of the few health-related groups in Washington that could bestow honors on prominent conservative (Gail Wilensky) and liberal (Uwe Reinhardt) health care economists, as well as longtime Republican and Democratic congressional staffers, on the same night. And it was reassuring to see that family medicine had not one but many seats at the table, with the American Academy of Family Physicians' CEO, immediate past President, President, and President-Elect all in attendance.

Another nonpartisan health policy group that I've been following for the past few years is the Milbank Memorial Fund, which focuses on developing evidence to support state-level population health strategies, including but not limited to insurance reforms. In three recent reports, the Fund examined how some states achieved "significant, sustained improvements ... in one or more key population health outcome measures" and what lessons could be generalized from those experiences. For example, Georgia and Florida both made significant strides in reducing infant mortality relative to the rest of the nation between 2004 and 2014. In Georgia, a campaign led by then-public health commissioner Dr. Brenda Fitzgerald (now director of the Centers for Disease Control and Prevention), the Fund concluded that stakeholder engagement, champions, strategic use of data, and partnerships focused on postnatal care were crucial elements.

My third reason for optimism is my students. It strikes me as ironic that the medical school course that I co-direct at Georgetown was not even part of the curriculum of my own alma mater (NYU) or any other school of medicine in the 1990s. This year, for the first time, the course is concentrated into two intensive one-week blocks - one last week on Health Disparities and Health Equity, and another next spring on Health Policy and Advocacy - rather than being parceled out through five months of the academic year in direct competition with basic science courses. The result has been the most engaged, enthusiastic group of first-year medical students whom I've had the pleasure to teach. These students not only understand social determinants of health, they are ready to take action to address the root causes of health disparities where people live, work and play. They are prepared to advocate for patients in their neighborhoods and communities, far outside the walls of the hospital and clinic. They are motivated to change the culture of medical education to provide more than lip service to the social mission of caring for historically disadvantaged populations. They are part of the future of medicine and population health in this country, and they give me reason to believe that the future is bright.

What we choose to name a disease matters

A couple of years ago around this time, I was dealing with a series of minor health problems. I developed a sinus infection that took several weeks to resolve. I twisted one of my knees ice skating, and for a while I feared that I had torn a meniscus. Occasionally after eating a heavy meal, I had the sensation that food was getting stuck on the way to my stomach - so along with an x-ray and MRI for my knee, my doctor also sent me for an upper GI series. Finally, my blood tests for a new life insurance policy came back with a slightly high hemoglobin A1c level. The A1c test was once used only to monitor glucose control in patients with established diabetes, but in 2010 the American Diabetes Association changed their diagnostic criteria to classify an A1c level of 6.5% or greater as consistent with diabetes, 5.7% to 6.4% as prediabetes, and 5.6% or lower as normal. So on top of knee tendinitis and gastroesophageal reflux disease (GERD), I also found out that I had prediabetes.

Intellectually, I knew that there was no evidence that screening for prediabetes is beneficial (the life insurance company, not my doctor, had ordered the test), and that a screen-and-treat approach to diabetes prevention leads to lots of overdiagnosis. Emotionally, it was a different story. I had recently turned 40 and was feeling old. It had been years since I had gotten the recommended amount of physical activity for adults, and now I was doing even less because my knee hurt. It didn't help that the afternoon I found out about my A1c level, my wife called and asked me to pick up some Burger King sandwiches and fries to bring home for dinner. Not exactly what a pre-diabetic adult with GERD should be eating.

Would I have felt less sick if I had instead been told that I had "slightly high blood sugar"? In recent years, oncologists have recommended re-naming slow-growing lesions that we currently call cancer, such as "ductal carcinoma in situ" of the breast, indolent lesions of epithelial origin (IDLE), hoping that a less scary term will discourage patients from pursuing unnecessarily aggressive (and potentially harmful) treatment. Similarly, some doctors believe that telling patients that they have a "chest cold" rather than "acute bronchitis" will make them less likely to ask for antibiotics.

A systematic review published this year in BMJ Open supported the notion that what clinicians choose to name a disease influences patients' management preferences. Some study examples: women who were told they had "polycystic ovary syndrome" were more likely to want a pelvic ultrasound than those who were told they had a "hormone imbalance." Women were more likely to want surgery if they had "pre-invasive breast cancer cells" versus "abnormal cells" or a "breast lesion." Patients were more likely to expect surgery or casting of a "broken bone" or "greenstick fracture" than a "hairline fracture" or "crack in the bone." In each of these cases, the use of a more medicalized or precise term led patients to prefer invasive management options that were no better than more conservative choices.

How will I apply this knowledge to my daily practice? Although I already use the term "prediabetes" sparingly (preferring "increased risk for diabetes"), I'm going to start telling more patients with A1c levels similar to mine that they have high blood sugar instead. That they have heartburn rather than GERD. That they have overuse knee strains instead of tendinitis. And certain medical terms, such as "advanced maternal age" (i.e., pregnancy after the age of 35, or my wife's age when she gave birth to 3 of our 4 children), I will strive to eliminate from my vocabulary entirely.

Medication-assisted treatment for opioid addiction: the family physician's role

Millions of Americans suffer from a potentially fatal disease that has become so common over the past decade that it has lowered the average life expectancy and has particularly devastated vulnerable populations, such as adults with mental health disorders. Although effective medications exist to treat this national health emergency, only a small fraction of family physicians can prescribe them, and even certified physicians face numerous obstacles to providing treatment where their services were most needed. Instead, efforts have focused on disseminating guidelines to prevent this condition, mostly by reducing known risk factors. Unfortunately, most of what we know about prevention is only supported by low-quality evidence on patient outcomes.

I am writing, of course, about the epidemic of opioid use disorder and overdoses. In an editorial in the Sept. 15 issue of American Family Physician, my fellow editor Dr. Jennifer Middleton argued that while reducing the risk of addiction through the selective and responsible prescribing of opioid medications for pain is important, it is not sufficient to turn the tide. Observing that there is a critical shortage of substance abuse subspecialists, she encouraged family physicians to obtain a Drug Abuse Treatment Act of 2000 (DATA 2000) waiver to prescribe buprenorphine:

Family physicians ... are already adept at combining behavioral interventions with medication management for chronic diseases such as diabetes, cardiovascular disease, and chronic obstructive pulmonary disease; addiction treatment requires a similar combination of lifestyle coaching and prescription oversight. ... 

Buprenorphine is no more complex or difficult to manage than many other treatments routinely used in primary care. Additionally, our specialty has historically embraced the needs of populations labeled as difficult or challenging, such as homeless persons, refugees, and those with developmental disabilities or mental illness. Patients who are struggling with addiction are no less deserving of our attention.

Whether or not medication-assisted treatment (MAT) for opioid use disorder should become part of every family physician's scope of practice is a subject of intense debate, most recently in a pair of Point/Counterpoint editorials in the Annals of Family Medicine. Echoing Dr. Middleton, Dr. David Loxtercamp wrote about his "conversion experience" - the 19 year-old patient with whom he realized that he needed to be able to prescribe MAT to provide adequate care to her and so many others like her. "I am still involved [in MAT]," he wrote, "because I am a doctor and this is the epidemic of our time, a social tsunami that can be traced to my prescription - and yours. ... Addiction is a chronic disease that is decimating our communities. We need no other reason to embrace its treatment within every primary care practice."

Taking the opposite view that not every family physician can "be at the front lines" of the fight against the opioid epidemic, Dr. Richard Hill outlined several other factors that weigh against most family physicians prescribing MAT: specialized treatment required, comorbid psychiatric illness, methods shortcomings of emerging models of care, and the risk that taking on this additional responsibility would create more job dissatisfaction and burnout. "Even if further research establishes an 'optimal' model of care for use in primary care," he asserted, "the nature of the disease [opioid use disorder] itself will place undue clinical burden on an already overextended clinical workforce. Perhaps future efforts and funding should be directed toward the development of readily accessible referral networks of mental health/addiction centers, both public and private."

Both sides of the debate make compelling points. Personally, I am torn. What do you think the family physician's role should be in prescribing MAT for opioid addiction?

**

This post first appeared on the AFP Community Blog.