Wednesday, April 25, 2018

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 2016 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 Common Sense Family Doctor on December 19, 2016.

Sunday, April 15, 2018

Keep your options open - become a family physician

One of the persistent fallacies that I hear from medical students at my institution who are trying to decide between residency programs in internal and family medicine is that by choosing internal medicine, they can "keep their options open" to either become a generalist or to specialize, while choosing family medicine will close off all options except practicing traditional office-based primary care. In fact, nothing could be farther from the truth. If you choose an internal medicine residency, I counsel these students, the odds are overwhelmingly high that you will end up as a subspecialist (-ologist) at a tertiary care medical center. In contrast, the options available to a family medicine residency graduate are nearly limitless. Among my family physician colleagues are hospitalists, infectious disease and HIV experts, urgent care and team physicians; those who perform C-sections, colonoscopies, and appendectomies in the U.S. and throughout the world; teachers, researchers, guideline gurus, health system leaders, and public health officials; those who are comfortable practicing in rural areas, urban areas, and in every community size in between.

I often characterize my own career in family medicine as atypical, but that implies (falsely) that there is a "typical" path. I usually spend Monday mornings blogging or editing papers written by others, then precept family medicine residents in the afternoon. Tomorrow, I will actually be seeing my own patients in clinic all day, but the next five Mondays after that illustrate many of the options available to an academic family physician:

Monday, April 23
AM: Give the "What Is Family Medicine?" lecture to the new clerkship students. It's late in the 3rd year, but perhaps one or more can still be persuaded to "keep their options open" and fall in love with my specialty.
PM: Attend a multidisciplinary panel meeting for the American Academy of Otolaryngology-Head and Neck Surgery clinical practice guideline on epistaxis (nosebleeds).

Monday, April 30
Travel to Leawood, Kansas for a two-day American Family Physician editors meeting. Never in my wildest dreams as a medical student could I have imagined that I would become Deputy Editor of the second-largest medical journal (by print circulation) in the world, and the most monthly website views of any medical journal.

Monday, May 7
Attend the Society of Teachers of Family Medicine Annual Spring Conference in DC, where I am a co-presenter on two seminars and a scholarly poster.

Monday, May 14
Travel to Lancaster, PA, where the following morning I will present Grand Rounds at my alma mater (Lancaster General Hospital Family Medicine Residency).

Monday, May 21
Attend Georgetown's 2018 Teaching, Learning and Innovation Summer Institute as a member of this year's Technology-Enhanced Learning Colloquium for faculty across all university campuses.

Wednesday, April 11, 2018

Guest Post: Growing family medicine means changing med school admissions

- Larry Bauer, MSW, MEd

One of the things that I’ve always enjoyed about working with and supporting family physicians was the sense that I was helping not only the underdog, but one of the only groups within the house of medicine that could demonstrate its value in terms of improving the health of the population while reducing the cost of care; doing more with less.

I’ve also encountered elitism in medicine as an educator, as a faculty member, as a family member whose relations have encountered elitism and its effects, and as a patient myself. I want the underdog to lead the charge to reform the U.S. health care system. We would all be better off if family medicine and primary care led.

In Dr. Lin's description of remedies to the problem of too few family physicians, I think he left out the critical element. Our nation’s medical schools are becoming a playground for children from families of special means. Research clearly shows that a very disproportionate number of students admitted to our medical schools are from families with high and exceptionally high income expectations.

Children from families with limited means are disproportionately not making it over the hump. We know from 30 years of research that if more children from first generation to college families were admitted into our medical schools, and if those who have been out for a few years (not only a "gap year") were admitted to our medical schools, and if those from rural backgrounds were admitted to our medical schools, we would have more graduates choose family medicine and primary care, and probably general surgery and psychiatry as well.

This literally is the elephant in the room. I find that very few in family medicine and none outside of family medicine are willing to consider this issue.

I was on the forefront when I was on the faculty in the Department of Family and Community Medicine at Penn State University, as we collectively fought to increase family medicine faculty's teaching of students from first year to fourth year. We invest extraordinary faculty time and energy into teaching in most medical schools in the U.S. Family Medicine faculty are stretched thin because they want to increase students’ exposure to family physicians throughout all years of medical school.

But unless we address the core issue - the monolithic socioeconomic backgrounds of the students our medical schools are admitting - all of this additional expenditure of faculty time (which by the way is a very scarce and valuable resource) is not likely to change the picture. It’s time to focus on this issue. This can not be done by Family Medicine alone. It’s going to take a coalition of people within the medical school and in the larger community.

And a comment on AAMC’s response: the issue is not changing the interview process to address the “personal” side of the candidate. The issue is who is being interviewed in the first place. The second issue is who does the selecting. If basic science and non-clinical faculty continue to make up a large proportion of admissions committees, nothing will change.

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Larry Bauer is CEO of the Family Medicine Education Consortium.

Thursday, April 5, 2018

A family physician's favorite podcasts - updated for 2018

Late last year, I announced that I was planning to start my own podcast, to be called Common Sense Family Doctor after this blog. I did some reading about podcasting, downloaded Audacity to my laptop, and purchased the rights to some cool-sounding podcast theme music. Then life intervened. Patient care, teaching, editing, and other professional responsibilities completely consumed the time I thought that I would devote to the podcast, which remains on the drawing board. So what is the way forward? With the support of Georgetown's Center for New Designs in Learning & Scholarship, I now plan to explore podcasting to replace selected lecture content in my Patients, Populations and Policy course for first-year medical students. I hope that this "blended learning" project will give me the impetus I need to move forward with podcasting to a general audience sometime this summer. In the meantime, I've updated my previous list of favorite podcasts for your listening pleasure.

Health policy

HealthCetera
The Impact
POLITICO's Pulse Check
RoS: Review of Systems
State of Reform
What the Health?

Current events and popular culture

Every Little Thing
The Forward
How I Built This
TED Radio Hour
This American Life
30 for 30 Podcasts

History

Backstory
The Civil War: A History Podcast
Presidential
Revisionist History
Uncivil

Science and medicine

Air/Space
American Family Physician podcast
Hidden Brain
Houston We Have a Podcast
Methods
Sidedoor

Wednesday, March 28, 2018

For hypertension and diabetes, lower treatment targets are not necessarily better

In a previous Medscape commentary, I criticized the 2017 American College of Cardiology / American Heart Association clinical practice guideline on high blood pressure in adults, which proposed lowering the threshold for hypertension from 140/90 to 130/80 mm Hg. Independently, the American Academy of Family Physicians and the American College of Physicians both declined to endorse this guideline, citing concerns about its methodology (e.g., no quality assessment for included studies), management of intellectual conflicts of interest, and lack of information on harms of intensive drug therapy.

The March 15th issue of American Family Physician included a Practice Guideline summary and an editorial perspective on the ACC/AHA guideline by Dr. Michael LeFevre, a member of the panel that developed the JNC 8 guideline for hypertension in adults. In his editorial, Dr. LeFevre pointed out that the guideline's strengths include its emphasis on proper blood pressure measurement technique to avoid overtreating adults with normal out-of-office blood pressures. On the other hand, he argued that "it is an overreach" to classify everyone with a blood pressure above 130/80 as having uncontrolled hypertension. He predicted that since intensive behavioral counseling has only modest benefits in lowering blood pressure, many patients at low risk of cardiovascular disease will end up being treated with medication:

Much harm will come if this change [to the definition of hypertension] is widely accepted and implemented, particularly if quality measures that echo this definition are put into place. Harms from the consequences of poor measurement, overmedication, and arbitrary quality measures can easily offset the small reduction in CVD events found in trials of high-risk persons.

Blood pressure is not the only area of family medicine where there is ongoing debate about appropriate treatment thresholds. In a recent clinical guidance statement, the American College of Physicians recommended that clinicians "aim to achieve an HbA1c level between 7% and 8% in most patients with type 2 diabetes," and "consider deintensifying pharmacologic therapy in patients with type 2 diabetes who achieve HbA1c levels less than 6.5%." This statement elicited a critical response from the American Diabetes Association and endocrinology groups, who argued that lower blood glucose targets are sometimes appropriate to reduce the risk of microvascular and perhaps cardiovacular complications.

This debate between lower and higher A1c targets has been ongoing for years, as illustrated by a pair of Pro and Con editorials on this topic that appeared in AFP in 2012. On the whole, however, more relaxed glucose control can have substantial benefits, especially for older persons with type 2 diabetes, as Dr. Allen Shaughnessy and colleagues argued in 2015:

A large part of the acceptance that “lower is better” hinges on a false belief that a pathophysiologic approach to decision making is always correct. It seems logical that reducing blood glucose levels to nondiabetic normal, no matter the risk or cost, should result in improved patient outcomes. But it doesn't. Today, an older patient with type 2 diabetes is more likely to be hospitalized for severe hypoglycemia than for hyperglycemia.

Underlining this point, a vignette-based study in the March/April issue of Journal of the American Board of Family Medicine found that primary care clinicians (particularly internists and nurse practitioners) would often chose to intensify glycemic control in an older adult with a HbA1c level of 7.5% and multiple life-limiting comorbidities. As family physicians look for opportunities to improve care for patients with hypertension and diabetes, we should not miss opportunities to avoid harm.

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

Wednesday, March 21, 2018

Family physicians are underdogs among medical specialties

I only pay attention to college basketball during the first week of the NCAA tournament. Like many March Madness fans, I love rooting for underdogs. When the UMBC Retrievers became the first men's #16 seed to knock off overall #1 seed Virginia last week, I was in heaven. It broke my heart in 2016 when the upstart #14 seeded Stephen F. Austin Lumberjacks fell to Notre Dame in the second round on a last-second tip-in, a heartbeat from crashing the Sweet 16. In past tournaments, I was captivated by #11 seed George Mason's run to the Final Four in 2006 and #11 seed VCU's similar run from the First Four to the Final Four in 2011.


Family physicians are underdogs among medical specialties. If one were to rank student interest in the 24 specialties represented by the certifying boards of the American Board of Medical Specialties, the ROAD specialties (Radiology, Ophthalmology, Anesthesiology, Dermatology) would likely be #1 seeds, while Family Medicine, with its lower relative pay and more challenging work-life balance, would probably be seeded somewhere in the bottom half. Although the American Academy of Family Physicians cheered the results of last week's Residency Match, which saw another modest uptick in the number of U.S. medical students matching into Family Medicine residency programs, I have observed in a Medscape commentary that student interest in primary care is no "Match" for higher-income specialties. My own institution sent just 7 students out of a class of 200 into Family Medicine this year; nearly 3 times as many students matched into Orthopedic Surgery programs. It's no wonder that urgent cares, retail clinics, and telemedicine are thriving in the frontline health care void created by a growing shortage of primary care physicians.

What can medical educators do to increase student interest in primary care careers? Here's what I suggested in my commentary:

Early primary care exposure and required clerkships are necessary but not sufficient. ... Medical schools also need to "create a school culture that values primary care." That means advocating for excellence and innovation in primary care must be an explicit school goal, along with seizing every opportunity to discuss the foundational role of primary care in courses on health systems, and offering primary care tracks for selected students. Similarly, the Family Medicine for America's Health leadership team recommended creating longitudinal, integrated curricula in family medicine that allow students to make meaningful contributions to patient-centered care teams and have plenty of opportunities for faculty mentorship.

Embracing these strategies doesn't mean that family physicians won't continue to be viewed as the underdogs at tertiary academic medical centers where medical students receive the majority of their training, but it may give us more of a fighting chance to recruit students to our specialty before next year's medical version of March Madness.

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This is an updated version of a post that originally appeared on Common Sense Family Doctor on March 23, 2016.

Monday, March 12, 2018

Public health and advocacy resources for family physicians

Shaping local and national policies to improve patients' health outcomes is an appropriate and important role for family physicians. For the past several years, I have taught public health and advocacy skills to medical students, and last month, I attended Academy Health's National Health Policy conference in Washington, DC, for the first time. Although the majority of participants were researchers or policy analysts, family physicians were well-represented as medical directors, public health and insurance officials, and leaders of privately funded community health improvement projects.

In a previous blog post, I discussed the concept of assessing social determinants of health through "community vital signs," geocoded and individually linked data derived from public data sources. Although American Family Physician focuses on health interventions that clinicians provide in offices, emergency rooms, hospitals, and long-term care facilities, it also publishes resources to help family physicians improve social determinants outside of health care settings. For example, a 2014 editorial examined the role of the family physician in preventing and managing adverse childhood experiences, and a review article in the February 1 issue discussed implications for physicians of childhood bullying.

Previous editorials and articles have addressed environmental health hazards such as lead, radonair pollution and climate change, and a 2011 Letter to the Editor urged family physicians to take action to affect the built environment of American communities by "working to ensure that our patients have safe, convenient, and enjoyable places to walk, run, and bike." Other public health issues where physician advocacy can make a positive difference include food insecurity, homelessness, and firearm safety.

Family physicians are often first responders to natural and unnatural disasters in their communities. From influenza pandemics to bioterrorism, preparedness and early recognition is essential to protecting our patients. A 2015 editorial by my Georgetown colleague, Dr. Ranit Mishori, argued that the rapid spread of infectious diseases and migration and displacement of diverse populations have made global health knowledge essential for every family physician, regardless of location: "As the recent Ebola epidemic demonstrated, the world is not only smaller than ever, but it is also more intricately connected. Exotic diseases once confined to the third or developing world are now everyone's concern. Global has truly become local." For example, clinicians are likely to encounter victims of sex trafficking and labor trafficking in their practices.

AFP's sister publication, FPM, also provides resources for primary care clinicians with community and public health roles, from launching a community-wide flu vaccination plan, to following the Grand Junction, Colorado example of improving health system cost and quality outcomes, to working with community-based senior organizations. Finally, family medicine advocates can stay abreast of national initiatives that will shape the specialty's future, such as direct primary care, the patient-centered medical home, and the Medicare Access and CHIP Reauthorization Act (MACRA).

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This post first appeared on the AFP Community Blog.

Tuesday, March 6, 2018

Once again, the Agency for Healthcare Research and Quality stands in the line of fire

For the past 30 years, a little-known U.S. health agency has supported and produced volumes of groundbreaking research on how to make health care safer, less wasteful, and more effective. Dubbed "the little federal agency that could," AHRQ has accomplished this feat with a small fraction of the budgets of its higher-profile cousins, the Centers for Disease Control and Prevention and the National Institutes of Health. Nonetheless, its work has often been politically unpopular and unheralded outside of a small community of health services researchers and patient advocates. Sadly, when all medical waste is somebody's income, there is little enthusiasm in the medical-industrial complex or on Capitol Hill in allocating the $3 trillion the U.S. spends on health care more wisely or efficiently. In fact, our legislative and executive branches have periodically proposed that AHRQ's budget be slashed or eliminated entirely.

In 1994, the agency (then known as the Agency for Health Care Policy and Research) dared to publish a back pain guideline that suggested that there was little role for surgery in most patients. As later documented in Health Affairs, this act raised the hackles of back surgeons with powerful allies in Congress who were already annoyed by the agency's association with the failed Clinton health reform plan. The agency's budget was zeroed out by the House of Representatives and narrowly restored by the Senate in 1995 after a 21 percent cut and a name change to emphasize that its mission would be to produce evidence to inform policy, rather than attempt to actively shape policy.

Despite this deliberately circumscribed mandate (I lost count of the number of times during my tenure as an AHRQ medical officer from 2006-2010 that I was told, "We don't make guidelines. We make evidence that other groups use to make guidelines"), the passage of the Affordable Care Act made AHRQ a target again in 2012, when a House appropriations subcommittee voted to zero out its budget again. AHRQ survived that episode, only to be zeroed out by the House once again in 2015, when the danger to the agency's survival seemed real enough that former Senate majority leader Bill Frist and former CMS director Gail Wilensky both penned op-eds urging their Republican colleagues to reconsider - which they eventually did.

Ironically, the need for AHRQ's work has never been greater. The proliferation of clinical practice guidelines of varying quality and conflicting recommendations has led to calls to systematically evaluate guidelines for their impact on patient outcomes. AHRQ would be a natural place for this evaluation to occur, as its National Guideline Clearinghouse already summarizes and synthesizes guidelines that meet certain evidence-based development criteria. But funding to maintain the NGC will run out a little more than 4 months from now, and there seems to be little hope of rescue.

In the meantime, the Trump Administration has proposed dissolving AHRQ as an independent agency in the next fiscal year and transferring its current functions into a new institute within the NIH, with a 21 percent budget cut from 2017. Although such an arrangement has both potential pros and cons, as a previous AHRQ director observed, it's hard to imagine that the shrunken agency would not be marginalized and lost amid NIH's biomedical research behemoth.

Why do I care? Why should you? You need not be ill enough to be hospitalized or care about practice guidelines to suffer if AHRQ is eliminated for good. Not only does it produce several important tools and resources for primary care practice, but it disseminates and implements evidence about what works to improve health, through its National Center for Excellence in Primary Care Research. AHRQ supports research that generates evidence about "effective models of care, patient- and family-centered care, shared decision making, quality improvement, and health information technology." This is research and evidence that no one, healthy or ill, can afford to lose. Academy Health maintains an advocacy toolkit for use by any person or organization who wants to help #SaveAHRQ from becoming a casualty of ignorance, indifference, and/or conflicts of interest. I hope that I have persuaded you to join the fight.

Thursday, March 1, 2018

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 2016 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.

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This post first appeared on Common Sense Family Doctor on October 6, 2016.

Friday, February 23, 2018

Enthusiasm shouldn't outweigh evidence on vitamin D

In 2005, my colleague Dr. Mark Ebell, also a family physician and medical editor, authored an editorial on the rise and fall of vitamin E, subtitled "lessons in patient-oriented evidence." Observational studies had associated lower vitamin E levels with coronary artery disease, leading many physicians to recommend that patients take vitamin E supplements for cardiovascular protection. 19 randomized, controlled trials later, the verdict was in: vitamin E supplementation actually increased all-cause deaths. Dr. Ebell viewed the "vitamin E saga" as an instructive cautionary tale:

It is important to remember that biochemical theory does not equal clinical benefit. Improvements in disease-oriented outcomes, such as free-radical activity, are no substitute for patient-oriented outcomes, such as all-cause mortality. Sometimes our enthusiasm for unproven treatments may harm our patients.


Physicians and patients, it turns out, were already turning to testing and treatment with another vitamin that was a marker of chronic health conditions in observational studies: vitamin D. Between 2000 and 2010, the volume of serum 25-hydroxyvitamin D levels in Medicare patients increased 83-fold, and by 2014, 4 out of 10 adults 70 years or older reported taking a daily vitamin D supplement of at least 1,000 IU, and nearly 7 percent of adults over 60 were taking more than 4,000 IUs daily, a level that the National Academy of Medicine considers to be potentially toxic.

Unfortunately, the vitamin D saga has much in common with the vitamin E saga. According to a review article in the February 15th issue of American Family Physician by Drs. Michael LeFevre and Nicholas LeFevre, vitamin D supplementation in community-dwelling adults has not demonstrated any benefits for ischemic heart disease, cerebrovascular disease, or cancer in clinical trials. The U.S. Preventive Services Task Force and the American Academy of Family Physicians concluded that there is inadequate evidence that supplements improve psychosocial or physical functioning in persons with lower vitamin D levels.

In an accompanying editorial, I argued that the harms of routine screening and supplementation with vitamin D outweigh the benefits, especially when the costs of testing (more than $300 million annually in Medicare alone) are considered:

It is time for clinicians and patients to curb our enthusiasm for vitamin D screening and supplementation. Strategies to decrease unnecessary testing could include distributing the patient handout on vitamin D tests created by Consumer Reports for the Choosing Wisely campaign and implementing clinical decision support for ordering laboratory tests. ... Family physicians should also counsel patients on the recommended dietary allowance for vitamin D (600 IU per day in adults 70 years and younger, and 800 IU per day in adults older than 70 years), and discourage most patients from using supplements, especially in dosages near or above the tolerable upper limit of 4,000 IU per day.


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This post first appeared on the AFP Community Blog.

Tuesday, February 13, 2018

Why I teach health policy and advocacy in medical school

From 2009 to 2012, I directed the graduate course "Fundamentals of Clinical Preventive Medicine" at Johns Hopkins University's Bloomberg School of Public Health. It was a required course for Hopkins preventive medicine residents, and also usually attracted other Master's level public health students and undergraduates with a strong interest in medicine. The class size was 15 to 25 students. In that setting, with a small group who generally believed that the material was important, if my teaching was inspired and the presentation compelling, I could reasonably hope for positive feedback from nearly every student.

In every academic year since (after returning to the family medicine faculty at Georgetown), my primary teaching responsibility has been co-directing a mandatory course in population health, health policy and advocacy for about 200 first-year medical students. I am proud that student ratings for the course overall and the course directors in particular have improved every year, though I suspect that at least some of this improvement is the result of more students being already aware of the health impacts of national, state, and local policy decisions, even those that ostensibly have nothing to do with medical practice.

A case in point is the U.S. Department of Agriculture's recent proposal to save money by replacing food stamps with food boxes containing nonperishable food items for poor families that qualify for financial assistance. Historically, Native American tribes who were forced to live on reservations, cut off from natural water and food sources, were supplied with boxes of dry and canned foods high in sodium and calories and low in nutritional value. The result was a catastrophic rise in obesity, hypertension and type 2 diabetes in this population. The USDA eventually modified the program to incorporate fresh produce, which begs the question of why anyone should take seriously this new proposal whose end result would be making the national obesity epidemic many times worse than it already is.

But back to my course. Every year, a few students complain in their evaluations that what we teach just isn't relevant to their future careers, or more commonly, that the content is "too political." This is a tough criticism for me to stomach, as we go to great lengths to present a broad spectrum of perspectives on health and the health care - what the "system" does well and where it fails by every conceivable standard. To me, that U.S. life expectancy has declined for two years in row means that business as usual just isn't cutting it. Yes, solutions to these problems invariably involve advocacy and political choices. And it's perfectly fine for my students to debate the relative contributions of various determinants of health, and in particular rising economic inequality, in this unfolding disaster. It is not okay for a student to turn a blind eye to health policy and think that everything will turn out fine as long as he or she is accepted into a residency program in a reliably high-paying subspecialty of choice.

So kudos to Faiz Kidwai, a second-year medical student who wrote a thoughtful editorial for STAT about why medical schools shouldn't divorce education from politics. One particularly eloquent point hit home for me:

A class on health policy cannot replace classes on pathology or pharmacology, nor should it. But without making policy and public health a major component of medical education instead of a side interest to be pursued on students’ own time, medical schools will continue to churn out exceptionally talented physicians who are exceptionally ill-prepared to deal with the medical bureaucracy and byzantine health care policies that hit them the moment they begin to care for patients.

Another piece that recently hit home, by pediatrician and former CMS Administrator Don Berwick (whose selected previous writings have long had a place in my course), was "Moral choices for today's physician," in JAMA. Berwick argued that for physicians "to try and avoid the political fray through silence is impossible, because silence is now political." Berwick obviously has no love for the Trump Administration, but what he wrote could apply to any clinician - conservative, libertarian or liberal, Republican or Democrat, or none of the above:

Healers cannot deny that leaving refugees at our gates unwanted, or children unfed, or families unhoused, or basic medical care uncovered, or relying on conflict, rather than compassion, are health problems. ... The work of a physician as healer cannot stop at the door of an office, the threshold of an operating room, or the front gate of a hospital. The rescue of a society and the restoration of a political ethos that remembers to heal have become the physician's jobs, too. Professional silence in the face of social injustice is wrong.

These quotes from Kidwai and Berwick explain why I continue to be energized year after year to teach students who are at times excited, and at times indifferent to health policy and advocacy. I know that most didn't come to medical school to learn about politics or public health. But it's my job to make sure that my students don't graduate ill-prepared or professionally silent in the face of human suffering.

Wednesday, February 7, 2018

The changing of the guard at American Family Physician

The February 1 issue of AFP marked the first time since 1988 that a family physician other than Dr. Jay Siwek was serving as the journal's editor-in-chief. Dr. Siwek, who bade farewell to readers in a poignant, memory-filled editorial in the January 15 issue, will stay on as editor emeritus. This month, Dr. Siwek introduced his successor, longtime associate editor Dr. Sumi Makkar Sexton. You can read about Dr. Sexton's extensive qualifications and experience in Dr. Siwek's latest piece, and learn about her plans for the future of AFP, which include making journal content more usable at the point of care, in her introductory editorial.

It has been my good fortune to know Jay and Sumi for the past 14 years, since I arrived at Georgetown University School of Medicine as AFP's medical editing fellow in the summer of 2004. Both played critical roles in my development as a family physician and medical editor, during and after my one-year fellowship. It was Jay, in his previous capacity as Chair of Georgetown's Department of Family Medicine, who hired me as a junior faculty member and supported each of my subsequent promotions to assistant, associate, and full professor. After I left the department for several years to work as a medical officer at the Agency for Healthcare Research and Quality and earn a master's degree in public health, it was Jay who convinced me to return and deploy my new skills to direct the department's health policy fellowship and eventually take on other leadership and teaching positions in population health.

On the other hand, it was Sumi, as the editor of Tips from Other Journals (an AFP department that ended in 2013) who continued to hone my writing and evidence-based medicine skills for years after my fellowship ended. Under her supervision, from 2005 to 2010 I wrote more than 60 summaries of primary care-relevant research studies for AFP. And after my first post-fellowship clinical position unexpectedly fell through, it was Sumi who hired me to see patients at her thriving practice, Premier Primary Care Physicians, which was an early adopter of innovations such as electronic medical records and advanced-access scheduling.

As AFP's new deputy editor, I have worked closely with Sumi and Jay for the past several months to support their changing of the guard at editor-in-chief, and I look forward to many more years of collaborating with them both. Moving on from Dr. Siwek to Dr. Sexton is an important transition, but the best-read journal in primary care won't miss a beat.

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This post first appeared on the AFP Community Blog.

Monday, January 29, 2018

Should a mobile app be your next prescription?

Earlier this month, a blog post from Dr. Jennifer Middleton highlighted recent content in American Family Physician that can help family physicians support resolutions to make healthy lifestyle changes. Increasingly, I also recommend that my patients consider using smartphone apps to give them extra motivation and allow them to chart their progress toward personal goals. The latest in a series of articles on medical apps in FPM reviewed four mobile apps designed to encourage healthy habits, including healthy eating, physical fitness, substituting water for sugary drinks, and taking prescribed medications. Although the evidence that apps provide greater benefits than usual care remains limited (a randomized trial of a fitness app reviewed previously by FPM found no statistical differences in weight loss, blood pressure, or satisfaction), "digital therapy" is now being used to promote wellness and improve self-management of chronic conditions as diverse as substance use disorder and atrial fibrillation.

A draft technical brief issued by the Agency for Healthcare Research and Quality reviewed the evidence on health outcomes for 11 commercially available mobile apps for self-management of type 1 or type 2 diabetes. For five apps, studies demonstrated clinically significant improvements in hemoglobin A1c levels at 3 to 12 months. However, no studies showed improvements in quality of life, blood pressure, weight, or body mass index.

Regarding apps for clinicians, the U.S. Food and Drug Administration (FDA) clarified in a recent guidance document how it intends to treat digital decision support software going forward. Software that functions as a diagnostic device will be regulated, while digital tools that merely assist clinicians in making diagnoses will be excluded from regulation and "cleared" for use. On its website, the FDA provides a list of examples of mobile medical apps that it has cleared or approved to date.

Whether mobile apps will complement traditional prevention, diagnosis and treatment in primary care, or replace them in some cases, remains to be seen. Health professionals: do you routinely prescribe apps to your patients, or do you expect to do so in the future? Everyone else: has your doctor suggested using an app to improve your health, and if so, did you find it helpful?

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This post first appeared on the AFP Community Blog.

Wednesday, January 24, 2018

A simple, reassuring test for heart murmurs in children

It happens all the time to family physicians at well-child visits: we listen to the heart with our stethoscopes, hear a murmur that wasn't documented as being there before, and wonder if it's necessary to obtain an echocardiogram and/or refer the child to a cardiologist. A previous article in American Family Physician by Drs. Jennifer Frank and Kathryn Jacobe listed several "red flags" that make a serious cause more likely:

- Holosystolic or diastolic murmur
- Grade 3 or higher murmur
- Harsh quality
- Abnormal S2
- Maximum murmur intensity at the upper left sternal border
- A systolic click
- Increased intensity when the patient stands

The authors also recommended referral to a pediatric cardiologist if historical findings suggest structural heart disease, if cardiac symptoms are present, or if the family physician is unable to identify a specific innocent (physiologic) murmur. Even though innocent murmurs share several characteristics, some of these are subjective or difficult to distinguish, and the fear of missing a heart disease diagnosis may still lead to unnecessary referrals.

In an important research study published in the November/December issue of Annals of Family Medicine, Dr. Bruno Lefort and colleagues prospectively evaluated 194 consecutive children aged 2 or older referred for heart murmur evaluations at 2 French medical centers to test the hypothesis that a simple, objective clinical test could exclude serious cardiac conditions. 100 children had a murmur that was present when lying down but completely disappeared when they stood up, per the pediatric cardiologists' examinations. Of these children, only two had an abnormal echocardiogram result, and only one required further evaluation and treatment for a non-trivial problem (an atrial septal defect that required percutaneous closure). The authors calculated that the complete disappearance of the heart murmur on standing had a positive predictive value of 98%, specificity of 93%, and sensitivity of 60% for innocent murmurs in children. This "clinical standing test" had superior predictive value compared to features of physiologic murmurs traditionally taught in medical school, such as change in murmur intensity, location, or timing.

The investigators concluded that the complete disappearance of the murmur on standing may be a valuable test to rule out serious heart murmurs in children and prevent unnecessary imaging and referrals. They recommended that a larger study confirm the value of this test and its reproducibility between pediatric cardiologists and primary care physicians (whose assessments were not evaluated in this study).

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

Wednesday, January 17, 2018

There are few parachute-like practices in family medicine

I try my best to practice evidence-based medicine on a daily basis. When I know that the test or intervention that I am recommending for my patient is based on expert opinion rather than reliable data on patient-oriented outcomes that matter, I invariably make a point of saying so. It has been my position for several years that despite the impressive effectiveness of newer antiviral medications for hepatitis C at producing a sustained virologic response (SVR), there are still not enough data to be certain that SVR always represents a "cure," and therefore not enough data to warrant age cohort-based screening of adults without known risk factors for the infection. In a recent Medscape commentary, I went one step further, mentioning a famous 2003 BMJ paper on "Parachute use to prevent death and major trauma related to gravitational challenge," which asserted that the health benefits of some interventions are so glaringly obvious that, like parachutes, they do not need to be evaluated in randomized, controlled trials (RCTs). Screening for hepatitis C, I contended, should not be considered a "parachute" for clinical research purposes. As some colleagues and I argued a few years ago, a randomized trial of screening versus usual care would not only be ethical, but logistically feasible and well worth the investment.

In an ingenious analysis published today in CMAJ Open, a team of researchers that included my friend, colleague, and prolific tweeter Dr. Vinay Prasad used Google Scholar to identify articles that cited the BMJ parachute paper to argue that a medical practice was analogous to a parachute - or in other words, so obviously beneficial that RCTs were not needed. The team then searched the literature for previous or subsequent RCTs that tested the practice in question. Of the 35 practices, 22 have, in fact, been tested in one or more RCTs. Guess how many of these practices ended up being backed up by trials that showed a statistically significant benefit? Only 6 out of 22, barely edging out the 5 "obviously beneficial" practices that were actually found to be ineffective in RCTs (the remaining 11 had mixed results or halted or ongoing trials). The investigators concluded: "Most parachute analogies in medicine are inappropriate, incorrect or misused."

Although some interventions that were refuted by RCTs lie outside of the scope of family medicine, I took note of two that not only sounded familiar (because I had once been told by an "expert" that they were true), but where I could personally make an impact on decreasing ineffective, potentially harmful care. Compared to medical therapy, stenting for renal artery stenosis does not reduce cardiovascular events. Compared to standard hemoglobin A1c targets, tighter control of blood glucose levels in persons with type 2 diabetes does not reduce cardiovascular deaths. In particular, I have inherited several adult patients with type 2 diabetes whose previous physicians tried to push their hemoglobin A1c levels to 6.5% or lower by adding expensive second or third drugs that increased their risk for hypoglycemia, based on the faulty assumption (parachute!) that these would prevent a heart attack or stroke somewhere down the line. But I practice evidence-based medicine, not parachute-based medicine. I discontinued those unnecessary medications to prevent further injury to these patients or their pocketbooks.

Monday, January 8, 2018

Does convenience outweigh continuity of care?

Several years ago, after leaving my scientific position at AHRQ and feeling that my patient care skills had become rusty, I took a part-time job as a staff physician at a rapidly growing chain of urgent care centers. I thought that urgent care's relatively limited scope of practice would ease my transition back into the clinic, and though the pace was often intense, I quickly became comfortable sewing up lacerations, draining abscesses, diagnosing fractures, and fishing various objects out of ears and noses. All in all, it was a rewarding experience: my physician colleagues were friendly and experienced, the support staff skilled and professional, and since we stayed open from from 7 AM to 10 PM every day of the year, our walk-in patients were generally grateful to be seen.

After about a year of this work, I decided to return to academic medicine. During my interview, I mentioned to the then-Department Chair that I had been working in urgent care. He visibly grimaced, then said something about urgent care centers "skimming the cream" of primary care and leaving full-service family practices with the more complex and less lucrative types of visits. And I couldn't really disagree. If there's one axiom at the heart of family medicine, it's the importance of continuity of care - meaning, whether you feel sick or well, seeing a doctor who knows you will make it more likely you will get the care you need. A systematic review in the Journal of Family Practice and another review in the Journal of Evaluation in Clinical Practice both concluded that increased continuity was associated with higher quality care, better outcomes, and higher patient satisfaction.

The problem with prioritizing continuity of care is ensuring access. My current practice is open until 8 PM two evenings per week and, for a few years, we also saw patients on Saturday mornings. But none of us really like to work on Saturdays, and we recently learned that of all the primary care practices in our health system, we are the only ones who have even been open on that day. Further, the nature of an academic practice is that my colleagues and I are only each at the office a day or two per week, further limiting the ability of patients to see the same doctor every time. Can continuity of care be said to have the same value if it's only with the same office, rather than the same person? It's a question that needs answering, as a study from the Robert Graham Center found that an increasing proportion of Americans identify an office or facility, rather than an individual clinician, as their usual source of health care.

Finally, retail health clinics (think CVS's Minute Clinics), like urgent care centers, have emerged and prospered as a response to deficiencies in primary care access, but handle a more limited range of acute problems and are staffed by nurse practitioners rather than physicians. On one hand, retail clinics may disrupt continuity of care, but on certain measures of quality, such as antibiotic prescribing for respiratory infections, they are more likely to adhere to national guidelines. And even a respected health policy researcher such as Dr. Aaron E. Carroll, a professor of pediatrics at Indiana University, admitted that he would rather take his child to a retail clinic for a sore throat than deal with the hassle of getting a same-day appointment with their usual physician. So much for continuity of care and the patient-centered medical home that physician groups have been advocating for the past decade as the solution to excessive health spending and mediocre outcomes! Or can these concepts coexist with the convenience of urgent and retail health care?

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This post originally appeared on Common Sense Family Doctor on May 23, 2016.