Saturday, July 21, 2018

A "well-regulated militia": can doctors prevent gun violence?

Family physicians have long recognized that gun violence is a national public health epidemic. In 2015, a coalition of nine medical, public health, and legal organizations, including the American Academy of Family Physicians and the American Bar Association, endorsed several specific recommendations for preventing firearm-related injury and death. These measures included universal criminal background checks for all firearm purchases; educating patients about gun safety and intervening in those at risk of self-harm or harm to others; improving access to mental health care; regulating civilian use of firearms with large capacity magazines; and supporting more research on evidence-based policies to prevent gun violence. A 2014 editorial in American Family Physician also reviewed the role of primary care clinicians in counseling about gun safety based on the best available evidence.

After the February massacre of 17 people at Marjory Stoneman Douglas High School in Parkland, Florida by a 19 year-old former student wielding a legally purchased semiautomatic AR-15-style rifle, the medical editors of AFP felt that we needed to do more to empower clinicians. Surely, when the Founding Fathers endorsed the necessity of a "well-regulated Militia" in the Second Amendment to the U.S. Constitution, they did not envision mentally disturbed teenagers toting weapons with enough firepower to overwhelm entire regiments of Minutemen.

In a special editorial recently published online ahead of print, Dr. Sumi Sexton, I, and the AFP medical editors argue that family medicine's emphasis on care of the whole person creates a duty to "confront the epidemic of violence by persons using guns." We review the evidence of the effects of firearm regulations, mental health counseling, and active shooter training on gun safety and violence. Unfortunately, evidence for many interventions remains limited:

A 2018 RAND review of U.S. studies on gun policy published since 2003 concluded that child-access prevention laws (e.g., safe gun storage) reduce self-inflicted and unintentional firearm deaths and nonfatal injuries among youth, and may reduce unintentional firearm injuries among adults. The review also found moderate evidence that laws requiring background checks and prohibiting firearm purchases by individuals with mental illness reduce violent crime and deaths. In contrast, state stand-your-ground laws are associated with increased homicide rates. There was insufficient evidence to determine whether any laws prevent mass shootings. 

Notably, almost two-thirds of the 36,000 firearm-related deaths in the U.S. each year are suicides, leading to our recommendation that "strategies to mitigate firearm suicides should include depression screening and nonjudgmentally asking anyone with depression whether they have a gun in the home." Useful clinical tools include the FIGHTS screening tool for adolescent firearm carrying, the SAD PERSONS suicide risk assessment scale, and the Violence Screening and Assessment of Needs tool for assessing risk of violence in military veterans.

Finally, we encourage clinicians to address the epidemic by making their voices heard in community meetings, online forums, and local publications and communicating with elected state and federal officials to advocate for funding research to study ways to reduce gun violence: "Whether it is speaking up in clinical settings, within our community, or with our elected officials, our voices can make a meaningful difference for our patients, our communities, and our nation."

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This post was first published on the AFP Community Blog.

Thursday, July 5, 2018

For lower respiratory infections, procalcitonin-guided therapy disappoints

American Family Physician has supported the Choosing Wisely campaign in several ways since it began in 2012, from maintaining a searchable database of primary care-relevant recommendations, to including tables of best practices in clinical review articles, to publishing an occasional editorial containing suggestions of how to implement it into practice. Although Choosing Wisely remains very much a work in progress, staff at the American Board of Internal Medicine Foundation recently identified a "Top 12" list of recommendations that are successfully reducing overuse in health systems across the United States. Leading that list is antibiotics for patients with upper respiratory tract infections.

A more challenging task is deciding which patients with lower respiratory tract infections need antibiotics - distinguishing acute bronchitis from chronic obstructive pulmonary disease exacerbations or community-acquired pneumonia. Although clinical decision tools exist, their usefulness in outpatient settings is limited. A Cochrane for Clinicians in the July 1 issue reviewed the benefits and harms of procalcitonin-guided antibiotic therapy compared with routine care for acute respiratory infections on mortality, treatment failure, duration of antibiotic exposure, and antibiotic-related adverse effects. In a meta-analysis of 26 randomized, controlled trials (n = 6708), patients receiving procalcitonin-guided therapy had lower 30-day all-cause mortality (NNT=71) across all settings, but no difference in primary care settings. Rates of treatment failure were similar. Total duration of antibiotic exposure was 2.4 days lower in the procalcitonin group, corresponding to a lower percentage of patients in the procalcitonin group experiencing antibiotic-related adverse effects (16.3% vs. 22.1% in the control group).

Should this evidence lead family and emergency medicine physicians to adopt procalcitonin-guided therapy algorithms to improve antibiotic stewardship for acute respiratory infections? Limitations of the Cochrane review are worth noting: the studies were relatively small (mean 258 participants); most were in Europe rather than in the U.S.; and most were in emergency department rather than primary care settings. After the review's publication, Dr. D.T. Huang and colleagues reported the results of a large (n=1656) RCT in 14 U.S. hospitals that compared procalcitonin-guided antibiotic therapy with usual care for patients with lower respiratory tract infections in the emergency department and on the inpatient service, if applicable (782 patients were hospitalized). In contrast to the Cochrane review, the investigators found no significant differences between the groups in duration of antibiotic exposure or adverse outcomes. They concluded that the addition of procalcitonin results did not significantly improve antibiotic decision-making or patient outcomes.

A take-home message from the Cochrane review and the recent U.S. trial is that the effects of procalcitonin measurement on diagnosis and management of acute respiratory infections depend on the clinical setting, patient characteristics, and preexisting adherence of clinicians to high-value care guidelines for antibiotic prescribing. This test may be helpful in certain cases, but probably should not be used routinely.

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This post first appeared on the AFP Community Blog.

Saturday, June 30, 2018

Why do-it-yourself blood tests are a bad idea

It sounded too good to be true when I first heard about Theranos, a company that promised to revolutionize medical testing by making it possible to perform dozens of tests on a single drop of blood, rather than the several tubes that would typically be required. And that wasn't all. Former Theranos CEO Elizabeth Holmes, a Stanford dropout and media magnet whose wardrobe seemed to consist solely of all-black outfits, promised to empower patients by giving them the ability to order their own tests, rather than needing to ask a doctor to do so. As described in John Carreyrou's new book, Bad Blood: Secrets and Lies in a Silicon Valley Startup, Holmes took Silicon Valley's "fake it till you make it" philosophy one step too far: she never stopped faking it.

Even if the technology Theranos claimed to have developed had actually existed, FiveThirtyEight reporter Katherine Hobson pointed out that routine blood testing in healthy people has numerous downsides that Holmes never mentioned, including poor predictive value, false positives, and overdiagnosis. And even if a test accurately diagnoses a risk factor such as high blood sugar levels, a United Kingdom study found that persons invited to diabetes screening were no more likely than controls to quit smoking, reduce alcohol consumption, or become more physically active.

Yet the fascination with do-it-yourself medical testing continues. A 2016 New York Times article led with the story of Kristi Wood, a 49 year-old woman who was experiencing fatigue and cognitive problems. Rather than seeing a doctor, she turned to a direct-to-consumer testing service which told her that her vitamin D levels were too high, apparently because she had been overdosing on vitamin D supplements. Once she reduced her supplement dose, "she almost immediately felt better." She credited the testing service for making this (obvious) diagnosis and now has a bunch of blood tests repeated every 4 months.

Although Ms. Wood would do well to read Ms. Hobson's FiveThirty Eight article and my American Family Physician editorial on the lack of evidence supporting vitamin D screening and supplementation, at least the results were clear-cut and actionable. That isn't true for most abnormal results, which require clinical context, careful interpretation, and sometimes additional testing, to distinguish a false from a true positive. A normal laboratory range means that the vast majority - but not all - of healthy people's results will be found between these values. Statistically, 1 in every 20 tests is likely to be abnormal simply by chance. Since blood tests are usually ordered in panels, I estimate that about half of my own patients' result reports have at least one item flagged, with nearly all of them being false positives. In the absence of an informed explanation and reassurance from a health professional who spent 4 years in medical school, 3 years in residency, and 14 years in practice, these results could be alarming and/or trigger unnecessary action like starting a potentially harmful testosterone supplement, as did another do-it-yourself testing patient in the New York Times article.

On a related note, a blog post by family physician colleague Jennifer Middleton raised some good questions about do-it-yourself screening for ovarian cancer. For $295, a woman concerned about her ovarian cancer risk can request on a commercial website that an instructional kit be shipped directly to her home. According to the website, the test is intended to be "routine." But there's absolutely nothing routine about it. The ongoing randomized trial evaluating the test's effectiveness hasn't yet determined if it causes more good than harm. For women at low risk, the American College of Obstetricians and Gynecologists and the Society of Gynecologic Oncology recommend against being tested. The moral of this story: if you aren't feeling well or worry about getting sick in the future, don't seek out do-it-yourself testing. Don't be duped by companies such as Life Line Screening. Make an appointment to see a family doctor instead.

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This post first appeared on Common Sense Family Doctor on June 8, 2016.

Friday, June 22, 2018

Safe summer travel tips for doctors and patients

As children finish school and the summer vacation season gets underway, regular or occasional readers of American Family Physician should know about all of the free resources available for prevention and management of medical conditions in travelers, the best of which are included in our Travel Medicine collection. Brush up on key components of the pretravel consultation for international travelers, including vaccination updates and malaria prophylaxis. Patients who plan to play in the water can be provided with recommendations for preventing recreational waterborne illnesses and tips for avoiding neurologic complications of scuba diving or surfing-related injuries. And anyone can learn to recognize and prevent heat-related illness.

Depending on the vacation destination, clinicians may need to counsel patients on risk factors and symptoms of altitude illness (which includes acute mountain sickness and less commonly, cerebral and pulmonary edema) or emerging vector-borne diseases such as West Nile virus, Dengue, Chikungunya, and, of course, Zika virus. A 2015 editorial reviewed advice for protection against mosquitoes and ticks that carry these and other diseases (such as Lyme disease, which doesn't always present with a classic "bull's eye" rash).

And whether your own summer plans include going on a medical humanitarian mission or just relaxing at your favorite fishing hole, AFP has you covered. Clinicians who plan to spend time near any body of water - including the backyard swimming pool - should consider familiarizing themselves with the essentials of prevention and treatment of drowning.

You can access patient education handouts on all of these activities and more from AFP and FamilyDoctor.org at home or on the go. Stay safe, and have fun!

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

Thursday, June 14, 2018

Should divided guideline panels publish minority views?

When I give presentations on the guideline development process of the U.S. Preventive Services Task Force, a question I'm often asked is how many votes of the 16-member panel are needed to approve a recommendation statement. The answer is a two-thirds majority, with a minimum of 10 votes in favor in case of absences or conflict-of-interest recusals. In reality, though, during the four years I attended Task Force meetings, I can't recall a statement passing without overwhelming (15-1 or 14-2) or, more commonly, unanimous support. The feeling among members seemed to be that the lack of a strong consensus on a recommendation suggested that there was something missing about the way they were approaching the evidence.

The Supreme Court of the United States always provides justices in the minority the option to write a dissenting opinion for the record, whose legal reasoning sometimes informs future decisions. In contrast, minority opinions rarely accompany medical guidelines. In an unusual case, after the JNC 8 committee published its guideline for management of high blood pressure in adults, five former panel members who disagreed with the guideline's target systolic blood pressure of 150 mm Hg in persons aged 60 years or older formally published their minority view. Even then, this dissenting report appeared some time later, in a different journal than the original guideline.

In a 2016 article in Mayo Clinic Proceedings, Dr. Daniel Musher, a professor of medicine and infectious diseases at Baylor College of Medicine, made the case for regularly publishing dissenting opinions in medical guidelines. He cited his experience as a member of the Advisory Committee on Immunization Practices (ACIP) working group that recommended the use of 13-valent pneumococcal conjugate vaccine (PCV13) in adults 65 years and older, despite his strong disagreement. As is standard process for the ACIP and most guideline panels, he did not have the opportunity to voice his dissenting opinion and rationale in the text of the guideline. His view did not see publication until more than 18 months later, after the new recommendation had been largely implemented into clinical practice. Dr. Musher wrote:

The perceived problems with publishing dissenting opinions are that this practice would (1) cause confusion within the medical community and (2) diminish the force of the recommendations. Regarding the former, the current situation, in which dissent is not included but in which subsequent articles dispute the formal recommendations or different professional societies publish divergent guidelines, is amply confusing—witness the differing guidelines for screening for breast, lung, or prostate cancer. It defies reason to believe that every member of the American Cancer Society's committee thought that breast cancer screening should begin at age 40 years, whereas all who participated in the US Preventive Services Task Force agreed that screening should wait until age 50 years. Inclusion of dissenting opinions in the final version of published guidelines may well have reduced polarization and confusion by bringing dissent into the recommendation process.


I can't testify to the presence or absence of internal discord on the panels that produced the 2015 ACS or 2016 USPSTF guidelines on breast cancer screening, but my best recollection of the July 2008 meeting where the USPSTF first voted to recommend routine mammography starting at age 50 is that, contrary to Dr. Musher's suggestion, there was no minority view. When there is one, I agree with him and the Slow Medicine bloggers that making a forum available to describe conflicts that occurred within the guideline narrative (including all of the various options that were considered and later discarded) could reduce the intensity of second-guessing and better inform clinicians about the guideline's nuances and potential limitations. Now that I have had experience as a voting member of guideline panels on atrial fibrillation and cerumen impaction, though, I wonder if the explication of dissents belongs in the guideline itself, rather than as a separate stand-alone perspective.

Would the airing of minority views within medical guidelines provide useful perspectives for patients, clinicians, or policymakers, or are conflicting guidelines from different organizations already confusing enough as it is?

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A slightly different version of this post first appeared on Common Sense Family Doctor on June 24, 2016.

Friday, June 8, 2018

Health Systems Science - population health by another name?

In my book review of this textbook in the June 2018 issue of Family Medicine, I took the opportunity to comment not only on the strengths and weaknesses of the text, but the broader movement to incorporate population health concepts into medical education. Here are some excerpts:

Since Abraham Flexner published his report on the state of American and Canadian medical education in 1910, the pillars of medical education have been the basic and clinical sciences. Although in the past century both pillars have experienced dramatic changes, this educational structure has remained the same. Increasingly, however, medical educators have recognized that mastery of the basic and clinical sciences alone is insufficient preparation for clinical practice. In the early 20th century, there were no health maintenance organizations, continuous quality improvement processes, clinical informatics, or population health management—all concepts that are essential for today’s physicians to know.

In 2013, the American Medical Association formed the Accelerating Change in Medical Education Consortium, a group of 11 medical schools tasked with developing innovative curricula to encompass the additional knowledge, attitudes, and skills necessary to prepare students and residents for 21st-century practice. Although my home institution was not part of the consortium, as director of a required first-year course in health disparities and health policy, and as advisor for our population health scholarly track, I have followed its work with great interest. In a series of papers in
Academic Medicine, consortium leaders proposed adding a third pillar of medical education called “health systems science. ...

A concluding chapter suggests structural reforms to make it easier to integrate this content into medical education, such as preferentially admitting students with well-developed teamwork skills, teaching with simulation and in community-based settings, and involving students in real-life practice improvement and health care delivery transformation.

Whether or not this collection of topics truly constitutes a new “science” rather than a blending of existing fields is debatable, but it is certain that in the future, more physicians will be caring for populations within health systems rather than individual patients one at a time.

Monday, June 4, 2018

Curiosity and family medicine

I have never been invited to give a commencement address. The closest I came was my own high school graduation, when I was the unofficial valedictorian. Since my school did not have a tradition of the highest-ranked student addressing the class on graduation day, though, I didn't get the chance. Our commencement speaker, a television news anchor and former graduate, delivered a great speech that I still remember more vividly than the addresses by bigger names at my college, medical school, and public health graduation ceremonies.

Obviously, I have not had the good fortune of hearing Dr. Atul Gawande speak at a commencement. (Atul, if you're reading this, Georgetown University School of Medicine would be delighted to have you address a future graduating class.) Instead, three days ago he delivered a profoundly insightful address at UCLA that has been going viral on social media. It's worth reading in its entirety, but the point he drove home is that in a time when discrimination and unequal treatment have become as socially acceptable in some circles as in the pre-American Civil Rights era, it remains the sacred calling of medicine to recognize that all lives have equal worth, and that doctors and patients share a "common core of humanity":

Without being open to their humanity, it is impossible to provide good care to people—to insure, for instance, that you’ve given them enough anesthetic before doing a procedure. To see their humanity, you must put yourself in their shoes. That requires a willingness to ask people what it’s like in those shoes. It requires curiosity about others and the world beyond your boarding zone.

Curiosity. If medicine were only about the science of the human body in health and disease, I would never have become a family doctor. Fortunately, that isn't so; in fact, after years of practice I often feel that the science has become incidental to doctoring. Yes, the knowledge base for medicine is always expanding, but as I tell students, regardless of what field of medicine you choose, the technical aspects eventually become routine. Even emergency and family physicians, who encounter the largest variety of symptoms and diagnoses, get acclimated to bread-and-butter encounters: back pain, chest pain, respiratory infections, the management of common chronic conditions under or out of control.

What keeps my work meaningful is learning about the details of my patients' lives that aren't strictly medical. As Dr. Faith Fitzgerald wrote in a classic article nearly two decades ago:

What does curiosity have to do with the humanistic practice of medicine? ... I believe that it is curiosity that converts strangers (the objects of analysis) into people we can empathize with. To participate in the feelings and ideas of one’s patients—to empathize—one must be curious enough to know the patients: their characters, cultures, spiritual and physical responses, hopes, past, and social surrounds. Truly curious people go beyond science into art, history, literature, and language as part of the practice of medicine.

Then, as now, pressures to be efficient in evaluating patients threatened to suppress natural curiosity. Dr. Fitzgerald bemoaned an educational system that produces medical students who were too un-curious to ask a patient how he had been bitten in the groin by a snake ("How could one not ask?"), or to question the "BKA (below-knee amputation) times two" description in the chart of a patient who obviously had legs. Finally, she mentioned one patient who had been deemed by the housestaff to be the "dullest" (least interesting) on the service: an old woman who (upon further inquiry) turned out to have survived the sinking of the Titanic.

2018 graduates, I wish that more of you were entering family medicine, but regardless of the medical specialty you've chosen, don't ever stop being curious - especially about the most "difficult" patients and the ones you least understand. It is that skill, more than any other, that will sustain you in your work and that separates the merely competent doctors from the truly great ones.

Monday, May 28, 2018

Requiem for the National Guideline Clearinghouse

Absent a last-minute, lifesaving intervention, after 20 years of reviewing and summarizing clinical practice guidelines in a continuously updated database, the Agency for Healthcare Research and Quality's National Guideline Clearinghouse (NGC) will go offline on July 16th. Prior to its untimely death due to budget cuts, the NGC not only served as a one-of-a-kind online resource for clinicians, researchers, and educators, but raised the bar on guideline development, recently introducing the National Guideline Clearinghouse Extent Adherence to Trustworthy Standards (NEATS) assessment tool to evaluate how well guidelines meet the National Academy of Medicine's (formerly Institute of Medicine) standards for trustworthiness.

To be sure, some will not mourn the deaths of the NGC and its companion online resource, the National Quality Measures Clearinghouse (NQMC). Front-line clinicians have viewed guidelines with increasing suspicion as recommendations with tenuous links to patient-oriented outcomes that matter (e.g., lower hemoglobin A1c targets) have been unwisely converted into formal performance measures that are linked to physician compensation. The Performance Measurement Committee of the American College of Physicians recently evaluated the validity of 86 primary care-relevant measures included in the 2017 Medicare Merit-based Incentive Payment System (MIPS) Quality Payment Program and found that only 37% were valid, 35% were invalid (the majority due to insufficient supporting evidence), and 28% had uncertain validity.

It is also clear that the universe of medical quality, especially in primary care, is not and cannot be restricted to adherence to recommendations in evidence-based guidelines. Dr. Richard Young and colleagues have previously critiqued the application of traditional quality improvement processes to the "complex adaptive systems" of primary care practices and proposed some reasonable alternatives for assessing quality:

Our priorities for primary care quality management include patient-centered reporting; quality goals not based on rigid targets; metrics that capture avoidance of excessive testing or treatment; attributes of primary care associated with better outcomes and lower costs; less emphasis on patient satisfaction scores; patient-centered outcomes, such as days of avoidable disability; and peer-led qualitative reviews of patterns of care, practice infrastructure, and intrapractice relationships.

That being said, the premature ends of the NGC and NQMC will make it more difficult for clinicians to identify good clinical practice guidelines and are unlikely to slow the momentum of the "paying for value" movement, which aims to reward clinicians for their outcomes of care rather than the volume of services they provide. Killing these resources to save a few hundred thousand dollars per year is a penny-wise, pound-foolish decision, and your health and mine will be poorer for it.

Thursday, May 17, 2018

Few family physicians are delivering babies, and few women are having VBACs. What's stopping them?

In 2017, fewer than one in five members of the American Academy of Family Physicians (AAFP) reported providing obstetric care. In a previous Graham Center Policy One-Pager, Dr. Tyler Barreto and colleagues reported that between 2009 and 2016, the percentage of family physicians practicing high-volume obstetrics (more than 50 deliveries per year) fell from 2.1% to 1.1%. A subsequent study in Family Medicine by Dr. Sebastian Tong and colleagues found that 51% of recent family medicine residency graduates intended to provide prenatal care, and 23% intended to deliver babies; however, less than 10% were delivering after 1 to 10 years in practice.

In a recent policy brief in the Journal of the American Board of Family Medicine, Dr. Barreto and colleagues analyzed data from the 2016 Family Medicine National Graduate Survey to identify barriers faced by residency graduates who stated interest in delivering babies but did not do so in practice. Almost 60% of respondents cited the lack of opportunity to do deliveries in the practice they joined and lifestyle considerations as the most important factors. Fewer than 10% felt that inadequate training or reimbursement were major issues.

Although these recent studies did not specifically focus on family physicians who perform surgical deliveries, prior research has established that Cesarean delivery outcomes are comparable whether performed by family physicians or obstetrician-gynecologists. To support women who choose to attempt labor and vaginal birth after Cesarean delivery (VBAC), the AAFP published a 2015 guideline that was largely based on an Agency for Healthcare Research and Quality review of the benefits and harms of VBAC versus elective repeat Cesarean. I summarized the key findings of this review in American Family Physician's "Tips From Other Journals":

The risk of uterine rupture was statistically higher in women undergoing a trial of labor (0.47 percent) compared with women undergoing an elective repeat cesarean delivery (0.026 percent). Fourteen to 33 percent of women who experienced a uterine rupture underwent a hysterectomy. Maternal mortality was rare, but higher in women undergoing an elective repeat cesarean delivery (13.4 deaths per 100,000 deliveries) than in those undergoing a trial of labor (3.8 per 100,000). In contrast, trial of labor was associated with higher perinatal mortality (1.3 deaths per 1,000 deliveries) than elective repeat cesarean delivery (0.5 per 1,000). ... The evidence suggests that most of the differences in maternal and perinatal outcomes between these delivery options are statistically, but not clinically, significant.

Access to VBAC remains limited or nonexistent in many parts of the U.S., and debates continue about its safety for mothers and babies. This month in CMAJ, Dr. Carmen Young and colleagues analyzed a Canadian hospital database containing information on women with a single prior Cesarean between 2003 and 2015 and a second singleton birth at 37 to 43 weeks gestation. They found that rates of the composite outcomes "severe maternal morbidity and mortality" and "serious neonatal morbidity and mortality" were significantly higher after attempted VBAC compared to elective repeat Cesarean. However, absolute differences in these outcomes were low, with NNTs of 184 and 141, respectively.

This new study may give some hospitals and maternity care providers pause about continuing to support women who desire VBAC, and, together with the dwindling numbers of family physicians providing delivery services, could push the overall U.S. Cesarean rate of 32% higher in future years.

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This post originally appeared on the AFP Community Blog.

Monday, May 7, 2018

Top primary care research studies of 2017

In the most recent installment in an ongoing series, my family physician colleagues Mark Ebell, MD, MS and Roland Grad, MD, MSc summarized research studies of 2017 that were ranked highly for clinical relevance by members of the Canadian Medical Association who received daily summaries of studies that met POEMs (patient-oriented evidence that matters) criteria. This year's top 20 studies included potentially practice-changing research on cardiovascular disease and hypertension; infections; diabetes and thyroid disease; musculoskeletal conditions; screening; and practice guidelines from the American College of Physicians and the U.S. Preventive Services Task Force.

The April issue of Canadian Family Physician, the official journal of the College of Family Physicians of Canada, also featured an article on "Top studies relevant to primary care practice" authored by an independent group that selected and summarized 15 high-quality research studies published in 2017. Not surprisingly, some POEMs ended up on both lists:

1) Home glucose monitoring offers no benefit to patients not using insulin

2) Treatment of subclinical hypothyroidism ineffective in older adults

3) Pregabalin does not decrease the pain of sciatica

4) Steroid injections ineffective for knee osteoarthritis

The common theme running through these four studies is "less is more": commonly provided primary care interventions were found to have no net benefits when subjected to close scrutiny.

On the other hand, in a randomized trial that appeared on CFP's but not AFP 's list, adults and children with small, drained abscesses who received clindamycin or trimethoprim-sulfamethoxazole were more likely to achieve clinical cure at 10 days than those who received placebo, although the antibiotics also caused more adverse events, particularly diarrhea (number needed to harm = 9 to 11). As Dr. Jennifer Middleton explained last year, these findings challenge a previous Choosing Wisely recommendation from the American College of Emergency Physicians that states, "Avoid antibiotics and wound cultures in emergency department patients with uncomplicated skin and soft tissue abscesses after successful incision and drainage and with adequate medical follow-up." More can sometimes be, well, more.

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This post first appeared on the AFP Community Blog.

Wednesday, May 2, 2018

Obstacles to stopping cancer screening in older adults

I recognized a glitch in my electronic medical record's decision support software when it prompted me to consider prostate and colorectal cancer screening in a 93 year-old man, who, though remarkably vigorous for his age, was unlikely to live for the additional 10 years needed to benefit from either test. Although deciding not to screen this patient was easy, determining when to stop cancer screening in older patients is often more challenging. In a 2016 article in American Family Physician, Drs. Brooke Salzman, Kathryn Beldowski, and Amanda de la Paz presented a helpful framework for decision making in these clinical situations, where population-level guidance derived from studies of screening younger patients "generally do not address individual variations in life expectancy, comorbid conditions, functional status, or personal preference."

The authors recommended that clinicians take into account not only average life expectancy at a given age, but also significant variations in life expectancy linked to functional impairment and comorbid conditions, using one or more validated prognostic tools. Although the U.S. Preventive Services Task Force (USPSTF) found insufficient evidence about screening mammography in women 75 years or older, modeling studies suggest that women with projected life expectancies of greater than 10 years may still benefit from this test - with these important caveats:

Although the sensitivity and specificity of mammography increase with age, overdiagnosis also increases because of reduced life expectancy and an increased proportion of slower-growing cancers. In other words, women with breast cancer diagnosed at an older age are more likely to die of something else, compared with younger women. In addition, treatment of breast cancer in advanced age is associated with greater morbidity, including an increased risk of postoperative complications and toxicity from chemotherapy.

Similar considerations apply to screening for colorectal cancer, which the USPSTF made a "C" grade recommendation (small population-level benefit, use individual decision making) for adults 76 to 85 years of age and recommended against screening adults older than 85 years, when the harms clearly exceed the potential benefits. Nonetheless, surveys have found that 31% of adults age 85 years and older, and 41% of adults with a life expectancy of less than 10 years, received screening colonoscopies. To discourage overuse of cancer screening without alienating patients, the authors advised: "It is important to convey that a decision to stop cancer screening does not translate into decreased health care. Rather, discussions can focus on health promotion strategies that are most likely to benefit patients in the more immediate future, such as exercise and immunizations."

A qualitative study in JAMA Internal Medicine explored the reluctance of primary care clinicians to explicitly incorporate long-term prognosis in the care of older adults. Most study participants relied on their own clinical experience, rather than validated tools, to estimate a patient's life expectancy, and were reluctant to stop screening in relatively younger patients even with limited life expectancies. Barriers mentioned by participants included inadequate training, time constraints, concern about negative patient reactions, competing practice incentives, and fear of lawsuits. Readers, how should we communicate with older adults whose age or life expectancy warrant stopping cancer screenings because harms outweigh benefits?

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This post first appeared on Common Sense Family Doctor on April 26, 2016.

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.