Monday, October 15, 2018

We should be alarmed that congenital syphilis is on the rise

The Tuskegee Syphilis Study will always be a black mark on American medicine. Designed to record the natural history of untreated syphilis in a population of illiterate African American men in rural Alabama, it continued for 25 years after penicillin became widely available and an accepted cure for the disease. Participants were deceived into believing that they were receiving effective treatment and never informed that they had the option of leaving the study. Although the ethics of these practices were occasionally questioned, the study did not end until it had received widespread negative publicity and Congressional hearings had been called.

In 1972, the last year of the Tuskegee study, I hadn't been born yet. But when I was a medical student doing my Internal Medicine clerkship in early 2000, an older African American man was admitted to our hospital service with memory loss, confusion and difficulty walking and was eventually diagnosed with tertiary neurosyphilis. Based on what he told me about his sexual history and prior symptoms (genital ulcers, rashes, muscle and joint pains), he had likely been infected decades before. Though he was a U.S. citizen by birth, he did not have a family physician and had rarely received health care due to not having insurance or the ability to pay. I don't remember what happened after we started penicillin, but much of the damage already done to his nervous system was irreversible. This patient's illness wasn't quite as outrageous as doctors knowingly withholding antibiotics for decades, but I have little doubt that it could have turned out differently if he had had access to primary care earlier in his life.

Last month, the Centers for Disease Control and Prevention (CDC) announced that the number of reported cases of congenital syphilis in the U.S. rose from 362 in 2013 to 918 in 2017, paralleling increases in syphilis infections in reproductive-age women during this time period. From 2016 to 2017, congenital syphilis cases rose from 16 to 23 per 100,000 live births. Although two-thirds of affected infants have no symptoms at birth, congenital syphilis is associated with increased neonatal mortality and a variety of early (through 48 months of age) and late complications.

The first line of prevention against congenital syphilis is screening for syphilis in all pregnant women at the first prenatal visit, a well-established standard of care that the U.S. Preventive Services Task Force (USPSTF) recently reaffirmed. Although some cases occur in infants whose mothers receive no prenatal care, about one-third of women who delivered a baby with congenital syphilis in 2016 were screened during their pregnancies.

The CDC, the American Academy of Pediatrics, and the American College of Obstetricians and Gynecologists all recommend repeating syphilis screening in women at high risk for syphilis at around 28 weeks of gestation and at time of delivery. Women at high risk include those living in higher-prevalence communities or geographic areas; those living with HIV infection; those with a history of incarceration or commercial sex work; and those exposed to a sexual partner with confirmed syphilis infection. Early penicillin treatment of infected pregnant women reduces the risk of congenital syphilis.

It is alarming that nearly a thousand American babies born last year were afflicted with congenital syphilis. Medically speaking, preventing this condition through detection and treatment of syphilis is straightforward. This is a population health failure, resulting from an underfunded public health infrastructure and a fragmented health system that makes it hard for women at high risk to access timely prenatal and primary care. Our country can do much better.

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Parts of this post first appeared on the AFP Community Blog.

Saturday, October 6, 2018

What works and what doesn't for chronic sleeplessness

Can't sleep? Then spend your extra awake time reading the latest installment of Implementing AHRQ Effective Care Reviews in the September 1 issue of American Family Physician, on management of insomnia disorder in adults. This evidence review, which supported an American College of Physicians practice guideline, examined the effectiveness of behavioral therapies and medications for adults with insomnia disorder, defined as "poor sleep quality or quantity that causes distress or dysfunction and lasts for longer than three months."

The most beneficial sleep intervention overall is cognitive behavior therapy for insomnia (CBT-I), which produced sustained improvements for at least 6 months. CBT-I consists of cognitive therapy, sleep restriction and stimulus control, and sleep hygiene education. Medications that have sufficient evidence demonstrating improvement in short-term (3 months or less) sleep outcomes include eszopiclone, zolpidem, and suvorexant; there was insufficient data to evaluate benzodiazepines or over-the-counter sleep aids (diphenhydramine, doxylamine, or melatonin). For most patients, medications should not be prescribed for longer than five weeks.

Physicians commonly prescribe antipsychotic medications off-label to treat insomnia in older persons. The Practice Guidelines in the September 15 issue summarized a Canadian guideline for deprescribing antipsychotics for behavioral and psychological symptoms of dementia and insomnia, produced by the Deprescribing Guidelines in the Elderly Project. Due to the potential harms of these medications and the lack of evidence of benefits (a single randomized trial with 13 participants found nonsignificant differences in sleep latency in patients taking quetiapine), the guideline recommends that antipsychotics prescribed for primary or secondary insomnia in which comorbidities are under control be discontinued without tapering, regardless of treatment duration.

AFP's sister journal, FPM, recently published an article on deprescribing unnecessary medications that featured a four-step process (review current medications; identify inappropriate, unnecessary, or harmful medications; plan deprescribing with the patient; and regularly re-review medications) and links to additional resources on medication reconciliation and deprescribing.

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This post first appeared on the AFP Community Blog.

Monday, October 1, 2018

Setbacks and a milestone for evidence-based medicine

For my students in 2018, it's difficult to imagine an era when there was no such thing as evidence-based medicine (EBM). When I started medical school in 1997, though, the term had only been in use for six years, having been introduced by Dr. Gordon Guyatt at McMaster University (though EBM's intellectual origins can be traced to several key individuals). When I tell trainees how recently EBM began, they often ask, "Well, then, what kind of medicine did physicians practice before?" The answer is, we largely practiced "eminence-based" medicine (but this tongue-in-cheek article offered some equally poor alternatives).

Although it may be well established, the primacy of EBM is more fragile than it seems. In the September 15 issue of American Family Physician, my longtime mentor and editor emeritus Jay Siwek, MD reviewed common misconceptions, barriers, and practical solutions. For example, evidence can be distorted by financial conflicts, misinterpreted though the lens of one's preexisting beliefs, or ignored by those who deride evidence-based practice guidelines (incorrectly) as "cookbook," "one-size-fits-all" medicine. A recent essay in BMJ also described threats to evidence-informed policy making driven by ideological decisions on both ends of the political spectrum:

We tend to alight on examples of harmful interventions that fit our own political preferences. For example, ... public health researchers leaning towards the left might cite evidence that abstinence only sex education is more likely to lead to increased sexual risk behavior than comprehensive sex education. ... But only referring to examples where the evidence aligns with our own preferences risks suggesting to those on the left that they do not need evidence to know what does not work (as it is just obvious), and to those on the right that evidence informed policy is a liberal conspiracy.

EBM has experienced serious setbacks in the past few months. One, which I discussed previously, was the shuttering of the National Guideline Clearinghouse, a vital repository of evidence-based guidelines that was maintained by the Agency for Healthcare Research and Quality. Another is the Sept. 14 resignation of health services researcher Dr. H. Gilbert (Gil) Welch from Dartmouth College. Described as "an internationally recognized expert on the effects of medical screening and overdiagnosis" in his official Dartmouth biography, Welch literally wrote the book on overdiagnosis, which makes the university's determination that he plagiarized ideas in a 2016 paper puzzling at best. Welch resigned in response to Dartmouth's demands that he make his accuser the first author on the paper and stop teaching at the school. He has denied the plagiarism accusation, and the New England Journal of Medicine has declined to retract the article, viewing it as an authorship dispute rather than a breach of ethics. Although I hope that Dr. Welch's work will continue, his resignation is not only a huge loss for Dartmouth, but for all who have followed and benefited from his seminal work on the downsides of screening, including me.

On the same day as Dr. Welch's resignation, another giant in evidence-based medicine, Dr. Peter Gotzsche, was unceremoniously dismissed from the governing board of the Cochrane Collaboration and expelled from membership in the group. Previously the director of the Nordic Cochrane Center and author of 17 Cochrane reviews, Dr. Gotzsche called his explusion from the organization emblematic of a "moral governance crisis" and accused Cochrane's executive team of sacrificing scientific rigor and open debate in a "growing top-down authoritarian culture and an increasingly commercial business model." Cochrane leadership had been annoyed by Dr. Gotzsche's co-authorship of a BMJ Evidence-Based Medicine critique of a Cochrane review of HPV vaccines, which some felt was overblown and might shake public confidence in the vaccine. But their action sent the chilling message - antithetical to the democratic values at the heart of EBM - that open dissent would not be tolerated.

Thankfully, the news isn't all bad for EBM. An article by fellow AFP Deputy Editor Mark Ebell and colleagues in the September Annals of Family Medicine celebrated the top 20 POEMs (summaries of studies of patient-oriented evidence that matters) of the past 20 years. Since 1998, this group has systematically reviewed more than 100 clinical medical journals for such studies. My EBM teaching favorites from the top POEMs list include those from 2002 (hormone replacement overall is not beneficial), 2009 (prostate-specific antigen screening does not reduce mortality from prostate cancer), and 2013 (fasting is not necessary before measuring lipid panels). Congratulations to the "POETs" for their past contributions, and for continuing to do the yeoman's work of bringing medical evidence to the point of care in primary care.

Wednesday, September 19, 2018

Underperforming big ideas in diabetes and breast cancer

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

But what if these underlying theories are wrong?

In a 2016 editorial in JAMA, Drs. Michael Joyner, Nigel Paneth, and John Ioannidis explored how the "big idea" or narrative that investments in genetics and information technology will lead to a revolution in health care has captured a large share of biomedical research funding and journal publications. They then illustrated how this big idea has "underperformed," as central assumptions of precision/personalized medicine have not been borne out in studies and tens of billions of dollars invested into electronic health records since 2009 have not made patient care measurably better or patient data more accessible to researchers.

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

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

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

Monday, September 3, 2018

Fracture prevention in older adults: what the evidence says

Hip fractures are a significant preventable cause of morbidity and mortality in older adults. Strategies to reduce hip fracture rates include preventing falls, screening for osteoporosis and prescribing bisphosphonate drugs to increase low bone density, and vitamin D supplementation. Recent studies and guidelines have clarified some of the evidence surrounding hip fracture prevention.

In a Putting Prevention Into Practice case study in the August 15 issue of American Family Physician, Drs. Tina Fan and Elizabeth Erickson discussed two updated U.S. Preventive Services Task Force (USPSTF) recommendations on interventions to prevent falls and supplements for primary prevention of fractures. Although the USPSTF continues to recommend exercise interventions to prevent falls in community-dwelling adults 65 years or older at increased risk of falls, it no longer recommends vitamin D supplements to prevent falls, due to evidence of no benefit and potential harms (increased falls and kidney stones). The Task Force found insufficient evidence to assess the balance of benefits and harms of vitamin D and calcium supplements at daily doses greater than 400 IU of vitamin D and 1,000 mg of calcium (lower doses are not effective) in postmenopausal women without a history of osteoporosis, which may come as a surprise, given how many are taking such supplements.

The USPSTF also recently reaffirmed its previous recommendation to screen for osteoporosis with bone measurement testing in women 65 years and older. Earlier this year, The Lancet published the first randomized controlled trial of osteoporosis screening with fracture outcomes. Although screening did not affect the primary outcome of all osteoporosis-related fractures over 5 years (HR 0.94, 95% CI 0.85-1.03), it reduced the incidence of hip fractures (HR 0.72, 95% CI 0.59-0.89). More controversial was the Task Force's recommendation to screen postmenopausal women younger than 65 years at increased risk for osteoporosis. In a JAMA editorial, Dr. Margaret Gourlay argued that the 2-step screening strategy advised by the USPSTF - clinical risk assessment tool followed by bone density testing if indicated - may not produce a net benefit to patients. Although screening women younger than age 65 has potential benefits, it is unclear if these benefits outweigh the opportunity costs:

If complicated risk tools perform no better than age alone to identify screening candidates, women younger than 65 years may be subjected to inefficient screening procedures. … The clinician could spend half of a 15-minute clinical visit accessing a risk tool and asking the patient about unfamiliar risk factors (eg, secondary causes of osteoporosis) to make 1 decision out of the dozen or more compressed into an annual physical examination. … Given the myriad responsibilities of primary care practices caring for patients with high-acuity conditions, implementation of screening programs that are needlessly complex is burdensome and distracts from high-value medical care.

Finally, for patients with osteoporosis who are eligible for treatment, given concerns about long-term adverse effects of bisphosphonates, including rare osteonecrosis of the jaw, for how long should these drugs be prescribed? A FPIN Help Desk Answer found low-quality evidence that for most women, bisphosphonate therapy beyond 5 years does not further reduce clinical vertebral fractures, nonvertebral fractures, or mortality. However, women with persistent femoral neck T-scores lower than -2.5 may benefit from longer treatment durations.

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This post first appeared on the AFP Community Blog.

Thursday, August 30, 2018

Heart disease in the American South: echoes of the Civil War?

He displayed an extraordinary ability to absorb the conflicting wills of a divided people and reflect back to them an unbending faith in a unified future. 

Although historian Doris Kearns Goodwin was describing President Abraham Lincoln when she wrote these words in a recent Harvard Business Review article, they could have been said of a statesman of a later era. The longtime Republican "maverick" Senator John McCain, who passed away on August 25, implored Americans in a farewell letter to "not despair of our present difficulties," but to instead "give each other the benefit of the presumption that we all love our country, we will get through these challenging times. We will come through them stronger than before, we always do."

I had the privilege of meeting Senator McCain in 2014 at a Smithsonian Associates event for Thirteen Soldiers, a book he co-authored with Mark Salter that included the stories of soldiers serving in each of America's thirteen major conflicts, from the Revolutionary War to the current wars in Afghanistan and Iraq. I had seen McCain speak on television countless times, but experiencing his outsized, generous, wisecracking personality in the flesh was something else entirely. And I hope he's right about "our present difficulties."

Outside the John Brown House in Chambersburg, PA

While I have long been fascinated by the American Civil War era, when these United States (as opposed to the United States) were more divided than they have been before or since, I gain no pleasure from watching the ceaseless warring of present-day political factions who have seemingly lost the ability to compromise for the public good.

Mount Hebron Cemetery, Winchester, VA

Along with the end of slavery, another positive outcome of the the Civil War was advances in medicine. In 2004 and 2013, I taught a class at Georgetown University School of Medicine called "Civil War Medicine In the Modern Age," and I have enjoyed attending the National Museum of Civil War Medicine's scholarly Annual Conference, which includes educational talks and entertaining trips to nearby historical sites.

Just north of the Mason-Dixon line

Although the Civil War ended more than 150 years ago, its health effects have echoed through the ages. They echo in the hundreds of thousands of soldiers and civilians who perished prematurely from battles or disease; the hundreds of thousands more who were permanently disabled or disfigured by wounds; and - as reported in the Washington Post in 2016 - in the legacy of increased mortality from heart disease concentrated in the South:

To Richard Steckel, an Ohio State University economist, that striking pattern raises a seemingly outlandish, but utterly serious question: Could the heavy toll of heart disease in the American South today have been triggered, in part, by the region's rapid rise out poverty since the 1950s? In a new paper, Steckel argues that decades of poverty caused by the Civil War shaped people's organs and physiology in a way that left them particularly unsuited for a cushy life. The current health disparities in the South, Steckel says, developed as Southerners encountered more prosperous lifestyle than their bodies were prepared for, including more food and less manual labor.

Monterey Pass Battlefield Park, Franklin County, PA

Steckel's hypothesis is intriguing, but even if correct, it is only part of the story. Surely poor diet, physical inactivity, and unrelieved stress caused by a century of segregation and continuing discrimination against African Americans also had a lot to do with the sky-high heart disease rates. And it doesn't help that most of these states have not expanded their Medicaid programs to extend health insurance coverage to those who are most likely to benefit. But that's something to write about another day.

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I took all of the photos in this blog post on various Civil War-themed summer trips. This is what I do when I'm not seeing patients, editing articles, blogging, or teaching medical students about health policy.

Thursday, August 23, 2018

Overdiagnosis of lung cancer: don't tell, don't ask?

Although the U.S. Preventive Services Task Force recommended in 2013 that current and recent smokers 55 to 80 years of age with at least a 30 pack-year history receive annual low-dose CT screening for lung cancer, family physicians have been slow to implement this recommendation in their practices. Concerns about this screening test include the quality of the supporting evidence (which the American Academy of Family Physicians judged to be insufficient) and potential harms, including overdiagnosis and overtreatment of tumors that, left undetected, would never have caused symptoms during a patient's lifetime. An analysis of the National Lung Cancer Screening Trial (NLST) suggested that one in five lung cancers were overdiagnosed. In recognition of the balance of benefits and harms of lung cancer screening, the Centers for Medicare & Medicaid Services requires that eligible patients first have a "counseling and shared decision making visit" with a clinician that utilizes a patient decision aid prior to undergoing a scan.

A previous study of screening for other cancer types found that clinicians mentioned overdiagnosis as a potential harm less than 10 percent of the time. Are lung cancer screening discussions any different? In a study published this month in JAMA Internal Medicine, researchers evaluated shared decision making (SDM) using the validated Observing Patient Involvement in Decision Making (OPTION) scale in a sample of transcribed physician-patient conversations. Relative to the mean total visit length (just over 13 minutes), physicians spent a mean of 59 seconds discussing lung cancer screening. None of the conversations mentioned decision aids, and the mean total OPTION score was 6 out of 100 (where 0 indicates no evidence of SDM and 100 indicates SDM at the highest skill level), reflecting that physicians rarely informed patients about harms of low-dose CT scans or asked patients how they valued these harms.

This lack of attention to harms of lung cancer screening is concerning because the magnitude of overdiagnosis may be considerably higher than previous estimates. Researchers recently analyzed data from the Danish Lung Cancer Screening Trial, in which participants underwent 5 annual low-dose CT screenings (compared to 3 in the NLST) and concluded that two-thirds of lung cancers were likely overdiagnosed. In an accompanying commentary that compared the methods used to estimate overdiagnosis, AFP Deputy Editor Mark Ebell, MD, MS and I stressed the importance of communicating with patients about this "often underappreciated harm of screening":

Patients can make informed choices about low-dose CT only if practitioners fully disclose all the potential harms of screening, including the risk of overdiagnosis. It will be important to researchers to continue to refine estimates of lung cancer overdiagnosis, allowing physicians to provide more accurate information to our patients.

To best serve patients, primary care physicians and pulmonologists must do better than 59-second conversations about lung cancer screening that only mention potential benefits. We need to take the time to tell patients about harms such as overdiagnosis, and ask them how they value these harms relative to the benefits, before ordering the scan.

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This post first appeared on the AFP Community Blog.

Sunday, August 19, 2018

Will tuition-free NYU produce more primary care physicians?

When I graduated from NYU School of Medicine in 2001, I was one of four in my class to enter a residency program in family medicine. That turned out to be the largest number of family physicians that an NYU class would yield in the 21st century. In several subsequent years there were none at all, and the Class of 2018 produced only two. In one sense, this meager output is unsurprising - NYU, like Harvard, has never had a Department of Family Medicine - but my class also produced only a handful of primary care internists (internal medicine residency-trained physicians who did not subspecialize) and general pediatricians. NYU did not always undervalue primary care. When I attended the annual alumni brunch in Washington, DC, I met many generalist NYU graduates from the 1980s and earlier who asked me when going into primary care specialties started becoming so unfashionable, and who is going to "take care of the folks" when they all start retiring.

Last Thursday, when my best friend from medical school (now an emergency medicine physician in San Francisco) texted me about NYU's stunning announcement that its current and future medical students will no longer pay any tuition, my first reaction was: why didn't they come up with this idea 20 years ago? But when I got over that, I carefully pored over the press release, which implied that the goals of this generous policy are to increase the socioeconomic and racial diversity of their classes, and to encourage more students to choose primary care:

Overwhelming student debt is fundamentally reshaping the medical profession in ways that are adversely affecting healthcare. Saddled with staggering student loans, many medical school graduates choose higher-paying specialties, drawing talent away from less lucrative fields like primary care, pediatrics, and obstetrics and gynecology. Moreover, the financial barriers discourage many promising high school and college students from considering a career in medicine altogether due to fears about the costs associated with medical school.

I am fortunate that student loan debt did not play a role in the type of physician I became. I took out a modest amount of loans during medical school - less than one-third of the average $190,000 debt of 2016 medical school graduates - and knew that I would be able to pay them off regardless of the specialty I chose. In the wake of NYU's announcement, a spirited debate occurred on Twitter about whether the tuition-free school will actually attract more medical students to primary care, or simply vault it past its rivals in the U.S. News rankings and subsidize the education of radiologists, ophthalmologists, anesthesiologists, and dermatologists (the so-called R.O.A.D. specialties, with some of the highest incomes and best lifestyles).

It is hard to imagine that a school with no family medicine department or required clerkship, and few visible outpatient primary care role models, is suddenly going to start churning out family doctors by the dozens. But NYU's decision to go tuition-free may put pressure on other medical schools with similar fundraising prowess and stronger primary care infrastructures to follow its lead. Then the question becomes: will reducing financial obstacles to medical school attract more applicants who are likely to become family physicians?

A recent observational study of the distribution of medical education debt by specialty found that family physicians were the least likely of all the medical specialties to have no student loans at graduation, with 16% and 20% of 2010 and 2016 graduates, respectively, reporting no debt. (Since internists and pediatricians don't decide to subspecialize until well into their residency programs, the researchers could not assess the debts of those who might ultimately choose primary care.) In contrast, in 2016, 40% of future ophthalmologists and 36% of future dermatologists reported no debt. These findings suggest, paradoxically, that physicians with the highest debt burden are preferentially choosing a specialty with among the lowest income expectations - why on earth would that be? What it says, actually, is that students from less well-off backgrounds are more likely to be attracted to primary care in the first place.

Although making medical school tuition-free for all is an inefficient strategy for producing more family physicians, I predict that increasing the diversity of medical school applicants (and accepted students) will likely have a small, but measurable, positive effect on primary care. To magnify that effect, health care institutions must also invest resources into pipeline programs for underrepresented high school and undergraduate students such as the Comprehensive Medical Mentoring Program and ARCHES, academic family medicine departments (looking at you, Harvard and NYU), and community-based residency training programs such as Teaching Health Centers.

I'm proud to be an NYU School of Medicine graduate, and I'm happy for current and future students who now have one less obstacle to fulfilling their dreams. Perhaps they, too, can aspire to be family physicians someday.

Monday, August 13, 2018

Food insecurity hurts health. Here's what doctors can do.

As screening for social determinants of health in clinical settings "moves from the margins to the mainstream," research has focused on how to efficiently identify and address social needs in practice. An article in the May/June issue of FPM by Drs. David O'Gurek and Carla Henke provided a suite of practical approaches, including tools, workflow, and coding and payment considerations. Dr. Sebastian Tong and colleagues reported the experiences of primary care clinicians screening for social needs in 12 northern Virginia practices in the Journal of the American Board of Family Medicine. Knowledge of a social need changed care delivery in 23% of patients and improved communication in 53%, but clinicians often felt ill-equipped to help patients with identified needs or connect them to appropriate services.

Help is on the way. The American Academy of Family Physicians (AAFP) recently launched an interactive online tool, the Neighborhood Navigator, to make it easier for family physicians to connect patients with community organizations and social services. This tool complements other resources in the AAFP's EveryONE Project to support patients' health outside of the office that Dr. Jennifer Middleton discussed in a previous AFP Community Blog post.

In the August 1 issue of American Family Physician, Dr. Shivajirao Prakash Patil and colleagues reviewed the problem of food insecurity, defined as "limited availability of nutritionally adequate and safe food or the inability to acquire these foods in socially acceptable ways," which affected an estimated 12% of American households in 2016. According to the authors, food insecurity (FI) has a cyclical relationship with chronic disease, constraining dietary options in ways that increase the risk for development and progression of diseases in children and adults. They recommended that family medicine practices follow the SEARCH mnemonic and utilize food security resources and food assistance programs in appropriate patients:

S (Screen) - "An affirmative response to either of the following statements can identify FI with 97% sensitivity and 83% specificity: (1) Within the past 12 months we worried whether our food would run out before we got money to buy more, and (2) Within the past 12 months the food we bought just didn't last, and we didn't have money to get more."

E (Educate) - "Educate patients at risk of FI about appropriate coping strategies. Although some individuals with limited resources manage without major disruptions to food intake, many eat less or eat less healthy foods to get by."

A (Adjust) - "Adjust the patient's medication if it should be taken with food. Prescribe medications that minimize the likelihood of hypoglycemia for patients with FI who have diabetes."

R (Recognize) - "Recognize that FI is typically recurrent but is usually not chronic."

C (Connect) - "Connect patients with assistance programs and encourage patients with FI to use food banks."

H (Help) - "Help other health care professionals recognize that poor health and FI often exacerbate one another."

Family physicians can also choose to advocate to improve the quality and quantity of food resource programs available in their communities and across the nation. A recent episode of the Review of Systems podcast discussed the public health implications of upcoming Farm Bill legislation affecting the Supplemental Nutritional Assistance Program (SNAP).

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This post first appeared on the AFP Community Blog.

Tuesday, August 7, 2018

Announcing a media skills workshop for health professionals

Join me and family physician colleagues Ranit Mishori, Douglas Kamerow, and Amber Robins at Georgetown University on Friday, September 7 for a day-long Media Skills Workshop sponsored by the Family Medicine Education Consortium and our Department of Family Medicine. Pre-registration is available through September 1, and lunch will be provided. Don't miss this opportunity to learn best practices for interacting with the media and how to advocate for patients and primary care in Op-Eds, blog posts, and Twitter!


Thursday, August 2, 2018

Giving it away: philanthropy and medicine

My wife and I aim to give about 10 percent of our pre-tax income to charity each year. Much of this amount goes to our church, which struggles to make ends meet despite being situated in a rapidly gentrifying area of Washington, DC. We divide the remainder between a variety of causes, such as historical preservation efforts, summer programs for poor kids, and education and leadership programs for young family physicians. Historically, we have allocated a very small fraction of our charitable contributions to our college, graduate, and medical school alma maters (Harvard, Johns Hopkins, and NYU for me; Cornell, Cornell, and Stony Brook for her), and then generally give directly to student organizations, such as the Big Red Marching Band and the Phillips Brooks House Association. It isn't that we don't have fond memories of attending these schools or don't appreciate the education we received there, but in our view they have deeper pockets than almost every other organization that asks for our financial support.

Two episodes of Malcolm Gladwell's "Revisionist History" podcast provided more convincing arguments against making big donations to top ranked universities. Gladwell made headlines in 2015 with a Twitter rant criticizing hedge fund manager John Paulson's $400 million donation to Harvard (whose endowment at that time was valued at more than $36 billion). In "Food Fight," Gladwell compared the funding priorities of Bowdoin and Vassar, two small Northeast liberal arts colleges that appear pretty similar on the surface. One notable difference is that cafeteria food at Bowdoin is gourmet dining, while Vassar's is mediocre at best. Using public information sources and interviews with staff and students at both colleges, Gladwell drilled down to a major reason for this dining disparity: Vassar devoted more of its endowment income to financial aid in order to increase the social and economic diversity of its student body. If you're a wealthy individual who wants to advance social justice, Gladwell argued, choose Vassar over Bowdoin and supporting education for poor students over serving the rich breakfasts of eggplant parmesan pancakes.

Then, in "My Little Hundred Million," Gladwell explored the phenomenon of philanthropists such as Nike's Phil Knight choosing to give hundreds of millions of dollars to private universities that educate the elite rather than public universities who reach many more students of modest means. Gladwell included excerpts from an almost comical discussion with Stanford president John Hennessy, who accepted a $400 million donation from Knight to endow a graduate program for 100 students per year, even though Stanford's endowment is $22 billion. In comparison, a $100 million donation to little-known Glassboro State College (now Rowan University) in New Jersey in the 1990s transformed opportunities for 16,000 students each year and inspired this moving a cappella tribute from students after their benefactor's death.



As I've written before, hospitals and health care organizations are similar to institutions of higher education in that both have skyrocketing costs, little transparency, and few objective measures of quality. They are also alike in that they rely on philanthrophy to supplement the income they receive from patients/students and insurers/lenders. Famous cancer centers have turned fundraising into an art form, too often relying on emotion rather than fact to attract patients and donors. But just because it may be more attractive to donate to the Memorial Sloan-Ketterings and their associated academic institutions doesn't mean that they should be receiving an outsized share of my or your charitable dollars. Especially since we know that U.S. News top ranked (and well funded) medical schools end up near the bottom of the heap when ranked according to their social mission: the percentage of graduates who practice primary care, work in health professional shortage areas, and are underrepresented minorities. Similarly, a disproportionate amount of Medicare's $10 billion per year graduate medical education subsidy goes to institutions that train few primary care physicians or clinicians who practice in underserved areas.

Dear Mr. Paulson, Mr. Knight, Mr. Buffet, Mr. Gates, do you want to improve health outcomes in America? Then write a big check to John Peter Smith Hospital in Fort Worth, Texas, #6 on the list of producers of primary care graduates that received a modest $4.5 million from Medicare in 2008. Or Banner - University Medical Center in Phoenix, Arizona, #15 on the list. (Both institutions, not coincidentally, have outstanding family medicine residency programs.) Don't worry about my alma mater NYU, whose hospitals received more than $55 million from Medicare in 2008 but ranked #156 in primary care production. Or Memorial Sloan-Kettering, for that matter, which ranked #158 out of #158 primary teaching sites with at least 150 graduates - dead last.

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This post first appeared on Common Sense Family Doctor on July 25, 2016.

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.