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.

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.

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.

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.

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!

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.