Tuesday, August 6, 2019

What is the appropriate role of experts in primary care guidelines?

This week, a Health Affairs blog post titled "Fixing Clinical Practice Guidelines" echoed several concerns I've discussed previously: practice guidelines are being produced in abundance but often have variable methodological quality, financial conflicts of interest that threaten objectivity, and/or poor applicability to the clinicians and populations for whom they are intended. To address these problems, the authors reasonably suggested restoring funding for AHRQ's National Guideline Clearinghouse and giving this centralized guideline repository the authority to require that guidelines meet a universal, rigorous methodology standard (including policies to avoid conflicts of interest) for inclusion.

My only real quibble with the commentary is its title: clinical practice guidelines have problems, but they're not broken. I am currently a volunteer panel member for three guidelines in various stages of development, sponsored or co-sponsored by three different medical specialty societies. Each guideline is following the National Academy of Medicine's (formerly Institute of Medicine's) standards for trustworthy guideline development and on track to produce practical recommendations for clinicians that are consistent with the best evidence on each topic. If I didn't think that these guidelines were worthwhile endeavors, I wouldn't have agreed to spend so many hours reviewing and discussing studies, systematic reviews, and meta-analyses, and drafting the text of the recommendations.

Drs. Benjamin Djulbegovic and Gordan Guyatt recently argued in a JAMA Viewpoint that we should not make false distinctions between evidence-based and consensus-based guidelines, since the "evidence alone never speaks for itself" and interpretation of evidence by guideline panelists via a consensus process is always required. Therefore, consensus-based does not necessarily imply weak or insufficient evidence; rather, "the crucial difference between evidence-based medicine and non-evidence-based medicine methods is that the former necessitates that judgments are consistent with underlying evidence, whereas the latter do not."

To me, "non-evidence-based" or "expert consensus" calls to mind an outdated process for developing guidelines (though some groups still use it): assemble a group of distinguished subject matter experts, ask them to formulate some recommendations based on their own practices (which, since they're the experts, must be the most effective and efficient ways to manage patients with the condition), find some published references to support what the experts already know, then write up a report. Bonus points if the guideline panel has an authoritative-sounding name such as the Joint National Committee (whose hypertension guidelines, until JNC 8 at least, largely followed an expert consensus process).

Applying the evidence-based paradigm to primary care guidelines, then, what is the appropriate role of experts? Since a well-conducted systematic review ought to retrieve all relevant research evidence, and guideline panelists should already have expertise in evidence interpretation and grading of recommendations, what more can experts bring to the table? In a BMJ analysis, Dr. Holger Schunemann and colleagues make a useful distinction between "expert evidence" and "expert opinion": evidence is factual, while opinion is a judgment that may (or may not) be based on facts:

For example, a patient might say: “I had prostate cancer detected by prostate specific antigen (PSA) screening and I am alive 10 years later.” That is evidence. It is not the same as saying: “PSA screening saved my life.” That is an opinion. Similarly, a clinical expert might say: “I operated on 100 patients with prostate cancer and none of them died from prostate cancer.” That is evidence. It is not the same as saying: “Prostatectomy is effective.” That is an opinion. In both cases, the opinions might be based on that evidence, but the evidence is clearly not the same as the conclusion.

Schunemann and colleagues review several pitfalls of expert evidence and opinion: not distinguishing between the two; untimely introduction of expert evidence; inadequate disclosure or management of financial and intellectual conflicts of interest; and inadequate appraisal of expert evidence. To make the influence of expert evidence on guidelines more transparent, they advise (and I agree) that it be collected systematically and appraised using the same methodology as for research evidence, which gives more weight to experimental studies or systematically collected observations that are less likely to be biased than a subspecialist physician's personal experiences.

Sunday, July 28, 2019

Deliberate clinical inertia protects patients from low value care

Clinical inertia is usually considered to be a negative term, used to refer to situations in which clinicians do not appropriately initiate or intensify therapy for uncontrolled chronic conditions. For example, a recent study in JAMA Internal Medicine found that less than one-quarter of patients with chronic hypercalcemia in the Veterans Affairs health system received recommended parathyroid hormone level testing, and only about 13 percent of patients who met diagnostic criteria for primary hyperparathyroidism underwent parathyroidectomy.

However, clinical inertia has also been described as a "clinical safeguard" against aggressive consensus guideline prescriptions that do not account for patient preferences and/or potential harms of intensifying treatment. For example, an analysis of the incremental benefits of and harms of the 2017 American College of Cardiology / American Heart Association guideline that redefined hypertension as a sustained blood pressure of >= 130/80 mm Hg concluded:

For most adults newly classified as having high blood pressure under the ACC/AHA guideline (the 80% of those newly diagnosed who have <10% 10-year risk), there is no incremental benefit in CVD risk reduction, but potential incremental harms from disease labeling, and, for those who meet the threshold for drug treatment, from adverse drug effects.

In this instance, a large number of patients with systolic blood pressures between 130 and 140 mm Hg could potentially benefit from clinical inertia by avoiding a hypertension diagnosis, additional testing, or prescription medications.

In a 2011 JAMA commentary, Drs. Dario Giugliano and Katherine Esposito observed that clinical inertia "also may apply to the failure of physicians to stop or reduce therapy no longer needed," but that "this neglected side of clinical inertia does not seem to generate as much concern among physicians or scientific associations." A review of polypharmacy in the July 1 issue of American Family Physician noted that regular use of at least five medications is associated with decreased quality of life, increased mobility problems and falls, greater health system use, and increased long-term care placement. Judicious deprescribing can help reduce polypharmacy and improve patient outcomes.

Another (sometimes better) strategy is not starting nonbeneficial medications for unclear reasons in the first place. In a 2018 article in Emergency Medicine Australasia, Dr. Gerben Keijzers and colleagues defined "deliberate clinical inertia" as "the art of doing nothing as a positive response." Arguing that doctors generally have a bias to intervene with diagnostic tests, drugs, or procedures, they suggested reframing the typical decision-making approach:

In clinical practice, 'risk versus benefit' is usually considered in terms of missing a diagnosis rather than potential risks of treatment, so a better approach to care may be to ask, 'Is this intervention more likely to cause harm than the underlying condition with its possible harm or risk?' There are many reasons why 'doing nothing' is difficult, but doing what we can to provide excellent care while preventing medical harm from unnecessary interventions must become one of the pillars of modern holistic healthcare.

Health professionals may readily grasp the rationales behind campaigns to avoid harms and costs of low value care such as Choosing Wisely and Right Care, but patients may be skeptical. Dr. Keijzers and colleagues suggested several ways to support deliberate clinical inertia in practice: empathy and acknowledgment; symptom management; clinical observation; explanation of the natural course of the condition; managing expectations; and shared decision-making ("communicating rather than doing").


This post first appeared on the AFP Community Blog.

Tuesday, July 23, 2019

Admissions straight talk from ... me!

Many thanks to Linda Abraham for interviewing me on Admissions Straight Talk about my path in medicine and recent blog post critiquing the U.S. News & World Report's medical school rankings. You can either listen to the full podcast episode embedded below or read a summary of the high points on her Accepted website.

Wednesday, July 17, 2019

The places in America where doctors won't go

Two years ago, I attended the annual Teaching Prevention conference in Savannah, Georgia. Since I hadn't spent much time in Georgia outside of Savannah and Atlanta, the welcoming plenary on improving health outcomes for the state's rural and underserved populations was eye-opening. According to Dr. Keisha Callins, Chair of the Department of Community Medicine at Mercer University, Georgia ranked 39th out of 50 states in primary care physician supply in 2013 and was projected to be last by 2020. 90% of Georgia's counties are medically underserved. Mercer supports several pipeline programs that actively recruit students from rural areas, expose all students early to rural practice and community health, and provide financial incentives for graduates who choose to work in underserved areas of the state. But it's an uphill battle. Even replicated in many medical schools across the country, these kinds of programs likely won't attract enough doctors to rural areas where they are most needed.

When people talk about places where doctors won't go, they tend to focus on international destinations, such as war zones in Syria or sparsely populated areas of sub-Saharan Africa. It's hard to believe that many places in America are essentially devoid of doctors, and access to medical care is as limited as in countries where average income is a tiny fraction of that in the U.S. Providing health care coverage for everyone, while important, won't automatically ensure the availability of health professionals and resources in rural communities. In a JAMA Forum piece, Dr. Diana Mason discussed the financial struggles of rural hospitals that support community health alongside primary care clinicians, which become more acute when budget cuts to rural health programs and grants occur.

Georgia is hardly the only state struggling to attract doctors to rural communities. In the Harper's Magazine story "Where Health Care Won't Go," Dr. Helen Ouyang chronicled the tuberculosis crisis in the Black Belt, a swath of 17 historically impoverished, predominantly African American counties in rural Alabama and Mississippi. In Marion, Alabama, a single family doctor in his mid-fifties and an overwhelmed county health department grappled daily with the lack of resources to contain the spread of the disease:

There is no hospital in town. The nearest one, twenty minutes away in Greensboro, has minimal resources. The road to get there is narrow, unlit at night, and littered with roadkill. Perry County has only two ambulances, one of which is on standby for the local nursing home. Life expectancy here is seven years lower than the U.S. average, and the percentage of obese adults is almost a third higher; by the latest count, more than a quarter of births take place without adequate prenatal care. [Dr. Shane] Lee’s clinic is Marion’s only place for X-rays.

Ouyang went on to describe the University of Alabama's Rural Health Leaders Pipeline, a program that recruits and trains medical students from rural communities to eventually become primary care physicians for those communities. Although the program has been modestly successful (since 2004, "more than half have gone on to work in rural areas, compared with only 7 percent of their classmates"), many Black Belt counties have yet to benefit from it. Many medical schools use a minimum score cutoff on the Medical College Admission Test (MCAT) that tends to penalize applicants from rural and minority communities, even though those students are more likely to become primary care physicians for underserved populations:

The purpose of doctors, after all, is to tend to patients’ ultimate needs. Increasing the supply of primary care physicians is linked to lower mortality rates; after compiling data from studies across different parts of the country, a group of public health researchers found that by adding one more doctor for every 10,000 people, as many as 160,000 deaths per year could be averted. When the same researchers considered race as a factor, this benefit was found to be four times greater in the African-American population than among white people. Studies have also observed that the availability of primary care significantly reduces health disparities that result from income inequality.

The problem of too few primary care clinicians is not limited to rural America, but those communities are where the need is greatest, since a town without a family doctor is unlikely to have any other types of physicians. Medical schools can't easily change social determinants of health on their own, but they can rewrite their mission statements to emphasize providing health care to everyone regardless of geography, and implement recruitment and admissions policies that actually support that goal.


This post first appeared on Common Sense Family Doctor on June 5, 2017.

Tuesday, July 9, 2019

Population health, colorectal cancer screening, and guideline development

Although a recent vacation and catching up after returning to work have delayed posting to the blog, I wanted to share three of my recent publications in other venues that you might find to be of interest. In my latest Medscape commentary, I added my voice to an ongoing debate about the future role of family physicians in addressing population health and social determinants. Should we expect all family physicians to be "experts in population health," or limit population health training to basic competencies that are generally tied to clinical settings?

My view is that medical schools and residency programs should offer a scope of population health training that falls somewhere in between Dr. DeVoe's aspirational goals and Dr. Campos-Outcalt's minimum objectives, consistent with their institutional mission statements, faculty resources, and existing connections with community organizations. 

For example, over the past several years, my students and family medicine residents have benefited from classroom and experiential learning from faculty in Georgetown's Department of Health Systems Administration, its law school, and its school of public policy. Each year we raise the bar for population health in undergraduate medical education so that our graduates will be able to utilize population health skills in residency and, if desired, incorporate them into their future practices.

Meanwhile, over at American Family Physician, fellow Deputy Editor Mark Ebell, MD, MS and I launched a feature that evaluates new diagnostic tests:

[Diagnostic Tests: What Physicians Need to Know] uses a structured approach to review key test characteristics, including discussions of accuracy, benefits, harms, cost, and cost-effectiveness. It concludes with a clinical bottom line: Is there a role for this test in primary care practice and, if so, for which patients? We aim for this new feature to cut through the “hype” and provide independent, objective assessments of new diagnostic tests that readers are considering incorporating into their practices.

Family physicians and other primary care clinicians who read AFP can find my first piece in the series, mSEPT9 Blood Test (Epi proColon) for Colorectal Cancer Screening, in the July 1 issue of the journal.

Finally, on the AFP Community Blog, I took readers "behind the scenes" of the updated American Academy of Family Physicians (AAFP) clinical practice guideline on depression following acute coronary syndrome events. Those of you who are interested in learning more about how the AAFP develops guidelines can check out some of their background resources, such as a short video series and the detailed Clinical Practice Guideline manual. I am currently working with the AAFP to develop clinical practice guidelines on two common conditions encountered by family physicians.

As Common Sense Family Doctor approaches its 10-year anniversary (July 24, 2019), topics on deck for future posts include artificial intelligence (AI) in primary care, the upside of clinical inertia, and more developments in overdiagnosis. Stay tuned.

Saturday, June 22, 2019

Fear-mongering in thyroid and breast cancer screening

A large part of practicing primary care consists of providing reassurance to healthy persons. The patient who asks me to look at the mole on her back to make sure it isn't melanoma. The patient who recently recovered from a cold but is still coughing and wants to know that it isn't a sign of something more serious. The patient whose friend's doctor found a lump on his thyroid gland and wants to have his neck checked too.

The last time the U.S. Preventive Services Task Force recommended against screening for thyroid cancer was in 1996. That it took more than 20 years to release an updated recommendation statement (still a "D," or don't do) speaks to how non-controversial the Task Force judged this topic to be. Unfortunately, in the interim many clinicians and patients ignored this advice. In South Korea, a national cancer screening program that began in 1999 encouraged general practitioners to routinely perform thyroid ultrasound scans, resulting in an "epidemic" of new thyroid cancers but no change in thyroid cancer deaths. In the United States, papillary thyroid cancer diagnoses have quadrupled since 1995, again with no change in mortality. In both countries and around the world, physicians are finding and treating thousands of pseudo-cancers that would not have otherwise been found and don't need to be treated. Overdiagnosis begets more overdiagnosis: patients who are "successfully" diagnosed and treated tell friends and relatives to have their necks palpated or scanned for thyroid tumors. And if that feedback cycle wasn't enough, advocacy groups such as the Light of Life Foundation initiated fear-mongering awareness campaigns, as Dr. Gilbert Welch described in an editorial accompanying the USPSTF recommendation:

About a decade ago, public service announcements began to appear encouraging people to have their physicians “check your neck.” The Light of Life Foundation campaign featured actual testimonials of patients describing their positive health behaviors on the day before they were diagnosed with thyroid cancer. The ads used compelling language: “Thyroid cancer doesn’t care how healthy you are. It can happen to anyone. Including you. That’s why it is the fastest growing cancer in the US. Ask your doctor to check your neck. It could save your life.” The campaign’s title—and its main slogan—was “Confidence Kills.” That’s a great public health message: if you feel good, you are about to die.

Fear-mongering isn't limited to thyroid cancer, of course. From the 1980s-era American Cancer Society print advertisement that lectured women, "If you haven't had a mammogram, you need more than your breasts examined," promoters of breast cancer screening long used fear to motivate women to undergo screening mammography. In 2015, several advocacy organizations successfully persuaded the U.S. Congress to override the U.S. Preventive Services Task Force's "C" grade (small net benefit) on screening mammography for women aged 40-49 with a "Stop the Guidelines" campaign that included full-page advertisements in major newspapers asking the rhetorical question "Which of our wives, mothers, daughters, and sisters would be be OK to lose?"

The major difference between screening for thyroid and breast cancer is that the latter actually reduces cancer deaths. But women under 50 are less likely to benefit because there is less lethal breast cancer to be found in younger women, and consequently much higher false positive rates that affect more than half of all women receiving annual mammograms from age 40 to 50. And the USPSTF didn't tell clinicians don't screen - more accurately, they said don't screen reflexively, and the message to younger women is not to avoid mammograms, but to talk about the pros and cons with your doctor.

That hasn't stopped a new alliance of radiologists and breast cancer surgeons from targeting the Task Force with a 40not50 campaign which encourages women in their 40s to turn off their brains, eschew shared decision-making, and demand that their doctors start screening them at age 40 because mammograms save lives, and a government-appointed panel (whose 16 current members include 6 women) wants to prevent women from seeing their 50th birthdays. Notwithstanding the ulterior motives behind this absurd campaign, it is insulting to women. It says that they can't be trusted to consider the medical evidence, have conversations with their primary care physicians, and make decisions about their healthcare that are right for them.


This post first appeared on Common Sense Family Doctor on May 16, 2017.

Monday, June 17, 2019

For most, an aspirin a day won't keep the doctor away

A daily low-dose (81 mg) aspirin was once considered an essential component of cardiovascular disease (CVD) prevention for middle-aged and older adults. In 2006, the National Commission on Prevention Priorities ranked "discussing aspirin use in high-risk adults" the highest priority preventive service based on clinically preventable burden and cost effectiveness, and two years ago, in an updated set of rankings, it still rated aspirin use as the fifth highest priority for improving utilization. However, in 2018 the results of three large randomized trials suggested that the harms of aspirin taken to prevent a first CVD event outweigh its benefits for most persons. In an editorial in the June 1 issue of American Family Physician, Dr. Jennifer Middleton and I reviewed the latest evidence and concluded:

The new data do not exclude the possibility that aspirin may still benefit adults at very high CVD risk (e.g., 20% or more over 10 years) or those at lower risk who are unable to tolerate statins, but the data otherwise suggest that the risks of low-dose aspirin therapy for primary prevention outweigh any potential benefits. For most patients, we should be deprescribing aspirin for primary prevention of CVD. To prevent heart attacks and strokes, family physicians should focus instead on smoking cessation and lifestyle changes, controlling high blood pressure, and prescribing statins when indicated.

In a 2019 clinical practice guideline, the American College of Cardiology / American Heart Association largely concurred, recommending against prescribing aspirin for primary prevention of CVD in adults older than age 70 and downgrading its role in other adults at high risk to "may be considered" on a case-by-case basis.

Although aspirin is still strongly recommended to prevent recurrent CVD events, its rise and fall in primary prevention seems to have become another case of medicine reversing itself. Unlike other notable examples of medical reversal such as menopausal hormone therapy and tight glucose control in type 2 diabetes, the effectiveness of aspirin was supported by many well-conducted randomized, controlled trials. Aspirin worked ... until it didn't. In a recent commentary in the Journal of General Internal Medicine, Palmer Greene and colleagues suggested that it may be a good idea to consider established evidence-based practices as having an "expiration date":

An “evidentiary statute of limitations” would require the occasional reassessment of accepted therapies to consider which might no longer be of use—possibly because of changes in the population as a whole, a changing understanding of whom the treatment is appropriate for, or evolving therapies for the prevention or treatment of the disease in question. Not only should we consider if older data still applies, we should also strive to anticipate the factors to which the results of a newly published positive study might be sensitive. For instance, is there an event rate in the control group below which the harms of the therapy might outweigh the benefit? Is there a treatment success rate that, when achieved, would make screening inefficient?

Not starting aspirin is relatively straightforward, but patients who have taken aspirin for many years without adverse effects or CVD events may resist discontinuing it. After making sure that we are appropriately treating all of their risk factors (e.g., high blood pressure, high cholesterol, diabetes, tobacco use), I have taken a shared decision-making approach to these deprescribing discussions, emphasizing the small additional benefit of aspirin compared to the increased risk of serious bleeding events.


This post first appeared on the AFP Community Blog.

Monday, June 10, 2019

The problems with using population-level data to estimate prostate screening benefits

Almost any debate about the effectiveness (or lack thereof) of PSA-based screening for prostate cancer in the U.S. will usually involve whether the results of the two largest randomized screening trials or national mortality statistics more accurately represent the effects of intensive screening from the early 1990s to the late 2000s. Putting aside the conflicting results of the U.S. Prostate, Lung, Colorectal, and Ovarian Cancer Screening (PLCO) trial and the European Randomized Study of Screening for Prostate Cancer (ERSPC) - for which there are many plausible explanations - even the most optimistic statistical interpretation of these trials suggests that PSA screening reduces prostate cancer mortality by 25-30% at best, which does not fully account for the observed 40% decline in prostate cancer mortality from 1991 to 2008. Since the effectiveness of standard prostate cancer therapy did not change significantly during this time frame, PSA screening advocates have suggested that the discrepancy is probably due to flaws in the trials, rather than issues with "real-world evidence" derived from population-level mortality data.

However, in a thoughtful commentary recently published in Mayo Clinic Proceedings, Drs. Joaquin Chapa, Alyson Haslam  and Vinay Prasad provide lots of good reasons to question the validity of prostate cancer mortality trends. First, as any clinician who has filled out a death certificate knows, determining the underlying cause of death can be difficult in a patient with several serious health conditions. Patients with metastatic prostate cancer may die with incurable cancer, but not of it. Then, the algorithm used by the Mortality Medical Data System may introduce error, noise, and bias because prostate cancer is accepted as an underlying cause of death for many conditions (e.g., cirrhosis, bacterial endocarditis) that could be related to the cancer but could also simply co-exist.

In addition, studies show that patterns in attribution of causes of death often change over time due to factors other than actual changes in underlying causes. Changes in population composition (e.g., increases in the Hispanic and Asian proportion of the population relative to whites and African Americans) can also result in different overall prostate cancer mortality rates by increasing the percentages of populations who have lower cancer mortality.

In contrast, the methods used to determine causes of death in PLCO and ERSPC were much more rigorous; the cause listed on the death certificate was double-checked by 1 to 3 independent, blinded reviewers. These processes demonstrated that assigning a cause of death is potentially fraught with error and subject to human bias. As Chapa and colleagues observe:

Even with more rigorous processes for determining COD in the PLCO and ERSPC trials, COD determination remains difficult and is subject to uncertainty. Of all deaths in the PLCO study, 28% required additional human review because of discordance between the death certificate and the initial human reviewer. Of reviewed cases, 3% required a conference call to resolve discordance among 3 reviewers.

I've always thought that crediting PSA screening for the historical decline in U.S. prostate cancer mortality made little sense; for one thing, one wouldn't expect a mortality difference to be visible for at least 7-8 years after screening became common in clinical practice, the earliest point in the ERSPC trial when the survival curves separate. That would have been 1997 or 1998 at the earliest, not 1991. Other studies have observed that prostate cancer mortality also began falling in the U.K. in the 1990s, even though PSA screening was uncommon. This new analysis provides even more reason to doubt that there is a straightforward cause-and-effect relationship - if, indeed, there is any relationship at all.

By the way, I'd like to give a shout-out to the terrific medical podcast Plenary Session, hosted by Dr. Prasad. An interview with Dr. Chapa in a recent episode was the reason I knew about his paper in the first place. Plenary Session is too new to have made my most recent list of favorite podcasts, but you can bet that it will be on the next one.

Wednesday, May 29, 2019

Reforming medical school rankings and admissions criteria to meet urgent national needs

If you read my curriculum vitae, you might assume that I must have a high opinion of the U.S. News & World Report higher education rankings. I earned my bachelor's degree from Harvard University, #2 behind Princeton in the "Best National Universities" category. My Master of Public Health degree is from Johns Hopkins, the #1 public health school. And my medical degree is from NYU, tied with Cornell and the Mayo Clinic as the 9th ranked research medical school, and likely to move up due to its decision to go tuition-free last fall (though whether NYU will improve its middling primary care ranking is uncertain at best). To top it all off, I even wrote a blog for U.S. News for a year called "Healthcare Headaches."

I admit that when I applied to college and medical school, I placed a great deal of stock - far too much - in these rankings. (I ended up at Johns Hopkins for public health because it was local, offered a part-time/online option, and I already had connections there.) But as my formal education recedes into the rearview mirror of my career, I find, instead, that I agree with Northwestern University professor William C. McGaghie's renewed critique of the U.S. News rankings published recently in Academic Medicine.

Dr. McGaghie observed that "the methods used by U.S. News & World Report to rank medical schools are based on factors that can be measured easily but do not reflect the quality of a medical school from either a student or patient perspective." For example, 20% of the research and primary care ranking reflects "student selectivity," a combination of incoming students' mean undergraduate grade point averages (GPAs), Medical College Admission Test (MCAT) scores, and acceptance rates. These criteria may modestly predict academic performance in preclinical courses, but have virtually no impact the quality of doctors schools produce. They also have real downsides. As Dr. Arthur Kellermann, dean of the Herbert School of Medicine at Uniformed Services University, wrote in explaining his school's 2016 decision to stop participating in the U.S. News medical school rankings:

Schools have a perverse incentive to boost their rank at the expense of applicants and the public. Based on the methodology used by U.S. News, a medical school that wants to boost its rank should heavily favor applicants with super-high MCAT scores and grade point averages and ignore important attributes such as character, grit, and life experiences that predict that a student will become a wonderful doctor. A school might also encourage applications from large numbers of people with little or no chance of acceptance simply to boost its “selectivity” score.

This isn't to say that prospective medical students can't have stellar test scores and GPAs and great character and life experiences - I interview several every year. But I wonder how many outstanding future physicians we also prematurely weed out by our slavish devotion to the former metrics. I write from personal experience: my overall undergraduate GPA was 3.4, and my GPA in science prerequisite courses closer to 3.2, which caused my applications to be automatically rejected at several medical schools I applied to - including the one where I'm now a full Professor.

From the perspective of a patient or a community, the outcome that matters most for a medical school is how well it fulfills its social mission: to produce physicians who improve the health of the communities it serves, including an optimal mix of generalists and subspecialists; urban, suburban, and rural physicians; practicing physicians, teachers, and researchers. In 2010, Dr. Fitzhugh Mullan and colleagues published the first ranking of medical schools based on social mission, which eventually evolved into the Robert Wood Johnson Foundation-supported Social Mission Metrics Initiative, a national survey that enables dental, medical, and nursing school deans to receive confidential feedback on their performance in 18 social mission areas.

As Dr. Eric Topol wrote in Deep Medicine, the forthcoming integration of artificial intelligence (AI) into medical care over the next few decades is another good reason to change the way we evaluate medical school applicants:

Are we selecting future doctors on a basis that can be simulated or exceeded by an AI bot? ... Knowledge, about medicine and individual patients, can and will be outsourced to machine algorithms. What will define and differentiate doctors from their machine apprentices is being human, developing the relationship, witnessing and alleviating suffering. Yes, there will be a need for oversight of the algorithmic output, and that will require science and math reasoning skills. But emotional intelligence needs to take precedence in the selection of future doctors over qualities that are going to be of progressively diminished utility.

In another Academic Medicine commentary, Dr. Melanie Raffoul (a former Georgetown Health Policy Fellow) and colleagues offered a starting point for medical and other health professions schools to "meet the needs of tomorrow's health care system." Among other things, they proposed 1) incorporating emotional intelligence testing into admissions criteria; 2) specifically recruiting from rural and underserved settings; 3) "consciously reaching out to disadvantaged and underrepresented students at the primary and secondary education levels"; 4) establishing community partnerships to develop pools of eligible trainees; 5) bridging gaps between health care and public health; and 6) supporting health professions education research. Ironically, the most effective way to motivate schools to make these wide-ranging changes might be for U.S. News to weigh these factors heavily in next year's rankings. If that happened, my current dim view of the rankings would change dramatically.

Saturday, May 25, 2019

Reducing medication cost burden in primary care: challenges and opportunities

Earlier this month, the Centers for Medicare & Medicaid Services (CMS) finalized a new rule requiring that pharmaceutical companies disclose drug list prices in direct-to-consumer television advertisements for drugs that cost more than $35 for a month's supply or usual course. A fact sheet further explaining the rule noted that "the 10 most commonly advertised drugs have list prices ranging from $488 to $16,938 per month or usual course of therapy." Although pricing transparency could push patients to select more affordable or non-pharmacologic alternatives, and help clinicians improve high-value prescribing, it unfortunately does not make these drugs any less expensive.

In an editorial in the April 1 issue of American Family Physician, Dr. Randi Sokol discussed four strategies for helping patients with type 2 diabetes mellitus afford insulin while providing evidence-based care: 1) Relax A1c goals to 8% or less; 2) Switch to human insulins instead of insulin analogues; 3) use Health Resources and Services Administration-certified 340B pharmacies and patient assistance programs; and 4) join advocacy efforts to reduce the high cost of insulin and other drugs, such as the Lown Institute's Right Care Alliance and the American Medical Association's Truth in Rx.

Family physicians can take a systematic approach to reducing prescription costs for all of their patients. In an article published in FPM, Dr. Kevin Fiscella and colleagues described the approach taken by 7 primary care practices in New York, Georgia, and California. Office staff screen patients for prescription cost concerns by privately asking them, "Is the cost of any of your medications a burden for you?" For patients who answer yes, clinicians briefly explore the circumstances (e.g., unmet deductible, use of brand name drugs) and employ several cost-reducing strategies, including deprescribing unnecessary medications, using extended (90-day) prescriptions, and substituting lower-cost medications or referring patients to large chain pharmacy discount programs (e.g. "$4 lists").

In a preliminary study published in a supplement to the Annals of Internal Medicine, Dr. Fiscella's team found that a single 60-minute training for clinicians and staff on cost-of-medication importance, team-based screening, and cost-saving strategies increased the frequency of cost-of-medication conversations from 17% to 32%. Other helpful articles in the same supplement supported by the Robert Wood Johnson Foundation included "The 7 Habits of Highly Effective Cost-of-Care Conversations" and "Tools to Help Overcome Barriers to Cost-of-Care Conversations." The American College of Physicians offers several additional cost-of-care conversation resources on its website.


This post first appeared on the AFP Community Blog.

Tuesday, May 21, 2019

Is Common Sense Family Doctor a professional liability?

In the many talks I've given about blogging and social media over the years, one question that almost always came up was some variation of, "can being opinionated on social media hurt my career?" My usual response is no, provided that you don't do unprofessional things like post photos of identifiable patients or insult current or former supervisors. And even if some readers have been turned off by my less-is-more medical philosophy (which my friend and cardiologist John Mandrola recently termed "being a medical conservative"), for me any negative consequences of blogging are greatly outweighed by the positives. These include many speaking and writing invitations, positive recognition in family and conservative medicine communities, and appointments to practice guideline and advisory panels such as the Advisory Committee on Breast Cancer in Young Women. At the Society of Teachers of Family Medicine conference in Toronto, I was humbled by how many people introduced themselves to me the way I imagine one would approach a celebrity or high-ranking dignitary, simply because they counted themselves among my ten thousand or so Twitter followers.

That was my view, anyway, until this year. Now I wonder if my nearly 10-year commitment to blogging for Common Sense Family Doctor and other outlets (e.g., Medscape) is more of a professional liability than I believed.

Before getting into that, I want to make clear that I recognize how fortunate I've been in my career path to this point. I divide my time between teaching, editing, writing, and patient care so that these activities often complement each other, and I greatly appreciate the flexibility and support that the family medicine department at Georgetown/Medstar has provided for the past several years since I returned to academic practice. Being deputy editor of the most-read medical journal in primary care is a great privilege. I have a terrific relationship with the editor-in-chief, who goes out of her way to acknowledge the value of my contributions and has been extremely understanding when I have pursued other opportunities that could significantly reduce the time I have to devote to American Family Physician.

That said, last month I experienced a crushing professional disappointment. I had the opportunity to interview for a senior science position at an organization I greatly respect, and for which I have volunteered hundreds of hours of time over the past 5 years. The position would have involved moving my family across the country, and frankly, I could not imagine a more qualified candidate being willing to do so. In short, I thought that I had the inside track on the job. So I was shocked to receive a form e-mail from their Human Resources department just two days after my on-site interview, informing me that they had decided to move forward with another candidate. A more personal follow-up e-mail the next day explained that they wanted to fill the position more quickly than I was willing to leave my current institution and clinical practice.

Fair enough. Except this: the position is now being widely advertised again on social media and multiple listserves to which I subscribe. It clearly has not been filled by a competing candidate, and if negotiations with that candidate unexpectedly fell though, they haven't reached out to me to extend a backup offer. Did I really bomb the interview that badly? Were my shirt buttons misaligned, or was there something hanging out of my nose? It got me thinking about something that vaguely bothered me about the interview and the telephone interview that preceded it: their repeatedly asking me if I would be willing to publicly support organizational positions that I personally disagreed with. I repeatedly answered yes, explaining that I understood the nature of the position required it, and as long as I had input in coming up with any scientific stance (as they assured me I would), that would be fine by me. Maybe they didn't buy my assurances. Maybe they didn't believe that an opinionated social media star could suppress his ego in order to toe the party line. (They would have been wrong. Had I accepted this position, I fully intended to stop writing this blog and substantially tone down my Twitter feed.)

So is Common Sense Family Doctor sometimes a professional liability? It probably is; I can't say for certain either way. But as a dear friend consoled me after learning that I was not offered this position that I coveted, "they are truly missing out and we get to retain a fabulous family doc and educator at Georgetown." I hope she's right. I am grateful to my colleagues, students, and patients for making this latest disappointment sting a little bit less than it could have.

Monday, May 6, 2019

Making the case for primary care-led, federally funded clinical practice guidelines

Talk about throwing down the gauntlet. In a provocative editorial published last year in Circulation: Cardiovascular Quality and Outcomes, Dr. John Ioannidis, who in 2005 shocked the scientific research community with his article "Why Most Published Research Findings Are False," took aim at medical professional societies authoring clinical practice guidelines and disease definition statements. He observed that despite notable progress in improving the trustworthiness of guidelines since the 2011 Institute of Medicine report Clinical Practice Guidelines We Can Trust, guideline panels continue to be plagued by financial conflicts of interest, lack of methodologist involvement, and domination by specialists "who have overt preferences (even without overt conflicts)."

Recent studies support Dr. Ioannidis's points. One study found that more than half of authors of gastroenterology guidelines received industry payments between 2014 and 2016. Another study of the top 10 highest-revenue medications of 2016 determined that more than half of authors of related guidelines had financial conflicts of interest, many of which were not disclosed in the journal publications. Finally, a study evaluating levels of evidence supporting U.S. and European cardiology guidelines from 2008-2018 found that only 8 to 14% of recommendations were supported by evidence from multiple randomized, controlled trials (RCTs) or a single, large RCT, while 42% and 55% of U.S. and European recommendations, respectively, were based on expert opinion only. In sum, even when guideline authors weren't on the take, eminence-based medicine trumped evidence-based medicine.

Poorly conducted professional society guidelines don't benefit front-line clinicians, but Ioannidis noted that they do have other benefits:

Guidelines writing activities are particularly helpful in promoting the careers of specialists, in building recognizable and sustainable hierarchies of clan power, in boosting the impact factors of specialty journals and in elevating the visibility of the sponsoring organizations and their conferences that massively promote society products to attendees. However, do they improve medicine or do they homogenize biased, collective, and organized ignorance?

A way to move beyond the production of clinical practice guidelines that are essentially "industry-friendly opinion pieces" is to centralize development efforts within government health agencies, or publicly-supported independent panels such as the U.S. Preventive Services Task Force (USPSTF). A recent review of 421 clinical practice guidelines for noncommunicable diseases in primary care concluded that guidelines developed or financed by governments were substantially more likely to be rated high-quality according to the AGREE-II tool than those developed by others. Dr. Michael LeFevre, a family physician colleague and former USPSTF chairman, suggested in a 2017 editorial that public investment is "essential" to producing trustworthy guidelines:

A substantial and consistent funding stream should be available for the development of clinical practice guidelines and should be awarded competitively through a process similar to research grant funding. The logical place for this funding to occur is through the Agency for Healthcare Research and Quality (AHRQ). ... The topic, guideline development panel, and methodology would be part of a competitive grant proposal. ... Proposals receiving funding would be assigned an evidence-based practice center (EPC) to work with the guideline development panel to provide an independent systematic review of the literature. The [EPC] program would need additional funding, but the focus of the efforts would shift to be channeled to producing reviews that would be assured of being used in the development of a clinical practice guideline we can trust.

Unfortunately, funding for AHRQ has always been politically precarious, and the closure of the National Guideline Clearinghouse last year does not bode well for starting a major new program to support guideline development and assessment, even as AHRQ-supported researchers continue to break new ground with the National Guideline Clearinghouse Extent of Adherence to Trustworthy Standards (NEATS) instrument.

And what about the problem of intellectual bias - being unable to see beyond the scope of one's own limited clinical experience to evaluate evidence impartially? Dr. Ioannidis first proposed having methodologists and patients write guidelines, with content experts serving as non-voting reviewers. Alternatively,

another possibility is to recruit also to the writing team medical specialists who are unrelated to the subject matter. Involvement of such outsiders (eg, family physicians involved in cardiology guidelines) could be refreshing. These people may still have strong clinical expertise, but no reason to be biased in favor of the specialized practices under discussion. They may scrutinize comparatively what is proposed, with what supporting evidence, and at what cost. Devoid of personal stake, they can compare notes to determine if this makes sense versus what are typical trade-offs for evidence and decisions in their own, remote specialty.

As a family physician who has served on guideline panels for cardiology (Pharmacologic management of newly detected atrial fibrillation) and otolaryngology (Cerumen impaction) topics, I find a great deal of merit in the latter approach, and a similar effort led by Dr. Ray Moynihan and primary care colleagues to reform disease definitions so that potential harms of expanding diagnostic criteria are considered along with the benefits for chronic conditions such as hypertension. It's no accident that the USPSTF has long been considered an exemplar of guideline development: the panel's members are all primary care clinicians or methodologists, and have one of the strictest conflict-of-interest policies in the field. Their recommendations don't make everyone happy or anyone wealthy, and that's most likely a good thing for patients.


This post first appeared on The Daily Physician.

Wednesday, May 1, 2019

High blood pressure: is lifestyle change counseling underutilized?

Since July 2018, the U.S. Food and Drug Administration (FDA) has issued more than 20 recalls of the angiotensin-receptor blockers (ARBs) valsartan, irbesartan, and losartan because they contained potentially carcinogenic contaminants. As a result, there are now widespread shortages of these blood pressure lowering drugs that have affected many of my patients. Although the FDA's internal analyses and published studies suggest that the excess cancer risk is small even with long-term use, and the FDA has posted a list of currently available ARBs that have been tested and found safe, identifying substitutes has been difficult. Many patients prescribed ARBs already take other first-line anti-hypertensive drugs at maximum doses and/or are unable to tolerate angiotensin-converting enzyme (ACE) inhibitors due to cough.

One underutilized alternative is motivating patients with high blood pressure to make therapeutic lifestyle changes. In a Lown Right Care article in the March 15 issue of AFP, Drs. Ann Lindsay, Ajay Sharma, and Alan Glaseroff observed that "physicians ... often go straight to telling patients what to do without listening to what the patient thinks or is willing to do." Evidence suggests that patients are more likely adhere to treatment plans if physicians first get to know the patient's story and health goals, and that five key clinician behaviors are associated with better health outcomes: "(1) emphasizing patient ownership—work on patient goals; (2) partnering with patients on what they are willing and able to do; (3) identifying small steps to ensure success; (4) scheduling frequent follow-up visits to cheer successes or problem solve; and (5) showing care and concern for the patient."

A recent commentary in the Annals of Internal Medicine noted that the 2017 ACC/AHA hypertension guideline barely mentioned the value of lifestyle interventions for persons with hypertension or the barriers to providing them in primary care settings:

Practices that are not structured and staffed to systematically assess patient lifestyle factors, support behavior modification counseling, and provide follow-up will face obstacles to implementation. Clinicians in these practices also must be supported by relevant competencies; professional guidelines; routine feedback; and on-site training in practice change, such as academic detailing and practice facilitation. ... Ensuring that clinicians knowledgeable in behavior change theory and evidence-based lifestyle interventions are part of the primary care team is even more important.

Clinicians and patients may question if exercise programs have the same blood pressure-lowering benefits as medications. The answer appears to be yes. Although no randomized, controlled trials have directly compared exercise against medication, a systematic review and network meta-analysis of 391 trials found that in persons with hypertension, endurance or dynamic resistance exercise was equally effective for lowering systolic blood pressure as ACE inhibitors, ARBs, beta-blockers, and diuretics.


This post first appeared on the AFP Community Blog.

Monday, April 22, 2019

Well-woman exams: the road to poorer health is paved with good intentions

For each full day that I see patients, I generally perform 3 to 4 physical examinations in well children and adults. I am well aware of the evidence that general health checks may not improve health outcomes in adults, as well as the limitations of such studies (which are decades old and included many screening tests that are now known to be ineffective). My sense is that most of the health benefits my patients derive from checkups are not from the examination itself, but from listening and counseling. In a recent Medscape commentary, I observed that guidelines for well-woman care have appropriately moved away from largely pro forma gynecologic exams since the turn of the century:

At that time, it was not unusual for me to screen for cervical cancer in a sexually active teenager, and to advise most women to return for a Pap smear and clinical breast exam every year. I remember our clinic's medical director admonishing the residents not to skip routine breast and pelvic exams in women without symptoms.

However, I am concerned that this positive movement - de-intensifying or eliminating components of the well-woman exam that don't benefit women - appears to have stalled:

Recent federal regulations and recommendations now threaten to replace discontinued components of the well-woman exam with other well-intentioned services that unfortunately have little basis in evidence.

I discussed three examples in my commentary:

FDA-mandated language about breast density in mammography reports, leading to further testing in women with dense breasts: "While we do know that additional testing in women with dense breasts increases false-positive rates, we don't know if it improves breast cancer outcomes or only leads to more anxiety, more biopsies, and more overdiagnosis."

Annual screening for urinary incontinence, "even though the [Women's Preventive Services Initiative] group's own review found insufficient evidence that systematic annual screening improves health outcomes."

Screening for anxiety in all adolescent and adult women, "which has a similar dearth of supporting evidence on benefits and harms."

Each of these recommendations is intended to address a known problem: mammograms are less likely to identify breast tumors in women with higher breast density; urinary incontinence is common, frequently bothersome, and underreported; and anxiety reduces quality of life in many women (and men, for that matter). But a high prevalence of unidentified disease and the availability of effective treatments aren't enough to warrant screening on their own. Women deserve better than preventive care based on good intentions, which in the past led to mistakes such as prescribing menopausal hormone therapy for millions of women who either did not benefit or experienced harm. Instead, they deserve evidence-based, data-driven care.

Sunday, April 14, 2019

Reimagining advance care planning

It is difficult to overstate the damage done by the fictional political term "death panel," which claimed that a 2009 legislative proposal to pay physicians for providing counseling to Medicare patients about advance directives and end-of-life care options amounted to a group of federal bureaucrats deciding whether an older or disabled person would be permitted to live or die. Not until 2016 did the Centers for Medicare & Medicaid Services (CMS) create Current Procedural Terminology (CPT) codes that allowed billing for advance care planning services, and clinicians have been slow to use them. According to a recent study in JAMA Internal Medicine, only about 2% of Medicare fee-for-service beneficiaries age 65 years or older had advance care planning visits. As expected, geriatricians and palliative medicine specialists were more likely to use the codes than other physicians. Even so, two-thirds of hospice and palliative medicine specialists did not use the codes at all in 2017, which suggested that billing did not reflect actual counseling practices.

Other articles have documented the challenges of incorporating patients' values and preferences into care plans when they are already experiencing serious illness. An analysis of recorded clinician-family conferences about critically ill patients found that in more than half, "there was no deliberation about how to apply patients' values and preferences in the current clinical situation," and in 1 out of every 4 discussions, the patient's values and preferences were not even mentioned. Similarly, a medical oncologist reflected in Health Affairs about the care team's failure to manage expectations of a patient with advanced (and ultimately fatal) lung cancer who, "because she was looking for rescue," declined to discuss goals of care as an outpatient even as treatments proved ineffective and her health deteriorated:

I'm not sure how well we managed Wendy's care at the end of her life. On the one hand, she achieved her short-term goal of attending the family gathering. On the other hand, she spent nearly the entire last month of her life hospitalized. She died in an intensive care unit, intubated, on a ventilator, and unable to say goodbye to love ones. She was not enrolled in hospice. We don't know whether we met Wendy's goals of care because we never managed to define them.

Two editorials in the March 1 issue of American Family Physician addressed how physicians can prepare patients better for end-of-life decisions by "thinking about [advance care planning] as an iterative and integrative process," rather than as a document to be filled out and then filed away. Primary care teams can use the Serious Illness Conversation Guide to assess patients' understanding of their illness, explore what matters most to them, and communicate goals of care to family members and subspecialists. Lack of training and time constraints remain barriers, however. Innovative residency curricula on advance care planning, such as this medical-legal partnership described in Family Medicine, may improve physicians' comfort level with these conversations. Having Medicare and private insurers pay for advance care planning discussions is a helpful first step, but as Drs. Joanna Paladino and Erik Fromme observed, "clinicians cannot improve the care of people with serious illness alone—to be successful, they need health system changes that support better conversations over the continuum of care."


This post first appeared on the AFP Community Blog.

Sunday, April 7, 2019

Unequal treatment: physician payment disparities and their health consequences

As a family physician and medical school faculty member, I'm naturally a big booster of primary care. America needs more generalist physicians, and much of my professional activity involves encouraging medical students to choose family medicine, or, failing that, general pediatrics or general internal medicine. But it's an uphill battle, and I fear that it's one that can't be won without major structural changes in the way that generalist physicians are paid and rewarded for their work.

In a Medicine and Society piece in the New England Journal of Medicine, Dr. Louise Aronson (a geriatrician) described visits with two of her doctors, a general internist and an orthopedist. The primary care physician worked in a no-frills clinic, often ran behind schedule, and devoted much of the visit and additional post-visit time to electronic documentation. The orthopedist worked in a newer, nicer office with an army of medical and physician assistants; generally ran on time; and was accompanied by a scribe who had competed most of the computer work by the end of the visit. Although there are undoubtedly a few family doctors with income parity to lower-earning orthopedists, according to Medscape's 2017 Physician Compensation Report, the average orthopedist makes $489,000 per year, while an average general internist or family physician makes around $215,000 per year. Here's what Dr. Aronson had to say about that:

It would be hard, even morally suspect, to argue that the salary disparities among medical specialties in U.S. medicine are the most pressing inequities of our health care system. Yet in many ways, they are representative of the biases underpinning health care’s often inefficient, always expensive, and sometimes nonsensical care — biases that harm patients and undermine medicine’s ability to achieve its primary mission. ...

Those structural inequalities might lead a Martian who landed in the United States today and saw our health care system to conclude that we prefer treatment to prevention, that our bones and skin matter more to us than our children or sanity, that patient benefit is not a prerequisite for approved use of treatments or procedures, that drugs always work better than exercise, that doctors treat computers not people, that death is avoidable with the right care, that hospitals are the best place to be sick, and that we value avoiding wrinkles or warts more than we do hearing, chewing, or walking.

Medical students are highly intelligent, motivated young men and women who have gotten to where they are by making rational decisions. For the past few decades, as the burden of health care documentation has grown heavier and the income gap between primary care physicians and subspecialists has widened, they have been making a rational choice to flee generalist careers in ever-larger numbers.

The cause of these salary disparities - and the reason that more and more primary care physicians are choosing to cast off the health insurance model entirely - is a task-based payment system that inherently values cutting and suturing more than thinking. I receive twice as much money from an insurer when I spend a few minutes to freeze a wart than when I spend half an hour counseling a patient with several chronic medical conditions. That's thanks to the Resource-Based Relative Value Scale, a system mandated by Congress and implemented by Medicare in 1992 in an attempt to slow the growth of spending on physician services. Every conceivable service that a physician can provide is assigned a number of relative value units (RVUs), which directly determines how much Medicare (and indirectly, private insurance companies) will pay for that service.

As new types of services are developed and older ones modified, the RVUs need to be updated periodically. Since the Centers for Medicare and Medicaid Services (CMS) chose not to develop the in-house expertise to do this itself, it farms out the updating task to the Relative Value Scale Update Committee (RUC), a 31-member advisory body convened by the American Medical Association (AMA) and nominated by various medical specialty societies. Here is where the fix is in. Only 5 of the 31 members represent primary care specialties, and over time, that lack of clout has resulted in an undervaluing of Evaluation and Management (E/M) and preventive services (the bulk of services provided by generalist physicians) compared to procedural services. Although an official AMA fact sheet pointed out that some RUC actions have increased payments for primary care, a 2013 Washington Monthly article countered that these small changes did little to alter the "special deal" that specialists receive:

In 2007, the RUC did finally vote to increase the RVUs for office visits, redistributing roughly $4 billion from different procedures to do so. But that was only a modest counter to the broader directionality of the RUC, which spends the vast majority of its time reviewing, updating—and often increasing—the RVUs for specific, technical procedures that make specialists the most money. Because of the direct relationship between what Medicare pays and what private insurers pay, that has the result of driving up health care spending in America—a dynamic that will continue as long as specialists dominate the committee.

We teach our medical students to recognize that inequities in where patients live, work and play are far more powerful in determining health outcomes than the health care we provide. A child living in a middle-class suburb has built-in structural advantages over a child living in a poor urban neighborhood or rural community, due to disparities in economic and social resources. The same goes for how physicians are paid in the U.S. Until the RUC is dramatically reformed or replaced with an impartial panel, the $3.5 trillion that we spend on health care annually (20 percent of which pays for physician services) will continue to produce shorter lives and poorer health compared to other similarly developed nations.


This post first appeared on Common Sense Family Doctor on July 20, 2017.

Monday, April 1, 2019

Apps that detect atrial fibrillation may not improve health

The March 15 issue of American Family Physician included a recommendation statement from the U.S. Preventive Services Task Force (USPSTF) and Putting Prevention Into Practice case study on screening for atrial fibrillation with electrocardiography (ECG). The USPSTF concluded that current evidence is insufficient to assess the balance of benefits and harms of testing for atrial fibrillation in primary care patients without suggestive symptoms. In an accompanying editorial that I solicited, cardiologists John Mandrola and Andrew Foy discussed several potential downsides of ECG screening for atrial fibrillation: low prevalence, a high number needed to screen to prevent one stroke, high costs, false positive results, and uncertainty about the effects of anticoagulants in persons with subclinical atrial fibrillation.

At the American College of Cardiology (ACC) meeting last month, Dr. Mandrola interviewed Dr. Mintu Turakhia, a co-principal investigator of the Apple Heart Study, regarding initial findings reported at the conference. More than 400,000 U.S. adults with Apple Watches installed a paired smartphone app that used an algorithm to analyze heart rate variability and notified users if five out of six samples over a 48-hour period suggested an irregular heart rate. Of the 2100 individuals (~0.5%) who received these notifications, the positive predictive value for ECG-confirmed atrial fibrillation was 84%. The app's sensitivity and false negative rate are unknown because users who did not receive notifications did not have ECG monitoring. Also, the study was not designed to evaluate health outcomes. In a Medscape commentary, Dr. Mandrola chided the ACC for calling so much attention to these preliminary, disease-oriented data:

Given the stark inequities of care in the United States and globally, I question the morality of dedicating this much attention to a study on a low-risk population, a group that already enjoys relatively excellent health. ... Smart watches and digital health will deliver oodles more information. This, along with hype, will surely enrich the makers of devices, and in turn the medical industry. I remain skeptical that it will improve the human condition. It could even make us sicker.

A planned pragmatic randomized trial will enroll adults age 65 years and older to determine if screening for atrial fibrillation and other heart rhythm abnormalities using the Apple Watch app leads to reduced stroke rates and/or improved cardiovascular health. In the meantime, family physicians will likely start seeing more patients for evaluation of possible cardiac rhythm abnormalities detected by wearable devices. A recent JAMA article reviewed the limitations of such devices at detecting atrial fibrillation, tachycardia, and bradycardia and offered a suggested approach to evaluation and management.


This post first appeared on the AFP Community Blog.

Sunday, March 24, 2019

Patients, Populations and Policy: Season 1, Episode 2

This is the second of two podcast episodes that I created specifically for my first-year medical student class. It discusses the evolution of physician payment, the major components of the Affordable Care Act, and proposals for future health care reforms. If you haven't yet listened to episode 1, which provides some basic background information on the U.S. health system, you can find it here. And I don't intend to stop at two episodes, so if you like what you hear, please subscribe to the podcast feed to receive notifications when I release more later this year. My P3 podcast will also soon be available on ITunes, Google Play, Spotify, and Stitcher. Thanks for listening!

Thursday, March 14, 2019

Nonselective full-tuition scholarships don't produce more primary care physicians

Last August, I wrote about NYU School of Medicine's decision to award full tuition scholarships to all current and future medical students, and my skepticism that this generous policy would achieve my alma mater's stated goals of recruiting a more socioeconomically diverse student body and sending more graduates into primary care fields. I was not the only person to gently criticize NYU's approach to these important issues; a few days later, Kaiser Health News editor and former emergency medicine physician Elisabeth Rosenthal wrote in a New York Times opinion piece that "instead of making medical school free for everyone, NYU - and all medical schools - should waive tuition only for those students who commit to work where they are needed most." As an example, she pointed to selective scholarships awarded by NYU's law school each year to 20 students who commit to careers in low-wage public service. Dr. Rosenthal also argued that since academic medical centers receive billions of dollars in public funds to train new doctors and don't pay taxes due to their nonprofit status, "Every academic medical center should see training the medical work force America needs not as charity but as an obligation, a 'community benefit' of the highest order."

As for increasing diversity, another laudable goal, Dr. Billy Thomas wrote in a JAMA Viewpoint:

If medical school admissions processes continue to be weighted toward metrics [e.g., GPAs, MCAT scores] and the number of minority, disadvantaged, and marginalized applicants remains stagnant, attempts to diversify the health care workforce will fall far short, despite reduced or free tuition. ... The NYU program may increase diversity at NYU, but taken in context with the stagnant national applicant pool, the increased enrollment at NYU may result in a “zero sum effect” on the national health care workforce as it relates to diversity and, by extrapolation, have no significant effect on our efforts to reduce health disparities and improve population health.

When I interviewed prospective Georgetown medical students this year, NYU usually came up in conversation, from the medical diploma hanging on my wall, if nothing else. Of course they had all applied to NYU, and if accepted, they'd most likely attend, no matter how much they loved Georgetown or Hopkins or Harvard or anywhere else without free tuition. Indeed, total applications increased by almost 50 percent, and applications from underrepresented groups more than doubled.

Another problem: according to an analysis of public data on medical school endowments, enrollment, and tuition expenses by two students at Mount Sinai (which had a brief but unsuccessful merger with NYU in the late 1990s), only 20 of 141 U.S. medical schools are financially positioned to afford going tuition-free for all students. Notably, even NYU shrunk its class size by at least a third from its size at the time of my graduation, presumably to lower the cost of providing every student with a scholarship. Like NYU, Harvard, which unsurprisingly tops the list of wealthy schools, doesn't even have a family medicine department, where establishing one would be an investment more likely to pay off for primary care than simply making school free with no service requirement.

Meanwhile, Dr. Bich-May Nguyen, a family physician with whom I've previously collaborated, just published a report in Family Medicine of a survey of 74 physicians who graduated from two BS/MD programs in Texas from 2003 through 2013 that provided full scholarships for college and medical school. 18 of these physicians went into primary care, which is about average for medical students nationally. Dr. Nguyen and her coauthor noted that the motivations for these physicians' specialty choice were similar to those from surveys of physicians who only received partial or no tuition assistance:

People interested in primary care were also interested in serving underserved or minority populations, health promotion, patient continuity, and patient advocacy. ... The second theme was found in statements supporting high income potential, prestige among colleagues, inpatient hospital care, and quick results from interventions. ... Additionally, the respondents most interested in high incomes did not enter primary care.

Ultimately, there are far less expensive solutions to the problems that NYU was supposedly trying to address by waiving medical school tuition. Want a more diverse student body? Admit more minority and low-income students. Want more students to go into family medicine and primary care? Establish and support departments in those fields, and admit more of the types of students who tend to pursue primary care. They won't necessarily have the highest GPAs or MCAT scores or the social advantages bestowed by wealthy parents (and potential future donors), but as the recent college admissions scandal showed, those things are overrated anyway.

Wednesday, March 6, 2019

Do subspecialist-led guidelines serve patients better - or worse?

In December 2017, the Health News Review blog posted a story questioning why there had been such extensive news coverage of the American College of Cardiology / American Heart Association hypertension guideline but so little of the American Academy of Family Physicians' announcement that it was not endorsing the guideline (the only other news outlets to have reported this decision are the AAFP's own news publication and Medscape). In this case, the AAFP decided to continue to adhere to blood pressure targets established by the JNC-8 hypertension guideline and its joint guideline with the American College of Physicians for adults aged 60 years or older.

Earlier that year, an editorial in the cardiology journal Hypertension criticized the ACP-AAFP guideline for the lack of "experts" on its panel. The 30 named authors of this 3-page piece, most of whom I suspect did not meet the International Committee of Medical Journal Editors' authorship criteria, collectively have a list of disclosures of commercial conflicts of interest that takes up nearly a column of text. Those concerns aside, Dr. Franz Messerli and colleagues stated correctly that "guidelines are traditionally scripted by a panel of experts who are intimately familiar with the topic in question." They went on to compare the glittering resumes of the JNC-8 panel ("most of them were indeed true experts") with the more pedestrian ones of the ACP/AAFP panel and asserted that the latter's dearth of expertise did not qualify them for guideline development:

As per PubMed, 3 of the 7 guideline authors have never authored an article on hypertension and 1 has coauthored a single study only. Moreover, not one of the authors of the ACP/AAFP guideline is known to be a hypertension specialist certified by the American Society of Hypertension or of the American Heart Association Council for High Blood Pressure. ... No ACP/AAFP guideline author is currently serving on the editorial board of a journal dealing with hypertension. ... The mere fact that you know how and when to prescribe hydrochlorothiazide does not make you an expert in hypertensive cardiovascular disease.

This argument echoed past complaints by subspecialty groups that the U.S. Preventive Services Task Force (USPSTF), made up entirely of primary care clinicians, could not possibly know what it was doing when it recommended fewer screening mammograms (without any radiologists!) or less prostate-specific antigen testing for prostate cancer (without any urologists!)

The question is not whether subspecialists should be involved in developing guidelines for diagnosis and management of common conditions such as hypertension: of course they should be. The question is, on what level? At the guideline review and revision phase (ACP/AAFP) or in developing the key recommendations? The ACC/AHA selected as one of its guideline co-chairs Dr. Paul Whelton, a renowned expert in hypertension who was the principal investigator for the SPRINT study, the only major trial to show that a blood pressure target of 120/80 yielded more benefits than harms compared to a blood pressure target of 140/90 in a selected group of very high-risk patients. In recognition of this intellectual bias, Dr. Whelton was relieved from chairing duties when SPRINT came up, but apparently was able to fully participate in the discussion and vote.

I had the pleasure of meeting Dr. Whelton at a conference a few years ago and came away enormously impressed by his intelligence and equanimity. But it's very hard for anyone to see something - in this case, harms of lower blood pressure thresholds - if your scientific reputation depends on your overlooking it. Also, in my experience as a staffer for the USPSTF, panel members who did not treat the condition being screened for were able to follow the evidence without being biased by clinical experience. Pediatricians who weren't conditioned to order yearly mammograms or obstetrician-gynecologists who never ordered PSA tests were more often assets than liabilities on these topics.

Primary care clinicians, particularly family physicians, have unrivaled expertise in treating the whole person, not only one body part or organ system. As I noted in a Medscape commentary on the ACC/AHA hypertension guidelines, "Cardiologists have the luxury of only needing to be concerned with cardiovascular disease, but the vast majority of my patients with hypertension have comorbid chronic conditions and take several medications. Adding one more anti-hypertensive drug means more potential side effects, medication interactions, and costs to the patient and the health system." Kudos to the AAFP for having the courage to stick with the evidence and buck the one-low-blood-pressure-target-fits-all trend.


This  post first appeared on Common Sense Family Doctor on December 21, 2017.

Wednesday, February 27, 2019

Improving outcomes that matter for patients with type 2 diabetes

When comparing therapies for type 2 diabetes, physicians, patients, and quality measures often get caught up in the disease-oriented outcome of glycemic control. However, a 2014 editorial in American Family Physician pointed out that of the medications then available to lower blood sugar levels, only metformin reduced mortality and clinically relevant complications. Since that time, studies of some newer diabetes medications have demonstrated mortality benefits in patients with cardiovascular disease. However, the best second-line medication after metformin remains unclear. Although the World Health Organization guideline recommended inexpensive sulfonylureas as second-line therapy in low-resource settings, the American College of Physicians and the American Academy of Family Physicians suggested "the choice of drug [after metformin] should be based on a conversation with the patient about benefits, possible harms, and cost."

In the February 15 issue of AFP, Drs. Joshua Steinberg and Lyndsay Carlson applied the STEPS criteria (safety, tolerability, effectiveness, prince, and simplicity) to each of the 10 categories of diabetes medications (including insulin). Their analysis confirmed that metformin should be first-line pharmacotherapy for most persons with type 2 diabetes. Other key points from this article include:

Safety - Sulfonylureas, insulins, meglitinides, and pramlintide increase risk of hypoglycemia. Metformin and acarbose require monitoring, dose adjustments, or discontinuation in patients with chronic kidney disease.

Tolerability - Side effects across different drug classes range from gastrointestinal effects (metformin, acarbose, meglintinides, pramlintide, GLP-1 receptor agonists, SGLT-2 inhibitors) to weight gain (sulfonylureas), edema (TZDs), severe arthralgias (DPP-4 inhibitors), and genital and urinary tract infections (SGLT-2 inhibitors).

Effectiveness - Recent trials showed improved patient-oriented outcomes from some GLP-1 receptor agonists and SGLT-2 inhibitors in patients at high cardiovascular risk or with known cardiovascular disease. Acarbose also reduces cardiovascular events.

Price - Metformin, acarbose, sulfonylureas, and generic pioglitazone are the most affordable options.

Simplicity - Acarbose and meglitinides are taken three times daily before meals, while insulins, GLP-1 receptor agonists, and pramlintide require subcutaneous injections.


This post first appeared on the AFP Community Blog.