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.

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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.

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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.

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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.

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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."

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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.

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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.

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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.

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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.

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This post first appeared on the AFP Community Blog.

Tuesday, February 19, 2019

Living, teaching, and valuing the pursuit of health equity

My younger son, who turned seven last week, had a minor health scare in December. After a few days of a cough and runny nose, one morning he complained that he didn't want to walk because his legs hurt. We gave him some liquid ibuprofen, wondering if these were just growing pains, but the pain kept coming back. Adding to our concern, this is a child with a high threshold for pain; for example, he barely blinked when having a cavity filled at age three. Over the next week or so, he developed red and purple blotches on his lower legs and feet that looked like this and this.

After consultations with our family doctor and other physician friends and family, he was diagnosed with Henoch-Schonlein purpura, a relatively rare condition that, fortunately, resolves spontaneously in most but can cause kidney disease in up to half of affected patients. Through the first week of January, his legs continued to hurt off and on as the rash slowly faded, but his kidney function remained normal, and the only medical bills we received were from a single clinic visit and some outpatient blood tests covered by our health insurance. We were lucky, not only because my son avoided complications, but because we had the advantage of being well positioned to obtain further care for him had they occurred.

Adjusted U.S. ESRD incidence rates, 2000-2015

Last week, I led a team-based learning exercise for the first-year class at Georgetown University School of Medicine on disparities in kidney (renal) disease. Not only are some racial and ethnic groups more likely to suffer from end-stage renal disease (when kidney function has deteriorated to the point that dialysis or a kidney transplant is often needed), but this unequal burden is unevenly distributed geographically, reflecting disparities in socioeconomic status. The graphic below, showing much higher rates of end-stage renal disease in the majority-African American northeast and southeast quadrants of Washington, DC, coincides with my years of practicing in these areas and noticing clusters of fast-food chains and dialysis centers around primary care clinics.

End-stage Renal Disease in Washington, DC

Similar large disparities in mortality and life expectancy are present nationally. In a 2006 paper, Dr. Christopher Murray (profiled in Jeremy Smith's "Epic Measures") described "Eight Americas," collections of U.S. counties defined by a mixture of race, geography, socioeconomics, and population density that demonstrated striking differences in mortality patterns. In a more recent analysis, Dr. Murray and colleagues concluded that geographic disparities in life expectancy have worsened over the past three decades: "Compared with the national average, counties in Colorado, Alaska, and along both coasts experienced larger increases in life expectancy between 1980 and 2014, while some southern counties in states stretching from Oklahoma to West Virginia saw little, if any, improvement over this same period."

Observing that overall U.S. life expectancy has been falling since 2015 after decades of steady improvement, a recent editorial in the Annals of Internal Medicine called on health research funders to "honestly recognize the interactive roles of biology and the socioeconomic and political environment ... [and] align health research resources toward an integrative model of science that seriously investigates the socioeconomic and political determinants of health alongside the biological ones." Reducing disparities in HIV/AIDS, for example, will require not only more clinical resources and affordable drugs, but more studies of policy interventions to improve social and living conditions that increase the risk of acquiring HIV infections in the first place. This means going beyond meeting individual-level social needs to changing the conditions that make people sick in communities and populations (including the Eight Americas).

As "value-based" health care payment models rapidly expand, based on the argument that we ought to be paying for good health outcomes rather than the volume of health services, we are recognizing that social determinants put some populations at a health disadvantage that effective interventions, such as increasing primary care physician supply, cannot fully overcome. As a result, physicians and health systems who serve underserved populations may be judged as providing "poor quality" care (and paid less) simply because their patients' outcomes were so much worse to begin with.

What can be done about this? Dr. Krisda Chaiyachati and colleagues have argued for a "disparities-sensitive frame shift" in value-based payment:

The health care industry cannot ignore true instances of poor quality, but it also should not worsen health care for at-risk populations. To address this tension, value-based payment models should ... integrate measures of equity into hospitals' financial calculus, incentivizing hospitals to tackle the disparities challenge without losing sight of quality. ... Concurrently, we should start paying hospitals to reduce disparities directly.

Similarly, Dr. Christopher Frank observed that "value-based payments will only work when we decide that health equity is an important value to reward."

Make no mistake: I'm happy that my son got well and has stayed well. I'm not happy that it is inherently more difficult for other children to have the positive outcome that he experienced. Reducing these disadvantages and pursuing health equity informs my clinical practice, teaching in population health, and writing projects.

Monday, February 11, 2019

Does subspecialist-oriented medical care add sufficient value to be worth the added cost?

The latest Graham Center One-Pager in the February 1 issue of American Family Physician contained good news and bad news for primary care. Examining the entry of medical students into residency programs between 2008 and 2018, Dr. Robert Baillieu and colleagues reported that the total number of graduates who entered Family Medicine through the National Residency Matching Program increased by 64% over the past decade. However, the annual proportion of U.S. allopathic (MD) graduates remained static at around 50%, reflecting the continued migration of most students into higher-paying medical subspecialties.

Two of my previous posts reviewed research demonstrating that students entering family medicine are more likely to make patient-centered, cost-conscious clinical decisions and that primary care physicians who trained in low-cost hospital service areas are more likely to provide high-value care in practice. The late health services researcher Barbara Starfield, MD, MPH once argued that a lack of investment in primary care is a major reason that the U.S. health system spends so much but produces poor outcomes:

The thing that is wrong with our current health care system is that it is not designed to produce the best effectiveness, efficiency and equity in health services because it is too focused on things that are unnecessary and of high cost rather than arranging services so that the most needed services are provided when needed and with high quality. [This] is the case because the country has not put sufficient emphasis during the past 50 years on a good infrastructure of primary care. ... We have done a reasonably good job at making subspecialty care available, but a lot of subspecialty care is not necessary if you have good primary care. So we end up with a very expensive system that does things unnecessarily.

In a recent nationally representative study in JAMA Internal Medicine, Dr. David Levine and colleagues examined associations between receipt of outpatient primary care and care value and patient experience. Using Dr. Starfield's definition of primary care as "first-contact care that is comprehensive, continuous, and coordinated," the authors compared the quality and experience of care in more than 70,000 U.S. adults with and without primary care who participated in the Medical Expenditure Panel Survey from 2012 to 2014. 70% of the primary care clinicians identified by patients were family physicians (19% were general internists). After adjustment for potential sources of confounding, respondents with primary care were more likely to receive high-value preventive care and counseling and to report better patient experiences than those without primary care. However, respondents with primary care were also slightly more likely to receive low-value prostate cancer screening and antibiotics for respiratory infections.

In an accompanying editorial that noted the disparity in primary care investment between the U.S. (7% of total health care spending) and the health systems of other industrialized nations (20%), Dr. Allan Goroll asked: "Does primary care add sufficient value to deserve better funding?" Although this formulation recognizes that the American status quo is a subspecialist-oriented health system, it seems to me that the question ought to be, "Does subspecialist-oriented medical care add sufficient value to primary care be worth the added cost?" From this study and previously published evidence, the answer appears to be no.

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This post first appeared on the AFP Community Blog.

Wednesday, January 30, 2019

What do recent publications mean for men with localized prostate cancer?

From 2012 to 2018, the U.S. Preventive Services Task Force and the American Academy of Family Physicians recommended not screening for prostate cancer, based on evidence that the then-widespread practice produced no net benefit. As a result, fewer family physicians subsequently screened their patients with the PSA test, and fewer men were diagnosed (or overdiagnosed) with localized prostate cancer. However, the USPSTF's recent change to a more permissive approach to PSA-based screening has increased the likelihood that more men will need to make difficult decisions regarding what to do about a prostate cancer diagnosis.

As I discussed in a previous AFP Community Blog post, surveyed men with newly diagnosed localized prostate cancer expected to gain a whopping 12 years of life expectancy by undergoing surgery or radiation. In fact, two randomized, controlled trials found no gains in prostate cancer-specific or all-cause mortality. After nearly 20 years of follow-up, the U.S. Prostate Cancer Intervention versus Observation Trial (PIVOT) reported in 2017 that radical prostatectomy reduced the likelihood of treatment for asymptomatic, local, or biochemical (PSA) disease progression compared to observation, but caused more urinary incontinence, erectile dysfunction, and limitations in activities of daily living. Similarly, the U.K. Prostate Cancer for Testing and Treatment (ProtecT) trial found that active surveillance was comparable to radiotherapy or prostatectomy, with a slightly greater likelihood of clinical progression and metastatic disease in the active surveillance group.

A 2018 article reviewed the evolving National Comprehensive Cancer Network guidelines for treatment of localized prostate cancer, which recommend incorporating comorbidity-adjusted life expectancy into screening and treatment decisions:

The comorbidity-adjusted life expectancy is particularly important because the number of comorbid diseases is among the most significant predictors of survival after prostate cancer treatment. Prostate cancer is usually slow growing, and the survival benefit of treatment may present only after 10 years. Therefore, patients with low-risk or very low-risk prostate cancer should be treated only if the patient has a comorbidity-adjusted life expectancy of at least 10 years.

An older Swedish randomized trial comparing radical prostatectomy to watchful waiting in men with predominantly clinically-detected (rather than PSA-detected) localized prostate cancer found that radical prostatectomy was associated with less than 3 years of life gained after 23 years of follow-up. Altogether, the evidence suggests that curative treatments may be worthwhile for selected men with symptoms, but that there is little or no benefit to looking for prostate cancer in men who feel well.

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This post first appeared on the AFP Community Blog.

Monday, January 21, 2019

When deprescribing is the best medicine

Physicians who care for older adults or others with multiple chronic conditions understand that deprescribing unnecessary or inappropriate therapies is central to providing high-quality care and improving patient safety. An editorial by Drs. Barbara Farrell and Dee Mangin in the January 1 issue of American Family Physician reviewed the health risks associated with polypharmacy (taking five or more chronic medications) and provided a table of resources for each step of the deprescribing process, including several evidence-based guidelines co-written by the authors. AFP's Practice Guidelines department summarized their guideline on deprescribing antipsychotics for dementia and insomnia last year and reviewed how to taper benzodiazepine receptor agonists for insomnia in adults in the January 1 issue.

A 2018 systematic review in the British Journal of General Practice reviewed data from 27 randomized, controlled trials of deprescribing a range of drug classes in adults aged 50 years or older in primary care settings. In 19 studies, at least half of patients in the intervention groups were able to stop their medications completely, and adverse effects were uncommon. However, the risk of "relapse" (needing to resume the drug after completely discontinuing it) ranged from 2 to 80 percent.

Patient expectations, medical culture, and organizational constraints can present barriers to deprescribing. A qualitative study of New Zealand primary care physicians in the Annals of Family Medicine described deprescribing as "swimming against the tide." Study participants recommended several practice and system-level interventions to support deprescribing that could also be applied to practices in the U.S.:

- Targeted funding for annual medicines review
- Computer alerts to prompt physicians’ memories
- Computer systems to improve information sharing between prescribers
- Improved access to non-pharmaceutical therapies
- Research to build the evidence base in multimorbidity, education and training
- Ready access to expert advice and user-friendly decision support
- Updating guidelines to include advice on when to consider stopping medicines
- Tools and resources to assist in the communication of risk to patients
- Activating patients to become more involved in medicines management and alert to the possibility that less might be better

Along those lines, the AFP editorial also provided a Table of examples of language that family physicians can use to discuss deprescribing with patients and facilitate shared decision-making.

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This post first appeared on the AFP Community Blog.

Thursday, January 17, 2019

Birthday reflections: envisioning my third act

I'm celebrating my 43rd birthday today, and nearly a decade of blogging at Common Sense Family Doctor. Although 2018 was the first year in which I wrote fewer than one post per week (46 total), I haven't slowed my writing output overall, authoring or co-authoring ten journal articles or textbook chapters last year and kicking off 2019 with a new study in the Journal of the American Board of Family Medicine on conversations on Twitter about women and Black men in medicine. I am grateful to my longtime colleague Dr. Ranit Mishori (@ranitmd) for coming up with this novel research idea and inviting me to join the team.

The changing of the calendar prompts me to reflect more on my career arc as a family physician, researcher, educator, and author. I have been thinking of my career thus far as an ongoing series of "acts," each lasting for several years. The first act began in 2004 with a year-long editing and faculty development fellowship at Georgetown, continued through my time as a medical officer at AHRQ, followed by a year working in urgent care, and concluded with my re-joining the family medicine department as a full-time faculty member and associate deputy editor of American Family Physician and earning my Master of Public Health degree from Johns Hopkins.

In the second act, beginning around 2012-2013, I gradually built my outpatient primary care practice in northwest DC (a handful of patients found me first through my blog); developed and enhanced medical school courses and a fellowship program involving population health, health policy and advocacy; and was promoted to professor of family medicine and deputy editor of AFP. To be sure, there have been setbacks along the way, including, recently, the disappointment of not advancing to the interview stage in my application for the open editor position at the Annals of Family Medicine.

2019 feels to me like the start of Act 3, although I can't fully articulate why. Maybe it's because in my 15th year of practice I have clearly entered mid-career. My patients are getting older, and more of them now struggle with chronic diseases and chronic pain and are spending time in various local hospitals. With my paths to editorial leadership of prominent family medicine journals closed off for at least the next decade (barring the unexpected), I have turned my energies toward developing new features such as AFP's Lown Right Care department and, together with collaborators at Lown, Georgetown, and in Louisiana, am working on a systematic review for the first time in years. My public speaking continues to focus on overuse, particularly of screening tests whose benefits are overvalued and harms are underappreciated. My four kids (ages 4 through 12) keep growing, my wife's house calls practice and nonprofit are thriving, and our family has no plans to leave the DC area anytime soon - again, barring the completely unexpected.

Act 3. The curtain rises. What does this next act have in store for me?

Monday, January 7, 2019

Guest Post: How the medical profession can help heal divisions as well as diseases

Richard Gunderman, MD, PhD, Indiana University

Medicine need not be confined to the role of cultural bellwether, a sheep with a bell on its neck that reveals where the whole flock is headed. Along with other professions such as law, clergy and education, medicine can and should play the leadership role of a shepherd, helping our society to develop more thoughtful, balanced and generous approaches to the challenges that face us. After all, the word doctor means teacher, and our culture needs the best instruction we can offer. The dawn of a new year makes the time ripe for such a shift in medicine’s role.

Doctors as teachers

In serving as educators, doctors have many resources to draw on. They are among the best educated groups in our society, having pursued one of our the longest and most intense courses of study. In practice, they regularly participate in moments that help to clarify what life is all about – birth and death, growth and aging, suffering and relief. And they serve as trusted confidantes and counselors to patients and families at some of life’s most meaningful moments.

Popular culture has reflected an erosion of the doctor as teacher and role model. In the 1960s and 70s, television doctors such as Dr. Kildare and Marcus Welby epitomized virtues such as dedication and compassion. Then along came “M.A.S.H.” and “St. Elsewhere,” which adopted a more irreverent attitude toward medicine and the people who practice it. By 2004’s “House,” which ran for eight seasons, the doctor had degenerated into a clever but deeply misanthropic opioid addict.

First, do no harm

As a physician and educator, I think that, for medicine to help heal our culture, doctors must embrace their role as advocates for principles that have long represented the core of the healing professions. Although “Primum non nocere, or ”First, do no harm,“ does not appear in the writings of the "father of medicine” Hippocrates, it is often cited as medicine’s first principle. And the idea that doctors should avoid harm is part of the modified Hippocratic Oath that most doctors take when they graduate from medical school.

This principle does not imply that doctors should never harm. After all, no surgeon could ever operate and no oncologist could ever administer chemotherapy if they rigorously adhered to it. It means instead that risks and harms must always be balanced against benefits, and that where the balance is too uncertain or unfavorable, it is better to do nothing. More broadly speaking, we should avoid saying things or acting in ways that cause needless injury.

What would “Do no harm” look like in our popular culture? First, it would mean eschewing personal attacks, which seek to label people as unworthy, disgusting, or evil. In public discourse, our goal should be to understand different points of view, to educate one another, and to take the interests of others into account in arriving at decisions. Physicians are expected to take good care of even patients they find disagreeable, and this an outlook sorely deficient in the U.S. today.

Get the whole story

A second habit deeply ingrained over the course of medical training is to recognize that there are usually more than two sides to any question. Suppose a patient complains of pain in the right lower quadrant of the abdomen, a classic symptom of appendicitis. Only poor physicians would confine their attention to the question, “Is it appendicitis or not?” The real issue at hand is to determine what is causing the pain and what needs to be done about it.

In popular culture, complex matters are often reduced to highly simplified dichotomies, in which the two sides are portrayed as sporting white and black hats. It seems as though all Americans need to know is whether a person is a Democrat or Republican, a conservative or a liberal, or a reader of The Washington Post or The Wall Street Journal. In fact, however, making good choices requires an understanding far deeper than which side of a political divide a person is on.

Good doctors learn quickly that a cursory inspection can be deeply misleading, as a story once told by a colleague reveals. An elderly, disheveled, incoherent woman was brought to the emergency room with a broken arm. The staff took her for a homeless person. Later, however, she started to make sense, and provided her phone number. When her family came to pick her up, they arrived in a chauffeured limousine. In this as in so many cases, what first met the eye turned out to be quite deceptive.

Put service before self

To become really good doctors, medical students need to learn something: Patients do not exist to provide careers to physicians; instead, physicians exist to care for patients. Like other professionals, doctors need to put the interests of their patients first. The overarching goal is not to advance the physician’s career, to generate more income, or to secure the business interests of a medical practice or hospital. The goal is to care well for the patient.

The founders of the U.S. knew that human beings are not angels, but they also believed that people can look beyond narrow self-interest and do what is best for others and the larger whole. They knew that serving a purpose beyond self is one of the surest ways to find meaning and purpose in life, and that those who contribute the most often lead the fullest lives. They bet their own lives on the proposition that Americans could answer the call of their better selves.

By serving as exemplars of what a life of service looks like in communities across the country, doctors and other professionals can remind Americans of all ages what human beings at their best are really capable of. To look out only for number one is to lose hope in neighbors, communities and society. To get to know others, to take an interest in their stories, and to reach out and serve when they need help and support is one of the signs of a hopeful, thriving culture.

The idea of medicine as a cultural beacon of goodness may seem profoundly counter-cultural. Our appetite seems much greater for stories of doctors whose financial or sexual misconduct has disgraced themselves and the profession. Yet for the professions to play a role in reshaping our habits of mind and heart, their members must act courageously, not waiting until the cultural winds have shifted but letting their better voices speak even when no one else seems to be listening.The Conversation

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