Thursday, July 9, 2020

Reopening schools (or anything else) safely depends on first containing the virus

If you have young children, you probably breathed a huge sigh of relief when the school year ended. For my wife and me, working from home while taking turns keeping track of our kids' various Zoom meetings and their teachers' creative class assignments (including science projects involving neighborhood nature walks and open flames in the kitchen) was an exhausting ordeal. Yet in some ways we were lucky; unlike many children who lost educational ground, our kids adapted well to online learning, and the older ones were able to help the younger ones stay on task when their attention spans faltered.

Surely, we expected, by the start of the school year in the fall, the pandemic would be under control.

Unfortunately, with less than two months until Labor Day, COVID-19 still very much has the upper hand in the United States. Although pockets of the nation (including the Washington, DC area) have successfully reduced viral spread, two-thirds of states have seen increasing case numbers over the past two weeks, driving new national record highs each day. Belying President Trump's contention that the rising numbers are solely the result of increased testing, the number of infected patients hospitalized and in intensive care units are rising overall and skyrocketing in several states, and the number of daily deaths, which had been trending down since mid-April, is also on the rise.

If you want to read about how the U.S. became an international outlier in the fight against COVID-19 and who is to blame, check out James Fallows' story in The Atlantic, "The 3 Weeks That Changed Everything," and Jonathan Mahler's profile of Michigan governor Gretchen Whitmer's response to the crisis in The New York Times Magazine. A recent JAMA viewpoint also explored four types of cognitive bias that drove poor policy responses: identifiable victim effect (responding more aggressively to threats to identifiable lives than to projected statistical deaths), optimism bias (assuming that the best case scenario is most likely), present bias (preferring smaller immediate benefits to larger future benefits), and omission bias (preferring that a harm occur by failure to take action than as a direct consequence of actions taken). Regarding the latter, the authors wrote:

Policy makers who do not advocate for increasing the ventilator supply, and clinicians who follow triage guidelines, may perceive that they are responsible for the [COVID-19] deaths. In contrast, responsibility is more effortlessly evaded for causing greater numbers of deaths through failures to enact policies that effectively suppress viral spread.

Omission bias explains why federal and state leaders moved heaven and earth to increase supplies of mechanical ventilators and hospital capacity, but dragged their feet on recruiting public health contact tracers, mandating mask wearing, and keeping businesses and schools closed where community spread of the infection remained high.

The American Academy of Pediatrics (AAP) published guidance for school re-entry that "strongly advocates that all policy considerations for the coming school year should start with a goal of having students physically present in school." On the surface, this guidance seems to support the Florida education commissioner's order that all public and charter schools open in the fall for in-person instruction and President Trump's recent declaration that schools will re-open nationally or forego federal funds. However, the AAP's president clarified that states should not force school districts to re-open where transmission of the virus is clearly out of control.

There is much that we still don't know about the contribution of school-aged children to COVID-19 spread and the potential risks classroom exposures to adult teachers, administrators, cafeteria workers, and janitorial staff (who will likely shoulder the additional burden of frequently sanitizing shared spaces). Guidance from the Centers for Disease Control and Prevention (CDC) and the public health organization Resolve to Save Lives combines the best science and common sense to provide schools with strategies to minimize risk when and if they hold in-person instruction. But as former CDC Director Tom Frieden and the Education Secretaries under Presidents Obama and George W. Bush wrote in an editorial today:

The single most important thing we can do to keep our schools safe has nothing to do with what happens in schools. It’s how well communities control the coronavirus throughout the community. Such control of COVID-19 requires adhering to the three W’s—wear a mask, wash your hands, watch your distance—and boxing in the virus with strategic testing, effective isolation, complete contact tracing, and supportive quarantine—providing services and, if necessary, alternative temporary housing so patients and contacts don’t spread disease to others.

I hope that all of my children can return to school in person in the fall. But if they do, I want it to be because elected representatives and public health leaders have taken appropriate steps to contain COVID-19 and make school environments as safe as humanly possible, not due to political pressure or reckless executive orders.

Monday, June 29, 2020

A graduation address for the COVID-19 era

If you watched your child graduate this year, as I did my older son's junior high school ceremony at the end of May, you most likely did so online. The same for my participation in the virtual graduation ceremony for Georgetown University School of Medicine's Class of 2020, which included 17 family physicians who start their internships in July. Two years ago, I was inspired to write about Dr. Atul Gawande's moving graduation address to UCLA's newest physicians. This year, I turn the clock back to 2012, when Dr. Don Berwick addressed Harvard Medical School's graduating students; his speech later appeared as an essay in JAMA's A Piece of My Mind.

Dr. Berwick, as longtime readers of Common Sense Family Doctor know, is one of my heroes. I finally had the opportunity to meet him in person in early March, when he delivered the Georgetown University School of Nursing & Health Studies Values Based Lecture. He recently captured the essence of that talk about the "Moral Determinants of Health" in another JAMA essay that is well worth reading, but in this post I will focus on "To Isaiah," his Harvard graduation address from eight years ago.

Isaiah is the name of one of Dr. Berwick's past patients, a Black teenager from the Roxbury neighborhood of Boston who developed acute lymphoblastic leukemia and received the "the best of care ... the glory of biomedical science," including chemotherapy and a curative bone marrow transplant. But biomedical science - then and now - proved to be no match for poverty and despair:

Isaiah smoked his first dope at age 5. He got his first gun before 10, and, by 12, he had committed his first armed robbery; he was on crack at 14. Even on chemotherapy, he was in and out of police custody. For months after his transplant he tricked me into extra prescriptions for narcotics, which he hoarded and probably sold. Two of his five brothers were in jail—one for murder; and, two years into Isaiah's treatment, a third brother was shot dead—a gun blast through the front door—in a drug dispute. ...

His world was the street corner and his horizon was only one day away. He hated it, but he saw no way out. He once told me that he thought his leukemia was a blessing, because at least while he was in the hospital, he couldn't be on the streets. And Isaiah died. One night, 18 years after his leukemia was cured, at 37 years of age, they found him on a street corner, breathing but brain-dead from a prolonged convulsion from uncontrolled diabetes and even more uncontrolled despair. ...

Isaiah, my patient. Cured of leukemia. Killed by hopelessness.

Dr. Berwick went on to tell HMS's Class of 2012 that Isaiah's story demonstrated that they had two duties as new physicians. One, to "go to the mat" for their patients, always putting their needs first and advocating for health care to be recognized as a human right in the United States. The second duty was "more subtle - but no less important":

Maybe this second is not a duty that you meant to embrace; you may not welcome it. It is to cure, not only the killer leukemia; it is to cure the killer injustice. ... One million American children are homeless. More people are poor in the United States today than at any other time in our nation's history; 1.5 million American households, with 2.8 million children, live here on less than $2 per person per day.

I am not blind to Isaiah's responsibilities; nor was he. He was embarrassed by his failures; he fought against his addictions, his disorganization, and his temptations. He tried. I know that he tried. To say that the cards were stacked against him is too glib; others might have been able to play his hand better. I know that; and he knew that.

But to ignore Isaiah's condition not of his choosing, the harvest of racism, the frailty of the safety net, the vulnerability of the poor, is simply wrong. His survival depended not just on proper chemotherapy, but, equally, on a compassionate society. ... Isaiah, in his legions, needs those in power—you—to say to others in power that a nation that fails to attend to the needs of those less fortunate among us risks its soul. That is your duty too.

Our nation's health care professionals have been "going to the mat" to treat patients with COVID-19 for the past four months. In doing so, hundreds have already lost their lives. To their credit, the Congress and the President rapidly enacted legislation to reduce obstacles to coronavirus testing and care created by our patchwork health care system, where at least 27 million are uninsured and tens of millions with insurance still cannot afford to see a doctor or pay for essential medications. Thus far, there has been no similar national initiative to eradicate injustice, even as millions have peacefully protested incidents of police violence and people of all races, from all places, have signaled support for the Black Lives Matter movement.

Doctors have participated in many protests, leading some to label them hypocrites because of the real possibility that the protests could accelerate COVID-19 community spread (though early findings from Washington State suggest that their contribution has been minor as compared to indoor social gatherings without masks). Thus far, the Washington, DC metro area is one of few in the country that has seen a sustained decline in cases despite large protests and tear gassing of protestors. But as imposing a public health problem COVID-19 remains, it pales in comparison to the morbidity and mortality toll of racism, social injustice, institutionalized inequality, and poverty - all factors which have fed the pandemic and contributed to the disproportionate devastation the virus has caused in communities of color. To respond to Dr. Berwick's "second duty," it is absolutely right and appropriate for all physicians to take a knee against injustice, and to use the power of our medical degrees to make our political representatives "go to the mat" for the most vulnerable Americans.

Wednesday, June 24, 2020

Artificial intelligence in primary care: progress and challenges

As applications of artificial intelligence (AI) in health care multiply, AI-enabled clinical decision support is coming to primary care. For example, a recent article in the Journal of Family Practice discussed applications of machine learning (ML) software to screening for diabetic retinopathy (DR) and colorectal cancer, and a study in the Journal of the American Board of Family Medicine utilized ML to create a new clinical prediction tool for unhealthy drinking in adults. Although research on primary care AI remains limited in scope and diversity of authorship, Drs. Winston Liaw and Ioannis Kakadiaris argued in a Family Medicine commentary that appropriately guided, such research could help preserve the parts of primary care that physicians and patients value most:

The digital future is not a passing trend. We will not return to paper charts. The volume of information we are expected to manage will not decline. Without a strategy for our digital present and future, our specialty risks being paralyzed by data, overwhelmed by measures, and more burned out than we already are.

We can define our future, by embracing AI and using it to preserve our most precious resource—time with patients. Adaptation to this new reality is key for our continued evolution, and AI has the potential to make us better family physicians. ... For AI to elevate the practice of family medicine, family medicine needs to participate in relevant design, policy, payment, research, and delivery decisions.

Evaluation and implementation of AI-based clinical approaches is challenging. In addition to being externally validated and corrected for biases, ML models should be transparent about data sources and assumptions and quantify and communicate uncertainty. In addition, involvement of clinicians in model building and adoption into clinical decision support systems is essential.

In the Diagnostic Tests feature in the March 1 issue of American Family Physician, Dr. Margot Savoy reviewed an application that adheres to all of the best practices for AI in primary care. IDx-DR, a software program that uses AI to analyze retinal images from an automated nonmydriatic camera, is approved by the U.S. Food and Drug Administration for DR screening in adults 22 years and older. In a prospective study of 819 adults with diabetes recruited from 10 primary care practices, IDx-DR correctly identified 173 of the 198 patients with more than minimal DR according to the reference standard.

In a separate project, Google Health researchers evaluated the implementation of a deep learning algorithm for DR detection in 11 clinics in Thailand, a country with low screening and early treatment rates due to a shortage of ophthalmologists. Unexpected issues arose, according to an article in the MIT Technology Review:

When it worked well, the AI did speed things up. But it sometimes failed to give a result at all. Like most image recognition systems, the deep-learning model had been trained on high-quality scans; to ensure accuracy, it was designed to reject images that fell below a certain threshold of quality. With nurses scanning dozens of patients an hour and often taking the photos in poor lighting conditions, more than a fifth of the images were rejected.

Patients whose images were kicked out of the system were told they would have to visit a specialist at another clinic on another day. If they found it hard to take time off work or did not have a car, this was obviously inconvenient. Nurses felt frustrated, especially when they believed the rejected scans showed no signs of disease and the follow-up appointments were unnecessary.

Like all primary care tools, the way that AI-enabled decision support is implemented in real life will contribute as much to its success or failure as test results under optimal conditions.


This post first appeared on the AFP Community Blog.

Thursday, June 18, 2020

Less medicine, more health? COVID-19 pandemic provides a natural experiment

One of my favorite health care books of 2015 was Less Medicine, More Health: 7 Assumptions That Drive Too Much Medical Care, by Dr. Gil Welch, a general internist who was then a health services researcher at Dartmouth. After resigning his position at the college in 2018 in the wake of an at-best-questionable accusation of plagiarism, he joined the Center for Surgery and Public Health at Brigham and Women's Hospital and has continued to produce excellent work, including an insightful analysis of prostate cancer mortality trends and more recently, a CNN opinion piece with Dr. Vinay Prasad about "the unexpected side effect of COVID-19." In their CNN piece, Welch and Prasad pointed out that the much lower utilization of the U.S. health care system during the pandemic has provided a unique opportunity to for researchers to examine if certain high-volume medical interventions (e.g., physicals, cancer screenings, orthopedic surgery, and surgery for low-risk cancers) actually improve health outcomes:

After Covid-19, if we dare imagine the day, it will be important to ask who was harmed by delayed and forgone medical care. But the severe financial strains on individuals and public budgets make it just as essential to ask who benefited from avoiding interventions with no salutatory effect. ... Covid-19 provides a once in a lifetime opportunity to study what happens when the well-oiled machine of medical care downshifts from high to low volume in order to focus on acutely ill patients. It will be comfortable for physician researchers to study what was lost. It will be courageous for them to study what was gained.

If a physical necessarily includes laying hands on patients, I haven't done one in more than 3 months, as my practice has shifted almost entirely to telehealth. To tell the truth, I haven't missed these physicals much. I've long been a skeptic of the value of a general health checkup in adults, even though in our fee-for-service payment system they are essential to primary care practices paying the bills (and their absence has led to many practices facing bankruptcy as the pandemic grinds on). It's not just that physicals are often a waste of time and money, though - sometimes, they can even be harmful.

In a 2014 JAMA essay that was re-published in this year's theme issue marking 40 years of of "A Piece of My Mind," Dr. Michael Rothberg recounted the near-fatal cascade of testing that began with his 85 year-old father's checkup with a new primary care physician. This doctor, who felt a possible aortic aneurysm on the abdominal examination, ordered an ultrasound scan (which revealed no aneurysm, but saw something in the pancreas), followed by a CT scan (which revealed a normal pancreas, but saw a lesion on the liver), followed by a liver biopsy that revealed a hemangioma, a benign but extremely vascular tumor that bled profusely and required the transfusion of 10 units of blood. He spent a painful week in the hospital not being able to urinate without a catheter and received a $50,000 bill for his troubles - inspiring the essay's title, "The $50,000 Physical."

I could tell you several similar stories of testing cascades that went wrong from my own decade-and-a-half in practice; probably every general internist or family physician who isn't fresh out of residency has at least one. Of course, no organization recommends screening for an aortic aneurysm in a healthy 85 year-old man, but no one recommends ordering a chest x-ray or electrocardiogram at a physical either, or doing a Pap smear in a woman younger than 21 or older than 69, and these "low value" (really, "no value") screening tests still happen far too often. A retrospective cohort study published last week in JAMA Internal Medicine found that adults in Ontario who received those 3 particular tests ended up having significantly more subspecialist visits and subsequent (likely unnecessary) diagnostic tests or procedures in the next 90 days.

"De-implementation" is the formal health services research term for "figuring out how to do fewer things to patients that do more harm than good." Just as COVID-19 has accelerated an overdue transition to providing more health care virtually, I hope that it will also inspire researchers to "study what was gained" from postponed or cancelled appointments with family doctors and surgeons. If the pandemic has a silver lining, this might be it.

Sunday, May 31, 2020

An epidemic of inequality

On June 23, 1982, when I was six years old, Vincent Chin, a Chinese American resident of Michigan celebrating his bachelor party with friends, was bludgeoned to death with a baseball bat by two white men. Ronald Ebens and stepson Michael Nitz, auto workers who had both been affected by competition from Japanese companies (Nitz had been recently laid off), hurled racial slurs at Chin, whom they mistook for being of Japanese descent. Both men were charged with second-degree murder and pleaded guilty to manslaughter, which typically carries up to a 15 year jail sentence. Instead, Judge Charles Kaufman fined them a total of $3000 and sentenced them to 3 years' probation, stating in a letter that "these weren't the kind of men you send to jail."

Outraged Asian Americans in the Detroit metro area and around the nation took to the streets to protest the verdict. As documented in the final episode of the PBS documentary "Asian Americans," this senseless murder was a particularly bitter pill for Asian Americans to swallow; after a century of being labeled the "model minority" and doing everything we could to blend in, we were in fact still viewed by most whites as "perpetual foreigners."

Chin's family eventually brought federal civil rights charges against Ebens and Nitz, the first time that this statute had been used for a hate crime against someone other than African Americans. Although Ebens was sentenced to 25 years in prison, the verdict was overturned on appeal. Chin's mother Lily, who died in 2002, was quoted as saying: "What kind of law is this? What kind of justice? This happened because my son is Chinese. If two Chinese killed a white person, they must go to jail, maybe for their whole lives... Something is wrong with this country."

Something is still wrong with this country. Although reported hate crimes against Asian Americans had been declining since 2003, and in 2017 were a small fraction of the number reported against black, Muslim, and Jewish Americans, this changed with the arrival of COVID-19. Fueled by politicians throughout March calling SARS-CoV-2 the "Chinese virus," Chinese Americans, and other Americans of Asian descent who are confused with being Chinese, have increasingly been the targets of racist tirades and worse as the pandemic spread throughout the U.S.

Meanwhile, in the words of a Medscape commentary, COVID-19 has "unveiled a tale of two Americas," as it has ruthlessly exploited entrenched health disparities in black and Hispanic Americans who have long suffered the effects of structural racism. Nationally, black Americans are three and a half times more likely, and Hispanic Americans twice as likely, to die from COVID-19 than white Americans. You can see this on a local level in the District of Columbia, where the largely minority-populated Northeast and Southeast quadrants have had many more cases diagnosed than the largely white Northwest quadrant, and black residents (who comprise just 46% of the population) have suffered a stunning 86% of the deaths. As Ed Yong wrote in his latest article in The Atlantic:

Vulnerability to COVID-19 isn’t just about frequently discussed biological factors like being old; it’s also about infrequently discussed social ones. If people don’t have health insurance, or can afford to live only in areas with poorly funded hospitals, they cannot fight off the virus as those with more advantages can. If people work in poor-paying jobs that can’t be done remotely, have to commute by public transportation, or live in crowded homes, they cannot protect themselves from infection as those with more privilege can. These social factors explain why the idea of “cocooning” vulnerable populations while the rest of society proceeds as normal is facile. That cocooning already exists, and it is a bug of the system, not a feature. Entire groups of people have been pushed to the fringes of society and jammed into potential hot zones.

Thousands of Americans have taken to the streets this weekend to protest the murders of George Floyd and Ahmaud Arbery by Minnesota police officers and self-appointed vigilantes, respectively. Whether the offenders will receive punishments commensurate to these crimes, or if they will be let off with slaps on the wrist, like Ebens and Nitz in 1982 or George Zimmerman in 2013, remains to be seen. But in a larger sense, the protests are about more than simply the unjust deaths of individuals. They are about the continuing tolerance of too many Americans to fatal inequalities in our systems of justice, housing and health care that stack the deck against persons of color and rob them of more than a decade of life. Whether it's the President of the United States repeatedly lying about the impact of COVID-19; the closing of essential hospitals in underserved minority or rural communities; or a modern-day epidemic of amputations in black Americans in Southern former slave states; these protests are an expression of deep-seated rage about an epidemic of inequality that men and women in power have long minimized, dismissed or ignored.

Wednesday, May 27, 2020

Multisystem inflammatory syndrome associated with COVID-19 in children

One of the few comforting findings in the COVID-19 pandemic has been that most children older than one year of age have a less severe clinical course than adults. A large case series from China suggested that about half of infected children have mild symptoms (acute upper respiratory tract infection or gastrointestinal symptoms, including diarrhea) while only 1 in 20 develop hypoxia, respiratory failure, or other organ failure. In a U.S. case series, two-thirds of infants younger than 12 months were hospitalized; the corresponding figure in older children was 5 to 15 percent. As a pediatric infectious diseases specialist at New York University told a New York Times reporter, "The idea that children either don't get COVID-19 or have really mild disease is an oversimplification."

On April 7, Hospital Pediatrics published a case report of a 6 month-old infant who was hospitalized for classic Kawasaki disease and had a positive result on a reverse transcription polymerase chain reaction (RT-PCR) test for COVID-19. At that time, it was not clear if the COVID-19 diagnosis was coincidental or associated with this rare vascular inflammatory condition. On May 7, the Lancet published a report of a cluster of 8 cases of children with hyperinflammatory shock (atypical Kawasaki disease, Kawasaki disease shock syndrome, or toxic shock syndrome) who presented to a children's hospital in London during a 10-day period in the middle of April. Within one week, more than 20 children with similar clinical features were admitted to the pediatric intensive care unit (PICU), half of whom tested positive for SARS-CoV-2. Around the same time, reports in a pediatric journal described severely ill children with COVID-19 in Washington, DC and New York City.

In Bergamo, Italy, the incidence of Kawasaki-like disease increased 30-fold between February and April at the height of the epidemic. Compared to a historical group of children with Kawasaki disease prior to the pandemic, these children were older and had a higher rate of cardiac complications. Investigators in France and Switzerland described a series of 35 children (31 of whom tested positive for SARS-CoV-2) who were treated in PICUs for acute heart failure due to a severe inflammatory state.

On May 14, the U.S. Centers for Disease Control and Prevention (CDC) issued an official health advisory to provide information to clinicians about multisystem inflammatory system in children (MIS-C) associated with COVID-19. The case definition for MIS-C is as follows:

- An individual aged < 21 years presenting with fever, laboratory evidence of inflammation, and evidence of clinically severe illness requiring hospitalization, with multisystem (>2) organ involvement (cardiac, renal, respiratory, hematologic, gastrointestinal, dermatologic or neurological); AND

- No alternative plausible diagnoses; AND

- Positive for current or recent SARS-CoV-2 infection by RT-PCR, serology, or antigen test; or COVID-19 exposure within the 4 weeks prior to the onset of symptoms.

Fortunately, standard treatment for Kawasaki disease (described in a 2015 article in American Family Physician), including intravenous immunoglobulin, corticosteroids, and aspirin, thus far appears to be effective in treating MIS-C associated with COVID-19.


This post first appeared on the AFP Community Blog.

On June 17, the Center for Health Journalism hosted an informative webinar on MIS-C. A pediatrician spoke for the first 20 minutes about the experience of Washington, DC's Children's National Hospital, followed by noted journalist Pam Belluck answering questions about responsible health reporting on this syndrome.

Wednesday, May 20, 2020

The end of the beginning?

On November 10, 1942, after British forces led by Generals Harold Alexander and Bernard Montgomery decisively defeated a German-Italian army led by the "Desert Fox" (Field Marshal Erwin Rommel), at the Battle of El Alamein in Egypt, Prime Minister Winston Churchill gave a speech where he memorably declared of the war against the Nazis, "Now this is not the end. It is not even the beginning of the end. But it is, perhaps, the end of the beginning."

Although the progress of the fight against the COVID-19 in the U.S. remains, in the words of science writer Ed Yong, a "patchwork pandemic," the numbers of new cases of and deaths from the virus have either stabilized or are heading downward in most states and in the Washington, DC area, while hospital and public health contact tracing capacity has been growing. Practically every state has started cautiously easing restrictions on movement and public places and allowing shuttered businesses to reopen with social distancing measures in place. Although some politicians would like to declare victory over the virus, this is not the end. It is not even the beginning of the end. But it is, perhaps, the end of the beginning.
After I deployed this Twitter survey, some colleagues in medicine and public health suggested that I had left off some important terms, notably "social distancing," "exponential growth," and "flatten the curve." I agree. Notably, though, all four options received votes, and the top vote-getter, herd immunity, did not quite receive a majority. So I thought I'd provide my perspective, as a family physician and population health teacher, on what each of these terms mean and how they have sometimes been misinterpreted by the general public.

Herd immunity: the concept that once a pathogen has infected a certain percentage of the population (how much depends on how contagious it is) and they have developed immunity, there are fewer susceptible hosts, which not only slows the spread but also indirectly protects non-immune persons. For vaccine-preventable infections like measles and pertussis (which causes whooping cough), herd immunity is especially important for protecting persons who have contraindications to immunization (for example, infants too young to be vaccinated or immune-compromised persons).

However, for COVID-19, some have suggested that rapidly achieving herd immunity should be a national goal, even in the absence of an effective vaccine. They pointed at Sweden, an country that stands alone among developed nations in not instituting an economic lockdown (though mass gatherings have been banned and social distancing is still strongly encouraged). Nonetheless, by early May, only about 25 percent of the population of Stockholm had developed antibodies to SARS-CoV-2 and Sweden currently has the highest per-capita COVID-19 death rate in the world without any perceptible economic benefits. In New York City, in March and April the epicenter of the pandemic in the U.S., a study found that only 1 in 5 people had antibodies to the virus - far short of a herd immunity threshold even though hospitals and morgues were overrun and 1 out of every 400 people died. As Five Thirty Eight calculated, "If the [COVID-19] fatality rate is around 0.5 percent and 70 percent of Americans have to get sick before their immunity starts protecting others, that means more than 1.1 million people would die." Personally, I think that the most likely projection of 140,000 U.S. deaths given existing social distancing measures is a national catastrophe, but 1,100,000 deaths is totally unacceptable.

Quarantine: refers to the isolation of persons who have been exposed to a contagious disease for the maximum duration of the time it takes from the time of exposure to becoming symptomatic. For COVID-19, the recommended duration is 14 days. This is not the same thing as "self-isolation" of persons with known infections or "lockdown" (government-mandated travel restrictions). Yes, I intentionally misused this term in my previous post, but "self-isolation / lockdown reading" just sounded too weird.

Contact tracing: refers to the practice of identifying and contacting persons who have been exposed to a known infected individual so that they can be assisted in quarantining themselves and connected to resources (including health care) if needed. Smartphone tracking apps can help facilitate this process, but are not a substitute for real people working the phones. If you are interested in learning more about becoming contact tracers for your states and communities, Johns Hopkins University is offering an excellent free online course on this topic. For contact tracing to be effective in preventing new COVID-19 outbreaks, however, it is critical that the general population trusts the tracers and adheres to their recommendations. In a widely suspicious community, riled up by armed protests about government encroachment on their freedoms (to travel to one's second home, to work out at the gym, to go bowling, etc.), I worry that many people may ignore public health workers telling them to stay home, and will continue infecting others.

Antibody testing: blood testing for antibodies to SARS-CoV-2 that can help determine if an individual has been exposed to the virus. My colleague Dr. Mark Ebell has pointed out that with current far-from-perfect tests and a low prevalence in most communities (particularly in persons without respiratory symptoms), false positive test results will be common. Most critically, even a "true positive" antibody test result does not guarantee that an individual is protected from COVID-19, or for how long. We just don't know yet how durable immunity is or how long it lasts. So if you get a blood test that suggests you have antibodies, don't discard your mask or stop social distancing because you think you can't get infected or infect others.

Tuesday, May 12, 2020

Quarantine reading list: my collected book reviews

Whether you are self-isolating at home because your state remains under a stay-at-home order, you had recent close contact with someone with COVID-19 (as have several members of the White House's Coronavirus Task Force), or you have been presumptively or definitely diagnosed with the disease yourself, you may have more time to read. If you are interested in reading about a health topic other than the current pandemic, here are links to all of the book reviews I have written for Family Medicine and Common Sense Family Doctor over the past decade.

Generally positive reviews:

Range: Why Generalists Triumph in a Specialized World, by David Epstein (2020)

Pulse, Voices From the Heart of Medicine. Editor’s Picks. A Third Anthology, edited by Paul Gross, Diane Guernsey, Johanna Shapiro, and Judy Schaefer (2017)

Ending Medical Reversal, by Vinay Prasad and Adam Cifu (2015)

Epic Measures, by Jeremy N. Smith (2015)

What Every Medical Writer Needs to Know, by Robert B. Taylor (2015)

The Great Prostate Hoax, by Richard Ablin (2014)

Between the Lines: Finding the Truth in the Medical Literature, by Marya Zilberberg (2012)

Your Medical Mind, by Jerome Groopman and Pamela Hartzband (2011)

Overdiagnosed: Making People Sick in the Pursuit of Health, by H. Gilbert Welch (2011)

The Color of Atmosphere, by Maggie Kozel (2011)

The Immortal Life of Henrietta Lacks, by Rebecca Skloot (2010)

Medicine in Translation, by Danielle Ofri (2010)

Mixed reviews:

Health Systems Science, edited by Susan E. Skochelak and Richard E. Hawkins (2018)

Fractured: America's Broken Health Care System and What We Must Do to Heal It, by Ted Epperly (2012)

In Stitches, by Anthony Youn (2011)

Another source of book recommendations is my annual top ten favorite public health and health care book lists from the past five years:


Finally, I highly recommend two notable new books by the above-named authors: Dr. Vinay Prasad's Malignant: How Bad Policy and Bad Evidence Harm People with Cancer (which I peer reviewed and later endorsed for the Johns Hopkins University Press) and Dr. Danielle Ofri's When We Do Harm: A Doctor Confronts Medical Error.

Saturday, May 2, 2020


The late Senator John McCain has long been one of my heroes. His story is familiar to most Americans: as a 31 year-old naval aviator during the Vietnam War, he was shot down and captured by the North Vietnamese in October 1967. He remained a prisoner of war for five and a half years. During that time, he was frequently subjected to unimaginably harsh physical and psychological torture, including two full years in solitary confinement. It may be less well known that he had an easy way out. After his father, a U.S. Navy Admiral, was named commander of all U.S. forces in the Vietnam theater in mid-1968, McCain's captors offered to release him. By this time, McCain had lost 50 pounds and was near death. Nonetheless, he refused, citing the U.S. military code of conduct, which advises officers not to accept special favors from the enemy and to agree to be released in the order they were captured. It's likely that McCain was motivated not only by adherence to the code, but by solidarity with his fellow prisoners-of-war, many of whom had endured captivity for considerably longer.

Americans have now endured several weeks of "shelter-in-place" or "lockdown" orders enacted to mitigate the effects of COVID-19, which as of May 2 had claimed nearly 65,000 lives nationally, including more than 2,000 in DC, Maryland, and Virginia. As states begin to cautiously loosen public health restrictions in the hope of restarting their economies, there are increasing signs that many citizens are losing patience with social distancing: cell phone data show increased movement outside of homes, large crowds in California turned out to protest beach closures, and heavily armed men invaded Michigan's state capitol to protest the governor's stay-at-home order.

I've written before about the "girl in the well" phenomenon, a psychological effect that causes us to be captivated by news about one or small numbers of endangered persons (remember the Thai Cave Rescue in 2018?) but shrug our shoulders when thousands or millions are at risk. If you don't personally know anyone who has been hospitalized or died from COVID-19, you might be wondering if the continuing sacrifice is really worth it. You miss going out to dinner with family and friends, worshiping with your faith community, watching or participating in your favorite sports. Maybe your child or favorite niece or nephew won't be able to attend their prom this year or experience the thrill of an in-person graduation ceremony. Maybe you wonder: is the cure worse than the disease?

I am a doctor, but I'm not on the front lines. Thus far, all of my patients who have had COVID-19 have recovered, and most haven't needed to be hospitalized. But the hundreds of patients who have been admitted to my hospital haven't been nearly as fortunate, and some, sadly, aren't making it out alive. Every day at the office (yes, I still commute to a physical office, even though I haven't seen a patient in person in more than a month), I strongly advise my most vulnerable patients to stay home or keep their distance from others when they must go out for grocery shopping or exercise. But I can't protect them adequately without your help. You can take the easy way out: start getting together with friends again, discard the mask - and frankly, odds are that you, personally, will probably be okay. Or, in the patriotic spirit of John McCain, who championed a "cause greater than self," you can stoically endure this shelter-in-place for as long as it takes to flatten the curve on this unprecedented pandemic, out of solidarity for millions of potential victims you don't know but who are depending on you to do the right thing.

Tuesday, April 28, 2020

Mitigating the effects of widespread school closures

Excepting a few countries like Denmark that have managed to flatten their infection curve, primary and secondary schools around the world have now been closed for a month or more due to the public health imperative to slow the spread of COVID-19 through physical distancing. Parents and guardians, many of whom have lost jobs or recently transitioned to telework themselves, have struggled to keep track of and connect their children with online educational activities designed to replace in-person learning. I know - I'm one of those parents.

Unfortunately, evidence suggests that distance learning, no matter how carefully designed, does not fully replace in-person instruction. A 2016 report from the National Alliance of Public Charter Schools found that students who attended full-time virtual public charter schools had consistently lower engagement, academic gains, and performance than those in traditional public schools, regardless of demographics. Worse, a considerable proportion of U.S. students have not participated in online learning due to not having personal computers or home Internet access.

Extrapolating from studies of summer learning loss, the educational nonprofit Northwest Evaluation Association recently projected that relative to a typical academic year, students returning to school this fall may only retain 70 percent of reading gains and 50 percent or less of math gains. To make up for these losses, some school districts are planning to extend school into the summer, shrink their curricula, or repeat some of last year's lessions next year. Another controversial idea for high-poverty schools is having all students repeat their current grade, given the potential for further interruptions due to a second or third wave of COVID-19 in the fall.

Prior to COVID-19, chronic absenteeism (defined as missing at least 10 percent of the academic year, or about 18 days) already affected about 14% of American students from kindergarten through 12th grade. According to an American Family Physician article on school absenteeism, it not only has negative effects on academic performance and graduation rates, but also worsens future social functioning, health status, and life expectancy. Reasons for absenteeism vary from chronic or serious illness (including mental illness) to academic challenges, parenting problems, bullying and victimization, and other social stressors such as food insecurity and homelessness. Family physicians and pediatricians can help by performing an assessment of students with frequent absences and referring students and families to one or more appropriate interventions.


This post first appeared on the AFP Community Blog.

Tuesday, April 21, 2020

Don't miss these important prostate and lung cancer screening studies

In a time when the most common cause of death in older Americans is COVID-19, it seems nearly old-fashioned to write about screening for prostate and lung cancers, which, respectively, account for a small proportion of overall deaths in men (prostate) and only in smokers rivals mortality from heart disease (lung). But while the pandemic has riveted media attention on COVID-19 studies of questionable value, including non-peer reviewed preprints and uncontrolled case series, I think it's still important to highlight two notable recent publications on pitfalls of cancer screening.

I generally advise my average-risk patients not to have prostate cancer screening. Even viewing the evidence in the most optimistic light, few men are helped and many more are harmed. Notably, for this linked graphic the U.S. Preventive Services Task Force used the prostate cancer mortality risk reduction estimated in the European screening trial, the only one of three major PSA screening trials (the others were conducted in the U.S. and United Kingdom) to show any benefit whatsoever. And, as I explained in an earlier blog post, relying on observational trends in prostate cancer mortality to deduce benefits from screening is fraught with problems.

In a new analysis in the New England Journal of Medicine, Drs. Gil Welch and Peter Albertsen dive deeper into the prostate cancer mortality data and its implications for screening. They propose an explanation for a trend that I had always found puzzling: before starting to decline in the early 1990s (which some experts attribute to the effect of screening, but Welch and Albertsen argue convincingly must also be the result of improved treatment), mortality rose between 1970 and 1990 by more than 30 percent. This earlier mortality increase likely resulted from "sticky diagnosis bias," which occurred because transuretral resections of the prostate (TURP) procedures were widely used to treat benign prostatic hyperplasia (BPH) in older men, leading to many more incidental diagnoses (or overdiagnoses) of prostate cancer that ended up on death certificates. Welch and Albertsen go on to explain why "decreasing prostate cancer mortality may be a misleading metric in evaluating PSA screening":

Screening may more easily change the distribution of causes of death (trading off one cause for another) than extend life (as implied by promises to “save lives”). This issue is particularly relevant to PSA screening, since the median age at death due to prostate cancer is so high — 80 years (as compared with 72 for lung cancer and 68 for breast cancer). For the elderly, the combination of a high burden of competing risks for death and high rates of intervention-related complications conspires to limit any reduction in all-cause mortality offered by screening.

Of course, length of life is not the only relevant outcome; quality of life is equally important. If screening helped avert the pain that can be associated with metastatic disease, that would change the calculus, but it is not clear that it often does. Furthermore, the quality-of-life question has two sides. Prostate cancer treatment itself results in substantial morbidity: surgery and radiation can produce impotence and bowel and bladder problems; antiandrogen therapy leads to hot flashes, decreased stamina, and metabolic syndrome. Which group of men — the treated or the untreated — feels a bigger effect on quality of life can be debated.

From a statistical perspective, screening for lung cancer has always held more promise than screening for prostate cancer, since many more people (men and women) die prematurely from the former. Based on consistent results from several randomized trials, the medical consensus is that low-dose CT screening in carefully selected older smokers (or former smokers) reduces lung cancer mortality, and, possibly, all-cause mortality. However, as I've argued in the past, the potential harms of LDCT make it essential that clinicians discuss the pros and cons of screening with patients first, rather than universally recommending it.

A study in JAMA Internal Medicine assessed the informational content of 162 lung cancer screening program websites, half at academic medical centers and half at community medical centers. The authors found that 98 percent of web sites described potential benefits, but only 48 percent described potential harms, with community centers being even less likely (40 percent) to mention any harms. Overdiagnosis, which is arguably the most substantial harm since it usually leads to unnecessary invasive treatment, was mentioned by only 14% of academic centers and none of the community centers. Granted, going to a website is only the first step toward actually being screened for lung cancer, but it's discouraging that this content is so unbalanced.

On the Lown Institute blog,  Judith Garber pointed out one reason for the "big benefit, little or no harm" messages that these websites send:

It is important to acknowledge the profit motive behind screening. If we reimbursed hospitals not for the volume of procedures done, but the outcomes for patients, we would likely a much greater effort to target individuals who would most benefit from screening, rather than hospitals trying to persuade as many people as possible to get screened.

Thursday, April 9, 2020

Learning health policy during a pandemic

Last week marked my first major foray into virtual teaching. At Georgetown, the first-year medical student class was told to stay home after Spring Break in order to slow the spread of COVID-19 in Washington, DC and its suburbs. The week of teaching health policy went about as well as I could have expected - my home wireless network held up, no one Zoom bombed any lectures or large group activities, I figured out how to use Panopto, and with fewer distractions than during a normal year, few students missed learning sessions. I also updated my podcast from last year, recording a new conclusion to the episode (embedded below) on health care reforms since the Affordable Care Act.

We are living in unprecedented times, with our health care system under enormous stress from the COVID-19 pandemic and little relief in sight. At this time last year, I predicted that incremental health care reforms would be the most likely outcome of the upcoming Presidential and Congressional elections, regardless of who won. But the evolving U.S. response to the novel coronavirus has exposed glaring deficiencies in our national preparedness, as well as the organization of the health care workforce and the usual way we practice medicine. It’s forced us to re-examine questions such as: how much health care really needs to be provided in person? Does our current physician-centered payment system discourage developing innovative models of care? And perhaps most importantly, in the face of a highly contagious disease, is excluding 25 or more million uninsured persons from the health care system no longer justifiable, if it ever was?

As the COVID-19 curve begins to show signs of flattening in New York and New Jersey after a staggering death toll, the pandemic continues to expand rapidly in Illinois, Michigan and Louisiana. And public health observers are starting to realize that this novel coronavirus does, indeed, discriminate, hitting majority-minority communities much harder than others. Perhaps that explains why Alabama, whose population is 26 percent African American, was projected just a few days ago to have the highest COVID-19 mortality rate in the nation - even greater than New York's? (A revised projection now places it in the middle of the pack.)

Coincidentally, there's a feature article in this week's New Yorker about another deadly health disparity in Alabama that disproportionately affects minorities. Cervical cancer is one of clinical prevention's great success stories. Women who have periodic Pap smears and, more recently, tests for cancer-causing subtypes of human papillomavirus (HPV), can have precancerous lesions identified and treated long before they progress to cancer. Vaccines against high-risk HPV subtypes, when administered before exposure through sex, prevent infections in the first place, and are routinely recommended for women and men between the ages of 11 and 26. So nearly all of the 13,000 U.S. women who are diagnosed with cervical cancer and the 4,000 who die from it each year have one thing in common: it's been too long since they saw a gynecologist or family doctor.

Why is this tragedy more likely to occur in Alabama, as compared to New York City (25% African American) or Washington, DC (47%)? In Alabama, to qualify for Medicaid as a parent in a family of four, one's household income must be below 18% of the federal poverty level - that is, less than $393 per month. Try to house, feed and clothe a family of four and pay for health insurance or health care of any type (including inexpensive direct primary care) on $400 or $500 a month! The numbers don't even come close to adding up.

Enter health policy. In 2014, a key provision of the Affordable Care Act went into effect that provided at least 90% federal matching funds to states that expanded Medicaid eligibility to 138% of the poverty level. Alabama said no, and it and 13 other states - including most of the solid South, continue to say no, even though studies suggest that additional budgetary costs to states from Medicaid expansion would be more than offset by improvements in the health and earning potential of their residents and the financial footing of their health care institutions.

Developing preventable cancers while being poor and uninsured in Alabama and 13 other states is not only a problem for African Americans, but for persons of all races and backgrounds. If Alabama expanded Medicaid today, the expansion "would provide coverage for roughly three hundred and forty thousand additional Alabamians. About half of the newly insured would be low-income whites." Among other benefits, these newly insured persons could then access coronavirus testing and treatment. Social distancing, widespread testing, contact tracing, and vaccine development won't be enough to halt the pandemic if we leave millions of Americans behind; it's no wonder that Medicaid expansion has been proposed as a potent policy tool for mitigating the health and economic impact of COVID-19.

Monday, March 30, 2020

Breast cancer screening is likely to be harmful after age 75

To increase acute care capacity during the COVID-19 pandemic, hospitals have suspended elective surgical procedures, and family medicine practices have postponed visits for preventive care and monitoring of stable chronic diseases - particularly in patients older than 70 years, whose risk of developing serious illness from SARS-CoV-2 contracted in a health care setting likely outweighs potential benefits. For example, women in this age group should cancel or postpone screening mammograms.

Even in the best of times, though, it's not known if screening mammography beyond 75 years of age is helpful or harmful. The U.S Preventive Services Task Force found insufficient evidence to assess the balance of benefits and harms of breast cancer screening after age 75, and decision tools have been developed to help women decide whether or not to continue to be screened, relying on limited evidence and the patient's predicted life expectancy. As the authors of a recent American Family Physician editorial observed, though, discussing the clinical implications of life expectancy with older patients can be challenging and fraught with pitfalls.

Since it is unlikely that a randomized controlled trial of screening mammography in older women will be performed, researchers recently used observational data from the U.S. Medicare program to emulate such a trial in more than 1 million beneficiaries aged 70 to 84 years with a life expectancy of at least 10 years and no previous breast cancer diagnosis. The primary outcome was eight-year risk of breast cancer mortality.

While women age 70 to 74 years who continued to have screening mammograms had a 22 percent lower risk than those who stopped being screened, there was no mortality benefit for women who continued screening after age 75 years. Although guidelines already discourage screening for cancer in adults with a life expectancy of less than 10 years, this study suggested that stopping breast cancer screening after age 75 may be the right decision for all women, regardless of health status.


This post first appeared on the AFP Community Blog.

Sunday, March 22, 2020

Curiosity: what makes a doctor truly great

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

Obviously, I have not had the good fortune of hearing Dr. Atul Gawande speak at a commencement. (Atul, if you're reading this, Georgetown University School of Medicine would be delighted to have you address a future graduating class.) In 2018 he delivered a profoundly insightful address at UCLA that went viral on social media. It's worth reading in its entirety, but the point he drove home is that in a time when discrimination and unequal treatment have become as socially acceptable in some circles as in the pre-American Civil Rights era, it remains the sacred calling of medicine to recognize that all lives have equal worth, and that doctors and patients share a "common core of humanity":

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

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

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

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

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

2020 graduates, I am delighted that many of you will be entering family medicine this year, but regardless of the medical specialty you've chosen, don't ever stop being curious - especially about the most "difficult" patients and the ones you least understand. It is that skill, more than any other, that will sustain you in your work and that separates the merely competent doctors from the truly great ones.


This post first appeared on Common Sense Family Doctor on June 4, 2018 and in a slightly different form as "What Makes A Doctor Truly Great" in the November/December 2018 FPM.

Monday, March 16, 2020

Insomnia and sleep apnea in adults: evidence-based treatments

At an American Family Physician editors' meeting several years ago, a colleague, who marveled at the amount of academic and clinical activities that I cram into a typical workweek, asked half-seriously, "Do you sleep?" Yes, I answered, not only do I need at least seven hours of uninterrupted sleep each night, I don't feel the least bit guilty about making it a priority. As Dr. Jennifer Middleton wrote in a previous blog post, the negative health consequences of chronic sleep deprivation are legion. Unfortunately, a recent survey found that nearly half of U.S. military personnel report poor sleep quality. From 2003 to 2011, the incidence of insomnia and obstructive sleep apnea (OSA) in active duty U.S. Army soldiers increased by 652% and 600%, respectively.

Concerns about these two common sleep disorders led the U.S. Departments of Veterans Affairs (VA) and Defense (DoD) to develop a joint clinical practice guideline for their diagnosis and management; a synopsis was published last month in Annals of Internal Medicine. Key recommendations for treating chronic insomnia (insomnia occurring for three or more nights per week for three or more months) generally agree with those from a 2016 American College of Physicians guideline and Agency for Healthcare Research and Quality review: offer cognitive behavioral therapy for insomnia (CBT-I) as first-line treatment, and reserve short-term pharmacologic therapy (low-dose doxepin or nonbenzodiazepine benzodiazepine receptor agonists, such as zolpidem) for patients who are unable to access or complete CBT-I.

The VA/DoD panel suggests not using antipsychotic drugs, benzodiazepines, or trazodone for chronic insomnia due to harms outweighing benefits or lack of benefit. It also advises against two common ingredients in over-the-counter sleep aids, diphenhydramine and melatonin. The panel suggests that clinicians not use sleep hygiene education as a standalone treatment due to its limited effectiveness and potential to discourage patients from pursuing the more effective CBT-I.

For OSA, the VA/DoD guideline suggests using the STOP Questionnaire (Snoring, Tiredness, Observed Apnea, High Blood Pressure) to stratify risk in patients who report sleep symptoms and performing home sleep apnea testing rather than in-laboratory polysomnography in patients with a high pretest probability of OSA. Although continuous positive airway pressure (CPAP) therapy is recommended for persons with severe OSA, mandibular advancement devices may be used as an alternative in mild or moderate cases. The VA/DoD panel did not evaluate positional therapy (techniques to promote side sleeping) for OSA. However, a recent Cochrane review found that patients are more likely to tolerate and adhere to positional therapy than CPAP, compensating somewhat for the former's lesser effectiveness.


This post first appeared on the AFP Community Blog.

Friday, March 13, 2020

Today's podcast on COVID-19

Thanks to my friend Larry Bauer, CEO of the Family Medicine Education Consortium, for suggesting that I have this timely conversation with Dr. Michael Fine, a fellow family physician and former director of the Rhode Island Department of Health, about the evolving COVID-19 situation in the U.S. Although this podcast is aimed at an audience of family physicians and other front-line clinicians, others may find it helpful as well.

Tuesday, March 10, 2020

COVID-19 has arrived, in Washington DC and likely your home town, too

Although I typically cross-post any relevant writings 5 to 7 days after they appear on the AFP Community Blog, the novel coronavirus pandemic is evolving so quickly that I'm afraid what I wrote today may be out of date one week from now. So go and read the new post now, and this graphic from Wikipedia will make more sense. Wash your hands, stay home when you're sick, and work from home if you can.


Monday, March 2, 2020

Guest Post: The problem with health care price transparency: we don't have cost transparency

Michael Williams, MD, University of Virginia

US $2.4 million. $1.5 million. $2.28 million. These are the amounts of money the health system where I work, teach and receive health care spent purchasing a PET scanner, a CT scanner and a three-month supply of pembrolizumab, a drug that treats a variety of solid-organ cancers.

To meet the clinical (read “market”) demands of patients, who are typically disinclined to wait for diagnosis or treatment, UVA Health already owns seven CT scanners (that I know of) and three PET scanners, which are used to detect small deposits of known cancer. It also has enough “Pembro” to treat all patients who will or might benefit from it. Guess how much of their costs are billable to insurance? Zero.

In my dual roles at the University of Virginia, as both associate chief medical officer for clinical integration for the health system and director of the Center for Health Policy at the Frank Batten School of Leadership and Public Policy, I see this disconnect play out continuously.

For some drugs, Medicare doesn’t pay everything

Here’s why. Hospitals and physician practices have a single source of revenue: payment for patient care services rendered. To buy the PET scanner, CT scanner or Pembro, the university health care system collects money from our patients, largely through the insurer. In turn, our clinics, operating rooms and emergency departments treat the patient.

Simply put, the money collected from patients is used to buy everything the hospital uses to provide health care. Sometimes the health system borrows money from banks or the public, but even that debt is almost entirely serviced through payment for services rendered. Consumers bear the brunt; as in any business, those costs are passed on to the customer.

To be fair, Medicare Parts B and D may offset, but not pay for, the cost of many drugs. For Pembro, for example, a Medicare recipient may be left with a 20% co-pay, or $30,000 a year. Different drugs incur different costs driven by market forces, including greed.

Which brings me to my point: Price transparency is the wrong goal for the free-market health care structure we have in the U.S. Instead, consumers need to know not so much the price, but the costs of things.

The difference between price and cost

Here’s an analogy: There’s the sticker price of the car you want to buy, and then there’s the price you pay. Those numbers are almost always different, and no two buyers necessarily pay the same. Instead, a negotiation between buyer and seller (the dealership, in this example) takes place. Ultimately a price is agreed upon. But whatever that number is, it’s never the actual cost of producing the car.

The carmaker knows, down to the penny, the production cost of that car. The consumer doesn’t know.

The dealership doesn’t know, either; the dealer is privy only to the acquisition cost (price per vehicle) it pays. The automaker aggregates the costs of the aluminum and steel, the electronics, the glass, the tires, etc., and incorporates it all to derive a unit price per vehicle. The manufacturer knows all the costs of each component before the company starts to build a single vehicle, including labor and overhead.

Think of hospitals and physicians as the dealership. They don’t know the actual cost of things either, partly because there’s not just one “maker.” Instead, many “makers” are in the supply chain – all the companies providing hospitals and doctors with thousands of medical products and services. Just imagine all the suppliers involved in making sure a patient receives a chemo treatment.

For far too long, the lay media has confused price and cost. So have health professionals and policymakers. When the Centers for Medicare and Medicaid Services references costs, it’s essentially telling consumers how much it will pay to Medicare in premiums, deductibles and co-pays. Or, alternatively, it is telling consumers how much it will pay based on what each hospital indicates its costs are. These costs are different for every facility, because they are by-and-large derived, not calculated, numbers. No payer – that is, the insurance company for the patient – ever asks about how much it actually costs to provide health care. Here’s why: No one knows. Health care prices are made-up numbers.

The practice goes back to the earliest days of modern medicine. Prices (also known as “fees”) are determined by the time-honored standard of “usual and customary fees” charged locally and regionally for a service. That’s it. The federal government added the word “reasonable” to its definition some years ago.

Health care reform proposals such as “Medicare for All,” and its variations, will never control the cost of doing business until there’s a better understanding of what precisely that is. Big Pharma claims that research and development of drugs costs so much that pricing has to recoup the investment. I don’t subscribe to this claim at all, because they didn’t provide sufficient data to convince me.

Our country has never even had the corresponding conversation in health care, writ large.

There are better ways to do it. Activity and time-driven cost accounting have emerged as methods to actually calculate how much individual units of health care cost. Essentially, each step in a care process, be it bypass surgery, antibiotic administration or an MRI, is costed out and aggregated through direct observation of the care processes. This is not something that might be implemented in the distant future – in some places, it’s happening now. I’m proud to state that the University of Virginia Health System has taken the first steps to join them.

How much time does the technician take to perform a task? How much is she paid per hour? How much fringe benefit does she receive? How much time does the patient transporter take? How much does he earn per hour plus fringe? What is the purchase price of the MRI machine?

To calculate the true cost of care per care unit, a hospital must add up all the costs of all the component parts of the procedure or process. This allows hospitals to apply some rigor to their pricing schema. Some are doing this already with good results. Seeing how much care costs and the prices all hospitals charge would allow market forces to actually inform consumerism in health care.

From that starting point, a national dialogue concerning prices in health care might have meaning. So would public policymaking. “Out-of-network bills” and “price transparency” would have real-world relevance. Finally, our country could have the long-overdue dialogue about health care costs as a profession, an industry and a nation.


Michael Williams is Associate Chief Medical Officer for Clinical Integration; Associate Professor of Surgery; and Director of the UVA Center for Health Policy, University of Virginia.

This article is republished from The Conversation under a Creative Commons license. You can read the original article here.

Wednesday, February 26, 2020

COVID-19: preparing for an epidemic

Testifying to the rapidly evolving nature of the epidemic, the following post on COVID-19, which I wrote for the AFP Community Blog just 3 weeks ago, is already somewhat out of date (at that point, for example, the novel coronavirus didn't have a formal name). Yesterday, an official at the Centers for Disease Control and Prevention (CDC) warned that an outbreak of COVID-19 in the U.S. is no longer a matter of "if," but "when," and that Americans need to be prepared for a "significant disruption" in their lives. Although only 14 U.S. cases (12 of them travel-related) had been confirmed as of Feb. 24, only a few hundred persons have actually been tested due to problems with the test kits. It's hard to have much confidence that an administration that has repeatedly sought to slash funding for the CDC is prepared to mobilize the nation's public health infrastructure to confront this significant health threat. As the president of the American Academy of Family Physicians, Dr. Gary LeRoy, predicted last month, family physicians will be on the front lines of identifying and preventing the spread of this new respiratory illness.


In a 2015 editorial on global health in American Family Physician, Drs. Ranit Mishori and Jessica Evert noted that "the world is not only smaller than ever, but it is also more intricately connected," with transportation networks facilitating the spread of exotic infectious diseases across oceans and borders. These words seem prescient today as China, the World Health Organization, and the international community work feverishly to contain the outbreak of the 2019 novel coronavirus (2019-nCoV), which was initially reported in patients with pneumonia in Wuhan, Hubei Province, China but has spread via travel and person-to-person transmission to 24 other countries, including 11 confirmed cases in the United States as of February 3. As scientists race to answer basic questions about this new respiratory infection, travel to China has been heavily restricted, U.S. citizens have been evacuated from the region, and travelers recently returned from Hubei Province are being quarantined by state governments.

To keep clinicians up-to-date on the evolving epidemic, the Centers for Disease Control and Prevention (CDC) has posted a comprehensive collection of resources for health care professionals who encounter patients with suspected 2019-nCoV, including an assessment flowchart and interim management guidance for patients with confirmed infection. Forward-thinking family physicians can also consult a previous Family Practice Management (now FPM) article for tips on on preparing your office for an infectious disease epidemic. Key points highlighted in this article include:

- Begin planning now.
- Master the detection, prevention and management of seasonal influenza and community-acquired pneumonia.
- Practice scrupulous infection control - "wash in and wash out."
- Communicate at all levels, and coordinate with public health agencies.
- Focus on staff management and business continuity.

Although the origin of the 2019-nCoV is not known, the linkage of the majority of early infections to a wholesale seafood market suggests the existence of an animal reservoir. A previous novel coronavirus outbreak that began in China, severe acute respiratory syndrome (SARS), was eventually traced to infected bats. However, the estimated 2% fatality rate of 2019-nCoV is substantially lower than the 10% fatality rate of SARS. In addition, it's important to remind worried patients that the CDC projects that the less lethal but far more prevalent (and preventable) seasonal influenza virus will cause 180,000-310,000 hospitalizations and 10,000-25,000 deaths during the current flu season.