Like public health, primary care is in critical condition

The COVID-19 pandemic has exposed the negative consequences of two decades of neglecting public health at the local, state, and federal levels. After 9/11 and the following month's anthrax scare brought a temporary infusion of funds to public health departments to combat bioterrorism, the Great Recession of 2007-2009 resulted in deep budget cuts and layoffs that were never completely reversed. Even the Affordable Care Act's Prevention and Public Health Fund, a mandatory spending source for public health programs, was derided as a "slush fund" by opponents and repeatedly raided by both parties to pay for clinical initiatives such as launching the national insurance marketplace Healthcare.gov and avoiding cuts to Medicare physician payments. 

A less recognized but equally important problem is how a similar period of primary care neglect made the U.S. ill-prepared to deploy the most potent weapon we have against morbidity and mortality from the virus: three safe, effective vaccines. Mass vaccination events and making shots available in chain pharmacies were only ever going to take us so far. Since most vaccinations have historically been delivered by primary care physicians, failing to involve primary care organizations earlier in the vaccine rollout was a huge unforced error. Still largely reliant on fee-for-service payment models, primary care practices were battered financially during the early part of the pandemic when office visits plummeted. Although most family physicians weathered that storm, there aren't nearly enough of us in the first place. A recent study estimated that increasing the density of primary care physicians in U.S. counties with shortages could increase mean life expectancy by 56 days; increasing the supply of subspecialists, by contrast, doesn't extend life at all.

When she titled a recent editorial "Prioritizing Primary Care Can Save the U.S. Health Care System," Dr. Ada Stewart, President of the American Academy of Family Physicians, wasn't exaggerating. Even before last year's precipitous drop in life expectancy due to the pandemic, the U.S. already badly trailed most high-income countries. As Dr. Stewart wrote:

Our current system financially rewards individual health care transactions and financially penalizes long-term relationships between a patient and primary care team. It undervalues the essential care that occurs outside of the examination room. Benefit designs that place high cost-sharing requirements on patients, have onerous in-network and out-of-network rules, and rely heavily on utilization management make primary care less accessible for patients. Coupled with the crippling administrative functions placed on physicians and the low compensation rates for primary care services, we have a system that deemphasizes rather than prioritizes primary care.

There have been some promising efforts to finally prioritize primary care. A consensus report published this spring by the National Academy of Medicine declared that "primary care is a common good" and proposed five broad objectives that, if met, would dramatically improve population health:

1. Pay for primary care teams to care for people, not doctors to deliver services.

2. Ensure that high-quality primary care is available to every individual and family in every community.

3. Train primary care teams where people live and work.

4. Design information technology that serves the patient, family, and the interprofessional care team.

5. Ensure that high-quality primary care is implemented in the United States.

Reaching these objectives will require coordinated leadership from federal health agencies such as the Department of Health and Human Services, the Department of Veterans Affairs, the Health Resources and Services Administration, and the Office of the National Coordinator for Health Information Technology. It will require investments in primary care research from the Agency for Healthcare Research and Quality and the National Institutes of Health. And it will require reorienting a U.S. health care industry that isn't built for primary care to instead make primary care the fulcrum of a true health care system. As Elation Health CEO Kyna Fong wrote, "There has long been a sense that reinventing primary care is a key to fixing health care. This key hasn’t been working because we’ve been giving primary care doctors the wrong roles and measuring 'success' the wrong way. Primary care is uniquely positioned to explore the root cause of poor health and create a path to wellness. In order to do that, physicians need time to build relationships and trust with patients using tools to manage care in a complex and fragmented system. So many of health care’s problems could be solved if we started with that fundamental understanding."

Why am I - a career family physician who has never worked outside of the U.S., after all - so confident that boosting primary care is the answer to many, if not most, of our country's lagging health performance? Because other countries have already done it successfully. Dr. Atul Gawande described the latest example in his recent New Yorker article "The Costa Rica Model," where he observed that Costa Rica's average life expectancy is higher than that in the U.S. even though their per-capita income is a sixth of ours and the fraction they spend on health care even smaller. How do they manage to do this? After developing an outstanding public health system in the 1970s and 1980s, in the 1990s they combined their public health and medical care departments and assigned every single Costa Rican to a local primary care team (a doctor, a nurse, and a community health worker). In the U.S., by contrast, one-quarter of adults don't have a source of primary care. When these people get sick, they must seek care from a clinician they've never met and are unlikely to fully trust, whether it's in the emergency department, urgent care, or a random primary care office. And when they feel well, they don't have access to any of the preventive services that will help them stay well. That's a perfect recipe for living shorter, not longer.

The challenge of correctly diagnosing high blood pressure

Screening for high blood pressure in adults can seem straightforward, but actually can be quite complex. The U.S. Preventive Services Task Force (USPSTF) recently reaffirmed its longstanding recommendation to screen for hypertension with office blood pressure measurement but advises confirming the diagnosis with measurements outside of the clinical setting. The diagnostic standard for out-of-office measurement is 24-hour ambulatory blood pressure monitoring (ABPM), but ABPM is often unavailable, not covered by insurance, or inconvenient for patients.

A more accessible alternative, reviewed by my colleagues in the September issue of American Family Physician, is home blood pressure monitoring (HBPM). In addition to confirming a hypertension diagnosis, HBPM can be used to identify white coat hypertension (elevated readings in the office but normal readings at home) and masked hypertension (elevated readings at home but normal readings in the office). Patients can purchase a clinically validated blood pressure monitor for $37 to $100 without insurance, and this expense may be reimbursed from a health care flexible spending account. The downside of HBPM - which I can testify to as a doctor and a patient myself - is that patients sometimes forget to check their blood pressures at home or forget to record and bring in the readings.

What is the role of automated oscillometric office blood pressure (AOBP) devices such as those used in the Systolic Blood Pressure Intervention Trial (SPRINT)? A systematic review and meta-analysis previously summarized in AFP found that AOBP systolic measurements were on average 14.5 mm Hg lower than manual blood pressures in patients with hypertension and better aligned with values obtained with ABPM. In a Letter to the Editor in the August issue, Dr. Lenard Lesser argued that the USPSTF "missed an opportunity to promote AOBP measurements as an easier-to-implement alternative to ambulatory blood pressure monitoring." Dr. Lesser pointed out that the only randomized trial of hypertension screening cited by the USPSTF that reported improvements in clinically meaningful outcomes actually used AOBP.

In the latest entry in JAMA's Rational Clinical Examination series, Dr. Anthony Viera and colleagues systematically reviewed studies that addressed the question, "Does This Adult Patient Have Hypertension?" Comparing AOBP with HBPM, they found that 

The thresholds for defining hypertension and the prevalence of hypertension were similar in office BP measurement and home BP measurement studies, and the estimated predictive values of office oscillometric BP measures and HBPM were numerically nearly identical. ... The combination of results from office BP measurement and HBPM has better diagnostic accuracy than the independent results alone, and when concordant, is likely sufficient for diagnosis. However, 24-hour ABPM should be considered when results are discordant, especially for patients with a higher pretest probability of hypertension.

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This post first appeared on the AFP Community Blog.

International alliance of health journals calls for emergency action on climate change

Two weeks ago, more than 200 health journals simultaneously published an editorial calling on health professionals, policy makers, and governments to support emergency actions to limit average global temperature increases to below 1.5 degrees Celsius. Asserting that increases above that level would "risk catastrophic harm to health that will be impossible to reverse," the editorial's authors advocate for "fundamental and equitable changes to societies" to alter the world's current catastrophic temperature trajectory:

Equity must be at the center of the global response. Contributing a fair share to the global effort means that reduction commitments must account for the cumulative, historical contribution each country has made to emissions, as well as its current emissions and capacity to respond. Wealthier countries will have to cut emissions more quickly, making reductions by 2030 beyond those currently proposed and reaching net-zero emissions before 2050.

In August, a landmark report from the Intergovernmental Panel on Climate Change (IPCC) concluded that human activities since 1850, primarily burning of fossil fuels, have already warmed the planet by 1.1 degrees Celsius. At 1.5 degrees, the IPCC warned, extreme weather patterns would become more frequent, and rising sea levels, vector-borne diseases, life-threatening heat waves, and severe droughts would affect billions of people worldwide. Currently, the 10 countries with the greatest greenhouse gas emissions (China, the U.S., the European Union, India, Russia, Japan, Brazil, Indonesia, Iran, and Canada) account for more than two-thirds of global emissions.

American Family Physician, where I have been Deputy Editor since 2018, strongly supports this global effort to prevent future environmental catastrophes. Our first full-length clinical review article about the health impacts of global warming appeared in 2011. An accompanying editorial highlighted the physician's role in efforts to slow global warming, including reducing the carbon footprints of hospitals and health care facilities. In 2016, my Georgetown colleague Caroline Wellbery, MD, PhD observed that the 2015-2020 Dietary Guidelines for Americans' "heart-healthy recommendations align with ... environmental concerns," making eating less meat a healthy and environmentally responsible dietary choice.

A 2019 update on managing health impacts of climate change discussed ways that clinicians can mitigate "morbidity and mortality from worsening cardiopulmonary health, worsening allergies, and greater risk of infectious disease and mental illness, including anxiety, depression, and posttraumatic stress disorder from extreme weather events." Health professionals must recognize how their workplaces directly contribute to making climates less healthy: "The U.S. health care sector is responsible for 10% of all greenhouse gas emissions, 10% of smog formation, 12% of air pollution emissions, and smaller but significant amounts of ozone-depleting substances and other air toxicants." The article also suggested counseling patients on the personal and environmental benefits of utilizing active transport and a consuming plant-based diets.

Physicians' lack of training in climate science and global warming's negative impacts on health may be an obstacle to leveraging the collective authority of the medical profession to address the climate crisis. This gap is closing, though, as recent editorials in Academic Medicine have called for critical curricular reforms in medical school and residency education, and in some cases, medical students themselves have been leading these educational efforts.

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This post first appeared on the AFP Community Blog.

Selections from last week's #COVIDtweets

I've had limited time for blogging for the past several weeks, as I've been working on some academic projects and spending more time on Twitter promoting COVID-19 vaccination in everyone aged 12 years and older (#ThisIsOurShot) and debunking misinformation and disinformation posted by "antivaxxers." As a family and public health physician, it is enormously frustrating to watch the U.S. squander its early advantages in vaccine distribution as other countries that started later have surpassed us in the percentages of their populations that have been fully vaccinated. Although the vaccines have already prevented hundreds of thousands of deaths in the U.S., we are still losing 1,500 overwhelmingly unvaccinated persons to the virus every day, and nearly all of these deaths - unlike during the "third wave" in December and January - were avoidable. Online influencers who stoke distrust of government and public health institutions are largely responsible for prolonging this ongoing tragedy. Unfortunately, some of these people are practicing physicians who have flaunted the ethical standards of our profession by refusing to get vaccinated themselves.

If any US doctor at this point is not fully vaccinated for any reason other than an anaphylactic reaction to vaccine, that doctor should surrender his/her license to their state medical board for violating ethical rule #1 of our profession: first, #donoharm.

— Kenny Lin, MD, MPH (@kennylinafp) September 5, 2021

As you might imagine, this tweet generated a wide spectrum of responses. Perhaps my favorite was the one that accused me of being "militant," which I won't disagree with, since the U.S. Department of Defense has mandated COVID-19 vaccination for all active military service members.

Here is a selection of other recent tweets that didn't go quite as viral, but represent my deeply held scientific and religious views on this topic.

“If you insist on refusing the vaccine, that is your right. But please do not bring God into it.” Well said from a fellow Christian. https://www.nytimes.com/2021/09/06/opinion/religious-exemptions-vaccine-mandates.html 

Declining to vaccinate your adolescent against COVID-19 because “kids usually have mild illness” and you worry about vaccine side effects is like not buckling your seat belt b/c you worry about seat belt injury in a car accident.

I am sick and tired of seeing so many who should know better sacrificing their vulnerable neighbors, elders, and children on the altar of their delusion that the vaccine is worse than the disease. #COVID19 #GetVaccinatedNow

If all employers followed @NFL's example, our current 75% vaccinated rate could rise to their 93% (or even beyond) in a hurry. #GetVaccinatedNow #CarrotsAndSticks

I don't have a crystal ball, so I don't know when the off-ramp for masks in schools and indoor public places will arrive. But I do know it will continue to move farther away the longer people refuse to wear masks or get vaccinated to protect each other. #COVID19

Submitted my proof of COVID-19 vaccination to @MedStarHealth (employer) and @_DCHealth today. Thanks for requiring me and local health professionals to keep their colleagues and patients safe by reducing their risk of contracting / spreading SARS-CoV-2! #COVIDVaccineMandate

Any person of faith should understand that #freedom is not the same thing as "I can and should do anything I want regardless of how it may affect others." In fact, it's just the opposite. #COVIDthoughts

Science: a randomized controlled trial of 350,000 people showed that encouraging mask wearing prevents COVID-19 spread. Florida: we are taking away your school district’s funding for making people wear masks. 

Worried about myocarditis if you let your 12-15 y/o get the Pfizer vaccine? In @AmerAcadPeds study, children <16 y/o were 37 times more likely to develop myocarditis if COVID infected than if not. Risks/ benefits not even close! #GetVaccinatedNow

A reminder that "having preexisting conditions" or "living in a nursing home" DOES NOT mean "would have died soon anyway." #BadCOVIDTakes #ProtectTheVulnerable #GetVaccinated

As we study the value of infection vs. vaccine-mediated immunity to SARS-CoV-2, a reminder that "developing immunity to COVID" is not a goal in itself (if it was, we'd just hold huge parties, infect everyone, ignore the resulting morbidity & mortality). (1/2)

Rather, the goal is for the fewest # of people to get seriously ill or die from COVID-19. The safest way to do that is through widespread vaccination. COVID-19 vaccines are safe, effective, and unlike the virus, don't expose people to the risk of intubation, ICU, and death. (2/2)

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

A few years ago, I wrote about NYU Grossman 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; 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 interview prospective Georgetown medical students, NYU usually comes up in conversation, from the medical diploma hanging on my wall, if nothing else. Of course most of them apply 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, NYU's total applications increased by almost 50 percent, and applications from underrepresented groups more than doubled.

Another problem: according to a 2018 analysis of public data on medical school endowments, enrollment, and tuition expenses, only 20 of 141 U.S. medical schools were financially positioned to afford going tuition-free for all students. Notably, 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, 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 around the 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 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 2019 college admissions scandal showed, those things are overrated anyway.

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This post first appeared on Common Sense Family Doctor on March 14, 2019.