The case for supporting more American immigrants, not less

As a senior faculty member at a medical school and now a residency program, I'm used to writing letters of recommendation (LOR) for students, residents, and junior faculty applying for promotions. A few years ago, I received a LOR request from a fellow (a physician who has completed residency and is pursuing specialized training) whom I'd never met before and who wasn't applying for faculty position or promotion. Instead, this foreign-born physician was applying to stay in the U.S. The reason he was asking me to support his application is that one of my papers had cited one of his research studies. As a "well-known physician and researcher in the field of Family Medicine," I could testify to the importance of his contribution to medical science in this country. He hoped to extend his visa in the EB-2 National Interest Waiver category, which requires that applicants "have an advanced degree or extraordinary ability and prove their work can significantly contribute to the US economy." I wrote the LOR, and though I did not hear back about the outcome, I recently Googled his name and was pleased to see that he was able to complete his training and is now an attending physician at a respected medical institution.

The contribution of international medical graduates (IMGs) to the U.S. physician workforce is, and has always been, substantial. My late grandfather (a neuropsychiatrist), uncle (an emergency medicine physician) and aunt (an ophthalmologist), all attended medical school in China before immigrating to the U.S. to teach and practice medicine. According to a recent article in JAMA, "there are currently more than 230,000 licensed IMGs who graduated from more than 2000 different medical schools in 169 countries." Some of these IMGs were immigrants like my relatives, while others were U.S. citizens who attended medical schools outside of the U.S. (most often in the Caribbean). Since U.S. medical school graduates tend to settle and practice in urban areas and enter higher-paying medical subspecialties, IMGs fill essential gaps in primary care and underserved rural areas - though a recent study suggested that fewer of them are choosing to do so.

This year's race for the Republican Presidential nomination, which concluded with the nomination of Donald Trump for the third election in a row, had the distinction of including two candidates who are the children of Indian immigrants: Nikki Haley and Vivek Ramaswamy. Both candidates, sensitive to the prevailing anti-immigrant sentiment in the GOP, were careful to note that their parents were "legal immigrants," presumably in contrast to the thousands of "illegals" migrating across the Mexican border. There are, of course, well-established pathways for highly educated foreign-born persons like their parents and mine to enter and remain in the U.S. That influx of talented doctors, scientists, engineers, and others is essential to maintaining America's technological preeminence.

But the U.S. doesn't just need highly educated professionals - it also needs factory laborers, construction workers, farm workers, nannies, housecleaners, and other working-class professions that don't qualify for EB-2 National Interest Waivers. Even if "mass deportation" of tens of millions of undocumented immigrants living in the U.S. was possible - and contrary to popular belief, the Biden administration expelled more migrants (2.8 million) during its first two years than Trump did during his entire 4-year term - it would result in wholesale economic disaster. What America needs isn't a way to get rid of more immigrants who are holding useful jobs and making our country better; instead, as I wrote ten years ago, it needs to create more legal pathways to citizenship that don't require a LOR from a professor of family medicine.

Despite recent study findings, jury is still out on screening ECGs

It’s not unusual for adult patients to undergo a 12-lead electrocardiography (ECG) during or soon after a preventive health visit. A 2017 analysis of administrative data in Ontario, Canada, found that more than 1 in 5 patients had an ECG within 30 days of a routine checkup. Unsurprisingly, patients with screening ECGs were more likely than others to receive additional cardiac tests, visits, or procedures. However, no significant differences in mortality, hospitalizations for cardiac reasons, or coronary revascularization between the groups were reported.

The U.S. Preventive Services Task Force (USPSTF) has consistently recommended against using ECG to screen for coronary heart disease in asymptomatic, low-risk adults. This recommendation was also included in the Choosing Wisely campaign. The rationale for not testing is that ECGs are unlikely to benefit these patients but can initiate harmful cascades of care. Nonetheless, research on the use of ECGs to identify patients with undiagnosed atrial fibrillation and other potentially serious abnormalities has continued. A 2019 report summarized previous studies that found associations between abnormal screening ECGs and worse cardiovascular outcomes after adjusting for traditional risk factors.

A recent study took advantage of the practice of performing ECGs as a mandatory part of annual health checks in Japanese adults 35 to 65 years of age. In the study, 3.7 million individuals with no history of cardiovascular disease or prior abnormal ECGs had an ECG in 2016 and were followed for a median of 5.5 years for the composite outcome of all-cause death or hospital admission for cardiovascular disease; 17% had one minor ECG abnormality, 4% had two or more minor abnormalities, and 1.5% had a major abnormality. Compared with people with normal ECGs, those with any ECG abnormality had a greater risk of experiencing the composite outcome.

In an accompanying commentary, former USPSTF member and family physician Alex Krist, MD, MPH, explained why these results probably will not change current recommendations:

For clinicians and patients, merely knowing that someone is at risk for an adverse event is not helpful without knowing what should be done to reduce that risk. There are multiple effective and recommended strategies to reduce people’s risk of CVD, including statin use for people at risk, screening for and managing hypertension, and counseling for healthy diet, exercise, and smoking cessation. Clinicians should routinely offer all of these preventive services to patients irrespective of whether their ECG result is normal or abnormal. Before recommending screening ECG, future studies will need to show that doing something different in response to an abnormal ECG changes a health outcome for a person.

A 2018 Lown Right Care article by Drs. Alan Roth, Andy Lazris, and Sarju Ganatra discussed overuse of cardiac tests in asymptomatic patients, including ECG, stress tests, and coronary artery calcium scoring.

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This post first appeared on the AFP Community Blog.

Can large language models handle the complexity of family medicine?

Should family physicians be excited or apprehensive about the potential applications of artificial intelligence (AI) and large language models (LLMs) in primary care? An article by Dr. Richard Young and colleagues in the Journal of the American Board of Family Medicine recently made the case for both. Observing that primary care is a “complex adaptive system,” the authors suggested that AI “will likely work when its tasks are limited in scope, have clean data that are mostly linear and deterministic, and fit well into existing workflows.” On the other hand, AI may struggle to incorporate contextual and relational factors, process noisy and inaccurate data, or document vague symptoms that do not indicate a single disease condition.

In an editorial on chatbots and LLMs in the June 2024 issue of American Family Physician, Dr. Aaron Saguil discussed how family medicine practices are turning to LLMs to “help decrease administrative burden and combat burnout.” These tools can already compose visit notes, remotely monitor patients with interactive chats, and draft replies to patient portal messages.

In the future, LLMs may be integrated into electronic health records to provide real-time clinical decision support, suggesting “diagnostic possibilities, recommended ancillary evaluations, and possible treatment strategies.” To minimize the risks of LLMs propagating biased data, generating misinformation, or usurping the family physician’s role on health care teams, Dr. Saguil advised being actively involved in their implementation:

The best defense against AI risks becoming realities is conscientious physicians guiding the development and implementation of LLMs into clinical care settings, pointing out what LLMs can do and what they cannot. In family medicine, no LLM can yet address a complex patient in a unique sociocultural situation with overlapping comorbidities and health states from the vantage point of a longitudinal relationship.

A related FPM article by Dr. Steven Waldren, chief medical informatics officer at the American Academy of Family Physicians, explored other uses of LLMs in primary care, such as rewriting medical or legal forms for patients with lower health literacy or native languages other than English; summarizing information from a medical record, guideline, or research articles; drafting referral letters, prior authorization requests, and insurance appeals; and populating clinical registries. Dr. Waldren recommended three safeguards when using AI in medical practice: using LLMs only “when the physician or other user is able to easily verify the accuracy of the AI output”; not entering protected health or private organizational information in open online LLMs such as ChatGPT; and for now, using LLMs only in low-risk (nonclinical) situations. Echoing Dr. Saguil, Dr. Waldren called on family physicians to “weigh in on the design, development, and deployment of AI in medicine to ensure it is more helpful than harmful to patients, primary care physicians, and practices.”

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This post first appeared on the AFP Community Blog.

Clinical documentation and health inequities

Poor treatment by a clinician leads to suspicion of the motives of the health care system, increasing one’s reluctance to seek necessary care and the risk of a having an uncomfortable health care interaction in the future. For many patients—particularly those who identify with one or more racial, sexual, gender, and religious minority groups—this vicious cycle often leads to worse health outcomes.

A Lown Right Care article in the June 2024 issue of American Family Physician addresses the consequences of stigmatizing clinical documentation. In the case scenario, a patient feels stereotyped by his new primary care physician, who incorrectly describes him as African American (he self-identifies as Dominican Hispanic) and noncompliant for not filling a prescription or seeing a subspecialist he could not afford. Drs. Alan Roth and Andy Lazris explain how this language could negatively affect encounters with other clinicians:

Patients who identify as Black are more likely than those who identify as White to have comments using negative words or connotations in their history and physical documentation and may be subject to systemic bias in physicians' perceptions of their credibility.… The stigmatizing language used to describe patients in medical records can influence other clinicians and physicians-in-training in their attitudes toward the patient and their medication-prescribing behavior. This is an important and potentially damaging pathway by which bias can be propagated from one clinician to another.

In a previous AFP editorial, Drs. Megan Healy and Khameer Kidia presented several strategies to reduce bias and avoid stigmatizing language in medical records and other clinical communications. These strategies include not using labels, not blaming patients for their conditions, and not beginning presentations with race, ethnicity, language, socioeconomic status, or other social identifiers that may activate unconscious bias.

In 2021, a controversial JAMA social media post questioned the existence of structural racism and made the incredible claim that “no physician is racist.” This unfortunate episode contrasted with AFP’s active approach to advancing health equity, including sharing and promoting antiracist practices. Nonetheless, the medical profession has a long way to go to align its behaviors with its ideals. In a first-person narrative published in the New England Journal of Medicine, a Black health equity researcher visiting the emergency department receives callous treatment from two nurses and is mocked by a physician for suggesting that her area of expertise had something to do with the indifferent care she received. Making excuses for the health professionals involved (e.g., the emergency department was overcrowded, the nurses were tired and harried, the doctor was just having a bad day) amounts to being part of the problem. Instead, family physicians and other primary care clinicians can choose to be part of the solution to eliminating health inequities in kidney transplant, infertility care, skin conditions, asthma and lung diseases, cardiovascular disease, end-of-life care, and preventive care, among others.

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This post first appeared on the AFP Community Blog.

Contemplating colorectal cancer screening choices

Invitations to patients eligible for colorectal cancer screening need not be limited to office visits. A 2018 systematic review and meta-analysis of 73 randomized clinical trials of U.S.-based interventions found that mailing fecal tests more than doubled the likelihood that targeted patients received colorectal cancer screening. A recent trial in Clinical Gastroenterology and Hepatology compared screening completion in community health center patients randomly offered one of three options in an outreach mailing: colonoscopy referral only, fecal immunochemical test (FIT) only, or an active choice of colonoscopy or FIT. At 6 months, 12.8% of patients in the active choice arm had completed screening compared with 11.3% in the FIT-only arm and 5.6% in the colonoscopy-only arm.

As I discussed in a previous post, one problem with screening colonoscopy is that it is frequently repeated at shorter intervals than the recommended 10 years without a good reason. In fact, 10 years may not be long enough. A cohort study in JAMA Oncology suggested that a 15-year rescreening interval may be appropriate for average risk patients without a family history of colorectal cancer and with negative findings on their first screening colonoscopy. Using Swedish register-based data sources, researchers showed that individuals meeting these two criteria between 1990 and 2016 had 15-year standardized colorectal cancer incidence and mortality ratios that were lower than the 10-year cumulative risks in a matched control group.

A U.S. cross-sectional study that relied on data from the national Gastrointestinal Quality Improvement Consortium registry found that most patients with an episode of acute diverticulitis were not more likely to have colorectal cancer diagnosed on a follow-up colonoscopy than asymptomatic patients undergoing a screening colonoscopy. Only those with complicated diverticulitis (i.e., diverticulitis with perforation or abscess) were significantly more likely to have colorectal cancer (adjusted odds ratio = 3.57; 95% CI, 1.59 to 8.01).

Regarding the multitarget stool DNA (MT-sDNA) test for colorectal cancer screening, a study of 500 randomly selected patients in a Midwest health system found that about 1 in 5 had the test ordered inappropriately. The most common reasons for inappropriate ordering were having had a colonoscopy within the previous 10 years, having a family history of colorectal cancer, reporting symptoms suggestive of possible colorectal cancer, being younger than 45 years old, and having a previous diagnosis of adenomatous polyps.

A multitarget stool RNA (MT-sRNA) test with performance characteristics similar to those of the MT-sDNA test was approved in May 2024 by the U.S. Food and Drug Administration. Both tests are more sensitive for colorectal cancer and advanced adenomas than FIT but have lower specificity, resulting in higher false positive rates and more diagnostic colonoscopies. Of note, a research letter demonstrated that lowering the threshold for a positive FIT produced similar sensitivities and specificity as the MT-sRNA test, even without the RNA component of the test.

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This post first appeared on the AFP Community Blog.

Canadian mammography kerfuffle echoes U.S. screening debate, 15 years later

In November 2009, I was a medical officer with the U.S. Preventive Services Task Force (USPSTF) at the Agency for Healthcare Research and Quality. The health reform legislation that would eventually become law as the Affordable Care Act (or "Obamacare" after then-president Obama) was being fiercely debated in Congress. Politicians who opposed expanding health insurance to the poor, self-employed, and employees of small businesses launched all sorts of spurious charges, the worst being that the law would establish "death panels" that would determine whether elderly patients with chronic medical conditions would be allowed to live or die. Into this political maelstrom stepped the USPSTF, releasing an ill-timed update that recommended against routinely screening women aged 40-49 for breast cancer. Contrary to popular belief, this language didn't mean they were advising all women in this age group NOT to be screened; instead, they were empowering patients to make this decision individually in consultation with their physicians, based on their preferences and values.

The current Task Force looked at essentially the same evidence and come to a different conclusion: start screening everybody at age 40, never mind the potential harms. In a Medscape commentary, I explained why I don't believe this change is justified. However, it put a great deal of pressure on our neighbors to the north and the Canadian Task Force on Preventive Health Care to reassess its recommendations and come to a similar conclusion. If Americans are getting screened for breast cancer in their 40s, why shouldn't Canadians too?

The Canadian Task Force released its draft recommendations two weeks ago. In short, they echo the USPSTF's recommendations in 2009 and 2016 and maintain that breast cancer screening should be a "personal choice," particularly for females younger than age 50. "For women aged 40 to 49, based on the current evidence (trials, observational studies, modelling and a review on values and preferences), we suggest not to systematically screen with mammography [emphasis mine]. Because individual values and preferences may differ, those who want to be screened after being informed of the benefits and harms should be offered screening every 2 to 3 years." The supporting data, much of it derived from systematic reviews, is extensive and compelling, including discussion tools for women in various age groups.

Unlike the U.S. 15 years ago, Canada isn't in the midst of a major health reform debate - they've already had an equitable universal health care system for decades, thank you very much. But that hasn't stopped one health official from trying to score cheap political points. The Canadian Minister of Health, Mark Holland, a lifelong politician without any health professions training, has forcefully objected to the CTFPHC's draft recommendations and ordered an unprecedented "external review" that will, no doubt, include conflicted experts such as radiologists who have obvious financial incentives to perform as many mammograms on asymptomatic women as possible.

Here is Holland being interviewed on an Ottawa news channel. When the anchor asks him what he would do if the external review confirms the Task Force's recommendations, he dodges and weaves and avoids answering.

As a former USPSTF member once said, "we can follow the evidence wherever it leads," or we can start with a preordained conclusion and cherry-pick data that supports what we already know to be true. Canada, Mark Holland, and the CTFPHC would do well not to mimic the most expensive, inequitable health care system in the world and associate higher percentages of women receiving mammography in their 40s with better preventive care "quality."