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.