Wednesday, January 20, 2021

Gender equity gaps persist among family physicians

In a Policy One-Pager in the January 1 issue of American Family Physician, Dr. Yalda Jabbarpour and Elizabeth Wilkinson from the American Academy of Family Physicians' Robert Graham Center examined the growing role of women in family medicine. Compared to 2010, when 34% of practicing family physicians in the American Medical Association Physician Masterfile were identified as women, the share of women rose to 42% in 2020, mirroring increases in the share of female physicians in primary care and all medical specialties during the past decade. Another recent analysis by Dr. Jabbarpour and others found a statistically significant increase in female first and last authorship of research articles published in 3 family medicine journals (Family Medicine, Journal of the American Board of Family Medicine, and Annals of Family Medicine) between 2008 and 2017. However, they noted that women represented less than 40% of the combined editorial boards of these journals, which did not change significantly during this time.

A Graham Center study utilizing 2017 and 2018 certification survey data from the American Board of Family Medicine found that women self-reported working an average of 49 total hours and 34 direct patient care hours per week compared to 54 and 39 hours, respectively, self-reported by men. In an accompanying commentary on this "gender penalty," Dr. Kathryn Hart (an academic family physician colleague of mine) observed:

Traditional gender roles are still very much at play. The “invisible work” of raising children often falls on mothers, regardless of employment status. This begins with breastfeeding (and the natural carry-over to the intensive caregiving responsibilities of infancy) and evolves into scheduling doctor's appointments, completing school forms, coordinating activities, and arranging childcare, among thousands of other small tasks that cumulatively take up hours over the course of the week.

The work disparities that affect female-male dual professional couples have widened over the past year. The widespread transition to virtual learning from home during the COVID-19 pandemic has substantially increased the burdens of unpaid work (domestic chores and family care) that employed women perform relative to employed men worldwide.

Whether the physician gender pay gap can be attributed solely to female physicians working fewer hours than men was the subject of a recent analysis of data from more than 24 million primary care office visits in 2017. Despite spending 2.6% more observed time in visits overall than male primary care physicians, female primary care physicians conducted 10.8% fewer total visits and consequently generated 10.9% less revenue. Female physicians spent 15.7% more time (2.4 minutes) with each patient than male physicians did, but generated no more revenue per visit. In addition to the many other good reasons to retire the antiquated fee-for-service payment system in primary care, this study suggested that it remains an inherent obstacle to pay equity between male and female physicians.

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This post first appeared on the AFP Community Blog.

Monday, January 11, 2021

Personally responsible: President Donald Trump and America's Plague Year

A notable historical site in Lancaster, Pennsylvania, where I completed my residency in Family Medicine, is Wheatland, the estate of the 15th American President, James Buchanan. Buchanan, who preceded Abraham Lincoln in office and is often considered by historians to be the worst President ever, did absolutely nothing as the first 7 states of the 11 that would go on to form the southern Confederacy seceded from the Union. Although Buchanan believed that secession was unconstitutional, he did not interpret his oath to "preserve, protect, and defend the Constitution of the United States" as giving him the authority to use force to prevent states from leaving. In the four months between Lincoln's election and inauguration (until 1937, Inauguration Day was March 4th), Lincoln watched helplessly as Buchanan's inaction and the scheming of his Southern-dominated Cabinet (including Secretary of War John B. Floyd, who later became a Confederate general) allowed the country to break in two.

Although there were some tense moments in early 1861 and in the summer of 1864, when Confederate General Jubal Early's Army of the Valley briefly skirmished with Union forces in the ring of forts surrounding Washington, DC, no insurrectionists would succeed in breaching the U.S. Capitol with a Confederate battle flag until January 6, 2021. On that date, a violent mob incited by the current President overpowered police and broke into the Capitol building, intending to stop the Congressional certification of November's election result, in which former Vice President Joe Biden defeated President Donald Trump by 7 million popular and 74 electoral votes. They threatened to hang Vice President Pence from a noose for not going along with Trump's illegal plan to disqualify enough electors to swing the election his way, and, before authorities reoccupied the building, mortally wounded one Capitol police officer and likely contributed to the suicide of a second officer three days later.

When historians assess the Trump Presidency, will they judge his anti-democratic actions to be worse for the nation than James Buchanan's inaction? Will they judge Trump to have been personally responsible for creating the movement that, if not for the quick thinking of courageous Capitol Police officer Eugene Goodman, could very well have resulted in live-streamed assassinations of Senators and staffers?

I hold President Trump personally responsible for a large portion of the 375,000 U.S. deaths from the pandemic to date. Admittedly, it's impossible to assign an exact number. As convincingly argued in the tour-de-force New Yorker article "The Plague Year," there were 3 critical missed opportunities to decisively alter the trajectory of COVID-19 deaths in the U.S.: 1) China's initial suppression of evidence of SARS-CoV-2's human-to-human transmission capability, including refusing to allow the CDC to conduct its own outbreak investigation; 2) the CDC's failure to develop and distribute an error-free test for the virus in February when doing so could have facilitated effective isolation of small numbers of infected patients by state health departments; and 3) Trump's refusal to wear a face mask in public and repeatedly suggesting that doing so was a sign of weakness, particularly when the mask-wearer was his election opponent. It's hard to blame the President for the first two, but the third was all on him.

Trump's responsibility - personal and historical - is even clearer for what happened at the Capitol last week. When you spend months telling supporters that if you don't win the election it will have been due to "massive voter fraud"; when you refuse to concede that you've lost a free and fair contest and file a blizzard of lawsuits that are so legally feeble that conservative judges that you appointed dismiss them out of hand; when you encourage supporters to show up in force on January 6th, appear before them in person to fire them up even more, then send them marching toward America's seat of democracy - you knew exactly what would happen, Mr. President. It's why you deserve to be removed from office before your term expires in 9 days, or failing that, be impeached by the House and convicted by the Senate so that you can never hold public office and wound or sicken this country again.

Monday, December 28, 2020

Common Sense Family Doctor's 2020 Year in Review

With a total of 48 posts (this will be the 49th), this has been my most prolific year of blogging since 2017. Nearly a third of these were on or related to the COVID-19 pandemic and its public health consequences, but I wrote about many other topics, too. With a nod to the ongoing 12 days of Christmas, I've picked 12 posts to highlight here, one from each month.

January 15 - When a cancer diagnosis predicts future good health

For early prostate, breast (including ductal carcinoma in situ, which was considered separately), thyroid cancer, and melanoma, relative survival was not only better than disease-specific survival, but greater than 100%. In other words, patients with these particular early cancer types were more likely to survive than similar individuals without cancer.


A year's membership in a DPC practice can generally be had for about one month of Presidential candidate Andrew Yang's Freedom Dividend, making it accessible not only to the middle and upper classes, but to patients who are can't afford traditional primary care. Medical schools should prioritize exposing more students to this new primary care model for us to have any hope of attracting one-quarter of them into family medicine.


While women age 70 to 74 years who continued to have screening mammograms had a 22 percent lower risk [of death from breast cancer] than those who stopped being screened, there was no mortality benefit for women who continued screening after age 75 years.


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.


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.


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.


For their "Best Hospitals for America" rankings, Lown created a Hospital Index that incorporated not only patient outcomes (mortality, safety, and satisfaction), but also civic leadership (community benefit, representativeness of patients compared to the surrounding community, and institutional salary distribution) and medical overuse.


Just as emergency medicine physicians are often justified at taking a more aggressive testing and treatment approach to a patient with chest pain than a family physician evaluating a patient in his or her office, it's arguable that the greater long-term risk of cardiovascular events in patients who see cardiologists warrant more intensive treatment of blood pressure than patients in primary care settings.


Although age and race inequalities largely explain America's uneven experience of COVID-19 to date, that is no assurance that it will stay that way. HIV/AIDS was a viral disease that only affected urban gay men and intravenous drug users - until it wasn't.


Family physicians' expertise in cancer mostly involves screening and diagnosis, while treatment is managed by medical and/or surgical oncologists. However, as the long-term survival of patients with cancer improves, the important care role of primary care clinicians in survivors of childhood and adult cancers has been increasingly recognized.


I don't believe that prisons should be abolished, any more than I believe that police departments should be defunded. But if the U.S. is going to continue to pour hundreds of billions of dollars into incarceration every year, a large chunk of those dollars ought to be devoted to peacemaking - making the offender whole and less likely to offend again - rather than punishment.


State-mandated screening at birth for rare, serious medical conditions occurs in 4 to 5 million newborns and detects 5,000 to 6,000 affected infants each year. With a combined incidence of 1 out of every 1,500 births, inborn errors of metabolism are the most common conditions detected by newborn screening.

Thursday, December 24, 2020

My favorite public health and health care books of 2020

Christmas Eve may be a little late in the holiday season to be recommending books, but then again, e-books can be a great last-minute gift for procrastinators. One constant that has helped keep me sane during this tumultuous pandemic year has been always having a physical or virtual shelf of intriguing books to read next. As in previous years (see 2019, 2018, 2017, 2016, and 2015), this favorite books list is ordered alphabetically and includes a few that were new to me even though they were published before 2020.

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1. Fallible: A Memoir of a Young Physician's Struggle with Mental Illness, by Kyle Bradford Jones


2. Heart: A History, by Sandeep Jauhar


3. Hidden Valley Road: Inside the Mind of an American Family, by Robert Kolker


4. Inside the FDA: The Business and Politics Behind the Drugs We Take and the Food We Eat, by Fran Hawthorne


5. Malignant: How Bad Policy and Bad Evidence Harm People with Cancer, by Vinay Prasad


6. The Long Fix: Solving America's Health Care Crisis with Strategies That Work For Everyone, by Vivian Lee


7. Together: The Healing Power of Human Connection in a Sometimes Lonely World, by Vivek Murthy


8. Upstream: The Quest to Solve Problems Before They Happen, by Dan Heath


9. When Death Becomes Life: Notes From A Transplant Surgeon, by Joshua Mezrich


10. When We Do Harm: A Doctor Confronts Medical Error, by Danielle Ofri

Saturday, December 19, 2020

New guideline for managing acute pain from musculoskeletal injuries

In a 2017 practice guideline based on a systematic review of noninvasive treatments, the American College of Physicians (ACP) recommended superficial heat, massage, acupuncture, and spinal manipulation as initial treatment options for patients with acute low back pain, in addition to a nonsteroidal anti-inflammatory drug (NSAID) or skeletal muscle relaxant if desired. But is a similar approach effective for treating pain from acute musculoskeletal injuries not involving the lower back? To answer this question, the American Academy of Family Physicians (AAFP) joined the ACP in developing another practice guideline on management of acute pain from non-low back, musculoskeletal injuries in adults, a synopsis of which appeared in Practice Guidelines in the December 1 issue of American Family Physician. These are some key practice points from the guideline:

• Topical NSAIDs are the most effective intervention for acute musculoskeletal pain other than low back pain.

• Although oral NSAIDs and acetaminophen are effective for acute pain relief, combining them does not improve effectiveness.

• Although moderately effective for pain relief, opioids increase gastrointestinal and neurologic adverse effects and lead to long-term use in 6% of people treated.

• Acupressure and transcutaneous electrical nerve stimulation techniques are effective nonpharmacologic options for acute pain.

In an accompanying editorial, Dr. David O'Gurek and I, who represented the AAFP on the guideline committee, and Dr. Melanie Bird, AAFP Clinical and Health Policies Manager, discussed some of the guideline's highlights and limitations. A systematic review and network meta-analysis of randomized, controlled trials provided direct and indirect comparisons of various treatment options on outcomes that included pain relief and physical functioning, symptom relief, treatment satisfaction, and adverse events.

Topical NSAIDs improved all efficacy outcomes with minimal adverse effects, while oral NSAIDs and acetaminophen improved fewer outcomes and were more likely to cause adverse events. We suggested against using opioids, including tramadol, for acute musculoskeletal injury pain due to their poor adverse effect profile and the risk of prolonged use, ranging from 6% in low-risk to 27% in high-risk populations. We also noted that "equitable coverage and affordability of first-line treatments" are essential to reduce well-known racial and socioeconomic disparities in pain management; for example, though a topical NSAID is now available over-the-counter, it costs significantly more than oral NSAIDs and acetaminophen and may not be covered by health insurance plans.

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This post first appeared on the AFP Community Blog.

Sunday, December 13, 2020

Long-term benefits of newborn metabolic screening

State-mandated screening at birth for rare, serious medical conditions occurs in 4 to 5 million newborns and detects 5,000 to 6,000 affected infants each year. A 2017 American Family Physician article reviewed various conditions that are targeted by newborn screening: amino acid disorders, fatty acid oxidation disorders, organic acid disorders, hemoglobinopathies, endocrine disorders, and miscellaneous diseases (including congenital hearing loss and critical congenital heart defects). With a combined incidence of 1 out of every 1,500 births, inborn errors of metabolism are the most common conditions detected by newborn screening.

After tandem mass spectrometry made it possible to test for many conditions using a single blood sample, the federal Health Resources and Services Administration's Maternal and Child Health Bureau commissioned the American College of Medical Genetics (ACMG) to create a uniform list of conditions for newborn screening panels in 2005. However, the ACMG's recommended core panel of 29 conditions was criticized by the U.S. Preventive Services Task Force (USPSTF) for not taking an evidence-based approach. In a position paper, the USPSTF noted that the ability to detect a condition with high diagnostic accuracy was insufficient to include it in the panel:

A newborn screening program is not just a panel of screening tests. ... It is also parental education, follow-up, diagnosis, treatment and management, and program evaluation, and all of the various parts of the system must be in place and working well to realize the benefits of screening. ... Moreover, a newborn screening panel should be expanded only if the newborn screening program is fully prepared to make all the components of the complex system available for the new disorders. Expansion would be costly and might not be the best use of scarce health care resources, given the many other unmet child health needs.

Reinforcing the USPSTF's concerns, an analysis by the Centers for Disease Control and Prevention projected that if all 50 states expanded their newborn screening panels to align fully with the ACMG recommendations, "although such an expansion would have increased the number of children identified by 32% (from 4,370 to 6,439), these children would have had many rare disorders that require local or regional capacity to deliver expertise in screening, diagnosis, and management." A cross-sectional survey of Ontario primary care clinicians found that family physicians had limited knowledge of conditions identified by newborn screening tests, and many were not comfortable leading detailed discussions of abnormal results with parents or guardians.

The U.S. Secretary of Health and Human Services' Advisory Committee on Heritable Disorders in Newborns and Children (SACHDNC) subsequently developed a more rigorous framework to evaluate conditions nominated as additions to the uniform screening panel, requiring an independent systematic evidence review of key questions based on an analytic framework similar to those used for USPSTF reviews. In a separate document, the SACHDNC outlined questions for newborn screening long-term follow-up data systems to answer to make sure that programs achieve their goals of improved outcomes for children and families.

An observational study published last month in Pediatrics reported the clinical outcomes of 306 individuals with inherited metabolic diseases identified by a university hospital laboratory performing Germany's newborn screening panel from 1999 to 2016. The German national panel is less extensive than the ACMG's, consisting of 2 endocrine and 12 inherited metabolic diseases, and the nearly 2 million newborns screened during the study period represented 15 percent of Germany's live births. 28 individuals presented with metabolic symptoms prior to newborn screening results being available; the rest were successfully enrolled in specialized metabolic/nutritional therapy while still asymptomatic. Although nearly 1 in 4 individuals eventually developed irreversible disease-specific clinical signs, 88% had normal cognitive outcomes, and more than 95% showed normal development and attended regular kindergarten and primary schools.

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This post first appeared on the AFP Community Blog.