Monday, September 20, 2021

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.

Tuesday, September 7, 2021

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.

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. Man shrugging

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)

Wednesday, September 1, 2021

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.

Monday, August 16, 2021

Using risk calculators in lung cancer screening discussions

As readers may recall, I changed my mind on lung cancer screening last year and have been working on incorporating screening discussions into visits with eligible patients in my clinical practice. The American Academy of Family Physicians recently endorsed the U.S. Preventive Services Task Force (USPSTF)'s 2021 recommendation to offer annual lung cancer screening with low-dose computed tomography (LDCT) to adults aged 50 to 80 years with at least a 20 pack-year smoking history who have smoked within the past 15 years. Although a meta-analysis of 8 randomized controlled trials found that people screened with LDCT are 19% less likely to die from lung cancer (NNS = 250), it also concluded that about 20% of tumors are overdiagnosed, in line with a previous report from the U.S. National Lung Screening Trial. Unfortunately, doctors do not often discuss harms of lung cancer screening such as overdiagnosis, overtreatment, and complications of diagnostic procedures performed for positive tests.

Deciding if the potential benefits outweigh the harms of lung cancer screening for an individual patient requires a way to personalize estimates of benefit based on patients' risk factors. In a Letter to the Editor regarding a 2019 American Family Physician article on the pros and cons of lung cancer screening, Dr. Abbie Begnaud and colleagues suggested:

If an eligible patient is reasonably healthy, clinicians could consider calculating individualized lung cancer risk using one of several well-validated risk models. We and others have developed web-based tools to help clinicians incorporate individualized risk calculations into decision-making. Individualized risk assessment can be helpful because patients at higher risk of developing lung cancer are also more likely to benefit from early detection through screening. When lung cancer risk increases, uncertainty about whether to recommend screening decreases when the person has a reasonable life expectancy.

Unlike risk prediction tools for cardiovascular disease and breast cancer, however, there is no consensus on which lung cancer risk calculator should be used. A systematic review published earlier this year in the Journal of General Internal Medicine identified 10 publicly available risk calculators and assessed their performance in 16 hypothetical patients across the continuum of lung cancer risk. The calculators used varying inputs (demographic factors, cancer history, smoking status, and personal and environmental factors) to generate lung cancer risk estimates; unsurprisingly, there were substantial differences in risk estimates for 10 of the 16 hypothetical patients. The authors concluded that the lack of standardization of lung cancer risk factors and consistency in risk estimates from web-based calculators may be an obstacle to shared decision making.

Notably, the USPSTF statement "recommends using age and smoking history to determine screening eligibility rather than more elaborate risk prediction models because there is insufficient evidence to assess whether risk prediction model–based screening would improve outcomes relative to using the risk factors of age and smoking history for broad implementation in primary care." In a Putting Prevention Into Practice case study in the July issue of AFP, Drs. Howard Tracer and James Pierre explained how to apply the Task Force recommendations in clinical practice. It will be interesting to see if the Centers for Medicare and Medicaid Services decides to follow the USPSTF and waive its current requirement for a shared decision-making visit prior to lung cancer screening.

Monday, August 9, 2021

Why you should just say no to "routine blood work"

You're at your family doctor's office to have a complete physical. Maybe you're starting a new job, or have recently joined a wellness program in your community, or it's been more than a few years since you've had a checkup and you (or your spouse or significant other) just want to make sure that everything's OK. Your doctor briefly reviews your medical history, performs a physical examination, says a few encouraging words about eating a healthier diet and exercising more, and then you're done.

You picked this doctor out of the five in the practice because your friend told you he was a sharp young fellow, but now you're not so sure. What about the blood work? You don't need any blood work, he says. Not even a urine sample? This is confusing. You've always had blood work and urine tests at your other physicals, and your insurance is footing the bill, after all. You wonder if this doctor really knows what he's doing.

This is a common situation that I face in primary care practice. For years, patients have been used to having blood samples drawn even if they felt completely well. Even today, when we know better (or ought to), up to one-third of primary care physicians still perform "routine blood work" (usually consisting of a complete blood count, a chemistry panel, liver function tests, thyroid tests, and a urine analysis) at adult physical examinations. So why is this such a bad idea? In 2007, I co-authored an editorial in the journal American Family Physician about this topic. We wrote:

"Big-ticket" tests [such as CT scans and MRIs] are easy targets for those seeking to reduce waste in health care. But what about the seemingly innocuous practice of performing routine tests such as a complete blood count (CBC) or urinalysis? ... These tests would be useful only if they provided additional diagnostic information that would not otherwise be obtained during a history and physical examination. In fact, large prospective studies performed in the early 1990s concluded that these tests rarely identify clinically significant problems when performed routinely in general outpatient populations. Although the majority of abnormal screening test results are false positives, their presence usually mandates confirmatory testing that causes additional inconvenience, and occasionally physical harm, to patients.

Don't misunderstand me. There are certain situations in which targeted screening tests can provide valuable information for the early detection of diseases. To learn more about which tests are recommended for your or your family members, I recommend that you visit the excellent website Healthfinder.gov. But the next time you go to a doctor's office and he or she proposes to check some "routine blood work," be sure to ask what these tests are for and what would happen if any of them turn out to be positive, so that you can make an informed choice about what's right for you.

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This post first appeared on Common Sense Family Doctor on September 13, 2009, and remains as relevant now as it was then.

Monday, August 2, 2021

Pharmacogenetic testing's usefulness remains limited

For patients with frequent episodes of gout, I often prescribe the drug allopurinol to lower their uric acid levels and prevent future episodes. This drug isn't for everyone, though. In 2019, Dr. Carl Bryce wrote a diagnostic test review in American Family Physician about the allopurinol hypersensitivity assay, "a blood test to detect the presence of a human leukocyte antigen B [HLA-B] genetic variant that increases the risk of life-threatening, severe cutaneous [skin] reactions in patients taking allopurinol." According to this article and a rapid evidence review of gout, testing was recommended for Korean adults with stage 3 or higher chronic kidney disease and all adults of Han Chinese or Thai descent, who have a higher frequency of the variant, prior to initiating allopurinol. In 2020, the American College of Rheumatology (ACR) simplified and broadened this testing recommendation to "people of Southeast Asian and African American descent."

Though pharmacogenetic testing holds promise for improving clinical decision-making, a recent JAMA viewpoint contended that race-based testing recommendations are problematic. Even a racially homogenous European country such as Switzerland exhibits wide genetic diversity in the frequency of the HLA-B*58:01 allele, with one city (Basel) actually having a higher frequency than the overall U.S. African American population. Further examination of the ACR's race-based guidance reveals additional complexities and contradictions:

The ACR guideline cites Han Chinese, Korean, and Thai as examples of Southeast Asian descent, even though China and Korea are not typically considered Southeast Asian countries. The guideline then states that screening is cost-effective in Asian populations generally. However, Japan is in Asia, but the allele frequency of HLA-B*5801 in Japan is even lower than that of White individuals in the US, who are not recommended for screening. In addition, the recommendation to screen all African American patients in the US before prescribing allopurinol belies wide-ranging HLA-B*5801 variation across Africa, where reported HLA-B*5801 frequencies, based on small sample sizes, range from 1% (comparable with White individuals in the US) to 10% (comparable with Thailand).

In a noteworthy editorial, Dr. Bonzo Reddick took aim at a related issue: the widespread use of diagnostic and clinical prediction tools that, like pharmacogenetic tests, incorrectly utilize race as a proxy for genetic differences. These include the atherosclerotic cardiovascular disease (ASCVD) Pooled Cohort risk calculator, equations for glomerular filtration rate (GFR), a calculator for predicting the likelihood of a successful vaginal birth after cesarean delivery, and pulmonary function testing "correction factors" for Black and Asian patients.

Recognizing that "claims about pharmacogenetic testing ... are inconsistently supported by scientific evidence, and most tests have not been examined by the U.S. Food and Drug Administration [FDA]," Drs. Wendy Rubinstein and Michael Pacanowski shared the FDA's perspective on what clinicians need to know in the July issue of AFP. In a table of selected pharmacogenetic associations, they summarized known and potential gene-drug interactions and recommendations for clinical practice. In a diagnostic test review in the same issue, Dr. Natasha Pyzocha evaluated GeneSight Psychotropic, an expensive test panel that analyses 12 genes with possible interactions with 57 neuropsychiatric medications. Dr. Pyzocha concluded that while this test may help patients who have had multiple unsuccessful trials of therapy, "because only a small population of patients are expected to have genetic phenotypes that would necessitate medication changes, ... routine genetic testing is not recommended," and "choosing antidepressants based on health history and symptoms should still be the standard initial approach."

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This post first appeared on the AFP Community Blog.