Wednesday, March 30, 2016

Tackling the long-term impact of concussions

After years of publicly denying that football players who sustain repeated concussions are at increased risk for degenerative brain disorders such as chronic traumatic encephalopathy (CTE), the National Football League (NFL) did a dramatic "about face" earlier this month in a hearing before the House of Representatives' Energy and Commerce Committee. Responding to a legislator's question about whether there is a link between CTE and football, Jeff Miller, the NFL's executive vice president of Health and Safety Policy, said, "The answer to that is certainly, yes."

There were other recent signals that the NFL had finally gotten serious about shedding its unscientific and defensive approach to concussions. Last year, the NFL Foundation partnered with the American Academy of Family Physicians (AAFP) to sponsor a series of 3 webcasts for primary care clinicians and a patient brochure addressing head injuries in sports at all levels. Although the long-term effects of concussions in professional football players have been well-documented, there is an urgent need to collect information on the outcomes of concussions in recreational athletes, especially in children and adolescents. In a recent JAMA study, one-third of Canadian children reported persistent somatic, cognitive, or behavioral symptoms 28 days after being diagnosed with an acute concussion in the emergency department.

According to a 2012 American Family Physician article on subacute to chronic mild traumatic brain injury (TBI), patient groups more likely to experience persistent postconcussive symptoms include women, older adults, persons with less education, and persons with a previous mental health diagnosis. Surveillance data from the National Collegiate Athletic Association (NCAA) show that in most comparable sports (soccer, basketball, softball), female athletes experience concussions at significantly higher rates than male athletes. Pink Concussions, which supports research into female concussions caused by sports, abuse, or military service, sponsored an international summit on concussion and TBI at Georgetown University in February.

The coming years will hopefully provide more research findings to inform parents, coaches and health professionals on best practices to minimize the long-term impact of concussions. In the meantime, primary care clinicians can access additional educational resources and clinical tools, including relevant AFP content, on the AAFP's website.


This post first appeared on the AFP Community Blog.

Wednesday, March 23, 2016


I only pay attention to college basketball during the first week of the NCAA tournament. Like many March Madness fans, I love rooting for underdogs. It broke my heart this year when the upstart #14 seed Stephen F. Austin Lumberjacks fell to Notre Dame in the second round on a last-second tip-in, a heartbeat from crashing the Sweet 16. In past tournaments, I was captivated by #11 seed George Mason's run to the Final Four in 2006 and #11 seed VCU's similar run from the First Four to the Final Four in 2011.

Family physicians are underdogs among medical specialties. If one were to rank student interest in the 24 specialties represented by the certifying boards of the American Board of Medical Specialties, the ROAD specialties (Radiology, Ophthalmology, Anesthesiology, Dermatology) would likely be #1 seeds, while Family Medicine, with its lower relative pay and more challenging work-life balance, would probably be seeded somewhere in the bottom half. Although the American Academy of Family Physicians cheered the results of last week's Residency Match, which saw another modest uptick in the number of medical students matching into Family Medicine residency programs, I observed in my latest Medscape commentary that student interest in primary care is no "Match" for higher-income specialties. My own institution sent just 6 students out of a class of 200 into Family Medicine this year; in the past decade, the most we've ever produced was 14. It's no wonder that urgent cares, retail clinics, and telemedicine are thriving in the frontline health care void created by a growing shortage of primary care physicians.

What can medical educators do to increase student interest in primary care careers? Here's what I suggested in my commentary:

Early primary care exposure and required clerkships are necessary but not sufficient. ... Medical schools also need to "create a school culture that values primary care." That means advocating for excellence and innovation in primary care must be an explicit school goal, along with seizing every opportunity to discuss the foundational role of primary care in courses on health systems, and offering primary care tracks for selected students. Similarly, the Family Medicine for America's Health leadership team recommended creating longitudinal, integrated curricula in family medicine that allow students to make meaningful contributions to patient-centered care teams and have plenty of opportunities for faculty mentorship.

Embracing these strategies doesn't mean that family physicians won't continue to be viewed as the underdogs at tertiary academic medical centers where most medical students receive training, but it may give us more of a fighting chance to recruit students to our specialty before next year's medical version of March Madness.

Wednesday, March 16, 2016

The promise and challenges of telehealth

Last fall, I attended a conference on patient-centered medical homes where one of my fellow attendees shared how after-hours videoconferencing with a primary care physician had allowed him to avoid spending a night with his child in the emergency department. This story made me wonder if primary care practices without virtual visit capabilities might someday be viewed as anachronisms, something like banks before automated teller machines and smartphone check depositing apps.

According to a Graham Center Policy One-Pager in the January 15th issue of American Family Physician, only 15% of family physicians surveyed in 2014 were using telehealth (defined as "the use of medical information exchanged from one location to another via electronic communications to improve a patient's health"), even though most agreed that it improves access and continuity of care. Geographical and generational differences influenced telehealth use; according to the original study report, telehealth users were more likely to see patients in rural settings and have practiced for 10 or fewer years than non-users. Non-users were more likely to cite barriers such as equipment cost, lack of reimbursement, lack of training, and potential liability issues.

Private insurers have been gradually expanding coverage for telehealth services, according to a recent article in Modern Healthcare. Since Medicare has traditionally been less willing to reimburse such services, bipartisan legislation, the Creating Opportunities Now for Necessary and Effective Care Technologies (CONNECT) for Health Act, was introduced in the U.S. Congress this year to remove many of the program's current restrictions. Family physicians and other primary care clinicians are poised to benefit from these changes. In recognition of the changing payment landscape, the American College of Physicians, the American Academy of Family Physicians, and the American Academy of Pediatrics all published policies or position papers on appropriate telemedicine use and reimbursement last year.

In addition to payment, there are other factors family physicians must consider in deciding whether or not to treat patients virtually. A 2015 article in Family Practice Management reviewed the most common elements of care that have implications for telehealth services:

1) Formation of a doctor-patient relationship
2) Proper evaluation and treatment
3) Responsible prescribing
4) Protection of the patient
5) Safeguarding patient privacy

If you or a family member have received telehealth services, I would love to hear about your experience. If you are a clinician who currently offers telehealth servcies, how has this capability benefited your patients and your practice? If you don't, what has been holding you back?


This post first appeared on the AFP Community Blog.

Thursday, March 10, 2016

"The most powerful group of doctors no one has ever heard of"

I would disagree with Washington Post reporter Lena Sun's dramatic description of the U.S. Preventive Services Task Force - the American Medical Association's Relative Value Scale Update Committee (RUC), which recommends how much Medicare should pay for practically every piece of work that doctors do, would have my vote for "most powerful physician group." However, her recently published investigative piece provides rare behind-the-scenes insight on the inner workings of the USPSTF panel, the scientific and political controversies its work has engendered over the years, and the unwanted regulatory authority that was bestowed on it by the Affordable Care Act. It's a must-read for anyone interested in the intersection of preventive medicine and health policy. Even though it has been more than 5 years since I was a staffer for the Task Force, the concluding paragraphs resonate with the end of my experience:

Such groups as the American Cancer Society say the best way to shelter the task force from even subliminal pressure is to keep it focused on what the evidence shows. Figuring out how that translates into what insurance should pay for ought to be the job of a separate entity, one that ACS notes could weigh broader public-health and social impacts.

For instance, if colonoscopies are strongly recommended as a preventive service — therefore costing consumers nothing extra — does the coverage also include the anesthesiologist involved in the procedure? What about the office visit that takes place beforehand? And what happens if the doctor finds a polyp and a pathologist determines it is benign — is it still covered? (Yes to all.)

Task force members “were pigeonholed into this role,” said Caroline Powers, a director of federal affairs for the cancer society’s advocacy arm. “It’s an inappropriate role.”

Also this week, my editorial "A Public Health Framework for Screening Mammography: Evidence-Based vs Politically Mandated Care" appeared in print in the Journal of the American Medical Association (it was posted online in mid-January). My students were more impressed at my being mentioned in the Post, but this publication was a personal milestone. Many thanks to my co-author, Georgetown University law professor Larry Gostin, for organizing my initial thoughts and helping to complete and publish this paper in record time.

Saturday, March 5, 2016

There are many ways to know cancer

In my line of work, it's not uncommon for a civil debate about the evidence for a cancer screening test (such as the PSA test for prostate cancer) to rapidly degenerate into the other person questioning my motives or suggesting that the real reason I oppose disseminating or requiring insurers to pay for a test is because I secretly want patients to suffer lingering and painful deaths. ("He obviously doesn't care about truth or patients," an academic urologist once tweeted in response to my blog post on pitfalls of interpreting screening studies.) Another charge that screening advocates level at skeptical family physicians is that we "don't know cancer" because we are generalists who don't see cancer patients day in and day out. I have countered that it's entirely possible to care for patients who die from cancer and still require high-quality evidence of net benefit before widespread adoption of interventions that might prevent such deaths.

This begs a larger question, though: how can any physician or researcher who has never personally suffered from cancer claim to "know cancer"? Is it enough to have spent years or decades studying the epidemiology, diagnosis, and/or treatment of a particular type of cancer? Must one have diagnosed or treated a certain number of persons with cancer? Or can one only know cancer though enduring the trauma of having an afflicted parent, sibling, child, or spouse?

Dr. Peter Bach, a pulmonologist and epidemiologist at Memorial Sloan Kettering Cancer Center in New York City, holds the unfortunate distinction of being able to answer "Yes" to all of the above questions. He is a nationally recognized expert on lung cancer, leading a 2012 systematic review on the benefits and harms of low-dose CT screening that informed guidelines from the American Cancer Society and the American College of Chest Physicians (which he also co-authored). Dr. Bach has also been one of the few voices of caution regarding the U.S. Preventive Services Task Force's sweeping recommendation for annual lung cancer screening in heavy smokers age 55 and older. Here is his trenchant explanation of why the Task Force should not have relied on decision models to extrapolate beyond empirical evidence from screening trials:

The Task Force seems to have looked for findings where there was “consensus” between the models as a way of overcoming the heterogeneity between them. However, because they are starkly different on so many fronts, looking only for the overlap is reminiscent of the Texas sharpshooter and the fallacy that accompanies him. The sharpshooter shoots first at the barn and then draws the target around the greatest cluster of hits.

What made Dr. Bach a household name in the cancer community is none of these things, however. Instead, it was his moving article about losing his wife, Ruth, to metastatic breast cancer in the May 6, 2014 issue of New York Magazine, "The Day I Started Lying to Ruth." Although I have long respected Dr. Bach for his incisive scientific publications, this was the first time I'd read him writing this personally (he also authored a series of Well Blogs in the New York Times in 2011 about Ruth's cancer diagnosis). One passage jumped off the page at me as a perfect illustration of hope overwhelming evidence when a loved one is suffering:

As he [Ruth's oncologist] wrote out the prescription for her to start the next treatment, what doctors call “second-line treatment,” I recalled a colleague of mine explaining the progression from first-line to second-line to third-line treatment. Each successive change brings more side effects with less chance of benefit. As my colleague put it, the cancer gets smarter, the treatments get dumber. Somewhere in this progression the trade-off no longer makes sense. Where that is may differ for each patient, but I’ve often thought that cancer doctors go well past that point.

None of that mattered to me, the medical professional to whom all these nuances and trade-offs should. All I could think about was the blood test telling us the tumor marker was too high. With that, any dreamy conceit—that patients should be given enough knowledge that they can weigh the risks and benefits for themselves, then come to the choice that best suits them—flew out the window. Our choice wasn’t a choice. Take the chemo.

There is no doubt in my mind that Dr. Bach would, in a heartbeat, exchange any moral authority he derives from having "known cancer" in this intimate way to have his wife back. All of us involved in confronting cancer in all its forms - specialist and primary care clinicians, advocates, patients, family and loved ones - know cancer in different ways, and none should be held up as inherently superior to any other. In debates about cancer screening, we may disagree about "truth," but like Dr. Bach, we all care about patients.


This post first appeared on Common Sense Family Doctor on June 5, 2014.