Thursday, December 20, 2018

My favorite public health and health care books of 2018

For the fourth year running, here is a list of the top 10 health-related books I read, ordered alphabetically. Although most were published within the past year, a few older books made it in as well. If you have already read these, feel free to peruse my lists from 2017, 2016, and 2015 for other worthwhile health and medicine reads for the holidays.


1. Bad Blood: Secrets and Lies in a Silicon Valley Startup, by John Carreyrou

What amazed me about this sordid tale wasn't the degree of corporate malfeasance involved, but how a charismatic college dropout managed to dupe so many investors and reporters (except for the author, notably) for so long.

2. Called for Life: How Loving Our Neighbor Led Us Into the Heart of the Ebola Epidemic, by Kent Brantly

Although there have been many excellent profiles of Dr. Brantly, a Texas family physician who survived an infection with Ebola virus during the 2014 outbreak in Liberia, nothing compares to hearing the story in his own words.

3. The Comeback: Greg LeMond, the True King of American Cycling, and a Legendary Tour de France, by Daniel de Vise

Though you'll likely find this biography in the sports section of your local bookstore, it is as much about medicine as cycling: LeMond's remarkable recovery from a nearly fatal hunting accident, as well as the pharmaceutical doping practices that spread through the rest of the peloton in the early 1990s and led to his premature retirement from the sport.

4. The Fears of the Rich, The Needs of the Poor: My Years at the CDC, by William Foege

The compelling memoir of a public health legend who tacked infectious disease threats from Legionnaires disease to smallpox.

5. The Fever: How Malaria Has Ruled Humankind for 500,000 Years, by Sonia Shah

What is by far the deadliest creature in human history? The mosquito.

6. In Shock: My Journey From Death to Recovery and the Redemptive Power of Hope, by Rana Awdish

A critical care doctor became a critical care patient, and after multiple near-death experiences emerged on the other side a more compassionate and capable physician.

7. Next in Line: Lowered Care Expectations in the Era of Retail and Value-based Health, by Timothy Hoff

A management professor explores, through patient and physician interviews, how efforts to standardize and improve primary care quality have instead created an environment that is toxic to the therapeutic relationships that make family medicine effective in the first place.

8. The Public Health Crisis Survival Guide, by Joshua Sharfstein

Dr. Sharfstein, currently Vice Dean and director of the Bloomberg American Health Initiative at Johns Hopkins University (where I earned my Master of Public Health degree), relates war stories and lessons learned from his days as a city, state, and federal health official.

9. Surgeon General's Warning: How Politics Crippled the Nation's Doctor, by Mike Stobbe

As this book illustrates, past U.S. Surgeon Generals have struggled with the high-profile but low-authority nature of the position and the political considerations that shadowed their every public utterance. I'm a fan of the current SG, Dr. Jerome Adams, whose recent declaration that teenage vaping has now reached "epidemic" proportions reminded me of his predecessor, Dr. C. Everett Koop.

10. What the Eyes Don't See: A Story of Crisis, Resistance, and Hope in an American City, by Mona Hanna-Attisha

Dr. Hanna-Attisha's crusade to protect the children of Flint, Michigan from lead-poisoned drinking water represented a rare triumph of the disenfranchised over racial and social injustices. Her family's interweaved immigration story serves as a reminder of what America stands to lose from policies that seek to close our borders.

Monday, December 17, 2018

Family medicine and the value of long-term therapeutic relationships

A commentary in the November 22 issue of the New England Journal of Medicine titled "Beyond Evidence-Based Medicine" received much well-deserved criticism for not only mis-characterizing EBM, but advocating for a novel approach, "interpersonal medicine," that was explicitly codified in the recognition of the U.S. specialty of Family Practice nearly 50 years ago. Here's what the authors wrote about this practice of medicine that is, apparently, new to them but well-known to the rest of us:

Interpersonal medicine would recognize clinicians’ influence on patients and informal caregivers and the relationships among them. It would be anchored in longitudinal, multidirectional communication; broach social and behavioral factors; require coordination of the care team; and constantly evaluate and iterate its own approach.

After reading these sentences via a tweet from Dr. Eric Topol, I quickly added my perspective on "interpersonal medicine," which, judged by the volume of likes and retweets, was greeted enthusiastically by other primary care clinicians and their allies: 

It was one of the few times in recent memory that other physicians were eager to jump on the #FMRevolution bandwagon, as geriatricians, general internists, and general pediatricians tweeted that their generalist fields provide "interpersonal medicine" too. I agree. But I draw the line there. No matter how excellent one's beside manner, a subspecialist whose job description revolves around treating a specific a body part, organ system, or disease state, or intermittent contacts during specific periods of illness (e.g., emergency medicine, hospitalists) is not using the generalist approach described by longtime Annals of Family Medicine editor Kurt Stange in a 2009 editorial:

A generalist approach involves working on the parts while paying attention to the whole; being connected by sustaining relationships; having a broad base of knowledge while being grounded in specific information; scanning and prioritizing, then focusing on what is most meaningful; moving back and forth between the universal and the particular. The generalist approach is rooted in recognizing connection to person, community, and cosmos.

The skills of generalist physicians - and family physicians in particular - have long been devalued by our health system's mechanisms of measuring and paying for clinical work in discrete tasks, rather than for caring for the whole person. The movement toward "paying for performance" has not helped. As Dr. Dhruv Khullar and colleagues observed in a recent JAMA Viewpoint, "because these programs are disconnected from the needs of patients and physicians within organizations, they often result in erroneous metrics, gaming of the system, and unidirectional assessments that emphasize meeting thresholds over open dialogue."

In other words, never mind that I carefully reviewed with my 65 year-old patient of the past 5 years with a recent blood pressure of 145/92 the pros and cons of intensifying his medication regimen, the limitations of the evidence, and his personal values and preferences; 140/90 is my practice's non-negotiable cutoff for poor quality. This is hardly surprising, since quality management has rarely accounted for what makes a difference to patients in primary care - particularly, as Dr. Justin Mutter and colleagues suggested in "Core Principles to Improve Primary Care Quality Management," prioritizing therapeutic relationships over time. Reflecting on changes in the role of the personal physician since the dawn of the specialty, a group of senior leaders in academic family medicine has observed:

We have watched our patients age with us. They beg us not to retire. For our patients, we are caregivers, healers, advisors, friends, and navigators through a complex system. Our patients are admirable human beings who taught us our craft, offering clinical challenges and providing us with the gratification that makes practicing medicine worthwhile. A principal challenge for the present and future ... is to be able to establish and maintain the long-term trusting relationships that have characterized family doctors and our role in health systems and society.

In a similar ode to continuity of care, Dr. Adam Cifu, a general internist who has cared for the same patient panel for more than 20 years, wrote in JAMA Internal Medicine: "In our own practices and in our roles engineering health care systems, we should prioritize the maintenance of these relationships. We are losing much more than easy clinic days as we foresake long-term physician-patient relationships." This assertion is not merely anecdotal, but supported by evidence: a recent analysis of Medicare data by Dr. Andrew Bazemore and others at the Robert Graham Center found that higher primary care physician continuity is associated with lower costs and hospitalizations. At the same time, one of my colleagues notes that insurers are paying five times as much for patients to have a video or telephone visit with a "teladoc" than with their family physician.

Enough with "interpersonal medicine"! EBM is not the problem, and it never has been. Rather, the patient experience in the U.S. will not improve without first recognizing that family physicians and other generalists have expertise in whole person care, grounded in long-term therapeutic relationships. Then, policymakers must create conditions that support providing generalist care from the continuum of medical training through clinical practice.

Tuesday, December 11, 2018

Just released from prison? Good luck finding a primary care physician.

A young man with schizophrenia, opioid use disorder (OUD) and chronic hepatitis C infection completed a 5-year prison sentence and was discharged back into the community. While he was incarcerated, he received antipsychotic medications and periodic laboratory monitoring of his liver disease; medication-assisted treatment for OUD was unavailable. At the time of his release, he was given a 30-day supply of pills and told to follow up with a primary care physician. The next few weeks will be a critical time for this patient's health, according to an article on care of incarcerated patients in the November 15th issue of American Family Physician:

Most inmates are discharged from correctional facilities without a supply of medications or referrals to primary care, mental health services, or substance abuse treatment. Lack of care coordination directly affects the health of former inmates. In the two weeks following release, former inmates are 129 times more likely to die of a drug overdose and 12 times more likely to die of any cause than members of the general public.

Former inmates face two significant obstacles to accessing primary care: affording care, and the reluctance of some clinicians to accept formerly incarcerated patients. Before 2014, an estimated 80 percent of incarcerated persons lacked health insurance or the financial resources to pay for basic health care. Even after the expansion of Medicaid to single and childless adults earning up to 138% of the federal poverty level in 36 states and the District of Columbia, many patients continue to slip through the cracks. A 2016 Kaiser Health News article recounted the case of Ernest, a man with severe mental illness who served prison time in Indiana for killing his 2 year-old daughter during a psychotic delusion. Even though Indiana had expanded Medicaid by the time of Ernest's release and set up a system to enroll all eligible prisoners, records show that he was forced to enroll in the program on his own, wasting valuable time and delaying his transition of care:

Ernest’s letters to Medicaid and a clinic before he got out didn’t help. He had to start the application process from scratch after he got home, making increasingly frantic calls and scrambling to find his birth certificate and other paperwork as his supply of lithium and perphenazine, an antipsychotic, dwindled. “Somebody who’s committed a violent felony because of a mental illness is getting out of prison, and we don’t have anything set up yet?” he said.

Having health insurance does not necessarily mean that a patient will be able to access care, as illustrated in a recent Canadian study published in the Annals of Family Medicine. Researchers posing as prospective patients telephoned all family physicians listed as accepting new patients in British Columbia. The only difference between the patient roles was that one set mentioned that he or she had been released from prison a few months before. Among the 250 family physicians who answered the phone and were still providing primary care, control patients were twice as likely to be offered an appointment compared to persons recently released from prison (absolute risk difference = 41.8%).

In 2017, I co-authored a position paper on Incarceration and Health for the American Academy of Family Physicians that suggested "family physicians can promote the health of individuals during the transition from correctional facilities to the community by supporting reentry processes that begin prior to release; collaborations between prison and community health services; integrated models of care; and linkages to housing, employment, and mental health support." To that, I would add that we should not discriminate against patients with a history of incarceration.


This post first appeared on the AFP Community Blog. Via responses on Twitter, I was pleased to learn that some family physicians prioritize appointments for these vulnerable patients.

Wednesday, December 5, 2018

Lowering cholesterol with a statin - when is it worth it?

Although I have never been a big fan of modeling studies, viewing their appropriate role as hypothesis-generating rather than clinical decision-supporting, a study published yesterday in the Annals of Internal Medicine deserves kudos for trying to do what neither the American College of Cardiology/American Heart Association nor the U.S. Preventive Services Task Force did in their respective guidelines on primary prevention of cardiovascular disease for adults aged 40 to 75 years: empirically assess the balance of benefits and harms of statins. (In case you missed it, I recently recorded a Medscape commentary on the 2018 ACC/AHA guideline, which has flaws but overall represents an improvement over the 2013 version.)

In persons at low risk of having a heart attack or stroke, the harms of statins offset (or may be greater than) the benefits, but at what 10-year risk threshold do the benefits begin to outweigh the harms (positive net benefit)? In 2013 and again in 2018, the ACC/AHA proposed an arbitrary threshold of 7.5%, and the USPSTF's slightly higher threshold of 10% is just as arbitrary, even as it compensates for the tendency of the Pooled Equations risk calculator to overestimate true risk and potentially lead to unnecessary therapy. But neither group quantitatively weighed the relatively low probability of preventing a serious cardiovascular event against the higher probability of causing muscle aches, diabetes, and other adverse effects, as this research team did.

The modeling study's results will appeal to patients (including my own) who would prefer that their physicians be conservative in prescribing statins, suggesting that in men the risk threshold where benefits exceed harms ranges from 14% to 21%, while in women it ranges from 17% to 22%. The study's methods are not particularly transparent, relying in part on a network meta-analysis that is not yet published. Even if the model's inputs were clearer, there is no consensus that several of the harms that they attribute to statins (hemorrhagic stroke, renal dysfunction, cancer, and cataracts) are actually medication-related.

Setting the numbers aside, I agree with one general conclusion: although the risk of having a heart attack or stroke rises with age, so, too, does the threshold when it makes sense to take preventive action. Side effects of statins are more common in older persons, and the older you are, the more likely you are to die from something other than cardiovascular disease (so-called "competing causes of death"). Over age 75, it becomes very unlikely that starting or continuing a statin for primary prevention will do more good than harm.

Monday, November 26, 2018

Out-of-hospital management of low-risk patients with acute pulmonary embolism

I've practiced family medicine long enough to remember when treatment of any patient with acute deep venous thrombosis (DVT) required hospitalization for several days administering intravenous unfractionated heparin and oral warfarin while waiting for the patient's international normalized ratio (INR) to reach a therapeutic level. Thanks to the development of low molecular-weight heparins and direct-acting oral anticoagulants (DOAC), outpatient treatment of uncomplicated DVT is now the norm. But patients with newly diagnosed pulmonary embolism (PE) are still typically hospitalized, since they often have hemodynamic instability or other potentially life-threatening conditions.

According to a 2017 article in American Family Physician, the American College of Chest Physicians suggests considering outpatient treatment of acute PE "if the risk of nonadherence is low and the patient is clinically stable; has no contraindications to anticoagulation, such as recent bleeding, severe renal or liver disease, or platelet count of less than 70; and feels capable of managing the disease at home." A recent Point-of-Care Guide reviewed clinical decision tools that predict mortality in patients with newly diagnosed PE. The simplified Pulmonary Embolism Severity Index (sPESI) stratifies patients into low and high risk categories. Low risk patients have a 30-day mortality rate of 1%, while high risk patients have a 9% mortality rate.

A prospective cohort study published in CHEST earlier this year enrolled 200 consecutive adults with newly diagnosed PE and a low risk of mortality using the related Pulmonary Embolism Severity Index (PESI). Participants were observed in the emergency department (ED) for 12 to 24 hours, then treated with anticoagulant medications in the outpatient setting (173 patients were treated with DOACs). After 90 days, no patients had died or suffered a recurrent venous thromboembolism (VTE). One patient had a major bleed after a traumatic thigh injury that required a blood transfusion and surgery.

A pragmatic controlled trial in Annals of Internal Medicine evaluated the effect of implementing an electronic clinical decision support system (CDSS) that included the PESI tool and an educational intervention on decision making for patients with acute PE in the 21 community EDs of Kaiser Permanente Northern California. 10 EDs received access to the CDSS and in-person education and feedback from an onsite emergency physician-researcher ("study champion"); the other 11 EDs served as control sites. The primary outcome was discharge to home from the ED or an ED-based outpatient observation unit. At the intervention sites, home discharge increased from 17.4% to 28%, while there were no changes in discharge practices at control sites. The intervention was not associated with increases in 30-day major adverse events (recurrent VTE, major hemorrhage, or all-cause mortality).

One day, one of my trainees will be able to write, "I've practiced family medicine long enough to remember when even low-risk patients with acute PE required hospitalization ..."


This post first appeared on the AFP Community Blog.

Tuesday, November 20, 2018

Delving deeper into the problem of overdiagnosis in medicine

Over the summer, two family physician colleagues and I published a commentary in Public Health Reviews on the implications of overscreening for carotid artery stenosis, prediabetes, and thyroid cancer. A theme connecting these three abnormalities (I won't call them "diseases," as evidence suggests that the most persons who receive these diagnoses through screening would be better off not knowing and being spared premature, costly, and/or invasive therapies) is that they are largely creations of modern medicine. A person can't feel a narrowing in a carotid artery, a slightly higher than normal blood sugar level, or a tiny thyroid nodule - instead, they learn about them after a doctor performs a test, either specifically to look for the abnormality or as an incidental finding. If the diagnosis leads to improved health outcomes, that's good news; if it only causes anxiety and unnecessary interventions, that's overdiagnosis.

2018 has seen the publication of several excellent reviews of the effects of overdiagnosis in primary care. In the Annals of Internal Medicine, Evidence-based Practice Center researchers affiliated with the U.S. Preventive Services Task Force (USPSTF) wrote about defining, estimating, and communicating overdiagnosis in cancer screening. They observed that several different study designs and approaches have been used to estimate the percentages of cancer cases that are overdiagnosed, all with limitations. (Sidebar: in a commentary in JAMA Internal Medicine, former USPSTF member Mark Ebell, MD, MS and I explored how these methods were used to produce varying estimates of overdiagnosis in randomized trials of lung cancer screening with low-dose CT scans.)

Members of the Canadian Task Force on Preventive Health Care (the evidence-based prevention panel after which the USPSTF was modeled) reviewed "causes and consequences" of overdiagnosis in primary care in a case-based discussion in Canadian Family Physician. Across the pond, the BMJ published a state-of-the-art review by two U.S. internists. Drs. Minal Kale and Deborah Korenstein pointed out that drivers of overdiagnosis include broadening disease definitions, advanced technology, public health screening programs, culture around medicine and health (e.g., "more screening is always better"), system factors (e.g., profit-driven testing, direct-to-consumer advertising, industry influence on guidelines and medical education), and limitations in evidence application. Finally, the World Organization of Family Doctors (WONCA) Europe released a position paper that defined overdiagnosis as "transforming people into patients unnecessarily" and urged family physicians, on behalf of their patients, to "demand balanced evidence informed and non emotional information material from providers and authorities in relation to cancer screening, health checks, etc."

Potential solutions to the problem of overdiagnosis should address each of the drivers, as outlined in a 2017 BMJ article by researchers at Bond University in Australia, which will co-host next year's international Preventing Overdiagnosis conference. One cancer-specific solution is to re-name low risk conditions currently labelled as cancer, such as small papillary thyroid cancers, ductal carcinoma in situ (DCIS), localized low-grade prostate cancer, melanoma in situ, and certain small lung and kidney cancers.

Tuesday, November 13, 2018

For mild hypertension in low-risk adults, harms of drug therapy outweigh benefits

Prior to publication of the controversial 2017 ACC/AHA clinical practice guideline, stage 1 or "mild" hypertension was defined as a systolic blood pressure of 140-159 mm Hg and/or diastolic blood pressure of 90-99 mm Hg. Although guidelines have recommended that persons with mild hypertension receive anti-hypertensive drug therapy if lifestyle modification does not lower blood pressure below 140/90, a Cochrane review found that such therapy did not reduce cardiovascular disease (CVD) events, stroke, or mortality compared to placebo. A 2015 meta-analysis that included high-risk persons (patients with diabetes and/or who had received prior antihypertensive treatment) suggested that drug therapy for mild hypertension may prevent CVD events, but others have argued that this analysis mixed apples with oranges and did not establish benefits for adults at low CVD risk.

A retrospective cohort study recently published in JAMA Internal Medicine sought to clarify the benefits and harms of drug therapy in low-risk adults with mild hypertension using data from 40,000 patients in an electronic health records database in the United Kingdom. The authors compared the outcomes of persons aged 18 to 74 with mild hypertension who were prescribed anti-hypertensive medications within 12 months of diagnosis to those in similar untreated persons. Persons with a history of CVD, left ventricular hypertrophy, atrial fibrillation, diabetes, chronic kidney disease, or a family history of premature heart disease were excluded from the study.

After a median follow-up duration of 5.8 years, there were no differences between the groups in all-cause mortality, stroke, myocardial infarction, acute coronary syndrome, or heart failure. However, the treated group had an increased risk of hypotension (number needed to harm = 41 at 10 years), syncope (NNH = 35), electrolyte abnormalities (NNH = 111), and acute kidney injury (NNH = 91).

Although ideally the findings from this observational study should be confirmed in a randomized, controlled trial, it is unlikely that a trial will ever be performed due to the large number of participants that would be needed in order to provide enough statistical power to detect a difference in mortality or rare CVD events in this population. In the meantime, the best available evidence suggests that the harms of drug therapy outweigh benefits for low-risk adults with a systolic blood pressure of 140-159 mm Hg and/or diastolic blood pressure of 90-99 mm Hg (recently redefined by the ACC/AHA as stage 2 hypertension). In these patients, family physicians and other primary care clinicians should emphasize nonpharmacologic management strategies such as a diet with a high intake of vegetables, fruits, and whole grains; moderating excessive sodium intake and alcohol consumption; and at least 150 minutes per week of moderate-intensity aerobic physical activity, as recommended in the latest Physical Activity Guidelines for Americans.


A slightly different version of this post first appeared on the AFP Community Blog.

Monday, October 29, 2018

PSA screening: USPSTF recommendations changed, but the evidence did not

Comparing the 2018 U.S. Preventive Services Task Force (USPSTF) recommendation statement on prostate cancer screening in the October 15th issue of American Family Physician with its previous recommendation, the first question family physicians ought to ask is: what new evidence compelled the USPSTF to move from recommending against PSA screening in all men to determining that there was a small net benefit for screening in some men? Did another major randomized trial show a reduction in all-cause or prostate cancer-specific mortality in men invited to screening? Did other systematic reviewers re-analyze the evidence and find a mortality benefit where none previously existed? Have urologists or radiation oncologists developed new treatments for localized prostate cancer that no longer cause erectile dysfunction, urinary incontinence, or infections?

No, no, and no.

One of the Top 20 Research Studies of 2017 for Primary Care Physicians, the only U.S. trial of PSA-based screening for prostate cancer, reported that after a median followup of 15 years, there were still no differences in mortality between the two groups. In 2018, a large U.K. randomized trial of a single PSA screening also reported no effect on prostate cancer mortality after a median followup of 10 years. In both trials, more prostate cancers were diagnosed in the groups assigned to routine screening, but treating these cancers did not lead to improved health outcomes.

Last month, the authors of a 2010 Cochrane review of PSA screening (previously summarized in AFP's Cochrane for Clinicians) published an updated meta-analysis in the BMJ that incorporated the U.K. trial findings and extended followup of the U.S. and European screening trials and concluded that "at best, screening for prostate cancer leads to a small reduction in disease-specific mortality over 10 years but does not affect overall mortality." They also estimated that "for every 1000 men screened, approximately 1, 3, and 25 more men would be hospitalized for sepsis, require pads for urinary incontinence, and report erectile dysfunction, respectively." Another U.K. trial comparing active surveillance for localized prostate cancer with immediate surgery or radiation therapy found higher rates of clinical progression in the active surveillance group, but no differences in health-related quality of life or mortality.

Representing the views of American Academy of Family Physicians (AAFP), Drs. James Stevermer and Kenneth Fink explained in an editorial why "the AAFP believes that the net benefit [of PSA screening] does not justify routine screening or routinely offering shared decision making." The AAFP took the unusual step of declining to endorse the USPSTF recommendation statement and instead writing its own clinical preventive services recommendation that emphasizes the harms of routine screening. Men who bring up the topic of PSA screening should engage in shared decision-making with their physicians about the benefits and harms of screening and express a clear preference to be screened before undergoing the test.


This post first appeared on the AFP Community Blog.

Monday, October 15, 2018

We should be alarmed that congenital syphilis is on the rise

The Tuskegee Syphilis Study will always be a black mark on American medicine. Designed to record the natural history of untreated syphilis in a population of illiterate African American men in rural Alabama, it continued for 25 years after penicillin became widely available and an accepted cure for the disease. Participants were deceived into believing that they were receiving effective treatment and never informed that they had the option of leaving the study. Although the ethics of these practices were occasionally questioned, the study did not end until it had received widespread negative publicity and Congressional hearings had been called.

In 1972, the last year of the Tuskegee study, I hadn't been born yet. But when I was a medical student doing my Internal Medicine clerkship in early 2000, an older African American man was admitted to our hospital service with memory loss, confusion and difficulty walking and was eventually diagnosed with tertiary neurosyphilis. Based on what he told me about his sexual history and prior symptoms (genital ulcers, rashes, muscle and joint pains), he had likely been infected decades before. Though he was a U.S. citizen by birth, he did not have a family physician and had rarely received health care due to not having insurance or the ability to pay. I don't remember what happened after we started penicillin, but much of the damage already done to his nervous system was irreversible. This patient's illness wasn't quite as outrageous as doctors knowingly withholding antibiotics for decades, but I have little doubt that it could have turned out differently if he had had access to primary care earlier in his life.

Last month, the Centers for Disease Control and Prevention (CDC) announced that the number of reported cases of congenital syphilis in the U.S. rose from 362 in 2013 to 918 in 2017, paralleling increases in syphilis infections in reproductive-age women during this time period. From 2016 to 2017, congenital syphilis cases rose from 16 to 23 per 100,000 live births. Although two-thirds of affected infants have no symptoms at birth, congenital syphilis is associated with increased neonatal mortality and a variety of early (through 48 months of age) and late complications.

The first line of prevention against congenital syphilis is screening for syphilis in all pregnant women at the first prenatal visit, a well-established standard of care that the U.S. Preventive Services Task Force (USPSTF) recently reaffirmed. Although some cases occur in infants whose mothers receive no prenatal care, about one-third of women who delivered a baby with congenital syphilis in 2016 were screened during their pregnancies.

The CDC, the American Academy of Pediatrics, and the American College of Obstetricians and Gynecologists all recommend repeating syphilis screening in women at high risk for syphilis at around 28 weeks of gestation and at time of delivery. Women at high risk include those living in higher-prevalence communities or geographic areas; those living with HIV infection; those with a history of incarceration or commercial sex work; and those exposed to a sexual partner with confirmed syphilis infection. Early penicillin treatment of infected pregnant women reduces the risk of congenital syphilis.

It is alarming that nearly a thousand American babies born last year were afflicted with congenital syphilis. Medically speaking, preventing this condition through detection and treatment of syphilis is straightforward. This is a population health failure, resulting from an underfunded public health infrastructure and a fragmented health system that makes it hard for women at high risk to access timely prenatal and primary care. Our country can do much better.


Parts of this post first appeared on the AFP Community Blog.

Saturday, October 6, 2018

What works and what doesn't for chronic sleeplessness

Can't sleep? Then spend your extra awake time reading the latest installment of Implementing AHRQ Effective Care Reviews in the September 1 issue of American Family Physician, on management of insomnia disorder in adults. This evidence review, which supported an American College of Physicians practice guideline, examined the effectiveness of behavioral therapies and medications for adults with insomnia disorder, defined as "poor sleep quality or quantity that causes distress or dysfunction and lasts for longer than three months."

The most beneficial sleep intervention overall is cognitive behavior therapy for insomnia (CBT-I), which produced sustained improvements for at least 6 months. CBT-I consists of cognitive therapy, sleep restriction and stimulus control, and sleep hygiene education. Medications that have sufficient evidence demonstrating improvement in short-term (3 months or less) sleep outcomes include eszopiclone, zolpidem, and suvorexant; there was insufficient data to evaluate benzodiazepines or over-the-counter sleep aids (diphenhydramine, doxylamine, or melatonin). For most patients, medications should not be prescribed for longer than five weeks.

Physicians commonly prescribe antipsychotic medications off-label to treat insomnia in older persons. The Practice Guidelines in the September 15 issue summarized a Canadian guideline for deprescribing antipsychotics for behavioral and psychological symptoms of dementia and insomnia, produced by the Deprescribing Guidelines in the Elderly Project. Due to the potential harms of these medications and the lack of evidence of benefits (a single randomized trial with 13 participants found nonsignificant differences in sleep latency in patients taking quetiapine), the guideline recommends that antipsychotics prescribed for primary or secondary insomnia in which comorbidities are under control be discontinued without tapering, regardless of treatment duration.

AFP's sister journal, FPM, recently published an article on deprescribing unnecessary medications that featured a four-step process (review current medications; identify inappropriate, unnecessary, or harmful medications; plan deprescribing with the patient; and regularly re-review medications) and links to additional resources on medication reconciliation and deprescribing.


This post first appeared on the AFP Community Blog.

Monday, October 1, 2018

Setbacks and a milestone for evidence-based medicine

For my students in 2018, it's difficult to imagine an era when there was no such thing as evidence-based medicine (EBM). When I started medical school in 1997, though, the term had only been in use for six years, having been introduced by Dr. Gordon Guyatt at McMaster University (though EBM's intellectual origins can be traced to several key individuals). When I tell trainees how recently EBM began, they often ask, "Well, then, what kind of medicine did physicians practice before?" The answer is, we largely practiced "eminence-based" medicine (but this tongue-in-cheek article offered some equally poor alternatives).

Although it may be well established, the primacy of EBM is more fragile than it seems. In the September 15 issue of American Family Physician, my longtime mentor and editor emeritus Jay Siwek, MD reviewed common misconceptions, barriers, and practical solutions. For example, evidence can be distorted by financial conflicts, misinterpreted though the lens of one's preexisting beliefs, or ignored by those who deride evidence-based practice guidelines (incorrectly) as "cookbook," "one-size-fits-all" medicine. A recent essay in BMJ also described threats to evidence-informed policy making driven by ideological decisions on both ends of the political spectrum:

We tend to alight on examples of harmful interventions that fit our own political preferences. For example, ... public health researchers leaning towards the left might cite evidence that abstinence only sex education is more likely to lead to increased sexual risk behavior than comprehensive sex education. ... But only referring to examples where the evidence aligns with our own preferences risks suggesting to those on the left that they do not need evidence to know what does not work (as it is just obvious), and to those on the right that evidence informed policy is a liberal conspiracy.

EBM has experienced serious setbacks in the past few months. One, which I discussed previously, was the shuttering of the National Guideline Clearinghouse, a vital repository of evidence-based guidelines that was maintained by the Agency for Healthcare Research and Quality. Another is the Sept. 14 resignation of health services researcher Dr. H. Gilbert (Gil) Welch from Dartmouth College. Described as "an internationally recognized expert on the effects of medical screening and overdiagnosis" in his official Dartmouth biography, Welch literally wrote the book on overdiagnosis, which makes the university's determination that he plagiarized ideas in a 2016 paper puzzling at best. Welch resigned in response to Dartmouth's demands that he make his accuser the first author on the paper and stop teaching at the school. He has denied the plagiarism accusation, and the New England Journal of Medicine has declined to retract the article, viewing it as an authorship dispute rather than a breach of ethics. Although I hope that Dr. Welch's work will continue, his resignation is not only a huge loss for Dartmouth, but for all who have followed and benefited from his seminal work on the downsides of screening, including me.

On the same day as Dr. Welch's resignation, another giant in evidence-based medicine, Dr. Peter Gotzsche, was unceremoniously dismissed from the governing board of the Cochrane Collaboration and expelled from membership in the group. Previously the director of the Nordic Cochrane Center and author of 17 Cochrane reviews, Dr. Gotzsche called his explusion from the organization emblematic of a "moral governance crisis" and accused Cochrane's executive team of sacrificing scientific rigor and open debate in a "growing top-down authoritarian culture and an increasingly commercial business model." Cochrane leadership had been annoyed by Dr. Gotzsche's co-authorship of a BMJ Evidence-Based Medicine critique of a Cochrane review of HPV vaccines, which some felt was overblown and might shake public confidence in the vaccine. But their action sent the chilling message - antithetical to the democratic values at the heart of EBM - that open dissent would not be tolerated.

Thankfully, the news isn't all bad for EBM. An article by fellow AFP Deputy Editor Mark Ebell and colleagues in the September Annals of Family Medicine celebrated the top 20 POEMs (summaries of studies of patient-oriented evidence that matters) of the past 20 years. Since 1998, this group has systematically reviewed more than 100 clinical medical journals for such studies. My EBM teaching favorites from the top POEMs list include those from 2002 (hormone replacement overall is not beneficial), 2009 (prostate-specific antigen screening does not reduce mortality from prostate cancer), and 2013 (fasting is not necessary before measuring lipid panels). Congratulations to the "POETs" for their past contributions, and for continuing to do the yeoman's work of bringing medical evidence to the point of care in primary care.

Wednesday, September 19, 2018

Underperforming big ideas in diabetes and breast cancer

Management of type 2 diabetes and screening for breast cancer make up a large portion of most family physicians' practices, including my own. Care and prevention for these patients is based on straightforward underlying theories of disease causation and behavior. Patients with type 2 diabetes have high blood glucose levels; treatment involves normalizing blood glucose through lifestyle modification and medication. Small, nonpalpable breast cancers eventually become large, symptomatic tumors. Smaller tumors are more likely to be curable, so undergoing regular screening mammography is preferable to not doing so.

But what if these underlying theories are wrong?

In a 2016 editorial in JAMA, Drs. Michael Joyner, Nigel Paneth, and John Ioannidis explored how the "big idea" or narrative that investments in genetics and information technology will lead to a revolution in health care has captured a large share of biomedical research funding and journal publications. They then illustrated how this big idea has "underperformed," as central assumptions of precision/personalized medicine have not been borne out in studies and tens of billions of dollars invested into electronic health records since 2009 have not made patient care measurably better or patient data more accessible to researchers.

Is tight glycemic control for patients with type 2 diabetes mellitus an underperforming clinical big idea? In an analysis in Circulation: Cardiovascular Quality and Outcomes, Drs. Rene Rodriguez-Gutierrez and Victor Montori compared clinical policy statements and practice guidelines for patients with type 2 diabetes between 2006 and 2015 with evidence from randomized controlled trials. Despite little or no evidence that tight glycemic control (hemoglobin A1c less than 6.5 or 7.0%) improves microvascular or macrovascular outcomes compared to less strict hemoglobin A1c goals, the majority of guidelines continued to endorse tight control for one or both of those outcomes. (In contrast, American Family Physician editorials and articles have asserted that "Physicians should not let well-intentioned but misguided concern for glucose levels distract them from attending to other interventions that more profoundly affect mortality [in patients with type 2 diabetes]: smoking cessation, blood pressure control, metformin therapy, and lipid reduction.")

And do small breast tumors detected by mammograms become large, lethal ones? Sometimes, but not as often as most patients and physicians think, according to an observational study in the New England Journal of Medicine that concluded: "Women [with tumors detected on mammography] were more likely to have breast cancer that was overdiagnosed than to have earlier detection of a tumor that was destined to become large." This study also concluded that most of the reduction in breast cancer mortality over the past 40 years could be attributed to improved systemic therapy rather than earlier tumor detection. In an editorial on counseling women about breast cancer screening, Dr. Mark Ebell and I discussed the benefits and harms of mammography in younger women and noted that for every additional breast cancer death prevented by starting at age 40, two women will be overdiagnosed with (and overtreated for) breast tumors that never would have become clinically apparent.


This post first appeared on Common Sense Family Doctor on October 26, 2016.

Monday, September 3, 2018

Fracture prevention in older adults: what the evidence says

Hip fractures are a significant preventable cause of morbidity and mortality in older adults. Strategies to reduce hip fracture rates include preventing falls, screening for osteoporosis and prescribing bisphosphonate drugs to increase low bone density, and vitamin D supplementation. Recent studies and guidelines have clarified some of the evidence surrounding hip fracture prevention.

In a Putting Prevention Into Practice case study in the August 15 issue of American Family Physician, Drs. Tina Fan and Elizabeth Erickson discussed two updated U.S. Preventive Services Task Force (USPSTF) recommendations on interventions to prevent falls and supplements for primary prevention of fractures. Although the USPSTF continues to recommend exercise interventions to prevent falls in community-dwelling adults 65 years or older at increased risk of falls, it no longer recommends vitamin D supplements to prevent falls, due to evidence of no benefit and potential harms (increased falls and kidney stones). The Task Force found insufficient evidence to assess the balance of benefits and harms of vitamin D and calcium supplements at daily doses greater than 400 IU of vitamin D and 1,000 mg of calcium (lower doses are not effective) in postmenopausal women without a history of osteoporosis, which may come as a surprise, given how many are taking such supplements.

The USPSTF also recently reaffirmed its previous recommendation to screen for osteoporosis with bone measurement testing in women 65 years and older. Earlier this year, The Lancet published the first randomized controlled trial of osteoporosis screening with fracture outcomes. Although screening did not affect the primary outcome of all osteoporosis-related fractures over 5 years (HR 0.94, 95% CI 0.85-1.03), it reduced the incidence of hip fractures (HR 0.72, 95% CI 0.59-0.89). More controversial was the Task Force's recommendation to screen postmenopausal women younger than 65 years at increased risk for osteoporosis. In a JAMA editorial, Dr. Margaret Gourlay argued that the 2-step screening strategy advised by the USPSTF - clinical risk assessment tool followed by bone density testing if indicated - may not produce a net benefit to patients. Although screening women younger than age 65 has potential benefits, it is unclear if these benefits outweigh the opportunity costs:

If complicated risk tools perform no better than age alone to identify screening candidates, women younger than 65 years may be subjected to inefficient screening procedures. … The clinician could spend half of a 15-minute clinical visit accessing a risk tool and asking the patient about unfamiliar risk factors (eg, secondary causes of osteoporosis) to make 1 decision out of the dozen or more compressed into an annual physical examination. … Given the myriad responsibilities of primary care practices caring for patients with high-acuity conditions, implementation of screening programs that are needlessly complex is burdensome and distracts from high-value medical care.

Finally, for patients with osteoporosis who are eligible for treatment, given concerns about long-term adverse effects of bisphosphonates, including rare osteonecrosis of the jaw, for how long should these drugs be prescribed? A FPIN Help Desk Answer found low-quality evidence that for most women, bisphosphonate therapy beyond 5 years does not further reduce clinical vertebral fractures, nonvertebral fractures, or mortality. However, women with persistent femoral neck T-scores lower than -2.5 may benefit from longer treatment durations.


This post first appeared on the AFP Community Blog.

Thursday, August 30, 2018

Heart disease in the American South: echoes of the Civil War?

He displayed an extraordinary ability to absorb the conflicting wills of a divided people and reflect back to them an unbending faith in a unified future. 

Although historian Doris Kearns Goodwin was describing President Abraham Lincoln when she wrote these words in a recent Harvard Business Review article, they could have been said of a statesman of a later era. The longtime Republican "maverick" Senator John McCain, who passed away on August 25, implored Americans in a farewell letter to "not despair of our present difficulties," but to instead "give each other the benefit of the presumption that we all love our country, we will get through these challenging times. We will come through them stronger than before, we always do."

I had the privilege of meeting Senator McCain in 2014 at a Smithsonian Associates event for Thirteen Soldiers, a book he co-authored with Mark Salter that included the stories of soldiers serving in each of America's thirteen major conflicts, from the Revolutionary War to the current wars in Afghanistan and Iraq. I had seen McCain speak on television countless times, but experiencing his outsized, generous, wisecracking personality in the flesh was something else entirely. And I hope he's right about "our present difficulties."

Outside the John Brown House in Chambersburg, PA

While I have long been fascinated by the American Civil War era, when these United States (as opposed to the United States) were more divided than they have been before or since, I gain no pleasure from watching the ceaseless warring of present-day political factions who have seemingly lost the ability to compromise for the public good.

Mount Hebron Cemetery, Winchester, VA

Along with the end of slavery, another positive outcome of the the Civil War was advances in medicine. In 2004 and 2013, I taught a class at Georgetown University School of Medicine called "Civil War Medicine In the Modern Age," and I have enjoyed attending the National Museum of Civil War Medicine's scholarly Annual Conference, which includes educational talks and entertaining trips to nearby historical sites.

Just north of the Mason-Dixon line

Although the Civil War ended more than 150 years ago, its health effects have echoed through the ages. They echo in the hundreds of thousands of soldiers and civilians who perished prematurely from battles or disease; the hundreds of thousands more who were permanently disabled or disfigured by wounds; and - as reported in the Washington Post in 2016 - in the legacy of increased mortality from heart disease concentrated in the South:

To Richard Steckel, an Ohio State University economist, that striking pattern raises a seemingly outlandish, but utterly serious question: Could the heavy toll of heart disease in the American South today have been triggered, in part, by the region's rapid rise out poverty since the 1950s? In a new paper, Steckel argues that decades of poverty caused by the Civil War shaped people's organs and physiology in a way that left them particularly unsuited for a cushy life. The current health disparities in the South, Steckel says, developed as Southerners encountered more prosperous lifestyle than their bodies were prepared for, including more food and less manual labor.

Monterey Pass Battlefield Park, Franklin County, PA

Steckel's hypothesis is intriguing, but even if correct, it is only part of the story. Surely poor diet, physical inactivity, and unrelieved stress caused by a century of segregation and continuing discrimination against African Americans also had a lot to do with the sky-high heart disease rates. And it doesn't help that most of these states have not expanded their Medicaid programs to extend health insurance coverage to those who are most likely to benefit. But that's something to write about another day.


I took all of the photos in this blog post on various Civil War-themed summer trips. This is what I do when I'm not seeing patients, editing articles, blogging, or teaching medical students about health policy.

Thursday, August 23, 2018

Overdiagnosis of lung cancer: don't tell, don't ask?

Although the U.S. Preventive Services Task Force recommended in 2013 that current and recent smokers 55 to 80 years of age with at least a 30 pack-year history receive annual low-dose CT screening for lung cancer, family physicians have been slow to implement this recommendation in their practices. Concerns about this screening test include the quality of the supporting evidence (which the American Academy of Family Physicians judged to be insufficient) and potential harms, including overdiagnosis and overtreatment of tumors that, left undetected, would never have caused symptoms during a patient's lifetime. An analysis of the National Lung Cancer Screening Trial (NLST) suggested that one in five lung cancers were overdiagnosed. In recognition of the balance of benefits and harms of lung cancer screening, the Centers for Medicare & Medicaid Services requires that eligible patients first have a "counseling and shared decision making visit" with a clinician that utilizes a patient decision aid prior to undergoing a scan.

A previous study of screening for other cancer types found that clinicians mentioned overdiagnosis as a potential harm less than 10 percent of the time. Are lung cancer screening discussions any different? In a study published this month in JAMA Internal Medicine, researchers evaluated shared decision making (SDM) using the validated Observing Patient Involvement in Decision Making (OPTION) scale in a sample of transcribed physician-patient conversations. Relative to the mean total visit length (just over 13 minutes), physicians spent a mean of 59 seconds discussing lung cancer screening. None of the conversations mentioned decision aids, and the mean total OPTION score was 6 out of 100 (where 0 indicates no evidence of SDM and 100 indicates SDM at the highest skill level), reflecting that physicians rarely informed patients about harms of low-dose CT scans or asked patients how they valued these harms.

This lack of attention to harms of lung cancer screening is concerning because the magnitude of overdiagnosis may be considerably higher than previous estimates. Researchers recently analyzed data from the Danish Lung Cancer Screening Trial, in which participants underwent 5 annual low-dose CT screenings (compared to 3 in the NLST) and concluded that two-thirds of lung cancers were likely overdiagnosed. In an accompanying commentary that compared the methods used to estimate overdiagnosis, AFP Deputy Editor Mark Ebell, MD, MS and I stressed the importance of communicating with patients about this "often underappreciated harm of screening":

Patients can make informed choices about low-dose CT only if practitioners fully disclose all the potential harms of screening, including the risk of overdiagnosis. It will be important to researchers to continue to refine estimates of lung cancer overdiagnosis, allowing physicians to provide more accurate information to our patients.

To best serve patients, primary care physicians and pulmonologists must do better than 59-second conversations about lung cancer screening that only mention potential benefits. We need to take the time to tell patients about harms such as overdiagnosis, and ask them how they value these harms relative to the benefits, before ordering the scan.


This post first appeared on the AFP Community Blog.

Sunday, August 19, 2018

Will tuition-free NYU produce more primary care physicians?

When I graduated from NYU School of Medicine in 2001, I was one of four in my class to enter a residency program in family medicine. That turned out to be the largest number of family physicians that an NYU class would yield in the 21st century. In several subsequent years there were none at all, and the Class of 2018 produced only two. In one sense, this meager output is unsurprising - NYU, like Harvard, has never had a Department of Family Medicine - but my class also produced only a handful of primary care internists (internal medicine residency-trained physicians who did not subspecialize) and general pediatricians. NYU did not always undervalue primary care. When I attended the annual alumni brunch in Washington, DC, I met many generalist NYU graduates from the 1980s and earlier who asked me when going into primary care specialties started becoming so unfashionable, and who is going to "take care of the folks" when they all start retiring.

Last Thursday, when my best friend from medical school (now an emergency medicine physician in San Francisco) texted me about NYU's stunning announcement that its current and future medical students will no longer pay any tuition, my first reaction was: why didn't they come up with this idea 20 years ago? But when I got over that, I carefully pored over the press release, which implied that the goals of this generous policy are to increase the socioeconomic and racial diversity of their classes, and to encourage more students to choose primary care:

Overwhelming student debt is fundamentally reshaping the medical profession in ways that are adversely affecting healthcare. Saddled with staggering student loans, many medical school graduates choose higher-paying specialties, drawing talent away from less lucrative fields like primary care, pediatrics, and obstetrics and gynecology. Moreover, the financial barriers discourage many promising high school and college students from considering a career in medicine altogether due to fears about the costs associated with medical school.

I am fortunate that student loan debt did not play a role in the type of physician I became. I took out a modest amount of loans during medical school - less than one-third of the average $190,000 debt of 2016 medical school graduates - and knew that I would be able to pay them off regardless of the specialty I chose. In the wake of NYU's announcement, a spirited debate occurred on Twitter about whether the tuition-free school will actually attract more medical students to primary care, or simply vault it past its rivals in the U.S. News rankings and subsidize the education of radiologists, ophthalmologists, anesthesiologists, and dermatologists (the so-called R.O.A.D. specialties, with some of the highest incomes and best lifestyles).

It is hard to imagine that a school with no family medicine department or required clerkship, and few visible outpatient primary care role models, is suddenly going to start churning out family doctors by the dozens. But NYU's decision to go tuition-free may put pressure on other medical schools with similar fundraising prowess and stronger primary care infrastructures to follow its lead. Then the question becomes: will reducing financial obstacles to medical school attract more applicants who are likely to become family physicians?

A recent observational study of the distribution of medical education debt by specialty found that family physicians were the least likely of all the medical specialties to have no student loans at graduation, with 16% and 20% of 2010 and 2016 graduates, respectively, reporting no debt. (Since internists and pediatricians don't decide to subspecialize until well into their residency programs, the researchers could not assess the debts of those who might ultimately choose primary care.) In contrast, in 2016, 40% of future ophthalmologists and 36% of future dermatologists reported no debt. These findings suggest, paradoxically, that physicians with the highest debt burden are preferentially choosing a specialty with among the lowest income expectations - why on earth would that be? What it says, actually, is that students from less well-off backgrounds are more likely to be attracted to primary care in the first place.

Although making medical school tuition-free for all is an inefficient strategy for producing more family physicians, I predict that increasing the diversity of medical school applicants (and accepted students) will likely have a small, but measurable, positive effect on primary care. To magnify that effect, health care institutions must also invest resources into pipeline programs for underrepresented high school and undergraduate students such as the Comprehensive Medical Mentoring Program and ARCHES, academic family medicine departments (looking at you, Harvard and NYU), and community-based residency training programs such as Teaching Health Centers.

I'm proud to be an NYU School of Medicine graduate, and I'm happy for current and future students who now have one less obstacle to fulfilling their dreams. Perhaps they, too, can aspire to be family physicians someday.

Monday, August 13, 2018

Food insecurity hurts health. Here's what doctors can do.

As screening for social determinants of health in clinical settings "moves from the margins to the mainstream," research has focused on how to efficiently identify and address social needs in practice. An article in the May/June issue of FPM by Drs. David O'Gurek and Carla Henke provided a suite of practical approaches, including tools, workflow, and coding and payment considerations. Dr. Sebastian Tong and colleagues reported the experiences of primary care clinicians screening for social needs in 12 northern Virginia practices in the Journal of the American Board of Family Medicine. Knowledge of a social need changed care delivery in 23% of patients and improved communication in 53%, but clinicians often felt ill-equipped to help patients with identified needs or connect them to appropriate services.

Help is on the way. The American Academy of Family Physicians (AAFP) recently launched an interactive online tool, the Neighborhood Navigator, to make it easier for family physicians to connect patients with community organizations and social services. This tool complements other resources in the AAFP's EveryONE Project to support patients' health outside of the office that Dr. Jennifer Middleton discussed in a previous AFP Community Blog post.

In the August 1 issue of American Family Physician, Dr. Shivajirao Prakash Patil and colleagues reviewed the problem of food insecurity, defined as "limited availability of nutritionally adequate and safe food or the inability to acquire these foods in socially acceptable ways," which affected an estimated 12% of American households in 2016. According to the authors, food insecurity (FI) has a cyclical relationship with chronic disease, constraining dietary options in ways that increase the risk for development and progression of diseases in children and adults. They recommended that family medicine practices follow the SEARCH mnemonic and utilize food security resources and food assistance programs in appropriate patients:

S (Screen) - "An affirmative response to either of the following statements can identify FI with 97% sensitivity and 83% specificity: (1) Within the past 12 months we worried whether our food would run out before we got money to buy more, and (2) Within the past 12 months the food we bought just didn't last, and we didn't have money to get more."

E (Educate) - "Educate patients at risk of FI about appropriate coping strategies. Although some individuals with limited resources manage without major disruptions to food intake, many eat less or eat less healthy foods to get by."

A (Adjust) - "Adjust the patient's medication if it should be taken with food. Prescribe medications that minimize the likelihood of hypoglycemia for patients with FI who have diabetes."

R (Recognize) - "Recognize that FI is typically recurrent but is usually not chronic."

C (Connect) - "Connect patients with assistance programs and encourage patients with FI to use food banks."

H (Help) - "Help other health care professionals recognize that poor health and FI often exacerbate one another."

Family physicians can also choose to advocate to improve the quality and quantity of food resource programs available in their communities and across the nation. A recent episode of the Review of Systems podcast discussed the public health implications of upcoming Farm Bill legislation affecting the Supplemental Nutritional Assistance Program (SNAP).


This post first appeared on the AFP Community Blog.

Tuesday, August 7, 2018

Announcing a media skills workshop for health professionals

Join me and family physician colleagues Ranit Mishori, Douglas Kamerow, and Amber Robins at Georgetown University on Friday, September 7 for a day-long Media Skills Workshop sponsored by the Family Medicine Education Consortium and our Department of Family Medicine. Pre-registration is available through September 1, and lunch will be provided. Don't miss this opportunity to learn best practices for interacting with the media and how to advocate for patients and primary care in Op-Eds, blog posts, and Twitter!

Thursday, August 2, 2018

Giving it away: philanthropy and medicine

My wife and I aim to give about 10 percent of our pre-tax income to charity each year. Much of this amount goes to our church, which struggles to make ends meet despite being situated in a rapidly gentrifying area of Washington, DC. We divide the remainder between a variety of causes, such as historical preservation efforts, summer programs for poor kids, and education and leadership programs for young family physicians. Historically, we have allocated a very small fraction of our charitable contributions to our college, graduate, and medical school alma maters (Harvard, Johns Hopkins, and NYU for me; Cornell, Cornell, and Stony Brook for her), and then generally give directly to student organizations, such as the Big Red Marching Band and the Phillips Brooks House Association. It isn't that we don't have fond memories of attending these schools or don't appreciate the education we received there, but in our view they have deeper pockets than almost every other organization that asks for our financial support.

Two episodes of Malcolm Gladwell's "Revisionist History" podcast provided more convincing arguments against making big donations to top ranked universities. Gladwell made headlines in 2015 with a Twitter rant criticizing hedge fund manager John Paulson's $400 million donation to Harvard (whose endowment at that time was valued at more than $36 billion). In "Food Fight," Gladwell compared the funding priorities of Bowdoin and Vassar, two small Northeast liberal arts colleges that appear pretty similar on the surface. One notable difference is that cafeteria food at Bowdoin is gourmet dining, while Vassar's is mediocre at best. Using public information sources and interviews with staff and students at both colleges, Gladwell drilled down to a major reason for this dining disparity: Vassar devoted more of its endowment income to financial aid in order to increase the social and economic diversity of its student body. If you're a wealthy individual who wants to advance social justice, Gladwell argued, choose Vassar over Bowdoin and supporting education for poor students over serving the rich breakfasts of eggplant parmesan pancakes.

Then, in "My Little Hundred Million," Gladwell explored the phenomenon of philanthropists such as Nike's Phil Knight choosing to give hundreds of millions of dollars to private universities that educate the elite rather than public universities who reach many more students of modest means. Gladwell included excerpts from an almost comical discussion with Stanford president John Hennessy, who accepted a $400 million donation from Knight to endow a graduate program for 100 students per year, even though Stanford's endowment is $22 billion. In comparison, a $100 million donation to little-known Glassboro State College (now Rowan University) in New Jersey in the 1990s transformed opportunities for 16,000 students each year and inspired this moving a cappella tribute from students after their benefactor's death.

As I've written before, hospitals and health care organizations are similar to institutions of higher education in that both have skyrocketing costs, little transparency, and few objective measures of quality. They are also alike in that they rely on philanthrophy to supplement the income they receive from patients/students and insurers/lenders. Famous cancer centers have turned fundraising into an art form, too often relying on emotion rather than fact to attract patients and donors. But just because it may be more attractive to donate to the Memorial Sloan-Ketterings and their associated academic institutions doesn't mean that they should be receiving an outsized share of my or your charitable dollars. Especially since we know that U.S. News top ranked (and well funded) medical schools end up near the bottom of the heap when ranked according to their social mission: the percentage of graduates who practice primary care, work in health professional shortage areas, and are underrepresented minorities. Similarly, a disproportionate amount of Medicare's $10 billion per year graduate medical education subsidy goes to institutions that train few primary care physicians or clinicians who practice in underserved areas.

Dear Mr. Paulson, Mr. Knight, Mr. Buffet, Mr. Gates, do you want to improve health outcomes in America? Then write a big check to John Peter Smith Hospital in Fort Worth, Texas, #6 on the list of producers of primary care graduates that received a modest $4.5 million from Medicare in 2008. Or Banner - University Medical Center in Phoenix, Arizona, #15 on the list. (Both institutions, not coincidentally, have outstanding family medicine residency programs.) Don't worry about my alma mater NYU, whose hospitals received more than $55 million from Medicare in 2008 but ranked #156 in primary care production. Or Memorial Sloan-Kettering, for that matter, which ranked #158 out of #158 primary teaching sites with at least 150 graduates - dead last.


This post first appeared on Common Sense Family Doctor on July 25, 2016.

Saturday, July 21, 2018

A "well-regulated militia": can doctors prevent gun violence?

Family physicians have long recognized that gun violence is a national public health epidemic. In 2015, a coalition of nine medical, public health, and legal organizations, including the American Academy of Family Physicians and the American Bar Association, endorsed several specific recommendations for preventing firearm-related injury and death. These measures included universal criminal background checks for all firearm purchases; educating patients about gun safety and intervening in those at risk of self-harm or harm to others; improving access to mental health care; regulating civilian use of firearms with large capacity magazines; and supporting more research on evidence-based policies to prevent gun violence. A 2014 editorial in American Family Physician also reviewed the role of primary care clinicians in counseling about gun safety based on the best available evidence.

After the February massacre of 17 people at Marjory Stoneman Douglas High School in Parkland, Florida by a 19 year-old former student wielding a legally purchased semiautomatic AR-15-style rifle, the medical editors of AFP felt that we needed to do more to empower clinicians. Surely, when the Founding Fathers endorsed the necessity of a "well-regulated Militia" in the Second Amendment to the U.S. Constitution, they did not envision mentally disturbed teenagers toting weapons with enough firepower to overwhelm entire regiments of Minutemen.

In a special editorial recently published online ahead of print, Dr. Sumi Sexton, I, and the AFP medical editors argue that family medicine's emphasis on care of the whole person creates a duty to "confront the epidemic of violence by persons using guns." We review the evidence of the effects of firearm regulations, mental health counseling, and active shooter training on gun safety and violence. Unfortunately, evidence for many interventions remains limited:

A 2018 RAND review of U.S. studies on gun policy published since 2003 concluded that child-access prevention laws (e.g., safe gun storage) reduce self-inflicted and unintentional firearm deaths and nonfatal injuries among youth, and may reduce unintentional firearm injuries among adults. The review also found moderate evidence that laws requiring background checks and prohibiting firearm purchases by individuals with mental illness reduce violent crime and deaths. In contrast, state stand-your-ground laws are associated with increased homicide rates. There was insufficient evidence to determine whether any laws prevent mass shootings. 

Notably, almost two-thirds of the 36,000 firearm-related deaths in the U.S. each year are suicides, leading to our recommendation that "strategies to mitigate firearm suicides should include depression screening and nonjudgmentally asking anyone with depression whether they have a gun in the home." Useful clinical tools include the FIGHTS screening tool for adolescent firearm carrying, the SAD PERSONS suicide risk assessment scale, and the Violence Screening and Assessment of Needs tool for assessing risk of violence in military veterans.

Finally, we encourage clinicians to address the epidemic by making their voices heard in community meetings, online forums, and local publications and communicating with elected state and federal officials to advocate for funding research to study ways to reduce gun violence: "Whether it is speaking up in clinical settings, within our community, or with our elected officials, our voices can make a meaningful difference for our patients, our communities, and our nation."


This post was first published on the AFP Community Blog.