Thursday, December 26, 2019

My favorite health and health care books of 2019

Looking for some good reads for this holiday season and the coming year? Here is my annual top ten list of health and medicine-related books (read, not necessarily published, in 2019), in alphabetical order. I've provided links to the publishers' websites for your convenience, but I don't receive any financial incentives or extra web traffic if you buy these books from them. So if one or more catch your fancy, feel free to pick up a used copy on Amazon or a free one at PaperBackSwap or your local library.


1. The Addict: One Patient, One Doctor, One Year, by Michael Stein

2. Bellevue: Three Centuries of Medicine and Mayhem at America's Most Storied Hospital, by David Oshinsky

3. Crisis in the Red Zone: The Story of the Deadliest Ebola Outbreak in History, and of the Outbreaks to Come, by Richard Preston

4. Deep Medicine: How Artificial Intelligence Can Make Healthcare Human Again, by Eric Topol

5. Patient H.M.: A Story of Memory, Madness, and Family Secrets, by Luke Dittrich

6. Priced Out: The Economic and Ethical Costs of American Health Care, by Uwe Reinhardt

7. Radical: The Science, Culture, and History of Breast Cancer in America, by Kate Pickert

8. Recapturing Joy in Medicine, by Amaryllis Sanchez Wohlever

9. Vaccines Did Not Cause Rachel's Autism: My Journey As a Vaccine Scientist, Pediatrician, and Autism Dad - Peter Hotez

10. Well: What We Need to Talk About When We Talk About Health, by Sandro Galea

Saturday, December 14, 2019

Proposals to lower prescription drug prices: too little, too late?

A bright spot in the annual U.S. health spending report published last week by the Centers for Medicare and Medicaid Services (CMS) was a 1% decrease in retail prescription drug costs from 2017 to 2018, due to greater use of generics and a slower rise in brand-name prices. According to CMS, this was the first time that these costs have declined since 1973. A previous American Family Physician Community Blog post described ongoing efforts by physician groups, payers, and government to restrain rising drug prices; a 2017 editorial reviewed actions that individual health professionals could take to help patients; and a 2019 editorial discussed the high costs of insulin and what family physicians can do. It's possible that some of these efforts are beginning to bear fruit.

Prescription drug prices vary considerably across pharmacies, geographic regions, and even within the same town or metropolitan area. A cross-sectional study of cash prices for 10 common generic and 6 brand-name drugs in the fall of 2015 obtained using the online comparison tool GoodRx (which AFP uses to estimate drug prices) found that generic drugs were least expensive in big box pharmacies, followed by large chain (more than 100 retail locations) and grocery pharmacies, while small chains (4 to 100 stores) and independent pharmacies had the highest prices. For example, the mean price of one month of generic simvastatin 20 mg was $35 at big box pharmacies, $42 at large chains, $50 at groceries, $112 at small chains, and $138 at independent pharmacies. Cash prices for brand-name drugs varied less; one month of esomeprazole (Nexium) 40 mg, for example, cost between $302 and $345 across pharmacy types.

The American College of Physicians recently joined a growing number of groups advocating that CMS be given the authority to directly negotiate drug prices in Medicare Part D, which is currently forbidden by law. In contrast, the Department of Veterans Affairs (VA) Health System already controls prescription costs through direct negotiation and a closed formulary. A study in JAMA Internal Medicine calculated that in 2017, Medicare could have saved $1.4 billion on inhalers for asthma and chronic obstructive pulmonary disease by paying lower VA-negotiated prices, and $4.2 billion if it had paid VA prices and instituted the VA formulary.

But what about the pharmaceutical industry's assertion that lower negotiated prices would stifle innovation and reduce incentives for drug development? In a recent commentary, Dr. Peter Bach proposed that CMS adopt a "too little" or "too late" strategy, selectively negotiating prices of drugs that have either received conditional FDA approval based on a surrogate rather than a patient-centered outcome ("too little") or have passed their guaranteed 5-year period of FDA monopoly protection ("too late"). In 2019, if CMS had negotiated the prices of the top 10 most costly drugs in each category down to those in the United Kingdom (an average savings of 57%), Dr. Bach estimated that it could have saved $1 billion on the 10 "too little" drugs and $26 billion on the 10 "too late."

The potential savings are substantial. But compared to the staggering $336 billion the U.S. collectively spent on prescription drugs in 2018, are these proposed pricing reforms too little, too late?


This post first appeared on the AFP Community Blog.

Wednesday, December 4, 2019

The health dividend: reducing medical waste to improve population health

For  most people, the term "medical waste" probably brings to mind images of discarded syringes, soiled gauze and bandages, and garbage containers filled with the ubiquitous plastic packing for sterilized instruments. They probably don't think about inconceivably large piles of money evaporating into thin air. But in addition to having the most expensive health care system in the world, the U.S. also leads the world in wasted health care spending. In a recent analysis in JAMA, Dr. William Shrank and colleagues updated prior estimates based on published literature from 2012 to 2019 and concluded that approximately 25% of national health care spending, or about $800 billion each year, is wasted. The main culprits are administrative complexity ($266 billion); excessively high prices ($231-$241 billion); failure of care delivery ($102-$166 billion); overtreatment or low-value care ($76-$101 billion); fraud and abuse ($59-$84 billion); and poor care coordination ($27-$78 billion).

These are huge amounts of money. When American life expectancy has been falling for three consecutive years after more than half a century of steady increases, it would seem that reallocation to population health initiatives of the portion of health care waste that is potentially recoverable with existing interventions, $191 to $282 billion according to the JAMA study (by comparison, annual funding for the Affordable Care Act's Prevention and Public Health Fund has yet to exceed $1 billion), would go a long way toward addressing the root causes of increasing premature deaths - problems such as poverty, segregation, and low social support which comprise the actual causes of death in the U.S.

So why don't we? In an accompanying editorial, former CMS administrator Dr. Don Berwick hit the nail on the head:

What Shrank and colleagues and their predecessors call “waste,” others call “income.” ... When big money in the status quo makes the rules, removing waste translates into losing elections. ... For officeholders and office seekers in any party, it is simply not worth the political risk to try to dislodge even a substantial percentage of the $1 trillion of opportunity for reinvestment that lies captive in the health care of today, even though the nation’s schools, small businesses, road builders, bridge builders, scientists, individuals with low income, middle-class people, would-be entrepreneurs, and communities as a whole could make much, much better use of that money.

Living in Washington, DC during the Great Recession of 2007-2009, I observed that the only two industries that managed to thrive and expand during those otherwise dismal years were the federal government and health care. While that was good for me personally, as a health care professional then employed by the federal government, it also meant that billions of dollars that otherwise could have contributed to the economy and individual incomes were, as Dr. Berwick noted, "captured" by the health care industry, most clearly in the form of rising costs of health insurance.

After the collapse of the Soviet Union and the end of the Cold War, Presidents George H. W. Bush and Bill Clinton both talked about a "peace dividend" consisting of lower military spending that could be diverted into other government programs, used to pay down budget deficits, or returned to the people in the form of lower taxes. Although it is debatable how much the military-industrial complex really shrunk in the 1990s, the gargantuan health care-industrial complex is likely to be at least as tenacious, if not more, in resisting efforts to reduce wasteful spending in order to generate a "health dividend" for all Americans.

Wednesday, November 27, 2019

Is telehealth good or bad for doctor-patient relationships?

These days, it's hard to open a newspaper or the home page of one's favorite online media source without running across a story about telehealth. Last week, Eli Saslow of The Washington Post gave readers a compelling narrative about "the most remote emergency room," a telemedicine center in South Dakota that provides remote emergency care for 179 rural hospitals in 30 states. As the story ended, one of the center's emergency medicine physicians was trying to coach an inexperienced nurse in a hospital 400 miles away through a difficult intubation of a patient with respiratory failure from pneumonia and sepsis.

Meanwhile, the retailer Best Buy, which in April began pilot sales of a $300 telehealth device kit "that allows consumers to perform medical tests on areas including heart, lungs, throat and ears and connect with physicians to remotely diagnose symptoms," recently announced that it would start selling the kits in its stores nationwide. In a press release, Tyto Care, the kit manufacturer, touted itself as "transforming primary care by putting health in the hands of consumers." And last month, telehealth vendor American Well announced plans to offer virtual consultations with Cleveland Clinic physicians across a range of subspecialties.

These examples illustrate the best and the worst of telehealth innovation in our health care system. Having a virtual critical care physician looking over your shoulder to provide guidance in a challenging medical situation is clearly better than having no help at all. But as rural hospitals across the U.S. increasingly struggle to make ends meet and to recruit new physicians to their communities, it's worth exploring the financial and structural disincentives prevent these hospitals from offering in-person critical care services in the first place.

Similarly, while Best Buy customers are willing to spend $300 (plus $60 per virtual visit) to have 24/7 access to a primary care doc in a literal box, it's fair to question why in Washington, DC, where the physician to population ratio is higher than anywhere else in the country except perhaps Boston and New York City, a new patient still must wait an average of 3 months to get an appointment to see me for primary care. And though virtual consultations for conditions where qualified providers are in short supply, such as opioid use disorder, make a great deal of sense, the rapid spread of telehealth consults is rapidly outstripping the limited evidence that they improve clinical outcomes and patient satisfaction. Rather than consulting their local family physician for a sprained ankle or acne, will patients instead call on a virtual Cleveland Clinic orthopedist or dermatologist?

Unlike direct primary care, where a predictable revenue stream from monthly subscriptions gives physicians the freedom to care for patients in whatever setting is most appropriate, the dominant fee-for-service model is still lagging behind the demand for convenient in-person and virtual care. I am not paid for making a 15-minute followup phone call, much less having a video encounter with a patient. Telehealth has great potential to strengthen the traditional therapeutic relationship between doctors and patients, or weaken it, depending on how this technology is deployed and regulated in the coming years.

Wednesday, November 20, 2019

Caring for military veterans

Although the United States government designates a single day (Veterans Day) to specifically honor persons with a history of military service, family physicians provide care to veterans all 365 days of the year. A review article and editorial in the November 1 issue of American Family Physician discussed selected health issues and resources for the estimated 18 million veterans living in the U.S., most of whom seek primary care in the community rather than at a Veterans Health Administration or military treatment facility. A pocket card developed by the U.S. Department of Veterans Affairs (VA) provides a list of suggested questions related to military service that can help clinicians and trainees take more careful, veteran-centered histories.

Conditions highlighted in the AFP review article included lower extremity overuse injuries, osteoarthritis, posttraumatic stress disorder, moral injury, sexual trauma, traumatic brain injury, chronic pain, depression and suicide. A recently published synopsis of the 2018 VA/Department of Defense clinical practice guideline on patients at risk for suicide provided evidence-based recommendations for assessing for current suicide risk and managing persons at low, intermediate, and high acute risk for suicide. In addition to facilitating access to nonpharmacologic and pharmacologic treatments, the guideline also found evidence to support firearm restrictions and safety counseling; reduced access to poisons and medications associated with overdose; and installing barriers to prevent jumping from lethal heights.

Percentage of Veterans Among the Adult Population
Source: U.S. Census Bureau

In an editorial in the Annals of Internal Medicine, Dr. Edward Manning, a physician-scientist who was an officer in the U.S. Marine Corps prior to medical training, made some personal observations about bridging the "cultural divide" between military and civilian life that can present unintended obstacles to the physician-patient relationship. Dr. Manning noted that "from the veteran's point of view ... all physicians in the military are officers," warranting the formal greeting of "Ma'am" or "Sir." However, "one unfortunate aspect of military culture may be the inherent distrust of physicians," whose physical and mental fitness evaluations can exclude candidates from all or some types of military service (e.g., piloting military aircraft). Family physicians who make the effort to ask patients about their military service and empathize with a veteran's point of view will be better equipped to provide personalized care to this diverse population.


This post first appeared on the AFP Community Blog.

Thursday, November 7, 2019

Family physicians caring for fewer children: reversing the trend

"How did you choose family medicine?" I've lost count of the number of times I've been asked this question by a medical student. The truth is, I entered medical school thinking that I would become a general pediatrician and focus my energies on keeping children healthy. It was only after I realized how much I also enjoyed adult medicine and well-woman care that I decided to enter the only specialty that would allow me to provide continuous, relationship-centered primary care to patients from their first until their last day of life.

In 2005, a Robert Graham Center report, whose key findings later appeared as a Policy One-Pager in American Family Physician, sounded an alarm. The authors reported that the share of children who saw family physicians for primary care had declined from one in four to one in six since the early 1990s. A subsequent article in Family Practice Management (now FPM) explored some reasons for the decline: expansion of the pediatrician workforce; fewer family physicians providing prenatal, newborn, and pediatric inpatient care; and a lack of awareness among the public and the media about the broad scope of family medicine training. The FPM article recommended several strategies for individual family physicians to increase their opportunities to recruit children to their practices:

- Build relationships with Ob/Gyns and pediatricians in your community.
- Heighten your visibility in the hospital.
- Get to know the nurses in labor and delivery and the nursery.
- Don't rely solely on word-of-mouth marketing.
- Talk with patients whose children might be outgrowing their pediatrician's office about transferring.
- Create a kid-friendly environment.
- Make sure your hours and appointment access are sensitive to the needs of young families in your community.

Nearly 15 years later, according to the American Academy of Family Physicians member census, 80 percent of family physicians are still caring for adolescents, while 74 percent see infants and younger children. But a recent population-based analysis of an all-payer claims database in Vermont suggested that family physicians' share of children's health care has continued to erode. Between 2009 and 2016, children residing in Vermont were 5% less likely to be attributed to a family physician practice, a trend that included urban and rural areas. Older children, girls, and children with Medicaid were somewhat more likely than others to see family physicians.

Caring for children benefits family physicians and their patients. In an article in the September/October issue of FPM, Drs. Sumana Reddy and Jaydeep Mahasamudram observed that "the satisfaction that comes from taking care of children shouldn't be underestimated in a time of increasing physician burnout." Not only can family physicians smooth young patients' transitions from child to adult care, but by caring for parents and grandparents, they gain perspectives on inter-generational social interactions that pediatricians don't. One example: "As family physicians, we can see all of the ill members together, we can care for both the newborn and the breastfeeding mother with postpartum depression, and we can understand the teenager's mood disorder because we know the parents have been dealing with severe stressors even if the teen doesn't disclose this."

So how can family physicians counter national trends and provide care to more children? In addition to the strategies already mentioned, Drs. Reddy and Mahasamudram suggested taking advantage of opportunities to refresh one's knowledge on child-specific issues (e.g., Kawasaki disease); asking local internists and obstetricians for referrals; volunteering to give community talks on child health topics; and becoming more familiar with Current Procedural Terminology (CPT) codes for visits with young patients, especially those for vaccine administration.

Incidentally, my personal doctor is a family physician, and my wife and children all see a longtime family physician colleague of mine for primary care. Although primary care should stick together to provide a counterweight to the subspecialist-oriented U.S. health system, I also think that it's important for the future of our specialty that patients don't perceive family physicians to simply be another flavor of general internists.


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

Thursday, October 31, 2019

Heading to the 2019 FMEC Annual Meeting

The Family Medicine Education Consortium (FMEC) is a major family medicine organization in the Northeast U.S. that serves as a "catalyst, convener, [and] incubator" for initiatives and programs in medical education, primary care, and community health. I first presented at their annual meeting in 2006, when it was still known as the Society of Teachers of Family Medicine Northeast Region meeting. I continued to attend regularly through 2011, when I, my wife, and our then-three children (one in utero) were involved in a major traffic accident on the Massachusetts Turnpike that ended up totaling our car and damaging six other vehicles. My older son sustained a scalp laceration from shattered window glass, and the rest of us were psychologically traumatized for varying lengths of time. Whether because I from then on associated this meeting with the accident or it was just easier to be the parent who stayed home with the kids while my wife traveled, I haven't been to an FMEC Annual meeting since, other than in 2014 when it was held in nearby northern Virginia.

That changes tomorrow at the FMEC's 2019 Annual Meeting.

Although I originally meant to deliver only a single presentation on a research paper I've been fortunate enough to work on with colleagues at Georgetown, Virginia Commonwealth University, Thibodaux Regional Medical Center in Louisiana, and the Lown Institute, somehow I've ended up having four. In addition to discussing our estimate of annual serious harms from overuse of screening colonoscopy in the U.S. (which number in the thousands to tens of thousands), I'm joining my wife and our family doctor to give a short lecture/discussion on when the doctor's child has a rare disease - in this case, Henoch-Schonlein Purpura, which afflicted our younger son last year around Christmas but fortunately resolved without any complications.

I was also invited by FMEC CEO Larry Bauer to co-lead a seminar on gun violence as a public health issue, a topic I've written about previously on this blog and in American Family Physician, but about which I'm certainly no expert. When I asked Larry why he thought I was best suited to present the evidence on this emotionally charged issue, he said that he was looking for someone who is respected across the political spectrum and perceived as being fair to all points of view. Larry, I promise I'll do my best.

Finally, Dr. Andrea Anderson, a longtime friend and DC-area colleague, asked me to join her in an Advocacy 101 workshop, where I will present tips on using blogs and social media to achieve one's advocacy goals. We will be joined by Dr. Joe Gravel, who will review the new Accreditation Council for Graduate Medical Education (ACGME) milestones for advocacy in family medicine training.

So it promises to be a whirlwind couple of days in Lancaster, Pennsylvania, the town where I grew from a freshly minted M.D. into a full-fledged family physician, and of course, where I met the love of my life. I'm looking forward to coming back.

Monday, October 21, 2019

To prevent pregnancy deaths, clinical care is just the beginning

According to the Centers for Disease Control and Prevention (CDC), about 700 U.S. women die from pregnancy-related complications every year. The U.S. maternal mortality rate has increased over the past 30 years and is much higher than rates in other high-income countries, and 60 percent of maternal deaths were potentially preventable through medical care. Around one-third of deaths occur during pregnancy, one-third during delivery or the first week postpartum, and one-third from one week to one year postpartum.  In an article in the October 15 issue of American Family Physician, Dr. Heather Paladine and colleagues discussed an overall approach to the "fourth trimester" (the first 12 weeks postpartum) and optimal strategies for prevention and prompt detection of some of the most frequent causes of postpartum deaths identified by the CDC: hemorrhage, hypertensive disorders, thromboembolic disorders, and infections. They also reviewed other common issues with health implications for the mother and newborn, such as thyroiditis, depression, urinary incontinence, constipation, weight retention, and breastfeeding problems.

In an accompanying editorial on "What Family Physicians Can Do to Reduce Maternal Mortality," Drs. Katy Kozhimannil and Andrea Westby encouraged clinicians to look beyond clinical risks to also address social determinants of health. These factors, which include "housing instability, food insecurity, community violence, firearms access, financial insecurity, and social isolation," are likely responsible for the large and persistent racial and ethnic disparities in pregnancy-related deaths. For example, the CDC reported that black and American Indian/Alaska Native women aged 30 years and older are four to five times as likely to die as a result of pregnancy complications than white women in the same age group.

Outside of the clinic, Drs. Kozhimannil and Westby suggested several strategies for family physicians to support pregnant patients in their communities: advocating for continuous health insurance coverage for the more than half of women who have public insurance at the time of delivery; supporting increased access to postpartum doulas and community health workers; continuing to provide obstetric services at rural hospitals; and reflecting on "one's own privilege and role in perpetuating or disrupting systems of oppression" that remain obstacles to attaining health equity.

For its part, the American Academy of Family Physicians (AAFP) took aim at the maternal mortality crisis by convening a Maternal Mortality Task Force in April and June to recommend evidence-based methods to decrease maternal morbidity and mortality, reduce implicit bias and disparities, and collaborate with other key stakeholders to stop the accelerating loss of rural obstetrical services. In its report to the 2019 Congress of Delegates (access restricted to AAFP members), the Task Force made a series of recommendations for improving maternal care quality and data collection; retaining family physicians and other clinicians who deliver babies in rural communities; and working with departments and residency programs in family medicine to develop sustainable maternity care workforce goals.


This post first appeared on the AFP Community Blog.

Wednesday, October 9, 2019

Should dietary guidelines suggest that people eat less meat?

There is a widespread consensus among nutrition and environmental scientists that reducing dietary meat intake, particularly red and processed meats, is not only beneficial for personal health, but also benefits the planet by reducing deforestation, freshwater consumption, and greenhouse gas emissions associated with cattle farming. As my colleague Caroline Wellbery, MD wrote in a 2016 editorial: "According to the 2015–2020 [U.S.] dietary guidelines, moderate to strong evidence demonstrates that healthy dietary patterns that are higher in fruits, whole grains, legumes, nuts, and seeds, and lower in animal-based foods are associated with more favorable environmental outcomes."

Although the effects of individual dietary counseling in patients without cardiovascular risk factors are limited, the Dietary Guidelines for Americans, which are updated every 5 years, have been influential in changing eating patterns. A recent analysis of cross-sectional data from the National Health and Nutrition Examination Survey found small but significant decreases in consumption of refined grains and added sugar and increased consumption of plant proteins, nuts, and polyunsaturated fats from 1999 to 2016. Bigger changes could be on the horizon, if the efforts of entrepreneurs profiled in a recent article in The New Yorker to bioengineer and distribute plant-based hamburger patties and other products that are indistinguishable from real meat prove to be successful.

The next iteration of the Dietary Guidelines will need to consider new evidence that beneficial health effects of eating less meat may not be as large or as certain as previously thought. In a clinical guideline published last week in the Annals of Internal Medicine, an international panel from the Nutritional Recommendations and Accessible Evidence Summaries Based on Systematic Reviews (NutriRECS) consortium made the somewhat shocking suggestion that adults can continue their current (over)consumption of red and processed meats without major health consequences. Four linked systematic reviews found low-quality evidence of small to no benefits on cardiometabolic and cancer outcomes from consuming less red and processed meat in cohort studies and in randomized trials, and a review of health-related values and preferences suggested that "omnivores are attached to [eating] meat and are unwilling to change this behavior when faced with potentially undesirable health effects." Importantly, none of the guideline authors or systematic reviewers received any financial support from the meat industry, though the lead author previously received funding from the International Life Sciences Institute, an industry trade group.

Critical responses from the medical and public health community have been swift and plentiful. Some experts challenged the guideline panel's assessment of the magnitude of beneficial health effects of eating less meat as "very small." For example, meta-analyses estimated that after about 11 years, dietary patterns with 3 fewer servings of red meat per week are associated with absolute risk differences of 6 fewer cardiovascular-related deaths (number needed to treat = 167) and 14 fewer persons developing diabetes (NNT = 71) out of every 1000 persons. To an individual, these differences seem small, but if true, they compare favorably with the NNTs of established clinical preventive services such as colorectal cancer screenings and therapy for osteoporosis. Others faulted the guideline for excluding benefits to animal welfare and the environment from lower population-wide meat consumption. Goals and guidelines for what constitutes a healthy diet will continue to evolve, but this one has provided much food for thought.


This post first appeared on the AFP Community Blog.

Monday, September 30, 2019

Screening for autism spectrum disorder: the jury is still out

In 2007, the American Academy of Pediatrics (AAP) first recommended using a standardized autism-specific tool to screen all children for autism spectrum disorder at the 18- and 24-month well-child visits. In a recent national survey, most pediatricians reported following this guidance, but I suspect that screening rates are considerably lower among family physicians. In my practice, I don't use an autism-specific screening instrument unless either I or the child's parent or guardian have behavioral concerns, in which case it's no longer screening, but evaluation.

Why not? In 2016, the U.S. Preventive Services Task Force concluded that "current evidence is insufficient to assess the balance of benefits and harms of of screening for autism spectrum disorder (ASD) in young children for whom no concerns of ASD have been raised by their parents or a clinician." The Task Force observed that most ASD treatment studies included children who were considerably older than those identified through screening, and that no controlled studies have looked at the comparative clinical outcomes of screening-identified children with ASD, which is what a guideline writer would definitely want to know before recommending universal screening, even if the AAP didn't think so.

Dr. Doug Campos-Outcalt, a longtime colleague who has served as the American Academy of Family Physicians' liaison to the USPSTF, wrote in American Family Physician that four critical questions needed to be answered before screening for ASD would be "ready for prime time":

1. What are the sensitivity and false-positive rate of the best screening test for ASDs available in an average clinical setting?

2. How much earlier can screening tests detect ASDs compared with an astute clinician who asks a few key questions about, and acts on, parental concerns regarding a child's communication and interactions?

3. What are the potential harms of testing?

4. Does earlier detection by screening result in meaningful and long-lasting improvements compared with detection through routine care?

Although the answers to the second and fourth questions are arguably the most important, until last week there was little evidence to answer the first and third, either. If the recommended screening test, the Modified Checklist for Autism in Toddlers, Revised, with Follow-Up (M-CHAT-R/F), can't reliably detect most children who will eventually develop symptoms of ASD in later life, or there are so many false positives that the harms of parent anxiety and unnecessary diagnostic evaluations would outweigh the benefits, then universal screening is unlikely to work. Unfortunately, the first large study (n=26,000) of near-universal screening for ASD in 31 primary care clinics affiliated with Children's Hospital of Philadelphia just provided disappointing results on both of these fronts. Using an older version of the M-CHAT, the sensitivity of screening was only 38.8%, and only 14.6% of children who screened positive ultimately received an ASD diagnosis, with even lower positive predictive value in children residing in lower-income households.

The authors pointed out that nearly 60% of children with initial positive screens did not return for a follow-up interview that might have reduced false positives and improved predictive value, and that children with positive screens who were diagnosed with ASD were more likely to receive interventions at a younger age, potentially improving outcomes. But the former simply shows how a two-stage screening test performs in real life, rather than in a controlled research setting. As for the latter, outside of anecdotes from screening advocates, we still have no conclusive evidence that long-term outcomes turn out better in these children. The bottom line? For universal screening for ASD in toddlers, the jury is still out.

Monday, September 23, 2019

Using life expectancy and prognosis to support shared decision-making

Due to competing causes of death (e.g., heart disease, stroke, dementia), the benefits of most screening tests decline with increasing age; for example, screening for breast and colorectal cancers is not recommended in persons with a life expectancy of less than 10 years. However, estimating how much time an individual has left to live and incorporating that estimate into shared decision-making with patients is challenging. As a result, a 2014 U.S. population-based survey found that 31% to 55% of participants with a greater than 75% risk of death in the next 9 years were still receiving breast, colorectal, or prostate cancer screenings.

There are many reasons why physicians provide so many unnecessary and potentially harmful screening tests to older persons with limited life expectancies. In an editorial in the September 1 issue of American Family Physician, Dr. Emma Wallace and Norah Murphy observed that "barriers to discussing life expectancy include uncertainty in prognostic estimates, limited time to broach this sensitive topic, and concerns about upsetting the patient or getting negative reactions."

A systematic review of the prognostic value of the "Surprise Question" approach (which asks clinicians, "would you be surprised if this patient died in the next 12 months?") found that the answer has varying degrees of accuracy at identifying patients in their last year of life. The QMortality tool, in contrast, generates a more precise estimate of one-year mortality in persons age 65 to 99 years utilizing multiple clinical and demographic variables, and was found to have good predictive accuracy in 500,000 family practice patients in England.

Some patients may feel uncomfortable about stopping nonbeneficial screening tests even if they are objectively unlikely to benefit from them. In a mailed survey of patients age 50 years or older in the Veterans Affairs health system, nearly 30 percent reported being "not at all comfortable" with discontinuing screening colonoscopy in a hypothetical patient scenario where a colorectal cancer-specific risk calculator predicted a low likelihood of benefit. To help physicians sensitively incorporate prognostic information into discussions about continuing or discontinuing screening, the University of California San Francisco's ePrognosis website provides risk calculators and video examples demonstrating key communication skills.


This post first appeared on the AFP Community Blog.

Monday, September 16, 2019

Too much medicine: research spotlights tests and interventions to consider avoiding in practice

In the fourth installment of an annual series, Drs. Roland Grad and Mark Ebell presented the "Top POEMs of 2018 Consistent with the Principles of the Choosing Wisely Campaign" in the September 1 issue of American Family Physician. Unlike the official list of Choosing Wisely campaign recommendations produced by the American Academy of Family Physicians and many other medical organizations, these suggested clinical actions were generated from recent research studies whose findings were judged by members of the Canadian Medical Association to help reduce overdiagnosis and overtreatment in practice. Drs. Grad and Ebell reviewed 13 of these POEMs (patient-oriented evidence that matters) in a previous article on the top 20 research studies of 2018 for primary care physicians.

This year's Choosing Wisely review article covered musculoskeletal conditions, respiratory disease, infections, cardiovascular disease, and miscellaneous topics. Here is a handy "cheat sheet":

1. Subacromial decompression surgery does not work.

2. Amitriptyline has no long-term benefits for chronic lower back pain.

3. In adults with mild asthma, as-needed budesonide/formoterol is as effective as a daily inhaled steroid.

4. In children with acute respiratory infections, broad-spectrum antibiotics are not more effective, but cause more adverse events, than narrow-spectrum antibiotics.

5. For chronic sinusitis, saline irrigation helps, and irrigation plus an intranasal steroid may help a little more.

6. A lower threshold for defining high blood pressure may harm patients at low risk for cardiovascular disease.

7. Don't order a high-sensitivity troponin level for a patient with a low pretest likelihood of myocardial infarction.

8. For women with symptomatic postmenopausal atrophic vaginitis, a nonprescription nonhormonal lubricant may be as effective as a vaginal estrogen tablet.

9. In adults with type 2 diabetes, NPH insulin is a cost-effective alternative to insulin analogues.

10. Ibuprofen is as effective as oral morphine for pain relief in children after minor outpatient orthopedic surgery, and has fewer side effects.

11. Skip the bath oil in children with atopic dermatitis.

Many of these overused tests and interventions are based on faulty pathophysiologic reasoning (e.g., if lowering blood pressure somewhat is good, then lowering blood pressure more should be even better).

Another valuable review of other research studies published in 2018 that highlighted medical overuse and health care services of questionable benefit appeared in JAMA Internal Medicine last week.

In a recent commentary on overuse in BMJ Evidence-Based Medicine, Drs. David Slawson and Allen Shaughnessy argued that "reducing overuse begins with the recognition and acceptance of the potential for unintended harm of our best intentions." They provided five examples of unintended harms of making medical decisions based on "what ought to work" rather than "what does work": activism gone awry (believing that no one is harmed by screening); innocent bystanders (traumatized loved ones of newborns with false positive screening results); the worried well we create (prediabetes); the butterfly effect (higher motor vehicle accident rates in patients with diabetes due to medication-induced hypoglycemia); and out of Oz and back to Kansas (over-extrapolating from research studies performed in ideal circumstances to real-world practice).


This post first appeared on the AFP Community Blog.

Tuesday, September 10, 2019

Draft USPSTF statement on screening for illicit drug use requires major revisions

It may surprise some observers that for its first quarter century, the U.S. Preventive Services Task Force did not post draft research plans, recommendation statements or systematic reviews online for public comments. Instead, these documents were developed and discussed on private conference calls and voted on at invitation-only Agency for Healthcare Research and Quality meetings, which I attended as a medical officer from 2006 through 2010. This policy changed after the media uproar over the USPSTF's 2009 mammography recommendations, which included criticism for the Task Force's lack of transparency in guideline development. Reluctant to open their meetings to the public out of fear that it would stifle candid debates about politically sensitive subjects, the USPSTF chose, instead, to institute a one-month public comment period on draft documents before finalizing their recommendations.

For the first few years, public comments resulted in few significant changes to draft statements. However, there are now examples of the public comment period leading to substantial changes in recommended testing options and letter grades in high-profile topics such as screening for colorectal cancer and cervical cancer. That's a good thing, since the USPSTF draft statement on screening for illicit drug use, which recently closed to public comments*, requires major revisions.

In 2008, the USPSTF concluded that "the current evidence is insufficient to assess the balance of benefits and harms of screening adolescents, adults, and pregnant women for illicit drug use." What specific evidence gap prevented them from making a recommendation?

The most significant research gap identified by the USPSTF is the lack of studies to determine if interventions found effective for treatment-seeking individuals with symptoms of drug misuse are equally effective when applied to asymptomatic individuals identified through screening.

Consequently, the research plan finalized by the USPSTF in October 2016 to update their 2008 statement focused on summarizing evidence of the benefits and harms of counseling interventions to reduce drug use in "screen-detected persons." Focusing the systematic review on this population recognized that their willingness and motivation to change their drug use behavior in response to an intervention likely differs from those who actively seek medical treatment.

The draft review produced by the team that carried out this research plan determined that a great deal more applicable evidence was published in the past decade: 27 randomized, controlled trials with a total of 8,705 participants. The studies' findings, however, were disappointing for advocates of screening:

Across all 27 trials, in general, there was no consistent effect of the interventions on rates of self-reported or biologically confirmed drug use at 3- to 12-month followup. Likewise, across 13 trials reporting the effects of the interventions on health, social, or legal outcomes, none of the trials found a statistically significant difference between intervention and control groups on any of these measures at 3- to 12-month followup.

In other words, interventions for persons who had illicit drug use detected by screening didn't reduce drug use, improve physical health, or lead to fewer brushes with the law. No benefit + no harm (though only 4 studies reported on potential screening harms) = no net benefit. So the appropriate response to the evidence would be to either recommend against primary care screening for illicit drug use (since it adds burden to practices without benefiting patients), or, if the studies were considered too heterogenous to make that definitive a conclusion, to declare the evidence insufficient to determine the balance of benefits and harms.

Here, though, is where the Task Force appears to have gone off the rails. Rather than draw one of these two evidence-based conclusions, they instead commissioned a second systematic review from a completely different team (without posting a new research plan for public comment) seeking evidence on interventions in treatment-seeking populations. This draft review concluded that psychosocial interventions increase the likelihood of abstinence from drug use for up to 12 months, and that there are effective medications for opioid use disorder in persons who desire treatment (nice to confirm, but hardly a novel finding). The USPSTF relied on this second review (and apparently ignored the first one) to support their draft "B" recommendation to screen for illicit drug use in adults age 18 years or older.

Don't primary care clinicians already ask their patients about illicit drug use? We certainly do, as part of taking the social history of a new patient, but not in the methodical, intensive way that the USPSTF is now recommending. Perhaps the Task Force felt compelled by the pressure of the opioid epidemic to offer something more in terms of clinical prevention than an "I" statement or a politically unpalatable "D" recommendation against screening. Regardless of their rationale, by bypassing their published methods and processes to produce a statement that the evidence clearly doesn't yet support, the USPSTF has ventured onto dangerous ground, raising questions about their scientific credibility at a time when evidence-based institutions need to be defended more than ever.


* - A summary of my assertions in this post was submitted to the USPSTF during the public comment process.

Thursday, September 5, 2019

What we choose to name a disease matters

A few years ago around this time, I was dealing with a series of minor health problems. I developed a sinus infection that took several weeks to resolve. I twisted one of my knees ice skating, and for a while I feared that I had torn a meniscus. Occasionally after eating a heavy meal, I had the sensation that food was getting stuck on the way to my stomach - so along with an x-ray and MRI for my knee, my doctor also sent me for an upper GI series. Finally, my blood tests for a new life insurance policy came back with a slightly high hemoglobin A1c level. The A1c test was once used only to monitor glucose control in patients with established diabetes, but in 2010 the American Diabetes Association changed their diagnostic criteria to classify an A1c level of 6.5% or greater as consistent with diabetes, 5.7% to 6.4% as prediabetes, and 5.6% or lower as normal. So on top of knee tendinitis and gastroesophageal reflux disease (GERD), I also found out that I had prediabetes.

Intellectually, I knew that there was no evidence that screening for prediabetes is beneficial (the life insurance company, not my doctor, had ordered the test), and that a screen-and-treat approach to diabetes prevention leads to lots of overdiagnosis. Emotionally, it was a different story. I had recently turned 40 and was feeling old. It had been years since I had gotten the recommended amount of physical activity for adults, and now I was doing even less because my knee hurt. It didn't help that the afternoon I found out about my A1c level, my wife called and asked me to pick up some Burger King sandwiches and fries to bring home for dinner. Not exactly what a pre-diabetic adult with GERD should be eating.

Would I have felt less sick if I had instead been told that I had "slightly high blood sugar"? In recent years, oncologists have recommended re-naming slow-growing lesions that we currently call cancer, such as "ductal carcinoma in situ" of the breast, indolent lesions of epithelial origin (IDLE), hoping that a less scary term will discourage patients from pursuing unnecessarily aggressive (and potentially harmful) treatment. Similarly, a study showed that telling patients that they have a "chest cold" rather than "acute bronchitis" will help them feel more satisfied when they don't receive an antibiotic prescription.

systematic review published in BMJ Open supported the notion that what clinicians choose to name a disease influences patients' management preferences. Some study examples: women who were told they had "polycystic ovary syndrome" were more likely to want a pelvic ultrasound than those who were told they had a "hormone imbalance." Women were more likely to want surgery if they had "pre-invasive breast cancer cells" versus "abnormal cells" or a "breast lesion." Patients were more likely to expect surgery or casting of a "broken bone" or "greenstick fracture" than a "hairline fracture" or "crack in the bone." In each of these cases, the use of a more medicalized or precise term led patients to prefer invasive management options that were no better than more conservative choices.

How will I apply this knowledge to my daily practice? Although I already use the term "prediabetes" sparingly (preferring "increased risk for diabetes"), I'm going to start telling more patients with A1c levels similar to mine that they have high blood sugar instead. That they have heartburn rather than GERD. That they have overuse knee strains instead of tendinitis. And certain medical terms, such as "advanced maternal age" (i.e., pregnancy after the age of 35, or my wife's age when she gave birth to 3 of our 4 children), I will strive to eliminate from my vocabulary entirely.


A slightly different version of this post first appeared on Common Sense Family Doctor on October 5, 2017.

Thursday, August 22, 2019

Vaping and health: some answers, more questions

As the Centers for Disease Control and Prevention is actively investigating a cluster of severe lung illnesses in 14 states that may be linked to e-cigarette use among adolescents and young adults, an article in the August 15 issue of American Family Physician discusses common questions and answers about vaping and health. Since my colleague Dr. Jennifer Middleton's 2016 blog post on the promise and perils of e-cigarettes, more data has accumulated about the potential harms and benefits of this increasingly common activity. In 2017, one in five high school students reported e-cigarette use in the previous year, leading U.S. Surgeon General Jerome Adams to issue an advisory last year that labeled e-cigarette use in youth a "public health epidemic." More recent data from the Monitoring the Future survey suggested that this epidemic shows no signs of slowing:

Put in historical context, the absolute increases in the prevalence of nicotine vaping among 12th-graders and 10th-graders are the largest ever recorded by Monitoring the Future in the 44 years that it has continuously tracked dozens of substances. These results indicate that the policies in place as of the 2017–2018 school year were not sufficient to stop the spread of nicotine vaping among adolescents.

Although a nationally representative survey of parents of middle and high school students found that nearly all are aware of e-cigarettes, only 44% accurately identified an image of the "pod mod" device Juul; less than one-third reported concerns about their own child's use of e-cigarettes; and nearly three-quarters had received no communication from their child's school regarding the dangers of e-cigarettes. To help clinicians counsel parents and adolescents about vaping and Juuls, a patient education handout accompanying the AFP article highlights important discussion points.

It remains unclear whether e-cigarettes can help adults who are trying to quit smoking. E-cigarettes are not approved by the U.S. Food and Drug Administration as smoking cessation devices; however, a recent randomized trial in the U.K. National Health Service found that in smokers receiving weekly behavioral support, the 1-year abstinence rate in the e-cigarette group was superior to that of smokers using traditional nicotine replacement products. Notably, 80 percent of the e-cigarette group was still vaping after 1 year, compared with only 9 percent of the nicotine-replacement group - a troubling secondary finding given the unknown long-term health consequences of e-cigarette use.

In addition, the AFP article cautions that "unlike nicotine replacement therapy, the advertised nicotine dose on the labeling of e-cigarettes is not always consistent with laboratory analysis of the e-cigarette liquid, and the device and user behavior may affect the dose of nicotine received." Consequently, the authors recommend that clinicians first counsel patients to quit using evidence-based smoking cessation guidelines such as those from the U.S. Preventive Services Task Force, and only discuss using e-cigarettes if these methods are ineffective. In my own practice, I've yet to meet a patient who has successfully quit smoking by switching to e-cigarettes.


This post first appeared on the AFP Community Blog.

Tuesday, August 6, 2019

What is the appropriate role of experts in primary care guidelines?

This week, a Health Affairs blog post titled "Fixing Clinical Practice Guidelines" echoed several concerns I've discussed previously: practice guidelines are being produced in abundance but often have variable methodological quality, financial conflicts of interest that threaten objectivity, and/or poor applicability to the clinicians and populations for whom they are intended. To address these problems, the authors reasonably suggested restoring funding for AHRQ's National Guideline Clearinghouse and giving this centralized guideline repository the authority to require that guidelines meet a universal, rigorous methodology standard (including policies to avoid conflicts of interest) for inclusion.

My only real quibble with the commentary is its title: clinical practice guidelines have problems, but they're not broken. I am currently a volunteer panel member for three guidelines in various stages of development, sponsored or co-sponsored by three different medical specialty societies. Each guideline is following the National Academy of Medicine's (formerly Institute of Medicine's) standards for trustworthy guideline development and on track to produce practical recommendations for clinicians that are consistent with the best evidence on each topic. If I didn't think that these guidelines were worthwhile endeavors, I wouldn't have agreed to spend so many hours reviewing and discussing studies, systematic reviews, and meta-analyses, and drafting the text of the recommendations.

Drs. Benjamin Djulbegovic and Gordan Guyatt recently argued in a JAMA Viewpoint that we should not make false distinctions between evidence-based and consensus-based guidelines, since the "evidence alone never speaks for itself" and interpretation of evidence by guideline panelists via a consensus process is always required. Therefore, consensus-based does not necessarily imply weak or insufficient evidence; rather, "the crucial difference between evidence-based medicine and non-evidence-based medicine methods is that the former necessitates that judgments are consistent with underlying evidence, whereas the latter do not."

To me, "non-evidence-based" or "expert consensus" calls to mind an outdated process for developing guidelines (though some groups still use it): assemble a group of distinguished subject matter experts, ask them to formulate some recommendations based on their own practices (which, since they're the experts, must be the most effective and efficient ways to manage patients with the condition), find some published references to support what the experts already know, then write up a report. Bonus points if the guideline panel has an authoritative-sounding name such as the Joint National Committee (whose hypertension guidelines, until JNC 8 at least, largely followed an expert consensus process).

Applying the evidence-based paradigm to primary care guidelines, then, what is the appropriate role of experts? Since a well-conducted systematic review ought to retrieve all relevant research evidence, and guideline panelists should already have expertise in evidence interpretation and grading of recommendations, what more can experts bring to the table? In a BMJ analysis, Dr. Holger Schunemann and colleagues make a useful distinction between "expert evidence" and "expert opinion": evidence is factual, while opinion is a judgment that may (or may not) be based on facts:

For example, a patient might say: “I had prostate cancer detected by prostate specific antigen (PSA) screening and I am alive 10 years later.” That is evidence. It is not the same as saying: “PSA screening saved my life.” That is an opinion. Similarly, a clinical expert might say: “I operated on 100 patients with prostate cancer and none of them died from prostate cancer.” That is evidence. It is not the same as saying: “Prostatectomy is effective.” That is an opinion. In both cases, the opinions might be based on that evidence, but the evidence is clearly not the same as the conclusion.

Schunemann and colleagues review several pitfalls of expert evidence and opinion: not distinguishing between the two; untimely introduction of expert evidence; inadequate disclosure or management of financial and intellectual conflicts of interest; and inadequate appraisal of expert evidence. To make the influence of expert evidence on guidelines more transparent, they advise (and I agree) that it be collected systematically and appraised using the same methodology as for research evidence, which gives more weight to experimental studies or systematically collected observations that are less likely to be biased than a subspecialist physician's personal experiences.

Sunday, July 28, 2019

Deliberate clinical inertia protects patients from low value care

Clinical inertia is usually considered to be a negative term, used to refer to situations in which clinicians do not appropriately initiate or intensify therapy for uncontrolled chronic conditions. For example, a recent study in JAMA Internal Medicine found that less than one-quarter of patients with chronic hypercalcemia in the Veterans Affairs health system received recommended parathyroid hormone level testing, and only about 13 percent of patients who met diagnostic criteria for primary hyperparathyroidism underwent parathyroidectomy.

However, clinical inertia has also been described as a "clinical safeguard" against aggressive consensus guideline prescriptions that do not account for patient preferences and/or potential harms of intensifying treatment. For example, an analysis of the incremental benefits of and harms of the 2017 American College of Cardiology / American Heart Association guideline that redefined hypertension as a sustained blood pressure of >= 130/80 mm Hg concluded:

For most adults newly classified as having high blood pressure under the ACC/AHA guideline (the 80% of those newly diagnosed who have <10% 10-year risk), there is no incremental benefit in CVD risk reduction, but potential incremental harms from disease labeling, and, for those who meet the threshold for drug treatment, from adverse drug effects.

In this instance, a large number of patients with systolic blood pressures between 130 and 140 mm Hg could potentially benefit from clinical inertia by avoiding a hypertension diagnosis, additional testing, or prescription medications.

In a 2011 JAMA commentary, Drs. Dario Giugliano and Katherine Esposito observed that clinical inertia "also may apply to the failure of physicians to stop or reduce therapy no longer needed," but that "this neglected side of clinical inertia does not seem to generate as much concern among physicians or scientific associations." A review of polypharmacy in the July 1 issue of American Family Physician noted that regular use of at least five medications is associated with decreased quality of life, increased mobility problems and falls, greater health system use, and increased long-term care placement. Judicious deprescribing can help reduce polypharmacy and improve patient outcomes.

Another (sometimes better) strategy is not starting nonbeneficial medications for unclear reasons in the first place. In a 2018 article in Emergency Medicine Australasia, Dr. Gerben Keijzers and colleagues defined "deliberate clinical inertia" as "the art of doing nothing as a positive response." Arguing that doctors generally have a bias to intervene with diagnostic tests, drugs, or procedures, they suggested reframing the typical decision-making approach:

In clinical practice, 'risk versus benefit' is usually considered in terms of missing a diagnosis rather than potential risks of treatment, so a better approach to care may be to ask, 'Is this intervention more likely to cause harm than the underlying condition with its possible harm or risk?' There are many reasons why 'doing nothing' is difficult, but doing what we can to provide excellent care while preventing medical harm from unnecessary interventions must become one of the pillars of modern holistic healthcare.

Health professionals may readily grasp the rationales behind campaigns to avoid harms and costs of low value care such as Choosing Wisely and Right Care, but patients may be skeptical. Dr. Keijzers and colleagues suggested several ways to support deliberate clinical inertia in practice: empathy and acknowledgment; symptom management; clinical observation; explanation of the natural course of the condition; managing expectations; and shared decision-making ("communicating rather than doing").


This post first appeared on the AFP Community Blog.

Tuesday, July 23, 2019

Admissions straight talk from ... me!

Many thanks to Linda Abraham for interviewing me on Admissions Straight Talk about my path in medicine and recent blog post critiquing the U.S. News & World Report's medical school rankings. You can either listen to the full podcast episode embedded below or read a summary of the high points on her Accepted website.

Wednesday, July 17, 2019

The places in America where doctors won't go

Two years ago, I attended the annual Teaching Prevention conference in Savannah, Georgia. Since I hadn't spent much time in Georgia outside of Savannah and Atlanta, the welcoming plenary on improving health outcomes for the state's rural and underserved populations was eye-opening. According to Dr. Keisha Callins, Chair of the Department of Community Medicine at Mercer University, Georgia ranked 39th out of 50 states in primary care physician supply in 2013 and was projected to be last by 2020. 90% of Georgia's counties are medically underserved. Mercer supports several pipeline programs that actively recruit students from rural areas, expose all students early to rural practice and community health, and provide financial incentives for graduates who choose to work in underserved areas of the state. But it's an uphill battle. Even replicated in many medical schools across the country, these kinds of programs likely won't attract enough doctors to rural areas where they are most needed.

When people talk about places where doctors won't go, they tend to focus on international destinations, such as war zones in Syria or sparsely populated areas of sub-Saharan Africa. It's hard to believe that many places in America are essentially devoid of doctors, and access to medical care is as limited as in countries where average income is a tiny fraction of that in the U.S. Providing health care coverage for everyone, while important, won't automatically ensure the availability of health professionals and resources in rural communities. In a JAMA Forum piece, Dr. Diana Mason discussed the financial struggles of rural hospitals that support community health alongside primary care clinicians, which become more acute when budget cuts to rural health programs and grants occur.

Georgia is hardly the only state struggling to attract doctors to rural communities. In the Harper's Magazine story "Where Health Care Won't Go," Dr. Helen Ouyang chronicled the tuberculosis crisis in the Black Belt, a swath of 17 historically impoverished, predominantly African American counties in rural Alabama and Mississippi. In Marion, Alabama, a single family doctor in his mid-fifties and an overwhelmed county health department grappled daily with the lack of resources to contain the spread of the disease:

There is no hospital in town. The nearest one, twenty minutes away in Greensboro, has minimal resources. The road to get there is narrow, unlit at night, and littered with roadkill. Perry County has only two ambulances, one of which is on standby for the local nursing home. Life expectancy here is seven years lower than the U.S. average, and the percentage of obese adults is almost a third higher; by the latest count, more than a quarter of births take place without adequate prenatal care. [Dr. Shane] Lee’s clinic is Marion’s only place for X-rays.

Ouyang went on to describe the University of Alabama's Rural Health Leaders Pipeline, a program that recruits and trains medical students from rural communities to eventually become primary care physicians for those communities. Although the program has been modestly successful (since 2004, "more than half have gone on to work in rural areas, compared with only 7 percent of their classmates"), many Black Belt counties have yet to benefit from it. Many medical schools use a minimum score cutoff on the Medical College Admission Test (MCAT) that tends to penalize applicants from rural and minority communities, even though those students are more likely to become primary care physicians for underserved populations:

The purpose of doctors, after all, is to tend to patients’ ultimate needs. Increasing the supply of primary care physicians is linked to lower mortality rates; after compiling data from studies across different parts of the country, a group of public health researchers found that by adding one more doctor for every 10,000 people, as many as 160,000 deaths per year could be averted. When the same researchers considered race as a factor, this benefit was found to be four times greater in the African-American population than among white people. Studies have also observed that the availability of primary care significantly reduces health disparities that result from income inequality.

The problem of too few primary care clinicians is not limited to rural America, but those communities are where the need is greatest, since a town without a family doctor is unlikely to have any other types of physicians. Medical schools can't easily change social determinants of health on their own, but they can rewrite their mission statements to emphasize providing health care to everyone regardless of geography, and implement recruitment and admissions policies that actually support that goal.


This post first appeared on Common Sense Family Doctor on June 5, 2017.

Tuesday, July 9, 2019

Population health, colorectal cancer screening, and guideline development

Although a recent vacation and catching up after returning to work have delayed posting to the blog, I wanted to share three of my recent publications in other venues that you might find to be of interest. In my latest Medscape commentary, I added my voice to an ongoing debate about the future role of family physicians in addressing population health and social determinants. Should we expect all family physicians to be "experts in population health," or limit population health training to basic competencies that are generally tied to clinical settings?

My view is that medical schools and residency programs should offer a scope of population health training that falls somewhere in between Dr. DeVoe's aspirational goals and Dr. Campos-Outcalt's minimum objectives, consistent with their institutional mission statements, faculty resources, and existing connections with community organizations. 

For example, over the past several years, my students and family medicine residents have benefited from classroom and experiential learning from faculty in Georgetown's Department of Health Systems Administration, its law school, and its school of public policy. Each year we raise the bar for population health in undergraduate medical education so that our graduates will be able to utilize population health skills in residency and, if desired, incorporate them into their future practices.

Meanwhile, over at American Family Physician, fellow Deputy Editor Mark Ebell, MD, MS and I launched a feature that evaluates new diagnostic tests:

[Diagnostic Tests: What Physicians Need to Know] uses a structured approach to review key test characteristics, including discussions of accuracy, benefits, harms, cost, and cost-effectiveness. It concludes with a clinical bottom line: Is there a role for this test in primary care practice and, if so, for which patients? We aim for this new feature to cut through the “hype” and provide independent, objective assessments of new diagnostic tests that readers are considering incorporating into their practices.

Family physicians and other primary care clinicians who read AFP can find my first piece in the series, mSEPT9 Blood Test (Epi proColon) for Colorectal Cancer Screening, in the July 1 issue of the journal.

Finally, on the AFP Community Blog, I took readers "behind the scenes" of the updated American Academy of Family Physicians (AAFP) clinical practice guideline on depression following acute coronary syndrome events. Those of you who are interested in learning more about how the AAFP develops guidelines can check out some of their background resources, such as a short video series and the detailed Clinical Practice Guideline manual. I am currently working with the AAFP to develop clinical practice guidelines on two common conditions encountered by family physicians.

As Common Sense Family Doctor approaches its 10-year anniversary (July 24, 2019), topics on deck for future posts include artificial intelligence (AI) in primary care, the upside of clinical inertia, and more developments in overdiagnosis. Stay tuned.

Saturday, June 22, 2019

Fear-mongering in thyroid and breast cancer screening

A large part of practicing primary care consists of providing reassurance to healthy persons. The patient who asks me to look at the mole on her back to make sure it isn't melanoma. The patient who recently recovered from a cold but is still coughing and wants to know that it isn't a sign of something more serious. The patient whose friend's doctor found a lump on his thyroid gland and wants to have his neck checked too.

The last time the U.S. Preventive Services Task Force recommended against screening for thyroid cancer was in 1996. That it took more than 20 years to release an updated recommendation statement (still a "D," or don't do) speaks to how non-controversial the Task Force judged this topic to be. Unfortunately, in the interim many clinicians and patients ignored this advice. In South Korea, a national cancer screening program that began in 1999 encouraged general practitioners to routinely perform thyroid ultrasound scans, resulting in an "epidemic" of new thyroid cancers but no change in thyroid cancer deaths. In the United States, papillary thyroid cancer diagnoses have quadrupled since 1995, again with no change in mortality. In both countries and around the world, physicians are finding and treating thousands of pseudo-cancers that would not have otherwise been found and don't need to be treated. Overdiagnosis begets more overdiagnosis: patients who are "successfully" diagnosed and treated tell friends and relatives to have their necks palpated or scanned for thyroid tumors. And if that feedback cycle wasn't enough, advocacy groups such as the Light of Life Foundation initiated fear-mongering awareness campaigns, as Dr. Gilbert Welch described in an editorial accompanying the USPSTF recommendation:

About a decade ago, public service announcements began to appear encouraging people to have their physicians “check your neck.” The Light of Life Foundation campaign featured actual testimonials of patients describing their positive health behaviors on the day before they were diagnosed with thyroid cancer. The ads used compelling language: “Thyroid cancer doesn’t care how healthy you are. It can happen to anyone. Including you. That’s why it is the fastest growing cancer in the US. Ask your doctor to check your neck. It could save your life.” The campaign’s title—and its main slogan—was “Confidence Kills.” That’s a great public health message: if you feel good, you are about to die.

Fear-mongering isn't limited to thyroid cancer, of course. From the 1980s-era American Cancer Society print advertisement that lectured women, "If you haven't had a mammogram, you need more than your breasts examined," promoters of breast cancer screening long used fear to motivate women to undergo screening mammography. In 2015, several advocacy organizations successfully persuaded the U.S. Congress to override the U.S. Preventive Services Task Force's "C" grade (small net benefit) on screening mammography for women aged 40-49 with a "Stop the Guidelines" campaign that included full-page advertisements in major newspapers asking the rhetorical question "Which of our wives, mothers, daughters, and sisters would be be OK to lose?"

The major difference between screening for thyroid and breast cancer is that the latter actually reduces cancer deaths. But women under 50 are less likely to benefit because there is less lethal breast cancer to be found in younger women, and consequently much higher false positive rates that affect more than half of all women receiving annual mammograms from age 40 to 50. And the USPSTF didn't tell clinicians don't screen - more accurately, they said don't screen reflexively, and the message to younger women is not to avoid mammograms, but to talk about the pros and cons with your doctor.

That hasn't stopped a new alliance of radiologists and breast cancer surgeons from targeting the Task Force with a 40not50 campaign which encourages women in their 40s to turn off their brains, eschew shared decision-making, and demand that their doctors start screening them at age 40 because mammograms save lives, and a government-appointed panel (whose 16 current members include 6 women) wants to prevent women from seeing their 50th birthdays. Notwithstanding the ulterior motives behind this absurd campaign, it is insulting to women. It says that they can't be trusted to consider the medical evidence, have conversations with their primary care physicians, and make decisions about their healthcare that are right for them.


This post first appeared on Common Sense Family Doctor on May 16, 2017.