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.