Wednesday, February 26, 2020

COVID-19: preparing for an epidemic

Testifying to the rapidly evolving nature of the epidemic, the following post on COVID-19, which I wrote for the AFP Community Blog just 3 weeks ago, is already somewhat out of date (at that point, for example, the novel coronavirus didn't have a formal name). Yesterday, an official at the Centers for Disease Control and Prevention (CDC) warned that an outbreak of COVID-19 in the U.S. is no longer a matter of "if," but "when," and that Americans need to be prepared for a "significant disruption" in their lives. Although only 14 U.S. cases (12 of them travel-related) had been confirmed as of Feb. 24, only a few hundred persons have actually been tested due to problems with the test kits. It's hard to have much confidence that an administration that has repeatedly sought to slash funding for the CDC is prepared to mobilize the nation's public health infrastructure to confront this significant health threat. As the president of the American Academy of Family Physicians, Dr. Gary LeRoy, predicted last month, family physicians will be on the front lines of identifying and preventing the spread of this new respiratory illness.


In a 2015 editorial on global health in American Family Physician, Drs. Ranit Mishori and Jessica Evert noted that "the world is not only smaller than ever, but it is also more intricately connected," with transportation networks facilitating the spread of exotic infectious diseases across oceans and borders. These words seem prescient today as China, the World Health Organization, and the international community work feverishly to contain the outbreak of the 2019 novel coronavirus (2019-nCoV), which was initially reported in patients with pneumonia in Wuhan, Hubei Province, China but has spread via travel and person-to-person transmission to 24 other countries, including 11 confirmed cases in the United States as of February 3. As scientists race to answer basic questions about this new respiratory infection, travel to China has been heavily restricted, U.S. citizens have been evacuated from the region, and travelers recently returned from Hubei Province are being quarantined by state governments.

To keep clinicians up-to-date on the evolving epidemic, the Centers for Disease Control and Prevention (CDC) has posted a comprehensive collection of resources for health care professionals who encounter patients with suspected 2019-nCoV, including an assessment flowchart and interim management guidance for patients with confirmed infection. Forward-thinking family physicians can also consult a previous Family Practice Management (now FPM) article for tips on on preparing your office for an infectious disease epidemic. Key points highlighted in this article include:

- Begin planning now.
- Master the detection, prevention and management of seasonal influenza and community-acquired pneumonia.
- Practice scrupulous infection control - "wash in and wash out."
- Communicate at all levels, and coordinate with public health agencies.
- Focus on staff management and business continuity.

Although the origin of the 2019-nCoV is not known, the linkage of the majority of early infections to a wholesale seafood market suggests the existence of an animal reservoir. A previous novel coronavirus outbreak that began in China, severe acute respiratory syndrome (SARS), was eventually traced to infected bats. However, the estimated 2% fatality rate of 2019-nCoV is substantially lower than the 10% fatality rate of SARS. In addition, it's important to remind worried patients that the CDC projects that the less lethal but far more prevalent (and preventable) seasonal influenza virus will cause 180,000-310,000 hospitalizations and 10,000-25,000 deaths during the current flu season.

Wednesday, February 19, 2020

A family doctor's favorite podcasts - updated for 2020

Since publishing my first list of favorite podcasts in 2016, followed by a second list in 2018, I have continued to try new podcasts to replace ones that either lost my interest or stopped dropping new episodes. How do I find the time? I listen while commuting in my car, on foot, or on the Metro. I listen while folding or putting away laundry. There are a lot of moments when I'd rather listen to a podcast than to music or a typical talk show where all people seem to do is try to talk over each other. And if I run into a dull episode or the topic just doesn't fit my mood that day, I cut it short and move on.

Health policy

The American Health Podcast
An Arm and A Leg
The Impact
POLITICO's Pulse Check
What the Health?

Current events and popular culture

Against the Rules
The Forward
The Happiness Lab
TED Radio Hour
30 for 30 Podcasts
This American Life
Wait, Wait ... Don't Tell Me!


The Civil War: A History Podcast
Q & Abe
Revisionist History

Science, medicine and exploration

American Family Physician Podcast
Explore The Space
Hidden Brain
Houston We Have a Podcast
Medicine and the Machine
Plenary Session
Primary Care Update

Thursday, February 6, 2020

Inspire future family physicians by teaching them about direct primary care

My last post ended with a cliffhanger. After discussing the America Needs More Family Doctors collaborative, which aims to double the percentage of U.S. medical students who enter family medicine by 2030, I mentioned that one nontraditional practice is attracting medical students "in droves." Yes, it's the title of today's post. This week, I gave a talk on international health systems in Georgetown's 4th year / resident Health Policy Elective during which I pointedly observed that several health systems whose outcomes are superior to those in the U.S. (Canada, Germany, the United Kingdom, and Japan) all have a roughly 1:1 ratio of primary care to subspecialist physicians, as opposed to the more than 2:1 ratio of subspecialists to primary care in the U.S. A sharp student rose to ask if the income disparities between primary care and subspecialists are as large in these countries as in the U.S. Great question! They're not. And, I added, doctors in these countries also don't finish medical school with anywhere near the degree of educational debt that most U.S. graduates have.

But it isn't only dollars and cents that discourage medical students from considering primary care. In a recent qualitative study of 26 primary care physicians, nurse practitioners, and physician assistants with a mean of two decades of clinical experience, Dr. Sumit Agarwal and colleagues explored "factors contributing to burnout and low professional fulfillment." They introduced the apt term professional dissonance, or "discomfort from working in a system that seems to hold values counter to their values as clinicians." For example, many doctors chose primary care to utilize critical thinking skills to diagnose patients with undifferentiated problems, but the system values checking boxes to meet metrics such as immunization or screening rates. Family physicians want to care for and form long-term relationships with patients, but the system instead values volume as "productivity" and treats patients as widgets on an assembly line.

An analysis of claims data from a national private health insurer from 2008-2016 suggested that despite the expansion of insurance coverage due to the Affordable Care Act, adults have become less likely to visit primary care offices or have a usual source of primary care. Although it's possible that Dr. Google has reduced the need for acute visits for self-limited conditions, and that telehealth services may also be replacing some portion of office visits, the authors and an editorialist worried that patients are being "priced out" of primary care by rising deductibles and cost-sharing. Another study found that patients who responded to the Behavioral Risk Factor Surveillance System telephone survey in 2017 were substantially more likely to be unable to see a physician for several chronic medical conditions due to cost compared to 1998, even though they were more likely to be insured.

To not only survive, but thrive, primary care needs to be organized and paid differently. I am skeptical that the CMS Primary Cares Initiatives, though promising, will be the answer for most physicians. Though prospective payments may give practices more flexibility to provide virtual or asynchronous care, rather than doing away with checkboxes, it doubles down on them as a poor surrogate for measuring care quality. On the other hand, direct primary care, which slashes administrative costs that are strangling health care budgets and steadily sapping the morale of non-administrators, is changing the health system from the ground up and restoring critical elements of the doctor-patient relationship. A year's membership in a DPC practice can generally be had for about one month of Presidential candidate Andrew Yang's Freedom Dividend, making it accessible not only to the middle and upper classes, but to patients who are can't afford traditional primary care. Medical schools should prioritize exposing more students to this new primary care model for us to have any hope of attracting one-quarter of them into family medicine.