Monday, December 28, 2020

Common Sense Family Doctor's 2020 Year in Review

With a total of 48 posts (this will be the 49th), this has been my most prolific year of blogging since 2017. Nearly a third of these were on or related to the COVID-19 pandemic and its public health consequences, but I wrote about many other topics, too. With a nod to the ongoing 12 days of Christmas, I've picked 12 posts to highlight here, one from each month.

January 15 - When a cancer diagnosis predicts future good health

For early prostate, breast (including ductal carcinoma in situ, which was considered separately), thyroid cancer, and melanoma, relative survival was not only better than disease-specific survival, but greater than 100%. In other words, patients with these particular early cancer types were more likely to survive than similar individuals without cancer.

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.

While women age 70 to 74 years who continued to have screening mammograms had a 22 percent lower risk [of death from breast cancer] than those who stopped being screened, there was no mortality benefit for women who continued screening after age 75 years.

Social distancing, widespread testing, contact tracing, and vaccine development won't be enough to halt the pandemic if we leave millions of Americans behind; it's no wonder that Medicaid expansion has been proposed as a potent policy tool for mitigating the health and economic impact of COVID-19.

Whether it's the President of the United States repeatedly lying about the impact of COVID-19; the closing of essential hospitals in underserved minority or rural communities; or a modern-day epidemic of amputations in black Americans in Southern former slave states; these protests are an expression of deep-seated rage about an epidemic of inequality that men and women in power have long minimized, dismissed or ignored.

Just as COVID-19 has accelerated an overdue transition to providing more health care virtually, I hope that it will also inspire researchers to "study what was gained" from postponed or cancelled appointments with family doctors and surgeons. If the pandemic has a silver lining, this might be it.

For their "Best Hospitals for America" rankings, Lown created a Hospital Index that incorporated not only patient outcomes (mortality, safety, and satisfaction), but also civic leadership (community benefit, representativeness of patients compared to the surrounding community, and institutional salary distribution) and medical overuse.

Just as emergency medicine physicians are often justified at taking a more aggressive testing and treatment approach to a patient with chest pain than a family physician evaluating a patient in his or her office, it's arguable that the greater long-term risk of cardiovascular events in patients who see cardiologists warrant more intensive treatment of blood pressure than patients in primary care settings.

Although age and race inequalities largely explain America's uneven experience of COVID-19 to date, that is no assurance that it will stay that way. HIV/AIDS was a viral disease that only affected urban gay men and intravenous drug users - until it wasn't.

Family physicians' expertise in cancer mostly involves screening and diagnosis, while treatment is managed by medical and/or surgical oncologists. However, as the long-term survival of patients with cancer improves, the important care role of primary care clinicians in survivors of childhood and adult cancers has been increasingly recognized.

I don't believe that prisons should be abolished, any more than I believe that police departments should be defunded. But if the U.S. is going to continue to pour hundreds of billions of dollars into incarceration every year, a large chunk of those dollars ought to be devoted to peacemaking - making the offender whole and less likely to offend again - rather than punishment.

State-mandated screening at birth for rare, serious medical conditions occurs in 4 to 5 million newborns and detects 5,000 to 6,000 affected infants each year. With a combined incidence of 1 out of every 1,500 births, inborn errors of metabolism are the most common conditions detected by newborn screening.

Thursday, December 24, 2020

My favorite public health and health care books of 2020

Christmas Eve may be a little late in the holiday season to be recommending books, but then again, e-books can be a great last-minute gift for procrastinators. One constant that has helped keep me sane during this tumultuous pandemic year has been always having a physical or virtual shelf of intriguing books to read next. As in previous years (see 2019, 2018, 2017, 2016, and 2015), this favorite books list is ordered alphabetically and includes a few that were new to me even though they were published before 2020.


1. Fallible: A Memoir of a Young Physician's Struggle with Mental Illness, by Kyle Bradford Jones

2. Heart: A History, by Sandeep Jauhar

3. Hidden Valley Road: Inside the Mind of an American Family, by Robert Kolker

4. Inside the FDA: The Business and Politics Behind the Drugs We Take and the Food We Eat, by Fran Hawthorne

5. Malignant: How Bad Policy and Bad Evidence Harm People with Cancer, by Vinay Prasad

6. The Long Fix: Solving America's Health Care Crisis with Strategies That Work For Everyone, by Vivian Lee

7. Together: The Healing Power of Human Connection in a Sometimes Lonely World, by Vivek Murthy

8. Upstream: The Quest to Solve Problems Before They Happen, by Dan Heath

9. When Death Becomes Life: Notes From A Transplant Surgeon, by Joshua Mezrich

10. When We Do Harm: A Doctor Confronts Medical Error, by Danielle Ofri

Saturday, December 19, 2020

New guideline for managing acute pain from musculoskeletal injuries

In a 2017 practice guideline based on a systematic review of noninvasive treatments, the American College of Physicians (ACP) recommended superficial heat, massage, acupuncture, and spinal manipulation as initial treatment options for patients with acute low back pain, in addition to a nonsteroidal anti-inflammatory drug (NSAID) or skeletal muscle relaxant if desired. But is a similar approach effective for treating pain from acute musculoskeletal injuries not involving the lower back? To answer this question, the American Academy of Family Physicians (AAFP) joined the ACP in developing another practice guideline on management of acute pain from non-low back, musculoskeletal injuries in adults, a synopsis of which appeared in Practice Guidelines in the December 1 issue of American Family Physician. These are some key practice points from the guideline:

• Topical NSAIDs are the most effective intervention for acute musculoskeletal pain other than low back pain.

• Although oral NSAIDs and acetaminophen are effective for acute pain relief, combining them does not improve effectiveness.

• Although moderately effective for pain relief, opioids increase gastrointestinal and neurologic adverse effects and lead to long-term use in 6% of people treated.

• Acupressure and transcutaneous electrical nerve stimulation techniques are effective nonpharmacologic options for acute pain.

In an accompanying editorial, Dr. David O'Gurek and I, who represented the AAFP on the guideline committee, and Dr. Melanie Bird, AAFP Clinical and Health Policies Manager, discussed some of the guideline's highlights and limitations. A systematic review and network meta-analysis of randomized, controlled trials provided direct and indirect comparisons of various treatment options on outcomes that included pain relief and physical functioning, symptom relief, treatment satisfaction, and adverse events.

Topical NSAIDs improved all efficacy outcomes with minimal adverse effects, while oral NSAIDs and acetaminophen improved fewer outcomes and were more likely to cause adverse events. We suggested against using opioids, including tramadol, for acute musculoskeletal injury pain due to their poor adverse effect profile and the risk of prolonged use, ranging from 6% in low-risk to 27% in high-risk populations. We also noted that "equitable coverage and affordability of first-line treatments" are essential to reduce well-known racial and socioeconomic disparities in pain management; for example, though a topical NSAID is now available over-the-counter, it costs significantly more than oral NSAIDs and acetaminophen and may not be covered by health insurance plans.


This post first appeared on the AFP Community Blog.

Sunday, December 13, 2020

Long-term benefits of newborn metabolic screening

State-mandated screening at birth for rare, serious medical conditions occurs in 4 to 5 million newborns and detects 5,000 to 6,000 affected infants each year. A 2017 American Family Physician article reviewed various conditions that are targeted by newborn screening: amino acid disorders, fatty acid oxidation disorders, organic acid disorders, hemoglobinopathies, endocrine disorders, and miscellaneous diseases (including congenital hearing loss and critical congenital heart defects). With a combined incidence of 1 out of every 1,500 births, inborn errors of metabolism are the most common conditions detected by newborn screening.

After tandem mass spectrometry made it possible to test for many conditions using a single blood sample, the federal Health Resources and Services Administration's Maternal and Child Health Bureau commissioned the American College of Medical Genetics (ACMG) to create a uniform list of conditions for newborn screening panels in 2005. However, the ACMG's recommended core panel of 29 conditions was criticized by the U.S. Preventive Services Task Force (USPSTF) for not taking an evidence-based approach. In a position paper, the USPSTF noted that the ability to detect a condition with high diagnostic accuracy was insufficient to include it in the panel:

A newborn screening program is not just a panel of screening tests. ... It is also parental education, follow-up, diagnosis, treatment and management, and program evaluation, and all of the various parts of the system must be in place and working well to realize the benefits of screening. ... Moreover, a newborn screening panel should be expanded only if the newborn screening program is fully prepared to make all the components of the complex system available for the new disorders. Expansion would be costly and might not be the best use of scarce health care resources, given the many other unmet child health needs.

Reinforcing the USPSTF's concerns, an analysis by the Centers for Disease Control and Prevention projected that if all 50 states expanded their newborn screening panels to align fully with the ACMG recommendations, "although such an expansion would have increased the number of children identified by 32% (from 4,370 to 6,439), these children would have had many rare disorders that require local or regional capacity to deliver expertise in screening, diagnosis, and management." A cross-sectional survey of Ontario primary care clinicians found that family physicians had limited knowledge of conditions identified by newborn screening tests, and many were not comfortable leading detailed discussions of abnormal results with parents or guardians.

The U.S. Secretary of Health and Human Services' Advisory Committee on Heritable Disorders in Newborns and Children (SACHDNC) subsequently developed a more rigorous framework to evaluate conditions nominated as additions to the uniform screening panel, requiring an independent systematic evidence review of key questions based on an analytic framework similar to those used for USPSTF reviews. In a separate document, the SACHDNC outlined questions for newborn screening long-term follow-up data systems to answer to make sure that programs achieve their goals of improved outcomes for children and families.

An observational study published last month in Pediatrics reported the clinical outcomes of 306 individuals with inherited metabolic diseases identified by a university hospital laboratory performing Germany's newborn screening panel from 1999 to 2016. The German national panel is less extensive than the ACMG's, consisting of 2 endocrine and 12 inherited metabolic diseases, and the nearly 2 million newborns screened during the study period represented 15 percent of Germany's live births. 28 individuals presented with metabolic symptoms prior to newborn screening results being available; the rest were successfully enrolled in specialized metabolic/nutritional therapy while still asymptomatic. Although nearly 1 in 4 individuals eventually developed irreversible disease-specific clinical signs, 88% had normal cognitive outcomes, and more than 95% showed normal development and attended regular kindergarten and primary schools.


This post first appeared on the AFP Community Blog.

Sunday, December 6, 2020

To beat COVID-19, focus on vaccine distribution and building trust

Even as the numbers of persons hospitalized for and dying daily from COVID-19 are surpassing all-time highs, America is suffering from pandemic fatigue. Although millions have curtailed social gatherings or changed holiday travel plans, exhortations by public officials, school closings, and renewed stay-at-home orders don't seem to be slowing the spread of the virus in most states. In September, I warned that a vaccine against SARS-CoV-2 was unlikely to be a "magic bullet" for the pandemic unless it had very high efficacy and population uptake well beyond the historical standard set by annual influenza vaccines. As it turns out, though, the first two messenger RNA vaccines developed by Pfizer/BioNTech and Moderna/National Institutes of Health appear to be highly efficacious (despite these important caveats) in preventing mild to severe COVID-19 infections, and both could receive an emergency use authorization from the U.S. Food and Drug Administration to begin administering the first doses within the next two weeks. Historians of medicine will likely chronicle the "warp speed" development of these vaccines as an amazing achievement given the intense political and humanitarian pressures involved. But in terms of ending the pandemic, that may turn out to be the easy part.

Physicians like me have some sayings about other strongly recommended medical interventions. "The best screening test for colorectal cancer is the one that gets done." "The best blood pressure medication is the one the patient can afford to buy and is able to take every day." Conversely, I agree with the title of a recent Washington Post article by the director of the Yale Institute of Global Health: "Rapid development of a [coronavirus] vaccine won’t help much if people refuse to take it." On one hand, I don't place a great deal of stock in (and feel that there's been entirely too much journalistic hand-wringing about) surveys that found that sizeable percentages of Americans were reluctant or unwilling to receive a coronavirus vaccine; nearly all were polled when no viable vaccine candidate existed, and it's unsurprising and, frankly rational, that people would have reservations about being injected with a completely theoretical foreign substance.

Since it will be at least several months before enough vaccine doses are available for the entire population, the first wave will be administered to health care workers and residents of long-term care facilities, followed by essential workers and adults at high risk due to age or other medical conditions. I suspect that the vast majority of persons in these categories will choose to receive a vaccine. Personally, it will be a great relief to have protection against becoming severely ill due to an occupational exposure to COVID-19, and potentially (if the vaccine prevents asymptomatic viral transmission, which is uncertain but probable) protecting my spouse and children until they are eligible to receive the vaccine themselves.

The big question is: will other Americans who don't consider themselves to be at "high risk" for severe COVID-19, who have suspicions about the motivations of the federal government and/or pharmaceutical companies, or are concerned about the safety of the vaccine (whose long-term side effects are obviously not known, though it's hard to imagine that they could be worse than what thousands of COVID-19 "long-haulers" are already suffering) accept vaccination in high enough numbers to provide herd immunity to the population and halt the pandemic? And will our inefficient, fragmented public health and health care systems be up to the task of delivering a vaccine to everyone who wants it?

A Commonwealth Fund report found that states with higher COVID-19 case counts and larger percentages of Black, Latino, and American Indian populations (who have a disproportionately higher risk for hospitalization and death than Asian Americans and non-Hispanic Whites) have been less successful than other states in administering annual influenza and H1N1 vaccines, and nearly all states report historically lower vaccine uptake in the same racial and ethnic groups that are at highest risk. A modeling study in Health Affairs suggested that problems with implementation of a national vaccination program - how quickly vaccine doses can be manufactured and deployed, for example - could easily blunt the population benefits of a vaccine that is highly effective in individuals:

The benefits of a vaccine will decline substantially in the event of manufacturing or deployment delays, significant vaccine hesitancy, or greater epidemic severity. Our findings demonstrate the urgent need for health officials to invest greater financial resources and attention to vaccine production and distribution programs, to redouble efforts to promote public confidence in COVID-19 vaccines, and to encourage continued adherence to other mitigation approaches, even after a vaccine becomes available.

The stakes could not be higher, and there is no more time to waste. The vaccine scientists have done their job, and we owe them an enormous debt of gratitude. Now it's time for medical professionals and their allies (you, who are reading this blog post) to spread the word that being vaccinated against COVID-19 when your turn comes is not only good for your own health and personal safety, but benefits our communities, our states, and our country. There is no Democratic vaccine or Republican vaccine, and who you happened to vote for President no longer matters. We are all in the fight against this virus together, as we have always been. As Benjamin Franklin is thought to have said at the signing of America's Declaration of Independence, "We must all hang together, or, most assuredly, we shall all hang separately."