Sunday, September 25, 2022

The evidence is in: WIC improves maternal and child health

Food insecurity is increasingly recognized as a modifiable social determinant of health. The American Academy of Family Physicians has endorsed "sustained funding for evidence-based policies and programs to eliminate disparities in healthy food access, including ... the Special Supplemental Nutritional Program for Women, Infants, and Children (WIC)." In a 2019 editorial about interventions to reduce maternal mortality, Drs. Katy Kozhimannil and Andrea Westby recommended postpartum screening for food insecurity. But how strong is the evidence that WIC improves maternal and child health?

Since 2012, American Family Physician's Implementing AHRQ Effective Health Care Reviews feature has summarized dozens of primary care-relevant systematic reviews from the Agency for Healthcare Research and Quality's Effective Health Care Program with accompanying clinical commentaries. A team of investigators in this program recently reviewed maternal and child outcomes associated with WIC and published a synopsis of their report in Annals of Internal Medicine. Investigators identified 82 studies that examined associations between WIC participation and maternal, birth, infant, and child health outcomes.

Based on direct evidence from 49 studies, they concluded that WIC participation likely reduces the incidence of preterm birth, low birth weight, and infant mortality. Lower strength of evidence suggested WIC is associated with less inadequate gestational weight gain and alcohol use and better diet quality during pregnancy, and it may increase child preventive care visits and immunizations. WIC was not associated with differences in breastfeeding rates or premature (before 4 months) introduction of solid foods. Children of families receiving WIC had better diet quality, increased household purchasing of healthy foods compared to less healthy foods and beverages, and higher cognitive development than WIC-eligible children not receiving benefits. There was insufficient evidence that WIC reduced childhood obesity or affected health status or risk of hospitalization.

The U.S. Department of Agriculture (USDA) found that food insecurity in households with children declined to its lowest rate in two decades in 2021, despite the negative impact of the COVID-19 pandemic on the economy. The nonpartisan Center on Budget and Policy Priorities observed:

About 10.2 percent of U.S. households were food insecure in 2021, meaning they struggled to afford enough food for an active, healthy life year-round. That the rate held steady during the pandemic — when accounting for statistical noise it’s not significantly different from the 10.5 percent rate for 2019 and 2020 — is a testament to robust relief measures policymakers enacted. These include Economic Impact Payments, an expanded Child Tax Credit, improved unemployment insurance, and expanded food assistance, along with [the Supplemental Nutrition Assistance Program]'s built-in ability to respond to increased need.

On the negative side, food insecurity increased from 2020 to 2021 in households without children and for women and older people living alone. Households headed by Black, Hispanic, and American Indian / Alaska Native persons were more likely to experience food insecurity than other households. Finally, the expiration of temporary pandemic emergency relief measures, such as free meals for all children attending public schools, may worsen food insecurity in low-income families.

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This post first appeared on the AFP Community Blog.

Thursday, September 22, 2022

Malcolm Gladwell on trust in medicine and the devaluing of primary care

This week I'm back in Washington DC, attending and presenting educational sessions at the American Academy of Family Physicians FMX (Family Medicine Experience), the first in-person version of this conference since 2019. For me the highlight of this conference is usually the invited celebrity speaker, someone with an inspirational story outside of medicine: past speakers have included political pundits Mary Matalin and James Carville and Aron Ralston, who survived a canyoneering accident in which he had to cut off his own arm to save his life. But this year's speaker, the author and podcaster Malcolm Gladwell, topped them all. I've been a huge Gladwell fan since I read The Tipping Point, avidly listen to his Revisionist History podcast (and featured a past episode on philanthropy on this blog), and couldn't wait to hear what he had to say yesterday to an audience of family physicians who have spent the past two plus years fighting pandemic misinformation.

The theme of his talk was that the decline in trust in medicine and public health that has manifested as tenacious resistance to Covid vaccination among certain demographics and/or areas of the country may have less to do with true anti-science sentiment and more to do with people having a hard time adjusting to strange new things. He shared several examples of this phenomenon in other fields: focus groups panning pilots of television sitcoms that ended up becoming classics (e.g., the Mary Tyler Moore Show, All In The Family, Cheers, and Seinfeld); the near rejection of the prototype of a mesh office chair that ended up earning billions of dollars for its inventor; and the Marines transforming its service from the misfits of the U.S. military to "the Few, the Proud" elite branch that we know today. Gladwell noted that trust in a profession doesn't always correlate with its effectiveness, and that pouring billions of dollars into amazing technological solutions to the pandemic (vaccines and antiviral treatments) while neglecting to support the family doctors whose job it is to persuade patients, based on preexisting trusting relationships, to accept these medical innovations was "nuts." (I made a similar point in an editorial in the Annals of Family Medicine last year). It's no wonder that many of our patients turned to the well established - but totally ineffective - drugs hydroxychloroquine and ivermectin instead.

Public health holds many stories of initial mistrust in effective interventions. Gladwell talked about how despite clear evidence showing that supplementing water or salt with iodine eliminated goiter, there was widespread public resistance to the idea ("I'll take my chances with the goiter"). The same thing happened when health officials proposed adding fluoride to water to prevent dental caries. This time, though, one official got clever and announced that fluoride would be added to the municipal water supply on a certain date, then when numerous people experienced adverse effects from drinking water on that date, mentioned that he had actually delayed the date but forgotten to tell anyone. So there is reason to hope that one day, receiving annual flu and Covid-19 vaccines will be less about one's partisan allegiances and more about following your doctor's common sense recommendation to protect yourself and others against severe illness and death.

Monday, September 12, 2022

Neurosyphilis, ocular syphilis, and otosyphilis are don't-miss diagnoses

When a patient with a history of migraine headaches presents with a "severe frontal headache and left-eye blurred vision and pain," neurosyphilis is unlikely to be foremost in the differential. Even after she mentions a two-month history of a diffuse maculopapular rash, clinicians may feel reassured because it doesn't involve the palms and soles. But syphilis, the great imitator, was in fact the eventual diagnosis in this patient, the subject of a case report published in Cureus.

In the August issue of American Family Physician, Dr. Jennifer Jones-Vanderleest reviewed detection and treatment of neurosyphilis, ocular syphilis, and otosyphilis, which can occur at any stage of syphilis regardless of immune status. Early neurosyphilis (within the first few years of infection) can present with "headache, dizziness, altered mental status, cranial neuropathies, motor and sensory deficits, meningitis, or stroke." Neurosyphilis is diagnosed with the combination of neurologic signs and symptoms and reactive syphilis serology and cerebrospinal fluid (CSF) tests. The 2021 Centers for Disease Control and Prevention (CDC) Sexually Transmitted Infections Treatment Guidelines recommend that patients with neurosyphilis be treated with 18 to 24 million units of aqueous crystalline penicillin G per day for 10 to 14 days, administered as a continuous infusion or 3 to 4 million units intravenously every 4 hours. These patients should be tested for HIV and be offered HIV preexposure prophylaxis if HIV negative. After treatment, normalization of the serum RPR titer predicts normalization of CSF parameters; thus, repeated CSF sampling is not needed unless the patient is HIV positive and not receiving antiretroviral therapy.

As I discussed in a previous post, the incidence of syphilis in the U.S. has been rising steadily for the past two decades (beginning in my third year in medical school and continuing throughout my family medicine residency and practice) due to stagnant health department funding for contact tracers and the recent impact of the COVID-19 pandemic. Far from being ancient history, "in 2020, 133,945 cases of all stages of syphilis were reported, including 41,655 cases of primary and secondary syphilis," according to the CDC. Although a disproportionate number of cases occur in men who have sex with men, rates in women have increased sharply since 2016. A current review of the epidemiology, natural history, diagnosis and treatment of syphilis is available in the Journal of Lancaster General Hospital.

A draft recommendation statement from the U.S. Preventive Services Task Force (USPSTF) reaffirmed the importance of screening adolescents and adults at increased risk for syphilis infection. The USPSTF also recommends that all pregnant patients be screened for syphilis as early as possible in pregnancy. The American Academy of Pediatrics and the American College of Obstetricians and Gynecologists recommend rescreening women at high risk for syphilis at 28 weeks of gestation and again at delivery to prevent congenital syphilis.

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This post first appeared on the AFP Community Blog.

Wednesday, August 31, 2022

Hot topics in health policy

Last night, in a short talk to medical students and residents on "Health Policy in Family Medicine," I outlined three paths to become involved in the health policy space as a family physician, paralleling the ways that policy has intersected with my own career:

1. Clinical guidance and practice guidelines. How do research findings make their way into clinical practice recommendations? Where evidence is lacking or inconclusive, how are the judgment calls made and who gets to make them? Examples include my experiences as a medical officer for the U.S. Preventive Services Task Force, a guideline panelist for the American Academy of Family Physicians and collaborating specialty groups, and a member of the HHS Secretary's Advisory Committee on Breast Cancer in Young Women.

2. Advocacy for patients and population health. Advocacy can take many forms: interpersonal (e.g., lobbying local, state, or federal officials), writing opinion pieces, or serving as a source for a news story. I consider Common Sense Family Doctor and my Twitter account to be my main advocacy platforms, though on occasion I've written editorials in high-profile publications such as JAMA. During the COVID-19 pandemic, I spent a good deal of time pushing back against vaccine hesitancy and anti-vax sentiments in my community and online.

3. Advocacy for health professionals and primary care. While at Georgetown, I directed a health policy fellowship that trained recent family medicine residency graduates in research that demonstrated the value (and financially undervalued nature) of primary care. I continue to support the Robert Graham Center's work by publishing an ongoing series of Policy One-Pagers in American Family Physician.

Health policy isn't an abstract subject for me. In my medical career, I've seen firsthand the benefits to patients of the 2003 Medicare Modernization Act (which provided prescription drug coverage to millions of older adults), the 2010 Affordable Care Act (which extended access to affordable health insurance to tens of millions and provided consumer protections and guaranteed preventive services to all), and this year's Inflation Reduction Act, which allows Medicare to negotiate the prices of a limited number of expensive drugs, caps Medicare patients' out-of-pocket insulin costs at $35 per month and their total prescription out-of-pocket costs at $2000 per year. In addition, the IRA extended enhanced health insurance marketplace subsidies that were set to expire this year through 2025, which will preserve the affordability of private plans for lower-income patients who are self-employed or work for small employers that don't offer health care benefits. This legislation will make a major difference in many of my patients' lives by making it easier for me to provide them with the best care possible.

Friday, August 19, 2022

Diabetes is an increasingly common pregnancy complication

My clinical experiences suggest that more pregnant patients have been developing diabetes over the past several years, and it turns out this is a national phenomenon. A recent report from the Centers for Disease Control and Prevention documented a precipitous rise in the rate of gestational diabetes in the U.S. from 2016 to 2020, based on data collected from birth certificates. In 2020, gestational diabetes affected 7.8% of all pregnancies, reflecting a 13% increase since 2019 and a 30% increase since 2016. Prevalence increased with increasing age (2.5% in patients younger than 20 years and 15.3% in those aged 40 or older) and increasing pre-pregnancy body mass index (BMI). Both factors are likely driving the overall rise in gestational diabetes; the median age at which U.S. women gave birth reached an all-time high of 30 years in 2019 and only 2 in 5 women with a live birth in 2020 had a normal BMI prior to pregnancy.

The U.S. Preventive Services Task Force (USPSTF) recommends screening for gestational diabetes in asymptomatic pregnant patients at or after 24 weeks of gestation. Although the USPSTF did not identify a preferred test, a previously discussed study suggested that the two-step approach (a non-fasting 50 gram oral glucose challenge test followed by a fasting 100 gram glucose tolerance test if the first test is positive) "produces equivalent benefits, and fewer harms, than the one-step approach."

Adverse outcomes associated with gestational diabetes include gestational hypertension, preeclampsia, shoulder dystocia, macrosomia, and Cesarean delivery. Gestational diabetes also confers a 7-fold greater maternal risk of developing type 2 diabetes later in life and 1.5 times greater risk of the child being overweight in childhood or adolescence. Management of gestational diabetes begins with glucose self-monitoring and lifestyle modifications, followed by oral medication or insulin if target blood glucose levels are not achieved.

Prevention of gestational diabetes includes counseling on appropriate weight gain goals based on pre-pregnancy BMI, which can generally be achieved by averaging "350 to 450 calories per day above the previous intake (e.g., two slices of bread with half an avocado, ¾ cup of Greek yogurt or 1 cup of blueberries with two hard-boiled eggs)." Additionally, "patients should be encouraged to engage in moderate aerobic activity most days of the week for at least 20 to 30 minutes at a time, for a total of at least 150 minutes per week." The USPSTF recommends offering behavioral counseling interventions for healthy weight and weight gain in pregnancy; effective interventions generally started at the end of the first trimester and varied in duration and intensity (from 15 to 120 minutes and from 1 to more than 12 total contacts).

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This post first appeared on the AFP Community Blog.

Monday, August 8, 2022

Preventive services mandate can be improved, but eliminating it isn't the answer

Over the past 12 years since the Affordable Care Act became law, individuals, business groups, and state officials who object to one or more of its provisions have filed a lengthy list of mostly unsuccessful lawsuits seeking to have part or all of it declared unconstitutional by the courts. The latest legal challenge involves the requirement that private health insurers cover without patient cost-sharing all evidence-based preventive services, defined as more than 100 services recommended by the Advisory Committee on Immunization Practices, the U.S. Preventive Services Task Force, Bright Futures, or the Women's Preventive Service Initiative. When I went to my family doctor last month and received screening tests for colorectal cancer, high blood pressure, and cholesterol, these tests were all covered under the ACA's preventive services mandate. When I take my kids to receive their school-required vaccinations, those shots are fully covered too. The same goes for the costs of clinicians counseling pregnant patients about healthy weight and weight gain to prevent complications such as gestational diabetes, and similar counseling for to midlife women (aged 40 to 60 years) to maintain weight or limit weight gain to prevent obesity.

Why would anyone have a problem with requiring insurers to cover preventive services? Some employers have religious or ideological objections to paying for birth control and sterilization, preexposure prophylaxis for HIV prevention, or testing for sexually transmitted diseases. Others might oppose the increased employer or government contribution to insurance premiums that may result from mandating that these services be covered, though in reality the types of health care that drive up premiums tend to be pricey procedures and medications such as the Alzheimer's drug Aduhelm, whose initial projected price of $56,000 per year drove the highest-ever increase in Medicare premiums from 2021 to 2022.

Ensuring that patients can afford preventive services is only the first step toward getting them done. Only about two-thirds of eligible adults are up-to-date on colorectal cancer screening, for example, and a much lower percentage of current or past heavy smokers over age 50 have been offered or received lung cancer screening. Behavioral health preventive services such as screening for depression, intimate partner violence, and unhealthy alcohol use can be difficult to fit into clinical practice workflows that rely on dysfunctional electronic health records (systems that are optimized for billing rather than patient care).

The narrow focus of the ACA's preventive services mandate on health care services also leaves out other private and public programs that can have large benefits on disease prevention and care. For example, the final report of the National Clinical Care Commission included population-level diabetes prevention recommendations involving the U.S. Department of Agriculture, the Food and Drug Administration, the Federal Trade Commission, and the Department of Housing and Urban Development. A related analysis article in Health Affairs bemoaned the fragmented state of US health care and policy that has stalled progress in preventing and controlling type 2 diabetes:

At the population level, fragmentation and lack of shared population health goals across stakeholders mean that there is no ownership for large segments of the population who are at risk for or have diabetes. Payers carry the liability for the health service costs of their beneficiaries and can track utilization. Enrollee churn reduces payers' incentives to take on long-term responsibility or investments in higher-quality preventive services for which returns are only realized in the long term. ... Similarly, the movement of people between health systems undermines incentives for long-term, high-value care.

So you'll get no pushback from me if you observe that there are lots of flaws and loopholes in the preventive services mandate (beginning with the fact that it doesn't even apply to half of Americans who are either publicly insured or uninsured). But getting rid of it is throwing the baby out with the bathwater: an exceedingly dumb and harmful proposition that would result in more preventable illness and poorer quality of life for millions of Americans.

Thursday, July 28, 2022

Mismeasuring quality in primary care

After several years of doing family medicine commentaries for Medscape as part of a collaboration with Georgetown University Medical Center, I recently wrote my first commentary as a clinician and faculty member at the Lancaster General Hospital Family Medicine Residency Program about my mostly unsuccessful pursuit of elusive "quality" bonuses and the problems with current metrics used to judge care provided by primary care physicians. Here's an excerpt that discusses another notable perspective that inspired me to write about this topic: 

In a recent commentary, Drs. Christine Sinsky and Jeffrey Panzer distinguished "solution shop" from "production line" work in primary care and argued that though the medical training physicians receive makes us uniquely qualified to do the former, we end up spending most of our time and energy on the latter. Similarly, they observed that "most quality-improvement efforts have focused on improving production line–type measures and not on improving the conditions for sound medical decision-making and relationship building." Being able to correctly diagnose and treat patients who come in for chest or abdominal pain, for example, counts less (or not at all) toward my quality score compared with the percentage of patients who receive lead screening or diabetic eye exams.

Saturday, July 16, 2022

Peanut allergy: prevention and treatment advances

People with severe peanut allergy are at risk of life-threatening anaphylaxis from unintentional ingestion of small amounts of peanuts. A new drug review in American Family Physician discussed oral immunotherapy with peanut allergen powder, which increases tolerance for ingesting the amount of peanut protein in a single peanut by 63% but has important downsides: 1 in 10 patients need to use epinephrine after administration (compared to 1 in 20 in a placebo group); common short-term adverse effects include abdominal pain, throat irritation, and oral pruritus; and a price of approximately $3000 annually.

Although it was once believed that children should not consume peanuts early in life, a United Kingdom randomized trial in infants 4 to 11 months of age at high risk of developing peanut allergies found that early consumption of peanuts reduced the risk of developing peanut allergy by age 5 years by 80% (absolute risk reduction=14%, NNT=7). This finding led the National Institute of Allergy and Infectious Diseases to recommend in 2017 that peanut-containing foods be introduced into the diet of infants with severe eczema, egg allergy, or both at 4 to 6 months of age. In 2021, a consensus document on the primary prevention of food allergy from three North American professional allergy societies recommended introducing peanut-containing products to all infants around 6 months of age, regardless of their risk of developing peanut allergy.

A similar change to infant feeding guidelines in Australia occurred in 2016, recommending that all infants be introduced to peanuts before age 12 months. A recent study in JAMA evaluated changes in feeding practices and the prevalence of peanut allergy across two population-based cross-sectional samples recruited in 2007-2011 and 2018-2019. Although infants in the later sample were much more likely to have consumed peanuts before 12 months than infants in the earlier sample (86% vs. 22%), overall there was no statistical difference in peanut allergy prevalence. Noting that East Asian ancestry is considered a risk factor for peanut allergy, the authors hypothesized that the increased representation of infants with parents from East Asia in the later sample may have contributed to finding no effect. Another possible explanation is that early introduction of peanut-containing foods does not significantly modify peanut allergy development in infants not at high risk.

In a previous paper on identifying and using clinical practice guidelines, Dr. David Slawson and I observed: "The ultimate test of a good guideline is whether or not it has been prospectively validated; that is, has its adoption been shown to improve patient-oriented outcomes in real-world settings?" Based on the JAMA study, infant feeding recommendations to prevent peanut allergies have not yet passed this test. On the other hand, an accompanying editorial argued that "given the potential for benefit and the low risk of harm, the [study results] should not dissuade clinicians from following current consensus guidance that recommends early peanut introduction for infants." The challenge of identifying children at increased risk for peanut allergy (as noted in the consensus document, definitions have varied across studies and guidelines) and the inherently artificial nature of previous guidance restricting what an infant would otherwise naturally eat make this a reasonable course of action in the face of imperfect evidence.

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This post first appeared on the AFP Community Blog.

Friday, July 1, 2022

Race-based medicine and routine PSA screening in Black men

Five years ago on this blog, I asked whether routinely screening African American men for prostate cancer was warranted when evidence suggested that harms exceeded benefits in the general population. Even though many experts felt that it was, I disagreed:

What troubles me about this position is that race is as much a social construct as it is a biological one. Much of the disparity in prostate-cancer mortality between African-American and Caucasians can be explained by lower access to and quality of care, rather than a genetic predisposition for more aggressive and/or lethal cancers. In contrast to national data, studies of equal-access healthcare systems in the U.S. such as the Veterans Health Administration and the Department of Defense found no differences in prostate cancer mortality between Black and White men.

Since that time, the U.S. Preventive Services Task Force partially reversed itself and now states that "for men aged 55 to 69 years, the decision to undergo periodic prostate-specific antigen (PSA)-based screening for prostate cancer should be an individual one." Individual decision-making relies in part on assessing risk factors for potentially fatal prostate cancer, but aside from family history, the only other known risk factor is Black race.

Race-based medicine's drawbacks have become increasingly evident, however, and groups across the spectrum of medicine have been working to eliminate the inappropriate use of race from clinical decision-making. In this context, a group of urologists and oncologists recently updated a 2009 analysis of the effects of PSA screening in the U.S. and concluded that the benefit to harm ratio of screening over the past 3 decades was considerably more favorable in Black men than in the American population as a whole.

So was I wrong about not approaching Black men differently in PSA screening? Or as the title of the accompanying editorial asked, "Should recommendations for cancer screening differentiate on race?" Drs. Gil Welch (who authored the original analysis of PSA screening) and Adewole Adamson observed that assuming that the effectiveness of PSA screening or the harm of overdiagnosis are not substantially modified by race, then the higher prostate cancer death rate in Black men suggests that they would be more likely to benefit from screening than men of other races.

On the other hand, they argued, "in the context of addressing health disparities, cancer screening is a massive distraction. ... Cancer-associated health disparities not biased by early detection are related primarily to unequal treatment after diagnosis, not screening." All but a small fraction of the increased risk of lethal prostate cancer in Black men is likely to be mediated by social determinants of health and structural racism rather than genetics. Shockingly, "in Black men, the median age of prostate cancer death is 76 years, 4 years older than their average life expectancy [emphasis mine]," which is a strong argument for devoting more resources to improving the lives of the >95% of Black men who die from something other than prostate cancer (e.g., heart disease, lung cancer, chronic kidney disease).

I will continue to inform Black and multiracial patients in the age group highlighted by the USPSTF about population-level risks and the (increasingly inexcusable) paucity of empiric data on the benefits and harms of PSA screening in Black men. Some will choose to be screened, some will not. But I continue to believe that race-based screening for prostate cancer - i.e., screening a man only because of the color of his skin - is the wrong approach.

Friday, June 17, 2022

Podcasting in medical education: a review and example

A recent scoping review in Academic Medicine examined the published literature on the use of podcasts in undergraduate (medical school) and graduate medical education (GME; residency). The researchers identified a total of 62 articles; 44 studies reported descriptive outcomes and 38 reported educational outcomes. The latter group assessed learner reaction and attitudes, knowledge retention, and behavior change; no studies reported on system change or patient outcomes. Medical podcasts appeared to communicate knowledge as well as traditional teaching methods; are valued by learners for their portability, efficiency, and entertainment value; and measurably improved skills in documentation and selected clinical practices.

If you are new to medical podcasts, you can check out some of my favorites or a family medicine-specific list compiled by residents and faculty at the University of Arizona College of Medicine Phoenix Family Medicine Residency Program, which produces the American Family Physician podcast.

During the 2018-2019 academic year, I created two episodes of a podcast for a first-year medical course in health policy as my project for an interdisciplinary Technology-Enhanced Learning (TEL) Colloquium for Georgetown faculty. Below is an excerpt from my final report describing the project.

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I created an audio podcast to provide an overview of the U.S. health system in spring 2019. The podcast episodes replaced a 90-minute lecture from the previous year, enabling better integration between the background health system content and two small group sessions during the same week on the patient-centered medical home and implications of the Affordable Care Act for patients and physicians.

During the TEL colloquium, I read about using podcasts for teaching in publications identified in PubMed and utilized resources on the Gelardin New Media Center website. Then, I became familiar with the recording and editing software program Audacity by viewing a tutorial on Lynda.com, accessed through the Georgetown University library. I posted finished podcast episodes on the P3 Canvas webpage and, through the podcast hosting service Libsyn, made them available on popular podcast directories, including Apple ITunes, Google Play, and Stitcher. I wanted to give students the option of listening to the podcast on their commutes or during workouts, rather than sitting at a desk or a library carrell.

Listening to and reflecting on the podcast episodes was not a stand-alone assignment, but instead incorporated into preparation for the small group sessions. I adjusted my teaching strategies in several ways. First, in the absence of a live audience, I switched to a less lecturing, more conversational tone of voice when recording. Although I posted a few key visuals (e.g., pie charts of insurance coverage types, percentages of national spending on various health services) from the previous year’s lecture slide set on Canvas for students to view during or after the podcast, most of the slides containing text simply weren’t necessary to reproduce. It was a little humbling to realize how much “slide reading” I must have been doing the year before.

My originally stated goal in joining the 2018 TEL Colloquium was to develop a blended learning project to “help me and course faculty engage in new and deeper ways with future [GUSOM] classes to better prepare them to be well-rounded physicians who are prepared to advance and advocate for their patients’ health outside of medical settings.” My two major objectives were to reduce course didactic time and to integrate online / asynchronous and in-person learning activities. I didn’t change my overall goal or specific objectives as the Colloquium progressed, but I did change the timing of the project in response to feedback from CNDLS faculty and peers. I originally envisioned the podcast beginning during the October intensive course week, continuing through the months in between, and concluding during the March course week. I fairly quickly realized that this timing was impractical, as students would not have time or motivation to listen to P3 podcasts while they were taking other courses with tests. So I instead decided to focus on the March course week, where the U.S. health system overview lecture was most amenable to being converted into a podcast because 1) I was the assigned lecturer; 2) the content had been identified by past students as being too much to digest in a single sitting.

Were students able to better absorb and engage with this material in a podcast versus a lecture? It’s hard to say for certain. Unfortunately, I did not think to add a specific question or questions about the podcast to the student course survey, and none of the free text comments from students thus far mentioned the podcast. Anecdotally, several students in my own small group of 10 said that they found the podcast to be informative and easy to digest, and course faculty e-mailed some encouraging comments about it:

“I definitely think you should write this up as an innovative way of teaching!”
“Your podcasts are excellent!
“I think it is so nice for them to get this info via a different medium than lectures or reading.”


I came into the TEL Colloquium with the prior experience of having blended learning (specifically, team-based learning exercises) not having gone particularly well in the past – a lot of time and effort invested, but mostly negative feedback. In contrast, the podcast was fun to create and seemed to have a positive, or at least neutral, effect on the faculty and student experience. Although I don’t have any specific plans to integrate podcasts into my other teaching roles, I certainly would consider doing so if an opportunity arises.

Monday, June 13, 2022

Supervised injection sites prevent overdose deaths, improve public safety

In a fortuitous alignment, the medical journals with the three largest print circulations (JAMA, American Family Physician, and The New England Journal of Medicine) each recently published editorials or features making the case for opening supervised sites for injection drug use in the United States as a form of harm reduction for patients with substance use disorders.

A news feature in JAMA observed that these sites come in many varieties depending on agency resources and patient needs: 

Supervised consumption sites can be as modest as a social service agency restroom stall, the door shortened at the bottom to make it easier to spot an unconscious person, or as expansive as Vancouver’s trailblazing Insite, which averaged 312 injection room visits per day in 2019 and offers detox rooms with private bathrooms, transitional housing for people in recovery, and other wraparound services.

In the U.S., a legal statue forbidding the operation of establishments where illicit drugs are consumed has generally forced these sites underground. Nonetheless, a research report on the outcomes an unsanctioned site located in an undisclosed U.S. city reported that over 5 years, 33 overdoses were successfully treated with naloxone administered by trained staff, with no patients requiring transfer to an outside medical institution. Advocates of supervised consumption sites argue that they do not "enable" substance use; rather, they relocate use that otherwise occur without medical supervision, often in public places, and prevent deaths from overdoses. The JAMA article quoted Sam Rivera, executive director of a nonprofit organization that operates two sites in New York City, as saying: “Every person who walks in has tried treatment and detox. We want them to be able to try again when they're ready, and in order to do that they have to be alive.”

An editorial in AFP by Drs. Jorge Finke and Jie Chan cited abundant evidence demonstrating that supervised injection sites improve health outcomes for persons who use illicit drugs and the surrounding community:

One study found a 26% net reduction in overdose deaths in the area surrounding a supervised injection site in Vancouver, Canada, compared with the rest of the city. A supervised injection site in Barcelona, Spain, was associated with a 50% reduction in overdose mortality from 1991 to 2008. People who inject drugs are significantly less likely to share needles if they regularly use supervised injection sites. ... Supervised injection sites can also reduce the number of publicly discarded syringes, and they improve public safety. ... One study in Vancouver, Canada, observed an abrupt, persistent decrease in crime after the opening of a supervised injection site.

In addition, modeling studies predict that opening supervised injection sites could be cost-saving "by preventing HIV, hepatitis C, hospitalizations for skin and soft-tissue infections, overdose deaths, ambulance calls, and emergency department visits and by increasing uptake of addiction treatment."

NEJM Perspective article asserted that the Biden administration should take action to "[make] it clear that the federal government won't stand in the way of organizations or state or local governments that want to establish overdose-prevention centers," given that the Department of Justice under the Trump administration asked courts to block the opening of a sanctioned site in Philadelphia in 2019. Arguably, Section 856 of the Controlled Substances Act (also known as the "crack house statute") was not intended to limit the operations of public health facilities, but continued legal ambiguity makes it difficult for state health officials to gain support for supervised injection sites. In a related NEJM Perspective, two clinicians at a primary care and buprenorphine clinic in Chicago emphasized that these sites are desperately needed to save people's lives:

We hand out naloxone, distribute cookers and syringes, and counsel our patients on safer injection practices — such as not injecting alone — but this work isn’t enough to keep them safe. In the clinic, we use a low-threshold model for prescribing buprenorphine to reduce harm and increase access to lifesaving medications for opioid use disorder, offering same-day buprenorphine initiation, van-based outreach, telehealth appointments, and recovery-support services. It still isn’t enough. Our patients continue to die in the largest numbers we’ve ever seen.

The largest numbers we’ve ever seen. The Centers of Disease Control and Prevention reported that in 2021, more than 107,000 people died of a drug overdose, a 15% increase over the previous record high in 2020 and "roughly one U.S. overdose death every 5 minutes." By publishing pieces that provide compelling rationales for opening supervised injection sites, the top three journals in medicine have made a statement that these effective public health interventions should be employed widely to reverse this terrible trend.

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This post first appeared on the AFP Community Blog.

Monday, June 6, 2022

Monkeypox: catching up with the next viral outbreak

The World Health Organization (WHO) has been tracking an outbreak of monkeypox in 27 non-endemic countries that, as of June 2, included at least 780 laboratory confirmed cases, including 17 confirmed cases in 9 U.S. states. This outbreak is highly unusual because many infected persons do not have a history of travel to an endemic country or contact with infected animals. During the only other large U.S. outbreak (involving 77 individuals) of monkeypox in 2003, patients contracted the virus through contact with infected prairie dogs purchased as pets; a case-control study found that case patients were more likely than controls to have cleaned cages and bedding of a sick animal or touched a sick animal. Although no patients died, 19 were hospitalized. In July 2021, monkeypox was diagnosed in a Dallas, Texas emergency department in a traveler returning from Nigeria. This patient was hospitalized for one month, and no secondary infections developed in any of the 223 identified U.S. contacts.

Monkeypox is a zoonotic double-stranded DNA poxvirus that causes clinical disease in humans that is similar to, but less severe than, smallpox. It is endemic to western and central Africa, particularly the Democratic Republic of Congo. The virus was originally isolated from a monkey in 1958, and the first human case was identified in 1970. African rodents are believed to be the virus's natural reservoir. Transmission occurs through contact with bodily fluids, skin or mucosal wounds, respiratory droplets, or contaminated objects. The usual incubation period is 7-14 days, and symptoms resolve within 14-21 days. Infected persons are considered to be contagious for one day before and 21 days after the onset of symptoms. 

Since routine smallpox vaccination ended in the U.S. in the 1970s, a large proportion of the population is susceptible to monkeypox infection. JYNNEOS, a live, nonreplicating vaccine that is recommended by the Advisory Committee on Immunization Practices for prevention of smallpox and monkeypox in persons at occupational risk aged 18 years or older, may be given for post-exposure prophylaxis within 4 days from the date of exposure to prevent disease and is preferred over the older smallpox vaccine (ACAM2000) due to a lower risk of adverse effects, though 100 million doses of the latter have been stockpiled in the event of a widespread bioterrorist attack.

Early reports from the current outbreak suggest that it has been causing minimal prodromal symptoms (fever, chills, lymphadenopathy) and that the rash is first appearing in patients' genital or perianal areas before progressing to the extremities, rather than more typically beginning in the mouth and face. Although monkeypox is not considered a sexually transmitted infection, many of the initial confirmed case patients are men who have sex with men. It remains unclear if, or to what extent, human-to-human transmission of monkeypox is occurring. "Given the current unfolding outbreak," advised two physicians from the Johns Hopkins Center for Health Security, "clinicians seeing patients with new onset of febrile illness and rash should consider monkeypox, especially if lymphadenopathy is also present."

Along with SARS-CoV-2, monkeypox is another example of the potential of increasingly frequent interactions between humans and wildlife to spread infectious diseases. As this latest viral outbreak continues to evolve, it underlines the importance of physicians and veterinarians taking a One Health approach to optimizing the health and well-being of humans and animals.

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This post first appeared on the AFP Community Blog.

Tuesday, May 31, 2022

Confronting the hidden toll of alcohol use disorders

Over the past two years, many of my patients have been drinking more alcohol than in the past, reflecting a troubling national response to COVID-19 pandemic-related stress. Two recently published studies assessed the increased death toll of unhealthy drinking habits. Alcohol-related deaths occur due to direct effects of alcohol on the body, such as alcoholic hepatitis (severe cases have a 16-30% mortality rate at 28 days and 56% at one year) or via indirect contributions to fatal traffic and nontraffic injuries (e.g., drowning, falls, aspiration, hypothermia, firearm injuries).

The first study used death certificate data from the National Center for Health Statistics to compare numbers and rates of alcohol-related deaths among individuals 16 years or older in 2019 and 2020. Both the absolute number and age-adjusted rate of deaths involving alcohol increased by about 25%, greater than the 16-18% increases in all-cause deaths and death rate during this period. The largest increases (37-40%) were observed in adults aged 25 to 44 years. A second study used data from the National Vital Statistics System to evaluate mortality trends in adults with the diagnosis of alcohol use disorder (AUD) before (2012-2019) and during (2020-2021) the pandemic. Similarly, deaths with AUD listed as a primary or contributing cause during 2020 and 2021 exceeded projected deaths based on pre-pandemic data by 25% and 22%, respectively, with the 25 to 44 year-old age group demonstrating the largest increases (40% and 34%).

For patients who survive alcoholic hepatitis and other alcohol-related life-threatening injuries, it is critical for physicians to offer evidence-based medical therapy for AUD, outlined in a 2020 American Family Physician article. Since the effects of risky drinking and AUD may not be clinically evident, the U.S. Preventive Services Task Force recommends screening and brief behavioral counseling interventions in adolescents and adults to reduce unhealthy alcohol use. Managing alcohol withdrawal syndrome and referring patients to Alcoholics Anonymous and other 12-step facilitation programs for AUD are also important mitigation strategies.

What about patients who have long been told that having a glass of wine with dinner is good for the heart? Setting aside the question of whether patients underestimate personal alcohol consumption, a large (n=371,463) United Kingdom cohort study recently challenged the theory that light alcohol use lowers cardiovascular risk. Investigators found that after adjustment for healthier lifestyles, light alcohol use (up to 1 drink per day) was associated with increased risk for hypertension and coronary artery disease compared to no use, and heavy use (more than 2 drinks per day) was associated with exponentially increasing cardiovascular risks.

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This post first appeared on the AFP Community Blog.

Tuesday, May 24, 2022

Making schools safe for students and staff during the pandemic

Since fall 2020, I have served as a medical and public health consultant for a private K-12 school system in the Washington, DC area. At that time, many schools were trying to figure out how to safely reopen for in-person instruction after having taught students online after the COVID-19 pandemic began with unacceptable results. With vaccines for adults and children still in development, schools were implementing a variety of interventions in the hope that some would mitigate viral spread: spacing students six feet apart, universal masking, temperature and symptom screening, regular testing, frequent sanitizing, improving ventilation, hybrid scheduling, cohorting, and quarantines. New studies appeared constantly, and it was my job to sift through the imperfect data to advise the best course of action in the context of changing community infection rates and parents who either felt that the school system wasn't doing enough to protect their children or was doing "too much" and unnecessarily restricting classroom or extracurricular activities.

When effective and safe vaccines became available, first for adults, then adolescents, then for children aged 5 or older, we strongly encouraged everyone to receive them, and I personally hosted virtual and in-person question and answer sessions for employees. The schools I advised required that students and staff wear masks until February 2022, after the vast majority had been vaccinated and boosted, if eligible. Given the increasing frequency of (mostly mild) infections in vaccinated persons and continued skepticism about the value of masks in preventing viral spread, though, I have continued to keep up with the literature on these topics. Two recent large observational studies are worth highlighting.

During the 2021-22 school year, schools could require that everyone wear masks (universal masking), that some grades wear masks or that masks be required at a community infection threshold (partial masking), or make masks optional. A study of more than 1 million students and 150,000 staff across 61 school districts in 9 states found a clear benefit of universal compared to optional masking: "Districts that optionally masked throughout the study period had 3.6 times the rate of secondary transmission as universally masked districts; and for every 100 community-acquired cases, universally masked districts had 7.3 predicted secondary infections, whereas optionally masked districts had 26.4." This finding was consistent with a prior study that compared COVID-19 incidence in school districts in Arkansas during the tail end of the delta wave (August-October 2021) and found that "districts with universal mask requirements had a 23% lower incidence of COVID-19 among staff members and students compared with districts without mask requirements."

Masks are not perfect, and some types of masks work better than others. But they do work!

An online survey of more than 1 million respondents living with school-aged children in all 50 states and Washington, DC examined the COVID-19 risk associated with in-person schooling during spring 2021, when most adults were vaccine-eligible but most students were not.  By June, about 75% of respondents had received at least one COVID-19 vaccine dose, a slightly higher proportion than the general population at that time. As expected, living in a household with a child in full-time in-person schooling was associated with an increased odds of experiencing COVID-19-like illness (adjusted odds ratio, 1.32). However, as the number of school-based mitigation measures increased, the risk decreased: "By May to June, risks of all COVID-19 related outcomes disappeared when four or more mitigation measures were reported." Among more than 116,000 teachers included in the survey, those who taught students in person had a higher risk of testing positive (aOR, 2.04) and losing one's taste or smell (aOR, 1.37). However, being vaccinated lowered this risk, to the point where "vaccinated teachers working outside the home were less likely to report COVID-19-related outcomes than unvaccinated teachers reporting no work outside the home."

Vaccines are not perfect, and they are more protective against some viral variants than others. But they do work!

We have reached the point where reinstituting community mask mandates is politically impossible in most parts of the U.S. and mandatory vaccination policies have limited by the courts to employees of the federal government (including active military) and health care organizations. Closing schools and businesses early in the pandemic did buy time to develop vaccines and antiviral drugs, but the societal and economic costs were devastating. By comparison, masks are uncomfortable and vaccines have rare adverse effects that are many orders of magnitude lower than the risks associated with COVID-19. Keeping schools open without facilitating community transmission will continue to remain a challenge as variants continue to evolve. It's been a humbling experience for me, as it has been for all professionals doing our best to protect the public's health.

Monday, May 16, 2022

Does advance care planning improve decision-making in serious illness?

Since 2008, April 16 has been designated National Healthcare Decisions Day, a day that "exists to inspire, educate and empower the public and providers about the importance of advance care planning," according to The Conversation Project. Advance care planning makes sense for everyone because despite modern medicine's best efforts to prolong life, death will eventually come for us all. And although most Americans imagine a "good death" as taking place at home, peacefully passing away surrounded by grieving loved ones, the reality is that acute clinical deterioration may be unpredictable; signs of the end of life are not always well defined; and challenging decisions about medical interventions may need to be made precisely when the patient is least capable of making them.

Most doctors receive little formal training in advance care planning. To the extent that I was aware of advance directives in medical school and residency, it was their relationship to the "DNR/DNI" (do not resuscitate, do not intubate) order that my attending physicians urged discussing with critically ill patients with little chance of survival if their hearts stopped beating or they required invasive respiratory support. And then, these directives often made little sense, as documents that expressed life sustaining treatment wishes at an earlier stage of life often conflicted with the patient's best interests as judged by their spouse or surrogate decision maker and the medical team. Indeed, it's possible that traditional advance directives can undermine advance care planning, since in the words of one older adult, "if you have it [the advance directive] in writing, you do not have to worry about it [having uncomfortable serious illness conversations]."

In a 2021 JAMA Viewpoint, three national palliative care leaders observed that our current model of advance care planning has failed to achieve its goals of promoting goal-concordant end-of-life care and reducing heroic end-of-life interventions with little or no value. Citing two reviews of more than 1600 research studies, they concluded that advance care planning had essentially no effect on health care use, quality of life, or the likelihood of patients receiving care consistent with their expressed goals and values. Noting the complicated series of steps that are essential to the success of advance care planning, they argue that trying harder and providing more incentives for patients and physicians to have serious illness conversations in advance of serious illness is unlikely to yield better results and may cause unintended consequences by causing health care organizations to neglect other areas of clinical care. Instead, they suggested that efforts focus on improving communication and shared decision making between clinicians and health care proxies / surrogate decision makers designated by patients to carry out their wishes at the end of life.

To be sure, not everyone agrees that advance care planning is broken beyond repair. Dr. J. Randall Curtis, a palliative care physician who was diagnosed last year with amyotrophic lateral sclerosis (ALS; "Lou Gehrig's disease"), wrote a related piece in JAMA that offered three personal examples of the process working as it should: his mother-in-law, his mother, and his own soon-to-be-fatal diagnosis. He admitted that these anecdotes do not "prove" the effectiveness of advance care planning or override the rigorous research performed by others in his field, but are "examples of the diverse ways that advance care planning can support resilience, understanding, feelings of peace, and recovery from grief even in circumstances where this advance care planning doesn't change the care received or other measurable outcomes." To those who debate whether advance care planning is inherently ineffective or could be made more effective, his view was that "both sides are right."

Unfortunately, like every sector of health care in the U.S., end-of-life care is inequitable. A recent editorial in American Family Physician discussed racial disparities at the end of life, noting that compared to white patients, "Black patients receive more aggressive and nonbeneficial medical care at the end of life," whether for terminal cancer, trauma, or accessing hospice and palliative care services. Ironically, one of the authors' proposed strategies to mitigate these disparities is "making advance care planning a standard for every adult patient." For some it is the problem, to others it is the solution. And relatively few doctors and patients are doing it, even though Medicare has paid clinicians for having this conversation since 2016. For me, the bottom line is that a static document that a patient can fill out and forget is unlikely to be useful in the future, while a prolonged series of discussions with trusted clinicians and family members - particularly one's spouse or life partner - may be more helpful in guiding end-of-life care, though there are no guarantees.

Tuesday, May 10, 2022

In patients with heart failure, a low-sodium diet does not improve outcomes

Anecdotally, a common contributor to acute exacerbations of chronic heart failure is having one or more high-sodium meals prior to the onset of symptoms. It seems reasonable, then, to recommend that patients with heart failure adhere to a low-sodium diet to reduce readmissions and mortality and improve quality of life. But until recently, there was limited evidence to support or refute this line of thinking. In a 2014 editorial, my colleague Barry Weiss, MD discussed several studies showing that a low-sodium (less than 1,800 mg per day) diet produced no benefits and increased the risk of death compared to a normal diet in heart failure patients in outpatient and inpatient settings. Consequently, he advised that "based on current evidence and until further studies are completed, patients with heart failure should probably be discouraged from reducing their sodium consumption to less than 2,300 mg per day."

Two subsequent systematic reviews of studies of dietary sodium restriction in heart failure also questioned the low-sodium diet dogma. A 2018 review of 9 randomized trials with 479 participants with heart failure found insufficient data on cardiovascular-associated and all-cause mortality, stroke, and myocardial infarction and conflicting evidence on changes in New York Heart Association functional class. Similarly, a 2021 systematic review and meta-analysis of 10 trials (1011 participants) found that low-sodium diets did not improve quality of life and possibly increased readmission rates and mortality. However, most trials included fewer to 100 participants, leaving open the possibility that a larger trial powered to detect differences in clinical outcomes could still show benefits.

Last month, the Study of Dietary Intervention under 100 mmol in Heart Failure (SODIUM-HF) trial, with 806 participants from 26 sites in Australia, Canada, Chile, Colombia, Mexico, and New Zealand reported its primary findings. All participants in this pragmatic randomized trial were receiving optimally tolerated guideline-directed medical treatment for chronic heart failure. Participants were randomly assigned to usual care or a low sodium diet of <100 mmol/day (<1,500 mg/day). The primary outcome was a composite of cardiovascular-related hospitalization, emergency department visit, and all-cause mortality within 12 months. Median sodium intake decreased in the low-sodium group from 2,286 mg to 1,658 mg/day and in the usual care group from 2,119 mg to 2,073 mg/day by the end of the trial. However, researchers found no statistical differences between the groups in the composite outcome or in each of the individual outcomes.

As Dr. Weiss cautioned in his editorial, "the possibility that aggressive sodium restriction may lead to unfavorable outcomes in patients with heart failure should not ... be misconstrued as meaning that we should lose our focus on reducing sodium intake in the general population." Indeed, there is good evidence that population-level interventions are effective in preventing cardiovascular disease, including a large Chinese randomized trial of a salt substitute that Dr. Jennifer Middleton discussed in a previous AFP Community Blog post. That's why recent guidance for industry from the U.S. Food and Drug Administration that aims to reduce the average American's daily sodium intake from 3,400 mg to 3,000 mg/day over the next few years could have a positive public health impact.

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This post first appeared on the AFP Community Blog.

Tuesday, April 26, 2022

How did family medicine fare in this year's National Resident Match?

Well into the fourth year of the America Needs More Family Doctors: 25 X 2030 Collaborative, Match Day 2022 brought some good news: the "largest class of [incoming family medicine] residents ever," according to the American Academy of Family Physicians (AAFP). As Dr. Clif Knight, then the AAFP's Senior Vice President for Education, wrote after the 2020 Match, it was uncertain how the COVID-19 pandemic would affect the number of fourth-year students who matched into family medicine residency programs, even as practicing family physicians were demonstrating their value to health care systems:

The increasingly prominent role of family physicians during the past few months highlights the versatility of family medicine training and competencies. Family physicians have flexed into inpatient, community outreach, and emergency coordination roles. ... The future for family physicians will be promising in the postpandemic era if the opportunities to appropriately reform primary care practice, regulation, and payment are enacted swiftly and with permanence.

A recent commentary in the New England Journal of Medicine pointed out that stable Match rates from year to year can obscure worrisome trends in the residency selection process. For example, the proportion of U.S. MD seniors who match to their top-ranked program has decreased steadily since the mid-2000s, while the proportion who match to their fourth choice or lower has increased. During this time, the number of applications submitted per applicant increased dramatically:

Between 2007 and 2020, ... the number of applications submitted per applicant doubled, with the average U.S. medical school graduate submitting 70 residency applications and the average IMG submitting 139 in 2020. The average internal medicine or general surgery residency program now receives more than 100 applications for every available position. As a consequence, programs interview and rank more applicants than they did in the past. Even though program fill rates are unchanged, there has been a steady increase in the number of applicants that programs must rank to fill each position, from 9.2 in 2002 to 15.4 in 2021. In other words, despite the stability in applicant match rates, program fill rates, and the ratio of PGY-1 positions to applicants, the residency-selection process has grown increasingly stressful, inefficient, and expensive as applicants have applied to more programs.

Delving deeper into the results of the 2022 Match reported by the AAFP provides ample reasons for pessimism. The number of U.S. MD seniors matching into Family Medicine fell from 1,623 in 2021 to 1,555 in 2022, representing only 8.4% of all matched U.S. MD seniors and at 31.5%, their lowest Family Medicine fill rate in history. (In contrast, the 30.3% fill rate of U.S. DO seniors was the highest ever, with 22.4% of all U.S. DO seniors matching to Family Medicine.) Overall, only 12.2% of U.S. medical school graduates will be entering family medicine residency programs in July, less than half of the specialty's 25% X 2030 goal.

In a critical analysis of the past four decades of Match results, Drs. Richard Young and Sophia Tinger observed that Family Medicine interest among U.S. MD graduates has stagnated for the past 10 years, and "there are no indications in the present environment (reimbursement by specialty, legislative mandates, new strategies to increase student interest in family medicine, the COVID-19 pandemic, or anything else) to suggest that the current trends will change over the next 9 years." Or to put it bluntly, "the 25 X 2030 Collaborative will almost certainly fail to reach its goal."

The consequences of an inadequate U.S. primary care workforce to the future health of all Americans could be dire. In a Graham Center Policy One-Pager in the April issue of American Family Physician, Dr. Yalda Jabbarpour and colleagues examined the association of the Community Health Index (CHI; "an average score of public health preparedness, primary care physician supply rates, and the social deprivation index (a proxy for community-level factors such as housing and transportation)") with county-level COVID-19 death rates before and after widespread vaccine availability. Counties with higher CHI scores had lower COVID-19 mortality rates overall, with the number of deaths per 100,000 individuals falling most drastically after vaccination in counties in the highest quintile of CHI scores.

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This post first appeared on the AFP Community Blog.

Wednesday, April 20, 2022

I'm taking my talents to Lancaster, Pennsylvania

When Common Sense Family Doctor was less than a year old and NBA superstar LeBron James and I were both a lot younger, LeBron made the unfortunate decision to announce his departure from the Cleveland Cavaliers for the Miami Heat in an ESPN television special where he told sportscaster Jim Gray, "I'm taking my talents to South Beach." LeBron eventually expressed regret for the way he handled "The Decision," not because it was the wrong one (he would go on to win two NBA championships with an all-star supporting cast in Miami), but because in not expressing his appreciation for all of the adulation and support he had received in Cleveland, he came off as a selfish, tone-deaf mercenary.

Although 10 million people won't be watching this particular announcement, I'm determined not to make the same mistake LeBron did.

I originally came to Georgetown's Department of Family Medicine in 2004 for a one-year medical editing fellowship, spent the next year as a part-time junior faculty member, then left to work at the Agency for Healthcare Research and Quality, where for four years I supported the U.S. Preventive Services Task Force in evaluating the evidence for a variety of screening tests that are well documented in this blog. After leaving AHRQ, I did a short but rewarding stint at an Urgent Care clinic before returning to Georgetown in 2012 to direct the department's health policy fellowship that would soon be named after former Robert Graham Center director (and current American Board of Family Medicine executive) Dr. Robert (Bob) Phillips, Jr. I had the opportunity to mentor several family and internal medicine physicians who have gone on to have impressive careers in clinical and policy settings: Dr. Laura Makaroff, Dr. John Parks, Dr. Melanie Raffoul, Dr. Tracey Henry, Dr. Yalda Jabbarpour, Dr. Julie Petersen, and Dr. Tyler Barreto.

In 2013, I began co-directing the course Patients, Populations, and Policy, which allowed me to teach health policy and advocacy to medical students. Thanks to fellow family physicians Dr. Yumi Jarris and Dr. Sarah Kureshi and extraordinary administrator Andrea Cammack, as well as Dr. Michael Stoto, Dr. Phil Nguyen, Dr. Susan Cheng, and the many other lecturers and small group faculty who enriched our students' experiences.

I've spent one afternoon a week for the past decade precepting family medicine residents at Fort Lincoln Family Medicine Center in Bladensburg, Maryland. The center and the residency transitioned from Providence to Medstar in 2019, but the high quality of the program and its patient care services remained the same. Thanks to past and present residency directors Dr. Pat Evans, Dr. Michelle Roett, Dr. Rachelle Toman, and Dr. Jamie Hill-Daniel, longtime faculty member Dr. Bill Gallagher and administrator April Wallace, and dozens of residents over the years for helping me to become the best preceptor I could be.

For the past decade, I've also had a fulfilling part-time family practice at Medstar Medical Group, with a group of wonderful family physicians and some of the best health care and administrative professionals in the DC area. As much as I will miss teaching and mentoring at Georgetown, I will miss my patients and colleagues at Spring Valley even more when I leave at the end of May.

So where am I going in June? Back to Lancaster, PA, where I completed my family medicine residency from 2001-2004 and where I will join the core faculty at one of the oldest and best respected training programs in the country. This blog shouldn't miss a beat, but I will need to change the tag line "from a family doctor in Washington, DC." As I'm looking forward to the next chapter in my career, I recognize everything that Georgetown has done to make me the family physician and educator that I am today.

Sunday, April 10, 2022

Curbing cascades and low-value care in children

In the March issue of American Family Physician, two editorials discussed different aspects of the problem of unnecessary health care services. In "Curbing Cascades of Care: What They Are and How to Stop Them," Dr. Ishani Ganguli, whose work in identifying low-value services I related in a previous post, presented the case of a healthy 30-year old man with a heart murmur detected at an annual wellness visit. The physician ordered an echocardiogram that suggested pulmonary hypertension, leading to a cardiology visit and a right heart catheterization which showed normal pressures. Of this "false alarm" and others like it, the author observed:

Such stories are viscerally familiar to most clinicians. This is a cascade of care: a seemingly unstoppable succession of medical services often initiated by an unnecessary test or unexpected result and driven by the desire to avoid even the slightest risk of missing a potentially life-threatening condition. ... Each step in a cascade seems to be a rational progression from the step before. Yet taken together, these cascades can cause substantial harm to patients, including procedural complications, out-of-pocket costs, psychological distress, and stigma from new diagnoses. Clinicians, especially those practicing in rural settings, report anxiety, frustration, and wasted time and effort.

Dr. Ganguli then discussed two health systems strategies to stop cascades of care: avoiding unnecessary services that may trigger cascades (though Choosing Wisely is often easier said than done) and mitigating cascades through providing better point-of-care guidance regarding management of incidentalomas and engaging patients in shared decision-making rather than assuming that they will always prefer more testing in the face of uncertainty.

In a second editorial, Dr. Kao-Ping Chua reviewed "The Importance and Challenges of Reducing Low-Value Care in Children," noting that use of unnecessary services in this population is widespread, harms children and their families, and is costly to families and the health care system. Commenting on a Lown Right Care article on the inappropriate use of an electrocardiogram (ECG) in a preparticipation sports examinations, Dr. Chua wrote:

Harms included the temporary exclusion from sports, the direct costs of ECGs and the cardiology visit, and the indirect costs to the family (e.g., costs of transportation to the cardiologist visit, missed school or work). The ECG may have also caused unnecessary emotional stress to the patient and family because it erroneously raised the possibility of a potentially life-threatening cardiac disorder.

On the other end of the age spectrum, a recent report in JAMA Network Open described the development of Evaluating Opportunities to Decrease Low-Value Prescribing (EVOLV-Rx), a tool for detecting 18 low-value prescribing practices in older adults based on scientific validity and clinical usefulness.

Ultimately, EVOLV-Rx, the KIDs List for potentially inappropriate medications in children, and other interventions to reduce low-value care should be evaluated on improvements in patient-oriented and/or reported outcomes (increased benefit, decreased harm, few unintended consequences) rather than reductions in services alone. A 2019 systematic review of more than 100 studies of such interventions found that clinically meaningful measures were often lacking. Nonetheless, individual clinicians can follow the suggestions of Drs. Ganguli and Chua to spend less time handling false alarms and more on concerns and conditions that matter to patients.

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This post first appeared on the AFP Community Blog.

Wednesday, March 30, 2022

How does the model minority myth harm Asian American aspirations and health?

The medical profession, including family medicine, benefits from having a racially and culturally diverse workforce. In my current practice, I care for a disproportionate number of older Chinese American patients even though I was born in the United States and know fewer than a dozen words of Mandarin. Yet my common heritage allows me to relate to these patients in ways that my non-Chinese colleagues cannot and improves their comfort and trust in my clinical recommendations.

In the mid-1990s, I applied for an 8-week summer laboratory research program at an Ivy League university that explicitly recruited college students from minority groups. Although I am a child of Chinese and Taiwanese immigrants, there was then, and is now, no shortage of Americans of east Asian descent in medical and other health care professions, including in my own extended family. I wondered if being a member of an "overrepresented" group would work against my being accepted to the program. As it turned out, it did not. Although the majority of my fellow students were African American or Latino, there were several other Asian Americans and even one white student. Looking back, the program was a great success, as most of us ended up becoming doctors. A few years ago, I began mentoring underrepresented in medicine (URM) college students in a similar program at my own institution.

Asian Americans are often mischaracterized as the "model minority" to contrast us with other non-white groups that have not achieved comparable economic success and health status on a population level. But lumping all Asian Americans together obscures the fact that many subgroups are actually URM. In a Letter to the Editor in Family Medicine, Dr. Oanh Truong highlighted the importance of data disaggregation to reveal these disparities:

When Asian American data are aggregated, the conclusions misleadingly suggest that Asian Americans as a singular population are thriving, perpetuating the harmful myth of Asian Americans being the model minority, where they are assumed to be doing better than other minority groups. ... However, data disaggregation would reveal that while Filipinos make up 18% of the nation’s Asian American population, they made up only 4.3% of the Asian American medical school applicants in 2019. Additionally, Laotians, Indonesians, and Cambodians altogether made up only 0.5% of the Asian American applicants.

The National Institutes of Health (NIH) highlighted "knowledge gaps, challenges, and opportunities in health and prevention research" for Asian Americans, Pacific Islanders (AAPI) and Native Hawaiians in a 2021 workshop whose proceedings were reported in the Annals of Internal Medicine. Although these groups collectively comprise nearly 8% of the U.S. population, the NIH spent just 0.17% of its budget on researching them between 1992 and 2018. The most telling figure in the report was a "heatmap" that illustrated the known prevalence of chronic health conditions in various AAPI subgroups compared to the U.S. white population. Some were lower, the same, or higher, but nearly half of the cells were blank, indicating insufficient data. We can't take action to reduce a health disparity if we don't even know if it exists.

Recent commentaries in Health Affairs and the Milbank Memorial Fund Blog expanded the argument that poor data quality combines with racial stereotypes to "fuel scientific and societal misperceptions that Asian Americans do not experience health disparities, [codifying] racist biases against the Asian American population in a mutually reinforcing cycle." According to the Milbank Fund, "one in four Pacific Islander adults report problems paying medical bills ... and there is wide variation in uninsurance rates across Asian American subgroups."

An article in press in Academic Medicine by a group of medical students and residents traces the history of discrimination and racism that AAPI have experienced from the 1882 Chinese Exclusion Act to the rise in anti-AAPI rhetoric and hate crimes since the start of the COVID-19 pandemic. The authors point out that discrimination is associated with underutilization of health care services and increased risk of chronic illnesses among non-elderly AAPI immigrants. They recommend that U.S. medical schools implement antiracist policies that recognize unconscious biases against AAPI patients, students, and faculty (e.g., the "bamboo ceiling") and "use disaggregated AAPI data so that the designation of [URM] is appropriately used to recruit diverse individuals who are collectively representative of the whole AAPI disapora."

Tuesday, March 15, 2022

Debating colorectal cancer screening recommendations: too young, too often?

Last year, the U.S. Preventive Services Task Force (USPSTF) updated its colorectal cancer screening recommendations, lowering the starting age for average-risk adults from 50 to 45 years; this change was reflected in the Putting Prevention Into Practice case study in American Family Physician's September 2021 issue. However, after reviewing the USPSTF statement and supporting documents, the American Academy of Family Physicians (AAFP) concluded that the evidence was insufficient to recommend a starting age younger than 50. Two editorials in the February issue of AFP outlined the arguments for and against starting routine screening at 45 years of age.

In the first editorial, Dr. Richard Wender argued that "lowering the starting age is a settled issue," noting that several organizations, including the American Cancer Society, the National Comprehensive Cancer Network, and the American College of Gastroenterology have all independently reviewed the data and come to the same conclusion as the USPSTF. He pointed out that "the incidence of colorectal cancer in 45 year-olds today is ... almost identical to the risk in 50-year-olds in 1979 when colorectal cancer screening was first recommended," and that nearly a quarter of deaths from colorectal cancer in the U.S. occur in individuals diagnosed between 45 and 54 years of age. Four microsimulation models have also concluded that starting screening at 45 years of age is the most efficient strategy to maximize life-years gained per colonoscopy regardless of the initial screening test used.

The second editorial, by Drs. Corey Lyon, Alexis Vosooney, and Melanie Bird, elaborated on the AAFP's position. The authors noted that "many of the trials used in the modeling studies did not include individuals younger than 50 years or did not provide separate data for this younger age group, decreasing confidence in the data inputs." They also expressed concern about costs to patients and the health care system from implementing the USPSTF recommendation as opposed to optimizing screening in patients age 50 years and older: "Expanding screening to up to 80% of eligible patients 50 to 75 years of age would prevent three times as many colon cancer deaths at one-third of the cost [of routinely screening Americans 45 to 49 years of age]." Finally, they argued that persistent disparities in colorectal cancer incidence and mortality in Black patients would be more appropriately addressed by improving insurance coverage and access to care in this population rather than lowering the age to start screening.

While colorectal cancer screening tests remain underused by many patients, studies have also documented that screening colonoscopies are sometimes performed more often than necessary - for example, being repeated 9 or fewer years after an initial high-quality colonoscopy showed no significant pathology, in contrast to the American Gastroenterological Association's Choosing Wisely recommendation. I co-authored a recent systematic review of 6 studies that estimated the rate of overuse of screening colonoscopy in U.S. populations found that it ranged from 17% to 25.7%. Overuse occurs when endoscopists recommend that patients have subsequent colonoscopies at intervals shorter than those supported by their own guidelines, and primary care physicians (PCPs) defer to subspecialists' recommendations. In an editorial, Drs. Archana Radhakrishnan and Craig Pollack acknowledged the obstacles that PCPs face in going against subspecialist advice but argued that they can still "play an important role in preventing overuse of colorectal cancer screening and surveillance colonoscopies" by directing referrals appropriately and communicating with endoscopists about their rationales for deviations from evidence-based practices.

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This post first appeared on the AFP Community Blog.

Monday, February 28, 2022

Benefits of COVID-19 vaccination in persons with past infection

Since the first COVID-19 vaccine received authorization for emergency use in December 2020, physicians and the public have vigorously debated whether infection-acquired ("natural") or vaccine-mediated immunity provides better protection against future infection and severe illness. The answer may never be known for certain, as it's hard to imagine a research ethics committee approving a trial that intentionally exposes immunologically naive people to a potentially lethal infection. A more important clinical question is: does getting vaccinated after recovery from COVID-19 provide additional benefits? Currently, the Centers for Disease Control and Prevention recommends routine vaccination in all persons aged 5 years or older, regardless of their history of past infection.

Two large cohort studies published earlier this month provided the strongest evidence to date that the answer is yes. The first study used electronic medical records from a health care organization covering more than half of the population of Israel to identify 149,000 patients age 16 years or older who had recovered from documented SARS-CoV-2 infection at least 100 days earlier and had not yet received COVID-19 vaccination as of March 1, 2021. 56% of these persons received at least one dose of BNT162b2 (Pfizer-BioNTech) vaccine by November 26, 2021. 2,168 of those who remained unvaccinated (3.3%) were reinfected during the study, compared to 354 of the vaccinated patients (0.4%). After adjustment for sociodemographic factors and coexisting illnesses, the estimated vaccine effectiveness was 82% for patients aged 64 years or younger and 60% for patients aged 65 years or older. A secondary analysis showed no difference in protection between one or two vaccine doses.

A second study in a highly vaccinated cohort of 35,768 health care workers in the United Kingdom tracked primary infections and reinfections between December 7, 2020 and September 21, 2021. Most participants received two doses of BNT162b2 (Pfizer-BioNTech) vaccine; 8% received the single-dose ChAdOx1 nCoV-19 vaccine (AstraZeneca). In previously uninfected participants who received the second dose of BNT162b2 six weeks or more after the first dose, adjusted vaccine effectiveness was 85% up to 73 days after the second dose but declined to 51% after 200 days. In comparison, adjusted effectiveness of the ChAdOx1 nCoV-19 vaccine was only 58% up to 73 days. In 6,169 participants who had COVID-19 prior to the study, long-term (>1 year) protection against re-infection was 69% in unvaccinated persons but remained high at 94% in persons who received one or two doses of BNT162b2.

Acknowledging some differences between the populations and the predominant variants circulating during the respective study periods, the results support the following conclusions. First, re-infection in unvaccinated persons is relatively uncommon during the first 9 months after a primary infection (1 in 30 in the Israeli study) but becomes more likely after 1 year (per the U.K. study). Similarly, the effectiveness of the initial two doses of BNT162b2 vaccine in preventing COVID-19 declines after 6-7 months, supporting booster doses. However, patients with past infections who subsequently receive one or two doses of BNT162b2 have sustained high levels of protection ("hybrid immunity") against re-infection for at least one year. In an editorial in The Guardian, Dr. Eric Topol recently argued that these and other data support re-defining "fully vaccinated" to include recovery from past infection plus a single dose of an mRNA vaccine.

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This post first appeared on the AFP Community Blog.