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.


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.


This post first appeared on the AFP Community Blog.