Tuesday, February 27, 2024

Birthday blessings

The following is a guest post from my sister-in-law, Dr. Therese Duane, a trauma surgeon who is blogging about her medical mission in Uganda. You can read more about the essential work she and her colleagues have been doing at Mercy Trips Healthcare Outreach.


As a little girl growing up in a big family, there were few things that I could actually call my own. Not only did I share a room, but for a long time my sisters and I even shared a twin bed. Going clothes shopping meant venturing into another sister’s closet for hand-me-downs, and toys belonged to whomever could run away fast enough without tripping and getting tackled by the rest of us. But there was one thing we could call our own, and that was our birthday—although I did share mine with an uncle and George Washington.

Still yet, in our home, my mother made an effort for each of her seven children to have a special birthday. I have fond recollections of sleepovers filled with giggles, scary movies, and not enough sleep that always culminated in Mickey Mouse pancakes my mother would prepare especially for me. I knew I was loved.

If someone had told me 40 years ago that I would have spent my birthdays in Uganda doing medical mission work, I am not sure I would have believed them. And yet, here I am turning 54 years old and instead of giggles with my girlfriends, I am getting chuckles from children who—despite being far from home undergoing painful procedures—still manage to share their smiles with strangers.

Caring for all these families, many of which are large, reminds me how the gift of family is universal. I see many women struggling with fertility with few options. One 42-year-old with only one child came to have her fibroids removed so she could carry another pregnancy to term, as she had previous miscarriages. Sadly, her evaluation demonstrated enormous tumors that were compressing her pelvic organs and causing significant pain. After explaining that her only option was removal of her uterus and more biological children weren’t possible regardless of surgery, I could see the devastation. She left clinic having been informed of the risks of delaying surgery and never returned, choosing instead to be in pain than accept the inevitable. Other women come in with many children, and want more, but need surgery for another complaint. Hence, fertility awareness education is incredibly important for this impoverished country so that couples can make healthy decisions for themselves as they cherish their gift of family.

So, as this birthday comes to a close, I have already been privileged to bring a baby boy into this world through a c-section for one patient and remove a diseased ovary of a different woman, preserving her other, healthy ovary in the hopes that this will help her future fertility. In Uganda, general surgery is certainly general as we provide a wide array of service to the best of our ability. We strive to ensure that the gift of family is embraced, preserved, and expanded based on God’s will and that every person knows they are loved.

Before I rest for the evening in preparation for another long day in the OR tomorrow, I will call my mother to thank her for the gift of my life and family. And as we reminisce about Micky Mouse pancakes, I will remind her that it was her example and that of my father’s that began this call for me. I see the same generosity of spirit in all my siblings and pray to set the right example for my four children just as my parents did for me.

Wednesday, February 21, 2024

Appreciation (the changing of the guard)

Originally posted on Common Sense Family Doctor on February 7, 2018.


The February 1, 2018 issue of American Family Physician marked the first time since 1988 that a family physician other than Dr. Jay Siwek was serving as the journal's editor-in-chief. Dr. Siwek, who bade farewell to readers in a poignant, memory-filled editorial in the January 15 issue, will stay on as editor emeritus. This month, Dr. Siwek introduced his successor, longtime associate editor Dr. Sumi Makkar Sexton. You can read about Dr. Sexton's extensive qualifications and experience in Dr. Siwek's latest piece and learn about her plans for the future of AFP, which include making journal content more usable at the point of care, in her introductory editorial.

It has been my good fortune to know Jay and Sumi for the past 20 years, since I arrived at Georgetown University School of Medicine as AFP's medical editing fellow in the summer of 2004. Both played critical roles in my development as a family physician and medical editor, during and after my one-year fellowship. It was Jay, in his previous capacity as Chair of Georgetown's Department of Family Medicine, who hired me as a junior faculty member and supported each of my subsequent promotions to assistant, associate, and full professor. After I left the department for several years to work as a medical officer at the Agency for Healthcare Research and Quality and earn a master's degree in public health, it was Jay who convinced me to return and deploy my new skills to direct the department's health policy fellowship and eventually take on other leadership and teaching positions in population health.

On the other hand, it was Sumi, as the editor of Tips from Other Journals (an AFP department that ended in 2013) who continued to hone my writing and evidence-based medicine skills for years after my fellowship ended. Under her supervision, from 2005 to 2010 I wrote more than 60 summaries of primary care-relevant research studies for AFP. And after my first post-fellowship clinical position unexpectedly fell through, it was Sumi who hired me to see patients at her thriving practice, Premier Primary Care Physicians, which was an early adopter of innovations such as electronic medical records and advanced-access scheduling.

As AFP's new deputy editor, I have worked closely with Sumi and Jay for the past several months to support their changing of the guard at editor-in-chief, and I look forward to many more years of collaborating with them both. Moving on from Dr. Siwek to Dr. Sexton is an important transition, but the best-read journal in primary care won't miss a beat.

Friday, February 16, 2024

Looking for a balanced approach to America's illicit drug use problem

In an earlier post about my frustrating experience serving on a District of Columbia grand jury that handled indictments for drug-related offenses, I wrote approvingly about Portugal's novel approach to decriminalizing illicit drug use. In short, rather than receiving criminal sentences and jail time, people caught using small amounts of drugs in Portugal receive citations and are offered counseling and medical treatment. Since then, the city of San Francisco and the state of Oregon have both implemented versions of Portugal's non-punitive approach, with mixed results.

A January 31 New York Times article compared Portugal to San Francisco, which saw its overdose death rate spike during the pandemic to more than twice the national average. Addiction treatment in San Francisco is fragmented and rarely accepted by people caught using drugs: "From May 30 [2023] to Jan. 4, just 25 people accepted treatment after an arrest, in a city where tens of thousands of people use drugs regularly." Harm reduction programs in San Francisco, unlike in Portugal, do not always push clients toward treatment. The culture of the California city is more libertarian than conservative Portugal, where drug use is discouraged and stigmatized. Finally, the drug response in San Francisco is not guided by a comprehensive strategy. The public health department and law enforcement agencies are divided on how much of the approach to recreational drug users should be carrots versus sticks, and other than reducing the overuse rate, the city has no clear goal.

A February 7 NPR story examined Portland, Oregon's experience with decriminalization of drug possession since a state ballot measure passed in November 2020: "So far, police have handed out more than 7,000 citations, but as of December, only a few hundred people had called the hotline to get assessed for a substance use disorder. And even fewer accessed treatment through the citation system." Opioid-related overdose deaths across the state rose from 280 in 2019 to 956 in 2022, though given the rise of fentanyl and homelessness and the impact of the pandemic on health care services, it's hard to know if the new approach contributed to the difference. The story quoted an addiction medicine physician arguing that the primary drivers of Oregon's rising overdose toll are "our decades-long, underbuilt system of behavioral health, substance abuse disorders, shelter and affordable housing" - not the decision to treat drug use as a medical problem rather than a crime.

The U.S. health care system is a culprit, too. Not only is a sizeable percentage of our population uninsured at any given time, people with drug use disorders are overrepresented in that group. And if you can afford to see a doctor, you can't necessarily find one willing to prescribe medications for opioid use disorder. My friend and fellow family physician, Dr. Corey Fogleman, recently co-authored a column in the Lancaster newspaper that observed how and why our county's outcomes have positively diverged from the rest of the state of Pennsylvania:

Lancaster County health care providers are unique in their willingness to provide buprenorphine treatment for opioid use disorder. Further, the Lancaster General Hospital Family Medicine Residency Program teaches this care to every medical student and medical resident educated in our system. Since 2016, Lancaster County has increased buprenorphine prescribing by 79% compared to a statewide average of 30%.

This has paved the way for crucial gains in fighting the opioid epidemic. Lancaster County has observed a notable and consistent downward trend in mortality due to this disease. Overdose deaths reached a peak in 2017, with more than 30 deaths per 100,000 residents that year. In 2022, per capita overdose deaths in Lancaster County dropped below 20 per 100,000 residents (106 total deaths). By comparison, Pennsylvania as a whole continues to observe a gradual upward trend in overdose fatalities, from 35 to more than 40 deaths per 100,000 residents during the same time frame (there were 5,155 total overdose deaths in the commonwealth in 2022).

It's true that local problems often require locally tailored solutions. Perhaps too much wishful thinking went into San Francisco's and Oregon's attempts to duplicate Portugal's successful approach to illicit drugs. On the other hand, Lancaster County has shown that it is possible to improve public health and save lives by engaging physicians and other health care professionals in overdose prevention efforts.

Sunday, February 11, 2024

Prenatal and congenital syphilis cases continue sharp rise in the U.S.

Last November, the Centers for Disease Control and Prevention (CDC) reported that cases of congenital syphilis in the U.S. had soared 755% over the past decade, peaking at more than 3,700 in 2022. The CDC’s review of that year’s cases revealed that nearly 90% were potentially preventable, resulting from a lack of timely testing and adequate treatment. An analysis of 2017-2019 Medicaid claims in 6 Southern states (Georgia, Kentucky, Louisiana, North Carolina, South Carolina, and Tennessee) found that despite state laws mandating prenatal syphilis screening, actual screening rates ranged from 56% to 91%.

In a previous blog post, I discussed how the diversion of public health personnel and resources during the COVID-19 pandemic had hampered contact tracing efforts to prevent the spread of syphilis and other sexually transmitted infections (STIs). Since June 2023, syphilis treatment has been affected by a global shortage of injectable benzathine penicillin, leading the CDC to advise prioritizing its use for infections in pregnant patients and babies with congenital syphilis (doxycycline can be used for infections in non-pregnant persons).

Although the U.S. Preventive Services Task Force recommends screening for syphilis in nonpregnant patients at increased risk so that persons testing positive can be treated to break the chain of infection, the number of syphilis cases in the U.S. continues to rise. The CDC’s latest Sexually Transmitted Infections Surveillance Report documented more than 207,000 cases in 2022 – a 17 percent increase over 2021 and the highest number reported since 1950. Few communities were spared; at least one case of congenital syphilis was reported in 47 states and the District of Columbia.

An editorial in the January 2024 issue of American Family Physician reviewed the management of STIs during pregnancy. At a minimum, all pregnant patients should receive screening for syphilis in the first trimester, with repeat screening recommended at 28 weeks and delivery for patients at high risk or living in high-prevalence communities. Clinicians should have a “low threshold of suspicion” for atypical presentations:

Although the classic syphilitic chancre is a single, sharply demarcated, painless ulcer, only 30% of patients have this presentation. Chancres may be hidden (e.g., in the cervix or rectum) or absent. Opt-out screening is essential because a large National Institutes of Health study found that 49% of pregnant women with syphilis from 2012 to 2016 had no identifiable risk factors.

A recent New England Journal of Medicine article reviewed the evaluation and management of neonates with congenital syphilis.

As my colleague Dr. Jennifer Middleton wrote, the CDC has proposed a novel prevention strategy called doxy-PEP (doxycycline preexposure prophylaxis for syphilis and other STIs) for cisgender men who have sex with men and transgender women who have sex with men with an STI diagnosis in the last year. Unfortunately, a recent trial of doxy-PEP in cisgender women in Kenya who were receiving HIV PrEP found no reduction in STI incidence, though participants’ overall adherence to doxycycline was low.


This post first appeared on the AFP Community Blog.

Wednesday, February 7, 2024

Research award recognition

I've written many papers for academic journals since my first article was published during my third year of my family medicine residency. My full-length CV that lists every one of them, which I update meticulously, now stretches to 18 pages in 11-point font. But the "Honors and Awards" section only takes up one-third of a page and includes three awards from residency. Until today, I would have said that the award I'm most proud of is the Article of the Year Award I received in 2009 from the Agency for Healthcare Research and Quality for my 2008 systematic review of the benefits and harms of PSA screening for prostate cancer. It launched my career in preventive medicine and guideline development and led to lots of invitations to speak and write other papers (like this one) on how to approach decision-making surrounding the PSA test in older men.

Today I learned that a recent systematic review that I co-authored on the harms of screening colonoscopy has won a major research award from the Society of Teachers of Family Medicine. I'm delighted, not only for the surprise recognition, but because earlier versions of this paper were rejected by several different gastroenterology and general internal medicine journals and panned by highly credentialed peer reviewers (who fervently believed that screening colonoscopy could only be a force for good) before it was finally accepted. It is testimony to the persistence of Dr. Alison Huffstetler and the rest of our team that the product of our many hours of slogging through the medical literature ever saw the light of day. Most importantly, I hope that this paper - like my prostate cancer paper in 2008 - makes a meaningful contribution to the conversations that family physicians and their patients have every day about the benefits and harms of cancer screening tests.