Blood pressure drug combinations, comparisons, and therapeutic intensity

Although blood pressure management is the bread and butter of family medicine, selecting antihypertensive medications is not always straightforward. A 2023 American Family Physician article on initial management of hypertension in adults recommended, “Initial antihypertensive treatment should include an angiotensin-converting enzyme (ACE) inhibitor, an angiotensin receptor blocker (ARB), a long-acting dihydropyridine calcium channel blocker, or a thiazide diuretic.” But how should one choose among drug classes and single vs combination therapy?

Compared with monotherapy, combination antihypertensive drugs have the advantage of reaching blood pressure goals quicker, with similar tolerability. Expert consensus suggests that initial combination therapy is preferred “in patients with systolic blood pressure higher than 160 mm Hg or greater than 20 mm Hg above goal, or with diastolic blood pressure higher than 100 mm Hg or greater than 10 mm Hg above goal.” A 2024 study of US adults taking two classes of antihypertensives found that patients on fixed-dose combinations were 1.78 times more likely to have controlled blood pressure than patients on two separate pills. In June 2025, the US Food and Drug Administration first approved a triple antihypertensive drug, a combination of telmisartan, amlodipine, and indapamide.

Specific antihypertensive classes are indicated for special populations (eg, patients with heart failure, chronic kidney disease, diabetes). A randomized trial of more than 11,000 patients with hypertension at high risk of cardiovascular events found that despite similar blood pressure control, benazepril plus amlodipine was superior to benazepril plus hydrochlorothiazide (number needed to treat [NNT] = 45 to prevent a composite cardiovascular end point over 36 months). In the general hypertensive population, a Cochrane review found that over 5 years, thiazide diuretics have small advantages over calcium channel blockers (NNT = 100 to prevent a cardiovascular event; NNT = 84 to prevent heart failure) and ACE inhibitors (NNT = 167 to prevent one stroke).

Although cholesterol-lowering drugs and doses are classified by intensity, until recently no similar schema was available for antihypertensive drugs. A systematic review and meta-analysis of 484 placebo-controlled trials classified the average systolic blood pressure-lowering effects of 57 monotherapies and 189 combinations as low (< 10 mm Hg), moderate (10-19.9 mm Hg), and high (> 20 mm Hg) intensity. Unsurprisingly, most monotherapies had low efficacy, whereas dual or triple therapies generally produced moderate or high effects. Clinicians can use an online calculator derived from the review to estimate the efficacy of any antihypertensive drug and dose combination depending on the patient’s baseline blood pressure.

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This post first appeared on the AFP Community Blog.

Recent and upcoming presentations and meetings

In September, I traveled to Oxford University for the international Preventing Overdiagnosis conference, where I presented on behalf of a research team that spent several years working to estimate the annual harms of screening colonoscopy overuse in the United States. We concluded that 2.1 million to 3.2 million low-value (unnecessary) screening colonoscopies are performed every year, leading to 9 to 12 thousand preventable cases of severe bleeding or bowel perforation.

Examination Schools, Oxford University

On October 20, I will deliver the cancer screening update lecture at the Temple University Fall Family Medicine Review course. For many years, this live course was delivered in person at a resort conference center in Lancaster, but the virtual format instituted during the pandemic proved so popular that it has continued so that family physicians and other primary care clinicians can join from anywhere in the world. Later that same day, I will lead a study session that allows American Board of Family Medicine Diplomates to complete the Health Counseling and Preventive Care Knowledge Self-Assessment. For readers who are interested, there is still time to register at https://medicine.temple.edu/cme

I've taught in this course since 2012.

Looking ahead, the week before Thanksgiving I will travel to Atlanta for the North American Primary Care Research Group (NAPCRG)'s annual meeting. Although I have never consciously defined myself as a researcher, many of my publications (including the colonoscopy overuse harms study mentioned above) can be classified as such. My relatively new role as the faculty member in charge of resident scholarly activity at the LGH Family Medicine Residency Program has me eager to learn from fellow educators about how to motivate learners to move beyond point-of-care references and artificial intelligence tools for answering clinical questions to designing an original research study or performance improvement project.

Correlation, causation, and Presidential pronouncements on health

The historical track record of major U.S. Presidential pronouncements on health is as abysmal as one might expect given their prior occupations (27 lawyers, zero physicians or medical researchers). In 1971, Richard Nixon famously declared a "war on cancer"; 54 years later, not only is cancer still very much with us, but the Trump administration is now waving the white flag and pulling back on research investments. In 2000, Bill Clinton announced the completion of the Human Genome Project, forecasting that sequencing the human genome would lead to all kinds of breakthroughs in preventing and treating genetic diseases. A quarter-century later, notable progress has been made on many conditions, but genomic insights have yet to transform medicine as initially promised. In 2016, Barack Obama launched the Cancer Moonshot as part of the 21st Century Cures Act, and after his Vice President, Joe Biden, ascended to the Presidency in 2021, he re-committed the U.S. to accelerating progress toward cancer cures. The jury is still out on this one, but the current Health and Human Services Secretary's blanket opposition to mRNA vaccines (including those for cancer) has stacked the deck against it.

So when President Donald Trump made a "major announcement" on autism at the White House earlier this week, the former real estate developer and reality TV show host was following in the ignominious footsteps of his predecessors who, to put it bluntly, should have stayed in their lane. Taking his cue from Robert F. Kennedy, Jr., who for years led a nonprofit organization that opposes routine childhood vaccinations, Trump blamed infant shots and acetaminophen (Tylenol) in pregnancy for the increased prevalence of autism diagnoses in the U.S. and around the world. Dismissing the pain and discomfort that often accompanies being pregnant, he implored women to "tough it out" rather than take a pain reliever that is considered by every major medical organization to be safe in pregnancy. (And yes, there absolutely are downsides to avoiding Tylenol, given the clearly established harms of alternatives for pain and fever.)

I wanted to simply dismiss what Trump said, but after two days of seeing patients and responses on my social media, it's clear that many people are taking him and RFK Jr. quite seriously. To explain why they (and perhaps you) shouldn't be concerned about your child's vaccines or taking Tylenol when needed, join the first-year medical student class in evidence-based medicine that I taught at Georgetown for many years. The question we would examine in our first meeting was: does radiation from cell phone use cause brain tumors? (TL;DR - although there isn't any way to prove without a doubt that cell phones don't cause cancer, most of the evidence suggests that the answer is no.)

But think like a researcher for a moment. How would you study this question? You could do what's called a case-control study and compare the cell phone use of persons with brain tumors to persons without them. (This type of study would have been easier to do in the days before cell phones were ubiquitous; I didn't purchase my first cell phone until 2002.) In addition to asking about ownership, you could ask people to recall how long they spent talking on the phone on average, and which side of their head they pressed it to their ear. (Again, easier to do in the days before hands-free earbuds.) But there's a big problem with this type of study: recall bias. Human beings have a tendency to come up with plausible explanations when bad things happen, and a brain tumor certainly qualifies as a bad thing. Just as a recently administered MMR vaccine is a convenient explanation for the subsequent diagnosis of autism, a cell phone is a convenient explanation for cancer.

So let's say you perform a better type of study, a cohort study where you compare two groups by a more objective measure of cell phone exposure: cell phone subscriptions and number of minutes used each month. Obviously this design poses complications as family and business cell phone plans may not reliably identify who was actually using the phone, even setting aside issues of privacy and phone companies allowing researchers to access granular data. But if you find an association between increased cell phone use and risk for brain tumors, you can feel more confident that it's a true correlation. Similarly, some studies have shown associations between Tylenol use and neurodevelopmental disorders, though others have not.

But it's a huge leap from showing correlation to proving causation. The latter requires systematically eliminating confounding factors that may affect both the exposure and the outcome. For example, perhaps the true correlation is that women carrying pregnancies with children who are genetically predisposed to develop autism are more likely to experience fever-causing infections or musculoskeletal pain. Naturally, they will be more likely to seek fever or pain relief from acetaminophen, making it appear - incorrectly - that exposure to acetaminophen caused the outcome. We do not know if this is happening, as the FDA made clear in its news release.

In the meantime, I am not going to change how I counsel patients about vaccines in childhood or Tylenol in pregnancy. These medications have clear benefits (preventing serious diseases and relieving fever and pain in pregnancy), and the burden of proof rests on proponents of hypothetical negative effects, including Trump and RFK Jr. Finally, I think it's unconscionable for the President to put a "I took Tylenol in pregnancy so maybe I gave my baby autism" guilt trip on mothers without ironclad proof of either correlation or causation.

Are cash benefits for families associated with positive childhood experiences?

In the U.S., state and federal governments employ vast bureaucracies that aim to ensure that only the "deserving" receive public assistance in the form of subsidized health care, food, and housing. 2025 has seen a near-complete reversal of the pandemic policy of keeping people on Medicaid by default; now, states will be required to not only confirm Medicaid eligibility every 6 months, but to verify that certain "able bodied" beneficiaries are enrolled in job training or working at least 80 hours per month. Never mind that Medicaid is only a health care benefit - you can't use it to pay the rent or feed your family - or that work requirements have been unequivocal failures in states that have tried implementing them in the past. The point of this cruel policy isn't to increase employment; it's to save money by removing people from health insurance rolls even if they are working.

What are the effects of financial insecurity on child health? A systematic review in AJPM Focus found that "financial strain was associated with poorer health and well-being and more behavior challenges among children of all ages, poorer academic performance among school-age children, and more depressive symptoms among adolescents." Adverse childhood experiences (ACEs) such as child neglect, abuse, and exposure to violence affect at least one in four American children and are associated with unhealthy behaviors and chronic diseases in adults. As one might expect, these experiences occur more often in neighborhoods with built-in disadvantages such as high concentrations of poverty, pollution, limited green-space, and poor access to healthy food sources. A medical approach to this problem would be to screen patients for ACEs and provide some sort of intervention to counteract the negative effects of childhood trauma. It's unclear if such an approach actually helps, though, and even if it does, the public health professional in me thinks there must be better ways to prevent ACEs in the first place.

A recent cross-sectional study in 4 states (Kansas, Montana, South Carolina, and Wisconsin) turned the concept of ACEs on its head and instead asked more than 20,000 adults if they had experienced one or more of the following positive childhood experiences (PCEs):

1. Adult made you feel safe and protected

2. Felt you belonged in high school

3. Felt supported by friends

4. At least 2 adults took an interest in you

5. Felt your family stood by you

6. Enjoyed community traditions

7. Felt able to talk to your family

Adults who reported higher numbers of PCEs were more likely to have attended postsecondary school, had greater household incomes, were less likely to smoke, and had fewer chronic medical conditions than those reporting lower numbers. So how can our society reduce exposure to ACEs and increase exposure to PCEs? An analysis in the Milbank Quarterly illustrated that state policies that improve economic security are associated with better mental health outcomes in children and adults. More bureaucracies, then? Hardly. Arguably the most effective social policy implemented during the pandemic was the temporary 2021 expansion of the Child Tax Credit, which effectively provided "a near universal, unconditional child cash benefit," reducing child poverty to historically low levels.

Closer to home, since 2022 Philadelphia has experimented with providing no-strings attached cash assistance to low-income families rather than making them wait for inadequate public housing or limited numbers of vouchers to become available. Families (households had to have at least one child under the age of 16) fortunate enough to receive monthly payments ranging from $15 to $2057 (with a median of $1000) have generally applied them toward rent. Not only were households who received cash less likely to be evicted or become homeless, they also had fewer concerns about the quality of their housing.

I attended a conference recently where a presenter half-facetiously, half-seriously, summed up all of the risk factors for developing a chronic health condition as "Don't Be Poor." Our historic societal response to poverty has been to create difficult-to-navigate welfare programs with ever-changing eligibility requirements that help poor people with health care and food and housing but basically force them to stay poor to keep receiving benefits. What if we cut through the red tape and just gave them cash instead? Would fewer ACEs and more PCEs occur, leading to better health for everyone in the long run? It's not the kind of research that the National Institutes for Health will fund any time soon - they're too busy trying to prove that vaccines cause autism - but it's definitely a question worth studying.

Courage and consequences at the CDC

In a recent presentation to preventive medicine residents at Johns Hopkins, I reflected on the painful circumstances that led to my resignation from the Agency for Healthcare Research and Quality (AHRQ) in November 2010. In short, political decision-makers well above my pay grade attempted to protect Democratic congressional majorities from blowback from an anticipated recommendation against prostate cancer screening by forcing the U.S. Preventive Services Task Force to cancel a scheduled meeting. Until this year, when Health and Human Services Secretary Robert F. Kennedy, Jr. cancelled the USPSTF's July meeting and expressed his intent to replace the entire panel, it was arguably the worst example in the Task Force's history of politics trumping science. (This time is worse - a LOT worse.)

Last week, the HHS Secretary fired recently confirmed Centers for Disease Control and Prevention (CDC) Director Susan Monarez over her unwillingness to “to rubber stamp [vaccine] recommendations that flew in the face of science.” In protest, three senior CDC officials simultaneously resigned. On his Inside Medicine Substack, Dr. Jeremy Faust posted the full text of the e-mails that Dr. Deb Houry, Dr. Demetre Daskalakis, and Dr. Daniel Jernigan sent to their colleagues announcing their respective resignations. Without question, these three doctors were far more critical to the day-to-day work of the CDC and HHS than I ever was or might have been at AHRQ. But their collective departure, like mine nearly 15 years ago, raises an important question: when a public servant who is also a health care professional witnesses the federal government taking immoral or profoundly troubling actions, is it more courageous to step down (and draw attention to how these actions endanger health) or to remain in place and continue to resist from the inside, hoping that eventually new leadership will restore the primacy of science and evidence-based medicine?

My red line was that the delay - which ended up being 17 months long - in ratifying the USPSTF's "D" recommendation against PSA-based prostate cancer screening would ultimately injure hundreds of thousands of patients who accepted screening without being aware of the Task Force's determination that it was more likely to cause them harm than good. My primary professional identity was and remains that of a family physician, and inherent in this identity is an obligation to provide patients with the best understanding of the science to help them make health decisions. Being told that I had to set this obligation aside because it might damage the electoral prospects of a Presidential administration and his political party was, in my view, unconscionable.

On the other hand, I admire my colleagues at AHRQ who chose to stay and sustain the USPSTF from the inside. A few still work there; others, unfortunately, were given pink slips by Elon Musk's Office of Government Efficiency when his group of twenty-something contractors couldn't figure out what the agency did that was important enough to warrant employing a few hundred scientists. No doubt the Task Force would have been much worse off if every member of its support staff had walked out with me on my last day and switched to careers in academic medicine. Leaving an impossible situation can be courageous, but staying on is, too. I salute Dr. Monarez and her departed senior leaders at CDC for their principled public resistance, but I also support the many staff who have remained despite RFK Jr.'s horrific interference with the agency's mission to protect the public's health.

Do pharmaceutical conflicts of interest compromise the AAP guideline on childhood obesity?

In January 2023, the American Academy of Pediatrics (AAP) published a clinical practice guideline on the evaluation and treatment of obesity in children and adolescents. Dr. Kathryn McKenna and I noted in an editorial in American Family Physician that the recommendation to consider prescribing weight loss drugs in adolescents 12 years and older was based primarily on short-term studies: “only 5 out of 27 randomized controlled trials [available to the AAP] included results beyond six months.” Although the percentage of US adolescents with obesity who were prescribed drugs rose modestly between 2018 and 2023, a recent study found that prescribing increased immediately after the guideline’s publication and every month thereafter through the end of 2024.

To be sure, the effects of nondrug interventions for obesity have been discouraging. A Cochrane review from 2020 found that combined dietary and physical activity interventions in adolescents 13 years and older did not lead to statistically significant changes to body mass index. Nonetheless, the US Preventive Services Task Force found insufficient evidence on the harms of long-term obesity medication use in children and decided to recommend only intensive behavioral interventions.

An analysis in the BMJ highlighted undisclosed financial conflicts of interest involving several authors of the AAP guideline and its accompanying technical report. Three guideline authors and one systematic review author received payments from pharmaceutical companies for consulting, travel, and other compensation between 2017 and 2023 ranging from $2,750 to $46,000; five other guideline authors received smaller amounts for meals and honoraria. From 2012 to 2024, 11 developers of glucagon-like peptide 1 (GLP-1) receptor agonist drugs made an estimated $1.9 to $2.6 million in corporate sponsorship payments to the AAP, including Novo Nordisk (semaglutide) and Eli Lilly (tirzepatide).

The AAP is hardly alone in permitting financial ties to drug companies. Other studies identified industry payments to the authors of the American Diabetes Association and the Infectious Diseases Society of America clinical practice guidelines, and 12 of 17 members of the 2023 board of directors and scientific committee of the Global Initiative for Asthma (GINA) received personal fees from AstraZeneca, which makes a brand-name inhaler used in the single maintenance and reliever therapy (SMART) treatment approach recommended by GINA guidelines.

Some would argue that the AAP guideline authors may have erred in not disclosing their pharmaceutical ties, but they would have likely come to the same conclusions about the effectiveness of GLP-1 receptor agonists and other weight loss drugs for adolescents. A counterpoint is that industry payments to individuals, regardless of amount, influence prescribing behavior and that those in a position to change the standard of care for children with obesity should refuse such payments. Finally, sound reasoning strongly supports that disclosing conflicts of interest is not enough to safeguard against bias in guidelines and other journal publications.

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This post first appeared on the AFP Community Blog.

Research supports moving away from race as a risk factor

In a 2021 American Family Physician editorial on the dangers of incorporating a patient’s race into medical decision-making, Dr. Bonzo Reddick observed, “Although we may hear about biologic or genetic differences between races, there is more variation within races than there is between them.” A recent landmark report from the National Institutes of Health’s All of Us Research Program compared self-identified race and ethnicity categories to continental and subcontinental genetic variation. Analyzing about 2 million common variants in the genomes of more than 230,000 unrelated participants, they found that “participants within self-identified race and ethnicity groups exhibit gradients of genetic variation rather than discrete clusters.”

Among White participants, 8% were found to have some South Asian ancestry, whereas smaller percentages had more than 50% African or Native American ancestry. Similarly, 1 in 100 self-identified Black participants had more than 50% European ancestry. The study also found notable regional differences in ancestry percentages among self-identified Black, Hispanic, and White participants. The researchers concluded that these gradients reflect “the historical impacts of US colonization, the transatlantic slave trade, and recent migrations” and “demonstrate that social constructs of race and ethnicity do not accurately reflect underlying genetic variation.”

Maternal race—specifically, Black race—is associated with increased risk for the development of preeclampsia. In its 2021 recommendation statement on aspirin to prevent preeclampsia and related morbidity and mortality, the US Preventive Services Task Force included Black race as a moderate risk factor, although it noted that it was a proxy for “environmental, social, and historical inequities, … not biological propensities.” However, a multicenter cohort study in JAMA Network Open found that Black race, similar to other moderate risks such as nulliparity, maternal age older than 35 years, and body mass index above 30, was not clearly associated with preeclampsia in the absence of a high risk factor (eg, chronic hypertension).

Finally, a narrative article in the New England Journal of Medicine traced the historical debate over race-based hemoglobin thresholds that began in the 1970s, when epidemiologic analyses showed that on average, Black children’s serum hemoglobin levels were 0.5 g/dL lower than those of White children. Did this disparity reflect inherent biological differences between races or differences in nutrition? Should it support race-based definitions of normal hemoglobin levels? Although some analyses accounting for socioeconomic status and diet no longer found significant racial differences, conflicting guidance from the Institute of Medicine (now the National Academy of Medicine) and the Centers for Disease Control and Prevention persisted into the early 2000s. Today, the World Health Organization, American Academy of Pediatrics, and American College of Obstetricians and Gynecologists all recommend against using race-adjusted cutoffs for diagnosing anemia.

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This post first appeared on the AFP Community Blog.

RFK Jr. is wrong about the US Preventive Services Task Force

Responding to President Trump's criticism of a federal judge who ruled against his asylum policy during his first term, Supreme Court Chief Justice John Roberts released this statement: "We do not have Obama judges or Trump judges, Bush judges or Clinton judges. What we have is an extraordinary group of dedicated judges doing their level best to do equal right to those appearing before them." I am not qualified to comment on how closely federal and Supreme Court justices adhere to the partisan positions of the Presidents who appointed them. However, I was reminded of this statement when, over the weekend, the Wall Street Journal and multiple other news outlets reported that HHS Secretary Robert F. Kennedy, Jr. was planning to fire all the members of the U.S. Preventive Services Task Force (USPSTF) because he considers them "too woke."

I worked for the USPSTF during the Bush and Obama administrations. The transition was seamless; the work went on as before. In the November 2009 uproar caused by the unfortunate timing of the USPSTF's release of a new statement recommending that routine mammography begin at age 50 rather than 40, then-HHS Secretary Kathleen Sebelius clumsily tried to throw the Task Force under the bus by observing (correctly) that all of its members were appointed during the Bush administration - but this completely missed the point that members were selected for scientific expertise, not political ideology. In that respect, the USPSTF has been similar to the ACIP prior to RFK Jr.'s recently replacing all of the latter's members for nakedly political reasons.

"Woke" is such an overused pejorative in conservative political circles that it has lost all meaning, but it seems that the current HHS Secretary is responding to the Task Force's recent efforts to ensure that their recommendations are implemented equitably across people of all races and ethnicities, despite geographic and economic disparities in access to primary care and other resources critical for ensuring health. For example, it's well-documented that eligible Black patients are less likely than others to be offered or undergo lung cancer screening, and that interventions are needed to close this unacceptable gap. This is about as uncontroversial an idea in health care as there is, but apparently it is too much for RFK Jr. More likely, it's merely an excuse to replace the current highly qualified members with his handpicked ideologues. In the words of a former USPSTF member (and my friend and academic collaborator) Russ Harris, MD, MPH:

It may seem excessive [for the USPSTF] to spend so much time and energy on reviewing the evidence for health issues. After all, aren’t people supposed to “do your own research.” I wish it were that easy. What “doing your own research” usually leads to is finding a biased source on the internet or from an “influencer” on social media that is happy to give you their answer. That answer is certainly simple, but often wrong. Such answers are often based on self-interest, or on an ideological agenda, not on a careful review of the relevant evidence.

Recent letters to RFK Jr. from the American Medical Association and 104 health organizations (including 6 of which I am a current or former member) have rightly pointed out that federal policymakers and health insurance plans rely on the USPSTF recommendations to provide coverage of effective preventive services (those rated "A" or "B" with at least moderate certainty of moderate net benefit) such as certain cancer screenings, depression screenings, and preventive services for cardiovascular disease. To tell the truth, I'm less worried about my patients losing access to these services than I am that replacing the current Task Force would result in a flood of signoffs on services where the evidence is insufficient to know if they work (e.g., multicancer screening tests) or tests that sound great intuitively but have been proven to not work, such as screening for asymptomatic carotid artery stenosis, which causes more strokes than it prevents but is nonetheless performed by lots of for-profit companies. The USPSTF is a bulwark in protecting Americans against ineffective or potentially harmful preventive health care, and if RFK Jr. follows through on firing the members of the current panel, that protection will almost certainly cease to exist.

Barrett esophagus and esophageal cancer: sometimes, less treatment is more

Affecting approximately 6% of persons older than 50 years, Barrett esophagus is a premalignant condition that increases the risk of developing esophageal cancer. However, the annual risk of progression to adenocarcinoma in the absence of high-grade dysplasia is low (0.12%-0.24%). Although expert consensus recommends endoscopic surveillance every 3 to 5 years in asymptomatic persons with Barrett esophagus, optimal intervals and the effectiveness of surveillance are not known.

A randomized controlled trial at 109 centers in the United Kingdom compared the outcomes of surveillance endoscopy every 2 years with “at need” endoscopy for symptoms only. In the trial, 3,453 participants with a recent diagnosis of Barrett esophagus with no or low-grade dysplasia were followed for a minimum of 10 years (mean 12.8 years). Symptoms that prompted endoscopy in the “at need” group included dysphagia, unexplained weight loss of more than 7 pounds, iron-deficiency anemia, recurrent vomiting, or worsening upper gastrointestinal symptoms. Within the participants, 93% of the surveillance group and 59% of the “at need” group received at least one endoscopy, with means of 3.5 and 1.4 endoscopies, respectively. Overall, 71 patients (2.1%) were diagnosed with esophageal cancer. There were no statistical differences in time to diagnosis of esophageal cancer, cancer stage at diagnosis, cancer-specific or overall survival.

Standard treatment for locally advanced esophageal cancer involves neoadjuvant chemoradiotherapy followed by esophagectomy. However, rates of serious postoperative complications (30%-50%), and in-hospital mortality (5%) are high. Active surveillance is a strategy to defer or avoid surgical complications in patients with a complete clinical response to chemoradiotherapy. A multicenter, cluster randomized, non-inferiority trial in 12 Dutch hospitals compared survival in 309 persons who received active surveillance vs esophagectomy within 2 weeks of chemoradiotherapy. Patients were eligible if they had no evidence of residual tumors on endoscopic biopsies, ultrasound, or PET-CT after chemoradiotherapy. After a median follow-up of 38 months, the intention-to-treat analysis found that a higher percentage of persons in the active surveillance group (75%) were alive than in the surgery group (70%). Those in the active surveillance group who underwent later surgery experienced similar postoperative complications as those who had standard surgery.

Although this study suggested that active surveillance may be a reasonable option for some with esophageal cancer, there are concerns about the durability of the findings beyond 2 years. A commentary on the study noted that the majority of patients do not have a complete response to chemoradiotherapy and would be ineligible for active surveillance. Surgeons outside of the trial also commented that the assessments for metastatic disease may not have been complete enough, resulting in many persons undergoing esophagectomy without benefit and reducing the apparent effectiveness of surgery.

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This post first appeared on the AFP Community Blog.

Health policy that is neither big nor beautiful

During my second and third years of residency (2002-2004), I periodically volunteered to see patients at a bare-bones clinic at a homeless shelter in Lancaster. We had limited amounts of donated supplies and medications and mostly treated acute problems. One evening, a patient with diabetes came in. He had been taking oral medications but could no longer afford them and was instead giving himself shots of insulin whenever he could afford a few vials. His hemoglobin A1c level was 15, meaning that he was walking around with an average blood sugar level of around 400 and was one mild illness away from a health catastrophe. I asked him to come see me in my faculty supervised clinic at the hospital and referred him to a social worker. Miraculously (in those pre-Affordable Care Act days, Medicaid eligibility was much less generous for single "able bodied" working adults without children), it turned out that he qualified for Medicaid. By the time I graduated, his diabetes, blood pressure, and cholesterol were well-controlled and he had saved enough money to move into his own apartment.

Like every major medical and hospital association in the United States, I lobbied against the budget reconciliation bill that squeaked through the House and Senate and that President Trump signed on July 4th. I send multiple e-mails to my representatives in Congress and encouraged others to do the same. The cuts to Medicaid and the USDA's Supplemental Nutrition Assistance Program (SNAP), totaling $1 trillion over the next several years, don't even come close to filling the $4.3 trillion budget hole created by extending tax cuts that overwhelmingly benefit people like Elon Musk, Jeff Bezos, and Trump himself.

When some health policy researchers got wind of the options being considered to reduce federal Medicaid spending, they published a timely analysis in the Annals of Internal Medicine that projected the impacts of various cuts on Medicaid enrollment and the uninsured. The bill then being considered by the House was estimated to reduce the number of people with Medicaid by more than 10 million and increase the number of uninsured persons by nearly 8 million (because some people would be able to obtain another form of insurance due to increased income or becoming eligible for workplace coverage).

These estimates were horrifying enough, but the Senate version of the bill - the one that President Trump signed on America's 249th birthday - cut even deeper. 11.8 million people are expected to become uninsured, and (outside of the bill, due to Congressional inaction) an additional 5 million will lose private marketplace coverage due to no longer being able to afford to pay the premiums.

Medicaid is just the tip of the iceberg. As a fellow Pennsylvania physician observed, Medicaid cuts will hurt all American children - not just those publicly insured, since pediatric hospitals and health systems rely heavily on Medicaid rather than the relatively more generous Medicare payments that fund adult health care. States will either try to stretch reduced Medicaid funds to cover the same number of people, lower payments to doctors and hospitals, or both. Hospitals will be forced to close, leading to mass layoffs and more people with few insurance options other than Medicaid. Similarly, SNAP cuts will hurt American farmers and grocery stores in underserved areas where people will have less to spend on food. The Commonwealth Fund estimates that by 2029, the bill's impacts will include 1.2 million jobs lost nationally, depressing collective state gross domestic products by $154 billion and state and local tax revenue by $12.2 billion.

By then, a new administration will have been inaugurated that will need to clean up one big, ugly mess that the federal government created.

AI: augmenting the intelligence of family physicians

In a recent editorial, Dr. Joel Selanikio discussed how 24/7 access to generative artificial intelligence (AI) tools such as ChatGPT empowers patients to retrieve health information and self-manage low-acuity conditions that would have previously involved visiting a clinician. By embracing the capabilities of AI to reduce administrative burdens and improve clinical outcomes, Dr. Selanikio argued that practices can demonstrate “the unique and irreplaceable value doctors bring to health care.” Another opinion envisioned the rise of “AI-augmented generalists” who integrate the knowledge base of subspecialists and use large language models (LLMs) as “active cognitive collaborators.” New competencies required for the AI era include “AI system proficiency,” “collaborative problem-solving,” and “contextual adaptation.” Recently published and ongoing research provides several real-world examples.

A 2025 Graham Center Policy One-Pager synthesized information from online peer forums and vendor websites to compare costs and pros and cons of commercially available AI scribes. A study funded by the Agency for Healthcare Research and Quality is interviewing primary care clinicians and patients to identify barriers and facilitators to successful adoption of ambient digital scribe technology and to develop a prototype implementation guide for diverse primary care settings.

In addition to office notes, LLMs can be used to generate hospital discharge summaries. A study from the University of California, San Francisco, evaluated the accuracy and quality of LLM-generated discharge summaries for 100 randomly selected inpatient stays of 3 to 6 days’ duration. A team of blinded reviewers that included hospitalists, primary care physicians, and skilled nursing facility (SNF) physicians rated LLM and physician-authored summaries on comprehensiveness, concision, coherence, and errors (inaccuracies, omissions, and hallucinations). Overall, LLM narratives contained more errors but were rated as more concise and coherent than physician-generated narratives. Of note, primary care and SNF physicians—the end-users of discharge summaries—had more favorable views of LLM narratives than did hospitalists.

AI is being evaluated for its potential to assist clinical decision-making. In a single-center study of virtual urgent care visits for respiratory, urinary, vaginal, eye, or dental symptoms, AI-generated recommendations agreed with physician recommendations in 57% of cases and were more likely to be rated as optimal:

Our observations suggest that AI showed particular strength in adhering to clinical guidelines, recommending appropriate laboratory and imaging tests, and recommending necessary in-person referrals. It outperformed physicians in avoiding unjustified empirical treatments. … Conversely, physicians excelled in adapting to evolving or inconsistent patient narratives, … [and] also seemed to demonstrate better judgment in avoiding unnecessary ED referrals.

However, the AI in this study reported that it had insufficient confidence to provide a recommendation in 21% of cases.

Finally, a randomized trial examined the diagnostic accuracy of 50 US-licensed physicians who responded to clinical questions about a standardized chest pain video vignette featuring either a White male or Black female patient before and after receiving input from ChatGPT-4. This study showed that physicians were willing to modify their initial decisions based on suggestions from ChatGPT and that these changes led to improved accuracy without introducing or exacerbating demographic biases (eg, being less likely to diagnose the Black female patient with acute coronary syndrome).

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This post first appeared on the AFP Community Blog.

On chronic disease prevention, RFK Jr.'s actions speak louder than words

Secretary of Health and Human Services Robert F. Kennedy, Jr.'s agenda, he says, is chronic disease prevention. He wants Americans to eat fewer ultra-processed foods; to decline long-established childhood vaccines against diseases like the measles, which we never see anymore; and to drink public water supplies without fluoride, apparently as a boon to the dental profession. HHS recently announced that it will spend $10-20 million on a "Take Back Your Health Campaign" that is intended to "alert Americans to the role of processed foods in fueling the diabetes epidemic and other chronic diseases, inspire people to take personal responsibility for their diets, and drive measurable improvements in diabetes prevention and national health outcomes."

Diabetes is a big problem. I'm all for preventing diabetes through healthier eating. But the longest-running longitudinal study of diabetes prevention, the Diabetes Prevention Program Outcomes study, was terminated in March when the Trump administration froze hundreds of millions of dollars in federal health grants to Columbia University, where the study coordinating center is located:

The lapse in funding means that the Diabetes Prevention Program Outcomes Study can no longer continue to collect patient data as planned; it can no longer pay staff to do blood work, collect urine samples, scan brains, or conduct neurocognitive tests. Even worse, the study’s existing data are at risk. Scientists need funds to properly store and retrieve samples; they need money to pay for computer servers and to hire statisticians and analysts, who clean and curate the data.

HHS has traditionally relied on panels of non-government experts to guide its work in prevention, and after the DOGE-driven cuts that resulted in the departure of 20 percent of its workforce, it needs outside help more than ever. For decades, five independent scientific advisory panels made evidence-based recommendations on clinical preventive services, community preventive services, newborn screening tests, infection prevention, and immunizations. Two of these panels have already been dissolved, and the remaining three are on life support.

I wrote a Medscape commentary about current threats to the U.S. Preventive Services Task Force (USPSTF), which include the hobbling and proposed elimination of its convening agency (AHRQ) and a lawsuit that the Supreme Court should decide any day now. The USPSTF's sister panel, the Community Preventive Services Task Force, which "evaluates evidence and recommends effective interventions to improve health in the community, home, school, work, and health care settings," hasn't been convened at all this year.

The Advisory Committee on Heritable Disorders in Newborns and Children (ACHDNC), which since 2003 had been making evidence-based recommendations about a list of conditions for which every newborn should be screened, was disbanded by HHS in April for no particular reason. As a result, states have been left on their own to evaluate new screening tests:

Each year, newborn screening identifies about 14,000 infants with serious conditions that benefit from early intervention. Early detection can prevent death or irreversible harm in disorders like metabolic diseases, immune deficiencies, and muscular atrophies. Eliminating the ACHDNC creates a dangerous vacuum in the nation’s newborn screening system, stalling progress on adding life-saving tests to the RUSP and increasing the risk that diagnoses will be delayed or missed for some babies—with potentially tragic results.

The same fate befell the Healthcare Infection Control Practices Advisory Committee (HICPAC), which was created in 1991 to advise the Centers for Disease Control and Prevention (CDC) on critical infection prevention and control practices. Over the past three-plus decades, HICPAC "advised and worked with the CDC to develop clinical guidelines, training resources, and expert guidance that were subsequently widely used throughout health care settings." Chronic diseases that can be prevented by reducing the risk of transmission in health care include HIV, hepatitis B and C, tuberculosis, and long COVID. HICPAC was dissolved by HHS at the end of March.

Finally, there is the Advisory Committee on Immunization Practices (ACIP), which RFK Jr. first bypassed by making unilateral changes to the COVID-19 vaccine recommendations for children and pregnant women, then remade by firing the entire committee and replacing them with a group that includes a physician who proudly identifies as an anti-vaxxer. This morning, 6 former chairs of the ACIP wrote an Op Ed in STAT that warns about millions of Americans losing access to safe, effective vaccines and the ability to develop new ones in response to future infectious threats:

Without transparent, evidence-based processes, vaccines may become inaccessible, unaffordable, or unavailable. Public trust will erode, innovation will stall, and lives will be lost unnecessarily. The systematic unraveling of our vaccine infrastructure endangers our freedom to protect ourselves and our communities. We urge congressional leaders to reflect on how these fragmented decisions collectively dismantle our ability to prevent disease and save lives.

Public health advocates frequently bemoan political obstacles to investing in evidence-based initiatives aimed at preventing chronic diseases. Today we have an HHS Secretary who is clearly interested in chronic disease prevention, but equally uninterested in evidence or established mechanisms for translating evidence into policy. As a former ACIP member recently told STAT, the message is clear: "Scientific expertise is no longer of use" unless it happens to align with what RFK Jr. already believes to be true. His terrible actions speak louder than words.

Pathways to primary care for underserved communities

Several past colleagues in the family medicine department at Georgetown recently published an informative scoping review of specialty disrespect in the medical learning environment. As they point out, specialty disrespect (also known as bad-mouthing) is common, based on "stereotypes, biases, and perceived specialty hierarchies," and play a significant, but not dominant, role in specialty choice. Although I don't recall experiencing overt disrespect when I told residents and attendings at my subspecialist-oriented medical school that I planned to practice primary care, unspoken assumptions about what I'd need to know as a family doctor sometimes led to my being assigned to patients with less challenging medical problems or greater social needs. Most family physicians have at some point heard the old saw "jack of all trades, master of none," which I have come to view as less insulting than is usually intended. (Wouldn't most people prefer to hire a single handyman to make several miscellaneous home repairs rather than a bunch of specialists in each area?)

A research study in Health Affairs charts "physicians' trajectories from medical school graduation through postgraduate training into primary care specialties" for MD, DO, and international medical graduates from 2001-15. The authors term "primary care yield" as the percentage of physicians who start training in primary care and complete it in primary care. So, a family physician who does a geriatric fellowship would count as positive primary care yield, while a physician who starts training in internal medicine and ends up a gastroenterologist would not. Unsurprisingly, they find that 97% of physicians who enter family medicine residency programs become primary care physicians, while the corresponding figures for internal medicine and pediatrics are 35.5% and 54.4%. Schools with primary care pathway programs that send a majority of students into non-family medicine residencies may not be creating future primary care physicians.

It's well documented that schools that are ranked highly by U.S. News & World Report produce a lot of subspecialists, while schools ranked highly by social mission graduate relatively more primary care physicians. A research letter in JAMA Network Open reported that in 2015 and 2020, graduates of U.S. News's top 20 medical schools were less than half as likely to be practicing in socioeconomically deprived areas compared to other medical graduates, and among physicians, family and emergency medicine were the most likely to practice in these areas. 

At the residency level, federal investments in rural and federally qualified health center (FQHC)-based programs have resulted in significant training expansions in underserved settings. Another Health Affairs study documented that the percentages of residency programs with rural and FQHC training sites rose from 6.2% and 3.6%, respectively, in 2008-09 to 14.3% and 11.2% in 2023-24. Training health professionals in FQHCs is essential to staffing those FQHCs and improving community health in the future; when community health centers close, county-level mortality increases, as illustrated in another study. Of note, the Trump administration's HHS reorganization plan and the "one big, beautiful bill" passed by the House of Representatives would eliminate the agency that funds, and most of the funding for, these training programs.

Health professionals speak out against the new nuclear arms race

During the Cold War, the United States and the former Soviet Union amassed nuclear weapon stockpiles with a collective destructive power hundreds of thousands of times that of the two bombs that obliterated the Japanese cities of Hiroshima and Nagasaki in August 1945. After peaking at more than 70,000 in 1986, the absolute number of weapons gradually declined from the implementation of various arms control treaties to 12,331 today. However, as stated plainly in a recent editorial published in more than 120 medical journals worldwide, “This does not mean humanity is any safer.” The authors urged readers to make the elimination of nuclear weapons an urgent public health priority, reiterating a 2023 editorial on similar themes:

Any use of nuclear weapons would be catastrophic for humanity. Even a “limited” nuclear war involving only 250 of the 13,000 nuclear weapons in the world could kill 120 million people outright and cause global climate disruption leading to a nuclear famine, putting 2 billion people at risk. A large-scale nuclear war between the US and Russia could kill 200 million people or more in the near term, and potentially cause a global “nuclear winter” that could kill 5 to 6 billion people, threatening the survival of humanity.

The last of the nuclear arms accords, the New START treaty between the United States and the Russian Federation, is set to expire in 2026. Both countries are spending enormous amounts to modernize their existing arsenals. A 2024 editorial in Science, noting rising tensions between the United States and Russia, China, and North Korea, observed that “the risk of nuclear war has not been so high since the Cuban Missile Crisis.” The historical events depicted in the Academy Award–winning film Oppenheimer are no longer just history; at New Mexico’s Los Alamos National Laboratory, for the first time in decades, the United States has resumed building plutonium cores. Despite safety precautions, factory workers and bystanders will be at high risk of radiation exposure and subsequent cancer, lung, and kidney problems.

The world is woefully unprepared for the health consequences of the use of a single nuclear device, much less a nuclear war. In 2024, the New York City Department of Health held a series of workshops on hospital emergency responses to an improvised nuclear detonation by a nonstate terrorist actor. Health professionals who survive a nuclear explosion (90% of those in Hiroshima were killed instantly) would likely face a catastrophic loss of communications, impassable transportation routes, and “risk their lives amid destroyed infrastructure, dangerous radioactivity, and limited healthcare facilities and supplies.”

At last month’s World Health Assembly, the World Health Organization (WHO) overwhelmingly passed a resolution to update Cold War era reports on the health and environmental effects of nuclear weapons and war by 2029. (The United States was absent, having withdrawn from the WHO in January.) Doctors have been at the forefront of campaigns against nuclear weapons since 1961, when Physicians for Social Responsibility was founded. The organization, which later expanded its list of “gravest threats to health and survival” to include excessive military spending, fossil fuels, and climate change, provides education on the health effects of nuclear testing and reality checks on government messages (eg, duck and cover) that suggest that nuclear war could be survivable. A current exhibit at Harvard University’s Countway Library highlights the social activism of former medical school and public health faculty.

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This post first appeared on the AFP Community Blog.

Lung cancer screening in primary care: more pragmatic research needed

The US Preventive Services Task Force, the American Academy of Family Physicians, and the American College of Chest Physicians recommend annual low-dose computed tomography (CT) screening for adults 50 to 80 years of age who have at least a 20 pack-year smoking history and currently smoke or have smoked within the past 15 years. A 2020 meta-analysis of eight randomized controlled trials (summarized in a POEM in American Family Physician) concluded that low-dose CT screening prevents one lung cancer death for every 250 people screened. A 2023 Cochrane for Clinicians article found similar benefits but also noted that for every 10,000 people screened, 363 unnecessary invasive tests are performed. Despite private and public insurance plans fully covering lung cancer screening in the United States, only 10% to 30% of eligible individuals in were receiving it in a recent state-by-state survey.

Barriers to implementing findings from lung cancer screening trials into typical clinical practice include the nonrepresentative nature of research participants (younger, healthier, and less racially and geographically diverse than the target populations) and the superior infrastructure and clinical support available to them. Although an analysis of the National Lung Screening Trial suggested that the eligible people in the United States would experience similar benefits as trial participants, questions about the generalizability of other studies remain.

In a research paper in the January/February 2025 issue of the Journal of the American Board of Family Medicine, Dr. Erin Hirsch and colleagues rated lung cancer screening trials and the nonrandomized Veterans Health Administration Demonstration Project with an established tool that evaluated each study through a primary care lens. Domains included eligibility, recruitment, setting, organization, flexibility of delivery, flexibility of adherence, follow-up, primary outcome, and primary analysis. The investigators scored studies on a 5-point scale, with 1 being completely explanatory and 5 being completely pragmatic. The mean study scores ranged from 2.12 to 3.33, indicating that even the most pragmatic studies fell well short of simulating conditions in community settings.

A lack of pragmatic research may explain why interventions intended to increase lung cancer screening rates have had mostly disappointing results. A systematic review and meta-analysis of intervention studies identified five randomized controlled trials and one prospective observational study. Interventions included patient navigation, outreach calls, and decision aids; control groups received usual care or informational materials. Only two of the studies found statistically significant increases in participation in the intervention group, and a meta-analysis found no difference overall (relative risk = 1.30; 95% CI, 0.74-2.29). A subgroup analysis suggested that multistep interventions targeting multiple barriers may be more effective than single-step ones.

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This post first appeared on the AFP Community Blog.

Food for thought on food as medicine

This month, President Trump nominated Dr. Casey Means, a former ear, nose, and throat surgeon who dropped out of residency and reinvented herself as a wellness influencer and New York Times bestselling author, for Surgeon General. I read Means's book, "Good Energy: The Surprising Connection Between Metabolism and Limitless Health," a few months ago. It discourages intake of processed foods, eschews fad diets, aligns with mainstream nutrition guidance (e.g., Michael Pollan's pithy "eat [real] food, not too much, mostly plants"), and has received positive reviews in publications ranging from NPR to Family Medicine.

My main concern about the book is that it seems aimed mostly at well-off households with the health literacy and leisure time to read self-help books and the disposable income to do most of their shopping at farmer's markets and Whole Foods stores. If Dr. Means ends up being confirmed by the Senate, she should consider writing a sequel ("Great Energy"? "Good Energy for the Budget-Conscious"?) for the 11 million families headed by single parents who often work two or more jobs to get by and have fewer options for buying groceries. For these families, the healthiness of food may not be their top priority. A Pew Research Center survey found that overall, Americans ranked taste as the most important factor in choosing food, followed by cost, then healthiness and convenience. So it isn't enough to tell people what foods are best for their health (or make labels on packaged foods simpler to understand); we also need to make the healthy option the default option.

There is good evidence that federal nutrition programs such as the Supplemental Nutrition Assistance Program (SNAP, previously known as "food stamps") and Special Supplemental Nutritional Program for Women, Infants, and Children (WIC) improve health. A Research Letter in JAMA documented increases in food insecurity and days with poor physical health after the end of a temporary pandemic increase to SNAP benefits in March 2023. An Agency for Healthcare Research and Quality evidence synthesis that I previously discussed showed that WIC improves important maternal and child health outcomes. Conversely, a longer-term study suggests that food insecurity in childhood increases cardiovascular risk and obesity in young adulthood, since one is more likely to eat excess food of poor nutritional value if they don't know where their next meal is coming from.

Although I support banning soda purchases from SNAP, eliminating food insecurity by making the program more generous could have an equally beneficial an effect on health. Currently, a four-person household in Pennsylvania must earn less than $62,000 per year to be eligible for SNAP, and the average benefit is $6 per day, or $42 per week. A national program that provided low-income adults with additional vouchers averaging $63 per month for produce purchases (the majority of households were already enrolled in SNAP and/or WIC) led to improvements in food security, diabetes control, weight loss, and blood pressure.

In a recent statement, the U.S. Preventive Services Task Force found insufficient evidence to assess the benefits and harms of screening for food insecurity in health care settings. That doesn't mean that targeted "food as medicine" programs, which should be "understood as complementing and not supplanting existing food and nutrition assistance programs," can't be effective. Ten states have piloted Medicaid managed care projects to address poor nutrition as a health-related social need and use health care dollars to pay for food pharmacies, healthy food vouchers, and medically tailored meals. 

It's worth noting, though, that these promising programs are likely to be defunded if the nearly $1 trillion in Medicaid and SNAP cuts in the recent federal budget bill passed on a party-line vote by the House of Representatives eventually becomes law. Either way, I will continue giving to our local food bank, as the prescription for food insecurity is food, and hungry patients do not make healthy patients.

Fecal immunochemical testing for colorectal cancer is effective and cost-effective

The U.S. is one of only a few countries in the world that relies on colonoscopy as a primary method of screening for colorectal cancer (rather than reserving it for the evaluation of people who test positive on stool-based screenings). I recently wrote a commentary in Medscape about new evidence that supports a continued role for fecal immunochemical testing (FIT) as a colorectal cancer screening test. My article concluded:

When reviewing colorectal cancer screening test choices with patients, family physicians can continue to recommend annual or biennial FIT as a comparable option to colonoscopy. If FIT is selected, we should provide a kit with liquid vial sample collection, if possible, and include a suggested return date in patient instructions. Finally, clinicians in leadership and population health management roles should advocate for cost-effective investments in patient navigation to enhance colorectal cancer screening and diagnostic colonoscopy completion rates, because these initiatives play a crucial role in preventing colorectal cancer deaths.

Exact Sciences, which sells a $600 stool-based screening test that combines FIT with a test for colorectal cancer DNA, would like physicians and patients to believe that its test ("Cologuard") provides superior value to practices and health systems than FIT alone. But an analysis published this week in the Annals of Internal Medicine indicates that it does not. Using data from the original Cologuard diagnostic performance study and a study of a second-generation version (Cologuard Plus), Dr. Hermann Brenner and colleagues at Heidelberg University in German showed that the cost per colorectal cancer detected is 7- to 9-fold higher for Cologuard and Cologuard Plus compared to FIT, depending on what percentage of patients undergo colonoscopy after a positive test result.

Identifying and managing gambling-related harms

The Supreme Court under Chief Justice John Roberts (the Roberts Court) has made several high-profile rulings affecting health care over the past two decades, including its 2012 decision that upheld the Affordable Care Act’s Medicaid expansion but made it optional for states and its 2022 decision that abortion was not a fundamental right protected by the US Constitution.

A less heralded ruling with health implications occurred in 2018, when the Roberts Court held that a prior federal law forbidding states to legalize sports betting was unconstitutional. This decision led to the rapid proliferation of online sports gambling platforms and their ubiquitous television advertisements. No longer do people need to travel to brick and mortar casinos to place bets on players or teams; now they can legally win and lose large sums through a variety of smartphone apps. 68 million Americans, or one in four adults, planned to wager an estimated $15.5 billion on the NCAA Division I basketball tournaments (March Madness) this year.

Expanded access to sports gambling has fueled a rise in the number of people affected by gambling disorder. Previously known as pathologic gambling, gambling disorder manifests as “impaired control over gambling, gambling taking precedence over other life interests, and the continuation or escalation of gambling despite negative consequences.” Young males are the demographic group most likely to have gambling disorder, and comorbid alcohol use disorder and depression are common. Although prevalence estimates in North America are low (1.5% of women, 2.7% of men), hazardous gambling—risky or compulsive gambling behavior that does not meet criteria for gambling disorder—is thought to be far more common, particularly in older adults with more leisure time.

A recent article in the BMJ summarized a National Institute for Health and Care Excellence (NICE) guideline on identification and management of gambling-related harms. Based on expert opinion and low-certainty evidence, NICE recommends that clinicians ask direct questions about gambling in patients with mental health concerns, alcohol or substance use disorders, housing or financial insecurity, justice involvement, and certain higher-risk professions (eg, active-duty military, veterans, sports professionals, people working in the gambling or financial industries). People with gambling disorder are at increased risk for self-harm and suicide attempts. Effective treatments include referral to self-help groups such as Gamblers Anonymous, group or individual cognitive behavioral therapy, motivational interviewing, and naltrexone. Psychology Today maintains a national directory of therapists with training in CBT for gambling disorder.

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This post first appeared on the AFP Community Blog.

Migraine headaches: diagnostic and treatment tips

A patient with a history of headaches is brought by ambulance to the emergency department for the abrupt onset of weakness and decreased sensation in their left arm and leg. A code stroke is called. Are these symptoms of an acute stroke or a stroke mimic, such as a hemiplegic migraine?

A retrospective analysis of characteristics of 15 consecutive years of code stroke cases at a hospital in Barcelona, Spain, found that patients who were ultimately diagnosed with migraine headache with aura (1.1%) were more likely to be younger, female, and have fewer vascular risk factors than patients with ischemic strokes. In addition, an initial NIH Stroke Scale of greater than 6 (odds ratio = 3.74) and a fibrinogen level of greater than 400 mg/dL (odds ratio = 2.98) distinguished strokes from migraine headaches.

An article on acute migraine headaches in the April 2025 issue of American Family Physician reviewed current treatment strategies for acute migraine headaches, which “account for … 3.6 million primary care visits annually and are the fifth most common reason for emergency department visits” in the United States. The POUND mnemonic (ie, pulsatile quality, one-day duration, unilateral headache, nausea or vomiting, disabling intensity) can help clinicians make the diagnosis of migraine in primary care, and the Migraine Disability Assessment (MIDAS) quantifies headache severity. Scores that indicate MIDAS grades III and IV should prompt clinicians to consider targeted migraine medications rather than simple analgesics.

Although several drug classes are effective for acute migraine, a 2024 systematic review and network meta-analysis of 137 randomized controlled trials (summarized in a POEM in the April 2025 issue of AFP) found that triptans produced greater pain relief at 2 hours and less use of rescue drugs in the first 2 to 24 hours than the newer and more expensive medications ubrogepant, rimegepant, and lasmiditan.

Clinical practice guidelines on the management of episodic migraine headache, including the 2023 US Veterans Affairs/Department of Defense guideline, preferentially recommend triptans for most patients. In March, the American College of Physicians released a pharmacologic treatment guideline that recommends adding a triptan in nonpregnant adults with moderate to severe migraines who have not responded to a nonsteroidal anti-inflammatory drug or acetaminophen. Triptans can cause vasospasm, so they are contraindicated in patients with coronary artery disease, cardiovascular disease, and peripheral artery disease and should not be used in combination with ergot alkaloids.

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This post first appeared on the AFP Community Blog.

For family medicine workforce, HHS reorganization plan receives a failing grade

Match Day on March 21, 2025 unfolded similarly to the National Resident Matching Program in previous years. My program successfully recruited a full class of 13 future interns from medical schools across the country, but family medicine as a whole, despite the typically rosy American Academy of Family Physicians news story, didn't even come close, with 15% of slots unfilled and a quarter of programs needing to enter the Supplemental Offer and Acceptance Program (SOAP, previously known as the "Scramble"). The sub-headline from a Medscape news article said it all: "Anesthesiology Still Hot, Family Medicine Is Not."

Before becoming a core faculty member at the Lancaster General Hospital Family Medicine Residency Program, I spent more than 15 years teaching in Georgetown's family medicine department. Part of my job was to encourage students' interest in primary care careers and mentor those who chose to enter family medicine. Out of a typical graduating class of 200 students, our largest family-medicine bound group was 15 (7.5%) and the smallest was 6 (3%). Most years, two or three times as many students matched into Anesthesiology or Orthopedic Surgery.

While I'm grateful for subspecialists who alleviate pain, rescue patients who are unable to breathe on their own, manage complicated fractures, and replace worn-out hips and knees, the gap between the number of family doctors we need and the number we have keeps getting wider. The number of visits to primary care physicians fell by 43% from 2010 to 2021 despite 7.4% growth in the U.S. population, and a near-doubling in outpatient visits to advanced practice providers (the majority of whom work in medical subspecialties) wasn't enough to make up for this deficit. Challenges in accessing timely primary care affect not only private practices and health systems, but also the publicly funded Veterans Affairs system.

How can we train more family physicians? A recent study in Family Medicine found that contrary to conventional wisdom, more graduating students switch in to family medicine from another specialty than switch out of it after intending on family medicine upon matriculation. (I'm an example of this pattern, having intended to become a pediatrician when I started medical school.) Although this doesn't diminish the importance of nurturing students who (like my wife) declare their interest in family medicine starting on day one, it seems to make representation on admissions committees less critical. Other proposals include streamlining pathways for international medical graduates to enter residency programs in fields with physician shortages.

A report funded by the Milbank Memorial Fund highlighted five states - Virginia, Rhode Island, Connecticut, Oklahoma, and California - that are or will be setting spending targets for primary care as a percentage of their overall health care spend in order to increase their supply of clinicians and give practices more of the resources they need to improve health outcomes. This is, to put it mildly, easier said than done, starting with how to define primary care, estimate the health care dollars flowing into it, and determine the optimal percentage of those dollars. And if you build it, will they come?

We can hope and pray that some combination of interventions in premed programs, medical school, residency, and financial compensation will build the primary care infrastructure that America needs and prevent our health outcomes from getting much worse than they already are. But we need more research to design and implement these efforts. Dr. Rochelle Walensky, who directed the Centers for Disease Control and Prevention (CDC) from 2021 to 2023, calls the current state of affairs an "evidence emergency":

There is no more urgent research need than addressing the health of the workforce that is charged primarily with caring for the people of its nation. And yet, there is neither a funding stream nor a cohesive research community to do so. An investment in the evaluation of initiatives to strengthen the physician workforce is critical, and such research should not be conducted in silos. Data must be shared and evidence compiled and then directly interpreted and acted on for program and policy decision making.

Foundations such as Milbank, the Kaiser Family Foundation, and the Commonwealth Fund can't support this work by themselves. This is where the federal government must step up. But the Trump administration's radical shrinking and restructuring of the Department of Health and Human Services (HHS), which decimated the workforces and research grant-issuing functions of the better-known National Institutes of Health and the CDC, has also vanished the agency responsible for supporting health services research. According to HHS, the Agency for Healthcare Research and Quality will be merged into an "Office of Strategy," and the Health Services and Resources Administration (HRSA), which supports the backbone of federally qualified health centers that provide primary care to 1 in 11 Americans, will be consolidated into RFK Jr.'s "Administration for a Healthy America." To use a professional football analogy, it's as if the general manager of the team with the league's worst record used their premium draft picks to select a bunch of recreational players who wouldn't have been drafted by any other team in the first place. Instant analysis: a failing grade for HHS.

What's new in osteoporosis screening and fracture prevention?

In the two years since publication of the latest American Family Physician review article on osteoporosis, new guidelines and research studies have enhanced management of this common condition. In early 2025, the U.S. Preventive Services Task Force (USPSTF) updated its recommendations on screening for osteoporosis. Although on the surface these are unchanged from the 2018 version—recommending screening in all women 65 years or older and postmenopausal women younger than 65 years at increased risk for an osteoporotic fracture and finding insufficient evidence to screen men—an accompanying editorial noted a small, but significant, difference.

Previously, the USPSTF defined increased risk by a threshold on the Fracture Risk Assessment Tool (FRAX) that corresponded to the 10-year fracture risk of an average 65-year-old White woman. However, evidence indicates that the predictive value of FRAX without bone mineral density is poor and inferior to simpler tools such as the Osteoporosis Self-Assessment Tool and the Osteoporosis Risk Assessment Instrument. In its updated recommendations, the USPSTF recommends only a “clinical risk assessment” and notes that if FRAX is used, it “does not intend that these 10-year risk levels be used as mechanistic thresholds” to decide who should undergo dual-energy absorptiometry screening.

A recent analysis of the performance of the Osteoporosis Self-Assessment Tool, Osteoporosis Risk Assessment Instrument, and the Osteoporosis Assessment of Risk tools in a subgroup of Women’s Health Initiative participants 50 to 64 years of age found that each had “fair to moderate discrimination” in identifying osteoporosis, with areas under the receiver operating characteristic curve of 0.633 to 0.663, with 1.0 being perfect and 0.5 being no better than chance.

Not only is it difficult to clinically predict osteoporosis risk, fragility fractures can occur in patients without osteoporosis. In January 2025, researchers published a randomized, placebo-controlled trial of an alternative strategy for reducing fractures: treating women in early menopause with antiresorptive therapy regardless of bone mineral density. There were 1,054 women 50 to 60 years of age with bone mineral density T-scores at the lumbar spine or hip from 0 to -2.5 at baseline assigned to one of three groups: zoledronate intravenous infusion at baseline and repeated at 5 years; zoledronate infusion at baseline, placebo at 5 years; and placebo infusions at baseline and at 5 years. After 10 years, new fractures had occurred in 11.1% of the placebo-placebo group, 6.6% of the zoledronate-placebo group, and 6.3% of the two dose zoledronate group. The relative risk of fractures in the two-dose zoledronate compared with the placebo-placebo group was 0.72, with a number needed to treat of 25 to prevent one fracture. The comparative benefits and cost effectiveness of this prevention strategy vs fracture risk assessment and treating women at increased risk remains to be seen.

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This post first appeared on the AFP Community Blog.