Tuesday, February 13, 2018

Why I teach health policy and advocacy in medical school

From 2009 to 2012, I directed the graduate course "Fundamentals of Clinical Preventive Medicine" at Johns Hopkins University's Bloomberg School of Public Health. It was a required course for Hopkins preventive medicine residents, and also usually attracted other Master's level public health students and undergraduates with a strong interest in medicine. The class size was 15 to 25 students. In that setting, with a small group who generally believed that the material was important, if my teaching was inspired and the presentation compelling, I could reasonably hope for positive feedback from nearly every student.

In every academic year since (after returning to the family medicine faculty at Georgetown), my primary teaching responsibility has been co-directing a mandatory course in population health, health policy and advocacy for about 200 first-year medical students. I am proud that student ratings for the course overall and the course directors in particular have improved every year, though I suspect that at least some of this improvement is the result of more students being already aware of the health impacts of national, state, and local policy decisions, even those that ostensibly have nothing to do with medical practice.

A case in point is the U.S. Department of Agriculture's recent proposal to save money by replacing food stamps with food boxes containing nonperishable food items for poor families that qualify for financial assistance. Historically, Native American tribes who were forced to live on reservations, cut off from natural water and food sources, were supplied with boxes of dry and canned foods high in sodium and calories and low in nutritional value. The result was a catastrophic rise in obesity, hypertension and type 2 diabetes in this population. The USDA eventually modified the program to incorporate fresh produce, which begs the question of why anyone should take seriously this new proposal whose end result would be making the national obesity epidemic many times worse than it already is.

But back to my course. Every year, a few students complain in their evaluations that what we teach just isn't relevant to their future careers, or more commonly, that the content is "too political." This is a tough criticism for me to stomach, as we go to great lengths to present a broad spectrum of perspectives on health and the health care - what the "system" does well and where it fails by every conceivable standard. To me, that U.S. life expectancy has declined for two years in row means that business as usual just isn't cutting it. Yes, solutions to these problems invariably involve advocacy and political choices. And it's perfectly fine for my students to debate the relative contributions of various determinants of health, and in particular rising economic inequality, in this unfolding disaster. It is not okay for a student to turn a blind eye to health policy and think that everything will turn out fine as long as he or she is accepted into a residency program in a reliably high-paying subspecialty of choice.

So kudos to Faiz Kidwai, a second-year medical student who wrote a thoughtful editorial for STAT about why medical schools shouldn't divorce education from politics. One particularly eloquent point hit home for me:

A class on health policy cannot replace classes on pathology or pharmacology, nor should it. But without making policy and public health a major component of medical education instead of a side interest to be pursued on students’ own time, medical schools will continue to churn out exceptionally talented physicians who are exceptionally ill-prepared to deal with the medical bureaucracy and byzantine health care policies that hit them the moment they begin to care for patients.

Another piece that recently hit home, by pediatrician and former CMS Administrator Don Berwick (whose selected previous writings have long had a place in my course), was "Moral choices for today's physician," in JAMA. Berwick argued that for physicians "to try and avoid the political fray through silence is impossible, because silence is now political." Berwick obviously has no love for the Trump Administration, but what he wrote could apply to any clinician - conservative, libertarian or liberal, Republican or Democrat, or none of the above:

Healers cannot deny that leaving refugees at our gates unwanted, or children unfed, or families unhoused, or basic medical care uncovered, or relying on conflict, rather than compassion, are health problems. ... The work of a physician as healer cannot stop at the door of an office, the threshold of an operating room, or the front gate of a hospital. The rescue of a society and the restoration of a political ethos that remembers to heal have become the physician's jobs, too. Professional silence in the face of social injustice is wrong.

These quotes from Kidwai and Berwick explain why I continue to be energized year after year to teach students who are at times excited, and at times indifferent to health policy and advocacy. I know that most didn't come to medical school to learn about politics or public health. But it's my job to make sure that my students don't graduate ill-prepared or professionally silent in the face of human suffering.

Wednesday, February 7, 2018

The changing of the guard at American Family Physician

The February 1 issue of AFP 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 14 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.

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This post first appeared on the AFP Community Blog.

Monday, January 29, 2018

Should a mobile app be your next prescription?

Earlier this month, a blog post from Dr. Jennifer Middleton highlighted recent content in American Family Physician that can help family physicians support resolutions to make healthy lifestyle changes. Increasingly, I also recommend that my patients consider using smartphone apps to give them extra motivation and allow them to chart their progress toward personal goals. The latest in a series of articles on medical apps in FPM reviewed four mobile apps designed to encourage healthy habits, including healthy eating, physical fitness, substituting water for sugary drinks, and taking prescribed medications. Although the evidence that apps provide greater benefits than usual care remains limited (a randomized trial of a fitness app reviewed previously by FPM found no statistical differences in weight loss, blood pressure, or satisfaction), "digital therapy" is now being used to promote wellness and improve self-management of chronic conditions as diverse as substance use disorder and atrial fibrillation.

A draft technical brief issued by the Agency for Healthcare Research and Quality reviewed the evidence on health outcomes for 11 commercially available mobile apps for self-management of type 1 or type 2 diabetes. For five apps, studies demonstrated clinically significant improvements in hemoglobin A1c levels at 3 to 12 months. However, no studies showed improvements in quality of life, blood pressure, weight, or body mass index.

Regarding apps for clinicians, the U.S. Food and Drug Administration (FDA) clarified in a recent guidance document how it intends to treat digital decision support software going forward. Software that functions as a diagnostic device will be regulated, while digital tools that merely assist clinicians in making diagnoses will be excluded from regulation and "cleared" for use. On its website, the FDA provides a list of examples of mobile medical apps that it has cleared or approved to date.

Whether mobile apps will complement traditional prevention, diagnosis and treatment in primary care, or replace them in some cases, remains to be seen. Health professionals: do you routinely prescribe apps to your patients, or do you expect to do so in the future? Everyone else: has your doctor suggested using an app to improve your health, and if so, did you find it helpful?

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This post first appeared on the AFP Community Blog.

Wednesday, January 24, 2018

A simple, reassuring test for heart murmurs in children

It happens all the time to family physicians at well-child visits: we listen to the heart with our stethoscopes, hear a murmur that wasn't documented as being there before, and wonder if it's necessary to obtain an echocardiogram and/or refer the child to a cardiologist. A previous article in American Family Physician by Drs. Jennifer Frank and Kathryn Jacobe listed several "red flags" that make a serious cause more likely:

- Holosystolic or diastolic murmur
- Grade 3 or higher murmur
- Harsh quality
- Abnormal S2
- Maximum murmur intensity at the upper left sternal border
- A systolic click
- Increased intensity when the patient stands

The authors also recommended referral to a pediatric cardiologist if historical findings suggest structural heart disease, if cardiac symptoms are present, or if the family physician is unable to identify a specific innocent (physiologic) murmur. Even though innocent murmurs share several characteristics, some of these are subjective or difficult to distinguish, and the fear of missing a heart disease diagnosis may still lead to unnecessary referrals.

In an important research study published in the November/December issue of Annals of Family Medicine, Dr. Bruno Lefort and colleagues prospectively evaluated 194 consecutive children aged 2 or older referred for heart murmur evaluations at 2 French medical centers to test the hypothesis that a simple, objective clinical test could exclude serious cardiac conditions. 100 children had a murmur that was present when lying down but completely disappeared when they stood up, per the pediatric cardiologists' examinations. Of these children, only two had an abnormal echocardiogram result, and only one required further evaluation and treatment for a non-trivial problem (an atrial septal defect that required percutaneous closure). The authors calculated that the complete disappearance of the heart murmur on standing had a positive predictive value of 98%, specificity of 93%, and sensitivity of 60% for innocent murmurs in children. This "clinical standing test" had superior predictive value compared to features of physiologic murmurs traditionally taught in medical school, such as change in murmur intensity, location, or timing.

The investigators concluded that the complete disappearance of the murmur on standing may be a valuable test to rule out serious heart murmurs in children and prevent unnecessary imaging and referrals. They recommended that a larger study confirm the value of this test and its reproducibility between pediatric cardiologists and primary care physicians (whose assessments were not evaluated in this study).

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A slightly different version of this post first appeared on the AFP Community Blog.

Wednesday, January 17, 2018

There are few parachute-like practices in family medicine

I try my best to practice evidence-based medicine on a daily basis. When I know that the test or intervention that I am recommending for my patient is based on expert opinion rather than reliable data on patient-oriented outcomes that matter, I invariably make a point of saying so. It has been my position for several years that despite the impressive effectiveness of newer antiviral medications for hepatitis C at producing a sustained virologic response (SVR), there are still not enough data to be certain that SVR always represents a "cure," and therefore not enough data to warrant age cohort-based screening of adults without known risk factors for the infection. In a recent Medscape commentary, I went one step further, mentioning a famous 2003 BMJ paper on "Parachute use to prevent death and major trauma related to gravitational challenge," which asserted that the health benefits of some interventions are so glaringly obvious that, like parachutes, they do not need to be evaluated in randomized, controlled trials (RCTs). Screening for hepatitis C, I contended, should not be considered a "parachute" for clinical research purposes. As some colleagues and I argued a few years ago, a randomized trial of screening versus usual care would not only be ethical, but logistically feasible and well worth the investment.

In an ingenious analysis published today in CMAJ Open, a team of researchers that included my friend, colleague, and prolific tweeter Dr. Vinay Prasad used Google Scholar to identify articles that cited the BMJ parachute paper to argue that a medical practice was analogous to a parachute - or in other words, so obviously beneficial that RCTs were not needed. The team then searched the literature for previous or subsequent RCTs that tested the practice in question. Of the 35 practices, 22 have, in fact, been tested in one or more RCTs. Guess how many of these practices ended up being backed up by trials that showed a statistically significant benefit? Only 6 out of 22, barely edging out the 5 "obviously beneficial" practices that were actually found to be ineffective in RCTs (the remaining 11 had mixed results or halted or ongoing trials). The investigators concluded: "Most parachute analogies in medicine are inappropriate, incorrect or misused."

Although some interventions that were refuted by RCTs lie outside of the scope of family medicine, I took note of two that not only sounded familiar (because I had once been told by an "expert" that they were true), but where I could personally make an impact on decreasing ineffective, potentially harmful care. Compared to medical therapy, stenting for renal artery stenosis does not reduce cardiovascular events. Compared to standard hemoglobin A1c targets, tighter control of blood glucose levels in persons with type 2 diabetes does not reduce cardiovascular deaths. In particular, I have inherited several adult patients with type 2 diabetes whose previous physicians tried to push their hemoglobin A1c levels to 6.5% or lower by adding expensive second or third drugs that increased their risk for hypoglycemia, based on the faulty assumption (parachute!) that these would prevent a heart attack or stroke somewhere down the line. But I practice evidence-based medicine, not parachute-based medicine. I discontinued those unnecessary medications to prevent further injury to these patients or their pocketbooks.

Monday, January 8, 2018

Does convenience outweigh continuity of care?

Several years ago, after leaving my scientific position at AHRQ and feeling that my patient care skills had become rusty, I took a part-time job as a staff physician at a rapidly growing chain of urgent care centers. I thought that urgent care's relatively limited scope of practice would ease my transition back into the clinic, and though the pace was often intense, I quickly became comfortable sewing up lacerations, draining abscesses, diagnosing fractures, and fishing various objects out of ears and noses. All in all, it was a rewarding experience: my physician colleagues were friendly and experienced, the support staff skilled and professional, and since we stayed open from from 7 AM to 10 PM every day of the year, our walk-in patients were generally grateful to be seen.

After about a year of this work, I decided to return to academic medicine. During my interview, I mentioned to the then-Department Chair that I had been working in urgent care. He visibly grimaced, then said something about urgent care centers "skimming the cream" of primary care and leaving full-service family practices with the more complex and less lucrative types of visits. And I couldn't really disagree. If there's one axiom at the heart of family medicine, it's the importance of continuity of care - meaning, whether you feel sick or well, seeing a doctor who knows you will make it more likely you will get the care you need. A systematic review in the Journal of Family Practice and another review in the Journal of Evaluation in Clinical Practice both concluded that increased continuity was associated with higher quality care, better outcomes, and higher patient satisfaction.

The problem with prioritizing continuity of care is ensuring access. My current practice is open until 8 PM two evenings per week and, for a few years, we also saw patients on Saturday mornings. But none of us really like to work on Saturdays, and we recently learned that of all the primary care practices in our health system, we are the only ones who have even been open on that day. Further, the nature of an academic practice is that my colleagues and I are only each at the office a day or two per week, further limiting the ability of patients to see the same doctor every time. Can continuity of care be said to have the same value if it's only with the same office, rather than the same person? It's a question that needs answering, as a study from the Robert Graham Center found that an increasing proportion of Americans identify an office or facility, rather than an individual clinician, as their usual source of health care.

Finally, retail health clinics (think CVS's Minute Clinics), like urgent care centers, have emerged and prospered as a response to deficiencies in primary care access, but handle a more limited range of acute problems and are staffed by nurse practitioners rather than physicians. On one hand, retail clinics may disrupt continuity of care, but on certain measures of quality, such as antibiotic prescribing for respiratory infections, they are more likely to adhere to national guidelines. And even a respected health policy researcher such as Dr. Aaron E. Carroll, a professor of pediatrics at Indiana University, admitted that he would rather take his child to a retail clinic for a sore throat than deal with the hassle of getting a same-day appointment with their usual physician. So much for continuity of care and the patient-centered medical home that physician groups have been advocating for the past decade as the solution to excessive health spending and mediocre outcomes! Or can these concepts coexist with the convenience of urgent and retail health care?

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This post originally appeared on Common Sense Family Doctor on May 23, 2016.