Wednesday, August 17, 2016

Immigration and health care

I am a child of immigrants. My parents migrated from Taiwan to the United States in the 1950s and 1960s, my father as a graduate student and my mother as a toddler, at that time the youngest member of a family of seven. Both eventually became naturalized citizens.

The ship my mother's family took from China to the U.S.
It is much more difficult to immigrate legally to the U.S. today. Current policies overwhelmingly emphasize family re-unification, reserving two-thirds of "green cards" to persons who already have relatives residing in the U.S. Millions of highly skilled potential immigrants like my parents and grandparents - my father eventually programmed the Hubble Space Telescope, and my mother's father was a neurologist whose biography appeared in the 9th edition of Who's Who in the World - now compete for a comparatively small number of resident permits. Most must wait for years; many lose hope and return their talents to their native countries. As former Florida governor and Presidential candidate Jeb Bush wrote in 2014 about the U.S.-Mexican border crisis, "A chief reason so many people are entering through the back door, so to speak, is that the front door is shut."

My mother's family in 1950. The baby is my mother.
The deluge of unaccompanied minors from Honduras, El Salvador, and Guatemala through this "back door" has substantial physical and mental health needs. But Drs. Douglas Bishop and Rina Ramirez observed in American Family Physician that the legal status of these children, which can vary from state to state, complicates efforts to provide them with adequate medical care:

Those of us on the front lines of community medicine continue to struggle daily with the challenges that this vastly complex and heterogeneous population brings, and we look forward to others sharing best practices to care for and foster resiliency in these children. For now, physicians caring for unaccompanied minors need to begin developing office protocols and medical evaluations that fit with state laws and financial realities while working to engage these children and keep them out of the shadows.

Meanwhile, some undocumented residents who migrated to the U.S. before their 17th birthdays prior to June 15, 2012, better known as "Dreamers," have been completing college and applying to graduate schools. In a commentary in Academic Medicine, Drs. Mark Kuczewski and Linda Brubaker explained why Loyola University Chicago Stritch School of Medicine decided to welcome applications from academically qualified Dreamers and encourages other schools to establish similar admissions policies:

The ethical obligation to train the best potential workforce pulled from all of the best candidates intersects with the social justice value that requires medical schools to form physicians who have the capacity and skills, including cultural awareness and competence, to provide all patients with high-quality, compassionate care. ... Dreamer students represent a very valuable resource in achieving the diversity necessary to meet the health care needs of contemporary U.S. society.

Neither a porous southern border nor a too-narrow pathway to legal residency will benefit the U.S. in the long run. At least 10 million undocumented persons already live in the U.S., often doing jobs that citizens don't want, from child care to cleaning homes to construction. The idea that our country could somehow deport all of them is more of a fantasy than President Abraham Lincoln's early Civil War notion of resettling all 4 million African American slaves in a foreign land instead of granting them citizenship.

Me and my sister with my father's parents in the early 1980s.
Immigration policy is complicated, no doubt, and one might ask what fixing it has to do with medicine. Here are a few ways maintaining the immigration status quo harms health and health care in the U.S. There are millions more people to care for, and few options for them to access care in continuous, cost-effective ways. Loyola University Chicago aside, the best and brightest undocumented immigrants who arrived in the U.S. as children face huge obstacles to becoming part of the diverse health care workforce that America desperately needs. And the "front door" of U.S. immigration remains, for all practical purposes, firmly closed to foreign-born persons with aspirations similar to those my own parents had half a century ago.

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This post first appeared on Common Sense Family Doctor on December 23, 2014.

Thursday, August 11, 2016

Do firearm counseling or legal restrictions reduce injuries and deaths?

An online reader of an American Family Physician article on prevention of unintentional childhood injury wondered why the article did not mention counseling about firearm safety. It was a fair question, since in the U.S. more than 7,000 youth under the age of 20 are hospitalized each year for injuries from firearms, and three-quarters of such injuries in children younger than 10 are unintentional (in contrast, most firearm injuries in adolescents are from assaults). According to a subsequent AFP editorial, studies suggest that counseling about safe gun practices such as storing firearms unloaded in locked containers and separately from ammunition may increase the use of such practices.

A national poll conducted last year found that two-thirds of non-firearm owners, and a majority of firearm owners, agreed that health care provider discussions about firearms are at least sometimes appropriate. Outside of Florida, there are no state legal restrictions on physicians' ability to ask patients about firearms, even the Florida statute (which was struck down by a U.S. District Court for violating the First Amendment and remains suspended pending a decision by the 11th Circuit Court of Appeals) contains exceptions. The authors of a perspective paper in the Annals of Internal Medicine recommend that physicians consider asking patients about firearm access when they are at acute risk of violence to self or others; have one or more individual level risk factors (e.g., a history of violence, substance abuse, serious mental illness); or belong to a demographic group at increased risk for violence or unintentional injury (older white men, young African American men, and children).

Although recent high-profile mass shootings have drawn attention to gun violence as a public health problem in the U.S., these represent only 1 in 50 gun homicides in the U.S., most of which are not committed with assault weapons. A recent New York Times analysis of two crowd-sourced databases of 358 shootings with 4 or more casualties found that most occurred in poor neighborhoods, and most victims were African American men in their twenties:

They [the databases] chronicle how easily lives are shattered when a firearm is readily available - in a waistband, a glove compartment, a mailbox or garbage can that serves as a gang's gun locker. They document the mayhem spawned by the most banal of offenses: a push in a bar, a Facebook taunt, the wrong choice of music at a house party. They tally scores of unfortunates in the wrong place at the wrong time: an 11 month-old clinging to his mother's hip, shot as she prepared to load him into a car; a 77 year-old church deacon, killed by a stray bullet while watching television on his couch.

Gun violence has been called an "epidemic" based on the disproportionate numbers of firearm homicide deaths in the U.S. compared to other nations, but also because it spreads much like a sexually transmitted disease within networks of people, where the victim one time becomes the assailant the next. Unfortunately, it isn't clear if legal restrictions (e.g., background checks, waiting periods, concealed carry laws, bans on certain types of firearms) can reduce injuries and deaths. A 2005 review by the Task Force on Community Preventive Services found insufficient evidence to determine the effectiveness of any law in preventing violence, and it doesn't appear eager to take up the topic again. Even though the Centers for Disease Control and Prevention is no longer forbidden from researching gun violence, it hasn't received any Congressional funding for such studies. So U.S. policymakers are left with extrapolating from observational studies, many done in other countries. These studies suggest that implementing multiple firearm restrictions simultaneously (as Australia did in 1996) is associated with reductions in deaths; that laws requiring background checks reduce intimate partner homicides; and that laws requiring safer storage of firearms reduce unintentional deaths in children.

Of course, meaningful firearm legislation in the U.S. remains politically impossible, especially when a Presidential nominee openly calls for "Second Amendment people" to assassinate his opponent should she be elected. Which brings me back to physician counseling. We can start by counseling Donald Trump's doctor to tell him to bow out of the race for the good of the Republican Party and the country, and go back to being a harmless reality show star.

Monday, August 8, 2016

Family physicians are natural health system leaders

The subtitle of a 2014 JAMA editorial on accountable care caught my attention: "The paradox of primary care physician leadership." The authors observed that although a typical family physician's or general internist's patient panel accounts for about $10 million in annual health care spending (of which only $500,000 is primary care revenue), primary care physicians have been "underused" as role players in health system reform. They further suggested that claiming leadership positions in accountable care organizations could be "a powerful opportunity [for family physicians] to retain their autonomy and make a positive difference for their patients - as well as their practices' bottom lines."

The editorial’s urging that family physicians take on more leadership in health care brought to mind the American Academy of Family Physicians’ ongoing initiative Family Medicine for America's Health, an effort to define family medicine’s role in the current health care system. One of the key questions considered by this initiative is "What are the core attributes of family medicine today?" Dr. Robert L. Phillips, Jr., and colleagues from seven U.S. family medicine organizations answered the question in a special article on the future role of the family physician in the Annals of Family Medicine:

Family physicians are personal doctors for people of all ages and health conditions. They are a reliable first contact for health concerns and directly address most health care needs. Through enduring partnerships, family physicians help patients prevent, understand, and manage illness, navigate the health system and set health goals. Family physicians and their staff adapt their care to the unique needs of their patients and communities. They use data to monitor and manage their patient population, and they use best science to prioritize services most likely to benefit health. They are ideal leaders of health care systems and partners for public health.

This forward-looking definition of family physicians as natural health system leaders contrasts the "foil definition" that the researchers envisioned family physicians fitting if they were to accept passive roles and allow themselves to be acted on by the various forces changing American health care:

The role of the US family physician is to provide episodic outpatient care in 15-minute blocks with coincidental continuity and a reducing scope of care. The family physician surrenders care coordination to care management functions divorced from practices, and works in small, ill-defined teams whose members have little training and few in-depth relationships with the physician and patients. The family physician serves as the agent of a larger system whose role is to feed patients to subspecialty services and hospital beds. The family physician is not responsible for patient-panel management, community health, or collaboration with public health.

But are tomorrow's family physicians prepared to be leaders instead of followers?

A research study published in Family Medicine explored relationships between specialty plans and clinical decision making in a national survey of 4,656 senior medical students. Students were asked to choose between management options in patient vignettes that exemplified principles of health reform: evidence-based care, cost-conscious care, and patient-centered care. Compared to all others, students entering family medicine were statistically more likely to recommend generic over brand-name medications and favor initial lifestyle-change counseling to starting medication for a mild chronic condition. Future family physicians were also more likely to prefer U.S. Preventive Services Task Force recommendations on preventive care to those from disease-oriented or patient advocacy groups, although this finding was not statistically significant.

This study’s take-home message is that future family physicians are well positioned to take the lead in implementing health system reforms that improve value and patient-oriented outcomes. Primary care physician leadership is not a paradox; on the contrary, it’s hard to imagine health reform succeeding in the long term without family doctors at the helm.

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A version of this post was first published on the AFP Community Blog and then appeared in Progress Notes on July 24, 2014.

Tuesday, August 2, 2016

Reflections on my summer publications

When I haven't been blogging, editing, teaching, or seeing patients this summer, I have experienced the satisfaction of having reports of a couple of my longer-term projects appear in medical journals. In contrast to a blog post, which can be conceived, written, and published in a few hours (although the thought process often takes much longer), the timeline from submission to publication in a journal is usually several months at a minimum.

For example, in the spring of 2014, after having helped to develop a search tool for primary care-relevant Choosing Wisely recommendations, I wondered what proportion of these recommendations were based on evidence of patient-oriented outcomes, as opposed to expert consensus. I convinced a collaborator, a family physician at Fort Belvoir Community Hospital, to help me apply the Strength of Recommendation Taxonomy (SORT) to 224 different recommendations that had been generated by various medical specialty societies. It took many hours of working on our own and several conference calls to complete this project, which we presented at the Preventing Overdiagnosis conference at the National Institutes of Health last September. We then wrote the paper and submitted it to what we thought was an appropriate journal, but the editors of the journal (which will remain nameless) disagreed, rejecting it without even sending it for peer review. So we resubmitted it to the Journal of the American Board of Family Medicine, which accepted it after peer review and revision and finally published it in their July/August issue. Here is the bottom line:

We found that a majority of primary care–relevant Choosing Wisely recommendations are based on expert consensus or disease-oriented evidence. In light of other factors that drive unnecessary medical interventions, such as patient satisfaction and fee-for-service reimbursement, this may make it more difficult to convince clinicians to change established practices. Further research is warranted to strengthen the evidence base supporting these recommendations in order to improve their acceptance and implementation into primary care.



Not long afterward, the journal Family Medicine published a book review that I wrote about Dr. Robert Taylor's enjoyable and useful What Every Medical Writer Needs to Know. I love reading good books about the process of writing, medical or otherwise, and recommended it highly:

Although students and novice writers may want to purchase a more traditional and/or less expensive book on the craft, I recommend What Every Medical Writer Needs to Know as a valuable resource not only for “serious” medical authors who write for a living but for family physicians and clinicians who write occasionally for publication and would enjoy learning more about the inspiring history of the profession.


After it was published, a residency mentor, whom I credit for giving me my start in medical writing, e-mailed me to say that he had decided to purchase a copy of the book based on my review!

Although blogging has advantages over traditional medical publications (perhaps my favorite being that I get to be the writer and the editor), I am glad that I invested the time to be published in these family medicine journals.

Saturday, July 30, 2016

Can point-of-care tests reduce inappropriate antibiotic use?

Why do physicians prescribe antibiotics for viral infections when they ought to know better? An editorial from the Centers for Disease Control and Prevention in the August 1st issue of American Family Physician suggests several talking points that may persuade the patient who wants "Vitamin Z" (azithromycin) for his (or his child's) common cold and reviews evidence that delayed antibiotic prescriptions, effective communication strategies, and public commitments to use antibiotics appropriately reduce unnecessary antibiotic use. But what if these interventions aren't enough?

The rapid strep test helps to distinguish a viral sore throat from streptococcal pharyngitis. In patients with an intermediate pre-test probability, a negative rapid strep test lowers the post-test probability of strep enough for doctors (and most patients) to feel comfortable withholding antibiotics. Wouldn't it be nice if other point-of-care tests could effectively rule out bacterial infections and curb antibiotic prescribing in patients with acute respiratory symptoms?

Procalcitonin seems ready to go. A FPIN Clinical Inquiry in the July 1st issue of AFP evaluated the effects of a procalcitonin-guided antibiotic therapy algorithm on antibiotic use and clinical outcomes. A Cochrane review and meta-analysis of 14 randomized, controlled trials (RCTs) comparing procalcitonin-guided to standard care in European adults with acute respiratory infections found that patients in the procalcitonin group received 3.47 fewer days of antibiotic therapy with no differences in 30-day mortality or treatment failure. In a single RCT of 337 children presenting to pediatric emergency departments in Switzerland, patients in the procalcitonin group were as likely as the standard care group to receive antibiotic prescriptions, but received nearly 2 fewer days of therapy.

C-reactive protein (CRP): the jury is still out. A Cochrane for Clinicians examined the performance of point-of-care measurement of CRP on similar outcomes. Although treatment thresholds varied, most studies considered a CRP level of less than 20 mg per L to suggest a viral infection and no need for antibiotics. A Cochrane review of 6 RCTs conducted in primary care settings (mostly in adults) in Europe and Russia found that groups assigned to CRP-assisted evaluation were 22 percent less likely to receive antibiotic prescriptions for acute respiratory infections, with no differences in clinical improvement at day 7, complications, or mortality. However, Dr. Irbert Vega observed in the Practice Pointers that "the meta-analysis did not identify an optimal algorithm and therefore should be considered proof of concept until further research can be performed, including research in the U.S. population."

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This post first appeared in a different form on the AFP Community Blog.

Monday, July 25, 2016

Giving it away: philanthropy and medicine

My wife and I aim to give about 10 percent of our pre-tax income to charity each year. Much of this amount goes to our church, which struggles to make ends meet despite being situated in a rapidly gentrifying area of Washington, DC. We divide the remainder between a variety of causes, such as historical preservation efforts, summer programs for poor kids, and education and leadership programs for young family physicians. Historically, we have allocated a very small fraction of our charitable contributions to our college, graduate, and medical school alma maters (Harvard, Johns Hopkins, and NYU for me; Cornell, Cornell, and Stony Brook for her), and then generally give directly to student organizations, such as the Big Red Marching Band and the Phillips Brooks House Association. It isn't that we don't have fond memories of attending these schools or don't appreciate the education we received there, but in our view they have deeper pockets than almost every other organization that asks for our financial support.

Two recent episodes of Malcolm Gladwell's "Revisionist History" podcast provided more convincing arguments against making big donations to top ranked universities. Gladwell made headlines last year with an Twitter rant criticizing hedge fund manager John Paulson's $400 million donation to Harvard (whose endowment at that time was valued at more than $36 billion). In "Food Fight," Gladwell compared the funding priorities of Bowdoin and Vassar, two small Northeast liberal arts colleges that appear pretty similar on the surface. One notable difference is that cafeteria food at Bowdoin is gourmet dining, while Vassar's is mediocre at best. Using public information sources and interviews with staff and students at both colleges, Gladwell drilled down to a major reason for this dining disparity: Vassar devotes more of its endowment income to financial aid in order to increase the social and economic diversity of its student body. If you're a wealthy individual who wants to advance social justice, Gladwell argued, choose Vassar over Bowdoin and supporting education for poor students over serving the rich breakfasts of eggplant parmesan pancakes.

Then, in "My Little Hundred Million," Gladwell explored the phenomenon of philanthropists such as Nike's Phil Knight choosing to give hundreds of millions of dollars to private universities that educate the elite rather than public universities who reach many more students of modest means. Gladwell included excerpts from an almost comical discussion with Stanford president John Hennessy, who accepted a $400 million donation from Knight to endow a graduate program for 100 students per year, even though Stanford's endowment is $22 billion. In comparison, a $100 million donation to little-known Glassboro State College (now Rowan University) in New Jersey in the 1990s transformed opportunities for 16,000 students each year and inspired this moving a cappella tribute from students after their benefactor's death.



As I've written before, hospitals and health care organizations are similar to institutions of higher education in that both have skyrocketing costs, little transparency, and few objective measures of quality. They are also alike in that they rely on philanthrophy to supplement the income they receive from patients/students and insurers/lenders. Famous cancer centers have turned fundraising into an art form, too often relying on emotion rather than fact to attract patients and donors. But just because it may be more attractive to donate to the Memorial Sloan-Ketterings and their associated academic institutions doesn't mean that they should be receiving an outsized share of my or your charitable dollars. Especially since we know that U.S. News top ranked (and well funded) medical schools end up near the bottom of the heap when ranked according to their social mission: the percentage of graduates who practice primary care, work in health professional shortage areas, and are underrepresented minorities. Similarly, a disproportionate amount of Medicare's $10 billion per year graduate medical education subsidy goes to institutions that train few primary care physicians or clinicians who practice in underserved areas.

Dear Mr. Paulson, Mr. Knight, Mr. Buffet, Mr. Gates, do you want to improve health outcomes in America? Then write a big check to John Peter Smith Hospital in Fort Worth, Texas, #6 on the list of producers of primary care graduates that received a modest $4.5 million from Medicare in 2008. Or Banner - University Medical Center in Phoenix, Arizona, #15 on the list. (Both institutions, not coincidentally, have outstanding family medicine residency programs.) Don't worry about my alma mater NYU, whose hospitals received more than $55 million from Medicare in 2008 but ranked #156 in primary care production. Or Memorial Sloan-Kettering, for that matter, which ranked #158 out of #158 primary teaching sites with at least 150 graduates - dead last.