Thursday, October 20, 2016

The missing piece in diabetes prevention

Some of my posts, like this one on problems with proliferating systematic reviews, have very brief gestational periods. I read something that stirs my thinking on a topic, I am inspired, and I write about it in one sitting. Others can take longer, such as this post about direct primary care entering the mainstream of medicine, which came together after a few months of reading and speaking with others about the topic. And sometimes I have a topic in mind to write on but just can't decide where it fits best: this blog, the AFP Community Blog, my Medscape commentary series, or a "professional" publication such as a medical journal.

What I had in mind was a sequel of sorts to last summer's post about the folly of screening for prediabetes, which I believed was more likely to cause harm by labeling more people as being diseased than it was to motivate them to take action to prevent diabetes. As the American Medical Association and the Centers for Disease Control and Prevention stepped up their efforts to identify people "at risk" for prediabetes (and an analysis published in JAMA Internal Medicine calculated that 60% of U.S. adults under age 60, and 80% of adults age 60 or older, would fall into this category), I wanted to say more about this over-medicalized approach to diabetes prevention and what a better alternative could look like. Several times I started writing, but couldn't quite decide where the post was leading.

My thoughts finally gelled in a Medscape commentary published earlier this week, where I pointed out three problems with preventing diabetes by screening for prediabetes:

1) The evidence suggests that this approach doesn't help people live longer (mortality) or better (quality of life).

2) Screening (especially with the CDC's tool) will lead to lots of overdiagnosis.

3) By ignoring social determinants of health, such as poverty and inequality, that resist lifestyle changes, this strategy may worsen health disparities.

Here is what I concluded:

Changing unhealthy environments can be a far more effective and long-lasting intervention than one-on-one clinical counseling. In the late 1990s, the US Department of Housing and Urban Development randomly assigned 4500 women with children in high-poverty urban areas to no housing vouchers, unrestricted traditional vouchers, or vouchers that could only be redeemed for housing in low-poverty areas. Ten to 15 years later, the group receiving traditional vouchers was no healthier than the control group, but the group receiving low-poverty vouchers had significantly lower body mass index and glycated hemoglobin levels.

Although the Medicare DPP as proposed should improve the health of many of our patients, in order to prevent diabetes without worsening health disparities, family physicians also require resources to address social determinants of health. To this end, the American Academy of Family Physicians recently published a position paper describing strategies for collaborating effectively with public health partners to lead the prevention of chronic diseases in our communities.

Monday, October 17, 2016

How family physicians can reduce diagnostic errors

Due to our broad scope of practice, family physicians are likely the most vulnerable of all physicians (with the possible exception of emergency medicine physicians) to diagnostic errors. Patients of all ages and different co-morbidities come in with undifferentiated complaints that could be attributed to multiple organ systems. In an editorial in the September 15th issue of American Family Physician, Drs. John Ely and Mark Graber reviewed underlying reasons for incorrect diagnoses:

Most diagnostic errors are caused by the physician's cognitive biases and failed heuristics (mental shortcuts), such as anchoring bias (overly relying on the initial information received or initial diagnosis considered), context errors, or premature closure of the diagnostic process. More than 40 of these biases have been described, but most lead to a single pathway in which the physician fails to generate an adequate differential diagnosis or to even consider the correct diagnosis as a possibility. The single most common reason for a diagnostic error is simply, “I just didn't think of it."

In a previous Curbside Consultation, Dr. Caroline Wellbery explored some of these cognitive biases in greater detail. For example, availability bias "refers to the ease with which a particular answer comes to mind," and can lead physicians toward making diagnoses based on other recent patients with similar presenting symptoms. Premature closure may occur when a framing/anchoring bias causes a physician to view the patient through a familiar lens and dismiss evidence that is not consistent with that frame. Similarly, confirmation bias may lead physicians to overemphasize test findings that support their preliminary diagnoses. Dr. Allan Detsky brought some of these dry concepts to life in a recent narrative in JAMA where he compared difficult diagnoses to the plastic snakes that he used to scare away ducks from the dock at his family's vacation home:

When faced with a difficult and ongoing diagnostic dilemma, refocus on the key assumptions that have driven the strategy to search for the "snakes." Start by dividing the findings into those that are based on facts and those that are based on inferences derived from those facts. Design an experiment to see if those inferences are indeed true, like holding the snakes under the water to see what they will look like on the bottom of the lake.

In their AFP editorial, Drs. Ely and Graber suggested three approaches to reduce diagnostic errors in primary care: 1) Involve the patient as a partner in the diagnostic process; 2) Get second opinions from colleagues or consultants who have not been previously involved in the patient's care; 3) Use a diagnostic checklist to make sure that all appropriate differential diagnoses have been considered. On a health system level, the National Academies of Medicine published a report on "Improving Diagnosis in Health Care" last year, and the Society to Improve Diagnosis in Medicine is leading a coalition of professional organizations, including the American Academy of Family Physicians, to devise and implement strategies to prevent diagnostic errors across all specialties and healthcare settings.


This post first appeared on the AFP Community Blog.

Wednesday, October 12, 2016

What can Rwanda teach the U.S. about primary care?

The relative underinvestment of resources in primary care in the U.S. has a great deal to do with the fact that we spend far more on health services than anywhere else in the world, but rank near the back of the pack in health metrics such as life expectancy, infant mortality, and disability compared to other high-income countries. Although inequality, lack of insurance coverage, and shrinking public health budgets are also part of the problem, I'd argue that diverting dollars from redundant multi-million dollar proton beam facilities to provide a patient-centered medical home for every American would have positive effects on population health.

Even though I feel that the U.S. has a lot to learn from other countries about building infrastructure to support high-quality primary care, it was still hard for me to get my head around the premise of an Atlantic headline that caught my eye a few years ago: "Rwanda's Historic Health Recovery: What the U.S. Might Learn." Like most Americans who have never traveled there, I suspect, my impressions of Rwanda have been strongly influenced by popular dramatizations of the 1994 genocide such as the movie "Hotel Rwanda" and Immaculee Ilibagiza's memoir Left to Tell. I had a difficult time imagining how any semblance of a functioning health system could have emerged even two decades later, much less a system that would have something to teach the U.S. But a 2013 BMJ article by Paul Farmer and colleagues documented impressive gains in Rwandan life expectancy, led by declines in morbidity and mortality from tuberculosis, HIV, and malaria that resulted not only from investments in lifesaving drugs but in preventive and primary care. 93% of Rwandan girls have received the complete HPV vaccine series to prevent cervical cancer, compared to only 33% of eligible U.S. girls in 2012.

Here's the thing, though: the foot soldiers in the Rwandan primary care revolution aren't doctors. In fact, there were only 625 practicing physicians in the entire country in 2011. (According to a report published in the same year, Washington, DC alone has about 3,000.) How, then, has Rwanda been able to staff its network of community health cancers and reach out to its eleven million people, many of whom are so poor that they can't afford the national health insurance premium of $2 per person? They do it primarily by relying on community health workers, trusted local residents who receive a minimum of basic medical training and are then integrated into more comprehensive primary care teams. As described further in a BMC Health Services Research article by the group Partners in Health:

Each district is served by a network of community health workers (CHWs) — three per village — offering health education, basic preventive and curative services, and family planning. CHWs are supported by local health centers, which serve approximately 20,000 people and are staffed by nurses, most of whom have a secondary school education level. Health centers provide vaccinations, reproductive and child health services, acute care, and diagnosis and treatment of HIV, tuberculosis, and malaria. District hospitals, staffed in part by 10-15 generalist physicians, provide more advanced care, including basic surgical services, such as cesarean sections.
Image courtesy of BMC Health Services Research.

The lesson to take home isn't that the U.S. can get away with training fewer primary care physicians than it already does. Indeed, Rwanda has every intention of training more doctors with assistance from other countries, including the U.S. What's important is the pyramidal structure of their health system, with primary care at the base and more specialized care at the apex. If you took the U.S. physician workforce, which consists of about 70% specialists and 30% generalists, and mapped it to a similar structure, it would look more like this (apologies for my poor graphical skills):

At the top, you have the super sub-specialists, who are experts on a single narrow spectrum of diseases confined to one organ system (e.g., hepatologists). Lower down are the ordinary specialists, such as gastroenterologists, cardiologists, and pulmonologists, whose expertise is limited to a single organ system and age group (e.g., adults). Still lower are generalists whose scope of practice is limited by age group. Finally, at the bottom, are the family physicians, the only type of physician whose scope is not limited by age, gender, or organ system.

The problem with this upside-down pyramid is that it's inherently unstable. In Washington, DC, it's sometimes easier for a patient with musculoskeletal low back pain to get an appointment with a spine surgeon or for a patient with panic attacks see a cardiologist than it is to find a family physician. You can get a same-day MRI for any number of problems that probably don't require any imaging at all. Such a health system is inefficient and wasteful at best, harmful at worst, and destined to get the extremely poor results it does. To improve population health in the U.S., we need to flip the pyramid so that primary care services are the base for all other health care structures.


This post first appeared on Common Sense Family Doctor on December 2, 2013.

Thursday, October 6, 2016

Does a rising tide of health outcomes lift all boats?

Politicians who favor reducing taxes and other financial policies that predominantly benefit "the rich" have argued that wealthy people have an outsized influence on the general health of the economy, and that their prosperity will benefit lower earners by directly or indirectly creating new or higher-paying jobs. A more pithy expression for this sentiment that President Kennedy first made famous is: "a rising tide lifts all boats." I don't have the expertise to comment on the veracity of this statement in an economic sense, but a recent study in Preventing Chronic Disease by Dr. David Kindig and colleagues asked an analogous question: can states simultaneously improve health outcomes and reduce health outcome disparities?

The study authors used age-adjusted mortality data from a Centers for Disease Control and Prevention database to compare the annual percent change in combined black and non-Hispanic white mortality by state with the annual change in black-white mortality disparities in those states from 1999 through 2013. Overall, in states where sufficient mortality data was available for analysis, combined-race mortality fell by a mean of 1.1% and the black-white disparity fell by a mean of 3.6% per year. However, there was no relationship between combined mortality and racial disparity reductions across states. A few states (Georgia, Maryland, Massachusetts) experienced above average improvements on both measures, but others (Oklahoma) were below average on both, and most states experienced relatively greater improvement on one measure than on the other.

Figure courtesy of CDC.

The implications of these findings are that strategies to improve health across all populations (the "rising tide") may be different from those aimed at eliminating racial health disparities ("all boats"). They also provide a baseline for what state health departments may reasonably expect when setting health improvement and disparity reduction goals in future years.

Monday, October 3, 2016

Guest Post: Hotspotting meets patients where they are

- Kimberly McGuinness, MS, ANP-C

I walked out of my office just in time to watch D.M. pass out, falling backwards off of the scale, narrowly missing my medical assistant. He had come to his primary care visit drunk and hypoglycemic again. I made changes to his medications and insulin, referred him to specialists and had him see our nurse and behaviorist, whom he could only see once because he would not be able to afford her copayment. At each subsequent visit, he was able to repeat all of our prescribed changes back to my nurse and me before he left the office to return to his life and world. He would then return for primary care follow-up after even more ER visits and hospital admissions and without having made any progress. We continued this trend for weeks and months until one day his death certificate arrived on my desk. I failed this patient. We failed this patient. Our system failed this patient.

At the time, I was practicing at a Philadelphia-based federally qualified health center (FQHC) providing primary care for the sickest of the sick. I am an Adult Nurse Practitioner and, when I started to work at the FQHC, I was fresh out of graduate school with a decade’s worth of registered nursing experience. As time went on, I was expected to see more and more of these complex patients, many of whom didn’t speak English, and often waited too long to seek care. As I pushed back on rising productivity expectations, administrators told me that if we went bankrupt and closed our doors, then no one else was going to help these patients. So I became a hamster on the wheel. I might have been keeping our clinic open, but I was not making a difference in the well-being of these patients. I would see one patient, make adjustments to medications, and they would return (maybe) without any discernible improvements to their health. This work was not fulfilling to me. When I walked in the door on Friday evenings, I’d say hello to my husband and then burst into tears – the release of tension from a frustrating week at work. And Monday I would go get back on the hamster wheel.

Then I learned about the Hotspotting Fellowship run by Dr. Jeff Brenner’s Camden Coalition of Healthcare Providers (The Coalition) and the Crozer-Keystone Family Medicine Residency Program in Springfield, Pennsylvania. Dr. Brenner developed a community-based care coordination model that provides quality care for high utilizers of emergency rooms and hospitals through a team-based approach – with the intent of keeping them out of emergency rooms and hospitals. Without a doubt, I knew this was the way that we need to practice medicine.

I got the fellowship, which is now coming to a close. Had I met D.M. during this program, I would have attempted to get to know who he really was and where he came from. I would have asked, “What happened to you?” and not “What is wrong with you?” I would have surrounded D.M. with a team to address the social and psychological issues that might be hindering his medical care and to work toward empowering him to take responsibility for his own care. He would be placed at the center of this care, and we would assist by breaking down barriers and providing him with solid relationships to help build his trust in the health system.

Over the last year, I have learned how to pool data and manage a super-utilizer intervention. I have been welcomed into C-suite meetings and negotiations with insurance companies in order to learn how to develop a successful hotspotting program for their beneficiaries. I have attended state legislative sessions to enact policies designed to break down the silos that intensify the need for a team-based approach. I have had the opportunity to travel to conferences around the country to present the data that we have been working on and to learn from and absorb the knowledge of others who are pushing the boundaries of our current practices.

But most importantly, I have spent my days working in interprofessional teams, providing high-touch, high-intensity care for these high-priority patients in their homes (or wherever they call home). Now when a patient like D.M. walks into my office, I take a step back from the pressing issue, like uncontrolled diabetes, to look at him as a whole. Together with the patient, we try to get to the root of the issue – no refrigerator to keep insulin because the patient is homeless, for example – because that is likely the cause of the uncontrolled diabetes. Having the opportunity to visit the patient on his turf and to deploy a pharmacist or social worker to assist with needs that arise – this feels like real medicine.

The faculty and team at Crozer and the employees of the Camden Coalition have provided me with unbelievable opportunities. They have opened my eyes to the infinite possibilities that are available to aid patients in healing and growing. And for the first time in my practice, I have started to meet patients where they are, not where I am or where my studies tell me they should be. For the first time in my career, I am practicing commonsense medicine and I am watching patients flourish.


Kimberly McGuinness is an adult nurse practitioner who is completing a year-long Super-Utilizer and Hotspotting Fellowship run by the Camden Coalition of Healthcare Providers and the Crozer-Keystone Family Medicine Residency Program. She hopes to continue to work with the underserved, breaking down silos and redesigning primary care. This post was first published on Progress Notes.

Wednesday, September 28, 2016

Public speaking: events and information

Since I began blogging in July 2009, my posts have been featured in widely read blogs such as, The Doctor Weighs InThe Health Care Blog, The Doctor Blog, and Gary Schwitzer's HealthNewsReview, as well as the websites of major national health and news outlets such as Proto Magazine, the Costco Connection, the New York Times, the Wall Street Journal, USA Today, and the Boston Globe. I also previously wrote the consumer health blog Healthcare Headaches for U.S. News and World Report.

Like the vast majority of physicians who blog, I write in my spare time. I have never accepted advertising or paid web links on Common Sense Family Doctor, and the choices of topics for posts are my own and not influenced by financial or other conflicts of interest. In order to support the time I devote to blogging, and to encourage high-quality medical writing and clinical practice, I give lectures and workshops to medical and non-medical audiences on a variety of topics. These include the uses of social media in medicine and education, developing and implementing clinical guidelines, and the evidence supporting prevention recommendations. Here's a clip from a 2014 talk I gave at the National Press Foundation on cancer screening.

If you or your organization would like to invite me to speak, please send me an e-mail at or

Future events:

November 8, 2016
Testosterone: Screening Older Men
- Temple University School of Medicine Family Practice Board Review Course, Lancaster, PA

Past events:


AAFP's Choosing Wisely Update: How to Help Your Patients Choose Wisely
- AAFP Family Medicine Experience (FMX), Orlando, FL

The Art of Blogging
- Georgetown University / Family Medicine Education Consortium Media Workshop, Washington, DC

Advantages and Pitfalls of Online Medical Information for Physicians and Patients
- American College of Medical Quality Annual Meeting, Washington, DC

Integrated Training for Population Health and Prevention in Medical Education
- Teaching Prevention 2016, Albuquerque, NM


Are Your Patients Choosing Wisely?
- Society of Teachers of Family Medicine Conference on Practice Improvement, Dallas, TX

How Care Teams Can Support Shared Decision-Making in Primary Care
- Patient-Centered Primary Care Collaborative Team Care Challenge, Washington, DC

The Connections and Disconnections of Science and Policy
- Association of Health Care Journalists Workshop on Evidence-Based Medicine, Washington, DC

Evaluating the Evidence for Choosing Wisely in Primary Care Using the Strength of Recommendation Taxonomy (SORT)
- Preventing Overdiagnosis Conference, Bethesda, MD

Men's Health Forum: Preventive Practices
- American College of Cardiology, Washington, DC

Politics of Prevention
- Fundamentals of Clinical Preventive Medicine, Johns Hopkins University Bloomberg School of Public Health

Choosing Wisely: Preventive Medicine Pearls
- Uniformed Services University of the Health Sciences Preventive Medicine Residency

Choosing Wisely: Pearls for Primary Care Physicians
- District of Columbia Academy of Family Physicians

The Physician's Perspective on Consumer Health Technology
- International Consumer Electronics Show, Las Vegas, NV


Cancer Screening: An Updated Primer for Journalists
- National Press Foundation's Cancer Issues 2014, Washington, DC

Lung and Bronchial Cancer
- American Academy of Family Physicians Assembly, Washington, DC

Policy and Funding for Preventive Care Programs
- Georgetown University Health Systems, Policy, and Public Health Elective


CT Screening for Lung Cancer: Evaluating the Evidence
- National Capital Consortium Family Medicine Residency, Fort Belvoir, VA

Thinking Like An Editor
- Society of Teachers of Family Medicine Annual Spring Conference, Baltimore, MD

Politics of HIV Testing
- Georgetown University School of Medicine

Burnout Prevention for Healthcare Professionals
- Teaching Prevention 2013, Washington, DC

Evidence-Based Literature Searching: A Primer
- National Capital Consortium Family Medicine Residency, Fort Belvoir, VA

Less is More: New Approaches to Cancer Screening in Primary Care
- Primary Care Coalition of Montgomery County, Maryland


Science and Public Policy in Conflict: PSA Screening
- Johns Hopkins University Bloomberg School of Public Health Fall Policy Seminar

Screening Mammography for Women in their 40s: Exploring the Controversy
- National Capital Area Regional Breast Healthcare Improvement Initiative

Why You Should Stop Screening Patients for Prostate Cancer
- Ephrata (PA) Community Hospital Grand Rounds

Identifying and Using Good Practice Guidelines
- Temple University School of Medicine Family Practice Board Review Course


Cancer Screening: A Primer for Journalists
- National Press Foundation's Cancer Issues 2011, Washington, DC

What to Do When Screening Guidelines Conflict: HIV and Mammography
- Grand Rounds, Georgetown University Department of Family Medicine

Overdiagnosed: Making People Sick in the Pursuit of Health
- William J. Bicknell Lecture (panelist)
- Boston University School of Public Health

For Geeks and Geezers: With Social Media Skills You Can Change the World
- Family Medicine Education Consortium Northeast Region Meeting

Screening for Diabetes: What Does the Evidence Say?
- Spanish Catholic Center of Catholic Charities of Washington, DC

Don't Do It! Preventive Health Services That Harm More Than They Help
- District of Columbia Academy of Family Physicians

Using the Medical Literature to Make Decisions About Preventive Health Services
- Medical Library Association Annual Meeting

2008 - 2010

Medical Blogging and Other Professional Uses of Social Media
- Grand Rounds, Virginia Commonwealth University Internal Medicine

Spilling Ink: An Expert's Guide to Getting Your Work Published
- Society of Teachers of Family Medicine Annual Meeting