Sunday, April 15, 2018

Keep your options open - become a family physician

One of the persistent fallacies that I hear from medical students at my institution who are trying to decide between residency programs in internal and family medicine is that by choosing internal medicine, they can "keep their options open" to either become a generalist or to specialize, while choosing family medicine will close off all options except practicing traditional office-based primary care. In fact, nothing could be farther from the truth. If you choose an internal medicine residency, I counsel these students, the odds are overwhelmingly high that you will end up as a subspecialist (-ologist) at a tertiary care medical center. In contrast, the options available to a family medicine residency graduate are nearly limitless. Among my family physician colleagues are hospitalists, infectious disease and HIV experts, urgent care and team physicians; those who perform C-sections, colonoscopies, and appendectomies in the U.S. and throughout the world; teachers, researchers, guideline gurus, health system leaders, and public health officials; those who are comfortable practicing in rural areas, urban areas, and in every community size in between.

I often characterize my own career in family medicine as atypical, but that implies (falsely) that there is a "typical" path. I usually spend Monday mornings blogging or editing papers written by others, then precept family medicine residents in the afternoon. Tomorrow, I will actually be seeing my own patients in clinic all day, but the next five Mondays after that illustrate many of the options available to an academic family physician:

Monday, April 23
AM: Give the "What Is Family Medicine?" lecture to the new clerkship students. It's late in the 3rd year, but perhaps one or more can still be persuaded to "keep their options open" and fall in love with my specialty.
PM: Attend a multidisciplinary panel meeting for the American Academy of Otolaryngology-Head and Neck Surgery clinical practice guideline on epistaxis (nosebleeds).

Monday, April 30
Travel to Leawood, Kansas for a two-day American Family Physician editors meeting. Never in my wildest dreams as a medical student could I have imagined that I would become Deputy Editor of the second-largest medical journal (by print circulation) in the world, and the most monthly website views of any medical journal.

Monday, May 7
Attend the Society of Teachers of Family Medicine Annual Spring Conference in DC, where I am a co-presenter on two seminars and a scholarly poster.

Monday, May 14
Travel to Lancaster, PA, where the following morning I will present Grand Rounds at my alma mater (Lancaster General Hospital Family Medicine Residency).

Monday, May 21
Attend Georgetown's 2018 Teaching, Learning and Innovation Summer Institute as a member of this year's Technology-Enhanced Learning Colloquium for faculty across all university campuses.

Wednesday, April 11, 2018

Guest Post: Growing family medicine means changing med school admissions

- Larry Bauer, MSW, MEd

One of the things that I’ve always enjoyed about working with and supporting family physicians was the sense that I was helping not only the underdog, but one of the only groups within the house of medicine that could demonstrate its value in terms of improving the health of the population while reducing the cost of care; doing more with less.

I’ve also encountered elitism in medicine as an educator, as a faculty member, as a family member whose relations have encountered elitism and its effects, and as a patient myself. I want the underdog to lead the charge to reform the U.S. health care system. We would all be better off if family medicine and primary care led.

In Dr. Lin's description of remedies to the problem of too few family physicians, I think he left out the critical element. Our nation’s medical schools are becoming a playground for children from families of special means. Research clearly shows that a very disproportionate number of students admitted to our medical schools are from families with high and exceptionally high income expectations.

Children from families with limited means are disproportionately not making it over the hump. We know from 30 years of research that if more children from first generation to college families were admitted into our medical schools, and if those who have been out for a few years (not only a "gap year") were admitted to our medical schools, and if those from rural backgrounds were admitted to our medical schools, we would have more graduates choose family medicine and primary care, and probably general surgery and psychiatry as well.

This literally is the elephant in the room. I find that very few in family medicine and none outside of family medicine are willing to consider this issue.

I was on the forefront when I was on the faculty in the Department of Family and Community Medicine at Penn State University, as we collectively fought to increase family medicine faculty's teaching of students from first year to fourth year. We invest extraordinary faculty time and energy into teaching in most medical schools in the U.S. Family Medicine faculty are stretched thin because they want to increase students’ exposure to family physicians throughout all years of medical school.

But unless we address the core issue - the monolithic socioeconomic backgrounds of the students our medical schools are admitting - all of this additional expenditure of faculty time (which by the way is a very scarce and valuable resource) is not likely to change the picture. It’s time to focus on this issue. This can not be done by Family Medicine alone. It’s going to take a coalition of people within the medical school and in the larger community.

And a comment on AAMC’s response: the issue is not changing the interview process to address the “personal” side of the candidate. The issue is who is being interviewed in the first place. The second issue is who does the selecting. If basic science and non-clinical faculty continue to make up a large proportion of admissions committees, nothing will change.

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Larry Bauer is CEO of the Family Medicine Education Consortium.

Thursday, April 5, 2018

A family physician's favorite podcasts - updated for 2018

Late last year, I announced that I was planning to start my own podcast, to be called Common Sense Family Doctor after this blog. I did some reading about podcasting, downloaded Audacity to my laptop, and purchased the rights to some cool-sounding podcast theme music. Then life intervened. Patient care, teaching, editing, and other professional responsibilities completely consumed the time I thought that I would devote to the podcast, which remains on the drawing board. So what is the way forward? With the support of Georgetown's Center for New Designs in Learning & Scholarship, I now plan to explore podcasting to replace selected lecture content in my Patients, Populations and Policy course for first-year medical students. I hope that this "blended learning" project will give me the impetus I need to move forward with podcasting to a general audience sometime this summer. In the meantime, I've updated my previous list of favorite podcasts for your listening pleasure.

Health policy

HealthCetera
The Impact
POLITICO's Pulse Check
RoS: Review of Systems
State of Reform
What the Health?

Current events and popular culture

Every Little Thing
The Forward
How I Built This
TED Radio Hour
This American Life
30 for 30 Podcasts

History

Backstory
The Civil War: A History Podcast
Presidential
Revisionist History
Uncivil

Science and medicine

Air/Space
American Family Physician podcast
Hidden Brain
Houston We Have a Podcast
Methods
Sidedoor

Wednesday, March 28, 2018

For hypertension and diabetes, lower treatment targets are not necessarily better

In a previous Medscape commentary, I criticized the 2017 American College of Cardiology / American Heart Association clinical practice guideline on high blood pressure in adults, which proposed lowering the threshold for hypertension from 140/90 to 130/80 mm Hg. Independently, the American Academy of Family Physicians and the American College of Physicians both declined to endorse this guideline, citing concerns about its methodology (e.g., no quality assessment for included studies), management of intellectual conflicts of interest, and lack of information on harms of intensive drug therapy.

The March 15th issue of American Family Physician included a Practice Guideline summary and an editorial perspective on the ACC/AHA guideline by Dr. Michael LeFevre, a member of the panel that developed the JNC 8 guideline for hypertension in adults. In his editorial, Dr. LeFevre pointed out that the guideline's strengths include its emphasis on proper blood pressure measurement technique to avoid overtreating adults with normal out-of-office blood pressures. On the other hand, he argued that "it is an overreach" to classify everyone with a blood pressure above 130/80 as having uncontrolled hypertension. He predicted that since intensive behavioral counseling has only modest benefits in lowering blood pressure, many patients at low risk of cardiovascular disease will end up being treated with medication:

Much harm will come if this change [to the definition of hypertension] is widely accepted and implemented, particularly if quality measures that echo this definition are put into place. Harms from the consequences of poor measurement, overmedication, and arbitrary quality measures can easily offset the small reduction in CVD events found in trials of high-risk persons.

Blood pressure is not the only area of family medicine where there is ongoing debate about appropriate treatment thresholds. In a recent clinical guidance statement, the American College of Physicians recommended that clinicians "aim to achieve an HbA1c level between 7% and 8% in most patients with type 2 diabetes," and "consider deintensifying pharmacologic therapy in patients with type 2 diabetes who achieve HbA1c levels less than 6.5%." This statement elicited a critical response from the American Diabetes Association and endocrinology groups, who argued that lower blood glucose targets are sometimes appropriate to reduce the risk of microvascular and perhaps cardiovacular complications.

This debate between lower and higher A1c targets has been ongoing for years, as illustrated by a pair of Pro and Con editorials on this topic that appeared in AFP in 2012. On the whole, however, more relaxed glucose control can have substantial benefits, especially for older persons with type 2 diabetes, as Dr. Allen Shaughnessy and colleagues argued in 2015:

A large part of the acceptance that “lower is better” hinges on a false belief that a pathophysiologic approach to decision making is always correct. It seems logical that reducing blood glucose levels to nondiabetic normal, no matter the risk or cost, should result in improved patient outcomes. But it doesn't. Today, an older patient with type 2 diabetes is more likely to be hospitalized for severe hypoglycemia than for hyperglycemia.

Underlining this point, a vignette-based study in the March/April issue of Journal of the American Board of Family Medicine found that primary care clinicians (particularly internists and nurse practitioners) would often chose to intensify glycemic control in an older adult with a HbA1c level of 7.5% and multiple life-limiting comorbidities. As family physicians look for opportunities to improve care for patients with hypertension and diabetes, we should not miss opportunities to avoid harm.

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

Wednesday, March 21, 2018

Family physicians are underdogs among medical specialties

I only pay attention to college basketball during the first week of the NCAA tournament. Like many March Madness fans, I love rooting for underdogs. When the UMBC Retrievers became the first men's #16 seed to knock off overall #1 seed Virginia last week, I was in heaven. It broke my heart in 2016 when the upstart #14 seeded Stephen F. Austin Lumberjacks fell to Notre Dame in the second round on a last-second tip-in, a heartbeat from crashing the Sweet 16. In past tournaments, I was captivated by #11 seed George Mason's run to the Final Four in 2006 and #11 seed VCU's similar run from the First Four to the Final Four in 2011.


Family physicians are underdogs among medical specialties. If one were to rank student interest in the 24 specialties represented by the certifying boards of the American Board of Medical Specialties, the ROAD specialties (Radiology, Ophthalmology, Anesthesiology, Dermatology) would likely be #1 seeds, while Family Medicine, with its lower relative pay and more challenging work-life balance, would probably be seeded somewhere in the bottom half. Although the American Academy of Family Physicians cheered the results of last week's Residency Match, which saw another modest uptick in the number of U.S. medical students matching into Family Medicine residency programs, I have observed in a Medscape commentary that student interest in primary care is no "Match" for higher-income specialties. My own institution sent just 7 students out of a class of 200 into Family Medicine this year; nearly 3 times as many students matched into Orthopedic Surgery programs. It's no wonder that urgent cares, retail clinics, and telemedicine are thriving in the frontline health care void created by a growing shortage of primary care physicians.

What can medical educators do to increase student interest in primary care careers? Here's what I suggested in my commentary:

Early primary care exposure and required clerkships are necessary but not sufficient. ... Medical schools also need to "create a school culture that values primary care." That means advocating for excellence and innovation in primary care must be an explicit school goal, along with seizing every opportunity to discuss the foundational role of primary care in courses on health systems, and offering primary care tracks for selected students. Similarly, the Family Medicine for America's Health leadership team recommended creating longitudinal, integrated curricula in family medicine that allow students to make meaningful contributions to patient-centered care teams and have plenty of opportunities for faculty mentorship.

Embracing these strategies doesn't mean that family physicians won't continue to be viewed as the underdogs at tertiary academic medical centers where medical students receive the majority of their training, but it may give us more of a fighting chance to recruit students to our specialty before next year's medical version of March Madness.

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This is an updated version of a post that originally appeared on Common Sense Family Doctor on March 23, 2016.

Monday, March 12, 2018

Public health and advocacy resources for family physicians

Shaping local and national policies to improve patients' health outcomes is an appropriate and important role for family physicians. For the past several years, I have taught public health and advocacy skills to medical students, and last month, I attended Academy Health's National Health Policy conference in Washington, DC, for the first time. Although the majority of participants were researchers or policy analysts, family physicians were well-represented as medical directors, public health and insurance officials, and leaders of privately funded community health improvement projects.

In a previous blog post, I discussed the concept of assessing social determinants of health through "community vital signs," geocoded and individually linked data derived from public data sources. Although American Family Physician focuses on health interventions that clinicians provide in offices, emergency rooms, hospitals, and long-term care facilities, it also publishes resources to help family physicians improve social determinants outside of health care settings. For example, a 2014 editorial examined the role of the family physician in preventing and managing adverse childhood experiences, and a review article in the February 1 issue discussed implications for physicians of childhood bullying.

Previous editorials and articles have addressed environmental health hazards such as lead, radonair pollution and climate change, and a 2011 Letter to the Editor urged family physicians to take action to affect the built environment of American communities by "working to ensure that our patients have safe, convenient, and enjoyable places to walk, run, and bike." Other public health issues where physician advocacy can make a positive difference include food insecurity, homelessness, and firearm safety.

Family physicians are often first responders to natural and unnatural disasters in their communities. From influenza pandemics to bioterrorism, preparedness and early recognition is essential to protecting our patients. A 2015 editorial by my Georgetown colleague, Dr. Ranit Mishori, argued that the rapid spread of infectious diseases and migration and displacement of diverse populations have made global health knowledge essential for every family physician, regardless of location: "As the recent Ebola epidemic demonstrated, the world is not only smaller than ever, but it is also more intricately connected. Exotic diseases once confined to the third or developing world are now everyone's concern. Global has truly become local." For example, clinicians are likely to encounter victims of sex trafficking and labor trafficking in their practices.

AFP's sister publication, FPM, also provides resources for primary care clinicians with community and public health roles, from launching a community-wide flu vaccination plan, to following the Grand Junction, Colorado example of improving health system cost and quality outcomes, to working with community-based senior organizations. Finally, family medicine advocates can stay abreast of national initiatives that will shape the specialty's future, such as direct primary care, the patient-centered medical home, and the Medicare Access and CHIP Reauthorization Act (MACRA).

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This post first appeared on the AFP Community Blog.