Monday, August 22, 2016

Overcoming obstacles to HPV vaccination

- Kenny Lin, MD, MPH

Human papillomavirus (HPV) vaccines, which prevent infection with HPV genotypes that cause cervical, anal, vaginal, and penile cancers, are hardly new. The quadrivalent and bivalent HPV vaccines were reviewed in AFP in 2007 and 2010, respectively, and a 9-valent vaccine was approved by the U.S. Food and Drug Administration in 2014. Although long-term studies have yet to demonstrate that HPV vaccines reduce cancer rates, a recent systematic review found that introduction of the quadrivalent vaccine in 9 countries (including the U.S.) was associated with a 90% reduction in infections from the targeted genotypes and similar reductions in genital warts and high-grade cervical abnormalities. Women who receive HPV vaccine are at considerably lower risk for undergoing colposcopy and associated invasive diagnostic or therapeutic procedures.

The Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices (ACIP) recommends that all boys and girls receive the 3-dose HPV vaccine series at age 11 to 12. However, CDC data from 2014 show that only 40% of girls and 21% of boys had completed the series by age 17. In contrast, 80% of 13 to 17 year-olds had received meningococcal vaccine, and 88% had received TdaP (tetanus, diphtheria, and acellular pertussis) vaccine, which provide protection against serious, but comparably rare, infections. Earlier this year, all 69 National Cancer Institute-designated Cancer Centers released a consensus statement expressing concern about persistently low HPV vaccination rates in the U.S. compared to other countries, which they labeled a "serious public health threat."

A 2015 AFP editorial by Drs. Herbert Muncie, Jr. and Alan Lebato examined parental and physician impediments to HPV vaccination. Parents often express concerns about vaccine safety and worry that their children may be more likely to start having sex after receiving the vaccine. Family physicians can reassure parents on both of these questions:

Parental safety concerns about the HPV vaccine increased from 4.5% in 2008 to 16% in 2010, although the reported adverse effects have been minor (e.g., injection site reactions, syncope, dizziness, nausea, headache). Studies have shown that adolescents who receive the HPV vaccine do not initiate sexual activity earlier, nor is their risk of acquiring an STI increased.

In other cases, physicians have been the primary obstacles to vaccination: they are sometimes reluctant to bring up the topic of sex, they believe the vaccine is unnecessary because Pap smears will detect early cervical cancer, or they present the vaccine as "optional" or don't offer it at all. Drs. Muncie and Lebato suggested several effective strategies for improving HPV vaccination rates:

Instead of discussing the vaccine as a means of STI prevention, physicians can present it as a way to prevent cervical cancer in women and oropharyngeal cancer in men. They can mention that immunologic response is greater in younger adolescents, so earlier immunization is prudent. Physicians should encourage HPV vaccine administration at the same time that other adolescent vaccines are given. They should review immunization status at every visit, and administer the HPV vaccine at any time—including during sick visits.

An editorial in AFP's July 15th issue by Drs. Jamie Loehr and Margot Savoy provided additional tips for physicians on addressing and overcoming vaccine hesitancy in general. More immunization resources, including the latest childhood and adult immunization schedules from the ACIP, are available in AFP's Immunizations Topic Collection.

Monday, August 15, 2016

Relieving chronic work-related pain and job insecurity

- Marselle Bredemeyer

A Curbside Consultation article in AFP’s July 15th issue highlights the difficulties that immigrants working in low-wage jobs experience when it comes to addressing workplace hazards without the support of advocates and health care professionals. This challenge is not unique to immigrants, although they are disproportionally affected; underreporting of workplace injuries is a widespread problem. The Occupational Safety and Health Act, which was passed in 1970, covers persons working in nearly all sectors and protects all employees regardless of immigration status.

The Occupational Safety and Health Administration (OSHA), formed to enforce elements of the labor act, has its weak points, however. In a response to recent requests that sought reduced production line speeds at poultry plants, an OSHA representative cited “limited resources” as one factor precluding the implementation of definitive rules from being considered. The expectation for employers is broad, in any sense—they have a “general duty” to ensure a safe workplace.

Where does this leave patients like the one in the Curbside Consultation article? Although workers can’t anticipate that there are explicit regulations applying to individual aspects of their job, such as the amount of weight they are permitted to lift, there are actions that can be taken—like those described in the article commentary—to prevent long-term injury from repetitive motion.

Unlike the legal right to work in a safe environment, immigration status has a huge bearing on a person’s access to health care. In the case scenario described in the journal feature, the patient’s Cuban origin ensured her Medicaid eligibility for a temporary time. Many immigrants who are legally present are ineligible for Medicaid for five years after arrival, however, and those who are undocumented cannot shop for private coverage on the Patient Protection and Affordable Care Act’s (ACA) exchanges. Refugees and asylees, along with other select groups, whether from Cuba or dozens of other countries, have immediate access to health care assistance for at least eight months.

There are still a number of questions that researchers need to tackle regarding occupational health among immigrants. How can employers reduce the undue risk of harm migrants face in the workplace? Why does this disparity exist? Fear of job loss is, unfortunately, all too often well founded. Family physicians who are aware of existing labor protections and legal and community resources can not only guide the treatment of occupational disorders, but also empower patients who choose to take steps to improve workplace safety. Without a physician to take a directed history in the first place, connections between acute and chronic illnesses and workplace conditions will remain in the dark.

Monday, August 8, 2016

Virtuous cycling: lower diabetes risk, but wear a helmet

- Kenny Lin, MD, MPH and Jennifer Middleton, MD, MPH

I (Jennifer) live in a community with a wonderful bicycle path system, and around this time of year it gets a lot of use. In a 2011 Letter to the Editor titled "The Virtuous Cycle," AFP Deputy Editor Mark Ebell, MD, MS encouraged readers to advocate in their communities for "safe, convenient, and enjoyable places to walk, run, and bike" rather than continuing to "harangue our patients about exercise and be frustrated when they do not listen to us."

Sensible advice, but do recreational and commuter cyclists have better health outcomes than non-cyclists, is it enough to cycle during only part of the year, and is it ever too late to get on the bike? A prospective cohort study of more than 50,000 Danish men and women recruited between the ages of 50 and 65 and followed for an average of 14 years recently provided answers to these questions. In a multivariable analysis, both seasonal and year-round cyclists had up to a 20 percent reduced relative risk for developing type 2 diabetes, even if they started cycling late in life.

The health benefits of cycling can be easily negated, though, by the risks of not wearing a helmet. Even though helmet-wearing cyclists are more likely to survive trauma than those not wearing helmets, and despite laws mandating helmets across the country, many bicycle riders continue to go bareheaded. A 1999 survey found the most common reasons for not wearing a helmet included "uncomfortable," "annoying," "it's hot," "don't need it," and "don't own one." This survey also found that peer and/or parent wearing of helmets increased the likelihood that children wore them too.

A review of children's cycling accidents from the National Trauma Data Bank found that white children and/or children with private insurance were much more likely to wear a helmet than African-American children and/or children with Medicaid. Another study in Los Angeles County found lower helmet use among older children, non-white children, and children from a low socioeconomic status. Programs that give away free helmets to children either in schools or in physicians’ offices increase helmet use and may reduce health disparities. Although physician counseling also increases helmet wear in patients under age 18, in one survey less than half of physicians providing care to this age group provided it. Unfortunately, there haven't been any studies of interventions to increase helmet wearing in adults.

The bottom line is that encouraging patients to start cycling for long-lasting health benefits should be accompanied by counseling on the importance of wearing helmets.

Monday, August 1, 2016

Guest Post: preventing sexual assualt

- Yalda Jabbarpour, MD

“You don’t know me, but you’ve been inside me, and that’s why we’re here today.” So began the statement of Brock Turner’s victim at his sentencing this spring. Turner, a former Stanford University student, was found guilty of three counts of sexual assault, but his 6 month sentence sparked outrage. Although this case brought renewed interest to the problem of sexual assault, the sad truth is that it is not unique. A recent poll conducted by the Washington Post and Kaiser Family Foundation found that 20 percent of young women reported being sexually assaulted on their college campuses in the past four years. 1 in 5 women. As a mother and family physician who cares for adolescents, these statistics are frightening, especially considering the life-long physical and psychological consequences for the victims.

According to a 2010 article in AFP, sexual assault is associated with sexually transmitted infections (STIs), posttraumatic stress disorder, anxiety, depression, chronic pain syndromes, drug and alcohol abuse, irritable bowel syndrome, headaches, fibromyalgia and sexual dysfunction. Sexual assault is a true public health crisis. What can family physicians do to curb this epidemic?

Much of the literature on the physician’s role in sexual assaults deals with the aftermath: collection of the rape kit, post-exposure STI prophylaxis, identifying and treating long term physical and psychological sequelae. But I would argue that, as is the case in much of what we do, prevention is the key. I propose we start by defining the problem for our patients. In the Post/Kaiser poll, 46 percent of college-aged respondents said it’s unclear whether sexual activity that occurs when both people have not given clear agreement constitutes sexual assault. This means that we need to have open and honest conversations with adolescents and young adults about the need for both parties to give consent before having sex. Establishing rapport is key to broaching sensitive topics with adolescents, and to do this, it is important to ask adolescents specific questions about their practices rather than stating general facts.

Once we have defined the problem, we need to counsel patients on the risk factors associated with it and how to mitigate those. Race, ethnicity, social class, study habits or religious practices were not related to sexual assault in the Kaiser poll. However, women who said they sometimes or often drink more than they should are twice as likely to be victims of completed, attempted or suspected sexual assault compared with those who rarely or never do. Therefore, counseling men and women on responsible drinking strategies—such as using a buddy system, pouring their own drinks, and knowing their limits—is key.

Certainly, physicians alone cannot solve the issue of sexual assault, but we should consider addressing it in every preventive health discussion we have with college-aged students. When sharing her solidarity with other victims of sexual assault, the Stanford victim appropriately quoted Anne Lamott: “Lighthouses don’t go running all over an island looking for boats to save; they just stand there shining.” It may not be within our power, or our job description, to stamp out sexual assault, but physicians can serve as lighthouses, helping to illuminate for our patients a safe path through their college careers.


Dr. Jabbarpour is the Robert L. Phillips, Jr. Health Policy Fellow at Georgetown University School of Medicine.

Monday, July 25, 2016

Stepping up counseling about sun safety

- Jennifer Middleton, MD, MPH

The U.S. Preventive Services Task Force (USPSTF) is currently updating its 2012 recommendations regarding counseling to prevent skin cancer, and it couldn’t come at a better time, as the incidence of malignant melanoma continues to rise. The USPSTF found previously that counseling fair-skinned individuals aged 10-24 increases the use of sun-protective behaviors, but this counseling isn’t happening frequently enough in primary care.

A 2004 study of family physicians found that only 60% were routinely providing counseling about sun protection and skin cancer prevention; commonly cited barriers to doing so included lack of time and limited information about the effectiveness of counseling. A more comprehensive survey in 2014 found that family physicians provided sun safety counseling far less frequently, and usually only in association with specific patient diagnoses such as actinic keratosis or a history of other skin problems. In contrast to what the evidence supports, the age group most likely to receive counseling in this study was adults in their 70s; counseling at child and young adult visits was rare. Since only 30% of adults regularly follow sun safety practices, and tanning in young adults remains highly prevalent, there are ample opportunities for family physicians to make a difference for our patients by providing this counseling.

Other effective interventions may be worth incorporating into your practice as well. Mailing personalized handouts about skin cancer prevention increased sun safety behaviors (use of sunscreen, protective clothing, hats, and sun avoidance) more than providing generic handouts in one study. In another study, calculating a melanoma risk score (SAMScore) and targeting counseling to patients at higher risk decreased sunbathing. Counseling young adults about tanning should elicit the specific reasons why they tan; physicians can then target their messages, such as discussing sunless tanning products, alternative methods to relax, or debunking the myth that a tan protects against further skin damage. 

Helping patients adopt healthier behaviors is an important part of the primary care clinician's role, and applying motivational interviewing techniques along with tailoring our counseling to each patient’s stage of change may be useful. Having a structured practice intervention to help patients adopt sun safety measures may also reduce the burden on individual clinicians.

Monday, July 18, 2016

25 podcast episodes every family physician should listen to

- Marselle Bredemeyer

As an associate editor in the AFP editorial offices in Leawood, KS, I work alongside our authors and other non-physician staff to help craft each issue of the journal. We use checklists, stylebooks, and calculators to prepare articles for press, guided by our readers and their needs throughout the process. More than merely gauging the readability of a sentence, this means visualizing the big picture: the information we provide being used at the point of care, as research material, or for continuing education. This picture comes together over time, by staying tuned in to comments we receive on the website, phone, through e-mail, and via social media (Twitter and Facebook), where I love to see replies and messages about the content I am sharing.

My sketch of the family medicine specialty has largely been shaped by these experiences, but the voice that sticks in my mind as I work comes from a podcast, an early episode of Slate’s “Working” that featured a family physician from Washington, D.C. Whether you’re new to podcasts or a long-time listener, the format’s storytelling power and lasting impact are what make it stand out.

As the number of podcasts continues to grow, so has an emphasis on the deep-listening strategies that can improve patient care in the office setting. Shared decision making is often a central part of care, from screening practices to end-of-life planning. Hearing what patients are saying and communicating with them in a way that meets their needs can transform their health, even at routine visits.

With that in mind, podcasts, and their ability to make us engage with others’ stories, might be useful to physicians as they look for ways to take in new information, and above all, try to stay tuned in to the underlying messages their patients are sharing. Want to start listening or add new favorites to your queue? With the help of AFP Podcast hosts Steve Brown, MD, Jake Anderson, DO, and Luke Peterson, DO, the four of us have come up with a family medicine podcast playlist that features a variety of shows talking about medicine, public health, and patient relationships. If the tweet might help medical students learn better note-taking, the podcast might help us all be better listeners.

What are you listening to? Share this post and add your own favorite episodes when you do!

AFP Podcast
Bonus Episode with J. Lloyd Michener, MD

Only Human
Doctor Stories: The Patient I’ll Never Forget
How to Stop an Outbreak

This American Life
Something Only I Can See

The House
The Hospital

Questioning Medicine
The Dexa Scam

Sawbones: A Marital Tour of Misguided Medicine
Heroes of Patent Medicine

The Secret History of Thoughts
The Problem with the Solution

Best Science Medicine
Televised Medical Talk Shows (paid subscription required; listen to new episodes for free on iTunes)

The Cathedral
Staph Retreat
Patient Zero: Updated

A Gobbet o’ Pus 810
Occam and Fallacies

99% Invisible
Fountain Drinks

Planet Money
The Experiment Experiment
Black Market Pharmacies
Your Organs Please
Clipping Coupons for Health Care

How to Become Great at Just About Anything
How Many Doctors Does It Take to Start a Healthcare Revolution?