In defense of forbidden words and evidence-based medicine

- Kenny Lin, MD, MPH

I was a federal employee in the Department of Health and Human Services (HHS) during the George W. Bush and Obama administrations. Although the current era of "fake news" and "alternative facts" lay in the future, some subjects were inherently more sensitive than others, depending on which party controlled Congress and the White House. For example, breast cancer screening with mammography made political waves when the U.S. Preventive Services Task Force released updated recommendations in 2009 (while Congress was debating the Affordable Care Act) and again in 2015 (as the House of Representatives repeatedly voted to repeal it).

Over the weekend, the Washington Post, STAT, and multiple other news outlets reported that the Centers for Disease Control and Prevention (CDC) and another unidentified HHS agency were recently provided with a list of seven "words to avoid" when writing budget proposals. These banned or forbidden words are: "vulnerable," "entitlement," "diversity," "transgender," "fetus," "evidence-based" and "science-based." Although CDC director Dr. Brenda Fitzgerald e-mailed agency staff and tweeted yesterday that "there are no banned words at CDC," neither she nor an HHS agency spokesperson denied the reports.

The unprecedented news created a firestorm on Twitter and elicited an immediate response from Dr. Michael Munger, President of the American Academy of Family Physicians (AAFP), who said in a statement:

The American Academy of Family Physicians, which represents 129,000 family physicians and medical students, is both surprised and concerned by the Administration’s clear disregard for the importance of science and evidence-based medicine. ... This action is an obvious attempt to politicize the most fundamental tenets of medicine and research, which will have a chilling effect on the CDC’s ability to rely on science to justify the work it does to protect public health.

American Family Physician is editorially independent from the AAFP, but the journal's editors stand with the organization in urging the Administration to "fully assess the broader implications of this purely political maneuver and reconsider its recent directive to the CDC." Further, we condemn censorship of science and public health in any form and will not allow it to infiltrate our content, which includes and will continue to include all of the seven forbidden words. Finally, we consider evidence-based medicine to be the essential foundation for ethical patient care, by distinguishing effective health care from tests and treatments that are unnecessary and harmful.

What's new with flu?

- Jennifer Middleton, MD, MPH

We're starting to see our first few cases of influenza where I practice, and the Centers for Disease Control and Prevention (CDC) confirms that the 2017-18 influenza season is off and running in the United States. The predominant activity thus far has been influenza A(H3N2), which is included in all formulations of the influenza vaccine available in the US. Less than 40% of eligible children and adults in the US have received this year's vaccine, but it's not too late to increase our practices' vaccination rates. Here are some simple tips and tools to help do so from the primary care literature.

The Annals of Family Medicine's latest issue includes a randomized controlled trial using text messages to encourage influenza vaccination that had modest success in an Australian multi-center trial. The researchers chose to focus on high-risk populations within these 10 practices including the elderly, young children, pregnant women, individuals with co-morbid health conditions, and certain ethnic minorities. An average of 29 patients (or parents) received text messages for every patient who was vaccinated, costing the practices $3.48 per additional vaccinated patient (at $0.12/text message). That "number needed to text" (my wording) may seem unimpressive, but the cost and time investment that resulted in those vaccinations was modest. The greatest increase in vaccination rates was in children under the age of 5.

An article from Family Practice Management reviews five simple steps to improving vaccination rates: find a champion, use standing orders, optimize your documentation, provide regular reminders to providers, and give ongoing feedback. The authors describe a template for their vaccination standing order, tips for documenting vaccines received elsewhere and vaccine refusals, the use of electronic health record (EHR) and visual reminder systems, and tracking vaccination numbers with simple office metrics. They review the evidence base behind each of these five steps and provide specifics regarding how to implement each one.

A recent AFP Practice Guideline reviews the CDC's Advisory Committee on Immunization Practices' (ACIP) recommendations for the current season. It includes descriptions of the currently available vaccination products and also provides guidance regarding vaccinating persons with a history of Guillain-Barre syndrome (only in individuals at high risk of complications from influenza) or egg allergy (closely monitor persons with a history of anaphylactic egg allergy immediately after vaccination).

The AFP By Topic on Influenza provides many more resources, including patient information handouts and tips for conversing with vaccine-adverse individuals. The CDC's weekly FluView report is another useful tool that I recently added to my AFP Favorites page.

What strategies has your practice used to encourage influenza vaccination?

A simple test to rule out pathologic heart murmurs in kids

- Kenny Lin, MD, MPH

It happens all the time to family physicians at well-child visits: we listen to the heart, 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 review in American Family Physician by Drs. Jennifer Frank and Kathryn Jacobe listed several "red flags" that make a pathologic murmur 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 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 disease. 100 children had a murmur that was present when supine 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 traditionally taught clinical features of physiologic murmurs, 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 pathologic 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).