Guest Post: Transcend helplessness, advocate for transgender patients

- Hayley E. Cummingham, MD and Tonia Poteat, PA-C, PhD

Do you remember that feeling as a medical student, back against a wall as you watched life and death unfold? You may have felt disappointed when that sense of helplessness did not disappear with a medical degree. It is easy to feel helpless when your patients fear being “defined out of existence.” In October 2018, the New York Times uncovered a memo from the U.S. Department of Health and Human Services (HHS) that proposed redefining “sex” as written in numerous anti-discrimination laws to be “based on immutable biological traits identifiable by or before birth.” This represented a dramatic policy reversal from 2016, when HHS passed a regulation clarifying that discrimination on the basis of sex encompasses gender identity.

Emboldened by the current administration’s perceived animosity toward the transgender community, conservative state representatives and organizations sued the HHS in 2016, rendering it unable to enforce protections against gender identity discrimination as the executive branch reviewed the regulation. The outcome was a proposed rule issued last month, which includes a narrowed definition of “sex” that will allow health care providers and insurers to refuse to provide or cover medically necessary and potentially life-saving care.

According to a 2015 survey, 40% of transgender adults have attempted suicide and 82% have seriously considered it. Rates of suicidal ideation and attempts among transgender adolescents reach 51% and 30%, respectively. A growing body of evidence indicates that access to gender affirming therapies, including but not limited to exogenous hormones and surgery, can reduce the risk for suicide among transgender people.

It is easy to feel helpless in the face of injustice, but physicians have the power to influence social and political determinants of health. For example, having entered a 60-day period for public comment on the proposed HHS regulation, physicians and others can voice their opposition at https://protecttranshealth.org. Physicians can attend advocacy events wearing white coats, meet with elected representatives, or publish opinion pieces. Consider keeping a de-identified record of patient stories and reach out to an advocacy organization for guidance on using them to advocate for those patients. Physician educators, testing boards, and residency programs can train future physicians on the health care needs of gender-diverse individuals.

Within your own practice, ensure that you are not part of the problem, and empower yourself to provide gender-affirming care. One third of transgender persons have had at least one negative experience with a clinician in the past year related to being transgender, including verbal harassment (6%), treatment denial (8-11%), invasive or unnecessary questioning (15%), or clinician ignorance requiring education by the patient (24%). Reading the December 2018 AFP article, Caring for Transgender and Gender-Diverse People: What Clinicians Should Know, is an excellent place to start. In addition to the steps outlined in the article, you can offer to write “carry letters,” which explain that a patient is undergoing gender transition and that appropriate pronouns and facilities are medically necessary. These documents advocate for patients in situations involving bathrooms, airport security, police interactions, employers, residential placement, etc. You can dive deeper by familiarizing yourself with national and global guidelines and utilize online resources offered by the Fenway Institute. Before making referrals, contact providers to assess their level of comfort caring for transgender patients or use a gender-affirming provider directory.

Every day that we care for patients, we put ourselves at risk for feeling helpless. When our patients face increasing social and political injustice, we cannot be wallflowers. For the well-being of our patients and ourselves, we must advocate.

Behind the scenes of the AAFP guideline on depression after acute coronary syndrome

- Kenny Lin, MD, MPH

The June 15 issue of AFP features the original publication of an updated guideline from the American Academy of Family Physicians (AAFP) on screening and treatment of patients with depression following acute coronary syndrome. This is the first product of a new partnership between the best-read journal in primary care and the AAFP's Clinical Practice Guidelines development team. As a past Chair (2015-2017) of the AAFP's Subcommittee on Clinical Practice Guidelines (SCPG) of its Commission on Health of the Public and Science (CHPS), I know how much time and effort goes into creating evidence-based guidelines for family physicians. A series of four short videos on the AAFP website provides a general overview of the clinical practice guideline development and assessment process, which is documented in detail in its Clinical Practice Guideline Manual.

For this specific topic, a panel of 4 family physicians, an internist, a patient representative, and a PhD clinical policies strategist with no relevant conflicts of interest updated a 2009 AAFP guideline on detection and management of post-myocardial infarction depression. This topic was deemed still relevant to family medicine and nominated by the AAFP in 2016 to the Agency for Healthcare Research and Quality (AHRQ)'s Effective Health Care Program for an updated systematic evidence report. The independent systematic review team solicited input from subject experts and panel members to develop a structured research protocol that focused on answering two key questions:

1. What is the accuracy of depression screening instruments or screening strategies compared to a validated criterion standard for post-acute coronary syndrome (ACS) patients?

2. What are the comparative safety and effectiveness of pharmacologic and nonpharmacologic depression treatments in post-ACS patients?

The completed evidence report, posted on AHRQ's website and published in condensed form in the Annals of Internal Medicine in November 2017, served as the basis for the panel's recommendations. The panel rated the evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology, which differs somewhat from AFP's Strength of Recommendation Taxonomy. GRADE provides a framework to assess the certainty of the evidence and develop structured statements based on that evidence and the values/considerations that influenced the recommendation.

The draft post-ACS depression guideline was internally peer reviewed by members of the SCPG and the AAFP's Science Advisory Panel, followed by external reviews by cardiology experts, mental health professionals, and representatives of other relevant organizations. After changes were made in response to peer review comments, the revised guideline was reviewed by the full SCPG and CHPS, then forwarded to the AAFP's Board of Directors for approval. The guideline makes two major recommendations:

1. The American Academy of Family Physicians recommends that clinicians screen for depression, using a standardized depression screening tool, in patients who have recently experienced an acute coronary syndrome event (weak recommendation, low-quality evidence). Individuals should undergo further assessment to confirm the diagnosis of depression (good practice point).

2. The American Academy of Family Physicians strongly recommends that clinicians prescribe antidepressant medication, preferably selective serotonin reuptake inhibitors or serotonin-norepinephrine reuptake inhibitors, and/or cognitive behavior therapy to improve symptoms of depression in patients who have a history of acute coronary syndrome and have been diagnosed with depression (strong recommendation, moderate-quality evidence).

Notably, although treating depression after ACS improves depression symptoms, there remains insufficient evidence that depression treatments reduce cardiovascular or overall mortality. A Practice Guidelines synopsis in the June 15 issue also discusses barriers to implementing the guideline in practice such as lack of time, reimbursement, and institutional support for routine depression screening; and limited access to behavioral health services. Implementation resources available in the guideline itself include Tables comparing depression screening tools and medications and advice about use of practice champions.

Has aspirin for primary prevention of CVD reached its expiration date?

- Kenny Lin, MD, MPH

A daily low-dose (81 mg) aspirin was once considered an essential component of cardiovascular disease (CVD) prevention for middle-aged and older adults. In 2006, the National Commission on Prevention Priorities ranked "discussing aspirin use in high-risk adults" the highest priority preventive service based on clinically preventable burden and cost effectiveness, and two years ago, in an updated set of rankings, it still rated aspirin use as the fifth highest priority for improving utilization. However, in 2018 the results of three large randomized trials suggested that the harms of aspirin taken to prevent a first CVD event outweigh its benefits for most persons. In an editorial in the June 1 issue of AFP, Dr. Jennifer Middleton and I reviewed the latest evidence and concluded:

The new data do not exclude the possibility that aspirin may still benefit adults at very high CVD risk (e.g., 20% or more over 10 years) or those at lower risk who are unable to tolerate statins, but the data otherwise suggest that the risks of low-dose aspirin therapy for primary prevention outweigh any potential benefits. For most patients, we should be deprescribing aspirin for primary prevention of CVD. To prevent heart attacks and strokes, family physicians should focus instead on smoking cessation and lifestyle changes, controlling high blood pressure, and prescribing statins when indicated.

In a 2019 clinical practice guideline, the American College of Cardiology / American Heart Association largely concurred, recommending against prescribing aspirin for primary prevention of CVD in adults older than age 70 and downgrading its role in other adults at high risk to "may be considered" on a case-by-case basis.

Although aspirin is still strongly recommended to prevent recurrent CVD events, its rise and fall in primary prevention seems to have become another case of medicine reversing itself. Unlike other notable examples of medical reversal such as menopausal hormone therapy and tight glucose control in type 2 diabetes, the effectiveness of aspirin was supported by many well-conducted randomized, controlled trials. Aspirin worked ... until it didn't. In a recent commentary in the Journal of General Internal Medicine, Palmer Greene and colleagues suggested that it may be a good idea to consider established evidence-based practices as having an "expiration date":

An “evidentiary statute of limitations” would require the occasional reassessment of accepted therapies to consider which might no longer be of use—possibly because of changes in the population as a whole, a changing understanding of whom the treatment is appropriate for, or evolving therapies for the prevention or treatment of the disease in question. Not only should we consider if older data still applies, we should also strive to anticipate the factors to which the results of a newly published positive study might be sensitive. For instance, is there an event rate in the control group below which the harms of the therapy might outweigh the benefit? Is there a treatment success rate that, when achieved, would make screening inefficient?

Not starting aspirin is relatively straightforward, but patients who have taken aspirin for many years without adverse effects or CVD events may resist discontinuing it. What approaches have you taken to this complex discussion?

Making the most of screen time: recommendations for families

- Jennifer Middleton, MD, MPH

With the academic year wrapping up, planning for the summer months is a reality for many American families. While planning for vacations and other away activities is often paramount, considering in advance how to spend days at home can be equally valuable. Setting expectations and limits on screen time at the beginning of the summer break can set families up for success in encouraging physical activity and good sleep habits.

The American Academy of Pediatrics (AAP) recommends no screen time for children younger than ages 18-24 months and limiting screen time to one hour of “high-quality programming” for children aged 2-5 years. For older children, the AAP advises setting limits that are consistent with “your family’s values and parenting style.” Engaging in media use with children and teens is preferred to unsupervised use, and families are discouraged from placing televisions, computers, and video game consoles in children’s bedrooms. Parents and guardians can use a Family Media Plan tool to develop personalized screen time expectations.

Last summer, the American Heart Association (AHA) also weighed in on screen time recommendations, publishing a scientific statement in Circulation describing concerns with increased sedentary behavior, obesity, and future health risks linked to excessive screen time. The authors cited data showing that adolescents who exceed two hours of screen time daily are 1.8 times more likely to be obese (odds ratio 1.82 [95% confidence interval 1.06-3.15]); this study also found that “screen time is a stronger factor than physical activity in predicting weight status in both children and adolescents.” The AHA has similar recommendations as the AAP regarding screen time use: set time limits, keep screens out of bedrooms, and engage in media together as a family.

You can find more recommendations from the AAP, including specifics about social media safety for teens, at this website. A wealth of parent and patient education materials is available at healthychildren.org’s Media page, including advice about when to give children their first smartphone, identifying age-appropriate media, and combating cyberbullying. The American Academy of Family Physicians' Familydoctor.org website also offers a helpful patient education handout on healthy habits for TV, video games, and the Internet.