Introducing the 2020-2021 AFP Jay Siwek Medical Editing Fellows: Dr. Joanna Drowos

Jennifer Middleton, MD, MPH

It's my pleasure to introduce the first of our 2020-2021 Jay Siwek Medical Editing Fellows, Dr. Joanna Drowos, whose fellowship year began on June 1. Here are some highlights from a recent interview with Dr. Drowos:

1. Tell us a little about yourself and your background.

I grew up in Toronto Canada, my family moved to South Florida when I was in high school. I went to University of Miami for my undergraduate degree (huge Canes fan) and then Nova Southeastern University College of Osteopathic Medicine for my DO and MPH degree. I chose an Osteopathic medical school and spent an extra year there completing a fellowship in Osteopathic Principles and Practice. I love using Osteopathic manipulation in my practice. I completed both family medicine and preventive medicine residency programs. I worked for our local county health department as the medical director for our communicable disease clinic before joining the faculty at FAU’s Charles E. Schmidt College of Medicine. I direct our Family Medicine Clerkship using an LIC model, and I also serve as the Associate Dean for Faculty Affairs.

 

LICs are longitudinal integrated clerkships. When medical students spend 4 weeks in an office, they may see a patient once or twice. When they are there for a longer time, in our case a year, they get to know patients better, see diseases progress, and earn trust to participate in their care. Many studies show educational outcomes are as good as those from traditional clerkships (evaluations and scores on standardized tests) however students demonstrate less “ethical erosion” or loss of empathy toward patients.

 

I use Osteopathic Manipulative Therapy as part of our Integrative Medicine practice. I am certified by both the ABFM and the AOBFP, and I spent an extra year in medical school completing a fellowship in Osteopathic Principles and Practice. I use these hands-on-techniques to move a patient’s muscles and joints using techniques that include stretching, gentle pressure, and resistance to relieve dysfunctions in the body. Many of my patients suffer with chronic pain, and I like to offer them an alternative other than prescription medications. My partner in the practice offers eastern practices such as acupuncture, cupping, traditional Chinese medicine, as well as micronutrient therapy.

 

2-3. What got you interested in medical editing and writing? What are you hoping to get out of the fellowship?

I really enjoy writing for scholarly purposes and was drawn to the medical editing fellowship because I feel it will make me a better author and critical reviewer for my colleagues. I want to develop my skills as both a reviewer and editor this year and feel grateful for the opportunity to be a part of the journal’s editorial team.

 

4. Is there anything else you'd like AFP readers to know about you?

I’ve been married to my husband Bryan for 16 years, we have 2 children, Lila (9) and Jackson (8), and a rescue dog named Coco. We love to travel and will spend some of our COVID time exploring in our new RV. I enjoy reading, visiting art museums, and attending live theater (you will have to ask me for the story about the Tony award).

Guest Post: Podcasts in Medical Education: Top Podcasts Every Family Physician Should Listen To

 - Viktoria Krajnc, MD and Michelle Sommer, MD

Podcasts play an important role in medical education. They allow busy medical students and residents to engage in asynchronous learning “on the go.” Listening to podcasts is also a useful way for attending physicians to engage in lifelong learning. Physicians can turn on a podcast at their convenience to hear the latest updates in medical practice, or to be entertained and inspired by their colleagues.

There are so many medical podcasts, it can be difficult to decide which one to listen to! There is scant research regarding podcast quality and credibility. A systematic review published in 2015 identified 151 potential quality indicators for medical blogs and podcasts, later narrowed to 13 and categorized into themes of credibility, content, and design. A 2018 AFP Community Blog post by our residency program director and AFP Podcast host Steven Brown, MD acknowledged that there had been little research performed regarding medical education podcast quality.  A 2016 AFP Community Blog post that has been viewed more than 4200 times to date provided an excellent “family medicine podcast playlist” of episodes.

Our question 

We sought to answer the following question: “With hundreds of podcasts with potential relevance to family medicine, how might educators recommend podcasts to learners and incorporate them into an educational program?” In response, we devised a systematic approach to reviewing podcasts relevant to family medicine and curated two lists of “Top Podcasts Every Family Physician Should Listen To.”

Our team 

Our team included Dr. Brown and residency faculty and AFP Podcast hosts Dr. Jake Anderson and Dr. Sarah Coles. At the time of this project, we were senior residents at the University of Arizona College of Medicine Phoenix Family Medicine Residency Program.

Methods

Dr. Brown curated our list of podcasts based on recommendations from Gabrielle Mayer and iTunes (where each podcast had at least a 4.5 star rating and multiple reviews). Our list consisted of 34 medical education or story-telling podcasts from family medicine, internal medicine, pediatrics, and obstetrics and gynecology. The AFP Podcast was excluded to avoid conflict of interest. Emergency medicine podcasts were excluded to focus on primary care. We devised a Ranking Rubric to appraise each podcast, with categories including length of episode, sound quality, credibility, entertainment, ease of listening, likelihood of listening regularly, and relatability. Each category was scored on a 1-5 scale, based on specific criteria for each numeric value. For narrative/story-telling podcasts, we did not include considerations for minutes to medical knowledge or credibility. We assigned 2 people to listen to a minimum of 3 episodes of each podcast. We then re-ranked every listener’s top 5 list using the rubric.

Our Lists

Top 5 Podcasts Every Family Physician Should Listen To For Medical Knowledge (Besides AFP Podcast) 

1. JAMA Clinical Reviews

2. Primary Care Update

3. Frankly Speaking About Family Medicine

4. Best Science Medicine

5. Peds in a Pod

Top 4 Story-telling/Narrative Podcasts Every Family Physician Should Listen To

1. Sawbones

2. This Podcast Will Kill You

3. The Nocturnists

4. Bedside Rounds

Considerations

It is impossible to find and listen to ALL medical podcasts, since the podcasting world is dynamic! Also, the target audience matters – certain podcasts are geared towards board exam review, while others try to teach students the basis of clinical practice. Our “Top 5” list was geared towards practicing family physicians.

The intent of listening varies: you may listen to a podcast one day for the latest evidence-based clinical updates, and may seek another podcast for entertainment or inspiration the next day.

Finally, these lists are based on the podcasts we listened to and our rankings. We hope that you find our Ranking Rubric to be useful in creating your own list.

We greatly value your feedback and look forward to your comments on Twitter or the AFP Facebook page! We hope that you listen to our virtual Society of Teachers of Family Medicine talk on August 24, 2020, titled “Podcasts in Medical Education,” where we will explain this project in greater detail.

**

Drs. Krajnc and Sommer were co-hosts of Season 5 of the AFP Podcast.

Microscopic hematuria: to refer, or not to refer?

 - Jennifer Middleton, MD, MPH

The American Urological Association (AUA) updated its guideline last month for evaluating microscopic hematuria. The AUA defines microscopic hematuria, or "microhematuria," as "greater than 3 red cells per high powered field," and the Choosing Wisely campaign advocates against diagnosing microscopic hematuria based solely on urine dipstick testing. While the AUA's 2012 guideline advised computed tomography (CT) imaging and cystoscopy for all persons over the age of 35 years with microscopic hematuria, the 2020 guideline tailors the diagnostic approach by risk factors, and a study published last month further validates one of these risk assessment tools.

The 2020 AUA guideline on microhematuria includes guidance on diagnosis and evaluation with a new emphasis on risk stratification. Patients with microscopic hematuria that the authors considered to be at low risk of bladder malignancy include women under the age of 50, men under the age of 40, a less than 10-pack-year tobacco smoking history, a single abnormal UA with no more than 10 red cells per high powered field, and no risk factors for urothelial cancer (family history, occupational exposures, history of pelvic radiation). The authors acknowledge that, while there is data linking various risk factors with a cancer diagnosis, little data exists regarding morbidity and mortality outcomes. Additionally:

While there are similarities between the current risk categories outlined in the Guideline and published risk score models...it should be acknowledged that these risk categories are not based on meta-analyses or original studies, and instead represent the Panel’s consensus based on a review of available data on risk factors for urinary tract malignancy.

One of the those risk score models, the Hematuria Risk Index (HRI), was developed in 2013 and was  further validated by a retrospective case study published just one month after this updated AUA guideline. The researchers performed a retrospective analysis of just over 1000 patients with asymptomatic microscopic hematuria and applied the HRI; they then performed a cost benefit analysis. Almost all of the patients had cystoscopy and CT imaging, and none with a score less than 5 were found to have cancer. The potential cost savings from avoiding these evaluations in the low-risk group were sizable:

[T]he cost to find one high-grade clinically significant lesion/cancer was $136,125.3 for the overall group. When the low-risk group was removed, the cost to find a high-grade clinically significant lesion/cancer decreased to $55,417.3 without missing any significant lesions. 

Family physicians, who typically care for a broad population, should think carefully about the adoption of subspecialty guidelines. Some, such as the American College of Cardiology/American Heart Association hypertension and cholesterol guidelines, have failed to receive endorsement by primary care groups such as the AAFP and the American College of Physicians. This new AUA guideline includes some statements that are, by its own admission, consensus-based, though the primary literature surrounding the HRI seems more robust. Avoiding unnecessary care is part of the inherent stewardship in primary care, and both the AUA guideline and this HRI study support de-escalating invasive testing for what is a benign symptom in many patients. Applying the HRI, and discussing with our urology colleagues which patients should undergo further testing, may be reasonable steps.

How do primary care physicians prioritize preventive services?

- Kenny Lin, MD, MPH

Although many clinical preventive services, including childhood immunizations, have unfortunately been deferred during the COVID-19 pandemic, it was difficult to address the lengthy list of screening tests, counseling, and preventive therapies with an "A" or "B" letter grade from the U.S. Preventive Services Task Force (USPSTF) even when most primary care visits were in person. In a previous AFP Community Blog post, I wrote about the National Commission on Preventive Priorities' (NCPP) ranking of preventive services based on population health impact and cost-effectiveness. The NCPP's highest-ranked services were the childhood immunization series; counseling and medications to assist smoking cessation in adults; and counseling to prevent initiation of tobacco use in children and adolescents. However, it isn't known how family physicians and other primary care clinicians actually prioritize the services we provide at health maintenance visits.

In a recent study published in JAMA Network Open, researchers from the Cleveland Clinic and Case Western University surveyed 137 internists and family physicians in their health system about 2 hypothetical adult patients who were each eligible for at least 11 preventive services. Based on the patient profiles and visit lengths (20 or 40 minutes), physicians were asked if they would find it necessary to prioritize preventive services, the factors they considered, and what their top 3 priorities were. The researchers compared physicians' stated priorities with a mathematical model that predicted what preventive services were most likely to improve life expectancy.

Unsurprisingly, physicians were more likely to need to prioritize services during a shorter visit, and they selected services that they thought would improve the patient's quality of life, help the patient live longer, and were strongly recommended by their professional organization or guidelines. Cost and patient adherence were less important in determining the services physicians discussed. Across both hypothetical patients, smoking cessation, hypertension control, glycemic control, and colorectal cancer screening were the most highly prioritized services. Only 35% of physicians included a lifestyle intervention (diet and exercise or weight loss) in their top 3 services, even though the mathematical model ranked both lifestyle interventions among the top 3 improving life expectancy for both patients.

As the researchers acknowledged, the intensive behavioral counseling interventions recommended by the USPSTF for adults with cardiovascular risk factors are not feasible in most primary care settings; lifestyle change presents substantial adherence challenges; and diet and exercise counseling are not generally included in quality of care metrics. However, brief evidence-based strategies to encourage health behavior change, as described in a 2018 FPM article, may be effective to prevent cardiovascular disease in individual patients. A recent post on FPM's Getting Paid Blog suggested three steps for family physicians to improve patients' utilization of preventive services during the pandemic.

Addressing racism and health inequities: a call to action

- Jennifer Middleton, MD, MPH

AFP Editor-in-Chief Dr. Sumi Sexton's online letter, "We're Listening and Taking Action on Racism and Health Inequities," outlines AFP's plan to "to take a deep dive and understand what transformations will be necessary for the journal going forward." We can each follow Dr. Sexton's lead to transform our own practices to eliminate health disparities, improve health outcomes for our Black patients, and support our Black colleagues.

First, family physicians must learn to recognize how different conditions may present in persons of color, especially dermatologic diagnoses. A recent letter to the editor re: the AFP article on "Erythema Multiforme: Recognition and Management" asserts that 

Family physicians must learn how dermatologic conditions present in skin of color to serve our increasingly diverse patient population better and to avoid incorrect or delayed diagnoses. Any article about dermatologic disorders...must include how the skin disorder presents in skin of color.

Dr. Lin's response to this letter includes a reference to the 2013 AFP series on "Dermatologic Conditions in Skin of Color" (Part I and Part II). Educating ourselves - and improving our educational structures - to consider all skin types is imperative to accurate diagnoses in persons of color.

Another letter to the editor this past week criticized "the use of race in guiding the selection of antihypertensive medications without acknowledging that race is socially constructed" regarding this hypertension treatment article. Dr. Lin and Dr. Sexton replied that, "[u]nfortunately, the literature contains many examples of the uncritical use of Black race in clinical decision-making," and "we need research that explores the complexities of health disparities and their effects on clinical outcomes so that we can encourage our authors to include these types of studies in their qualitative reviews of the literature." As readers, we need to critically question the use of race in clinical studies, and researchers need to heed Dr. Lin and Dr. Sexton's call to expand their scope.

The Annals of Family Medicine's website is featuring two articles from its archives on its website that can help us broaden our perspective on racism. The 2016 article "Racism in Medicine: Shifting the Power," written by Dr. J. Nwando Olayiwola, a Black female physician, outlines her experience of hearing a rant of hateful language, including a racial slur, from a white patient during an office encounter. Reading this account can be uncomfortable, but we must lean into that discomfort, acknowledging that this incident is only one of an innumerable multitude:

Black women (and other professional minority women) have to justify professional qualifications that should speak for themselves. We have to be “twice as”…good, smart, talented, aggressive, outspoken, witty, etc than everyone else in our professional or work environments; proving that we are not “imposters;” biting our tongues and tempering our words because we don’t want to appear “angry;” being passed up or looked over, underpaid, undervalued, and under-appreciated.

The 2018 article, "White Privilege in a White Coat: How Racism Shaped my Medical Education," written by Max J. Romano, a white medical student, provides a poignant contrast. Unlike Dr. Olayiwola, who is constantly aware of racism, Mr. Romano recognizes that he is not:

Most white doctors do not think race affects them or their clinical decisions and are taught to ignore their own racial privilege in favor of a meritocratic social myth. However, multiple studies reinforce the existence of racial bias among physicians and its negative implications for patient care.

If we are to provide optimal patient care for our Black patients, we must confront our role in maintaining the systems that reinforce racism. Those of us who are white must undertake the work to recognize the privilege our skin color has afforded us and understand our implicit biases. We must reach out to our Black colleagues and patients with genuine caring; we must also take care, however, not to expect them to educate us about the racist structures that pervade our society, as resources already exist for us to educate ourselves. Let us each commit to do so; our Black patients and colleagues deserve nothing less.