The top ten AFP Community Blog posts of 2020

 - Kenny Lin, MD, MPH

Unsurprisingly, 7 of our 10 most-viewed blog posts from this pandemic year were related to COVID-19. Beginning in February, when I wrote with concern about initial reports of a novel coronavirus that was rapidly spreading from its original epicenter in Wuhan, China, the pandemic accelerated, transmitting exponentially across the United States by mid-March and causing state governments to close schools and non-essential businesses. In addition to the worldwide death toll (which, per the Johns Hopkins University Coronavirus Resource Center, stood at nearly 1.8 million as of today), we forecasted the staggering mental health impacts of the virus and prolonged economic disruption and social isolation.

Contributing editor Allen Shaughnessy, PharmD and his colleague Dr. Andrea Gordon provided ten points to consider when applying evidence-based medicine in a pandemic. Dr. Middleton described one of the more unusual manifestations of COVID-19 infection, "COVID toes," and our 2019-20 Resident Representative, Dr. Enkhee Tuvshintogs, discussed how medical students were adapting to disruptions in their educational programs and personal lives. Finally, we reviewed fraudulent COVID-19 research publications and the summer of #BlackLivesMatter protests against police violence and the persistence of structural racism that produced, among other things, vast disparities in coronavirus infections and mortality among African Americans.

Of course, 2020 included other important medical stories. Personally, we mourned the passing of AFP executive editor Joyce Merriman, who capably led our professional editor team for 15 years. Two past AFP Podcast co-hosts reviewed 9 other highly ranked podcasts for family physicians for medical education or moving health narratives. And Dr. Middleton argued that the results of a recent randomized controlled trial could mean that intermittent fasting's time in the popular diet limelight may be up.

All of us at American Family Physician hope that you and your loved ones are having an enjoyable holiday season, and we look forward to 2021 being a less unprecedented and more optimistic year.

Here come the COVID vaccines

 - Jennifer Middleton, MD, MPH

Last month, I wrote about the process for vaccine approval by the United States (US) Food and Drug Administration (FDA). Since then, the Pfizer/BioNTech SARS-CoV-2 vaccine has received Emergency Use Authorization (EUA), joined by the National Institutes of Health (NIH)/Moderna vaccine at the end of last week. These two vaccines use a novel mRNA process to induce immunity; a third vaccine by Oxford/AstraZeneca, which instead uses a chimpanzee adenovirus vector ("viral vector"), has just published its interim analysis data.

The Oxford/AstraZeneca ChAdOx1 vaccine was tested in nearly 35,000 individuals across Brazil, the United Kingdom (UK), and South Africa in phase 2/3 trials. Importantly, only adults aged 18-55 were enrolled. When researchers received the manufactured vaccine in the UK, though, their measurement of the viral particle concentration was higher than expected. To maximize safety while their teams resolved this discrepancy, they chose to inoculate the first group of participants with a lower dose for their first injection. Once the researchers settled the issue with their quantification methods, all participants then received the originally planned full dose of the vaccine for their second injection. Later UK enrollees and participants at the other trial sites received the full dose for both injections. 

Interestingly, the low dose cohort had better protection against COVID-19 than the participants who received two full dose injections:

In participants who received two standard doses, vaccine efficacy was 62·1% (95% CI 41·0–75·7; 27 [0·6%] of 4440 in the ChAdOx1 nCoV-19 group vs71 [1·6%] of 4455 in the control group) and in participants who received a low dose followed by a standard dose, efficacy was 90·0% (67·4–97·0; three [0·2%] of 1367 vs 30 [2·2%] of 1374; pinteraction=0·010).

The researchers did not have an explanation for this surprising finding, though they rightly point out that the confidence intervals are quite wide for both values.

This vaccine is unlikely to achieve EUA status in the US soon. Oxford/AstraZeneca failed to promptly notify the FDA of the dosing snafu as well as the decision to pause trials in September after a participant was diagnosed with transverse myelitis. The FDA reportedly learned about these issues via the lay press and not the study investigators, which reportedly did not sit well with FDA leadership. The FDA didn't clear Oxford/AstraZeneca to resume vaccine trials in US until October, which put them behind Pfizer/BioNTech and NIH/Moderna in the race to generate phase 3 trial data. And, they have yet to produce any data regarding their vaccine's efficacy in adults over the age of 55, the population arguably at greatest risk of COVID-19 mortality.

Assuming it eventually catches up, the Oxford/AstraZeneca vaccine has several appealing properties. Unlike the two mRNA vaccines by Pfizer/BioNTech and NIH/Moderna, the Oxford vaccine does not require ultra-cold storage and is much less expensive to produce. For parts of the world where storing and/or procuring an mRNA vaccine is not affordable or practical, the Oxford/AstraZeneca vaccine offers an alternative. 

The AAFP held a virtual town hall last week about the COVID-19 vaccines, and the Centers for Disease Control and Prevention (CDC) has also outlined its allocation recommendations for the initially limited supply of vaccine. We'll also continue to update the AFP By Topic on Coronavirus Disease 2019 (COVID-19). 

New guideline for managing acute pain from musculoskeletal injuries

 - Kenny Lin, MD, MPH

In a 2017 practice guideline based on a systematic review of noninvasive treatments, the American College of Physicians (ACP) recommended superficial heat, massage, acupuncture, and spinal manipulation as initial treatment options for patients with acute low back pain, in addition to a nonsteroidal anti-inflammatory drug (NSAID) or skeletal muscle relaxant if desired. But is a similar approach effective for treating pain resulting from acute musculoskeletal injuries not involving the lower back? To answer this question, the American Academy of Family Physicians (AAFP) joined the ACP in developing another practice guideline on management of acute pain from non-low back, musculoskeletal injuries in adults, a synopsis of which appeared in Practice Guidelines in the December 1 issue of American Family Physician. These are some key practice points from the guideline:

• Topical NSAIDs are the most effective intervention for acute musculoskeletal pain other than low back pain.

• Although oral NSAIDs and acetaminophen are effective for acute pain relief, combining them does not improve effectiveness.

• Although moderately effective for pain relief, opioids increase gastrointestinal and neurologic adverse effects and lead to long-term use in 6% of people treated.

• Acupressure and transcutaneous electrical nerve stimulation techniques are effective nonpharmacologic options for acute pain.

In an accompanying editorial, Dr. David O'Gurek and I, who represented the AAFP on the guideline committee, and Dr. Melanie Bird, AAFP Clinical and Health Policies Manager, discussed some of the guideline's highlights and limitations. A systematic review and network meta-analysis of randomized, controlled trials provided direct and indirect comparisons of various treatment options on outcomes that included pain relief and physical functioning, symptom relief, treatment satisfaction, and adverse events.

Topical NSAIDs improved all efficacy outcomes with minimal adverse effects, while oral NSAIDs and acetaminophen improved fewer outcomes and were more likely to cause adverse events. We suggested against using opioids, including tramadol, for acute musculoskeletal injury pain due to their poor adverse effect profile and the risk of prolonged use, ranging from 6% in low-risk to 27% in high-risk populations. We also noted that "equitable coverage and affordability of first-line treatments" are essential to reduce well-known disparities in pain management; for example, though a topical NSAID is now available over-the-counter, it costs significantly more than oral NSAIDs and acetaminophen and may not be covered by health insurance plans.

The polypill: promise & perils

 - Jennifer Middleton, MD

The promise of a simple "polypill" to reduce cardiovascular disease (CVD) morbidity and mortality has been tantalizing researchers for decades. A 2012 analysis suggested that "[p]olypill use by US adults age ≥ 55 years is projected to potentially prevent 3.2 million CHD events and 1.7 million strokes over 10 years." The third iteration of an international research effort examining a combination of 40 mg of simvastatin, 100 mg of atenolol, 25 mg of hydrochlorothiazide, and 10 mg of ramipril known as TIPS-3 (The International Polycap Study 3) demonstrates promise, but a significant minority of enrollees struggled to tolerate it.

TIPS-3 enrolled over 7500 adults identified at intermediate to high risk of CVD using a 2x2x2 factorial design. Most of the participants were from the Philippines or India. Enrolled men were at least 50 years old, and enrolled women were at least 55 years old. Participants were predicted to be at intermediate or high risk of CVD events by their INTERHEART risk score. They completed a 3 to 4 week run-in period, during which time researchers assessed their adherence to lower doses of the full regimens. Notably, 9.5% of initially enrolled participants did not complete the run-in due to complaints of side effects, and another 7.4% could not achieve the minimum 80% adherence required to be randomized into the trial. 

The primary outcome differed by group: for the polypill and polypill + ASA groups, it was a composite of CVD death, myocardial infarction (MI), CVA, cardiac arrest, heart failure, and/or cardiac revascularization; for the ASA group, the primary outcome was only a composite of CVD death, MI, and/or CVA. Participants in the polypill vs placebo group had a hazard ratio (HR) of its primary outcome of 0.79 (95% confidence interval [CI] 0.63, 1.00). The ASA vs placebo group had an HR of its primary outcome of 0.86 (95% CI 0.67, 1.10), and the polypill + ASA group had a HR for its primary outcome of 0.69 (95% CI 0.50, 0.97). The researchers had intended to continue their enrollment and data analysis through 2020, but the COVID-19 pandemic forced a halt to their plans.

The TIPS-3 results are promising, but future research should focus on overcoming this study's shortcomings. Participants who did not experience disabling side effects and were able to adhere to their regimen lowered their risk of CVD events, but it's concerning that more than 1 in 6 enrolled participants could not get past the run-in period to enter the full trial. Physicians should exercise caution extrapolating results from this study to patients deemed at intermediate to high risk of CVD events using a different tool than INTERHEART (for example, the ASCVD calculator is used far more often in the United States). Lastly, a longer study period and larger number of participants may result in a better-powered study with more convincing confidence intervals; the HR of both polypill groups had wide confidence intervals perilously close to non-significance. With its lower HR, the polypill + ASA group appears to have been more effective than the polypill alone, but the confidence intervals of both groups overlap; this finding also conflicts with recent robust evidence showing that ASA is ineffective for primary CVD prevention among both average and higher risk persons. 

You can read more at the AFP By Topics on Coronary Artery Disease/Coronary Heart Disease and Stroke and TIA along with this review of an earlier polypill benefit analysis by Dr. Kenny Lin.

Newborn screening for metabolic conditions has long-term benefits

 - Kenny Lin, MD, MPH

State-mandated screening at birth for rare, serious medical conditions occurs in 4 to 5 million newborns and detects 5,000 to 6,000 affected infants each year. A 2017 American Family Physician article reviewed various conditions that are targeted by newborn screening: amino acid disorders, fatty acid oxidation disorders, organic acid disorders, hemoglobinopathies, endocrine disorders, and miscellaneous diseases (including congenital hearing loss and critical congenital heart defects). With a combined incidence of 1 out of every 1,500 births, inborn errors of metabolism are the most common conditions detected by newborn screening.

After tandem mass spectrometry made it possible to test for many conditions using a single blood sample, the federal Health Resources and Services Administration's Maternal and Child Health Bureau commissioned the American College of Medical Genetics (ACMG) to create a uniform list of conditions for newborn screening panels in 2005. However, the ACMG's recommended core panel of 29 conditions was criticized by the U.S. Preventive Services Task Force (USPSTF) for not taking an evidence-based approach. In a position paper, the USPSTF noted that the ability to detect a condition with high diagnostic accuracy was insufficient to include it in the panel:

A newborn screening program is not just a panel of screening tests. ... It is also parental education, follow-up, diagnosis, treatment and management, and program evaluation, and all of the various parts of the system must be in place and working well to realize the benefits of screening. ... Moreover, a newborn screening panel should be expanded only if the newborn screening program is fully prepared to make all the components of the complex system available for the new disorders. Expansion would be costly and might not be the best use of scarce health care resources, given the many other unmet child health needs.

Reinforcing the USPSTF's concerns, an analysis by the Centers for Disease Control and Prevention projected that if all 50 states expanded their newborn screening panels to align fully with the ACMG recommendations, "although such an expansion would have increased the number of children identified by 32% (from 4,370 to 6,439), these children would have had many rare disorders that require local or regional capacity to deliver expertise in screening, diagnosis, and management." A cross-sectional survey of Ontario primary care clinicians found that family physicians had limited knowledge of conditions identified by newborn screening tests, and many were not comfortable leading detailed discussions of abnormal results with parents or guardians.

The U.S. Secretary of Health and Human Services' Advisory Committee on Heritable Disorders in Newborns and Children (SACHDNC) subsequently developed a more rigorous framework to evaluate conditions nominated as additions to the uniform screening panel, requiring an independent systematic evidence review of key questions based on an analytic framework similar to those used for USPSTF reviews. In a separate document, the SACHDNC outlined questions for newborn screening long-term follow-up data systems to answer to make sure that programs achieve their goals of improved outcomes for children and families.

An observational study published last month in Pediatrics reported the clinical outcomes of 306 individuals with inherited metabolic diseases identified by a university hospital laboratory performing Germany's newborn screening panel from 1999 to 2016. The German national panel is less extensive than the ACMG's, consisting of 2 endocrine and 12 inherited metabolic diseases, and the nearly 2 million newborns screened during the study period represented 15 percent of Germany's live births. 28 individuals presented with metabolic symptoms prior to newborn screening results being available; the rest were successfully enrolled in specialized metabolic/nutritional therapy while still asymptomatic. Although nearly 1 in 4 individuals eventually developed irreversible disease-specific clinical signs, 88% had normal cognitive outcomes, and more than 95% showed normal development and attended regular kindergarten and primary schools.

COVID-19 vaccine updates

 - Jennifer Middleton, MD, MPH

In the last week, two pharmaceutical companies have released preliminary data indicating that their mRNA vaccines against the SARS-CoV-2 virus are efficacious and safe. Critics are arguing that these preliminary data releases only serve to drive up manufacturers' stock prices, but others are gladly grasping at their potential to help end the COVID-19 pandemic. Before these vaccines will be released to the United States (US) public, though, they must be evaluated by the Food and Drug Administration (FDA). 

To be approved by the FDA, vaccine manufacturers must prove their product's efficacy and safety through a rigorous, methodological process. First, manufacturers must submit an Investigational New Drug application, detailing the vaccine's proposed mechanism of action and previous animal model study results. Then,

Pre-marketing (pre-licensure) vaccine clinical trials are typically done in three phases, as is the case for any drug or biologic. Initial human studies, referred to as Phase 1, are safety and immunogenicity studies performed in a small number of closely monitored subjects. Phase 2 studies are dose-ranging studies and may enroll hundreds of subjects. Finally, Phase 3 trials typically enroll thousands of individuals and provide the critical documentation of effectiveness and important additional safety data required for licensing. 

As of November 12, 2020, the World Health Organization (WHO) was tracking 48 candidate vaccines. Nine of those candidate vaccines are in phase 3 trials, and two of them recently released interim data analyses. The Pfizer/BioNTech vaccine, BNT162b2, is currently in a phase 3 trial with over 43,000 participants; interim analysis suggests it is at least 90% effective. The National Institutes of Health (NIH)/Moderna vaccine, mRNA-1273, also in a phase 3 trial (the "COVE" trial) with over 30,000 participants, announced similar findings in their interim analysis with 94.5% effectiveness. 

Vaccine manufacturers can apply for an Emergency Use Authorization (EUA) to bypass the full approval process; the FDA has already issued EUAs during the pandemic for several SARS-CoV-2 diagnostic tests as well as for therapeutics such as baricitinib, remdesivir (in pediatric patients; already FDA-approved in adults), and convalescent plasma. (The FDA revoked the EUAs for hydroxychloroquine and chloroquine in June 2020.) The FDA has posted guidance for vaccine EUA applications and has pledged to make all submitted data for EUAs transparently available to the public. 

As Dr. Kenny Lin has previously pointed out on the blog, it's unlikely that a vaccine alone will stem the pandemic's tide; handwashing, social distancing, and face coverings remain essential. You can estimate the risk of an unknowingly COVID-19 infected person at your gathering using this online tool; you'll likely see why the Centers for Disease Control and Prevention (CDC) is recommending we only gather with immediate family for the upcoming Thanksgiving holiday. 

We'll continue to regularly update the AFP By Topic on Coronavirus Disease 2019 (COVID-19), and, as 2020 comes to a close, don't forget that the AAFP has a robust offering of CME learning activities about COVID-19. 

Mental health disorders are associated with COVID-19

- Kenny Lin, MD, MPH

Eight months ago, during the first wave of the pandemic, Dr. Jennifer Middleton discussed World Health Organization and Centers for Disease Control and Prevention (CDC)-recommended strategies and resources for optimizing mental health in health care workers, patients, and children. A CDC representative national survey conducted in late June found a strikingly high prevalence of symptoms of anxiety or depressive disorder (30.9%), trauma- and stressor-related disorder (26.3%) and new or increased substance use (13.3%). By comparison, a 2019 survey found that only 8.1% and 6.5% of people had symptoms of anxiety or depression, respectively. 1 in 10 respondents to this year's survey also reported having seriously considered suicide in the preceding 30 days, with disproportionately higher suicidality in younger adults (age 18-24 years), racial and ethnic minorities, essential workers, and unpaid adult caregivers.

In a recent commentary, Dr. Christine Moutier from the American Foundation for Suicide Prevention recommended several COVID-19-specific suicide prevention strategies that fuse clinical, health system, and policy interventions: reduce risk for people with mental illness or addiction; increase social connectedness; address risk at the moment of crisis; reduce access to lethal means; address COVID-19 increases in alcohol consumption and drug overdoses; mitigate financial strain; address domestic violence and unsafe environments; and prevent unsafe media and entertainment messaging on suicide.

The rise in anxiety, depression, stress, and suicidality coincided with the widespread conversion of office-based visits for behavioral and psychiatric conditions to telehealth, which may have restricted access to mental health care for existing and new patients. As three psychiatrists observed in a JAMA Viewpoint:

Patients with psychiatric disorders are particularly vulnerable to COVID-19 due to high rates of overweight, tobacco smoking, medical comorbidities, and poor self-care. ... Daily news of large-scale COVID-19–related disease and death in the community over months or years is almost certain to elevate psychiatric burden in the population. As such, the pattern of stress resembles that experienced by refugees or others exposed to chronic violence. ... A sustained increase in demand for psychiatric services may well exceed the existing capacity of the system over time and may last for years, depending on the course the pandemic takes.

Persons with prior psychiatric diagnoses may be at higher risk of death from COVID-19 infection. A cohort study of 1685 patients who were hospitalized with COVID-19 from February through April found that after controlling for demographics, medical comorbidities, and hospital location, patients with a psychiatric disorder were 1.5 times as likely to die as those with no psychiatric diagnosis. Citing a kinship network study that suggested that each COVID-19 death in the U.S. leaves nine bereaved close family members, some have suggested that primary care physicians screen relatives of persons who die from COVID-19 for symptoms of depression, prolonged grief, or post-traumatic stress disorder and provide evidence-based interventions if needed.

On the other hand, a diagnosis of COVID-19 may increase the risk for developing a mental health disorder. A retrospective cohort study that utilized electronic health record data from more than 62,000 U.S. patients between January 20 and August 1 found that COVID-19 survivors were more likely to have a first psychiatric diagnosis, a new psychiatric diagnosis, or a relapse of a previously stable diagnosis within 14 to 90 days than six other unrelated health events. However, this study design could not determine if these additional diagnoses were preexisting and unrecognized prior to COVID-19 infection or a direct consequence of the infection or medical management (including isolation at home or in the hospital).

Stress from COVID-19 pandemic fuels increased alcohol misuse

- Jennifer Middleton, MD, MPH

A survey of 1540 adults in the United States recently found that alcohol use has increased over the last year, especially in women:

On average, alcohol was consumed 1 day more per month by 3 of 4 adults. For women, there was also a significant increase of 0.18 days of heavy drinking (95% CI, 0.04-0.32 days)...an increase of 41% over baseline....For women there was an average increase in the Short Inventory of Problems scale of 0.09 (95% CI, 0.01-0.17 items)...representing a 39% increase, which is indicative of increased alcohol-related problems independent of consumption level for nearly 1 in 10 women.

Memes jesting about "mommy juice" abound right now, along with depictions of wine and coffee arguing regarding "who she loves more." These memes reflect the increasing normalization of alcohol as a coping mechanism but also trivialize the physical and psychological consequences of increased alcohol consumption. Excess alcohol use is linked with cardiovascular disease, several cancers, and intimate partner violence; it exacerbates depression and anxiety; and it can result in injuries, including motor vehicle accidents. An increase in these short- and long-term conditions will place further stress on individuals, families, workplaces, and healthcare systems already buckling under the weight of COVID-19. 

The pandemic has increased stress for countless individuals, and reports suggest women are bearing a disproportionate share. Women have been more likely to lose their jobs and are more likely to be primarily managing child care given decreased daycare access and increased virtual schooling. The pandemic's effect on women of color is even more profound. COVID-19 is widening gender-poverty gaps in the US and abroad. It's no surprise that alcohol misuse is increasing. 

The United States Preventive Services Task Force (USPSTF) recommends screening all adults for hazardous alcohol consumption and providing brief counseling to those who screen positive; we must urgently identify our patients who are using alcohol to cope with COVID-19 and offer help. 

There's an AFP By Topic on Alcohol Use Disorders if you'd like to read more, and this 2019 Community Blog post provides a brief overview of alcohol screening and treatment. The CDC also has a webpage with a lengthy list of resources for coping with increased stress due to COVID-19.

Advantages and limitations of mobile monitoring for cardiac arrhythmias

 - Kenny Lin, MD, MPH

During the first wave of the pandemic, when hydroxychloroquine was still thought to be an effective treatment for hospitalized patients with COVID-19 (subsequent studies have shown otherwise), some U.S. hospitals used personal electrocardiogram (ECG) devices to monitor these patients for drug-induced QT interval prolongation to conserve personal protective equipment and telemetry monitors. Such devices were already being used by patients with known cardiac conditions to monitor their heart rhythms in out-of-office settings.

As I discussed in a previous AFP Community Blog post, wearable devices such as the Apple Watch are also being studied to detect atrial fibrillation in asymptomatic primary care patients. In a 2019 study of more than 400,000 U.S. Apple Watch wearers with no self-reported history of atrial fibrillation, about 1 in 200 individuals received an irregular pulse notification and were scheduled for a telemedicine visit with a clinician to confirm study eligibility and triage those with urgent symptoms to the emergency department. Participants without urgent symptoms were mailed an ECG patch to wear for up to 7 days and then mail back to the study center.

Of the 450 participants who returned an ECG patch, 34% were confirmed to have atrial fibrillation, with a higher diagnostic yield in persons age 65 years or older. Of the 86 patients whose watches generated irregular pulse notifications when they were wearing the ECG patch, the positive predictive value for atrial fibrillation was 84%. In a survey completed at 90 days by patients who received an irregular pulse notification, 28% reported being prescribed a new medication, 33% were referred to a specialist, and 36% were recommended to have additional testing.

In the November 1 issue of American Family Physician, Dr. Madhavi Singh and colleagues reviewed the diagnostic test features of KardiaMobile, a $99 single-lead device that connects wirelessly to a smartphone app to generate an ECG tracing with automated interpretation. In studies of patients with known or suspected arrhythmias, KardiaMobile had greater than 90% sensitivity and specificity for atrial fibrillation or atrial flutter compared to a standard 12-lead ECG. However, no studies have compared its accuracy with a Holter or event monitor, and effects on patient outcomes are uncertain, particularly in populations at low risk for arrhythmias. (In 2018, the U.S. Preventive Services Task Force found insufficient evidence to assess the balance of benefits and harms of screening for atrial fibrillation, which has several potential downsides.) The authors concluded that similar to the Apple Watch, "further studies are needed before KardiaMobile can be recommended for use in seemingly healthy patients."

Can contact tracing apps slow the spread of COVID-19?

 - Jennifer Middleton, MD, MPH

"Outpatient Management of COVID-19: Rapid Evidence Review," in the current issue of AFP, discusses current testing and treatment recommendations. It includes quarantine recommendations for close contacts of COVID-19 individuals; to identify those contacts, the Centers for Disease Control and Prevention (CDC) recommends that public health departments conduct contact tracing for all confirmed COVID-19 positive persons. With infrastructure challenges limiting contract tracing in many parts of the US, contact tracing apps have been proposed as a possible solution, but they also bring several barriers to widespread implementation of their own.

The CDC advises that all close contacts of COVID-19 positive persons should be tested, and those who test negative should quarantine for 14 days. Robust contact tracing has the potential to dramatically decrease COVID-19 spread, and contact tracing apps promise to do what manual contact tracing has thus far struggled to keep up with:

[Y]our phone will regularly send out a beacon via Bluetooth that includes a random Bluetooth identifier — basically, a string of random numbers that aren’t tied to a user's identity and change every 10-20 minutes for additional protection...Other phones will be listening for these beacons and broadcasting theirs as well.....If you later come down with COVID-19, open the health app on your phone and log a diagnosis. The phone then uploads the last two weeks' worth of beacon data, and asks for your permission to anonymously share your results and notify others.

Similarly, if someone you have been in contact with reports a positive COVID-19 test, you can then be notified to get tested and begin quarantining. Concerns with privacy have affected uptake of these apps, and surveys suggest that many persons using them are unwilling to follow through on testing and quarantine recommendations. Of course, owning a smartphone is a prerequisite to using such an app as well; in the US, 19% of adults don't own a smartphone, and in adults over the age of 65, that percentage is 47%. 

Given these concerns, health leaders in Europe have raised concerns that contact tracing apps may be one part of the solution but cannot fully substitute for manual tracing efforts. Public health has been underfunded in the US for decades, despite data showing that most people find public health to be valuable; indeed, for every $1 spent in public health efforts in high-income countries, $14 in future health expenditures are saved. Perhaps the COVID-19 pandemic will provide the necessary momentum to improve our investment in these vital services.

In the meantime, you can continue to find current COVID-19 information and resources at the AFP By Topic: Coronavirus Disease 2019 site.

Cancer survivorship: what is the family physician's role?

 - Kenny Lin, MD, MPH

Family physicians' expertise in cancer mostly involves screening and diagnosis, while treatment is managed by medical and/or surgical oncologists. However, as the long-term survival of patients with cancer improves, the important care role of primary care clinicians in survivors of childhood and adult cancers has been increasingly recognized. The National Cancer Institute estimated that in 2019, cancer survivors numbered 16.9 million, or about 5 percent of the U.S. population. During the past few years, American Family Physician has published clinical reviews of the American Cancer Society's guidelines on primary care for survivors of prostate cancer, colorectal cancer, and breast cancer. The American Academy of Family Physicians' policy on Cancer Care recommends that "the physician workforce, including family physicians, should be educated about the protocols for survivorship management."

A recent qualitative study published in the Annals of Family Medicine found that the reality on the ground is more complex than current guidelines and policy suggest. Dr. Benjamin Crabtree and colleagues recorded lengthy interviews with 38 clinicians in 14 U.S. primary care practices that had been previously recognized for workforce innovation by the Robert Wood Johnson Foundation. In these interviews, clinicians were "asked to describe how they viewed their role in cancer survivorship, decisions of when and where to refer patients, and knowledge about new primary care–friendly survivorship care guidelines."

Analysis of the interviews revealed a lack of consensus about the role of primary care in cancer survivorship. For example, several clinicians felt that follow-up cancer care was exclusively the responsibility of oncologists, but the majority expressed that providing this care fell within their purview. However, they reported obstacles ranging from inadequate knowledge / education to "an uneasy relationship with oncology" and a lack of clarity about when care could be transitioned from the oncologist to primary care.

Clinicians also disagreed about whether cancer survivors should be treated as a "distinct patient population" (requiring a systematic health system approach) or like any other patient with a chronic disease. The researchers theorized that these divergent views reflected an "identity crisis" about their care roles for these patients:

Several clinicians expressed mixed opinions, contradicted themselves, vacillated on their stance, or paused when asked about their/primary care’s role in cancer survivorship care. In fact, some clinicians struggled to talk about cancer survivorship at all in their interviews. ... These clinicians, with an identity based on delivering whole-person, comprehensive, coordinated care, appeared to hit a wall of identity confusion when confronted with a swiftly changing highly specialized knowledge base and a highly variable group of patients referred to as “cancer survivors.”

Options for resolving this identity crisis, according to the researchers, could involve developing new cancer-focused curricula for primary care residency programs and continuing medical education; constructing more well-defined management boundaries between primary care and oncology; and/or having their professional organizations "consider coproducing and translating new knowledge about care for cancer survivors that primary care clinicians can prioritize, personalize, and integrate to address patients’ needs and values within a shared decision-making framework." With the population of cancer survivors expected to increase by 30 percent over the next decade, clarifying the appropriate role of family physicians remains an urgent national need.

Is intermittent fasting's time up?

 - Jennifer Middleton, MD, MPH

As obesity rates continue to rise, the elusive search for a solution persists. Intermittent fasting (IF) offers a simple approach; eat whatever you want within a designated time interval and then do not eat the rest of the time. Early, small studies suggested that intermittent fasting (IF) was more effective for weight loss than traditional calorie restriction diets, and IF's popularity has been boosted by disease-oriented studies demonstrating improvement in metabolic markers. A multitude of famous adherents have also contributed to IF's rising profile.

More recent, rigorous studies, however, may dampen the enthusiasm for IF. In 2018, a systematic review of intermittent fasting's effectiveness found similar rates of weight loss with IF compared to traditional calorie restriction. Later that year, a trial randomized 150 obese or overweight adults to either continuous energy restriction, IF using the "5:2" method (5 days a week of normal intake and 2 days a week of 25% intake), or placebo and then followed them for 50 weeks. It found that intermittent fasting "may be equivalent but not superior" to the traditional calorie restriction method.

And, now we have a new, 2020 randomized controlled trial. Researchers randomized 141 participants to either a "16:8" IF regimen (eat anything desired between noon-8 pm, then fast for the next 16 hours) or a "consistent meal timing" plan and then followed them for 12 weeks. The difference in weight loss between the two groups was non-significant (-0.26 kg [95% confidence interval −1.30, 0.78]). The IF group also demonstrated a decrease in lean muscle mass (-0.16 kg/m2 [95% CI -0.27, -0.05]) compared to the comparison group. 

If this loss of muscle mass is replicated in other studies, IF's time might truly be up. This seemingly never-ending search for a "magic" diet plan additionally fails to account for the complex mechanisms behind obesity. Systemic environmental factors are the primary drivers of the obesity epidemic, not individual choice and a scarcity of willpower. The over-abundance of super-processed, inexpensive foods set humans, genetically hard-wired to crave fat and sugar, up for failure. Chronic stress and epigenetics affect both dietary preferences and metabolism. As long as we continue to neglect these powerful drivers of behavior, obesity will remain a public health crisis, one that COVID-19 will likely also continue to exploit. 

You can read more in the AFP By Topic on Obesity, which includes this Curbside Consultation on "Obesity: Psychological and Behavioral Considerations."

Guest Post: Virtual Conferences - New Possibilities in the New Normal

- Suzanne Minor, MD; Andrea Berry, MPA; Weichao Chen, PhD

Many conferences have transitioned to a virtual format, including FMX and regional conferences. While many physicians have experience with online CME sessions, attending an entire conference through virtual technology will likely be a new experience for many of us. Even though virtual conferencing is different than our usual conference experience, attending a virtual conference can still be an effective way to learn best practices of clinical care and to engage with colleagues and our professional organizations. In fact, virtual conferencing presents unique opportunities for participation and engagement. This blog post outlines strategies to make the most of virtual conference experiences and seize unique opportunities offered in a virtual format.

Strategies to Maximize Learning

Before the conference begins, take the time to outline your overall goals and plans. According to a recent review, taking time to plan activities and outline a schedule sets you up for success.

Review the conference schedule carefully to identify high-yield sessions to attend live, taking into consideration time zone differences. Virtual conferences offer different types of virtual sessions, ranging from plenary, paper and poster presentations, workshops, small groups, demonstrations, and social events. Some sessions may require live participation at a set time, while others offer more flexibility. Prioritize the sessions that you plan to attend live and watch recordings of other didactic-based sessions on demand. Explore novel formats of participation afforded by virtual conferencing, such as preconference virtual rooms.

Familiarize yourself with the technologies to be used. Different conferences might use a variety of technologies for synchronous sessions, backchannel communication, and social networking. Install the applications (apps) and necessary plug-ins beforehand. If you plan to join the conference from work, check if technology usage might be blocked by your institutional Internet firewall.

Actively combat Zoom fatigue, or the feeling of being overloaded by video conferencing. Recommended strategies include scheduling regular break times between live sessions and avoiding multitasking and reducing on-screen distraction during live sessions, including the distraction from watching your own video. Based on your personal schedule, block time free of patient care and other job and life duties for live or priority sessions. Locate a space with less distraction for you to engage in productive online learning and dialogue during virtual conferencing.

Despite the difference in virtual conference experiences, many strategies useful in traditional conferences remain helpful:

During the conference, network actively, remain open minded to unfamiliar topics, share major take-away and useful resources via social media, and support your colleagues by attending their sessions. After the conference, obtain CME credits, add your presentation into your resume, fill out evaluation forms to provide feedback to conference organizers, reflect on the new ideas gleaned and plan for application in your practice, reach out to newly met colleagues for collaboration opportunities, and thank your institution, office staff or covering colleagues for supporting your attendance.

Unique Opportunities Offered by Virtual Conferences

Virtual conferences provide unique opportunities beyond what is possible in a traditional face-to-face format. Many conferences integrate a twitter connection within the app to allow participants to connect with like-minded physicians by posting thoughts, pearls, and questions about presentation content. This can be especially meaningful for physicians from minority groups who have found these tools invaluable in seeking support and meaningful interactions to combat isolation.

Beyond the unique tools, virtual conferences afford more physicians the opportunity to access learning that may have been previously beyond their reach. Cost and number of days out of the practice are reduced as there is no need to pay for transportation or hotels and no additional time needed to travel to distant locations. Additionally, the influx of new participants brings new opportunities to expand your network and access diverse perspectives throughout the program.

Is physical therapy beneficial for acute back pain with sciatica?

 - Kenny Lin, MD, MPH

Although a referral to physical therapy is a standard part of my treatment plan for patients with subacute or chronic low back pain, there is little data on the effectiveness of physical therapy for acute back pain. A 2018 Family Physicians Inquiries Network (FPIN) Clinical Inquiry published in American Family Physician found that physical therapy begun within 24 hours of clinical presentation provides minimal improvements in pain, satisfaction, and mental health at one week that disappear by one month. Physical therapy started within 48 to 72 hours of presentation had no significant effects on pain or disability. A 2002 randomized trial found no differences in pain or activities of daily living in patients with acute low back pain with sciatica who were assigned to bed rest, physical therapy, or a control group. A 2008 study reported that physical therapy added to usual care from a general practitioner improved patients' global perceived effect but had no effects on pain or disability. Another FPIN Clinical Inquiry on treatments for sciatica concluded that nonsteroidal anti-inflammatory drugs, systemic steroids, topiramate, pregabalin, traction, and best rest were all ineffective and had potential adverse effects. The authors did not review physical therapy.

A single-blind randomized controlled trial published today in the Annals of Internal Medicine compared early referral to physical therapy to usual care in 220 adults aged 18 to 60 years with acute back pain with sciatica for less than 90 days. Participants were recruited from primary care practices in two health care systems (Intermountain Healthcare and University of Utah). All participants received an evidence-based patient education booklet about low back pain; patients assigned to the intervention group were scheduled for 6 to 8 exercise and manual therapy sessions over 4 weeks with one of the study physical therapists. The primary outcome was change in the Oswestry Disability Index (OSW) score from baseline after 6 months.

Compared to the usual care group, intervention group participants reported greater improvements in OSW scores at 6 months (5.4 points) and 1 year (4.8 points). They also had lower back pain intensity and were more likely to report treatment success after 1 year (45% vs. 28% for usual care). However, health care use and missed workdays were not significantly different between groups.

Although this study's results appear to support early referral to physical therapy for patients with acute back pain with sciatica, they come with some caveats. The minimal clinically important difference on the OSW for this condition is 6 to 8 points, greater than the mean point estimates of between-group differences seen in this study. Also, since participants were not blinded to their group assignment and the usual care group did not receive sessions with a comparable contact time as the physical therapy sessions, it's possible that the modest improvement had less to do with the therapy than the caring attention that patients received from the therapists. The cost-effectiveness of referring every patient with this condition to a physical therapist is also uncertain.

Nonetheless, given the limited options currently available for patients with acute back pain with sciatica, it seems reasonable for family physicians to offer a referral to a physical therapist rather than prescribing ineffective pharmacotherapy or obtaining unnecessary and potentially harmful imaging studies.

Guest Post: A New Approach to Preventing Firearm Injuries

- Gregory Engel, MD, MPH, FAAFP 

As family physicians, we see the effects of firearm injuries every day in our clinics and hospitals. We treat not only the bullet wounds but also their myriad consequences for patients and their families. At this year’s annual meeting, the AAFP House of Delegates will consider a resolution in support of creating a National Bureau for Firearm Injury Prevention. The resolution, passed by the King County Academy of Family Physicians and the Washington Academy of Family Physicians and supported by the King County Medical Society, addresses the fact that, in spite of rising firearm fatalities over the past two decades, our country lacks a comprehensive, coherent, long-term public health-based strategy to prevent the 40,000 fatal and 80,000 nonfatal firearm injuries that occur in the United States every year.

The United States has successfully faced a long-term challenge of this magnitude before. In the 1960s, the National Highway Safety Bureau - an agency dedicated to reducing motor vehicle injuries and deaths – reduced the motor vehicle death rate by two-thirds. Analogously, a National Bureau for Firearm Injury Prevention would lead a comprehensive, long-term, public health-based effort to reduce firearm deaths and injuries. Like the National Highway Safety Bureau, the National Bureau for Firearm Injury Prevention (NBFIP) would take the lead in setting the nation’s research agenda and developing, testing, and implementing firearm safety technologies. It would oversee campaigns to encourage behaviors likely to reduce firearm injuries, set out legislative priorities for saving lives, and direct priorities for enforcing firearm laws. Importantly, as a single agency dedicated to reducing firearm injuries, the NBFIP could coordinate the synergistic action of research, technology, public awareness, and legislation.

Momentum toward this approach has been building. Washington’s governor recently signed a law creating the country’s first state Office for Firearm Violence Prevention. Grassroots organizations throughout the country, like States United to Prevent Gun Violence, have endorsed as well.

As family physicians, we are the center of this health issue; it is our duty to do our part to safeguard the health of our patients and our communities. Creating a National Bureau for Firearm Injury Prevention is the most effective way to reduce firearm deaths and injuries in the decades to come.

Dr. Engel is a Copello Health Advocacy Fellow and serves on the National Steering Committee for Gun Violence Prevention. He is an attending physician at Samuel Simmonds Memorial Hospital in Utqiagvik, Alaska.

Coronavirus vaccine is unlikely to be a "magic bullet" that ends the pandemic

 - Kenny Lin, MD, MPH

Last week, federal health officials announced an ambitious plan to begin free distribution of a vaccine against SARS-CoV-2 within 24 hours of its approval or emergency authorization from the U.S. Food and Drug Administration (FDA). That an efficacious vaccine could, remarkably, become available less than one year after the isolation of the virus that causes COVID-19 is due in part to a public-private program to accelerate vaccine, diagnostic test, and therapy development led by the U.S. Departments of Defense and Health and Human Services known as "Operation Warp Speed." In a New England Journal of Medicine commentary, Drs. Moncef Slaui, Shannon Greene, and Janet Woodcock reviewed the progress of Operation Warp Speed on multiple fronts, including the most promising candidate vaccines in phase 2 and 3 clinical trials. Ultimately, though, the impact of any vaccine on the course of the pandemic in the U.S. and abroad will depend not only on how protective it is against infection and disease transmission, but how the allocation of initially limited supplies is prioritized (e.g., health care and essential workers, vulnerable groups) and what proportion of the population agrees to receive it in the absence of a requirement to do so.

A simulation study in the American Journal of Preventive Medicine estimated the efficacy and percent population coverage that a coronavirus vaccine would need to extinguish the epidemic in the absence of other public health measures such as social distancing and wearing face coverings - in other words, what it would take for a vaccine to allow life to "go back to normal." The effects of a vaccine on productivity losses, hospitalizations, medical costs, and deaths vary depending on what percentage of the population has already been exposed to SARS-CoV-2; one seroprevalence survey from late March to mid-May found a range from 1% to 7% at 10 sites in the U.S., but these figures are likely to be higher four or more months later. To extinguish the epidemic after 5% of the population has been exposed, for example, the AJPM researchers calculated that a vaccine would need to have at least 80% efficacy if administered to 75% of the population.

Unfortunately, expecting any of the coronavirus vaccines in development to have 80% efficacy is unrealistic.  By comparison, the Centers for Disease Control and Prevention (CDC) estimated that the 2019-20 influenza vaccine was only 45% effective, consistent with the 40-60% range in previous years when the available vaccines were antigenically matched to circulating influenza viruses. The highest influenza vaccine coverage was during the 2018-19 season, when 63% of children (state range, 46%-81%) and 45% of adults (state range, 34%-56%) received the vaccine. Although some may be more willing to be vaccinated against SARS-CoV-2 than influenza due to the former's greater morbidity and mortality, influenza vaccine also has a long safety track record that a coronavirus vaccine would not.

It is possible that public health measures in place to slow the spread of COVID-19 will substantially reduce the impact of influenza during the 2020-21 season. A CDC surveillance report showed that U.S. cases of laboratory-confirmed influenza fell sharply after the national COVID-19 emergency declaration on March 1, reflecting not only the natural waning of the flu season but also mitigation interventions implemented by states around this time. In the Southern Hemisphere nations of Australia, Chile, and South Africa, where influenza activity normally peaks in June or July, COVID-19 mitigation was associated with a near-complete suppression of influenza circulation.

For family physicians, preparing for flu season during the COVID-19 pandemic, with a coronavirus vaccine potentially around the corner, means adapting to many uncertainties. What hasn't changed from previous years is that the CDC's Advisory Committee on Immunization Practices continues to recommend influenza vaccination for all people six months and older who do not have contraindications, ideally by the end of October. Whenever it arrives, the coronavirus vaccine is unlikely to be a "magic bullet" that ends the pandemic on its own. So it's critical that clinicians all continue to echo the message about cloth face coverings that CDC Director Robert Redfield, MD delivered at a recent Senate hearing: "These face masks are the most important, powerful public health tool we have" for controlling the pandemic.

Preparticipation physical exam and return to sports during the COVID-19 pandemic

 - Kenny Lin, MD, MPH

For primary care practices that care for children, the preparticipation physical exam (PPE) is an annual rite. My residency program usually sets aside two full days in late summer where the residents and attending physicians do nothing but "sports physicals" in order to meet the demand for these exams from prospective high school athletes. Although the utility and effectiveness of this traditional evaluation has long been debated - a 2019 AFP article on Right Care for Children included the PPE in its list of overused interventions - many clinicians also use the time to address non-sport related issues, making the visit "a potential preventive care entry point and an opportunity to provide routine immunizations, screen for other conditions, and provide anticipatory guidance." Last year, the American Academy of Family Physicians, the American Academy of Pediatrics, and several sports medical societies published the 5th edition of the Preparticipation Physical Evaluation monograph, which was summarized in the June 1 issue of AFP.

The COVID-19 pandemic closed schools and cancelled youth sports nationwide beginning in early March. As schools are now reopening in virtual, in-person, and hybrid models, some students are also returning to competitive sports. To address the medical needs of these athletes, the American Medical Society for Sports Medicine (AMSSM) recently released Interim Guidance on the Preparticipation Physical Exam for Athletes "to provide clinicians with a clinical framework to return athletes of all levels to training and competition during the pandemic."

In addition to the physical risks inherent in playing a sport, student athletes now must also be concerned about minimizing their risk of contracting SARS-CoV-2 where maintaining physical distancing is not possible. The AMSSM notes that unlike professional teams, high school and most college teams will not have the resources to perform testing, contact training, and quarantine. It advises discussing COVID-19 risks in detail with the patient and family at the time of the PPE, and considering factors "such as the disease burden in the community, the overall health of the athlete, the living environment, [and] each athlete's network of friends and family members who have have comorbid conditions" in the decision to play.

Athletes who have apparently recovered from COVID-19 "may have silent clinical pathology in any organ, including the heart," and consequently "should be evaluated in their medical home prior to resuming physical activity and organized sports." Table 2 in the guidance document (p. 27) outlines the recommended cardiopulmonary evaluation in athletes with prior COVID-19 infection, depending on the specific clinical scenario.

The AMSSM also provides guidance on specific conditions that may pose an increased risk for severe COVID-19, including pregnancy, diabetes, hypertension, asthma, and severe obesity. Although athletes with sickle cell trait are not at higher risk for adverse outcomes in general, they may have an increased risk of hypercoagulability complications for several months after recovery.

Introducing the 2020-2021 AFP Jay Siwek Medical Editing Fellows: Dr. Natasha Pyzocha

Jennifer Middleton, MD, MPH

It's my pleasure to introduce our second 2020-2021 Jay Siwek Medical Editing Fellow, Dr. Natasha Pyzocha, whose fellowship year also began on June 1. Here are some highlights from a recent interview:

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

I was born and raised in a small town in New Hampshire and my childhood was filled with memories of adventuring outdoors. I enjoyed the sciences and thought I’d become a palentologist, veterinarian, or doctor. After tearing my anterior cruciate ligament playing soccer, I enjoyed seeing the impact that doctors could have on an individual. I shadowed our local Family Physician, volunteered in domestic and international hospitals, and during college fell in love with the profession. I always had an interest in the military as well, so I joined the Army through the Health Professions Scholarship and attended medical school at the University of New England College of Osteopathic Medicine.

After medical school I was fortunate enough see many parts of the world. Most notably, I enjoyed my time during residency in Washington and as a Flight Surgeon in Colorado. Treating soldiers and their families was the best, but running aid stations with my medics and flying in helicopters was awesome as well. During my time in the Army, I also worked with the World Class Athlete Program and now continue to volunteer with the United States Olympic Committee. I’ve enjoyed teaching medics, medical students, peers, or anyone will listen throughout my various jobs and am currently working as adjunct faculty at Rocky Vista University College of Osteopathic Medicine. My most recent employer is a primary care telemedicine company and I’ve enjoyed the technical component of modernizing medicine.

 

2. What got you interested in medical editing and writing?

In residency, part of the graduation requirement was scholarly activity, so as an intern in an attempt to knock out my preconceived notion of a ‘check the box’ event, I fell in love with being able to learn from others and make an impact on education. Many of my Army residency faculty were so inspirational that I owe my initial interest efforts to them. I still continue to collaborate with some of these physicians on a regular basis! Even though the writing requirement is no longer there, I’ve continued to enjoy it so much I sought out the fellowship.

 

3. What are you hoping to get out of the fellowship?

Personally, I aim to refine the skills I have in both writing and editing by learning from a highly experienced editorial team. Writing for the different departments for AFP will increase my ability to think outside the box and become intimately involved in different styles of writing. Ultimately though, I hope to make an impact and inspire other Family Physicians to become leaders in writing. 

 

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

In my free time I enjoy skiing, snowboarding, hiking, biking, and paddleboarding with my husband, two year-old daughter, and two dogs. I’m looking forward to safe travel again in the future! I am a Fellow of the Academy of Wilderness Medicine and also am a physician volunteer with the United States Ski and Snowboard Association.

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.