Introducing the 2022-23 AFP Jay Siwek Medical Editing Fellow: Dr. Jarrett Sell

 - Jennifer Middleton, MD, MPH

It's my pleasure to introduce our 2022-23 Jay Siwek Medical Editing Fellow, Dr. Jarrett Sell, whose fellowship year will begin June 1. Here are some highlights from a recent interview:

1. Tell us a little about yourself.

I grew up in a rural area of Maryland and entered medical school at the University of Virginia with an interest in practicing family medicine in an area of need. After residency in Phoenix, I was able to return to a small town in Virginia where I practiced traditional family medicine without OB for 8 years. Eleven years ago, I made the switch from private practice to academic medicine and have enjoyed the breadth of teaching, scholarship, and clinical practice which has focused on local community needs and marginalized populations, such as those who identify as LGBTQ+ and those affected by HIV.  

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

As a life-long reader of fiction, nonfiction, and medical journals, I found that medical editing and writing brings together my natural curiosity and passion for teaching.  The American Family Physician (AFP) journal has personally served as an invaluable resource throughout my career as a student, resident, practicing physician, and clinical educator in its clear presentation of evidence-based approaches to care. I started medical writing as I entered academic medicine and found writing to be a great way to dive deeper into clinical topics of interest with a focus on how the current evidence can inform patient care, particularly for primary care providers. I also found that I enjoyed collaborating with students, residents and other faculty with the goal of improving patient care and advocating for better care for marginalized populations.   

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

I look forward to advancing my skills in medical editing, enriching medical education, collaborating to enhance the journal’s innovation, and improving patient care.  I hope to gain a better understanding of the editing process through collaboration with the diverse and experienced AFP team of editors, and I hope to share some of these skills with other learners.  

 

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

Outside of work I enjoy live music, reading, time with family, getting outdoors to hike, ski and boat, and I have recently restarted playing tennis after last playing seriously over 20 years ago.   

Welcome to AFP, Dr. Sell!

How did Family Medicine fare in this year's National Resident Match?

 - Kenny Lin, MD, MPH

Well into the fourth year of the America Needs More Family Doctors: 25 X 2030 Collaborative, Match Day 2022 brought some good news: the "largest class of [incoming family medicine] residents ever," according to the American Academy of Family Physicians (AAFP). As Dr. Clif Knight, then the AAFP's Senior Vice President for Education, wrote after the 2020 Match, it was uncertain how the COVID-19 pandemic would affect the number of fourth-year students who matched into family medicine residency programs, even as practicing family physicians were demonstrating their value to health care systems:

The increasingly prominent role of family physicians during the past few months highlights the versatility of family medicine training and competencies. Family physicians have flexed into inpatient, community outreach, and emergency coordination roles. ... The future for family physicians will be promising in the postpandemic era if the opportunities to appropriately reform primary care practice, regulation, and payment are enacted swiftly and with permanence.

A recent commentary in the New England Journal of Medicine pointed out that stable Match rates from year to year can obscure worrisome trends in the residency selection process. For example, the proportion of U.S. MD seniors who match to their top-ranked program has decreased steadily since the mid-2000s, while the proportion who match to their fourth choice or lower has increased. During this time, the number of applications submitted per applicant increased dramatically:

Between 2007 and 2020, ... the number of applications submitted per applicant doubled, with the average U.S. medical school graduate submitting 70 residency applications and the average IMG submitting 139 in 2020. The average internal medicine or general surgery residency program now receives more than 100 applications for every available position. As a consequence, programs interview and rank more applicants than they did in the past. Even though program fill rates are unchanged, there has been a steady increase in the number of applicants that programs must rank to fill each position, from 9.2 in 2002 to 15.4 in 2021. In other words, despite the stability in applicant match rates, program fill rates, and the ratio of PGY-1 positions to applicants, the residency-selection process has grown increasingly stressful, inefficient, and expensive as applicants have applied to more programs.

Delving deeper into the results of the 2022 Match reported by the AAFP provides ample reasons for pessimism. The number of U.S. MD seniors matching into Family Medicine fell from 1,623 in 2021 to 1,555 in 2022, representing only 8.4% of all matched U.S. MD seniors and at 31.5%, their lowest Family Medicine fill rate in history. (In contrast, the 30.3% fill rate of U.S. DO seniors was the highest ever, with 22.4% of all U.S. DO seniors matching to Family Medicine.) Overall, only 12.2% of U.S. medical school graduates will be entering family medicine residency programs in July, less than half of the specialty's 25% X 2030 goal.

In a critical analysis of the past four decades of Match results, Drs. Richard Young and Sophia Tinger observed that Family Medicine interest among U.S. MD graduates has stagnated for the past 10 years, and "there are no indications in the present environment (reimbursement by specialty, legislative mandates, new strategies to increase student interest in family medicine, the COVID-19 pandemic, or anything else) to suggest that the current trends will change over the next 9 years." Or to put it bluntly, "the 25 X 2030 Collaborative will almost certainly fail to reach its goal."

The consequences of an inadequate U.S. primary care workforce to the future health of all Americans could be dire. In a Graham Center Policy One-Pager in the April issue of AFP, Dr. Yalda Jabbarpour and colleagues examined the association of the Community Health Index (CHI; "an average score of public health preparedness, primary care physician supply rates, and the social deprivation index (a proxy for community-level factors such as housing and transportation)") with county-level COVID-19 death rates before and after widespread vaccine availability. Counties with higher CHI scores had lower COVID-19 mortality rates overall, with the number of deaths per 100,000 individuals falling most drastically after vaccination in counties in the highest quintile of CHI scores.

Treating acute asthma symptoms with beclomethasone (instead of albuterol) decreases rate of exacerbations

 - Jennifer Middleton, MD, MPH

The most recent global asthma guidelines advocate against the routine use of short-acting beta agonists (SABAs) for patients with mild asthma, and now a randomized controlled trial (RCT) has found that albuterol (a SABA) was inferior to beclomethasone, an inhaled corticosteroid (ICS), for acute symptom control in persons with asthma regardless of baseline asthma severity.

The researchers only enrolled Black and Latinx patients in this RCT, acknowledging that "guideline recommendations have not been based on studies in these populations." They randomized 1201 outpatients with moderate-to-severe asthma to either albuterol (usual care) or beclomethasone (intervention group) for acute symptom relief and followed them for 15 months. They found that "[t]he annualized rate of severe asthma exacerbations was 0.69 (95% confidence interval [CI], 0.61 to 0.78) in the intervention group and 0.82 (95% CI 0.73 to 0.92) in the usual-care group (hazard ratio, 0.85; 95% CI, 0.72 to 0.999; P=0.048)." Asthma symptoms and missed days of work, both secondary outcome measures in the study, also favored the beclomethasone intervention group.

In 2020, the Global Initiative for Asthma (GINA) guidelines recommended against SABA use as monotherapy for mild asthma, citing data showing increased mortality and exacerbations in patients who only used albuterol for even mild asthma symptoms. The GINA guidelines instead recommend the use of an ICS in combination with formoterol, a long-acting beta agonist (LABA), for acute relief of asthma symptoms in all patients with asthma, regardless of baseline severity. The guidelines do list use of an as-needed SABA as an acceptable option for patients on an ICS already at baseline; this newest study suggests that, even in those patients, SABAs are inferior to ICS for acute symptoms.

Switching from albuterol to either ICS or ICS/LABA inhalers will require substantial changes in the US from both the Food and Drug Administration (FDA) and insurance companies. Symbicort, the only ICS/formoterol product currently FDA-approved in the US, is not FDA-approved for as needed use. Symbicort comes with 60 doses per inhaler; insurance companies in the US do not typically cover  more than 1 inhaler a month, which may be sufficient for patients who do not need treatment daily, but patients with more severe asthma could easily exceed 60 doses in a month using it for both daily control and as needed. Without insurance, Symbicort costs at least $200/month and is not available yet as a generic; even with insurance, many patients pay significant co-pays. Beclomethasone (Qvar) is also quite expensive, costing at least $200 per inhaler.

Advocating for these changes was precisely what the RCT researchers intended, according to the study registry on clinicaltrials.gov:

The investigators have consulted with AA [African American] and H/L [Hispanic/Latinx] patients, health care providers, leaders of professional societies, advocacy groups, health policy leaders, pharmacists, and pharmaceutical manufacturers. All groups have indicated that asthma decision making would be changed if it was demonstrated that implementing PARTICS [Patient Activated Reliever-Triggered Inhaled CorticoSteroid] improves important asthma outcomes such as reducing rates of exacerbations.

The researchers' efforts to partner with patients and advocacy groups is laudable, and hopefully this study helps to spur needed change in asthma inhaler affordability and access. 

If you'd like to read more, this AFP article on "Asthma: Updated Diagnosis and Management Recommendations from GINA" provides a useful overview of the GINA recommendations, which is included in the AFP By Topic on Asthma.

Curbing cascades and low-value care in children

 - Kenny Lin, MD, MPH

Both editorials in the March issue of AFP discussed aspects of the problem of unnecessary health care services. In "Curbing Cascades of Care: What They Are and How to Stop Them," Dr. Ishani Ganguli, whose work in identifying low-value services was featured in a previous AFP Community Blog post, presented the case of a healthy 30-year old man with a heart murmur detected at an annual wellness visit. The physician ordered an echocardiogram that suggested pulmonary hypertension, leading to a cardiology visit and a right heart catheterization which showed normal pressures. Of this "false alarm" and others like it, the author observed:

Such stories are viscerally familiar to most clinicians. This is a cascade of care: a seemingly unstoppable succession of medical services often initiated by an unnecessary test or unexpected result and driven by the desire to avoid even the slightest risk of missing a potentially life-threatening condition. ... Each step in a cascade seems to be a rational progression from the step before. Yet taken together, these cascades can cause substantial harm to patients, including procedural complications, out-of-pocket costs, psychological distress, and stigma from new diagnoses. Clinicians, especially those practicing in rural settings, report anxiety, frustration, and wasted time and effort.

Dr. Ganguli then discussed two health systems strategies to stop cascades of care: avoiding unnecessary services that may trigger cascades (though Choosing Wisely is often easier said than done) and mitigating cascades through providing better point-of-care guidance regarding management of incidentalomas and engaging patients in shared decision-making rather than assuming that they will always prefer more testing in the face of uncertainty.

In a second editorial, Dr. Kao-Ping Chua reviewed "The Importance and Challenges of Reducing Low-Value Care in Children," noting that use of unnecessary services in this population is widespread, harms children and their families, and is costly to families and the health care system. Commenting on a Lown Right Care article in the same issue on the inappropriate use of an electrocardiogram (ECG) in a preparticipation sports examinations, Dr. Chua wrote:

Harms included the temporary exclusion from sports, the direct costs of ECGs and the cardiology visit, and the indirect costs to the family (e.g., costs of transportation to the cardiologist visit, missed school or work). The ECG may have also caused unnecessary emotional stress to the patient and family because it erroneously raised the possibility of a potentially life-threatening cardiac disorder.

On the other end of the age spectrum, a recent report in JAMA Network Open described the development of Evaluating Opportunities to Decrease Low-Value Prescribing (EVOLV-Rx), a tool for detecting 18 low-value prescribing practices in older adults based on scientific validity and clinical usefulness.

Ultimately, EVOLV-Rx, the KIDs List for potentially inappropriate medications in children, and other interventions to reduce low-value care should be evaluated on improvements in patient-oriented and/or reported outcomes (increased benefit, decreased harm, few unintended consequences) rather than reductions in services alone. A 2019 systematic review of more than 100 studies of such interventions found that clinically meaningful measures were often lacking. Nonetheless, individual clinicians can follow the suggestions of Drs. Ganguli and Chua to spend less time handling false alarms and more on concerns and conditions that matter to patients.

Post-op complications increase < 8 weeks after COVID-19 diagnosis

 - Jennifer Middleton, MD, MPH

Health care systems across the world have paused elective surgeries at various points during the COVID-19 pandemic. Numerous asymptomatic patients have also been surprised by a positive pre-op COVID-19 test and had to reschedule their planned surgery. In the health system where I work, once those patients have finished their quarantine, they are free to reschedule their procedures. A new database study suggests that a longer waiting period might reduce post-operative complications; the study reviewed the records of over 5000 persons who had a positive COVID-19 PCR test and had surgery, either in the 4 week period before their positive test or in the weeks after their COVID-19 diagnosis; the study found an increased risk of post-operative complications for patients who had elective surgery within 8 weeks of documented COVID-19 infection.

The study authors used the COVID-19 Research Database, which "includes de-identified and limited datasets from medical and pharmacy claims data, EHR data, mortality data, and consumer data" from across the United States. Over 316 million unique individuals are captured in this database, which the researchers searched to identify persons with positive COVID-19 tests who had undergone elective surgeries in the weeks prior to or following their positive test. The study authors included a wide range of major, but not urgent or emergent, surgeries including mastectomies, colorectal resections, joint replacements, spinal fusions, and coronary artery bypass grafting (CABG). They identified 5479 patients who met study criteria, about half of whom had their surgeries before their COVID-19 diagnosis and about half of whom had their surgeries after their COVID-19 diagnosis. They divided patients into 4 categories: "pre-COVID-19" (control group), "peri-COVID-19" (0-4 weeks after diagnosis), "early-post-COVID-19" (4-8 weeks after diagnosis), and "late-COVID-19" (more than 8 weeks after diagnosis). Less than 2% of included patients had COVID-19 disease considered severe or critical. The researchers found that:

After adjustment for patient characteristics and type of surgery, peri-Covid-19 patients had a significantly higher risk of developing postoperative pneumonia [adjusted odds ratio (aOR), 6.46; 95% confidence interval (CI), 4.06–10.27], respiratory failure (aOR, 3.36; 95% CI, 2.22–5.10), PE (aOR, 2.73; 95% CI, 1.35–5.53) and sepsis (aOR, 3.67; 95% CI, 2.18–6.16) when compared to pre-Covid-19 patients. For most complications, early post-Covid-19 patients did not have a higher risk when compared to pre-Covid-19 patients; however, early post-Covid-19 patients did have a higher risk of developing postoperative pneumonia (aOR, 2.44; 95% CI: 1.20–4.96). 

The study authors appropriately note that "the balance between the risk of postoperative complications and the risk of worse overall survival associated with delayed surgical treatment should be carefully discussed;" for some patients, especially those with cancer, postponing surgery may not be the best balance of benefit and harms. When appropriate, though, discussing this apparent benefit of postponing surgery with our patients - and our surgical colleagues - may help decrease patients' risk of post-operative pneumonia, respiratory failure, and sepsis.

You can find AFP content with the keyword "perioperative care" here, including this article on "Preoperative Testing Before Noncardiac Surgery: Guidelines and Recommendations." The AFP By Topic page on COVID-19 also continues to be regularly updated if you'd like to read more. 

Neurocognitive symptoms in patients with celiac disease and non-celiac gluten sensitivity

- Lilian White, MD

Celiac disease is an autoimmune disorder that results from antibodies to components of gluten. Globally, about 0.7-1.4% of the population has celiac disease. When people with celiac disease eat gluten, their bodies respond by forming antibodies to components of the gluten protein. These antibodies also bind to the villi of intestinal cells, resulting in a variety of signs and symptoms. Classic celiac disease typically presents with localized gastrointestinal (GI) symptoms, including diarrhea, constipation, malabsorption, abdominal pain, bloating, and weight loss. Patients with non-classic celiac disease (which, interestingly, is more common than classic celiac disease) develop symptoms that do not significantly involve the GI tract. These signs and symptoms can include fatigue, joint pain, dermatitis herpetiformis, iron deficiency anemia, migraines, depression, attention deficit disorder, epilepsy, infertility, and low bone density. Some experts prefer to use the terms “intestinal” and “extraintestinal” in place of classic and non-classic celiac disease.

Non-celiac gluten sensitivity is characterized by signs or symptoms associated with gluten ingestion without laboratory findings associated with celiac disease or wheat allergy. Estimates of its prevalence range widely from 0.49% to 14.9%. Symptoms vary and may present in a wide variety of ways, like the intestinal and extraintestinal manifestations of celiac disease.

Neurocognitive symptoms are commonly described by patients with celiac disease; however, there has been little formal study of these symptoms. Neurologic effects of celiac disease have generally been limited to descriptions of neuropathy, epilepsy, and ataxia. A recent survey study of 1396 patients with celiac disease and non-celiac gluten sensitivity was conducted to better understand neurocognitive effects (referred to more informally as “brain fog”) in patients following gluten ingestion. Participants were recruited from the e-mail contact database and social media platforms of the patient advocacy organization Beyond Celiac. 9 in 10 participants reported acute neurocognitive symptoms after gluten ingestion, including forgetfulness, difficulty concentrating, and grogginess. Both groups also noted similar onset and peak of symptoms at 1-2 days, with many continuing to have symptoms 3-5 days later.

While limited by the self-selected population, this study suggests that both patients with celiac disease and non-celiac gluten sensitivity have neurocognitive symptoms following gluten ingestion. The duration of symptoms observed demonstrates the potential to significantly affect patients’ work and/or school performance. It may be helpful for family physicians to ask patients with celiac disease and non-celiac gluten sensitivity if they experience neurocognitive symptoms to better understand how these may be affecting their cognitive functioning and performance.

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Dr. White, a second-year resident at the Cleveland Clinic Family Medicine Residency Program, is a 2022 AFP Resident Representative.