Tuesday, January 21, 2020

America needs more family doctors: working toward the 25 x 2030 goal

- Kenny Lin, MD, MPH

Last summer, a Graham Center Policy One-Pager reported that the percentage of the active U.S. physician workforce in primary care practice declined from 32 percent in 2010 to 30 percent in 2018. Although family physicians represent 4 in 10 primary care physicians, in several states a large percentage of family physicians are older than 55 years and anticipated to transition to part-time practice or retire by 2030. Recognizing the imperative to not only maintain, but expand the family medicine workforce to meet the population's needs, the Workforce and Education Development team of Family Medicine for America's Health recommended adoption of a shared aim known as 25 x 2030: to increase the percentage of U.S. medical students choosing family medicine from 12% to 25% by the year 2030. Supported by the American Academy of Family Physicians and seven other national and international family medicine organizations, the America Needs More Family Doctors: 25 x 2030 collaborative was officially launched in August 2018.

In an editorial in the January 15 issue of American Family Physician, Dr. Jacob Prunuske, a member of the 25 x 2030 Steering Committee, described the collaborative's guiding principles, benefits to physicians at all levels of experience, and how family doctors in the trenches can support progress toward this ambitious aim:

Recruit before medical school. Encourage children and young adults to not only go to medical school, but to become a family doctor. Active recruitment is especially valuable in underserved or rural communities and for those underrepresented in medicine.

Change the medical school experience. When you have the opportunity to work with medical students, say yes. If you must say no, reflect on what it would take to get you to say yes, and share your reflections with your health care system, institution, or the 25 × 2030 working groups so that they can address barriers to teaching. As preceptors for medical students, family doctors not only teach family medicine principles, but also serve as mentors and role models. Embrace this role. Debunk myths and counter negative stereotypes of family medicine. Family doctors provide high-value care by delivering high-quality outcomes while controlling costs. Medical students need this experience with practicing family doctors to combat the alternative messages of other specialties.

Advocate for family medicine. Legislative leaders need to hear about the value of family medicine from voters. Respond to advocacy calls, and advocate at the local, state, and national levels for changes that support family medicine. Share your advocacy efforts with your patients and tell them why these issues matter to you, them, and all of us.

Embrace change. Patient expectations, technology, and health systems will evolve. Rather than react, help guide these changes to fit the principles of family medicine.

An excellent resource for interested medical students is AFP's 2016 article, "Responses to Medical Students' Frequently Asked Questions About Family Medicine," which answers common questions about the importance of the specialty, residency and fellowship training, procedural skills and scope of practice, economic realities, and future prospects. The article advised students that "the best way to know if family medicine is the right fit for you is to work with family physicians in action, by doing a rotation with a family physician in practice." An upcoming AFP editorial will discuss why even more community family physicians should take the time and effort to precept students in their practices.

Monday, January 13, 2020

Should schools screen for adolescent idiopathic scoliosis?

- Jennifer Middleton, MD, MPH

I still remember lining up with my female peers in junior high gym class, clad only in undergarments (quite the height of teenage mortification), to bend over and have our spines checked for scoliosis. Such school-based screenings remain commonplace across the US, though there is considerable debate regarding their benefit. The January 1 AFP review on "Adolescent Idiopathic Scoliosis: Common Questions and Answers" discusses the current United States Preventive Services Task Force "I" statement regarding screening and its rebuttal by several medical organizations including the American Academy of Pediatrics and the American Academy of Orthopedic Surgeons. Although the evidence base leans away from screening, family physicians are still likely to encounter adolescents and their worried parents with positive screens in our offices.

Repeating the forward bend test in the office and looking for an abnormal appearance of the back or ribs is a reasonable first step. The AFP authors review a study that found the forward bend test has a 92-100% sensitivity for detecting a Cobb angle of at least 20 degrees. While the patient is bending over, clinicians may also use a scoliometer or a scoliometer app to quantify trunk rotation. Sensitivity to detect a Cobb angle of at least 10 degrees is highest with a scoliometer cutoff of 5%, but a cutoff of 7% has a better specificity (87% compared to 47%) with a small corresponding loss of sensitivity (down to 83%). Radiography can definitively make the diagnosis and quantify severity.

The AFP authors point out that evidence is lacking regarding the benefit of referring all but the most severe cases of scoliosis (Cobb angle of 40 degrees or greater) to an orthopedic surgeon. Family physicians should also discuss the prognosis for mild to moderate scoliosis with their patients and parents; the evidence review that informed the USPSTF's "I" decision found that:

Quality of life [measures]...were similar between observed and braced participants at adult followup, though braced participants felt their body appearance was more distorted than did untreated participants, and braced participants reported more negative treatment experiences than those treated surgically. No significant adult outcome differences were found between braced and surgically-treated participants on the Oswestry Disability Index, general well-being, or self-esteem and social activity. Pulmonary outcomes and childbearing and pregnancy outcomes were similar in braced and surgically-treated participants.

School-based nursing programs might more effectively target their efforts toward other disease processes (and their risk factors). In an era of school nursing shortages across the US, prioritizing school-based health efforts is more important than ever. The National Association of School Nurses does not include reference materials about scoliosis anywhere on their website, focusing instead on more prevalent and more impactful issues such as childhood obesity, drugs of abuse, mental health, and reproductive health.

There's an AFP By Topic on Musculoskeletal Care if you'd like to read more, and here is additional AFP content specifically regarding scoliosis as well.

Tuesday, January 7, 2020

AAFP-endorsed practice guideline supports limiting testosterone prescriptions

- Kenny Lin, MD, MPH

Is age-related low testosterone normal or a disease? If it is a disease, what are the benefits and harms of testosterone therapy? A previous AFP Community Blog post reviewed the controversy surrounding screening for low testosterone in older men and the U.S. Food and Drug Administration's requirement that prescription testosterone product labeling include warnings about a possible increased risk of heart attacks and strokes. A recent analysis of Medicare data found that testosterone prescribing peaked in 2013 and has since declined, but that prescribing rates were actually higher for men with coronary artery disease (CAD) than men without CAD. Meanwhile, another study suggested that men prescribed testosterone therapy have an increased risk of developing venous thromboembolism in the first 6 months of use.

Today the American College of Physicians (ACP) published a clinical practice guideline, endorsed by the American Academy of Family Physicians (AAFP), to provide evidence-based recommendations for primary care and subspecialist clinicians on treatment of men with age-related low testosterone. Based on an independent systematic review of the efficacy and safety of testosterone treatment, the ACP and AAFP suggested that clinicians discuss potential benefits, harms and costs of therapy with patients with age-related low testosterone and sexual dysfunction. The guideline recommended against initiating testosterone treatment for the purpose of improving energy, vitality, physical function, or cognition, due to the lack of benefits in randomized trials. Since some men will not respond to treatment, the guideline suggested re-evaluating symptoms within 12 months of initiating testosterone therapy, and discontinuing treatment if sexual function does not improve.

Studies assessing patient preferences reviewed by the ACP showed mixed preferences for injectable versus topical testosterone; the most bothersome symptoms were erectile dysfunction, decreased sex drive, and loss of energy; and moderately high therapy discontinuation rates in two studies (30 and 62 percent). Since transdermal testosterone costs an average of 14 times as much as intramuscular ($2135 vs. $156 for a year's supply in 2016, respectively) and has similar clinical effects and harms, the ACP and AAFP suggested considering intramuscular rather than transdermal formulations.

Although the guideline did not directly address the relatively common phenomenon of testosterone treatment in men without low testosterone levels, the American Society of Clinical Pathology, the American Urological Association, and the Endocrine Society have all advised against this type of prescribing to improve erectile dysfunction or any other symptom.

Monday, December 30, 2019

Changing physician behavior to avoid unnecessary steroid prescriptions

- Jennifer Middleton, MD, MPH

"Short-Term Systemic Corticosteroids: Appropriate Use in Primary Care," e-published ahead of print this past week, reviews several diagnoses that steroids are commonly prescribed for along with the evidence base - or lack thereof - to support their use. Regarding the latter, Drs. Dvorin and Ebell review the evidence against short-term steroid use in allergic rhinitis, acute sinusitis, carpal tunnel syndrome, and acute bronchitis (in the absence of an underlying asthma or COPD diagnosis). Besides not improving patient-oriented outcomes for these conditions, the risks of a short-term course of steroids are not negligible. Changing treatment habits can be challenging for physicians, but implementing strategies that do successfully promote physician behavior change may be one worthwhile resolution to make for the upcoming new year.

Two recent articles provide guidance regarding the promotion of physician behavior change. The first, a comprehensive review published in 2017, found that "[c]ollaborative team-based policies involving primarily family physicians, nurses, and pharmacists were found to be most effective:" 
"Interactive and multifaceted continuous medical education programs including training with audit and feedback, and clinical decision support systems were found to be of benefit in improving knowledge, optimizing prescriptions...enhancing patient outcomes, and reducing adverse events." 
Interestingly, financial incentives were not found to meaningfully effect long-term behavior change regarding physician prescribing and/or treatment habits.

The second article, a rapid review conducted in Australia, specifically examined "changing prescribing behaviors with educational outreach:"
"Educational outreach involves a trained facilitator delivering a face-to-face program in a health professional’s setting (e.g. GP clinic) with the aim to change clinician behaviour, such as prescribing behaviours [sic]. Educational outreach programs can focus largely on education...or include a variety of supplemental or additional strategies like providing reminder letters or audit and feedback." 
This review found that educational outreach can be effective, but it was most effective when it focused on "specifically targeting barriers" to change. Semi-structured interviews of physicians included in the review additionally suggested that the "[c]ontent of EO visits needs to be practical, skills-focused and engaging to facilitate participation and uptake, as opposed to didactic or lecture-based."

These studies found that simple interventions, such as financial incentives and generic didactic content, were not effective, while more complex solutions, such as involving interdisciplinary teams in crafting policy change and tailoring educational outreach, were effective. If healthcare leaders and organizations want to promote meaningful change in physician behavior, then investment in these more complex solutions may be worth the effort.

The transition to a new year is often a time for resolutions regarding behavior change; in addition to avoiding unnecessary steroid prescriptions, perhaps you might also consider resolving to expand how you access AFP's content, such as using the Favorites feature on the homepage, listening to the podcast, viewing our YouTube videos, or following us on Twitter.

Monday, December 23, 2019

The top ten AFP Community Blog posts of 2019

- Kenny Lin, MD, MPH

Looking back over the year, the posts that resonated most with readers explored cardiovascular prevention dilemmas, meaningful outcomes in type 2 diabetes, diagnosis and prevention of serious bacterial infections, and low-value medical care.

1. Should physicians de-prescribe statins in older adults? (May 13) - 4038 views

Deprescribing decisions will still require individualized shared decision making. An older adult without vascular events can likely stop a statin with minimal effect on risk, while a patient with a prior event will still benefit from continuing the statin, provided that he or she isn't experiencing adverse effects.

2. Has aspirin for primary prevention of CVD reached its expiration date? (June 8) - 1848 views

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

3. The family physician's role in vaccine-preventable disease outbreaks (February 11) - 1574 views

Increasing vaccination rates is a critical but challenging component of the solution. With vaccine hesitancy now among the World Health Organization's (WHO) top 10 threats to global health, it's critical that we redouble our efforts to combat the spread of misinformation about vaccines.

4. Bye-bye Benadryl? (December 2) - 954 views

First-generation antihistamines (diphenhydramine, chlorpheniramine, and hydroxyzine) have more worrisome side effects than newer generation antihistamines (loratidine, cetirizine, and fexofenadine), and both generations have equal treatment efficacy.

5. Therapies for type 2 diabetes: improving outcomes that matter (February 19) - 771 views

When comparing therapies for type 2 diabetes, physicians, patients, and quality measures often get caught up in the disease-oriented outcome of glycemic control.

6. Is "prediabetes" a useful term? (August 12) - 770 views

Higher hemoglobin A1c levels (i.e., 6.0% to 6.4%), but also other important risk factors, such as family history of diabetes, higher fasting plasma glucose levels, and higher triglyceride levels, may predict greater risk of progression to diabetes.

7. Deliberate clinical inertia: protecting patients from low-value care (July 22) - 738 views

Ways to support deliberate clinical inertia in practice include: empathy and acknowledgment; symptom management; clinical observation; explanation of the natural course of the condition; managing expectations; and shared decision-making ("communicating rather than doing").

8. Does subspecialist medical care add sufficient value to be worth the added cost? (February 5) - 731 views

After adjustment for potential sources of confounding, respondents with primary care were more likely to receive high-value preventive care and counseling and to report better patient experiences than those without primary care.

9. Farewell to Close-ups (November 25) - 704 views

Our deepest gratitude goes to our patients for taking the time to tell their stories and their family physicians for transcribing and submitting them. The many patients and their physicians who have contributed to Close-ups are a testament to the strong bonds family physicians have with their patients.

10. Ruling out serious bacterial infections in the first weeks of life (October 7) - 684 views

We should resist the temptation to extrapolate this new decision rule to settings beyond the Emergency Department, though further studies in those settings could cement its role in helping us better predict which young infants with fever need aggressive testing and treatment - and which do not.

Seasons Greetings from all of us at American Family Physician!

Monday, December 16, 2019

Hair dye and cancer risk

- Jennifer Middleton, MD, MPH

While white women are slightly more likely to get breast cancer than black women, black women are more likely to be diagnosed with aggressive breast cancers and also have a higher mortality rate. A large prospective cohort study examining "Hair dye and chemical straightener use and breast cancer risk in a large US population of black and white women" is making headlines with its findings that purport to explain at least some of this difference.

The researchers examined data from over 46,000 U.S. women with at least one sister with breast cancer who are participants in the Sister Study, a project supported by the National Institutes for Health. The Sister Study enrolled these women between 2003 and 2009, tracking any new onset of breast cancer among them along with possible associations of a wide array of variables. Some of these variables centered on hair products, specifically hair dye and chemical straighteners. Enrollees completed a questionnaire regarding their use of these products in the year prior to their enrollment; 55% reported the use of permanent hair dye. The participants were followed for an average of 8.3 years; during this time, nearly 2,800 of the Sister Study women developed breast cancer.

After controlling for menopausal status, age at menarche, educational attainment, smoking history, and age at first birth, the researchers found that the risk of developing breast cancer was higher in women who had reported hair dye use than those who had not, with a disparity in the effect based on ethnicity. Black women had a 45% increase in risk with permanent hair dye use (hazard ratio 1.45, 95% confidence interval 1.10-1.90) while the 7% higher risk in white women was not statistically significant (HR 1.07, 95% CI 0.99-1.16). The use of chemical straightener was also associated with an increased risk of developing breast cancer, though this risk was also not statistically significant (HR 1.18, 95% CI 0.99-1.41). The use of semi-permanent dye ("highlights") and temporary dyes were not associated with an increased risk of cancer. The researchers note the consistency of their findings with earlier, smaller studies.

When asked whether women should stop using these projects, the co-lead investigator of the study responded:

"We are exposed to many things that could potentially contribute to breast cancer, and it is unlikely that any single factor explains a woman’s risk. While it is too early to make a firm recommendation, avoiding these chemicals might be one more thing women can do to reduce their risk of breast cancer."

It's important to note that an observational study, like this one, can only determine correlation, not causality, between these hair products' use and the development of breast cancer. It also may not be appropriate to generalize this study's findings to women who don't have a sister with breast cancer; the women enrolled in the Sister Study may have been at higher risk of developing breast cancer to begin with since they had a positive family history. Discussing the study design, findings, and limitations with our patients can help them make an informed choice regarding their use of these products. There's an AFP By Topic on Cancer with a Breast Cancer subheading which includes information about risk reduction strategies, screening and diagnosis, and care of survivors if you'd like to read more.