Monday, September 21, 2020

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.

Monday, September 14, 2020

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.

Monday, September 7, 2020

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 FellowDr. 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.


Monday, August 31, 2020

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).

Friday, August 21, 2020

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.

Monday, August 17, 2020

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.