Monday, October 12, 2020

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."

Thursday, October 8, 2020

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.

Tuesday, October 6, 2020

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.

Monday, September 28, 2020

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.

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.

Monday, August 10, 2020

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.

Monday, August 3, 2020

Addressing racism and health inequities: a call to action

- Jennifer Middleton, MD, MPH

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

First, family physicians must learn to recognize how different conditions may present in persons of color, especially dermatologic diagnoses. A recent letter to the editor re: the AFP article on "Erythema Multiforme: Recognition and Management" asserts that 
Family physicians must learn how dermatologic conditions present in skin of color to serve our increasingly diverse patient population better and to avoid incorrect or delayed diagnoses. Any article about dermatologic disorders...must include how the skin disorder presents in skin of color.
Dr. Lin's response to this letter includes a reference to the 2013 AFP series on "Dermatologic Conditions in Skin of Color" (Part I and Part II). Educating ourselves - and improving our educational structures - to consider all skin types is imperative to accurate diagnoses in persons of color.


The Annals of Family Medicine's website is featuring two articles from its archives on its website that can help us broaden our perspective on racism. The 2016 article "Racism in Medicine: Shifting the Power," written by Dr. J. Nwando Olayiwola, a Black female physician, outlines her experience of hearing a rant of hateful language, including a racial slur, from a white patient during an office encounter. Reading this account can be uncomfortable, but we must lean into that discomfort, acknowledging that this incident is only one of an innumerable multitude:
Black women (and other professional minority women) have to justify professional qualifications that should speak for themselves. We have to be “twice as”…good, smart, talented, aggressive, outspoken, witty, etc than everyone else in our professional or work environments; proving that we are not “imposters;” biting our tongues and tempering our words because we don’t want to appear “angry;” being passed up or looked over, underpaid, undervalued, and under-appreciated.
The 2018 article, "White Privilege in a White Coat: How Racism Shaped my Medical Education," written by Max J. Romano, a white medical student, provides a poignant contrast. Unlike Dr. Olayiwola, who is constantly aware of racism, Mr. Romano recognizes that he is not:
Most white doctors do not think race affects them or their clinical decisions and are taught to ignore their own racial privilege in favor of a meritocratic social myth. However, multiple studies reinforce the existence of racial bias among physicians and its negative implications for patient care.
If we are to provide optimal patient care for our Black patients, we must confront our role in maintaining the systems that reinforce racism. Those of us who are white must undertake the work to recognize the privilege our skin color has afforded us and understand our implicit biases. We must reach out to our Black colleagues and patients with genuine caring; we must also take care, however, not to expect them to educate us about the racist structures that pervade our society, as resources already exist for us to educate ourselves. Let us each commit to do so; our Black patients and colleagues deserve nothing less.

Wednesday, July 29, 2020

Guest Post: Providing house calls during the COVID-19 pandemic

- Marguerite Duane, MD, MHA

As a family physician with a house calls-based direct primary care practice, almost all of my in-person visits are conducted in patients’ homes. House calls and telemedicine visits form the foundation of our practice. Therefore, when the COVID-19 pandemic hit, we were prepared to transition most of our care to telemedicine. However, there have been instances when the patient’s illness or injury necessitated an in-person visit.

For instance, in March soon after the pandemic began spreading locally, a mother texted me that her young son had a fever of 101.9 degrees, associated with a mild sore throat and productive cough, She had kept him home from school for four days, but his symptoms were not improving. At that time, our practice had not yet acquired N-95 masks, but I knew I needed to “see” the patient and possibly perform a rapid strep or flu test. Therefore, the boy's mother and I agreed to meet on her front porch where I took the full history, including additional pertinent positives (specifically headache), and negatives, such as no shortness of breath, body aches, ear pain, nausea or vomiting.

Since streptococcal pharyngitis and influenza were at the top of my differential, I needed to evaluate the patient, but since COVID-19 was also possible, I wanted to limit my exposure so I did not go inside the home. Instead, I asked the mother to take a picture of her son’s throat (Figure 1) and then via a video call collected more information which indicated that a rapid strep test was necessary. I demonstrated for the mom how to swab the back of her son’s throat to collect the sample, which she did. Then I was able to run the test, which was positive. The diagnosis was a huge relief for the mother, as her son's fever was diagnosed without ever having to leave her home, minimizing their risk for possible exposure to the coronavirus.

Figure 1. Streptococcal pharyngitis.
I pride myself on caring for the whole person in the context of their community, considering not only their physical symptoms, but their social determinants of health. Rather than focus on one bodily system or disease, I consider patients’ preventive and chronic health care needs, as well as address acute issues or injuries.

Over the last couple of months, I did a series of family visits, conducting well child checks and administering vaccines, screening adults for disease, and in general providing the care patients needed in the comfort of their homes. One afternoon, I saw a father for an acute injury, addressed early pregnancy symptoms in the mother, and did well child checks for all of their children, including vision and hearing screens. A few days later, I received a call that one of the children had fallen and cut her head. The mother texted me a photo (Figure 2) from which I knew she needed to be seen. Rather than send her to an urgent care, I was able to treat the child's laceration appropriately at home.

Figure 2. Traumatic laceration treated at home.
House calls are a wonderful way to care for patients of all ages, and, in the midst of the COVID-19 crisis, allow patients to receive care more safely. By seeing patients and families in their homes, family physicians can minimize their exposure to infection and still address almost all of their health care needs. I hope that more of my colleagues will be inspired to integrate house calls into their practices.

**

Dr. Duane practices comprehensive family medicine with Modern Mobile Medicine, a direct primary care practice serving patients in the Washington, DC metro area. She co-authored the August 15 AFP article on house calls.

Monday, July 27, 2020

An epidemic within a pandemic: syphilis and COVID-19

- Kenny Lin, MD, MPH

In many communities, the same people who work on preventing the spread of sexually transmitted diseases such as syphilis have been called on to help prevent the spread of COVID-19. Departments are reporting mass interruptions in STD care and prevention services. 
- Kaiser Health News, June 4, 2020

Contact tracing is a public health tool that was developed long before the current pandemic. It is an essential element of sexually transmitted disease (STD) prevention and treatment programs that rely on notifying partners of infected persons so that they can be treated with antibiotics in time to stop the chain of transmission. As discussed in the review article "Syphilis: Far From Ancient History" and my accompanying editorial in the July 15 issue of AFP, the national increase in the number of primary and secondary syphilis infections since 2000 has fueled increases in the incidence of congenital syphilis, with 1306 cases diagnosed in 2018.

Although the essentially flat (40% decreased in inflation-adjusted dollars) Centers for Disease Control and Prevention (CDC) budget for STD prevention programs since 2003 has likely worsened this problem, a CDC analysis of year 2018 cases identified four types of missed prenatal prevention opportunities that can be addressed by family physicians, obstetricians, and other maternity care providers: 1) lack of timely prenatal care (and consequently no syphilis screening); 2) lack of timely syphilis screening despite timely prenatal care; 3) inadequate maternal syphilis treatment; 4) diagnosing syphilis less than 30 days before delivery. In my editorial, I added that "family physicians can prevent congenital syphilis by following national screening guidelines; taking accurate, detailed sexual histories; providing evidence-based interventions to people who use injection drugs; and advocating to reduce structural barriers to care."

COVID-19 has complicated congenital syphilis prevention by diverting health department personnel who would typically staff STD programs and discouraging expectant mothers from attending in-person prenatal visits due to infection concerns. In a Health Affairs blog post, Dr. Marcus Plescia and Elizabeth Ruebush from the Association of State and Territorial Health Officials affirmed that "there’s nothing non-essential about prenatal care and appropriate testing and treatment for syphilis," and discussed strategies for continuing to provide these critical health care services:

In our current environment, we’re seeing healthcare providers develop creative strategies to limit the number of in-person clinical visits by concentrating care around critical visits (e.g., for tests and ultrasounds) and leveraging the use of telemedicine when appropriate. Telemedicine visits should incorporate a comprehensive sexual history, and timely syphilis testing should be a key consideration when planning for prenatal care visits. ... It's also important to take a closer look at the maternal syphilis treatment regimen, which—depending on how long the mother has had syphilis—can involve three shots of penicillin, each seven days apart. ... Text and email reminders can be used to prompt individuals to return for their complete series of penicillin shots, and partnerships with clinical sites in the community can provide alternative models for delivering injectable therapy.

Monday, July 20, 2020

PPI use and COVID-19 infection: a meaningful correlation?

- Jennifer Middleton, MD, MPH

In its current issue, the American Journal of Gastroenterology preliminarily published the results of a health survey correlating proton pump inhibitor (PPI) use with COVID-19 infection. The journal placed a disclaimer at the top of the document noting that "[t]his version will undergo additional copyediting, typesetting and review before it is published in its final form." Its findings, widely reported in the lay press, may result in patient questions regarding PPI safety during the pandemic, but discontinuing PPIs on the basis of this study is likely premature.

The authors enlisted an online research firm to conduct a health survey throughout the United States. The survey asked participants about their use of PPIs or H2-receptor antagonists (H2RA) and also asked if they had been diagnosed with COVID-19. The manuscript does not specify how the 250,000+ adults were chosen to receive a survey invitation, but they report that over 86,000 took the survey. Of those persons who responded between May 3 and June 24, 2020, just over 53,000 reported gastroesophageal reflux disease (GERD) symptoms. This cohort of 53,160 individuals comprised the study population. 6.4% of this group reported a positive COVID-19 test. The researchers then compared PPI and H2RA use among participants who did and did not report a positive COVID-19 test. The odds ratio (OR) for a positive COVID-19 test among participants reporting use of a PPI once a day, compared to those not taking any antacid therapy, was 2.15 (95% confidence interval [CI] 1.90-2.44); the odds ratio among those reporting use of a PPI twice daily for a positive COVID-19 test was 3.67 (95% CI 2.93-4.60). The results for H2RA use were not deemed statistically significant (though the CI for once daily H2RA, compared to no therapy, fell just below 1.0 [OR 0.85, 95% CI 0.74-0.99]).

Methodological concerns with this study include an inadequately-described participant recruitment strategy and the decision to narrow the study cohort to only those participants who self-reported GERD symptoms. The demographic information in Table 1 also brings up some odd discrepancies; while it's not unexpected that a larger percentage of participants with COVID-19 used tobacco, identified as Latinx, and had not completed high school, it's harder to explain why a significantly higher percentage of participants with COVID-19 were married compared to those without a COVID-19 diagnosis (74.5% vs 27.1%) or reported an annual income of greater than $200,000 (63.5% vs 7.4%).

PPI use has previously been associated with an increased risk of enteric infections, pneumonia, and fractures, though a 2019 meta-analysis of PPI safety largely refuted those claims. Hopefully, future research will further elucidate any possible PPI-COVID connection; in the meantime, it's certainly advisable to continue to discourage twice-daily PPI use for most patients, since once-daily PPI use results in similar symptom improvement


Monday, July 13, 2020

Addressing adverse childhood experiences and their sequelae in primary care

- Kenny Lin, MD, MPH

In a recent editorial on the relationship between stress and chronic disease, Dr. Jennifer Middleton mentioned that adverse childhood experiences (ACEs), "such as physical or sexual abuse, witnessed domestic violence, loss or incarceration of a parent, and poverty," are associated with later development of diabetes, cardiovascular disease, asthma, and cancer. A 2019 report from the Centers for Disease Control and Prevention (CDC) found that 60% of U.S. adults surveyed from 2015 to 2017 had experienced at least one ACE, while 1 in 6 adults had experienced four or more. In addition, the CDC identified a dose-response relationship between number of ACEs and prevalence of health risk behaviors, socioeconomic challenges, and chronic health conditions.

In a Curbside Consultation in the July 1 issue of AFP, Drs. Jennifer Hinesley and Alex Krist discussed the primary care approach to a woman who presented with irritability, depression and anxiety and a history of childhood physical and sexual abuse. The U.S. Preventive Services Task Force (USPSTF) does not have a recommendation for screening for ACEs; however, a sample screening tool is available in a recent FPM article. In patients who disclose a history of ACEs, Drs. Hinesley and Krist suggested assessment for mental health conditions such as post-traumatic stress disorder and substance use disorders. For other health care needs, including preventive care, applying principles of trauma-informed care may reduce the risk of re-traumatization and increase patients' comfort.

Can screening for ACEs at well-child visits improve resilience and prevent future ACEs and associated toxic stress? Similarly, what types of interventions might help adults with a history of ACEs but no symptoms of related chronic issues? Dr. Krist previously wrote an AFP editorial about the necessary prerequisites for the USPSTF to recommend routine screening for social needs:

an accurate screening test to identify patients with the social need, an effective treatment to address the social need once identified, and evidence demonstrating a meaningful health outcome improvement for patients. We know that having a social need leads to poorer health. In some cases, we even know that screening identifies those with a need, but often we do not know what to do after we have identified the need.

Substituting "ACE" for "social need" highlights some potential problems with systematic identification of ACEs in primary care. As Dr. Thomas Campbell noted in a JAMA Viewpoint, the evidence is lacking that ACE-related clinical interventions in children or adults improve any health outcomes. It is possible that screening for ACEs might inadvertently cause harm by reducing trust between clinicians and patients or parents/guardians, or by erroneously labeling patients as "high risk" for future problems based on a high number of ACEs alone.

Monday, July 6, 2020

Should we screen all adolescent and adult women for anxiety?

- Jennifer Middleton, MD, MPH

At first glance, the question mark in that title might seem misplaced. Anxiety is prevalent among both women and men, and the current stress of the global COVID-19 pandemic is exacerbating those symptoms for many. A new recommendation statement making the lay press rounds urges us to screen all adolescent and adult women for anxiety, but the evidence behind that recommendation merits further examination.

The Women's Preventive Services Initiative (WPSI) is a "national coalition of women's health professional organizations and patient representatives" led by the American College of Obstetricians and Gynecologists (ACOG) which includes the AAFP and the American College of Physicians (ACP). The WPSI's "Screening for Anxiety in Adolescent and Adult Women" recommendation statement, published last month, describes the prevalence and scope of anxiety disorders in women and also reviews available treatment methods in detail. Its recommendation to adopt universal screening is based on a systematic review, published alongside the recommendation statement, which sought to "evaluate evidence on the effectiveness of screening for anxiety disorders in primary care in improving symptoms, function, and quality of life; harms of screening; accuracy of screening instruments; and effectiveness and harms of treatments." The systematic review's abstract transparently states that "[n]o studies evaluated the overall effectiveness or harms of screening;" it did identify valid screening instruments and confirm the treatment benefits of both cognitive behavioral therapy and anti-anxiety medications.

The WPSI is citing this systematic review, which found that "[e]vidence on the overall effectiveness and harms of screening for anxiety is insufficient," to justify its universal screening recommendation. While most physicians and patients would agree that patients with generalized anxiety disorder deserve recognition and treatment, screening initiatives that fail to justify the costs of doing so relative to their benefits, as well as fail to adequately consider potential harms, may not result in the health gains they promise. The WPSI's website states that "participation in the WPSI does not constitute organizational endorsement of the recommendations,"and it remains to be seen whether the AAFP and/or ACP will endorse this guideline.

In the meantime, you can find resources for diagnosing and treating anxiety disorders in the AFP By Topic on Anxiety Disorders.

Monday, June 29, 2020

The impact of COVID-19 on childhood immunizations

- Natasha Pyzocha, DO

During COVID-19, routine preventive and non-emergency care has been a secondary priority in the minds of patients and physicians. With everyone being told to shelter-in-place, stay at home, and limit movement to essential activities, it is understandable that many parents delayed routine childhood immunizations due to possibly contracting COVID-19 at the doctor’s office. Luckily most COVID-19 cases in children have been mild, although reports of multisystem inflammatory syndrome may have scared parents to further delay well-child visits.

In May 2020, the Centers for Disease Control and Prevention (CDC) reported significant and concerning nationwide decreases in routine childhood vaccine ordering and administration due to COVID-19 in the United States. When comparing January to April of 2020 to 2019, childhood vaccines declined beginning the week after the national emergency declaration. Children younger than 24 months were less affected by missing immunizations than older children. From mid-March to mid-April 2020 in the U.S., there were 2.5 million fewer doses of routine non-influenza vaccinations ordered and 250,000 fewer doses of measles containing vaccines ordered when compared to 2019. This decrease in MMR administration in school-aged children is concerning. Internationally, the World Health Organization estimates that more than 100 million children could be currently vulnerable to measles.

A decline in vaccinations affects herd immunity and could spur outbreaks of other diseases, that, combined with COVID-19, would overwhelm healthcare systems. The CDC, American Academy of Family Physicians (AAFP), and American Academy of Pediatrics continue to recommend providing essential health services, including immunizations, during the COVID-19 pandemic. Normalizing and confirming the safety of vaccine administration is crucial given that a COVID-19 vaccine may be available soon and for the upcoming influenza season.

I have talked to many parents of healthy and sick children since the pandemic started. Many are scared of their child becoming sick from COVID-19 and think that the best way to protect them is to keep them at home. Parents have delayed treatment of serious etiologies because they are worried about disease transmission. Putting healthy children at risk for COVID-19 for the purpose of immunizations doesn’t seem intuitive to many parents, so education remains vital. If your practice doesn’t have a good system in place for immunization reminders, this is a great time to make this a primary focus.

Contact families whose children have missed vaccinations and encourage them to bring their child in for immunizations. Have patience and provide education as needed. Evidence has shown that community discussions, community meetings, and information campaigns may increase immunization uptake, so consider hosting a virtual forum for your patients. The AAFP has immunization resources, COVID-19 guidance for family physicians on preventive and non-urgent care during the pandemic, and a variety of practice tools that give advice on opening guidelines, expanding operations, and more. Proactively reassure patients of the steps your office has taken to maximize safety.

Continue to think outside of the box and share procedures you have developed to make childhood immunizations safe and convenient for patients. Have you continued seeing children up to age 24 months for an exam and immunizations? Did you implement virtual care visits for children older than 24 months and have them come in for parking lot vaccinations? Are you increasing the testing of your clinical staff to ensure they are not unknowingly spreading COVID-19? Many physicians are offering house calls to boost vaccinations or making these parking lot visits a reality. It is important to remain flexible and advocate for patients in a system where legislative or insurance rules can make navigation frustrating. Pioneering drive-through immunization clinics or having a drone deliver and administer a vaccine may seem like futuristic ideas, but may be increasingly feasible in this era of enhanced disease prevention precautions.

**

Dr. Pyzocha is one of AFP's 2020-21 Jay Siwek Medical Editing Fellows.

Monday, June 22, 2020

Guest Post: Advance Family Medicine with Practice-Based Research

- Jen Carroll, Director AAFP National Research Network and Christina Hester, Research Director AAFP National Research Network
The program name is lengthy: the Family Medicine Discovers Rapid Cycle Scientific Discovery and Innovation Initiative, also known as FMD RapSDI. The program goal is concise: Help family physicians research and scale great ideas, quickly.

“This is a groundbreaking opportunity for family physicians on Main Street to explore the phenomenal ideas they have that will bring about change,” says Richard Smith Jr., an AAFP Foundation Board of Trustee and co-chair of the FMD RapSDI Work Group. “The healthcare system is fraught with barriers to innovation. This approach helps mitigate that.”

As a collaboration between the AAFP Foundation and the AAFP National Research Network, FMD RapSDI is open to family physicians whether they have research backgrounds or not. By providing the infrastructure and resources needed, the FMD RapSDI awards empower the physicians to explore small projects that can yield results in a 12-month timeframe.

What does Family Medicine Discovers offer to scholars?
Selected scholars are awarded a monetary grant to cover costs associated with completing their research projects and/or to offset a portion of the scholar’s salary (up to 20% FTE) to develop and complete a project in 12 months. The AAFP National Research Network will provide scholars with research infrastructure to empower scholars to successfully develop and implement their research projects and to stimulate their professional development. FMD RapSDI Scholars will begin projects on June 1, 2021.
In its inaugural year, Family Medicine Discovers received 45 research proposals from 40 different physicians and ultimately, two projects were awarded. The scholars selected for the inaugural program and their topics are:

Dr. Vijay Singh, a clinical assistant professor at the University of Michigan Medical School in Ann Arbor, will use evidence-based family medicine interventions, proven successful with adolescents, to help identify men with anger issues and provide relevant services. “I was interested in applying to be a FMD RapSDI scholar to access program resources to complete a research project, with salary support and dedicated time to adapt an evidence-based male intimate partner violence intervention to the needs of family medicine patients and providers," said Dr. Singh.

Dr. Lauren Ciszak, a family physician with the South End Community Health Center in Boston, will research the impact of providing meal kits and nutritional education to patients with chronic diseases, rather than ready to heat/eat meals, the standard approach.m“I hope we get strong enough evidence to convince insurance companies to cover this,” said Dr. Ciszak. “If this was covered, it could open so many doors for us and help our patients live better.”

This investment in building a robust family medicine research infrastructure will advance knowledge and discovery in our specialty; it will also prepare our specialty for the transformation needed to deliver upon the Quadruple Aim. FMD RapSDI has exceptional potential to advance new evidence and knowledge while fostering a culture shift of what it means to participate in family medicine research.

Do you have a patient care-inspired question, clinical problem, or clinical conundrum you'd like to investigate? Apply to be an FMD RapSDI Scholar! The application period for FMD RapSDI will open July 1st, 2020 and run through August 23rd, 2020. During the open period, the application portal will be accessible here.
Please spread the word about this program, and/or consider applying yourself!
For more information, please visit the FMD RapSDI website or contact us at nrn@aafp.org.