Common Sense Family Doctor

Primary care supply and access challenges around the world

2026-03-10T15:53:00.001-04:00

Although as an American family physician, I tend to focus on the primary care crisis in the United States, a recent New York Times story highlighted the familiar challenges of recruiting family doctors to rural communities in Canada. In a "Hunger Games"-style competition, cash-strapped communities with doctor shortages outbid each other with signing bonuses of up to $51,000 ($70,000 Canadian) each to foreign-trained primary care physicians who agree to move to town and start new practices. Stettler, an Alberta town that couldn't keep its emergency room open 24/7 due to a dearth of doctors, shelled out $300,000 to lure seven young physicians from Nigeria and Ghana. A Milbank Quarterly perspective by my family physician colleague Bob Phillips (the namesake of Georgetown's Robert L. Phillips, Jr. Health Policy Fellowship) and primary care leaders in the United Kingdom, Australia, Canada, the Netherlands, and New Zealand outlined how policies that deprive primary care of funding and other necessary resources have compromised care and access around the world, even in otherwise high-performing health systems.

Producing enough primary care clinicians to meet population demand is a problem worldwide, but North Americans are at a disadvantage compared to peer countries, according to the results of a Commonwealth Fund survey in this month's issue of Health Affairs. In 2022, 44 and 47 percent of U.S. and Canadian primary care physicians reported burnout, respectively, trailing only New Zealand. U.S. physicians also reported high rates of dissatisfaction and stress from 2012-2022, with a higher burden in females than males. These factors cause physicians to cut back on patient care hours or retire early, further depleting the primary care pool.

How many more primary care clinicians do we need? Traditional calculations which divide the eligible patient population by a standard panel size of 2,000 for a full-time physician fail to account for the aging population with multiple chronic conditions and the increasing complexity of medicine in general. Two recent studies used novel methods to approach this question at a national and state level. In JAMA Internal Medicine, Dr. Katherine Morgan and colleagues examined trends in the numbers of primary care clinicians accepting new patients from 2013 to 2021, with availability defined as billing >11 new visit evaluation & management codes for fee-for-service Medicare beneficiaries annually. They found a steady decline in primary care physician availability that was incompletely offset by a rise in advanced practice clinician availability. It's not only harder to find a new doctor than it was a decade ago, it's harder to find a new primary care clinician of any kind.

Dr. Jacqueline Britz and colleagues measured primary care workforce capacity in Virginia from 2016 to 2021, and their data told a similar story. Of the 4,508 primary care physicians (PCPs) practicing in the state, more than one-third are older than age 60, while only 24 percent are younger than age 50. The median number of unique patients each PCP saw in 2021 was 1,290, with each patient being seen twice per year. In order for every Virginia resident to have a PCP, researchers calculated that 1,305 additional PCPs would be needed, a 29 percent shortfall compared to an 18 percent shortfall in 2016.

One policy solution for Virginia and other states facing widening gaps in primary care supply is to open more training programs. After all, the majority of family physicians still choose to practice in the state where they were trained. (I rejoined that group when I moved back to Pennsylvania 4 years ago.) But Dr. Morgan Stickler and colleagues pointed out in a commentary that the family medicine residency Match isn't exactly a "Field of Dreams": if you build it, they don't come. Since 2012, the number of family medicine positions offered in the Match has almost doubled to 5,357, but the number of unfilled slots has quintupled from 142 to 805, involving 288 unfilled programs. The absolute number of students attempting to match in Family Medicine decreased by 16.6 percent from 2019 to 2024.

As Dr. Arch Mainous reminded us in a 2025 Family Medicine editorial, the increasing production of nonphysician clinicians and capabilities of artificial intelligence means that the family physician-dominated model of primary care could rapidly become as archaic as the "Great Horse Manure Crisis of 1894" (which ended with the onset of cars and other motorized vehicles). That doesn't mean that doctors will all be replaced by chatbots or that we don't need to find ways to remove ever-multiplying tasks from overwhelmed physicians' plates (the "everything bagel" problem). It does mean that we will need to question old assumptions about primary care scarcity and come up with creative solutions to meet the primary care needs of the future, without resorting to zero-sum competitions.

Smartwatch screening for hypertension

2026-03-07T09:17:00.002-05:00

An analysis of 2021-2023 National Health and Nutrition Examination Survey (NHANES) data found that among nonpregnant adults with hypertension (defined as systolic blood pressure 130 mm Hg or higher, diastolic blood pressure 80 mm Hg or higher, or use of antihypertensive medication), nearly 80% had a mean of three blood pressure (BP) measurements higher than 130/80 mm Hg. Of this group with uncontrolled BP, based on some practice guidelines, fewer than 40% were taking antihypertensive medications. Although undertreatment of high BP may result from therapeutic inertia, many adults do not have a regular source of care and simply do not know that they have hypertension.

Identifying undiagnosed hypertension is the goal of the Apple Watch’s hypertension notification feature, which was cleared in September 2025 by the US Food and Drug Administration for use in nonpregnant people 22 years or older. The watch is not a substitute for a home BP monitor, and it does not provide individual BP measurements. Instead, it uses an optimal sensor that collects photoplethysmography (PPG) data during waking hours over 30-day intervals, analyzes that data with a machine-learning algorithm, and alerts the wearer if hypertension is suspected. The alert encourages patients to monitor their BP at home for 7 days and consult their doctor about next steps.

A clinical validation study involving more than 2,000 participants found that the Apple Watch correctly identified 214 of 585 people with BP of 130/80 mm Hg or higher (sensitivity = 41.2%) with a specificity of 92.3%. The alert’s positive and negative likelihood ratios were 5.35 and 0.64, respectively. In a research letter in JAMA, Dr. Jordana Cohen and colleagues applied the Apple Watch’s screening performance characteristics to the nationally representative NHANES population. The researchers calculated the posttest probabilities of hypertension after a positive or negative alert based on the prevalence of hypertension in different subgroups:

Among eligible individuals aged younger than 30 years, an alert increases the probability of hypertension from 0.14 (95% CI 0.11-0.17) to 0.47 (95% CI 0.39-0.56), wherein the absence of an alert lowers it to 0.10 (95% CI 0.07-0.12). Among individuals aged 60 years or older, an alert increases the probability of hypertension from 0.45 (95% CI 0.39-0.50) to 0.81 (95% CI 0.76-0.86) and the absence of an alert lowers it to 0.34 (95% CI 0.29-0.39).

Similar to the heart-rhythm monitoring and obstructive sleep apnea detection features of various wearable consumer devices, the Apple Watch’s hypertension screening feature may nudge some patients to seek appropriate care for an undiagnosed chronic condition. For others, it may cause unnecessary anxiety or provide false reassurance. Given the popularity of these devices, though, smartwatch screening for hypertension will become increasingly common.

This post first appeared on the AFP Community Blog.

Continuity of care: health benefits and compensation

2026-02-20T10:31:00.002-05:00

Continuity of care—a trusting relationship with a personal physician based on recurring interactions over time—is an essential ingredient of the secret sauce of family medicine. Numerous studies have demonstrated that higher care continuity is associated with more appropriate care and lower costs. Data also support positive effects on health outcomes. A retrospective analysis from Alberta, Canada, reported that physician and clinic continuity (seeing a clinical partner when one’s primary physician was unavailable) correlated with fewer emergency department visits across all levels of patient complexity and fewer hospitalizations for highly complex patients. A similar US cohort study of Medicare fee-for-service claims from a nationally representative sample of 4,940 medical practices found that patients with higher primary care physician continuity were 5.5% to 6.8% less likely to be hospitalized and 4.9% to 6.3% less likely to visit the emergency department.

In 2023, the Accreditation Council for Graduate Medical Education changed the emphasis of family medicine resident training requirements from volume of encounters to continuity of care. In a special article published in Family Medicine, Dr. Gregory Garrison and colleagues described five domains of care continuity. In addition to traditional clinician-patient or “relational” continuity, they discussed benefits of informational (medical record), managerial (interdisciplinary care), family (caring for multiple family members), and geographical (care in multiple locations or environments, such as home, office, and hospital) continuity.

Unfortunately, the percentage of the US population who experience continuity of care has been decreasing since the turn of the century. A 2015 Graham Center Policy One-Pager found that fewer adults reported a personal physician (as opposed to a practice or facility) as their usual source of health care. From 2000 to 2019, the percentage of US patients who reported having a usual source of care declined from 84% to 74%.

To support continuity and compensate primary care clinicians for the additional complexity and cognitive load involved in these longitudinal relationships, the Centers for Medicare and Medicaid Services (CMS) introduced the add-on G2211 code in January 2024 and refined its use in 2025. Some private health insurers also recognize and pay for this code. A 2024 Graham Center analysis projected that applying the G2211 code to all eligible Medicare evaluation and management (E/M) visits would increase annual reimbursement by an average of $2,667 per physician. Attaching the G2211 code to E/M visits with 25 modifiers (approved by CMS in 2025) resulted in another $990 per physician. This year, G2211 codes also can be applied to home-based primary care visits. Relative to the established benefits of care continuity, the added compensation seems modest at best. In addition, a research letter published this week in JAMA found that in 2024, the largest share of G2211 codes (43%) was billed by specialist physicians, not primary care physicians (40%), many for diagnoses "that may not qualify as serious or complex" as CMS originally intended.

This post first appeared on the AFP Community Blog.

RFK Jr. is making measles great again: why it matters to everyone

2026-02-04T11:37:00.002-05:00

2025 was a banner year for the measles. 2026 is already looking like it will be much worse.

Last year, there were more than 2,200 confirmed measles cases in the U.S., the highest number since 1991. More than 1 in 10 infected persons became sick enough to be hospitalized, and 3 people died.

This year, an ongoing measles outbreak in northwest South Carolina is up to 876 cases, more than 500 of which occurred after January 1. The first 5 cases of measles in Pennsylvania were just diagnosed here in Lancaster County. Measles spreads like wildfire. Vaccination denies it fuel. But county-level measles, mumps, and rubella (MMR) vaccination coverage has been falling for the past 5 years, creating pockets of vulnerability due to low immunity - perfect tinder for a highly contagious virus.

Now, you may wonder why this worsening epidemic should matter to you personally. If some people, for whatever reason, fear the MMR vaccine more than the measles (and mumps, and rubella), or want their "health freedom" so badly that they are willing to risk their well-being or that of their children, to each his own. You got your MMR vaccine as a child and made sure that your children did, too. You may sympathize with doctors and public health workers who have to clean up the mess that antivaxxers like Andrew Wakefield and Robert F. Kennedy, Jr. have made, but your good choices mean than you are protected, right?

Yes and no. Setting aside the issue that infants can't be vaccinated against the measles until they are 6 months old (and don't routinely receive their first dose of MMR vaccine until they turn one), those who have received two doses of measles vaccine are 97% protected against developing the measles from an exposure. On the individual level, 97% is about as good as it gets. That's much better protection than vaccines against Covid-19 or influenza or practically every other vaccine. But on a population level, because measles is so incredibly contagious, a kid with measles could attend school where every one of other the 500 students had received 2 doses of MMR, and 15 kids could still catch the virus. Someone with the measles could go to Disneyland, expose thousands of fully vaccinated people, and spread it to dozens.

An article in last week's Morbidity and Mortality Weekly Report described a measles outbreak investigation associated with an unvaccinated traveler who caught the measles in Colorado, then went to the airport in Denver and boarded an international flight. Epidemiologists painstakingly identified at least 17 measles cases that could be traced back to this traveler. Of the 9 cases in Colorado residents, 5 caught it at the airport and 4 on the flight. What I found striking was that 4 of the 9 had received two doses of MMR vaccine. Someone who doesn't understand statistics might look at that figure and say, well, the vaccine must not be very effective. Wrong: it's 97% effective. What almost certainly happened is that the index patient exposed at least 100 people at the airport and on the plane, most of whom were vaccinated. The unvaccinated people all caught the measles, while a few of the vaccinated did too.

Measles was once a common childhood illness. Thankfully, most of the time it resolves without any need for medical intervention. (That doesn't mean that patients don't experience significant suffering - take it from someone who caught chickenpox at age 16 and missed two full weeks of school, a few years before the varicella vaccine was approved.) But most of the time isn't all of the time. Per the MMWR article: "Complications occur in approximately 10% of patients with measles, including ear infections and diarrhea; serious complications including pneumonia (5%), encephalitis (0.1%), and death (0.1%–0.3%) also occur." Though rare, being unable to breathe, becoming comatose due to brain swelling, or dying are all real consequences of the measles. As a family physician who provides hospital care, I've seen plenty of patients with these complications as a result of other conditions that I can't prevent with two shots. I don't want to see them from an infection that is almost completely preventable. But as the measles wildfire burns on, and more communities become tinder, it's only a matter of time until I do.

Preventing RSV bronchiolitis in infants

2026-01-23T13:04:00.000-05:00

In young infants, bronchiolitis caused by respiratory syncytial virus (RSV) is a common cause of hospitalization, with an annual incidence of 17.9 hospitalizations per 1,000 infants two months or younger in the United States. Although 4 in 5 children hospitalized for RSV have no risk factors, until 2023, prevention strategies for healthy term newborns were limited. That year, the US Food and Drug Administration approved two new options: the monoclonal antibody nirsevimab and maternal vaccination with a bivalent RSV vaccine, both of which are discussed in a STEPS new drug review in American Family Physician. (In June 2025, a second monoclonal antibody, clesrovimab, became available in the United States.)

In a multicenter randomized trial involving more than 8,000 infants, RSV hospitalization occurred in 0.3% of the group that received nirsevimab during the first winter of life compared with 1.5% of the usual care group (NNT = 83). A study of pediatric emergency departments in Spain found that universal RSV prophylaxis with nirsevimab beginning in the 2023-2024 season was associated with decreases in acute bronchiolitis, related hospital admissions, and pediatric intensive care unit admissions of 59%, 63%, and 63%, respectively. Similarly, infants up to 6 months of age whose mothers received RSV vaccine had a lower likelihood of medically attended severe RSV (0.5% vs 1.8% in the control group; NNT = 81). A Cochrane review of six randomized, placebo-controlled trials confirmed the benefits of RSV vaccination during pregnancy, and a retrospective cohort study of more than 54,000 pregnancies found no increases in preterm birth, premature rupture of membranes, or hypertensive disorders of pregnancy.

The American Academy of Pediatrics, American Academy of Family Physicians, and American College of Obstetricians and Gynecologists recommend routine maternal vaccination or monoclonal antibody administration to prevent RSV infections in infants. Two studies at different institutions found that total uptake (vaccine or nirsevimab) was more than 80%, with acceptance of nirsevimab even in individuals who declined other maternal or infant vaccines. In one of the studies, 43% of parents who refused RSV, influenza, and Tdap vaccines during pregnancy consented to nirsevimab for their newborns. As a result, RSV hospitalization rates during the 2024-25 season were 41% to 51% lower than expected rates and rates in prior years, with the largest benefits observed in infants younger than 2 months.

Presented with two equally recommended prevention options, parents may ask whether one is more effective than the other. Although no head-to-head trials have occurred, a population-based cohort study in France found that compared with infants who were protected by maternal vaccination, those who received nirsevimab had lower risks of RSV hospitalization (adjusted hazard ratio = 0.74) and severe respiratory outcomes, including pediatric intensive care unit admission and the need for oxygen therapy and mechanical ventilation. It is unclear how to apply this finding to the United States, where neither prenatal nor well-child care are universally guaranteed. In a pregnant patient between 32 and 36 6/7 weeks gestation from September 1 through January 31 who is willing to receive RSV vaccine, it makes more sense to vaccinate than to wait to give a monoclonal antibody to the newborn.

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This post first appeared on the AFP Community Blog.

Safely stopping screening for cervical cancer

2026-01-13T16:00:00.003-05:00

All cancer screening tests have diminishing benefits and increasing harms as people age. An article in the December 2025 issue of American Family Physician reviewed considerations for discontinuing cancer screenings in older adults. For cervical cancer, the authors observed that 21% of new cases and 38% of deaths occur after 65 years, the usual age to stop screening. Notably, this stopping age applies only to patients without conditions that put them at high risk of cervical cancer (eg, HIV infection) who have had adequate prior screening, defined as “three consecutive negative cytology results or two consecutive negative cotesting results within 10 years.”

In a recently published guideline, the American Cancer Society (ACS) clarified that the last negative test before exiting cervical cancer screening should occur “at an age no younger than 65 years,” with primary human papillomavirus (HPV) testing at 60 and 65 years of age being preferred. The ACS reiterated its previous recommendation that clinicians continue screening beyond 65 years in those with a history of grade 2 or greater cervical intraepithelial neoplasia within the past 25 years.

An analysis of data from the 2013 and 2015 National Health Interview Surveys found that nearly 1 in 5 women 61 to 65 years of age had not been screened for cervical cancer with a Papanicolaou test in the preceding 5 years. Even in those with a more recent test, determining eligibility to stop screening after 65 years can be challenging. A retrospective study of electronic health records of 42,000 patients older than 65 years in two health systems in Dallas and Boston determined that 69% were not eligible to stop screening because “too few screening tests were documented”; nonetheless, 84% of these patients received no further screening. Of the 16% who continued screening, 2% had high-grade precancerous lesions detected, and 0.7% were diagnosed with cervical cancer.

Clinical studies of cervical cancer screening did not enroll women older than 65 years, so the evidence for the stopping age is derived from a modeling study commissioned by the US Preventive Services Task Force (USPSTF) to support its 2018 recommendations. (The USPSTF released a draft recommendation update in December 2024 that continues to support stopping screening at 65 years in women with adequate prior screening who are not otherwise at high risk of cervical cancer.) A large cohort study sponsored by the National Institutes of Health aims to add to this evidence base by estimating the effects of stopping vs continuing screening after 65 years on cancer outcomes and medical complications resulting from diagnostic procedures and surgical interventions.

This post originally appeared on the AFP Community Blog.

DIY medicine - the good, the bad, and the ugly

2026-01-09T14:21:00.002-05:00

In a time when artificial intelligence chatbots can answer all of your medical questions, and it's possible to access laboratory testing and imaging scans without a health professional's order, who needs actual doctors?

That's the unwritten premise behind an unsettling article in STAT News that documents the growing phenomenon of empowered patients bypassing doctors and ordering direct-to-consumer tests that they think they need. The article begins with the story of a middle-aged man who shelled out $200 for dozens of lab tests that he didn't think his doctor would want to order, in the hope of obtaining more information to manage his metabolic conditions and lower his risk of developing dementia.

“This is the stuff that if I went to my doctor [with], my doctor would kind of look at me like I’m weird,” he said of the tests. ... Sidaway didn’t want to wait “20 years for the long-term studies and double-blind, placebo-controlled studies for them to say X, Y, and Z works,” he said. “Doctors are going to have to get used to this and navigate this.”

Do-It-Yourself, or DIY medicine, isn't a unique phenomenon among highly trained professions. I'm sure that there are building contractors who roll their eyes at homeowners who get in over their heads with DIY renovations, or trial lawyers who wince when they see people without training try to represent themselves competently in court. Some days, I am tempted to point to the diplomas hanging on my home office wall and proclaim that if a patient believes that a chatbot or Dr. Google can equal my decades of medical training and practice, they are welcome to put their lives in DIY medicine's hands.

On the other hand, I know that the traditional medical system does not serve many people well, and I support the democratization of health information and broadening of access to care - provided that it is effective care. One example that might fall into the DIY medicine bucket is being able to self-screen for cervical cancer from the privacy of one's home. The Department of Health and Human Services (HHS) announced this week that starting in 2027, it will mandate insurance coverage of FDA-approved self-sampling tests for patients who are not at high risk for cervical cancer. That's a win for women who dread going to the doctor for a speculum exam and Pap smear, and it's based on good evidence, synthesized more than a year ago by the U.S. Preventive Services Task Force, whose work has, ironically, been suspended indefinitely by RFK Jr. and the Trump administration.

One particular sentence in the HHS announcement got under my skin: "These additional steps demonstrate the Trump administration’s strong commitment to advancing women’s health and preventing chronic illnesses, including cancer." Really? They are so committed to preventing chronic illnesses and cancer that they have immobilized the panel of highly credentialed experts whose mission it is to review the evidence to identify effective screening tests? In addition, RFK Jr.'s DIY approach to childhood vaccinations (which HHS misleadingly and unethically calls "shared clinical decision making") is likely to increase the incidence of certain cancers.

Parents who follow the new, expertise-free HHS guidance and disregard their pediatrician or family physician's advice to give their children hepatitis B vaccine at birth, or at all, will expose them to the risk of acquiring chronic viral hepatitis, which will put them on a path to developing liver cancer. (Hepatitis B is treatable with antivirals, but not curable.) And dropping the second dose of the human papillomavirus (HPV) vaccine based on promising but incomplete evidence from other countries who have done so mainly for cost reasons could put more people at risk for not only cervical, but oropharyngeal and anorectal cancers caused by HPV. (The U.S. Food and Drug Administration, which is part of HHS, has not approved a single dose HPV vaccine regimen for cancer prevention.) Finally, cutting $1.1 trillion from Medicaid in last year's budget reconciliation bill is projected to lead to "over 1 million missed [breast, lung, and colorectal] cancer screenings and hundreds of avoidable deaths within 2 years," according to a just-published analysis.

America's experiment with DIY medicine is underway, for better or for worse. Almost certainly, for worse.

De-implementation as quality improvement in primary care

2026-01-05T15:05:00.001-05:00

One of my roles as a residency faculty member is to make sure that every resident completes a quality improvement (performance improvement) project by the time they graduate. Nearly all of these projects focus on getting clinicians to do more of something that improves health outcomes: lowering blood pressure, prescribing controller medications for asthma, controlling blood glucose and cholesterol levels in diabetes, providing guideline-consistent postpartum care. But quality improvement also includes doing less of things that don't improve (and may worsen) patients' health: vitamin D screening and supplementation, antireflux medications for healthy infants, cancer screening in older adults with limited life expectancies.

The American Board of Internal Medicine Foundation's Choosing Wisely campaign, which concluded in 2023 but remains active in many countries outside of the U.S., identified hundreds of "low value care" interventions, such as preventive care that is provided too soon or too often (e.g., screening colonoscopy). A 2020 paper reviewed more than 400 opportunities for stopping or scaling back unnecessary services in primary care and narrowed the field to 37 valid, high-priority recommendations. But identifying health care services to do less often or stop doing is the easy part; as "too much medicine" is often deeply embedded in systems, de-implementation is the real challenge.

A systematic review and meta-analysis of randomized trials of primary care de-implementation strategies identified 140 studies that aimed to reduce antibiotic use (54%), other drug treatments (30%), imaging (12%), and/or laboratory testing (11%). The authors found moderate certainty evidence that provider education combined with audit and feedback reduced targeted low value care, while provider education, audit and feedback, and/or patient education alone had limited or no benefits. Interventions that incorporated multiple strategies were the most effective, reducing relative risks of low value care provision by 30% to 35% over a median of 287 days of follow-up.

Compared to the much larger research base on intensifying care - I suspect there are hundreds, if not thousands, of studies on lowering blood pressure alone - the foundation for de-implementing low value care clearly needs to be expanded and strengthened. But there's more than enough here for a motivated learner - say, a family medicine resident - to build on.

Primary care for all Americans: a status update

2025-12-23T14:29:00.003-05:00

As 2025 draws to a close, how much closer/farther is the U.S. health system to/from the goal of providing primary care for all Americans? Much of the news isn't good. A recent analysis in the Annals of Family Medicine documented an 11% decrease in the number of family physicians practicing in rural areas from 2017 to 2023, with the Northeast suffering the largest proportional losses. As a faculty member at a Northeast residency program where many graduates have historically provided primary care to rural communities, this statistic hits home. Some of the "lost" physicians no doubt migrated to suburban or urban areas and continued to practice, but others developed burnout and left medicine altogether.

More and more clinicians, family physicians included, are participating in concierge or direct primary care practices, which collect an affordable up-front monthly fee per patient rather than rely on delayed insurance payments and provide relief from the burdensome paperwork that comes with third-party payers of health care. A study in Health Affairs used a national directory of direct primary care practices to create a longitudinal data set of clinicians from 2018 to 2023. During this five-year time frame, the number of practices and participating clinicians grew by 83 and 78 percent, respectively. Corporate-affiliated practices have made significant inroads into what was previously a clinician-owned model, with the percentage of independent practices shrinking from 84 to 60 percent. Although proponents tout its many advantages to clinicians and patients, the math is inescapable: every direct primary care physician who is caring for a panel of 500 patients rather than 1500 makes it more difficult for the other thousand to access traditional primary care.

With that context, what has PC4AA, the nonprofit group that I first highlighted in a blog post last year, been doing to improve primary care access? Rather than take a top-down approach like the National Academy of Medicine, they've chosen to tackle the problem from the ground up, community by community. One of those communities is New Bedford, Massachusetts, a multicultural, multilingual city of 101,000 people with just 36 practicing primary care clinicians, including 15 physicians. Of the 15 physicians, 10 are pediatricians and only 5 care for adults. An estimated 20 to 25 percent of the population does not have a relationship with a primary care clinician. Wait times for a new patient appointment range from two to nine months.

I've never been to New Bedford or spoken with anyone who provides health care there. So how do I know so much about this community and its ongoing primary care crisis? From the report released in October by PC4AA's New Bedford chapter, which contains an in-depth analysis of the state of primary care in New Bedford as well as a multi-pronged strategy to recruit more primary care clinicians to meet the needs of the population. The original working group is now convening task forces that will focus on enhancing the primary care training pipeline, making training more affordable through scholarships and loan repayment, encouraging the development of new residency programs, and supporting existing primary care practices financially to allow them to expand services to more patients in the future.

It's much too early to tell whether PC4AA will succeed in reinvigorating U.S. primary care where others have so conspicuously failed. But if, like me, you are looking for a reason to be optimistic about health care in 2026 - a year that is forecast to see the first increase in the percentage of the population that is uninsured since the Affordable Care Act's passage in 2010 - this is it. Community by community, rebuilding and remaking the system from the ground up.

Smartphones, social media, and adolescent health outcomes

2025-12-19T10:31:00.002-05:00

The negative health consequences of social media use in adolescents and young adults are increasingly being recognized. In a previous American Family Physician Blog post on screen time use in children, Dr. Lilian White mentioned a correlation between greater social media use and reduced life satisfaction in adolescents. A 2017 Curbside Consultation discussed the relationship between social media use and mood disorders, fueled by the fear of missing out (FOMO), and reviewed resources and tools for unplugging or limiting time spent on social media.

Recently, a prospective cohort study in JAMA Network Open used objective data from a “digital phenotyping” app to evaluate the effects of a 1-week social media detox intervention on mental health. 373 U.S. young adults aged 18 to 24 years with smartphones completed a 2-week baseline assessment of their use of Facebook, Instagram, Snapchat, Tik Tok, and X. The optional intervention decreased 295 participants’ daily social media screen time from 1.9 to 0.5 hours. These changes were associated with statistically significant reduced symptoms of anxiety by 16.1%, depression by 24.8%, and insomnia by 14.5%.

Adolescents access social media platforms through smartphone apps. Another recent study examined associations of various health outcomes with smartphone ownership in a sample of more than 10,000 participants in the Adolescent Brain Cognitive Development Study. At age 12 years, 64 percent of children owned a smartphone. Compared to those without a smartphone, smartphone owners had higher risks for depression (odds ratio=1.31), obesity (OR=1.40), and insufficient sleep (OR=1.62). Risks of obesity and insufficient sleep increased with earlier age at smartphone acquisition, and the 1546 children who acquired a smartphone between the ages of 12 and 13 had worse mental health and sleep outcomes than the 1940 children who remained without smartphones at age 13.

Restricting use during school hours does not appear to affect overall smartphone or social media use or mental health. A cross-sectional study in the United Kingdom compared students at 20 secondary schools with restrictive phone policies (recreational use not permitted) with those at 10 schools with policies permitting recreational phone use. 1227 students age 12 to 15 years participated in the study, which assessed mental wellbeing using the Warwick-Edinburgh Mental Well-Being Scale. Students who attended schools with restrictive policies compensated for lower phone use during school hours by using their phones and accessing social media more after school and on weekends. Not surprisingly, there were no differences in mental well-being between the groups.

On December 10, Australia implemented the world’s first ban on social media accounts for children younger than age 16. Instagram, Facebook, Threads, Snapchat, YouTube, TikTok, Kick, Reddit, Twitch and X were all required to deactivate existing accounts for younger children and use age verification software for new accounts to avoid millions of dollars in fines. The potential health benefits of this policy remain to be seen.

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This post first appeared on the AFP Community Blog.

Shared decision making for colorectal cancer screening tests

2025-12-06T17:08:00.000-05:00

Most of the major cancer types have a single recommended screening test. For breast cancer, mammography. For cervical cancer, cytology and/or human papillomavirus testing. For lung cancer, low-dose computed tomography (CT). Colorectal cancer is unique in that physicians and patients have a menu of acceptable screening options, ranging from various stool-based tests to CT colonography, colonoscopy, and most recently, a blood test for circulating tumor DNA.

Guidelines recommend shared decision making with average-risk adults aged 45 to 75 years to select a colorectal cancer screening strategy that aligns with patients’ preferences and values. A recent scoping review of 28 studies in the United States and Canada explored factors that play important roles in these conversations. Researchers identified 4 domains that influence patients’ decision making: test attributes (accuracy, cost, convenience, and complications); recommendations from their personal physician; fear, discomfort and embarrassment for some regarding colonoscopy and stool tests; and external factors (culture, family input, socioeconomic status, and transportation access).

The U.S. Preventive Services Task Force assigned a “C” grade (offer selectively, individualized decision) to colorectal cancer screening in adults aged 76 to 85 years due to a small net benefit of screening in this age group. A cluster randomized trial in older adults evaluated the effect of physician training in shared decision-making on receipt of patient-preferred colorectal cancer screening (which could include no testing) and on overall screening rates. At 12 months, about half of patients in each group had received their preferred approach, with no significant difference between the groups in test uptake.

A pitfall for clinicians is limiting patients’ test options to colonoscopy due to a belief that it is the “gold standard” test, even though no data have demonstrated clear superiority over fecal immunochemical tests. An editorial in the September 2025 issue of American Family Physician discussed optimizing the role of noninvasive colorectal cancer screening tests, and an editorial in the October 2025 issue reflected on downsides of colonoscopy as a primary screening strategy. For patients who choose to undergo colonoscopy, adherence to evidence-based surveillance guidelines is critical to preventing harms associated with repeating colonoscopy at inappropriately short intervals.

This post first appeared on the AFP Community Blog.

My favorite public health and health care books of 2025

2025-11-29T20:19:00.001-05:00

This year's best of list includes only three titles that were actually published in 2025. Six books were written by doctors, and two provide complementary perspectives on the infamous Andrew Wakefield and the epidemics of vaccine-preventable diseases resulting from falsified research and shameless self-promotion of a thoroughly debunked theory. As always, books are listed alphabetically by title. For more favorite reads, feel free to browse my lists from 2024, 2023, 2022, 2021, and previous years.

1. Booster Shots: The Urgent Lessons of Measles and the Uncertain Future of Children’s Health, by Adam Ratner

2. The Doctor Who Fooled the World: Andrew Wakefield’s War on Vaccines, by Brian Deer

3. Dopamine Nation: Finding Balance in an Age of Indulgence, by Anna Lembke

4. Dr. Mutter’s Marvels: A True Tale of Intrigue and Innovation at the Dawn of Modern Medicine, by Cristin O’Keefe Aptowicz

5. Facing the Unseen: The Struggle to Center Mental Health in Medicine, by Damon Tweedy

6. Gettysburg Surgeons: Facing A Common Enemy in the Civil War’s Deadliest Battle, by Barbara Franco

7. My Father’s Brain: Life in the Shadow of Alzheimers, by Sandeep Jauhar

8. One by One by One: Making A Small Difference Amid A Billion Problems, by Aaron Berkowitz

9. A Return to Healing: Flexner, Osler, and How American Medicine Went Astray, by Andy Lazris and Alan Roth

10. Slow Cooked: An Unexpected Life in Food Politics, by Marion Nestle

Upcoming article on mental health disorders during the Civil War

2025-11-27T09:24:00.004-05:00

Update: The full article is now available in the Winter 2025 issue of the Journal of Lancaster General Hospital.

State and federal support for primary care: meaningful but insufficient

2025-11-19T16:04:00.000-05:00

For a clear-eyed view of the U.S. health system factors that have collectively conspired to cripple primary care, the five-part New England Journal of Medicine series "The Primary Care Puzzle" by cardiologist and medical reporter Dr. Lisa Rosenbaum is a worthwhile read. Although I would usually frown on a subspecialist writing a pessimistic view of the problems in my field of medicine (family medicine comprising the majority of primary care in Lancaster and elsewhere), Rosenbaum has interviewed all of the key informants and gets most of the story right.

Since it has become clear that primary care is a common good, like law enforcement and public libraries, it's fair to ask what state and federal governments have been doing to support high-quality primary care. A systematic review in JAMA Health Forum discussed 5 federally-supported programs in primary care "transformation" from 2011 to 2021: 4 demonstration projects in paying primary care practices prospectively and EvidenceNOW Advancing Heart Health, which focused on improving cardiovascular outcomes. The numbers of participating practices ranged from 500 to nearly 3000. None of these programs was a failure or an unqualified success (improving health outcomes, the patient and clinician experience, or saving the system money).

The Trump administration has shown little interest in supporting primary care beyond allowing persons to use health savings accounts to pay membership fees to direct primary care practices. This change will help some access primary care, but huge funding cuts to Medicaid and premium subsidies for health insurance marketplace plans will result in millions more losing access to their doctors. (Further damaging to primary care are the hostile takeover and suspension of activities of the Advisory Committee on Immunization Practices and the U.S. Preventive Services Task Force, respectively.)

States have taken different approaches to better resource primary care. Oregon, Delaware, Colorado, and California recently passed legislation aiming to gradually increase the proportion of all health care spending on primary care from 5-7% to 11.5% to 15% over the next decade. Delaware and Rhode Island have combined primary care spending targets with caps on overall health care spending increases.

In September, the Milbank Memorial Fund published a policy menu for states looking to strengthen primary care, organized by 5 priority areas and spotlighting examples of policy actions taken by states that are diverse geographically and ideologically:

1. Make and Keep Primary Care a Top Policy Priority

2. Pay Primary Care More and Differently

3. Make It Easier for People to Access Their Primary Care Clinician

4. Expand and Support and Current and Future Primary Care Workforce

5. Build Provider Capacity to Provide Patient-Centered, Whole-Person Care

These initiatives are a good start, but they are not nearly enough to close the gap between the inadequate primary care workforce we have and the one we need to make the lagging U.S. competitive internationally in health care spending and outcomes.

Hepatitis B vaccine birth dose protects infants against lifelong health consequences

2025-11-12T07:54:00.005-05:00

Since 2018, the American Academy of Pediatrics and the Centers for Disease Control and Prevention’s (CDC) Advisory Committee on Immunization Practices (ACIP) have recommended universal hepatitis B vaccination of medically stable newborns weighing at least 2,000 grams within 24 hours of birth. After the unprecedented wholesale dismissal and replacement of the ACIP membership in June 2025, the American Academy of Pediatrics posted a fact sheet on its website emphasizing the significance of the hepatitis B vaccine birth dose and infant series in preventing acquisition of chronic infection. Although the U.S. Preventive Services Task Force recommends screening for hepatitis B virus at the first prenatal visit, a recent study found that more than 1 in 7 pregnant patients are never tested; some women do not receive any prenatal care or become infected later in pregnancy.

Perinatal hepatitis B infection has lifelong health consequences; 90% of infected infants develop chronic hepatitis B, and 15% to 25% of those die from cirrhosis or liver cancer in adulthood. In addition to being vertically transmitted from infected mothers, hepatitis B virus can also be passed on to infants through incidental contact with blood or body fluids of infected household members. The birth dose thus functions as a safety net for thousands of children who, before 1990, were being overlooked by risk factor–based vaccination strategies. Since its implementation in the United States, the birth dose has not only been associated with higher completion rates for the full hepatitis B vaccine series but also higher odds of receiving all recommended vaccines by age 19 months. A study of birth dose use in Washington, DC, found that vaccine refusals declined from 12.1% in 2017 to 4.1% in 2020 and remained below 4% in 2021 and 2022.

Nonetheless, when the reconstituted ACIP met in September 2025, it came close to voting to delay the first dose of hepatitis B vaccine to 1 month of age in infants born to hepatitis B surface antigen-negative mothers. This occurred despite the presentation of a systematic review by CDC staff that found no increased risk of any serious safety outcome when the vaccine was administered within 24 hours of birth. As highlighted in an in-depth analysis of the meeting by former ACIP members, the new committee repeatedly ignored its established processes for evaluating evidence and deliberating recommendations. Family physicians and former ACIP workgroup members Doug Campos-Outcalt and Jonathan Temte observed in a JAMA Viewpoint: “The evidence-based processes used by the ACIP were adopted to prevent exactly what happened at the first 2 meetings this year: presentation of anecdotes, selective quoting of single studies, and a lack of in-depth evaluation of some of the evidence presented.”

Ultimately, the ACIP deferred its vote on hepatitis B vaccine, preserving access to the birth dose for now. But in October, nearly all of the CDC staff that provided logistical support and subject-matter expertise to the ACIP was laid off, imperiling production of the 2026 vaccine schedules and making future departures from evidence-based recommendations more likely.

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This post first appeared on the AFP Community Blog. On December 2, the Vaccine Integrity Project posted an independent review of data on the efficacy, safety, and public health impact of hepatitis B vaccine at birth. In a decision analysis posted as a preprint, authors affiliated with the Hepatitis B Foundation projected that "delaying Hep B vaccination to 12 years for infants of both HBsAg-negative and HBsAg-unknown parents resulted in an additional 2,351 acute infections, 744 deaths, and $368 million in excess costs."

Flood preparation, prevention, and an epidemic of short-term thinking

2025-11-08T09:28:00.001-05:00

On July 4th, a flash flood in Kerr County, Texas killed 27 young girls and counselors at Camp Mystic, a Christian girls' summer camp whose staff alumni included former first lady Laura Bush. The campers and more than one hundred other local residents who also perished in the flood reacted too late, or not at all, to the National Weather Service's flash flood warning and emergency text alerts issued at 1:14 and 4:30 A.M., respectively. According to an article in the New Yorker, "many people simply ignored the warnings, or had their phones silenced or turned off." The article mentioned that after a flood in 2015 that killed 13 people, Kerr County officials decided against installing a $1 million siren system that would have warned upriver towns when a flood was coming.

In Vermont, which also experienced devastating flash floods in 2023 and 2024, the political response was different. In order to reduce the risk of recurrent floods, legislators passed a Flood Safety Act that gave the state broad jurisdiction over all of its waterways:

Beginning in 2028, when the new regulations take effect, Vermont’s rivers will be managed not as channels but as “corridors,” which will comprise all the land within the river’s natural meander pattern, plus fifty feet of riparian borders on both banks. The river will have the freedom to move and reconnect to floodplains. Riverside property owners will no longer have the automatic right to armor banks; in some cases they must allow the river to meander, even if that means it meanders through their land.

What does preventing and preparing (or not) for flash floods have to do with health care? Our federal government is trapped in cycles of short-term thinking. Even before the current shutdown, it had been nearly 30 years since Congress last passed the dozen annual appropriations bills that collectively constitute the federal budget prior to the October 1 start of the fiscal year. Most of the time, it passes "continuing resolutions" (CRs) that maintain spending at current levels and kick the can a few months down the road. (H.R. 1, aka the "One Big Beautiful Bill Act," which in large part precipitated the current legislative standoff, was an omnibus bill that also bypassed the normal budget process.)

Without action, the enhanced health insurance marketplace premium tax credits that Congress initially passed in 2021 and extended in 2022 will expire on December 31. Not only will the rollback of the tax credits place additional burdens on working class people and jeopardize small businesses, it is projected to lead to 340,000 jobs lost in 2026, the majority in states that voted for President Trump in the 2024 election. Trump may not care, since they can't vote for him again in 2028, but the Republican Party should, and their myopia will likely result in lost seats in next year's midterm elections.

The Department of Health and Human Services has ceased planning for long term health threats. Layoffs have decimated key staff at the Centers for Disease Control and Prevention (CDC) and the Agency for Healthcare Research and Quality (AHRQ), two organizations that are essential to carrying out any coherent strategy to address the epidemic of chronic diseases. The U.S.'s exit from the World Health Organization means that the CDC has been receiving far fewer samples of circulating influenza viruses that are essential to selecting strains for next year's flu vaccine. The U.S. Preventive Services Task Force, which AHRQ last convened in March, had its second meeting in a row canceled. HHS officials are publicly blaming the shutdown, but the government was open when the previous meeting was canceled in July (no explanation was ever given).

It's plausible that the Trump administration and its health officials are of the mindset that the COVID-19 pandemic was a once-in-a-century event, like the "superstorm" that inundated a large swath of lower Manhattan in 2012. But a better analogy than hurricanes is the periodic flash floods in Kerr County and neighboring Kendall County that have given their collective valley the moniker "Flash Flood Alley." Due to an epidemic of short-term thinking, a flash flood of preventable disease and deaths is barreling right toward us, with phones silenced, no early warning siren, and no way to evacuate to higher ground.

Improving cardiovascular health in Asian American patients

2025-10-26T15:52:00.000-04:00

Although the Asian American population is the fastest growing racial group in the United States, having more than doubled since 2000, data are limited on the distribution of risk factors for cardiovascular disease among ethnic subgroups. A recent research letter in the Annals of Internal Medicine found significant differences in age-standardized cardiovascular mortality between 2018 to 2023, with Filipino males having the highest rates, followed by Indian males and Filipino females. Notably, Indian American individuals had high mortality associated with heart disease and diabetes, whereas Chinese American individuals had higher mortality from stroke and hypertension-related conditions.

A 2024 American Family Physician editorial by Drs. Asha Shajahan and Saavia Girgla highlighted cardiovascular disparities in people of South Asian ancestry. Earlier risk calculators (Framingham, Pooled Cohort Equations) underestimate cardiovascular risk in South Asians; it is unclear whether the estimates from the newer PREVENT equations have greater accuracy in this population. The authors recommended routinely asking about family histories of premature heart disease and providing culturally informed lifestyle counseling to South Asian patients with insulin resistance (including type 2 diabetes) and metabolic syndrome.

Some national and international studies support lower body mass index (BMI) thresholds for overweight and obesity in Asian American patients. The World Health Organization identified BMIs of 23 and 27.5 kg/m2 as public health action points, corresponding with BMIs of 25 and 30 kg/m2 in non-Asian populations. However, pooling data from all Asian individuals can obscure concerning trends in subpopulations. An analysis of 2012-2023 data from Kaiser Permanente Northern California found that adults 30 to 49 years of age identifying as Native Hawaiian and other Pacific Islander had the highest overall prevalence of obesity; rapid temporal increases in high BMI (>27.5 kg/m2) were also seen among Filipino and other Southeast Asian populations. Oral semaglutide was effective in reducing body weight in a 68-week randomized trial conducted in Japan and Korea (-14.3% change in body weight in the semaglutide group vs -1.3% in the placebo group).

In 2024, the American Heart Association published a scientific statement on the social determinants of cardiovascular health in the Asian American population. Key upstream determinants include “socioeconomic position, immigration and nativity, social and physical environments, food and nutrition access, and health system-level factors,” all potentially modified by interpersonal discrimination and structural racism. The American Heart Association called on the federal government to collect disaggregated data on cardiovascular risk factors and health outcomes in self-identified Asian subgroups and to support research on community-level determinants of poor cardiovascular health to inform primary prevention strategies.

This post first appeared on the AFP Community Blog.

Oral cancer screening is ineffective; will the USPSTF weigh in?

2025-10-22T14:42:00.003-04:00

The U.S. Preventive Services Task Force (USPSTF) normally meets in person three times per year: in March, July, and November. This year, they did meet in March, but their meetings have since been suspended as they await the federal government's reopening and Health and Human Services (HHS) Secretary RFK Jr.'s postponed decision on whether to fire them all. Even if they could meet and vote on new or updated recommendations, their support staff at the Agency for Healthcare Research and Quality (AHRQ) has been gutted, and it isn't clear if the Evidence-Based Practice Centers that AHRQ contracts with to produce systematic evidence reviews are still being funded. Is the USPSTF better off remaining intact but non-functional as opposed to the reconstituted Advisory Committee on Immunization Practices, which is technically operating but has been producing nonsense? I don't know. But while the Task Force's activities remain at a standstill, prevention science is moving on.

One of the last topics I worked on as an AHRQ medical officer was screening for oral cancer. The USPSTF's last recommendation statement, concluding that the evidence was insufficient to determine the effectiveness of an oral screening exam in primary care, is nearly 12 years old. At the time, the only direct evidence was a cluster randomized trial performed in an Indian state with an extremely high incidence of oral cancer due in part to widespread betel quid chewing, and the Task Force reasonably concluded that it wasn't possible to extrapolate the mortality benefit seen in that trial to an American primary care population. In 2023, the USPSTF did a quick search for new evidence and determined that there wasn't enough to warrant updating the previous recommendation. The National Cancer Institute's latest summary of the evidence on oral and nasopharyngeal cancer screening, updated in April 2025, reaches a similar conclusion.

Then, the results of a new study were published. It turns out that Taiwan, where betel quid chewing is also common, launched the world's first national oral cancer screening program in 1999. Screening exams were conducted every two years in all male persons aged 30 and older who chew betel quid and/or smoke, as well as in indigenous males starting at age 18. An observational study of the outcomes associated with this screening program found that despite a 2.4 fold increase in early-stage oral cancer diagnoses, there was little change in late-stage incidence and no reduction in oral cancer mortality from 2004 to 2022. The researchers concluded that oral cancer screening is ineffective.

Taiwan isn't the United States, and if members of the USPSTF have reviewed this study, they may have been tempted to conclude that its results aren't any more applicable to our population than the trial from India. My view is different. If oral cancer screening doesn't work in Taiwan, it isn't likely to work anywhere else, especially in a dysfunctional U.S. health system reliant on opportunistic primary care screening in the absence of a robust public health infrastructure. As cigarette smoking and betel nut use have plummeted in the past two decades, this is likely the best evidence that we will ever have on this topic.

This is a small sample of the studies that the USPSTF and its support team should be reviewing but are likely unable due to irresponsible and damaging decisions being made (or intentionally not made) by HHS department leadership. Here's hoping that the Task Force's limbo ends sometime soon and that they emerge with renewed support and funding - but I'm not holding my breath.

Blood pressure drug combinations, comparisons, and therapeutic intensity

2025-10-11T21:18:00.002-04:00

Although blood pressure management is the bread and butter of family medicine, selecting antihypertensive medications is not always straightforward. A 2023 American Family Physician article on initial management of hypertension in adults recommended, “Initial antihypertensive treatment should include an angiotensin-converting enzyme (ACE) inhibitor, an angiotensin receptor blocker (ARB), a long-acting dihydropyridine calcium channel blocker, or a thiazide diuretic.” But how should one choose among drug classes and single vs combination therapy?

Compared with monotherapy, combination antihypertensive drugs have the advantage of reaching blood pressure goals quicker, with similar tolerability. Expert consensus suggests that initial combination therapy is preferred “in patients with systolic blood pressure higher than 160 mm Hg or greater than 20 mm Hg above goal, or with diastolic blood pressure higher than 100 mm Hg or greater than 10 mm Hg above goal.” A 2024 study of US adults taking two classes of antihypertensives found that patients on fixed-dose combinations were 1.78 times more likely to have controlled blood pressure than patients on two separate pills. In June 2025, the US Food and Drug Administration first approved a triple antihypertensive drug, a combination of telmisartan, amlodipine, and indapamide.

Specific antihypertensive classes are indicated for special populations (eg, patients with heart failure, chronic kidney disease, diabetes). A randomized trial of more than 11,000 patients with hypertension at high risk of cardiovascular events found that despite similar blood pressure control, benazepril plus amlodipine was superior to benazepril plus hydrochlorothiazide (number needed to treat [NNT] = 45 to prevent a composite cardiovascular end point over 36 months). In the general hypertensive population, a Cochrane review found that over 5 years, thiazide diuretics have small advantages over calcium channel blockers (NNT = 100 to prevent a cardiovascular event; NNT = 84 to prevent heart failure) and ACE inhibitors (NNT = 167 to prevent one stroke).

Although cholesterol-lowering drugs and doses are classified by intensity, until recently no similar schema was available for antihypertensive drugs. A systematic review and meta-analysis of 484 placebo-controlled trials classified the average systolic blood pressure-lowering effects of 57 monotherapies and 189 combinations as low (< 10 mm Hg), moderate (10-19.9 mm Hg), and high (> 20 mm Hg) intensity. Unsurprisingly, most monotherapies had low efficacy, whereas dual or triple therapies generally produced moderate or high effects. Clinicians can use an online calculator derived from the review to estimate the efficacy of any antihypertensive drug and dose combination depending on the patient’s baseline blood pressure.

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This post first appeared on the AFP Community Blog.

Recent and upcoming presentations and meetings

2025-10-03T16:44:00.001-04:00

In September, I traveled to Oxford University for the international Preventing Overdiagnosis conference, where I presented on behalf of a research team that spent several years working to estimate the annual harms of screening colonoscopy overuse in the United States. We concluded that 2.1 million to 3.2 million low-value (unnecessary) screening colonoscopies are performed every year, leading to 9 to 12 thousand preventable cases of severe bleeding or bowel perforation.

Examination Schools, Oxford University

On October 20, I will deliver the cancer screening update lecture at the Temple University Fall Family Medicine Review course. For many years, this live course was delivered in person at a resort conference center in Lancaster, but the virtual format instituted during the pandemic proved so popular that it has continued so that family physicians and other primary care clinicians can join from anywhere in the world. Later that same day, I will lead a study session that allows American Board of Family Medicine Diplomates to complete the Health Counseling and Preventive Care Knowledge Self-Assessment. For readers who are interested, there is still time to register at https://medicine.temple.edu/cme

I've taught in this course since 2012.

Looking ahead, the week before Thanksgiving I will travel to Atlanta for the North American Primary Care Research Group (NAPCRG)'s annual meeting. Although I have never consciously defined myself as a researcher, many of my publications (including the colonoscopy overuse harms study mentioned above) can be classified as such. My relatively new role as the faculty member in charge of resident scholarly activity at the LGH Family Medicine Residency Program has me eager to learn from fellow educators about how to motivate learners to move beyond point-of-care references and artificial intelligence tools for answering clinical questions to designing an original research study or performance improvement project.

Correlation, causation, and Presidential pronouncements on health

2025-09-24T10:06:00.002-04:00

The historical track record of major U.S. Presidential pronouncements on health is as abysmal as one might expect given their prior occupations (27 lawyers, zero physicians or medical researchers). In 1971, Richard Nixon famously declared a "war on cancer"; 54 years later, not only is cancer still very much with us, but the Trump administration is now waving the white flag and pulling back on research investments. In 2000, Bill Clinton announced the completion of the Human Genome Project, forecasting that sequencing the human genome would lead to all kinds of breakthroughs in preventing and treating genetic diseases. A quarter-century later, notable progress has been made on many conditions, but genomic insights have yet to transform medicine as initially promised. In 2016, Barack Obama launched the Cancer Moonshot as part of the 21st Century Cures Act, and after his Vice President, Joe Biden, ascended to the Presidency in 2021, he re-committed the U.S. to accelerating progress toward cancer cures. The jury is still out on this one, but the current Health and Human Services Secretary's blanket opposition to mRNA vaccines (including those for cancer) has stacked the deck against it.

So when President Donald Trump made a "major announcement" on autism at the White House earlier this week, the former real estate developer and reality TV show host was following in the ignominious footsteps of his predecessors who, to put it bluntly, should have stayed in their lane. Taking his cue from Robert F. Kennedy, Jr., who for years led a nonprofit organization that opposes routine childhood vaccinations, Trump blamed infant shots and acetaminophen (Tylenol) in pregnancy for the increased prevalence of autism diagnoses in the U.S. and around the world. Dismissing the pain and discomfort that often accompanies being pregnant, he implored women to "tough it out" rather than take a pain reliever that is considered by every major medical organization to be safe in pregnancy. (And yes, there absolutely are downsides to avoiding Tylenol, given the clearly established harms of alternatives for pain and fever.)

I wanted to simply dismiss what Trump said, but after two days of seeing patients and responses on my social media, it's clear that many people are taking him and RFK Jr. quite seriously. To explain why they (and perhaps you) shouldn't be concerned about your child's vaccines or taking Tylenol when needed, join the first-year medical student class in evidence-based medicine that I taught at Georgetown for many years. The question we would examine in our first meeting was: does radiation from cell phone use cause brain tumors? (TL;DR - although there isn't any way to prove without a doubt that cell phones don't cause cancer, most of the evidence suggests that the answer is no.)

But think like a researcher for a moment. How would you study this question? You could do what's called a case-control study and compare the cell phone use of persons with brain tumors to persons without them. (This type of study would have been easier to do in the days before cell phones were ubiquitous; I didn't purchase my first cell phone until 2002.) In addition to asking about ownership, you could ask people to recall how long they spent talking on the phone on average, and which side of their head they pressed it to their ear. (Again, easier to do in the days before hands-free earbuds.) But there's a big problem with this type of study: recall bias. Human beings have a tendency to come up with plausible explanations when bad things happen, and a brain tumor certainly qualifies as a bad thing. Just as a recently administered MMR vaccine is a convenient explanation for the subsequent diagnosis of autism, a cell phone is a convenient explanation for cancer.

So let's say you perform a better type of study, a cohort study where you compare two groups by a more objective measure of cell phone exposure: cell phone subscriptions and number of minutes used each month. Obviously this design poses complications as family and business cell phone plans may not reliably identify who was actually using the phone, even setting aside issues of privacy and phone companies allowing researchers to access granular data. But if you find an association between increased cell phone use and risk for brain tumors, you can feel more confident that it's a true correlation. Similarly, some studies have shown associations between Tylenol use and neurodevelopmental disorders, though others have not.

But it's a huge leap from showing correlation to proving causation. The latter requires systematically eliminating confounding factors that may affect both the exposure and the outcome. For example, perhaps the true correlation is that women carrying pregnancies with children who are genetically predisposed to develop autism are more likely to experience fever-causing infections or musculoskeletal pain. Naturally, they will be more likely to seek fever or pain relief from acetaminophen, making it appear - incorrectly - that exposure to acetaminophen caused the outcome. We do not know if this is happening, as the FDA made clear in its news release.

In the meantime, I am not going to change how I counsel patients about vaccines in childhood or Tylenol in pregnancy. These medications have clear benefits (preventing serious diseases and relieving fever and pain in pregnancy), and the burden of proof rests on proponents of hypothetical negative effects, including Trump and RFK Jr. Finally, I think it's unconscionable for the President to put a "I took Tylenol in pregnancy so maybe I gave my baby autism" guilt trip on mothers without ironclad proof of either correlation or causation.

Are cash benefits for families associated with positive childhood experiences?

2025-09-17T17:08:00.002-04:00

In the U.S., state and federal governments employ vast bureaucracies that aim to ensure that only the "deserving" receive public assistance in the form of subsidized health care, food, and housing. 2025 has seen a near-complete reversal of the pandemic policy of keeping people on Medicaid by default; now, states will be required to not only confirm Medicaid eligibility every 6 months, but to verify that certain "able bodied" beneficiaries are enrolled in job training or working at least 80 hours per month. Never mind that Medicaid is only a health care benefit - you can't use it to pay the rent or feed your family - or that work requirements have been unequivocal failures in states that have tried implementing them in the past. The point of this cruel policy isn't to increase employment; it's to save money by removing people from health insurance rolls even if they are working.

What are the effects of financial insecurity on child health? A systematic review in AJPM Focus found that "financial strain was associated with poorer health and well-being and more behavior challenges among children of all ages, poorer academic performance among school-age children, and more depressive symptoms among adolescents." Adverse childhood experiences (ACEs) such as child neglect, abuse, and exposure to violence affect at least one in four American children and are associated with unhealthy behaviors and chronic diseases in adults. As one might expect, these experiences occur more often in neighborhoods with built-in disadvantages such as high concentrations of poverty, pollution, limited green-space, and poor access to healthy food sources. A medical approach to this problem would be to screen patients for ACEs and provide some sort of intervention to counteract the negative effects of childhood trauma. It's unclear if such an approach actually helps, though, and even if it does, the public health professional in me thinks there must be better ways to prevent ACEs in the first place.

A recent cross-sectional study in 4 states (Kansas, Montana, South Carolina, and Wisconsin) turned the concept of ACEs on its head and instead asked more than 20,000 adults if they had experienced one or more of the following positive childhood experiences (PCEs):

1. Adult made you feel safe and protected

2. Felt you belonged in high school

3. Felt supported by friends

4. At least 2 adults took an interest in you

5. Felt your family stood by you

6. Enjoyed community traditions

7. Felt able to talk to your family

Adults who reported higher numbers of PCEs were more likely to have attended postsecondary school, had greater household incomes, were less likely to smoke, and had fewer chronic medical conditions than those reporting lower numbers. So how can our society reduce exposure to ACEs and increase exposure to PCEs? An analysis in the Milbank Quarterly illustrated that state policies that improve economic security are associated with better mental health outcomes in children and adults. More bureaucracies, then? Hardly. Arguably the most effective social policy implemented during the pandemic was the temporary 2021 expansion of the Child Tax Credit, which effectively provided "a near universal, unconditional child cash benefit," reducing child poverty to historically low levels.

Closer to home, since 2022 Philadelphia has experimented with providing no-strings attached cash assistance to low-income families rather than making them wait for inadequate public housing or limited numbers of vouchers to become available. Families (households had to have at least one child under the age of 16) fortunate enough to receive monthly payments ranging from $15 to $2057 (with a median of $1000) have generally applied them toward rent. Not only were households who received cash less likely to be evicted or become homeless, they also had fewer concerns about the quality of their housing.

I attended a conference recently where a presenter half-facetiously, half-seriously, summed up all of the risk factors for developing a chronic health condition as "Don't Be Poor." Our historic societal response to poverty has been to create difficult-to-navigate welfare programs with ever-changing eligibility requirements that help poor people with health care and food and housing but basically force them to stay poor to keep receiving benefits. What if we cut through the red tape and just gave them cash instead? Would fewer ACEs and more PCEs occur, leading to better health for everyone in the long run? It's not the kind of research that the National Institutes for Health will fund any time soon - they're too busy trying to prove that vaccines cause autism - but it's definitely a question worth studying.

Courage and consequences at the CDC

2025-09-01T11:54:00.004-04:00

In a recent presentation to preventive medicine residents at Johns Hopkins, I reflected on the painful circumstances that led to my resignation from the Agency for Healthcare Research and Quality (AHRQ) in November 2010. In short, political decision-makers well above my pay grade attempted to protect Democratic congressional majorities from blowback from an anticipated recommendation against prostate cancer screening by forcing the U.S. Preventive Services Task Force to cancel a scheduled meeting. Until this year, when Health and Human Services Secretary Robert F. Kennedy, Jr. cancelled the USPSTF's July meeting and expressed his intent to replace the entire panel, it was arguably the worst example in the Task Force's history of politics trumping science. (This time is worse - a LOT worse.)

Last week, the HHS Secretary fired recently confirmed Centers for Disease Control and Prevention (CDC) Director Susan Monarez over her unwillingness to “to rubber stamp [vaccine] recommendations that flew in the face of science.” In protest, three senior CDC officials simultaneously resigned. On his Inside Medicine Substack, Dr. Jeremy Faust posted the full text of the e-mails that Dr. Deb Houry, Dr. Demetre Daskalakis, and Dr. Daniel Jernigan sent to their colleagues announcing their respective resignations. Without question, these three doctors were far more critical to the day-to-day work of the CDC and HHS than I ever was or might have been at AHRQ. But their collective departure, like mine nearly 15 years ago, raises an important question: when a public servant who is also a health care professional witnesses the federal government taking immoral or profoundly troubling actions, is it more courageous to step down (and draw attention to how these actions endanger health) or to remain in place and continue to resist from the inside, hoping that eventually new leadership will restore the primacy of science and evidence-based medicine?

My red line was that the delay - which ended up being 17 months long - in ratifying the USPSTF's "D" recommendation against PSA-based prostate cancer screening would ultimately injure hundreds of thousands of patients who accepted screening without being aware of the Task Force's determination that it was more likely to cause them harm than good. My primary professional identity was and remains that of a family physician, and inherent in this identity is an obligation to provide patients with the best understanding of the science to help them make health decisions. Being told that I had to set this obligation aside because it might damage the electoral prospects of a Presidential administration and his political party was, in my view, unconscionable.

On the other hand, I admire my colleagues at AHRQ who chose to stay and sustain the USPSTF from the inside. A few still work there; others, unfortunately, were given pink slips by Elon Musk's Office of Government Efficiency when his group of twenty-something contractors couldn't figure out what the agency did that was important enough to warrant employing a few hundred scientists. No doubt the Task Force would have been much worse off if every member of its support staff had walked out with me on my last day and switched to careers in academic medicine. Leaving an impossible situation can be courageous, but staying on is, too. I salute Dr. Monarez and her departed senior leaders at CDC for their principled public resistance, but I also support the many staff who have remained despite RFK Jr.'s horrific interference with the agency's mission to protect the public's health.

Do pharmaceutical conflicts of interest compromise the AAP guideline on childhood obesity?

2025-08-16T11:01:00.004-04:00

In January 2023, the American Academy of Pediatrics (AAP) published a clinical practice guideline on the evaluation and treatment of obesity in children and adolescents. Dr. Kathryn McKenna and I noted in an editorial in American Family Physician that the recommendation to consider prescribing weight loss drugs in adolescents 12 years and older was based primarily on short-term studies: “only 5 out of 27 randomized controlled trials [available to the AAP] included results beyond six months.” Although the percentage of US adolescents with obesity who were prescribed drugs rose modestly between 2018 and 2023, a recent study found that prescribing increased immediately after the guideline’s publication and every month thereafter through the end of 2024.

To be sure, the effects of nondrug interventions for obesity have been discouraging. A Cochrane review from 2020 found that combined dietary and physical activity interventions in adolescents 13 years and older did not lead to statistically significant changes to body mass index. Nonetheless, the US Preventive Services Task Force found insufficient evidence on the harms of long-term obesity medication use in children and decided to recommend only intensive behavioral interventions.

An analysis in the BMJ highlighted undisclosed financial conflicts of interest involving several authors of the AAP guideline and its accompanying technical report. Three guideline authors and one systematic review author received payments from pharmaceutical companies for consulting, travel, and other compensation between 2017 and 2023 ranging from $2,750 to $46,000; five other guideline authors received smaller amounts for meals and honoraria. From 2012 to 2024, 11 developers of glucagon-like peptide 1 (GLP-1) receptor agonist drugs made an estimated $1.9 to $2.6 million in corporate sponsorship payments to the AAP, including Novo Nordisk (semaglutide) and Eli Lilly (tirzepatide).

The AAP is hardly alone in permitting financial ties to drug companies. Other studies identified industry payments to the authors of the American Diabetes Association and the Infectious Diseases Society of America clinical practice guidelines, and 12 of 17 members of the 2023 board of directors and scientific committee of the Global Initiative for Asthma (GINA) received personal fees from AstraZeneca, which makes a brand-name inhaler used in the single maintenance and reliever therapy (SMART) treatment approach recommended by GINA guidelines.

Some would argue that the AAP guideline authors may have erred in not disclosing their pharmaceutical ties, but they would have likely come to the same conclusions about the effectiveness of GLP-1 receptor agonists and other weight loss drugs for adolescents. A counterpoint is that industry payments to individuals, regardless of amount, influence prescribing behavior and that those in a position to change the standard of care for children with obesity should refuse such payments. Finally, sound reasoning strongly supports that disclosing conflicts of interest is not enough to safeguard against bias in guidelines and other journal publications.

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This post first appeared on the AFP Community Blog.

Research supports moving away from race as a risk factor

2025-08-04T17:59:00.002-04:00

In a 2021 American Family Physician editorial on the dangers of incorporating a patient’s race into medical decision-making, Dr. Bonzo Reddick observed, “Although we may hear about biologic or genetic differences between races, there is more variation within races than there is between them.” A recent landmark report from the National Institutes of Health’s All of Us Research Program compared self-identified race and ethnicity categories to continental and subcontinental genetic variation. Analyzing about 2 million common variants in the genomes of more than 230,000 unrelated participants, they found that “participants within self-identified race and ethnicity groups exhibit gradients of genetic variation rather than discrete clusters.”

Among White participants, 8% were found to have some South Asian ancestry, whereas smaller percentages had more than 50% African or Native American ancestry. Similarly, 1 in 100 self-identified Black participants had more than 50% European ancestry. The study also found notable regional differences in ancestry percentages among self-identified Black, Hispanic, and White participants. The researchers concluded that these gradients reflect “the historical impacts of US colonization, the transatlantic slave trade, and recent migrations” and “demonstrate that social constructs of race and ethnicity do not accurately reflect underlying genetic variation.”

Maternal race—specifically, Black race—is associated with increased risk for the development of preeclampsia. In its 2021 recommendation statement on aspirin to prevent preeclampsia and related morbidity and mortality, the US Preventive Services Task Force included Black race as a moderate risk factor, although it noted that it was a proxy for “environmental, social, and historical inequities, … not biological propensities.” However, a multicenter cohort study in JAMA Network Open found that Black race, similar to other moderate risks such as nulliparity, maternal age older than 35 years, and body mass index above 30, was not clearly associated with preeclampsia in the absence of a high risk factor (eg, chronic hypertension).

Finally, a narrative article in the New England Journal of Medicine traced the historical debate over race-based hemoglobin thresholds that began in the 1970s, when epidemiologic analyses showed that on average, Black children’s serum hemoglobin levels were 0.5 g/dL lower than those of White children. Did this disparity reflect inherent biological differences between races or differences in nutrition? Should it support race-based definitions of normal hemoglobin levels? Although some analyses accounting for socioeconomic status and diet no longer found significant racial differences, conflicting guidance from the Institute of Medicine (now the National Academy of Medicine) and the Centers for Disease Control and Prevention persisted into the early 2000s. Today, the World Health Organization, American Academy of Pediatrics, and American College of Obstetricians and Gynecologists all recommend against using race-adjusted cutoffs for diagnosing anemia.

This post first appeared on the AFP Community Blog.