What's in a name?

The following is a guest post from my sister-in-law, Dr. Therese Duane, a trauma surgeon who is on a medical mission in Uganda. You can read more about the essential work she and her colleagues have been doing at Mercy Trips Healthcare Outreach.

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Taking poetic license from Shakespeare, I recently found myself contemplating the value attributed to names and titles as I prepared for my next mission trip. For so long, my focus had been achieving more of these—whether it be professor of surgery, program director, or chair of the department. Fortunately, in His goodness, God stripped them away and left me with what really mattered—the names of wife, mother, sister, daughter, aunt, niece, friend, Godmother and now Mom Mom.
#Perspective #LegacyOverLabels #AmericanCollegeofSurgeons

In my family, Mom Mom is the sobriquet of the matriarch instead of grandmother. It has always represented the woman in the generation whose strength kept the family together. I grew up in awe of my Mom Mom, my mother’s mom, who as the mother of eight, built a newspaper alongside my Pop Pop while raising diligent and devout children. My mother, my children’s Mom Mom, followed in her footsteps embodying the same fortitude. With my Dad, she raised seven children who learned determination and discipline through tough love at an early age. So, when our eldest daughter Alejandra—who joined our family 17 years ago as our au pair and quickly became our 5th child—had her first, I could not be prouder to strive to deserve the name of Mom Mom.
#BlendedFamily #ChosenFamily #MomMomMoments

Being Mom Mom began as we walked her pregnancy together with all the anxieties and anticipation culminating in the birth. After 38 hours of labor, multiple positions, four hours of pushing and me supporting her mostly by yelling “GET OUT” to the baby and suggesting things that her wonderful OB/GYN, @JaimeObst, politely told me, “They don’t do that anymore,” baby Bella was born! My own experience in childbirth had been very different—having 4 kids in less total time than it took her to have one—ahh the benefits of being on call the night before giving birth! Hence, Bella’s delivery was transformative for all of us. Ale recognized her inner strength and responsibility as a new mother and me the power and privilege of being a Mom Mom.
#WomensHealth #BirthStory #GenerationalStrength

So what does this have to do with a mission trip? It all has to do with prioritizing the roles we do have. Just one day after getting Ale settled at home, I left to serve the community at IntegrisHealth Baptist as an acute care surgeon for a week, came home for one day and then was off for a four-day band trip with my two youngest as chaperone and band doctor—to fulfill my other name as Mom. Grateful that my professional family supports my flexible work schedule, I can fulfill all my roles. Of course, none of it would be possible without an understanding husband holding down the fort. This wife was able to spend two days in four weeks at home before leaving to fulfill my privileged role as missionary.

#MissionWork #FaithInAction #MedicalMissions #MomLife #GratefulHeart

So perhaps Shakespeare had it right. The name or title does not matter in and of itself—what is more important is how you fulfill the role. Becoming a missionary has made me appreciate so much more all the titles I have that really matter, none of which include monetary value and yet are invaluable to the people they bless and to the God who made me for the purpose. In Uganda, I see women labor with no pain medicine and pushing through it with a stoicism that is humbling. I am grateful for what we have in the US and for the care my daughter and granddaughter received. Moreover, as a mother and now as a Mom Mom trying to emulate those who came before me by setting the example of unconditional support, I know my family are in the good hands of each other and more importantly of God.

#GlobalHealth #ServingOthers #MercyInAction #Gratitude #PurposeDriven

Hence, I had no qualms returning soon after Bella’s birth to the country where these strong people survive under harsh circumstances to do what I can to help them. Ultimately, as I have learned through this missionary work with Mercy Trips, kindness, compassion and generosity fulfill the ideals of the most important name of all which we each should embrace—Child of God.

#MomMom #LegacyOfLove #FaithFamilyMission #LivingYourPurpose

Measles, vaccine hesitancy, and the ACIP

As of March 27, 2025, 19 states had confirmed a total of 483 measles infections, with 444 cases associated with an ongoing outbreak in West Texas and New Mexico that began in late January. 70 people (14%) have been hospitalized for serious illnesses, and one child and one adult have died. For comparison, there were 285 cases of measles in the United States in 2024, and there have already been more reported cases than in all but two years since 2000. In a 2024 American Family Physician editorial, Dr. Doug Campos-Outcalt reviewed best practices for diagnosis and prevention of measles. Of note, “a person with measles is infectious 4 days before through 4 days after the appearance of the [erythematous, maculopapular] rash.”

Increasing vaccine hesitancy has depressed measles, mumps, and rubella (MMR) vaccination rates in the affected jurisdictions, making more people vulnerable to the highly contagious illness. Parents may refuse vaccinations for their children due to concerns about adverse effects, such as the repeatedly debunked myth that MMR increases the risk of autism. (Studies show a 4 in 10,000 risk of a febrile seizure after receiving MMR at 12 to 15 months of age, considerably lower than the risk associated with measles infection.) Although the American Academy of Family Physicians and the American Academy of Pediatrics discourage nonmedical exemptions from childhood immunizations required for daycare or school attendance, “philosophical” or religious exemption policies have been increasing in the United States. In West Virginia, where the last reported case of measles was in 2009, physician advocacy groups successfully petitioned the governor to veto a 2024 bill passed by the state legislature that would have allowed private and parochial schools to opt out of state immunization requirements.

Currently, infants 6 to 11 months of age are recommended to receive an early MMR dose before international travel. In a recent JAMA Viewpoint, former Centers for Disease Control and Prevention (CDC) director Rochelle Walensky, MD, MPH, and colleagues proposed “updating the existing recommendation for an additional early MMR dose to infants aged 6 to 11 months traveling to any region with increased probability of measles exposure, whether international or domestic.” Although several federal agencies play a role in vaccine development and use, the CDC’s Advisory Committee on Immunization Practices (ACIP) has been the authoritative source of vaccine recommendations since its formation in 1964. Members of this independent committee are required to disclose financial conflicts of interest and recuse themselves from deliberations and votes about a vaccine, its potential competitors, and any other products of the company that makes the vaccine. An investigation by the journal Science concluded that contrary to accusations by leaders of antivaccine groups such as Robert F. Kennedy, Jr., there was “no sign that [ACIP] vaccine advisors are beholden to industry.” After the ACIP’s February 2025 meeting was postponed for unclear reasons, the CDC has announced that the committee will meet next month. According to the Federal Register notice, the agenda includes recommendation votes on meningococcal vaccines, chikungunya vaccines, and RSV vaccines for adults, as well as “an update on the current [Texas/New Mexico] measles outbreak.”

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This post first appeared on the AFP Community Blog. More than 100 new measles cases have been reported in the U.S. since last week.

Once again, the Agency for Healthcare Research and Quality is in the line of fire

This post first appeared on March 6, 2018, during the first Trump administration's failed attempt to eliminate the Agency for Healthcare Research and Quality (AHRQ). Now the Department of Government Efficiency is trying again, threatening 90% staff reductions that would decimate the agency. Please join me and hundreds of medical organizations in standing with AHRQ and preserving its vital contributions to the health of all Americans.

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For the past 30 years, a little-known U.S. health agency has supported and produced volumes of groundbreaking research on how to make health care safer, less wasteful, and more effective. Dubbed "the little federal agency that could," AHRQ has accomplished this feat with a small fraction of the budgets of its higher-profile cousins, the Centers for Disease Control and Prevention and the National Institutes of Health. Nonetheless, its work has often been politically unpopular and unheralded outside of a small community of health services researchers and patient advocates. Sadly, when all medical waste is somebody's income, there is little enthusiasm in the medical-industrial complex or on Capitol Hill in allocating the $3 trillion the U.S. spends on health care more wisely or efficiently. In fact, our legislative and executive branches have periodically proposed that AHRQ's budget be slashed or eliminated entirely.

In 1994, the agency (then known as the Agency for Health Care Policy and Research) dared to publish a back pain guideline that suggested that there was little role for surgery in most patients. As later documented in Health Affairs, this act raised the hackles of back surgeons with powerful allies in Congress who were already annoyed by the agency's association with the failed Clinton health reform plan. The agency's budget was zeroed out by the House of Representatives and narrowly restored by the Senate in 1995 after a 21 percent cut and a name change to emphasize that its mission would be to produce evidence to inform policy, rather than attempt to actively shape policy.

Despite this deliberately circumscribed mandate (I lost count of the number of times during my tenure as an AHRQ medical officer from 2006-2010 that I was told, "We don't make guidelines. We make evidence that other groups use to make guidelines"), the passage of the Affordable Care Act made AHRQ a target again in 2012, when a House appropriations subcommittee voted to zero out its budget again. AHRQ survived that episode, only to be zeroed out by the House once again in 2015, when the danger to the agency's survival seemed real enough that former Senate majority leader Bill Frist and former CMS director Gail Wilensky both penned op-eds urging their Republican colleagues to reconsider - which they eventually did.

Ironically, the need for AHRQ's work has never been greater. The proliferation of clinical practice guidelines of varying quality and conflicting recommendations has led to calls to systematically evaluate guidelines for their impact on patient outcomes. AHRQ would be a natural place for this evaluation to occur, as its National Guideline Clearinghouse already summarizes and synthesizes guidelines that meet certain evidence-based development criteria. But funding to maintain the NGC will run out a little more than 4 months from now, and there seems to be little hope of rescue. [Update: the NGC ceased operating in 2018.]

In the meantime, the Trump Administration has proposed dissolving AHRQ as an independent agency in the next fiscal year and transferring its current functions into a new institute within the NIH, with a 21 percent budget cut from 2017. Although such an arrangement has both potential pros and cons, as a previous AHRQ director observed, it's hard to imagine that the shrunken agency would not be marginalized and lost amid NIH's biomedical research behemoth.

Why do I care? Why should you? You need not be ill enough to be hospitalized or care about practice guidelines to suffer if AHRQ is eliminated for good. Not only does it produce several important tools and resources for primary care practice, but it disseminates and implements evidence about what works to improve health, through its National Center for Excellence in Primary Care Research. AHRQ supports research that generates evidence about "effective models of care, patient- and family-centered care, shared decision making, quality improvement, and health information technology." This is research and evidence that no one, healthy or ill, can afford to lose. Academy Health maintains an advocacy toolkit for use by any person or organization who wants to help #SaveAHRQ from becoming a casualty of ignorance, indifference, and/or conflicts of interest. I hope that I have persuaded you to join the fight.

Book Review: Has Medicine Lost Its Mind? by Dr. Robert C. Smith

The COVID-19 pandemic and the isolation caused by public health measures to slow its spread exacerbated a mismatch between the need for mental health care and the number of professionals trained to provide that care. Even though stigma prevents many persons with mental health problems from seeking care, there has never been enough go around. In Has Medicine Lost Its Mind? Why Our Mental Health System is Failing Us and What Should Be Done to Cure It, Dr. Robert C. Smith, a general internist and professor of medicine and psychiatry at Michigan State University, explains why our medical system consistently prioritizes physical over emotional health and presents some ambitious proposals for how to rectify this harmful disparity.

This relatively slim volume is divided into three parts. The first few chapters discuss the problems with mental health care in the U.S. and the suffering that they cause. Dr. Smith shares the stories of several patients he met during residency and his early years in practice who illustrate the bad outcomes that accompany not attending to patient's emotions and focusing solely on their physical problems. These experiences motivated him to complete a two-year fellowship in behavioral health and psychiatry, where he learned the biopsychosocial model and decided to make primary care mental health the teaching focus of his academic career. Dr. Smith notes that less than 5 percent of the preclinical and clinical curricula in medical school, absent electives, is devoted to teaching students about behavioral health or psychiatry. Thus, he argues, physicians were ill-prepared to confront the opioid epidemic, increasing rates of depression and anxiety in conjunction with chronic illness, and the negative effects of COVID-19 on mental health. 

The second part of the book traces the history of the "mind-body split" in medicine, starting with Hippocrates, through the Flexner Report (1910) to the present day. In contrast, he presents the infrequently taught patient-centered interview as a paradigm shift (a la Thomas Kuhn) with the potential to revolutionize medicine. In the concluding chapters, Dr. Smith proposes a pathway to redirect the medical-industrial complex "back to a more humanistic orientation," which involves commissioning a "New Flexner Report" and federally-led reforms to medical education to require schools to fully embrace the biopsychosocial model. Primary care medical and residency faculty will learn the principles of mental health care via a train-the-trainer approach.

Although I dispute Dr. Smith's assertion that primary care physicians receive next to no training in mental health care (though I can only speak to my specialty of family medicine), I agree that structure of our health system discourages meaningful doctor-patient interactions, and that the assembly-line mentality of traditional primary care practice incentivizes drug prescribing over active listening. Medicine could do a far better job of diagnosing and treating mental health conditions, but absent a robust public health structure, their root causes - worsening economic and political inequality, a deteriorating environment, and a weak social safety net - will remain. And having the federal government or the Association of American Medical Colleges (AAMC) lead a national effort to dramatically expand the footprint of behavioral health in medical education is likely a pipe dream. This is not to say that this book is not worth reading - far from it. But I fear that it is too far ahead of its time.

"Sludge audits" identify obstacles to completing colorectal cancer screening

In a traditional health care setting, many administrative burdens and barriers stand in the way of patients receiving evidence-based care. Paperwork required to sign up for health insurance and to establish care with a practice. Calling to schedule the next available appointment and taking time off work. Travel to the doctor’s office. Wait times. More travel to a laboratory or a different office for a test or procedure. Remembering to eat or not eat, or what to eat, before being tested. The list goes on.

A 2022 article in the Harvard Business Review introduced the term sludge to describe “these types of situations in which the design of a specific process consistently impedes individuals from completing their intended action.” A sludge audit is “a systematic approach to identifying the presence and cost of sludge and figuring out how to eliminate it.” Although not originally applied to health care processes, sludge audits can improve the efficiency of health systems and patients’ experiences. The article identified four approaches to reduce sludge: (1) reduce the number of steps, (2) add a digital option, (3) remove roadblocks, (4) offer virtual alternatives to in-person processes.

Dr. Michelle Rockwell and colleagues at the Carilion Clinic in Roanoke, Virginia, performed a sludge audit of their colorectal cancer (CRC) screening services in 2021 and 2022. They quantified time, paperwork, communication, technology (number of mouse clicks to order a CRC screening test), other administrative tasks, and low-value CRC screenings. They found that clinicians needed a median of 17 mouse clicks to order a screening colonoscopy; the median wait time between primary care referral and scheduling was more than 6 weeks; wait time between scheduling and having the procedure was more than 6 months; some patients were asked to attend multiple preoperative visits; and nearly 1 in 3 follow-up colonoscopies was judged as being performed at a shorter interval than necessary. Finally, neither patients nor primary care clinicians could easily access the results of colonoscopies or stool-based tests.

Unsurprisingly, patients’ experiences with the health system’s CRC screening process were suboptimal; 37% of surveyed patients reported that their tests were delayed or not done because of “excessive or unnecessary paperwork, communication, technology or waiting.” Patients who chose fecal immunochemical tests needed to visit another location to pick up test kits, and some stated that they could not understand the instructions with the tests. Patients with Medicaid insurance or dual Medicare-Medicare coverage were more likely than those with private insurance to report sludge. In contrast, patients who reported no or minimal sludge were more likely to complete screenings and less likely to report distrust in the health system.

Even in a population where everyone has the same health insurance, having more social needs is associated with lower CRC screening rates. A cross-sectional study of Kaiser Permanente patients ages 50 to 75 years who completed a social needs survey in 2020 found that those who reported severe financial strain, severe social isolation, and severe food insecurity were statistically twice as likely to not be up to date on CRC screening than other patients.

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This post first appeared on the AFP Community Blog.

Is there enough time for prevention in primary care?

Family physicians are being squeezed by two accelerating trends: (1) too few of us to care for the growing US population and (2) the rising number of tasks that we are asked to accomplish for each patient. A 2024 analysis projected that by 2040 a shortage of 58,000 primary care clinicians (including nurse practitioners and physician assistants) will occur. Meanwhile, the estimated time needed to provide guideline-recommended preventive care, chronic disease care, and acute care to a nationally representative panel of 2,500 adult patients is an impossible 26.7 hours per day, with more than one-half of that time (14.1 hours) allocated to preventive care.

As science advances, the number of US Preventive Services Task Force (USPSTF) A and B graded recommendations grows, and the size of the affected populations expands. Since 2020, the starting ages for breast, lung, and colorectal cancer screening were lowered to 40, 50, and 45 years, respectively. The USPSTF also has endorsed screening most adults for anxiety disorders and unhealthy drug use. In an editorial in the February 2025 issue of American Family Physician, Dr. Mark Ebell and I discussed concerns about the quality of the evidence for several recommendations. "To justify the extra time and effort associated with implementing new or expanded screening recommendations," we cautioned, "clinicians must have confidence in the reliability of USPSTF assessments regardless of the task force’s membership at any point in time."

A 2025 commentary in the BMJ proposed a radically different solution to the workforce crisis: Take prevention for low-risk patients off the plate of primary care. The authors noted that as measured by the number of patients needed to treat to prevent one negative outcome, “care for symptomatic patients provides substantially greater benefit than preventive care.” Rather than counseling patients individually to quit smoking, drink less alcohol and sugar-sweetened beverages, and consume fewer highly processed foods, medicine should defer prevention to public policy measures (eg, taxes on cigarettes and laws restricting where people can smoke) that achieve these goals more effectively. Not only would this approach free time for family physicians to focus on patients with acute complaints and chronic diseases, the authors argued, but it would also remove the “ethical stress” that comes with “the mismatch between the patient’s needs and the burden of preventive care” in the form of quality metrics.

The problem with this proposal is that in the United States, the public health workforce is not positioned to handle routine screenings and immunizations. This month, the Centers for Disease Control and Prevention (CDC), the federal agency sponsor of the USPSTF’s sister panel, the Community Preventive Services Task Force (CPSTF), was forced to lay off 10% of its work force. Portions of the CPSTF’s website, including the biographies of its current members, are still missing after thousands of CDC web pages were abruptly removed or altered. There may not be enough time for prevention in primary care, but family physicians need to keep providing it the best we can.

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This post first appeared on the AFP Community Blog.