By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

People almost invariably arrive at their beliefs not on the basis of proof but on the basis of what they find attractive.”

-Blaise Pascal

Clinicians strive to base our diagnostic and treatment practices on appropriate interpretation of scientific studies. The Evidence Based Medicine (EBM) movement has grown in the past 50 years to help create frameworks for evaluation and application of such studies. The worthy goals of EBM are to avoid unnecessary interventions that can potentially harm patients, and improving the health care that we do provide.

The term “evidence based” is sometimes misused.

I recall a resident physician from UCSF, commenting on a particular intervention: “there is no good evidence that this intervention works.” In this case, however, there was no strong evidence for any other intervention, including the one used at UCSF. The resident earlier had pointed to previous studies that showed both a lack of statistical improvement with an intervention, and a “trend towards benefit.”

On the other hand, a study can be done that shows that an intervention has no benefit. These two situations are not equivalent. “Lack of evidence of benefit” is not the same as “evidence that an intervention does not work.”

In the first case, a clinician can very defensibly try out the intervention if there is not established superior treatment. In the second case, when studies definitively show no benefit, a clinician would arguably be practicing substandard medicine to use the particular intervention.

Evidence based medicine was also misused several times in the Covid-19 pandemic. Transmission of earlier Coronaviruses causing SARS-1 and MERS was found to be impeded by use of masks. Early in the Covid-19 pandemic, before studies could have been conducted proving that use of masks also reduced transmission, the Center for Disease Control and Prevention (CDC) stated that mask wearing by the public was not recommended, because of the absence of evidence that masks helped. It incorrectly implied that absence of evidence of benefit meant that there was no benefit, even though the prior probability based on related viruses suggested that a benefit was likely. When the evidence became available and the message flipped to recommend masks and later highly effective masks to prevent transmission, this fundamental change in recommendation contributed to lack of trust in the CDC.

In behavioral health and social science research, the “evidence-based practice” is a standard requirement for programs to be funded. For example, an academic study of a new behavioral counseling technique might show that it reduces depression symptoms by 5%, from an average PHQ9 score of 20 to 19. Technically, this is evidence based—a published study showing a benefit of this intervention. Many government grants would allow this intervention to be implemented more widely.

Implementing this “evidence-based” intervention would be a mistake, for two reasons:

First, the setting that this academic study was done almost certainly differs from any real-world setting. “Implementation science” studies such questions. In general, four different replications of a behavioral intervention in different settings all with a similar benefit are needed to have a 95% or greater confidence than another implementation of this intervention will also have the same benefit.

Second, although the 5% reduction may be statistically significant, is it not clinically meaningful. Sadly, one often has to read scientific studies carefully to see if a difference is clinically meaningful.

The term “evidence based” has also been used to disparage a person’s educational level. For example, a community health worker (CHW) with at 10^th grade education may be intuitively skilled at connecting with clients and getting them to change behavior yet lose a job to a more educated and articulate applicant if the hiring manager, instead of recognizing that the CHW has not been trained on “evidence-based approaches,” says that the CHW does not use such approaches. This statement is arguably a reflection of implicit bias against someone with less formal education.

All of these examples of misuse of “evidence based” are a reflection of cognitive biases of one form or another. In the first case, the resident preferred one approach over another and incorrectly used the term “evidence based” to disparage one approach and prop up another. This is sometimes called the “confirmation bias” or the “my side” bias, a very common and very human bias to which scientists are not immune. In the second case, many Asian countries commented on the bias against public mask wearing in the United States, which likely played a role in the early recommendation to NOT wear masks to limit the spread of Covid-19. In the third case, the confirmation bias is also at play, because the researcher really wants something important to come out of their research, as this more often leads to publication of studies, invitations to give talks, and academic reputation.

When someone smart uses “evidence based” to promote or disparage a particular practice or treatment, our internal bias-detection should move into high gear. Switch to system 2 thinking (slow thinking), and critically review the underlying evidence for statistical significance, clinical meaningfulness, and replicability.

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“It is the curse of humanity that it learns to tolerate even the most horrible situations by habituation.”

-Dr. Rudolf Virchow

Paul Farmer, MD PhD, an infectious disease specialist and anthropologist who started a foundation to provide care to impoverished populations in Haiti and around the world, died suddenly of an apparent heart attack this past week, at age 62.

Dr. Farmer studied Haitian culture as a medical anthropologist before becoming a physician and a specialist in infectious diseases. Through his direct patient care activities and by developing a public health infrastructure in a remote area of central Haiti, he cultivated a deep understanding of the links between disease, poverty, and political power. He wrote several books on this topic, using patients’ experiences to drive home his arguments.

Biographer John Tracy Kidder in “Mountains Beyond Mountains: The Quest of Dr. Paul Farmer, a Man who Would Cure the World,” relates this story:

A TB patient from a village hadn’t shown up for his monthly doctor’s appointment. So—this was one of the rules—someone had to go and find him. The annals of international health contain many stories of adequately financed projects that failed because “noncompliant” patients didn’t take all their medications. Farmer said, “The only non-compliant people are physicians. If the patient doesn’t get better (because they don’t take medications as prescribed), it’s your own fault. Fix it.”

Of the many moving and interesting parts of Farmer’s life detailed in the book, this one sticks with me, because it is so at odds with how many of us think about “non-compliant” patients. Attributing failure of an intervention to non-compliance is a way for health care professionals to assign responsibility or blame to our patients for them not getting better, because they don’t follow our scientific advice. The alternative term “non-adherence” was initially used with an intent to look for underlying factors that could be impacted, but it has come to be used in place of “non-compliant” just to sound less judgmental, but with the same implicit intent and outcome. The clinician moves on to their next task, their next patient.

Dr. Farmer believed that an understanding of a patient’s culture is essential to build trust between the physician and the patient allowing a skilled physician to devise a way to form an alliance with the patient that will lead them, long after they feel better, to complete an antibiotic treatment for tuberculosis, to cure them of the infection. This is difficult work in many ways. It requires time spent listening to the patient, as well as mental creativity, and tenacity.

This belief is what drove Dr. Farmer, a handful of Haitian doctors, a larger group of community health workers, and the community health center/hospital he ran in Haiti, to uncompromisingly provide quality health care to an impoverished population about the size of Shasta County. No one in the region served by his health center had died of measles or tuberculosis in many years (unlike other areas of Haiti, where deaths from these diseases were sadly common).

Dr. Farmer said his role model, since his undergraduate years, was Dr. Rudolf Virchow, a 19^th century German physician of many skills and interests. Dr. Virchow was known as both the father of modern pathology (with an understanding of the central role of cells in tissues and diseases), and also the father of the field of social medicine. Like Farmer, Virchow was an anthropologist and a scientist as well as a prolific writer on both scientific and socio-political topics.

The work that you do in your health centers and offices follows the same spirit of service to the most vulnerable members of our community. Let Farmer and Virchow inspire us to not accept mediocrity, bureaucratic barriers, or blame our patients for poor outcomes. We must develop a deep understanding of the cultures of the patients we serve, the system we are working within, and combine this with compassionate medical care to meet the challenge of caring for the individual patients before us.

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“No one has ever become poor by giving.”

-Anne Frank

Twenty years ago when I was the Medical Director of Community Health Clinic Ole in Napa, someone I still don’t know placed one hundred $50 gift cards to a grocery store in my home mailbox, with a note, saying that I should distribute them to needy patients of our Health Center. Our outreach team mobilized and distributed them to 50 particularly needy individual patients and families. The same thing happened the following year. The anonymous donor trusted me to make sure that their charity would go to a person who needed it; that person would never know who gave this gift, because even I did not know who it was. The charity was given without the desire or expectation of being recognized publicly, or even privately.

Eight years ago, a retired businessman –who came to the United States from India to build a business selling medical supplies—lent a 17 year old young man from his hometown in India the money to be able to attend UC Davis where he was accepted as an undergraduate aerospace engineering student. The young man’s family was of modest means; they could not afford to send him abroad to be educated. The retired businessman was not related to the family, but he made this high-risk personal loan to help him achieve his dream to be a high-tech engineer, and to support his family in the process. This young man met my daughter and is now my son-in-law.

Around this time of year, many people call local homeless shelters offering to help. Thanksgiving dinner at the Napa homeless shelter was purchased, cooked, and served by the local painters union. They called and volunteered to do this, without being asked.
All of these are examples of the highest level of charity. About 950 years ago, a physician-philosopher named Maimonides identified eight levels of charity. Paraphrasing them in order from highest to lowest:

1. The greatest level: Support a member of your community with a gift, a loan, or helping find employment to strengthen his hand so that he will not need to be dependent on others. This is the charity provided by the Indian businessman.
2. Give to the poor without knowing to whom one gives, and without the recipient knowing from whom he received it. It is given in secret to a trustworthy intermediary. This is the charity of my unknown neighbor, who provided the gift cards for my patients. Leaving a generous tip for the low-income housekeeping staff at a hotel could fit in this category, as well.
3. Give to someone that is known to the donor, but the recipient does not know who gave the gift.
4. Provide a donation when the donor does not know who they are helping, but the recipient does know.
5. Give directly to someone, with both the donor and recipient knowing each other, but the gift is given without being asked. The painters who prepared and served Thanksgiving dinner to the homeless of Napa would fit in one of these three levels (3, 4, or 5); although the donor and recipient could see each other, they did not know each other’s names.
6. Giving to a poor person after being asked.
7. Giving inadequately, but gladly and with a smile.
8. The lowest level of charity is to give unwillingly.

In the progressively lower levels of charity, much of the purpose of the charity is to be seen by others as being charitable (called virtue signaling by psychologists). This charity is still very important, as many U.S. charitable organizations rely on these lower levels to gather donations. In the higher levels, the charity is not intended to improve one’s social capital but rather aims to increase the opportunities of others and positively impact communities.

Here are three takeaways for each of us:

1. Contemplate these eight levels of charity; talk them over with your family and friends.
2. This holiday season think about ways you can give at one of the higher levels.
3. Let humility guide your giving practices. Celebrate those who quietly, give without expecting recognition.

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“The only way you can stay on top is to remember to touch bottom and get back to basics.”

-Shane Black (Director, Screenwriter, Actor)

The COVID pandemic has had a number of ripple effects on the health of your patients, beyond the consequences of infection and stress-induced exacerbation of mental health status. Many clinical quality metrics saw plummeting performances in the past two years. For example, the proportion of those with a diagnosis of hypertension whose blood pressure is controlled dropped by over 10%. A major driver is decreased in-office visits where blood pressure is checked, with a relatively small proportion of patients using home BP monitors to follow their own blood pressure. Drops in well-child visits, breast, and cervical cancer screening are other examples.

The summer wave of the delta variant of COVID-19 led to increased infection rates, staffing disruptions, and new vaccination recommendations. It is becoming clear that COVID is so infectious and the level of protection from infection conferred by the initial vaccination series and prior infection is transient, so it will not be disappearing but rather become an endemic disease for the foreseeable future.

With this in mind, it is a good time to remind ourselves of other health issues facing the patients we serve, issues that were often deferred by patients and clinicians in the midst of the waves of pandemic cases. They include core preventive activities, like screening for breast and cervical cancer, use of nicotine products, and misuse of alcohol and other drugs. They include control of chronic conditions like hypertension, diabetes, asthma, and COPD.

In the next couple of months, we encourage you to pause, take a breath, and start to think about how you will re-engage your organization with these important core preventive and chronic disease activities!

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“If you have knowledge, let others light their candles in it.”

-Margaret Fuller,
American Journalist and Women’s Right Advocate

Most organizations that implemented Electronic Medical Record (EMR) systems in the last two decades found that this implementation led to increased clerical workload of clinicians, leading to increased burnout and job dissatisfaction. Additionally, overuse and misuse of templates led to longer but less accurate and less useful clinical notes.

Several primary care organizations in our region added a new position to address these issues like medical scribes, who perform real-time electronic health record documentation, in the exam room (or video call) with the clinician.

A survey of the published literature on medical scribes have shown increased efficiency, clinician productivity and provider experience, while patient experience with scribes is mixed.

Shasta Community Health Center (SCHC) reports that the increased efficiency of scribes leads clinicians to finish their work earlier at the end of the day, with administrative tasks completed which allows them to go home to their families on time. Since first implementing a scribe program over a decade ago, SCHC has refined their model to increase the quality of documentation in the medical record and to drive quality performance in the Primary Care Providers Quality Incentive Program (PCP QIP) measures.

1. Training: SCHC has developed a training curriculum to train promising candidates in medical language, standards of documentation, etc., which is now being adapted to be offered in community college courses.
2. Continuity: a clinician-scribe diad often develops short cuts and non-verbal communication methods to work rapidly as a team to support the patient. This may include sending instant messages to the clinician during the visit, such as ordering preventive screenings.
3. Quality focus: Assigning the scribe responsibility for measures amenable to their intervention, like ordering labs that are due or scheduling well child visits.
4. Incentives: A pilot showed that a small incentive for scribes linked to a single measure worked well, but Shasta CHC is cautious about unintended negative consequences, such as removing intrinsic motivation for improving quality.

This “tip from the field,” was collected by Partnership HealthPlan of California’s (PHC’s) Medical Directors, Dr. Robert Moore and Dr. Jeff Ribordy, at our first trip to Redding in many months. We will be working our way out to visit other counties and providers in the months to come.

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“Ancient medicine had once had a name for this something present in the living body but missing from the corpse. Spiritus was the breath, the regular, rhythmic breathing of the live body that is so shockingly absent from the dead.”

-Dr. Victoria Sweet, Author and Medical Historian

October is National Lung Health Month, sponsored by the American Lung Association. Why October? Possibly to coincide with the prime season for influenza vaccination.
Here are few ways (besides flu vaccination) primary care clinicians can support our patient’s lungs.

1. Asthma Treatment: Use combination formoterol-corticosteroid inhalers (such as Symbicort or Dulera) instead of albuterol or levalbuterol for short-acting relief of mild to moderate asthma. International and national guidelines and a strong evidence base support this approach.
2. Asthma Misdiagnosis: Be on the lookout for the 10% of patients with a diagnosis of asthma who have other conditions. Order spirometry or pulmonary function tests if the diagnosis is unclear, especially if not responding as expected to usual asthma treatment.
3. COVID: About 20% of patients hospitalized with COVID develop long-term lung damage, causing dyspnea and decreased exercise tolerance. Prevent permanent lung damage caused by COVID by encouraging all eligible patients to be vaccinated, especially pregnant women and teens. Consider use of monoclonal antibodies to treat early COVID infection to prevent it from becoming severe.
4. COPD: Ensure that patients discharged from emergency departments and hospitals for COPD exacerbations receive prescriptions for tapering oral corticosteroids and combination bronchodilators (long acting beta agonists and long acting muscarinic agonists).
5. Action Plans: Ensure that patients with COPD and Asthma have action plans to allow them to self-manage exacerbations.
6. Pneumococcal Vaccination: When giving annual influenza vaccine, co-administer pneumococcal vaccine for those who have not been previously vaccinated. Who are eligible? Adults over age 65, those with immuno-compromising conditions, chronic CSF leak, and those with cochlear implants.
7. Smoking cessation: ask about smoking status, provide counselling to those using tobacco products, and prescribe smoking cessation medications when appropriate.

Although these are core primary care activities, we sometimes are distracted by other clinical issues that come up in our visits. Please pass this along to your clinicians to remind them to think about more than just flu vaccine, this month.