Just Read: #WhatADoctorLooksLike – Implicit Bias in Academic Medicine – via JAMA

Where I went to medical school (University of Arizona College of Medicine), we had the typical “wall of fame” of all the previous graduating classes prominently mounted, covering the history of the school’s first class from 1967 to the present.

It was amusing to note that as you walked along the wall that the number of women in each class steadily increased, to the year after mine, when for the first time there were more women than men in incoming class.

Except that in retrospect, it wasn’t really funny.

The other thing I noticed was that the Nursing School building, erected a few years after the medical school building next to it, didn’t seem to have very many men’s rooms…

The wall showed another thing, that there were no LGBTQ human beings enrolled in this school. Except that there were. However, all the signs and signals in our curriculum and the behavior of our faculty conspired to keep this just an “allegation.”

And so…we can now measure the impact.

This issue of JAMA Internal Medicine includes three studies looking at sex and racial bias in academic medicine, and as it has been shown in many (many) other studies, the profession tends to mirror the society around it. No more, no less. This is a link to the editorial accompanying the studies, written by Molly Cooke, MD (@mollymcooke) at the University of California, San Francisco.

Cooke M, AJM A, RA G, E M, M N-S. Implicit Bias in Academic Medicine. JAMA Intern Med [Internet]. 2017 Mar 6 [cited 2017 Mar 15]; Available from: http://archinte.jamanetwork.com/article.aspx?doi=10.1001/jamainternmed.2016.9643

This wouldn’t be a problem (actually, it would always be a problem, but maybe not as high-stakes) if our society’s health didn’t depend on physicians who understand the life experience of the communities they serve (It does).

Another bank of studies show clearly that people learn better from people who resemble their life experience more closely. It’s just science, not an opinion. And so, when people are selected to present at grand rounds:

To the extent that those role models do not mirror the sex and racial composition of the trainee pool, we are delivering the implicit but powerful message that these leadership roles and examples of excellence are for someone else. Women, blacks, Asians, and Latinos need not apply.

I have previously posted on the environment around LGBTQ trainees, also studied, and also with outcomes that parallel these.

Just Read: Sexual and Gender Minority Identity Disclosure: “In the Closet” in Medical School

This gendered quote from a general practitioner in 1966 (the ancestors of my medical specialty, family medicine) is relevant here:

S/He does more than treat them when they are ill; he is the objective witness of their lives. They seldom refer to him as a witness…that is why I chose the rather humble word clerk: the clerk of their records.

If this is what doctors do (it is), then we have an interest in examining our biases and modulating them. And there’s science to show that can be done, too. Isn’t this century grand 🙂 .

One more from Shania Twain, because it’s my RSS feed.

She’s a geologist, a romance novelist
She is a mother of three
She is a soldier, she is a wife
She is a surgeon, she’ll save your life
She’s, not, just a pretty face
She’s, got, everything it takes

I’ll post again on the actual studies referenced.

Just Read: Marriage equality = 134,000 less suicide attempts in adolescents

We estimated that, each year, same-sex marriage policies would be associated with more than 134 000 fewer adolescents attempting suicide. These results reflect an important reduction in adolescent emotional distress and risk of mortality from suicide.

Equality does equal health.

I did read the paper and reviewed the analysis – these numbers are possible because 29% of sexual minority adolescents (lesbian, gay, bisexual) report attempting suicide in the last 12 months compared to 6% in the general population.

This is the impact modeled from just one policy change (that has since been applied across the United States) for a subset of the LGBTQ population.

Imagine if every State in the United States was as supportive of equality as Washington, DC is.

Diversity allows the human species to survive 🙂 .

SCOTUS  26251
More love. Less suicide. 2013.06.26 – SCOTUS 26251 (View on Flickr.com)

Raifman J, Moscoe E, Austin SB, McConnell M. Difference-in-Differences Analysis of the Association Between State Same-Sex Marriage Policies and Adolescent Suicide Attempts. JAMA Pediatr [Internet]. [cited 2017 Feb 21]

Just Read: Listening to Physiology instead of a Wearable for Weight Loss

Comparison Wearable induced vs Physiologic  induced weight loss 161003
Comparison Wearable induced vs Physiologic induced weight loss 161003 (View on Flickr.com)

After reading the study about the impact of (a certain type of) wearable devices on weight loss (See: Just Read: Study – Wearables don’t improve weight loss – can you outrun a bad diet? ) – answer, not much – I also read this study at the same time that focused on exercise and diet in a very different way, and had much different outcomes.

In Mark S, Toit S Du, Noakes TD, et al. A successful lifestyle intervention model replicated in diverse clinical settings. South African Med. J. 2016;106(8):763. Available at: http://www.samj.org.za/index.php/samj/article/view/10136 [Accessed October 2, 2016], a few conventional and unconventional things were tried in a group of willing subjects interested in weight loss:

  1. Behavioral intervention – variable timeframe (conventional)
  2. Caloric restriction until the reaching of weight goal, including fat, sugar, refined cardohydrate restriction (conventional)
  3. NO moderate or vigorous exercise until weight goal achieved (UNconventional)
  4. HIGH fat diet after weight goal achieved (UNconventional>

Foods consumed on the maintenance diet included beef, poultry, fish, eggs, oils, moderate amounts of hard cheeses, and small amounts of nuts, nut butters, seeds and berries.

I can’t determine the actual time to follow-up for the groups, but it looks to be around 2 years, which is the same time as the group in the wearables study. Therefore, I charted the two groups (S1 and S2, for “site 1” and “site 2” in rural practices in British Columbia, Canada) along side the results of the subjects in the wearable study, above (click to enlarge).

Lots of caveats

  • The interventions were different, however both interventions involved manipulation of diet. For the wearables subjects, it was caloric restriction and low-fat (high carbohydrate). For the Canadian subjects it was caloric restriction initially, and then transition to high fat (low carbohydrate).
  • The populations are different, and the starting weights of the subjects makes it hard to compare % weight loss, although to my eyes, they started out pretty close in weight
  • Neither study controlled for diet, meaning there was no comparison group of people who didn’t have their diet manipulated

This is also the part where conflict of interest disclosures are important.

For the wearables article:

Conflict of Interest Disclosures: Dr Jakicic reported receiving an honorarium for serving on the Scientific Advisory Board for Weight Watchers International; serving as principal investigator on a grant to examine the validity of activity monitors awarded to the University of Pittsburgh by Jawbone Inc; and serving as a co-investigator on grants awarded to the University of Pittsburgh by HumanScale, Weight Watchers International, and Ethicon/Covidien. Dr Rogers reported serving as principal investigator on a grant awarded to the University of Pittsburgh by Weight Watchers International. Dr Marcus reported receiving an honorarium for serving on the Scientific Advisory Board for Weight Watchers International. No other disclosures were reported.

For the lifestyle intervention article:

Conflicts of interest. SDT, KN, DC, MM, SVDS and JF have no conflicts of interest to declare. SM is the founder of a sole proprietorship, Approach Analytics, providing analytical support to clinical and public health initiatives. JW is on the Scientic Advisory Board for Atkins Nutritionals Inc. and has accepted honoraria and travel expenses to attend meetings. TN is the author of the books Lore of Running and Waterlogged and co-author of e Real Meal Revolution, Raising Superheroes and Challenging Beliefs. All royalties from the sales of e Real Meal Revolution and Raising Superheroes and related activities are donated to the Noakes Foundation, of which he is the chairman and which funds research on insulin resistance, diabetes and nutrition as directed by its Board of Directors. Money from the sale of other books is donated to the Tim and Marilyn Noakes Sports Science Research Trust, which funds the salary of a senior researcher at the University of Cape Town, South Africa. The research focuses on the study of skeletal muscle in African mammals with some overlap to the study of type 2 diabetes in carnivorous mammals and of the e ects of (scavenged) sugar consumption on free- living (wild) baboons.

The unconventionality of the the intervention is mentioned in the article as something that was hard for others to accept:

Despite the rigour of our quality improvement process, our efforts to communicate the merits of this intervention to health system administrators met with a frustrating lack of uptake. This is not surprising, given that the research literature has many competing ‘solutions’ for the epidemics of obesity and diabetes,[15] many of which are difficult to falsify.[16]

From my understanding of the culture of medicine, something like this written in a scholarly article is usually a vast understatement.

The next several months/years are going to be exciting in this part of health, now that we have a better understanding of physiology and newer tools to (potentially) change our environment and our behavior (maybe).

Just Read: Study – Wearables don’t improve weight loss – can you outrun a bad diet?

I stopped wearing a fitness tracker because it DEmotivated me, by reminding me of the times I was not meeting my activity goals

This is what an attendee said at the recent convening on Making Health Care Measurement Patient-Centered (a proxy for respecting people in health care).

This study published in JAMA a few weeks ago (September, 2016), produced unexpected (and curious) results.

Overweight and obese younger people randomized to receive wearable devices as part of a weight loss program gained back more weight than users who did not receive wearables, after an initial 6 month weight loss.

Both sets of subjects did not have significantly different rates/intensity of physical activity over the 2 year study, and their dietary intake was not statistically significant from each other (calories taken in slightly less for the wearables group at the end). Specifically, the group with the wearable did not exercise more than the group without the wearables.

I was of course curious and decided to look more closely at the data. I produced some charts below.

Here are the things I noticed

  • Subjects were randomized at the very beginning of the study, not at the 6 month mark, when the wearables were initiated. Did they know which group they were in at the beginning and did this shape their behavior?
  • I ask the question above, because the one thing I noticed in charting the data is that the group with the wearables (EWLI – stands for “Enhanced Weight Loss Intervention”), experienced a visible plunge in MVPA: “Nonsupervised moderate-to-vigorous physical activity” even before they got the wearables, that continued well past the time they had the wearables. Overall, though, across the 24 months, there was not found to be a significant difference in physical activity.
  • The subjects were placed on what are essentially high carbohydrate diets with caloric restriction, which remained restricted throughout the 24 months.

Outrunning a bad diet?

I was recently introduced to the work of Tim Noakes (@ProfTimNoakes) (about 5 years behind the rest of the world, but maybe 1-2 years ahead of part of the world) and decided to look more closely at other factors.

Focusing on the diet of the subjects, here’s what it said in the study details (supplemental materials)

All subjects will be prescribed an energy restricted dietary intervention that we have shown to effectively reduce body weight by 8-10% within the initial 6 months of treatment. This will include reducing energy intake to 1200 to 1800 kcal/d based on initial body weight (<200 pounds = 1200 kcal/d; 200 to 250 pounds = 1500 kcal/d; >250 pounds = 1800 kcal/d). Data from our research studies [14, 15] and the National Weight Control Registry [26] indicated that macronutrient composition in the most successful participants consists of 20-30% dietary fat intake, 50-55% carbohydrate intake, and 20-25% protein intake. Therefore, a similar dietary composition will be recommended in this study. However, we do recognize that low carbohydrate/high protein diets are currently popular, have demonstrated some initial efficacy, and some participants may gravitate towards this macronutrient composition, and this will be acceptable provided that total energy intake is within the prescribed range. To facilitate the adoption of the dietary recommendations, individuals will be provided with meal plans (see Appendix B), that will allow them to plan for modifications in their daily and weekly meal plans, and a calorie counter book.

So they were permitted to lower their carbohydrate intake as long as they maintained the same amount of calorie restriction. As a group they did not do this, though. They stuck to their high carbohydrate diets over the long run.

From this paper:

Malhotra A, Noakes T, Phinney S. It is time to bust the myth of physical inactivity and obesity: you cannot outrun a bad diet. Br. J. Sports Med. 2015;49(15):967–8.

Regular physical activity reduces the risk of developing cardiovascular disease, type 2 diabetes, dementia and some cancers by at least 30%. However, physical activity does not promote weight loss.

And there was the September 12, 2016 cover story of Time Magazine:

For all its merits, however, exercise is not an effective way to lose weight, research has shown. In a cruel twist, many people actually gain weight after they start exercising, whether from new muscle mass or a fired up appetite.

This study is about wearables, not exercise, because both groups of people exercised about the same over time.

However, because both groups were on a high-carbohydrate diet throughout the intervention, it’s possible that even if the wearables “worked” (they exercised more), that the results would be the same.

Still pro exercise…

I, like Bob Sallis, MD, who is quoted in the Time magazine article, support exercise for the numerous health benefits it offers – just look up any of my presentations on the topic, oh like this one:

Presentation/Photos: Quantified Community, Population Sensors at WalkHackNight, Transportation Techies

What if listening to a wearable device isn’t as effective as listening to your body? I’m going to post on another approach tomorrow….

Charts from Effect of Wearable Technology on Weight Loss
Charts from “Effect of Wearable Technology Combined With a Lifestyle Intervention on Long-term Weight Loss. JAMA. 2016;316(11):1161.” (View on Flickr.com)

Just Read: Transforming the Health Care Response to Intimate Partner Violence

Co-authored by one of my favorite physician colleagues, Brigid McCaw, MD (@BrigidMcCaw) whose work is an example of what happens when physicians lead.

Clinicians use tools embedded in the electronic health record to facilitate screening, intervention, documentation, and referrals. Electronic health record questionnaires and progress note tem- plates include prompts for further inquiry (eg, “Are you currently in a relationship where you feel threatened by your partner?”), assessment, and response. Diagnostic documentation related to intimate partner violence is confidential (eg, not visible on after-visit summaries, billing statements, or online patient portals). Microsites linked to the electronic health record offer practice rec- ommendations for clinicians and easy-to-print resources on safety planning and advocacy organizations for patients. Electronic health record functionality also provides automated, deidentified diagnostic databases that allow for population description and research to identify predictors and outcomes associated with intimate partner violence exposure.

You can read more about Brigid in this blog post I wrote previously: Giving the voiceless a voice using social media, family violence prevention, and a walk with Brigid McCaw, MD.

I follow Brigid’s work because there are lessons in what she does for all efforts to improve human health. She makes wicked problems less wicked. She is one of a group of physicians I know who don’t see a large health system as a hurdle. For them it’s the opposite – an unlimited opportunity to make a lot of people’s lives better. Take a look, you’ll see it, too 🙂 .

Just Read: Transgender Person Care Moves into the Mainstream | JAMA

As the title says, and another significant milestone for the medical community.

For the record, New England Journal of Medicine also ignited the future on this topic, in 2013: Now Reading: Care of Transsexual Persons — NEJM, in the era of inclusion

The reasoning used by all groups (in deciding to have surgery) reflected a desire not just to live, but also to live authentically.

“[T]his is not rocket science; these are human beings,” said (Jamison) Green (PhD, President of WPATH). “[T]he endo- crine differences that they might have, [or] if they’ve had genital reconstruction, are not insurmountable challenges. [It’s] a varia- tion: you just deal with it in a logical way.”

My one critique, if I can give it (I can, it’s my blog) is the alternating use of appropriate and inappropriate terminology. The author refers to genital surgery as “gender reassignment” which is INcorrect, alternating with “gender affifmration” which is correct. No one has their gender reassigned by surgery. Their gender is their gender.

Part of being a journalist in this space is to double check style rules, so as not to perpetuate the bias you are trying to eliminate. There’s a handy style guide available, that’s quick and easy to read:GLAAD Media Reference Guide – Transgender Issues | GLAAD

And, my role here is to thank JAMA and author Laura Buchholz for creating something that the medical profession can look at and realize that it really is the 21st Century for the rest of the world, including in health care. Much appreciated.