 Okay, my friends, so I am going to get today's talk started and it is my great pleasure and I want to thank everybody for joining us. I've been looking forward to this lecture on a personal level for a long time, but it's my pleasure to introduce today's speaker, Dr. Stephen, aka Steve Martin, who is an associate professor of family and family medicine and community health at the University of Massachusetts Medical School, where he is residency faculty and co-directs the Rural Health Scholars Program. In 2017, he co-directs the UMass Project ECHO for opioid use disorder. He is board certified in family medicine and addiction medicine. Steve began his medical career as a national health service scholar in a Rural Community Health Center and Federal Prison Center. He has worked for the past 10 years at the Bari Family Health Center in Rural Central Massachusetts, where he's co-director of an office-based addiction treatment program. Steve's clinical and research interests are broad and include primary care, oral health, complex care, addiction medicine, chronic pain, diagnostic error, and health disparity. He is the lead author on publications in the British Medical Journal, JAMA Lancet, Annals of Internal Medicine, and the American Journal of Public Health. And one of my favorite articles that Steve wrote with the woman named Christine Sinski, which I think is terrific, and I'll put it in the chat because I want everybody to read it as gold. The map is not the territory. Medical records and 21st century practice. And when we were coming up with this topics for the lecture series, obviously there are many... Oh, there's Christine Sinski. Welcome. Hi, Chris. Good to have you. Okay. When we were coming up with ideas for the lecture series and Steve floated this idea of the adult checkup and, you know, just the periodic health exam, I thought it was an absolutely perfect topic and it's just so funny because this week I had another patient that came in, you know, as a primary care physician and said, oh, I'm supposed to be here for my, you know, my yearly health physical. So I knew what to say, but now I'm going to get the whole back. Give my friend and colleague Steve Martin the floor and we'll look forward to hearing his talk today. Thank you. Thank you so much, Mindy, and everyone, Elena, for your help and for this invitation and it's a gift to be with you. I wish it were in person and someday it will. But thank you so much for making this possible. I have also appreciated all the past lectures. I've been able to watch a good number of them and the bar is high, which I recognize. So we will see, you know, where we can go with that. Maybe we should stop while I'm ahead. But if we're not going to do that, I just want to emphasize that I'm only speaking for myself and these are my views and not the views of any organization I'm affiliated with. And as sort of a warning, I'm not trying to offend anyone with this talk. There's no ad hominem element to the talk. But it is a contrarian point of view that is shared by others. But it is not sort of a mainstream view as yet. And hope that intrigues you and that you'll stay on board and please really appreciate your impressions and feedback. So I'm just going to come back over here. As I mentioned, my disclosure, I'm a medical director for a company that provides telehealth for substance use disorders. And these are my views. So I did have some alternative titles for the talk. This one I floated, there was a question, a rhetorical question, why do health systems proactively call patients to schedule colorectal cancer screening, but they don't call patients who are discharged from the ER after an opioid overdose. That was sort of a long title. So I didn't use that one. Another one though was ounces of prevention or breaking the back of American primary care. And that is really embedded in the talk here. And I hope to persuade you that we don't have much time to waste. If we don't rethink the way we provide preventive care in the country, and by extension, how we provide primary care. So it's important to note, I think it's always important to start with a historical figure in this case, Jesus Christ, who has similar sentiments over two millennia ago in the original Greek heresy of my friend, Professor Kirby, Jesus answered them that it is not the healthy you need a doctor, but the sick. And let's proceed from there. This is actually in three of the four Gospels, the same proverb. A few instructive quotations, if it's okay, and please put thumbs up if you want to the chat or otherwise, if you feel similarly, from 2016 primary care is like this shed at the bottom of my garden. I put so much stuff in it over the years. I now can't find the space inside to reorganize it. The only approach is to put another shed alongside it, and take out the stuff that doesn't need to be in the first shed anymore. So I don't know if that speaks to anyone about the work we do in primary care. Paul frame, who is very instrumental in the history I'll be describing is quoted as saying an ounce of prevention is a ton of work. And Proust was well ahead of all of us for each illness that doctors cure in medicine. They provoke 10 and healthy people by inoculating them with a virus a thousand times more powerful than any microbe. The idea that one is ill. We're going to begin on the left side in a chronology that that's going to take us up to the present. This is far as I can tell from great research done by others is one of the first mentions in the English literature about a call for action regarding prevention. And that prevention is is much more favorable than fighting a battle against acute disease. This is by Horace DeVell. Sorry, if Dr. DeVell not pronouncing it correctly. But in 1861, he was actually a life insurance adjuster in London. And that had in thinking that as we evaluate people for life insurance, we should evaluate everyone in terms of their risks and potential for a longer shorter life. Just want to remind everyone that neither Dr. DeVell nor a lot of any other physicians really have much to work with. We were bleeding people. We were lancing them. We were putting mercury in them. We were giving them cathartics. There wasn't a lot of preventive elements to healthcare that really had evidence behind them. But nonetheless, Dr. Bell proceeded to say that there should be a custom, a system of periodical examination, to which all persons should submit themselves and to which they should submit their children. So he was he didn't start slow. He went bigger. He went home and continued. There's certainly no one could conduct this examination for the usual consultant fee. But nonetheless, the poor should have access to the same prevention, and that every hospital and dispensary should provide such examinations and giving the necessary advice, returning to the duties of life. Well, to return to this, the important fact that Dr. DeBell was a life insurance adjuster. He also wrote in 1853, two years later, that the directors of a London life insurance company named withheld, have assigned him to create forms so that when people outside of London want to apply for life insurance, they will have absolutely well with copy of the slides, they will, they will have they have to be standardized. And what if you were in, you know, what if you're in Manchester, and you were evaluated by an adjuster who's more lenient than someone in London, well, that would be a bad, you know, customer for the life insurance company. So he had the minute minute detail, because of this reason. And this is I know, it's very small, and it'll be great when you can see it on your own. But we're asking questions like, Have you been rejected by other life insurers? Do you have a disease of the brain? Do you have a cancer or tumor and what kind? And how is your site? Do you have a fistula or stricture? Do you rare trust a few of our hernia? So these were questions that Dr. DeBell had developed, so that his insurance company would not lose on too many claims. On the physical exam, do you as they're spitting of blood? Is there a pulse that's weak or forcible? Is there an inspiration that seems diseased and on we go? So this is the formal bureaucratic in entrance form for life insurance is the beginning of our quest. It continues not many years later in the Civil War in the US, where examinations of recruits are provided to have men at the time, pass certain tests and inspections to walk briskly in a circuit around the room, increasing his speed until he has made three or four rounds. And then he will be placed in the position of a shoulder soldier under arms to make sure that he can hold a rifle. So inspections are in physical exams are becoming more common place, certainly with the military, and that continues afterwards. But it's really, and this is the form actually, I'm sorry for that World War Two. Well, I'm sorry for the Civil War. Preparation have you had gonorrhea and when have you had a sore of any kind on your penis and when any spawning about your testicles there's a lot of perineal questions in this exam. And have you had to give up any occupation on account of your health or habits. So then we have the exam on the right and proceed to advance. It was actually in Philadelphia where the president of the AMA and Oculus or ophthalmologist at the time, set the American standard for the imprimatur of institutional medicine upon the complete physical exam and the usual parallels obtained. The Rangeman has his annual roundup merchant yearly count of stocks, balancing of books, machinist his engine. And so just like these examples, then there must be a way to examine human beings and also provide prevention. He begins out with with these statement that is going to be recurrent for us to the present day. True medicine is to stop the cause of symptoms and prevent the symptoms forever arising. That would be amazing. That would be pretty amazing if we could do that. I have yet to really understand if we can do that in scale and medicine. It's not really our strong suit. We don't really know how to prevent disease and at some point someone is going to get a disease or some condition that will bring them to an end. And so this prevention idea from the very start, it seems to me, is not evidence based. And not only is it not evidence based, but it was already built on the back of the general practitioner, not just the general practitioner, but the poor plundered general practitioner who has given up his sick, his patients to specialists. And they've robbed him, he has left a hardly a soldier or patient. And the function of the family physician is basically referring to others. And it is really the last straw that unfortunately ethics, given the McLean ethics theme, ethics will not permit these others to divide their fees with him. It is so sad. That AMA address was informed the medical inspection of immigrants that happened here in Ellis Island, looking for Tacoma. And the medical inspection of immigrants continues to the present day. It is essentially an Exclusion Act, Exclusivatory Act, and exclusively directed so that people will not be on the public wheel, should they obtain citizenship. In World War II, we start to see this scientification I'll use of the medical exam. So here we have not only the obtaining of data like height and weight. But we have the beginnings of scientific testing, in this case, the Wasserman test for syphilis. And I had a chance to write about this test and passing with Jeremy Green and Scott Podolsky before. And it was so illuminating and continues to be because please help me understand which is a positive and which is a negative Wasserman test. And it actually led to difficulty with recruitment because so many of the men were thought to be positive for syphilis. So false positive testing is not new to our age, but it certainly affected World War I examinations. The history form then was offered by the AMA in Haven Emerson in a 1923 JAMA paper that's been cited ever since. This history form actually, I was looking at this with my wife Ruth a couple nights ago. Sorry it's so small, but again, in person, you'll be able to see our favorite question is question 13. How frequently do you use candy? Which is not so infrequent, I think on my part. But other really interesting questions, how are your sleeping conditions? How often do you eat? What are your home conditions like? Do you support yourself? Do you often consult your dentists? Have you been protected against smallpox, typhoid, diphtheria or other diseases by vaccination and when these are not unfamiliar questions to us in the modern age? And especially how much do you drink daily of water, milk, tea, coffee, soft drinks or alcoholic drinks? Also familiar question. And then the physical exam continues with an inspection of the urine and feces, the specific gravity and sugar elements of the urine, other objective data, and whether the weight is theoretically normal for age and height. I will return to this. And teeth, thumbs, tongue, nonsoles, pharynx, all of it. The whole smear is available to the complete physical exam in 1923 with the imprimatur of the AMA. Medical societies, municipalities and industry pick up on this momentum. And in the Massachusetts Department of Public Health on the left, warning people of dangerous signals of cancer. And this is why they should see a doctor at once. So not really a complete, and it's to the, what can I say, to completely accurately a screening exam. But the idea that prevention could happen or secondary or tertiary prevention could happen by way of your physician in 1928. Or the menace of metal age could be met in New York, which is pretty cool. I have to look forward to that. If I just have a health examination on the right. Another one here also from New York that father Syracuse wants you to have a health examination by your physician every year. And again, this ad, we will return to this later in the talk. But how's your health and a much of this work was done through the joint efforts between cities, municipalities, states, medical care, regarding public health, regarding tuberculosis. So this is from the New Jersey Tuberculosis League, and which really helped build the framework for people to begin to trust and not be wary of time at the medical office. In industry, when examined, these are comparisons of 1000 industrial and commercial employees. My favorite is in the red circle. In Detroit, this this that is 0% chance of a perfect exam. No physical impairment found no advice for correction of living habits needed. But there is a 1% chance in New York. So those people are pretty much on the perfect side. But lo and behold, there's a lot of morbidity in the world. We've spoken recently of with the current pandemic of what the country is facing in the 1920s after the pandemic of influenza. At the end of the 20s, we were already starting to see non infectious disease rise to the four. In this case, I'm sorry, it's a little dark, but the US Census is finding influenza and auto fiend, basically tying for for first place while typhoid is well behind. But angina pectoris is moving quite up there looking like a velociraptor. And then this is the one I think, if we were to look at a trope or a touchstone for this work. This picture says 1000 words. Here we have a gentleman skating in a very formal outfit and trying to avoid cancer, kidney trouble, arterioscarosis, diabetes, heart disease. And medical scientist with his, I'm not sure how to describe the service tag on his right neck says that beware the thin ice you're heavy, implying maybe duly that the gentleman weighs more than he should. We'll come back to that. Or that, you know, risk is out there and the medical scientist is there to, to alleviate it or mitigate it. And lastly, in the same series from the Life Extension Institute, 1931, we have a medical reactionary, which I'm sure I'll be tagged with later today. But talking with a scientist and again, this sort of development of a professional acumen and objectivity, where we do find disabilities, but most of them can be remedied if taken in time. And again, this sort of bill of goods to my mind sold that finding things is the same thing as making them better, which lo and behold, will be a constant theme up until February 16th at 123 Eastern time. World War II continues the theme of regular checkups to keep him on the job. And making men as fit as our machines. Again, this machine connection is not trivial. It's a tune up. It's a maintenance check. It's a you're looking under the hood. These themes continue throughout the past century into the present day. And then there becomes this sort of 1950s. This is where I'll be grateful for help for him. Others on the on the call and other colleagues in the world. But something goes differently. Which Paul Starr has captured brilliantly in his in his work. But there begins to be this restlessness, even disillusion in the early 50s as to whether this periodic checkup really had an impact. And at the same time, there was also a fierce development of almost a rivalry between the health department and medicine. And who would take on what role post World War II? And why? Who would have capital who would have less of it? Who would have the public's trust? And who would sort of have the spoils of healthcare? To this end, the the first in color drawing that I've I've seen here, this is from 1951. I put at the bottom that this was made possible by Grant from Wyeth. So the color that is. And I love clinical epidemiology. And I've read this 17 times. And I, I'm still not quite getting it. But basically, there's a test, which is the calendar. There are red and green people. And the green people that are round get through and those are true positives. Red people that get through our false positives. And then square people do not have the disease, but some green people are there even though they don't have the disease. I think that's quite it. But we have a better explanation a year, showing the red and green figures. So first of all, we had a test. Some tests happen magically somewhere. Often in public health, often a tuberculin test, perhaps. And then people need to be sorted out and here they're sorted out by a doctor behind a desk. And then the part that is so like curious and narrative here is, who's this that in the in the caption here, the assistance of the public health nurse is obvious. As she pulls back someone with disease who is trying to escape this line. This is there's so much in this picture. First of all, it's beautifully drawn. And we see the people who are green and squares, the false positives leaping off to the right. As they're sad. And I don't know, dejected true positives are going into the prescription and therapeutic hallway of doom, perhaps. It isn't until 1961 that there are actually some empiric trials of what the hell is going on. And this is one of my favorite phrases in all the medical literature. We were astonished. You don't want to see the word astonished in your medical literature usually, we were astonished to observe the prevalence of false positive results, remarkably high for all routine tests and procedures. And indeed, sigmoidoscopy has no false positives. But everything else in the chart shaded in yellow starts at 43% false positive for an EKG up to 93% false positive for urine white blood cells. That is a lot of false positives. But the cool thing is, when you were a doctor, then in the last sense, you could disregard or judge to be non contributory over 50% of these abnormal findings, which is what my malpractice lawyers tell me all the time just just disregard or don't worry about it, Steve, it surely won't be a problem. I'm not really sure how how those are chosen by these physicians. But it makes life a lot easier when you can just do that. One of the most curious examples now here is the multi phase screening test where this is like the center or emblematic of this public health and medicine tension that we all have aren't fans of I would say myself. Who does the testing? And this is the this is in JAMA 1951. In the second paragraph, the individual should not go to the health center. And then we sent to the doctor, he should see the physician first and be referred for testing and AIDS. The primary responsibility of preventive service rests upon the practicing physician and not the health department. That is fascinating. Medicine had been practiced for several millennia. And now we have an organization response that says we're not just good at medicine and treatment and diagnosis, and we are actually good at preventing disease. And not only are we good at it, but it's our job. And this is to me, sort of how one could imagine John Snow at the at the cholera pump in London, sort of saying the doctor saying leave that hand on the pump. We're good. We will just treat a bunch of cholera for and not look upstream. So I think this is a decisive point in how the physical exam is used in the United States. There's a recognition that there aren't enough people to help provide care for a complete physical examination. And so we have to do these basically factory type kinds of tests, where you have your fat fold measured with your caliper that thing looks like a nightmare actually. There is a test for the Achilles tendon and whether it's hyporeflexive as a symbol as a sign of hypothyroidism. You have your eyes looked at you have something you're drinking some glucose solution to test your blood sugar. We have an entire drawing of what this map looks like. And what this all leads us to by the end of the 1960s, early 70s, is that the attitudes toward illness have now been modified. And 1921, the physician, a male on the left is very sad about acute illness. But in 1951, that a physician is happy. And again, chronic 1921, what are you going to do? But now we have the answers in 1951, we're just going to keep studying and solve this chronic problem. So this is, you know, one of the most sanguine approaches to public health I've ever seen. And now we enter the common era, or common, at least for someone as old as myself. So in 1975, Paul Freeman's co author Stephen Carlson, began a series of papers in journal family practice to examine the feasibility of screening procedures for 36 selected diseases. This comes in four parts, starting with respiratory cardiovascular and central nervous system. And I think the language here is interesting, it's to examine the feasibility. And that's, it's defined a little bit more in the paper, but feasibility is a very precise word. It's not efficacy, it's not scalability, but feasibility. And I remember seeing this diagram in medical school and in residency and being my head hurt, and still hurts a little bit. This is from the American College of Physicians 1981, where each of these tiny little boxes has four quadrants. And they refer to four different recommendations. The recommendations are from the Canadians, and then three other the American Cancer Society, then two other case studies and investigations such as Dr. Frames. And you can see here that all four seem to agree on stool for cold blood, after the age of 50. And on the medical or physician breast exam after the age of 50. But there's not a lot of consensus elsewhere in this document. And the ACP sort of left to practitioner to sort of like, I don't know, I guess I'll do X. And to individualized care, which is makes sense in some ways, but screening usually isn't completely individualized or in this case, you know, as there's such a lack of consensus, it's really hard to know what to do. This was resolved to an extent in 1989, when the United States, United States Preventive Services Task Force released its first report in book form, looking at 169 interventions. I remember this book, because it had these cool cards inside, that you could look at any age group and then know what that person needed, because I was scared out of my mind and residency, and medical school, and had no idea what to do and try to memorize these to no avail. But I just some of the language that was used in this first edition, I think, is illuminating. I know it's small and I apologize for that, but there, there is some serious, what can I say, roots of our work in the present day that are that have been that have been sunk into the ground here. One is the first one is that, you know, it's interesting to do a lot of tests, but really counseling is where it's at. Poor nutrition, physical and activity, smoking, alcohol, drug abuse, that's really where the money is for public health. So that's where we're going to put our focus. And we're going to have to know about risk factors because pretest probability makes a difference. And that's absolutely true for base rates. The third one is, I had to reread it again, but it continues to strike me. The third finding is that conventional clinical activities like diagnostic testing may be of less value to patients than activities once considered outside the traditional role of the clinician counseling in patient education. This suggests a new paradigm in defining the responsibilities of the primary care provider. That is a that's a major statement to make. Like, we're going to completely redefine your scope of practice and what we are expecting you to do and do effectively. I don't know that a lot of people sort of signed up for that, but that is the point of view of the USPSTF in 1989. So we've gone sort of full circle here. This is 1918, where diseases are unsuspected until it's too late. And Lord knows what the hell you do in 1918. If you suspected kidney or heart disease in either of these gentlemen. But it continues. Here's 2000, where we have CT scanners and church parking lots. Or 2007, where we have ultrasounds traveling around doing the same thing. And just to point fingers at myself, here's Boston Medical Center where I trained 2009. Pfizer is sponsoring the Boston Heart Party so that we can get our cholesterol and blood sugar checked. Wow, right? I mean, this is now getting into the ether in a way that we really haven't seen to date. Why would that be? Well, one thing is that there is now a public consensus to an extent and political consensus about third rails of prevention. And one of those third rails is mammograms. So there was a Senate vote in I believe in 1998 that was 99 or 100 to zero, not the kind of bipartisanship we see today that denounced a prevention recommendation that provided some thoughtful constraints on screening. Here it comes up again in 2009. But but what's going on here? Cancer Society disagrees. Women insistent on cancer screening poll find support. Well, last time I checked, polling was not really how we determine scientific evidence. But lo and behold, when you want to do something at scale, it is a political operation, and always will be breast cancer screening policy won't change you as officials say, new mammogram guidelines unlikely to curb policy coverage. Well, that got a lot of attention just as it had in 1998. And now we have what ends up being sadly, I think, is a process that has political elements to it that are inevitable, and that Rudolph Verkau spoke of over a century ago. You know, the political and medical are the same when it comes to a culture of health or illness. What do we see today? This is from this will look familiar, I think Dr. Welsh. But this is the American Cancer Society, supporting legislation to cover a liquid biopsy, or as they call, they call it again, a multi something multi cancer early detection screening, right? So this would look at your blood for DNA shards, and let you know all the different kinds of cancers that you have right now. And not let you know if you can do anything about it. But but we're going to do that because boy, people deserve it. And you know, Rachel, Rachel really deserves it. And you know what, we're going to show an African American gentleman here, because we're going to make the case that this is going to solve inequality. By giving people a blood test, and getting their cancer found early, we will have solved inequality. I kid you not, happy to share the links. This is despicable to me. I this is not going to solve anybody's inequality. And it's only going to siphon funding from social determinants that need it more. And I want to thank Dr. Welch and Dr. Kramer for writing a response, saying as much earlier this year. Just I could have asked for better, you know, metatum for what we're discussing today than this, I don't want this to be the case. But this is an active and very tension filled or not tension filled because of the political domains choice before Americans currently. Well, how are things going with this approach? How do we think about preventing things through primary care? Well, many of these recommended services reach half less than half of the US population. That's not great. How about 36 seconds is the average time of physicians spend speaking with adolescent patients about sexuality. I think I can get pretty much all I think birds be stored. We're good, right? That's about 30 36 seconds, I think. How about doctors who are under mounting pressures from insurance companies and others to prove they're giving quality care, they're just covering as much of the wellness recommendations that they can in the grand information dump. That's the new clinical preventive exam. That's the annual physical is now a grand information dump. And one patient compared it to Charlie Brown's teacher saying one, one, one, one, one. That's what she remembered of her annual visit. How about 10 million women who don't have a cervix being screened for cervical cancer? A great study from I believe Dartmouth and so much of this literature is from your group. And I just and the explanation reflects doctors habits and women's expectations. Just that's not good enough. I'm sorry, like my habits aren't good enough to screen you for a disease you can't get. How about the greatest public health achievement in the late 20th century reduction in adult smoking having almost nothing to do with clinical care and everything to do with tax and work play policy? How about public health being responsible for more than 25 years of the 30 plus year life expectancy increase in the 20th century? How about more recommendations than ever? And yet US life expectancy is decreasing. And my work focuses quite a bit on opioid use disorder. No more than 4% of primary care doctors have become trained, let alone treat opioid use disorder, which is an embarrassment to the field. But I think as we're seeing a natural prediction of time constraints in the field, even if there were interest. And I'd submit that primary care is broken, it's breaking further. We're less able to help people with more complex medical needs because we're getting less good at it. And we're contributing to rise and referrals has been well documented to other specialties and urgent care centers and ERs increasingly fragmenting care. This is to me, not correlative, but but there's a causal element here. I hope to show you in this way. So I love the work of James McCormick and colleagues, University of British Columbia. And this is one of those papers where you go to PubMed and say, are there similar articles like this? There are not similar articles like this, which is a shame. But here they looked at social screening or health promotion, no benefit, counseling for physical activity, insufficient evidence, fairly violent screening, people are more aware, but not improved outcomes. How about screening for obesity? No evidence improved outcomes. Nothing involving counseling works at scale. Because you know what? People are complicated. And 36 seconds of telling them to do something is fruitless. However, if we look at cancer screening itself, we still have numbers needed to screen basically of 1000 over generally over three to 10 years, meaning 1000 people screen will lead to one person having their life affected or extended positively. Next, how about those compared with other things we're supposed to do in primary care, like acute symptoms? Pretty good number to treat there, like we might help some people or long term symptomatic conditions, not a bad number to treat seven. How about cancer screening? Well, that's about 1000. Like we mentioned, and you might see four to 11 of those patients over a career of 30 years. How about social screening or health promotion? Those would be zeros. And again, kudos to the Canadian colleagues putting out this test that primary care providers should not abandon caring for people with symptomatic medical concerns. What a bizarre paradoxical Kafka situation we have, where we're focusing on prevention and people are sick and dying. This is to me sort of the Deus Ex Machina. This is the machine element that we saw in 1901 by George Gould. The ranchman has his annual roundup. Well, we have a car that needs maintenance. And if we just check these boxes, then the car will be better. Well, you know what? People are not like that. We have to be smarter than that. And I'm frightened, literally frightened that in 2022, we're now weighing screening for atrial fibrillation. Because I don't know if you saw that for all positive before from EKGs, that was a 46% false positive rate. And I don't know if you've had any issue diagnosing for atrial fibrillation or placing leads in the wrong position before ever have something like an ST wave elevation, but it's actually J point elevation. I this is going to be a freaking nightmare and lead is so much downstream effects. I mean, the crystal ball is very clear. Nonetheless, just need some more data. That's all. Eventually, I mean, I can't see how this won't be happening at some point after enough lobbying from interested parties. Well, how about this one? It's not just the USP STF that gets to inform me about my job. I have other interested parties in very prominent places who would like to tell and have told primary care some good things they could do. And you know what? They're not doing something so well. Let's look at these situations. Here we have the family health history. You know what? It's not meaningful. Such an effort should harmonize things. People aren't doing it very well. It's really come on people. So what we should do is we should have the National Committee of Quality Assurance National Quality Forum have a metric to a standard family history. I'm incredulous. Does anyone know how long it takes to think of family history? Is this going to go to the sort of mythical team that I have? We'll talk about later. How can you possibly recommend this where there's zero data to show that this is helpful for people's lives? I'll tell you what. Asking about somebody's aunt doesn't really affect somebody's life. I'm sorry. Or how about these numbers? These are not just numbers. These are red numbers. And red numbers that you know what? God, your numbers could change your life. Thank you, AMA. Thank you, American Heart Association, the Ad Council. And I didn't show the ones that show someone's chest being ripped open and their scar from their cabbage. It gets much more graphic. But why would now I get the opportunity to have the American College of Cardiology and American Heart Association tell me how I should perform? And interestingly, this was developed in collaboration with nobody in primary care. Because that's pretty much the level of respect we've garnered from our colleagues. So what do they want me to do? They I'm going to fly through these in a way. But believe me, they're worth looking over if you have some, you know, some fortitude to do so. These are performance measures. Here are some non pharmacologic interventions that I should be doing. And we've measured in the chart. There's strong evidence for all of these. There's strong evidence for all conversely among blacks, a US Southern style diet characterized by high intake of fried foods, processed meats, contributes to disproportion. You know what I'm going to do? I'm going to change an entire culture of Southern eating through primary care. That's what I can do. I can't imagine. I can't wait to go out tomorrow and just advise people to eat different meals than they have for generations. That is going to work. It's going to be so easy. Don't worry about it. How about some clinical recommendations about a heart healthy diet, like the dash diet, or losing weight or motivational motivational interviewing? Well, that'd be that'd be so awesome. Except interestingly, less than 1% of the US population has a dash diet. And the AHA's model of ideal cardiovascular health through the 15% of the US has six or seven of these elements. These recommendations are being written in some sort of alternate reality that does not comport with the human condition. And has the very mechanistic 15 point maintenance visit for my car as a model, that if I turn this screw, the alternator will be better. If I put oil in the engine will last longer. The cause and effect here is so bewildering to me. I can't believe this isn't writing. But you know what? It's these are, by the way, on the left, all of my things that I need to do to manage hypertension, which let's be clear, is not a disease. It is a risk factor. But I have team based care. I can detect and reverse non adherence. I like magic powers people that the AHA has just given me. But the thing is Tom Frieden, who some of his work, I certainly respect. We've done such a poor job in primary care that he's going to make blood pressure control one of only three quality metrics for primary care. Because we are basically a tool to be used for the interest of public health. Risk adjusted total cost of care. I'll be responsible for that. Patient satisfaction and blood pressure control. That's it. That is now primary care in 2022. But we know for a long time, this is from Jared Stamler, I believe from Chicago in 1998. You can't do that. You cannot change public health in the back of primary care medicine. Doesn't work. These I'll go on with the measures a little bit. And the last one just to be clear at the end of the day, I'm going to go on with the distribution healthcare provider. Me, I'm the one responsible to get systolic blood pressure below 130. Even though my own professional society doesn't agree with his guidance and the data from Sprint are so flimsy in their application. But I'm the one on the one right here, baby. Now taking a blood pressure that must be of course the easiest thing to do, including having someone sit for more than five minutes in a quiet room, which is just like my health center. That's just like we do everything this way. And you know what? We separate our measurements by one to two minutes. Usually we're always getting those multiple measurements. Of course, we're not doing this. We're taking care of sick people. Remember that part? It's ludicrous to think that this is scalable. But you know this part again is such a trope and it's such a canard. Here we have the H.A. telling me to solve people's social determinants of health. You know why? Because there are strong determinants of A.S.CVD risk internationally. Well, thank you. That's a shocker. I mean, of course they are. It's idiotic. How about the training of volunteers to make a database? How about integration of staff members? Like the social workers I have and case managers, registered dieticians. None of those people that I have to link them with community resources. We can make people better primary care. Thank you. Okay. Now, we're getting close to the end. I can't quite tell if anyone's still with me, but we'll continue on. Winston Churchill like. If you're going through hell, just keep going. So there are artifacts as to why the annual exam is as popular as it is. One is it has no co-payment. For the vast majority of commercial insurers and government insurers. So most people don't want to talk about the preventive health surprise for an entire visit. They want to talk about a problem they have. But I can't bill a problem visit for a problem they have without encumbering them with a co-payment. So let's just get very granular about this. Because I can either charge a problem-based visit or a problem-based visit and a preventive visit. And that patient is going to get a bill. And a high deductible health plan bill, that's going to be $200, $300. And the bloody facility charge in my health center is going to add another couple hundred on you. I make one check box and someone's got a $500 bill. But if I say it's a problem I don't do any quality metrics for prevention, then I look pretty bad there too. So that's a real, that's a great solution. How about insurance? I wanted to know people's hips or conference and lipids, height, weight, blood pressure to basically risk stratify them as we saw back in the day for life insurance. How about marketing and promotion? That never happens I'm sure for healthcare. But we do have a little bit of that even in the preventive realm in shame and guilt. Just in case you have a mammogram, you need more than your breasts examined. From a terrific paper by Steve Walsh in Lisa Schwartz, Barry Kramer, back in New England Journal 2012. Right, here's another one. How about this one? I've never written a story where so many of my sources cried during interviews where they shook with anger describing their interactions with doctors. Everything you know about obesity is wrong. That's what we've helped in gender in the American public. How about marketing? Here's SIGNA with TV doctors promoting the annual checkup. Here's whole logic. Just earlier this week buying its first full-time Super Bowl ad that looked like this. And you know what, this is not just any screening. This is the science of sure. You've got to be kidding me. Like you really have to be kidding me. But I saw that ad and my family and friends I think were a gas that I was so focused on it rather than the game. But here we are. Now let's say hypothetically a patient came to you with this list. Instead this patient needs help with housing. That gets a lot of stars. Schooling, employment, addiction support. These are actually things that I should be able to help with. Addiction support, medication support, primary care physician. Okay, you can do that. And then project hope subs. Oh, suboxone. Oh, that patient needs help with their opioid use disorder, I bet. Well, I bet I can do that. Why don't we try that? And I'll try to get them help with the other things. Well, they've brought in this list. What's going to be a nice patient centered approach? This is for an annual physical. So if you could please put away your list. I know they matter. That's what matters too, but I can really only talk about prevention. Sorry. So let's look at these top two things. I really only have 10 minutes. I'm going to have to charge you for a problem visit. And that might cost a bit, but, you know, that's, it's really about problems here. Or let's look at all these things you're concerned about. I'm going to be late for all my other patients. That's okay. We won't do any prevention either. And my patient satisfaction is going to plummet. But maybe that seems like the right patient center thing to do. This part should be the most, you know, captures in total. I hope the sort of apology I've been making throughout the talk. Primary prevention is now about a fifth of all primary care. I was very grateful actually to the CDC epidemiologist who helped me construct this table. They didn't begin asking this question until 1997, but we were able to extrapolate back to 1991. So this, this goes up and down depending on how old you are. They haven't yet done studies in 65 and older. Now that the malnit Medicaid wellness exam is covered. So that would be interesting to see if that number goes up from 16%. But this is the money slide. If you want to copy a slide, this is the tattoo. I'm going to be wearing a temporary tattoo and make temporary tattoos for colleagues who would like them. On the left, you have the Institute of Medicine report on primary care in 2013 looking at eight hour day. Add up all those blocks. You don't do any, there's no other work. Like you can't do any non-visit work. That's just seeing patients. Interesting. But that's a big zero at the top. Non-visit work, not accounted for. But actually on the right is my 26.9 hour day. And that's because to account for all the recommendations I have in chronic care. That's 10.6 hours of every clinical day. Prevention, 8.6 hours. Of every clinical day. And I'm very grateful. Dr. Maybe she'll update me as to this. But I put sort of four, which I think is sort of a low ball. Maybe hours per clinical day depending what you're doing. But in all fairness, this number did not include when it was evaluated documentation, order entry, inbox management, any of that wasn't included. This is impossible. I hope if we can start there, know that we can. This is an impossible ask. And so we have to go to our friends across the pond who, when things are impossible, develop sarcasm and parody that are really refreshing. So why the health presumption is that general practitioners have too much to do and too little time, but no one has asked obvious follow-up questions. Have they no evenings or weekends? In other words, they are lazy. They have a large, untapped reservoir of time. And here we have some ideas. Less leisure, more prevention. More work hours and squeeze in that shared decision-making. More bathroom efficiency for more shared decision-making. Those are ways that we could sort of shrink and expand, shrink the home and expand the work pie. And then also we're kind enough to include this tally of 100 general practitioners of which 56 are burned out and 27 are hanging by a threat. So keeping that in mind, was it Frederick Taylor or was it Health Affairs who mentioned that we could really shove in 24 appointments per day. That's 20 minutes of visit. They actually have to the 100th place, 19.01 minutes for the entire patient population per visit. They were kind enough to round up to 20. That's so awesome. Thank you. I'm really psyched about that. There are physician breaks and interruptions. So a conservative estimate of 28 slots a day. Well, that is very nice by researchers who don't practice primary care, which I'm getting a little sick of reading. And just to give an example of what my life looks like and that of my colleagues. This is a text from last week. Just a heads up. We only have one medical office assistant on the floor today. Nursing will be helping with rooming. I should mention that I'm not the only physician or practitioner at my clinic. There are about 10 of us working in any one time. So this is the one team member that we have to help us room patients, which I'm happy to do. But this last quotation that the coronavirus has been an extinction level event for primary care that are damn well be recognized quickly. And this is a great representation of what we're faced with. We cannot. I mean, we're coming back to Proust. We're coming back to, you know, our cough go. We cannot make up time. Time and attention are our superpowers. Along with knowledge and listening. And this is a great representation of what we're faced with. We cannot, I mean, we're coming back to Proust. And if we don't deploy time people will stay sick and get sicker and the well people won't get any more well or less. Well. Here's another one this always gets my attention. How common is that for all of us. Not because we want it to be but because the computer is an intention grabbing object. And we have really lost our connection with patients as a whole. Also, we're asked to do a shitload, a lot. I know this is being recorded, beat that out please, but we're asked to do a lot, like document and all the other things we talked about. This is Van Gogh's old man and sorrow on the threshold of eternity. You cannot look at your computer. You cannot do 10.7 hours of other things and still focus on this gentleman. It cannot be done. That's not what we're good at. We should be good at this gentleman before us. We should be good at the patient who texted me here saying, I can't do this anymore. I'm all alone. I'm surrounded by drugs. I need help. We should be able to respond to that. We should be able to respond to this gentleman who after 20 years coming in has now been sober. And maybe it takes 10 attempts to do that. Somebody needs to be two, three and seven. You never know which number you are. That's our job. We can't do that job now. We can't do this job. This job also requires time and coordination from New England Journal, showing the kind of effort it takes to coordinate care. It is not a joke to do this. And that time is currently being sucked up by other elements. These involve 40 different communications with other different clinicians. Our friends across the pond have been worried about this as we have, I think more vociferously than we have in the States. Again, coming back to time. So again, we have the impossible ask. And the editorial for the impossible ask really made me unsettled because it's by Sandra Galea, whom I very much respect as the Dean of the School of Public Health at Boston University where I trained. At an intuitive level, we all recognize we would rather not get a disease to begin with and receive treatment even in effective. Yeah, sure, that is true. And then the example of dementia here doesn't seem to make sense because we don't know anything to prevent dementia. We argue it is a problem, fundamentally resting the structure of our healthcare system oriented toward treatment and cure. That is right. A healthcare system should be oriented toward treatment and cure. That's what we've been doing for millennia. That's what you do when you take care of people who are sick. That's what you have to do. I don't understand why we even think prevention is part of that range of possibilities, but ARC does. And this past week there were both, the past couple of months there was both a webinar on gaps in clinical prevention of which there are many. And then gaps in care for multiple chronic conditions of which there are many. And you know what? You can't do this one and you can't do that one together because this takes a ton of work to do it well. And we're already, as we saw earlier, hanging by a thread. Barbara Starfield is really respected along with Ayanna Heath. Thank goodness in this world. And I'm gonna go through these. They're great to read on your own. It's gone, it has gone astray. It's gone completely off its rocker. This was written in 2008. 2008. And we're still in the same place. These are my unintended consequences. Number one is crowding out of care for people who are sick and suffering. You know, the USPSDF looks at time that I've looked under the hood. I don't really see that because it's not just the time there, it's the time for everybody else who gets affected by the cascade of care from one false positive. Everybody gets affected by that. The folks who work with me on scheduling, the folks who work to schedule that biopsy, everything comes from this preventive work getting in the way. And it's not making primary care any healthier either. I mentioned this toxic focus on individual responsibility for systemic faults. Nowhere is that more clear than with weight, which is primarily associated economic finding and not individual responsibility as we calculated it is in the US. And lastly, you know, we're liable for everyone's recommendations and nobody can get in their primary care because we're stuffed full of people for whom we're doing prevention. So I would say that we're the wrong tool for this job and that any additional recommendations for primary care need to be zero sum, that we need to follow the laws of physics for any future ones. Things that involve counseling are unlikely to work. We need some sort of independent evaluation of what the hell is going on in American medicine in this way. And I don't know who to trust with that independent evaluation. I appreciate your thoughts. The quality metrics need to be revisited because they are distorting our care. And let's let full-time clinical care and people in primary care make any decision, be part of that decision process. So I realized by putting this in Google that no one else has said this, so I'm gonna say it. It's hard to make it a healthy person healthier, but it's too easy to make a sick person sicker. And a more tragic and much more elegant phrasing, one of the most tragic events in our time is we know more than ever the pains and sufferings of the world and less and less able to respond to them. So thank you for spending time with me today and considering these thoughts. And I'd be grateful for your feedback, your constructive feedback, your any reflections and hope we can work together along the way. Thank you. Well, that was a powerful discussion both on primary care and on the role of the periodic health exam. I just had a couple of thoughts before we open up the question and answer session. I mean, if anything, what you really clearly highlighted is how healthcare does not occur in a vacuum, right? The role of insurance companies and how the rise of the risk factor became diseases, the role of finance and in many ways, it's absolutely fascinating to be in this moment because we are in a world where healthcare is a business and a big business and there's this primate. I mean, on one hand you spoke so eloquently about the competing interests. I have an article that I will be happy to share called Estimation of Time Needed to Deliver the 2020 US Preventive Task Service Recommendations. And what did it say? If we just did that alone, it's like 8.6 hours. So one of the things I would like to do, Steve, after this talk is not only put together the slides but also a list of references that people can follow up with because there's a lot of richness in this. The other thing I think, two other themes, and then I'm gonna open it up for question. One of the things I've been really struck by is this obsession with numeracy as a marker of quality. And personally, I think that it's funny when we're talking about AFib, a patient whose chief complaint this week is, my Apple Watch said I'm an AFib. Okay, I did an EKG, I examined him, he's not an AFib now, I'm happy to follow up, but talk about big brother. My watch told me my rhythms have normal and I think we're all living in the 21st century so this is a reality. The other thing is we have these competing interests. On one hand, we're supposed to do personalized medicine. We're supposed to do, the whole thing with the Medicare wellness exam is to identify the people who are incontinent, people who are really at risk, people who have hidden dementia so we can identify those people and get them into whatever care we have. On the other hand, with the compression of the time, you think to yourself, nothing is more of a perfect storm to create a financial, you see people quickly, you don't have the time to think you do a million tests, you do a million labs, you'll do it, you'll think about it next Thursday when you have your first day off and it's like, it would be funny if it wasn't so heartbreaking. One of the things I just wanted to say as we share resources is that one of the other participants said, start, sorry, needed to step off, but he said that the Canadian task force found that the checkups did, annual checkups do not result in better health. Canadian task force affirms, so I think that your experience and also Christine Sinski obviously identified her seminal article, which is masterclass about that for every hour of direct patient care was associated with two hours of the electronic health record. And I think that's a huge issue is, I mean, in some ways there's no better marker for why we have to study history. Nobody in their right mind 20 years ago would have thought that the electronic health record would have made our life more challenging. All of us who used to pray to be able to look at the ophthalo note or to see the labs only thought it would be good, but it moved from, it's these unanticipated consequences and it's also the big business that's in healthcare, which is just a huge, I mean, financially you can't incentivize people to go into primary care because if you're an orthopedic surgeon the first year you know what I'll make in 10. I mean, that's just the realities of it. And we also haven't done a good job of showing that the meaningful work in primary care is kind of worth the money. So I'm gonna leave this open and I would love to hear. There's a great chat here. There's a lot of interesting things in the chat. I'm happy Elena will do that. So let's let Dana give her opinion. Oh, I don't have an opinion to give. I wanted to hear yours on something. Thank you for a great talk Dr. Martin. I was wondering if you could comment, not to add to the additional burdens that we're considering these days, but if you could comment on the potential or actual effects, I'm not in primary care, but that the 21st century Cures Act is having on the demands for primary care to address for example, lab results and pathology results that are released to the patients with the absence of, you know, basically clinical framing of what they mean. And if you can see any positive sides of that on the converse. Thank you. That's really a wonderful question. I've been grateful to sort of bear witness to parts of the open notes movement and have a lot of compassion and concordance with that. And in the main, I think it's a really, it's a thoughtful approach. And I, thanks to the guidance of a faculty member long ago, always write my notes thinking that someone, including the patient is going to read them end of story. And I don't know why people don't do that, but that's what, that's a great advice from back then and still follow it today. I think the, we just looked here and you know, remember the desk, remember the prior testing and now the doctors, they're sorting people out and the public health nurses grabbing someone. I mean, that is a classic sort of example of like, here's a test and back in the day, we would do your HIV test and the pre-test probability would be low enough that you had a much better chance of having a false positive than a true positive. And people were told before the Western blot came back and people are still affected today from that experience. So I've had only one case thus far where a patient saw a biopsy for malignancy before I was able to see it and talk with her. I think the, I think the thrust of the idea of that the people don't necessarily need mediation is reasonable with a caveat. And Gordy Schiff taught me this, the caveat that they can call me on my phone if they're worried. And I saw Gordy do that at a diagnostic error medicine conference in Chicago. I'll never forget it. It totally changed my life because he was talking with someone about her biopsy and that person could reach him in Chicago when she needed to. So that would be, I think Dana, that would be the caveat if that's okay is that otherwise it's just, it's a free-for-all, unmediated reports. And these reports still have data and language in them. For example, DCIS stuck with carcinoma in situ where we can't get the name to get changed when it needs to be changed because it's not a carcinoma. So on and on it goes, but that's an excellent question. And I'm grateful. I think we're heading in the right direction but with those caveats. John, you wanna take it away? Just a question, very practical. 75 year old friend was just diagnosed with heart problems, severe heart problems. Virtually all of his arteries are blocked. And another 80 year old guy suddenly with PFIP. So are you basically saying with this report that the medical system today is not prepared to catch these sorts of things in advance? And help them. Yes, I am saying that. Yeah, we do know that the major risk factor for atrial fibrillation overwhelmingly is age. Overwhelmingly. And I can't recall the actual preponderance but after the age 85, it's something that would have tended 20% perhaps. So that is the major risk factor. And so that's the prediction model for atrial fibrillation. For cardiac disease, we've been advised to use the risk score from the American College of Cardiology even though it was found to be like a black box and totally over-call disease early on. And it's still not mapped very well to a post-Framingham population. And that risk model would tell us to treat everybody over the age of 70 with a statin, everybody. Just by walking in the door and being 70, you should be on a medication. So I think what we're wrestling with here is the human condition and the development of disease that is going to happen. And unless we live in a tribal hunter gather sort of society where blood pressure doesn't increase with age and they still exist, we are more susceptible. And we each have individual, what? Ways of navigating that and being with that risk and far be it for me to tell people what they should do. So I try to meet people where they are with their concerns but we do know that exercise stress testing is a screening procedure, should not be used, should not be used in executive physicals. It's still used for firefighters and airline pilots. And EKGs should not be done for screening purposes for now, thank God. So I hear you, sir, that the development of cardiac disease as you describe is very scary. And yet, you know, the preventive methods for a person, primary prevention with aspirin is a classic here. Two decades ago, one decade ago, five years ago, we would have said, oh, a friend who's 75 with three vessel disease, that person should have been on an aspirin. Well, that person's chance of bleeding out would have been greater than the person's risk of having a myocardial infarction. So that data we know is very different now than it was with Birmingham and other modeling studies. And we don't have a great crystal ball all the time and Nicholas Krzysztofak just wrote a great book on our inability to prognosticate medicine. And it continues to this day, I'm afraid. Well, I'll propose to your issue, there's a UFC faculty named Tammy Polanski who's actually doing a study to look at the efficacy, the benefit of statins and people over 75. So hopefully we'll be able to get that information at some point. Mindy, just to speak to that very briefly, though. So I get judged on whether someone's picking their statin up at the pharmacy. I don't get judged on whether they had a shared decision making conversation on whether they really don't like statins. But believe me, I hear about it if someone didn't pick up their statin. And I've had colleagues basically say, I will go pick up your statin for you and gain the system because the system is so stupid it doesn't recognize shared decision making as a worthwhile or honorable approach. But the system has to be speaking with one voice. I mean, that's the thing is you can't get these conflicting values of shared decision, you're supposed to have this discussion with people and then grade you on the number of colonoscopies or mammograms or something that you have only so much control over. But I think what we'll do is this, we're gonna give you a little, a few minutes of to go get a glass of water. Sorry, yeah. Sorry to be back with this highly activated group. No, great to see everyone. I'm really, thank you so much for spending this time and I'm grateful.