Wednesday, January 11, 2017

Overuse of health care: can -ologists help themselves?

In a previous post, I reviewed a terrific conference presentation by four orthopedic surgeons on what should have been on the American Academy of Orthopaedic Surgeons' "Choosing Wisely" list instead of the timid and low-impact items that the society actually published. In the question-and-answer session that followed, someone asked if the presenters had shared their evidence-based list with their society's leaders at one of their national meetings. They hadn't. "We would probably have gotten tossed out of the building," one joked, then added more seriously, "A lot of our members make their living by doing these procedures day in and day out."

Lest I seem to unfairly single out orthopedic surgeons and urologists for turning a blind eye to evidence that refutes long-standing medical practices, a 2015 research letter in JAMA Internal Medicine found that specialist societies (membership organizations of physicians whom my friend and family medicine colleague Richard Young dubs "-ologists") are generally likely to resist reversals of practice. In 20 examples of high-quality, high-profile studies that provided evidence for medical reversals, nearly half of official -ologist society responses defended the practice, an effect that was more pronounced when a reversed practice was rated by the authors as of high importance to members of the responding society (e.g., mammography to radiologists).

Resistance to what physician and health services researcher Peter Ubel calls "de-innovation" is driven by more than just fear of declining income. In a Health Affairs commentary, Dr. Ubel identified several psychological biases that cause -ologists to reject new evidence that contradicts established practices: preconceptions (tendency to favor information that confirms prior beliefs), clinical experiences, mistaking association for causality, and reduction of cognitive dissonance.

Primary care clinicians are not immune to these biases, but a family physician's greater tolerance for uncertainty may be advantageous in adapting to medical reversals and reducing overuse of low-value (or no-value) care, such as PSA screening for prostate cancer. In contrast, -ologists may perform unnecessary tests in attempts to eliminate uncertainty, such as an unenhanced CT scan to "rule out" a 2-mm nonobstructing kidney stone that would not change management:

What drives doctors to order tests? We order tests because we must know why. Anything can be known morphs into everything must be known. ... We order CTs because we can. The CT heals us, and our patients. Uncertainty ails. Our intolerance of uncertainty is neither congenital nor stochastic. Our dislike of uncertainty has grown with the availability of imaging. It has reached its apotheosis because of rapid door-to-CT time, the removal of barriers to ordering, and the speed with which reports are rendered. ... So much waste can be avoided by using probability and numbers and applying judgment—the components of rational medical decision making.

Although the relationships between providers of health care, costs, and overuse are complex, recent evidence supports associations between comprehensive primary care and lower costs and higher continuity of care and less overuse. Given these findings, it's not surprising that Dr. Atul Gawande's New Yorker piece, "Overkill," concluded that tackling overuse in health care meant supporting and empowering clinicians whose generalist training, experience, and tolerance for uncertainty makes them best suited to replace unnecessary care with necessary care: family physicians.

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This post first appeared on Common Sense Family Doctor on May 18, 2015.

Wednesday, January 4, 2017

Ethical foundations of health reform

It's been a rough past couple of months not only for millions of Americans whose health care futures depend on decisions to be made by the new Congress and incoming Trump administration, but for those of us who teach about the U.S. health system for a living. As one health policy expert I follow tweeted, only half-facetiously, on election night: "Dear students: all that stuff I taught you about the ACA? You can forget about it now."

Senate Republicans yesterday took the first steps toward repealing and replacing (or more likely, repealing and delaying) the Affordable Care Act through a procedure called budget reconciliation. As I recently told a MedPage Today reporter, although reconciliation can't completely undo Obamacare, it can undo more than enough. Stop the flow of federal funds for the Medicaid eligibility expansion adopted by 31 states and Washington, DC, and most will be forced to drop coverage or cut back on benefits to balance their budgets. Stop the federal tax subsidies to low-income persons who purchase individual insurance plans on the health insurance marketplaces, and insurers - already forced to sharply raise premiums because not enough young and healthy adults bought in - will leave the marketplaces. Stop enforcing the individual mandate, and even more people won't buy health insurance, pricing premiums even more out of reach and potentially leading to an adverse selection death spiral.

As a piece of legislation, the ACA was 100% partisan, passing Congress without a single Republican vote and signed into law by a Democratic president. But historically, it originated as the conservative (Republican!) alternative to President Bill Clinton's American Health Security Act that failed to even come to a vote in Congress.

I was a college freshman from 1993-1994, and much more interested in Imperial Russian history than in modern U.S. politics, so I have no personal memories of the protracted health care reform debates that occurred in the halls of Congress or between ordinary Americans watching "Harry and Louise" advertisements on television (which I also have no memory of whatsoever). But I recently obtained a paperback copy of the Clinton White House Domestic Policy Council's blueprint for what became known as "Hillarycare." Not surprisingly, it contains some good ideas - particularly those supporting more training programs for and higher payments to primary care physicians - and many that probably wouldn't have worked out very well. But one chapter, "Ethical Foundations for Health Reform," resonated with me, as I imagine it would with others across our diverse political spectrum. It asks, then answers in 14 briefly defined concepts, the essential question: what values and principles should shape our health system?

Universal access
Comprehensive benefits
Choice
Equality of care
Fair distribution of costs
Personal responsibility
Inter-generational justice
Wise allocation of resources
Effectiveness
Quality
Effective management
Professional integrity and responsibility
Fair procedures
Local responsibility

Always, the devil is in the details. For example, how broad or generous do "comprehensive" benefits need to be? What is a "fair" distribution of health care costs? Who decides what is a "wise" allocation of resources? How much "local" responsibility should be reserved for states and communities versus the federal government? But as the patchwork U.S. health system seems primed to undergo another political upheaval, I think it's more important than ever to seek consensus on the destination for health reform before embarking on the journey.

Sunday, January 1, 2017

We need to know more about psychological harms of screening

A decade ago, a few colleagues and I performed a systematic evidence review to help update the U.S. Preventive Services Task Force's recommendations on screening for prostate cancer. One of our key questions asked about the harms associated with prostate cancer screening, other than the overdiagnosis (and resulting unnecessary treatment) of clinically insignificant tumors. Since routine prostate-specific antigen screening had been going on since the early 1990s, we expected to find plenty of studies measuring anxiety and other mental health changes caused by false positive or indeterminate screening results.

In fact, after sifting through more than four hundred citations, we only found four articles describing three studies. Only one of the studies followed men for as long as one year. Here's what we wrote about that study:

[The authors] compared 167 men who had an abnormal screening result but a benign biopsy specimen with 233 men who had a normal PSA level. After 6 weeks, 49% of men in the biopsy group reported thinking about prostate cancer “a lot” or “some of the time,” compared with 18% of the control group. In addition, 40% of the biopsy group worried “a lot” or “some of the time” about developing prostate cancer compared with 8% of the control group. ... Statistically significant differences between the biopsy and control groups in anxiety related to prostate cancer and perceived prostate cancer risk persisted 6 months and 1 year later.

One might think that men with normal biopsies following an elevated PSA level should have been reassured that they had dodged a bullet and been pronounced prostate cancer-free. In fact, exactly the opposite occurred. And that's hardly surprising, since prostate biopsies, unlike breast biopsies, usually don't aim for a particular location of concern, leaving open the worrisome possibility that the biopsy needle just didn't sample the cancer if it was there. (How uncommonly cancer cells found in the prostate spread and lead to symptoms or death is another issue entirely.)

In the years since that review was published, the USPSTF has recommended against PSA-based screening for prostate cancer and recommended for low-dose CT screening for lung cancer in selected patients. There has been a major shift in how scientists view cancer screening and more interest in studying previously undescribed harms. In a review of psychological harms of screening published in the Journal of General Internal Medicine, Dr. Jessica DeFrank and colleagues assessed the literature on the burden or frequency of psychological harm associated with screening for prostate cancer (42 studies), lung cancer (11 studies), osteoporosis (6 studies), abdominal aortic aneurysm (8 studies), and carotid artery stenosis (1 study). They observed that for most screening tests, there remain large gaps in the evidence about the magnitude and frequency of such harms in populations representative of those receiving the tests. (I hasten to add that neither the USPSTF nor any other legitimate medical organization recommends ultrasound screening for carotid artery stenosis.) 

Causing needless worry about cancer or another absent health condition can seem trivial compared to the prospect of saving a life. But increasing recognition of the limitations of screening for cancer and disease in general, and the nearly nonexistent effect of these tests on all-cause mortality, have altered the equation. If more than 96 percent of initially positive screens turn out to be false positives (as is the case for lung cancer screening), just how much anxiety and worry are we as a society willing to inflict to merely exchange one cause of death for another?

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This post first appeared on Common Sense Family Doctor on March 4, 2015.

Saturday, December 24, 2016

My favorite public health and health care books of 2016

I took a different approach to this year's top 10 list: rather than selecting only books published in this calendar year, as I did in 2015, I decided to make eligible any book that I read this year, regardless of when it was published. Books are listed in alphabetical order rather than order of preference/enjoyment: they were all compelling reads in their own ways.

Merry Christmas, Happy Holidays, and Happy New Year to all!

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1. Adventures of a Female Medical Detective: In Pursuit of Smallpox and AIDS, by Mary Guinan with Anne D. Mather

2. Dying and Living in the Neighborhood: A Street-Level View of America's Health Care Promise, by Prabhjot Singh

3. The Gene: An Intimate History, by Siddhartha Mukherjee

4. In A Different Key: The Story of Autism, by Jon Donvan and Karen Zucker

5. League of Denial: the NFL, Concussions, and the Battle for Truth, by Mark Fainaru-Wada and Steve Fainaru

6. Pandemic: Tracking Contagions, from Cholera to Ebola and Beyond, by Sonia Shah

7. The Practical Playbook: Public Health and Primary Care Together, by J. Lloyd Michener and co-editors

8. Pulse - Voices from the Heart of Medicine: Editor's Picks: A Third Anthology, by Paul Gross and co-editors

9. Religion As a Social Determinant of Public Health - by Ellen Idler, editor

10. Twelve Patients: Life and Death at Bellevue Hospital, by Eric Manheimer


Wednesday, December 21, 2016

Yes, health policy agendas can be bipartisan

Between the party-line Democratic votes to pass the Affordable Care Act in 2010 and the very likely party-line Republican votes to repeal critical parts of it in early 2017, a bipartisan group of state health policy leaders (Reforming States Group) recently released a letter to the incoming Administration that proposes a modest federal-state policy agenda designed to advance the Triple Aim.

Three members of the group summarized their proposals in a Perspective article in the New England Journal of Medicine that began with language that was music to my public health-trained ears:

State leaders understand that as a society we are spending our health care dollars in the wrong ways for the wrong things — emphasizing treatment over prevention and medical care over social services. ... High-cost, high-need patients swamp Medicaid programs; prisons have become de facto treatment systems for substance use disorders; today’s neglected children are tomorrow’s state responsibilities; low- and middle-income families struggle with rising health care payments; and the demands of an aging population increasingly tax families, health care systems, and communities.

The four key components of their agenda are as follows:

1) Support state efforts for broad reforms of health care payment and delivery.
2) Support state efforts to address causes and improve management of chronic illness.
3) Support state use of data to inform policy.
4) Strengthen the state-federal partnership on health to assure the greatest impact from federal investments.

Limited as it is, this bipartisan policy consensus has a chance to gain traction as a "long-term agenda for governing" because intentionally "avoids focusing on any single health care issue currently grabbing headlines." Improving population health is, after all, a long-term proposition that requires vision rarely seen in national politics these days. For example, buried in the acclaim heaped upon the recently enacted 21st Century Cures Act was that well over half of it was paid for by gutting the Prevention and Public Health Fund, which had already sustained substantial cuts in previous years to offset more visible or politically advantageous budget priorities.

In an era of increasing federal government paralysis, perhaps state leaders can find a way forward on priorities for health reform. Before Obamacare, there was Romneycare. There are still too many people in this country who can't access essential social services or medical care (even if they have health insurance). Too many people who have health insurance but delay dental care they can't afford and suffer permanently debilitating consequences. If President-Elect Trump wants to "make America great again," he can start by recognizing that we are far too great a nation to continue to allow these things to happen.

Monday, December 19, 2016

How can medical educators support students' well-being?

Even twenty years later, I remember well the pervasive despair that engulfed me for much of my first two years of medical school. Even with a personal support system that included my family and several former college roommates and friends who lived in the same city, I struggled to find my bearings, academically and emotionally. Now that I spend much of my time teaching first-year medical students, I have wondered if the learning environment that I and other faculty provide contributes negatively or positively to their well-being.

A recent systematic review in JAMA examined the self-reported prevalence of depression, depressive symptoms, and suicidal ideation in medical students from 43 countries who were surveyed from 1982 to 2015. Longitudinal studies showed that students' mental health worsened significantly after starting medical school, with a median absolute increase in symptoms of 13.5%. On average, 27 percent of students reported depression or depressive symptoms, but only 16 percent of those students sought formal treatment. In contrast to my own experience, which was feeling much happier once I began third-year clerkships, there was no significant difference in depression prevalence between the preclinical and clinical years. Most alarmingly, 11 percent of students in these studies reported having suicidal thoughts during medical school.

A second systematic review examined associations between learning environment interventions and medical student well-being. The evidence base was limited: only 3 of 28 included studies were randomized trials, and most studies were conducted at a single site. Interventions that appeared to be effective in improving students' well-being included pass/fail grading systems, increased time with patients during the preclinical years, mental health programs, wellness programs including mind-body stress reduction skills, and formal advising/mentoring programs. In an accompanying editorial, Dr. Stuart Slavin observed that the educational culture of some medical schools is often an obstacle to implementing these kinds of reforms:

When signals of problems involving student mental health arise, the reaction in medical education has commonly been failure to recognize that the main problem is often with the environment, not the student. The response has often been limited, such as advising students to eat well, exercise, do yoga, meditate, and participate in narrative medicine activities. These approaches ... may distract educators from recognizing that the learning environment is at the core of the problem, and more must be done to improve it.

To be sure, maximizing student well-being is not the only or even the most important goal of medical education. But just as it is possible to create positive practice environments that protect clinicians from burnout, educators can prepare students to practice medicine competently in learning environments that are least likely to harm their mental health.

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This post first appeared on the AFP Community Blog.