Antibiotics, sinusitis, and swine flu

For the past few months, the Giant supermarket chain has offered a free supply of certain antibiotics to customers with a doctor's prescription. As a family physician who is always explaining to patients why antibiotics are ineffective for the common cold, I wish that Giant executives had chosen a more useful class of drug to promote: drugs for high blood pressure or diabetes, for example. While doctors in past years (and, unfortunately, many doctors practicing today) handed out antibiotics like candy, recent scientific studies have shown how limited the medical uses of these drugs really are.

Take sinus infections, for example. They're sometimes caused by bacteria, so antibiotics should help, right? And some studies have in fact suggested that a few patients with laboratory-proven bacterial sinusitis may recover more quickly with antibiotics. But since tests for bacterial sinusitis are not available in primary care practices, it would be useful to identify clinical findings associated with a positive response to antibiotics. In a 2006 study published in the Annals of Family Medicine, Dr. An De Sutter and colleagues at Ghent University in Belgium studied the utility of clinical signs and symptoms of sinusitis and sinus x-rays for predicting duration of illness and the effect of amoxicillin, a commonly prescribed antibiotic.

The study enrolled 300 patients age 12 and older who visited their family physician with signs or symptoms suggestive of a sinus infection. Patients were randomized to take 10 days of either amoxicillin or a sugar pill. No clinical sign, symptom, or x-ray finding had any relationship to duration of illness or response to amoxicillin. The authors concluded that clinical information cannot be used to select patients who would benefit from antibiotic treatment. Consequently, they recommended symptomatic treatment (e.g. over-the-counter pain medication, nasal decongestants), rather than antibiotics, for patients with sinus infections. And so do I.

You may also wonder what you should do if you think you may have the H1N1 (also known as "pandemic" or "swine") flu. The Centers for Disease Control and Prevention has put together a nice web page that answers the most commonly asked questions. When an H1N1 flu vaccine is available next month, it is especially important that pregnant women and young children are at the head of the line, since they are the most likely to become very sick if they get the flu.

Re-priming the primary care pipeline

If you've been reading this blog since its inception, you are now well aware that primary care is essential to any high-performing health system, including those in other countries, but that the "pipeline" for primary care physicians in the U.S. has been drying up, with large student debt burdens and discrepancies in income between generalist and subspecialist physicians playing a large part in driving medical students away from careers on the front lines of medicine. So how can the supply of primary care physicians be increased to adequate levels in the context of health care reform?

A group of family physicians and health policy analysts at the Robert Graham Center for Policy Studies in Family Medicine and Primary Care recently did an exhaustive study on the factors that affect medical students' selection of careers. In their exceptional March 2009 report, subtitled "What Influences Medical Student & Resident Choices?" Dr. Robert L. Phillips, Jr. and colleagues made several evidence-based recommendations for policymakers that bear repeating (and tweeting) loudly in the White House and halls of Congress:

1. Create more opportunities for students and young physicians to trade debt for service.
2. Reduce or resolve disparities in physician income.
3. Admit a greater proportion of students to medical school who are more likely to choose primary care, rural practice, and care of the underserved.
4. Study the degree to which educational debt prevents middle class and poor students from applying to medical school and potential policies to reduce such barriers.
5. Shift substantially more training of medical students and residents to community, rural, and underserved settings.
6. Support primary care departments and residency programs and their roles in teaching and mentoring trainees.
7. Reauthorize and revitalize funding through Title VII, Section 747 of the Public Health Service Act. (Title VII is a small, little known federal program that supports primary care residency training, but has been severely shrunk by budget cuts during the past decade.)
8. Study how to make rural areas more likely practice options, especially for women physicians. (The report found that "female physicians are twice as likely as men to choose primary care but helf as likely to practice in rural areas.")
9. New medical schools should be public with preference for rural locations. (One recently established medical school, the Commonwealth Medical College in Scranton, PA, exemplifies how this recommendation will encourage students to pursue primary care careers.)

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In the interest of full disclosure, I'd like you to be aware that the Robert Graham Center is an editorially independent subsidiary of one of my employers, the American Academy of Family Physicians, and I did some freelance editing assignments for the Center from 2005-06. I no longer have any direct professional connections with their staff, but I encourage them to read my blog!

More technology, better medicine? Maybe not

I took creative writing courses throughout medical school and during my 3-year residency in family medicine. Although these often provided a much-needed outlet from the stress and intensity of long days and nights spent in one hospital or another, paradoxically I usually ended up writing about patients I'd met, or how I felt about doctoring in general. I wrote the following reflections during a creative non-fiction class that I took at Elizabethtown College (PA) in the spring of 2003.

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Lancaster General Hospital doesn’t stand out from the air. Looking down from a twin-engine Cessna taking off from the Smoketown Airport on the outskirts of Pennsylvania’s Amish Country, the most noticeable features are the farms, the country roads connecting them, and a hundred or more churches. One might still imagine a midwife going from house to house delivering babies with nothing more than clean towels and a basin of water, or even (in the not-so-distant past) the old-time family doctor with his black bag of tools and potions.

My mother gave me one of those shiny black bags after my medical school graduation. The most I can say is that I’ve used it as a carry-on for weekend trips. Not once have I taken it to see a patient. But I did hold one of these bags years ago, from a retired mentor who had inscribed his initials on the gold-plated clasp. The leather was worn through in several places, and it smelled quite old and promised magic inside. The contents – a stethoscope, reflex hammer, tuning fork, and blood pressure cuff – were disappointingly standard, and the thermometer was electronic rather than mercury. The bag seemed to imply that there was no room in medicine for nostalgia.

Modern-day medicine is often hidden behind layers of technology and increasingly sophisticated ways of diagnosing patients’ ills without actually having to touch them. The other day I read a newspaper story about a robot “virtual” doctor who makes rounds with a physician assistant, wheeling into and out of rooms with a video screen showing the real doctor, hundreds of miles or more away. This, the author implied, is progress. The story also quoted a physician’s prediction that robots would “transform the delivery of medical care.” He went on to compare the efficiency of the traditional “laying on of hands” to a gas-guzzling 1950s Chevy.

We doctors are trained from day one to create and maintain the illusion that all of medicine is an organized enterprise, from the numbers of specialists assigned a case to the technology purchased and utilized, to every order we write and action we take.

It’s not. Usually, it’s chaos and disharmony and waste. ...

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... which is why we need health reform now!

Health care for illegal immigrants

Pay a little now, or a lot later. It's that simple. In a previous blog post about irrational health care bills, I wrote:

"Illegal immigrants get sick too, and they end up going to U.S. emergency rooms when their health problems become too serious to ignore. The high-risk premature delivery that could have been prevented by routine prenatal care, and the heart attack that could have been prevented by controlling blood pressure and cholesterol levels (which primary care does very well and cheaply, given the opportunity), instead become expensive, catastrophic emergency visits, which are charged to your hospital, and therefore your health insurance, and therefore, you. Immigration policy is an important and divisive issue, but it should be separated from the issue of public health and the health reform debate."

Unfortunately, it appears that the only issue in health care reform that both liberals and conservatives actually agree on is that illegal immigrants should be excluded from coverage. This is a terrible mistake, regardless of one's political or ideological leanings. If we hope to ever stop undocumented workers from using hospital emergency rooms as their primary source of (overpriced, poorly coordinated) primary care, then every person living in the U.S. must have access to an affordable family physician under health care reform. (Notice that I wrote affordable, not free.)

A recent article in Newsweek argues that insuring illegal immigrants could actually drive down the cost of medical premiums, since this population is typically younger and has fewer chronic medical problems than American citizens. Also, requiring all workers to be insured regardless of immigration status would reduce or eliminate the income disparity that currently makes it attractive to hire undocumented immigrants, rather than citizens, for certain jobs.

Yes, Rep. Joe Wilson is an idiot, but I actually hope he was right - health reform will be better off if President Obama was lying about illegal immigrants not being included in health care reform.

Primary care: no next generation?

My wife and I are both family physicians, 9 and 8 years out from medical school graduation, respectively. Principal and interest payments on our remaining combined six-figure student loan debt consume about 5% of our pre-tax income each year, and at our current rate of repayment, we could still be paying off this debt when our oldest child starts college. But after attending my alma mater's annual Alumni brunch in Washington, DC recently, I realized that today's future family physicians are much worse off than we are.

Consider these figures from a follow-up solicitation letter for scholarship donations: "Among the 155 members of the Class of 2008, 78 percent graduated with an average debt load of nearly $143,000. 18 percent graduated with a debt load that exceeded $200,000." These figures are hardly atypical for most private (and some public) medical schools. Given these grim numbers, it's a wonder that any medical students choose careers in primary care - the lowest-paid specialties being general pediatrics, family medicine, and general internal medicine.

In a 2008 letter published in the Journal of the American Medical Association, family physician-educator Mark Ebell, MD, MS demonstrated a near-linear association between median income and the percentage of U.S. senior medical students who entered a medical speciality - put simply, students go where the money is. And given their increasingly staggering debt loads, who can really blame them?

That's why I was excited to hear that the recently established University of Central Florida College of Medicine awarded full scholarships to its entire inaugural class of 41 students. Other schools may soon follow suit. Not surprisingly, UCF was the most selective medical school in the country this year. But will the absence of student loan debt result in this school ultimately training more primary care physicians? Only time will tell.

Does the type of birth affect postpartum health?

My first child was born surgically via cesarean section, while my second arrived naturally by what maternity care providers call a “normal spontaneous vaginal delivery.” Surgical deliveries are rapidly becoming the norm rather than the exception in the U.S., reaching a record high of 31.8 percent of all births in 2007 (the 11th consecutive year that this percentage has increased). In most communities, trials of labor after a previous cesarean delivery are actively discouraged, even though 76% of women who attempt them (including my wife) have successful vaginal births.

The rising number of surgical deliveries is troubling, given that more than three-quarters of first-time mothers in the United States who are employed during pregnancy will return to the workforce within their infant’s first year of life. In a 2006 study in the Annals of Family Medicine, Dr. Pat McGovern and her colleagues at the University of Minnesota reported the relationship between delivery type and measures of postpartum health 5 weeks after childbirth.

Participants were 817 employed women who gave birth to single healthy infants at one of three Minneapolis-St. Paul community hospitals in 2001. Study personnel telephoned each woman to conduct an interview that lasted approximately 45 minutes. The interviews assessed overall physical and mental health as well as typical postpartum symptoms, including fatigue, decreased interest in sex, back and neck pain, constipation, hemorrhoids, and appetite problems.

The authors found that women who delivered by cesarean section reported significantly worse physical health 5 weeks after birth than women who delivered vaginally, although mental health scores were similar between the two groups. This is important to know, since while surgical deliveries aren’t always avoidable, there are some simple things that a woman can do to reduce her risk (such as asking her obstetrician, family physician, or midwife what the practice's average c-section rate is and their most common reasons for doing one). If you want more information, I refer you to a website that pulls no punches with the facts about how to avoid an unnecessary cesarean.

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Note: the above post is adapted from an article I wrote in the August 15, 2006 issue of American Family Physician.

Health and tort reform: it's not about saving money

Many good ideas that have been around for years have benefited from being included under the banner of health reform. However, the recent focus on the cost of reform has made it seem that only ideas that are guaranteed to save money are worth including in a comprehensive overhaul of the system. Viewed in this light, if critics of reform can make the argument that an idea isn't cost-saving, it should be discarded.

Frankly, that's one of the stupidest arguments I've ever heard. Almost everything worth doing in health care costs money. If our top priority is saving money, we should hand out free cigarettes and alcohol to minors and remove seat belts and airbags from cars, because early deaths from cancer, heart disease, and automobile fatalities would save the health care system billions of dollars in health care expenses for seniors in the long run!

As Dr. Steven H. Woolf of Virginia Commonwealth University argues in an excellent policy paper for the nonprofit group Partnership for Prevention, health reforms should emphasize interventions that provide good value, rather than cost savings. Mammograms and Pap smears don't save money (because most women do not have breast cancer or cervical cancer), but our society generally regards the prevention of late complications of breast and cervical cancer to be a good thing. Gym memberships and healthy food choices cost money, but since exercise and healthy eating prevent heart attacks in some people, most would agree that those costs are worthwhile.

Another good idea that's been taking a beating recently is tort reform, or putting limits on malpractice lawsuits that drive up the price of malpractice insurance, drive up overall medical costs through doctors who practice defensive (or in some circles, CYA) medicine by ordering unnecessary tests and procedures, and in some states have led to an exodus of specialists in high-lawsuit areas such as obstetrics and neurosurgery. Yet recent newspaper articles have asserted that enacting tort reforms would be unlikely to save significant health care dollars.

Although I think this point is debatable, it's another case where the answer really doesn't matter. Tort reform is a good idea, whether it saves money or not. It is ridiculous that the only way that a patient (or grieving family member) can obtain money to provide for someone crippled by a bad health outcome is to sue the doctor, whether or not the doctor was "at fault" or not. As a result, the vast majority (greater than 90 percent) of patients who probably deserve compensation for medical errors never see a dime, and those who do receive compensation after years of litigation end up giving much of what they win to their lawyers.

Health reform would benefit greatly from including tort reforms modeled on existing no-fault compensation programs, such as the National Vaccine Injury Compensation Program or the Virginia Birth-Related Neurological Injury Compensation Program. That way, patients who suffer medical misfortune would get the funds they needed for care, good doctors who made mistakes would be able to apologize without fear of a lawsuit, and aggressive malpractice attorneys would get exactly what they deserved: nothing.

The "single payer" should be you

When some people say that the U.S. should have a "single payer" health care system, they're generally talking about a system in which government is the exclusive payer of all health care bills. It's tempting to think that in such a system, the money comes from some magic place in the sky, but of course, it ultimately would come from higher payroll or other taxes.

If you take a broad perspective, though the U.S. already has multiple forms of single payer systems. Medicare and Medicaid and the Veterans' Health Administration provide health services that are directly funded by taxpayers. Employer-based and individual health insurers collect premiums from employers, employees, and individuals to create large pools of money that pay the health care bills of their members. In all of these cases, the "single payer" is, ultimately, you.

The trouble with all of these systems is that much of your payments (up to 40 percent in some cases) pay for administrative costs rather than actual health care services. But what if there was a way to cut out the middle men? The Seattle-based practice Qliance Primary Care has developed one innovative solution - charging a flat monthly fee for the full spectrum of primary care services. The practice offers "same or next-day appointments for urgent care, unhurried 30 to 60 minute office visits, 24 hour phone and email access to a physician and the convenience and cost savings of an on-site x-ray, laboratory and 'first-fill' prescription drug dispensary."

Previous medical groups that utilized this business model often charged exorbitant fees, leading critics to label them "boutique" or "concierge" medicine, available only to the wealthy. In contrast, Qliance's fees are quite affordable: from $49 to $79 per month. This fee, combined with a catastrophic health insurance policy to protect against unexpected ER visits or hospitalizations, is significantly less expensive than traditional insurance policies - which makes sense, since 100 percent of payments go directly to the practice rather than being filtered through insurance bureaucrats.

So why aren't there more advocates for a "single payer" health system in which the single payer is you?

Empathic intrusions: the art of medical interviewing

Almost every medical school requires that its students take some sort of "interviewing course," usually in their first and second year before they have much significant clinical interaction with patients. These initial encounters with real patients are in some sense the purest ones we will ever have, since our listening to the patient's story is not yet clouded by needing to "make the diagnosis" and impress the attending physician with our ability to recognize pathology. I wrote the following essay-reflection as a first-year student at the New York University School of Medicine in the fall of 1997. "Sean" is a pseudonym.

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As a first-year medical student, I knew or would soon know all about appendicitis, meningitis, Wilms' tumor, Pfeifer’s syndrome, and Tetralogy of Fallot. But what did I know about gangs and gunshots? About having a father in jail? About the depth of faith and courage required to endure a chronic illness, a life-altering injury, or fifteen operations over five years? My greatest apprehension before I began interviewing patients was not the prospect of seeing disease. I didn’t think that I would flinch at jagged sutures, missing digits, or other unsightly scars. Rather, what gave me anxiety was the question of empathy: how I would identify with these patients and put myself in their worlds? Although the diverse lives that our group witnessed in the pediatric wards at Bellevue and Tisch Hospitals often bore only a passing resemblance to my own, I had always heard that good physicians try to place themselves “in the patient’s shoes” before determining the nature of the medical problem. Were my white coat and identification badge, then, substitutes for life experience and understanding?

Perhaps not, but professional attire certainly permitted entry. As another doctor-in-training observed, “There is a frequent sense of surprise, a feeling that you are not entitled to the kind of intrusion you are allowed into patients’ lives. ... You get used to it all, but every so often you find yourself marveling at the access you are allowed, at the way you are learning from the bodies, the stories, the lives and deaths of perfect strangers.”[1] While I soon “got used to it,” no interview made the extent of this privileged access clearer to me than that of a teenager who had been caught in the middle of a gang war and wounded by a bullet in his right leg. The first thing I wanted to know was how it felt - not only being shot, but being seventeen, physically active, a year from graduation and with a promising future career, and for a few moments, facing the possibility of losing everything.

“So how did it feel, Sean, when you were shot? Was it a sharp pain? You know, having never been shot myself...” It was an awkward question, finessed by nervous laughs all around. I half expected him to say that it was impossible to describe unless I’d gone through it myself. He didn’t, though, and instead continued soberly that he knew in an instant that his leg was broken, and remembered lying on the ground unaware of the bleeding or how much time had passed. Once he arrived at the hospital, Sean said, he knew he was going to be all right, even though he would later receive three blood transfusions and suffer repeated clots as a result. I could tell that he believed in the skill of the doctors, and may have transferred this confidence to my uniform as well. His only disappointment seemed to be the delays in going home.

Where was his anger? Where was the question, “why did this have to happen to me?” At the very least, I expected some sadness at his being unable to return to sports, or even to walk normally. That’s how I would feel, I thought. I tried to probe deeper, to unearth these private emotions which surely lay beneath his facade of acceptance and good cheer. Only later, after coming up empty, did I realize that these well-intentioned questions might have constituted an intrusion. One might call it an “empathic intrusion,” for at that moment, I didn’t only feel sympathy for Sean. I wanted to identify with him and his experience the only way I could, by drawing out his feelings.

What else can I do with these and other lives that move me deeply but touch little of my own? In the future, will I be able to heal my patients as I treat their afflictions, by also understanding their emotional discomfort? One physician suggests that “empathy can be strengthened best through stories.”[2] By reading widely, he argues, medical students can obtain acquired, if not direct, experience. While I would agree, patient interviews are more personal and illuminating than the best of literature. Our profession permits us by custom to know things about people that they may not tell close family or friends, producing to the ever-present danger that these intrusions may merely satisfy our own curiosity. For several weeks this fall, I and my fellow students learned how to be intruders, in the interest of gaining empathy. Although interviews do not necessarily bestow life experience, they serve the vital purposes of allowing us to gradually “grow into” our white coats, to feel more comfortable with our empathic intrusions, and ultimately, to serve our patients in practice.

[1] Perri Klass, “Invasions,” in On Doctoring: Stories, Poems, Essays (New York: Simon and Schuster, 1995), eds. Richard Reynolds and John Stone, 407.
[2] Howard Spiro, “What Is Empathy and Can It Be Taught?”

Why you should just say no to "routine blood work"

You're at your family doctor's office to have a complete physical. Maybe you're starting a new job, or have recently joined a wellness program in your community, or it's been more than a few years since you've had a checkup and you (or your spouse or significant other) just want to make sure that everything's OK. Your doctor briefly reviews your medical history, performs a physical examination, says a few encouraging words about eating a healthier diet and exercising more, and then you're done.

You picked this doctor out of the five in the practice because your friend told you he was a sharp young fellow, but now you're not so sure. What about the blood work? You don't need any blood work, he says. Not even a urine sample? This is confusing. You've always had blood work and urine tests at your other physicals, and your insurance is footing the bill, after all. You wonder if this doctor really knows what he's doing.

This is a common situation that I faced while working as a physician in private practice in northern Virginia a few years ago. For years, patients have been used to having blood samples drawn even if they felt completely well. Even today, when we know better (or ought to), up to one-third of primary care physicians still perform "routine blood work" (usually consisting of a complete blood count, a chemistry panel, liver function tests, thyroid tests, and a urine analysis) at adult physical examinations. So why is this such a bad idea? In 2007, I co-authored an editorial in the journal American Family Physician about this topic. We wrote:

"'Big-ticket' tests [such as CT scans and MRIs] are easy targets for those seeking to reduce waste in health care. But what about the seemingly innocuous practice of performing routine tests such as a complete blood count (CBC) or urinalysis? ... These tests would be useful only if they provided additional diagnostic information that would not otherwise be obtained during a history and physical examination. In fact, large prospective studies performed in the early 1990s concluded that these tests rarely identify clinically significant problems when performed routinely in general outpatient populations. Although the majority of abnormal screening test results are false positives, their presence usually mandates confirmatory testing that causes additional inconvenience, and occasionally physical harm, to patients."

Don't misunderstand me. There are certain situations in which targeted screening tests can provide valuable information for the early detection of diseases. To learn more about which tests are recommended for your or your family members, I recommend that you visit the excellent website Healthfinder.gov. But the next time you go to a doctor's office and he or she proposes to check some "routine blood work," be sure to ask what these tests are for and what would happen if any of them turn out to be positive, so that you can make an informed choice about what's right for you.

The best recent posts you may have missed

Every other month or so, I've decided to post a list of my top 5 favorite posts since the preceding "best of" list on this blog, for those of you who have only recently started reading Common Sense Family Doctor or don't read it regularly. Here is my list for July 2009 through today:

1) My first experiences with end-of-life "care" (8/16/09)

2) Lowering costs and improving quality of care (7/29/09)

3) Medicine and the not-so-free market (8/7/09)

4) Heroic medicine vs. public health, part I (8/24/09)

5) What is "too much" health care? (9/2/09)

If you have a personal favorite that isn't on this list, please let me know. In the future, if enough people are interested and I can figure out how to do it in Blogger, I may set up an "audience vote" function to choose the most popular posts. Thanks for reading!

It's health care delivery, stupid

A recent article about the National Institutes of Health in Parade Magazine describes how funding of basic medical research has led to life-saving advances in cancer therapy. The problem with focusing exclusively on basic research, however, is that many patients in the disorganized U.S. health system do not receive recommended treatments, and, therefore, cannot benefit from them.

Making sure that the right therapy is delivered to the right patient at the right time is known as optimizing “health care delivery.” To date, investing in health care delivery has taken a back seat to investing in new therapies. On a governmental level, the Agency for Healthcare Research and Quality has an annual budget of $320 million, about one percent of the $32 billion budget of the National Institutes of Health and the $32 billion spent annually by pharmaceutical companies on new drug development.

In a 2005 article in the Annals of Family Medicine, Drs. Steven Woolf and Robert Johnson of Virginia Commonwealth University illustrate the concept of a “break even point” at which creating a new drug saves as many lives as maximizing the delivery of older drugs. They demonstrate convincingly that modestly improving the proportion of eligible patients who are prescribed the older (and less expensive) drugs aspirin and pravastatin to prevent strokes and heart attacks would produce far greater health benefits than investing hundreds of millions of dollars in developing drugs that work only slightly better (clopidogrel and rosuvastatin).

The authors concede that marketing campaigns for new drugs sometimes improve care delivery by calling physicians’ attention to under-recognized diseases. On the other hand, simple paper and electronic reminder systems are more successful at improving adherence to evidence-based treatment guidelines, at significantly less expense than what it costs to develop a new drug.

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Note: the above posting is adapted from an article I wrote in the July 1, 2006 issue of American Family Physician.

Primary care in developing countries

While this blog focuses on health and the dysfunctional health care system in the U.S., it's worth noting that many other countries have problems providing their citizens with good primary care. Last year, the World Health Organization released a report, titled "Primary Health Care: Now More Than Ever," that discussed the central role of universal access to primary care in improving the health of people in industrialized and developing nations. One of my previous posts mentioned a conversation I had with health officials from Kazakhstan about their efforts to train more primary care physicians. But what should one do in places where doctors are, and always will be, scarce? In the December 2008 issue of National Geographic, Tina Rosenberg describes how Jamkhed, a remarkable public health program operating in rural India, has trained teams of illiterate health workers to provide a remarkable degree of basic prenatal and primary care services in impoverished rural areas. Rosenberg writes:

"Even doctors who do treat villagers ... rarely spend time teaching them about nutrition, breast-feeding, hygiene, and using home remedies such as oral rehydration solutions. They don't help villages acquire clean water and sanitation systems or improve their farming practices—ways to eliminate the root causes of disease. They don't work to dispel myths that keep people sick. They don't combat the discrimination against women and low-caste people that is toxic to good health. ... 'Doctors promote medical care because that's where the money is,' says [health worker] Raj Arole. 'We promote health.'"

Promoting medical care instead of promoting health is the problem in America, too. While the National Health Service Corps, a program that provides financial incentives for health professionals to practice in medically underserved areas, is chronically underfunded, fire fighters and emergency medical technicians have become the de facto primary care providers to the poor. That's why, in the absence of health reform, the "developing country" title of this post applies to the U.S. as well as it does to places like India and Kazakhstan.

Improving your understanding of health risks

When there is a plane crash in the news, my mother-in-law, who dislikes flying anywhere but has driven coast-to-coast many times, says that she will never get on a plane again. But according to the National Center for Health Statistics, the odds of being in a serious car accident during your lifetime are a mere 1 in 100, while the odds of being in an accident involving a plane are 1 in 20,000. (And my mother-in-law did much of her driving in the days before child seat belt laws.)

Just as making rational decisions about traveling requires knowing the type and magnitude of risks involved, making informed decisions about one’s health requires understanding the risks associated with health conditions and treatments. In a 2007 study in the Annals of Internal Medicine , researchers examined how providing patients with an educational primer about risk improved their skills in interpreting medical data.

The study recruited 500 healthy adults between the ages of 35 and 79 from both high and low educational backgrounds and randomly assigned them to receive either an 80-page primer titled “Know Your Chances: Understanding Health Statistics” or a generic booklet containing general health advice. Steven Woloshin, Lisa Schwartz, and H. Gilbert Welch of Dartmouth Medical School were interested in seeing if their primer (which they revised and published in book form earlier this year) positively affected patients’ medical decision-making abilities.

Since the researchers could not ethically publish information about real-life medical decisions, they instead measured participants with an 18-item test of medical data interpretation from hypothetical advertisements, news stories, and clinical scenarios. Possible scores ranged from 0 to 100, with 75 considered “passing” and 90 (the average score of physicians who teach evidence-based medicine) considered “outstanding."

On average, the group that received the risk primer scored 6 to 7 points higher on the test than the other group – a gap that is equal to about one-third of the difference between the scores of medical experts and people with other postgraduate degrees. The researchers concluded that a primer on understanding health risks improved participants’ data interpretation skills, and that the effect size was similar across two groups with different educational status.

The bottom line? Doing a little homework before going to see the doctor (by reading this book or another source of information on health risks) could be well worth your time.

What is "too much" health care?

At first blush, inappropriate health care sounds like a contradiction in terms. Isn't "care" by definition something that is necessary and appropriate, and if so, how is it possible to get too much? Such talk inevitably invites accusations of "rationing," drawing unfavorable comparisons to the United Kingdom's National Institute for Health and Clinical Excellence (NICE), an agency that determines whether or not to pay for benefits in the UK's government health system, based on clinical and cost-effectiveness standards. Cost-effectiveness is an important issue that both sides of the health reform debate have unfortunately not addressed, but inappropriate health care isn't necessarily expensive care. It's care that does nothing to improve your health.

Although many preventive health services (screening tests and counseling for health behavior change) have been shown to improve quality and length of life, many remain unproven or are associated with significant harms. In particular, screening for prostate cancer with the prostate-specific antigen (PSA) test, which has been performed on millions of American men since it became common medical practice in the early 1990s, is often inappropriate. While the potential benefits of PSA screening (fewer deaths from prostate cancer) are still being debated by experts, the harms - diagnosing slow-growing tumors that would never have caused symptoms or affected health - are no longer in doubt.

A recent study in the Journal of the National Cancer Institute shows why. Some experts have argued that the decline in the prostate cancer death rate seen in the U.S. over the past 2 decades proves that screening and early detection are saving mens' lives. Assuming that this were true, the authors calculate that for every life saved by screening, more than 20 men had to be diagnosed with prostate cancer (and more than 75% of these men chose to be treated with surgery or radiation).

Let me put this information in plainer terms. If you were told by your doctor that having the PSA test could lead to detection of prostate cancer, but that 19 times in 20, treatment would make no positive difference to your health, would you choose to have this testing? (In fact, the number may be as high as 47 in 48, according to a recent European study.) Consider that up to half of all men who are treated for prostate cancer experience erectile dysfunction or urinary incontinence. Unfortunately, this message isn't getting through to clinicians or patients - more than 75% of U.S. men over 50 have had at least 1 PSA test in the past 3 years. By any measure, that's too much health care.

Anonymity

Since I started this blog in July, I have chosen to restrict the posting of comments and responses to readers who were willing to identify themselves publicly. The rationale for this restriction was to protect the blog against spam message. However, as Common Sense Family Doctor's readership has slowly grown through the online grapevine and social networking sites such as Twitter, I have re-thought this strategy and have now decided, in the interest of making the blog more interactive and to foster more healthy (as opposed to unhealthy) debate, to allow anyone who reads to post responses, starting today. I still encourage you to identify yourself voluntarily, but if for some reason you don't want to, you won't have to. Please respect the usual conventions of online etiquette, e.g. do not use profanity of any kind, and take issue with ideas rather than the person advocating those ideas. We'll see how this goes - I'm hoping for the best.

Thanks,

Kenny Lin, MD