Health reform forecasts and the Great Society

Even the most die-hard NCAA basketball fans should concede that the major headline of the past weekend was not Northern Iowa upsetting Kansas or Cornell advancing to the Sweet 16, but the health reform reconciliation bill squeaking through the House of Representatives by a 7-vote margin. So should we be celebrating along with President Obama's crowd or throwing in our lot with the Tea Party? I'll dodge that question for now, but suggest that history provides a possible answer, or at least an analogy. In her acclaimed biography of President Lyndon Johnson, historian Doris Kearns (now Goodwin) wrote this about Johnson's relentless political pursuit of the mid-1960s social welfare agenda that would collectively come to be known as the "Great Society":

Even in the more familiar areas of public policy, the need for haste often resulted in a failure to define the precise nature and requirements of social objectives. Legislative solutions were often devised and rushed into law before the problems were understood. Since time was limited and agreement on ends could be assumed, since surely all reasonable men - especially those likely to be consulted by a liberal Democratic President - favored the elimination of poverty, the expansion of educational opportunity, and improvement in the delivery of medical care, most of the attention was focused on means. ... as if putting more money into a poorly conceived system will inevitably make it better. Pass the bill now, worry about its effects and implementation later - this was the White House strategy.

Sound familiar? A common critique that has been leveled at the health reform bill from both extremes of the political spectrum (those who want a Canadian-style single-payer health system and those who are basically fine with the status quo) is that it isn't real reform at all, but sinking billions of additional dollars we don't have into the current system. Of course, some will be quick to point out that one of Johnson's "hastily" enacted Great Society programs was Medicare, the health insurance program for senior citizens that is not by any means flawless, but has become so successful and widely accepted that opponents of "government-run health care" were forced into the paradoxical position of attacking the bill because it might threaten the generous benefits currently provided by Medicare.

Like picking who will emerge from this year's March Madness at the beginning of the season, it's much too early to correctly forecast whether this health reform bill - which may not survive the next round of Congressional elections - will turn out to be (like Medicare) a rousing success, an incremental improvement, or a catastrophic failure. Liberal commentators such as the Washington Post's Ezra Klein are already calling for additional reforms, while 11 states, fearing the possible effect of unfunded mandates on their battered budgets, plan to sue the federal government to prevent implementation of the bill. In the meantime, my thoughts on this topic are perhaps best summed up by the question I asked my wife (also a family physician) as we were listening to the final hours of floor debate while driving home on Sunday evening:

"So what are those 32 million newly covered people going to do when they get their health insurance cards and can't find a family doctor to see them?"

How fragmented U.S. health care endangers expectant moms

As I noted previously, the steady rise in the percentage of babies delivered via Cesarean section (currently just under 1 in 3 deliveries in the U.S.) is due in large part to "too much care" - a high-technology mindset that permeates training programs in obstetrics and gynecology, combined with a low tolerance for uncertainty driven by concerns about malpractice lawsuits. While surgical deliveries are sometimes unavoidable, it's clear that less interventional maternity care providers such as midwives and family physicians can spare many more women from having C-sections, with comparable maternal and infant health outcomes.

However, for many expectant mothers, the problem is too little care - poor access to prenatal care to poverty, a lack of health insurance, non-citizen status, or other barriers. "Deadly Delivery," a report released earlier this month by Amnesty International, chronicles the failure of the high spending U.S. health system to provide adequate prenatal care for 1 in 4 women, leading to a maternal mortality rate that ranks 41st in the world and has more than doubled over the past two decades. The report observes that 13 million women between the ages of 15 and 44 are uninsured, and many who become pregnant have trouble obtaining Medicaid coverage due to bureaucratic obstacles. Even women who obtain coverage have a hard time accessing care due to a shortage of maternity providers in rural and urban areas.

Living and working in the Washington, DC area since 2004, I've seen firsthand how difficult it is for uninsured women to get good prenatal care, despite a physician to population ratio that is one of the highest in the nation. It isn't surprising, then, that pregnant women in the District of Columbia have a risk of death that is nearly 3 times the national average, and more than 7 times the Healthy People 2010 goal of 4.3 deaths per 100,000 live births. The only five states that have achieved that goal are Massachusetts, Vermont, Minnesota, Maine, and Indiana. Interestingly enough, Massachusetts, Vermont, and Minnesota are #1, 2, and 3 in state rankings of the lowest percentage of the population without insurance. Coincidence? I think not.

Eminence-based medicine and prostate cancer treatments

Until the arrival of evidence-based medicine (EBM) movement in the 1980s, medical training and continuing medical education in the U.S. were guided by what might be called the other EBM, "eminence-based medicine" - that is, physicians made decisions about patients based largely on what their attending physicians taught them to do in medical school, what therapies respected colleagues told them to do, and what review articles written by those gray-haired eminences instructed them to do, regardless of what actually worked. By the time I entered training in the late 1990s, a few things had changed for the better, and useless or harmful therapies such as estrogen for menopause, high-dose chemotherapy with bone marrow transplanation for breast cancer, and drugs to suppress cardiac arrhythmias were exposed for what they were in randomized clinical trials.

But sadly, much of medicine continues to operate in an evidence-based vacuum, and nowhere is this state of affairs more painfully evident than with treatments for clinically localized prostate cancer (prostate cancer that is detected via a blood test and confirmed by microscopic examination of a biopsy sample, but causes no symptoms in the patient). Not only is there little reliable data to support choosing one type of therapy over another, for many men the option of deferring therapy (called "watchful waiting" or "expectant management") may be superior to all of them.

So how do men decide what therapy to choose for this condition? They consult physicians, which would be a sensible thing to do if different types of physicians actually agreed what therapy to recommend in specific situations. Unfortunately, a recent study published in the Archives of Internal Medicine confirms what I had already suspected from my own experience: eminence-based medicine is alive and well. Rather than rationally selecting therapies based on their personal health status, tolerance of uncertainty, and preferences for certain side effects over others, patients with prostate cancer overwhelmingly choose therapies based on the type of physician they happen to see. Men who visit a urologist between the time of cancer diagnosis and treatment are most likely to choose surgery, men who visit a radiation oncologist are most likely to choose prostate irradiation. Meanwhile, men who also visited their primary care physician were most likely to defer therapy regardless of what specialist they saw, but only 1 in 5 men in the study actually had a primary care consultation.

While the health care bill pending in the House of Representatives will not solve this problem, it does contain some essential elements: support for primary care, research on the effectiveness of common therapies, and support for unbiased organizations that evaluate this research to decide what is or is not a worthwhile use of limited health care resources. These are the necessary first steps to ending the era of eminence-based medicine.

Favorite Guest Blogs

This post links to a selection of moving poetry and short fiction pieces previously featured on Common Sense Family Doctor, mostly republished with permission from the Bellevue Literary Review and Pulse: Voices from the Heart of Medicine. Many thanks to the respective physician-editors of these stellar publications, Danielle Ofri and Paul Gross, for allowing me to share my favorites.

October 2009:
Medicine in Translation by Danielle Ofri

November 2009:
Anatomy Lesson by Nellie Hill
Thanksgiving: Visiting My Brother on the Ward by Peter Schmitt

December 2009:
The Rudeness by Rick Kempa
Cleft by Jon Neher

January 2010:
Having an MRI/Waiting for Laundry by Jan Bottiglieri
Cure by Veneta Masson

February 2010:
Johnny Doe by Yvonne Estrada
Reflections from a Senior Citizen by Dorothy Kligerman

If you enjoy what you read here, please consider subscribing to these literary magazines and/or purchasing their "best of" collections, The Best of the Bellevue Literary Review and Pulse: The First Year.

The decline of VBAC: hearing hoofbeats, thinking zebras

My daughter, who turns two years old in June, is becoming something of a medical rarity. This isn't because she is showing signs of a late-developing handicap or extraordinary ability for her age - it's because she came into the world as a vaginal birth after Cesarean section (VBAC), delivered by a certified nurse midwife. Although more than three-quarters of women who choose a trial of labor over a repeat Cesarean section successfully deliver vaginally, studies showing slightly elevated risks of rupture or infection of the uterus with VBAC, pressure from insurance companies concerned about lawsuits, and restrictive medical guidelines discourage most women from even trying. After reaching a high in 1996 of 28.3 percent of women who previously delivered by Cesarean, the national VBAC rate today is fewer than 1 in 10. As a result of all of these repeat Cesareans, 1 in 3 births in the U.S. today occur by Cesarean.

For the past two days, a conference at the National Institues of Health has sought to understand the reasons for the decline of VBAC, and what might be done to reverse what most believe to be a negative trend. Later this morning, an independent panel will release a draft statement summarizing the take-home points from the conference. What the statement probably won't say, but what I believe to be a large part of the truth, is that the U.S. has such a low VBAC and high Cesarean rate because Ob/Gyns deliver most of our babies, and Ob/Gyns aren't primary care clinicians.

The old medical maxim "when you hear hoofbeats, think horses, not zebras" refers to the fact that common conditions are more likely to present than rare or estoteric conditions. A dry cough, for example, is more likely to be due to allergies than Erdheim-Chester disease. Vomiting and diarrhea are much more likely to be caused by rotavirus than Vibrio vulnificus. Primary care clinicians internalize this maxim during their community-based training programs; specialist physicians - who spend most of their training learning to diagnose and treat "zebras" at academic medical centers where patients with uncommon conditions are referred for care - typically abandon it early on. And even though many women visit Ob/Gyns for routine gynecologic care, when it comes to the primary care-specialist attitude divide, Ob/Gyns come down clearly on the side of the specialists.

I could offer lots of anecdotes about why the above is true from having worked with Ob/Gyn physicians throughout medical school and residency training (when I delivered more than 80 babies and assisted in about half as many Cesarean sections), but objective data support the notion that labor managed by family physicians and professional midwives is considerably more likely to result in a vaginal birth than labor managed by an Ob/Gyn, even controlling for factors such as maternal age and risk status. It isn't difficult to understand why. If an Ob/Gyn is feeling uncertain about how well a patient's labor is progressing and has an inflated estimate of the probability that something might go wrong (the zebra), it's very hard to resist the temptation to eliminate the uncertainty by delivering the baby surgically, then and there. On the other hand, if the surgeon is at least a phone call away (the American Academy of Family Physicians' 2005 guideline on trial of labor after Cesarean noted that there's no good evidence that having a 24-hour on-call surgeon and anesthetist in-house improves maternal or infant outcomes), the family physician or nurse midwife might be more patient with the hoofbeats, betting they're hearing a horse. And, in fact, in a 2004 study of nearly 18,000 women who attempted VBAC, the most feared complication of uterine rupture (which requires an emergency Cesarean), occurred in less than 1 percent of cases. As mentioned earlier, a trial of VBAC is successful more than 75 percent of the time. It's a real shame that women in the U.S. are discouraged from attempting them more often.

The best recent posts you may have missed

Every other month or so, I 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 are my favorites from January and February:

1) The dark side of "cancer awareness" (1/30/10)

2) Hospitalists: complicating continuity of care (1/7/10)

3) Life, death, and organ transplantation (1/21/10)

4) Of gatekeepers and unbridled imaging technologies (2/4/10)

5) Does patient-centered health care mean never saying "no"? (2/22/10)

If you have a personal favorite that isn't on this list, please let me know. As always, thank you for reading!

Book Review: The Immortal Life of Henrietta Lacks (Part 2)

This is the second of two posts, completing my review of Rebecca Skloot's The Immortal Life of Henrietta Lacks. The first post appeared on this blog on February 27.

**

In pursuit of eye-catching headlines, science journalists, and especially medical journalists, frequently overdramatize each new drug or treatment, each successful basic science experiment, as a historic "breakthrough." Few really are, and it is especially hard to assess the impact of laboratory work at the time that it happens. But it didn't take long for George Gey and the members of his lab to recognize that Henrietta Lacks' cervical cancer cells were something special. He was soon shipping HeLa cells to researchers all over the world, including Jonas Salk, who used vast quantities of HeLa cells in a field trial of polio vaccine in 2 million U.S. children. On a less heroic note, HeLa cells also found their way to Chester Southam, a virologist who injected them into hundreds of prison inmates and surgical patients (without getting informed consent) to study how the immune system fought off cancer.

In the meantime, Henrietta's surviving family members were struggling just to scrape by. Her daughter, Deborah, who is the second heroine of this book, became pregnant at 16 and contended with an abusive and drug-addicted husband. Henrietta's youngest son, Joe, was abused as a child and later went to prison for second-degree murder. Not until the mid-1970s, more than two decades after their mother's death, did they begin to learn about their mother's immortal cells' contributions to science. Stunned and confused by the news, and angered by the inaccurate but persistent portrayal of Henrietta's tumor sample as a "donation," the Lacks family eventually stopped talking to reporters - that is, until Rebecca Skloot came along in the late 1990s.

I asked Rebecca what had driven her to keep pursuing this story when it was clear that the Lacks family initially had no interest in speaking to her (on several occasions, she was stood up or hung up on by various family members). She said part came from just being hard-headed, but the deeper she dug, the more fascinating the story became, and the more determined she became that it would eventually be told. Skloot had no idea that the book would sell even modestly well, much less become a bestseller (which it now is, ranking #3 on the New York Times hardcover nonfiction list as of this writing).

Although the narrative of the science accomplished thanks to HeLa cells could have carried the book all by itself, the story of the Lacks family and Skloot's stubborn quest to help them understand and come to terms with Henrietta's contribution to that science are what make it truly exceptional. So go out and buy the book, and also know that charitable donations can be made to the Henrietta Lacks Foundation, a non-profit organization set up by Skloot to pay for health care and education expenses of Henrietta's descendants.

The Presidential Physical

Based on standards set by the U.S. Preventive Services Task Force (USPSTF), the widely respected independent committee of primary care health professionals that for more than 25 years has rigorously reviewed the evidence for benefits of clinical preventive services, President Obama's recent physical examination contained at least 3 screening tests that were either unnecessary or of uncertain health benefit. These tests included:

A prostate-specific antigen (PSA) test for prostate cancer. In 2008, the USPSTF found insufficient evidence that this test reduced mortality from prostate cancer, and 2 subsequent long-term studies of PSA screening published in March 2009 reported no mortality benefit and a very small survival benefit limited to men ages 55 to 69 years, respectively. (President Obama is 48 years old.)

A coronary calcium scan for coronary heart disease. In 2009, the USPSTF found insufficient evidence that patients who test positive and receive treatment for coronary artery blockages have fewer heart attacks compared to similar patients who don't have the test.

CT colonography ("virtual colonoscopy") for colorectal cancer. Most guidelines, including the USPSTF's, recommend that colorectal cancer screening start at age 50 in persons without a family history. However, in 2008 the USPSTF found insufficient evidence that CT colonography was as effective as older, established tests such as fecal occult blood testing and optical colonoscopy, exposed patients to higher doses of radiation, and commonly leads to unforeseen consequences of incidental scan findings in other parts of the abdomen. Based largely on these concerns, in 2009 the Centers for Medicare and Medicaid Services declined to extend Medicare coverage to CT colonography.

A colleague of mine argued that the Leader of the Free World might be subject to different standards than you and me, given the psychological impact it would have on the nation and the world were President Obama to be suddenly felled by a heart attack or belatedly diagnosed with metastatic prostate or colorectal cancer. But this argument cuts both ways. What if his PSA test (reportedly a normal 0.70) had been slightly high, leading to a prostate biopsy that showed a low-grade cancer? Or if the coronary calcium scan had suggested a non-critical blockage in a coronary artery? Or if CT colonography had picked up a suspicious mass on a kidney that couldn't be distinguished from cancer? All of these results would have potentially been false positives, but would have required additional invasive diagnostic tests and treatments with important adverse effects.

The experience of the late President Reagan, who underwent surgery during his Presidency to remove an apparently malignant colon tumor, reminds us that even the perception of poor Presidential health can dramatically affect the psyche of the nation. So regardless of your political persuasion, we should probably be happy that President Obama's physicians gave him a "clean bill of health" this time around. At any rate, I hope that they counseled him to stop smoking and offered medications to help him quit - a preventive service that the USPSTF reaffirmed in 2009 with an unequivocal "A" recommendation.