Public Speaking Update

Since I began blogging at Common Sense Family Doctor in July 2009, its posts have been featured in widely read blogs such as KevinMD.com, Better Health, The Health Care Blog, and Gary Schwitzer's HealthNewsReview, as well as the websites of major national newspapers such as the New York Times, the Wall Street Journal, and the Boston Globe.

Like the vast majority of physicians who blog, I write in my spare time. I have never accepted advertising or paid web links on Common Sense Family Doctor, and the choices of topics for posts are my own and not influenced by financial or other conflicts of interest. In order to support the time I devote to blogging, and to encourage high-quality medical writing and clinical practice, I give lectures and workshops to medical and non-medical audiences on a variety of topics. These include the uses of social media tools in medicine and education, developing and implementing medical guidelines, and the evidence supporting specific prevention recommendations. If you or your organization would like to invite me to speak, please e-mail me at linkenny@hotmail.com or KWL4@georgetown.edu.

Upcoming Events

Identifying and Using Good Practice Guidelines
36th Semi-Annual Family Practice Review Course
Temple University School of Medicine / Lancaster General Hospital
- March 12, 2012

Why You Should Stop Screening for Prostate Cancer
Journal Club, Preventive Medicine Residency
Uniformed Services University of the Health Sciences
- January 18, 2012

Cancer Screening: A Primer for Journalists
National Press Foundation
- December 14, 2011

Lists of my previous presentations and selected publications are available on other pages of this blog.

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 October and November:

1) In praise of individual health mandates (11/1/11)

2) Rethinking the war on drugs (11/8/11)

3) The meeting that wasn't, revisited (10/5/11)

4) Family physicians and the Goldilocks principle (10/13/11)

5) Solo practice: a disruptive innovation? (10/10/11)

If you have a personal favorite that isn't on this list, please let me know. Happy Thanksgiving!

"Pure Custer": our obsession with a flawed screening test

In the face of accumulating evidence and a U.S. Preventive Services Task Force finding that PSA screening for prostate cancer does more harm than good, the most frequent response I hear from physicians who continue to defend the test is that PSA is all we have, and that until a better test is developed, it would be "unethical" to not offer men some way to detect prostate cancer at an asymptomatic stage. (However, these physicians for the most part don't question the ethics of not offering women screening for ovarian cancer, which a recent randomized trial concluded provides no mortality benefit but causes considerable harms from diagnosis and treatment.)

I'm currently reading historian Stephen Ambrose's dual biography of Oglala Sioux leader Crazy House and Civil War cavalry general George Armstrong Custer, whose troops were routed by the Sioux at the famous Battle of Little Bighorn in 1876. One premise of the book is that the same aggressive instincts that served Custer so well during the Civil War - to always attack, even when the strength and disposition of his enemy was unknown - became fatal flaws when he became an "Indian fighter." For most of his post-Civil War career, Custer and his men blundered around the Great Plains looking for someone to fight, and not particularly caring if the Indians he engaged in battle were actually at war with the U.S. Army. In one telling description of Custer's first major Western engagement, Ambrose writes:

Here was audacity indeed. ... Custer had no idea in the world how many Indians were below him, who they were, or where he was. His men and horses were exhausted. ... He was going to attack at dawn from four directions at once. He had made no reconnaissance, held nothing back in reserve, was miles away from his wagon train, and had ordered the most complex maneuver in military affairs, a four-pronged simultaneous attack. It was foolish at best, crazy at worst, but it was also magnificent and it was pure Custer.

If readers of American Indian descent will kindly forgive my making this analogy with their 19th century ancestors, this passage is strikingly similar to the way we diagnose and manage prostate cancer. The vast majority of American Indians by this time had either signed peace treaties or were content to leave settlers alone. Under pressure to "do something" about a few troublesome tribes, however, the U.S. Army sent the overaggressive Custer out to do battle with whatever "warriors" he could find, assuming that in the process he would either kill, capture, or scare off those who aimed to do them harm.

That's pretty much what we do by deploying the PSA test to screen for prostate cancer. We cast as wide a net as possible, doing harm at every step of the way: false positives, adverse effects of prostate biopsies, and overdiagnosis and overtreatment of abnormal-appearing cells that we identify - usually inaccurately - as potentially lethal. For every man whose life may be extended by treatment, 30 to 50 will be treated for no benefit, and 10 to 20 will sustain permanent physical harm. And our continuing obsession with this flawed screening test not only flies in the face of evidence, it's pure Custer.

Graham Center: Integrate mental health into primary care

Based in part on a positive recommendation from the U.S. Preventive Services Task Force, the Centers for Medicare and Medicaid Services recently announced that it will cover annual depression screenings for Medicare patients in primary care settings "that have staff-assisted depression care supports in place to assure accurate diagnosis, effective treatment and follow-up." However, as the below Figure illustrates, translating the USPSTF guideline into practice has been challenging for many primary care physicians.

A Policy One-Pager from researchers at the Robert Graham Center, published in the November 1st issue of American Family Physician, details the obstacles that clinicians face in identifying and treating depression and other mental health problems. As Dr. Robert Phillips and colleagues observe, "Current health care policy makes it difficult for most primary care practices to integrate mental health staff because of insufficient reimbursement, mental health insurance carve-outs, and difficulty of supporting colocated mental health professionals, to name a few."

On a related note, an editorial in the same issue discusses strategies for improving adult immunization rates, which have historically lagged far behind rates of immunizations in children. According to Dr. Alicia Appel, immunization registries and electronic clinical decision-support systems can complement low-tech interventions such as patient reminders and standing orders. Clinicians, what has been your experience with incorporating depression screening and immunizations into routine health care for adults?

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The above post was first published on the AFP Community Blog.

Rethinking the war on drugs

A couple of years ago, I served for several weeks on a grand jury for the Superior Court of the District of Columbia. Mine was designated a RIP (Rapid Indictment Protocol) jury, assigned to efficiently hand down indictments for small drug-related offenses. These cases usually involved undercover officers posing as customers making purchases from street dealers, or uniformed police stopping suspicious vehicles and searching them for drugs. Although rarely we heard testimony about defendants caught with thousands of dollars of contraband, the vast majority of offenses were possession of small amounts of marijuana, heroin, or cocaine for "personal use." Many of the latter defendants had multiple such offenses, which had resulted in probation, "stay away" orders (court orders to avoid certain neighborhoods where drugs were highly trafficked), or brief stints in jail. Few, if any, had received medical treatment for their addictions.

After a few weeks of hearing these cases, my fellow jurors and I grew increasingly frustrated with this state of affairs. We felt like a cog in a bureaucratic machine, fulfilling a required service but making little difference in anyone's lives. A young man or woman caught using drugs would inevitably return to the street, violate the terms of his or her probation or "stay away" order, and be dragged before our grand jury again for a new indictment. We openly challenged the assistant district's attorneys about the futility of the process. They would just shrug their shoulders and tell us that was the way things were, and it wasn't our job to come up with a better strategy for dealing with illegal drug use. True enough, but then again, whose job was it?

An article by Michael Specter in the October 17th issue of the New Yorker reports on the recent experience of Portugal in decriminalizing personal drug use. To an American physician accustomed to our endless war on drugs, what Portuguese authorities did was hard to imagine: "For people caught with no more than a ten-day supply of marijuana, heroin, ecstasy, cocaine, or crystal methamphetamine - anything, really - there would be no arrests, no prosecutions, no prison sentences. Dealers are still sent to prison, or fined, or both, but, for the past decade, Portugal has treated drug abuse solely as a public-health issue." Rather than being paraded before grand juries for ritual convictions, people caught using drugs in Portugal are instead summoned before a 3-person panel (a judge, doctor, and psychologist or social worker) and assigned to counseling and medical treatment for their addictions.

Did this new policy result in an explosion in the number of Portuguese drug users, no longer cowed by the prospect of criminal prosecution? Hardly. In the words of a chief police inspector who initially resisted the change in tactics:

In the last years before the law, consumers were arrested by police. ... They were fingerprinted and made statements and took mug photos and were presented to court. And always, always, always released. It was a waste of everyone's time. It didn't stop drug use or slow down the dealers. So the idea that somehow people are getting away with what they did not get away with before is silly.

A public health approach to the consequences of illegal drug use in the U.S. might include increasing support for needle exchange programs, which have been banned from receiving federal funding for years but have been repeatedly shown to reduce rates of HIV transmission in controlled studies. Unfortunately, our inherent discomfort with such "permissive" interventions often gets in the way of recognizing the evidence that our current punitive approach to drug use is more harmful than beneficial to drug users and society in general. As Specter concludes:

It is common in the U.S. to judge drug addiction morally rather than medically, and most policy flows from that approach. ... Yet one has only to look at the American health-care system to be reminded that neither science nor evidence necessarily drives public-policy decisions. ... While it would make no sense to base American policy [toward drug use] on a decade-long Portuguese experiment, it seems even more foolish to ignore results that call so clearly for an increased focus on treatment, not jail time.

PSA and the Presidential Physical

Earlier this week, the White House released the results of President Obama's periodic physical examination. Pronounced "fit for duty" by his personal physician, the President, who turned 50 earlier this year, had an unremarkable examination and normal blood sugar and cholesterol levels. Also, it seems that he's finally managed to stop smoking - good for him. Interestingly, President Obama went against the advice of the U.S. Preventive Services Task Force and chose to receive a screening prostate-specific antigen test (which was normal), but, perhaps in recognition of the Task Force's recent finding that the PSA's harms outweigh its benefits, his physician felt it necessary to note in parentheses that this was an "informed patient request." There's no indication whether or not the President used any shared decision aids (such as this one from the Family Medicine department at Virginia Commonwealth University) to decide to undergo screening, but given the lengths his Administration went to prevent the new prostate recommendations from being released in the first place, this surely represents a small victory of science over politics.

Here's what I wrote on March 1, 2010 about the President's previous physical examination.

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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.

In praise of individual health mandates

Last month, my family was involved in a scary traffic accident en route to the Family Medicine Education Consortium's North East Region meeting. I was in the left-hand eastbound lane of the Massachusetts Turnpike when a westbound tractor trailer collided with a truck, causing the truck to cross over the grass median a few cars ahead of us. I hit the brakes and swerved to avoid the truck, but its momentum carried it forward into the left side of our car. Strapped into child safety seats in the back, both of my children were struck by shards of window glass. My five year-old son, who had been sitting behind me, eventually required twelve stitches to close a scalp laceration. Miraculously, none of the occupants of the other six damaged vehicles, including the truck driver, sustained any injuries.

Family physicians like me, and physicians in general, like to believe that the interventions we provide patients make a big difference in their eventual health outcomes. In a few cases, they do. But for most people, events largely outside of the scope of medical practice determine one's quality and length of life, and public health legislation is more likely to save lives than the advice of well-meaning health professionals. My colleagues can counsel parents about car seat safety until they're blue in the face, but state laws requiring that young children be belted into car safety seats are what made the difference for my son between a scalp laceration and a life-threatening injury.

The often-derided individual health insurance mandate that is a prominent feature of the 2005 Massachusetts law and the 2010 national health reform law is often compared by supporters to car insurance. If governments can require drivers to be financially responsible for their cars, the argument goes, why can't they require people to be financially responsible for their health-related expenses? The hole in this argument, of course, is that people aren't required to own cars the way that they "own" their bodies. But even the millions of children too young to drive and adults who choose not to are required to use seat belts or safety seats whenever they are passengers.

That, to me, seems to be the more apt comparison. As insurance against unexpected accidents and injuries, laws requiring seat belts and child safety seats are, essentially, individual health mandates. And constitutional challenges aside, it's well past time that all Americans buckled up.