Common Sense Family Doctor in 2012: a preview

I thought about titling this post "All I Wanted For Christmas was Common Sense Family Doctor," but decided that it was presumptuous to assume you would prefer reading a collection of my blog posts to receiving, say, a new IPad, Nook, or Kindle Fire. (For readers who want both types of gifts, I hope to make Common Sense Family Doctor available on those e-readers at some point in the future, as well as in a more traditional book format.)

Here is a sneak preview of a few topics that I plan to write about after the New Year:

1) Costs and charges of health care - As you may know if you have been reading this blog from the beginning, the hospital bill for my second child (a normal spontaneous vaginal delivery) was $8,569.27, a staggering sum of money that the hospital couldn't begin to explain in an itemized bill, and of which our then-health insurance company ultimately wrote off more than 40 percent and we paid $100. Now that my wife is covered by health insurance with a 20 percent deductible on all medical services other than preventive care (alas, though the Institute of Medicine has decreed that pregnancy prevention counts as preventive care, bringing a new life into the world does not), we're naturally very interested in what the bill for our soon-arriving third child might be. I'll detail our extensive efforts to pin down the same hospital on  its usual maternity care charges, and explain why it's so hard in the current health financing environment for patients to get any straight answers about health care costs.

2) Dissecting American Health Care - I first met former Assistant Surgeon General and current RTI International Chief Scientist Doug Kamerow, MD while precepting Family Medicine residents at the Fort Lincoln Family Medicine Center seven years ago, and since then he's written dozens of short essays for National Public Radio and BMJ on a variety of health care-related topics, now collected into a terrific book that was recently reviewed by patient advocate Jessie Gruman at the Prepared Patient Forum. I'll review highlights from my favorite Kamerow commentaries and explain how his perspectives point the way toward future reforms of our broken health system.

3) Cancer and the media - Building on a cancer screening talk that I gave to reporters at the National Press Foundation a few weeks ago, I will explore the pitfalls of reporting on cancer news and ways to improve communication about the latest research findings on screening tests and treatments to the public. Gary Schwitzer's recently renamed Health News Watchdog Blog has covered much of this territory already, but I hope to add some unique contributions to the dialogue from my experiences as a practicing family physician, teacher, researcher, and consumer health blogger.

My very best to you and yours for a happy and healthy 2012!

Kenny Lin, MD

23 1/2 hours

That's the title of this thoroughly enjoyable and informative lecture on the benefits of regular exercise by Canadian family medicine educator Mike Evans, MD. It's definitely worth 9 minutes of your time.

Guest Blog: My BHAG for Family Medicine

Jennifer Middleton, MD is a family physician and residency faculty member with whom I recently gave a social media presentation at the Family Medicine Education Consortium's annual Northeast meeting. The following post originally appeared on her blog, The Singing Pen of Doctor Jen.

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I have a BHAG (Big Hairy Audacious Goal).

I want people to hear "Family Medicine" and know that it refers to a medical specialty dedicated to providing relationship-based, patient-centered health care.

I want people to know that family docs take care of a lot of complicated, challenging diseases - and not usually in isolation. Our patients have high blood pressure, complications from type 2 diabetes, congestive heart failure, depression, chronic kidney disease, emphysema, anxiety, asthma, and coronary artery disease, to name a few; treating each of those conditions individually is nothing like treating them in relation to each other.

I want people to know that I trained for three years to become an expert in my specialty. During my Family Medicine residency, I learned about providing preventive care. I learned how to treat a multitude of acute problems - colds, fractures, lacerations, rashes, etc. I learned how to deliver babies, resuscitate victims of cardiac arrest, and drop a central line into a coding patient. I can take off your moles, skin tags, and warts. I can remove your ingrown toenail and treat your acne. I can obtain your pap smear, discuss your birth control options, and treat your STDs.

I want people to know that I can care for your kid and your grandparent. I routinely counsel teens about sex, drugs, and rock 'n' roll. I am comfortable in offices, hospitals, maternity wards, newborn nurseries, intensive care units, nursing homes, and even patients' homes.

I want people to know that Family Medicine residents learn about using the best medical evidence and the latest medical technology to guide decision-making conversations with patients. They can intelligently sift through the tremendous reams of medical studies that are published daily to pull out the information most relevant to their patients.

I want people to know that those residents learn how to work within a healthcare team. Nurses, medical assistants, pharmacists, care managers, social workers, administrative staff - it takes all of us to provide outstanding care. These incredibly important people are my hands, eyes, and ears into the thousands of little tasks that must get done every day in the office and at the hospital.

I want people to know that no medical specialty is as devoted to medical education as Family Medicine. The Society of Teachers of Family Medicine holds an annual meeting devoted solely to medical student education. We are one of only a handful of medical specialties with an entire fellowship (post-residency training) devoted to faculty development - training the next generation of academic Family Medicine teachers, researchers, and leaders.

Lastly, I want people to know that family docs do everything that they do in the context of our patients' belief systems, families, and communities. Our specialty is the only one that mandates dozens of hours of educational time during residency about the doctor-patient relationship. How to help folks quit smoking/over-eating/whatever, how to tell someone that the biopsy did show cancer, how to mediate family disagreements about end-of-life wishes - this behavioral instruction is just as important to a Family Medicine resident as the pathophysiology, treatment, and prevention of disease.

If you're not a family doc, I bet you didn't know all of those things. And the blame for that truth lies squarely with us as family docs. Frankly, other specialties have been better than us at promoting themselves. You all likely know what a dermatologist or a cardiologist is, even if you're not working in the medical field. Family docs can learn a lot from how other specialties have advanced the interests of their patients by advancing their specialty's cause; it's something we have failed to recognize the importance of until now.

Because of that failure, Family Medicine is not understood - and thus not valued - by the public, by politicians, by health plan administrators, and by too many of the other people who make decisions about health care in this country.

We need to show them what Family Medicine is all about.

My BHAG is to share Family Medicine with the people who don't know about us yet. I hope that this blog does that in some small way; certainly, many of the Family Medicine bloggers and tweeters out there are doing it in a bigger way.

But, I don't think that's enough. We need more. We need an #FMRevolution. I have to believe that there's something even bigger, hairier, and more audacious that we could do. I wish that I knew just what that that big, hairy, audacious thing was. Fortunately, though, I am but one of many.

It will take all of us to get the chorus of Family Medicine to echo across our nation.

Striking back at the true rationers of health care

In February, I predicted that Don Berwick would not survive the partisan politics surrounding his recess appointment as administrator of CMS (Centers for Medicare and Medicaid Services), and regrettably, Dr. Berwick indeed stepped down from that position last week despite a number of notable accomplishments in his too-short tenure. Speaking yesterday at the annual national forum of the Institute for Healthcare Improvement, which he led for nearly two decades, Dr. Berwick struck back fiercely at politicians who have used the myth of "death panels" to oppose health reform efforts, and others who he called the "true rationers" of health care. In his own words:

Cynicism grips Washington. It grips Washington far too much, far too much for a place that could instead remind us continually of the grandeur of democracy. ... Cynicism diverts energy from the great moral test. It toys with deception, and deception destroys. Let me give you an example: the outrageous rhetoric about “death panels” – the claim, nonsense, fabricated out of nothing but fear and lies, that some plot is afoot to, literally, kill patients under the guise of end-of-life care. That is hogwash. It is purveyed by cynics; it employs deception; and it destroys hope. It is beyond cruelty to have subjected our elders, especially, to groundless fear in the pure service of political agendas.

The truth, of course, is that there are no “death panels” here, and there never have been. The truth is that, as our society has aged and as we have learned to care well for the chronically ill, many of us face years in the twilight our lives when our health fades and our need for help grows and changes. Luckily, palliative care – care that brings comfort, company, and spiritual and emotional support to people with advanced illness and their families – has grown at its best into a fine art and a better science. The principle is simple: that we can and should offer people the very best of care at all stages of their lives, including the twilight.

The truth is, furthermore, that patient-centered care demands that the ways in which a person is cared for ought always to be under his or her control. The patient is the boss; we are the servants. They, not others, should direct their own care, and the doctors, nurses, and hospitals should know and honor what the patient wants. ... It is one of the great and needless tragedies of this stormy time in health care that the “death panel” rhetoric has denied patients the care that they want, denied caregivers the information they need to give that care, and denied our nation access to a mature, open, informed, and balanced discussion of the challenge of advanced illness and the commitment to individual dignity. It is a travesty.

If you really want to talk about “death panels,” let’s think about what happens if we cut back programs of needed, life-saving care for Medicaid beneficiaries and other poor people in America. What happens in a nation willing to say a senior citizen of marginal income, “I am sorry you cannot afford your medicines, but you are on your own?” What happens if we choose to defund our nation’s investments in preventive medicine and community health, condemning a generation to avoidable risks and unseen toxins?

Maybe a real death panel is a group of people who tell health care insurers that it is okay to take insurance away from people because they are sick or are at risk for becoming sick. Enough of “death panels”! How about all of us – all of us in America – becoming a life panel, unwilling to rest easy, in what is still the wealthiest nation on earth, while a single person within our borders lacks access to the health care they need as a basic human right? Now, that is a conversation worth having.

And, while we are at it, what about “rationing?” The distorted and demagogic use of that term is another travesty in our public debate. In some way, the whole idea of improvement – the whole, wonderful idea that brings us –thousands – together this very afternoon – is that rationing – denying care to anyone who needs it is not necessary. That is, it is not necessary if, and only if, we work tirelessly and always to improve the way we try to meet that need.

The true rationers are those who impede improvement, who stand in the way of change, and who thereby force choices that we can avoid through better care. It boggles my mind that the same people who cry “foul” about rationing an instant later argue to reduce health care benefits for the needy, to defund crucial programs of care and prevention, and to shift thousands of dollars of annual costs to people – elders, the poor, the disabled – who are least able to bear them.

When the 17 million American children who live in poverty cannot get the immunizations and blood tests they need, that is rationing. When disabled Americans lack the help to keep them out of institutions and in their homes and living independently, that is rationing. When tens of thousands of Medicaid beneficiaries are thrown out of coverage, and when millions of Seniors are threatened with the withdrawal of preventive care or cannot afford their medications, and when every single one of us lives under the sword of Damocles that, if we get sick, we lose health insurance, that is rationing. And it is beneath us as a great nation to allow that to happen.

Managing symptoms in end-of-life care

Family physicians who care for terminally ill patients must manage a wide range of bothersome symptoms, including pain, fatigue, dyspnea, delirium, and constipation. According to a Cochrane for Clinicians article in the December 1st issue of American Family Physician, constipation affects up to half of all patients receiving palliative care and nearly 9 in 10 palliative care patients who use opioid medications for pain. Unfortunately, a Cochrane systematic review found limited evidence on the effectiveness of laxatives in these patients, as Dr. William Cayley Jr. comments:

For patients with constipation, especially those with opioid-induced constipation, there is insufficient evidence to recommend one laxative over another. The choice of laxatives should be based on past patient experience, tolerability, and adverse effects. Methylnaltrexone is a newer agent that may be useful especially for patients with opioid-induced constipation that has not responded to standard laxatives, but there is limited evidence of potential adverse effects. Therefore, judicious use preceded by a discussion with patients about known risks and benefits is warranted.

The Cochrane Library recently discussed this review in its Journal Club feature, which includes open access to the full text of the review, a podcast by the authors, discussion points, and a Powerpoint slide presentation of the review's main findings.

Additional resources for physicians and patients on advanced directives, hospice care, and ethical issues are available in the AFP By Topic collection on End-of-Life Care.

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

The vital role of guideline narratives

A few weeks ago, I presented Family Medicine Grand Rounds at Georgetown University School of Medicine on resolving conflicts between screening guidelines. During the question and answer session, Department Chair James Welsh, MD asked how evidence from carefully conducted clinical trials can possibly overcome powerful emotional stories of "saved lives." I answered that evidence-based medicine's supporters must fight anecdotes with anecdotes. For every person who believes his or her life was extended by a PSA test or a mammogram, statistics show that many more are temporarily or permanently injured as a result - and their stories matter too. As blogger Kevin Pho, MD wrote about the USPSTF's recent prostate cancer guideline, "Task Force advocates will need to put a human face on the complications stemming from prostate cancer screening" in order to convince physicians and patients that it's okay to stop. Indeed, news stories about PSA test-related complications such as this one by Associated Press writer Marilynn Marchione will go a long way in balancing the scales.

An insightful commentary published in JAMA last month took this point one step further by asserting that narratives deployed to support evidence-based guidelines should include not only patients' stories, but the story of the guideline developers themselves:

Typically, experts present a “clean” version of their findings without any narrative about how they made sense of the data. This fulfills the scientific virtues of objectivity, coherence, and synthesis. When the USPSTF released its report on screening mammography to much controversy, it included no narrative about the process. Only later was the story of the task force deliberations revealed. This narrative, with multiple characters operating within the context of historical precedents, timing mandates, and a messy political milieu, created a substantially more compelling perspective. But the account came too late to engage a confused and angry public with the task force's conclusions.

Guideline developers could include as part of their reports the narrative of their internal workings: We started with what we knew, we looked at the evidence, we revisited our hypotheses, we argued about the findings, and ultimately we acted here and now because it was prudent, but there are more data to come, and here is what we plan to do as we learn more. Such stories could increase trust and therefore improve the translation of evidence for individual use and public policies.

I attended both of the Task Force's 2008 meetings when screening mammography was debated, and the difference between them spoke volumes. During the first meeting, the panel deadlocked multiple times over whether to recommend for ("B") or recommend against routinely ("C") mammograms for women in their 40s. Both sides made impassioned arguments in favor of their points of view, and after running hours beyond the time allotted for discussion, they finally admitted that they were unable to reach a consensus. In contrast, at the second meeting when the results of a new decision analysis were presented, there was - to everyone's great relief - near-unanimity that the benefits and harms of screening were closely balanced in this age group. (Incidentally, the Canadian Task Force on Preventive Health Care recently concurred with the USPSTF's 2009 recommendations.)

Given the potential for narratives to humanize guidelines for the public, it was disappointing that the USPSTF's first Report to Congress offered a thoroughly sanitized description of the lengthy and challenging process by which it identified and prioritized research gaps in clinical preventive services. This process, which I participated in as a medical officer, consisted of a series of spirited debates over more than two years about thorny questions such as: 1) Is there an objective, defensible way to prioritize certain preventive services more than others? 2) Is it more important to support research on services with insufficient evidence that are already in widespread practice (e.g., PSA tests), or less commonly provided services with potentially large benefits (e.g., CT scans for lung cancer)? Unfortunately, the Report doesn't even begin to hint at how we grappled with these and other contentious issues, much less the multiple impasses that were reached and eventually overcome.

Consequently, I couldn't agree more with the elegantly stated conclusion of JAMA commentators Drs. Zachary Meisel and Jason Karlawish:

Stories help the public make sense of population-based evidence. Guideline developers and regulatory scientists must recognize, adapt, and deploy narrative to explain the science of guidelines to patients and families, health care professionals, and policy makers to promote their optimal understanding, uptake, and use.

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.

"Making people sick in the pursuit of health"

I'm traveling to Boston tomorrow to participate in a panel discussion on Friday for this year's William J. Bicknell Lectureship at the Boston University School of Public Health. The keynote speaker is H. Gilbert Welch, MD, MPH, author of the books Should I Be Tested For Cancer? Maybe Not and Here's Why and Overdiagnosed: Making People Sick in the Pursuit of Health, which I reviewed in a previous blog post. Here's an excerpt to give you a flavor of that review:

As H. Gilbert Welch and colleagues argue convincingly in their new book, ... much of the rise in cancer diagnoses over the past several decades has been the result of overdiagnosis: the detection (through screening or incidental finding on medical images obtained for other reasons) of cancers that would otherwise never have caused problems for patients. In the absence of screening, patients would not have developed symptoms because the "cancer" would not have progressed, or the patient was destined to die from some other cause (typically, heart disease). In the presence of screening, however, they suffer the psychological effects of knowing that they have cancer, the complications of diagnostic procedures, and the consequences of unnecessary treatments.

Seen in this light, the rise in cancer survivorship is not a modern medical success story. For millions of patients who received diagnoses that they didn't need and would do nothing to improve their health, it is a catastrophe.

BU Today just published a nice interview with Dr. Welch that connects the theme of overdiagnosis with the U.S. Preventive Services Task Force's recent draft recommendation against PSA screening for prostate cancer and his sobering new paper in the Archives of Internal Medicine that estimates the likelihood that a patient with screen-detected breast cancer has had her "life saved" to be less than 15 percent.

I am very much looking forward to meeting Dr. Welch and fellow panelists Deborah Bowen and John Fallon and having a terrific discussion!

Screening tests that do more harm than good

The U.S. Preventive Services Task Force may have been slow to finalize new recommendations recently, but the same can't be said for its main Evidence-Based Practice Center at Oregon Health and Science University, which has been producing systematic reviews at a furious pace. On the heels of a news-making evidence update that I co-authored on screening for prostate cancer, this Monday another USPSTF review team published an update of screening for cervical cancer with liquid-based cytology and human papillomavirus (HPV) testing.

This review led the USPSTF to the preliminary conclusion that HPV-enhanced screening, though widely utilized in the U.S., does more harm than good in women younger than age 30. Furthermore, the Task Force concluded that there is insufficient evidence to support HPV screening in women age 30 or older. HPV, it seems, is yet another example of a test that, despite having genuine value in diagnostic situations (for example, evaluation of abnormal cervical cytology or histology), has flunked as a screening test.

Being carried away by premature enthusiasm to provide a proven test in unproven situations is nothing new; doctors have been doing it for years. As I wrote in an editorial in American Family Physician in 2007:

As family physicians, we often face difficult decisions about ordering tests for the early diagnosis or prevention of disease in healthy-appearing persons. It is hard to convince many patients to think about prevention, and those who come in for health maintenance visits often expect to undergo tests that they have heard about from advertising on the Internet, radio, or television, or in popular magazines. For example, a colleague recently saw a healthy, asymptomatic woman who scheduled an appointment to receive the results of an ultrasound examination that had been ordered by another physician to screen for abdominal aortic aneurysm (AAA). The results were normal, but because the test was not indicated by generally accepted standards, our colleague was perplexed at what reassurance to provide the patient, if any.

Although the U.S. Preventive Services Task Force (USPSTF) recommends against performing AAA screening in asymptomatic women of any age, the existence of these and other evidence-based guidelines have not prevented direct-to-consumer marketing of costly screening tests of uncertain value. There is a striking contrast between widespread public enthusiasm for technology (e.g., whole-body computed tomography [CT], coronary calcium scans) and the paucity of evidence that performing these tests improves outcomes for patients.

“Big-ticket” tests 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? Both are far less expensive than CT scans and can often be performed in the office at the time of the visit. More than one third of family physicians in the United States think that CBC and urinalysis should be offered routinely at health maintenance examinations, and these tests are ordered for 25 to 37 percent of patients who present for such visits.

Read the rest of "Are Some Screening Tests Doing More Harm Than Good?" here.

Cost-conscious medicine: a movement that's gathering steam

The past few months have offered encouraging signs that physicians and physician organizations are belatedly recognizing the need to take an active role in controlling health care costs by emphasizing "high-value" care and minimizing the use of low-value interventions with high costs and few clinical benefits. On the heels of a best practice guideline issued by his organization, American College of Physicians Executive VP Steven Weinberger, MD recently called for making cost-consciousness and stewardship of health resources a required general competency for graduate medical education.

In light of a recently published estimate that the top 5 overused clinical activities in primary care specialties led to $6.7 billion in wasted health spending in 2009, Dr. Weinberger's call comes none to soon. Below is an excerpt from my post on this topic from April 13, 2010.

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Several years ago, when my wife directed the third-year Family Medicine clinical clerkship at a highly ranked medical school, she developed a popular workshop on the cost of health care that presented students with scenarios of patients who were either uninsured or underinsured and challenged them to provide cost-conscious health care by selecting medications and tests that were clinically appropriate and financially affordable. Many students remarked that it was the only time during their two years of clinical rotations when they were required to consider costs in decision-making.

Now that the U.S. health reform bill is law, and over 95 percent of Americans (as opposed to today's 84 percent) are expected to have health insurance by 2014, many physicians may be tempted to think that they can ignore the costs associated with prevention, diagnosis, and management of patients' health conditions and just focus on doing what's "right" for the patient, since somebody else is footing the bill. But contrary to popular opinion, that "somebody else" isn't an insurance company or the government; ultimately, it's the patient, in the form of higher insurance premiums (or taxes) to pay for an ever-expanding range of tests or treatments of questionable or zero benefit.

In response to Dr. Howard Brody's challenge to the medical profession to identify lists of unnecessary tests and treatments, physicians have suggested antibiotics for colds, coronary calcium scans, PSA and thyroid tests in well patients, drugs for high blood pressure that are more expensive and offer fewer benefits than older drugs, MRIs and spinal fusions for low back pain. And if reform is to have any hope of slowing the extraordinary growth in the cost of health care in the U.S., doctors can't keep looking to patients, hospitals, pharmaceutical and medical device companies, and insurers for solutions. In an editorial in the New England Journal of Medicine, Dr. Molly Cooke argues convincingly that cost-consciousness must be systematically incorporated into medical and continuing education:

First, we should be honest about the choices that we make every day and stop hiding behind the myth that every physician should and does apply every resource in unlimited degree to every patient for even minimal potential benefit. Second, we must prepare every physician to assess not only the benefit or effectiveness of diagnostic tests, treatments, and strategies but also their value. Value can be increased through cost-conscious diagnostic and management strategies and by the engineering of better and less wasteful processes of care.

"Value" isn't about saving money, but means getting the maximum health benefit for our enormous investments in health care. This wake-up call needs to be delivered and reinforced to students, residents, and health professionals at every level - starting today.

Family physicians and the Goldilocks principle

A recent national survey of internal medicine and family physicians published in the Archives of Internal Medicine found that 42 percent of physicians felt that their patients were getting "too much" health care, while only 6 percent thought that patients were receiving "too little." These opinions contrast with multiple previous studies showing that primary care clinicians fall short when it comes to providing guideline-recommended care; a 2007 study, for example, found that children received less than half of indicated care.

So which is it: too much care, too little, or some of both? And how can AFP help family physicians avoid these extremes and strive for the happy medium, which in other fields is known as the "Goldilocks Principle"? In addition to bringing readers the latest Practice Guideline updates, such as the Centers for Disease Control and Prevention's 2011-12 recommendations for influenza vaccination, we provide information that allows you to evaluate these guidelines against the best design criteria previously proposed by AFP Deputy Editor Mark Ebell, MD, MS:

The best guidelines share several characteristics: they begin with a comprehensive review of the literature; they carefully assess the quality of the literature to identify the best studies; they base their recommendations on the best studies; and they tell us the strength of the evidence that supports each key clinical recommendation. In other words, they are founded on the principles of evidence-based medicine, which strives to make decisions on the best available information—“best” implying that the evidence is graded, so that one has a sense of what is good evidence and what is not, and “available” implying that the literature search is comprehensive. Transparency is the key: readers should know why each recommendation is made and whether it represents opinion, theory, or fact. Finally, guidelines should be independent of industry support (an all-too-common occurrence) and should clearly identify any potential conflicts of interest of the authors. Ideally, guideline authors should have no conflicts of interest, which can diminish the quality and validity of the guideline.

There are, of course, many reasons - financial, medical-legal, and practical, to name a few - that care may diverge from that supported by the best evidence-based guidelines. Still, we hope that every section of the journal makes it easier for family physicians to provide care that is "just right."

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

Solo practice: a disruptive innovation?

The buzzwords of cutting-edge primary care reform - the medical home, coordination of care, electronic health records - have usually been associated with large integrated health systems such as Intermountain Healthcare, Group Health, and Kaiser Permanente. If you believe the arguments that economies of scale and financial resources give such organizations built-in advantages over the traditional small group practice, you may be inclined to believe that solo practice is going the way of the dodo. Indeed, immediate past AAFP President Roland Goertz, MD, MBA penned an editorial a few months ago, "Helping Small Practices Survive Health System Change," that, while touting some services that the Academy offers family physicians in these practices, betrayed a decidedly pessimistic outlook on their long-term future.

Not everyone agrees, however. In the September issue of the Journal of Family Practice, Jeff Susman, MD cast solo practices as vital engines of primary care innovation:

The extraordinary, albeit sometimes idiosyncratic, approach to medicine practiced by solo FPs today is often overlooked. Nimble (no bureaucracy to consult when changing policies), in touch (no one knows the local population better), and increasingly likely to use EHRs and health information exchanges (like physicians in larger groups), these doctors are paving the way to a brighter future. Whether they’re focusing on lean design, integrating concepts of public health, or creating environments that foster holistic healing, I see a lot of innovation and passion among solo practitioners who aren’t afraid to take risks or fight for their patients. Moreover, practices with only one or two physicians are frequently on the cutting edge of change and leaders in providing quality health care. What’s more American than that?

Like most physicians of my generation, I've never been in solo practice. But I agree with Dr. Susman that practice models that encourage "the rebirth of the solo family doc" may turn out to be just as good for the health of our patients as the gargantuan, still largely unproven structures known as accountable care organizations. As family physician Doug Iliff wrote back in 1998, solo practice, rather than harkening back to a past epitomized by the 1970s drama Marcus Welby, MD, may yet be the way of the future.

Shannon Brownlee on the pros and cons of early cancer screening

CNN is reporting that the U.S. Preventive Services Task Force plans to release a "D" recommendation against screening for prostate cancer in all men for public comment next Tuesday. They didn't get that information from me, because I don't work for the Task Force any more and couldn't confirm it even if I wanted to. But if it's true, as I just told CNN Medical Correspondent Elizabeth Cohen, this recommendation is - despite the furor that is bound to ensue - long overdue and completely justified. This short video from Shannon Brownlee, one of the authors of the New York Times Magazine piece, "Can Cancer Ever Be Ignored?" explains why the science simply doesn't support the widespread belief that in prostate cancer, early detection always saves lives.

The meeting that wasn't, revisited

A New York Times Magazine story published on the newspaper's website this morning details the complicated history of screening for prostate cancer in the U.S. and revisits the related story of the U.S. Preventive Services Task Force meeting that was abruptly cancelled for political reasons on November 1, 2010, the day before the midterm Congressional elections. I was interviewed several times for this story, starting shortly after my resignation from my position at the Agency for Healthcare Research and Quality, where for 4 years I had supported the USPSTF's scientific activities on a wide range of topics.

I commend science journalists Shannon Brownlee and Jeanne Lenzer for their tireless reporting efforts and dogged persistence in pursuing the real reason for the meeting's cancellation, despite repeated and vigorous denials of senior government officials. Former USPSTF Chairman Ned Calonge confirms in the Times story that politics played a role: "In November 2010, just before midterm elections, the task force was again set to review its [prostate screening] recommendation when Calonge canceled the meeting. He says that word leaked out that if the November meeting was held, it could jeopardize the task force’s financing." It's true that several members of Congress had threatened to cut off funding for the Task Force after it recommended against routine mammography for women in their 40s. To the best of my knowledge, however, the order to cancel the meeting came directly from the White House, not Congress. And according to my superiors at the time, Dr. Calonge had no choice in the matter.

In a 2007 commentary in BMJ, former Assistant Surgeon General (and current Georgetown University colleague) Doug Kamerow, reflecting on the George W. Bush administration's attempts to censor government health officials' statements on controversial scientific issues, wrote:

Clearly a presidential administration should be allowed to attempt to set its agenda, to focus on what it thinks are important issues, and to prioritize. It also, of course, has a right to tout its accomplishments and take credit for even the serendipitous achievements that have taken place during its tenure. When, however, administration officials ... bend the rules of science or evidence in pursuit of a political agenda or policy, it is a different matter entirely. That is the time for honorable government employees - whether career status or political appointees - who are unable to persuade the administration to desist from such distortions to call attention to them in the only way they can: resignation.

During my tenure at AHRQ, there were in fact heated disagreements between the USPSTF and other Bush-era health agencies on politically charged recommendations such as screening for HIV and illicit drug use. But whatever the Bush Administration did to interfere with science, it did not go so far as to unilaterally cancel any scheduled meetings of the USPSTF. That distinction, unfortunately, belongs to the Obama Administration. I hope that the New York Times story sheds some much-needed light on the shadowy politics surrounding prostate cancer screening, and in so doing, allows the current Task Force to re-assert its recently curtailed independence and unfettered ability to make science-based recommendations for the good of the public, rather than the agenda of any politician or political party.

Upcoming seminar on social media in family medicine

For my clinician readers, I'd like to put a plug in for the upcoming annual Northeast meeting of the Family Medicine Education Consortium, taking place at the Coco Key Hotel and Water Resort in Danvers, MA from October 21-23. Please join me and family medicine social media gurus Pat Jonas, MD (who blogs at Dr. Synonymous), Jennifer Middleton, MD (who blogs at The Singing Pen of Dr. Jen), and Michael Smith, MS (Associate Director of Admissions at the UMass Worcester/Fitchburg Family Medicine Residencies) for a "nuts and bolts" seminar and interactive exercises on the uses of social media in medical education, practice, and policy. Here is the seminar description:

Social Media Nuts and Bolts: For Geeks to Geezers

A panel of family medicine educators will review their strategies for starting out and continuing use of several types of social media. Comments will include how they use Facebook, Twitter, LinkedIn, blogging, YouTube, and BlogTalk Radio in their teaching, research, practice and administrative activities. Presenters will engage the attendees as they reveal how medical students, residents, faculty, their residency program/department, and patients benefited from their social media use. Exercises for attendees will include using Facebook, starting and using Twitter or LinkedIn, and searching for blogs to hone their skills and insights.

Hope to see you there!

Public Speaking - Events and Information (Updated)

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, 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. I have also written the consumer health blog Healthcare Headaches for U.S. News and World Report since August 2010.

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 about any of these topics, please e-mail me at linkenny@hotmail.com or KWL4@georgetown.edu.

Upcoming events:

What to Do When Screening Guidelines Conflict: HIV and Mammography

- Grand Rounds, Georgetown University Department of Family Medicine

November 4, 2011

Overdiagnosed and Over-Prevented: Making People Sick in the Pursuit of Health

- William J. Bicknell Lecture (panelist)

- Boston University School of Public Health

October 28, 2011

For Geeks and Geezers: With Social Media Skills You Can Change the World: Blogs, YouTube, Facebook, Twitter, BlogTalk Radio – and the list goes on!

- Family Medicine Education Consortium Northeast Region Meeting

October 22, 2011

Screening for Diabetes: What Does the Evidence Say?

- Spanish Catholic Center of Catholic Charities of Washington, DC

October 5, 2011

Past events:

Don't Do It! Preventive Health Services That Harm More Than They Help

- District of Columbia Academy of Family Physicians

Using the Medical Literature to Make Decisions About Preventive Health Services

- Medical Librarians Association

Medical Blogging and Other Professional Uses of Social Media

- Virginia Commonwealth University Medical Center

Spilling Ink: An Expert's Guide to Getting Your Work Published

- Society of Teachers of Family Medicine

Health Promotion and Disease Prevention in Clinical and Community Settings

- Uniformed Services University of the Health Sciences

The Value of Preventive Health Services

- Employees of MetLife

COPD Update: A Prevention Perspective

- Maryland Academy of Family Physicians

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 August and September:

1) Actual causes of death in the U.S.: not what you think (8/26/11)

2) Why the Preventive Services Task Force keeps pulling its punches (8/18/11)

3) Care transitions: 4 key questions to ask your doctor (8/11/11)

4) The promise and pitfalls of medical apps (9/1/11)

5) Adverse effects (9/16/11)

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

Book Review: "Your Medical Mind" and the challenge of shared decision-making

Recently, I had a conversation with Shannon Brownlee (the widely respected science journalist and acting director of the Health Policy Program at the New America Foundation) about whether men should continue to have access to the PSA test for prostate cancer screening, despite the overwhelming evidence that it extends few, if any, lives and harms many more men than it benefits. She felt that if patients could be provided with truly unbiased information and appropriate decision aids, they should still be able to choose to have the test (and have it covered by medical insurance). Believing that one of the most important roles of doctors is to prevent patients from making bad decisions, I disagreed.

After reading Your Medical Mind, the new book by Harvard oncologist and New Yorker columnist Jerome Groopman, I think he would probably side with Brownlee's point of view. Groopman, whose authoring credits include the 2007 bestseller How Doctors Think, and wife Pamela Hartzband, MD have written a kind of sequel to that book that could have easily been titled How Patients Think. Drawing on interviews with dozens of patients about a wide variety of medical decisions - from starting a cholesterol-lowering drug, to having knee surgery, to accepting or refusing heroic end-of-life interventions - the authors explore many of the factors that influence people's health-related choices. The result is a compelling narrative that seamlessly blends "rational" factors such as interpreting medical statistics and decision analysis with personal factors such as past experience, emotional states, and personality styles.

Some of the ground in the first few chapters ("Where Am I In the Numbers?" and "Believers and Doubters") has been well-covered in other recent books, notably, in H. Gilbert Welch's Overdiagnosed and Know Your Chances. But Groopman and Hartzband go farther in challenging two notions that have strong advocates among current U.S. health reformers: 1) adherence to evidence-based guidelines is a panacea for improving care outcomes; and 2) preparing meticulous "advanced directives" will simplify and improve end-of-life decisions. The authors also observe that shared decision-making means just that: a shared decision by a doctor and patient on a level at which a patient feels comfortable, not the one-sided ritual of "obtaining consent" or complete abdication of responsibility by the doctor.

"If medicine were an exact science, like mathematics," Groopman and Hartzman conclude, "there would be one answer for each problem. Your preferences about treatment would be irrelevant to what is 'right.' But medicine is an uncertain science. ... The path to maintaining or regaining health is not the same for everyone." Even to a physician who spent several years of my career working on prevention guidelines and remains an unabashed supporter of guideline-driven care, these words ring absolutely true.

In practice, of course, patients make a lot of seemingly irrational decisions. A healthy 40 year-old male patient may, if he wants, request annual PSA tests and decline the HPV and influenza vaccines for his children. These are poor choices which some doctors would even take personally. As his doctor, and a believer in the mantra of shared decision-making, I would do my best to make sure that he understood the relevant statistics, and elicit any past experiences or personal beliefs that prevented him from considering my recommendations. But if he persisted, suggest Groopman and Hartzband, I would at some point need to stand aside and recognize the limits of persuasion and my comprehension of his motivations. It's a very hard thing to do. Which brings me to a last point: although Your Medical Mind was written for patients, doctors will find it worth reading, too - if only for the opportunity to get inside the heads of patients and find out what they were really thinking.

Diabetes prevention: don't just go through the motions

The first time I ever used an electronic medical record was 12 years ago, during my neurology rotation in medical school. Students were responsible for writing daily progress notes on each hospitalized patient that updated his or her treatment plan and list of ailments. A helpful senior doctor let me in on a time-saver: cut and paste. I could insert sections of the previous day's progress note into the current day's note, which I could then modify to account for any changes that had occurred.

He also unwittingly introduced a temptation: to document more than I had actually done. Perhaps I'd forgotten one day to urge a recovering stroke patient to stop smoking, for example, but had done so earlier in the week. Knowing that my final grade depended on covering all care guidelines, once or twice I might have cut-and-pasted, "Tobacco cessation counseling: Provided" into my notes when I technically hadn't, believing there was no harm done.

Today, electronic medical records– a novelty a decade ago – are used in most hospitals and many doctors' offices. The federal government touts their potential for improving the quality of medical care, from ensuring that all patients get recommended screening tests to improving care of chronic health problems such as diabetes. But as I first observed as a medical student, electronic progress notes have an important downside that – contrary to what I thought then – can and does harm patients.

In a recent study published in the Archives of Internal Medicine, researchers examined doctors' documentation of dietary and exercise counseling in the electronic medical charts of more than 5,000 patients with diabetes. Patients were divided into three groups: those in whom no counseling was documented; those whose progress notes appeared to have been cut-and-pasted from the previous visit; and those whose notes were distinct from notes made in previous visits. Only patients with "distinct" counseling language successfully lost weight and improved their diabetes control, while patients with cut-and-pasted language did no better than patients who received no counseling. That led authors to question whether their doctors were documenting imaginary conversations.

We know that lifestyle counseling is critical to preventing diabetes in millions of at-risk Americans. National data show that almost 30 percent of adults have prediabetes (blood sugar levels that are higher than normal, but lower than the diabetic range), but only 1 in 3 of them reports getting any dietary or exercise advice from their doctors in the previous year. (No information is available on how often doctors claim that counseling occurred.)

Recent research confirms the huge impact that convincing people to change their lifestyles can have on lowering their future diabetes risk. A study of more than 200,000 adults published last week in the Annals of Internal Medicine found that the odds of developing diabetes over an 11-year time frame were 30 to 40 percent lower for older adults with one or more good habits: healthy eating, moderate alcohol consumption, and being smoke-free and physically active.

For you to benefit personally from this research, though, you need to make sure that your doctor isn't just going through the motions of lifestyle counseling, electronic medical record or not. Given the myriad agenda-items doctors must squeeze into a 15-minute office visit, skipping counseling can be an easy way to cut corners and stay on schedule. Don't let it be. As the science clearly shows, there can be no better use of your visit than to discuss how to stay healthy and lower your risk of health problems down the road.

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This post was first published on my Healthcare Headaches blog at USNews.com.

Adverse effects

Flashback to summer of 2008. I'm looking forward to August 5--the day that I'll no longer be a faceless bureaucrat. The day that the US Preventive Services Task Force (USPSTF) will issue its new recommendations on screening for prostate cancer--recommendations I've labored on as a federal employee for the past year and a half.

For much of 2007 I combed the medical literature for every study I could find on the benefits and harms of prostate cancer screening. In November of that year I presented my findings to the USPSTF, a widely respected, independent panel of primary care experts. They discussed and debated what the evidence showed and then voted unanimously to draft new recommendations. I didn't get to vote, but it has been my job in 2008 to shepherd the draft statement and literature review through an intensive vetting process and to finalize both.

As August 5 approaches, my colleagues in public relations warn me that the last time the USPSTF said anything about prostate cancer screening, the phones started ringing off the hook. I'm not so secretly hoping that the same will happen this time.

And I'm not disappointed! After we release the statement, my normally placid government agency buzzes with excitement. In addition to sparking front-page stories in major national newspapers, the story brings our PR office "hits" from television, internet and radio outlets all over the country. With the volume of requests far exceeding what the Task Force's press-liaison person can handle, I offer to pitch in. I give two newspaper interviews and debate a respected urologist on a live radio call-in show. My colleagues cheer me on. I forward the radio clip to my friends and family.

The new recommendations surprise many people: They say that men age 75 and older should not be screened for prostate cancer.

Why not?

Because there's no convincing proof that the prostate-specific antigen (PSA) blood test--the one used to detect early prostate cancer--actually saves lives. Most abnormal PSA tests do not actually indicate cancer, and up to half of true prostate cancers detected with the test would never have caused health problems if they'd gone undetected.

On the other hand, there's lots of evidence that the PSA test causes physical and psychological damage. Abnormal tests lead to prostate biopsies, operations and other treatments whose adverse effects range from anxiety to surgical complications to death. For younger men with decades of life remaining, these adverse effects may be worth the potential benefits; in men aged 75 and older, they almost certainly are not.

I soon learn that cancer recommendations, like cancer screening tests, come with their own adverse effects.

Comments pour into health blogs and the editorial pages of my favorite newspapers, accusing the Task Force, and me personally, of "ageism" and "taking the first step toward government-sponsored euthanasia." The systematic review I worked so hard on is trashed as a "shoddy meta-analysis" (although it's neither shoddy nor a meta-analysis), and many elderly men and their spouses lambaste us for being in league with heartless insurance companies.

I realize that this report has hit a nerve--the one that distrusts the healthcare system and that lacks faith in government. Cancer inspires more fear and anxiety than many other diseases. People worry about being denied access to cancer care--even care that hurts more than it helps.

I'm most wounded by one comment, which says that those responsible for developing the guideline can't possibly understand what it's like to have, or to care for someone with, prostate cancer.

This one really pains me because I do understand.

I remember only too well a 75-year-old patient--I'll call him Kendall--whom I met during my residency training in Lancaster, Pennsylvania, an area best known as Amish country. Kendall wasn't Amish, yet he hadn't seen a doctor in decades. Before I met Kendall, he'd been hospitalized with bone pain and a PSA of over 5000 (more than 4 is considered suspicious) and had been diagnosed with advanced, metastatic prostate cancer.

Kendall responded dramatically to a course of hormone-deprivation therapy and returned home. As I learned over the course of our outpatient visits, he was a man of few words but big gestures. At the end of our time together, he'd stand and clasp my right hand tightly in both of his, saying, "See you in a few months, doc."

Later, when the cancer and its awful pain returned, and Kendall became weaker, he was one of my favorite home-visit patients.

The end came surprisingly quickly. A hospice nurse paged me with the news that Kendall was in the ER, disoriented and combative. I rushed over and tried to soothe him as we ran tests, hoping in vain to find something we could fix. Soon afterwards, he was transferred to an inpatient hospice. He died a few days later.

Would PSA testing and earlier detection have spared or prolonged Kendall's life? Given the aggressiveness of his cancer, I doubt it, but it's hard to know for sure. And I admit that Kendall often came to mind as I was working on a recommendation to stop PSA testing at age 75. If he'd ever bothered to visit a doctor, maybe he would have been one of the few men helped by such testing, rather than one of the many harmed. I'll never know.

My colleagues and I labored for months to present a thorough and accurate review that would help the USPSTF make sensible recommendations aimed at doing the most good and the least harm. We performed our work without considering healthcare costs or political fallout.

I'd hoped that August 5 would free me from being labeled a faceless bureaucrat. Ironically, it ended up tarring me as a heartless one.

Prostate cancer causes a lot of suffering--I know. In the face of that, it's tempting to try and detect it early, to "do something." But for now, unfortunately, our best science tells us that doing something to a man older than 75 is likely to do more harm than good.

For Kendall's sake and for my own--for I hope to be 75 myself one day--I wish it weren't that way.

I wish that on August 5, 2008, I'd had better news to share.

And I wish that everyone had understood that.

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This piece was originally published in Pulse Magazine. I wrote it on my own time while employed at the Agency for Healthcare Research and Quality in the fall of 2008 and had hoped to submit it to the humanities feature of a major medical journal, such as JAMA's "A Piece of My Mind" or Annals of Internal Medicine's "On Being A Doctor." My superiors at the time declined to give me permission to do so.

Guest Blog: Can patients differentiate quality care from amenities?

Richard Young, MD is a family physician educator and director of research at the John Peter Smith Hospital Family Medicine Residency in Fort Worth, Texas. The following post was originally published on his blog, American Health Scare.

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One of the approaches some corporations are taking to hold down health care costs is to put more responsibility on their employees through high-deductible health insurance plans. It makes sense that they would try this. After all, this reflects the daily life of the business community as they compete for consumers of their goods and services. They make choices based on cost and features, so why shouldn’t their employees?

When it comes to readily accessible items such as anti-inflammatory pain relievers, of course the consumer can make rational choices between trade-offs: brand name drug or generic, acetaminophen or ibuprofen. But what about big ticket items in health care? In an article in the New England Journal of Medicine late last year, the limits of consumer choice in holding down costs were addressed. The authors looked at the hospital market, for which $700 billion was spent in 2008 (I would estimate this is over $800 billion now).

The authors pointed out that hospitals actually compete on amenities, not quality of care or bang for the buck. Marketing campaigns tout the room views, hotel-style room service for meals, and other offerings that have nothing to do with a sick patient recovering to the point she can go home.

Consumers respond in surveys that these non-clinical features are more important than clinical reputation in choosing a hospital. Hospital administrators have learned that these added features cost more than quality improvement programs, but the improved amenities have a greater effect on hospital volume – i.e. bucks for the bottom line. And what tiny fraction of patients actually look up quality ratings for potential hospitals (and let’s not get into a discussion here of whether these rankings mean anything real)?

As much as I assume that a nation of people given the freedom and choices to make decisions for themselves leads to the strongest and most stable country, big-ticket healthcare items are an exception. There is just too much complexity in the industry for an individual to shop around. For example, even for the lower cost services, if your family physician thought there was a fair chance your abdominal pain was caused by gallstones, do you really want to then shop around for sonogram facilities to image your belly and labs to analyze your blood? If you find out you have gallstones, do you really want to then compare prices and amenities of all the hospitals and surgi-centers in your area, then interview surgeons and see if they work at the facility you chose? This is just too much for most people to navigate.

People should have choices, but it should be choices of plans or healthcare networks. However, if you want healthcare that is more affordable, one small step would be to forego hospitals with granite counter tops and mints on the pillows.

9/11

On the morning of September 11, 2001, I was a family medicine intern making rounds at a teaching hospital in Pennsylvania. As I started writing a progress note on one of my patients, my senior resident emerged from the next room with tears streaming down her face. I couldn't imagine what had gone wrong. Had we just lost someone? Could I have possibly missed the distinctive overhead page for the Code Blue team?

It was worse than that - much worse. "It's horrible," she managed to say. "Absolutely horrible. I feel so bad for their families." I stepped into the room and saw both televisions airing live footage of the wreckage of the twin towers of the World Trade Center, where not one, but two commercial airliners had just crashed.

The rest of the day was a blur. It was nearly impossible to concentrate on the day-to-day routine of patient care when all I could think about were the thousands of lives claimed in the space of a few minutes. Later in the day I learned that a third plane had hit the Pentagon, and a fourth had crashed into a field about 150 miles west of my home. "This means war," one of my attendings stated flatly.

I had recently graduated from medical school in New York City, and after going home from the hospital, I tried calling former classmates who had chosen residency programs there. But the phone lines were jammed all night. It wasn't until the next day that I heard from a friend about how an army of physicians and medical students had mobilized at NYU's Bellevue Hospital, waiting for a massive influx of injured patients who never came.

In the decade that has passed since that awful day, I completed my residency, got married to a wonderful woman, began my career as a family physician, and had two beautiful children who are, thankfully, still too young to begin to comprehend what kinds of warped beliefs would possess people to deliberately fly airliners into buildings full of their fellow human beings. Eventually, I know I will have to explain to them the events of 9/11. And tell them, too, about the healing that time, faith, hope, and love can bring about after even the most grievous of wounds.

To all the victims of 9/11, living and dead, may peace be with you, tomorrow and evermore.