The trouble with second terms

For the past half-century, history hasn't been kind to American Presidents who were fortunate enough to be elected to second terms. Whether through their own hubris or regression to the mean, re-elected Presidents seem unable to escape personal health issues, scandals, or disastrous domestic or foreign policies. Dwight Eisenhower suffered a stroke early in his second term and later fumbled through the embarrassing U-2 incident. After completing JFK's first term, Lyndon B. Johnson won a second and promptly passed Medicare and Medicaid, but finished his presidency hopelessly entangled in Vietnam. His successor, Richard Nixon, resigned in disgrace midway through his own second term rather than be impeached for his role in Watergate. Ronald Reagan won again in 1984, but his second term was marred by the Iran-Contra Affair, colorectal cancer, and (possibly) the onset of Alzheimer's. Bill Clinton fell to Monica Lewinsky and the Starr Report. George W. Bush: Iraq and the collapse of Wall Street. So in addition to asking if our current President deserves a second term, undecided voters might consider what stumbles he would make if he wins.

I didn't vote for Barack Obama in 2008. I thought that he had neither the leadership experience nor the political stature to unite the nation, and the events of the past four years haven't changed my impression. Any hope his campaign may have had of earning my vote in 2012 was dashed by two incidents that occurred when he was my boss (and I, a federal employee): trotting out the Secretary of Health and Human Services in November 2009 to disavow the USPSTF's new recommendations on screening for breast cancer, effectively throwing the Task Force under the health reform bus; and again permitting politics to trump science by cancelling the Task Force's November 2010 meeting to delay the release of a similarly damaging statement about screening for prostate cancer - then adding insult to injury by covering it up.

Do I have a higher opinion of Obama's competitor, an oft-caricatured tax-evading multimillionaire who wrote off 47% of Americans who pay no income taxes and wants to "end Medicare as we know it"? I guess it's all about perspective. Mitt Romney is a flawed man, but it's hard to believe that his motivation for pursuing the Presidency is to only make life better for the so-called one percent. If Romney had wanted to amass a greater fortune and not be lampooned by late-night comedians, he would have stayed put at Bain Capital and passed on saving the Salt Lake City Olympics or becoming Governor of Democratic-dominated Massachusetts. (He also could have chosen to hang on to more of his supposedly tainted earnings, rather than giving to his church and charities as much money each year as many others - even those in a similar income bracket - do in a lifetime.) Whatever Romney's view of the Affordable Care Act is, he worked with political polar opposite Ted Kennedy to pass a bipartisan health care plan 4 years before the ACA. As for his running mate throwing Grandma off the Medicare cliff, that advertisement may sway a few voters in the critical swing state of Florida, but could, like the original Harry and Louise ads, move this country even farther from tackling the problem of skyrocketing health costs.

I admit to hesitation and second-guessing about using my blog, which I think has earned a reputation for being evenhanded on the most politically charged of health care issues, to explicitly endorse a Presidential candidate. Perhaps some of you will think less of me or, worse, post all sorts of vitriolic comments, although I hope not. But for what it's worth (which isn't much at all, since I live in the District of Columbia), this Common Sense Family Doctor will cast his ballot for Mitt Romney for President on November 6, 2012, and encourages all who are reading to do the same.

Prevention potpourri

Several recent publications have highlighted the strengths and limitations of U.S. Preventive Services Task Force recommendations on commonly provided preventive services.

Screening and Interventions for Alcohol Misuse

Yesterday, the USPSTF released a draft recommendation statement on screening and behavioral counseling interventions for alcohol misuse, supported by a comprehensive systematic review published in the Annals of Internal Medicine. (Full disclosure: the lead author of the review is the son of family physician Pat Jonas, who blogs at Dr Synonymous and with whom I've given past presentations on social media.) Although the USPSTF review and statement affirm that brief behavioral counseling has positive effects on risky alcohol use, I believe that the Task Force missed an important opportunity to evaluate the effectiveness of medications such as acamprosate and naltrexone for alcohol-dependent patients in primary care settings. To expect, as the USPSTF appears to do, that alcohol-dependent patients identified by screening will all be referred to addiction specialists seems unreasonable, since the estimated lifetime prevalence of alcohol dependence in the U.S. is 12.5%.

Abdominal Aortic Aneurysm Screening

In 2005, the USPSTF recommended that men age 65 to 75 years who had ever smoked receive a one-time ultrasonography screening for abdominal aortic aneurysm (AAA), a condition that is usually causes no symptoms until the aneurysm ruptures, often leading to death. Previous studies had shown that identifying and repairing large (more than 5.5 centimeters in diameter) aneurysms could avert these deaths. However, a study published last week in the Archives of Internal Medicine found that despite Medicare coverage of AAA screening since 2007, few eligible men had undergone the test and there were no effects on rates of AAA rupture or death. I've always been uncomfortable with this Task Force recommendation because AAA repair surgery carries considerable risk to the patient even in the hands of the most skilled vascular surgeons, and many large AAAs that would not cause problems during men's lifetimes could potentially be overdiagnosed and unnecessarily treated. An accompanying editorial written by my friend and former USPSTF member Russ Harris and colleagues suggests that the population-level benefit of AAA screening may be declining, while the harms may be greater due to the increasing frequency of surgery for smaller AAAs that are even less likely to cause problems. It will be interesting to see if the USPSTF will reconsider its 2005 recommendation.

Counseling for Healthful Diet and Physical Activity

An ambitious project named Prescription for Health funded 22 primary care practice-based research networks between 2003 and 2007 to develop innovative, evidence-based strategies to address tobacco use, risky alcohol use, unhealthy diet, and physical inactivity in their patient populations. An analysis of a subset of 7 PBRNs published in the Journal of the American Board of Family Medicine reflects the mixed results that these interventions achieved and the numerous challenges of providing them in practice. Such considerations could be one reason that the USPSTF declined to endorse routine counseling for healthful diet and physical activity in the general adult population.

Screening for Prostate Cancer

Finally, a research letter in the Archives of Internal Medicine found a modest decline in PSA-based prostate cancer screening in Medicare recipients age 75 years and older (from 29.4% to 27.8%) associated with the USPSTF's 2008 recommendation to discontinue screening in this group. The screening rate remains much too high, especially since the Task Force now recommends against PSA-based screening in men of any age. I will share more of my thoughts about implementing this "don't do" guideline in primary care a future issue of the Journal of Lancaster General Hospital.

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:

1) Lung cancer screening: understanding "relative risk" (8/15/12)

2) Welcoming health centers to the medical neighborhood (8/22/12)

3) Would you like fries or cheesecake with your family medicine? (8/13/12)

4) Just say no to commercial screening tests (8/27/12)

5) Screening for chronic hepatitis C in baby boomers (8/29/12)

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

Integrating public health and primary care

In March, the Institute of Medicine published a landmark report on national strategies for better integrating primary care and public health to improve population health. It's worth reading in its entirety, but the essential take-home points are summarized in this report brief, as well as the just-released 13-minute video below.

Health communication: what not to do

To be effective, public health professionals must be well-informed not only in the science of their disciplines, but also in methods of communicating the implications of scientific findings to the general public. Dr. Tomas Stockmann, the protagonist of Henrik Ibsen’s A Public Enemy, provides a case study in (mostly) what not to do when a public health professional discovers a serious threat to his or her community. Stockmann’s message is further complicated by the fact that germ theory was not well established in the 19th century, making it critical that he enlist the support of other stakeholders in order to persuade the public of the necessity of immediate and decisive interventions (closing the municipal Baths and re-routing its water conduits to avoid contamination).

Act One of A Public Enemy establishes the importance of the “splendid, handsome new bathing establishment” that Stockmann’s brother, the Mayor, predicts “will become the very heart of our municipal life.” Speaking with Hovstad, editor of an influential newspaper, the Mayor observes that the popularity of the Baths has increased property values, reduced unemployment, and decreased the tax burden on the wealthy for supporting poor citizens. Foreshadowing the bad news to come, however, Dr. Stockmann is troubled by the news that Hovstad intends to soon publish his “confounded” article on the “excellent health record” of the town and Baths. After receiving a letter that contains a microbiological analysis of a sample of water from the Baths, Dr. Stockmann shocks his guests by indiscreetly proclaiming that the town’s major attraction is, in fact, a “pesthouse” and “the greatest possible danger to health.” Apparently, the Baths’ water source has been polluted by upstream industrial waste from his father-in-law’s tannery, among other sources. In Dr. Stockmann’s terminology, the water contains “putrefying organic matter” and “millions of infusoria,” and, rather than being salutary, is a “menace” to the health of everyone who uses the Baths. Basking in the reporter Billing’s prediction that this announcement will make him the “most important person in the town,” Dr. Stockmann incorrectly predicts that his brother will be “glad that such an important fact has come to light.”

As Act Two reveals, however, the Mayor is anything but pleased. He challenges the necessity of such an extreme remedy to the problem and observes that the financial effect on the Baths and the town from Dr. Stockmann’s recommendations would be devastating. “You would have ruined your native town,” the Mayor accuses. Threatened with dismissal from his position as Medical Officer of the Baths, Dr. Stockmann refuses the Mayor’s request to retract his report and postpone saying anything publicly about the matter. This is Dr. Stockmann’s first mistake: alienating the elected leader of the town by feeding their sibling rivalry, rather than negotiating the best way to communicate the news.

Dr. Stockmann believes he can count on the backing of the Hovstad and his newspaper’s financial benefactor, the printer Aslaksen, to communicate his findings over the Mayor’s objections. However, the Mayor soon persuades them that publication of Dr. Stockmann’s report will be ruinous for them and the town, and Dr. Stockmann finds himself completely isolated. Nevertheless, the self-proclaimed “patriot” moves ahead and calls a public meeting where, defying the Mayor and Aslaksen’s wishes, he tries to convince the townspeople of the truth of his findings. By the time he gains the floor, however, Dr. Stockmann is so upset that he instead lashes out at the “overwhelming stupidity of the authorities” and ridicules the remainder of those present as “fools” who “want to found the town’s prosperity on a quagmire of lies and fraud.” As a result, it is easy for the townspeople to “blame the messenger” (Markel 2009); Dr. Stockmann is proclaimed a “public enemy,” dismissed from his position, and his house is stoned by an enraged mob.

In addition to setting aside his rivalry with his brother and exploring ways to achieve both of their goals (protecting the health of the townspeople without bankrupting the Baths), how else might Dr. Stockmann have more effectively communicated the danger to his community? He erred in using the technical language of a scientific report (“millions of infusoria”), rather than simpler messages that people could grasp more easily. Even if Hovstad had published the report, it seems unlikely that most readers would have understood it, much less believed its conclusions. As one commentator noted, contemporary “epoch-making scientists (such as Pasteur and Koch) not only produced convincing and reliable data from a scientific point of view, but also acquired the skills and insights needed to enter into a dialogue with their cultural and societal environment” (Zwart 2004). In fact, Pasteur’s “true success” has been said to have been not proving germ theory, but “transmitting [it] to the greater world” (Matos 2008).

As Dr. Stockmann discovered, relying on his own authority as a “man of science” and taking for granted the support of other key stakeholders (the Mayor, the town paper, and the leader of the townspeople’s association) was a recipe for disaster. Confronted by a public health threat that they may not fully understand, most people instinctively turn to these authorities, who in this case were given no good reasons to endorse Dr. Stockmann’s recommendations. Finally, and most fatally, Stockmann “negates his professional effectiveness by succumbing to his own anger and lashing out at the public. By misfiring his alienating tirades at those he most needs to convince, Stockmann creates an insurmountable public health barrier: distrust of the very official the public needs to trust most” (Markel 2009).

References

1. Markel H. Physician, heal thyself: Arthur Miller, Henrik Ibsen, and the enemies of the people. JAMA 2009;301:2506-7.
2. Matos TC. Choleric fictions: epidemiology, medical authority, and An Enemy of the People. Modern Drama 2008;51:353-66.
3. Zwart H. Environmental pollution and professional responsibility: Ibsen’s A Public Enemy as a seminar on science communication and ethics. Environmental Values 2004;13:349-72.

Checking the resurgence of pertussis (whooping cough)

According to recent news stories, more than twice as many cases of pertussis have already been reported in the U.S. this year than in all of 2011. Although some of the resurgence of the infectious organism that causes whooping cough may be due to increasing rates of vaccine refusal, experts are concerned that another culprit may be waning immunity from the acellular pertussis vaccine that has been used in the U.S. since the 1980s. Although a recent Cochrane systematic review concluded that acellular pertussis vaccines (preferred due to their lower incidence of side effects) are as effective as the whole-cell vaccines that preceded them, the review relied mostly on indirect comparisons and limited follow-up intervals. In contrast, an Australian study published in the August 2nd issue of JAMA found that acellular vaccines were clearly inferior to whole-cell vaccines in preventing pertussis 10 to 12 years after vaccination.

In order to prevent new pertussis infections, especially in infants who are too young to be immunized, all adolescents and adults should receive Tdap immunizations instead of the traditional Td booster before 10 years have elapsed. To encourage patients to receive age-appropriate immunizations, parents should be counseled about vaccine safety, and standing orders and patient reminders instituted to prompt physicians and support staff when immunizations are recommended. Additional useful information on immunizations for pertussis and other vaccine-preventable diseases is available in the AFP By Topic collection.

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The above post first appeared on the AFP Community Blog.

Guest Post: Prostate screening shouldn't be a primary care initiation rite

Dear Dr. Lin,

For the past two years, I have been searching for a primary care physician who will not require that I undergo prostate cancer screening as a condition of accepting me as a new patient. Usually physicians don't admit this directly when I ask them in the initial interview; sometimes, they actually agree with me that the PSA test and digital rectal examination are neither necessary nor beneficial. But something strange and frustrating happens after I leave each office: these physicians decide that they require screening after all and send me a letter, telling me in a short sentence that they won't or can't accept me as a new patient.

One primary care physician tried to "sneak in" a digital rectal examination when all that I needed was pre-operative clearance, assuming that I wouldn't object! After I objected, he claimed that he had forgotten my preferences. It didn't end there. He went on to bill Medicare for prostate cancer screening and refused my four requests to correct the error. He finally withdrew the charge when I threatened to notify my insurance plan of possible fraud.

Variations of the same story occur each time I meet a new primary care physician. I am getting very concerned because I need refills of certain prescriptions. Do you know any open-minded primary care physicians in eastern Massachusetts who are familiar with the harms of prostate cancer screening and could take me on as a new patient? I would be forever grateful.

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The above post is a lightly edited version of an e-mail that I received recently from a resident of Massachusetts. If you would be willing to accept him as a patient, or could refer him to a primary care physician in his area, I would be happy to pass on any recommendations.