Wednesday, October 31, 2012

Why primary care is the future of health care

Several weeks ago, Primary Care Progress asked me to serve as one of their guest bloggers for this year's National Primary Care Week, writing on the theme: "Why is primary care the future of health care?" I didn't end up contributing a post, for a few reasons: 1) not enough time; 2) concern that the question was too physician-centric (rather than patient-centered); 3) the feeling that I had nothing new to say on the topic that I hadn't already written before. Today, however, while teaching a group of first-year medical students about the Patient-Centered Medical Home and its potential to put primary care back in the center of the health system (in my opinion, exactly where it belongs), I had second thoughts. As the "Healthcare Headaches" blogger for U.S. News and World Report from 2010-11, I often wrote about the future of health care though my perspective as a family physician. Below I've assembled some links to, and excerpts from, posts that I think do a good job of describing why primary care is the future of health care.

1. Your Primary Care Team Will See You Now - the future of health care includes working in integrated teams, which will allow primary care physicians to meet current and future increased demand for medical services.

In the primary care team model, the receptionist or a medical assistant could ask each patient to fill out a form with the necessary information. The medical assistant could then input this information into the tool and create a customized list of preventive recommendations. A medical assistant or nurse could then counsel patients about exercise habits, dietary practices, and smoking cessation before they even saw the doctor. They could also provide basic information about screening tests and immunizations, leaving the doctor to answer any remaining questions. If a referral was needed to obtain, say, a mammogram or a colonoscopy, the assistant could start the necessary paperwork while the doctor performed the examination.

2. New Electronic Medical Records Software Could Improve Your Health - Used properly, electronic health records will allow primary care practices to create registries to proactively manage the health of populations of patients.

The latest research suggests that electronic health records don't necessarily improve care unless they include interactive features: They should make it easier for doctors to implement proven guidelines for good care, providing the necessary shots and screenings, follow-up exams and treatments to help patients live longer with chronic diseases or to prevent these diseases altogether. Ideally, these records should include a software tool that periodically culls through patients' records looking for gaps in care such as who is overdue for a cholesterol screening or flu vaccine. The system would then send out reminders to patients to come in for a test or appointment.

3. Healthy Habits Are Hard to Maintain - Even If You Know What Lies Ahead - Genomic medicine is overrated, and will never be able to replace commonsense advice from a trusted family physician.

The take-home message is that providing personalized health information to my patients based on the “old fashioned” collection of family history data is likely to be at least as good, if not better, than sequencing their genomes. A potential reason for why participants in the New England Journal study weren’t able to change their health habits is that high-tech genetic profiles can’t substitute for personal contact. Much of the training primary care physicians receive is geared toward learning how to help people make good decisions about their health. So if you fear that your New Year’s resolution may be falling by the wayside, I encourage you to make an appointment to see your family doctor to discuss small, realistic steps that you can take to get back on track. Obviously, your doctor can only do so much by outlining your personal health risks and suggesting ways you can reduce them. The rest is up to you.

4. How to See A Doctor - Stat - New scheduling models such as open-access and technology such as secure patient portals will make it more convenient to consult a primary care physician than ever before.

Primary care offices have historically handled patients with urgent problems by assigning one doctor "acute care" responsibilities for the day or squeezing extra patients into already crammed schedules. The downside: Patients can end up seeing doctors who are unfamiliar with their medical histories, harried due to time pressures, or both, which raises the risk of misdiagnosis or improper treatment. That's why some practices (including the federally funded Veterans Heath Administration clinics) have switched to "advanced" or "open-access" scheduling. Rather than scheduling a visit weeks or months in advance, patients can call for an urgent or routine appointment the day before or the same day they want to be seen. A recent review of 28 studies found that advanced-access scheduling increases the chance that a patient will be able to see his or her doctor and reduces no-show rates.

5. Diabetes Prevention Starts With Your Doctor - Substitute "any chronic condition" for diabetes, and the primary care physician is the first line of defense, as the doctor that people are most likely to see when they are healthy. Good primary care, prevention, and health promotion go hand-in-hand.

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 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. 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.

So there you have it. Primary care is the future of health care because we will function in teams; use electronic registries to practice proactive rather than reactive care; make it more convenient for patients to see, speak to, or message us; provide personalized health counseling; and assist patients in making lifestyle changes to avoid preventable chronic conditions. And as regular readers of this blog know, these reasons represent only the tip of the iceberg.

Sunday, October 28, 2012

Guest Post: Telling family medicine's stories

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. He is the author of American HealthScare, a critically acclaimed book about the excesses of the current U.S. health system and potential primary care-based reforms. Dr. Young also regularly posts on his blog of the same name.


I think one of the underlying reasons Family Medicine continues to be under-supported in the U.S. is the very nature of storytelling, and the media's preference for telling stories over reporting facts.

The ologists have it easy. Their stories go something like this: A mother has a child who isn't doing very well both at home and at school (protagonist). She goes from one doctor to another, and they tell her there is nothing physically wrong with the child and one even tells her that bad parenting is to blame (antagonist and conflict). She refuses to take no for an answer, and she scours the Internet and finds an ologist at a major medical center who thinks he has the answer. They travel to see this medical fairy godmother, he waves his magic wand (a complete battery of tests), and the boy is saved and becomes normal again (resolution). Nightly news and magazine shows (60 minutes, Dateline) love these stories.

Here is family medicine's story. A patient comes to the family physician with a list of physical symptoms. The physician listens to the patient (in itself therapeutic), orders a few basic lab tests that are normal, and essentially asks the patient to be patient -- the symptoms don't raise any red flags for a serious underlying disease and will probably resolve on their own. A month later the patient feels better. BORING. There's no action and no conflict.

Other medical nonsense is magnified on shows like Private Practice and Grey's Anatomy -- when the characters aren't banging each other and actually taking care of patients -- in dialogue where they scream at each other lines such as, "You have to let her go!", then "I will not let my patient die. I swore an oath to do everything in my power for my patients and I will not give up!" And so on.

Therefore, the story of family medicine isn't what it does as much as what it doesn't do. Our quality care is best understood as a counterpoint to ologist excess. This is why Shannon Brownlee's book Overtreated and the recent video about the harms of overtreatment are a step in the right direction to get the American people to understand the tremendous cost, waste, and harms caused by an over-ologized physician workforce, and an American medical culture that is locked into the overall ologist philosophy of what is standard of care.

Some colleagues and I have collected some great stories of how family physicians deliver better care at a lower cost. The power of some of the stories we heard had their greatest impact when set against the ologist alternative. For example, a patient was taking 13 pills and seeing 5 different doctors multiple times per year and still feeling sick. Then a family physician took over all her care and got her down to 8 pills and 4 visits per year, and the patient felt better.

Patients and storytellers want certainty, but family physicians are the masters of managing uncertainty. Americans want action and immediate answers, but family physicians are the masters of patience, judgment, and prudence. Let's face it, family medicine is just un-American.

That's why our healthcare system is so costly and inefficient and why our children will have worse lives than their parents. The task is enormous, but the culture of America must change to right the listing ship. Americans need to develop a different understanding of what a healthcare system should even provide in the first place.

Thursday, October 25, 2012

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 September and October:

1) Health communication: what not to do (9/11/12)

2) The spiritual assessment: unnecessary or essential? (10/4/12)

3) Prevention potpourri (9/25/12)

4) Reducing overtreatment is the other side of quality improvement (10/8/12)

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

Monday, October 22, 2012

End the war metaphors for cancer screening and treatment

Like millions of cycling fans all over the world, I was very disappointed about revelations that 7-time Tour de France champion and cancer survivor Lance Armstrong had been using banned performance-enhancing substances for most of his career, despite years of increasingly vigorous denials. To many people, Lance transcended his sport through his seemingly indomitable will to win - not only Tours, but a very public fight against advanced testicular cancer. Lance's words of encouragement to other people struggling with cancer were marked with war metaphors: personal battles, wars to be won at all costs against a tenacious and unyielding enemy. And while there's no such thing as cheating in the effort to beat a medical condition, the evidence now shows that Lance's determination to win at all costs in sports led him down a path that has resulted in his disgrace.

On Thursday I will speak about cancer screening at the Johns Hopkins Bloomberg School of Public Health's Fall Policy seminar on "Science and Public Policy in Conflict." One of the messages I hope to leave with the audience is that we need to end, or at least soften, the harsh war metaphors for cancer screening and treatment, which endow screening tests such as mammograms with far more power than they really have to affect patient outcomes, and leads to uninformed advocacy and public policy that ignores the harms of overdiagnosis and overtreatment that inevitably result. As I blogged last June (and have reposted below), there are "no easy victories" in cancer screening when it comes to the evidence.


Nearly forty years ago, President Richard Nixon famously declared a "War on Cancer" by signing the National Cancer Act of 1971. Like the Manhattan Project, the Apollo program that was then landing men on the Moon, and the ongoing (and eventually successful) World Health Organization-led initiative to eradicate smallpox from the face of the Earth, the "War on Cancer" was envisioned as a massive, all-out research and treatment effort. We would bomb cancer in submission with powerful regimens of chemotherapy, experts promised, or, failing that, we would invest in early detection of cancers so that they could be more easily cured at earlier stages.

It was in the spirit of the latter that the National Cancer Institute launched the Prostate, Lung, Colorectal, and Ovarian Cancer (PLCO) Screening trial in 1992. This massive study, which eventually enrolled more than 150,000 men and women between age 55 and 74, was designed to test the widespread belief that screening and early detection of the most common cancers could improve morbidity and mortality in the long term. Not a few influential voices suggested that the many millions of dollars invested in running the trial might be better spent on programs to increase the use of these obviously-effective tests in clinical practice.

They were wrong. As of this week, the PLCO study is 0-for-2.

Miss #1 occurred in March of 2009 when the PLCO study first reported no mortality benefit from annual PSA testing, a test that a majority of men over 50 undergo routinely. Miss #2 occurred over the weekend, when the Journal of the American Medical Association published a landmark paper that ended with the following paragraph:

We conclude that annual screening for ovarian cancer as performed in the PLCO trial with simultaneous CA-125 and transvaginal ultrasound does not reduce disease-specific mortality in women at average risk for ovarian cancer but does increase invasive medical procedures and associated harms.

The lung and colorectal screening components of PLCO have not yet reported mortality data**, and there is reason to believe that at least the latter will likely yield some positive results. Although it has largely been supplanted by colonoscopy and CT colonography (aka "virtual colonoscopy") in the U.S., flexible sigmoidoscopy was already shown to reduce deaths from colorectal cancer in a randomized trial published in the Lancet last year. And PLCO's screening chest x-rays are probably a loser, but a preliminary report from NCI's National Lung Screening Trial suggest that screening CT scans can reduce lung cancer mortality in heavy smokers. (Even after this report is confirmed in a peer-reviewed scientific journal, there will still be plenty of reasons not to rush into lung cancer screening, as I outlined in a previous blog post.)

Still, these are hardly the magic bullets or the resounding victories that many expected from the "War on Cancer." The same can be said for chemoprevention, or the strategy of prescribing medications for healthy adults to prevent cancers from developing at all. The vast majority of "high risk" women have avoided breast cancer chemoprevention with tamoxifen and raloxifene due to their unpleasant side effects (which include hot flashes and life-threatening blood clots), despite a 2002 recommendation from the U.S. Preventive Services Task Force for clinicians to discuss these drugs with their patients. (This recommendation has not been updated since, largely due to politics, not science.) A new study published in the New England Journal of Medicine has reported that the drug exemestane reduces the risk of invasive breast cancer without the other drugs' side effects. But here's the rub: we can't be sure how many of those breast cancers are the ones that inevitably lead to symptoms and death, rather than the 1 in 3 that are thought to be overdiagnosed.

The bottom line from recent research is that there are no easy victories in cancer screening and prevention - just slow, incremental progress. Companies that have a profitable product to push would like you to believe otherwise, but when it comes to cancer prevention, there is no substitute for a healthy lifestyle: Don't Smoke. Drink in Moderation. Exercise. And Eat a Well-Balanced Plate.

** Note: the PLCO trial subsequently reported that chest x-ray screening did not reduce lung cancer deaths, while flexible sigmoidoscopy reduced colorectal cancer deaths by 26 percent. So PLCO's "final score" is 1 in 4 screening tests evaluated showing a positive effect on health.

Thursday, October 18, 2012

Dollars and sense of rising health insurance costs

If you watched Tuesday night's Presidential debate and were able to look past the highlights (or lowlights) of Governor Romney's "binders full of women" comment and President Obama's indignant denial that his administration politicized its various explanations of the Sept. 11 terrorist attack in Libya, you may have noticed the President say of his opponent, "he's the one who wants to turn Medicare into a voucher." Obama's tone of voice clearly indicated to the audience that he felt this would be a bad thing. But what's so bad about a voucher? To many people, receiving a "voucher" means getting something for free, and having a choice about what that something is. In the District of Columbia, for example, low-income students have taken advantage of tuition vouchers to attend private schools that they otherwise would not have been able to afford.

Many policymakers, including Romney, support transitioning Medicare from a "defined benefit" program (meaning that recipients are guaranteed benefits regardless of how much they cost) to a premium support program - essentially, a voucher for a specific dollar amount that could be used to pay for health insurance - by the year 2023. President Obama and others oppose the plan because they worry that the voucher wouldn't be enough to cover Medicare's premium costs, forcing seniors who want to keep their current benefits to pay more out of pocket or switch to a lower-cost plan with fewer benefits. Why? Health care costs vary widely across states, and even if premium support growth is indexed to general inflation (as Romney and running mate Paul Ryan have proposed), Medicare costs have grown faster than inflation for years.

A recent study by researchers at the Kaiser Family Foundation seems to confirm these fears. Modeling from available Medicare cost data, and making a few assumptions about how premium support would work, the authors concluded that if a Medicare voucher system had been in place in 2010, about 4 in 10 seniors nationally would have felt no difference. 59 percent of U.S. seniors would have had to pay higher premiums, assuming they did not change their plans. There was huge state-by-state variation, however. In DC, for example, 99 percent of seniors would have been fine. But in states with especially high health care costs (e.g., Florida), the average difference between the voucher and the premium cost would have been more than $100 per month. The authors did not model how insurance companies would have responded to these hypothetical shortfalls; one could argue that if enough customers can't afford to buy the plan you're selling, you would need to make the plan more affordable somehow. They also didn't predict if premium support would keep pace with actual insurance costs over time; given the track record of the past few decades, however, it is likely that the value of the vouchers would shrink relative to premiums with every passing year. Alternatively, keeping Medicare viable in its current form would require some combination of tax hikes (not just on "millionaires and billionaires") or deep spending cuts elsewhere in the federal budget.

It isn't only health care costs for seniors that are skyrocketing, of course - all health care costs are. So who pays the difference when employer-based health insurance premiums regularly outpace wage increases? Employees do, in the form of lower salaries. In a recent study in Family Medicine, my colleagues Richard Young and Jennifer DeVoe estimated just how much cash the average employed American family has lost due to health costs rising faster than inflation over the past 15 years. The answer: a whopping $8,410 per family, or nearly 14% of actual earnings. If this trend continues, the Affordable Care Act's laudable extension of insurance coverage to most Americans will be rapidly undone by unaffordable insurance costs for practically everyone.

Both Presidential candidates have failed to confront this issue squarely. Both deserve blame for not leveling with voters and admitting that taming health care costs is the only escape from the rock of "ending Medicare as we know it" and the hard place of shifting more insurance premium costs on to seniors. Since "the most expensive technology in health care is a physician's pen," argue Young and DeVoe, physicians - including primary care physicians - have a large role to play in this effort:

Family medicine has always thought of its physicians as being patient centered. Perhaps our patients would rather have more income and fewer marginally effective medical tests and treatments. Perhaps their health would improve less from having more screenings and scans but improve more from having more disposable income, less worry about losing their job, and less stress from living paycheck to paycheck. We should ask them. If they want to take advantage of this tradeoff, we should advocate for our patients to achieve this goal.

Monday, October 15, 2012

Why don't comparative effectiveness studies change practice?

The October 1st issue of American Family Physician features the third article in the "Implementing Effective Health Care Reviews" series, a summary of the Agency for Healthcare Research and Quality's comparative effectiveness report on treatments for gastroesophageal reflux disease. Notably, the report found no differences in efficacy between proton pump inhibitors; better symptom relief from continuous daily compared with on-demand dosing; and limited data on endoscopic treatments. What are the chances that results from this and other high-quality comparative effectiveness studies will quickly change clinical practice? Not very good, unfortunately. As I wrote in an editorial that introduced the series:

To date, the track record of translating comparative effectiveness research findings into clinical practice has been mixed, at best. For example, several years after a landmark randomized controlled trial demonstrated the superiority of thiazide diuretics compared with other first-line medications for hypertension, prescribing of thiazide diuretics had increased only modestly. An evaluation of diabetes practice guidelines produced after the publication of an Effective Health Care review of oral treatments found numerous inconsistencies between guideline recommendations and evidence-based conclusions. Despite extensive evidence that initial coronary stenting provides no advantages over optimal medical therapy for stable coronary artery disease, more than one-half of patients who undergo stenting in the United States have not had a prior trial of medical therapy.

In the current issue of Health Affairs, Justin Timbie and colleagues propose five reasons that scientific evidence is slow to change how physicians practice:

1) Misalignment of financial incentives - e.g., fee-for-service payment systems tend to reward invasive therapies, such as surgery for back pain, that may be no better than conservative management.

2) Ambiguity of results - "Without consensus on evidentiary standards prior to the release of comparative effectiveness results, ambiguous results become fuel for competing interpretations, making it difficult for providers, insurers, and policy makers to act on the evidence."

3) Cognitive biases in interpreting new information - e.g., a tendency to reject evidence that contradicts previous strongly held beliefs, such as the superiority of atypical to conventional antipsychotics.

4) Failure to address the needs of end users - e.g., designing a study to compare the benefits of two therapeutic strategies, but not the harms.

5) Limited use of decision support - e.g., poorly designed electronic or paper patient decision aids that do not fit into the workflow of primary care practices.

Do these reasons sound about right to you? How do you think these obstacles could be overcome in order for front-line family and specialist physicians to rapidly incorporate the best scientific evidence into their practices?


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

Tuesday, October 9, 2012

Guest Post: Speaking out for the uninsured

Dr. Laura Makaroff is the current Fellow in the Primary Care Health Policy Fellowship that I direct at Georgetown University's Department of Family Medicine and the author of the following post. Dr. Makaroff's patient gave permission for us to share her story on my blog.


I had a usual Monday seeing patients at an inner-city federally qualified health center (FQHC). Fifteen of the 16 patients I saw had health insurance. Of the 15 who had health insurance, all had some form of public health insurance (Medicaid, DC Chartered, or Medicare) which is common and expected in a FQHC setting. All 15 of these patients had multiple medical problems and multiple life stressors – also common occurrences in our patient population. I worked hard taking histories, doing physical exams, prescribing medications, coordinating care, referring for additional services, filling out forms, and providing culturally-sensitive patient education for all of these patients (but didn’t get my notes done. Those will have to be done remotely because I ran out of time at the end of the day - also a common occurrence on days spent on the front lines of patient care). All 15 of these patients left the clinic with at least some of their medical issues addressed and none of these patients were worried about going bankrupt because of their medical expenses. Certainly there are other issues they face, but bankruptcy due to medical costs is not one of them because they all qualify for public insurance.

One of the 16 patients I saw is not covered by public insurance, and she is concerned about bankruptcy due to medical bills. This young, mid-twenties professional came to the clinic yesterday to follow-up regarding a recent hospital stay for a pulmonary embolus. She went to the ER last week after collapsing while running. She was diagnosed with a large pulmonary embolus and is lucky to be alive today. She spent 2 days in the ICU with close monitoring and anticoagulation (blood thinning medication). She was then transferred to the general medical floor for more monitoring. She was discharged with appropriate bridging therapy for her anticoagulation and was told to follow up with a primary care physician.

So there she was, in tears, trying to be thankful for her life but burdened by the thought of the bills that are coming her way. She is facing tens of thousands of dollars of medical bills, if not hundreds of thousands of dollars. She makes too much money as an English-language interpreter to qualify for public insurance. She is not a candidate for the newly-approved high risk insurance pool due to her recent catastrophic coverage (she had been so afraid of a “catastrophic” event that she carried a short-term, non-renewable catastrophic health insurance plan that happened to expire one week prior to her hospital admission.) She has not been able to obtain individual insurance because of pre-existing conditions which include a high body mass index and a previous diagnosis of sleep apnea. She received yet another health insurance denial while she was hospitalized. The insurance applications missed the fact that she has been actively working on lifestyle changes (including running on a regular basis) and has lost 60 pounds in the last year. If there is a fortunate part of this story, it is that she lives in a metropolitan area where she has access to primary care at a community health center that receives funding in order to provide services to all.

Some might say that she should have not been so “risky” with her self-employment and instead “played it safe” by seeking a large employer in order to be a part of a larger risk pool. That might be the best answer for her future, but that is hardly a solution to the real problem. In addition, what ever happened to the American Dream of life, liberty, and the pursuit of happiness? Shouldn’t this patient be allowed to follow her dream of helping people with language interpretation services and be a positive contributor to society? What about the importance of individualism that is so much a part of American culture?

This patient got the care she needed and fortunately was able to stop her most expensive medication based on her recent lab results. She is able to follow up with me for necessary, repeat blood testing, but she will likely face decisions in the future that force her to decide between incurring more medical bills or getting the health care she needs.

This patient may have been an exception in my patient population on this day, but she is not an exception in the greater U.S., where high medical bills account for 60% of bankruptcies. Modern medicine can keep this patient alive, maintain her safely on necessary anticoagulation, and even look for unusual genetic disorders that may have predisposed her to having a blood clot in her lungs in the first place. The modern health care system cannot claim the same successes, and may actually do exactly what physicians vow not to: cause harm by creating insurmountable bills and a lifetime of interrupted access to care due to health insurance challenges.

Monday, October 8, 2012

Reducing overtreatment is "the other side of quality improvement"

Introducing several new articles about overdiagnosis and overtreatment, BMJ editor Fiona Godlee recently asked, "How much of what we offer to patients is unnecessary? Worse still, how much harm do we do to individuals and society through overtreatment?" Although prostate and breast cancer screening have been the poster children for for this increasingly recognized phenomenon, there are plenty of other situations where an aggressive approach can lead to unnecessary and potentially harmful care: screening for osteoporosis, treatment of mild hypertension, cholesterol screening in children, and screening for gestational and "pre" diabetes. The excellent 16-minute video below features Shannon Brownlee, Jeanne Lenzer, and fellow AFP and Essential Evidence Plus editor Mark Ebell, among others, discussing the scope of the problem.

For those of you interested in learning more about strategies to reduce overtreatment and rein in wasted health spending, including shared decision-making, I also highly recommend the PBS documentary Money & Medicine. This one-hour documentary, which premiered on September 25th, contrasts the approaches and outcomes of care at UCLA Medical Center in Los Angeles and Intermountain Medical Center in Utah.

A problem is that while health organizations are developing more and more measures to discourage undertreatment (e.g., not prescribing aspirin after a heart attack), it can be difficult to identify overtreatment in a systematic way. Noting that randomized trials have not found improved outcomes from low blood glucose targets in older patients with type 2 diabetes, Leonard Pogach and David Aron proposed in the Archives of Internal Medicine that a hemoglobin A1c of less than 7% be considered "as a threshold measure of potential overtreatment of persons older than 65 years who are at high risk for hypoglycemia." They explain that this measure would appropriately be a "warning signal" rather than an automatic indication of overly aggressive diabetes care. Although I feel that this proposal is modest and common-sense, its adoption would nonetheless be a much-needed first step in addressing what Pogach and Aron call "the other side of quality improvement," too often neglected.

Thursday, October 4, 2012

The spiritual assessment: unnecessary or essential?

Since it became possible to post online comments on American Family Physician content earlier this year, no single article has prompted as many comments as "The Spiritual Assessment," published in the September 15th issue. In the article, Drs. Aaron Saguil and Karen Phelps suggest assessing older patients, hospitalized patients, and patients with worsening or terminal illness, who are more likely to be interested in sharing their spiritual or religious beliefs. Other patients may bring up their faith or spiritual practices without prompting in the course of a normal conversation. Since 80 percent of patients and family physicians perceive religion to be important, according to the authors, acknowledging and supporting spiritual beliefs is a key component of holistic, patient-centered care:

The spiritual assessment allows physicians to support patients by stressing empathetic listening, documenting spiritual preferences for future visits, incorporating the precepts of patients' faith traditions into treatment plans, and encouraging patients to use the resources of their spiritual traditions and communities for overall wellness. Conducting the spiritual assessment also may help strengthen the physician-patient relationship and offer physicians opportunities for personal renewal, resiliency, and growth.

The range of comments received thus far reflects family physicians' diversity of views on this topic. For example, while one reader opined that spiritual concerns have "little to do with improving the health of our patients," another countered, "I do not think this article goes far enough in promoting this type of spiritual health assessment." Another reader argued that the spiritual assessment should "not be elevated to the status of another vital sign we must always take." Some readers expressed concerns that physicians might seek to impose their religious beliefs on vulnerable patients, while another suggested that "many physicians seem to have more fear of [discussing] spiritual issues than the patients do."

How important is it to perform a spiritual assessment in primary care? Is it essential, unnecessary, or somewhere in between? As a patient, do you think speaking with your physician about your religious or spiritual beliefs could be helpful for your health? I'd love to hear your thoughts.


A version of the above post was first published on the AFP Community Blog.

Monday, October 1, 2012

Cancer awareness can also be a negative thing

The incongruous spectacle of Cowboys and Bears players on ESPN's Monday Night Football sporting pink jersey patches and pink shoes in honor of National Breast Cancer Awareness Month prompted me to revisit (and slightly revise and update) the following piece, originally posted in January 2010.


The American Cancer Society designated this weekend "Suits and Sneakers Awareness Weekend" as part of its annual Coaches vs. Cancer program that featured well-dressed basketball coaches wearing "sneakers instead of dress shoes with their usual game attire during weekend games to demonstrate their support for the Society and the fight against cancer." The idea is to encourage people to exercise and eat a healthy diet to reduce their risk of cancer. Of all of the ACS's cancer prevention initiatives, this is probably one of the best.

I'm suspicious of other "cancer awareness" efforts, though - in particular, the increasing fad of designating particular months or weeks of the year as times for heightened awareness of individual cancer types. According to the 2012 ACS calendar, the fall months are particularly crowded: September was for ovarian cancer, childhood cancer, leukemia and lymphoma, thyroid cancer, and prostate cancer Month; October is for breast cancer (with "National Mammography Day" coming up on the 19th); and November is for lung and pancreatic cancer. January 2010 saw Facebook virtually consumed for a few days by a "breast cancer awareness campaign" with female users posting the colors of their bras in status updates. While advocacy groups denied any involvement in this apparently spontaneous campaign, they also professed to be pleased with the attention that breast cancer was getting.

Yet I wonder if breast cancer really needs any extra attention when a few years ago the release of painstakingly crafted recommendations to individualize mammography decisions for women in their 40s caused weeks of public furor and threatened to derail health reform legislation over the make-believe issue of "rationing." And from a public health standpoint, focusing on this single cancer to the exclusion of all other threats to women's health makes little sense. Among the causes of death in women, breast cancer doesn't even make the top five. It ranks 7th overall, and according to statistics from the Centers for Disease Control and Prevention, it isn't even the number one cancer cause of death. (That would be lung cancer, by a nearly two to one margin.) Even if breast cancer is detected and appropriately treated, there is scientific consensus that up to 1 in 3 women receiving treatment gain nothing from it, because the cancer was either slow growing or the patient was destined to die of some other cause (such as a heart attack or stroke) before the cancer would have caused any symptoms.

Finally, well-intentioned cancer awareness efforts can backfire by encouraging unnecessary or unproven screening for cancers. During the Facebook campaign, I was dismayed to see some of my friends discussing how a similar strategy might be used to persuade men to get testicular and prostate screenings (brief or boxer color?) or women to get checked for ovarian cancer (you've got me on that one). Unfortunately, there is no consistent evidence that detecting any of these cancers with existing tests saves lives (ovarian cancer screening, in fact, has been proven to cause net harm), and doing so can and does lead to emotional or physical damage from false positive tests.

I'm all for cancer awareness when the goal is to reduce the risk of developing cancer, or to deploy proven screening tests for early-stage cancers in age and risk groups that are supported by good scientific evidence. But naive "awareness" - that is, high doses of enthusiasm combined with misinformation - may actually hurt as many people as it helps.