Wednesday, December 26, 2012

The most unheralded posts of 2012

It is customary for bloggers to highlight their most popular posts at year's end (see, for example, this recent compilation of posts from the AFP Community Blog, several of which subsequently appeared on Common Sense Family Doctor), but this year I've decided to buck the trend. Instead, below are links to six of this year's "unheralded" posts that weren't read as much as I thought they deserved. If you missed any of these, I hope you enjoy them the second time around. Thank you for reading, and have a very happy New Year!

1. The best colorectal cancer screening test is the one that gets done (May 21)

Not only does screening colonoscopy cost a lot more money, it hasn't been shown to be more effective than flexible sigmoidoscopy. In fact, screening colonoscopy has never even been tested in a randomized trial, and may never be.

2. Changing unhealthy habits requires changing environments (June 4)

Strategies to stabilize, and eventually, reverse, national obesity rates will need to change obesity-promoting environments on the individual and community levels.

3. How would you rate your health care team? (June 7)

One way for physicians to meet the health care needs of a burgeoning and increasingly complex patient population is to delegate many of their traditional responsibilities - such as patient education, lifestyle counseling, medication titration, and medication-adherence counseling - to other health professionals.

To make a fully informed medical decision, whenever a doctor says, "Test X will reduce your risk of disease X (or death from disease X) by 20 percent," patients should always ask, "20 percent of what"?

Hospitals and large specialty practices have financial and material resources, while community health centers have the experience and know-how to manage care for high-risk patients with chronic conditions who generate a disproportionate share of health care costs.

People are fallible, but health systems need not be. Despite the staggering complexity involved in flying passenger jets and constructing skyscrapers, commercial airline accidents are rare and building collapses even rarer. (So it should be in health care, also.)

Saturday, December 22, 2012

False alarms and unrealistic expectations in preventive care

Shortly after we moved to Washington, DC eight years ago, my wife and I purchased a basic home security system, the kind with a programmable keypad, multiple door alarms and a motion sensor. The alarm has sounded about a dozen times since then. None of these times was a burglary actually in progress. On several particularly windy days, one of us forgot to lock the back door after leaving, and it blew open. Two or three other times, departing early for work, I accidentally hit "Away" on the keypad (arming the motion detector at the foot of the stairs) rather than "Stay," causing the klaxon to sound when my unsuspecting son or visiting mother-in-law came down the stairs later in the morning. We've also set off the fire alarm a few times while cooking. Although our security system cost little to purchase, at this point we've spent well over $3000 in monitoring fees, a sum that could easily surpass the value of what we might lose in an actual burglary.

There are, of course, intangible benefits to having a home security system - peace of mind being the most important. But our peace of mind has been achieved at the substantial cost of temporarily diverting multiple municipal police and fire units, disturbing our neighbors, receiving inconvenient cellular phone calls from the monitoring company, and briefly traumatizing a 5 year-old on his way to breakfast. All things considered, it's hard to argue that the benefits of this preventive measure have outweighed its cumulative harms.

I think about my home security system every time I'm asked to do a physical examination on an apparently healthy young adult. Although the periodic health examination is an established tradition in medicine, and probably builds trust and strengthens the doctor-patient relationship in preparation for future health crises, studies have shown that it doesn't help people live longer, or even better. The same may be said for many of the tests physicians routinely offer at these examinations - including blood pressure measurement (no benefit from treating mild hypertension) and diabetes screening (no benefit from nontargeted screening).

No doubt these routine examinations and tests (if normal), like my home security system, give patients peace of mind. And if patients had clear-eyed expectations of the small potential benefits of screening and preventive treatments, I would have no problem with continuing to do them. Unfortunately, a recent study in the Annals of Family Medicine showed that patients greatly overestimate the benefits of preventive interventions that primary care physicians commonly provide: breast cancer screening, colorectal cancer screening, and medications to prevent hip fractures and cardiovascular disease. In most cases, patients' "minimum acceptable benefit" (the lowest level of benefit that in their mind was required to justify the preventive intervention) far exceeded the actual benefit of the service established in randomized trials. Further, this study considered only the benefits of these services, and not the false alarms, which occur in more than 60 percent of women receiving annual mammography after 10 years.

Not only do inflated expectations of the benefits of preventive tests and treatments needlessly complicate shared decision making, they contribute to an environment where proposals to restrict screening tests of marginal benefit (such as the prostate-specific antigen test for prostate cancer) inevitably cause a political uproar. In the words of family physician and former U.S. Preventive Services Task Force member Steven Woolf:

If people are widely convinced that a screening test or drug is beneficial, confronting these beliefs can, if anything, engender suspicions about one's veracity and motives. Whether the messenger is one's physician, a health plan, or a government task force, attempts to set more realistic expectations about benefits, risks, and scientific validity are often taken as insensitivity to suffering, discrimination, or a pretext for cutting costs, rationing health care, or threatening personal autonomy. ... It is an increasingly difficult environment for the American public to receive, let alone absorb, undistorted scientific information from reputable bodies.

Unrealistic expectations therefore persist, surviving not only on misinformation but also by serving other purposes. For example, false beliefs meet the psychological needs of patients for hope and safety, as well as for action, agency, and a sense of control. They enable clinicians to feel they are making a difference; even physicians who know better order unnecessary tests to please their patients. False expectations fuel market demand for products, industries, and health delivery systems and can be fomented by misleading advertising. Confronting these expectations can not only dash hopes but potentially threaten profits, shareholders, clinical practices, industries, legislation, and political careers.

I recently had a testy social media exchange with an obstetrician-gynecologist who disagreed with my view that since cervical cancer screening is needed only every 3 to 5 years, and ovarian cancer screening is useless and potentially harmful, there is no good reason to do annual pelvic examinations in women at low risk for sexually transmitted diseases. However, a recent survey of U.S. gynecologists found that overwhelming numbers (including, presumably, this particular Ob/Gyn) continue to do these examinations despite the absence of proven health benefits. In my view, the only clear benefit (aside from "peace of mind") is financial - doctors can charge more for physicals that include a pelvic examination, payers will pay for them without question, and medical offices then have an easier time keeping their doors open.

Preventive health care has positive effects if offered to appropriately selected and informed patients. But the massive structure of "routine" preventive care, built upon a rotten foundation of false alarms and unrealistic expectations, only serves to increase harms and health care costs. It should be a New Year's resolution of conscientious physicians and policymakers everywhere to help people understand the difference.

Monday, December 17, 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 late October and November:

1) Dollars and sense of rising health insurance costs (10/18/12)

2) Why primary care is the future of health care (10/31/12)

3) To protect patients, practice guidelines must meet higher standards (11/4/12)

4) Lockboxes, Medicare reform, and the myth of "free stuff" (11/11/12)

5) Dissecting a hepatitis C screening recommendation (11/28/12)

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

Wednesday, December 12, 2012

Cancer epidemiology 101 for urologists (and others)

I've had many Twitter conversations with prostate cancer screening advocates who fear that the U.S. Preventive Services Task Force's "D" (don't do it) recommendation against PSA-based screening for prostate cancer will lead to a dramatic spike in prostate cancer deaths as primary care physicians screen more selectively, or perhaps stop screening at all. I seriously doubt these apocalyptic forecasts (for one thing, prostate cancer causes only 3% of deaths in men, and the decline in the U.S. prostate cancer mortality rate since 1990 hasn't had any appreciable effect on overall life expectancy). However, I recognize that reasonable people disagree with my review and the USPSTF's interpretation of the evidence. The American Cancer Society, for example, continues to support screening if men are adequately informed of the known risks and uncertain benefits. But it's one thing to argue from evidence, and quite another to argue from ignorance. Many of the tweets I've seen from urologists, unfortunately, represent the latter.

When I went to medical school, biostatistics and epidemiology was the course that no one took seriously. Things have changed for the better over the years - today I teach a rigorous course in evidence-based medicine and population health at Georgetown University School of Medicine - but there's still an appalling lack of basic knowledge about these topics among practicing physicians of all specialties. Below are a few key concepts in cancer epidemiology that anyone should understand before getting into a dispute about the value of prostate cancer screening.

Lead-time bias - "Prostate cancer survival has improved since we started PSA screening, so screening must work!" The first clause of this sentence is absolutely true: in the 1970s, about 70 percent of men diagnosed with prostate cancer were still alive 5 years after diagnosis, while today that figure is closer to 99 percent. The second clause could be true, but does not invariably follow from the first. By finding prostate cancers in men long before they become symptomatic (if they ever become symptomatic), screening advances the time of diagnosis, but could have no impact on mortality. In other words, 5-year survival always increases when a screening test is implemented, but its effect might only be giving patients an earlier cancer diagnosis without affecting their disease course. See chest x-ray screening for lung cancer (which was unfortunately a common practice for years) for an example of this phenomenon.

A variation on the above statement is the observation made by older urologists that "Before PSA testing, we used to see men with prostate cancer only when they came in with metastatic disease; today we see them with much less advanced tumors so that they can be cured." Much of this clinical experience reflects the effect of lead time, as well as overdiagnosis of cancer that didn't need to be found in the first place. In the words of urologic oncologist Willet Whitmore, "For a patient with prostate cancer, if treatment for cure is necessary, is it possible? If possible, is it necessary?"

Association does not equal causation - "Prostate cancer mortality has declined by 30 percent since 1990, which must be due to PSA screening." It's tempting to make sweeping conclusions based on observational data - the press has been doing this forever, linking caffeine use to cancer today, then reversing itself when a new headline is needed tomorrow. It's certainly possible that some of the decline in mortality is due to screening, but it's just as likely that some other factor is responsible. For example, men who smoke are less likely then male non-smokers to die from prostate cancer. Does that mean that tobacco use has a protective effect? Of course not; these men are dying prematurely from heart attacks and chronic obstructive pulmonary disease, and therefore not dying of prostate cancer. Also, the temporal association between the mortality decline and the PSA screening doesn't make any sense, since the only randomized trial to show that PSA screening reduces prostate cancer mortality (more on this later) found that it takes at least 9 years to do so. Since PSA screening was not widespread in the U.S. until the early 1990s, any benefit of screening wouldn't have changed the mortality statistics until 2000. But that's not what happened.

The most favorable study represents "the truth" - "Prostate cancer screening reduces prostate cancer mortality by 20 percent." If you only speak to urologists, you might come away thinking that there's only been one randomized trial of PSA screening: the European Randomized Study of Screening for Prostate Cancer (ERSPC), which reported this result in 2009 and again in 2012 after 11 years of follow-up. The usual description of the ERSPC as a single "trial" is problematic (it's actually a combined analysis of screening results from 7 European countries), but even allowing for that, it's only one of 5 randomized trials of screening, and (guess what?) the only one of the 5 to show a benefit.

In the old days, the process of writing reviews and guidelines went as follows: write up recommendations that you already know to be correct from clinical experience, then go to the literature to select evidence that supports your positions. A less biased approach is to evaluate all of the available evidence, regardless of one's preexisting biases, which is what my colleagues and I did and what independent reviewers did for the both the Cochrane Collaboration and BMJ. Here's what the Cochrane reviewers concluded: "Prostate cancer screening did not significantly decrease all-cause or prostate cancer-specific mortality in a combined meta-analysis of five RCTs."

Specialist-authored guidelines are superior to generalist-authored guidelines - "The USPSTF guidelines are invalid because there were no urologists on the panel." Let's put aside for the moment the fact that more prostate cancer diagnoses invariably lead to more business for urologists, and that guidelines authored by specialty societies are of lower quality than those authored by generalists. Dismissing the USPSTF recommendation on the basis of its primary care membership is still nonsense, pure and simple. The vast majority of prostate cancer screening occurs in primary care settings, and therefore primary care clinicians are the most appropriate experts to evaluate and weigh the evidence about screening. (The same can be said about mammography guidelines and radiologists.) Several urologists were, of course, consulted at multiple stages during and after the writing of our evidence review to make sure that no important studies were missed.

As I've said, I welcome debates with well-informed advocates of PSA screening, who tend to view this imperfect test as a glass half-full rather than half-empty (or shattered beyond repair). For the less-informed, I get it that you don't have time to go back to medical school for remedial epidemiology lessons. So consider this post your Cliff's Notes.

Friday, December 7, 2012

Fasting lipids study is a potential practice-changer

When I last saw my personal physician for a checkup, she recommended that I undergo screening for lipid disorders, per the guidelines of the U.S. Preventive Services Task Force. Although the office had a phlebotomist on site, my appointment was in the afternoon, and I had already eaten breakfast and lunch. Consequently, she instructed me to make a separate morning appointment to have my blood drawn after an overnight fast. Due to my hectic schedule, several months passed before I finally got around to doing this (fortunately, the results were normal). As family physicians know, many patients who are sent for fasting tests never have those tests done at all.

A recent study published in the Archives of Internal Medicine suggests that there may be little reason for most patients to endure the inconvenience of fasting before lipid testing. The authors analyzed the relationship of fasting duration to variations in cholesterol levels obtained in more than 200,000 patients in and around Calgary (Alberta, Canada). In this population, the time since one's last reported meal had no effect on mean total cholesterol and high-density lipoprotein (HDL) cholesterol levels. Mean low-density lipoprotein (LDL) levels varied by up to 10 percent, while mean trigylceride levels varied by up to 20 percent. The authors and two editorialists conclude that for most purposes in primary care, including global cardiovascular risk assessment and monitoring response to pharmacologic treatment, nonfasting cholesterol measurements are likely to yield equivalent information to measurements from traditional fasting samples.

Rare is the single study in the medical literature that changes usual clinical practice on its own, and for good reason. Consistent evidence from multiple studies is usually needed to verify or refute impressive initial findings. Further, the cross-sectional design of this particular study might have masked unmeasured variables that would have been better controlled for in a randomized clinical trial. That being said, if any single study should be called a practice-changer, I think this one fits the bill.


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

Tuesday, December 4, 2012

In health care, little details make all the difference

When I heard in October that Superstorm Sandy was projected to make landfall somewhere in the vicinity of DC and Maryland, I prepared for the worst. I stocked up on non-perishable goods and evacuated to higher ground. (The rest of my family was already coincidentally out of town and harm's way.) I put fresh batteries into two flashlights and installed a flashlight app on my smartphone for good measure. Although I didn't give it much thought at the time, I assumed that hospitals in Sandy's path were taking similar precautions - stocking medical supplies, testing backup generators and so forth. So when a power failure at NYU Langone Medical Center forced an evacuation of the entire hospital, with heart-stopping scenes of neonatal ICU nurses cradling respirator-dependent newborns down several flights of stairs to safety, I couldn't understand what had happened. How had they not been better prepared? Had NYU administrators been the equivalent of residents of low-lying coastal areas who ignored repeated warnings and defied evacuation orders?

As it turned out, NYU did a lot of things right before the storm. According to an article in ProPublica, after the scare of last year's Hurricane Irene, the hospital moved its emergency generators from street level to the rooftop and thoroughly waterproofed the generators' fuel pumps. Unfortunately, they neglected to relocate or protect the electricity distribution circuits, which remained in the basement and were quickly disabled by the flooding. As in many areas of health care, doing everything "almost right" wasn't good enough.

All people are fallible, and health professionals no less so than others. But medicine is usually less forgiving of simple mistakes. A technically perfect surgery is a disaster because it was performed on the wrong body part. A patient develops a life-threatening infection because a doctor forgot to wash his hands. A child dies three days after being discharged from an emergency room because his parents were not notified of critical lab values that came back hours after they left.

People are fallible, but health systems need not be. Despite the staggering complexity involved in flying passenger jets and constructing skyscrapers, commercial airline accidents are rare and building collapses even rarer. Atul Gawande argues in The Checklist Manifesto that checklists are the best way to make sure that small but critical details of health care are addressed systematically, so that every member of a care team feels empowered to preempt potential disasters. I believe that checklists and decision support tools are applicable not only to surgery or intensive care settings, but to primary care as well.

Fortunately, the emergency evacuation of NYU Langone Medical Center went off smoothly, and none of the patients who were transferred seem to have suffered as a result. But the good outcome of this near-miss and the low likelihood of another Sandy in the near future should not make anyone at NYU - or in any hospital or health system, for that matter - complacent about addressing the little details and vulnerabilities of health care that make all the difference.

Sunday, December 2, 2012

Yes, family medicine is an affordable career choice

The inexorable yearly rise of medical school tuition has led to corresponding increases in medical student debt. According to the American Medical Association, 86 percent of graduating medical students in 2011 had loans to repay, and their average debt was more than $160,000. The greater long-term income potential from choosing a subspecialist rather than a primary care career is only one of many factors that influence medical students' specialty choices. That being said, my students increasingly ask if they will be able to repay their loans, support spouses and children, and save enough for retirement on a family physician's income - a question that would have been unlikely to come up a generation ago.

In an innovative analysis published in Academic Medicine, researchers from the American Association of Medical Colleges and Boston University concluded that the answer is "yes." Using economic modeling software, they examined variety of loan amounts and repayment scenarios projected against average household expenses in a high-cost urban area (Boston) and income levels for primary care and subspecialist physicians. The bottom line:

Our economic modeling of a physician's household income and expenses across a range of medical school borrowing levels in high- and moderate-cost living areas shows that physicians in all specialties, including primary care, can repay the current median level of education debt. At the most extreme borrowing levels, even for physicians in comparatively lower-income primary care specialties, options exist to mitigate the economic impact of education debt repayment.

The authors defined "extreme" borrowing levels as $250,000 or greater, and noted that options for these highly indebted physicians include extended repayment terms and federal loan forgiveness programs such as the National Health Service Corps. They also noted that physicians who choose to live in rural or low-cost areas will have considerably more discretionary income after expenses.

Although this analysis did not address the equally (and some would say, more) important question of why the primary care-subspecialist income gap exists and what can be done to reduce it, these findings should be reassuring to students considering family medicine careers.


The above post first appeared in the AFP Community Blog.

Saturday, December 1, 2012

Some levity about the patient-centered medical home

In the past, I've written some serious posts about patient-centered medical homes here and here. This is not such a post, and I share it so that you know that primary care physicians doesn't always take themselves too seriously. Thanks to Georgetown Family Medicine colleague and Washington Post / Huffington Post columnist Ranit Mishori for calling this video to my attention. And by the way, please don't visit my office requesting an MRI scan without my having given you a diagnosis.