Conservative Medicine: Why am I the best person to write it?

In a recent New York Times editorial about exorbitant healthcare costs, Dartmouth professor H. Gilbert Welch (the author of Overdiagnosed: Making People Sick in the Pursuit of Health) asserted: "Medical care in America could use a dose of moral outrage." For all our hand-wringing about unsavory business practices in medicine, Dr. Welch explained, health care professionals have done shamefully little to counteract the interests that value profits over patients. His stance was subsequently supported by a JAMA survey showing that most physicians didn't feel it was their responsibility to contain medical costs.

I was reminded of Dr. Welch's editorial when reading a well-intentioned e-mail that advised me to tone down the "emotion" and "heat" in writings critical of providers of direct-to-consumer screening tests. Really? If companies were going around selling bargain-priced chemotherapy to healthy people at churches and community centers without advising potential customers that these therapies were not recommended for the general population and could be harmful, we wouldn't be gently chastising them in the editorial pages of access-restricted academic journals. No, there would be class-action lawsuits and high-profile investigations. Consumer-protection groups would be clamoring for regulators to shut these businesses down. Providers of unnecessary and potentially harmful screening tests (physicians included), on the other hand, get a pass. Diagnosis: insufficient outrage.

I felt similarly as an employee at the Agency for Healthcare Research and Quality in the demoralizing aftermath of the cancellation of the U.S. Preventive Services Task Force's November 2010 meeting. We were intentionally interrupting the work of the Task Force, and preventing millions of men and their clinicians from receiving their assessment that prostate cancer screening was harmful to their health, so that the President's political party could perhaps hold on to a few more Congressional seats in the midterm elections? Really?

Why am I the best person to write Conservative Medicine? It's not only because I'm a family physician with a public health degree who has spent my career examining the evidence on clinical preventive services. Though I may not write as eloquently as journalist and health policy expert Shannon Brownlee, or summon the gravitas of the American Cancer Society's chief medical officer Otis Brawley, I am passionate (and, occasionally, appropriately outraged) about reducing overdiagnosis and overtreament, exposing political interference in screening guidelines, and ensuring that people who come to me for health care are more likely to be helped than harmed by the encounter.

**

This is the fourth in a series of brainstorming posts about a book that I plan to write titled Conservative Medicine.

Conservative Medicine: What's new about this book?

How do you know when you are sick? This may seem like a silly question at first blush, but the proliferation of increasingly sensitive screening tests that aim to diagnose diseases long before they can cause symptoms (and, hopefully, deliver treatments that will be more effective during the asymptomatic stage) has changed the answer. Today, more patients than ever find out that they're sick not because they feel sick, but because a doctor tells them they are.

Your blood pressure or sugar level or cholesterol level is too high. You have a prostate cancer that you can't see or feel - that the doctor can't even feel - but that a pathologist diagnosed by looking at a small sample of cells from a blind biopsy needle that followed a "simple" blood test your doctor might not have bothered to tell you about. Some of these abnormalities will eventually cause suffering or premature death. Many of them won't. It's not possible to know for sure which is which. So naturally, you have aggressive treatment, just in case, and experience all of the resulting side effects.

Although long ignored or downplayed by screening advocates, overdiagnosis and overtreatment have been recognized as important problems in medicine for years. In a few weeks, I will attend an international conference on Preventing Overdiagnosis at the Dartmouth Institute for Health Policy and Clinical Practice. The conference website includes an excellent reading list of books about the topic written by prestigious experts. So where does Conservative Medicine fit in? What will my book say that hasn't been said already?

In my view, overdiagnosis would be much less of a medical problem if our definitions of disease weren't so elastic. A study published last week in PLoS Medicine determined that most expert guidelines published since 2000 expanded the definitions of diseases and eligibility for treatment - for example, lowering the threshold for "high" cholesterol or using a more sensitive diagnostic test for a heart attack. This might not necessarily be a bad thing if it meant that more patients would benefit from effective treatments, but the study researchers also found that 3 in 4 guideline panel members had received payments from pharmaceutical or device companies that stood to benefit directly from more expansive disease definitions. More people with "high" cholesterol meant more prescriptions for cholesterol-lowering drugs, and the scientists who lowered the threshold were on the payroll of the companies that sold those drugs. Hmm.

A related phenomenon is epidemics of "predisease" - people who do not have disease but are considered more likely than others to develop that disease in the future. Prehypertension, prediabetes, and osteopenia are common examples of such conditions. As family physician and public health specialist Anthony Viera explained in this Epidemiologic Reviews article, the concept of predisease only makes sense if people with predisease are at much greater risk than others of developing true disease, if an intervention exists to lower that risk, and if the benefits of that intervention outweigh the harms in the population. That last point is worth repeating: if the benefits of that intervention outweigh the harms. Just being told you have predisease will change your life, and not always for the better.

In addition to taking a hard look at the effectiveness of screening tests, Conservative Medicine will argue that expanding disease definitions and being careless about labeling patients as prediseased often lead to more harm than good.

**

This is the third in a series of brainstorming posts about a book that I plan to write titled Conservative Medicine.

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 June and July:

1) Should you be screened for lung cancer? Maybe not, and here's why (7/29/13)

2) $10 billion per year to train the wrong physicians (6/18/13)

3) Abandoning risk factor assessment for HIV and HCV (7/1/13)

4) Screening-illiterate physicians may do more harm than good (7/13/13)

5) Low-value care for acute chest pain in the ED (6/4/13)

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

Is prevention or treatment the heart of family medicine?

The comprehensive scope of family medicine has always made it a challenge to describe, in a nutshell, what family physicians do. Unlike subspecialists or general internists, surgeons, or pediatricians, family physicians do not define their patient populations by age, gender, or organ system. A series of editorials published a few years ago in the Annals of Family Medicine argued that family physicians practice a "science of connectedness" that includes a distinct approach to clinical problem-solving. A more recent study in Family Medicine asserted that the training and attitudes of family physicians make them uniquely qualified to provide cost-effective health care. The emergence of the Patient-Centered Medical Home model has emphasized the role of the family physician as a facilitator and leader of care teams for patients with multiple preventive and chronic care needs.

Dr. John Hickner, editor of The Journal of Family Practice, worries that well-intentioned initiatives to improve family physicians' skills at providing screening tests and facilitating behavioral change may come at the cost of neglecting patients' acute concerns. He wrote in a recent editorial:

At times I fear that all the focus on prevention and chronic disease management, necessary as these are, distracts us from our most important work: meeting the immediate needs and concerns of our patients. The agenda of the office visit used to be exclusively the patients’. Now a visit—and our attention—is often split between their agenda and ours, which includes screening for this and that and exhorting patients to a healthier lifestyle whether they want it or not. I had one irate patient tell me, “Don’t put me on that scale again! I know I’m fat and if I want your help, I’ll ask for it.”

Overemphasis on prevention and chronic disease management, I fear, has caused many physicians to undervalue diagnosis and acute care. The sad result? In some practices, the schedule is so full of routine follow-ups that patients must go to an urgent care center or the ED for complaints that could be easily managed in a doctor’s office.

As a family physician who teaches public health and preventive medicine, I appreciate the tension between prevention and treatment in my own practice. Previous studies concluded that paying exclusive attention to providing guideline-recommended preventive and chronic disease services would leave literally no time to address the many other reasons that patients come into the office. As Dr. Hickner noted, "The 'number needed to treat' to listen carefully and provide reassurance and proper treatment to a patient with an acute complaint is one!" So is prevention or treatment the heart of family medicine? Is the answer to this question different today than it would have been a generation ago, and is it likely to be different a generation from now?

**

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

Conservative Medicine: What's the book about?

Renowned American surgical pioneer William Halsted is probably best known for the cancer operation that bears his name: the Halsted radical mastectomy. First performed in 1882 and the treatment of choice for localized breast cancer until the 1970s, this extremely disfiguring surgery removed the entire affected breast, underlying pectoral (chest wall) muscles, and all of the adjacent lymph nodes. Dr. Halsted and his supporters felt that this operation was superior to removing only the affected breast (or only the affected part of the breast, known as lumpectomy) based on a theory of how breast cancer spread that was ultimately shown to be flawed. When evidence began to emerge in the 1940s that breast cancer recurrence rates following radical mastectomy were no better than those following more conservative surgical techniques, proponents of Halsted's aggressive surgery nonetheless fiercely resisted calls for change for nearly thirty years.

I share this notable episode of medical history to explain the working title of my book-in-progress, Conservative Medicine. In politics, the "conservative" label is usually attached to someone who resists change; in modern medicine, however, conservative physicians are frequently those who are calling for change. For example, the Choosing Wisely campaign sponsored by the American Board of Internal Medicine Foundation discourages physicians from providing, and patients from receiving, common "aggressive" medical tests and treatments that have no clinical benefits and often cause harm. (As general internist and medical educator John Schumann recently observed on his blog, even former U.S. Presidents are not immune to the tendency for physicians to do more than is medically necessary.)

Conservative Medicine will consist of three interweaving and complementary stories. The first is the story of the science of screening tests and other preventive interventions: a tale encompassing a few notable successes but many false hopes and unfulfilled promises. The second story is that of my patients and others whose health was affected by preventive medicine: a few who possibly benefited as well as others who were probably harmed. The third story is my own: the narrative of my gradual evolution as an increasingly skeptical clinician and scientist, including four tumultuous years as a staffer and researcher for the U.S. Preventive Services Task Force, the federally-supported panel that now decides which preventive services health insurers must provide for free.

Only recently have I realized that my personal story will - and must - end up being at the center of my book. Although I have posted many times on Common Sense Family Doctor (and published a longer literary piece) about the adverse effects I experienced from questioning the effectiveness of the prostate-specific antigen (PSA) test for prostate cancer, I wasn't sure who would want to sit through book chapters about the travails of a mid-level government health bureaucrat. On the other hand, working in a federal agency at the center of various political storms provided me with insights that were critical to developing my philosophy as a conservative family physician. The challenge will be using my narrative as a way to advance the larger story of how the good intentions of preventive medicine run amok in our present-day health system. I welcome your suggestions.

**

This is the second in a series of brainstorming posts about a book that I plan to write titled Conservative Medicine.

Estimating osteoporosis risk in older men

According to a recent review in American Family Physician, 1 to 2 million American men have osteoporosis, 13 percent of white U.S. men older than age 50 will experience an osteoporotic fracture in their lifetimes, and men are twice as likely as women to die in the hospital following a hip fracture. However, unlike screening guidelines in women, there is no consensus on when to screen for osteoporosis in men. The American College of Physicians recommends an individualized osteoporosis risk assessment for men age 65 or older, and dual energy x-ray absorptiometry (DXA) scans to measure bone density in men at increased risk. On the other hand, the U.S. Preventive Services Task Force found insufficient evidence to assess the balance of benefits and harms of screening for osteoporosis in men, although it observed that "men most likely to benefit from screening would have 10-year risks of osteoporotic fracture equal to or greater than those of 65-year-old white women with no additional risk factors."

Since neither organization recommends routinely screening older men for osteoporosis, family physicians require clinical tools to determine which men are at higher risk and therefore candidates for bone density measurement. One such tool, the Male Osteoporosis Risk Estimation Score (MORES), uses age, weight, and the presence or absence of chronic obstructive pulmonary disease to calculate a risk score and recommends further evaluation in men at a certain point threshold. However, since MORES was derived and validated in an historic national survey sample, until recently its utility in a present-day primary care setting was unknown.

In the July/August issue of the Journal of the American Board of Family Medicine, Drs. Alvah Cass and Angela Shepherd evaluated the performance of MORES in a cross-sectional sample of 346 men age 60 years or older presenting to family medicine, internal medicine, or geriatric outpatient practices at the University of Texas, Galveston. MORES correctly identified 12 of the 15 men in the study with osteoporosis of the hip, yielding a sensitivity of 80% and a specificity of 70%. Based on these results, 259 men would need to be screened with MORES to prevent one major osteoporotic fracture over 10 years, compared to 636 with a universal DXA strategy.

Will the results of this study make physicians more likely to use MORES to assess the risk of osteoporosis in older men? Or will clinicians gravitate toward a universal age-based DXA screening strategy (analogous to screening all women age 65 years or older) to avoid missing any men with osteoporosis?

**

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