Diagnosis: self-inflicted wounds

Every so often, a team (or individual athlete) comes along that's so good that the only way they can be stopped is to beat themselves. When they lose, it's from a self-inflicted wound.

It's the Seattle Seahawks in the closing seconds of Super Bowl XLIX, throwing an underneath pass from the New England Patriots' 1-yard line that was intercepted instead of handing the football to one of the best running backs in the game for the winning score.

It's the number one-ranked tennis player in the final of a Grand Slam tightening up and double-faulting on match point.

It's one of the top pro golfers of an era on the fairway of the 17th hole of the final round of a major with a 4-shot lead, deciding to go for the green in one (and finding a bunker) rather than taking the safe layup.

It's the U.S. health care system, which should be the envy of the world, lavishing nearly $10,000 per American on health services each year, but wasting billions on excessive administrative costs, unnecessary and harmful interventions, a fragmented delivery system, rationing care by ability to pay, and colossally failing to invest in primary care and community services that are the foundation for good health outcomes.

It's President Trump's discriminatory (and possibly illegal) executive order to halt immigration from seven majority-Muslim countries under the guise of "national security." Did Osama bin Laden really believe that the result of the 9/11 attacks would be armies of jihadists lining up for more suicide strikes on the U.S.? Or instead, did the Al Qaeda leader perhaps envision an injured America turning in on itself and dying slowly from a torrent of self-inflicted wounds: racism, xenophobia, Islamophobia, among other epidemics of dark suspicion of those who aren't like us? Like many of you, my family has an immigration story, and I stand in solidarity with those unfortunate souls who are being turned away or detained tonight at the airports all over the country solely because of where they came from.

The patient - America - is in critical condition, but may yet be saved by heroic measures. Don't wait. Protest peacefully. Sign a petition. Call your Congressional representative. And remember the words of pastor Martin Niemöller, who spent seven years in a Nazi concentration camp:

First they came for the Socialists
And I did not speak out
Because I was not a Socialist

Then they came for the Trade Unionists
And I did not speak out
Because I was not a Trade Unionist

Then they came for the Jews
And I did not speak out
Because I was not a Jew

Then they came for me
And there was no one left to speak for me

Guest Post: Voting is a vital sign

- Matthew Brown, MD

As a family doctor who works with the underserved in Rochester, New York, I have seen what happens when people do not have access to primary and preventive care. I have seen people admitted for diabetic complications because they couldn't afford their insulin. I have seen people diagnosed with end-stage cancer because they couldn't afford screenings to catch it when it could have been treated successfully. I have seen strokes, and heart attacks, and kidney failure, and a hundred other things that happened because people had to choose between medicine and food. Between doctor's visits and having a roof over their heads. Between what they needed in the long-term and what they needed right at that moment.

Medical care shouldn't be a political issue. I didn't get into this gig hoping I would get to lobby my congressman, or attend rallies, or research Supreme Court decisions. The reason I worked so hard in college, in medical school, in residency and as an attending was to help people who needed help. And I hope most of the people whom I've had the honor and privilege of serving would see that, even if I failed, I was trying with all of my heart to do that.

But the truth is, if I limit myself to studying diseases and medicines and tests and screenings, I'm not really doing all I can. Because it's not just about that any longer. Because, for all of the talk some years ago about "death panels," we are now seeing what the real death panel is: poverty, lack of power, lack of access to care. Because if you're rich, you can afford health care. And if you're poor, you cannot. Full stop.

I ask my patients about non-medical things all the time. I ask them about work, and about seat-belts and bike helmets. I ask them about guns (and I would do so even if I worked in Florida, law be damned). I ask them about their families, and about their favorite sports teams. I ask them how their weekends went. But now I'm asking them one more question:

Are you registered to vote?

If the answer is yes, then I am thanking them, and urging them to make sure they do vote. In every election. If the answer is no, then I am handing them a voter registration form complete with postage, and asking them to fill it out, providing help if necessary. If they have a felony on their record, I am reviewing the New York state rules (able to vote once off parole). If they have immigration issues, I'm getting a social worker involved.

And this is where The Ask comes in, what I am asking of you:

If you are a primary care clinician who works with the underserved, start asking people if they are registered to vote, then help them to do it. It doesn't take long, and it is so important. If you are a nurse or staff member in a primary care office, get your physicians to do this (they'll listen to you; they need you more than you need them, believe me). If you don't have any of those roles but you know someone who does, then for goodness sake share this message with them. If you know someone who knows someone, share this with them. Heck, just share it on the off chance.

And because everything needs a stupid hashtag these days, here's this one: #VotingIsAVitalSign

It shouldn't be political, but it is.

What's in a name? Obesity, ABCD, and prediabetes

A recent position statement from the American Association of Clinical Endocrinologists and the American College of Endocrinology proposed replacing obesity with the term "adiposity-based chronic disease," or ABCD for short. The authors argued that this new term emphasizes that most persons with obesity will struggle with weight gain for their entire lives; encourages a complications-centric as opposed to body mass index-based management approach; and "avoids the stigmata [sic] and confusion" associated with obesity in popular culture. They also asserted that ABCD is more amenable to interventions based on the Chronic Care Model, which explicitly recognizes that screening and office-based management need to be adapted to the patient's unique environment.

None of these concepts should surprise family physicians, though, and after reading through the AACE/ACE statement, I was not sold on the benefits of the new term. Some patients with body mass indexes above 30 don't like the obesity label, but would they respond any more positively to the disease acronym ABCD? There are potential harms to consider, too. One of my American Family Physician colleagues felt that the new term was "intimidating" and "not at all patient centered," while another thought that it "only hides the issue [of obesity] instead of confronting it."

This discussion brought to mind another medical term often associated with overweight and obese patients: prediabetes. On one hand, being classified as "prediabetic" or at risk for this exceptionally common diagnosis may motivate obese patients to lose weight through improved diet and physical activity. On the other, the term prediabetes is misleading: many of these patients will not develop diabetes, and the diagnostic accuracy of the most common screening tests (hemoglobin A1c and fasting glucose levels) is poor, according to a systematic review published in the BMJ. Due to the tests' low sensitivity and specificity, some persons are incorrectly diagnosed with prediabetes, and others who might actually benefit from interventions to prevent diabetes are falsely reassured. Therefore, the review authors concluded, "'screen and treat' policies alone are unlikely to have substantial impact on the worsening epidemic of type 2 diabetes."

For all its limitations, obesity is a diagnosis with well-established clinical utility. It is less clear how many patients have been helped (or harmed) by being diagnosed with prediabetes. With more study, adiposity-based chronic disease might someday become a useful term, but the current case for more widespread use is unconvincing.

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This post first appeared on the AFP Community Blog.

Overuse of health care: can -ologists help themselves?

In a previous post, I reviewed a terrific conference presentation by four orthopedic surgeons on what should have been on the American Academy of Orthopaedic Surgeons' "Choosing Wisely" list instead of the timid and low-impact items that the society actually published. In the question-and-answer session that followed, someone asked if the presenters had shared their evidence-based list with their society's leaders at one of their national meetings. They hadn't. "We would probably have gotten tossed out of the building," one joked, then added more seriously, "A lot of our members make their living by doing these procedures day in and day out."

Lest I seem to unfairly single out orthopedic surgeons and urologists for turning a blind eye to evidence that refutes long-standing medical practices, a 2015 research letter in JAMA Internal Medicine found that specialist societies (membership organizations of physicians whom my friend and family medicine colleague Richard Young dubs "-ologists") are generally likely to resist reversals of practice. In 20 examples of high-quality, high-profile studies that provided evidence for medical reversals, nearly half of official -ologist society responses defended the practice, an effect that was more pronounced when a reversed practice was rated by the authors as of high importance to members of the responding society (e.g., mammography to radiologists).

Resistance to what physician and health services researcher Peter Ubel calls "de-innovation" is driven by more than just fear of declining income. In a Health Affairs commentary, Dr. Ubel identified several psychological biases that cause -ologists to reject new evidence that contradicts established practices: preconceptions (tendency to favor information that confirms prior beliefs), clinical experiences, mistaking association for causality, and reduction of cognitive dissonance.

Primary care clinicians are not immune to these biases, but a family physician's greater tolerance for uncertainty may be advantageous in adapting to medical reversals and reducing overuse of low-value (or no-value) care, such as PSA screening for prostate cancer. In contrast, -ologists may perform unnecessary tests in attempts to eliminate uncertainty, such as an unenhanced CT scan to "rule out" a 2-mm nonobstructing kidney stone that would not change management:

What drives doctors to order tests? We order tests because we must know why. Anything can be known morphs into everything must be known. ... We order CTs because we can. The CT heals us, and our patients. Uncertainty ails. Our intolerance of uncertainty is neither congenital nor stochastic. Our dislike of uncertainty has grown with the availability of imaging. It has reached its apotheosis because of rapid door-to-CT time, the removal of barriers to ordering, and the speed with which reports are rendered. ... So much waste can be avoided by using probability and numbers and applying judgment—the components of rational medical decision making.

Although the relationships between providers of health care, costs, and overuse are complex, recent evidence supports associations between comprehensive primary care and lower costs and higher continuity of care and less overuse. Given these findings, it's not surprising that Dr. Atul Gawande's New Yorker piece, "Overkill," concluded that tackling overuse in health care meant supporting and empowering clinicians whose generalist training, experience, and tolerance for uncertainty makes them best suited to replace unnecessary care with necessary care: family physicians.

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This post first appeared on Common Sense Family Doctor on May 18, 2015.

Ethical foundations of health reform

It's been a rough past couple of months not only for millions of Americans whose health care futures depend on decisions to be made by the new Congress and incoming Trump administration, but for those of us who teach about the U.S. health system for a living. As one health policy expert I follow tweeted, only half-facetiously, on election night: "Dear students: all that stuff I taught you about the ACA? You can forget about it now."

Senate Republicans yesterday took the first steps toward repealing and replacing (or more likely, repealing and delaying) the Affordable Care Act through a procedure called budget reconciliation. As I recently told a MedPage Today reporter, although reconciliation can't completely undo Obamacare, it can undo more than enough. Stop the flow of federal funds for the Medicaid eligibility expansion adopted by 31 states and Washington, DC, and most will be forced to drop coverage or cut back on benefits to balance their budgets. Stop the federal tax subsidies to low-income persons who purchase individual insurance plans on the health insurance marketplaces, and insurers - already forced to sharply raise premiums because not enough young and healthy adults bought in - will leave the marketplaces. Stop enforcing the individual mandate, and even more people won't buy health insurance, pricing premiums even more out of reach and potentially leading to an adverse selection death spiral.

As a piece of legislation, the ACA was 100% partisan, passing Congress without a single Republican vote and signed into law by a Democratic president. But historically, it originated as the conservative (Republican!) alternative to President Bill Clinton's American Health Security Act that failed to even come to a vote in Congress.

I was a college freshman from 1993-1994, and much more interested in Imperial Russian history than in modern U.S. politics, so I have no personal memories of the protracted health care reform debates that occurred in the halls of Congress or between ordinary Americans watching "Harry and Louise" advertisements on television (which I also have no memory of whatsoever). But I recently obtained a paperback copy of the Clinton White House Domestic Policy Council's blueprint for what became known as "Hillarycare." Not surprisingly, it contains some good ideas - particularly those supporting more training programs for and higher payments to primary care physicians - and many that probably wouldn't have worked out very well. But one chapter, "Ethical Foundations for Health Reform," resonated with me, as I imagine it would with others across our diverse political spectrum. It asks, then answers in 14 briefly defined concepts, the essential question: what values and principles should shape our health system?

Universal access
Comprehensive benefits
Choice
Equality of care
Fair distribution of costs
Personal responsibility
Inter-generational justice
Wise allocation of resources
Effectiveness
Quality
Effective management
Professional integrity and responsibility
Fair procedures
Local responsibility

Always, the devil is in the details. For example, how broad or generous do "comprehensive" benefits need to be? What is a "fair" distribution of health care costs? Who decides what is a "wise" allocation of resources? How much "local" responsibility should be reserved for states and communities versus the federal government? But as the patchwork U.S. health system seems primed to undergo another political upheaval, I think it's more important than ever to seek consensus on the destination for health reform before embarking on the journey.

We need to know more about psychological harms of screening

A decade ago, a few colleagues and I performed a systematic evidence review to help update the U.S. Preventive Services Task Force's recommendations on screening for prostate cancer. One of our key questions asked about the harms associated with prostate cancer screening, other than the overdiagnosis (and resulting unnecessary treatment) of clinically insignificant tumors. Since routine prostate-specific antigen screening had been going on since the early 1990s, we expected to find plenty of studies measuring anxiety and other mental health changes caused by false positive or indeterminate screening results.

In fact, after sifting through more than four hundred citations, we only found four articles describing three studies. Only one of the studies followed men for as long as one year. Here's what we wrote about that study:

[The authors] compared 167 men who had an abnormal screening result but a benign biopsy specimen with 233 men who had a normal PSA level. After 6 weeks, 49% of men in the biopsy group reported thinking about prostate cancer “a lot” or “some of the time,” compared with 18% of the control group. In addition, 40% of the biopsy group worried “a lot” or “some of the time” about developing prostate cancer compared with 8% of the control group. ... Statistically significant differences between the biopsy and control groups in anxiety related to prostate cancer and perceived prostate cancer risk persisted 6 months and 1 year later.

One might think that men with normal biopsies following an elevated PSA level should have been reassured that they had dodged a bullet and been pronounced prostate cancer-free. In fact, exactly the opposite occurred. And that's hardly surprising, since prostate biopsies, unlike breast biopsies, usually don't aim for a particular location of concern, leaving open the worrisome possibility that the biopsy needle just didn't sample the cancer if it was there. (How uncommonly cancer cells found in the prostate spread and lead to symptoms or death is another issue entirely.)

In the years since that review was published, the USPSTF has recommended against PSA-based screening for prostate cancer and recommended for low-dose CT screening for lung cancer in selected patients. There has been a major shift in how scientists view cancer screening and more interest in studying previously undescribed harms. In a review of psychological harms of screening published in the Journal of General Internal Medicine, Dr. Jessica DeFrank and colleagues assessed the literature on the burden or frequency of psychological harm associated with screening for prostate cancer (42 studies), lung cancer (11 studies), osteoporosis (6 studies), abdominal aortic aneurysm (8 studies), and carotid artery stenosis (1 study). They observed that for most screening tests, there remain large gaps in the evidence about the magnitude and frequency of such harms in populations representative of those receiving the tests. (I hasten to add that neither the USPSTF nor any other legitimate medical organization recommends ultrasound screening for carotid artery stenosis.) 

Causing needless worry about cancer or another absent health condition can seem trivial compared to the prospect of saving a life. But increasing recognition of the limitations of screening for cancer and disease in general, and the nearly nonexistent effect of these tests on all-cause mortality, have altered the equation. If more than 96 percent of initially positive screens turn out to be false positives (as is the case for lung cancer screening), just how much anxiety and worry are we as a society willing to inflict to merely exchange one cause of death for another?

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This post first appeared on Common Sense Family Doctor on March 4, 2015.