My favorite public health and health care books of 2022

My Christmas post is the 7th in an annual series listing my 10 favorite public health and health care reads of the past year. Not all of these were first published in 2022. Happy holidays and warm wishes for a healthy and rewarding New Year!

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1. Empire of Pain: The Secret History of the Sackler Dynasty, by Patrick Radden Keefe

2. The Good Nurse: A True Story of Medicine, Madness, and Murder, by Charles Graeber

3. A Good Time to Be Born: How Science and Public Health Gave Children a Future, by Perri Klass

4. The Price We Pay: What Broke American Health Care - and How to Fix It, by Marty Makary

5. Searching for the Family Doctor: Primary Care on the Brink, by Timothy Hoff

6. Sickening: How Big Pharma Broke American Health Care and How We Can Repair It, by John Abramson

7. A Silent Fire: The Story of Inflammation, Diet, and Disease, by Shilpa Ravella

8. The Song of the Cell: An Exploration of Medicine and the New Human, by Siddhartha Mukherjee

9. White Hot Light: Twenty-Five Years in Emergency Medicine, by Frank Huyler

10. Within Our Grasp: Childhood Malnutrition Worldwide and the Revolution Taking Place to End It, by Sharman Apt Russell

Decoding doctor-speak, redux

Eleven years ago, I wrote a post for my U.S. News Healthcare Headaches blog titled "Decoding doctor-speak: translations of common medical terms" that walked non-health professionals through explanations of common blood tests such as the complete blood count, basic metabolic panel, liver function tests, and low-density lipoprotein; and diagnoses such prediabetes and metabolic syndrome. It turned out to be an enduring hit; the cross-posted version on Common Sense Family Doctor has been viewed more than 11,000 times. But have I or physicians in general have gotten any better at keeping insider medical jargon out of our conversations with patients?

A few weeks ago, JAMA Network Open published a cross-sectional study that assessed the general public's understanding of English phrases that have different meanings in a medical context (jargon) than they do in everyday life. Researchers surveyed 215 adult volunteers without a history of medical or nursing training who visited the 2021 Minnesota State Fair. Of the 13 questions concerning various terms, the percentage of participants who answered correctly ranged from the high 90s ("negative" cancer test results being good news) to 20 or less ("impressive" x-ray results, NPO = nothing by mouth, occult infection).

More people believed that the phrase “had an occult infection” had something to do with a curse than understood that this meant that they had a hidden infection. Fewer than half knew that their neuro examination being “grossly intact” was a good thing, possibly because the word “gross” more often means “unpleasant” than “in general” in common usage. These terms may not necessarily be recognized by clinicians as jargon because they do not land in the commonly understood category of technical, medical terminology. However, they have been shown to be used frequently in clinical settings.

Although I now have more than twice as much clinical experience as I did when I wrote my original blog post, keeping my "doctor-speak" free from jargon remains a work in progress. It's easy to fall into the trap of thinking that patients understand what I'm saying if they are nodding or not asking questions, but as often as that may be true, it could also mean that they are too intimidated or embarrassed to admit that I've lost them. And the burden of assuring that effective communication occurs ought not to fall primarily on the patient. So I resolve to keep trying to do better.

Can prostate MRI reduce the harms of PSA screening?

Without question, PSA screening for prostate cancer in asymptomatic patients does them both harm and good; the difficulty in quantifying how much harm versus good has historically been the source of disagreements among primary care physicians and urologists over how much screening we ought to be doing, or if we should be screening men at all. In 2012, the U.S. Preventive Services Task Force took the position (which it partially reversed in 2018) that the way to prevent harm from PSA screening was to generally stop doing it. But those who believe that selective testing saves lives that otherwise would have been lost to prostate cancer argue that too much testing isn't the problem, it's too much treatment. For every potentially fatal tumor identified by PSA testing, we also "overdiagnose" numerous low-grade, indolent prostate cancers that should perhaps not be called "cancer" at all but are nonetheless treated or at least monitored, exposing patients to harm with very little likelihood of benefit.

It's instructive to compare the typical evaluation for a positive prostate cancer screening test with a positive breast cancer screening test. If breast surgeons diagnosed breast cancer the way urologists diagnose prostate cancer, they would not only biopsy the area of the breast corresponding to an abnormality on a mammogram or ultrasound, they would also systematically biopsy 12 to 20 additional normal-appearing areas of the breast to make sure that no cancer is missed. If that sounds crazy, that's because it is. Multiparametric MRI is increasingly being used for targeted prostate biopsy and active surveillance of low-risk prostate cancer, but whether MRI-targeted biopsy can safely replace systematic prostate biopsy remains an unanswered question.

Unanswered, that is, until last week, when the New England Journal of Medicine published the results of a randomized trial comparing MRI-targeted versus systematic biopsy in men with a PSA level of 3 ng/mL or higher. The researchers found that men in the systematic biopsy group were twice as likely as those in the MRI-targeted group to be diagnosed with an "insignificant" cancer (as judged by pathologists) but slightly less likely to be diagnosed with a clinically significant cancer. In other words, the cost of reducing prostate cancer overdiagnosis is that a small number of clinically significant cancers that would only have been diagnosed with systematic biopsy are missed and not caught until later in the disease course. Granted, pathology does not correlate perfectly with tumor behavior, and it may not predict clinical prognosis since many men have comorbid medical conditions that are more likely to cause death than prostate cancer. But I think these findings make sense; whether and how they will affect academic or community urology practices remains to be seen. As a family physician, would I feel more comfortable with doing PSA screening if I knew that our local urologists performed MRI-targeted rather than systematic prostate biopsies? Absolutely.

New AAFP practice guideline sets blood pressure targets for adults with hypertension

From 1977 to 2003, seven Joint National Committees (JNC), sponsored by the National Heart, Lung, and Blood Institute (NHLBI), produced consensus multi-specialty guidelines on the diagnosis and management of hypertension. In 2013, well into the development of JNC8, the NHLBI abruptly turned the process over to the American College of Cardiology/American Heart Association (ACC/AHA). The JNC8 committee independently published an evidence-based guideline in JAMA that raised the blood pressure treatment threshold in most older adults from 140/90 to 150/90 mm Hg. Concerned about conflicts of interest and other deviations from Institute of Medicine-recommended practices for developing trustworthy guidelines, primary care groups, including the American Academy of Family Physicians (AAFP), declined to participate in the ACC/AHA guideline panel. And the longstanding edifice of hypertension guidelines fractured.

In 2017, the ACC/AHA released its clinical practice guideline, which most notably re-defined hypertension as sustained blood pressure over 130/80 mm Hg and recommending, based largely on the controversial SPRINT trial, that treatment should aim to reduce blood pressure below this new threshold. The AAFP decided against endorsing the guideline and advised its members to continue following the JNC8 report and its own 2017 practice guideline, co-authored with the American College of Physicians, that largely reiterated JNC8’s treatment thresholds for adults aged 60 years and older.

Last month, American Family Physician published an updated AAFP hypertension guideline, written by a panel of family physicians (including me), which focuses on updated evidence for optimal blood pressure targets in adults. Based on a Cochrane systematic review of randomized controlled trials that compared higher and lower blood pressure targets for primary prevention of cardiovascular disease (76% of study participants did not have preexisting CVD), the AAFP strongly recommends treating to a standard blood pressure target of less than 140/90 mm Hg to reduce all-cause and cardiovascular mortality. Since a lower blood pressure target of less than 135/85 mm Hg further reduces the risk of myocardial infarction (number needed to treat = 137 over 3.7 years) but not mortality, the AAFP recommends that clinicians consider treating to this lower target with shared decision-making. Notably, although the lower target did not increase serious adverse events compared to the standard target, it required patients to take one more anti-hypertensive medication on average and increased non-serious adverse events (number needed to harm = 33).

The AAFP guideline also applies to adults with hypertension and existing CVD, as another recent Cochrane review comparing standard to lower blood pressure targets in this population found no differences in total or cardiovascular mortality, conclusions that were unchanged from an earlier version. The AAFP guideline is mostly consistent with guidelines from the International Society of Hypertension that recommend a treatment threshold of 140/90 in office settings and lower thresholds for blood pressures obtained with home monitoring or 24-hour ambulatory monitoring.

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This post first appeared on the AFP Community Blog.