"Making people sick in the pursuit of health"

I'm traveling to Boston tomorrow to participate in a panel discussion on Friday for this year's William J. Bicknell Lectureship at the Boston University School of Public Health. The keynote speaker is H. Gilbert Welch, MD, MPH, author of the books Should I Be Tested For Cancer? Maybe Not and Here's Why and Overdiagnosed: Making People Sick in the Pursuit of Health, which I reviewed in a previous blog post. Here's an excerpt to give you a flavor of that review:

As H. Gilbert Welch and colleagues argue convincingly in their new book, ... much of the rise in cancer diagnoses over the past several decades has been the result of overdiagnosis: the detection (through screening or incidental finding on medical images obtained for other reasons) of cancers that would otherwise never have caused problems for patients. In the absence of screening, patients would not have developed symptoms because the "cancer" would not have progressed, or the patient was destined to die from some other cause (typically, heart disease). In the presence of screening, however, they suffer the psychological effects of knowing that they have cancer, the complications of diagnostic procedures, and the consequences of unnecessary treatments.

Seen in this light, the rise in cancer survivorship is not a modern medical success story. For millions of patients who received diagnoses that they didn't need and would do nothing to improve their health, it is a catastrophe.

BU Today just published a nice interview with Dr. Welch that connects the theme of overdiagnosis with the U.S. Preventive Services Task Force's recent draft recommendation against PSA screening for prostate cancer and his sobering new paper in the Archives of Internal Medicine that estimates the likelihood that a patient with screen-detected breast cancer has had her "life saved" to be less than 15 percent.

I am very much looking forward to meeting Dr. Welch and fellow panelists Deborah Bowen and John Fallon and having a terrific discussion!

Screening tests that do more harm than good

The U.S. Preventive Services Task Force may have been slow to finalize new recommendations recently, but the same can't be said for its main Evidence-Based Practice Center at Oregon Health and Science University, which has been producing systematic reviews at a furious pace. On the heels of a news-making evidence update that I co-authored on screening for prostate cancer, this Monday another USPSTF review team published an update of screening for cervical cancer with liquid-based cytology and human papillomavirus (HPV) testing.

This review led the USPSTF to the preliminary conclusion that HPV-enhanced screening, though widely utilized in the U.S., does more harm than good in women younger than age 30. Furthermore, the Task Force concluded that there is insufficient evidence to support HPV screening in women age 30 or older. HPV, it seems, is yet another example of a test that, despite having genuine value in diagnostic situations (for example, evaluation of abnormal cervical cytology or histology), has flunked as a screening test.

Being carried away by premature enthusiasm to provide a proven test in unproven situations is nothing new; doctors have been doing it for years. As I wrote in an editorial in American Family Physician in 2007:

As family physicians, we often face difficult decisions about ordering tests for the early diagnosis or prevention of disease in healthy-appearing persons. It is hard to convince many patients to think about prevention, and those who come in for health maintenance visits often expect to undergo tests that they have heard about from advertising on the Internet, radio, or television, or in popular magazines. For example, a colleague recently saw a healthy, asymptomatic woman who scheduled an appointment to receive the results of an ultrasound examination that had been ordered by another physician to screen for abdominal aortic aneurysm (AAA). The results were normal, but because the test was not indicated by generally accepted standards, our colleague was perplexed at what reassurance to provide the patient, if any.

Although the U.S. Preventive Services Task Force (USPSTF) recommends against performing AAA screening in asymptomatic women of any age, the existence of these and other evidence-based guidelines have not prevented direct-to-consumer marketing of costly screening tests of uncertain value. There is a striking contrast between widespread public enthusiasm for technology (e.g., whole-body computed tomography [CT], coronary calcium scans) and the paucity of evidence that performing these tests improves outcomes for patients.

“Big-ticket” tests are easy targets for those seeking to reduce waste in health care. But what about the seemingly innocuous practice of performing routine tests such as a complete blood count (CBC) or urinalysis? Both are far less expensive than CT scans and can often be performed in the office at the time of the visit. More than one third of family physicians in the United States think that CBC and urinalysis should be offered routinely at health maintenance examinations, and these tests are ordered for 25 to 37 percent of patients who present for such visits.

Read the rest of "Are Some Screening Tests Doing More Harm Than Good?" here.

Cost-conscious medicine: a movement that's gathering steam

The past few months have offered encouraging signs that physicians and physician organizations are belatedly recognizing the need to take an active role in controlling health care costs by emphasizing "high-value" care and minimizing the use of low-value interventions with high costs and few clinical benefits. On the heels of a best practice guideline issued by his organization, American College of Physicians Executive VP Steven Weinberger, MD recently called for making cost-consciousness and stewardship of health resources a required general competency for graduate medical education.

In light of a recently published estimate that the top 5 overused clinical activities in primary care specialties led to $6.7 billion in wasted health spending in 2009, Dr. Weinberger's call comes none to soon. Below is an excerpt from my post on this topic from April 13, 2010.

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Several years ago, when my wife directed the third-year Family Medicine clinical clerkship at a highly ranked medical school, she developed a popular workshop on the cost of health care that presented students with scenarios of patients who were either uninsured or underinsured and challenged them to provide cost-conscious health care by selecting medications and tests that were clinically appropriate and financially affordable. Many students remarked that it was the only time during their two years of clinical rotations when they were required to consider costs in decision-making.

Now that the U.S. health reform bill is law, and over 95 percent of Americans (as opposed to today's 84 percent) are expected to have health insurance by 2014, many physicians may be tempted to think that they can ignore the costs associated with prevention, diagnosis, and management of patients' health conditions and just focus on doing what's "right" for the patient, since somebody else is footing the bill. But contrary to popular opinion, that "somebody else" isn't an insurance company or the government; ultimately, it's the patient, in the form of higher insurance premiums (or taxes) to pay for an ever-expanding range of tests or treatments of questionable or zero benefit.

In response to Dr. Howard Brody's challenge to the medical profession to identify lists of unnecessary tests and treatments, physicians have suggested antibiotics for colds, coronary calcium scans, PSA and thyroid tests in well patients, drugs for high blood pressure that are more expensive and offer fewer benefits than older drugs, MRIs and spinal fusions for low back pain. And if reform is to have any hope of slowing the extraordinary growth in the cost of health care in the U.S., doctors can't keep looking to patients, hospitals, pharmaceutical and medical device companies, and insurers for solutions. In an editorial in the New England Journal of Medicine, Dr. Molly Cooke argues convincingly that cost-consciousness must be systematically incorporated into medical and continuing education:

First, we should be honest about the choices that we make every day and stop hiding behind the myth that every physician should and does apply every resource in unlimited degree to every patient for even minimal potential benefit. Second, we must prepare every physician to assess not only the benefit or effectiveness of diagnostic tests, treatments, and strategies but also their value. Value can be increased through cost-conscious diagnostic and management strategies and by the engineering of better and less wasteful processes of care.

"Value" isn't about saving money, but means getting the maximum health benefit for our enormous investments in health care. This wake-up call needs to be delivered and reinforced to students, residents, and health professionals at every level - starting today.

Family physicians and the Goldilocks principle

A recent national survey of internal medicine and family physicians published in the Archives of Internal Medicine found that 42 percent of physicians felt that their patients were getting "too much" health care, while only 6 percent thought that patients were receiving "too little." These opinions contrast with multiple previous studies showing that primary care clinicians fall short when it comes to providing guideline-recommended care; a 2007 study, for example, found that children received less than half of indicated care.

So which is it: too much care, too little, or some of both? And how can AFP help family physicians avoid these extremes and strive for the happy medium, which in other fields is known as the "Goldilocks Principle"? In addition to bringing readers the latest Practice Guideline updates, such as the Centers for Disease Control and Prevention's 2011-12 recommendations for influenza vaccination, we provide information that allows you to evaluate these guidelines against the best design criteria previously proposed by AFP Deputy Editor Mark Ebell, MD, MS:

The best guidelines share several characteristics: they begin with a comprehensive review of the literature; they carefully assess the quality of the literature to identify the best studies; they base their recommendations on the best studies; and they tell us the strength of the evidence that supports each key clinical recommendation. In other words, they are founded on the principles of evidence-based medicine, which strives to make decisions on the best available information—“best” implying that the evidence is graded, so that one has a sense of what is good evidence and what is not, and “available” implying that the literature search is comprehensive. Transparency is the key: readers should know why each recommendation is made and whether it represents opinion, theory, or fact. Finally, guidelines should be independent of industry support (an all-too-common occurrence) and should clearly identify any potential conflicts of interest of the authors. Ideally, guideline authors should have no conflicts of interest, which can diminish the quality and validity of the guideline.

There are, of course, many reasons - financial, medical-legal, and practical, to name a few - that care may diverge from that supported by the best evidence-based guidelines. Still, we hope that every section of the journal makes it easier for family physicians to provide care that is "just right."

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

Solo practice: a disruptive innovation?

The buzzwords of cutting-edge primary care reform - the medical home, coordination of care, electronic health records - have usually been associated with large integrated health systems such as Intermountain Healthcare, Group Health, and Kaiser Permanente. If you believe the arguments that economies of scale and financial resources give such organizations built-in advantages over the traditional small group practice, you may be inclined to believe that solo practice is going the way of the dodo. Indeed, immediate past AAFP President Roland Goertz, MD, MBA penned an editorial a few months ago, "Helping Small Practices Survive Health System Change," that, while touting some services that the Academy offers family physicians in these practices, betrayed a decidedly pessimistic outlook on their long-term future.

Not everyone agrees, however. In the September issue of the Journal of Family Practice, Jeff Susman, MD cast solo practices as vital engines of primary care innovation:

The extraordinary, albeit sometimes idiosyncratic, approach to medicine practiced by solo FPs today is often overlooked. Nimble (no bureaucracy to consult when changing policies), in touch (no one knows the local population better), and increasingly likely to use EHRs and health information exchanges (like physicians in larger groups), these doctors are paving the way to a brighter future. Whether they’re focusing on lean design, integrating concepts of public health, or creating environments that foster holistic healing, I see a lot of innovation and passion among solo practitioners who aren’t afraid to take risks or fight for their patients. Moreover, practices with only one or two physicians are frequently on the cutting edge of change and leaders in providing quality health care. What’s more American than that?

Like most physicians of my generation, I've never been in solo practice. But I agree with Dr. Susman that practice models that encourage "the rebirth of the solo family doc" may turn out to be just as good for the health of our patients as the gargantuan, still largely unproven structures known as accountable care organizations. As family physician Doug Iliff wrote back in 1998, solo practice, rather than harkening back to a past epitomized by the 1970s drama Marcus Welby, MD, may yet be the way of the future.

Shannon Brownlee on the pros and cons of early cancer screening

CNN is reporting that the U.S. Preventive Services Task Force plans to release a "D" recommendation against screening for prostate cancer in all men for public comment next Tuesday. They didn't get that information from me, because I don't work for the Task Force any more and couldn't confirm it even if I wanted to. But if it's true, as I just told CNN Medical Correspondent Elizabeth Cohen, this recommendation is - despite the furor that is bound to ensue - long overdue and completely justified. This short video from Shannon Brownlee, one of the authors of the New York Times Magazine piece, "Can Cancer Ever Be Ignored?" explains why the science simply doesn't support the widespread belief that in prostate cancer, early detection always saves lives.