Sunday, May 31, 2015

The best recent posts you may have missed

Every few months, 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 January through April:
If you have a personal favorite that isn't on this list, please let me know. Thank you for reading!

Tuesday, May 26, 2015

Do medical scribes improve doctor or patient experiences?

According to a national survey, a typical family physician spends nearly half of his or her working hours outside of the examination room doing follow-up care or documentation. I think most of my colleagues would agree that entering notes into the electronic health record is one of their least favorite parts of practicing medicine. After all, we went into medicine to care for patients, not to spend endless hours scrolling through screens full of check boxes to prove to payers that we are caring for patients. At the same time, patients may be unable to connect emotionally or convey subtle physical findings when their doctors spend so much of the visit looking at a computer screen.

One solution to the problems posed by electronic documentation requirements is for physicians to delegate the task to a medical scribe. As described in a recent article in Family Practice Management, this trained assistant (medical assistant, medical student, licensed practice nurse, or registered nurse) gathers initial data; documents the physician's examination, assessment, and plan; and provides patient education and implements the care plan while the physician moves on to the next patient. One of the authors reported that his increased efficiency and net revenue more than made up for cost of training and paying for an additional medical assistant functioning as a scribe. Further, the presence of the scribe seemed to have positive effects on the patients' experience:

We've also noted significant increases in our patient satisfaction scores as we've adopted this new model of care. One thing that surprised me was the relationships my patients developed with my MAs, sometimes telling my MAs things they won't tell me. Patients consider the MAs as additional advocates to whom they can go with problems or questions. I thought more patients would object to having another person in the exam room, but that has not been the case.

Beyond this suggestive anecdote, what is the evidence that medical scribes improve practice productivity, revenue, or the physician and patient experience? A systematic review on the use of medical scribes in the Journal of the American Board of Family Medicine found only five studies, none performed in primary care practices. In emergency department, cardiology, and urology settings, scribes appeared to improve clinician satisfaction, efficiency, revenue, and patient-clinician interactions, but did not improve patient satisfaction. Still, given the ever-increasing burden of documentation in primary care, the demand for medical scribes will doubtless increase in the future.


This post first appeared on the AFP Community Blog.

Monday, May 18, 2015

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 research letter published 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 Atul Gawande's latest 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.

Monday, May 11, 2015

PSA screening by the numbers: no benefits, many harms

Previous studies found that two-thirds of men who receive prostate-specific antigen (PSA) screening for prostate cancer didn't have shared decision making with their physicians. If shared decision making occurred at all, patients were more likely to remember hearing about the advantages than the disadvantages of PSA screening, and many older men with a high probability of death within the next 9 years were screened nonetheless.

These findings, along with a Cochrane review and another systematic review (that I co-authored) which both found no pooled mortality benefits in several randomized controlled trials, led the U.S. Preventive Services Task Force to recommend against PSA-based screening for prostate cancer in 2012. Since then, the American Academy of Family Physicians and the American College of Preventive Medicine have added this service to their Choosing Wisely lists of tests and procedures that patients and physicians should question.

The Medicine By the Numbers published in the May 1st issue of American Family Physician clearly illustrates that the harms of PSA screening exceed the benefits. 1 in 5 men who received PSA screening ended up undergoing a biopsy for a false-positive test; 1 in 34 and 1 in 56 screened men, respectively, suffered erectile dysfunction or urinary incontinence as a result of prostate cancer treatment. In contrast, PSA screening prevented zero deaths from prostate cancer or all causes. In other words, no benefits.

This review begs the question of why clinicians should bother with shared decision making in most average-risk men, rather than simply telling them that this test is a bad deal.


This post first appeared on the AFP Community Blog.

Tuesday, May 5, 2015

Everything but the kitchen sink in public health

The buzzwords many use in medicine today are "personalized," "individualized," or "targeted." Rather than doctors prescribing tests or treatments that work in most people but might not work for you, proponents argue, we should tailor medical interventions to unique patient characteristics, such as genomic data. (The White House's Precision Medicine initiative is an example of this kind of thinking.) Although I am skeptical that big data-driven genetic sequencing will soon trump the personalized experience of a physician sitting down and speaking with a patient, many areas of clinical medicine stand to benefit from an improved understanding of genetic and environmental causes of diseases in individuals.

On the other hand, public health problems rarely have a single cause or respond to a targeted intervention. Many policies and actions combined to lower the prevalence of smoking in U.S. adults from 45 percent in the 1960s to about 18 percent in 2013. Counseling and cessation medications played a role, but so did raising tobacco taxes; restricting advertisements; requiring warning labels; and banning smoking in airplanes, restaurants, parks, and other public places. These concurrent interventions drove a widespread culture change, making smoking "uncool" to the extent that many adults who smoke today are embarrassed by their habit.

Two stories I've read in the past month offer good examples of throwing "everything but the kitchen sink" at public health problems that defy straightforward solutions: high infant mortality and incarceration rates in African Americans. In Cincinnati, babies have been dying in the first year of life at more than twice the national average. The reasons are many: premature births, inadequate prenatal care, poor nutrition, exposure to tobacco smoke in the womb and in the cradle, to name a few. Cradle Cincinnati, the strategy that the city's medical and public health professionals created to reduce infant mortality, addresses three modifiable behavioral issues: smoking (stop), spacing (pregnancies at least 12 months apart), and sleep (baby alone, on its back, in an empty crib). Just as important was how to deliver these messages to prospective parents who were suspicious of the health system:

Using focus groups from African-American and Appalachian neighborhoods, the [nonprofit Center for Closing the] Health Gap found that many young mothers rely primarily on friends and family for maternity information: They simply don’t trust doctors and nurses. ... The distrust is often driven by not feeling valued “and not believing that the person who is giving them instruction about prenatal care even cares.” Now the Health Gap is looking for ways to train peers and neighborhood leaders to share accurate information. It’s also producing a video “letter” to community medical providers to school them in the day-to-day interactions that make a patient feel judged, devalued, and dismissed—interactions that may keep her from showing up to monitor her pregnancy or following up after her child is born.

Infant mortality in Cincinnati has fallen in each of the last few years; how much of a difference the three Ss campaign is making is hard to measure, but it does seem to be helping.

A few states northwest in Milwaukee, Wisconsin, a controversial District Attorney has been tackling a completely different but no less urgent problem: the huge racial disparity in African American men in prisons. The statistics are staggering: although they comprise only 6 percent of the state's population, African Americans represent 37 percent of the incarcerated population. A thirty-something African American man living in Milwaukee County is more likely to have served time than not. Not only are these sky-high rates devastating to relationships with partners and children, lengthy prison stays and subsequent criminal records make many former inmates unemployable.

The causes of this problem are far from obvious, certainly not as simple as the "racist police brutality" narrative that has swept the nation in recent days. Are African American men committing more crimes than others? More likely to be arrested? Being prosecuted and convicted at disproportionate rates? More likely to receive a jail term rather than parole? In Milwaukee, it turned out to be most of the above. Those who commit violent crimes should be jailed, but mandating years behind bars for shoplifting or drug possession turned teenagers and young men into hardened criminals and was ultimately counterproductive. (See my previous post for alternatives to the "war on drugs.") So D.A. John Chisholm changed the focus of his team from "winning every case" to ensuring that the punishment fit the crime, and sentencing selected nonviolent offenders to substance abuse treatment or educational programs rather than prison terms. He also charged his prosecutors with developing ways to prevent crime before it began by, for example, persuading community organizations such as Habitat to Humanity to renovate abandoned homes in low-income neighborhoods. As in Cincinnati, the jury is still out on Chisholm's methods, which have modestly shrunk the Milwaukee County prison population but doesn't seem to have affected crime rates.

Like patients with multiple complex medical conditions, public health problems require innovative solutions, but as the the executive director of Cradle Cincinnati was quoted as saying, "There's no silver bullet. It's silver buckshot, and it all needs to be fired at once." Or maybe you prefer my metaphor: everything but the kitchen sink.