Thursday, October 29, 2015

The most-tweeted quote from my AHCJ presentation was

"Experts" and laypersons view new medical evidence through the lens of their own biases.

That being said, it's important for patients to consider their physicians' biases in the context of their overall health. A man's urologist may be bound and determined to do everything he or she can to prevent death from prostate cancer (including annual PSA tests), but since 3% of men actually die from prostate cancer, 97% will die of something else. Family physicians and general internists who agree with the U.S. Preventive Services Task Force that the harms of PSA-based screening outweigh the benefits for most men are biased toward preventing statistically much more probable causes of premature death.

Thanks to NPR's Scott Hensley and the Association of Health Care Journalists for inviting me to speak at their Workshop in Evidence-Based Medicine today.

Saturday, October 24, 2015

Right Care Action Week and Choosing un-Wisely

This week, American Family Physician joined clinicians, patients and organizations all over the country in supporting the Lown Institute's RightCare Action Week (#RCAW), which aims to re-focus the U.S. health system on care that is "effective, affordable, needed and wanted by well-informed patients, and especially, free of clinical decisions that are made with financial or business considerations." This goal is more far-reaching than the three year-old Choosing Wisely campaign objective of encouraging conversations between physicians and patients about potentially unnecessary care. As my colleague and fellow editor Dr. Jennifer Middleton mentioned last week, AFP has developed several resources to help family physicians implement Choosing Wisely in their practices. On the patient side, Consumer Reports has worked with more than 20 physician groups to create and distribute educational content about specific items in the campaign.

Are these efforts to reduce unnecessary care making a measurable difference? JAMA Internal Medicine recently published a study of national insurance claims data by Dr. Alan Rosenberg and colleagues that analyzed trends among seven of the earliest Choosing Wisely "don't do" recommendations from 2010 through 2013. Although there were statistically significant declines in CT and MRI for uncomplicated headaches and cardiac testing in patients without heart conditions, use of two other inappropriate services increased (NSAID prescriptions in patients with hypertension, heart failure, or chronic kidney disease; and primary HPV testing in women younger than age 30). Since the study didn't include data from 2014 or 2015, the results could either mean that the campaign isn't working or that it was just too early to tell.

Family physicians and patients should keep in mind that even care that is recommended by evidence-based guidelines and incentivized by pay-for-performance programs can be harmful if provided to patients without regard to their individual circumstances. In an Annals of Internal Medicine essay titled "The Tyranny of Guidelines," Dr. George Sarosi described the six-year saga of Mr. O, an independent octogenarian with mild hypertension and diabetes who suffered a hip fracture and subsequent stroke as the unfortunate end result of a "relentless downhill medical care spiral fueled by interventions ... to tightly control both the blood sugar and the blood pressure."

The pitfall in this case wasn't the guidelines themselves as much as the one-size-fits-all way they were applied by "the system" to the patient. Dr. Sarosi concluded, "We need a system that rewards the physician who understands the limitations of guidelines." Indeed, a Right Care system would reward physicians who prevent patients from receiving too much medicine.


This post first appeared on the AFP Community Blog.

Wednesday, October 21, 2015

Some common sense on breast cancer screening

Yesterday, the American Cancer Society updated its guidelines on screening mammography for women at average risk, moving closer to the U.S. Preventive Services Task Force guidelines by recommending that most women start screening at age 45 (rather than 40) and be screened every other year (instead of annually) starting at age 55. The ACS also cast doubt on the effectiveness of the clinical breast examination in women who are already undergoing mammography screening. Although I don't agree with every aspect of the new guideline, it has the potential to make breast cancer screening more effective by preserving the benefits and reducing the harms.

A common critique I've heard about the ACS and USPSTF guidelines is that they will "confuse" women who have gotten used to the traditional routine of having annual mammograms starting at age 40. I don't disagree with this; incorporating new scientific evidence into medical practice is always confusing at first. But explaining the implications of new guidelines to individual patients is my job as a family physician - and it's your physician's job, too! I went on NPR's All Things Considered to offer my take on what the new guidelines mean for women. You can listen to the whole segment or read excerpts from the transcript below.

AUDIE CORNISH (HOST): So we heard in our report that the American Cancer Society still wants every woman to talk to her doctor to figure out what makes the most sense. How do you interpret all this?

LIN: What you've just said is probably the best way to describe it, that women should be talking to their doctors about mammography. It shouldn't be automatic. It shouldn't be reflexive. It shouldn't be like the experience of many of my friends who are in their early 40s and they show up at their doctor's and they get a slip and they say, "go get your mammogram." We instead should be raising the topic saying, look, we have this test. It could prevent you from either dying or having a serious illness from breast cancer. But it's not perfect. It has many harms as well, including false positives, diagnosis of a breast cancer that may not ultimately be true cancer but something that we might have to act on. So it's best viewed as an invitation to both patients and physicians to have that conversation if they haven't been having it before.

CORNISH: There have been several studies that have shown that doctors really don't talk all that much about the risks of cancer screenings. They don't give numbers for how many people actually do benefit from the screenings. Do you think these guidelines will change that?

LIN: I hope they do. Now in defense of those doctors, it is a challenging conversation. There are a lot of numbers. There's a lot of uncertainty about some of the numbers. I think that it can be helpful to present patients with either a handout or some sort of visual aid where you can show what the numbers really are for the benefits and the harms. And it's something that I've been doing, but I think a lot of doctors haven't been doing that and I'm hoping the new guidelines encourage them to because I think it's difficult to have this conversation without something to look at to visually illustrate those numbers.

CORNISH: If your doctor doesn't initiate this discussion, what kinds of questions should you ask? I mean, this kind of relies on women thinking of their own family history, race or whatever and somehow divining risk factors. What should patients be thinking about?

LIN: The guideline that the ACS released was a guideline for average risk women who are defined as not having one of the breast cancer genes or not having a family history where you have several family members with breast cancer or a single member at a young age. So the rest of women are kind of lumped into this average risk category. And certainly there are things that may not be accounted for in risk assessment tools that may be important to someone. So I think a patient should go to their doctor and say, look, this is how I feel about mammography. This is my experience with cancer, my family history. Perhaps they don't like having to go for repeated tests. You know, I'm worried about false positives. I think they should also ask their doctor, well, you know, what are downsides to this test? That's really the first question. Doctors always volunteer the upsides, but I think you have to ask specifically what are the downsides. And hopefully that will spark a conversation if your doctor seems otherwise inclined to gloss over it.

CORNISH: What do you say to women who today are are frustrated, maybe even angry or upset, women who have had annual mammograms for many years who've gone ahead with procedures that turned out to be unnecessary? Was that a waste?

LIN: Unfortunately in science this is kind of the way that things progress. We do the best we can with the information we have at a given time. The same thing sort of happened for prostate cancer screening in men. It used to be something that you started at age 50, you do it every year, and now organizations that say you don't do it at all, or if you do it, you have to be aware of the downsides. I understand it can be frustrating to patients. But the greater error is to cling to an old guideline and say, well, we're going to dig in our heels and keep starting at age 40 and doing it every year and ignore the new guideline, because that would be a worse mistake. We have to operate with the knowledge that we have. And I think the ACS has very comprehensively summarized what we know about mammography at the present time and their guidelines reflect that knowledge.

Thursday, October 15, 2015

Healthiness is Awesome

I've mentioned my four children occasionally in this blog, usually when referring to the circumstances of their births or the financial costs of my wife's pregnancies. Like most boys his age, my 9 year-old son Isaac spends a good chunk of his free time absorbed with Legos. He also plays golf and several other seasonal outdoor sports, and he's terrifically creative. Isaac submitted this video to the DC Growing Healthy Schools Art Contest, and even if it doesn't win, I hope that you are impressed as I was.

Friday, October 9, 2015

How can tech help Family Medicine for America's Health?

A randomized trial published last month in JAMA found that sending lifestyle change text messages to patients with coronary artery disease improved smoking cessation rates, increased physical activity, and reduced other cardiovascular risk factors. After only 6 months, the texted group had lower low-density lipoprotein, systolic blood pressure, and body mass index measurements than the usual care group. This was an impressive finding, but an unsettling one, since I had just finished reading an American College of Physicians position paper on the use of telemedicine in primary care settings. Taken together, these publications suggest that virtual care technologies, broadly defined, could make many in-person clinical encounters unnecessary. That's good for patient convenience, but potentially threatens one of the best parts about practicing family medicine: seeing patients in person.

Health information technology (IT), as embodied in electronic medical record systems that have replaced paper charts in most family practices, has thus far been a mixed blessing for our specialty. But what about tech beyond traditional health IT? The technology "tactic team" of Family Medicine for America's Health published a special article in Family Medicine that described strategies for family physicians to utilize an array of evolving technologies to strengthen therapeutic relationships and improve outcomes:

1) Smartphone apps and wearable devices that capture data about patients' health habits and give feedback to influence their behavior

2) Point-of-care musculoskeletal ultrasound

3) Web-based communication for "virtual" hospital rounding and specialist consultations

4) Web-based videos to provide patient and professional education

Although all of these initiatives have great potential to benefit patients, many are being developed in silos without leadership or input from family physicians. Therefore, the paper's authors proposed that Family Medicine for America's Health work to integrate these overlapping efforts into "a united front improving health IT and other technologies for the specialty."

Key opportunities for family physicians "to capitalize on our collective strengths" in the near future include partnering with developers to create health IT tools that improve clinical outcomes (rather than merely serving administrative or billing functions); supporting primary care-centric data models; participating in the development of primary care quality measures; and collaborating with patient and consumer organizations locally and nationally to identify and promote patient- and family-centered technology solutions that complement the vital functions of family medicine.


This post first appeared on the AFP Community Blog.

Friday, October 2, 2015

Liberty and health reform in America

Since 2007, I've participated in about a dozen American Civil War battlefield tours sponsored by the Smithsonian Associates. Even though a handful of Chinese Americans fought on both sides of the Civil War, none of my ancestors did, and friends and family are often perplexed by my endless fascination with this conflict. In Civil War museums and sites thronged by overwhelmingly white tourists, I'm even more of an oddity than the rare African American. This realization got me wondering why so few African Americans are passionate about the history of the war that freed so many of their ancestors from slavery. To Atlantic columnist and fellow Civil War buff Ta-Nehisi Coates, this antipathy stems from the efforts of white Americans over the past 150 years to write them out of the story:

For my community, the message has long been clear: the Civil War is a story for white people—acted out by white people, on white people’s terms—in which blacks feature strictly as stock characters and props. We are invited to listen, but never to truly join the narrative, for to speak as the slave would, to say that we are as happy for the Civil War as most Americans are for the Revolutionary War, is to rupture the narrative. Having been tendered such a conditional invitation, we have elected—as most sane people would—to decline.

As the campaigns gear up for the Presidential election of 2016, economic and racial divisions seem to be resurfacing, with the perennial Republican versus Democratic contest being portrayed in the media as a battle between the "rich" and the "poor," or white citizens versus those of every other color. But these stereotypes ignore the inconvenient facts that plenty of low-income white people who bear no racial grudges and a few minority voters in heavily Democratic states and the District of Columbia dependably vote Republican.

In his most recent book, subtitled "Why the Civil War Still Matters," historian James McPherson shed some light on this present-day paradox by explaining that liberty meant two different things to Southern and Northern leaders in 1861. To white Democrats in the pre-Civil War South (slaveholders or not - and the vast majority were not), liberty meant "freedom from" interference by a distant federal government. Historical figures such as Confederate general Robert E. Lee traced their cause back to the Virginian Founding Fathers and slaveholders George Washington and Thomas Jefferson, whose Revolutionary War was fought to break away from a distant British ruler whose arbitrary actions offended colonial sensibilities.

On the other hand, the Republican Party in the North viewed liberty as "freedom to," arguing that it's hard to achieve anything noteworthy when one is penniless, starving, or a slave. Even though the North won the Civil War, achieving full citizenship for African Americans took nearly a century after passage of the the Fifteenth Amendment to the U.S. Constitution. Only after the hard-won passage of the 1965 Voting Rights Act, which prohibited poll taxes and gave the federal government the power to end various discriminatory practices that prevented most Black citizens in Southern states from registering to vote, did African Americans finally gain freedom to participate in the political process.

The more recent history of how and why African Americans turned away from the party of Lincoln to embrace the party of their former oppressors is too long to recount here, but these differing views of personal liberty - "freedom from" versus "freedom to" - go a long way toward explaining the two political parties' diametrically opposed views of the Affordable Care Act. For the most part, Republican governors have resisted health insurance exchanges and rejected Medicaid expansions because they and their constituents have perceived these provisions of the law as encroachments on freedom by the Washington bureaucracy, while Democratic governors have recognized that it's hard to have freedom to achieve personal success if one is too ill, or too worried about the financial implications of unexpected illness or injury, to plan confidently for the future.

So you heard it here first: not only can you find the roots of modern medicine in the American Civil War, but the roots of our national health policy debate, too.