Monday, March 30, 2020

Breast cancer screening is likely to be harmful after age 75

To increase acute care capacity during the COVID-19 pandemic, hospitals have suspended elective surgical procedures, and family medicine practices have postponed visits for preventive care and monitoring of stable chronic diseases - particularly in patients older than 70 years, whose risk of developing serious illness from SARS-CoV-2 contracted in a health care setting likely outweighs potential benefits. For example, women in this age group should cancel or postpone screening mammograms.

Even in the best of times, though, it's not known if screening mammography beyond 75 years of age is helpful or harmful. The U.S Preventive Services Task Force found insufficient evidence to assess the balance of benefits and harms of breast cancer screening after age 75, and decision tools have been developed to help women decide whether or not to continue to be screened, relying on limited evidence and the patient's predicted life expectancy. As the authors of a recent American Family Physician editorial observed, though, discussing the clinical implications of life expectancy with older patients can be challenging and fraught with pitfalls.

Since it is unlikely that a randomized controlled trial of screening mammography in older women will be performed, researchers recently used observational data from the U.S. Medicare program to emulate such a trial in more than 1 million beneficiaries aged 70 to 84 years with a life expectancy of at least 10 years and no previous breast cancer diagnosis. The primary outcome was eight-year risk of breast cancer mortality.

While women age 70 to 74 years who continued to have screening mammograms had a 22 percent lower risk than those who stopped being screened, there was no mortality benefit for women who continued screening after age 75 years. Although guidelines already discourage screening for cancer in adults with a life expectancy of less than 10 years, this study suggested that stopping breast cancer screening after age 75 may be the right decision for all women, regardless of health status.


This post first appeared on the AFP Community Blog.

Sunday, March 22, 2020

Curiosity: what makes a doctor truly great

I have never been invited to give a commencement address. The closest I came was my own high school graduation, when I was the unofficial valedictorian. Since my school did not have a tradition of the highest-ranked student addressing the class on graduation day, though, I didn't get the chance. Our commencement speaker, a television news anchor and former graduate, delivered a great speech that I still remember more vividly than the addresses by bigger names at my college, medical school, and public health graduation ceremonies.

Obviously, I have not had the good fortune of hearing Dr. Atul Gawande speak at a commencement. (Atul, if you're reading this, Georgetown University School of Medicine would be delighted to have you address a future graduating class.) In 2018 he delivered a profoundly insightful address at UCLA that went viral on social media. It's worth reading in its entirety, but the point he drove home is that in a time when discrimination and unequal treatment have become as socially acceptable in some circles as in the pre-American Civil Rights era, it remains the sacred calling of medicine to recognize that all lives have equal worth, and that doctors and patients share a "common core of humanity":

Without being open to their humanity, it is impossible to provide good care to people—to insure, for instance, that you’ve given them enough anesthetic before doing a procedure. To see their humanity, you must put yourself in their shoes. That requires a willingness to ask people what it’s like in those shoes. It requires curiosity about others and the world beyond your boarding zone.

Curiosity. If medicine were only about the science of the human body in health and disease, I would never have become a family doctor. Fortunately, that isn't so; in fact, after years of practice I often feel that the science has become incidental to doctoring. Yes, the knowledge base for medicine is always expanding, but as I tell students, regardless of what field of medicine you choose, the technical aspects eventually become routine. Even emergency and family physicians, who encounter the largest variety of symptoms and diagnoses, get acclimated to bread-and-butter encounters: back pain, chest pain, respiratory infections, the management of common chronic conditions under or out of control.

What keeps my work meaningful is learning about the details of my patients' lives that aren't strictly medical. As Dr. Faith Fitzgerald wrote in a classic article two decades ago:

What does curiosity have to do with the humanistic practice of medicine? ... I believe that it is curiosity that converts strangers (the objects of analysis) into people we can empathize with. To participate in the feelings and ideas of one’s patients—to empathize—one must be curious enough to know the patients: their characters, cultures, spiritual and physical responses, hopes, past, and social surrounds. Truly curious people go beyond science into art, history, literature, and language as part of the practice of medicine.

Then, as now, pressures to be efficient in evaluating patients threatened to suppress natural curiosity. Dr. Fitzgerald bemoaned an educational system that produces medical students who were too un-curious to ask a patient how he had been bitten in the groin by a snake ("How could one not ask?"), or to question the "BKA (below-knee amputation) times two" description in the chart of a patient who obviously had legs. Finally, she mentioned one patient who had been deemed by the housestaff to be the "dullest" (least interesting) on the service: an old woman who (upon further inquiry) turned out to have survived the sinking of the Titanic.

2020 graduates, I am delighted that many of you will be entering family medicine this year, but regardless of the medical specialty you've chosen, don't ever stop being curious - especially about the most "difficult" patients and the ones you least understand. It is that skill, more than any other, that will sustain you in your work and that separates the merely competent doctors from the truly great ones.


This post first appeared on Common Sense Family Doctor on June 4, 2018 and in a slightly different form as "What Makes A Doctor Truly Great" in the November/December 2018 FPM.

Monday, March 16, 2020

Insomnia and sleep apnea in adults: evidence-based treatments

At an American Family Physician editors' meeting several years ago, a colleague, who marveled at the amount of academic and clinical activities that I cram into a typical workweek, asked half-seriously, "Do you sleep?" Yes, I answered, not only do I need at least seven hours of uninterrupted sleep each night, I don't feel the least bit guilty about making it a priority. As Dr. Jennifer Middleton wrote in a previous blog post, the negative health consequences of chronic sleep deprivation are legion. Unfortunately, a recent survey found that nearly half of U.S. military personnel report poor sleep quality. From 2003 to 2011, the incidence of insomnia and obstructive sleep apnea (OSA) in active duty U.S. Army soldiers increased by 652% and 600%, respectively.

Concerns about these two common sleep disorders led the U.S. Departments of Veterans Affairs (VA) and Defense (DoD) to develop a joint clinical practice guideline for their diagnosis and management; a synopsis was published last month in Annals of Internal Medicine. Key recommendations for treating chronic insomnia (insomnia occurring for three or more nights per week for three or more months) generally agree with those from a 2016 American College of Physicians guideline and Agency for Healthcare Research and Quality review: offer cognitive behavioral therapy for insomnia (CBT-I) as first-line treatment, and reserve short-term pharmacologic therapy (low-dose doxepin or nonbenzodiazepine benzodiazepine receptor agonists, such as zolpidem) for patients who are unable to access or complete CBT-I.

The VA/DoD panel suggests not using antipsychotic drugs, benzodiazepines, or trazodone for chronic insomnia due to harms outweighing benefits or lack of benefit. It also advises against two common ingredients in over-the-counter sleep aids, diphenhydramine and melatonin. The panel suggests that clinicians not use sleep hygiene education as a standalone treatment due to its limited effectiveness and potential to discourage patients from pursuing the more effective CBT-I.

For OSA, the VA/DoD guideline suggests using the STOP Questionnaire (Snoring, Tiredness, Observed Apnea, High Blood Pressure) to stratify risk in patients who report sleep symptoms and performing home sleep apnea testing rather than in-laboratory polysomnography in patients with a high pretest probability of OSA. Although continuous positive airway pressure (CPAP) therapy is recommended for persons with severe OSA, mandibular advancement devices may be used as an alternative in mild or moderate cases. The VA/DoD panel did not evaluate positional therapy (techniques to promote side sleeping) for OSA. However, a recent Cochrane review found that patients are more likely to tolerate and adhere to positional therapy than CPAP, compensating somewhat for the former's lesser effectiveness.


This post first appeared on the AFP Community Blog.

Friday, March 13, 2020

Today's podcast on COVID-19

Thanks to my friend Larry Bauer, CEO of the Family Medicine Education Consortium, for suggesting that I have this timely conversation with Dr. Michael Fine, a fellow family physician and former director of the Rhode Island Department of Health, about the evolving COVID-19 situation in the U.S. Although this podcast is aimed at an audience of family physicians and other front-line clinicians, others may find it helpful as well.

Tuesday, March 10, 2020

COVID-19 has arrived, in Washington DC and likely your home town, too

Although I typically cross-post any relevant writings 5 to 7 days after they appear on the AFP Community Blog, the novel coronavirus pandemic is evolving so quickly that I'm afraid what I wrote today may be out of date one week from now. So go and read the new post now, and this graphic from Wikipedia will make more sense. Wash your hands, stay home when you're sick, and work from home if you can.


Monday, March 2, 2020

Guest Post: The problem with health care price transparency: we don't have cost transparency

Michael Williams, MD, University of Virginia

US $2.4 million. $1.5 million. $2.28 million. These are the amounts of money the health system where I work, teach and receive health care spent purchasing a PET scanner, a CT scanner and a three-month supply of pembrolizumab, a drug that treats a variety of solid-organ cancers.

To meet the clinical (read “market”) demands of patients, who are typically disinclined to wait for diagnosis or treatment, UVA Health already owns seven CT scanners (that I know of) and three PET scanners, which are used to detect small deposits of known cancer. It also has enough “Pembro” to treat all patients who will or might benefit from it. Guess how much of their costs are billable to insurance? Zero.

In my dual roles at the University of Virginia, as both associate chief medical officer for clinical integration for the health system and director of the Center for Health Policy at the Frank Batten School of Leadership and Public Policy, I see this disconnect play out continuously.

For some drugs, Medicare doesn’t pay everything

Here’s why. Hospitals and physician practices have a single source of revenue: payment for patient care services rendered. To buy the PET scanner, CT scanner or Pembro, the university health care system collects money from our patients, largely through the insurer. In turn, our clinics, operating rooms and emergency departments treat the patient.

Simply put, the money collected from patients is used to buy everything the hospital uses to provide health care. Sometimes the health system borrows money from banks or the public, but even that debt is almost entirely serviced through payment for services rendered. Consumers bear the brunt; as in any business, those costs are passed on to the customer.

To be fair, Medicare Parts B and D may offset, but not pay for, the cost of many drugs. For Pembro, for example, a Medicare recipient may be left with a 20% co-pay, or $30,000 a year. Different drugs incur different costs driven by market forces, including greed.

Which brings me to my point: Price transparency is the wrong goal for the free-market health care structure we have in the U.S. Instead, consumers need to know not so much the price, but the costs of things.

The difference between price and cost

Here’s an analogy: There’s the sticker price of the car you want to buy, and then there’s the price you pay. Those numbers are almost always different, and no two buyers necessarily pay the same. Instead, a negotiation between buyer and seller (the dealership, in this example) takes place. Ultimately a price is agreed upon. But whatever that number is, it’s never the actual cost of producing the car.

The carmaker knows, down to the penny, the production cost of that car. The consumer doesn’t know.

The dealership doesn’t know, either; the dealer is privy only to the acquisition cost (price per vehicle) it pays. The automaker aggregates the costs of the aluminum and steel, the electronics, the glass, the tires, etc., and incorporates it all to derive a unit price per vehicle. The manufacturer knows all the costs of each component before the company starts to build a single vehicle, including labor and overhead.

Think of hospitals and physicians as the dealership. They don’t know the actual cost of things either, partly because there’s not just one “maker.” Instead, many “makers” are in the supply chain – all the companies providing hospitals and doctors with thousands of medical products and services. Just imagine all the suppliers involved in making sure a patient receives a chemo treatment.

For far too long, the lay media has confused price and cost. So have health professionals and policymakers. When the Centers for Medicare and Medicaid Services references costs, it’s essentially telling consumers how much it will pay to Medicare in premiums, deductibles and co-pays. Or, alternatively, it is telling consumers how much it will pay based on what each hospital indicates its costs are. These costs are different for every facility, because they are by-and-large derived, not calculated, numbers. No payer – that is, the insurance company for the patient – ever asks about how much it actually costs to provide health care. Here’s why: No one knows. Health care prices are made-up numbers.

The practice goes back to the earliest days of modern medicine. Prices (also known as “fees”) are determined by the time-honored standard of “usual and customary fees” charged locally and regionally for a service. That’s it. The federal government added the word “reasonable” to its definition some years ago.

Health care reform proposals such as “Medicare for All,” and its variations, will never control the cost of doing business until there’s a better understanding of what precisely that is. Big Pharma claims that research and development of drugs costs so much that pricing has to recoup the investment. I don’t subscribe to this claim at all, because they didn’t provide sufficient data to convince me.

Our country has never even had the corresponding conversation in health care, writ large.

There are better ways to do it. Activity and time-driven cost accounting have emerged as methods to actually calculate how much individual units of health care cost. Essentially, each step in a care process, be it bypass surgery, antibiotic administration or an MRI, is costed out and aggregated through direct observation of the care processes. This is not something that might be implemented in the distant future – in some places, it’s happening now. I’m proud to state that the University of Virginia Health System has taken the first steps to join them.

How much time does the technician take to perform a task? How much is she paid per hour? How much fringe benefit does she receive? How much time does the patient transporter take? How much does he earn per hour plus fringe? What is the purchase price of the MRI machine?

To calculate the true cost of care per care unit, a hospital must add up all the costs of all the component parts of the procedure or process. This allows hospitals to apply some rigor to their pricing schema. Some are doing this already with good results. Seeing how much care costs and the prices all hospitals charge would allow market forces to actually inform consumerism in health care.

From that starting point, a national dialogue concerning prices in health care might have meaning. So would public policymaking. “Out-of-network bills” and “price transparency” would have real-world relevance. Finally, our country could have the long-overdue dialogue about health care costs as a profession, an industry and a nation.


Michael Williams is Associate Chief Medical Officer for Clinical Integration; Associate Professor of Surgery; and Director of the UVA Center for Health Policy, University of Virginia.

This article is republished from The Conversation under a Creative Commons license. You can read the original article here.