"It is time to stop this [PSA] screening nonsense"

In an editorial in this month's issue of the Journal of Family Practice, Northeast Ohio Medical University dean and family physician Jeff Susman, MD joins the rising chorus of voices urging clinicians to stop offering the PSA test to screen for prostate cancer. Dr. Susman writes:

I am going to go out on a limb here and suggest that, until we have fundamentally changed strategies for targeted case finding or early intervention (think genomic and proteomic markers), it is time to stop this screening nonsense. The facts speak for themselves: A trial of 182,000 patients finds in a post hoc analysis of a very narrow population that death can be averted in one of 723 individuals who are screened. What about the complications associated with diagnosis, work-up, and treatment? It is time for urologists and primary care physicians to tell patients that PSA screening is unlikely to benefit them. Some of you will suggest that we counsel patients about PSA testing to facilitate informed decision-making. But do we advise patients to play the lottery or try futile therapies?

Notably, mortality results from one of the two "definitive" randomized studies of treatment versus watchful waiting for PSA-detected prostate cancer, the Prostate Cancer Intervention Versus Observation Trial (PIVOT), were presented in abstract form at the annual meeting of the American Urological Association last month. In brief, PIVOT found no overall survival benefit in men who underwent surgery (radical prostatectomy) compared to men who did not. The only men whom the study suggested might benefit from surgery were those with a PSA of greater than 10 - in other words, those men who would be least likely to be identified via screening alone.

As we continue to wait for the long-delayed verdict of the U.S. Preventive Services Task Force on PSA screening, public opinion may finally be turning against the test, at least in older men with no realistic possibility of benefit. When primary care blogger Kevin Pho, MD recently proposed on the New York Times's Room for Debate that Medicare stop paying for prostate screenings for men over 75, the majority of responses were favorable - a big difference from the way the USPSTF's recommendation against screening in this age group was originally received back in 2008.

Thank you, Dr. Susman, for taking a public stand on PSA screening that is consistent with the scientific evidence and most likely to benefit patients. Hopefully, it will soon become obvious to all that discouraging the misuse of this test is not "going out on a limb," but rather, should be the standard of care.

How to find good health information online

A recent survey found that 60 percent of adults have gone online at least once to look up health information. Unfortunately, finding high-quality health websites is a challenge. Several years ago, a review of 79 studies published in the Journal of the American Medical Association concluded that online health information for consumers is frequently flawed, inaccurate, or biased. Based on my experience, the situation isn't any better today.

Why do some health websites contain misleading information? One reason is that the group or organization running the site may have a hidden agenda. Drug companies often create consumer demand for expensive new drugs by financing groups that promote awareness of a previously unrecognized health condition, a sales tactic known as "disease mongering." (For example, Dartmouth Medical School researchers have argued that restless leg syndrome became a disease only when a drug was developed to treat it.) Unfortunately, a study published earlier this year in the American Journal of Public Health found that most health advocacy groups that receive drug-company funding don't disclose that on their websites.

Another reason that websites may contain misinformation is that some groups willfully disregard scientific evidence to promote certain health beliefs. For example, even though the U.S. Institute of Medicine found in 2004, after an exhaustive review of the medical literature, that there is no relationship between childhood vaccines and autism, it's easy to find websites that claim otherwise. Similarly, although most researchers have concluded that Morgellons disease—a bizarre skin condition that sufferers believe to be caused by an undiagnosed parasitic infestation—is likely to be a psychiatric delusional disorder, you wouldn't know it by simply Googling "Morgellons."

Because advising my patients to make an appointment every time they have a health-related question isn't a practical solution, I refer them to websites that I trust or that have been certified by an independent, quality rating organization such as the Health on the Net Foundation. This organization's search engine only retrieves results from websites that have agreed to provide objective, scientifically sound information. One such website—Healthfinder.gov, which is a clearinghouse on a variety of general health topics— links to the latest health headlines, and provides interactive health tools that give personalized advice about screening tests and other preventive health issues. Content on Healthfinder.gov is periodically reviewed by U.S. government health experts to assure its accuracy and consistency with results from the latest scientific studies.

When I want to give patients a handout about the basics of a preventive test or newly diagnosed health condition, I turn to FamilyDoctor.org, a nonprofit website supported by the American Academy of Family Physicians. (Full disclosure: I edit a medical journal that is the source of many of these handouts.) One such handout advises that patients ask themselves 3 questions about every health-related website they visit:

• Where did this information come from?
• How current is this information?
• Who is responsible for the content on this website?

As powerful a tool as the Internet can be in giving people access to health information, it is only a starting point. With few exceptions (for example, management of the common cold), patients should never use online information to self-diagnose or treat a medical problem. However, I believe that patients who visit high-quality health websites are usually better-informed and more capable of making complex choices, such as whether or not to get a screening test for cancer. And in my opinion, that's a good thing.

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The above post was first published on my Healthcare Headaches blog at USNews.com.

Guest Blog: EMRs and primary care

Josh Freeman, MD is Chair of the Department of Family Medicine at the University of Kansas School of Medicine. The following is an excerpt from a post first published on his blog, Medicine and Social Justice.

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One of the centerpieces of health reform as promulgated by almost everyone, and very much the Affordable Care Act (ACA) is the use of electronic medical records (EMR, also called, in a more inclusive formulation, electronic health records, or EHR). The Health Information Technology for Economic and Clinical Health Act (HITECH) specifically addresses specifications for EMRs. Demonstration of effective use of EMRs, including “e-prescribing” (in which prescriptions are routed electronically directly from the physician’s office to the patient’s pharmacy of choice), maintenance of patient registries (who in your practice has diabetes?) and compliance with a set of quality measures (What percent of the people in your practice with diabetes have had their sugar measured? What percent are in control?) account for a great deal of the added payment for chronic disease management, as well as payment for patient-centered medical homes.

EMRs are a good thing for many reasons. At the simplest level, the fact that the records are online, rather than in paper charts, means that they don’t get “lost” and any doctor can see the notes of any other doctor. A number of years ago, prior to going to a real EMR, a large public hospital with many clinics where temporarily lost charts often meant that patient notes generated in one clinic visit were unavailable to another clinic, scanned literally millions of pages into a very basic EMR. While having none of the advantages described below, even this primitive method was a real step forward for them in being able to access the records. At their best, EMRs allow effective communication between doctors in a practice. For large multispecialty practices, this can also be between different specialists, and can even be integrated with the hospital’s medical record so that information from hospitalizations is immediately available in the same “chart”. The more that information is put in “digitally retrievable” format rather than free text, the more easily and thoroughly that a patient’s health trajectory can be understood. This is not only for numeric values, such as lab results and blood pressures that can be displayed on a flowsheet or graph, but even for history and physical items: Was that heart murmur present at the last visit? What is the history of the different medications that the patient has been on? Patient registries become an effective way of evaluating and improving the care given in the entire practice, not just for one patient, and are almost impossible without an EMR.

EMRs are not problem-free, however. The most common issue for physicians is that charting takes longer; filling in all this data takes time. This is worst when a new EMR is implemented, as old data has to be input, but continues to be, on average, more time consuming than paper charting. In part, this may be because the notes are “more thorough,” or, looking at it the other way, that paper chart notes were inadequate. But it is also because the very structured nature of the EMR requires that a significant number of things be entered/clicked (even to indicate “not applicable” or its digital equivalent) that would have appropriately not been mentioned in a paper note. Much of this added documentation goes beyond the information necessary to provide medical care for the patient, but is required to comply with government regulations and ensure that the document is “legally” sound. In addition, some of those regulations require the physician, as opposed to another health professional such as a nurse, to personally document certain items in the record, often to a degree that seems unreasonable to physicians.

There is an ironic turn to this. Most discussion in public policy circles is directed to increased inter-professional function and teamwork, as characterized by the patient-centered medical home. In part, this is because the current and projected shortage of primary care physicians means that there is no way that they, working alone, will be able to meet the health needs of the American people; if they are already working on a “hamster wheel” (see Family Medicine in the Era of Health Reform - 3, May 23, 2011), the changes described by Phillips (see Primary Care, Medical School Debt, and US Health Needs: Analysis from the Graham Center, May 30, 2011 ) and discussed in detail by Margolius and Bodenheimer[1], will increase the burden beyond any hope of sustainability. In addition, an effectively functioning team of health professionals (including nurses, pharmacists, social workers, and others[2]) makes for higher quality care. This is very clearly articulated in Dr. Atul Gawande’s recent address to the Harvard Medical School commencement, “Cowboys and Pit Crews” published on his New Yorker blog.

The irony is that the increased requirements mentioned above, sometimes explicitly stated in law, but often in federal regulations and most commonly by Medicare “carriers” and interpreted by institutional compliance officers, have increased what the physician needs to document in the medical record (and, by implication, have actually done him or herself). These requirements both decrease effective team function, and increase the burden of electronic charting.

As in any new technology that increases the ease of accomplishing something, or the availability of a person or data, there is the corresponding tendency to expect it; this often has the ironic effect of increasing, rather than decreasing, workload. The internet and email allow us to work from home; cell phones, pagers, and email all increase our availability even when not at work or at home. This allows us more flexibility, but it has also led to the expectation of immediate access and, for many professionals including physicians, the virtual elimination of the concept of “work” versus “off” hours. The electronic medical record allows me to chart from home – or anywhere I can get an internet connection – and so I do.

An interesting, and perhaps important, sidelight of the introduction of the EMR in our family medicine clinic was that the implementation team, composed of experts from the computer company and “superusers” of nurses from our group practice, saw how much more complicated the practice – and thus the documentation – is in primary care than in other specialties. In most sub-specialty practices, a few diagnoses -- and thus a few types of workflow and documentation strategies -- account for almost all visits, while in primary care the breadth of encounters in a single session, combined with the complexity of dealing with multiple chronic conditions based in a variety of organ systems rather than one, is breathtaking (see, for example, Primary Care: What takes so much time? And how are we paying for it?, May 21, 2010, "Uncomplicated" Primary Care?, Oct 8, 2009). Contrary to what they had been led to believe, they discovered that primary care was harder and more complex and more difficult to document – and of course required seeing more patients in shorter amounts of time for less reimbursement (which also leads to an ability to afford fewer support staff). This team, at least, gained a new respect for what primary care practice involves.

No easy victories in cancer screening and prevention

Nearly forty years ago, President Richard Nixon famously declared a "War on Cancer" by signing the National Cancer Act of 1971. Like the Manhattan Project, the Apollo program that was then landing men on the Moon, and the ongoing (and eventually successful) World Health Organization-led initiative to eradicate smallpox from the face of the Earth, the "War on Cancer" was envisioned as a massive, all-out research and treatment effort. We would bomb cancer in submission with powerful regimens of chemotherapy, experts promised, or, failing that, we would invest in early detection of cancers so that they could be more easily cured at earlier stages.

It was in the spirit of the latter that the National Cancer Institute launched the Prostate, Lung, Colorectal, and Ovarian Cancer (PLCO) Screening trial in 1992. This massive study, which eventually enrolled more than 150,000 men and women between age 55 and 74, was designed to test the widespread belief that screening and early detection of the most common cancers could improve morbidity and mortality in the long term. Not a few influential voices suggested that the many millions of dollars invested in running the trial might be better spent on programs to increase the use of these obviously-effective tests in clinical practice.

They were wrong. As of this week, the PLCO study is 0-for-2.

Miss #1 occurred in March of 2009 when the PLCO study first reported no mortality benefit from annual PSA testing, a test that a majority of men over 50 undergo routinely. Miss #2 occurred over the weekend, when the Journal of the American Medical Association published a landmark paper that ended with the following paragraph:

We conclude that annual screening for ovarian cancer as performed in the PLCO trial with simultaneous CA-125 and transvaginal ultrasound does not reduce disease-specific mortality in women at average risk for ovarian cancer but does increase invasive medical procedures and associated harms.

The lung and colorectal screening components of PLCO have not yet reported mortality data, and there is reason to believe that at least the latter will likely yield some positive results. Although it has largely been supplanted by colonoscopy and CT colonography (aka "virtual colonoscopy") in the U.S., flexible sigmoidoscopy was already shown to reduce deaths from colorectal cancer in a randomized trial published in the Lancet last year. And PLCO's screening chest x-rays are probably a loser, but a preliminary report from NCI's National Lung Screening Trial suggest that screening CT scans can reduce lung cancer mortality in heavy smokers. (Even after this report is confirmed in a peer-reviewed scientific journal, there will still be plenty of reasons not to rush into lung cancer screening, as I outlined in a previous blog post.)

Still, these are hardly the magic bullets or the resounding victories that many expected from the "War on Cancer." The same can be said for chemoprevention, or the strategy of prescribing medications for healthy adults to prevent cancers from developing at all. The vast majority of "high risk" women have avoided breast cancer chemoprevention with tamoxifen and raloxifene due to their unpleasant side effects (which include hot flashes and life-threatening blood clots), despite a 2002 recommendation from the U.S. Preventive Services Task Force for clinicians to discuss these drugs with their patients. (This recommendation has not been updated since, largely due to politics, not science.) A new study published in the New England Journal of Medicine has reported that the drug exemestane reduces the risk of invasive breast cancer without the other drugs' side effects. But here's the rub: we can't be sure how many of those breast cancers are the ones that inevitably lead to symptoms and death, rather than the 1 in 3 that are thought to be overdiagnosed.

The bottom line from recent research is that there are no easy victories in cancer screening and prevention - just slow, incremental progress. Companies that have a profitable product to push would like you to believe otherwise, but when it comes to cancer prevention, there is no substitute for a healthy lifestyle: Don't Smoke. Drink in Moderation. Exercise. And Eat a Well-Balanced Plate.

Guest Blog: Production of Primary Care Doctors

John Delzell, Jr., MD, MSPH is an Associate Professor of Family Medicine and Assistant Dean for Graduate Medical Education at the University of Kansas Medical Center. Dr. Delzell is also an assistant medical editor on the journal American Family Physician. The following post first appeared on his blog, Education in Medicine.

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COGME has just released its 20th report, Advancing Primary Care. Unless you are a real geek like me, you probably don't know what COGME stands for. COGME is the Council on Graduate Medical Education. It was authorized by Congress in 1986 to provide an ongoing assessment of physician workforce trends, training issues and financing policies, and to recommend appropriate federal and private sector efforts to address identified needs. The legislation calls for COGME to advise and make recommendations to the Secretary of the U.S. Department of Health and Human Services (HHS), the Senate Committee on Health, Education, Labor and Pensions, and the House of Representatives Committee on Commerce. The Health Professions Education Partnerships Act of 1998 reauthorized the Council through September 30, 2002. Since then, the Council has been extended through successive annual appropriations governing the Department of Health and Human Services.(1)

Now, there is some history here. In January 1994, COGME released its Fourth report, Improving Access to Health Care Through Physician Workforce Reform. In that report the authors took the position that the physician workforce was not meeting the needs of the US healthcare system and the public need. The report concluded that we needed more generalist physicians. Their recommendation was that 50% of all graduates should enter practice as a generalist physician (Family Medicine, General Internal Medicine, and General Pediatrics). Their goal was to attain this by 2000. As we know that did not happen. In fact, it went the other direction.

But interestingly, in their Sixteenth report, Physician Workforce Policy Guidelines for the United States, 2000-2020(2005), COGME reversed themselves and said that market forces should determine the proportion of students in an in specific specialty. The exact recommendation was: The distribution between generalists and non-generalists should reflect ongoing assessments of demand; therefore, COGME does not recommend a rigid national numerical target. Wow, what an amazing mistake that was. Since that time, the proportion of students choosing family medicine and primary care in general has continued a downward trend. In 2008, the total proportion was down to 32%. Clearly market forces are not working.

Dr Jerry Kruse, Chair of Family & Community Medicine at Southern Illinois University who I wrote about in a recent blog, was Chair of one of the writing groups for the COGME report. According to Dr. Kruse, market forces didn't work because there is not a traditional supply and demand market in the US healthcare system. What we have is really a supply and supply market. We have a virtually unlimited amount of care that can be delivered (whether it should be is a different discussion) and a funding pot that rewards doctors, hospitals, DME companies, etc for doing more (See Dr. Lin's post at the Common Sense Family Doctor). The rewards are financial and huge. So, the market is designed to reward doctors financially in specialties that do more technical and procedural things. (A more detailed discussion of this can be found in a recent post by Matthews and McGinty on the Wall Street Journal Health blog.) These are specialties such as, Radiology, Orthopaedic Surgery, Anesthesiology, and Dermatology. The "ROAD", as some medical students have taken to calling it.

Medical students are not stupid. They figured out that the financial rewards of practicing in the higher paid specialties were extraordinary. The median lifetime income gap between a student choosing primary care versus a specialty is 3.5 million dollars.(2) Currently, US primary care doctors earn about 55 percent of what specialists earn on average. When primary care doctors' salaries dropped as a proportion of specialists' salaries, interest in family medicine and other primary care areas also drop. The key number seems to be around 70 percent. If the income of primary care doctors as a proportion of the income of specialty physicians goes up then student interest goes up as well. The Altarum Institute estimates that increasing primary care income to 80 percent of specialty income would double medical student interest in primary care. This would increase the percentage of students choosing primary care to about 40 percent.(3)

Canada had the same problem. From 1998 to 2004, they had a 25% drop in students choosing family medicine and it worried the Canadian health ministry.(4) In a country that has universal coverage, it is vital that the primary care base is adequate. In Canada, they understand and believe that they need a specific number of family doctors in order to be able to take care of the populace. To address this national crisis (their words, not mine) they invested in student interest by building up and supporting medical school family medicine interest groups (FMIG). And they raised the salary of family physicians. They did not make family medicine and specialist salaries the same, but they raised the proportion to 87%. By 2006, the median income of Canadian family physicians was $212,000 per year compared to the median annual specialty income of $245,000.(4) That was enough. Interest started going back up. Medical students choosing family medicine has increased by 27 percent each year since 2004.

Why can't we do that in the US? There are so many reasons that I don't think I could even begin to cover them all, but let me hit some of the highlights. We don't have a national universal coverage system. Doctors are mostly self-employed or work for large healthcare organizations (like hospitals). The government does not directly decide how much doctors are paid. (For more on this, read Dr. Freeman's post Outing the RUC: Medicare reimbursement and Primary Care.)

The most important reason is probably that we don't see this as a national crisis. Most people think that we have the best healthcare system in the world. Unfortunately, the data does not support that. We have a mediocre healthcare system compared to the rest of the world by any measure. The primary care base is the key to the system. We need to and should adopt the COGME recommendations. If we don't have enough primary care doctors (translate=enough students choosing family medicine), the US population will be less healthy. There is no question. Our population will be less healthy, people will die prematurely, and it will cost more.(5)

References
(1) http://www.cogme.gov/whois.htm
(2) Wilder V, Dodoo MS, Phillips RL Jr, Teevan B, Bazemore AW, Petterson SM, Xierali I. Income disparities shape medical student specialty choice. Am Fam Physician. 2010 Sep 15;82(6):601
(3) Altarum Institute. (2009). Updates to BHPR phy­sician supply and requirements models. Presenta­tion to COGME, p. 15. Rockville, MD, from COGME 20th report
(4) Canadian Institute for Health Information. (2007, December 13). Physicians in Canada: Average Gross Fee-For-Service Payments, 2005-2006. Re­trieved May 11, 2010, from http://secure.cihi.ca/ cihiweb/products/FTE_APP_2005_Eng_final.pdf
(5) Phillips RL Jr, Bazemore AW. Primary care and why it matters for U.S. health system reform. Health Aff (Millwood). 2010 May;29(5):806-10

The best recent posts you may have missed

Every other month or so, 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 late March, April and May:

1) Incidentalomas: reasons to think twice about getting a CT scan (4/24/11)

2) Low-value health care: coronary CT screening in Texas (3/25/11)

3) Partnering with community health workers for better primary care (5/3/11)

4) Genetic guilt and disease susceptibility testing in kids (5/19/11)

5) "Overdiagnosed" and the paradox of cancer survivorship (4/12/11)

If you have a personal favorite that isn't on this list, please let me know. As always, thank you for reading!