Thursday, November 19, 2009
Rethink pink: breast cancer screening evidence met politics and lost
The controversy started at exactly 5 p.m. Monday, when the Annals of Internal Medicine lifted its embargo on new breast cancer screening recommendations and the rest of the medical community simultaneously released opposing positions. With lines drawn and positions taken, a furor began ultimately pitted evidence-based medicine against political machinations. So far, medicine has lost.
The recommendations, issued by the U.S. Preventive Services Task Force, suggest that asymptomatic individuals with no family history or other risk factors could wait before starting mammograms and undergo screening every two years instead of annually. They balanced the benefits of less frequent screening against the harms of more frequent screening by reviewing the evidence and creating models.
The recommendations have since been on the pages of every newspaper in America, from the smallest locals to the biggest dailies. The American College of Physicians is tracking "impressions," as they're called, in the millions.
There's always a downside to new knowledge, and it's playing out in week following the announcement. It will take time for physicians to digest the new recommendations. It will take time to explain them to patients. In the meantime, public discourse has been messy.
Experts have told women to talk to their doctors about how evidence-based recommendations apply to individual circumstances. But other medical societies are sticking to their guns on annual screenings at earlier ages, and it's unsettling for patients to see doctors disagree and even more unsettling when shouting matches erupt on television.
But neither the government nor insurers are rushing out to make dramatic changes to existing practice of medicine. To calm fears, HHS Secretary Kathleen Sebelius clarified that the doctors who drafted the recommendations, the U.S. Preventive Services Task Force, comprise an independent body of experts who review evidence but don't set policy. To calm fears, she stated that women should still go to their doctors to discuss their individual needs. Insurers aren't going to change their policies, either.
In short, the recommendations inform the talks between doctors and patients. They give physicians something to consider during the informed consent process. Consider the words of family physician David Baron, MD, who said, "I respect [USPSTF] a great deal. They've got no horse in the race. They are independent experts." Take it from practicing physician Jan Gurley, MD, who summarized in plain language how recommendations should impact encounters between physicians and patients.
This is in contrast to internist and TV commentator Elizabeth Lee Vliet, MD, who went on the attack about a "distant and impersonal 'review of data' from published studies." In an op-ed shopped around to media outlets, she further ranted that, "I am profoundly concerned that government 'experts,' far removed from the daily care of patients, are sitting 'on high' to proclaim that women don't need to start mammograms at age 40."
And of course, Dr. Vliet decried it as a cost cutting measure and as the start of "government-mandated, guideline-based rationing of health care." Those are her poorly chosen words. But she's not alone.
U.S. Rep. Marsha Blackburn of Tennessee bemoaned that, "This is where you start getting a bureaucrat between you and your physician." Rep. Michele Bachmann of Minnesota joined the misinformation brigade, starting her press conference on the task force recommendations by blaming President Obama and Speaker of the House Nancy Pelosi. Watch for yourself.
Hijacking evidence-based recommendations to further partisan debate is a semantic trick. And it's a disgrace.
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Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.
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Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.
Controversies in Hospital
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).
db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.
Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.
David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.
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Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.
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Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.
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Other blogs of note:
American Journal of
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.
The Public Library of Science's open access materials include a blog.
One of the most popular anonymous blogs written by an emergency room physician.