Friday, December 28, 2012

ACP Internist calls for cases

Have you as a physician been a patient? If so, ACP Internist wants to hear from you. Our new column, "Doctor as Patient," will look at physicians' thinking as applied to their own health and wellness, based on real stories from readers. It will be written by Jerome Groopman, MD, FACP, and Pamela Hartzband, MD, FACP, coauthors of the bestseller "Your Medical Mind: How to Decide What Is Right for You." Both are on the Harvard Medical School faculty and serve as staff physicians at Boston's Beth Israel Deaconess Medical Center.

If your submission is chosen for print, you'll receive a $50 gift certificate good toward any ACP product, program or service. Contact us if you have a story to tell. We look forward to receiving your submissions!
Friday, December 21, 2012

Flu season hits earlier than in recent years

This year's flu season seems to be starting earlier than usual and is getting more intense by the week. The Centers for Disease Control (CDC) reported in its weekly summary of flu surveillance that flu cases are increasing across the country. California still is showing only sporadic flu activity, but 8 other states report widespread activity and 15 others report regional activity.

The CDC reminded us that it's not too late to protect yourself and those around you by getting a flu shot. The vaccine is recommended for everyone over 6 months of age. And the CDC also has other helpful suggestions for preventing flu transmission. If you're sick, stay home and limit contact with others. Avoid touching your eyes, nose, and mouth. Cover your coughs and sneezes with a tissue. And wash your hands frequently.

Learn more:
Unusually Early Flu Season Intensifies (NPR Health)
Situation Update: Summary of Weekly FluView (CDC)
Google Flu Trends for Los Angeles
Key Facts About Seasonal Flu Vaccine (CDC)
CDC Says "Take 3" Actions To Fight The Flu (CDC)

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. Holding privileges at Cedars-Sinai Medical Center, he is also an assistant clinical professor at UCLA's Department of Medicine. This post originally appeared at his blog.

Muddled mammography

To whatever extent the oft-troubled waters of breast cancer screening had cleared since the last salient controversy, they have been stirred up again by a study just published in the New England Journal of Medicine. The paper, which has received widespread media attention, suggests in essence that mammography routinely finds cancers that would be better left unfound--cancers that would not progress, and do not need treatment.

The authors assert that 1.3 million women in the U.S. over the past 30 years have been diagnosed with breast cancer that would have remained latent without treatment. In 2008, the most recent year for which data are included in their analysis, such unnecessary diagnoses affected 70,000 women, or just over 30% of all breast cancers diagnosed that year.

The authors make this case by examining time trends in the frequency with which both early-stage and late-stage breast cancer is diagnosed. They argue, reasonably, that the benefit of screening is finding early-stage cancers that would progress to late-stage cancers if not detected. And so, each early-stage cancer found through screening should--they tell us--be one less late-stage cancer. Over the past several decades, that has not been the case; the rise in incidence of early-stage cancers is much larger than the fall in incidence of late-stage cancers.

On this basis, the authors conclude: The discrepancy between the two represents over-diagnosis. They go on to suggest that the decisive decline in breast cancer mortality over recent years is due entirely to better treatments, not to the early detection offered by screening.

The researchers in this case may be right, which is why their paper was published in NEJM. But there are important ways in which they may be wrong.

Some early-stage cancers may progress despite treatment. Many late-stage cancers may be treated effectively, but the treatments required may be far more onerous than treatment at earlier stages. Mortality is an important measure, but so is survivable misery.

And then there is the fact that some studies have told us mammography does, indeed, reduce mortality. Other studies, all but indistinguishable, have refuted it.

Rather than revisit the particulars of the mammography debate, which are receiving abundant attention already, my intent here is to address why cancer screening, which is quite literally looking for trouble, can at times seem to be so in the figurative sense as well. Then, I'll suggest what we can do about it, individually, and collectively.

There are two basic problems with cancer screening in general, problems that pertain as much or more to prostate cancer as to breast cancer. The first is the challenge of accurate detection, and the second is the challenge of accurate prediction. Let's deal with them in turn.

The very point of screening is to find cancers when they are tiny and subtle, not when they are large, obvious masses eroding through other body parts. The earlier a cancer is found, the harder it is to see both because it's tiny, and because it may look a whole lot like the healthy tissue around it.

The challenge of finding something tiny and subtle is met, in statistical parlance, with sensitivity. Sensitivity is the ability, in this context, for a medical test to find what's there.

But there is a problem with extreme sensitivity, and one not limited to medical testing. Imagine you drop a contact lens in a large room with a multicolored floor and dim light. As you search for it, you are apt to react with a moment of excited hope to any glint off the floor. In order not to miss your contact lens, you will be highly sensitive to any such glint.

But you will, in all probability, get excited by a whole batch of glints that are not your contact lens. These are called "false positives" in statistical parlance, and they are one form of over-diagnosis to which screening programs are subject.

But unless you have a perfect ability to detect the glint off of a contact lens without fail, and never mistake it for any other kind of glint. These false positives are the price you pay for any hope of finding that lens. In cancer screening, they are the price paid for finding the cancers that are truly there, and need to be found.

The other goal of cancer screening is to rule out disease when it's absent. In statistical terms, specificity is the tendency for a test to give a negative result when disease is truly absent.

But here, too, there is a price to pay. If in the case of your missing contact lens you never want the rush of false hope, there is a good chance you will ignore the subtle clues emitted by the lens. In order to avoid false hope, you may lose your real chance. This is called a false negative, and in cancer screening, it's a test that says there is no cancer when, in fact, there is.

The solution to this problem is improved technology. Ideally, we would devise a perfect test: one that unfailingly finds what it needs to find, and never mistakes anything else for it. But tests that produce no false positives, nor false negatives are vanishingly rare in medicine.

The next-best thing is enhanced technology that produces very high levels of specificity and sensitivity. In the case of mammograms, this would mean enhanced imaging, or computer-aided interpretation of the images. It might mean alternatives to mammography, such as ultrasound, or thermography. Or combinations.

A combination of screening tests is used routinely for HIV, for example. The initial screening test, called an ELISA, is very sensitive, but not very specific. That makes it good for ruling out HIV, but not reliable for ruling it in. A highly-sensitive test will very reliably be positive when disease is present, and thus a negative result on a highly-sensitive test tells you with a high level of confidence that disease is, in fact, absent. A negative ELISA is taken to mean no HIV.

But since the ELISA is so sensitive, it can be positive even when HIV is not there. So a second test, a Western Blot, is used. This test is highly specific. Since a specific test will reliably be negative when disease is absent, a positive result on a highly-specific test tells you with a high level of confidence that disease is, in fact, present. A positive Western Blot means, alas, that HIV has been found.

Enhanced technologies for breast cancer screening are in various stages of development and testing. So are combinations of tests. One of the limiting factors, of course, is cost. Better technology usually costs more. Our society must confront the challenge of best-possible breast cancer screening at a price the system is able and willing to bear.

The second challenge is prediction. The new study doesn't really highlight the flaws in mammography. Rather, it suggests we don't know what to do with the information the test gives us. Some early-stage breast cancers, in particular, ductal carcinomas in situ, are destined never to progress. This is true of many prostate cancers as well, and the reason for formal recommendations against routine prostate cancer screening.

We don't want just to find cancer early; we want to change health outcomes for the better by finding cancer early. That doesn't happen when cancer is found that would never have progressed if left alone.

The solution here is deeper knowledge at the cellular level. Gene variants can help anticipate cancer behavior. A combination of reliable detection through better technology, and then better information from biopsy specimens, should lead us in the direction of treatment when it's needed, away from it when it isn't.

In the interim, I think we all need to suppress our passions so we can work through the challenge of decisions that are far from easy. Advocates of cancer screening tend, on the basis of emotion rather than evidence, to dismiss studies that argue against overwhelming benefits of screening. Therapeutic nihilists who think screening is just a money-making gimmick tend to have equally passionate reactions in the opposite direction. Browse cyberspace and you will readily find a mother lode of both.

But these really are tough calls. Any given individual woman is more likely to have a false positive mammogram at some point, than to have her life saved by one. Ditto for prostate cancer screening in men. But some women will indeed have their lives saved by mammography, just as some men will have their lives saved by PSA testing. We just have trouble knowing who's who.

And therein lies the trouble with the kind of looking for trouble cancer screening requires. You may be the one helped; you may be the one harmed.

I favor access to and reimbursement for mammography until or unless we have truly decisive evidence of more harm from it than benefit. I do not think that will happen. Even though the argument for prostate cancer screening is weaker, I favor access to and reimbursement for that as well. Individual choice should be informed by personal preference, family history, and customized guidance from a health-care professional you trust.

Mammography specifically, and cancer screening in general, is often something of a muddle. It doesn't help us to refute this, or simply rant in favor of our preconceived notions. We should acknowledge the trade-offs, work toward better screening methods, and in the interim, muddle through.

David L. Katz, MD, FACP, MPH, FACPM, 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. He is a board certified specialist in both Internal Medicine, and Preventive Medicine/Public Health, and Associate Professor (adjunct) in Public Health Practice at the Yale University School of Medicine. He is the Director and founder (1998) of Yale University's Prevention Research Center; Director and founder of the Integrative Medicine Center at Griffin Hospital (2000) in Derby, Conn.; founder and president of the non-profit Turn the Tide Foundation; and formerly the Director of Medical Studies in Public Health at the Yale School of Medicine for eight years. This post originally appeared on his blog at The Huffington Post.

QD: News Every Day--Clopidogrel pretreatment for PCI may not lower mortality risk

Clopidogrel pretreatment was not associated with a lower risk of mortality but was associated with a lower risk of major coronary events among patients scheduled for percutaneous coronary intervention (PCI), according to a meta-analysis of more than 37,000 patients.

Researchers reviewed six randomized controlled trials published between August 2001 and September 2012. They then conducted a confirmatory analysis of two observational reports of randomized, controlled trials and an analysis of seven observational studies.

Results appeared in the Journal of the American Medical Association.

Among more than 8,600 patients in the randomized, controlled trials, clopidogrel pretreatment was not significantly associated with a reduction of all-cause mortality (absolute risk, 1.54% vs. 1.97%; odds ratio [OR], 0.80; 95% confidence interval [CI], 0.57-1.11; P=.17). Observational analyses of randomized, controlled trials and of the observational studies confirmed these results.

Among randomized, controlled trials that reviewed mortality data, the association between clopidogrel pretreatment and reduction of cardiovascular death was not present (absolute risk, 1.54% vs. 1.97%; OR, 0.78; 95% CI, 0.44-1.39; P=.41). One observational study had consistent results with this (absolute risk, 1.44% vs 1.92%; OR, 0.80; 95% CI, 0.57-1.11; P=.17).

Researchers noted that clopidogrel pretreatment was not associated with a higher risk of major bleeding among the randomized, controlled trials (absolute risk, 3.57% vs. 3.08%; OR, 1.18; 95% CI, 0.93-1.50; P=.18), and that these results were also confirmed among the observational analyses of randomized, controlled trials and a pooled analysis of observational studies.

Researchers wrote, "This meta-analysis demonstrated, however, a significant association between clopidogrel pretreatment and the reduction of major coronary events or (myocardial infarctions) MIs in the primary (randomized, controlled trials) RCTs analyses combining all types of patients, with fully consistent results obtained from observational analyses of RCTs and observational studies. Although no significant heterogeneity existed for clinical presentation, the higher-risk (ST-elevated myocardial infarction) STEMI population appeared to gain the most benefit from pretreatment."

Editor's Note: QD--News Every Day will resume Jan. 2.
Thursday, December 20, 2012

Using technology in medicine, the good and the bad

There is a wonderful article in the New York Times, Redefining Medicine With Apps and iPads."

They do a great job of considering the benefits and the risks.

On my rounds I embrace technology in the right situations. My rounding day with students and residents starts with "pre-rounding." Before we go to the bedside I hear reports from the students and interns about each of our patients. They present the new patients. For each patient we use technology to review laboratory tests. We look at the X-rays on our computer. When questions come up on rounds, we do quick searches, most often on smartphones, but sometimes on tablets.

But when we go to the bedside, we refrain from technology. I believe in high touch bedside manner. When we go to the bedside, we focus solely on the patient, their story and their exam.

But when we go to the chart to write our notes and prescribe medications, we once again pull out our technology to get the doses right, to use the correct antibiotic for the presumptive diagnosis that we have made.

The key here, and the article suggests this implicitly, is that we physicians should never be "one trick ponies." We must embrace technology, but understand that technology is an aid. Technology helps us gather information quickly and accurately. It cannot replace what we do at the bedside, but it can augment our ability to minimize errors.

db is the nickname for Robert M. Centor, MD, FACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and is the Associate Dean for the Huntsville Regional Medical Campus of UASOM. He also serves as a frequent ward attending at the Birmingham VA Hospital. This post originally appeared at his blog, db's Medical Rants.

An open letter to Oklahoma Gov. Mary Fallin about health insurance exchanges

The Governor of Oklahoma announced on Nov. 19 her intention NOT to participate in either a state electronic health insurance exchange or to accept federal Medicaid dollars to provide coverage to 150,000 Oklahomans out of the 600,000 that currently have no health insurance.

You can read about the decision in brief, with cogent analysis, here.

Below is the text of a letter I faxed to her office yesterday:

Dear Governor Fallin:

I am extremely disappointed with the decision declining Oklahoma's participation in the expansion of Medicaid under ObamaCare.

As a practicing physician and medical educator, I see the impact of "uninsurance" on low income, chronically ill Oklahomans every day. Options for these folks are few. Since they aren't moneyed, and struggle to get by in every sense, they aren't well-represented at the ballot box.

The decision not to participate in a broadening of the safety net is morally, financially, and medically wrong.

The majority of those earning between 133-400% of the federal poverty level are working--without any safety net. They constitute "the working poor." They are not, as some suggest, "freeloaders." Quite simply, those with Medicaid attain better health. The data proves it.

Your alternative "plan" of doing more of the same strikes me as both mean-spirited and inhumane to your fellow Oklahomans--whether they voted for you or not.

Please reconsider this misguided decision. We taxpayers WANT our federal dollars coming back to help Oklahomans--not going only to more benevolent states.

Thank you for your consideration.

John Henning Schumann

This post by John H. Schumann, MD, FACP, originally appeared at GlassHospital. Dr. Schumann is a general internist. His blog, GlassHospital, seeks to bring transparency to medical practice and to improve the patient experience.

QD: News Every Day--Omega-3 supplements didn't reduce afib in patients with normal sinus rhythms

Pharmacological supplementation with 1 g of omega-3 supplements for 1 year did not reduce recurrent atrial fibrillation in patients with normal sinus rhythm, a prospective, randomized trial reported.

Researchers conducted FORWARD (Randomized Trial to Assess Efficacy of PUFA for the Maintenance of Sinus Rhythm in Persistent Atrial Fibrillation Fish Oil Research with omega-3 for Atrial fibrillation Recurrence Delaying). This was a double-blind, placebo-controlled, multicenter trial in 42 Argentinian centers with 586 outpatients with confirmed symptomatic paroxysmal atrial fibrillation. Among the cohort, 428 required cardioversion, 55 had at least 2 episodes of atrial fibrillation in the previous 6 months, and 103 had both.

FORWARD was stopped early because the trial's Steering Committee determined that a slower-than-expected recruitment rate and lower event rates meant that continuing it would not likely lead to a positive finding.

Results appeared Dec. 19 in the Journal of the American College of Cardiology.

There were no significant differences between patients allocated to placebo and those who received omega-3 supplements. At 12 months, 56 of 297 participants (18.9%) in the placebo group and 69 of 289 participants (24.0%) in the omega-3 group had a recurrent symptomatic atrial fibrillation (hazard ratio [HR], 1.28; 95% confidence interval [CI], 0.90 to 1.83; P=0.17).

Also, there was no difference between treatment and control groups for a composite of all-cause mortality, nonfatal stroke, nonfatal acute myocardial infarction, systemic embolism, heart failure development, or severe bleeding that occurred in 20 (6.7%) receiving placebo and 16 (5.5%) patients receiving omega-3s, (HR, 0.86; 95% CI, 0.44 to 1.66; P=0.65).

Although the FORWARD trial was stopped early, which might result in an underpowered clinical trial unable to verify its hypothesis, researchers noted of this and another trial of omega-3s, "[T]ogether they contributed >70% of patients and events in clinical research of this question and might constitute a refutation of the hypothesis of a protective role of these agents for this indication."
Wednesday, December 19, 2012

Call me a commie, I dare you

I've been following a discussion on Twitter about the work environment of post-docs and other scientists. There are a lot of parallels with medical training.

Medical training and science training both continue to follow a guild system, with apprentices, journeymen, and masters. Medical residents and post-docs are expected to work ridiculous hours for a pittance. One of the games we used to play as interns was to figure out our hourly wage (It came out to somewhere between $4 to $5).

The first argument against this system is quality of work. At least in medicine, multiple studies have shown fatigue to degrade quality of care. Similar data are seen in other industries. I don't know if it's ever been studied in academia, especially STEM academia, but I would be willing to bet that quality and quantity of work do not necessarily line up with hours worked.

There are certain tasks in medicine and in science that simply take time. One of the most frustrating ideas in medicine is that of the "hand-off," where a team on call hands over their patients to the new team. In the past we have always tried to minimize this since it can have a negative impact on quality of care. But so can fatigue.

Academics should look at the trends in medical training, where we are trying to bring hours more in line with what data shows works, and what reduces harm to the workers.

And that's really the other argument: Overworking post-docs and medical residents harms them, both physically and economically. Let's set aside for a moment such things as the data regarding medical residents and traffic accidents.

The system itself devalues labor, and thereby the people who perform the labor. We perpetuate the idea that medical schools and grad schools must be cut-throat-competitive. This may or may not be true, but this creates a system where laborers (medical and science trainees) are told they are "lucky to be here," that "there's a dozen others ready to take your place should you fall."

Once again, this may or may not be true, but it helps perpetuate a feeling among laborers that their position is always at risk, that they should be thankful for their abusively long hours and any other mistreatment they receive. And they should thank the boss that they get paid anything at all.

In many ways, this system has served us well; put a small percentage of us through the grinder, and a smaller percentage will survive to become the best of the best. But is that even true?

We need to question our most basic assumptions about medical and scientific training. How do we value the work that is done? How do we express that value? In medicine, we pay the survivors a living wage, one which is offset by crushing debt, and that discourages doctors from specialties that are most in need.

In science, it creates an academic underclass, where unless you manage to invent something very lucrative and get a nice cut from the university, you can only survive by perpetuating the system of undervaluing labor.

It's easy to imagine this system only affects those who are foolish enough to choose to enter it, but think about this. The shortage of primary care doctors, in fact our entire medical system that fails to care for those most in need is perpetuated by the system that underlies it.

And entire classes of people are discouraged from choosing these professions, limiting opportunity for people who are not already financially set.

Recognizing these facts does not make one a Republican or a Democrat or a Socialist.

Remember that inconvenient facts do not determine political ideology. Political ideology is created by facts.

Peter A. Lipson, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. After graduating from Rush Medical College in Chicago, he completed his internal medicine residency at Northwestern Memorial Hospital. This post first appeared at his blog, White Coat Underground. The blog, which has been around in various forms since 2007, offers "musings on the intersection of science, medicine, and culture." His writing focuses on the difference between science-based medicine and "everything else," but also speaks to the day-to-day practice of medicine, fatherhood, and whatever else migrates from his head to his keyboard.

The maybes of blood pressure management

"What's my blood pressure, Doc?"
"That means I have high blood pressure, right? We should start a medication, shouldn't we?"

Here we have a layer cake of definite maybes. On the bottom layer: the error inherent in measuring blood pressure. 143/94 is just an estimate. If by some superpower we were able to check the same blood pressure on the same person at the same time of day, everything the same, but do it 100,000 times, we might get something a few points lower (138/86, say) or a few points higher. Some of these might be under the magic 140/90 cutoff.

Blood pressure itself fluctuates according to time of day, and often--this is the icing on the cake--is not measured in the doctor's office according to the best evidence. Some have suggested payment incentives to make sure doctors' offices measure blood pressure correctly.

The next layer is the connection between blood pressure treatment and outcomes that matter to people, accepting for the sake of argument that the person in the dialogue above has, in fact, "mild hypertension" (less than 160 over 100), with no previous heart disease. In a recent meta-analysis from the Cochrane Collaboration, the authors concluded the following:

"Antihypertensive drugs used in the treatment of adults (primary prevention) with mild hypertension (systolic BP 140-159 mmHg and/or diastolic BP 90-99 mmHg) have not been shown to reduce mortality or morbidity in [randomized controlled trials]. Treatment caused 9% of patients to discontinue treatment due to adverse effects. More RCTs are needed in this prevalent population to know whether the benefits of treatment exceed the harms'.

The final layer is whether, despite the inconclusive studies, medications for blood pressure in this person, as opposed to diet and exercise, would have a net positive as opposed to negative effect.

All that, balanced on the knife-blade of a single visit, with you waiting for your doctor's answer.

Another slice?

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. He is also a poet, journalist and translator in Yiddish and English. This post originally appeared at his blog.

QD: News Every Day--Junk food may cause colon polyps in patients already susceptible to them

Junk food diets were associated with more colorectal adenomas in patients with Lynch syndrome, who are already at a high risk of developing colorectal cancer due to mutations in mismatch repair genes and who develop colorectal adenomas at a younger age, a study found.

Researchers used a food frequency questionnaire to collect dietary information from 486 patients with Lynch syndrome in the Netherlands. Four dietary patterns were identified: ---prudent, consisting of fruits and vegetables, whole grains, nonfat or low-fat dairy, poultry, fish and tea with added sweets,
--meat, heavily loaded on meats and coffee and negatively loaded on whole grains, peanut butter, cakes and cookies, and vegetable products,
--snacks, consisting of fried foods and snacks, butter, peanut sauce, ketchup, sweets, and diet sodas, and
--cosmopolitan, consisting of vegetables, fishes, dressings and spreads, and wine.

Results appeared online Dec. 17 in Cancer.

During a median follow-up of 20 months, colorectal adenomas were detected in 58 persons. After adjusting for age and sex, patients in the highest tertile of the snack pattern was associated with an increased risk of colorectal adenomas (HR, 2.16; 95% CI, 1.03-4.49).

Those in the highest tertiles of the other three dietary patterns did not have as much of an association for colorectal adenomas as the lowest tertiles, (prudent pattern; HR, 0.73; 95% confidence interval [CI], 0.32-1.66) (meat pattern; HR, 1.70; 95% CI, 0.83-3.52) (cosmopolitan pattern; HR, 1.25; 95% CI, 0.61-2.55).

The findings suggest that certain dietary patterns influence the development of polyps in individuals with Lynch syndrome, said the lead author in a press release. "Unfortunately, this does not mean that eating a diet low in snack foods will prevent any polyps from developing, but it might mean that those Lynch syndrome patients who eat a lot of snack foods might have more polyps than if they ate less snack foods."

Lynch syndrome is believed to be responsible for 2% to 7% of the 160,000 new cases of colorectal cancer that are diagnosed annually, according to the U.S. Library of Medicine.
Tuesday, December 18, 2012

Many terminally ill patients believe chemo might cure them

Metastatic (stage IV) colon cancer and lung cancer are fatal incurable illnesses. That doesn't just mean they are life-threatening. A fatal incurable illness is one which has zero survivors. You don't know anyone who had metastatic colon or lung cancer who survived and is no longer ill.

Chemotherapy is still occasionally used in such cases and sometimes can prolong life by a few months. Chemotherapy might also help temporarily alleviate some of the symptoms caused by the cancer. But what chemotherapy never does in these cases is cure the disease. The distinction is important because chemotherapy itself frequently has serious and uncomfortable side effects and patients who are considering undergoing it should understand the benefits they may gain.

A disturbing study in the New England Journal of Medicine suggests that many terminally ill patients misunderstand why they are receiving chemotherapy. The study was a survey of over 1,100 patients with a recent diagnosis of stage IV lung or colon cancer who had opted to receive chemotherapy.

The survey asked several questions about their expectations of chemotherapy. One such question was "After talking with your doctors about chemotherapy, how likely did you think it was that chemotherapy would cure your cancer?" Response options were "very likely," "somewhat likely," "a little likely," "not at all likely," and "don't know."

"Not at all likely" is the only response that conveys an accurate understanding of what chemotherapy can do for these patients. Yet 69% of patients with lung cancer and 81% of colon cancer patients chose one of the first three responses, reflecting mistaken expectations of their treatment. Though previous studies suggested that some patients are mistakenly optimistic in the face of a terrible prognosis, the very high fraction of patients in these studies who apparently believed they might be cured was surprising.

What could account for this? An accompanying editorial ponders the possibilities. Might the oncologists not be giving patients an honest explanation of their prognosis? Prior studies show that most oncologists give bad news honestly, so that is not likely to account for the majority of patients misunderstanding the goals of treatment. Perhaps patients actually know that a cure is impossible and have discussed this with their doctors and their families but are reluctant to share this painful realism with a researcher who is a stranger. Perhaps many patients heard the bad news and chose not to believe it.

Certainly some selection bias is involved. The study, after all, interviewed only patients who chose to undergo chemotherapy. That would include whichever patients were most likely to ignore bad news or exaggerate the possible benefits of treatment. Those who were mostly likely to accept bad news and minimize the possible benefits of treatment were the most likely not to have pursued chemotherapy and would not have been included in the study.

The distressing possibility is that many of the patients surveyed are fooling themselves. In other facets of life self-deception might be beneficial, or at least harmless. ("I look terrific." "I think I'll do great in this interview.") But in this case patients with limited time are choosing to spend that time in healthcare facilities experiencing side effects instead of at home (or on vacation) with loved ones.

One final worrisome finding is that the patients who reported better scores for how well their physician communicated with them were less likely to give accurate responses for the goals of chemotherapy. That means that patients who best understood that chemotherapy could not cure them reported that their physicians were worse communicators than patients who misunderstood their likelihood of cure. Does telling bad news inevitably strain the physician-patient relationship? Do patients bond best with physicians who misinform them with optimism or allow them to misunderstand important aspects of their care?

As patient satisfaction surveys begin to play a larger role in physician compensation we may ironically find that doctors will be increasingly paid to cater to patients' unstated desire for misinformation.

Learn more:
Many Terminal Cancer Patients Mistakenly Believe A Cure Is Possible (NPR Shots)
Study: We overestimate how much medicine can do (Washington Post, Wonkblog)
Patients' Expectations about Effects of Chemotherapy for Advanced Cancer (New England Journal of Medicine)
Talking with Patients about Dying (New England Journal of Medicine editorial)

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. Holding privileges at Cedars-Sinai Medical Center, he is also an assistant clinical professor at UCLA's Department of Medicine. This post originally appeared at his blog.

The potential danger of success

"This could be big," he said after I told him about the company who wants me to cover their 100+ employees. I pay him to give me the stark reality of things, but his optimism made me uncomfortable. "You've got to go for this. I know you don't feel ready for it yet, but this could really be huge for your business, and I don't think you should pass this up."

I sighed. Yes, this is a victory of sorts (still only theory, not reality), but what if I can't deliver? What if I fail?

"You know," a colleague told me during another phone conversation, "You are the buzz of the medical community right now. We talked about you for half an hour at lunch today ... and it was all good!" He went on to use phrases like "our only hope," and "the way out," to describe the potential for my practice model.

"No," I thought, "I am not Obi-Wan. I'm not your only hope." I sighed. I don't want that kind of pressure on me before I even see my first patient. What if I fail?

Even worse: What if I succeed?

One of the main things that separates good clinicians from the rest is the ability to think through contingencies. When I order a test or prescribe a treatment I have to consider the possible outcomes: if the test shows X, then we do Y; if it shows not-X, then we do Z. Or, here's the plan if you get better on the medication, and here's the plan if you don't. The more contingencies I can anticipate and plan for, the more direct the path to the ultimate destination: resolution (or management) of the problem. I find that my experience in thinking through contingencies serves me well in my current job of building a new and innovative practice.

Obviously, if I fail to get enough patients to support the business, things could get really tough. I have bills to pay and the evil overlords of college tuition to placate. The fear of this failure has driven me to spend a large part of most days over the past two months working. I don't want to fail and I will bust my butt to prevent that outcome. The question is not simply, "Can I succeed?" I must also consider the possible consequences of success, and plan how to deal with them. When I consider those consequences it quickly becomes clear how scary they could be.

Consequence 1: getting overwhelmed
This is the easiest danger caused by success to anticipate. When I open the practice, I may be met with an overwhelming number of people wanting to sign up. If I open the doors too wide and too many patients become my patients at once, I could have trouble keeping up with demands.

It's like a restaurant that opens up to a flood of patrons before it is ready to handle the volume. The result is poorer quality food and longer waits, which could doom the ultimate success of the business. This is one of the reasons I was nervous when I was contacted by the business about becoming their "company doctor." I don't want to put out a poor quality product.

The solution for this is to open the practice slowly, or have a "soft opening." As much as my former patients are banging on my doors to open up, I may be tempted to let people in before I am able to give care that is worthy of their trust.

Consequence 2: getting distracted

I had the husband of a patient pay me an off-handed compliment after hearing my presentation about my new practice: "So when you become real successful in this, how long will it be until you don't have time to see patients anymore?" I appreciated use of the word "when" rather than "if" in his question. He not only saw the merit in the idea of what I was doing, he saw the potential for building a big business on this idea.

My answer was simple (and perhaps somewhat over-confident): "Never," I said. "I am leaving my old job so I can do what I love: see patients. I am not going to allow this business to take me away from the very reason I started it."

Others have suggested starting a franchise, writing books, or making money as a consultant for practices who want to follow my path. I hate this, not only because I haven't seen a single patient or gotten a single check (and thus have the practice equivalent of vapor-ware), but because I see this as a real possibility.

The solution to this will largely depend on the people who I end up working with. If I hire well (which is not an easy thing by any stretch), then I can delegate to people worthy of those tasks. But I am not a micro-manager (unlike most docs), so my temptation will be to get lazy and put too much in the hands of people who haven't shown they deserve that trust.

Consequence 3: kicking the hornets' nest
Let's say I dodge consequences 1 and 2, have a thriving practice and a bunch of money coming from consulting and from my show on Oprah's TV network (giving Dr. Oz the heave-ho in the process). It's a roaring success, the money is coming in, and doctors are leaving traditional practices in droves to emulate my incredible business model. I've been able to dump the administrative tasks to others, leaving me to see patients and scoff at the pittance demanded by the tuition gods. That would be a dream come true, wouldn't it?

Not necessarily. One of the most common criticisms I hear for what I am doing (and one I often bring up to myself) is that it is not generalizable to the whole of health care. I am cutting back my patient load from approximately 4,000 patients (the number I carried in my old practices) to 1,000. That is one of the keys to this type of practice: keep patient volume down so patients get more time.

So what happens if this business model takes off and a significant percentage of primary care doctors "abandon" 75% of their patients? It turns a shortage of primary care providers into a crisis. It turns direct care practices into a real threat to the viability of the entire system.

It would create a huge backlash. Direct care would have enemies, and those enemies could do things like requiring doctors to accept Medicare and/or Medicaid to have a license to practice. I've heard it suggested already, and it terrifies me.

This is one of the main reasons I've become increasingly focused on a new goal: to grow my practice back to the same size it was in the old system. I would have to do so using my "organic medical home," hiring dietitians, home visiting nurses, social workers, counselors, and other professionals to manage aspects of my patients' care, allowing me to increase my overall panel size (and perhaps even lowering my monthly fees).

If primary care physicians can have a profitable business without selling their souls, if patients can be given more access to care, better care, and save money, and if all of this can be done without threatening to destroy the system itself, perhaps some specialists will become envious and come back to "real medicine."

Wouldn't that be cool?

Yes, this could be big. Now I have to decide if that's a good thing.

After taking a year-long hiatus from blogging, Rob Lamberts, MD, ACP Member, returned with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind), where this post originally appeared.

QD: News Every Day--More cancer mortality in men can't be easily explained

Men are 1.5 times more likely to develop non-sex specific cancers than women, and more likely to die from it even after the higher incidence rate is accounted for, a descriptive epidemiologic study found.

Men are more likely to be diagnosed with advanced stage cancer in 7 of the 10 most commonly occurring non-sex specific cancers comprising 78% of all cases--all but colorectal, urinary bladder and brain cancers--study authors reported in the Journal of Urology.

Researchers used Surveillance Epidemiology and End Results (SEER) data to conclude that the male to female relative mortality rate for any cancer was 1.060 (95% confidence interval [CI], 1.055-1.065) and that the relative mortality rate of men compared to women for the same cancer was 1.126 (95% CI, 1.086-1.168).

For 2012 only, more than 575,000 men vs. 457,000 women were estimated to be diagnosed with cancer. That resulted in an estimated death of 244,000 men and 183,000 women.

Furthermore, this gap has been stable for the last decade, researchers noted. While the rate of cancer deaths to cancer diagnoses has decreased by 10% for both sexes over the past decade, it's been consistently higher for men than women every year.

Possible reasons for the disparity include: Men are more likely to make lifestyle choices such as smoking that incur cancer; they are less likely to seek regular primary care; and biological differences such as estrogen and it's possibly protective role have an impact, researchers reported.
Monday, December 17, 2012

Forewarned is forearmed, except when it isn't

Those who don't learn from the follies of history, we are famously told, are destined to repeat them. One of the oft-repeated follies is to ignore vulnerability, and wind up dealing with the consequences of that neglect.

Our vulnerability arguably comes in two flavors. There's the kind we can't do much about except recover from it afterward. Perhaps earthquakes are an example of this kind, since we can do nothing to prevent them. Hurricanes may be an example as well, since they have long occurred with no help from us, although they are almost certainly getting help from us now.

But even hurricane damage can be pre-empted to some degree. The need for protective measures taken in New Orleans after Hurricane Katrina was well recognized before. Had such measures been taken in advance, the catastrophe would have been much diminished, if not averted. A similar case has been made about the calamitous effects of Hurricane Sandy along the Northeast coast.

And while we can't prevent earthquakes, we can build infrastructure to withstand them. So it may be the kind of vulnerability we can do nothing about doesn't really exist after all, or is very rare (as in, a-giant-asteroid-hurtling-toward-Earth rare). Most of the time, forewarned should be forearmed.

Which brings us to the other kind of vulnerability, the kind we can do much to alter. That kind prevails.

It may prevail with regard to monster storms, but that's not my field. So I can only repeat what I've heard experts say: Power lines could run in reinforced pipes underground, rather than between poles and among trees. Storm surges can be anticipated, confronted, and diverted in harbors and coastal lowlands. Such things are being done in parts of the world more inclined to look at vulnerability as an opportunity for self-defense than we seem to be.

Regardless of the causes of our severe weather, the consequences are clear to us all. It is penny wise and pound foolish to let infrastructure get destroyed and pay the costs of cleanup again and again, when better infrastructure would resist such destruction. But such investments need to be made before disaster strikes, and that's the dilemma.

It is a dilemma that bedevils the medical field, and particularly my specialty of preventive medicine, where I may rely on my own expertise and experience for insights. It is, in a word, silly to treat hundreds of thousands of myocardial infarctions annually while knowing how to eliminate almost all of them. Silly, and, of course, tragic.

It is silly and tragic to treat type 2 diabetes, formerly known as "adult-onset diabetes," not only in ever more adults, but ever more children while knowing how to prevent the condition in 90% of adults and eradicate it in children. After all, we invented type 2 diabetes in children within the span of just the past generation.

Prevention produces far better outcomes and costs less than treatment. But like hurricane-proof shorelines and earthquake-proof buildings, it requires up-front investments for returns over time. We tend to be bad at that. But we need to get better, because lives are at stake.

As may be the fate of the nation. The Centers for Disease Control and Prevention is projecting that by mid-century, should current trends persist, 1 in 3 American adults could have diabetes. Devastating though it is, the toll of Hurricane Sandy is small in comparison to this brewing storm.

The first message in these winds is that current trends cannot persist, because the dollar and human cost of that are apt to be unbearable. We currently have roughly 27 million diagnosed diabetics in the U.S., and struggle to pay the health care bill. When 1 in 3 of us has diabetes, that will be well over 100 million. There is no bank account big enough to write that check.

The second message may matter even more. Guess who those adults will be, burdened with more diabetes than the world has ever known? Our children and grandchildren. They will be the adults in 2050, dealing with the crushing burden of chronic disease we bequeathed them.

The trouble with even temporary neglect of vulnerability is that the longer you wait, the worse your options. At the individual level, if you address vulnerability after the onset of diabetes, or after a first heart attack or stroke, your health will simply never again be as good as it could have been. Chronic disease can be managed, but the adage about not being able to unscramble an egg applies to health. That's what Humpty Dumpty was supposed to teach us.

At the collective level, the more vulnerability converts to consequences, the more resources are diverted to deal with those consequences. Whatever search and rescue costs, we have no choice; the money must be spent. Whatever emergency angioplasty or coronary bypass costs, the money must be spent. The more often money is spent that way, the less likely allocations to prevention become because the money is already gone.

One tends not to hear any clamor for pinching pennies and shrinking government when it's time to send in the National Guard, bring helicopters into flood zones or over forest fires, or mobilize the Coast Guard for search and rescue. In contrast, in moments of calm and far better options, those voices gain volume. When there's time to make investments to prevent the next costly calamity, we are heeding the call to cut the deficit.

The trouble is that catastrophes are enormously expensive. Vulnerability to them is the quintessential case of a "pay now, or pay later" scenario in which the latter costs dwarf the former. Neglecting vulnerabilities we can fix is penny wise, pound foolish. The deficit grows.

When Ozymandias, king of kings, invited lesser sovereigns to look on his works and despair, he may have had intimidation in mind. But what is truly indelible is his vulnerability. As told most famously by Shelley, the kingdom of Ozymandias fell to ruin in the desert sand. We are misguided to think we are too mighty to do the same. Signs of our vulnerability abound.

The choice to take on vulnerability is never easy. Building a levee when the ground is dry may seem unnecessary, even frivolous. But of course, it's the only time to build a levee that will reliably prevent catastrophe, rather than one that might not be enough to mitigate it. Making a serious commitment to eating well and being active may not seem worth the effort or time before you are on your back staring at the roof of an ambulance or riding next to your child doing so. But afterward, the investment is larger and the return smaller.

We are vulnerable, and we know it. That knowledge is only power if we put it to use before the costs of that vulnerability come due. Forewarned is forearmed only if we take up the requisite arms against a sea of looming troubles, and by opposing, end them before ever they begin. Again.

David L. Katz, MD, FACP, MPH, FACPM, 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. He is a board certified specialist in both Internal Medicine, and Preventive Medicine/Public Health, and Associate Professor (adjunct) in Public Health Practice at the Yale University School of Medicine. He is the Director and founder (1998) of Yale University's Prevention Research Center; Director and founder of the Integrative Medicine Center at Griffin Hospital (2000) in Derby, Conn.; founder and president of the non-profit Turn the Tide Foundation; and formerly the Director of Medical Studies in Public Health at the Yale School of Medicine for eight years. This post originally appeared on his blog at The Huffington Post.

QD: News Every Day--Sitting-rising test a simple tool to assess longevity

Clocking how fast people can rise from a sitting position is associated with longevity, a study reported.

Researchers conducted a retrospective cohort study of more than 2,000 adults ages 51 to who were timed sitting on the floor and then rising again. Patients were scored from 0 to 5 for sitting, with one point subtracted for each hand or knee used for support. They were then scored for rising, and the two were totaled to a range from 0 to 10. Results were then stratified into categories of 0 to 3; 3.5 to 5.5; 6 to 7.5, and 8 to 10.

Results appeared in the European Journal of Preventive Cardiology.

There were 159 deaths (7.9%) during a median of more than 6 years of follow-up on patients. Lower scores were associated with higher mortality (P less than  0.001) and each increase in sitting-rising test scores conferred a 21% improvement in survival.

"Application of a simple and safe assessment tool such as SRT [sitting-rising test], which is influenced by muscular strength and flexibility, in general health examinations could add relevant information regarding functional capabilities and outcomes in non-hospitalized adults," the authors wrote.
Friday, December 14, 2012

Electronic medical records hold doctors hostage

Which of the following events is most traumatic for a practicing physician?
1) Your staff doesn’t show up because the roads are flooded, but the waiting room is full of patients.
2) Medicare notifies you that coding discrepancies will result in an audit of two years of Medicare records.
3) You receive an offer of employment by a corporate medical institution who will bury your practice if you do not sign.
4) Your key expert witness defending you in your upcoming medical malpractice case is incarcerated.
5) Your office electronic medical records (EMR) system suffers a cardiac arrest. Tough choices, I know. Our office lost complete access to EMR for three days, and it wasn’t pretty. I don’t grasp the technical (doubletalk) explanation for the temporary EMR coma, but we were reminded of how dependent we are on technology. Our IT gurus were working tirelessly, but their adversary was wily and formidable. Finally, they prevailed, but I wouldn’t regard this as a clean win for us. We were hobbling for three days. The fried server has been rebuilt and now has reinforcements to insulate against another crippling assault.

Ink and paper never crash.

Luckily, our brains were still functioning adequately during these 72 hours. We hadn’t yet lost the ability to obtain a medical history without pointing and clicking. Somehow, we managed to obtain a review of systems without trolling and scrolling across our laptop monitors. Ancient physician techniques, such as maintaining eye contact and offering nods of understanding to patients, were effortlessly recalled, like riding a bicycle. I even prepared a few paper prescriptions, once I was able to locate a yellowed and tattered prescription pad. I hope the pharmacies will accept these medical anachronisms.

The tough reality is that during these three days we had no records available for the patients we saw. We compensated when we could, with faxes and phone reports, but this is no substitute for a complete medical record. Patients arrived to review test results that we couldn’t access.

In some cases, I had faxed biopsy reports available, but not the accompanying endoscopy operative reports that were hiding in the EMR black hole. Patients were understanding of our dilemma, since many had faced their own computer rages. But, many of them did not receive a full measure of medical services from us. I asked some to return to see me for another visit, once the EMR was resuscitated, as I feared I may have overlooked some important issue during the three days of Stone Age medicine.
To paraphrase, the most famous phrase uttered by Karl Marx, "Technology is the opium of the people." We love technology. We demand it. We upgrade it. And, we are hooked on it. Like any addiction, when the fix isn’t there for us, withdrawal is painful.

I’m thinking of opening the first chapter of Techno-Addicts Anonymous. Of course, the first step of recovery is the toughest. “My name is Whistleblower and I am a ...”

This post by Michael Kirsch, MD, FACP, appeared at MD Whistleblower. Dr. Kirsch is a full time practicing physician and writer who 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.

QD: News Every Day--Primary care doctors more proactive with diabetes care

Regular primary care providers treat diabetic patients more proactively than covering physicians or midlevel providers, shown by an increased likelihood to boost medication regimens and offer more lifestyle counseling, a study found.

Researchers conducted a retrospective cohort study of more than 584,000 encounters for more than 27,000 patients with diabetes and elevated A1C, blood pressure and/or LDL. They followed the population for more than two years at primary care practices affiliated with two teaching hospitals in eastern Massachusetts.

Results appeared online Dec. 10 ahead of print at Diabetes Care.

Of the encounters, 83% were with primary care providers, 13% were with covering physicians, and 5% were with midlevel providers. Medication intensification, defined as either adding a new medication or increasing the dose of an existing medication, happened about 10% of the time and lifestyle counseling happened 40% of the time. The overall mean time between encounters was 1.6 months.

Primary care providers were more likely to intensify medicines than covering doctors, (49%, P less than 0.0001) and midlevel providers (26%, P less than 0.0001). They were more likely to offer lifestyle counseling than covering doctors (91%, P less than 0.0001) and midlevel providers (21%, P=0.0015).

During visits with acute complaints, covering physicians were even less likely to intensify medications by a further 52% (P less than 0.0001), and midlevel providers were even less likely to provide lifestyle counseling by a further 41% (P less than 0.0001).

This affected the occurrence of acute complaints, the authors noted. Compared with primary care providers, time to the next encounter after a visit without acute complaints were hazard ratio 1.11 for covering physicians and 1.19 for midlevel providers (P less than 0.0001 for both).

The authors noted that there should be less cross-covering by other physicians, better documentation of a primary doctor's treatment plan in the medical records, and structured algorithms in place to optimize diabetes care.

"Many studies have shown that midlevel providers can be more effective than PCPs in treatment of chronic diseases such as diabetes and hypertension, particularly with respect to medication intensification," the authors wrote. "The major difference between our study and these clinical trials is that the trials usually required midlevel providers to follow a structured algorithm, whereas midlevel providers in the practices we studied did not follow any particular algorithm. This current finding should be considered when designing new practice models, such as patient-centered medical homes."
Thursday, December 13, 2012

Poor adherence, non-compliance; should we label patients?

Almost 30 years ago I had pneumonoccal pneumonia. My symptoms were classic--seeming viral infection, then a drenching night sweat and a rigor, then a productive cough. My CXR should segmental consolidation.

My physician first put me on erythromycin, but we switched to Pen VK after I had severe nausea and vomiting with the 5th dose of erythromycin.

It took me 13 days to take all the penicillin. Taking medications 4 times a day is extremely difficult. I was poorly adherent.

A few years ago I had one toenail with a fungal infection. I took terbinafine daily, and only took 92 days to take my 90 pills.

Danielle Ofri has written a very insightful piece on labeling patients as non-compliant, When the Patient is 'Non-compliant'.

When we see patients in the hospital, or in clinic, and the patient does not comply with our wishes, then what should we do?

We must ask why the patient is not taking meds or dieting or stopping alcohol consumption. We have a responsibility to not give up on the patient.

Try, try again. Try to understand the patient, diagnose the patient as well as diagnosing the underlying diseases. Sometimes the problem is financial. Sometimes the patient has side-effects. Sometimes the patient just does not understand.

But we must not give up on the patient.

db is the nickname for Robert M. Centor, MD, FACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and is the Associate Dean for the Huntsville Regional Medical Campus of UASOM. He also serves as a frequent ward attending at the Birmingham VA Hospital. This post originally appeared at his blog, db's Medical Rants.

Mammogram screening: reconsidering the wisdom of saying 'no'

An article was published in the New England Journal of Medicine questioning the utility of mammogram screening for prevention of death from breast cancer. The authors were research professor Archie Bleyer, MD, at Oregon Health and Sciences University in Portland, an oncologist who was chief of pediatrics at MD Anderson Cancer Center, and H. Gilbert Welch MD, MPH, a professor at Dartmouth Medical School.

The article examines the ability of mammograms to prevent late stage breast cancer by diagnosing and treating breast cancer early as a result of detection by mammograms. They found that mammograms do detect lots of breast cancer, but when we compare women during the years 2006-2008 when mammogram screening was widely practiced to women during the years 1976-1978, there was no difference in the incidence of the really nasty breast cancers, ones that had spread beyond the regional lymph nodes, and only a small decrease in the less nasty but still significant regionally metastatic cancers. Many, many women were treated for breast cancer but only a few were saved from dying of late stage disease with mammogram screening.

Their evaluation was carefully done, making assumptions about the increase in rates of breast cancer over time that were designed to make the results of having a mammogram more favorable. They concluded, somewhat generously, that "Women should recognize that our study does not answer the question 'Should I be screened for breast cancer?' However, they can rest assured that the question has more than one right answer."

Mammograms are X-rays of breast tissue and were first introduced by a German surgeon named Albert Salomon in 1913 when he examined mastectomy specimens with X-rays. Mammograms were used rarely before 1978 when widespread use of mammography was introduced in an attempt to identify and treat breast cancer early to reduce mortality and morbidity.

The procedure has been controversial since 1978. The first objections regarded the danger of radiation to the breast. A mammogram is performed by squashing a breast between two plates and passing X-rays through it. A digital mammogram detects the X-rays with digital detectors and creates an image on a computer monitor. A film mammogram creates an actual negative on a piece of photographic film. These techniques are equally sensitive, but digital machines are replacing film machines due to the overall convenience of storage and communication of images. The dose of X-rays with a typical digital mammogram is 3.9 milligrays, the same as for a film mammogram, and about 4 times the radiation dose of a chest X-ray. It is a small dose and is probably not a significant danger.

After initial worry about radiation, very reasonable concerns remained about the quality of mammograms and mammogram readings. In 1992 the Mammography Quality Standards Act was passed to assure that facilities that performed mammograms were accredited by the FDA to be of adequate quality.

Mammograms are very big business. I can't find out how big, but if there are about 40 million women between the ages of 50 and 75, and half of those get mammograms at a cost of $100. That would be $4 billion spent on mammograms alone, not to mention repeat mammograms and other technology to further identify actual breast cancer. If I am off by a factor of 4, that's still $1 billion. It is a big deal to write an article questioning the utility of this test. Any move away from a recommendation of yearly mammograms starting at age 40 or 50 is met with outrage. Still, articles and studies continue to demonstrate that the benefit of screening mammography is limited.

Norway has been extensively studied with regard to mammogram screening because they keep excellent records and have had a staggered approach to universal mammogram screening for women. Over the last 20 years multiple studies have come out of Norway suggesting that breast cancer is overdiagnosed by mammogram.

Overdiagnosis is what happens when we find a breast cancer that would never have caused harm if it had not been detected. Some cancers do not kill people and are probably taken care of by a healthy immune system. In an article published last April, a study group evaluated the data and estimated that, of all the breast cancers diagnosed, about a quarter of them would never have caused harm. This week's article concurred, but suggested that number may be as many as 30% and that over a million women have been diagnosed with breast cancer since the inception of screening who would never have been affected had they not had mammograms.

But, one might ask, is it really a big deal to be diagnosed with breast cancer that would not have hurt or killed you? Yes. It is actually a very big deal. The British Medical Journal reported that 50% of women were depressed in the year after they were diagnosed with early breast cancer, the type of breast cancer most likely to be overdiagnosed.

But we don't really need studies to tell us this information. It is clear after treating women with breast cancer that they are profoundly affected by this diagnosis, feeling ugly, self-conscious, maimed. Treatment complications include disfigurement, chemotherapy side effects, infection, chronic pain, to say nothing of astronomical monetary costs.

Still, breast cancer kills, and fewer people die of it now that mammogram screening has become standard. How do we explain this? Some of it is due to mammograms. We are detecting lots of breast cancer early. Some of it we should be detecting early and some we should not. Still, some early breast cancers would have become late, bad, killer breast cancers. The study published this week suggests that there are not many of these, but there are definitely some.

The treatment of breast cancer has also gotten much better. People who used to die of metastatic breast cancer now remain on chemotherapy and remain in remission for many years, and some are cured. It is undoubtedly because of the huge increase in breast cancer awareness that therapy has improved, and likely the million women who were overdiagnosed were important in helping to pioneer excellent treatment.

What is a woman to do? What is a doctor to do? I think it might be good to start with recognizing that a decision not to do mammogram screening is not tantamount to a death wish. We give women who reject the recommendation for regular mammograms a really hard time, and that is neither fair nor evidence-based. Mammograms are quite good for evaluating lumps, especially in older women. They are also good for giving peace of mind, since a negative mammogram suggests (but does not prove) that a woman does not have breast cancer.

There may be a subset of women, those at particularly high risk of cancer for instance, who would be very wise to have regular mammograms. There may be technology that can help us identify which breast cancers need treatment and which do not. Tests that detect more breast cancers, such as MRI and PET scanning may not be particularly helpful in this situation unless they can reassure us that some breast cancers are of no significance.

If we accept that medical resources should be limited, we might look at places where money now used for universal mammogram screening of women might be more effectively spent.

Janice Boughton, MD, ACP Member, practiced in the Seattle area for four years and in rural Idaho for 17 years before deciding to take a few years off to see more places, learn more about medicine and increase her knowledge base and perspective by practicing hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling. Disturbed by various aspects of the practice of medicine that make no sense and concerned about the cost of providing health care to every American, she blogs at Why is American Health care so expensive?, where this post originally appeared.

QD: News Every Day--Older, sicker patients lead to rise in hospitalized patients' acuity, use of health care

Despite a rise in obesity and complex conditions such as end-stage renal disease in recent years, patients are living longer due to advances in medicine and improved use of health care services, which is creating an older and sicker population requiring hospitalization, a report concluded.

The American Hospital Association is making the case in a white paper that noted the potential for what could become a more complex population requiring more care for more chronic diseases.

The paper examined disease and population trends found in the medical literature and put them in the context of how reimbursement changed under the Medicare Severity-adjusted Diagnostic Related Groups (MS-DRGs) that were implemented in 2008 to account for these changes.

The AHA makes the case that in 2008, two-thirds of all Medicare beneficiaries had at least two or more chronic conditions, a factor that rises along with the increasingly aging population.

For example, obesity among Medicare beneficiaries has doubled since 1987, right along with accompanying diseases such as diabetes. Another examples is end-stage renal disease, which grew by more than half

Meanwhile, longer life expectancy and better medical treatments for chronic disease will result in a doubling of the number of Medicare beneficiaries in the next 40 years.

Already there are more Medicare inpatient admissions that included an ICU stay, with more ICU care for longer stays during the last six months of life. There are more observation stays involving sicker patients. And more seniors are presenting at the emergency department.

The AHA white paper points out, "Seeking to ensure that these changes alone did not lead Medicare to pay more for the same services and patients than it would have paid before, CMS made a downward adjustment to hospitals' payment rates. The AHA is asking policymakers to consider the results of these changes and as to whether that adjustment appropriately separates the effect of changes in how hospitals report severity from actual changes in the complexity and severity of illness of Medicare patients."
Wednesday, December 12, 2012

Update on health care reform

If a patient asks me "How much is this visit going to cost?" the only honest answer is, "I have no way of knowing." How can a patient plan for the coast of the visit? How can the practice as a business work on guesses?

It's just the way we as a nation have decided on. If I charge, say, $90 for a visit, the patient's insurance company may have contracted with me to have the visit discounted to $60. Then the patient may or may not have met their deductible or their out of pocket. They may or may not have money left in their health savings account.

Shopping around for a good price doesn't work all that well either. Prices tend to be set at the level of the insurance company. And do you really want to see the doctor with the best deals?

But let's say you have an unusual medical problem and you want to visit a bevy of specialists. Most people would rely on their primary care doc to coordinate this, but some folks will go off on their own based on their own research. Because different medical systems and different offices use different record keeping systems, each doc has no idea what the last one did.

Frequently, a patient will come to me with a folder full of results, many of which duplicate tests I've already done. Even emergency departments rarely contact the patient's doctor to see what's been done recently. Services are regularly duplicated.

The government has been pushing for the adoption of electronic medical records (EMRs), paying incentives, but eventually collecting penalties for offices that stick with pen and paper. There are a lot of pluses to EMRs, but prevention of redundant services isn't yet one of them.

You see, my office may choose one company, the nearby hospital another, and none of these systems talk to each other. There's a lot of competition in the EMR marketplace, which is good, but it means that one of EMRs most important features, improving communication between providers and preventing duplicate services, isn't going to happen.

Peter A. Lipson, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. After graduating from Rush Medical College in Chicago, he completed his internal medicine residency at Northwestern Memorial Hospital. This post first appeared at his blog, White Coat Underground. The blog, which has been around in various forms since 2007, offers "musings on the intersection of science, medicine, and culture." His writing focuses on the difference between science-based medicine and "everything else," but also speaks to the day-to-day practice of medicine, fatherhood, and whatever else migrates from his head to his keyboard.

No predictions

The blogosphere is alive with the sound of Silver--Nate Silver, that is, the head of what should be called the Five Thirty Eight Modeling Agency. Silver constructs statistical models to calculate the probability of electoral outcomes. Though he hasn't shared his model yet, the results fit his model very well.

Is that the point? Statistical models can be constructed to serve various ends, among which are predictive modeling ("Five Thirty Eight says Obama will win") and descriptive modeling ("In elections like these, the incumbent wins 35% of the time"). While Silver protested that he wasn't trying to predict, only to model [at a 538 post I can't find right now, can anyone oblige?], the two often overlap. Many disciplines care about prediction and de-emphasize explanation. (A nice article about the overlap between prediction and explanation is here.)

This difference gets to the heart of how impressive Silver's feats of statistical strength really were. If he was just predicting, any pocket calculator could do to average the polls and estimate that, in fact, Obama was a few points up. But this sheds no light on how Obama won or on what future candidates are likely to accomplish.

The same difference is also relevant in medicine, and how doctors often explain things to patients. A patient asks me if she should take an aspirin to prevent heart disease. I trot out the often used Framingham model. Like many models, it's a little bit country and a little bit rock and roll: it assigns probabilities to certain events, spitting out a 10-year probability that a person will develop heart disease. On the other hand, it also explains heart disease as largely dependent on a number of underlying factors.

Unfortunately, these models aren't very satisfying to us or our patients. They don't predict very well, and their explanations, though sensible, don't help much in telling patients what might happen to them.

At the end of the day, we all have to decide about our health based on incomplete information. If the model says we are at 50% risk of developing heart disease in the next 10 years, we have to interpret this proportion not as an oracular judgment that will chase us like something out of a Greek tragedy, but the best guess of a predictive model that was based on the history of populations. We as individuals are always different.

To put it another way: Nate Silver had a relatively easy time of it when you compare his task to the doctor's. He had oceans of data to swim in to predict (or explain) an outcome that has come about 45 times. But, for our patients, the most important outcomes happen approximately once, and missing them is deadly.

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. He is also a poet, journalist and translator in Yiddish and English. This post originally appeared at his blog.

QD: News Every Day--Medical practitioners seen as more honest, ethical than other professionals

Medical professionals, especially nurses, are perceived as vastly more ethical than other professions, a Gallup poll found.

Among 22 professions tracked in this year's poll, medical professions were six of the top ten ranked professions rated on the qualities of honesty and ethics. Nurses were the #1 profession, scoring high or very high among 85% of respondents, followed by pharmacists (75%) and physicians (70%).

Rounding out the top 10 were then engineers, dentists, police officers, college teachers, clergy, psychiatrists and chiropractors.

It seems natural that professions dedicated to healing, helping and counseling would be seen as more honest and ethical. The bottom half of the list is dominated entirely by professions where ethics are more complex, those involved in either civics/government (journalists, lawyers and politicians) or in capitalism (business executives including HMO managers, stockbrokers, and salespeople, with car salespeople ranking last).
Tuesday, December 11, 2012

Campaign promises

I had an amazing day on Friday. It started with a phone call from a local physician, one who I have never seen as an outside-the-box thinker, who was very excited about my transition to a direct-care model of primary care. He feels much of the same frustrations as me, and thinks my approach to the problem is intriguing. He asked me lots of questions--many of the ones I keep asking myself, actually--and had some good thoughts on the answers to some of these questions. Apparently, there is quite a buzz around town about what I am doing, and most of that buzz is positive. That's quite reassuring.

Then I got an email from a local business, asking me if I would consider being the doctor for their 100+ employees. I spoke to them on the phone and was very much encouraged by their insight and enthusiasm. They have seen their costs of insuring their employees go up dramatically over the past few years (as have all businesses, including mine), and are looking for a way to tame this cost.

They were even more excited about the possibility of working with me when I pointed out two things they didn't realize:
1. That a contract with my type of practice would, along with a high-deductible insurance policy, qualify them for the requirements of the Affordable Care Act (thus avoiding the fines), and
2. My focus on care on the continuum (care outside of the office between visits) would have a potentially big impact on reducing absenteeism. This is exactly what I was dreaming about a few months back when crystalizing the ideas of my practice, so the reality of having an employer contact me about this is incredible.

The coup-de-grace of my amazing day came in the evening, when I had dinner with a large group of my patients who belong to a Christian "community." This community has been very supportive of my practice for years, and has been even more excited with my new direction, as it speaks to their belief of community.

I was greeted with hugs and handshakes, handed a glass of wine, and directed toward pots of gumbo and lentil soup. The fellowship was loud and joyful, with updates on the health and life status of community members not there. Despite the fact that the group filled three rows of tables in this large living space, they apologized for the small turn-out. I smiled.

I was peppered with questions about the nature of my practice, what it would cost, and how it would work in comparison to my old practice. My answers were met with nods of understanding, and more questions. They were very happy with the answers I gave, and made it clear that they wanted to be on my list as early as possible. Then, one by one, each family recounted some way in which my care had impacted their lives: a child diagnosed with attention deficit disorder who was actually having petit-mal seizures, a quick discovery of an electrolyte imbalance in a mentally retarded child, the diagnosis of leukemia in another.

Tears were in everyone's eyes, including mine. What a privilege to not only know these people, to fellowship with them, and to consider them friends, but also to have really made a difference in their lives with my care. This is why I went into medicine, and this is why I am starting my new practice: to spend my time touching lives and making a difference.

In the aftermath of this momentous day, my sense of urgency has greatly increased. It's as if I have been overwhelmingly voted into office, given a huge vote of confidence for the campaign promises I've made, and now am met with the hardest part: to deliver the goods. It's one thing to say I am going to do something; it's a whole lot more to do it.

I don't want other doctors simply impressed with my ideas; I want them to be impressed by what I've done. I don't just want companies signing up for me as their doctor; I want to save them money by keeping their employees healthy and at work. I don't want people to love me for what I've done for them in the past; I want to do even more for them with my new practice.

This is the big difference between writing about change and doing it. Yes, my financial future and the success of my business depend on my ability to deliver the goods, but my big day showed me that this was much bigger than a business.

At the end of the dinner on Friday, one of the community members asked me directly, "Is there anything we can do to help you? We have people who can hang wallpaper, pound nails, whatever you need. You know we are all praying for you, but is there anything else we can do?"

I smiled, and said, "This dinner alone has done more for me than you can imagine." Then I thought for a moment longer, seeing that the offer was an earnest one, not simply a token offer of support. "I will think about it. Right now I've got a bunch of ideas that are forming something concrete, but I'm not there yet. But I know that to turn down a sincere offer of help is to take away the blessing of generosity, and I know you really mean it when you say you want to help."

My answer was met with a big smile and a long hug.

After taking a year-long hiatus from blogging, Rob Lamberts, MD, ACP Member, returned with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind), where this post originally appeared.

QD: News Every Day--Flu vaccinations rising as facilities enforce mandatory policies

The Hospital chain FirstHealth of the Carolinas is enforcing its mandatory flu shot policy that was adopted over the summer, telling employees who routinely work in patient care areas to get their annual flu vaccine.

The only exceptions are extreme allergy to eggs or a component of the flu vaccine or a history of Guillain-Barre Syndrome, documented by a physician. The chain noted that 32 staff members had been granted a medical exemption and will be required to wear a mask while in patient care areas during flu season.

"So far, only a few employees have indicated they would leave FirstHealth rather than have the flu shot," the hospital noted in a press release. Volunteers who do not have a medical exemption or have not received the flu vaccine by Dec. 31 will not be allowed to volunteer in a FirstHealth hospital, the Hospice House or in other patient care areas for the remainder of the flu season.

It's a move shared by many hospitals, and vaccination rates have risen for health care workers overall, the Centers for Disease Control and Prevention noted, although the goal is to have more than 90% compliance.

It's entirely possible for hospitals to achieve nearly complete compliance, notes Albert Wu, MD, FACP, of Johns Hopkins. He tweeted that more than 4,000 employees at his organization have a 99.9% flu vaccination rate.
Monday, December 10, 2012

'Men'opause and the risks of treating low testosterone

Everyone has heard of menopause, but is there a male equivalent? Two weeks ago at Personalized Primary Care Atlanta we discussed treatment of testosterone deficiency, or so called "andropause," in an evening health talk. PPC was happy to host Wayland Hsiao, MD, Assistant Professor of Urology from Emory University, as our discussant.

Dr. Hsiao pointed out that declining testosterone levels are normal as men age and that while some men may be asymptomatic, others may suffer with symptoms that may negatively impact quality of life.

What are the symptoms of testosterone deficiency? Loss of energy, decreased strength, reduced exercise capacity and erectile dysfunction are some. Testosterone deficiency may also contribute to metabolic syndrome, loss of lean muscle mass, and osteoporosis. The ADAM questionnaire is a validated tool that can help identify symptomatic men. [Morley et al. Validation of a screening questionnaire for androgen deficiency in aging males. Metabolism. 2000;49(9):1239-1242.]

Testosterone deficiency may be diagnosed on the basis of blood tests. Dr. Hsaio pointed out that saliva tests are not accurate. Typically total testosterone and free testosterone levels are measured. Free testosterone is the active version of the hormone. If levels are low and men are deemed symptomatic, treatment involves supplementation with testosterone, which is available in various delivery systems including transdermal gels, patches and pellets (implanted beneath the skin of the buttocks). Dr. Hsiao is of the opinion that injections of testosterone are not as well tolerated as the other delivery methods as they produce hormonal peaks and troughs that are associated with more adverse effects including flushes.

Given the common nature of some of the described symptoms of testosterone deficiency it is not always clear who should be treated. One approach, for symptomatic men who have low or borderline testosterone levels, is a three month trial of treatment to see if symptoms improve.

What is the downside of testosterone replacement? One large clinical trial reported in the New England Journal of Medicine in 2010 demonstrated increased cardiovascular events in men who were randomized to treatment, and the trial was terminated early because of these adverse outcomes. However, Dr. Hsiao is skeptical that these risks translate to all men, and he noted that the population studied was primarily elderly, frail and immobile.

Another concern with testosterone therapy is whether it has potential to promote prostate cancer growth in a man who may have subclinical prostate cancer or prostate cancer that has not yet been detected, and also whether it can cause enlargement of benign prostate tissue and contribute to worsening of urinary symptoms in men. Benign prostatic hypertrophy is another common condition that impacts quality of life in men as they age by causing reduced ability to urinate. Dr. Hsiao felt that evidence is lacking to suggest that either of these prostate conditions is affected much by testosterone therapy and sited data supporting this viewpoint.

It's good to know that testosterone therapy exists as an option to help men with symptoms of andropause, which can adversely affect quality of life. However, those of us who have doctored through the era of the Women's Health Initiative, which studied the effects of hormonal therapy for menopause, have to be somewhat cautious about prescribing treatment for a condition that affects a huge segment of the population.

In the case of estrogen and progestin therapy in women, as discussed in a recent blog, the pendulum has swung for, then against, and now recently partially back in favor of a cautionary approach to post-menopausal hormone replacement for symptom management during the time immediately following menopause in women.

To date testosterone therapy has been less well studied, and it could be years before the safety data for testosterone replacement in men is as good as the data for hormone replacement in women, which has been the subject of intense research in the previous decade.

Juliet K. Mavromatis, MD, FACP, is a primary care physician in Atlanta, Ga. Previous to her primary care practice, she served on the general internal medicine faculty of Emory University, where she practiced clinical medicine and taught internal medicine residents for 12 years, and led initiatives to improve the quality of care for patients with diabetes. This work fostered an interest in innovative models of primary care delivery. Her blog, DrDialogue, acts as a conversation about health topics for patients and health professionals. This post originally appeared there.