The Meeting That Wasn’t, Revisited

Kenneth Lin

First posted 10/05/11 on Common Sense Family Doctor

A New York Times Magazine story published on the newspaper’s website this morning details the complicated history of screening for prostate cancer in the U.S. and revisits the related story of the U.S. Preventive Services Task Force meeting that was abruptly cancelled for political reasons on November 1, 2010, the day before the midterm Congressional elections. I was interviewed several times for this story, starting shortly after my resignation from my position at the Agency for Healthcare Research and Quality, where for 4 years I had supported the USPSTF’s scientific activities on a wide range of topics.

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Actual Causes of Death in the US: Not What You Think

Kenneth Lin

First posted 8/26/11 on Common Sense Family Doctor

Any standard public health or medical school prevention text includes (or ought to include) some version of the figure below, which illustrates that the leading causes of death in the U.S. at the turn of the century (heart disease, cancer, stroke) were actually surrogates for what have come to be known as the actual causes of death: unhealthy behaviors such as tobacco use, poor diet, and physical inactivity.

The most effective preventive services that primary care clinicians provide, then, are not screening tests but counseling interventions that aim to change one or more of these behaviors for the better. Community-level initiatives such as tobacco-free restaurants and campuses, pedestrian-friendly cities, and the increasing access to nutritious food sources play a critical role in changing health-related behaviors, too.

Unfortunately, the impact of behavioral or “lifestyle” approaches to prevention is likely to be limited by two factors: 1) even intensive interventions produce very modest benefits; and 2) behaviors don’t exist in a vacuum, but are largely shaped by economic and social circumstances. Family medicine professor and former U.S. Preventive Services Task Force member Steven Woolf has published a number of studies showing that the risk of death is strongly associated with levels of college education and income; his research team at Virginia Commonwealth University worked with the Robert Wood Johnson Foundation to develop an interactive County Health Calculator that illustrates how many premature deaths could be avoided by eliminating educational and income disparities.

Researchers from Columbia University went a step further by publishing “Estimated Deaths Attributable to Social Factors in the United States” in this month’s issue of the American Journal of Public Health. Using estimates derived from the literature on social determinants of health and year 2000 mortality data, they found that the “actual” causes of death looked like this:

1) Low education: 245,000

2) Racial segregation: 176,000

3) Low social support: 162,000

4) Individual-level poverty: 133,000

5) Income inequality: 119,000

6) Area-level poverty: 39,000

Clearly, we know a great deal more about successful strategies for fighting clinical and behavioral causes of death than we do about social causes, some of which often appear intractable. But I could not agree more with the authors’ conclusion that “these findings argue for a broader public health conceptualization of the causes of mortality and an expansive policy approach that considers how social factors can be addressed to improve the health of populations.” The point being: poverty, discrimination, and low education aren’t just social or political issues best left to non-clinicians – they’re health issues, too.

Kenny Lin is a family physician practicing in the DC area.

Mammograms and Death Panels: Why the Preventive Services Task Force Keeps Pulling Its Punches

Kenneth Lin

First posted 8/18/11 on Common Sense Family Doctor

Health reform was supposed to have been good news for the U.S. Preventive Services Task Force. Until 2009, this independent panel of federally-appointed experts in primary care and preventive health was not particularly well known, and its evaluations of the effectiveness of clinical preventive services had no binding authority on public or private insurance plans. Within the small circle of physicians and policymakers who were aware of the their work, however, the USPSTF won accolades and respect for “calling it as they saw it,” sticking strictly to the evidence and writing screening recommendations that frequently conflicted with more expansive guidelines promulgated by other professional organizations.

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Politics in Service of Public Health

Kenneth Lin

First published 8/1/11 on Common Sense Family Doctor

Below is the text of a proposed resolution that will be submitted by the District of Columbia Academy of Family Physicians to next month’s Congress of Delegates of the American Academy of Family Physicians in Orlando, Florida.

WHEREAS family physicians rely on current, unbiased sources of evidence-based guidelines to select appropriate screening tests and counseling services for their patients;

WHEREAS the primary source of evidence-based prevention guidelines for family physicians is the federally-sponsored U.S. Preventive Services Task Force (USPSTF), whose recommendation statements commonly serve as the basis for AAFP clinical policies on preventive services;

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How Politically Unpopular Research Helps Us Make Better Medical Decisions

Kenneth Lin

First published 7/13/11 on the Healthcare Headaches Blog at USNews.

When a new drug goes on the market for, say, diabetes, doctors are typically bombarded by advertising messages that promote it. Patients may see television commercials touting the new drug’s advantages over older ones and advising them to “talk to your doctor” about obtaining a prescription. But since the U.S. Food and Drug Administration only requires drug companies to prove that new drugs work better than placebos (sugar pills), there’s often little or no reliable information about whether a new drug is actually an improvement over existing therapies.

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Doctor, Don’t Dispense As Written

Kenneth Lin

First posted 7/12/11 on Common Sense Family Doctor

I’ve always favored prescribing generic drugs over handing out brand-name samples, since the latter, while initially “free” for patients, can actually be less effective and cost them more money in the long run. In fact, the only patient for whom I can remember routinely writing “Dispense as Written” (forcing the pharmacy to dispense the brand-name drug rather than the generic) on prescriptions was a special case: she insisted that I do so, because she believed that the brand-name worked better for her condition than the generic did. (And she may very well have been right, although she would have been a rare exception to the rule that generics are therapeutically equivalent to the brand-name drugs they replace.)

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Malpractice Reform: Unfinished Business

Wednesday, July 6, 2011

In this week’s Journal of the American Medical Association, cardiologist Peter Kowey, MD describes a case in which a young athlete sees him for a second opinion after a single episode of presyncope. Despite extensive cardiovascular testing that found no evidence to suggest that this young man had an increased risk of sudden cardiac death, another cardiologist had nonetheless recommended the implantation of a defibrillator. Why the overly aggressive recommendation? Dr. Kowey discovers that his colleague, who had endured a lawsuit about a patient with similar circumstances, was practicing “defensive medicine.” He goes on to observe:

Defensive medicine is pervasive and takes many forms. It extends from ordering too many tests all the way to performing unnecessary surgical procedures. Lung nodules that used to be followed end up in a specimen jar in the pathology laboratory. Subcritical coronary artery lesions are dilated and stented. And the contamination is not just at the individual physician level. Practice guidelines are formulated by colleagues who hear the wolf at the door. In the absence of definitive data, wouldn’t it be logical that recommendations about the frequency of prostate biopsy in patients with abnormal PSAs would be on the more frequent side for safety’s sake? And once those guidelines are published, physicians who ignore them do so at their peril.

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Advice on Social Media For Physicians

Kenneth Lin

Originally posted 7/6/11 on the American Family Physician Community Blog

The Mayo Clinic’s Center for Social Media recently posted a short video of prominent physician bloggers Bryan Vartabedian (a gastroenterologist), Wendy Sue Swanson (a pediatrician), and Katherine Chretien (an internist) giving advice to young physicians on the potential and perils of social media use.

The advice and additional resources these experts provide should be helpful to family physicians at all stages of training who are new to using social media tools. Dr. Chretien also writes an insightful commentary in the July 1st issue of AFP in response to the question, “Should I be ‘friends’ with my patients on social networking web sites?” (Short answer: no, but there are less ethically questionable ways to interact with one’s patients online.) As Dr. Chretien points out, the American Medical Association has recently published guidance on professionalism in the use of social media.

We encourage family physicians to explore the health care social media landscape through posts and comments on the AFP Community Blog and the journal’s Facebook and Twitter accounts, as well as by visiting our links to blogs written by and for family physicians.

Advanced Access And Other Ways To See A Doctor – Stat

Kenneth Lin

First posted 6/23/11 on Healthcare Headaches on US News.

A few weeks ago, while at an out-of-state wedding reception, I began having chest pain that didn’t immediately go away with rest and antacids. Although it was unlikely to be an early symptom of a heart attack (I’m relatively young, have good cholesterol levels, and have no relatives with early heart disease), I felt uncomfortable enough to want another physician to confirm that it was only a bad episode of heartburn. But with my family doctor’s office hundreds of miles away, the only medical option seemed to be the nearest hospital emergency room. And like most people, I avoid emergency rooms unless I have a broken bone or life-threatening medical emergency.

Fortunately, the pain disappeared and I didn’t need to see a doctor that night. But you don’t have to be hundreds of miles from home to know that it’s tough to get a doctor’s appointment when you need one. According to a 2009 survey, the average wait time for an appointment with a family physician was nearly three weeks, and up to two months in some cities. Because last year’s health reform law is expected to result in more people having health insurance, these wait times may become even longer, as more patients compete for increasingly scarce spots in doctors’ schedules.

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Aspirin for Primary CVD Prevention: The Continuing Debate

Kenneth Lin

First published 6/23/11 on the American Family Physician Community Blog

In 2002, the U.S. Preventive Services Task Force (USPSTF) strongly recommended that primary care clinicians discuss preventive aspirin use with adults at increased risk of cardiovascular events. Four years later, the National Commission on Prevention Priorities (NCPP) ranked counseling for aspirin use the number one priority on its list of the most effective clinical preventive services. According to the NCPP, if the percentage of eligible patients using aspirin (then estimated to be about 50 percent) increased to 90 percent, 45,000 additional lives could be extended each year.

At that time, the benefits of aspirin use in men and women were assumed to be the same. However, an updated USPSTF recommendation statement published in the June 15th issue ofAmerican Family Physician indicates that aspirin use actually prevents heart attacks in men, but ischemic strokes in women. In addition, physicians and patients must weigh the benefits of reduced cardiovascular risk with the risk of gastrointestinal bleeding events, and use shared decision making when these risks are closely balanced.

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It’s Time To Stop This [PSA] Screening Nonsense

Kenneth Lin

First published 6/21/11 on Common Sense MD

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

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

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How To Find Good Health Information Online

Kenneth Lin

First published 6/10/11 on the Healthcare Headaches Blog at US News

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

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

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No Easy Victories in Cancer Screening & Prevention

Kenneth Lin

First published 6/7/11 on Common Sense Family Doctor

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

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

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

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Book Review: “Overdiagnosed” and the Paradox of Cancer Survivorship

Kenneth Lin

First published 4/12/11 on Common Sense Family Doctor

According to the National Cancer Institute and the Centers for Disease Control and Prevention, the number of cancer survivors in the U.S. has increased dramatically in my lifetime, from 3 million in 1971 to 11.7 million in 2007. From 2001 to 2007 alone, the number of persons living with a cancer diagnosis rose by nearly two million. Most people would probably see these statistics as good news: an indication that our cancer treatments are improving and allowing people to live longer, or that earlier diagnoses are giving people a better chance to survive by catching localized cancers before they spread and become impossible to cure.

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