U.S. Preventive Services Task Force and Mammography: Evidence-Based Medicine or Medical Rationing?

WELCOME TO MAMMOGATE!

This week, the revised U.S Preventive Services Task Force (USPSTF) mammography guidelines monopolized newsprint and airtime. Was this truly Page 1 news? For a few days, mammojournalism pushed aside stories on the war in Afghanistan, double digit unemployment, Iran’s hidden nukes, the president’s foreign nation tour and the war on terror.

(Note to readers: The phrase ‘war on terror’ is now verboten in the the Obama administration. No spokesmen will utter it, except on deep backround. I unabashedly use it since it seems that our enemies are still at war with us.)

Of course, it’s not the science of mammography that is white hot – it’s the politics of breast cancer that is volatile and combustible. Medical guidelines in every specialty are revised regularly, yet no conflagration erupts in the public square, as occurred last week. When my own specialty revises colonoscopy guidelines every few years, the public and the medical community respond with a collective yawn. Not so for breast cancer,which has lobbyists and political muscle that fights to make sure that their cause remains a national priority. Even mainstream medical organizations and public advocacy groups are in their corner. Maggie Mahar writes at HealthBeat that the initial reaction from many health professionals, breast cancer survivors and advocates has been outrage and anger, with many insisting that women’s health will be compromised if these recommendations are implemented...Leading this onslaught are some key members of the cancer establishment: The American Cancer Society, The American College of Radiology and the National Cancer Institute.

First, the USPSTF was accused of being a tool of medical cost control fanatics. I agree there was bias – from the accusers, not from the USPSTF. The mammogram brigades had an agenda and weren’t going to be derailed by solid medical data. The USPSTF has earned a reputation for objectivity and caution. They do not make recommendations that are beyond the data, despite political pressure to do so. Unlike most medical societies and advocacy groups, they are skeptical and conservative, two qualities that are often lacking in the medical arena. They should be applauded for calling it like they see it. Instead, they are chastised by those who are distressed by their recommendations. However, just because we dispute the outcome, doesn't mean that the system is flawed. For example, if we don’t like a jury’s verdict, does it mean that the trial was unfair?

Preventive medicine is overrated, a heretical statement from a physician who performs screening colonoscopies. While I support mammography and colon cancer screening, their medical benefits are much more modest than the public realizes. With respect to mammography, the data demonstrating meaningful benefit to women, particularly those under 50, have always shown relatively small gains for them. This test is often portrated as a lifesaver, but this is an exaggeration. Yet, there is a juggernaut of support for annual exams behind it.

What about the downsides of yearly mammograms for average risk women in their 40s? In addition to the test’s limited efficacy in this group, here are some real concerns from overuse.

• Radiation


• Anxiety for patients and families
  
• False postive results which lead to invasive medical care
  
• Detecting cancers that may never progress.
  
  

Of course, cost is also a factor, even though the USPSTF is prohibited from considering it in their deliberations. Where is the data that yearly mammograms in younger women are cost effective? This is analogous to the PSA test in men for prostate cancer. How many men are harmed by the PSA in order to save a single life? You cannot argue that saving a life is worth any cost, as this is not how our society operates. We all know that if we lowered the highway speed limit to 40 mph, or raised the driving age to 25, that we would save lives. Yet, we do not demand these revisions. We accept low risks of catastrophic events in our daily lives.

The USPSTF revisions are being co-opted by the political right as a prelude to medical rationing. I reject this broadside, just as I do the protests from the medical left, whose enthusiasm for mammography exceeds the evidence. If rationing means that every American cannot have every available medical benefit on demand, than I am a rationer. Of course, we all know that loaded terms like rationing are routinely sanitized to make them more palatable, even if their meaning doesn’t change. Here are a few sanitization examples.

New & Improved Sanitized Descriptions

Global War on Terror morphs to Overseas Contingency Operation

Medical Rationing is scrubbed to Evidenced Based Medicine

Whistleblower is buffed into Truth-teller

Interestingly, Kathleen Sebelius, Secretary of the Department of Health and Human Services, is sprinting at top speed away from the new USPSTF guidelines. I hope she doesn’t collapse from exhaustion. I am troubled by her retreat, as are fellow medical bloggers Medrants and The Covert Rationing Blog. The Obama administration is devoting over $1 billion dollars to fund comparative effectiveness research (CER), which is supposed to use solid medical data to determine which treatments actually work. Its objective is to eliminate ineffective care, which would result in billions of dollars of cost savings. Now, the USPSTF, appointed by the federal government, has issued solid CER guidelines that our government is rejecting with alacrity and zeal. Anyone want to wager on whether CER has a prayer to succeed? The Health Care Blog notes that our government's revised CER policy is 'not on our watch'.

The USPSTF presently endorses screening colonoscopy between the ages of 50 and 75. In the forseeable future, this guideline will be revised, when new technology replaces this procedure. When this occurs, should I welcome a development that will serve humanity, or grab a pitchfork and a microphone and cry foul. One of the most intractable challenges in health care reform is to separate one’s own interest from the public interest. If there is to be any chance of success, we need to be governed by science and medical evidence. The mammography mania we have just witnessed demonstrates that we are not equal to the task. The public and many physicians are convinced that more medical care means better health, a fallacy that may take at least a decade to unravel. This is the Gordian Knot of health care reform.

Ironically, the American College of Obstetricians and Gynecologists just announced that they think we are doing too many Pap smears. Hmm, first too many mammograms and now Pap smears also? Sounds like a vast GYN conspiracy is in the making.

A ‘Never Event’ In My Own Practice!

I have already opined on the ‘never events’ reform where hospitals would not be compensated for certain medical catastrophes that should never occur. We all agree that performing surgery on the wrong organ, or the wrong patient, should never happen. My fear is that the list of events will metastasize and will include many unfortunate medical outcomes that cannot be avoided by even the most diligent physicians and institutions, a point echoed at The Covert Rationing Blog, and elsewhere. Dr. Val, in a guest post at Health Care Law Blog argues that patient falls in the hospital, while regrettable, should not be a 'never event'. Dr. Wes, a cardiologist, irreverently suggests that the common cold may be added to the 'never events' list!

We bloggers know how easy it is to hurl opinions from our safe sanctuaries. I learned this when I wrote a post about excessive emergency room care. Folks who had never heard of me, an obscure gastroenterologist from Cleveland, were leaving comments on various websites that I hope my mother never saw. While I stand by the post, I realize now that I didn’t sufficiently consider the issue from the emergency room physicians’ vantage point.

Recently, I experienced a ‘never event’ in my own practice. I am no longer a smug blogger who is pontificating from a distance, but I am now a physician who has to explain to a real human being why something happened that never should have occurred.

Was it my fault? I don’t think so. Was I responsible? Of course. I’m the doctor.

Two months ago, an elderly man was referred to me with suspected silent internal bleeding, a medical issue that gastroenterologists commonly address. He was in his 80s and had many medical conditions. He was a very reluctant patient. To the surprise of the referring physician, he actually showed up. I gave him his options:

• Scope examinations of the large intestine (colonoscopy) and the stomach (EGD) to search for a source of the presumed bleeding. These tests are the most accurate, but have risk. He would be advised to stop his blood thinner several days before the test. He was anxious about stopping this medication, even though the risks of briefly interrupting a blood thinner in his case are extremely low.
  
• Radiographic tests of the colon and stomach. No risk, but less accurate. He could continue the blood thinner. These tests require the same cruel, but not unusual, laxative purge as required in colonsocopy. However, if a lesion is discovered on these noninvasive tests, then he may need a colonoscopy and an EGD on another day to remove it. This option is safer, but may result in the fun and excitement of a 2nd colonic cleansing.
  
• Do nothing and take your chances.
  

He agreed to contact me in a few days with his decision. While I would have wagered handsomely that he would have selected option #3, he surprised me. He chose option #2, so I scheduled him for a virtual ‘colonoscopy’, which examines the colon with a CAT scan. He preferred this over colonsocopy because it was safer and he could continue his blood thinner. He understood that if the CAT scan showed an abnormal finding, or wasn’t a high quality study, that he would be offered the ‘enlightening’ experience of a traditional colonoscopy.

Of course, the CAT scan showed a large growth high up in the colon. I related the news to him and then offered a colonoscopy. Now that he knew for certain that he harbored an unwelcome stowaway in his large intestine, this was an offer he could not refuse. For the second time in a month, he endured the liquid-dynamite cleansing agents that we gastroenterologists casually prescribe every day. I performed the colonoscopy and removed the large lesion and submitted it to the pathologist for analysis. The patient was to see me in 2 weeks.

Days later, in advance of his appointment, our office was called as the specimen was not received by the pathology department. No need to panic yet. This was likely a clerical oversight that would soon be rectified. Not quite. After several more phone calls, I learned the truth. The nurse had discarded the specimen. Let me restate this in more familiar language. She threw it in the garbage. Why? I’m still not sure. The nurse maintains that she asked what I wanted done with the specimen and she heard me reply, “I didn't need it.” So, she obediently complied and discarded the specimen.

There have been very rare instances when a specimen has been lost, but never has this been a deliberate act. What a colossal misunderstanding! Though I cannot recall my precise words to the nurse, I am sure that I wasn't talking trash.

I was shocked at this occurrence, which should have never occurred. I have removed thousands of colon polyps and every single one of them has been sent for analysis. We never discard a specimen. The nurse should not have deviated from an unbroken pattern of medical practice. Clearly, there was a complete disconnect between her inquiry and my response. I should be relieved that she didn’t ask if we should amputate his left leg. What if I nodded ‘yes’? Would she have taken out a chainsaw?

The patient and his wife returned and I disclosed what occurred. I apologized for the event and told him that the hospital was thoroughly investigating the event to assure that such an error will never happen again. I told him that the lesion appeared benign to my eye, but I couldn’t guarantee this, or that it was completely excised. I told him that another colonoscopy in a few months was advisable. He agreed to return to see me in the office 2 months later.

I saw him last week and scheduled him for another colonoscopy. As a precaution, I will be accompanied by a retinue of trained SWAT personnel to secure the site and guarantee that the chain of polyp custody will be seamless. Should I hire a Brink's truck?

Tort Reform for Lawyers!

The law has many privileges and protections for its own players that are necessary for the legal process to operate effectively. For example, we all accept that a judge should have absolute legal immunity for decisions and judgments made in his judicial capacity. If a judge could be sued because he ruled that certain evidence was inadmissible, for example, then the system would collapse. Immunity allows judges to decide legal issues freely, without any threat that he could be legally vulnerable. This is how it should be.

Earlier this week, the U.S. Supreme Court heard oral arugments that challenge legal immunity for prosecutors, under certain circumstances. As an aside, I learned an astonishing fact in the New York Times article that reported that …prosecutors cannot be sued for anything they do during trial, including knowingly submitting false evidence. Read this sentence again. I had to as I was sure I had misread it initially. Immunity for trial conduct was not the issue being argued before the Supreme Court this week. The case at bar was whether prosecutorial misconduct prior to trial should be protected also. Two Iowan prisoners, freed by the Iowa Supreme Court, are now suing two prosecutors for fabricating evidence against them and tainting witnesses before trial. A lower court ruled that their case could proceed. The prosecutors, who are now defendants, argue that their pre-trial activities are beyond the reach of the law and fall under the immunity umbrella.

We should be cautious before expressing outrage and demanding that lawyers’ immunity be stripped. If attorneys were vulnerable, then this could invite frivolous lawsuits against them by litigants who are dissatisfied with the outcome of their case.

Frivolous lawsuits? This phrase sounds familiar. Any physician who still has a pulse will develop a rapid heart beat just on hearing the term. While the medical profession isn’t the sole target of FLs, we have a rich and unwelcome experience with them.

The Supreme Court case is examining a concept that could relate to the medical malpractice quagmire. The reason that judges and lawyers are shielded is so they are free of extraneous distractions and fear of lawsuits. Immunity improves their judicial performance. Why should physicians be vulnerable for acts and judgments made during our official professional capacities? If physicians functioned with immunity, wouldn’t our performance improve? Why doesn't the immunity argument apply to the medical profession?

Of course, if physicians enjoyed the same immunity as our legal colleagues, we would need another mechanism to compensate injured patients. I’m open to suggestions. Although nearly any system would be better than the current one, there is no consensus on how to proceed. Tort reform is a volatile issue in the public square and in the blogosphere. Spirited and strident blog posts appear daily. Just this week EverythingHealth listed various factors that fuel medical malpractice litigation, but omitted medical negligence from the list. Shouldn't medical malpractice be the sole reason for a lawsuit? KevinMD opines in his usual measured manner, that the current tort system must be reformed, not for physicians' sakes, but for patients' sakes. On the other side of the issue, a Huffington Post blogger argues that tort reform advocates are self-serving disseminators of myths and misinformation. (Yes, the Whistleblower did comment on the sight.)

We can’t sue a teacher because little Johnny received a C- on his history test. We can’t sue a basketball coach because the team lost the championship. We can’t sue our congressman because he voted against our district’s interest. We can’t sue an army general because the military strategy failed. But, we can sue a doctor who has done his job in good faith.

Those who deride my reasoning will present arguments why we physicians are somehow different from other professions who are immune for their official conduct. Let’s see what they come up with. No matter how outrageous their arguments are, I guarantee them complete immunity. The Whistleblower is their sanctuary.

Where Have All the Bedside Manners Gone?

St. Anthony plagued by demons. 15th century work.

I read a thoughtful post at See First entitled, What Really Matters. The blog’s name, See First, is taken from a quote from Sir William Osler, one of medicine’s greatest luminaries who emphasized the importance of learning medicine at the beside. The post is a plea for physicians to strive to achieve caring and compassionate bedside manners. It emphasizes the importance of attentiveness, communication and empathy with patients. Though it is not stated, the author clearly understands that the doctor-patient relationship is the essential element of the healing art. While every physician knows this, we still need to be reminded of this truth, from time to time.

I commented on his blog that the piece was spot on. I agree unreservedly that patients deserve compassion and caring from their physicians. They deserve appointments without bleating pagers and phone calls. They deserve eye contact. They deserve an opportunity to say 3 or 4 sentences without interruption. They deserve enough time to get their point across. They deserve to be heard. They deserve a doctor who is focused solely on their medical interests, without extraneous distractions.

Although patients deserve all of this, they don’t always get it. Why are today’s bedside manners often less robust than they should be? I offer no excuses, but there are explanations for patients to be aware of.

There are many forces swirling in physicians’ minds today that distract us and threaten our doctor-patient relationships. We try to muffle these demons that are whispering in our ears. We try to compartmentalize them and stifle their interference, but we are members of the human species. Sometimes, they win and we fail. When you visit your physician, here are a few distractions that he won’t mention or record in your medical chart.

• Physicians are working harder each year for less money.



• Physicians battle insurance companies every day to receive money we have already earned.



• Physicians are demoralized by an unfair medical malpractice system.



• Private practice physicians are being driven out by corporate medicine.



• Employed physicians have limited professional autonomy and must genuflect to administrators and bean-counting bureaucrats.



• Medical practices in private medicine have all the stresses and challenges of running a business - payroll, inventory, staffing, overhead and unexpected crises.



• Physicians must plow through mounds of ridiculous paperwork every day.



• Physicians are required to participate in government and insurance company quality programs that have no effect on medical quality, but cost us money and time.



• Health care reform may proceed at the expense of the medical profession.

Despite these distractions, physicians should provide patients with the care and attention they deserve, even though this task is harder than ever. Ironically, we physicians increasingly feel that no one is giving us care and attention. We’re not getting it from the government. We’re not getting it from the insurance companies. We're not getting it from the press. We're certainly not getting it from the legal community. Our patients may be our last best hope for showing us some understanding. This gesture would revitalize us and shake off the demons. Then, we could try a little harder to give you Marcus Welby, M.D. instead of Dr. Gregory House.

Tort Reform vs Defensive Medicine: Place Your Bets!

In my 20 years of medical practice, no issue provokes more physician angst than the unfair medical malpractice situation we physicians endure. It is the wound that will not heal. Physicians pursue one primary strategy to protect ourselves at the expense of our patients and society; we practice defensive medicine. Defensive medicine is omnipresent and burns up billions of health care dollars that we need so desperately.

Defensive medicine, I strongly believe, is practiced by nearly every physician in the country. If you suspect that this is hyperbole, ask your own doctor, although you may find him defensive about the subject. It’s not actual lawsuits that are suffocating doctors; it’s the fear of of being sued. The aura of litigation hovers in your doctor’s office during your office visits. It's like carbon monoxide. You can't see it or smell it. But, it is real and it is potent.

Attorneys and others reject our defensive posture. They argue that we should simply perform tests and treatments that are medically necessary. Good medicine, they claim, will protect us. Their truth, however, will not set us free. A physician who has a dagger raised above his head cannot ignore this threat when advising patients. ‘Good medicine’ won’t stop a case from being filed against an innocent doctor. A system that can ensnare an innocent physician for months or years is patently defective. We practice defensively as a filter to keep us out of the medical arena in the first place. If we are ultimately released after discovery and depositions, from a case that should never have involved us, we don't agree that our belated dismissal is evidence that the system is working.

Casey Fiano at American Issues Project blames avaricious trial lawyers for forcing physicians to become diagnostic testing machines. I don’t. While I agree that many trial lawyers have lost sight of the noble mission of their profession, they are operating within a corrupt, but legal system. We need new rules. If football games had no rules or referees, then every game would become a melee. Would this be the players’ fault?

Overlawyered points out that many unnecessary hospitalizations result from physicians who want to minimize their legal risk. Do patients want this? Ironically, a hospital, a big building stuffed with germs, should be the last place that any patient wants to spend a weekend. Of course, once in the hospital, defensive medicine goes ‘viral’, as consultants carve you up according to their organ of interest.

WeStandFirm points out that none of the players supports defensive medicine. The ordering physicians don't like it. The radiologists reading these unnecessary scans don't like. Insurance companies don't like it. Patients don't like it. Yet, we physicians practice it every day.

Happy Hospitalist summarizes the situation with simple elegance. Rarely will a patient get only what they need to make the diagnosis. They get far more than is necessary. You can call it good medicine. I call it fear.

I remember our athletic coaches who always emphasized how important defense was. Defense wins ballgames is still a classic sports maxim. This strategy, however, is wrong for doctors. Medicine should not be a contact sport. When defensive medicine triumphs, then patients lose. Does the public want a system that forces physicians to order tests and medical care that it doesn't need? Tort reform, while imperfect, can help heal the wound that harms patients, incinerates a fortune of money and abuses the medical profession. Aren't these 3 defects worthy of reform?

Breaking News! Tort Reform Decreases Defensive Medicine.

Which doctors practice defensive medicine? Only those who are breathing. The president, however, wasn’t convinced of this reality when he spoke to the nation on September 9th at a joint session of Congress.

“I don’t believe malpractice reform is a silver bullet, but I have talked to enough doctors to know that defensive medicine may be contributing to unnecessary costs.”

May be contributing? Mr. President, if I may, in the gray and nebulous world of medicine, one truth is certain; defensive medicine cost billions of health care dollars every year. Physicians hold this truth to be self evident.

One month after the president’s speech, the non-partisan Congressional Budget Office (CBO) issued a report that reversed it’s own prior conclusions on the value of tort reform. It now states that tort reform could reduce “the use of diagnostic tests and other health care services when providers recommend those services principally to reduce their potential exposure to lawsuits.” The report also notes evidence that lower medical malpractice costs results in lower Medicare health care medical services. Shocking conclusions.

I wonder how many tax dollars were spent on these studies whose conclusions were already known in the guts of every practicing physician in the country. Aren’t we supposed to conduct studies when we are uncertain of the outcome? What’s next? A study to determine if the elderly will outlive their children?

CBO extimates that tort reform would reduce health care costs by 0.5% annually (0.2% from lower medical malpractice premiums and 0.3% in less defensive medicine expenses), saving $11 billion in 2009. In fairness to these low estimates, the report points out that some of savings have already occurred from state tort reform programs. Over the next decade, CBO estimates that tort reform would result in $54 billion in savings.

CBO included typical tort reform features in its analysis. Among them is the fair-share rule, which would replace joint-and-several liability. ‘Fair-share’ means that a defendant would only be responsible for damages in proportion to his liability. In other words, if a physician or a hospital was 2% responsible for the injury, then they would not be at risk for all of the damages. Wow, what a progressive concept! Imagine being responsible only for your share of the injury. Still think we don’t need tort reform?

What do trial attorneys think? Wayne Parsons, a Honolulu attorney, writes at InjuryBoard that CBO extimates of cost savings from tort reform are inaccurate. I agree, but unlike Wayne, I think the CBO has underestimated the savings we would realize. In addition, he believes that insurance companies are the villains, not trial attorneys. The folks at PopTort share findings from a Center for Justice & Democracy report which argues that tort reform may actually increase medical costs. They support repealing all existing tort reform legislation. Let's hope their wacky view is not contagious.

While I am not an economist, I suspect that CBO estimates are far too low. How can you quantify the costs of defensive medicine? While it is easy to define defensive medicine in a blog post, it’s a murky issue in the real world. When physicians defensively order specialty consultations, CAT scans, emergency room visits after hours, we always provide medical justification. You can study every medical chart in the country, and you will never the following notation: MRI ordered for defensive purposes. Since the bulk of defensive testing is deeply camouflaged, how can we estimate its cost?

I don’t even think that we physicians always know if our tests are defensive as there is often a combination of medical necessity and litigation fear present.

Estimates of defensive medical costs are further hampered because they are not one time expenses. As every physician knows, an unnecessary CAT scan lights the fuse for a medical cascade when the initial scan shows trivial and irrelevant ‘abnormalities’ that lead to more scans and specialty consultations.

I wonder what the next CBO report will show? While their current estimates of the costs of defensive medicine are low, at least they’ve admitted their existence and significance. Will the president now issue a more definitive statement on this issue to clarify his limp remark in his health care speech? If the president pushed for fair tort reform, he would earn a durable peace with the medical community. Imagine, two peace prizes in one year.

Is Health Care a Right?

The U.S. Supreme Court has opined that we cannot falsely scream Fire! in a crowded theater, despite our sacrosanct right of free speech. Even sacred rights have limits. When individual rights collide with societal rights, then each side’s arguments must be weighed to determine whose rights will prevail. This is not a clean or satisfying process as each claimant brings passion and legitimate arguments to the table.

I have been involved in a cyber colloquy with Maggie Mahar at Health Beat discussing if health care is a right. Maggie is well known in health care circles and examines health care policy from a liberal perspective. She’s on the left and I’m not. I hesitate to define health care is an absolute right before considering some of the broader ethical ramifications.

• Is health care a human right?


• Is health care a constitutional right?


• Is health care a privilege?


• Is health care a commodity to be purchased at the discretion of the consumer?


• Is health care a responsibility?

A laudable position is that every American has a right to health care. While this slogan sounds noble, what does it really mean? Does it mean that every citizen has a right to every available medical benefit? Or, would every American have a right to a basic package of medical benefits? Who would define these scaled down benefit packages? If someone with the guaranteed ‘no frills’ plan needed chemotherapy or a bone marrow transplant, which are not covered benefits, would we be prepared to act as the infamous ‘death panels’, recently vocalized by several conservative commentators?

My hesitancy in declaring a health care a right it that it ignores the necessary elements of personal responsibility and societal rights. While there is a potent moral argument that we provide every citizen with decent health care, this must be balanced against society’s interest in a system that allocates health care resources fairly. Here are some hypothetical issues to consider.

• If health care is a natural right, then, are illegal aliens entitled to it as a basic human right? If not, then what is our response when they develop chronic illnesses, which cannot be effectively treated in emergency departments?
• Do irresponsible or reckless individuals have an absolute right to health care? Is it fair to the rest of us to pay for health care for those who pursue a riskier lifestyle? Does a man with multiple DUI citations, for example, have the same right to health care as a practicing nun?
• Should individuals who won’t take cardiac medications that they can afford, or see their physicians when advised to do so, have a right for emergency treatment for a heart attack at our expense?
• If health care is truly a right, then should it be illegal for any citizen in America to not have medical coverage? If this were the case now, then who would be legally liable for the 46 million uninsured?
• Can folks waive their right to health care, as the Amish community now does? Who pays when this individual needs emergency surgery?

These are very delicate issues that torment folks on all sides of the political spectrum. The Nation, an organization on the far left and the more moderate newspaper USA Today, both agree that health care is a right. The Foundry, Crystal Clear Conservative and KevinMD have reached a different conclusion. It is an enormous challenge to establish a stable equilibrium balancing society’s rights, human compassion, personal rights, medical ethics and fiscal realities. I can’t solve it, but I know that the proclamation health care is a right is a quixotic mantra that fails to appreciate the enormous complexity of the issue. If rights were so easy to establish, then we wouldn't need a judiciary.

It is possible that the Supreme Court may hear this case. While this gang of nine are the last word on determining rights, this doesn't mean they will get it right.