Monday, December 11, 2017

As hospitals downsize, what will replace them?

Last week, I rounded on patients at Providence Hospital as the attending physician on the Family Medicine residency program's inpatient service. Providence recently closed its maternity ward as the first step in a planned redevelopment of the hospital grounds into a "health village." In the short term, the hospital's decision to stop delivering babies may worsen maternal health disparities, as the entire eastern side of Washington, DC is now a "maternity care desert" with no labor and delivery services. In Providence's defense, it lost $23 million in fiscal year 2016, and its long-term plan to replace hospital beds with ambulatory services and spaces that support community health and wellness is part of a broader national trend. As Dr. Neel Shah wrote recently in Politico's "The Case Against Hospital Beds":

Some corners of the health care world are already starting to embrace new, less bed-focused models of care. ... [At a] venture-capital based birthing center franchise, birthing families are often admitted and discharged on the same day, and beds are in the corner of the room (for resting and breastfeeding after the baby is born), rather than in the center; the idea is to encourage the mom to use movement as much as possible to support her labor by literally sidelining the bed. Health systems are increasingly investing in other types of spaces where bedrest is not the default, including skilled nursing and rehabilitation facilities, as well as home visiting nurses and health coaches to help high-need patients with acute and chronic conditions stay out of the hospital.

Before the hospital building boom that began after World War II, most acutely ill persons were cared for at home by family members with the help of visiting physicians. Emerging technology may enable this historical arrangement to become the future of health care. A recent JAMA Viewpoint argued that the expansion of telehealth and virtual care capabilities means that it's time to start training and credentialing a new physician specialty called the "medical virtualist," who would possess specific expertise in providing remote care the way a hospitalist possesses expertise in hospital care. (I'm not sold on this idea, as studies continue to show that primary care physicians who care for their own patients in the hospital have as good or better outcomes than do hospitalists.) In "A Hospital Without Patients," Arthur Allen described the Mercy Virtual Care Center, where teams of doctors and nurses use wireless devices to remotely monitor homebound patients around the clock and act as consultants in intensive care units in faraway hospitals:

For now, the future looks like this: Hospitals will keep doing things like deliveries, appendectomies and sewing up the victims of shootings and car wrecks. They’ll also have to care for people with diseases like diabetes, heart failure and cancer when they take bad turns. But in the future, the mission of the hospital will be to keep patients from coming through their doors in the first place.

For a family physician with a natural orientation toward prevention and public health, this is certainly an appealing vision. As the years have passed, I find myself enjoying my time at the hospital less and less, mostly because most of the patients on my service wouldn't need to be there if outpatient health and social services simply worked better. So many admissions could have been avoided if primary care clinicians were able to easily check on patients in their homes and intervene early on in flares of chronic obstructive pulmonary disease or congestive heart failure. If my homeless patient didn't have to wait months for housing; if my uninsured patient with diabetes didn't have to choose between buying insulin and glucose monitoring supplies; if my debilitated patient with Medicare could be transferred directly to a rehabilitation center rather than needing a hospital stay first.

There should be plenty of dollars available to redirect into prevention as hospitals downsize. Since 2014, Maryland has piloted a successful statewide experiment in giving hospitals financial incentives to keep patients well (and beds empty), overriding the traditional goal of keeping beds full to maximize revenue. The ever-present danger is that savings from hospital downsizing will go to pad executive salaries rather than flowing back into the community, as seems to be occurring at the fabulously wealthy "nonprofit" Mayo Clinic system.

Perhaps the future will see Providence Hospital's shuttered maternity ward replaced by a modern birthing center and comprehensive prenatal and postpartum care enhanced by telehealth services. Or today's maternity care desert could remain just that: a desert, where minority mothers continue to suffer pregnancy complications and deaths at appalling rates. In my view, the role of policymakers should be to encourage a health care environment that makes it easy for hospitals and health systems to do the right thing.

Thursday, December 7, 2017

Why don't doctors discuss cancer screening harms?

A few years ago, I attended a conference that included an exercise where attendees were asked how many patients they thought it was acceptable to diagnose and treat needlessly ("overtreat") in order to prevent one death from cancer. We stood at various points along a wall that represented different thresholds: at one end, 100 persons overtreated for every 1 life saved; at the other, 1 person overtreated for every 1 life saved. Not surprisingly, attendees held a wide range of opinions (I stood somewhere in the middle), but the exercise illustrated the tradeoff inherent in effective screening tests for breast, colorectal, and cervical cancer: for every person who benefits from screening, others will be harmed. This fact has led many physicians to advocate that shared decision-making be used more widely to integrate patients' preferences and values with the decision to accept or decline a screening test.

How often do physicians take the time to explain the harms of cancer screening to their patients? A 2013 research letter published in JAMA Internal Medicine explored this question in an online survey of 317 U.S. adults between 50 and 69 years of age. 83 percent of participants had attended at least 1 routine cancer screening; 27 percent had undergone 3 or more. However, less than 10 percent of participants had ever been informed by their physicians of the risk that the screening test(s) could lead to overdiagnosis and overtreatment. The few physicians who did attempt to quantify this risk generally provided information that was inconsistent with the medical literature.

If the results of this survey are representative of the practices of U.S. primary care clinicians, then more than 90 percent aren't telling patients that there are downsides to undergoing routine mammograms, colonoscopies, and Pap smears. Why not? Is it because they aren't familiar enough with the data to accurately describe these harms? Or is it because they fear that patients who receive information about cancer screening harms will choose to decline these tests?

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This post originally appeared on Common Sense Family Doctor on November 3, 2013.

Sunday, November 26, 2017

My favorite public health and health care books of 2017

With some extra free time this Thanksgiving weekend, I'm getting to my top 10 books list a bit earlier than in past years. I suppose that it's possible I will read a great book in December that would have made the cut - if so, I'll post its own review or include it in next year's list. As I did in 2016, I made eligible any health-related book that I read this year, regardless of the year it was published. Interestingly, all but three of these books were authored by physicians, although most of them are no longer actively seeing patients.

Books are listed in alphabetical order rather than order of preference/enjoyment.

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1. An American Sickness: How Healthcare Became Big Business and How You Can Take It Back, by Elisabeth Rosenthal

2. Banker to the Poor: Micro-lending and the Battle Against World Poverty, by Muhammad Yunus

4. Dreamland: the True Tale of America's Opiate Epidemic, by Sam Quinones


5. The Health Gap: The Challenge of an Unequal World, by Michael Marmot
6. Hillbilly Elegy: A Memoir of a Family and Culture in Crisis, by J.D. Vance

7. Inferno: A Doctor's Ebola Story, by Steven Hatch

8. Look It Up! What Patients, Doctors, Nurses, and Pharmacists Need to Know about the Internet and Primary Health Care, by Pierre Pluye and Roland Grad

9. Saving Normal: An Insider's Revolt Against Out-of-Control Psychiatric Diagnosis, DSM-5, Big Pharma, and the Medicalization of Ordinary Life, by Allen Frances
10. Unanticipated Outcomes: A Medical Memoir, by Jerome Kassirer

Saturday, November 18, 2017

When does it make sense to lower cholesterol with statins?

There has been no shortage of recent guidance on statin use for the primary prevention of cardiovascular disease (CVD). The American College of Cardiology / American Heart Association and the U.S. Preventive Services Task Force (USPSTF) disagree about the appropriate 10-year CVD event risk threshold at which clinicians should recommend statins - 7.5% and 10%, respectively - but both agree that the benefits significantly outweigh the harms. So what should clinicians make of the Medicine By the Numbers in the Nov. 1 issue of American Family Physician, which gave a Red (no benefits) rating to statins in persons at low (less than 20% 10-year) risk of cardiovascular disease?

Dr. John Abramson calculated the numbers needed to treat (NNT) to benefit and harm based on data from the 2012 Cholesterol Treatment Trialists (CTT) meta-analysis and the USPSTF's 2016 systematic review. Excluding patients with existing cardiovascular disease or a greater than 20% 10-year CVD event risk, the results showed no mortality benefit, but 1 in 217 persons avoided a nonfatal myocardial infarction and 1 in 313 avoided a nonfatal stroke. On the harms side of the scale, 1 in 21 persons experienced pain from muscle damage, and 1 in 204 developed diabetes mellitus as a result of taking statins. Dr. Abramson acknowledged that his conclusion of "no benefit" relied on value judgments about the importance of these harms compared with cardiovascular events prevented:

In summary, studies have found no significant overall mortality benefit with statin therapy in low-risk patients, as well as no reduction in the risk of serious illness overall and very small benefits for nonfatal heart attack and stroke. Statins also appear to cause diabetes. Although this is uncommon, diabetes may occur more often than the prevention of a heart attack or stroke in patients taking statins. ... With no mortality benefit, no reduction in serious illness, an approximately 1% chance of avoiding a nonfatal heart attack or stroke, a similar or greater chance of developing diabetes, and a one in 21 chance of muscle damage, it seems wiser to focus on lifestyle changes (such as adopting a Mediterranean diet, exercising, and not smoking) instead of cholesterol drugs in low-risk patients.

These findings are broadly consistent with a 2011 Cochrane for Clinicians that noted that because "most trials included large numbers of persons with known CVD, ... clear evidence of the effectiveness of statins to prevent a first cardiovascular event is lacking." Other Cochrane reviews have found that statins reduce all-cause mortality in patients with non-dialysis chronic kidney disease, but do not prevent dementia or cognitive decline. A previous AFP article summarized considerations for safe use of statins, which should be part of shared decision making discussions with patients when the benefits and harms are so closely balanced.

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This post first appeared on the AFP Community Blog. And yes, I plan to discuss the new ACC/AHA blood pressure guideline in future posts ...

Tuesday, November 14, 2017

We will not be intimidated

Recent weeks have seen a virtual avalanche of allegations of past harassment or inappropriate sexual behavior by (mostly) male politicians, talk-show hosts, and business executives. Since many of these revelations have come out years or decades later, partisans have been quick to suggest that their stories are politically motivated fabrications. If what happened was so despicable or immoral, they ask, why not come forward earlier? Why wait, for example, until the repeat offender is a in a position to be elected to the U.S. Senate? I'll tell you why in one word: intimidation. For the most part, sexual violence isn't driven by an excess of passion; it's driven by an excess of power. Violators count on a combination of embarrassment, guilt, and intimidation to keep their victims from talking, and more often than not, it works.

Intimidation is often used to injure on a societal level, too. As illustrated in the critically acclaimed film The Insider, the tobacco industry was ruthless in attempting to prevent whistleblower Jeffrey Wigand from revealing that its executives intentionally added substances known to be addictive and carcinogenic to cigarettes. More recently, a group that publicly supported a tax on sugary drinks in Colombia was threatened and censored in the weeks leading up to the vote in the legislature. And Dr. Pieter Cohen, a Massachusetts general internist who writes the Updates in Slow Medicine e-newsletter, was hit with a $200 million libel lawsuit by a supplement company after publishing a scientific paper that demonstrated the presence of a designer stimulant in its product. Dr. Cohen (whose lawsuit was eventually dismissed by a jury after a week-long federal trial) and colleagues wrote recently in JAMA Internal Medicine:

When lawsuits target scientists, it does not matter that plaintiffs almost never win. It does not even matter if the case goes to trial. The goal is to intimidate. In the lawsuit over dietary supplements, for example, the head of the company who brought the suit openly admitted that he was “hoping that we were able to silence this guy,” as well as other researchers who might raise questions about the supplement industry. The most frivolous lawsuit can generate substantial legal costs, distract scientists from research, force the indiscriminate disclosure of laboratory notebooks and emails, and create unnecessary stress for colleagues and families.

On August 13, 2013, after reading a blog post where I called his company "unscrupulous" based on its aggressive efforts to sell packages of non-recommended and potentially harmful tests to vulnerable elders at health fairs and churches, the chief medical officer of Life Line Screening mailed me a letter that called my characterization "potentially libelous and actionable" and copied their in-house legal counsel. After a lengthy defense of the technical accuracy of their testing process (which I have never questioned - my problem is that these tests are unnecessary and do not improve patients' health!), he went on to write: "You and I can disagree, but you do not have the right to attack our reputation, our passion for helping people, or the integrity of our team." I subsequently forwarded this letter to my department Chair, who forwarded it to my employer's legal counsel, who concluded that the probability of a libel lawsuit was low, and that of a successful lawsuit virtually nil. Nonetheless, it was enough to scare me into remaining silent for the next 4 years.

Dear Life Line Screening, I am not attacking your company's integrity. I am sure that the vast majority of your employees are passionate about helping people (why else work for a company named "Life Line"?) But the tests you portray to potential customers - like the retired ladies in the next pew at my church who live off fixed incomes - as bargains, however CLIA-certifiably accurate, are ineffective or, like screening for carotid artery stenosis, actually do more harm than good. And I will no longer be intimidated by you or anyone else from saying so.

Tuesday, November 7, 2017

Artificial intelligence will not make family physicians obsolete

Last week, I was speaking on the phone with Dr. Roland Grad, a family physician at McGill University and co-author of the new book "Look It Up! What Patients, Doctors, Nurses, and Pharmacists Need to Know about the Internet and Primary Health Care." We were discussing the (to us, preposterous) notion that there would be no future for primary care physicians because we will all be replaced by cognitive computing / artificial intelligence (AI) systems such as IBM's Watson. Roland told me that whenever someone asks him about this, he points out that Star Trek clearly shows that there will be human doctors well into the 24th century. Even the holographic Doctor on the U.S.S. Voyager is only pressed into service after the entire human medical staff is killed in an accident.

Many of the prospective medical students I interview have asked me about how AI will influence how I practice family medicine in the future. A recent Perspective on machine learning in the New England Journal of Medicine asserted that "the complexity of medicine now exceeds the capacity of the human mind." The authors argued that since doctors can no longer keep all relevant medical knowledge in their heads, and "every patient is now a 'big data' challenge," we will soon need to rely on massive computer-generated algorithms to avoid diagnostic and treatment paralysis.

It's no surprise that neither author of this piece is a family physician. Since I began my residency 16 years ago, and well before that, I knew that no matter how much I learned, it wouldn't be possible to keep everything I needed in my head. I never had to. In medical school I carried around a variety of pocket-sized print references, and in residency and clinical practice I had several generations of Palm Pilots and, eventually, smartphones that allowed me to look up what I didn't know or couldn't recall. The same goes for keeping up with the medical literature. Although I regularly read more journals than the average generalist (nine*), I know that there's no way that I can possibly read, much less critically appraise, every new primary care-relevant study. Drs. David Slawson and Allen Shaughnessy have argued that rather than pursue that hopeless (even for a super-subspecialist) task, clinicians should be taught information management skills, which consist of foraging (selecting tools that filter information for relevance and validity); hunting ("just in time" information tools for use at the point of care), and "combining the best patient-oriented evidence with patient-centered care."

And although Watson and its AI predecessors have made short work of the previously invincible Ken Jennings on Jeopardy! and vanquished world chess champions with ease, it is having a much harder time cracking medicine. Although IBM started selling Watson for Oncology as a "revolution in cancer care" to hospital systems worldwide in 2014 and has spent millions of dollars lobbying Congress to exempt its software from FDA regulation, a STAT investigation found that the system has fallen far short of its hype:

At its heart, Watson for Oncology uses the cloud-based supercomputer to digest massive amounts of data - from doctor's notes to medical studies to clinical guidelines. But its treatment recommendations are not based on its own insights from these data. Instead, they are based exclusively on training by human overseers, who laboriously feed Watson information about how patients with specific characteristics should be treated.

AI will no doubt play a supporting role in the future of health care, alongside smartphone physicals and precision medicine and many other promising innovations borrowed from other industries. But based on past experience, I'm not convinced that any of these innovations will be as revolutionary as advertised. In my own career, doctors have gone from using paper charts that were time-consuming to maintain and couldn't communicate with each other to electronic health records that are even more time-consuming to maintain and still can't communicate with each other. You get my point. Even if IBM or some other tech company eventually harnesses AI to improve primary care practice, here's what Roland and his colleagues have to say in Look It Up!:

Some might wonder whether this new automated world of information will create a medical world that is dominated by artificial intelligence, where doctors - if we even need them anymore - will just repeat what the machines say. On the contrary, as more information becomes readily available, doctors, nurses, pharmacists, and allied health professionals will become more important as the interpreters of that information in accordance with the specific clinical and social history, values, and preferences of the patient and her or his family. 

Right. I couldn't have said it better myself.


* - American Family Physician, Annals of Family Medicine, Annals of Internal Medicine, Health Affairs, JAMA, JAMA Internal Medicine, Journal of the American Board of Family Medicine, Journal of Family Practice, New England Journal of Medicine