American College of Physicians Breast Cancer Screening Guidance

The American College of Physicians released four guidance statements on detection of breast cancer in women with average risk and no symptoms of breast cancer.

  1. Doctors should discuss with their patients the pros and cons of screening with mammography for breast cancer in asymptomatic women with a modest risk of disease between ages 40- 49 years. The potential risks of screening are felt to outweigh the benefits.
  2. Clinicians should screen average risk women aged 50-74 years for breast cancer with mammography every other year.
  3. Clinicians should discontinue breast cancer screening in women aged 75 years or greater with an average risk of breast cancer and a life expectancy of 10 years or less.
  4. Clinical breast examinations SHOULD NOT be used to screen for breast cancer of average risk women of all ages.

These guidance statements DO NOT APPLY to women with a higher risk of breast cancers including those with abnormal screening results in the past, a personal history of breast cancer or a mutation in the BRCA1 or BRCA2 gene.

At the same meeting, data was presented discussing the problems with supplemental whole breast ultrasound in women with dense breasts.  The concern is that all this testing leads to invasive biopsies, over diagnosis and treatment of breast cancer in 1 in 5 patients and complications and increased cost to patients and insurers.  Like most recommendations on breast cancer, and prostate cancer in men, the results and conclusions from following these guidelines will not be apparent until 10 to 15 years from now.

Today’s adult women will either benefit from these suggestions, which have even included no longer teaching adult women how to perform breast self-exam, or they will be the unsuspecting research victims of cost containment. I question the competence of physicians in examining problematic breast disease if they are not being trained how to evaluate a breast and following that with clinical exams. In surgery we usually do not feel a clinician is competent and fully aware of the pitfalls of a procedure until the surgeon has done 200 or more. We additionally know that doing the procedure frequently results in better results than performing a procedure infrequently.

How will that apply if young physicians no longer examine breasts routinely?  How many, and how often, will they need to do an adequate exam to be able to perform when there is a real issue?  Do we actually wish to create a narrow panel of breast experts only at Centers of Excellence who actually know how to examine a breast and use the available imaging modalities safely and effectively?  It seems these ACP recommendations move in that direction.

For several years now I have been a supporter and champion of our community’s Women’s’ Center associated with Boca Raton Regional Hospital. Run by astute future thinking clinicians and researchers, and stocked with state of the art imaging equipment, it provides an option to meet with a counselor, assess your breast cancer risk and enter a screening pathway most individually suited to your personalized needs.  I will continue to support that choice.

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Lack of Vaccination Coverage in the Medical Office

This week a patient, going on a foreign trip, was required to fill out a vaccination and immunization record to obtain a visa. To his dismay he discovered his records were not available. On further questioning he realized his vaccinations were done at retail clinics and pharmacies up and down the Eastern seaboard. Yes, he had requested a record of the vaccination be sent to the office but it never arrived.

I am a firm believer in the recommendation of the CDC, American College of Physicians and Advisory Council on Immunization Practices. Their literature is displayed in my office and available as a resource to my patients. I find it abhorrent that CMS, through its Medicare Part D program, will pay for the shingles shots (Zostavax and Shingrix) and the pneumonia series (Prevnar 13 and Pneumovax 23) at the pharmacy but not at a doctor’s office. The pharmacies use these vaccinations as loss leaders to get individuals into the store hoping that they will buy additional items while there.

As a general internist and practitioner of adult medicine, I too use these vaccinations as a “loss leader.” When patients call for a vaccination and have not been seen in a long while we encourage an appointment. We check on prevention items recommended by the ACP. the AAFP and the USPTF and make sure the patients are current on mammograms, HPV or Pap testing, colonoscopies, eye exams, hearing evaluations, skin and body checkups and other essential health items. We make little or no money on vaccinations or immunizations but like the idea that once a patient is here we can provide a gentle reminder about those health tasks we all need to follow up on with some regularity.

I like the idea of making vaccinations and immunizations more convenient for patients. I just believe the same payment should be made if the patient is in your office or in the pharmacy. In addition, the law should require the pharmacy to send a record of the vaccination to the patient’s physician so we can have immunization records readily available.

The ACP, AMA, American College of Physicians and American Academy of Family Practitioners should be using their influence to encourage the Center for Medicare Services (CMS) to pay for these vaccines in doctors’ offices as well as in pharmacies and retail clinics. If encouragement doesn’t work then legal action is appropriate.

CDC and ACP: Stop Prescribing Antibiotics for Common Respiratory Infections

The Affordable Health Care Act has created patient satisfaction surveys which can affect a physician’s reimbursement for services rendered plus their actual employment by large insurers and health care systems. This has created a fear of not giving patients something or something they want at visits for colds, sore throats and other viral illnesses. Aaron M Harris, MD, MPH, an internist and epidemiologist with the CDC noted that antibiotics are prescribed at 100 million ambulatory visits annually and 41% of these prescriptions are for respiratory conditions. The unnecessary use of antibiotics has resulted in an increasing number of bacteria developing resistance to common antibiotics and to a surge in Emergency Department visits for adverse effects of these medications plus the development of antibiotic related colitis. To address the issue of overuse of antibiotics, Dr Harris and associates conducted a literature review of evidence based data on the use of antibiotics and its effects and presented guidelines for antibiotic use endorsed by the American College of Physicians and the Center for Disease Control.

  1. Physicians should not prescribe antibiotics for patients with uncomplicated bronchitis unless they suspect pneumonia are present”. Acute bronchitis is among the e most common adult outpatient diagnoses, with about 100 million ambulatory care visits in the US per year, more than 70% of which result in a prescription for antibiotics.” The authors suggested using cough suppressants, expectorants, first generation antihistamines, and decongestants for symptom relief.
  2. Patients who have a sore throat (pharyngitis) should only receive an antibiotic if they have confirmed group A streptococcal pharyngitis. Harris group estimates that antibiotics for adult sore throats are needed less than 2% of the time but are prescribed at most outpatient visits for pharyngitis. Physicians say it is quicker and easier to write a prescription than it is to explain to the patient why they do not need an antibiotic.
  3. Sinusitis and the common cold result in overprescribing and unnecessary use of antibiotics often. Over four million adults are diagnosed with sinusitis annually and more than 80% of their ambulatory visits result in the prescribing of an antibiotic unnecessarily. “ Treatment with antibiotics should be reserved for patients with acute rhinosinusitis who have persistent symptoms for more than ten days, nasal discharge or facial pain that lasts more than 3 consecutive days and signs of high fever with onset of severe symptoms. They also suggest patients who had a simple sinusitis or cold that lasted five days and suddenly gets worse (double sickening) qualified for an antibiotic

Last year two patients in the practice who were treated with antibiotics prescribed elsewhere for situations outside the current guidelines developed severe antibiotic related colitis. They presented with fever, severe abdominal pain and persistent watery bloody diarrhea. Usual treatment with oral vancomycin and cholestyramine did not cure the illness. One patient lost thirty pounds, the other sixty pounds. Fecal transplants were required to quell the disease. At the same time community based urine infections now require a change in antibiotic selection because so many of the organisms are now resistant to the less toxic, less expensive , less complicated antibiotics that traditionally worked.

“My doctor always gives me an antibiotic and I know my body and what it needs,” can no longer be the criteria for antibiotic use.

American College of Physicians Rejects “Heart Screening in Adults at Low Risk”

Heart screeningI am often asked by potential new patients, “What do you consider a complete annual checkup?” When I tell them it is a detailed history session reviewing their personal medical history and family history followed by a comprehensive medical physical examination they inquire about testing. We generally perform a urinalysis and a blood panel measuring things such as the blood sugar, the cholesterol and lipid profile, kidney and liver function plus thyroid function. In addition to that we personalize the testing based on the information presented by the patient during the history session and exam. Despite having few risk factors for the development of heart disease, peripheral arterial vascular disease or cerebrovascular disease they ask how often they can have a nuclear stress test, an echocardiogram and imaging of their hearts and blood vessels. When I tell them they probably do not need such testing they tell me about their highly fit and athletic friend with no symptoms who just had a stress test and ended up with a three vessel coronary bypass procedure “saving“ their life.

An article in the Annals of Internal Medicine the American College of Physicians (ACP) supported that position saying that individuals with a Framingham cardiovascular risk assessment of <10% over the next 10 years should not be tested. “These recommendations are based on the lack of evidence showing that screening improves clinical outcomes.” They went on to say that screening has unclear effects on risk reclassification and the use of risk reducing therapies and noted that while abnormalities discovered via resting or exercise EKG were associated with an increased risk of subsequent cardiovascular events, they had no effect on clinical outcomes. According to the authors, “even if a cardiac abnormality is uncovered via screening, the most effective treatment may be adjustments in diet, exercise and other modifiable CHD risk factors that would be recommended regardless of screening results.”

I am frequently asked about the health conscious individual who had the testing and was found surprisingly to have critical disease requiring a lifesaving procedure. The ACP cited a thorough Coronary Artery Surgery Study in which cardiac catheterization on patients with “nonspecific“ or unclear chest pain revealed atherosclerosis in 40% of men and 24% of women, but only 3% of men and 0.6% of women had severe enough disease to benefit from a revascularization procedure.

The ACP paper cited the harm done by screening low risk individuals including excessive radiation exposure and the cost and morbidity of doing additional testing and or procedures to follow up false positive test results. The group stated that a nuclear stress test exposed an individual to an effective radiation dose that is twice the dose of an abdominal CT scan (15.6 mSV) which is the equivalent of ten years’ worth of chest x-ray irradiation. They also projected an increased risk of 2 -25 cancer cases per 10,000 nuclear medicine stress tests in people age 50 or older.

What is clear from the ACP recommendations is that the decision to perform cardiovascular screening should be based on the personal and individual patient history and physical exam findings which indicate a significant possibility of their being cardiac or vascular disease. If in fact the risk is low then testing for the sake of wanting to know causes more problems than solutions.

Small Medical Practices Result in Fewer Hospital Admissions

Quantity-v-QualityThe American College of Physicians and the Affordable Care Act or “Obamacare”, are blatantly trying to make small independent medical practices obsolete. Under a barrage of rules, regulations and requirements all punishable by fines and or a reduction of payment for Medicare payments, the government is herding small practices into selling their practices to large hospital or health care systems. The goal is to provide more complete care in a paperless, seamless system of coordinated care. The American College of Physicians has gone as far as to aggressively push medical practices to become a Patient Centered Medical Home. This is all being done at the expense of mom and pop practices that have long term relationships with their patients but lack the resources to build and maintain the infrastructure that government and insurers demand from health care providers today.

It must have come as quite a shock to the ACP and the Center for Medicare Services (CMS) when a study published in Health Affairs and reviewed in the 08/21/2014 MedPage Today discussed a survey which showed that smaller primary care practices with fewer than 10 physicians had fewer preventable hospital admissions among their Medicare beneficiaries than larger practices.

The data was obtained between 2007 and 2009 and its publication produced the expected response from CMS and the ACP. They theorized that Patient Centered Medical Homes were just getting started and speculated that if the data from today was reviewed it would tell a different story. The problem is that when one looks at data from small medical practices, such as the data presented by the MDVIP concierge group from their small practices nationwide, you see exactly the same trend. Not only do the small practices hospitalize less but they score higher on quality measures designed by the government and insurers themselves.

The authors of the current study noted that 83.2% of US office based physicians are practicing in small practices of 10 or less physicians. Small practices in which physicians know their patients long term and are accessible and available clearly outperformed the larger health system and government sponsored mega groups.

Think about that the next time you look for a doctor. Which health care setting do you want your insurance plan to cover?

No Need For Routine Pelvic Exams?

Woman Sitting with Tea CupThe American College of Physicians created controversy and discord with the American College of Obstetrics and Gynecology by stating that women without symptoms of pelvic disease and of average risk” do not benefit from pelvic exams as part of routine care.” This recommendation received major media coverage. ACP panelist Russell Harris MD of the University of North Carolina in Chapel Hill in an interview with the University of Pennsylvania on line journal MedPage Today added further confusion to the recommendations by saying that “Our guidelines really have to do with women who do not have symptoms, who do not have a discharge or bleeding or pain. Our guidelines talk about screening of asymptomatic women who are not pregnant. Those women simply don’t need the exam. It’s not something that is useful for them.” The article goes on to say that “the guideline also does not apply to women who are due for cervical cancer screening.”

The concern is that the exam is intrusive in a private area and most findings lead to evaluations that lead one down an investigative path that is expensive, invasive and studies show very little yield in terms of finding preventable disease. This is based on the groups’ review of 52 published studies between 1946 and 2014.

Once again organized medicine has shown a way to be confusing, divisive and contributing to the appearance that the right hand does not know what the left hand is doing. The ACP and the American College of Obstetrics and Gynecology should have discussed this issue and released a joint recommendation which makes sense. The ACP guidelines suggest we should be visually inspecting the cervix which requires a speculum exam and using cervical swabs for cancer and or human apillomavirus. How much extra time and cost is involved if the clinician with the patient’s pre approval digitally and manually palpates the uterus, ovaries and rectum for the presence of unsuspected anatomical abnormalities? Is this, in fact, another effort by the American College of Physicians, and the American Board of Internal Medicine, to dumb-down and accelerate the training of future physicians? If we do not perform a certain number of pelvic exams on normal individuals how is one going to recognize an abnormal exam? This is the same type of short sighted thinking that led to the Institute of Medicine and US Preventive Task Force recommending that we do not teach women how to perform breast self -examination to detect breast irregularities? It reminds me of the recommendations years ago to stop doing chest x rays on smokers for the detection of lung disease and lung cancer because it was low yield and not cost effective. Funny how 20 years later the recommendations now call for screening low dose CT Scans of the Chest on smokers 55 years or older who have been smoking for many years.

I will continue to discuss the issue of a pelvic exam with my patients and suggest they discuss it with their gynecologist as well. I believe that 15 -20 years down the road the guidelines will once again insist on examinations of the uterus and ovaries when the politics of the times is not solely set on reducing health care costs! Hopefully those new suggestions will not be fueled by an increase in advanced gynecological cancer due to 20 years of no one examining their patients.

Statistics For Dummies: Primary Care Doctors’ Inability to Understand Statistical Concepts …

An article and editorial have appeared in the Annals of Internal Medicine demonstrating that primary care physicians do not understand simple statistical data presented to them regarding screening tests for cancer. The consequences, as outlined in an editorial written by a former chairperson of the much maligned Institute of Medicine, is that primary care doctors are over-using cancer screening tests because they do not understand the statistical ramifications and conclusions presented in the study. The editorialist recommends improving statistical courses at the medical school level and improving the editorial comments in journals when these studies appear.

As a primary care physician, out of medical school for 36 years, let me make a suggestion.  Keep It Simple Stupid.   Medical school was a four year program.  The statistics course was a brief three week interlude in the midst of a tsunami of new educational material presented in a new language (the language of “medicalese”) presented en masse in between students being used as cheap labor at all hours of the day to fill in drawing bloods, starting intravenous lines and running errands for the equally overworked interns and residents who were actually being paid to perform these tasks.

While internship and residency included a regular journal club, there was little attention paid to analyzing a paper critically from a statistical mathematical viewpoint.  I suggest applying the KISS principle to analyzing medical research papers. Make the language and definitions clear cut and understandable for the non math majors and non researchers.  We have eliminated the use of Latin, medical abbreviations and other time honored traditions of the profession in the name of clarity and safety.  It’s time to do the same with statistical analysis of research papers. Let authors and reviewers say what they mean at an understandable level. Practicing clinicians do not use this vocabulary regularly enough to master it.

It’s time for creating a “Khan Kollege” You-Tube video on statistical analysis and medical paper review that clinicians can refer to routinely to buff up their understanding of medical research papers.  If the American College of Physicians or American Academy of Family Practitioners already have such programs on their websites I apologize for not knowing where to find it.

Each year the economic advisors who freely give advice to us PCP providers have asked me to add three patients per day per year to my schedule to economically be able to stay in the same place.  Amidst that high volume and need to stay current and need to have some balance in my life I admit my statistical analysis skills have grown rusty.  I believe many of my colleagues have suffered the same fate. When the Medical Knowledge Self Assessment syllabus arrives every other year, the statistics booklet is probably one of the last we look at because not only does it involve re-learning material but you must first re–learn a vocabulary you do not use day to day or week to week.

I will make my effort to re-learn statistics to better understand the literature. It is my professional responsibility to do so. I ask my colleagues in academia to do a better job, however, of explaining and teaching the concepts so the data and the logical conclusions are understandable.