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.

Medicare, if you only knew…

The following guest post was written by Aimee Seidman, M.D., FACP.  Dr. Seidman is an award winning internal medicine physician in Rockville, MD, a suburb of Washington, D.C.

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If I could have a penny for every dollar I saved Medicare, I’d be rich. As a concierge physician, my patients can expect advocacy that stretches from the office to the home, hospital, rehab facility, long term care setting, and to the hospice. When I work with a patient, they can expect me to intervene between the various subspecialty physicians or hospitalists involved in their care, spread out my arms in front of them as if ready to take a bullet for them, and defiantly yell “get your paws off my patient until we hear what the plan is”.

How often are x-rays, ultrasounds, MRI’s, cardiac caths, and yada, yada, yada done in patients with a shortened life expectancy, poor quality of life, or clear living will instructions? How often is patient autonomy ignored in the rush to ‘complete work-ups’? Why do we have to work everything up? We need to stop what we’re doing (and stop the cowboys who are shooting from the hip) and think about the patient’s status and whether or not the proposed intervention is appropriate.

The last time I asked one of my 80-101 year olds how aggressively they wanted their medical treatment to be, they said “no way…leave me the hell alone! When my time comes, it comes. Just make a nice party!“  I shudder to think of the feeding tubes inserted and other interventions done in clear violation of a living will, even if that living will is right there with the patient or family members present.

I believe we scare the daylights out of people by telling them all the horrible things that will happen if they don’t consent to treatment plans. But it’s all defensive medicine. “I’ve got to be able to document that I warned them about this horrible death so I don’t get sued”. I suspect non-intervention, comfort measures, and hospice care are rarely offered to families in a way they can hear it. ER doctors and hospital physicians are just doing their jobs-they want to ‘save lives’ (or at least keep them alive until the next shift) and the primary care doctor is never consulted.

What do people think we do, order mammograms all day? Those of us in concierge medicine who have close relationships with our patients know them and their families well enough to expedite decision-making in a way that is medically and ethically appropriate. The whole point of my concierge practice is to first, do no harm (remember that?), allow my late stage Alzheimers disease patient to have a dignified death, and not spend millions of dollars on unnecessary procedures.

Not only that (I’m almost done), if all primary care physicians and the health care community made a conscious effort to inquire about living wills, explain the subtleties, and respect the choices made, fewer people would use ambulances, go to the ER, stay in the hospital, etc.

The other piece to this is the education of families regarding end of life issues, preparation, ethics, and closure. As it is, families deal with guilt, sadness, confusion, and anger when called upon to make these tough decisions or to respect an established living will. Most of us have seen families reluctant to honor a living will because they can’t bear the thought of letting grandpa starve to death.

If consulted about these decisions ahead of time, much of the combat will not occur. So how much have I saved Medicare by avoiding all this unnecessary stuff? Tens of thousands of patients, times a fortune of money, equals a boatload of bucks.

So, do you want to know ways to fix health care?

1.      Tort reform so docs aren’t so paranoid and aren’t playing “cover-your-butt medicine”;

2.      Docs, shut up and listen to your patients;

3.      Stop insulting the community of doctors who want to practice medicine in a particular model labeling them elitist and focus on things that will work (and by the way, most of us have scholarship patients, indigent patients and perform community service);

4.      A national campaign to educate consumers about the importance of living wills and have discussions over details, including family members in the discussion;

5.      Make it clear to the medical community that honoring a patient’s autonomy in the form of an advance directive is their obligation under the law

6.      Do no harm.

Just listen to me and give me a penny for every dollar I save Medicare, then I’ll really be rich.

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Please note, the opinions expressed in this guest blog post are those of Dr. Aimee Seidman, founder of Rockville Concierge Doctors.

Who Says Concierge Practice Is Unjust For Patients And Doctors Alike?

Medscape Medical Ethics published an article in August 2011 written by Art Caplan, PhD., Professor of Bioethics and Philosophy at the University of Pennsylvania claiming that Concierge Practice Is Unjust For Patients And Doctors alike.  A PDF of the article is attached for your review.  Concierge Practice Unjust For Patients and Doctors Alike by Art Caplan, PhD.

I am in disagreement with Mr. Caplan’s article.  Below is my perspective.

Like the shots fired at Concord and Lexington in 1776, concierge medicine and direct pay practices are the initial shots fired by concerned primary care physicians in the revolution against health care systems which limit access to physicians and destroy the doctor / patient relationship. Concierge medicine arose as a result of government, private insurance, and employer intrusion into the health care field destroying primary care and a physician’s ability to spend the time required with patients to adequately and comprehensively prevent and treat disease.

The only thing that is unjust or unethical about concierge and direct pay practices is that they had to be formed to begin with. They formed after 30 years of:

  1. Primary care doctors lobbying unsuccessfully for adequate compensation for evaluation and management services and for protesting the widening gap between cognitive services and procedural specialty practices.
  2. Going through channels protesting the unfair bureaucratic and administrative burdens placed on primary care practices by Medicare, Medicaid and private insurers.
  3. Warning that the population is aging and their chronic health care problems are far more complex requiring more time with a physician rather than less.
  4. Primary care physicians leaving medical practice for early retirement or for paid jobs with pharmaceutical companies, medical device manufacturers and hospital administrations where hard work and achievement were rewarded without having to deal with system imposed overheads of up to 65 cents on the dollar.
  5. Legislators providing no relief from frivolous lawsuits which makes seeing complex patients in 5-10 minute sessions for “single problem directed visits” a legal liability.
  6. Medical students realizing that the time and financial commitment to the practice of primary care medicine didn’t cover the bills essentially directing them toward more lucrative procedure dominated specialties.

Physicians also left after salaried academic physicians, who never took risk and invested a cent of their own money in building a practice, pontificated and moralized in peer journals supported wholeheartedly by biased pharmaceutical company ads that generating passive income through shared labs and imaging centers was a kickback.

If we look at the data accumulating on care from concierge and direct pay practices, we find that despite a sicker patient population these practices generate fewer visits to emergency departments and fewer acute emergent hospitalizations saving the system money.  These practices provide coordinated care for their patients steering them through a complex and confusing health care system riddled with inappropriate advertising and claims and, get the patients to the best people to treat their problems.

Concierge physicians have more time to spend with their patients thus, achieving unheard of levels of retention and patient satisfaction while giving pro bono scholarships to patients who cannot afford their membership fees but were with them prior to their conversion to a retainer model.

After years of being on the conveyor belt of having to see more patients per day, every day, to stay abreast of system generated overhead cost increases and declining payment for services, concierge physicians now have time to teach students, volunteer at health fairs and screenings and participate in the stewardship of what remains of their profession.

If anything is unjust and unethical it is salaried academic non-physicians writing articles about morality and justice about issues they have no hands-on experience practicing. As a primary care physician for 32 years, I feel like a chameleon having to change colors and practice style every few years based on new rules imposed by private insurers, employers and government programs. At no time were these new rules designed to improve the patients’ access to care or total care.  In each case the new rules were designed to save money and do nothing else.

Concierge and direct pay medicine is the first volley in a revolution to take outstanding care of a smaller panel of older sicker patients on a long term basis.  Its proponents have worked hard for decades to change the system through channels. Failure of legislators, government bureaucrats, health insurers, employers and professional associations such as the AMA and the ACP to react and fix the inequities has generated these practices which cost less than a cup of Starbucks grand latte per day to be a patient of and provide comprehensive care and access.

Should We Treat Sore Throats With Antibiotics?

How many of us have called our doctor with a scratchy throat, mildly swollen glands, congestion and overall malaise and requested an antibiotic?   “I know my body best and if I take an antibiotic I knock it out quickly.” is a common refrain.

In most cases, sore throats are due to viruses. Fewer than 10% of sore throats are caused by bacterial Group A streptococcus.  Antibiotics such as a Z-Pack (Zithromax), Penicillin or Ampicillin do not kill viruses.  If by chance a patient has a sore throat and an upper respiratory tract infection, the length of illness before recovery averages 4-7 days with or without antibiotics -whether strep is present or not.

How then did the throat culture and use of antibiotics begin and what is its rational? In the 1940’s and 1950’s when antibiotics were being introduced to the public it was determined that streptococcus pyogenes was the cause of Rheumatic Fever.  Researchers found that by administering antibiotics to patients with a strep throat they could reduce the rate of acute Rheumatic Fever from 2% to 1% (notice that even with appropriate antibiotic use we cannot prevent all the cases of Rheumatic Fever).

Applying this data in 2011 we find that there is about 1 case of Rheumatic Fever in the United States per 1 million cultured strep throats. In other words, we must prescribe one million prescriptions for antibiotics for sore throat to prevent one case of Rheumatic Fever. In turn, these antibiotics may cause 2,400 cases of allergic reactions, 50,000 cases of diarrhea and an estimated 100, 000 skin rashes.  It doesn’t make sense.

In a recent editorial article in MedPage, an online periodical supported by the University Of Pennsylvania School Of Medicine, George Lundberg M.D. presented a cogent case against throat culture use and antibiotics in sore throats and bronchitis. He suggested that “physicians should not prescribe antibiotics for sore throats….  They don’t help. They often hurt. First, do no harm!”

As an internist dealing with adult patients I am not seeing the groups most likely to catch a strep throat which is young children 2-7 years of age and their caregivers.  If patients present with fever, exudative tonsillitis and pharyngitis with large swollen cervical lymph nodes I will still culture them.  I will treat based on their immune status, general health and risk of having a significant bacterial infection. If I choose to prescribe an antibiotic I will make an adjustment based on the culture results.

Alzheimer’s Disease – Recent Data

Researcher’s gathered in Paris, France this month to present their data on new developments with Alzheimer’s disease.  In reviewing the meeting’s material, it is clear that much of what is “new” is old.

In the past we were taught that patients placed on medications for Alzheimer’s Disease would derive a benefit about 50% of the time. This benefit would last for six to twelve months.

One of the world’s authorities on this topic is Susan Rountree, M.D. of Baylor College of Medicine in Houston.  She has followed 641 patients since the late 1980’s.  In 2008 she reported that patients treated with medicines such as donepezil (Aricept) and rivastigmine (Exelon) survived about three years longer than patients who did not take these medications.  She re-analyzed that data, updated it and came to the conclusion that “using anti-dementia drugs doesn’t seem to prolong survival.”   She did however recommend continuing their use because her data showed that patients taking them had improved cognition and ability to function.

At the Paris event there was material presented that was not surprising but needs the legitimacy of a well planned study to turn theory into scientific evidence and fact.

The study showing that military personnel who suffered traumatic brain injuries during the Vietnam War were more likely to develop dementia has great implications for today’s veterans fighting in Iraq and Afghanistan where brain injuries are on the rise.  It will clearly help us as well in terms of long-term planning for the development of dementia in private citizens suffering from traumatic brain injuries.  It was not surprising either when certain medications were cited as being more likely to contribute to the development of Alzheimer’s Disease. This year’s culprits seem to be anticholinergic drugs which make a patient’s mouth dry and cause constipation.

What was not surprising were the studies that showed that elderly individuals who engaged in regular and vigorous physical exercise were less likely to develop cognitive impairment.  Those patients who get regular and vigorous exercise who show signs of cognitive problems declined at a slower rate than those who don’t.

While much of the material discussed confirmed the fact that healthy lifestyle is the best defense against this disease; there was also much hopeful discussion of research which is untangling the relationship between brain chemicals, development of plaques in the brain and its relationship to Alzheimer’s. On an encouraging note, we are much closer to early detection and therapeutic intervention than we were a decade ago.

“Colonoscopies Are Overdone In The Entire Population.”

Current recommendations by the American College of Gastroenterology call for colonoscopy as a screening test for colon cancer beginning at age 50 for Caucasians and 45 years old for African Americans. If the initial test is negative, and you have no symptoms, the recommended interval for follow-up colonoscopy is 10 years.  Despite this, a recent study published in the Archives of Internal Medicine revealed that nearly half of the the Medicare patients with negative findings on colonoscopy underwent repeat exams much sooner than the guideline recommended interval of 10 years.

The study looked at 24,000 Medicare enrollees who had a negative colonoscopy from 2001 through 2003.  Forty six percent of these individuals had a repeat exam in less than seven years.  According to lead author James S. Goodwin, M.D. of the University of Texas Medical Branch in Galveston, there was “no clear indication for the early repeated examination “in just under half of the recipients.   He said that even in patients 80 years of age and older repeat exams were done within 7 years in 32.9 % of the study group even though these patients were much more likely to die of something other than colorectal cancer in the near future.

Goodwin and his associates were surprised by the frequency of the repeat colonoscopies since Medicare regulations preclude reimbursement for screening colonoscopy within 10 years of a negative examination result. Despite this, only 2% of the repeat exams were denied by Medicare and not paid.

Brooks Cash, M.D., chief of medicine at the National Naval Medical Center in Bethesda, MD said, “I think colonoscopies are overdone in the entire population. “  He believes some of the frequent studies are provider driven and many are patient driven.

Colonoscopy is an invasive test with risks. The preparation can lead to fluid and electrolyte and volume problems in some individuals and the chance of a bowel perforation is rare but always present.  Patients need to talk to their personal physician about the need for a follow-up colonoscopy and the appropriateness of the timing suggested by the gastroenterologist before scheduling one.

Smoking Increases the Risk of Breast Cancer, Lung Cancer and Colon Cancer in Women

The Surgeon General of the United States issued another report on the dangers of smoking and its addictive potential last year.  At the time of release I was quite skeptical about the cost of the report and the need to remind Americans again that smoking is dangerous for you.  Then along comes a detailed review of the National Surgical Adjuvant Breast and Bowel Project. According to Stephanie Land, PhD, of the University of Pittsburgh, long-time smokers had a 59% increase in the risk of invasive breast cancer compared with nonsmokers.  The study looked at the links between four types of malignancy: breast, lung, colon, and endometrial cancer with smoking, alcohol use and leisure time activity.  The findings suggested that:

1.       Women who had smoked between 15 and 35 years had a 35% increase in the risk of breast cancer compared to non smokers. In that same group, if a woman smoked more than a pack a day she had a five – fold higher risk than non smokers.

2.       Women who had smoked 35 years or more had a 59% increase in the risk of breast cancer. These long-term smokers had a 30 times higher risk of lung cancer than non smokers.

3.       The risk of colon cancer among long–term smokers was five times higher than among non smokers.  A drink of alcohol a day reduced the risk of colon cancer by 65% compared to non drinkers.

4.       Inactive women had a 72% increased risk of uterine endometrial cancer compared to active participants in the study.

The study of almost 14,000 women highlighted the benefits of improving life style choices.  While researchers search for drugs and medication to prevent these life threatening illnesses, the study pointed out the benefits of altering the life style choices of women to prevent the development of cancer.

It is clear that smoking prevention and smoking cessation programs can do far more to prevent these cancers than pharmaceuticals. With cutbacks on funding for public health and the elimination of most health and hygiene classes in middle schools and high schools due to financial constraints, I wonder if we are being penny wise and pound foolish.