Vol. 204 December 1, 2018 “Why Doctors Hate Computers”

December 2, 2018


Digitization promises to make medical care easier and more efficient. But are
screens coming between doctors and patients?
 – Atul Gawande

I wished I had thought of this title.
I wished I had written the article in the New Yorker that went with it. (1) But, it was written by a better writer, and a surgeon no less; a proceduralist, not a cognitive doctor like us pediatricians and internists. Atul Gawande nailed the reasons for the frustrations of most doctors in dealing with electronic medical records, including graphic points of special irritation with one specific computer behemoth, Epic.

Epic is the $100 million computer software system now in place in the Partners Health Care system serving 70,000 employees in 12 teaching hospitals with dozens of different medical/surgical specialities as well as thousands of office-based providers and their staff. In Epic I have learned the 6 different ways of using 13 different tabs or, worse still, those tiny little icons stuffed into the margin of the screen to get the information I need to see the next patient in a pediatric office. As I traverse the various and varied screens I usually am exposed to too much data and not enough information. It is clear to most of my colleagues and our staff that Epic is chiefly designed as an “optimizer of insurance reimbursement”; probably one reason that large hospital systems and their associated physician networks buy it. A recent Epic “upgrade” was so devoid of any upgrade in clinical relevance that it did nothing to dissuade our view of it as a “reimbursement optimization tool”.

One of Dr. Gawande’s insight as to why doctors have some much trouble liking the new way of computer documentation of everything is that computers do not handle “surprises” very well. In seeking a diagnosis and determining treatment, not all doctor’s questions and certainly not all patients’ answers can be accurately recorded with a simple click in a box. The computer thrives on all those clicks in all those boxes. Doctors do not. We often meander around in our conversations with a patient guided by chance comments or even subtle physical clues. If we elicit a “surprise” we can pursue it much more intelligently and enlightening than the computer can document it. In Gawande’s words computer programs are “brittle, bureaucratic, inflexible, designed for large data bases, rule-based, inflexible, and very difficult to adapt”; in short, unable to handle “surprises” easily. 

Defenders of Epic view their efforts as optimization of the medical care process – “reconfiguring various functions according to feedback from users.” An Epic VP labeled that as the “Revenge of the Ancillaries”. The “users” of an MRI or a X-ray request from a doctor are radiology techs or radiology department secretaries.  The questions they want answered may have little clinical importance but have multiplied within the computer screen requisition that now requires more data entry, more reading, and more in-the-box clicking by the doctor. Some computer programs allow the doctor to delegate ordering tasks, some don’t, and some, like Epic, allow delegating some tasks but not for others. Doctors who are now embracing the delegation of tasks by hiring nurse practitioners and physician assistants are confronting computer programs which are restricting delegation.

Studies have documented that doctors spend two hours in front of a computer for every one hour in front of a patient. In response a new “delegated person”, a medical scribe, has been hired by some doctors. A medical scribe is a non-physician that observes the doctor-patient visit and enters information into the computer freeing the doctor up to maximize the face-to-face patient interaction. (In Quality Management, aka Quality Assurance or Performance Improvement, we call this a “work around” – a human adaptation to bypass a problem in a operating system.)

The Clinical Director of the Partners Epic system defends its as being “for the patients, not the doctors.” Patients gain more access to their medical records like their lab test results, their medications, summary of their visits, and increased opportunity for communication with their physicians. Patient access to their medical record is via a “patient portal”; often touted as a successful way to build a practice and be a modern practitioner. Unfortunately the patient portal has not been the slam dunk it was expected to be. It certainly has not been in our pediatric practice. “Why Are Patient Portals Such Duds?” and other recent reviews describe some of both doctor and patient barriers to their adoption.

The Clinical Director of Partners Epic takes the long view that patients will eventually use the EMR as currently hoped and hyped. We shall see, and in the meantime I hope that fewer practicing primary care doctors experience “burn out” and that fewer new medical school graduates shun primary care practice.

1. New Yorker Magazine, November 12, 2018, Atul Gawande

Vol. 195 July 1, 2018 BIG DATA and a whiff of AI in health care

July 1, 2018

Hub thumbnail 2015

“When it comes to health data, Watson hasn’t been much help.”
-STATNEWS, Ross and Swetlitz. Bos Globe 6/18/18

This week all the newspapers (at least in Massachusetts) have been abuzz with the announcement that Atul Gawande, MD has been picked by three moneyed titans of innovation to head their new company to revolutionize health care. Optimism, promise, and hope is in the air! Kind of like when IBM presented Watson, its supercomputer, in 2015 as the tool to provide workable insights into the financial and clinical dilemmas of U.S. hospitals in 2015 via Watson Health.

How is that working out? Watson Health has access to data on tens of millions patients, in part by spending $9 billion to acquire other companies. It’s initial focus was on developing workable products in oncology, designed to help physicians individualize cancer treatments. “With these acquisitions, IBM will be one of the world’s leading health data, analytics, and insights companies, and the only one that can deliver the unique cognitive capabilities of the Watson platform”, said the general manager of Watson Health in 2015.

They (the newly merged companies) struggled with the basic step of learning about the different forms of cancer and the rapidly changing landscape of treatments. Last week Watson Health laid off people partly because, according to some, even Watson had difficulty in digesting all that data. “…They also don’t understand the generation of information, and how it is used, and whether they can do something different with it,” said Robert Burns, professor of health management at U Penn Wharton School. You can almost hear every primary care physician that is struggling to get their new EMR system to give him/her more information and less data cheering loudly in the background, “We couldn’t have said it better!”

The goal of a great deal of innovative technology in health care is “ “zero patient harm”. if Atul can’t do it all with his surgical checklists and Watson can’t do it all with data from tens of millions of patients , what/who can? How about Artificial Intelligence (AI), aka “machine learning”? AI and machine learning is the converting of data into information without the need for human programmers. For instance, if the computer views enough pictures of different dogs, it will learn to correctly identify a cocker spaniel. I think a real test of AI would be to see if it can recognize a Labradoodle,  or any other of the many poodle cross breeds. (Don’t you sometimes worry about the moral standards of poodles that seem to be eager to mate with any kind of passing breed?)

The building of knowledge from patterns in data, both visual and language, is labeled “computer vision”. In some medical studies “computer vision” is used to monitor actual bedside events and identify omissions or non-compliance in procedures. It has apparently improved rapidly beyond just identifying dogs or skin rashes because of “deep learning”: a type of machine learning that uses “multilayered neural networks whose hierarchical computational design is partly inspired by biologic neutron’s structure.” (1)  Got that? Think Google’s self-driving cars. “Computer vision may soon bring us closer to resolving a seemingly intractable mismatch between the growing complexity of intended clinician behavior and human vulnerability to error.” (2)

So, the effort to cut the Gordian knot of patient safety and cost-effective medicine continues. I suspect that the three titans of innovation have turned to Atul Gawande, a health care innovator who successfully uses clinical insight and re-education to effect change, because they recognize the limitations that are becoming more apparent in big data.

  1.  NEJM April 5, 2018 378:14; 1271-2
  2. Ibid.

Vol. 193 May 15, 2018 Antibiotics are Beneficial: A Reminder

May 15, 2018

Hub thumbnail 2015

A disease outbreak anywhere is a risk everywhere.”
-Dr. Tom Frieden, Director U.S. CDC


We read a lot about the dangers of using too many antibiotics. The popularity of “organic foods” is due in part to their claim to be from “antibiotic-free” animals and plants. Concern about the increasing antibiotic resistance of germs due to antibiotic overuse is real as is frequently described in scientific journals as well as the general press. Why, then, would the New England Journal of Medicine publish an article describing the benefits of random, mass distribution of an oral antibiotic to nearly 100,000 children who had no symptoms or diagnosis! Maybe because that effort reduced the death rate of children aged 1-5 months by 25%!

As you’ll remember in my last blog,  I was impressed by Bill Gate’s knowledge of the medical literature because during his presentation he cited this antibiotic clinical trial which had been published that very same week. Well, full disclosure, he knew about the study because his foundation funded it! This study is the kind of innovative medical study related to global health that the Bill & Melinda Gates Foundation supports. I think it is worthwhile to review the details of the study, if just to remind us that antibiotics are good, that medical science advances on the shoulders of previous work, and that sometimes simple answers, like putting iodine into salt or fluoride into water, can prevent a whole lot of disease.

Previous studies in sub-Saharan Africa showed that blindness caused by trachoma, an infectious disease, could be reduced markedly through the mass distribution of an oral antibiotic, azithromycin. Other studies suggested that the same antibiotic could prevent other infectious deaths like malaria, infectious diarrhea, and pneumonia. It is known that azithromycin affects the transmission of infectious disease, so that treatment of one person might have benefits on others in the same community. The data in two of these studies of trachoma prevention in Ethiopia suggested that mass distribution of azithromycin “might” reduce childhood deaths. Since death (after the neonatal period) is a relatively rare event, even in these settings, the trial had to be conducted in a large population. Hence the need for a large grant to carry it out.

A single dose of oral azithromycin was given to 97,047 children aged from 1 month to 5 years in three African countries during a twice-yearly census. 93,191 children in different communities of the same countries were given a placebo. Over the two-year study the “treated” children received 4 oral doses of azithromycin, each about 6 months apart. Children were identified by the name of the head of the household and GPS coordinates of their location for subsequent censuses. Approval for the study was obtained from 9 ethics committees in 6 countries (3 in the US, 1 in the UK, and 2 in Africa).

The average reduction of annual death rates of children receiving a single dose of the antibiotic every 6 months was 13.5% . Children aged 1 month to 5 months receiving the antibiotic had a mortality rate reduction of 25%. At the conclusion of the trial all the children in the communities of Niger, which has one of the highest child mortality rates in the world and a mortality rate reduction of 18% for all ages in this study, were offered treatment with azithromycin.

This study is a beautiful example of the testing of a simple hypothesis, generated by the results of previous work, using innovative methods, requiring a large population for validity,  and implemented by a multi-national team of medical scientists with a large grant from a private foundation that resulted in clear benefits for better global health.

I, for one, am happy to trumpet some good news about antibiotics and this example of “medical research for all” at its best.

Azithromycin to Reduce Childhood Mortality in Sub-Saharan Africa, NEJM 378;17, April 26, 2018





Vol. 128 July 1, 2015 Obamacare is Five Years Old. Can It Walk and Talk?

July 1, 2015


“From a historical perspective,
5 years is a very short time.
Many of the key insurance provisions have been
in effect only since October 2013.” (1)

Now that the Supreme Court has decided that a key provision in the Affordable Care Act of 2010, the federal subsidy of health insurance for eligible citizens, is legal, the infancy of Obamacare is over. It looks like it is here to stay. How is the toddler doing? What has it done? Luckily, The Commonwealth Fund just published a summary of ACA effects so far. (1)

The Commonwealth Fund is a private foundation formed in 1918 with Harkness family money made from the early oil business, (Shell Oil).

“The Commonwealth Fund has sought to be a catalyst for change by identifying promising practices and contributing to solutions that could help the United States achieve a high-performance health system. The Fund’s role has been to establish a base of scientific evidence on what works, mobilize talented people to transform health care organizations, and collaborate with organizations that share its concerns. The Fund’s work has always focused particularly on the challenges vulnerable populations face in receiving high-quality, safe, compassionate, coordinated, and efficiently delivered care.”

This health-care-focussed fund and think tank reports that it is too early to see many benefits of the ACA, but lists some of its immediate, observable effects.

Access to care:

  • 7.0 to 16.4 million young adults from chronically uncovered populations ( hispanics, blacks, and those with low incomes) have gained health insurance coverage since 2010 (different survey methods and timing cause the difference in results).
  • 11.7 million Americans selected a health plan through the health insurance marketplaces established by the ACA. 87% of those people were eligible for federal subsidies of premiums.
  • 10.8 million additional Americans have enrolled in Medicaid since the ACA was passed.
  • 3 million previously uninsured young Americans have gained coverage through the ACA extension of dependent coverage to age 26.
  • 8-12 million Americans have benefitted from the ACA’s regulation that prevents insurers from discriminating against people with preexisting conditions.
  • 75% of those newly insured seeking appointments with primary care or specialist physicians have secured one within 4 weeks or less.

Delivery-System Reform:
“ The law constitutes one of the most aggressive efforts in the history of the nation to address the problems of the health care delivery system through funding many divergent experiments though lacking a coherent strategy.” (1)  The Commonwealth Fund report lumped the efforts into four categories.

1. Changes in Payments:
Reduce readmissions – There are 150,000 per year fewer Medicare hospital readmissions within 30 days of discharge partly attributed to ACA financial penalties to hospitals with higher than expected readmission rates.
Reduce hospital-acquired conditions – ACA financial penalties to hospitals in the highest quarter of avoidable hospital-acquired conditions may have helped the composite rates for those to drop by 17% from 2010 to 2013.
Pay for Performance – ACA payment incentives to hospitals and physicians to improve their performance on various cost and quality measures: “too early to tell”.
Bundled payments – This departure from fee-for-service reimbursement pays the hospital, the physician, and post-hospital services with a single payment for a procedure or condition. 7000 providers have signed up for it, but it is “too early to tell”.

2. Changes in the Organization of Health Care Delivery:
Accountable Care Organizations (ACOs) – An ACO is an organization of physicians and hospitals formed to improve the integration and coordination of ambulatory, inpatient, and post-acute services for a defined population of Medicare beneficiaries. 405 ACOs are participating in a program that allows them to keep a portion of any cost savings they can generate without degrading quality. Although the pilot program of about a dozen Pioneer ACOs “saved” $385 million in the first two years, it is “too early to tell” if the others will have a postive effect.
Primary Care Transformation – A pilot program to reduce costs and improve quality in primary care has shown a $14 per month cost reduction per Medicare enrollee and less emergency room visits and hospitalizations in the 2.5 million patients participating in its first year, but it is “too early to tell”.

3. Changes in Workforce Policy:
The effects of increased primary care reimbursement for Medicaid patient services, increased National Health Service Crops scholarships for practicing in underserved areas, and establishment of a National Health Care Workforce Commission (but remains to be funded by Congress) are all “too early to tell”.

4. Increase Innovation in Health Care Delivery:
The Center for Medicare and Medicaid Innovation (CMMI) was funded at $1 billion a year for 10 years to undertake a wide variety of experiments in improving quality for patients and reducing the 43% share of national health costs now paid by the government.

  • Commonwealth Fund says: CMMI is perhaps the most promising of the ACA efforts, but “way too early to tell”.
  • The CMMI itself reports it has launched 26 “demonstration models” of cost reduction and quality improvement. The Pioneer ACOs mentioned above is the first model “to meet the statutory criteria for expansion”.(2)
  • A separate report from Weil Cornell Medical College Department of Healthcare Policy and Research states that to date the CMMI has spent only one-third of its $10 billion, that it seems to be slow in distributing data from its experiments to participating organizations, and that it is hampered, as most quality improvement efforts are, by the lack of consensus on what constitutes “ improved quality”. So it is “too early to tell” (2)

Wow, that is definitely more than you may have ever wanted to know about the ACA so far!
It is certainly more than I can remember.
It is clear that Obamacare does have a lifetime before it.
As that lifetime unfolds one can only hope that responsible adults will guide it through its future developmental stages.

Bottom line: carry a small laminated copy of this blog in your pocket or purse to pull out when engaged … embroiled, …immersed, …or even entangled in any discussion about Obamacare, which will continue, even if Hilary renames it.

Remember, Medicare was just as controversial when first passed. One governor that opposed Medicare actually mobilized his state’s National Guard the day Medicare was passed in fear of the hordes of newly insured people that he expected to overwhelm emergency room departments.

1. NEJM June 18, 2015;  The Affordable Care Act at Five Years
2. NEJM May 21, 2015;  Assessing the CMS Innovation Center

Vol.111 October 1, 2014 ; How Does Your Doctor Rate?

October 1, 2014

hubI think this is actually a trick question. I know very few people who have only one doctor. They have several, spanning different specialities.

 “Doctor Rating” sems to be  a thriving business. Consumer Reports Magazine (October 2014) lists six websites that present some sort of doctor ratings that go beyond the basic info provided by the AMA, Medicare, and state Boards of Registration in Medicine and state medical societies.

I examined these websites to see what I could learn how each one rated some primary care doctors that I know in my own vicinity. What I found was not particularly helpful nor illuminating for a variety of reasons.

The websites usually used two sets of criteria for ratings, one for the office (“ease of making appointment, friendly reception, etc.”) and one for the physician (“bedside manner, waiting time, clarity of discussion”,etc.”). Most used a rating of 1-5 stars, but one used “A-F”. Physician groups were rated, but to learn about individual doctors within the groups I had to scroll through individual patient text comments.  All of the websites had errors such as listing physicians who were dead, retired, back in India, or now in New Zealand.

I searched under “internists” and often also got dentists, obstetricians, cardiologists, oncologists, and even “lice doctors”. There seemed to be no rhyme nor reason to the sequence in which doctors were listed, except for the one website that highlighted the “Top 10” (apparently “patient satisfaction” was the sole criteria). Some websites forced me to scroll through all the names alphabetically to find the one name I was looking for. Some allowed me to search by individual name. Despite entering my zip code as a clue I got lists of doctors from many miles away. Some websites listed nurse-practitioners (NP) in the list which is not bad, might even be helpful, but it was not always clear with which physician(s) the NP was affiliated.

In the instances that I was able to find physicians about whom I had my own rating opinion, I did find that the website ratings generally matched my own bias. In the few instances that I could find the same physicians on different websites, the website ratings agreed.

Here are comments on my experience with specific websites:

Angieslist.com    “A to F”    Access to doctors’ rating for a year costs you $20.($16 if you use PayPal)
Gives number of reviews used to decide the rating (usually single digits); Have to click and scroll individual patient comments to identify individual physician rating in a group; three“A” reviews plus one “F” review created a “B” rating (4 reviews).

Healthgrades.com      1-5 Stars   Free Listed
177 internists near me, but listed only alphabetically; the first dozen or so listed would fit my “marginal” category; gives number of reviews used to decide the rating, but no patient comments/reviews presented; also included cardiologists and ophthalmologists.

Vitals.com    “Where doctors are examined.” 1-4 Stars   Free
136 internists near me, but the highest number of dead, moved, or wrong specialty doctors; had search “filters” to help me narrow my list, and the “patients’ choice” was the most helpful; you can choose a video that presents the ratings in a pleasing, non-revealing, fourth-grade-educational-level cartoon.

RateMDs.com     1-5 Stars     Free
Can search by name or “find a doctor by locale”; lists a “top 10” presumably based on patient satisfaction, but my doctor was NOT listed even though he is “the BEST doctor in the world” because no patients had submitted reviews.

Yelp.com   1-5 Stars   Free
The worst mix of wrong specialities and very few physicians listed; I suspect that doctors have to enter their own offices to this website or even pay for a listing, but I am not certain.

CastleConnolly.com   “Lists America’s Top Doctors”  An annual List and Book
Doctors are nominated, reviewed, and screened by a professional staff for this list founded by two men (neither one a physician) on the Board of Trustees of NYU Medical School; list is heavily weighted to academics in the NY metropolitan area.

Whosmydoctor.com    A work in progress; “not yet ready for prime time”
Leana Wen, MD, Rhodes Scholar, Director of patient-centered research at George Washington University, and a recent TEDMED presenter surveyed patients about what they wanted to know about their doctors. Almost everyone wanted to know that their doctors were competent, certified, and free to make evidenced-based medical decisions uninfluenced by whom they were paid. No surprise there. BUT, she also found that patients wanted to know something about the doctor’s values; what the doctors held dear to their heart!

“One after another, our respondents told us that the doctor-patient relationship is a very intimate one, that to show their doctors their bodies and share their deepest secrets, they want to first understand their doctor’s values.”

Dr. Wen set up a website “Who is My Doctor?” in which doctors could voluntarily state their feelings about reproductive medicine, alternative medicine, and end-of-life-decisions. This information, obviously beyond competency and source of compensation information, would be accessible to all patients and potential patients in an effort toward “total transparency”. The website and Dr. Wen apparently ran into a hailstorm of resistance from some physicians who did not believe that “total transparency” was a good thing. The website is currently just collecting signatures of those who support the concept, 387 to date.

Bottom line:
Doctor rating lists are not very helpful if you are blindly doctor-shopping in your area. If you do the usual thing and get some names of “good docs” from your friends and neighbors, then the rating websites could help you check out the opinions of other patients. None of these websites are as illuminating nor as complete as Trip Advisor…yet.

Vol. 73 September 1, 2012 Two American Medical Care System Miracles

September 1, 2012

Yesterday a friend told me about his own recent medical care “miracle”.

He and his family were finishing up their last day of a two-week vacation on a remote New Hampshire pond (the one, I believe, where the fish called Walter once resided). He was designated to perform an essential rite of passage at the end of their annual visit, the trip to the dump. The dump, of course, is at the outer limits of their township, more remote than their cabin and out of cell phone range.

When he returned to the cabin from the dump he felt the first chest pains. Over the next few minutes they increased, and he didn’t feel or look well. In response to their 911 call the local ambulance raced out on the dirt road and whisked him off to the hospital in Plymouth, NH.

A few minutes after arriving in the ER he received an intravenous “clot-buster” medication and suffered a cardiac arrest! CPR was started immediately, during which he had a seizure. Resuscitation was successful, and a helicopter was called in from a Manchester, NH regional referral hospital. He barely remembers the helicopter ride, but thinks he heard the helicopter pilot getting “clearance to land in 23 minutes” even though the air space was restricted for President Obama’s visit. My friend is a certified pilot and not a supporter of Obama, so, of course, he WOULD remember that.

In the Manchester hospital an immediate cardiac angiogram showed one coronary artery with two narrowed segments, one after the other with a normal segment in between. A stent spanning the two narrowed segments was inserted via his radial artery.

Five hours after the onset of his chest pain and about four hours after his cardiac arrest, he was sitting up comfortably in his hospital bed, fully awake and hungry with a very sore chest from the CPR.

The next day his echocardiogram was normal, he passed his treadmill stress test with flying colors, and he was discharged home.

A week later his chest was still sore as he humbly showed his “before” and “after” angiograms to close friends and colleagues.

What a marvel of electronic communication, modern transportation, presence of trained clinical personnel, and access to state-of-the-art diagnostic and therapeutic equipment and processes.

What superb medical care.

My friend is over 65 years old and is covered by Medicare. He probably won’t even see a bill.

He is the father of three, the grandfather of five, a founding elder of a community church, the medical director of a clinical research center, a retired general surgeon, a member of several non-profit boards of directors, and a so-so pool player. What is the gain in quality-adjusted life years (QALYs) of this event? How could you even begin to calculate it?

How could anyone be against making this kind of medical care available to all Americans?

I heard this story Sunday night as an “oh, by the way” when my friend called to ask my help in arranging a second opinion with a pediatric neurologist for a visiting family.  Their five-year old child had been evaluated elsewhere for left-sided weakness and incoordination. The parents had his medical records, CT scans, and MRIs in hand, and they were looking for a second opinion about prognosis. The only problem was that they were visiting from the U.K. and were returning there in two days.

During my  phone calls to a pediatric neurologist I knew, the Urgent Appointment clinic for pediatric neurology at Boston Children’s Hospital, and the Pediatric Neurology Department at Boston Children’s hospital, I related the short story behind this request for an “urgent” second opinion, and left a few phone messages.. The best I could get, not surprisingly, was a referral to the International Medical Care office of Boston Children’s Hospital for an intake process and a future “second opinion” appointment in a month or two.

I reported this result to my friend on Monday afternoon and remarked how difficult this request would be to fill on such short notice. Later that day he got a call from the BCH Department of Pediatric Neurology with a request for more clinical details. The caller left her cell phone number to call that night after hours, since the family was not then available. The net result: the family went up tp Boston Tuesday afternoon, and received a thorough, reaffirming, and comforting second opinion about their son’s condition from a senior pediatric neurologist. They left for England the next day.

QED: The second American medical care system “miracle” of the week.

Vol. 71 July 15, 2012 When “Yes” Becomes “No” in Medicine

July 18, 2012


“PRIMUM NON NOCERE” – First, do no harm.

This quotation is considered to be the first rule for physicians, but it has a somewhat uncertain origin and a changing definition. The original definition of “harm” became more complicated and variable as medicine accepted the concepts of “risk vs. benefit” and “cost benefit analysis”. Since the values in these concepts are variable, the definition of “harm” has become more variable, more complex, and sometimes more relective of the bias of the definer.

Medicine is both an art and a science, and science, as we know, considers all of its “truths” as tentative. As new data is obtained these truths can change. Here are some recent examples of changes in medical recommendations based on new data AND new elements in“”cost benefit analysis” AND possible bias of the maker of the recommendation.

Men should not be screened for elevated PSA (Prostate Specific Antigen)
The initial excitement about this test for the early (“before symptoms appeared”) diagnosis of prostate cancer has been dissipated by data showing that positive tests (elevated levels of PSA) led to lots of referrals to urologist specialists, lots of biopsies, and lots of invasive surgical and radiation treatment which did NOT result in a reduced death rate or lessened disease burden from prostate cancer. Also, the interventions were associated with a bunch of serious complications.

Prostate cancer is usually an indolent disease. If a man lives long enough it will eventually appear in his body, but will rarely cause death or a heavy disease burden. PSA screening of asymptomatic men who have a normal digital (digital, as in finger) rectal exam and a negative test for occult fecal blood is now considered to cost more (in money, patient inconvenience, and medical complications) than its benefits. The PSA does not identify the less common case of aggressive prostatic cancer at a time that makes earlier treatment more effective.

Women under 50 don’t have to get an annual mammogram.
This 2009 recommendation caused a great deal of controversy because of the long term investments of several “stakeholders” in the mantra “get an annual mammogram to save your life.” But, by 2009, data conclusively showed that in order to save the life of one woman in her 40s from breast cancer, 1,904 women would have to be screened every year for up to 20 years. Because the U.S. Preventive Services Task Force judged that the risks of harm from false positives mammograms, subsequent biopsies, and overly aggressive treatment of indolent lesions that resulted from annual screening outweighed its benefits. Hence, the USPSTF panel’s recommendation that most women ages 40 to 49 need NOT get a routine annual mammogram.

Statins do not prevent fatal heart attacks in healthy people.
Studies in 1999 indicated that lowering cholesterol by taking statins (Lipitor, Zocor, etc.) in people who had had a heart attack reduced subsequent cardiac deaths in those people by 30% and reduced subsequent symptomatic coronary artery disease by 25-60%. This dramatic protective effect of statins in these high-risk patients was extrapolated to people without heart disease or risk factors and by 2008 half of U.S. men between the ages of 65-74 were taking statins. Last year a meta-analysis (a research analysis of a large number of studies) failed to show a reduction of death rates in healthy people taking statins.  “Only limited evidence showed that primary prevention with statins may be cost effective and improve patient quality of life.” (1)  More recent studies documenting the complications and side effects of statin use have also contributed to the change in this recommendation.

Colonoscopy for the prevention of death from colon cancer is no better than, and may be inferior to, flexible sigmoidoscopy.
Not so many years ago your primary physician would perform a screening examination of your lower colon with a flexible sigmoidoscope in his/her office, with just light sedation, no biopsy, and no annoying, rigorous bowel preparation. The reimbursement was modest. Since then, the norm for screening for colon cancer has become a colonoscopy, performed by a gastroenterologist or general surgeon in a hospital or an ambulatory surgical center with sedation heavy enough to warrant the presence of an anthesiologist and associated with an interpretation of the inevitable biopsy by a pathologist. The reimbursement all around is much more substantial.

Both procedures reduce the incidence and mortality of colon cancer, but “as reimbursement moves from fee-for-service to bundled payments for episodes of care, there will be a renewed focus on delivering evidence-based interventions in a manner that optimizes resource use.” (2)

Daily low-dose aspirin does not reduce cardiovascular deaths in healthy people.
Use of aspirin to prevent a subsequent heart attack in people who have already had one DOES reduce their death rate from another heart attack. Extrapolation of this widely accepted fact has prompted many  healthy people with no history of heart disease to take low dose aspirin daily. In yet another meta-analysis of over 100,000 people “at risk for” but not having coronary artery disease, daily aspirin did NOT lower the rate of fatal heart attacks. The rate of non-fatal heart attacks was reduced by 20%, but more importantly the use of aspirin INCREASED the rate of non-trivial bleeding (GI bleeding, stroke, hematuria, and nose bleeding) by 31%, ie. the risks of daily aspirin use outweighed its benefits.
SPOILER ALERT: The study recommends that physicians and patients should decide on a case-by-case basis about whether to continue daily aspirin if you are already taking it. My own physician noted that in several of the international studies in this meta-analysis the dose of aspirin was up to 300 mg a day (one adult aspirin) but that in the U.S. the usual recommended aspirin “low” dose is 81 mg. ( a baby aspirin) daily The higher the dose of aspirin the more likely it is to cause bleeding.

DEET insect repellent is safe to use on anyone over the age of two months.
“The American Academy of Pediatrics states that insect repellents with DEET are safe to use on children as young as two months old.” Apply only once a day, but you can use any concentration from 7% to 25%. The higher concentration isn’t any more effective, but its protection lasts longer. DEET protects against tick bites too.

Statistics NEVER lie, … or can they?
Published medical research produces data that meets statistical standards of “significance” which reassures the reader that the findings are “true”. Meta-analysis studies ( a technique of comparing data results from different studies and treating them as if they are all from the same study) are the current epitome of statistical correlations. The interpretation of statistics, however, is not standardized, and epidemiology (the science of statistics applied to large populations) has been called by some cynics as “the art of lying on a grand scale.”  Here’s an example of the potential pitfalls in interpreting statistics:

700,000 physicians “cause” 120,000 accidental deaths per year for a rate of
.171% accidental deaths per physician per year

There are 1,500 accidental gun deaths per year and 80 million (yes, million) U.S. gun owners for a rate of .0000188% accidental gun deaths per gun owner per year.

THEREFORE, statistically, doctors are approximately
9,000 times more dangerous than gun owners.

We withheld the statistics on ….Lawyers !
for fear the shock would cause people to panic and seek medical attention! (3)

1. Arch Int Med June 2010:170:1024
2. NEJM 366;25 June 21, 2012, pg. 2421
3.  thanks to Bob Harrington for picking this pearl off the web
4. Overdiagnosed: Making People Sick in the Pursuit of Health
H. Gilbert Welch, MD, Lisa M. Schwartz, MD, Steven Woloshin, MD

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