Monday, October 27, 2003

Point B Medicine - The VA 

When I trained we used to make fun of the VA. Now they do better then we do. See NEJM -- Medical Care -- Is More Always Better? and NEJM -- Hospital Use and Survival among Veterans Affairs Beneficiaries.

Here is something simlar: Ann Intern Med -- Abstracts: Fisher et al. 138 (4): 273 and Ann Intern Med -- Abstracts: Fisher et al. 138 (4): 288

Nobody in the culture I'm in wants to do less.

Friday, October 24, 2003

Point B Medicine - Mammograms 

Check out Yahoo! News - U.S. Doctors Do More Breast Cancer Tests and JAMA -- Smith-Bindman et al. 290 (16): 2129.

We do twice the mammograms to get the same outcome.
Point A medicine is doing the "right amount". Some mammograms are better than none. Point B medicine is extra ones for no benefit. Point C medicine is so many that we do harm.

I don't perceive any forces trying to reduce the number of mamograms. Under the guise of advocacy, all I see are strategies to do more.

The additional tests are harm. There is apprehension associated with the additional testing and extra biopsies.

We view normal biopsies as a success.

Monday, October 20, 2003

Colon Cancer Screening 

There is no doubt that dying of colon cancer is bad. Yet, the numbers don't make the screening decision easy for me.
I do initiate the subject with all patients at age >= 50.
We begin with: Do you want to participate in colon cancer screening or not? Start with the number needed to screen to prevent one death from Lancet, 1996 Nov 30;348(9040):1472-7 using a traditional method (occult blood then colonoscopy if abnormal).

RRR= 15%
ARR= 0.082%
Number needed to screen for 7.8 years [NNS] = 1220

What about the risks? Using Harm from endoscopy or colonoscopy from the Bandolier folks we get:

Number needed to harm [NNH] for death = 5000
NNH for morbidity = 440

At this point, some patients are not interested and I don't make any attempt to change their mind.

The alternative strategy is colonoscopy every 10 years.
The NNH is the same as before and known.
The NNS = ???

This is why we should hold new interventions to a higher standard. Colonoscopy ought to be better but we don't know. However, we do have a strategy with known risk and benefit.

To put it another way: What would the NNS need to be to offset the occasional injury to a patient without disease?
Harm to a patient evaluating rectal bleeding isn't the same as harm during screening.

Screening tests should be held to an even higher standard than diagnostic tests because it is morally worse to harm a well person than a sick person.

Friday, October 17, 2003

Medical Blogs 

I've been following several for the past few months.
Perhaps there are others I've not found.
Most spring from the fountain that I call the "bottom of the medical food chain". Medical and surgical subspecialists don't seem to have anything to say.

Thursday, October 16, 2003


In the past year I recertified my ACLS and declined to renew my family practice boards.
One is important and the other isn't.

It's only a matter of time until there is a code in my office plus my group practice requires maintenance of ACLS.

The physician executive committee struggled with requiring board certification. There isn't any research to support board certification so we fund it but don't require it.

I do note the consumer advocacy articles ("how to choose the right doctor...") that recommend choosing a board certified doctor. I suppose I can do without those potential patients.

I would rather be graded on outcomes and paid to manage a population.
This is a scary thought to doctors because it's so easy to get by while hiding behind a traditional medical education. Entry and completion are hard but you get to coast and quit learning when you are done.

Monday, October 13, 2003

Outcomes - Clopidogrel (Plavix) 

For combined anti-platelet therapy (aspirin and Plavix) there are two major outcomes studies:
1. CURE Trial, NEJM, Vol 345, No. 7, August 16, 2001, 494-502. This one is relevant for non-ST acute coronary syndromes. The cardiologists in my institution made Plavix a routine discharge Rx.
Yet, there isn't a death benefit, only the less powerful "combined endpoint" of death plus non-fatal MI plus stroke.
Relative risk reduction [RRR] = 18.4%
Absolute risk reduction [ARR] = 2.1%
Number needed to treat [NNT] = 48

Seems high to me since there isn't a death benefit.
Using $130/month for the drug x 9 months x 48 patients = $56,160 to prevent one non-fatal event. Hmmm...seems more like shared decision making to me rather than a recommendation. Most patients ask me in follow up how long they need this and how important it is.
Which leads me to the next trial. The reps claim this one changes the intervention from valid to important.

2. CREDO Trial, JAMA, November 20, 2002, Vol 288: No. 19, 2411-2420. This was additional Plavix with aspirin for elective percutaneous coronary intervention (PCI), i.e. "stents" in patients with known coronary artery disease (CAD). One endpoint (28 days out, combined death, MI and urgent revascularization) did not meet statistical significance. The other endpoint (1 year outcome with composite of death, MI and stroke) did reach significance (but with 37-39% dropout rates in the two groups):
RRR = 26.9%
ARR = 3%
NNT = 33

So, $130 x 12 months x 33 patients = 51,480 to prevent one combined endpoint.
The functional outcome is a hospital intervention and a discharge Rx for Plavix that the patient fills once.

There is a newer perspective: NEJM 2002; 346:1800–6, and a POEM: JFP POEM.

Friday, October 10, 2003

Help, I'm Spending Too Much Time With My Patients! 

I wondered if the "typical" office practice would compare favorably with reality using some national standards.
1. Start with the American Academy of Family Physicians (AAFP) resource FPM Toolbox.

2. Go to Getting Paid - July/August 2002 -- Family Practice Management. Assume a mature practice so the visits are established patients. Apply the benchmark distribution as %:
99211 = 3.64
99212 = 16.26
99213 = 61.16
99214 = 16.44
99215 = 2.50

3. Go to Coding on the Basis of Time. I figure the benchmarks are about right:
99211 = 5 minutes
99212 = 10 minutes
99213 = 15 minutes
99214 = 25 minutes
99215 = 40 minutes

4. There are 365 days in the year but 2 of 7 are weekend days and 7 are "major holidays". So, I can only see patients a maximum of 365 - (52 x 2) - 7 = 254 days/year. I can get 7 hours of patient care in an 8 hour business day.

5. Convert everything to hours: A year has, 254 x 7 = 1778 total patient care hours available but a vacation costs me 7 x 5 = 35 more. So, a year with 3 weeks off leaves me, 1778 - (35 x 3) = 1673 hours.

6. I don't take a 1/2 day out but most FP's I know do. That would cost, (52 - 3) x 3.5 = 171.5 hours each year. That means, 1673 - 171.5 = 1501.5 hours are available. Let's call that "supply".

7. Now, calculate "demand". Given, OV = number office visits/year, demand =
(OV x 0.0364 x 5 / 60) +
(OV x 0.1626 x 10 / 60) +
(OV x 0.6116 x 15 / 60) +
(OV x 0.1644 x 25 / 60) +
(OV x 0.0250 x 40 / 60).

8. The MGMA Medical Group Management Association, an organization for medical group practice managers (sorry but you have to be a member to get the report) says a group practice FP in my region needs 4608 office encounters/year.

So, an average FP (taking 3 weeks off and 1/2 day/week) = 1240 hours of demand.
Compare with supply and learn: 1501.5 - 1240 = 261.5 hours left over. That doc would need to take over 7 more weeks of vacation to be in balance!

9. What if I use my actual numbers? In the last 12 months, I saw 5784 office patients. So, my demand = 1557 hours of pre-determined care. Since I don't take a 1/2 day off but do take about 4 weeks of vacation/year, my supply = 1778 - (35 x 4) = 1638. If I compare suppy and demand, then 1638 - 1557 = 81 hours.
It would still take over 2 weeks vacation to be back in balance.
I guess another way of looking at it would be: 81 hours = 4860 minutes. When I compare that to 5784 visits/year it comes out to 50 seconds too much for each visit.

Thursday, October 09, 2003

Medical Parable #1 - The Sinking Ship 

My source: Quinn Parables

The ship was sinking---and sinking fast. The captain told the passengers and crew, "We've got to get the lifeboats in the water right away."

But the hospitals said, “First we need relief from indigent care and specialty hospital competition. Then we'll take care of the lifeboats."
Then the government said, "First we need medical errors eliminated and care for the uninsured. Then, we will mandate lifeboats without funding them.”
Then the insurance companies said, “First we need to approve lifeboats. The lifeboats you have are experimental and out of network."
Then the pharmaceutical companies said, “First we need our proprietary lifeboats deployed. We didn’t spend all this money on R&D (aka direct to consumer advertising and political donations) to use just any lifeboat.”

The captain said, "These are all important issues, but they won't matter a damn if we don't survive. We've got to lower the lifeboats right away!"

Then the primary care doctors said, “First we want equal pay for equal work. Then, the seating in the lifeboats will be allocated fairly.”
Then the specialists said, “First we need assurance that our professional autonomy remains unrestricted. We have valuable experience as the captain of a sinking ship.”
Then the nurses said, “First we need to know that our administrative burden won’t grow while we're in the lifeboat. Also, is there any opportunity for advancement? We are already over 100% of capacity so the lifeboats will just have to wait.”
Then the patients said, “First give us what we want, then what we need. We want the most expensive lifeboat now.”

Finally the ship sank, and because none of the lifeboats had been lowered, everyone drowned.
The last thought of more than one of them was, "I never dreamed that solving medicine’s problems would take so long---or that the ship would sink so SUDDENLY."

Weapons Grade Arrogance #3 - ACOG and Pap Smears 

I recall a recent press release that ACOG (American College of OB/Gyn) updated their Pap smear guidelines.
Interestingly, the National Guideline Clearinghouse NGC doesn't have any ACOG guidelines (try browsing by organization).

So, I go to their web site, American College of Obstetricians and Gynecologists Public Home Page, and find this: Cervical Cancer Screening: Testing Can Start Later and Occur Less Often Under New ACOG Recommendations.

So far so good until the statement (my emphasis): In its most comprehensive revision of Pap test and other cervical cancer screening recommendations in over a decade, The American College of Obstetricians and Gynecologists (ACOG) has issued a new, evidence-based practice bulletin, "Cervical Cytology Screening." ACOG notes that an increasing number of women will no longer need annual testing for cervical cancer and that screening can also begin later than previously recommended. However, annual pelvic examinations are still advised for women across a broad age range.

They finally acknowledge:
1. The interval between screening can be longer
2. The age to initiate is later, and
3. There is no basis for a Pap smear after a hysterectomy for benign disease.

However, they push the current evidence envelope too far for me (any outcomes data?):
1. Age 30?
2. HPV?
3. 2nd generation Pap smears?

I would like to see the references and grades of evidence but there aren't any.

Just as, "Patriotism is the last refuge of a scoundrel (Samuel Johnson)", so is throwing around "evidence-based" when it doesn't apply.

Wednesday, October 08, 2003

Collective Medical Nouns 

A shrewdness of apes [cardiologists]
A culture of bacteria [infectious disease docs]
A sleuth of bears [social workers]
A swarm of bees [residents]
An obstinacy of buffalo [neurosurgeons]
A brace of bucks [physiatrists]
A brood of chickens [hospitalists]
A clutch of chicks [nurses]
A bed of clams [occupational medicine]
A cover of coots [interns]
A float of crocodiles [urologists]
A murder of crows [oncologists]
A cowardice of curs [ER doctors]
A pod of dolphin [ER nurses]
A pace of donkeys [medical directors]
A convocation of eagles [pathologists]
A gang of elk [insurance companies]
A mob of emus [LASIK surgeons]
A business of ferrets [anesthesiologists]
A charm of finches [boutique physicians]
A gaggle of geese [internists]
A band of gorillas [proctologists]
A leash of greyhounds [physician assistants/nurse practitioners]
A down of hares [dermatologists]
A cast of hawks [ortho techs]
An array of hedgehogs [biostatisticians]
A hedge of herons [radiologists]
A bloat of hippopotami [gastroenterologists]
A deceit of lapwings [drug reps]
An ascension (exaltation) of larks [hospital administrators]
A pride of lions [surgeons]
A plague of locusts [ID, again]
A stud of mares [orthopedists]
A richness of martens [plastic surgeons]
A bevy of roebucks [plastic surgery patients]
A labor of moles [obstetricians]
A barren of mules [infertility specialists]
A watch of nightingales [neonatologists]
A parliament of owls [out of town consultants]
A pandemonium of parrots [pediatricians]
An ostentation of peacocks [CV surgeons]
A litter of pigs [paramedics]
An unkindness of ravens [mammograms]
A walk of snipe [physical therapists]
A run of salmon [sports medicine docs]
A flock of sheep [tradionalists, usually internists]
A host of sparrows [pink ladies]
A cluster of spiders [radiologists]
A murmuration of starlings [cardiologists]
A mustering of storks [office managers]
A flight of swallows [experts]
A sounder of swine [ENT's]
A mutation of thrushes [radiation oncologists]
An ambush of tigers [national guidelines by “experts”]
A knot of toads [surgeons]
A hover of trout [ICU intensivist's]
A pitying of turtledoves [hospice directors]
A school of whales [faculty]
A knob of wildfowl [rheumatologists]
A fall of woodcocks [geriatricians]
A descent of woodpeckers [docs on probation]
A zeal of zebras [third year medical students]

Friday, October 03, 2003

Stupid PCP Tricks #2, Ear Temps 

This morning, parents were in with a child. The issue of ear vs oral vs skin vs rectal temps came up.
Years ago, I figured out the actual temp reading in my office setting rarely changed the intervention.
Yet, we dutifully record ear temps in the chart that are not even compatible with life.
The expection that I have with my staff it not to routinely measure temps at all. Then, if I really need the number, I ask for it.

This got me thinking about some recent reading Wired 11.08: Totally Random. Turns out, a random number generator is already widely available. I call it the ear thermometer.

Stupid PCP Tricks #1, Pneumonia Vaccine 

It's that time of year, when some doctor that can't look something up starts allowing/recommending extra Pneumovax just because somebody else does. I've already been asked by two patients this week and a doctor about the interval for repeat vaccination.
According to the CDC, no one would ever get more than two and most will only ever have one Recommended Adult Immunization Schedule --- United States, 2002--2003.

Thursday, October 02, 2003

Medical Meme #1 Of Breasts, Caffeine and Vit E 

The surgeons and gyns are still telling my patients to avoid Caffeine and Vit E for pain or "fibrocystic" changes.
PCP's probably do too, I just wouldn't know.
Suspecting there isn't much to support this (pun intended), I did a literature search. My emphasis...

For Caffeine:
1. The effect of decreased caffeine consumption on benign proliferative breast disease: a randomized clinical trial.
Surgery. 101(6):720-30, 1987 Jun.
A single-blind, randomized clinical trial of 56 female subjects was conducted to determine whether decreased consumption of caffeine decreases breast pain/tenderness or nodularity in patients with suspected benign proliferative breast disease. The subjects were randomly assigned to one of three groups--a control group (no dietary restrictions), a placebo group (cholesterol-free diet), and an experimental group (caffeine-free diet). At the initial examination, the subjects reported on the presence of breast pain, the degree to which pain affects daily activities, the frequency of pain, the degree of pain associated with breast examinations, and the degree of pain associated with close-fitting clothing. Subjects were then examined and the four quadrants of each breast were rated on a scale of 0 to 3 (0 = normal, fatty tissue, 1 = little seedy bumps or fine nodularity, 2 = discrete nodules or ropy tissue, 3 = confluent areas, hard or soft masses). Subjects in all three groups returned for 2- and 4-month follow-up examinations. Total nodularity scores, degree of pain/tenderness, and compliance with dietary restrictions were analyzed. The data showed that decreased caffeine consumption did not result in a significant reduction of palpable breast nodules or in a lessening of breast pain/tenderness.

2. Effects of caffeine-free diet on benign breast disease: a randomized trial.
Surgery. 91(3):263-7, 1982 Mar.
There is considerable interest in the potential effect on benign disease of a diet free of methylxanthines (caffeine, theophylline, and theobromine) found in coffee, tea, colas, and chocolate. We randomly assigned 158 women who presented with a breast concern either to a group encouraged to abstain from methylxanthine-containing foods and beverages or to a group who received no dietary recommendations (controls). At the initial visit each patient's sociomedical history and data on methylxanthine consumption were obtained by interview, and clinically palpable breast findings were graded on a scale of 0 to 4 (no nodularity to confluent hard "dysplasia") for each quadrant of both breasts. On the follow-up visit approximately 4 months later similar information was obtained. Mammograms were taken at both visits for a subset of women in each group. We found a statistically significant reduction in clinically palpable breast findings in the abstaining group as compared with controls, but the absolute change was minor and may be of little clinical significance. Comparison of before-after mammograms offered little support for the methylxanthine hypothesis. There was no relation between clinically palpable breast finding scores at initial examination and caffeine consumption levels reported at that time.

For Vit E:
Vitamin E and benign breast "disease": a double-blind, randomized clinical trial.
Surgery. 97(4):490-4, 1985 Apr.
We report here the results of a double-blind, randomized trial of the effect of vitamin E on clinically palpable benign breast findings. Seventy-three women who attended a breast screening clinic were assigned randomly to either a daily regimen of 600 IU vitamin E (n = 37) or a placebo (n = 36). At the initial visit sociomedical information was obtained for each patient and breast examination performed, with a score ranging from 0 to 4 recorded for each quadrant of both breasts. Thirty-two women in the vitamin E group and 30 in the placebo group returned for follow-up breast examination approximately 2 months later. Scores for mean ages and breast findings at entry were similar for women in the two groups. We found no differences between the vitamin E and placebo groups in scores for changes in breast findings at the end of the study period and no differences in the proportion of women who reported feeling less premenstrual pain (40.0% and 41.4%, respectively). We conclude that in this group of women with breast findings, most of which were not currently serious enough to warrant biopsy, there was no beneficial effect of vitamin E taken during a 2-month course.

Wow, a couple hundred patients in the 80's sure impresses me.

Medical Memes aka "You can't go swimming after lunch..." 

...because you will get stomach cramps and drown.

Why do we perpetuate bad medical information?
Every time I try and track down the source of something already accepted as fact, I'm disappointed to find the lack of the original reference (the trail just ends) or the quality of the initial work (n=few).
I think there is something about early traditional medical education that causes this.
Along the line of, Urban Legend, I like to call these "Medical Memes" after Memes and Viruses of the Mind.

Evidenced Based Medicine (EBM) 

Disruptive technology or fad?
Religion or cult?

Wednesday, October 01, 2003

False Positive #1 

True story.
49 year old woman.
Earlier this year, we decided after shared decision making and the AAFP handout Breast Cancer Screening Counseling Tools -- American Academy of Family Physicians to wait on a mammogram until age 50.
She needed a hysterectomy go I sent her to a gyn.
The gyn recommended a mammogram and she agreed. The gyn scheduled the test. No result to me. I'm used to that...
The screening mammogram was inconclusive and since no comparison, the radiologist recommended a diagnostic mammogram and ultrasound. I get involved since she is one of my managed care patients.
The tests show a cyst and the radiologist recommended a repeat mammogram in 6 months.
My office lets her know that I'm OK with the radiology recommendation if she is. She is.
I send the gyn a copy of the diagnostic mammogram.
Gyn calls her to recommend seeing a general surgeon. Gyn then calls me. We discuss. I tell gyn that I would rather manage the problem.
Patient calls my office to get the approval.
I have her come in and we talk. She decides to wait and have the 6 month repeat rather than seeing a surgeon.
I explain "false positive" to her (again).

Weapons Grade Arrogance #2 

True story.
67 year old woman. Recent addition to my managed care panel.
Stage II breast cancer 6 years ago. Even survived the stem cell transplant that she did not need.
I get interrupted in an exam room to speak with the radiation oncologist. The patient is at the other office for an appointment and there is no authorization for the visit.
Turns out, the appointment was made one year ago.
The radiation oncologist tells me it is her routine to have patients come right over the same day from their mammogram with the films. She alleges only a radiation oncologist can accurately read the Xrays. Normal radiologists aren't qualified.
I point out the evidence Cancer.gov - Breast Cancer (PDQ?): Treatment.
I remind the radiation oncologist that the patient is 6 years out and doesn't need to see her anymore. The specialist says the patients refuse to leave her practice and reminds me how poorly she gets paid to see patients in the office (like an FP wouldn't know this?) when she could be aiming Xrays someplace.
I tell the specialist I could see her predicament but I did not have any flexibility since the patient was 6 years out. Maybe if the patient was < 5 years? Specialist says nope, would get the same advice. What if I sent a new diagnosis over? Could I count on the specialist to create a different expectation about the follow up care? Nope again.
Specialist chooses to see the patient without an authorization. We agree to disagree. The conversation takes 23 minutes.
Later, specialist calls me back and again I am pulled from a room. I am told the patient is going to change PCP's.
As luck would have it, I'm going to the utilization committee meeting the same day. I ask permission to tell this story. Just like the people interviewed in Bowling for Columbine she agrees. I guess when you are so sure you are right, you can't see the trap.
I tell the story. It resonates with the PCP's. The specialists at the meeting discount it because they are not convinced this kind of stuff happens very often.

Did I mention that the patient has type 2 diabetes and a previous CVA? Her chance of dying of cardiovascular disease dwarfs the chance of dying of breast cancer.

Take the Crestor Pledge! 

The doctors in my office agreed to refuse to Rx the new statin on the basis there are already competitors with long term safety (Baycol anyone?) and outcomes data (Lipitor?).
I was pleased to see the advocacy group had the same conclusion already and felt strongly enough to make the link free Worst Pills, Best Pills News Online - Do Not Use! Rosuvastatin (Crestor) - A New But More Dangerous Cholesterol Lowering 'Statin' Drug.

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