Archive for the ‘Uncategorized’ Category

PSA Police?

Sunday, November 29, 2015 // Uncategorized

Screening for prostate cancer is controversial for reasons outlined in this article from the Wall Street Journal, but now it is taking a new turn. The government is becoming more aggressive in determining what high quality care is. Before they would not pay for certain tests or medications that were unapproved. Now, they will actually penalize doctors. This goes way beyond educating the public. It interferes with shared decision making by patients and their doctors.

Doctors Could be Penalized for Ordering This Test
Wall Street Journal

November 20, 2015

By Melinda Beck

Medicare officials are considering a measure that would penalize doctors who order routine prostate-cancer screening tests for their patients, as part of a federal effort to define and reward quality in health-care services.

The proposal, which hasn’t been widely publicized, has prompted a flurry of last-minute comments to the Centers for Medicare and Medicaid Services, including more than 200 in the past two days, virtually all in opposition. The official comment period began Oct. 26 and ends Friday.

Many of those commenting said the measure would discourage doctors from discussing the pros and cons of screening for prostate-specific antigen (PSA) with their patients and allowing them to decide, as several major medical groups recommend.

“PSA screening is a very controversial topic. The debate is ongoing and people feel very strongly about it, one way or another,” said David Penson, chair of public policy and practice support for the American Urological Association, which urged CMS to reject the proposal. “To make it a quality measure would say, ‘You’re a poor quality doctor if your patients get this test.’ ”

The proposed measure is part of continuing federal efforts to develop ways to identify and reward value in health care. The Obama administration has said it plans to tie 50% of Medicare payments to such quality measures by 2018.

Since 2012, the U.S. Preventive Services Task Force has recommended against routine screening for prostate cancer for men of any age on the grounds that the benefits don’t outweigh the harms.

Studies have shown that screening reduces the risk of death from prostate cancers only minimally, if at all, because most grow so slowly they effectively are harmless.

Yet many men diagnosed with prostate cancer undergo surgery and radiation, which can have lifelong side effects.

Meanwhile, about 28,000 U.S. men die annually from aggressive prostate cancers, often despite getting regular PSA tests and fast treatment.

Both the rate of PSA testing, and diagnoses of early-stage prostate cancer, have declined significantly in the U.S. in recent years, according to studies published in the Journal of the American Medical Association this week. But whether treating fewer cancers early results in more deaths from late-stage prostate cancer later won’t be known for many years.

A CMS official said that as currently drafted, the proposed measure addresses only “non-recommended PSA screenings”—that is, “men who get PSA screening when, under current clinical guidelines, it is not recommended for them.” She said it wouldn’t restrict needed or medically necessary PSA tests.

“Physicians can still order PSA tests if they feel the test is recommended or if the patient requests it,” she said.

The proposal lists some categories of men who would be excluded from the measure, including those with a history of prostate cancer or enlarged prostate, prior elevated PSA levels, or those taking certain medications for prostate issues. It doesn’t mention men at high risk for prostate cancer due to family history or African-American heritage. Some experts say the benefits of screening may outweigh the harms for such patients.

Wanda Flier, president of the American Academy of Family Physicians, which is working with CMS on other quality measures, said it planned to urge the agency to adopt a more flexible measure for PSA screening that would allow for shared decision-making between a patient and physician based on individual circumstances.

“Our goal, as we move to value-based care, is to get to a system that is based on evidence and individual circumstances and not create harm to the patient or undue economic harm to the country,” she said.

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Blood Pressure: How Low Do You Go?

Sunday, November 15, 2015 // Uncategorized

retro This article got a lot of press and a lot of patient’s questions when the study was ended prematurely several months ago.  I couldn’t answer patient’s questions on the news release because the study hadn’t been published.  Now it has been on November 9th and the results only apply to high risk patients who are being treated for  hypertension.

Bottom line:Treating to a lower blood pressure goal in high risk individuals may be of benefit, but it comes at a potential cost.

Here is the summary from Journal Watch.

SPRINT: Intensive Blood Pressure Control Tied to Lower Adverse CV Events

By Allan S. Brett, MD

Dr. Brett is editor-in-chief of NEJM Journal Watch General Medicine, from which this summary was adapted. See full coverage at the link below.

Treating to a systolic blood pressure target of 120 mm Hg lowered the incidence of adverse cardiovascular events in a high-risk population, according to the SPRINT study published in the New England Journal of Medicine and presented at the American Heart Association’s annual meeting.

Researchers enrolled roughly 9400 patients (age 50 or older) with a systolic BP of 130 to 180 mm Hg and high cardiovascular risk but without diabetes or stroke. Patients were randomized to either intensive or standard treatment (systolic BP targets, 120 or 140 mm Hg, respectively). The researchers were permitted discretion in choosing drug regimens.

The trial was terminated early after a median follow-up of 3.3 years, during which participants’ average systolic BPs were 121.5 mm Hg and 134.6 mm Hg in the intensive- and standard-treatment groups, respectively. The primary composite outcome (myocardial infarction, non-MI acute coronary syndrome, stroke, heart failure, or CV-related death) occurred in 5.2% of intensive-treatment patients and 6.8% of standard-treatment patients. Two individual components of the composite outcome were significantly lower with intensive treatment — heart failure (1.3% vs. 2.1%) and CV-related death (0.8% vs. 1.4%). All-cause mortality also was significantly lower with intensive treatment (3.3% vs. 4.5%).

Several serious adverse events were significantly more common with intensive than with standard treatment: incidences of hypotension, syncope, and electrolyte abnormalities were each about 1 percentage point higher, and incidence of acute kidney injury was about 2 percentage points higher. Among patients without CKD at baseline, the incidence of a >30% decline in glomerular filtration rate was significantly greater with intensive treatment (3.8% vs. 1.1%).

SPRINT has demonstrated that aiming for a systolic BP of 120 mm Hg can lower the rate of adverse cardiovascular events; to prevent 1 event, 61 patients had to be treated for 3.3 years. Keep in mind that SPRINT was limited to middle-aged and older patients at above-average CV risk and that diabetic patients were excluded. Whether the decline in GFR associated with intensive treatment represents a harmless hemodynamic effect or more-serious renal injury is unclear.

Clinicians must understand that BP measurements in this study were based on the average of the three readings, taken automatically at 5-minute intervals with no clinician in the room. This method yields substantially lower readings than does a single measurement by a clinician. If SPRINT is applied without attention to proper BP measurement, substantial overtreatment — with a higher rate of adverse events — likely will occur.

Finally, note that the average achieved systolic BP in the intensive-treatment group (121.5 mm Hg) remained higher than the 120 mm target. This likely represents judicious balancing by treating clinicians who tried to approximate the 120 mm goal while avoiding side effects and excessive polypharmacy.

 

retro SPRINT: Intensive Blood Pressure Control Tied to Lower Adverse CV Events

By Allan S. Brett, MD

Dr. Brett is editor-in-chief of NEJM Journal Watch General Medicine, from which this summary was adapted. See full coverage at the link below.

Treating to a systolic blood pressure target of 120 mm Hg lowered the incidence of adverse cardiovascular events in a high-risk population, according to the SPRINT study published in the New England Journal of Medicine and presented at the American Heart Association’s annual meeting.

Researchers enrolled roughly 9400 patients (age 50 or older) with a systolic BP of 130 to 180 mm Hg and high cardiovascular risk but without diabetes or stroke. Patients were randomized to either intensive or standard treatment (systolic BP targets, 120 or 140 mm Hg, respectively). The researchers were permitted discretion in choosing drug regimens.

The trial was terminated early after a median follow-up of 3.3 years, during which participants’ average systolic BPs were 121.5 mm Hg and 134.6 mm Hg in the intensive- and standard-treatment groups, respectively. The primary composite outcome (myocardial infarction, non-MI acute coronary syndrome, stroke, heart failure, or CV-related death) occurred in 5.2% of intensive-treatment patients and 6.8% of standard-treatment patients. Two individual components of the composite outcome were significantly lower with intensive treatment — heart failure (1.3% vs. 2.1%) and CV-related death (0.8% vs. 1.4%). All-cause mortality also was significantly lower with intensive treatment (3.3% vs. 4.5%).

Several serious adverse events were significantly more common with intensive than with standard treatment: incidences of hypotension, syncope, and electrolyte abnormalities were each about 1 percentage point higher, and incidence of acute kidney injury was about 2 percentage points higher. Among patients without CKD at baseline, the incidence of a >30% decline in glomerular filtration rate was significantly greater with intensive treatment (3.8% vs. 1.1%).

SPRINT has demonstrated that aiming for a systolic BP of 120 mm Hg can lower the rate of adverse cardiovascular events; to prevent 1 event, 61 patients had to be treated for 3.3 years. Keep in mind that SPRINT was limited to middle-aged and older patients at above-average CV risk and that diabetic patients were excluded. Whether the decline in GFR associated with intensive treatment represents a harmless hemodynamic effect or more-serious renal injury is unclear.

Clinicians must understand that BP measurements in this study were based on the average of the three readings, taken automatically at 5-minute intervals with no clinician in the room. This method yields substantially lower readings than does a single measurement by a clinician. If SPRINT is applied without attention to proper BP measurement, substantial overtreatment — with a higher rate of adverse events — likely will occur.

Finally, note that the average achieved systolic BP in the intensive-treatment group (121.5 mm Hg) remained higher than the 120 mm target. This likely represents judicious balancing by treating clinicians who tried to approximate the 120 mm goal while avoiding side effects and excessive polypharmacy.

Why We Chose This as Our Top Story:

André Sofair, MD, MPH: This well-designed study reiterates the importance of individualized blood pressure control. It demonstrates that in certain high-risk patients, more aggressive BP targets may be warranted.

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Blog Is Back! Should Doctor’s Go Bare?

Wednesday, November 4, 2015 // Uncategorized

I was having technical difficulties that prevented me from blogging for the past month.  Fortunately, these have been resolved.

The white coat is a time honored symbol of the medical profession. Medical schools have a  White Coat Ceremony where they are given their white coats. I gave up white coats 12 years ago because I felt that they intimidated some patients possibly contributing to “White Coat Syndrome” and because I also felt that they could, like doctor’s ties, transmit disease.  More people have been advocating recently that doctors abandon this tradition.

Should Doctors Go Bare? Infection Control Debate Rages

Hospital-acquired infections and the rise of drug-resistant organisms has put new focus on whether requiring doctors to go “bare below the elbows” (BBE) would help infection control. BBE means no long sleeves, no neckties, no wristwatches, no jewelry other than a wedding band, and generally that physicians will wear scrubs.

The practice was adopted in the UK in 2008. But it appears to be a tough sell in the US. At a debate today at IDWeek 2015 in San Diego, two physicians squared off in a friendly—and highly entertaining—debate.

Michael Edmond, MD, MPH, MP,of the University of Iowa Hospitals and Clinics said his hospital is going BBE January 1, 2016.  He took the “yes” side of the debate. Neil Fishman, MD, of Penn Medicine in Philadelphia, PA, took the “no” side and closed his debate with a hip-hop style rap.

Edmond began by citing studies that showed how dirty and microbe-contaminated lab coats could get. Though some surveys have shown patients prefer to see their doctors in coats and ties, “Patients preferences vary” and the survey techniques may bias the answers, he said.

Edmond said he was convinced that BBE would help infection control since staph and other organisms persist on clothing, lasting over a month on white coats, particularly if they are polyester not cotton.

One survey showed the iconic white coats are laundered infrequently, with about half the physicians in one survey saying they washed them once a month. “Quite appallingly, 20% said they had never washed them,” Edmond said.

Though there have not yet been any random controlled studies showing that patients treated by physicians wearing white coats and ties had higher rates of preventable infections that those treated by BBE physicians the concept “has biologic plausibility,” Edmond said. Further, trying BBE has “no risk, except to some people’s egos” and minimal cost.

Nonsense said Fishman. “There is no evidence that BBE works,” he said. With all the headaches and challenges physicians and hospital face “You want us to be fashion police too?” Fishman presented a slide show that featured hairy forearms, tattooed forearms, and arms of men with plaque psoriasis, suggesting that baring forearms could be unprofessional and even hazardous.

And what about the “commit to sit” doctrine that encourages physicians to talk to patients at eye level, not tower above them. “Will going bare below the knee be next?” he asked. Edmond, showing photo of a filthy white coat he said belonged to a coworker, said it was simply common sense to think BBE would be safer and cleaner. “Your mother would tell you that,” Edmond said.

Fishman responded with quotes from a UK physician who charged that the BBE practice of wearing scrubs had led to a “less robust view of infection control” in which physicians began to neglect hand-washing and acquired “a slovenly personal appearance.” Other complaints were that doctors never knew what time it was and had “no place to put their stuff,” he said.

In a straw poll after the debate, the audience sided 58% to 42% with Fishman, who at one point showed a slide of himself in a white coat, his arm around the shoulders of a life-sized cutout of Pope Francis, a recent visitor to Philadelphia. The pontiff was wearing white vestments, Fishman pointed out.

Ending the debate on a more serious note, Edmond challenged Fishman to compare his hospital’s infection data with Edmond’s after the Iowa hospital ho has started its BBE policy. He is confident there will be fewer hospital-aquired infections, he said.

Editor’s note: An earlier version of this story misstated Dr. Edmond’s institutional affiliation.

– See more at: http://www.hcplive.com/conference-coverage/idweek-2015/should-doctors-go-bare-infection-control-debate-rages?utm_source=Informz&utm_medium=HCPLive&utm_campaign=Trending_News_10-12-15#sthash.UsEBkxH0.dpuf

By the way, in spite of not having a white coat, some patient’s blood pressure  runs higher in the office than it does at home.

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High Blood Pressure: How Low Should We Go?

Tuesday, September 15, 2015 // Uncategorized

How low she one’s blood pressure be when being treated for hypertension?  That question has been debated for decades.  The last updated guidelines were in late 2014.  They created controversy by raising the optimal levels in patients 60 and over.  Here is a summary from Journal Watch:

December 30, 2014 JNC 8: Raising the Blood Pressure (and Ire) of Many Jamaluddin Moloo, MD, MPH Jamaluddin Moloo, MD, MPH

The Joint National Committee recommends that patients older than 60 be treated for hypertension only when systolic blood pressure exceeds 150 mm Hg. Jamaluddin Moloo, MD, MPHThe Joint National Committee (JNC) 8 guideline (published online in late December 2013 and printed in a February 2014 issue of JAMA) addresses blood pressure (BP) thresholds at which drug therapy should be initiated, BP targets during hypertensive treatment, and choice of antihypertensive agents (NEJM JW Gen Med Dec 24 2013).For patients younger than 60, JNC 8 specifies that drug therapy should be considered when diastolic BP is >90 mm Hg or systolic BP is >140 mm Hg. For older patients (age, ≥60), the diastolic BP threshold remains >90 mm Hg, but the systolic BP threshold is >150 mm Hg. Among people with diabetes or chronic renal disease, the threshold to initiate drug therapy is 140/90 mm Hg, and the goal for treatment is <140/90.In black patients, initial drug choices include thiazide-type diuretics or calcium-channel blockers (CCBs); in nonblack patients, initial drug choices were expanded (relative to JNC 7 recommendations) to include not just thiazide-type diuretics, but also CCBs, angiotensin-converting-enzyme (ACE) inhibitors and angiotensin-receptor blockers (ARBs) — but not β-blockers. JNC 8 recommends that patients with chronic renal disease generally should be prescribed ACE inhibitors or ARBs.Compared with the JNC 7 writers, the JNC 8 writing committee drew its conclusions more strictly from randomized-trial evidence and limited the scope of the guideline to drug therapy for hypertension. The most controversial and contested recommendation is the higher threshold (systolic BP, >150 mm Hg) for people older than 60. Some experts, and the American Society of Hypertension, recommend a target this high only for patients older than 80 (NEJM JW Gen Med Dec 24 2013). – See more at: http://www.jwatch.org/na36491/2014/12/30/jnc-8-raising-blood-pressure-and-ire-many#sthash.xG89nuBp.dpuf

 

Now the latest salvo comes from the NIH and a study that was stopped prematurely.  They issued a press release describing the results.  The problem is that it hasn’t yet be published and subjected to scrutiny as occurs with important clinical trials.  Here is the article from the New York Times:

 

Lower Blood Pressure Guidelines Could Be ‘Lifesaving,’ Federal Study Says

September 14, 2015 NIH: Aggressive Blood Pressure Management May Cut CV Events, Save Lives By Amy Orciari Herman Edited by André Sofair, MD, MPH

Reducing systolic blood pressure to below currently recommended targets may lower risk for cardiovascular events and death, according to findings from the NIH-funded SPRINT study announced on Friday.Some 9300 hypertensive adults aged 50 and older who were at high risk for heart disease or had kidney disease were randomized to one of two systolic BP targets: an aggressive target below 120 mm Hg, or a more conventional target below 140 mm Hg. Patients with diabetes or prior stroke were excluded.Participants were randomized between 2010 and 2013, and the trial was expected to go until 2017, but the researchers stopped it early after seeing the benefits of the intensive strategy. In that group, the risk for cardiovascular events was cut by nearly a third, and the mortality risk by almost a fourth, relative to conventional treatment.NEJM Journal Watch Cardiology’s Dr. Harlan Krumholz said: “Kudos to the NIH and the investigators for delivering on a challenging trial in this controversial area.The challenge for doctors and patients is to have patience because we only have the announcement at this point and lack the details to know how best to translate the study into practice.” – See more at: http://www.jwatch.org/fw110623/2015/09/14/nih-aggressive-blood-pressure-management-may-cut-cv#sthash.0r5DVThj.dpuf

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Book Review: Medical Quarterbacking

Wednesday, September 9, 2015 // Uncategorized

I haven’t read the book, but the review makes it sound interesting.

Medical Quarterbacking

Providers are drowning in patients. As a result, you need to fight tenaciously to make sure that you get the best care.

By
David A. Shaywitz

Sept. 8, 2015 7:25 p.m. ET

 

With gleaming hospitals, highly trained professionals, and ready access to new medicines and technologies, the American health-care system seems poised to provide the best care in the world—and sometimes it does. More often, explains Leslie D. Michelson in “The Patient’s Playbook,” people who are confronted by a serious illness discover that “there is no map.” There is no one with the time, information and stamina to coordinate, or “quarterback,” their care.

Mr. Michelson seeks to change all this. He isn’t a physician, but he has spent the past decade delivering what might be called concierge medical quarterbacking—helping patients, generally people with a high net worth, manage complex medical challenges. Now he’s ready to share his “playbook” with the rest of us.

The advice is often disarmingly simple. Prepare for illness when you are healthy. Get hold of your medical records. (You have a legal right to them.) Figure out which hospital you would want to go to in an emergency. He tells the harrowing story of parents who brought their jaundiced 2-day-old infant to the hospital where she was born, only to discover that the emergency-room staff there were used to adult patients and had minimal experience taking care of children.

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The Patient’s Playbook

By Leslie D. Michelson
Knopf, 320 pages, $24.95
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Mr. Michelson emphasizes the importance of a good primary-care physician—someone with whom you can have a relationship and who will orchestrate your care if you get sick. The challenge, he says, is that the typical primary-care physician sees 20 to 40 patients a day. How can such doctors, he wonders, “think clearly and carefully about each one?”

You might consider splurging for a primary-care physician in a concierge practice. If you want someone “who can give you an abundance of quality time at the drop of a hat,” Mr. Michelson writes, “then you should expect to pay extra for it.” But even if you cannot afford the concierge option, it is worth investing time in the selection process: develop a list of qualities you feel are important in a doctor, solicit recommendations, interview candidates. “Don’t start from the position that you can’t judge,” advises Mr. Michelson. For serious conditions, he counsels patients to seek out super-specialists—doctors who spend all their time thinking only about the disease you have. These experts tend to be found at top academic medical centers and are often deemed “in-network” by insurers, representing a rare health-care bargain.

 

Above all, Mr. Michelson implores patients to be intensely involved in their own care. Many people, when speaking with a doctor about a health problem, “behave as if they were powerless,” he writes. Some become deferential; others just want to leave as fast as possible. He urges patients instead to “bring their A-game” to the doctor’s office. Use a trusted resource like the National Institutes of Health or the UpToDate medical website to educate yourself about your condition; then, during your appointment, take notes and ask questions.

Vigilance is especially needed in hospital wards, where more than 10% of patients suffer a hospital-associated complication: a fall, an infection, an adverse drug reaction. Mr. Michelson’s counsel: Post a summary of your medical information near your bed and engage with the hospital staff so that you’re viewed as, say, a doting grandmother rather than merely the broken hip in Room 12B. Don’t take new medicines or submit to procedures in a hospital without understanding why they were ordered and insist that new symptoms—swelling, fever, pain—be promptly evaluated.

Why such intense oversight? The answer, Mr. Michelson suggests, is that while doctors may have entered medicine “to develop strong emotional bonds with people and to help them through health challenges,” providers now find themselves overwhelmed, drowning in patients, process and data. As a result, you need to monitor your own care attentively—and tenaciously fight to ensure you wind up with the most experienced surgeon or, after a biopsy, the most expert pathologist.

To his credit, Mr. Michelson advocates smart care, not more care. He devotes a chapter to the harms of unnecessary testing and gratuitous procedures, reminding readers that “overtreatment can be as dangerous as undertreatment.” A rush to treatment can also be a problem. Short of an emergency, it is important for patients, and doctors, to think things through. Mr. Michelson recounts the story of a man whose shortness of breath led him to a new doctor, a reflexively scheduled angiogram and the insertion of stents in his heart arteries well before a careful diagnosis had been made. The man’s problem, it turned out, wasn’t the heart but the lungs. The stent procedure was unnecessary.

While Mr. Michelson asserts that his various strategies deliver improved outcomes for patients, he supports this view with anecdotes, not data. Leading care organizations like Kaiser Permanente and Florida-based ChenMed would surely contend that their own patients do at least as well as the tiger patients that Mr. Michelson touts—without the extra financial and emotional costs that the Michelson approach would often seem to entail. But “The Patient’s Playbook” isn’t offering policy; it’s offering practical advice, preaching what many physicians and health-policy gurus practice when a loved one gets sick. It’s a timely reminder that, in our worthy effort to improve the health of populations, we should not lose sight of medicine’s primary goal: delivering the best possible care to each individual patient.

Dr. Shaywitz is chief medical officer of DNAnexus, a cloud genomics company, and a visiting scientist in the Department of Biomedical Informatics at Harvard.

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Screening for Prostate Cancer: A Urologist’s View

Monday, July 27, 2015 // Uncategorized

From the New York Times Op Ed page:

 

MELVILLE, N.Y. — FOR years, research on prostate cancer has sought an approach to screening that is more individualized than a one-size-fits-all measurement of the level of prostate-specific antigen in a man’s blood. These efforts are now paying off.

That’s why it’s time to re-evaluate the nation’s current approach to prostate cancer. Even though we anticipate 221,000 new diagnoses this year, and 28,000 deaths, recommendations drafted in 2010 and finalized in 2012 strongly discourage PSA screening men without symptoms for this disease.

Those decisions didn’t take into account adaptations that urologists have made to help better identify patients likely to develop deadly prostate cancers. Some tools, called PSA derivatives, were being developed as early as the mid-1990s, and all have been refined since.

The result: Rather than use the historical arbitrary cutoff of a 4.0 PSA reading to define abnormal, we now have tools to adjust our interpretation of readings for age (PSA levels normally rise with age); for race (this, too, affects what is considered normal); and for the size of a man’s prostate, which affects how much PSA he produces. We can test for how fast PSA levels rise over time. And we can analyze how PSA circulates in the bloodstream (free or bound to serum proteins), which can predict prostate cancer risk.

When we use these markers together, these varied interpretations of PSA levels give us a clearer picture of who does, or doesn’t, need further testing.

And we keep refining our approach. Already, a urine test can find and measure the presence of genes associated with prostate cancer. M.R.I. images can help identify high-risk prostate lesions. And tests for the presence or activity, or both, of genes present in prostate tissue can help distinguish which patients can safely defer therapy from those who cannot.

When prostate cancer is found, we also have better actuarial data to help identify those men likely to live long enough for that cancer to become a fatal risk.

Nevertheless, in 2012 the United States Preventive Services Task Force made official its recommendation that no asymptomatic man undergo screening with a PSA test. And that decision grew in importance when the Affordable Care Act elevated the task force’s recommendations from advisory to a basis for Medicare payment policies.

To be fair, measuring PSA as a stand-alone test is far from perfect. Cancer is just one of several conditions that can elevate PSA Using the test alone often led to painful biopsies that found no cancer. And we faced a more difficult problem: Even when a biopsy found cancer, uncertainty remained. If aggressive cancer was present, a decision to treat it was straightforward. But prostate cancer can grow slowly or remain dormant — indolent, in medical parlance. And until recently, we didn’t have the tools to determine whether cancers were likely to spread quickly enough to shorten the patient’s life.

In that circumstance, some patients whose cancers might have grown very slowly chose surgery or other rigorous treatment just to be safe, not sorry. But the price could be high; surgery always involves some risk of complications, including death, and cancer treatment can reduce quality of life.

Adding to the confusion was conflicting data on the effectiveness of prostate cancer screening. Despite strong evidence that the prostate-cancer-specific death rate has decreased since PSA testing started in the 1980s, the two largest studies of the screening produced contradictory results — one saw a decrease in prostate-cancer-related deaths among men screened, the other no advantage. Equally problematic, both were flawed methodologically. Yet instead of acknowledging uncertainty, the task force said PSA testing offered no benefit to anyone.

No increase in cancer mortality has been observed, but that may be a matter of time; aggressive cancers are less treatable. One study concluded that annual prostate cancer deaths may increase as much as 5 percent, for the first time in more than 20 years.

That is what frustrates urologists most: Rather than using refined screening techniques to identify those who will benefit most from treatment, we’re just evaluating fewer men. So the task force needs to re-evaluate its recommendation based on the current state of medical knowledge.

But men should not wait for a government agency to tell them what’s best. My own strongest recommendation is that men insist on a baseline PSA test while in their 40s. From this baseline, a personalized screening regimen that considers risk factors and other indicators can be developed.

Men must understand that screening does not commit them to further testing or treatment, even if abnormalities are found. Screening, followed up with today’s sophisticated tools, simply provides information that helps them and their doctors make sound decisions — which could prolong their lives, or leave them reassured that they have little to fear from an indolent tumor.

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Generational Differences in Physicians

Sunday, July 26, 2015 // Uncategorized

This was a recent article on Doximity , a website for physicians, that highlighted generational differences in the way physicians practice medicine.  It occurs in every profession, but medicine is one area where older doctors are very vocal in their criticism of the latest generation.  I remember advising one medical student who was interviewing for residency programs to avoid using the word “lifestyle” to avoid alienating the interviewer.  We think of it as a profession, a calling and they think of it as a job.

New doctors are not kind to their predecessors. Here’s why.

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I had the good fortune of practicing family medicine from the 70s to the early 10s. It was the Golden Age. After doing a family practice residency in a community hospital and serving a short stint as an assistant residency director, I started out in my practice that lasted almost 40 years.

Here is the story of how I got the ball rolling. I was part of a large family practice group. Dr. A was an elderly GP with a devoted patient clientele. His patients loved him. He gave them prescriptions, vitamins, B-12 and cortisone shots. He did use the lab and x-ray but never referred. He would diagnose an MI correctly and then treat the patient with follow-up house calls. He didn’t really know what a cardiologist or most specialists actually did. Maybe he was lucky, but we never heard that many of his patients died. Yet, he was paternalistic and pre-patient education. Our group decided he was a risk and delegated to me the thankless job of convincing him to retire. I was successful, and surprisingly he asked me to take over his patient load.

During my practice career, I saw many, many patients that stayed with me my entire career including Dr. A’s patients. They must have sensed some of their beloved retired doctor in my style of practice, and they stayed with me and referred their family and friends. For most of my career, I had a lot of face to face and hand holding time, very little documentation, and minimal outside interference. I delivered babies for the first decade. I was a care coordinator, gatekeeper, and quarterback. I had a broad knowledge of medicine and a good skill level. I was practical and empiric yet didn’t skimp on testing and referring.

I played by the book we used at the time. I knew everything about my patients. I always worked them into my schedule for emergencies. I treated their infections, their pain, their depression and many other things. I kept them working and when necessary gave them the permission for respite. When frail, I visited them at home or at the nursing facility, never delegating their care. I certified in Hospice and Palliative Medicine and was also able to provide excellent end of life care. And at the end I quickly became computer and EMR savvy and spoke Epic fluently.

What was my reward? Lifelong “friends” that trusted my judgment, lots of positive feedback, and countless letters, gifts and calls of thanks. I had the respect of my colleagues. The ER doctors and specialists were in awe at the scope of my general knowledge, my ability to recall medications and medical histories without referring to the chart, and my thorough dedication to my patients.

Eventually, age, employer micro-management, EMR documentation, and insurance/government regulations got the best of me, and I retired and moved away. My patients could not find another doctor that fit my mold and, therefore, were scattered throughout the area for their care, with most establishing with new young doctors.  My patients still talk about me, send letters and emails, and update me on Facebook. Despite being gone from the scene, I am still special to all my patients. Not so, when it comes to my former colleagues.

Now, not even three years since I left the area, I am regarded by the new generation of doctors in the same way I once regarded Dr. A. The new generation now has their own Golden Age with many advances, new gadgets, digital information, a new idea of work-life balance and evidenced-based medicine.  I hear from my former patients that their new doctors tell them they aren’t going to do things the way I did. The new generation has abandoned much of the old practice style, and they often scoff at our lack of knowledge. No, the new generation is better and plays by the “new” book. But to their dismay, the new generation of doctors has to repeatedly hear my former patients defend my old practice style. And my patients report back to me with the responses from the new doctors:

“Dr. B was old school and needed to retire.” “He used to see drug reps and was known to pass out free samples to help poor patients.”  “He used to prescribe such outdated things like Premarin, vitamin D, and antibiotics.” “He treated UTIs, conjunctivitis, colds, and bronchitis at times without seeing the patient.” “He did routine mammograms, PSAs, vitamin D levels, physicals and other unnecessary things.” “He gave out a lot of pills — for pain, sleep, anxiety, depression.” “ He used to enter the office through his waiting room and sometimes even sit there and visit with the patients. True, he knew his patients and their families well but he  probably broke a lot of HIPPA rules in the process.”

I can’t think of another profession where the practitioners from the previous generation are held in such low esteem. Former athletes are still remembered, admired and honored even though the training and equipment have improved the stats. Former pilots are well respected by the current generation of aviators who realize they have it a lot easier nowadays. No one puts down a former teacher or CPA by casting doubts on their ability to read or to add.

Medicine is a field where rapid changes in technology and information make previous treatment and practices obsolete. I get that. Now that I am partially retired, I finally have ample time to read and think and evaluate. I know the “errors” of my ways but knew of no other ways back then. I know much more now about screening and testing and treating diseases.

The point is, that’s the way the medical profession is. Technology and knowledge change from generation to generation. I understand and accept that the new generation of doctors can’t practice with the old knowledge or the old technology or in the old style. They inherit a broken healthcare system and patients with antiquated expectations. I am sure some good things are still said about the departing generation.

I had my Golden Age. But I regarded Dr. A the way the new generation regards me. And the new generation of doctors will in turn be judged in a similar manner by the very next generation of ultra-smart doctors who will be heard to say about their predecessors: “Those millennial doctors were so behind the times. Imagine using toxic drugs and harmful treatments. It’s hard to believe they didn’t capitalize on nanotechnology, gene repair and manipulation, personalized medications, and robots!”

“Dr. B” is a family physician.

Image credit: Shutterstock.com

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New Business: Alamo Heights Care and Concierge

Monday, July 6, 2015 // Uncategorized

Some friends of ours have started a new business. Karel Hoffman, R.N. and Sheila Jackson have started a new business, Alamo Heights Care and Concierge. As the name implies it is to help patients and their families with their medical and living needs. This may be helpful for patients who need assistance and their relatives live out of town. The following are some of the services they offer:

  • Attend doctors’ appointments and communicate with all healthcare providers
  • Research options related to elder care
  • Organize personal documents and assist with bill paying
  • Assist with health insurance issues and questions
  • Manage medications at home; reorder from pharmacy and communicate with physicians when needed
  • Provide routine well-being visits to include medication reminders and blood pressure checks
  • Assist with shopping and errands
  • Communicate with family members on a regular basis
  • Assist with all aspects of moving

Sheila Jackson (210) 240-1743
Karel Hoffman, R.N (210) 410-1528

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Billing Service

Monday, July 6, 2015 // Uncategorized

For 12 years Group One, an electronic billing service in Jefferson, Missouri, has filed claims electronically for services that are not covered by our annual fee. They no longer will be able to do this in the coming months and we are going to bring that in house and have someone local do it for us. I will give you that information in the next newsletter.

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Suntan and Sunburn Free Online First

Monday, July 6, 2015 // Uncategorized

Amy E. Thompson, MD
JAMA. Published online July 02, 2015. doi:10.1001/jama.2015.8045

 

A suntan or sunburn is a sign that skin has been damaged by ultraviolet (UV) rays.

Melanin is the pigment that gives skin its color. People with light skin have less melanin than people with dark skin. When skin is damaged by UV rays, the body makes more melanin to try to protect against further damage. This extra melanin gives suntanned skin its darker appearance.

But a suntan does not provide good protection against the harmful effects of UV rays. In fact, a suntan is a sign that skin has already been damaged, and tanned skin can continue to be damaged when exposed to UV rays.

For people with light skin, exposure to UV rays can lead to sunburn in as little as 10 to 15 minutes. The redness of a sunburn is caused by increased blood flow to skin that has been damaged.

LONG-TERM RISKS

Exposure to UV rays is the leading cause of skin cancers, including basal cell carcinoma and squamous cell carcinoma. These cancers often occur on skin that has been damaged by years of sun exposure, although they can occur on other areas of the body as well.

If you tan frequently or have a history of severe sunburns, you are also at an increased risk of melanoma, the most dangerous type of skin cancer.

Exposure to UV rays increases the risk of premature skin aging and may also increase the risk of eye problems such as cataracts, macular degeneration, and corneal damage.

Indoor tanning is not a safe alternative to sunbathing. Tanning beds, booths, and lamps produce a similar amount of UV radiation as the sun. Skin damage (a tan or a burn) from indoor tanning increases the risk of skin aging, skin cancer, and eye problems, just like damage from sunlight.

HOW TO PROTECT YOURSELF

  • Apply broad-spectrum, water-resistant sunscreen with an SPF of 30 or higher before you go outside.
  • Use plenty of sunscreen—about 1 oz (2 tbsp) for your whole body.
  • Do not use sunscreen that is past its expiration date.
  • Reapply sunscreen after 2 hours in the sun and after swimming or sweating.
  • While outdoors, wear sunglasses and a hat with a wide brim (about 4 in) all the way around it.
  • Wear protective clothing (tightly woven long-sleeved shirts and long pants or skirts offer the most protection).
  • Limit your time in the sun and seek shade, especially between 10 am and 4 pm.
  • Do not use tanning beds.
  • Remember that skin damage from the sun can occur on cloudy days.

IF YOU GET A SUNBURN

Pain from a sunburn is usually worst between 6 and 48 hours after sun exposure. A cool bath, cool compresses, and over-the-counter medicines like ibuprofen or acetaminophen can help. Drink water to stay hydrated. If your skin is not blistered, apply moisturizing cream or aloe vera gel to help with discomfort.

Extreme sunburn can lead to shock, dehydration, and other serious reactions. If you experience rapid heartbeat, rapid breathing, dizziness, fainting, nausea, chills, fever, or headache with a sunburn, call your doctor right away.

Box Section Ref ID

For More Information

To find this and previous JAMA Patient Pages, go to the Patient Page link on JAMA’s website at jama.com. Many are available in English and Spanis

DERMATOLOGIST, DR. SCOTT DUNCAN’S ADVICE ON SUNSCREENS

I recommend them for any sun exposure, but UV light
intensifies 2 to 3 fold when above an angle of about 45 degrees, due to
having less of the ozone to traverse (the ozone layer is only about 3 feet
thick).

I tell patients to try to avoid exposure when your shadow becomes shorter than your height.

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