Author Archives: jpwmd

When your car needs servicing, you want a mechanic who is honest and reliable.  When you need to hire a lawyer, you want someone who knows your area of need and has a record of success.  Do you exercise the same level of scrutiny when you schedule a colonoscopy?  You should.

Background

Adenomas in the colon (i.e., the large intestine) are benign tumors that have the potential to turn into cancers.  Screening colonoscopies can detect these tumors and the colonoscopist can remove them without doing another procedure.  Widespread screening has reduced colon cancer and related deaths by detecting and removing cancers at a stage when they are more treatable.

How Good Is Your Colonoscopist?

A recent study examined colonoscopists’ adenoma detection rates (ADRs: the percentage of colonoscopies where at least one adenoma was found) in performing colonoscopies and compared the rates to the subsequent development of colon cancers.  Kaiser Permanente’s vast store of medical records supplied the data, and 852,624 colonoscopies were analyzed.  To make a long and somewhat complicated story short, the patients of physicians with lower ADRs had almost double the incidence of colon cancers compared to patients of physicians with higher ADRs (3.10 vs. 1.79 per 10,000 patient years).  And the higher the ADR, the better.  

Measuring Effectiveness

Currently, the minimum ADR for acceptable performance of colonoscopies  is 25 percent, according to an article published in Gastrointestinal Endoscopy in 2014. Alarmingly, in a survey of 250 gastroenterologists who perform more than 80 colonoscopies per month, 20 percent responded that they did not keep track of their ADRs.  Even more alarmingly, the worst performers miss more than 90 percent of the colonic adenomas.  

Nevertheless, overall, screening colonoscopy reduces the risk of death from colon cancer by about 70 percent.  Think how much better it could be.  For your next colonoscopy, ask your colonoscopist what his or her ADR is.  If the information is not available, find a colonoscopist who keeps track of this vital statistic.

You do not watch television if you have not seen the remarkable ad campaign for Prevagen, an over-the-counter supplement for “brain health.”  The advertising industry has outdone itself with slick, convincing anecdotes that report the amazing benefits of this drug that hit the market in 2007.  These efforts appear to be highly effective in tantalying people to buy the product.  In 2019, Quincy Bioscience, makers of Prevagen, spent $67 million on ads for the product, and realized $165 million in revenue for this product in 2015 (attempts to verify and update these numbers from the company have met with no response)

One little problem: the advertising campaign bears all the marks of fraud.

Background

First, what is the basis of the supplement?  There is a protein in jellyfish, apoaequorin, that is also in the human brain.  The idea is for people to ingest the supplement that has the protein and have it travel to the brain to improve “healthy brain function, sharper mind, and clearer thinking.”  The protein, however, is broken down in the digestive tract and has no chance to take up residence in the brain.

Undaunted, Quincy conducted one trial (serious science would require many studies in multiple settings with diverse populations) of the drug that found a slight advantage for memory in a small number of subjects.  The quality of the research has met with virtually universal derision.

Nevertheless, the FDA (the federal Food and Drug Administration) approved Prevagen as a supplement for over-the-counter sales.  The decision to market Prevagen as a supplement was critical to the approval process.  “Pharmaceuticals” are subject to far more rigorous testing, and, in the words of an executive at Quincy, they did not want to wait for the extended time that would be necessary to approve a drug, rather than a supplement.  In addition, the company was careful to refrain from asserting benefit for a described disease entity, like Alzheimer”s Disease, limiting itself to  claims for improvement in symptoms.  This avoided elevated levels of regulatory scrutiny.

A Fusillade of Criticism and Lawsuits

In recent years, Prevagen has gained notoriety for reasons Quincy had not planned on.  In 2017 the Federal Trade Commission (FTC) and the New York Attorney General sued Quincy Biosciences for making false claims,citing the senselessness of the “science” that underlies the supplement’s supposed benefits,  On the bandwagon of criticism of the inadequacy of the clinical studies that claimed benefit for taking Prevagen, the FTC noted that the company’s own clinical study in actuality showed no statistically significant improvement in memory and cognitive function between those given Prevagen and those given a placebo.  The FDA has opened a case stating that Prevagen did not warn its users that seizures and strokes were some of the many adverse side effects reported by people taking Prevagen.  Curiously, memory impairment and confusion are also possible side effects that the company has chosen to ignore.  Finally, by 2020, seven class action lawsuits have been filed against Quincy regarding allegations of false advertising. 

Failure on Multiple Fronts

Clearly there has been regulatory failure, maybe even mischief, in the approval of Prevagen.  But the libertarian streak in me thinks that people who allow themselves to be entranced by transparently exploitative advertising get what they deserve.  On the other hand, I am very angry at the naked cynicism of a company that pushes a useless, maybe even dangerous, product in the pursuit of profit.

In a recent post, I documented the wide disparity between the incomes of primary care physicians and procedure oriented specialists.  On average, the net incomes of primary care physicians are 69% of specialists’ net incomes.  How did our nation’s customs regarding such a skewed reimbursement policy come about?  I don’t know, but I know how the gap is perpetuated.

The Relative Value Scale Update Committee (RUC), created by Congress in 1986, is a body whose members are supposed to be representative of the various specialties of medicine. Although Medicare makes the final reimbursement decisions for physicians, the committee’s recommendations carry great weight with CMS (Centers for Medicare and Medicaid Services).* 

 Here are the areas of medicine represented on the committee:

• Anesthesiology
• Cardiology
• Interventional Cardiology
• Dermatology
• Emergency Medicine
• Family Medicine
• Gastroenterology
• General Surgery
• Geriatric Medicine
• Internal Medicine
• Nephrology
• Neurology
• Neurosurgery
• Obstetrics/Gynecology
• Ophthalmology
• Orthopedic Surgery
• Otolaryngology
• Pathology
• Pediatrics
• Physical Medicine & Rehabilitation
• Plastic Surgery
• Primary Care
• Psychiatry
• Radiology
• Thoracic Surgery
• Urology

Thus, although Primary Care doctors constitute a little over 40% of the practicing physician population, they represent only 16% of the voting members of the RUC.  “Rigged” would be an appropriate term for the composition of this committee that is supposedly representative of the medical community.

Training Choices That American Medical Graduate Make

Graduating medical students seem to be aware of all this.  Their choices for residency training programs correlate with the high incomes associated with the specialties.  A good measure of these preferences is reflected in the percentage of American medical graduates who fill positions in residencies.  Graduating senior medical students are the preferred candidates for residency positions, the balance of unfilled positions going to international medical graduates.  By far, the residency training programs that promise the highest incomes are the most popular, and they fill almost all of their positions with Americans.  Primary care residencies, on the other hand, struggle to reach a 40% fill rate with this group.

Implications for the Quality of Healthcare in the United States

So the pipeline for training primary care doctors is in jeopardy. Does this matter?  A raft of research illustrates the problem with the de facto deemphasis on primary care.  Doctors in primary care specialties do patient centered work, not organ centered work.  They provide integrated healthcare for a large majority of healthcare needs and foster a sustained partnership with patients, all while managing multiple medical conditions. They consult specialists as necessary, coordinating care in what is often a labyrinth of care options.  Studies show this results in a decreased annual number of visits to specialty providers, with less frequent hospitalizations, fewer diagnostic tests, and overall reduced total medical charges. A strong primary care presence helps prevent illness and death, and that it is associated with a more equitable distribution of healthcare in populations. 

The current payment system favors high cost procedures over time spent on evaluation or management of care.  The U.S. has a high ratio of specialists to primary care physicians. 

Remedies

First, let me acknowledge that specialists do good and important work.  My brief is that the imbalance in reimbursement is unfair and bad for healthcare in general.  But fixes to the scandalously imbalanced system are unlikely.  I have shown that the influential body that basically determines parameters for physician reimbursement is heavily stacked against primary care.  And the amount spent on federal lobbying for subspecialty care outnumbers primary care by an almost three to one ratio.  Relying on a feckless Congress for significant reform is quixotic.

Nevertheless, the issue that finds primary doctors to be compensated at a rate that produces incomes that are on average 69% of that of specialists has an easy theoretical fix…close the gap.  There are other issues besides money: the practice of primary care is more challenging–more paperwork and administrative burden, more off hour responsibilities, less perceived prestige.  But a policy that closes the gap in net incomes is surely the first step.

Raising primary care reimbursement is conceptually easy.  However, no one in this economy is looking to increase the nation’s healthcare bill.  And how much to increase primary care physician services?  Increase reimbursement to the point that primary doctors earn 80% of specialists’ incomes?  90%?  Equal?  Given the importance of primary care, maybe even more.

I don’t know what level of increased relative reimbursement for primary doctors would get the job done.  I propose an organic process:  freeze reimbursement for procedures that will close the gap until medical students start choosing primary care training in numbers that will populate primary care training programs to the point of what healthcare experts believe is an optimal ratio of primary care doctors to specialists.  This could take awhile, but the beginning of the fix could start tomorrow.

Homily

I suspect that a large part of the reason for the imbalance between compensation for primary care services as opposed to specialty services is the American tendency to value concrete data.  It is easy to quantify the value of, say, the removal of a diseased appendix, but much more difficult to reward an internist for a deft diagnosi of depression in a patient with multiple somatic complaints. The current payment system favors high cost procedures over time spent on evaluation or management of care.  A wise person once said that the most important things are the hardest to measure. 

*Private insurers generally pay more for healthcare services, but Medicare payments have a great influence on non-governmental insurance plan reimbursement, especially the relative reimbursement for different types of physicians.

I don’t know what a reasonable income is for physicians.  They are among the highest paid workers in the United States, but they also spend more time in training after undergraduate school (at least seven years, often more) and have heavy responsibility in making critical decisions and performing procedures that affect peoples’ very mortality.  Working off hours is expected and being on-call 24 hours a day is a common duty.  The average debt for medical school graduates in 2021 was $216,000, exclusive of debt incurred in undergraduate studies.  Surely some degree of income realization over the norm is fair.

The Data

Of course, no physician is lining up at the soup kitchen, and US doctors enjoy higher incomes than those of doctors in any other country–by a lot.  The average yearly net income for all physicians in America was $316,000 in 2021.  Here are average net incomes by specialty: 

• Plastic Surgery: $471K.
• Otolaryngology: $461K.
• Cardiology: $430K.
• Dermatology: $419K.
• Radiology: $419K.
• Gastroenterology: $417K.
• Urology: $408K.
• Orthopedics: $482K
• Plastic Surgery: $471K
• Otolaryngology: $461K
• Cardiology: $430K
• Dermatology: $419K
• Radiology: $419K
• Gastroenterology: $417K
• Urology: $408K
• Anesthesiology: $392K
• Ophthalmology: $366K
• Surgery, General: $362K
• Oncology: $359K
• Emergency Medicine: $353K
• Critical Care: $349K
• Pulmonary Medicine: $331K
• Pathology: $308K
• Physical Medicine & Rehab.: $306K
• Nephrology: $305K
• Ob/Gyn: $303K
• Allergy & Immunology: $275K
• Neurology: $267K
• Psychiatry: $260K
• Rheumatology: $259K
• Internal Medicine: $243K
• Infectious Diseases: $239K
• Diabetes & Endocrinology: $236K
• Family Medicine: $231K
• Pediatrics: $225K
• Public Health/Preventative Med.: $209K

The correlation between lower pay for primary care doctors (so-called “cognitive” doctors, i.e., those  who provide first contact and follow patients over time–mainly general internists, family medicine specialists, and pediatricians) versus specialists is notable.  On average, primary care doctors’ incomes are 69% of specialists’.   And the key for specialists is the performance of lucrative procedures, which primary care doctors rarely do.  Clearly, our reimbursement policies are heavily weighted in favor of paying handsomely for procedures.   

Ramifications

So, while I may not know what just compensation is for doctors in general, I do know the gap in incomes between primary care doctors and specialists is remarkable.*  How does this play out?  A study published in the Journal of the American Medical Association in 2013 is telling.  The researchers looked at two common procedures, colonoscopy and cataract extraction.  They found that specialists earned, for colonoscopy and cataract surgery, 368% and 486%, respectively, of the revenue primary care doctors realize in their work for the same amount of time spent.  Practice expenses for proceduralists are greater (especially malpractice), and proceduralists do spend more time in training, but these factors are not close to a justification for the majestically greater compensation.

Here is an example to illustrate the gap.  When I was a hospice physician, I was called upon to see patients for “recertification,” that is, I was required every three months to see a patient getting hospice care to certify continued eligibility for hospice services.  The patient might be 30 miles from my home, and I might often drive an hour each way.  I could spend about one half hour with the patient and the family, for which I would receive $85 dollars from my company if the patient lived in a facility, and $100 for a patient living at home.  I was not compensated  for the time spent driving, but I did receive mileage at about 43 cents per mile after the first 20 miles (there are arcane rules regarding mileage that are not worth going into).  If traffic was light and the visit was not complicated, I would earn about $34 an hour for my efforts.  I was also on-call 24 hours a day, being compensated only for the actual time spent on phone calls.  

I am not complaining–I loved my hospice work.  But I present the vignette to show the remarkable contrasting compensation for doing procedures compared to cognitive work. Gastroenterologists, for instance, currently get about $300 from Medicare (private insurance pays more) for a screening colonoscopy, which costs the colonoscopist anywhere from 15 to 60 minutes.  In uncomplicated cases, the doctor can easily realize about $1,000 an hour.**

Disclosure and Opinion

Full disclosure: I am a general internist (retired), and am in the bin of “cognitive” physicians, who  do not do highly compensated procedures.  Hospice doctors occupy the same category.  In presenting  the above examples, I have obviously stacked the narrative of the relative lack of reimbursement for primary care doctors, my goal being to illustrate the staggering difference that is possible in compensation for cognitive work versus procedural work.  

No doctor is poor, so the question is whether this discrepancy matters.  If so, what should be done about it?  And how did we get such a system?  Stay tuned.

*Another major gap in compensation practices involves women and minorities…..But that is subject for another time.

** The colonoscopist’s fee is typically 20 to 25% of the overall bill for the procedure–the rest is a facility fee and a fee for anesthesia;  if tissue is to be analyzed, that is another cost.

Here are some developments/news items that managed to escape treatment in the popular press.

A stroke is a stroke

When I trained in the 1970s, the concept of “transient ischemic attack” (TIA) reigned.  This term referred to sudden symptoms of a stroke that resolved in minutes to hours to one day and were associated with no evidence of brain tissue injury by cerebral imaging available at the time.  The idea was that rapid resolution of symptoms produced no permanent brain injury.

As magnetic resonance imaging (MRI) came into common use in the 1990s, it became clear that many patients who suffered TIAs had evidence of brain injury with the more detailed brain imaging.

The National Institutes of Health Stroke Scale now grades cerebral ischemia (reduced blood flow to the brain causing stroke symptoms) on a continuum, with TIAs classified as minor strokes.

So…minor or not, if you experience signs of a stroke such as sudden 

weakness/paralysis on one side of your body, even if it resolves quickly, you should seek medical assistance ASAP.  There are acute interventions that are effective in proportion to how soon therapy is instituted.

Speaking of Strokes…

If you have had a stroke, all is not lost.  A Canadian study spanning four years in Canada found that stroke victims who followed recommended levels of physical activity had a 50 percent reduction in mortality compared to sedentary victims.  The beneficial effect of exercise was more prominent in those younger than 75 (79 percent reduction in mortality), but still significant for people 75 and older (32 percent reduction in mortality).

The more exercise, the better, but the amount necessary to achieve benefit was startlingly modest: 10 MET-hours/week.  The optimum was 20 MET-hours/week.  A MET is a ratio of your working metabolic rate relative to your resting metabolic rate.  Cleaning your house , for instance, wins you 3.5 METS.  Other MET values are available on Healthline (go to the internet).

The benefit of exercise, which also decreases sedentary time, is also apparent in preventing strokes altogether.  So keep on truckin’.

E-cigs to quit smoking… maybe not

One of the benefits touted for the use of e-cigarettes (i.e., “vaping”) is that it can help cigarette smokers quit the habit.  In a recent large study, however, smokers who wanted to quit (quitting was defined as abstinence from smoking cigarettes for 12 months) had less success with using e-cigarettes as a aide to quit smoking compared to pharmaceutical cessation aids (e.g., Nicorette, either gum or lozenges) or behavioral therapy.  The combination of the latter two was the most effective.  

This finding, in addition to the fact that we still do not know the long term effects of e-cigarette use, leads experts in the field of smoking control to believe that vaping should not be recommended to those who want to quit smoking.

Vaping industry advocates point out that the study cited above lacked the power of the gold standard for medical research.  It was observational, that is, there was no randomization of participants that corrects for biases that are not obvious.  On the other hand, an expert in the field points out that, if public health limited itself to this kind of evidence, we would not know that smoking causes cancer.

In the study cited, the smokers who had the most success in quitting used none of the available aids to quit smoking.  Personal motivation and old fashioned will power carried the day.

If you doubt the addictiveness of nicotine, read on

Quitting smoking is an unquestioned health benefit: cigarette smokers who beat the habit enjoy up to a decade of greater life expectancy.  But what about quitting after getting diagnosed with lung cancer?  

In a large study from Russia, only 43 percent quit smoking after the diagnosis of lung cancer.  In an average of seven years of follow-up, however, smoking cessation was associated with a 33 percent reduction in mortality compared to those who  continued to smoke.

Editorialists in the Annals of Internal Medicine opined that smoking cessation therapy, in contrast to the current practice, should be a routine component of treating patients with lung cancer.

March 18 was a big day for graduating medical students: it was the day they found out where they are going to pursue training in the various specialties of medicine.  

Medical students typically attend medical school for four years, then undertake a specialty residency (this is called post graduate training in the medical lexicon),  This entails a minimum of three years of clinical training,  but many disciplines require more, and further subspecialty training tacks on even more years.  Nowadays, doing residency training is necessary to practice medicine–the one year of a general internship followed by practice no longer exists. 

The National Residency Matching Program (NRMP.org) provides the mechanism by which newly minted doctors-to-be and training programs are matched.  Candidates rank their preferences for residencies and residencies do the same for candidates.  A computerized mathematical algorithm determines who will train where. 

Results

A detailed look at the match results from this spring is a bit abstruse, so details for those curious readers are in the footnote.*

What is important to know is that the percentage of positions that disciplines fill in the match reveal their relative popularity among medical students.  Specialties that filled all available positions offered were, with a few exceptions, among the most lucrative in medicine.

A telling way to break down the results of the match is to look at the percentage of grads who are going into the primary care specialties.  These are mainly Internal Medicine, Family Medicine, and Pediatrics.  Primary care doctors are the first contact for patients and provide care over an extended period of time–not just episodic interventions.  Their work is mainly cognitive, i.e., they perform few procedures. 

The rubric of gauging the popularity of disciplines by the percentage of American grads (both MDs and DOs) who obtain positions in the match, highlights the relative lack of popularity of primary care among medical school graduates.  For instance, Dermatology  filled 91 percent of positions offered with MD and DO American grads.  Orthopedics: 95%; Anesthesiology: 87%  The fill rates for the primary care specialties ranged from  42 percent (Internal Medicine) to 63.5 percent for Pediatrics.

Implications

The results of the match are very important—they portend the composition of the physician workforce for years to come.  In a document entitled The Complexities of Physician Supply and Demand: Projections from 2018 to 2033, published in July of 2020, the Association of American Medical Colleges has produced an authoritative breakdown of things to come in the physician workforce (aamc.org). 

Notable is the projection of a physician shortage by 2033, estimates for which range from 54,000 to 139,000 (there are currently almost one million practicing physicians in the United States).  The estimated shortfall for primary care physicians is more stark than for subspecialties, especially procedure oriented ones.

If these projections are accurate, health care policy should clearly aim to increase the number of practicing physicians in the coming years.  And there should be a particular emphasis on increasing the number of primary care doctors.  The need for more primary care practitioners has been the subject of discussion, and no little amount of hand-wringing, for years, with leaders in medicine wondering how to plug the gap.  They have, however, largely avoided policies that address the elephant in the room, to wit, the net incomes of primary care doctors average about 69 percent that of subspecialists, who perform highly remunerated procedures.  

In subsequent posts, I will expand on this disparity.

*Residency programs, which are located in both university and community hospitals,  offered a total of 36,277 first year post graduate positions (i.e., PGY-1 positions offered for training in programs of at least three years duration), of which 51% were filled by graduating seniors from American medical school and 18.4% by graduating doctors of osteopathy (DOs receive training very similar to what MDs get, with more emphasis on musculo-sketetal disorders.  I have known many DOs who are outstanding doctors, and a few who are terrible; the same goes for MDs ).  The balance of the positions were filled by International Medical Graduates (IMGs), formerly known as Foreign Medical Graduates, the greatest percentage of whom are from India.  Many IMGs go unmatched, as residency training programs prioritize the recruitment of American grads.

Almost half of the graduating seniors matched to programs in primary care, but this number is misleading.  The number includes grads who are doing a year in Internal Medicine prior to going into a subspecialty such as, for instance, Dermatology.  Of those who are going into a 3 year residency in Internal Medicine, the great majority plan on further training in the subspecialties of Internal Medicine, such as Cardiology, Gastroenterology, etc.  These disciplines are procedure oriented and are not primary care.  A significant number are intending to become hospitalists.  These are hospital based physicians who care exclusively for inpatients–they are not primary care physicians either.

Some years ago, I hurt my right shoulder diving into a pool.  It did not improve with time, so I went to see an orthopedic surgeon who did a careful exam, diagnosed a muscle strain in the rotator cuff, and told me to stay away from activity that caused pain.

As I did not improve, he tried an injection with indifferent results and prescribed physical therapy.  I did this very conscientiously, but still had very limited range of motion.  It was time for an MRI.  

The MRI did not show a tear in the shoulder joint, so surgery was not recommended.  A “strain” is supposed to get better with PT, and I kept doing the prescribed exercises.  I continued to be unable to perform certain motions (such as throwing), however, so the doctor said it was time for surgery.

At surgery, the surgeon found a complete tear in one of the rotator cuff muscles.  He later told me that, while generally very accurate, MRIs occasionally missed important pathology.  He repaired the offending muscle, and I was throwing batting practice for my youth baseball team six months later.

Knee Pain: Garden Variety Arthritis or Something Else?

About four years ago, I developed pain in my right knee.  I was a bit of a runner (“loper” is a better term), and I thought, at my age of 71, arthritis was a good bet.  I tried to ignore it, using anti-inflammatory drugs as needed.  Pain persisted, however, so I consulted an orthopedic surgeon who specialized in knees.

From his exam, he felt my diagnosis was correct, did not do an X-ray, and said I could keep running while managing pain as I had been doing.  I was to return in three weeks if symptoms got worse.  Which they did.  He ordered an X-ray, which revealed the expected findings consistent with a joint that could be a good candidate for arthritis.  There was nothing else of note on the film.

I stopped running, but the pain persisted, so the doctor ordered an MRI, even though he felt it would not show anything more than what we already knew. Wrong. I had a stress fracture of the tibia (the bigger of two bones between the knee and ankle).  The prescription was to lay off high impact activity (i.e., running) until I got better,  Which I did with therapeutic success.

Another Diagnostic Dilemma 

Last year, I hurt my left wrist while breaking a fall after tripping on an uneven sidewalk.  I ignored the pain as long as I thought reasonable, then visited a hand surgeon.  He did a careful exam, and obtained X-Rays that revealed no fracture.  Based on minimal swelling and mild symptoms, he thought I had a mere strain, and gave me a brace, telling me to lay off any activity that caused pain.

I followed this advice without improvement, so the doctor ordered an MRI.  This revealed the fracture that the conventional X-Ray missed. He immobilized the wrist, predicted I would be better in a few weeks, and prescribed physical therapy to insure complete recovery of strength and motion.  Today, I have a hard time remembering which wrist I broke.

Thoughtful, Cost-effective Medicine

In each of the above described situations, some friends felt that my physicians were a trifle glib when evaluating my initial presentation.  They felt they should have been much more aggressive in getting to the diagnoses.  I, on the other hand, thought (and think), they practiced exemplary expectant management.  In each instance, they felt I would get better without the expensive diagnostic tests that only later proved to be necessary.  Critically, they persisted in follow-up until my situation was resolved.  Part of their decision making process was based on their belief that any delay in diagnosis would not compromise the eventual good outcome.  

Head CT Scans in Clinical Practice

Headache is one of the most common complaints in primary care outpatient medicine.  Too often, evaluating doctors order a CT scan of the head upon a patient’s initial visit for this complaint.  There are good reasons to obtain a scan quickly: for instance, patients who state their headache is by far the worst they ever had may have an intracranial bleed that requires immediate intervention.  But CT scans are expensive and expose patients to radiation that may not be necessary.  And most headaches can be characterized safely and accurately with a good history and physical exam.  Follow-up is critical and a scan may be justified if symptoms persist.  This is expectant management, and it is good, cost-effective medicine. 

*NOTE: The diagnostic restraint I am advocating in this post is only appropriate in selected situations.  Physicians must continually weigh a policy of embarking on a diagnostic adventure versus waiting in the expectation that a complaint will improve on its own.

The mantra with which I grew up in medicine was that appendicitis is a surgical disease.  A recent review in the Journal of the American Medical Association (JAMA), however, documents medical studies that show broad spectrum antibiotics can be useful in a selected group of patients in the treatment of acute appendicitis.  Non-surgical intervention, therefore, can be considered in patients for whom surgery is very risky and/or for whom findings on a CT scan indicate uncomplicated pathology.  Deciding on a non-surgical approach requires, however, careful consideration of outcomes, as well as patient desires.  Studies show that recurrence of appendicitis within one year of using the antibiotice approach can range from 15 to 40 percent.  Antibiotic treatment is not a panacea, but can be useful in selected situations.

I was reminded of the more consevrive approach to medical problems with a recent study of laser therapy for symptoms from vaginal atrophy in older patients.  This intervention has become very common in postmenapausal women with recurrent vaginal infections and sexual dysfunction.  Good clinical research, somewhat tardy in the investigation of the usefulness of laser therapy, however, shows that the laser procedure has no advantage over vaginal estrogen cream.  Another cottage industry has been threatened with the new data.

These studies have called to mind many procedures in medicine that have fallen from common use because of good research that revealed their uselessness.  

Swan Song for the Swan-Ganz

The Swan-Ganz catheter is a prominent example.  The determination of the hydrational status of critically ill patients (do they need more IV fluids, or less?) can be very challenging.  In the 1970s, the two physicians after whom the device was named, developed the balloon flotation catheter that could fairly easily be inserted into the lungs through the right side of the heart.  For arcane physiological reasons that are not important for the purposes of this article, accurate assessment of a patient’s fluid status, which is critical to the care of very ill patients, became much easier.  

The use of the Swan-Ganz became a routine standard of care in the 1980’s up to the turn of the century.  Investigators then began to ask the question of whether this elegant tool actually improved patient outcomes. The answer was negative–in fact there was a non-statistically significant trend toward harm.  The routine use of this procedure, which is still useful in selected situations, fell out of favor with these studies.  But not before billions of dollars were spent on the discredited intervention. 

Another Beguiling Procedure Proven Useless 

A similar fate befell the Extracranial-Intrcracnial Arterial Bypass procedure in common use by neurosurgeons and vascular surgeons in the 70’s and first part of the 80’s.  This technique bypassed the normal cerebral circulation, in much the same way that heart surgeons establish circulation around diseased arteries in the heart.  Studies were finally done, and, even though the procedure definitely improved circulation, the clinically relevant question was negative: it did not reduce mortality and strokes, large or small.

Breast Cancer: Progress Through Restraint

Another famous example of restraint in medical care involves the surgical treatment of breast cancer.  The Halsted procedure, established in the late 1800’s, was the surgical standard of care up until the 1970’s.  It involved radical surgery, with removal of the breast and the axillary lymph nodes (lymph nodes in the armpit), and later, the pectoral muscle overlying the affected breast.  This often resulted in morbidity such as intractable swelling of the arm on the affected side, not to mention the adverse cosmetic consequences.  Now breast surgery is much less mutilating, and along with improved staging and diagnostic techniques, it is associated with mortality outcomes equal to or greater than those with the Halsted procedure.

Bad News/ Good News

I am often disturbed by the mindless embrace of new technologies in healthcare that slip into the medical armamentarium before they are proven to actually help patients.  On the other hand, I am proud when medicine finally finds the wherewithal to critically examine the efficacy of interventions that have come into common use without adequate study.  Sometimes, less is more.

A recent opinion piece in the New York Times caught my attention: “Who Are We Caring for in the I.C.U.?”  I thought it would just be another exasperating chronicle of the staggering disproportion of unvaccinated people needing intensive care compared to the vaccinated.  But I was wrong.

Dr. Daniela Lamas is a pulmonary and critical care specialist.  In the article, she addressed a topic that often arises in the care of critically ill patients: what is a physician to do when the family of a loved one wants interventions that are clearly useless in a terminally ill patient who is unable to make his/her own decisions?  

Dr. Lamas tells the story of a family’s request to transfer a Covid-infected patient with respiratory failure to her institution, a larger hospital with greater resources than the transferring hospital.  Talking to the ICU doctor at the other institution, she felt that her hospital could do nothing that the other hospital had not already done.  Moreover, the transfer itself could be dangerous.

Nevertheless, she OK’ed the transfer.  Why?  First, let me tell you of a wise observation one of my esteemed medical mentors told me years ago: the care of the demented patient is largely the care of the patient’s loved ones.  This acknowledges the paucity of effective therapies for patients with end stage dementia, at the same time understanding the needs of family members.  They need to know that all reasonable interventions are being undertaken for loved ones, that the patient will be kept comfortable, and that mortal decisions are understandably excruciating.  Sometimes, misplaced guilt needs to be alleviated.   .

So Dr. Lamas’ action implicitly acknowledged the needs of the members of the family–they needed to know that they had done everything possible for their loved one.  Her decision was one that benefitted the family, but did not hurt the patient (the patient died two days after the transfer).  Her approach went beyond the mere X’s and O’s of medical care.

Families’ desires frequently are at odds with what a physician thinks is appropriate for a patient.  In the absence of a patient being able to make decisions (and in the absence of an explicit advance directive), some families want every measure taken that preserves life–every second of life is precious regardless of any other consideration.  

Many times, I have been in a situation where family desires conflict with my own sense of doing what is best for a dying patient.  Life is precious, but in desperate situations, my priorities were ensuring comfort and dignity.  

I have never come to peace in such fraught situations.  Physicians are taught, number one, to be the patient’s advocate, and doing CPR on an imminently terminal, hopelessly ill patient does not seem to be in the patient’s best interest.  

With Dr. Lamas’ thoughtful commentary, however, sheds light on the less than obvious challenges in making good decisions in the care of terminally ill patients.

Here are some excerpts from tobacco ads in the United States from the thirties up to 1964:  Lucky Strikes were “gentle on my throat.”  Phillip Morris advised: “Play safe with your throat.”  Old Golds were “fresh as mountain air.”  And, in the type of claim that must be illegal today, “smoking Camels stimulates the natural flow of digestive fluids … increases alkalinity.”

Addressing the Problem through Public Health

The prevalence of smoking in the US peaked in 1964 at 42% among adults.  In 2019, the number was 14% (males 15.3%. Females 12.7%).*  What happened in 1964?  The publication of the first Surgeon General’s report that explicitly warned of the dangers of tobacco use.

Over the years, a steady march of public health interventions amplified the messaging.  In 1966, individual packs of cigarettes were required to bear the message that smoking “may be hazardous to your health.”  Cigarette ads were banned from radio and television in 1971.  In 1988, that year’s Surgeon General’s report stated that smoking was addictive, just like heroin.  Attorneys generals and the largest tobacco companies agreed to prohibit advertising targeting youth.  Legal restrictions on smoking in public spaces became commonplace, and media counter-marketing campaigns became prominent.

Taxation   

A factor that was (and is) just as important as the public health interventions in decreasing smoking, if not more so, was taxation.  The price of cigarettes varies from state to state (the cost of smoking in tobacco growing states is generally less than the national average), but still high compared to the sixties.  The average smoker smokes 15 cigarettes per day, spending $3.90 per day in the states where cigarettes are least expensive (Missouri and Virginia).  In New York City, a similar consumption costs $9.60 per day, amounting to an expenditure of $3504 per year for tobacco. 

For arcane technical reasons, the federal tax on cigarettes varies from state to state, but ranges from about $1.00 per pack to $4.00. The impact of taxation is remarkable: in Chicago (where taxes on cigarettes are the highest in the nation), city taxes per pack are $1.18, county taxes $3.00, and state taxes $2.98.  And this does not include the federal tax. 

Results 

What is the effect of all of the anti-smoking interventions?  The incidence (new cases per year) of lung cancer in males has decreased by 47% since 1984 (the decrease in females, though real, is not as striking due to a lower prevalence of smoking).  This success is largely due to smoking cessation, though improved treatment and earlier detection are also factors.  And note this analysis does not even address mortality from other cancers and heart disease for which smoking is implicated.  

Remaining Challenges

We still have a ways to go. In 2018, 234,000 new cases of lung cancer were diagnosed in the US.  In 2015, the national expenditure for treatment of lung cancer was $13.4 B.  In 2019, 13.3% of cancer survivors were cigarette smokers. 

The Power Intervention: Prevention

The moral of this story is that low tech intervention can have a major impact on health.  Few public health campaigns have had the impact on well-being that the anti-smoking campaign in the US has had.  

But, another condition that cries out for urgent public health intervention is America’s weight problem. According to the National Institutes of Health, obesity and overweight together are the second leading cause of preventable death in the United States, close behind tobacco use. An estimated 300,000 deaths per year are due to the obesity epidemic.

President Biden has recently revived the concept of the “moonshot,” a federal initiative to decrease cancer deaths by 50%.  He is no doubt thinking about high tech interventions in the detection and treatment of conditions with high mortality. For the biggest and most cost effective interventions, however, he would do well to look at the power of prevention.

*These stats are from a trove of facts available to all at www.ncbi.nim.nih.gov,  Among the most interesting: those who hold a college degree have a 6.9% rate of smoking, while the percentage for non-college grads is 21.6%.  Households with incomes per year of more than $100,000 have a prevalence of smoking of about 7.1%; households with less than $35,000? 21.4%.