Wednesday, October 28, 2015

Washington Post Vs. Paternalistic Breast Cancer Guidelines

Washington Post editor Marisa Bellack speaks out against paternalistic mammography guidelines in her editorial, "Don't worry your pretty little head about breast cancer".

She notes that "anxiety" is being increasingly invoked as a (bad) reason to limit screening mammography, especially for women between ages 40-49:
And yet, there was a 19th-century echo in the American Cancer Society’s announcement this past week of revised guidelines for breast cancer screening. Whereas anxiety was once a reason for aggressive medical intervention, it is now invoked to avoid intervention — an argument that is both patronizing and unscientific. There may be good reasons for women in their early 40s to forgo regular mammograms, but this isn’t one of them.

A reference to anxiety appears in the very first paragraph of the harms-and-benefits analysis commissioned by the cancer society: While early screening “reduces breast cancer mortality, there are a number of potential harms, including false-positive results, which result in both unnecessary biopsies and increased distress and anxiety related to a possible diagnosis of cancer.”

But the idea that anxiety is a major harm doesn’t have much scientific support...

There will always be uncertainty in cancer screening. And that uncertainty understandably fuels anxiety. But most false-positive mammograms are quickly resolved by additional imaging. Among the cases that progress to biopsies, 9 out of 10 show no sign of cancer. And even when there is a breast cancer diagnosis, that’s not equivalent to a death sentence. Doctors should be able to respond to anxiety rationally, putting fears in context and expediting follow-up testing and results to limit what can be an agonizing wait.
For more details, read the full text of "Don't worry your pretty little head about breast cancer".

See also this related Washington Post piece, "Why this Harvard radiologist still recommends women get mammograms at age 40".

(Link via Dr. Evan Madianos.)

Monday, October 26, 2015

Hsieh Forbes Column On Doctor 'Report Cards' And Unintended Consequences

My latest Forbes piece is now out, "Doctor 'Report Cards' May Be Hazardous To Your Health".

I discuss the rise of physician "report cards" for heart surgeons and other advanced surgical specialties, as well as some of the unintended consequences these report cards can create for patients.

One take home point from my piece:
The report cards can tell you how many patients died under a particular surgeon’s care. But they can’t tell you how many of those patients would have died without surgery. And more importantly, the report cards can’t tell you how many of those same patients would have died if treated by a different surgeon — because each surgeon gets to choose which patients he or she will operate on.

The goal of recognizing good doctors is laudable. But the proposed “report cards” have serious limitations. Patients looking for a good surgeon should consider these report cards as merely one data point among many — and not necessarily the most reliable.
I also cover other ways patients can find a good surgeon, in addition to these "report cards".

Various private rating systems will be a mixed bag, each with their own strengths and flaws. I personally think all such ratings will have flaws that patients need to know about, which is one point of my article. Fortunately, patients can listen to (or ignore) those ratings as long as they remain private.

In contrast, government rating system will be very easily captured by those with agendas that don't necessarily align with patient interests (such as cost containment), and that's where we can potentially see big trouble.

For more details, read the full text of "Doctor 'Report Cards' May Be Hazardous To Your Health".

I also recommend a related article by Dr. Saurabh "Harry" Jha, "When a bad surgeon is the one you want: ProPublica introduces a paradox".

Sunday, October 25, 2015

Saturday, October 24, 2015

Ebola Quarantine Lawsuit

Doug Mataconis discusses: "Nurse Kaci Hickcox Sues Chris Christie For Civil Liberties Violations During Ebola Quarantine". 

This is some legal fallout from last year's big Ebola scare, in which many people were calling for restrictions on people coming to the US from affected areas in Africa.

From Mataconis' blog post:
[Kaci Hickcox] was detained at Newark Airport after arriving home from West Africa and not allowed to continue on to her connecting flight. Instead, she was taken into custody and detained in a tent outside a hospital in Newark, New Jersey before being allowed to return home to Maine.

Once in Maine, that state’s Republican Governor Paul LePage, who just happened to be running for re-election, attempted to impose severe restrictions on Hickox’s liberty notwithstanding the fact that she displayed absolutely no symptoms of having the Ebola virus and that asymptomatic patients are not contagious.

Governor LePage’s efforts were derailed by a Maine State Court Judge, who limited the requirements placed on Hickox to keeping local health authorities informed of her condition and location during the incubation period for the disease.

Now, Hickcox has filed a lawsuit alleging that Christie and other government authorities violated her civil liberties...
I fully agree with the principle that the government has the legitimate authority to quarantine people who carry a deadly infectious disease -- or who pose an objective threat of such -- based on best reasonable medical knowledge.

The key issue in this case is whether someone who displayed no symptoms and was supposedly not at risk of transmitting the disease to others posed such an "objective threat". 

Friday, October 23, 2015

In Defense Of Old Mammography Guidelines

In response to new mammography guidelines from the American Cancer Society, the Washington Post covered the controversy in their 10/20/2015 piece: "Why this Harvard radiologist still recommends women get mammograms at age 40".

They interviewed Dr. Daniel Kopans, professor of radiology at Harvard Medical School and a radiologist at Massachusetts General Hospital.  Dr. Kopans discussed why age 40 should be retained as a better threshold than 50 for screening, as well as issues of overdiagnosis and insurance coverage.

Read the full text for more information.

Wednesday, October 21, 2015

The Flip Side of Shopping Solely By Price

Health care reporter Sarah Kliff decided to go with the least expensive MRI scan to check for a stress fracture in her foot.

Her conclusion: "I didn't think I was making any trade-off when I chose a cheaper MRI. Now I know that isn't true."

(See earlier piece, "NPR: Pay Patients, Save Money".)

Monday, October 19, 2015

Get Out of Obamacare

The Atlantic lists "All the Ways to Get Out of Obamacare".

Lots of government fine print.  (Via Dr. Megan  Edison.)

Wednesday, October 14, 2015

NPR: Pay Patients, Save Money

NPR's Planet Money podcast discusses a novel program to help patients save money on health care by cutting them in for a piece of the savings: "Pay Patients, Save Money".

Although not a fully market-based mechanism, it does show that patients can respond to incentive when they have "skin in the game".

For similar reasons, I support Health Savings Accounts and other market-oriented mechanisms to give patients more flexibility and control over their health spending.