Guest Post: Telling family medicine's stories

Richard Young, MD is a family physician educator and director of research at the John Peter Smith Hospital Family Medicine Residency in Fort Worth, Texas. He is the author of American HealthScare, a critically acclaimed book about the excesses of the current U.S. health system and potential primary care-based reforms. Dr. Young also regularly posts on his blog of the same name.

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I think one of the underlying reasons Family Medicine continues to be under-supported in the U.S. is the very nature of storytelling, and the media's preference for telling stories over reporting facts.

The ologists have it easy. Their stories go something like this: A mother has a child who isn't doing very well both at home and at school (protagonist). She goes from one doctor to another, and they tell her there is nothing physically wrong with the child and one even tells her that bad parenting is to blame (antagonist and conflict). She refuses to take no for an answer, and she scours the Internet and finds an ologist at a major medical center who thinks he has the answer. They travel to see this medical fairy godmother, he waves his magic wand (a complete battery of tests), and the boy is saved and becomes normal again (resolution). Nightly news and magazine shows (60 minutes, Dateline) love these stories.

Here is family medicine's story. A patient comes to the family physician with a list of physical symptoms. The physician listens to the patient (in itself therapeutic), orders a few basic lab tests that are normal, and essentially asks the patient to be patient -- the symptoms don't raise any red flags for a serious underlying disease and will probably resolve on their own. A month later the patient feels better. BORING. There's no action and no conflict.

Other medical nonsense is magnified on shows like Private Practice and Grey's Anatomy -- when the characters aren't banging each other and actually taking care of patients -- in dialogue where they scream at each other lines such as, "You have to let her go!", then "I will not let my patient die. I swore an oath to do everything in my power for my patients and I will not give up!" And so on.

Therefore, the story of family medicine isn't what it does as much as what it doesn't do. Our quality care is best understood as a counterpoint to ologist excess. This is why Shannon Brownlee's book Overtreated and the recent video about the harms of overtreatment are a step in the right direction to get the American people to understand the tremendous cost, waste, and harms caused by an over-ologized physician workforce, and an American medical culture that is locked into the overall ologist philosophy of what is standard of care.

Some colleagues and I have collected some great stories of how family physicians deliver better care at a lower cost. The power of some of the stories we heard had their greatest impact when set against the ologist alternative. For example, a patient was taking 13 pills and seeing 5 different doctors multiple times per year and still feeling sick. Then a family physician took over all her care and got her down to 8 pills and 4 visits per year, and the patient felt better.

Patients and storytellers want certainty, but family physicians are the masters of managing uncertainty. Americans want action and immediate answers, but family physicians are the masters of patience, judgment, and prudence. Let's face it, family medicine is just un-American.

That's why our healthcare system is so costly and inefficient and why our children will have worse lives than their parents. The task is enormous, but the culture of America must change to right the listing ship. Americans need to develop a different understanding of what a healthcare system should even provide in the first place.

The best recent posts you may have missed

Every other month or so, I post a list of my top 5 favorite posts since the preceding "best of" list on this blog, for those of you who have only recently started reading Common Sense Family Doctor or don't read it regularly. Here are my favorites from September and October:

1) Health communication: what not to do (9/11/12)

2) The spiritual assessment: unnecessary or essential? (10/4/12)

3) Prevention potpourri (9/25/12)

4) Reducing overtreatment is the other side of quality improvement (10/8/12)

5) Why don't comparative effectiveness studies change practice? (10/15/12)

If you have a personal favorite that isn't on this list, please let me know. Thanks for reading!

End the war metaphors for cancer screening and treatment

Like millions of cycling fans all over the world, I was very disappointed about revelations that 7-time Tour de France champion and cancer survivor Lance Armstrong had been using banned performance-enhancing substances for most of his career, despite years of increasingly vigorous denials. To many people, Lance transcended his sport through his seemingly indomitable will to win - not only Tours, but a very public fight against advanced testicular cancer. Lance's words of encouragement to other people struggling with cancer were marked with war metaphors: personal battles, wars to be won at all costs against a tenacious and unyielding enemy. And while there's no such thing as cheating in the effort to beat a medical condition, the evidence now shows that Lance's determination to win at all costs in sports led him down a path that has resulted in his disgrace.

On Thursday I will speak about cancer screening at the Johns Hopkins Bloomberg School of Public Health's Fall Policy seminar on "Science and Public Policy in Conflict." One of the messages I hope to leave with the audience is that we need to end, or at least soften, the harsh war metaphors for cancer screening and treatment, which endow screening tests such as mammograms with far more power than they really have to affect patient outcomes, and leads to uninformed advocacy and public policy that ignores the harms of overdiagnosis and overtreatment that inevitably result. As I blogged last June (and have reposted below), there are "no easy victories" in cancer screening when it comes to the evidence.

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Nearly forty years ago, President Richard Nixon famously declared a "War on Cancer" by signing the National Cancer Act of 1971. Like the Manhattan Project, the Apollo program that was then landing men on the Moon, and the ongoing (and eventually successful) World Health Organization-led initiative to eradicate smallpox from the face of the Earth, the "War on Cancer" was envisioned as a massive, all-out research and treatment effort. We would bomb cancer in submission with powerful regimens of chemotherapy, experts promised, or, failing that, we would invest in early detection of cancers so that they could be more easily cured at earlier stages.

It was in the spirit of the latter that the National Cancer Institute launched the Prostate, Lung, Colorectal, and Ovarian Cancer (PLCO) Screening trial in 1992. This massive study, which eventually enrolled more than 150,000 men and women between age 55 and 74, was designed to test the widespread belief that screening and early detection of the most common cancers could improve morbidity and mortality in the long term. Not a few influential voices suggested that the many millions of dollars invested in running the trial might be better spent on programs to increase the use of these obviously-effective tests in clinical practice.

They were wrong. As of this week, the PLCO study is 0-for-2.

Miss #1 occurred in March of 2009 when the PLCO study first reported no mortality benefit from annual PSA testing, a test that a majority of men over 50 undergo routinely. Miss #2 occurred over the weekend, when the Journal of the American Medical Association published a landmark paper that ended with the following paragraph:

We conclude that annual screening for ovarian cancer as performed in the PLCO trial with simultaneous CA-125 and transvaginal ultrasound does not reduce disease-specific mortality in women at average risk for ovarian cancer but does increase invasive medical procedures and associated harms.

The lung and colorectal screening components of PLCO have not yet reported mortality data**, and there is reason to believe that at least the latter will likely yield some positive results. Although it has largely been supplanted by colonoscopy and CT colonography (aka "virtual colonoscopy") in the U.S., flexible sigmoidoscopy was already shown to reduce deaths from colorectal cancer in a randomized trial published in the Lancet last year. And PLCO's screening chest x-rays are probably a loser, but a preliminary report from NCI's National Lung Screening Trial suggest that screening CT scans can reduce lung cancer mortality in heavy smokers. (Even after this report is confirmed in a peer-reviewed scientific journal, there will still be plenty of reasons not to rush into lung cancer screening, as I outlined in a previous blog post.)

Still, these are hardly the magic bullets or the resounding victories that many expected from the "War on Cancer." The same can be said for chemoprevention, or the strategy of prescribing medications for healthy adults to prevent cancers from developing at all. The vast majority of "high risk" women have avoided breast cancer chemoprevention with tamoxifen and raloxifene due to their unpleasant side effects (which include hot flashes and life-threatening blood clots), despite a 2002 recommendation from the U.S. Preventive Services Task Force for clinicians to discuss these drugs with their patients. (This recommendation has not been updated since, largely due to politics, not science.) A new study published in the New England Journal of Medicine has reported that the drug exemestane reduces the risk of invasive breast cancer without the other drugs' side effects. But here's the rub: we can't be sure how many of those breast cancers are the ones that inevitably lead to symptoms and death, rather than the 1 in 3 that are thought to be overdiagnosed.

The bottom line from recent research is that there are no easy victories in cancer screening and prevention - just slow, incremental progress. Companies that have a profitable product to push would like you to believe otherwise, but when it comes to cancer prevention, there is no substitute for a healthy lifestyle: Don't Smoke. Drink in Moderation. Exercise. And Eat a Well-Balanced Plate.

** Note: the PLCO trial subsequently reported that chest x-ray screening did not reduce lung cancer deaths, while flexible sigmoidoscopy reduced colorectal cancer deaths by 26 percent. So PLCO's "final score" is 1 in 4 screening tests evaluated showing a positive effect on health.