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How training to become a doctor in France differs from the United States

Kevin — Sun, 22 Nov 2009 04:00:45 PST

by Yann Meunier, MD

Among the many differences between the U.S. and the French health-care systems is the approach to medical training. While U.S. medical school graduates in 2008 had an average debt of $154,000, French medical students receive their training virtually for free. For example, first-year medical students at the Faculte de Medecine Pierre et Marie Curie in Paris have only one mandatory cost for this year: an enrollment fee of $264.

The amount of debt facing a new physician has many effects on the health-care system. According to the Association of American Medical Colleges, heavily indebted doctors are less likely to choose primary care fields, and may work more hours, leading to fatigue and possible medical errors.

Here’s a closer look at how doctors are trained in France.

Medical education is made up of three cycles that are provided by 34 universities. The cycles are:

First cycle (PCEM) — Two years. It consists of general scientific training not delivered in hospitals. There is a competitive exam at the end of the first year. It is highly selective and charts the students towards research, clinical care, biology, etc. The number of students admitted is set by government regulation.

Second cycle (DCEM) — Four years. The first year is devoted to general medicine training. The three following years are dedicated to pathology and therapeutics. Courses are given in the medicine schools and hospitals.

Third cycle — Students reach the third cycle only after being certified, and then have a choice between two options:

* “Résidanat” or general medicine third cycle: Two-year program of theoretical and practical training (rotations in hospitals and a training course with a general practitioner). At the conclusion of the training, the student receives a state diploma of general medicine doctor.
* “Internat” or specialized medicine third cycle: Four- to five-year program which leads to a competitive exam in such fields as: medicine specialties, surgery specialties, anesthesia, industrial medicine, public health, biology and psychiatry. This specialized studies program culminates with a state diploma of medicine doctor, or DES. DES holders can improve aspects of their specialty by taking Complementary Specialized Studies programs.

My own medical training took place in France, Brazil and the United States, and so I’ve experienced the different approaches to physician training. In general, I found that medical education in France is more uniform and homogeneous because of government control. However, American universities have the freedom and funding to develop truly innovative programs.

If the United States were to subsidize medical education, I believe it would level the field in terms of socioeconomic discrepancies among those who want to become physicians and make it easier for doctors to choose primary-care fields by reducing their debt load, among other things. The drawback is that it would likely increase taxes and may hamper the innovation seen at individual medical schools.

What do you think? Would it be better for the U.S. health-care system if the government helped subsidize the costs of medical education? I look forward to hearing your thoughts.

Yann Meunier is the health promotion manager for the Stanford Prevention Research Center who blogs at Scope at the Stanford University School of Medicine.

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Using cell phone text messages to remind people to use sunscreen

Kevin — Sat, 21 Nov 2009 12:00:40 PST

Originally published in Insidermedicine

Daily text messages sent to individuals’ cells phones can help remind them to use sunscreen, according to research published in the latest issue of the Archives of Dermatology.

Here is some information from the American Academy of Dermatology on sun exposure, sunscreen use, and vitamin D synthesis:

• Unprotected ultraviolet (UV) exposure to the sun or indoor tanning devices is a known risk factor for the development of skin cancer

• There is no scientifically validated, safe threshold level of UV exposure from the sun that allows for maximal vitamin D synthesis without increasing skin cancer risk

• To protect against skin cancer, a comprehensive photoprotective regimen, including the regular use and proper use of a broad-spectrum sunscreen, is recommended

Researchers out of the University of California–Davis Health System in Sacramento randomized 70 volunteers aged 18 and older to receive text messages reminding them to apply sunscreen daily or receive no such messages. The text messages were sent to participants cellular phones and included information on the daily forecast as well as reminders to apply sunscreen. Adherence to sunscreen use was measured via electronic monitors adapted to participants’ sunscreen tubes that relayed an electronic message every time the cap was removed.

At the end of the six week trial, mean daily adherence to sunscreen application was 56.1% in the treatment group, compared with only 30.0% in the control group. Also, 69% of those who received text message reminders reported that they would continue to use them, and 31% said they would recommend them to others.

Today’s research highlights how poor adherence is to sunscreen use even among those who know they are being monitored. It also demonstrates, however, that simple electronic tools, such as reminder systems, can help improve adherence.

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Op-ed: Humor can be healing for both doctors and patients

Kevin — Sat, 21 Nov 2009 04:00:09 PST

A version of this op-ed, co-written with Doug Farrago, was published on October 26th, 2009 in Medscape.

It’s tough to be a doctor these days. Whether it’s listening to the difficulties of our medical colleagues as they try to best care for their patients, or engaging other health professionals about the uncertainties surrounding health reform, we’ve noticed a tense, sometimes gloomy, atmosphere among physicians.

A recent survey from the Annals of Internal Medicine bears this out. More than a quarter of primary care doctors reported being “burnt out,” in part due to worsening time pressures and a chaotic work pace, which were “strongly associated with low physician satisfaction.”

Worse, an alarming number of physicians, unable to cope with the pressures of practicing everyday medicine, succumb to the stress. Consider that 300 to 400 doctors in the United States kill themselves every year, or roughly one per day. Male doctors have suicide rates 1.4 times that of the general population, while female doctors have twice the rate of depression and 2.3 times the suicide rate when compared with women who are not physicians.

Maybe we all just need to laugh a little. Really.

Although doctors, in general, are known as a pretty serious group, humor is one of the best ways to cope with the harsh realities that we face daily. This concept isn’t new. The phenomenon of using humor in difficult situations was first studied by the psychologist Sigmund Freud centuries ago. He introduced the term, “gallows humor,” which is based on the theory that joking relieves anxiety and laughter can transform unpleasant feelings into ones that are more positive. Indeed, sociologists have pointed to humor as a way for doctors to express a wide array of stressful emotions, including, grief, disappointment, and anger, into ways they find more palatable. A study from the Annals of Emergency Medicine looked at how emergency physicians managed stress, and found that the ability to find humor in everyday experiences was among the most successful strategies to prevent burnout.

Humor itself won’t improve the obstacles facing doctors today, like an increasing bureaucratic burden or a worsening malpractice environment. But by poking fun at some of these inane situations, chronicled in satire-based medical publications like Placebo Journal for instance, perhaps some of that distress can be alleviated.

And think about how patients can benefit from some levity during their doctor’s visit. We’ve heard from many patients who are growing increasingly dissatisfied after receiving medical care, reporting little eye contact, decreased face-to-face time, and feeling depersonalized, all of which are consequences of a medical system that promotes rushed physician encounters. So, as the doctor-patient relationship deteriorates, can a well-placed, appropriate joke help?

Well, yes. Sharing lighter moments can make appointments feel less hurried, with patients thinking, “Hey, this doctor spent a few minutes to tell a joke, rather than going straight to the lab results or x-ray report.” Sensitive topics can be more easily broached, once a shared laugh breaks the proverbial ice.

Indeed, Hippocrates himself suggested that, when interacting with patients, doctors should use both wit and humor, as “dourness is repulsive both to the healthy and to the sick.” When patients are either in a hospital or at a clinic, most are anxious, and sometimes overwhelmed, while dealing with their illness. Sharing a joke or a smile not only can lighten the mood of a tense situation, but can better connect doctors with their patients, as they laugh at something in common. The medical journal, The Oncologist, interviewed cancer doctors who poignantly noted that, “the ability to laugh, for doctors to take a moment to detach themselves from medicine, [was] something that patients certainly appreciated.”

Of course, common-sense applies when trying to be funny in the exam room. Don’t tell sexually or racially-tinged jokes. When meeting a patient for the first time, get a sense of what’s an acceptable boundary of communication. Sometimes, when soliciting a social history for example, patients themselves may tell a joke, indicating they are open to humor on the doctor’s part. And finally, humor is never appropriate when delivering bad news. Patients in these cases want to know their situation is being taken seriously.

With the uncertain prospects of health reform dominating the headlines, and the debate often contentious, it’s a challenge to find anything amusing about health care today. Physicians, meanwhile, struggle to find ways to best practice medicine despite worsening regulatory impediments, along with fighting an uphill battle to rekindle the relationship they once had with their patients.

No matter how glum the situation appears to be, it’s important for doctors to try to find a ray of humor. It can only help.

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When women should have their first Pap smear; the new cervical cancer screening guidelines

Kevin — Fri, 20 Nov 2009 19:13:55 PST

Originally published in MedPage Today

by Charles Bankhead, MedPage Today Staff Writer

Women can wait longer for their first Pap smear and then repeat the test less frequently, according to recommendations from the American College of Obstetricians and Gynecologists (ACOG).

The organization now says women should begin cervical cancer screening with a Pap test at age 21. Subsequent tests should occur at two-year intervals until age 30, when the interval can be increased to once every three years for women who have had three consecutive negative tests.

ACOG previously advised women to have an initial Pap test within three years of becoming sexually active or at age 21, whichever came first. The organization also recommended annual screening.

The recommendation was published in the December issue of Obstetrics & Gynecology.

“The tradition of doing a Pap test every year has not been supported by recent scientific evidence,” Alan G. Waxman, MD, of the University of New Mexico in Albuquerque, said in a statement. “A review of the evidence to date shows that screening at less frequent intervals prevents cervical cancer just as well, has decreased costs, and avoids unnecessary interventions that could be harmful.”

Waxman served as a consultant to the ACOG Committee on Practice Bulletins-Gynecology during development of the recommendation.

Women with a history of cervical intraepithelial neoplasia or cervical cancer should consult their physicians about the need for more frequent screening, as should women with certain risk factors for cervical cancer, such as in utero exposure to diethylstilbestrol, HIV infection, or immunosuppression.

According to ACOG, changing the baseline Pap test to age 21 reflected a desire to avoid unnecessary treatment of adolescents. Although infection with human papillomavirus (HPV) is common in sexually active adolescents and teenagers, HPV-induced cervical dysplasia in that age group usually resolves without treatment. Cervical cancer rarely occurs in women younger than 21.

These other recommendations remain unchanged:

* Women who have undergone total hysterectomy no longer need a Pap test.
* Women ages 65 and older can discontinue cervical cancer screening if they have three consecutive negative Pap tests and no abnormal tests in the previous 10 years.
* Recommendations are the same for women with and without HPV vaccination.

Widespread use of the Pap test has led to a greater than 50% decline in cervical cancer incidence over the past 30 years, from 14.8 cases per 100,000 women in 1975 to 6.5 cases per 100,000 women in 2006.

According to the American Cancer Society, 11,270 women will have new diagnoses of cervical cancer in 2009, and 4,070 women will die of the disease. Most cervical cancer deaths in the U.S. involve women who have been screened infrequently for the cancer or not at all.

Although screening and early detection have made cervical cancer less of a threat in the West, it remains the second most common cancer in women worldwide and causes most cancer-related deaths among women in developing countries.

Visit MedPageToday.com for more oncology news.

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Discharged from the hospital without answers; the death of Jane Q. Patient

Kevin — Fri, 20 Nov 2009 12:00:41 PST

by Dan Walter

We found out that her real name was Cindy Chapman, and that she died alone and afraid.

Cindy was a paralegal, an activist and a fighter of lost causes who lived in Worcester, Massachusetts. She was part of an online community called RATEMDs, where she had many soul mates. Her posts on health care were funny and cynical and wise. Her screen name was Jane Q. Patient.

My wife, Pam, was especially fond of trading comments and barbs with her. Like others on the forum, Jane Q. was prone to drop off the screen for days or weeks at at time. But she always resurfaced with stories of her battles with the system, her fights for the poor as a paralegal, or her volunteer efforts with the Obama campaign. A few months ago, as the fight for health care reform was reaching a fever pitch, Jane started posting about her own medical complaints. She told of emergency room visits and fights over insurance, and pain, pain, pain. Her postings became erratic, with uncharacteristic typos, misspellings, and fragmented thoughts.

When Jane Q. dropped off the screen again, Pam set out to find her. Having traded some private emails, Pam knew Jane’s real name and had a general idea of where she lived.

After relentless Google searching, Pam hit upon a column by Diane Williamson in the Worcester Telegram. It was the story of Cindy Chapman’s final days. The 48 year old native New Yorker lived with her cat in a room off Worcester Common. She had been suffering terrible back pains over the summer and had been taken by ambulance to the University of Massachusetts Memorial Medical Center Emergency Room on four occasions.

Each time she was discharged with some pain killers, but no answers.

The last time she went there she refused to be discharged and the hospital called the police to eject her from the ER on the grounds that she was exhibiting drug seeking behavior. She was put in a cab and sent home. She called one of the few people she knew in the neighborhood. She said that she was in terrible pain and that she was scared and she didn’t know what to do.

Her neighbor called six primary care physicians before finding one who would accept Medicare and could see her without waiting a year. This doctor found that Cindy Chapman had end stage cancer of the lungs, liver and spine. Two weeks later she was dead.

As the Senate prepares to take up the health care bill, The New York Times quotes one analyst as saying that “All industries stand to gain from this legislation.” But the real question we need to be asking ourselves is whether the Cindy Chapmans of the world stand to gain anything from our new approach.

We’d better hope so. After all, there was a reason she called herself Jane Q. Patient.

Dan Walter is a writer based in Deale, MD.

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Are older nurses being forced out of the profession?

Kevin — Fri, 20 Nov 2009 10:00:15 PST

Originally published in HCPLive.com

by Colleen O’Leary, RN, MSN, AOCNS

Last time I talked about how I had never really experienced the concept of nurses eating their young in action.

However, I have seen the opposite begin to evolve. I see this as a bigger issue in nursing these days. The “putting out to pasture” of seasoned, experienced nurses is happening more often and for a variety of reasons.

First, and foremost, is simply the fact that the pool of nurses inevitably follows the general aging of the nation. As baby boomers who once filled the halls of healthcare institutions caring for others begins to age, they will certainly have a more difficult time meeting the demands of current healthcare. More and more institutions are requiring nurses to work longer and longer shifts, changing from an 8-hour day to a 12-hour day. This, along with the fact that patients in the inpatient settings have much higher acuity and a variety of complex issues, makes the demands on nurses even greater.

I know for myself that when I was working 12-hour shifts, I could only do two in a row. If I had to do the third one without a break, I was exhausted. I can only imagine how someone five, 10, or even 15 years older than me would feel. In fact, I remember one time when a new young nurse just starting out came to me and sheepishly asked, “What do you do when you go home after working a 12-hour shift?” He was finding that he was very tired and often unable to do anything but go home, have dinner, and go to bed. If someone that young has difficulty imagine how it is for the older nurse.

Not only are the hours and the complexity of patients difficult, but also the physical strain. Because patients have such high acuities, they often require turning, positioning, and moving that can cause stress on the nurse’s back, neck, arms, and legs. Injuries among nurses are much higher than even injuries among construction workers. Again, more stress and difficulty for the older nurse.

Another point to take into consideration is the advent of new technologies for diagnostics, assessment, and documentation. Often, when facilities start to change to electronic medical records, it’s the older nurses who have the most difficulty. The younger nurses grew up with advanced technology everywhere around them. I remember the first computer class I had to take in college taught us how to do keypunch machines. There were giant computers in a lab that you had to schedule time to use to do your work. Then you carried around a stack of cards with little computer generated holes punched in them, that when read, gave a story. Then many years later when I took a nutrition class and was told we had to do a computer program, I was terrified. I didn’t know how to use computer programs. How times have changed… But that’s the point. If you haven’t grown up with that being a part of your everyday life, it’s very difficult for some to catch on and take hold of new technology.

Finally, the recent change in the economy has put a different kind of strain on older nurses. Where they might have been thinking of retiring, they now find that they must remain in the workforce to survive. I’m just afraid of what is going to happen over the next couple years when the economy starts to rebound; people are feeling safer and we see a mass exodus of retiring nurses. I think it will be a time of extreme nursing shortage and we should start planning for it now.

But what makes nursing different than other professions that are facing an aging workforce, and what is it that really bothers me the most? It’s the concept of not just aging but of truly “putting out to pasture.” If an older nurse has not worked their way through the ranks and is still in the trenches of bedside or chairside nursing, how much support are they getting? Forget the concept of the seasoned nurses not nurturing and helping the newcomers.

As I’ve said, I have not seen that phenomena. But what I have seen is a sense of impatience towards the older nurse; an underlying feeling that they just can’t cut it and not a great sense of wanting to help them. Not only the impatience, but it’s almost a disdain for them. It’s as if they don’t highly regard the years of experience as valuable because the person might have a more difficult time with the newer techniques. I’m not sure how we got to this point. I’m sure it has something to do with the whole outlook that each of the generations have on work, socializing, and facing the world, but it is a bit disheartening to see around me. I have always learned to respect those with more experience and try to learn something from them. That doesn’t mean that I think that we should allow someone who cannot physically do the job stay in the job.

But I think we could, as a profession, hold up our experienced nurses and learn something from them instead of always thinking we need to teach them something.

Colleen O’Leary is a staff educator of medical oncology at Northwestern Memorial Hospital who blogs at Oncolog-e Nurse Talk.

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How should the FDA regulate the social media advertising of drugs?

Kevin — Fri, 20 Nov 2009 08:00:20 PST

Originally published in MedPage Today

by Emily P. Walker, MedPage Today Washington Correspondent

Drug and device makers are urging the FDA to establish clear guidelines that will allow the industry to discuss and promote products in the unsettled world of online social media.

The FDA is hearing testimony from drug and device companies, online marketing experts, and consumer groups about what steps the agency should take to move medical advertising and promotion into online communities.

“The Internet is an important tool for consumers looking for answers about medications,” Michele Sharp, a spokeswoman for Eli Lilly, said at the FDA gathering today.

“We must be visible and relevant in the places where patients, caregivers, and payers are looking. These days, that includes the Internet and social media. We believe we can and should pay a significant role to provide patients information.”

So far, despite growing use of social media platforms such as as blogs, Twitter, and Facebook, the bulk of drug company advertising is geared toward TV and magazines.

One reason is that the FDA has clearly spelled out the rules governing those traditional platforms: The ads must not be false, misleading, or lacking facts, and they must show a fair balance of the risks and benefits of the drug or device.

But how those rules apply online is unclear. For instance, if a drug company wanted to use Twitter to promote a new drug, does it have to include the risks of the drug in the tweet? Twitter only allows for 140 characters, and the litany of risks for some drugs could fill a tweet encyclopedia.

What if a compliant YouTube ad for a medical device is copied by a user who reposts it minus the last 30 seconds, when the narrator is rattling off the device’s risks? In that case, is the device company at fault?

Or, in another instance of many social media hypotheticals, what if a patient advocacy message board for diabetics is riddled with misinformation about a drug? Should the drug company correct the information? If so, should the company be required to list the drug’s side effects in its post?

Rules governing a company’s involvement on online platforms are so opaque that many companies just steer clear of communicating about their products on such sites.

But avoiding a growing arena where consumers and doctors have conversations about medical topics is ignoring reality, panelists at the FDA hearing said.

An estimated 83% of all Internet users search for health information on the Web, according to a survey by the Pew Research Center.

“We need to be a part of the online conversation,” agreed Elizabeth Forminard of Johnson & Johnson.

Sharp said Eli Lilly has mostly avoided using online media because it’s not sure how to comply with FDA rules. “We’re looking for the FDA to guide us,” she said.

One solution promoted by a number of speakers, including Jeffrey Francer of PhRMA, is for the FDA to approve use of its logo for drug companies to place on content that meets the agency’s standards.

Another panelist suggested that clicking on the logo would take the user to either an FDA Web page, or the company’s page, which would clearly list information, including benefits and risks, of the given drug.

One panelist who is an advocate for women and children’s issues, said using a standard logo to indicate FDA’s stamp of approval would be troublesome.

“The content of a blog or Web site can be accurate, but incomplete. It can be accurate about the benefit, but just fail to mention the risks,” said Diane Zuckerman, president of the National Research Center for Women and Children.

Zuckerman noted that today’s accurate information might be out-of-date tomorrow.

“Things change, and it would be very difficult to have some sort of FDA seal of approval,” she said.

Forminard of Johnson & Johnson suggested companies be held accountable for content they created, whether it is posted on the company’s own site, or a third-party site, such as a newspaper’s Web site.

But companies cannot be held accountable for content they don’t create, she said.

All companies at the hearing said they thought providing more information “just a click away” would suffice. This would be easier than having to jam a list of benefits and risks in a limited space, such as an ad that appears in search engine.

The companies also agreed that it would be unreasonable to expect drug and device companies to police the entire Internet for false or misleading statements about their products.

Online promotion of drugs and devices isn’t just geared toward consumers.

The FDA will have to grapple with rules for sites that are aimed at physicians, such as VuMedi, a surgeons-only site that allows users to share videos on surgical procedures and comment on them. Some of those videos are posted by device companies, but they are always clearly identified as such, said Robert Winder, CEO of VuMedi.

Winder said sites for physicians shouldn’t be subjected to the same rules as those that govern direct-to-consumer advertising.

The FDA’s hearing continues tomorrow, when more representatives from drug, device, and marketing companies are slated to speak about adverse event reporting.

The agency won’t be making decisions on industry involvement in social media anytime soon. It is keeping its public comment docket open on this subject until February 2010.

But in the constantly changing online world, one speaker had a word of advice as the agency develops its rules:

“If the rules are too narrow or inflexible, the minute we figure out how to do it, they will be out of date,” said Philomena McArthur of Johnson & Johnson.

Visit MedPageToday.com for more prescription news.

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Primary care disrespect starts early in medical school

Kevin — Fri, 20 Nov 2009 04:00:32 PST

In medical schools, primary care continues to be among the least respected fields a student can choose.

No where is that more starkly illustrated than in Pauline Chen’s recent New York Times piece, where she tells a story of a bright medical student who had the audacity to choose primary care as a career:

Kerry wanted to become a primary care physician.

Some of my classmates were incredulous. In their minds, primary care was a backup, something to do if one failed to get into subspecialty training. “Kerry is too smart for primary care,” a friend said to me one evening. “She’ll spend her days seeing the same boring chronic problems, doing all that boring paperwork and just coordinating care with other doctors when she could be out there herself actually doing something.”

This lack of peer respect is one reason why only 2 percent of medical students choose primary care internal medicine as a career.

Regular blog readers will know that the generalist-specialist salary disparity, combined with the paperwork and high professional dissatisfaction rate, are major reasons why future doctors are avoiding primary care medicine.

But there remains an implicit bias among medical educators favoring procedure-based medicine, mostly due to the disproportionate amount of dollars specialists bring to an academic institution. Hospitals and medical schools give specialists unspoken, preferential treatment, and that sentiment trickles down to medical students.

There’s no doubt that influencing future doctors away from primary care starts from the earliest stage of medical training.

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Can less aggressive cancer screening recommendations be better for patients?

Kevin — Thu, 19 Nov 2009 12:00:19 PST

by Amy Tuteur, MD

Doctors have understood for some time that it was inevitable. The American Cancer Society has acknowledged that cancer screening has been oversold.

It seems like every day you read in the newspaper that what was standard medical care yesterday is now no longer recommended. Don’t doctors know anything? Well, actually they do. And what seems like paradoxical behavior, no longer recommending aggressive screening for certain cancers, actually represents a more sophisticated understanding of the way in which cancer behaves.

The classic understanding of cancer is that once a cancer forms it will continue to grow steadily until it kills the patient. Cancer was viewed as if it were an infectious disease like syphilis. It starts small and easy to treat, may remain hidden for long periods of time, but eventually spreads to other parts of the body becoming incurable along the way. If cancer did indeed spread like that, the aggressive screening programs would make perfect sense.

But decades of research and clinical experience have led to a more sophisticated understanding of cancer. It has always been known that cancers from different parts of the body behave in very different ways. Ovarian cancer is extremely aggressive, while basal cell cancer of the skin grows very slowly. Breast cancer can and does spread to bones and brain, while colon cancer is most likely to spread only to the liver.

More recently we’ve learned that each cancer can be broken down into different subtypes, some more aggressive than others, and some better treated with one regimen instead of another. For example, breast cancers are now analyzed for the presence of hormone receptors on the outside of the cancer cells. The presence or absence of certain receptors tells us whether specific treatments will be helpful or useless, making it easier to target the cancer with the treatment most likely to work.

We have also learned that some cancers follow the model of an infectious disease like syphilis, starting small and curable and ending up throughout the body and incurable, many do not. Some cancers start small and explode aggressively. Others start small and stay small for decades. This more sophisticated understanding is a direct result of being able to diagnose cancer earlier. We now have a much better and far more nuanced understanding of the natural history of various cancers. It has become apparent that rather than finding all cancer, we need only find cancers that are aggressive and can ignore those that are known to grow very slowly if at all.

What’s the big deal? Isn’t cancer screening beneficial regardless of the natural history of the particular cancer? No, it’s not and therein lies the reason for the American Cancer Society’s call for less screening of certain cancers.

The goal of cancer screening is and has always been to reduce cancer deaths and disability, and therefore, that’s how cancer screening should be judged. By that standard, some forms of screening are total successes. For example, the Pap smear, the screening test for cancer of the cervix, has been an unalloyed bright spot in the war against cancer. The test is inexpensive and reliable, the follow up test to actually diagnose cancer (biopsies of the cervix) is harmless, and very few if any women are treated unnecessarily. Screening for cervical cancer saves many lives and has few long term side effects.

By the same standard, prostate cancer screening has been a terrible disappointment. The PSA blood test, the screening test, is notoriously unreliable. Even more problematic is the fact that many prostate cancers grow extremely slowly and are unlikely to spread. Most problematic is that the treatment has very serious side effects, impotence and incontinence. Screening for prostate cancer with the PSA test (and finding tiny cancers) saves no more lives than screening with a prostate exam (which can find cancers that are somewhat larger) and leaves many men with unnecessary long term side effects.

Whereas every cervical cancer is probably dangerous to the patient and the treatment has few long term side effects in any case (since cervical cancer is most commonly diagnosed in women who have completed childbearing), most prostate cancers are not dangerous to the patient and the treatment is often undertaken unnecessarily. It’s bad enough to endure impotence and incontinence as the side effect of life saving treatment. It is tragic to endure it as the side effect of unnecessary treatment.

Breast cancer is similar to prostate cancer. While frequent mammography is more likely to diagnose cancer, there has not been a corresponding decline in breast cancer deaths. Treating many more women with chemotherapy, lumpectomy and mastectomy has produced very few additional lives saved.

The solution to this conundrum, of course, is to develop more sophisticated screening tests, tests that can discriminate between life threatening cancers and non-life threatening cancers. In the meantime, the existing screening tests should be judged on their ability to save lives, not on their ability to diagnose cancer, since many cancers don’t need to be treated.

Screening everybody for everything and screening them often is a very blunt tool that seemed appropriate when we had an unsophisticated understanding of cancer. Now that our understanding of cancer has deepened, the use of screening tests should reflect our new knowledge.

Simply put, screening tests should be reserved for situations in which they save lives. Dialing back on screening tests is not a step backward, it is a step forward in treating only those who need to be treated and not harming anyone else in the process.

Amy Tuteur is an obstetrician-gynecologist who blogs at The Skeptical OB.

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How to choose the right electronic health record (EHR) consultant

Kevin — Thu, 19 Nov 2009 10:00:37 PST

Originally published in HCPLive.com

by Jonathan Bertman, MD

You may have seen advertisements, or may already have been contacted by people who’ve promised to help you figure it all out so you can get your share of the stimulus money. Be wary. The truth is that the Obama administration is still defining many essential elements of the Health Information Technology for Economic and Clinical Health Act (HITECH), and full details about the exact reimbursement process will not be known until the fourth quarter of this year, at the earliest.

Nonetheless, there is a growing field of people who call themselves “EHR consultants.” They promise to advise you on which system to purchase for your needs, help set up and integrate the necessary hardware and software, and perhaps even troubleshoot any on-going problems you may have. Sounds tempting, right?

The difference is in the details
Let me stress that many EHR consultants are legitimate and can provide valuable services at a reasonable price. But there are some pitfalls to avoid. First, let’s define the difference between a consultant and a reseller. A consultant should be completely independent and have no relationship, financial or otherwise, with the vendors they recommend or refer to you. Conversely, a reseller receives payments from an EHR vendor for providing leads or getting a practice to purchase that specific EHR. An ethical consultant (ie, a reseller) will let you know upfront that they have a fiduciary relationship with one or more vendors, and then you can make an informed decision on the advice they provide. Many consultants and EHR/technology “experts,” however, quietly arrange kick-backs with various EHR vendors and fail to disclose this conflict of interest to their perspective clients.

There is one quick way to tell if you’re dealing with a consultant or a reseller. A reseller’s services should be free to you because the vendor is picking up the tab by paying the reseller a percentage of the sale, or some other pre-arranged fee. You know in advance that a reseller is going to steer you toward a particular product, and you can thus take what they say with the same healthy dose of skepticism that we apply to information we receive from drug reps.

On the other hand, if you are paying for services and recommendations, then you are dealing with a consultant who should be giving you unbiased advice. Unfortunately, a good number of consultants accept fees from doctors but then also receive referral fees from vendors for sending them potential clients. These payments may be in the form of cash, discounted hardware and software, or anything else of value.

The wild frontier
The EHR industry is relatively young and appears to be one of the exciting growth areas in an otherwise slumping economy. But this has resulted in a Wild West-like frontier where the various players (eg, vendors, consultants, resellers, state and local groups, and other agencies) can say just about anything without disclosing anything. And many IT companies and other consultants (even physicians seeking to earn some extra money) have agreements with software companies to receive payment for steering potential clients toward a specific vendor. Surprisingly, many of these otherwise honest people feel that if they aren’t specifically asked if they receive compensation from vendors (whether it be for directing leads, providing a recommendation, reselling, or even providing consultant services to the EHR vendor), they don’t need to share this information with their client or colleague.

You need to ensure that the information you receive from these “experts” is unbiased and based on the reasonable approach of matching your practice’s needs with the available solutions. A few key steps could save you tens of thousands of dollars in hardware and software expenses, not to mention the frustration of being cajoled into purchasing an overpriced and unusable EHR that you’ll regret later:

• When considering an EHR consultant, ask them pointblank if they have any relationship with one or more vendors, and ask exactly how those relationships work.

• Ask the consultant how many practices of similar size and specialty they have helped in the past, and get at least three different practice names and contact information to confirm that they were pleased with the consultant, would recommend their services, and would use them again.

• For smaller practices, be especially wary of consultants who also sell IT hardware and/or technical support. In my experience, IT consultants tend to recommend significantly more complex (and expensive) hardware and software than is necessary for the average small medical practice.

The third point deserves a bit more discussion, since many of the consultants in the EHR space also provide IT services and sell computers, servers, and other hardware. The main problem with hiring an IT consultant for guidance is that all too often these technologically -minded people push equipment and policies that are significantly more expensive and complex than is reasonable to run a small practice.

In my experience as an EHR vendor, all too frequently when an IT consultant is used, the practice ends up not only spending much more on hardware than my non-IT-consultant practices, but they have much less of an understanding of their system and thus an inability to troubleshoot issues that arise from time to time. In fact, Amazing Charts (my EHR company) recently raised prices for additional providers because we found that larger practices tend to have overly complex technology infrastructures based on the recommendations of their IT consultants. These systems take more time and energy to troubleshoot, and much more frequently, hardware and network issues are the source of the difficulties that lead to downtime.

Everybody does it, right?
Even big companies can be guilty of up-selling unnecessary equipment to small practices. For example, Amazing Charts used to recommend our users contact Dell to get advice and affordable systems. While Dell certainly makes good and affordable hardware, many of our clients called Dell and ended up directed to Dell telesales representatives who regularly scared them into purchasing big servers, tape backup systems, and other equipment because they were a “medical practice.” Most of the up-selling of robust servers and other equipment is completely unnecessary if you perform regular data backups and follow basic networking guidance.

When a consultant does recommend a specific product, whether an EHR system or anything else, do some online research to find out what others have to say. The American Association of Family Physicians (www.aafp.com) has a good site for researching EHR software (ie, the Center for Health IT). Message boards can be another useful research resource, if you have time to sort through all the garble.

The most important take-away from this month’s column is to make sure that your independent EHR consultant is not actually shilling for someone else. Get it in writing so you have some legal recourse if you make a purchase and have buyer’s regret a few months later.

Jonathan Bertman is Physician Editor-in-Chief of MDNG: Primary Care/Cardiology Edition.

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