July 29, 2011 | 10:34 am

Mammogram Reading Not Better With Computer Assistance

Posted by Albert Fuchs, M.D.

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I went to college in the late 1980s, at perhaps the peak of optimism about computer intelligence. Personal computers had just become available and there was a general expectation that computers would soon be driving our cars, accepting our commands in spoken English, and generally doing everything better than humans could.

The reality has been much less consistent. There have been impressive gains in computer intelligence applied to some specific tasks, like chess. But there has been remarkably little progress in others fields, like transcribing spoken language. Transcription software is still notoriously error-prone, and transcription by humans remains much in use.

At first glance, reading a mammogram seems like the perfect task for a computer program. The software would just need to recognize the characteristic appearance of breast cancer and the appearance of normal breast tissue. It would not be biased by factors that can affect radiologists, like fatigue or anxieties about making an error.

Indeed, such software exists. Computer-aided detection (CAD) technology is computer software that performs a second reading of a mammogram which is supposed to point out abnormalities on the mammogram the radiologist may have missed. It does not replace a radiologist’s reading, but was intended to help the radiologist detect more cancers and perhaps detect cancers earlier. It was FDA approved and is currently used in the reading of about three quarters of mammograms in the US.

Except it might not help.

A study published this week in the Journal of the National Cancer Institute looked at 1.6 million mammograms done at 90 facilities over 8 years. Some facilities used CAD, and some did not. The study found that CAD did not lead to increased detection of cancers or to detection of cancers at earlier stages. Worse, CAD led to an increase in false positives – mammograms read as abnormal that led to normal biopsies. That means that CAD led to an increase in biopsies without actually helping patients.

That’s not exactly what we hoped for from intelligent machines. That’s much less like Rosie, the Jetsons’ unflappable household robot, and more like HAL, the computer in 2001: A Space Odyssey.

Of course this study shouldn’t be the last word on CAD. Technologies improve all the time, and the fact that it’s not helpful now doesn’t mean it won’t be in a few years. But until some improvements are made, the best software for reading mammograms is still behind the eyes of a radiologist.

Learn more:

Computers Still Not a Big Help With Reading Mammograms (Wall Street Journal Health Blog)

Mammograms: Computer-aided detection doesn’t help (LA Times Booster Shots)

Important legal mumbo jumbo:
Anything you read on the web should be used to supplement, not replace, your doctor’s advice.  Anything that I write is no exception.  I’m a doctor, but I’m not your doctor.

July 22, 2011 | 12:18 pm

The Power of Placebo

Posted by Albert Fuchs, M.D.

We’ve all heard of the power of the placebo effect – the benefit from receiving an inactive medication or a phony simulated treatment. But how do placebos work? Do they improve objective measures of disease? Do they improve the patient’s subjective symptoms? Do they do both? A cleverly designed study in last week’s New England Journal of Medicine (link 1 below) answers that question.

The investigators chose asthma as the disease in which to study the effect of placebo because asthma can cause uncomfortable symptoms – wheezing, breathlessness – but can also be assessed objectively through lung function tests. The study enrolled patients with stable mild or moderate asthma. Each patient attended treatment sessions on 12 different days in which they received one of four treatments, so they received each treatment three different times.

One treatment was an albuterol inhaler. Albuterol is the standard medication for rapid airway dilation and is very commonly used by asthma patients. The second treatment was an inhaler with no active medication. Patients taking either the albuterol or placebo inhalers were not informed about the contents of the inhaler, and neither were the investigators monitoring them.

The third treatment was sham acupuncture. Sham acupuncture looks to the patient as if needles are being inserted in his skin, just as in traditional acupuncture. The patient also feels the needle poke. But the needle actually retracts into a sleeve (like prop theater swords) and never penetrates the skin.

The fourth treatment was no intervention. The patient was simply asked to wait a few hours before leaving.

Before and after each of the treatments the patients’ lung function was measured. After each of the treatments the patients were also asked to rate the improvement of their asthma symptoms.

The results were fairly dramatic.

The lung function tests improved substantially after albuterol, as expected, and didn’t improve significantly with the placebo inhaler, sham acupuncture or no intervention. But the patients’ perceived improvement did not match their lung function improvement. Patients reported no symptom improvement after a session of no intervention. They perceived significant symptom relief after albuterol, and they perceived equal symptom relief after the placebo inhaler and after sham acupuncture even though their lung functions did not improve with these interventions.

So the patients’ symptoms were relieved equally by any kind of perceived treatment, by what the authors of the study call “the ritual of treatment”. But lung function improved only with active medication.

What are we to learn from this? The authors of the study assert that this means that in diseases such as asthma we should be sure to follow objective disease measures, since the patients’ reports may lead us astray. An editorial in the same issue (2) disagrees and asserts that symptom relief is point of asthma treatment, not necessarily normalization of objective tests.

The right balance likely depends on the disease. Some diseases, like high blood pressure, have no symptoms. Objective tests have to be the benchmark of treatment. Other diseases, like migraines and fibromyalgia, have no objective findings. Clearly these must be treated with subjective symptom relief as the goal. Most illnesses are somewhere in between, and both active medication and the “ritual of treatment” have a valuable role.

Learn more:

(1) New England Journal of Medicine article: Active Albuterol or Placebo, Sham Acupuncture, or No Intervention in Asthma (full text by subscription only)

(2) New England Journal of Medicine editorial: Meaningful Placebos — Controlling the Uncontrollable (full text by subscription only)

Wall Street Journal Health Blog: The Placebo Effect, This Time in Asthma

Los Angeles Times Booster Shots: Asthma study reveals the power of the placebo effect

Important legal mumbo jumbo:
Anything you read on the web should be used to supplement, not replace, your doctor’s advice.  Anything that I write is no exception.  I’m a doctor, but I’m not your doctor.

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July 8, 2011 | 3:27 pm

Spiral CT Scans Save Lives from Lung Cancer

Posted by Albert Fuchs, M.D.

In November I wrote about preliminary data from the National Lung Screening Trial, a large study funded by the National Cancer Institute that attempted to find out if catching lung cancer early with spiral CT scans made a difference. (See link 1 below for my November post.) Last week, the New England Journal of Medicine published the trial results (2) and an accompanying editorial (3).

The study randomized over 50,000 people who were

• aged 55 to 74,
• were either current smokers or had quit in the last 15 years,
• had not been diagnosed with lung cancer, and
• had a lifetime history of smoking at least 10,000 packs of cigarettes (the equivalent of smoking one pack per day for 30 years).

The study subjects were randomized to two groups. One group received annual chest X rays for three years. Chest X rays have already been proven not to save lives as a test for early lung cancer. The second group received annual spiral CT scans of their chest for three years. Both groups were followed for another three and a half years after the tests to assess for the development of lung cancer and death due to lung cancer.

The results were remarkably positive. The group receiving the CTs had a 20% lower rate of death from lung cancer. For every 320 patients screened by CT, one life was saved. That’s a number that compares favorably with other cancer screening tests, like mammography.

This is a very important discovery. Though lung cancer incidence has been declining with the decreasing number of smokers, it remains the number one cause of cancer death in the US. Use of CT screening in the appropriate groups of patients promises to significantly decrease lung cancer mortality.

So if you meet every point in the above list, talk to your doctor about a spiral CT of your chest. More importantly, if you smoke, stop. If you want to stop smoking and can’t, ask your doctor for help.

[Medical news posting resumes in two weeks.]

Learn more:

(1) My previous post about the National Lung Screening Trial: A Screening Test for Lung Cancer

(2) New England Journal of Medicine article: Reduced Lung-Cancer Mortality with Low-Dose Computed Tomographic Screening

(3) New England Journal of Medicine perspective article: Better Evidence about Screening for Lung Cancer

LA Times article: Study bolsters evidence that screening reduces lung cancer deaths

Wall Street Journal Health Blog: Lung-Cancer Screening Unknowns: Who Should Get it, How Much it Will Cost

Important legal mumbo jumbo:
Anything you read on the web should be used to supplement, not replace, your doctor’s advice.  Anything that I write is no exception.  I’m a doctor, but I’m not your doctor.

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July 1, 2011 | 11:26 am

Rescuing Primary Care

Posted by Albert Fuchs, M.D.

For almost any category of product or service you can think of, a huge variety of price and quality is available. From clothes to food to transportation we can all think of lousy but inexpensive choices that we wouldn’t like and incredibly luxurious choices that we can’t afford. For almost all of us somewhere in the middle there are choices that are both pleasing and affordable. That doesn’t mean that my choice is the same as yours. You may not be happy with anything less than a BMW, while I’m thrilled with my Mazda. But we both found something that meets our needs and doesn’t bankrupt us.

The peculiar thing about healthcare is that for many it’s simultaneously becoming increasingly mediocre and increasingly unaffordable. It’s hard to think of another good or service for which that’s true. In fact, most everything else is getting simultaneously better and cheaper. This crisis is most acute in primary care. Articles have been warning for years about the worsening shortage of primary care doctors as two worrisome trends intersect – fewer medical students are choosing careers in primary care just as the baby boomers age and will need more of it.

This week an article in the LA Times (link 1 below) asks “What happened to the family doctor?” and accurately reviews the dissatisfaction among both patients and physicians. Primary care physicians complain about flat or declining reimbursement, increasing demands on their time, and increasing insurance regulation. Not surprisingly, when most people in a profession are cranky, that doesn’t attract newcomers. The number of medical school graduates choosing primary care training dropped by almost half between 1999 and 2009. At the same time patients complain about increased waiting times, poor access to their physicians, very short visits, and inability to have questions answered by phone or email. And, of course, both physicians and patients are right.

Before we can understand how we got here, we have to understand how other marketplaces avoid this. Why is there no accountant shortage or shoe shortage? The answer is freedom of prices. If accountants became very scarce they would become very expensive. This would draw more people to accounting, alleviating the shortage and bringing their fees back down. Since in most marketplaces producers are free to set whatever price they wish, the result is multiple providers that compete on both quality and price, yielding a great number of options for the customer.

This doesn’t work in the current healthcare system because insurance fixes the price. In the insurance model all physicians contracted with a certain insurance company receive the same fee for the same service, regardless of whether the patient is irritated or delighted, or whether the care was outstanding or marginal. This has two destructive effects. First, it prevents doctors from competing on price. Second, it means that the only way to make more money is to see more patients. Since doctors can’t charge more per visit, the incentive is to maximize the number of visits.

How about that? A system that rewards visits and not patient satisfaction has resulted in many short unsatisfying visits. Why are we surprised?

There have been myriad attempts to fix this failed system without addressing the fundamental flaw. Countless acronyms like HMOs and IPAs have been vaunted as the solution for delivering affordable excellent care. None have. Now of course, new solutions are being proposed – group visits, virtual visits, medical homes – which will all add complexity and bureaucracy without improving care.

There is no way to fix the insurance model. The insurance model is the problem.

How can we attract more students to primary care? By demonstrating to them a primary care model in which doctors are reasonably paid, love what they do, and can practice as they were trained, not as insurance companies dictate. Escaping the insurance model by charging patients directly lets doctors do just that.

But in the very same LA Times issue Steve Dudley, a Seattle physician, writes a very critical and snarky article about concierge medicine (2). Some of his criticisms of concierge medicine are reasonable. For example he criticizes some concierge doctors for both accepting insurance money and charging an additional annual fee, a practice I also find distasteful. He also notes that many physicians set up concierge practices with the help of large impersonal corporate franchises.

But his main criticism is completely hollow. He worries that not all patients would be able to afford it. First of all, some physicians have escaped the insurance model and decided to work for their patients even in blue-collar towns. So working directly for patients need not be unaffordable. Second, having physicians work at different prices is part of what is desperately missing in this marketplace. Not everyone can afford a new car either, but we don’t blame BMW dealers.

Three years ago I wrote an op-ed for the LA Times (3) describing how I came to my current practice model. I think it answers Dr. Dudley’s criticisms. I encourage you to read it. Physicians choosing to work directly for their patients are part of the solution, not part of the problem.

Learn more:

(1) Los Angeles Times article: What happened to the family doctor?

(2) Los Angeles Times article: Concierge medicine has a cost for all patients

(3) My op-ed in the LA Times in 2008: Dollars to doughnuts diagnosis

My previous posts on rescuing primary care:

Torpedoing Primary Care

On Being Doc and Being Happy

Important legal mumbo jumbo:
Anything you read on the web should be used to supplement, not replace, your doctor’s advice.  Anything that I write is no exception.  I’m a doctor, but I’m not your doctor.

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