Mammograms In The Headlines

The U.S. Preventive Services Task Force issued new guidelines this week recommending that women should begin regular breast cancer screening – including getting a mammogram every two years – starting at age 50. For years, it has been widely recommended that women have mammograms done biannually starting at age 40; the new guidelines represent a significant departure from past medical advice.

The new guidelines are meant to limit the growing frequency of unnecessary extra tests and surgeries being performed because of unclear screening results. According to the Task Force, the “additional benefit gained by starting screening at age 40 years rather than at age 50 years is small and that moderate harms from screening remain at any age.” The Task Force did urge that women at high risk for breast cancer should continue being screened for the disease early on in their lives. Nevertheless, for the rest of the population, the Task Force believes that starting screening at age 40 doesn’t save enough lives¬ – 1 in every 1,940 – to make up for the extra tests and treatments, the accompanying anxiety and emotional distress, and the related financial burdens.

It didn’t talk long for other health experts around the country to respond to the Task Force’s new guidelines with guarded skepticism. A popular rebuttal: One in every 1,940 doesn’t seem like that much, but what if you’re the one? Influential groups such as the American Cancer Society and the American College of Obstetricians and Gynecologists quickly announced that they are sticking with the earlier guidelines.

In response to the confusion generated by the Task Force’s recommendations, Human and Health Services (HHS) Secretary Kathleen Sebelius issued a statement advising women to “Keep doing what you have been doing for years – talk to your doctor about your individual history, ask questions, and make the decision that is right for you.” According to Sebelius, the Task Force’s findings are not indicative of the HHS’s opinions and will not set federal policies. Furthermore, early mammograms should continue to be covered by health insurance policies, said Sebelius.

Breast cancer is the one of the most common forms of cancer in the United States; more than 200,000 women are diagnosed with breast cancer every year and about 40,000 die annually from breast cancer-related complications.

Learn more about the disease by visiting our breast cancer learning center: http://www.healthline.com/channel/breast-cancer.html

Learn when and how to test for breast cancer: http://www.healthline.com/channel/breast-cancer_tests

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A Foundation for the House of Medicine

When you build a house, you begin with the foundation. The same holds true for the U.S. health care system. The President and Congress are scrambling to put up a reform structure that would have a better chance to succeed if the cinderblocks and joists were in place. No health care system in our country can develop adequately unless supported by validated information, policies and procedures based upon accurate data related to its most important features, and updated continuously. While there are agencies and institutions that can answer some of our questions, a comprehensive assessment is lacking. We should learn much more - the sooner, the better. Conflicted entities cannot be relied upon for objectivity, so if the government would like to increase its role in health care, creating a method for objectifying the rationale for change is the correct place to start.

The need to do something about health care is predicated upon the notions that we spend too much, perhaps to achieve inadequate outcomes and leave too many people without access to a reasonable desired amount of care. The rush component is fiscal and therefore political. Predecessors created entitlement programs that have grown for many reasons and are projected to break our bank. So, we have come to the brink where there is little tolerance for growth in health care, and the rhetoric of rationing. Difficult choices lie ahead.

What might we do to establish the foundation? I believe that it will be best achieved by incremental processes that can be managed to significant contributions. I want to learn much more about what health care I should be receiving and why I should want it. While we spin expensive and frustrating cycles on global reform, biting off much more than we can chew, I urge federal and state governments, science agencies, medical societies and organizations, and academic institutions to put forth all necessary effort to accomplish the following, in order to provide a foundation for successful health care reform:

Focus on outcomes.

As a doctor, I can do the best job for my patients if I’m able to form an impression and make decisions based upon facts. A man comes to me with the worst headache of his life and a stiff neck. Does he have a migraine, meningitis, bleeding aneurysm, brain tumor, abscess or something else? My physical examination puts me in the ballpark, but then I need assistance. What tests are available and what are their costs and risks? Is there a decision tree for best practices that I can follow? Is there a neurologist or neurosurgeon available with whom I can consult? If he needs an operation, do I know the skill and success rates of the operators to whom I can refer him? Would he be better off staying in my hospital or being transferred?

We cannot afford to keep practicing medicine by impression when there is a clear need to objectify our behaviors. Whether by creating a national clearinghouse for health care-related data or accomplishing this through individual efforts, we should seek to be evidence-based. There are means to establish, for instance, the immediate and long-term outcomes of a similar, if not identical, brain surgery on a doctor-by-doctor, hospital-by-hospital, and state-by-state basis. The same way that we enjoy consumer reports for automobiles and computers, we should be privy to analyses that guide us to the best doctors, hospitals and practices. For starters, each medical specialty can accomplish systematic reviews. These will guide us to complete the necessary prospective evaluations needed to refine our initial conclusions about clinical, financial and societal implications.

Rationalize drug therapy. Assign the Food and Drug Administration to compare every drug on the U.S. market with branded and generic versions available anywhere, worldwide. If there are not yet reasonable comparative analyses, then design and implement them as soon as possible. Ensure drug quality, then purchase at low cost. Next, compare alternative drug therapies and regimens. Strive to determine the precise incremental differences in outcomes. Create scoring systems if need be, and make them understandable and functionally interoperable.

Define the needs and desires of the American people for health care. I’m tired of listening to middle-aged pundits preach the value of an elder’s life, as if they have insight. Let’s put the issues to the American people and find out what they really want. And whatever “it” is, let’s find out if the respondents are willing to pay for it for others, even if they don’t want it for themselves. Carefully designed interview and polling methods should shed light on the desires, if not necessarily the needs, of persons who pay taxes, care about their families and deserve credit for their life histories and ability to make these sorts of decisions.

Create a mandate for advance directives. This recommendation is directed at a potentially controllable aspect of cost containment, and relies upon on the explicit desires of individuals. As part of each person’s state tax return, he or she should be required to complete an advance directive, which could be changed or amended at any time for any reason. A person should be allowed to decline to complete the directive, but only by officially indicating their declination.

Pay active attention to medical manpower issues. The U.S. population is growing. The ratios of doctors to consumers, and the distribution of primary care physicians and specialists, will perpetually be out of whack unless there is active manipulation of training incentives and financial support for doctors who are necessary to keep this nation healthy. We are not training enough doctors to handle our increasingly elderly and medically complex population. There should be active management to train and recruit doctors, nurses, therapists, technicians and other allied health professionals.

Use computers for decision support. Someone needs to take a strong hand to prevent proliferation of an electronic Tower of Babel. My impression of current electronic medical record offerings is that they are designed for billing purposes, not to facilitate real-time clinical decision support. The promise of cost containment because of computer technology will not be fulfilled unless their use guides practitioners to be more effective, eliminate unnecessary hospitalizations and procedures, and diminish errors. Furthermore, electronic medical records are not yet easy to use. Do we really have our best and brightest software engineers working on these tools?

Create health coaches. Uncoordinated care is the most expensive kind, because it leads to delay in diagnosis, redundancies, excess testing and procedures and failure to put episodes into context. Every person, particularly elders, should have access to a qualified health coach, whose responsibility is to allow the patient to be aware of history and options.

Support medical science to the maximum degree possible. Consider this list: cancer, dementia, diabetes, stroke, arthritis, immunodeficiency, infectious diseases. All of these are unsolved mysteries unless we allow scientists to create new knowledge. Discovery advances all aspects of medicine. Arbitrarily restricting research budgets is a foolish approach to cost containment.

And while we’re at it…

Stop demonizing doctors. With the exception of a small percentage, physicians are not driven by the desire to make enormous sums of money. Physicians struggle with themselves constantly about providing expensive life-prolonging care to neonates, elders and terminally ill persons, the cost of drugs, and our current global financial dilemma. Our debates are also about decency, compassion, wanting to do our duty, and accepting enormous responsibilities each day of our careers. Physicians who succumb to perverse incentives to magnify their incomes should be controlled, but they do not define U.S. health care, any more than greedy lawyers define the legal profession, child molesters define the clergy or corrupt politicians define government.

Understand what rationing really means. We are nowhere near the need to ration healthcare in this country. What we are near is an unwillingness to devote the amount of financial resources necessary to support the projected rate of growth in health care spending. To understand which programs need to be curtailed, or never initiated, we have to get our priorities straight. Let’s deal with two situations that will never change. First, we are governed by elected officials who have varying degrees of health care knowledge and interest. They have never shown a willingness to allow doctors to take the lead on reforming the system, arguing that if the health care profession wanted change, it would have created it. The problem with that logic is that no industry in this country makes the laws, and changes in the system cannot come any other way. What our government should do is put the best and brightest doctors in charge of setting the standards and working within the system to make incremental changes that address the foundation issues I discussed above. The second situation is that you cannot teach people health care economics when they don’t feel well. It is human nature to seek relief from suffering and improvement in one’s personal situation. The enlightened individual at the end of his or her days may go quietly (and inexpensively) into the night, but that is not the basis upon which we should expect to build our health care system.

Analyze health care systems of other countries. How many opinions are there about whether or not U.S. citizens would be better off with the Canadian system, British system, Swedish system or some other system? Let’s decide what’s important to us – mortality, morbidity, life span, wait time for hip replacement, drug rehabilitation – and do the comparative analyses. If there is a system that performs better than ours on issues that really matter to us, then we ought to be able to understand why and determine whether and how we can make the situation better here.

Quit considering a visit to the emergency department to be a failure. The maturation of emergency medicine as a specialty, and the way our EDs have responded to the failure of the health care system is a success story. Unless a patient has immediate access to the right specialist, the ED is the fastest, most accurate, and often only reliable direct route to the doctor who knows how to treat the problem. Think about it. You need a CT scan, neurologist and perhaps interventional radiologist when you have a stroke. Will you find that in your general practitioner’s office? Never. You need hydration, antibiotics, metabolic testing and a chest x-ray when you have pneumonia. Call your family doctor? Not likely. Rather than trying to drive patients out of the ER to an understaffed and overbooked community clinic that will immediately bounce anyone who is truly ill, why not refine and expand the ER concept to provide cost effective urgent care to people? Which leads me to…

Don’t count on healthy lifestyles to solve our problems. I am not a pessimist by nature, but it is difficult to believe that non-mandated suggestions to correct our diets, lower our weight, stop drinking and using drugs, and show caution on the freeways will thrive in our culture of consumption, fast food and cars, diminishing exercise, and disregard for the environment. If our laws allow the use of tobacco, firearms and fast foods, then we will continue to have lung cancer, gunshot wounds and fat people. We actually have a “sick care system,” not a health care system, and to suggest that it could be otherwise any time soon is to put way too much faith in human nature. What is reality? I think we should plan to live longer while being less able to care for ourselves, continue to blow ourselves up during wars with weapons, birth too many babies, and celebrate the right to be sugar and grease eaters, not wear helmets and lay out without using sunscreen. We won’t live forever, and our health care system should be designed for how we actually live, not the way we have been instructed to live. If and when we wise up, we can make the adjustments.

So, if we wish to build a house of medicine upon a foundation of data, communication, collaboration, value and accountability, then let’s be real about where we are, what we want, and how quickly we can alter health habits. Let our best medical minds work together to control our destiny by gathering and facing the facts, with every measure at our disposal.

By Dr. Paul Auerbach

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The Weight Debate: Obama’s Pick for Surgeon General

Right around the time the Senate finished grilling Obama’s Supreme Court nominee, Sonia Sotomayor, Obama’s pick for surgeon general—Dr. Regina Benjamin—began her own version of a confirmation hearing in the arena of public opinion.

On one side of the scale is the above-average weight of Dr. Benjamin’s extraordinary resume; on the other side, her above-average personal weight. The question that is hanging in the balance and one that has sparked a lively (and hopefully healthy) debate in the blogosphere and beyond is this: Despite her credentials, does Regina Benjamin’s perceived weight issue disqualify her from being the country’s leading spokesperson on matters of public health?

Dr. Benjamin’s resume speaks for itself. She is a highly decorated family physician from rural Alabama and a champion of the medically underserved—having made headlines for her tireless work after Hurricane Katrina. She has had heaps of honors bestowed upon her, including a McArthur genius award and a Nelson Mandela Award. She was the first African-American woman elected to the American Medical Association’s board of trustees. This list goes on and on.

However, the full-figured Benjamin has been called out by many in online comment forums who think the surgeon general should, at the very least, look healthy at first glance, with the goal of leading by example. Some question the choice for a country plagued by obesity. Some question her stint as the president of Alabama Medical Association—in one of the unhealthiest states in the nation.

Talk to political experts, and most will agree that the surgeon general is a largely symbolic post with some inherent influence but without much administrative authority. Interestingly enough, that makes this debate even more relevant. But it seems symbolism is in the eye of the beholder. Do you see an award-winning African-American family doctor who works selflessly to help those who struggle to help themselves. Or do you see an overweight physician from one of the unhealthiest states in America. It’s a debate that has sparked conversations about health all across the country, which we all can agree is a good thing.

We want your thoughts: Which matters most—Dr. Benjamin’s credentials or her weight?

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Go for a Run, and Help Kids in Need

The Fresh Air Fund is looking for runners to join its NYC Half-Marathon team. Through sponsorships, each runner on the team raises money that will fund free programs for kids from low-income communities. More runners means more money going to kids in need.

The Fresh Air Fund has been around since 1877 and has provided free summer vacations for nearly 2 million children in that time. Last summer, nearly 5,000 kids escaped the hot, crowded streets of New York City to stay with host families in cities and towns across 13 U.S. states and Canada. The organization also hosts Fresh Air camps and other enrichment programs for thousands of kids throughout the year.

Last year, the Fresh Air Fund Racers raised more than $125,000 through the NYC Half-Marathon. That money directly funded their programs, and they are hoping to raise even more this year. It’s a great race and a great cause. Click here to register with the Fresh Air Fund Racers. The organization is also looking for families to host kids for a summer vacation. Find out how.

By Ryan Wallace

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Your Questions Answered

Our regular updates on the H1N1 virus have sparked a lot of questions among our readers, so we've provided a list of your most frequently asked questions and their answers in order to keep you informed, allay your fears, and help keep you safe and healthy.

Q: At what point should I seek medical attention if I believe I've been exposed to the swine flu?
A: You should seek medical attention if you've been suffering from any flu-like symptoms (such as fever, headache, body aches and cough) for more than 24 hours. Let your healthcare professional know if you suspect you've been exposed to the H1N1 virus (widely known as the "swine flu") because of recent travel to Mexico or contact with someone diagnosed with the disease.

Q: If I received a swine flu vaccine during the swine flu outbreak of 1976, am I safe from infection by the current swine flu virus?
A: No. The vaccine you were given to guard against the H1N1 virus is unlikely to provide protection against the current strain of the virus. But a new vaccine is being developed and could be available as soon as June, 2009.

Q: Can I get swine flu from eating pork products?
A: No. The flu is not spread through food, so there is no danger of getting swine flu from consuming pork products.

Q: Can I be infected with swine flu if I handle a pig fetus during a classroom dissection?
A: No, it's highly unlikely for you to be infected in this way. The preservatives used to prepare a pig fetus for dissection should kill any virus the fetus may have been exposed to.

Q: Can my pets become infected with swine flu?
A: Not likely. According to veterinarian Michael Watts, "There is no evidence that dogs, cats, or 'pocket pet' species can be infected with the new H1N1. Although the virus contains some genetic material from an avian influenza virus, there is no evidence this strain can infect birds." Even so," the doctor says, "You should contact your veterinarian any time your pet develops symptoms of a respiratory infection."

Q: How effective is the use of facemasks in preventing swine flu infection?
A: Masks can be effective when used properly. The mask should fit snugly over your mouth and nose, and it should be changed every couple of hours, because prolonged exposure to your own moist breath can turn the mask into a sponge that soaks up outside germs, making you even more susceptible to infection.

Q: I'm pregnant. Should I take greater precautions than others when it comes to the swine flu?
A: Yes. There's evidence that pregnant women could be at higher risk for complications when it comes to infection with H1N1, so pregnant women should be tested for H1N1 and get treatment immediately if they test positive.

Q: How can frequent travelers avoid becoming infected with the swine flu?
A: Frequent travelers should take the precautions everyone else does to prevent infection, including washing hands frequently and avoiding contact with sick people. Make sure to use disposable paper towels in public restrooms for drying hands, turning off faucets and opening doors.

Q: Why has there been such a high death rate for those infected with swine flu in Mexico?
A: The World Health Organization is still investigating the spread of H1N1 in Mexico and why mortality from the virus has been so high in that country. Some experts point to the poverty of the victims, the large concentration of people in such a small area, and the hesitation of those inflicted to seek swift medical attention as possible answers.

Q: What are my chances of a full recovery should I be infected with the swine flu?
A: Excellent. The anti-viral drug treatments Tamiflu and Relenza have proven extremely effective in combating the H1N1 virus. Just make sure you keep a close eye on your health and get treatment if you come down with symptoms that point to the swine flu.

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