Dr. House Was Right

I’m a big fan of the show House, which ran on the Fox TV network for 8 years and is now on Netflix. Gregory House, masterfully played by actor Hugh Laurie, is an brilliant doctor who diagnoses patients whose bewildering symptoms have stymied other doctors. He’s also unbelievably rude: he insults and harrasses his patients and his fellow doctors alike, but they tolerate him - usually - because he’s almost always right.

I doubt that any real doctor is as rude as House. But like any group of professionals, doctors vary widely in their people skills. Recently, though, Medicare has started using patient satisfaction as a component of how it pays hospitals. In response, some doctors now try harder to give patients what they want, rather than what they need, as described last year by Kai Falkenberg at Forbes.  On Medscape recently, William Sonnenberg wrote that “patient satisfaction is overrated” and said of Press Ganey, a company that runs patient satisfaction surveys:
Press Ganey has become a bigger threat to the practice of good medicine than trial lawyers.”
You can find Medicare's hospital survey online. Dr. House would fail, big time.

What’s wrong with giving patients what they want? It turns out that patient satisfaction is tied to higher costs and, even worse, a higher death rate. A large survey covering 52,000 patients, published by a team led by Joshua Fenton at the University of California-Davis  found that the most satisfied patients not only spent about 9% more than average, but had a 26% higher death rate. From the study: “The most satisfied patients had statistically significantly greater mortality risk compared with the least satisfied patients.”

For patients who think a nice doctor is a good doctor, this might come as very disappointing news. Was the effect due to patients already in poor health, who might be more inclined to like their doctors? No: when the researchers excluded the sickest patients and looked only at the healthier ones, the risk of dying was even higher. (It’s important to note here that this is relative risk; only 3.8% of patients died during the six-year followup to the study.)

Over at The Daily Beast last week, Daniela Drake summarized this trend as “You can’t Yelp your doctor.” (Not that Yelp isn’t useful for finding a good pizza place.) And yet, as Scott Hensley reported on the NPR blog Shots, online ratings of doctors are becoming very popular, even though they don’t measure how good a doctor is at diagnosing and treating illness.

This study has implications for so-called “alternative medicine” as well. Patients who frequent alternative providers such as acupuncturists, homeopaths, and naturopaths often report high levels of satisfaction, as if satisfaction correlated with better care. Now we have a large study showing that this is simply not the case.

It makes sense that patient satisfaction is related to cost: patients often demand treatments that they don’t need, and “Patient requests have also been shown to have a powerful influence on physician prescribing behavior”, as Fenton and colleagues reported. It is less clear why the most satisfied patients died at higher rates.

Obviously, doctors don’t need to act like Dr. House to be effective. But doctors need to be able to tell patients things they don’t want to hear. Just because you want an antibiotic for your sore throat or your child’s ear ache doesn’t mean you should get one.  The UC Davis study demonstrates that using patient satisfaction surveys to adjust reimbursement rates, as Medicare is currently doing, is a recipe for higher costs and lower quality of care.

Given a choice between a friendly doctor who gives me what I want and a brilliant doctor who gives me what I need, I’ll take Dr. House.

The PSA test for prostate cancer: more harm than good?

Millions of men are tested each year for high levels of prostate-specific antigen, or PSA, which is designed to detect early signs of prostate cancer. The test is covered by insurance, so most men readily agree to it. After all, what's the harm?

Well, plenty. PSA screening, we now know, "leads to a substantial overdiagnosis of prostate tumors." Many of these cancers grow very slowly, and men with slow-growing prostate tumors may never have symptoms. However, once a man is told he has cancer, there is a a strong tendency to treat it, and treatment has serious, often harmful side effects: 20-30% of men treated with surgery and radiation will have long-term incontinence and erectile dysfunction.

There is a furious debate going on right now over the evidence for and against PSA screening. The debate started with a large-scale US study called PLCO, which found no benefit from annual PSA screening. Soon after that, the US Preventive Services Task Force recommending that most men should not get regular PSA tests.  They concluded:
"Many more men in a screened population will experience the harms of treatment than will experience the benefit.... The USPSTF concludes that there is moderate certainty that hte benefits of PSA-based screening for prostate cancer do not outweigh the harms."
The American Academy of Family Physicians agrees, and has adopted a clear recommendation:
"Don't routinely screen for prostate cancer using a prostate-specific antigen (PSA) test or digital rectal exam."
which I wrote about last November.

In contrast, the American Urological Association responsed to the USPSTF report by issuing a statement that it was "outraged and believes that the Task Force is doing men a great disservice." Prostate surgery is big business for urologists, which may have biased their reaction. However, to their credit the AUA modified its guidelines on PSA screening, which now state
"The [AUA] Panel does not recommend routine screening in men between ages 40 to 54 years at average risk."
For men ages 55 to 69, they recommend "shared decision-making," but they still insist that there is a benefit for men in this group. Their 2013 press release says "the highest quality evidence for screening benefit was in men ages 55 to 69 screened at two- to four-year intervals."

Why does the controversy continue? One reason is that a large European study, called ERSPC, reported a small benefit from PSA screening. The European study is actually a combined analysis of 7 studies in 7 countries, each of which was run a bit differently.  Five of the studies reported no benefit, and just two, from Sweden and the Netherlands, showed a benefit.

So what was going on in those two countries? Did they do screening differently, or treatment differently? Well, it seems they did. In a letter published in Uro Today on May 6, Ian Haines and George Miklos lay out an explanation: in the Swedish study, many more patients in the control group (the group that did not receive PSA screening) were treated with androgen deprivation therapy, ADT, which recent evidence indicates may increase the risk of death. Haines and Miklos published a more detailed analysis last October, accompanied by an editorial by Otis Brawley, the Chief Medical Officer of the American Cancer Society.

Brawley pointed out that
"the harms of screening have been consistently demonstrated in all screening trials to date."
He calls for "an objective panel of experts with access to all of the data" to address the controversy over the possible bias in some of the European trials. Carlsson et al. responded last month in the Journal of the National Cancer Institute, defending their methods, but Haines and Miklos fired back in the same issue, arguing that the benefits found in the European study "rests entirely on the ... Goteborg trial from a single city.

Regardlesss of the evidence from that one city, though, the evidence today is strong that until we have much better treatments for prostate cancer, routine screening with PSA tests causes more harm than good. The side effects of surgery can be life-altering and devastating. Guys: unless you have a special reason to be concerned about prostate cancer, tell your doctor "no thanks" if he offers you a PSA test at your next checkup. That's what I did.

Stem cell therapy offers hope for “irreversible” heart damage

In December 2011, I reported on one of the first attempts to inject stem cells into damaged hearts. In that study, published in The Lancet, scientists grew stem cells from patients’ own hearts after the patients had suffered serious heart attacks. These were patients who had serious, irreversible heart damage. As the study leader, Dr. Roberto Bolli, said at the time
“Once you reach this stage of heart disease, you don’t get better. You can go down slowly, or go down quickly, but you’re going to go down.”
Amazingly, in that study, the patients got better. 14 of the 16 patients had improved heart function after 4 months, and the results were even better after one year. The stems cells grew into new, functioning heart cells.

That was just one study. Now there have been more, and the results continue to be very encouraging. Just last week, the Cochrane Collaboration published a review of 23 trials, all of them attempting stem cell therapy for heart disease. These trials looked at the use of bone marrow stem cells in patients whose hearts were failing. Unlike the 2011 study, which looked at heart attack patients, these studies looked at patients with advanced heart disease who had not suffered a heart attack. The results: overall, stem cell treatments reduced the risk of death and improved heart function, though the benefits were not as dramatic as in the patients with heart attacks. 

What is most exciting in the newest studies is the long-term reduction in the risk of death. Six of the studies reported long-term results (more than one year) on mortality. In these studies, 8 patients died out of 241 who received stem cell therapy (3.3%). In contrast, 30 patients died out of 162 (18.5%) who did not receive stem cells. The numbers are small, but this is a huge benefit: patients were about 5 times less likely to die. The Cochrane review concluded that
“The risk of mortality over long-term follow-up was significantly lower for those who received BMSC [bone marrow stem cell] therapy.”
An important caveat is that this is still “low quality” evidence, meaning that we need to see more data, on many more patients, before we can have confidence in the results. But it is still very encouraging, especially when no other treatment offers anything remotely this promising for advanced heart disease.

The evidence continues to build that stem cells can repair heart tissue damaged by heart attacks. Just a couple of months ago, Britain launched the largest study yet of stem cell treatments for heart attacks, involving 3,000 patients in Europe. This new review shows that they can help repair some of the damage from other types of heart disease as well.

Heart disease is the leading cause of death in the United States, and we should be pursuing every plausible treatment, though very few exist. Stem cells offer the hope that, for the first time ever, we might be able to reverse heart damage that was previously thought to be irreversible. Stem cell treatments are a true breakthrough, and rather than cutting medical research, as we have been doing for the past five years, we should be pouring resources into this remarkable new medical technology and the therapies that it makes possible.