Wednesday, March 25, 2015

Shared Decision Making, Cancer Risk Assessment, and The Doctor- Patient Relationship

Welcome to my world as a practicing physician. Here is your chance to learn of the secret sacrifices we doctors make in the inner sanctum of the temple of Evidence Based Based Medicine. 

The "joys" of mandated guideline-driven shared medical decision making come to life in a one act play.

Below Dr Kildare will welcome you to his world that we doctors and patients will increasingly inhabit as we worship at the altar of evidence based, cost effective care.

This article is about lung cancer, but the issues it raises apply to all healthcare including CLL: arbitrary guidelines, lies to game the system, the intrusiveness of the computer and electronic medical record, the farce that is "mandated" shared decision making, and the general loss of intimacy and trust in the patient-doctor relation as big government and big insurance and big medicine play a more and more invasive role in the clinic and hospital.

I am no Luddite.

I celebrate the use of technology and big data. I look at cost effectiveness when sharing decisions with my patients (or with my doctors when I am the patient), but we need to remember the human connection and to pay attention to the needs of the real person in front of us and not to some statistical metric.

This is a good read:

Here is the link and below I simply cut and pasted the text.

Thank you Dr. Grannis for feeling our pain. …

A Lung Cancer Screening “Shared Decision-Making” Session

Frederic W. Grannis, Jr, MD



PATIENTa patient named Hiram Wrisque
It is the near future. As the lights come up, a young physician, DR. KILDARE, is seated behind a desk working at a computer in consultation room. For dramatic emphasis, he is dressed in the white smock, pants, and shoes worn by interns during the mid-20th century. A stethoscope is draped over his shoulders.
There is a knock on the door.
DR. KILDARE. Come in.
The office door opens and PATIENT enters, stage left.
PATIENT. Good morning, Dr. Kildare.
DR. KILDARE. Please sit down, sir. For the record, what is your name and date of birth?
PATIENT. I am Hiram Wrisque. I have been a patient in this medical practice for almost 50 years; a patient of your granddaddy’s until his passing. I am not sure why this visit has been scheduled? I requested to be screened for lung cancer 3 months ago.
DR. KILDARE. Well, Mr. Wrisque…
PATIENT (interrupting). Mr. Wrisque was my daddy; please call me Hy.
DR. KILDARE. All right, Hy it is. We have scheduled this doctor–patient shared decision-making discussion because it is mandated in the Centers for Medicare and Medicaid Services—we call it CMS for short—decision of February 2015 for all patients who ask their doctors to order a screening CT scan.[1]
PATIENT. Seems like a waste of time, I have done a lot of reading on the subject, and given it a lot of thought. But if we must, then let’s get on with it.
DR. KILDARE. First thing is that we need to enter your eligibility information into this computer database. What is your age?
PATIENT. I am 65 years old.
DR. KILDARE types laboriously into his computer.
PATIENT (impatient). Look, doc, I have to get my wife to her chemotherapy, so why don’t you take this sheet of information I have prepared for you, and you can have your secretary type it into the computer later. That way you can make eye contact with me instead of that computer screen. Let me sum up what it says it for you.
First thing, I smoked two packs a day for 40 years, starting at age 10. I quit 15 years ago today, when your granddaddy convinced me that my bullous emphysema and COPD were caused by smoking, and that I was at high risk of lung cancer. I have worked since high school at the nuclear power plant maintaining the asbestos insulation. Mom and dad and my older sis all died of lung cancer. My own lung cancer was resected 7 years ago and the laryngeal cancer was radiated 6 years ago. They tell me there is no evidence of recurrence of either and that I am probably cured of both. I had pneumonia twice in the past 2 years. Almost forgot to mention that I had lots of exposure to second-hand smoke as well.
I am in otherwise good health and can even play two sets of doubles tennis a couple times a week.
DR. KILDARE. Thank you for organizing that risk information for me. It is very helpful and makes it clear to me that I must recommend that you are not a good candidate for screening.
DR. KILDARE. Yes, although you have a number of risk factors, Hy, you don’t meet the Medicare criteria for insurance coverage because you quit smoking 15 years ago.
PATIENT. Well first thing, doc, I asked to be screened 3 months ago, and it took all of this time to get the appointment.
DR. KILDARE (defensive). I am a very busy man and couldn’t get you in earlier.
PATIENT (exasperated). I have just about every risk factor for lung cancer imaginable and very clearly have a high risk of dying of lung cancer and yet you are telling me that I can’t be screened? That’s just plain nuts.
DR. KILDARE (irritated that this discussion is taking longer than anticipated). Here, Mr. Wrisque—sorry, Hy. I would like you to read this copy of an article from Chest by an eminent physician at Memorial Sloan Kettering named Dr. Peter Bach, who also wrote the guideline on lung cancer screening for the American College of Chest Physicians.[2] He explains how you don’t meet the criteria used in the National Lung Screening Trial and that it would be irresponsible to screen you without good evidence.[3]
PATIENT (cutting in). I told you I have read a lot on the subject. I read this article, and it makes no sense to me. Dr. Bach says elsewhere that if I get screened with CT scans and they find a lung cancer, that I have only a one out of five—20%—chance of survival,[4] but all studies, including the National Lung Screening Trial and International Early Lung Cancer Action Program show that the chance of survival with cancers detected by CT screening at 5 and even 10 years and beyond is between 60% to 90%.
DR. KILDARE. Hy, you need to leave this up to the experts.
PATIENT. Don’t be condescending with me, Sonny! I even went to the Web site at Memorial Hospital in New York and entered my personal information into their lung cancer risk calculator—I am told it was written by Dr. Bach himself. It told me that my risk of lung cancer is very high, that I have a 4% chance—that’s one out of twenty-five risk—of getting lung cancer in the next 6 years![5]
What’s more, this calculator didn’t ask if I had a previous cancer caused by cigarettes. Why, Dr. Bach himself has published data that indicates that because I had lung and laryngeal cancers in the past that my risk of lung cancer is at least 20%.[6]
DR. KILDARE (now flustered). Yes, all of that may be true, but since you had the good sense to quit smoking 15 years ago, your risk is now lower.
PATIENT. I understand that, but it’s still high enough that I am greatly concerned for my future. An article I read by Dr. Robert McKenna in Los Angeles, perhaps the busiest lung cancer surgeon in the country, informs me that more than half of the ex-smokers he operates on for lung cancer had quit more than 15 years earlier.[7]
DR. KILDARE. I am sorry that you are disappointed, Hy, but the Medicare rules are very clear.
PATIENT: This shared decision-making sure seems to happen on a one-way street.
DR. KILDARE. I suppose that you could pay for the CT out of pocket.
PATIENT. Look, doc, I am retired on a fixed income and have a lot of expenses for my wife’s medical care. It just isn’t possible for me to pay for screening. What’s more, it isn’t fair to put me in this bind when people with much lower risk will be covered by CMS or private insurance. On top of that, I asked at the hospital and they told me they can’t screen me without your say-so or they might lose their status as an expert center.
DR. KILDARE (whispering). You didn’t hear this from me, Hy, but if you, let’s say, revise your time estimate (he winks) on how long ago you quit, you would be eligible.
PATIENT. You mean if I lie to you. Sorry, but that’s not the way I was raised.
DR. KILDARE (worried). I was certainly not advising you to lie. That would not be ethical on my part.
PATIENT. But it is ethical for Medicare and Medicaid to ration access to a test that can save me and other people like me from suffering and premature death?
DR. KILDARE. Well, Hy, we seem to have reached an impasse, and I certainly don’t see this as rationing healthcare. I see no point in continuing this discussion further.
PATIENT reaches into his shirt pocket and takes out a pack, a brand recognizable by its prominent red logo, strips off the cellophane covering, opens the flip-top box and extracts a filtered cigarette.
OK, doc, you leave me with no alternative.
DR. KILDARE (agitated). Wait…what are you doing? You can’t do that here; it is against the law. Put out that match immediately or I will have to ask you to leave my office.
PATIENT (blowing a smoke ring from the cigarette he has just lit). I had no other choice, Sonny. Now that I am a current smoker again, I meet the damned Medicare criteria, so please just tell your computer to arrange for my screening CT scan ASAP. Now I have to be going. You have yourself a nice day.
DR. KILDARE shrugs resignedly and begins slowly typing the order into his computer as Hiram Wrisque exits stage left


1. Proposed Decision Memo for Screening for Lung Cancer with Low Dose Computed Tomography (LDCT) (CAG-00439N). Accessed January 14, 2015. (Scenario assumes that Final CMS decision of February 2015 will be substantially unaltered.)
2. Detterbeck FC, Mazzone PJ, Naidich DP, Bach PB. Screening for lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013;143(5 Suppl):e78S-92S.
3. Mazzone P, Powell CA, Arenberg D, et al. Components Necessary for High Quality Lung Cancer Screening: American College of Chest Physicians and American Thoracic Society Policy Statement. Chest. 2014 Oct 30. [Epub ahead of print]
4. Bach PB, Gould MK. When the average applies to no one: personalized decision making about potential benefits of lung cancer screening. Ann Intern Med.2012;157:571-3.
5. Memorial Sloan Kettering Cancer Center: Lung Cancer Screening Decision Tool. Accessed January 14, 2015.
6. Lou F, Huang J, Sima CS, et al. Patterns of recurrence and second primary lung cancer in early-stage lung cancer survivors followed with routine computed tomography surveillance. J Thorac Cardiovasc Surg. 2013;145:75-81
7. Mong C, Garon EB, Fuller C, et al. High prevalence of lung cancer in a surgical cohort of lung cancer patients a decade after smoking cessation. J Cardiothorac Surg. 2011;6:19.
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