Cave: Ignoring the NNT

How would you like to double your chances of winning the lottery? Just buy two tickets!

Statistically, this is true, but is that a reason to spend more money on something that most likely offers no return on investment?

Yet, in medical research, study after study shows impressive improvement in relative risk for this, that and the other intervention but a small or even negligible effect on absolute risk.

For example, I just read a study in the New England Journal of Medicine comparing giving a new osteoporosis drug to women with osteoporosis and a prior history of an osteoporotic fracture for one year, followed by an older drug for one year to just giving the older drug for two years. The two drug regimen lowered an osteoporotic woman’s risk of hip fracture by 38%.

The number of hip fractures in the combination treatment group was 41 out of 2046 patients, and in the single drug group it was 66 out of 2047 patients.

In absolute numbers, treating 2046 patients reduced the hip fracture risk by 25 cases. The number of women one would need to treat to avoid one hip fracture, the “NNT”, is 2046 divided by 25, or 81.

That NNT isn’t terribly impressive, especially in light of the fact that 12 more patients in the new drug group had a cardiovascular event in the first year than in the old drug group.

The editorial accompanying this article does say “In sum, ARCH revealed that romosozumab has great potential as a short-term anabolic treatment for osteoporosis. However, until the cardiovascular and endocrine effects of this antibody are clarified, romosozumab will remain more a part of our expectations than our armamentarium.” But if the drug company starts promoting the relative risk reduction of this treatment, doctors could be misled and patients could come to harm.

Here are some more examples of he Number Needed to Treat for some common health interventions, published in a post I wrote 7 years ago:

1) Shingles vaccine doses given in order to avoid one case of shingles: 59.

2) Ear infections treated with Amoxicillin to avoid one ruptured eardrum: 20.

3) Cortisone shots to relieve one sore shoulder: 3.

4) Aspirin prescriptions to prevent one heart attack: 200.

5) Prostate cancers treated in order to prevent one death: 18-48 (most men with prostate cancer don’t die from their disease).

6) Adenomatous colon polyps removed to prevent one colon cancer: 50 (only 2% of “precancerous polyps” actually turn into cancer).

May I never forget to consider the NNT…

A Physician’s Lack of Self Awareness

“Räta på ryggen! (Straighten your back!)” everybody seemed to be telling me during my formative years:

My mother said it, and so did my gym teachers all the way through school, not to speak of my drill sergeant during basic training in the Swedish army. Even my own inner voice in many situations, including standing next to my wife, one inch shorter than I but sometimes wearing two or three inch heels.

I never thought much about it, because I never had back pain, except when I tried to stand straight. I went on three-day hikes with a 40 lb. backpack as a Boy Scout and Explorer and during my brief stint in the army without experiencing more of a backache than anyone else.

More than 25 years into my medical career, I suddenly realized what was going on.

My wife and I were taking private ballroom dance lessons in a dusty upstairs studio with mirrored walls. One time, while our octogenarian instructor was rewinding his cassette tape with foxtrot tunes, my wife looked at my image in the mirror and said:

“Your belt looks crooked.”

It did look crooked, but it wasn’t. I shifted my weight around and made my old, familiar movements to straighten my back. It didn’t feel comfortable at all. Still waiting for the music to start, I shifted my weight from one leg to the other while trying to keep my back straight. With my weight on my left leg and my back straight I felt serious pain in my back and my right leg seemed too long to know what to do with. Shifting my weight to my right leg while lifting my left heel so that only my toes touched the parquet floor, something magical happened.

My back stopped hurting and I felt tall and straight. My belt looked horizontal in the mirror and I looked almost taller than my wife.

My simple leg length difference explained years of poor posture and occasional back pain trying to straighten a back that wasn’t crooked in the first place.

There is a medical lesson here, and as a physician in my early fifties I had heard it and probably preached it many times myself:

Don’t assume the pain originates where it is felt, examine the joints and other structures above and below.

In my case, I don’t even need a heel lift, I just stand square on my right foot and on my left tiptoes and I’m tall and straight. When I walk, I’m only on one foot at a time, so there is no problem then. And these days, I don’t stand still very often.

Physician, heal thyself.

A Flex Fuel Man

I met Andrew Dearborn about a year ago. He was an overweight diabetic with high blood pressure, high cholesterol and triglycerides treated with maximum doses of a statin medication, and a prior history of a heart attack.

We seemed to connect, maybe because he is a car collector. Not that I collect them, but I have had cars on my mind since my grandfather walked down Stockholm Street in my home town and pointed out all the postwar American cars that were parked near his antiques store.

I decided to try my car analogy on Andrew:

“Your body isn’t running well on regular gas anymore. But if you read the manual, it is actually a flex fuel body. It isn’t metabolizing carbs properly, but it can still run on fat and protein, and believe it or not, we now know that diets that are low in carbs and higher in protein and at least what we call good fats, are good for weight loss, diabetes control, lipid lowering and heart risk reduction.”

I waited.

His eyes slowly lit up.

“I can do that. So what do you recommend I eat?”

I asked him to walk me through what he was eating now and then made suggestions. I told him what I eat, hard boiled eggs and ham for breakfast, a roll up with lots of cheese and turkey ham with an apple for lunch and for dinner a salad with avocado, feta cheese, some kind of bean like garbanzos or lentils and grilled chicken, salmon or tuna. And as a snack if I need one, roasted almonds or one more apple.

“How about beef?”

“If you like.”

“I can definitely do that.”

And he did. Here are the numbers (notice his Hb A1c is now normal):

IMG_0341.PNG

Caught Between two Paradigms

In the very near future, clinics like ours will be paid according to how well our patients do medically, or at least according to how consistently we provide certain medical tests and interventions.

This includes frequency of diabetic blood tests, foot exams, eye exams, prescriptions for heart and kidney protective medications, achievement of pre-set targets for blood pressure, body mass index and immunization rates, and other measurable “quality indicators”.

But paychecks for medical providers as well as short term financial viability of clinics like my Federally Qualified Health Center depends, besides Federal grants for being open in the first place, almost entirely on the fixed revenue we receive from every face to face encounter we have with patients.

If I spend an extra ten minutes with a diabetic to help him quit smoking and avoid a heart attack ten years from now, I don’t bring in any more money than if I send him out the door with a pat on the back and “see you next time”. But if I cut his visit short and see his grandson for a sore throat, I generate as much income for us as I would have done for a lengthy visit with his newly diagnosed diabetic wife. Any face to face encounter generates the same revenue, no matter how short.

My productivity target clashes with my quality targets. I am constantly balancing between them. And so are physicians everywhere, even if non-FQHCs get paid per Relative Value Unit (RVU), which rewards them to a degree when patient visits are longer and more complex.

In the old paradigm, a physician is only working when he or she is face to face with a patient. The new paradigm claims the importance of reading and being aware of incoming reports from hospitals and specialists, conferences with nurses and care managers, review of population health data and planning future interventions.

But right now, those are money losing activities. How many organizations have the courage, and the deep pockets, to do right now what will hopefully be paid for some time in the coming years?

So, in reality, doctors skim over their incoming reports or sign them off unread. Nurses and care managers read them and enter diagnostic details and new medications prescribed by hospitalists and consultants in each patient’s EMR, but the busy providers don’t have enough time to talk in depth with the care managers whose chart entries take as long to read as the outside reports would have taken in the first place.

We struggle to find the time to talk to our patients, and rely on others to communicate with them. When we work that way, information can get lost or distorted, so we risk making tangential or inappropriate clinical decisions. A patient calls back reporting to the medical assistant or receptionist that they are not better from their antibiotic and the physician prescribes another one, when the real message may have been that they are only 75% better and most likely will be fine in another day or two. So resources are wasted, unnecessary treatments are prescribed, and opportunity for patient education is lost. All because we are too busy to gather the clinical information that we have the training and experience to collect.

It is obvious that this incongruence between paradigms is a setup for physician burnout, but on a bigger scale it also makes me wonder about organizations. Can they experience burnout too?

I read somewhere about the causes of burnout:

“Maslach, Schaufeli and Leiter identified six risk factors for burnout: mismatch in workload, mismatch in control, lack of appropriate awards, loss of a sense of positive connection with others in the workplace, perceived lack of fairness, and conflict between values.”

All of today’s healthcare seems to fit this description. We must go forward, or even back, but we can’t stay too long where we are right now.

Driving my Mini (iPad)

I’ve finally found my groove with our EMR. Maybe I’m even starting to like it.

A few weeks ago I got a new iPad, this time a mini, which lets me type with two thumbs the way some people text on a smartphone, and the voice transcription is good enough as long as you avoid fancy jargon and unusual generic drug names. Yesterday as I sat next to a patient and dictated her history, she added to it and her words transcribed perfectly into my office note, unintended but very elegantly.

Even the size difference from my personal iPad which I had been using, horse barn scented leather cover and all, made a difference because on the mini I can type faster with only my thumbs. Years ago I had a pen tablet computer that wasn’t bad, but I find that the smaller my device gets, the more unobtrusive it seems.

The iPad version of my EMR is growing on me. Its interface was obviously designed from the ground up, so while it looks different from the desktop version, once you’ve worked with it for a while, it is twice as fast.

The software can graph, instantly, any historical lab values and vital signs, which is extremely helpful when I sit next to a patient and want to show them their improving hemoglobin A1c or variable blood pressures. When I first started using the iPad, I saw a couple of patients who had subtly but steadily falling hematocrits and turned out to have erosive gastritis in one case and colon cancer in another. Without seeing the trend in a graph it would have been harder to spot.

Reading reports, I can enlarge them by spreading two fingers and I can move around by dragging them left to right, whereas on the desktop I have to enlarge the window, click “view”, then choose a percentage enlargement and then use the scroll bar to move left to right in order to to see each line completely, which is ridiculously cumbersome.

During today’s 7 hour Saturday clinic I saw 27 patients, one of them brand new to the practice, and I did 90% of my documentation on my mini in the room with each patient. Twenty minutes after closing, I walked out the door and drove home in the sparkling afternoon light, down winding roads flanked by the peaking fall foliage and the royal blue waters.

I felt like I hadn’t even worked today, that’s how easy my day was with my user friendly app and my new mini.

An Old, New Diagnosis

The middle aged woman started to pull down her jeans as she explained:

“I want you to look at this rash on my leg. I’ve had it for a month now.”

What I saw got my mind churning. On top of her left thigh was a brown discoloration about the size of the palm of my hand. It had a reticular pattern, like a coarse lace doily or irregular fish net. It was light brown, smooth to the touch and didn’t blanch when I pressed on it.

I knew I had read something about rashes that looked like that, but I couldn’t remember any details. So I did what I often do, I googled the description:

(Images) Brown reticular erythema.

Almost instantly I saw a perfect picture of the woman’s rash. The caption read “Erythema ab igne”.

Yes, that was it, but what was it again?

My trusted Wikipedia had a tidy little entry that echoed with memories in the recesses of my mind. I printed it out for her. It described the rash as often occurring in older patients who used hot water bottles or, in the old days, stood too close to the fire to keep warm.

I didn’t think my patient slept with a hot water bottle only on her left thigh.

“Is anything warm often touching that spot?” I asked.

“Yeah, my laptop”, she answered instantly.

“Try putting a folded towel or something between your leg and your laptop”, I said as we wrapped up her visit.

What an odd symmetry, I thought to myself: A diagnosis of historical interest, brought back by the use of modern technology and identified by the very device that causes it.

A Dream Job

“Jag ska bli doktor”, a four year old boy announced to his family sixty years ago.

Somehow, everything he did after that moment seemed to move him in that direction, even when, on the surface, his path through life seemed to be meandering.

As a student, he was just as interested in literature and philosophy as he was in scientific subjects. He even failed his first quiz in organic chemistry just after receiving the Berzelius scholarship for achievements in inorganic chemistry.

As a Boy Scout, he learned to find his way with or without map and compass, mastered the building of lean-tos and rope bridges, and came to travel the world, even following Baden Powell’s steps in the Swiss Alps. He edited the troop newsletter and, years later, he became a troop leader.

He spent a summer with a rural pastor, helped decorate his small church for midnight masses, read Scripture in the dark, played guitar from behind the altar, and watched the aging man of the cloth look up to the sky in tears and ask God for stronger faith and divine help in managing his own shortcomings and weaknesses.

He spent a year as an exchange student in Massachusetts, and although he was homesick for Sweden at first, he left the U.S. just as homesick for it as he had been for his native country when he first arrived.

He marched, stopped and turned in musty uniforms and sore army boots to the relentless commands of his drill sergeant and crawled in the mud under low-slung barbed wire. He conquered his fears and held on to the rope that pulled thirty soldiers on bicycles behind a military vehicle down Swedish gravel roads.

He worked as a substitute teacher with wide eyed, eagerly listening fifth graders and bored-to-death teenagers.

And at age 21 he entered the only medical school he thought of applying to; he just knew he wanted to go to Uppsala University. Only after the application deadline did it occur to him that perhaps he could have put down the Karolinska Institute as a backup plan.

As a medical student, he didn’t party and he didn’t study all that much. He took tidy notes with a fountain pen and spent much of his time on his second hand couch, listening to James Taylor, Simon and Garfunkel and cassette tapes of American FM radio he recorded on visits to the place he was longing for.

Today, he has lived much longer in America than in Sweden. He is part teacher, part pastor, part Boy Scout and still a student of literature and philosophy. He finds solace and inspiration in writing about his personal journey and that of the patients who put their lives in his hands.

And he is starting to feel a little bit like the doctor he set out to be.


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