Posts Tagged ‘physicians’

U.S. hospitals feeling the pain of physician burnout

November 21, 2017


By Julie Steenhuysen


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Dr. Brian Halloran. a vascular surgeon at Saint Joseph Mercy Ann Arbor, shows the canned vegetables from his garden across from Saint Joseph Mercy hospital

Dr. Brian Halloran. a vascular surgeon at Saint Joseph Mercy Ann Arbor, shows the canned vegetables from his garden across from Saint Joseph Mercy hospital in Ypsilanti, Michigan, U.S., August 23, 2017. REUTERS/Rebecca Cook

By Julie Steenhuysen

ANN ARBOR, Mich. (Reuters) – Dr. Brian Halloran, a vascular surgeon at St. Joseph Mercy Ann Arbor, starts planning his garden long before spring arrives in southeast Michigan.

His tiny plot, located in the shadow of the 537-bed teaching hospital, helps Halloran cope with burnout from long hours and the stress of surgery on gravely ill patients.

“You really have to find the balance to put it a little more in perspective,” he said.

Hospitals such as St. Joseph Mercy Ann Arbor have been investing in programs ranging from yoga classes to personal coaches designed to help doctors become more resilient. But national burnout rates keep rising, with up to 54 percent of doctors affected.

Some leading healthcare executives now say the way medicine is practiced in the United States is to blame, fueled in part by growing clerical demands that have doctors spending two hours on the computer for every one hour they spend seeing patients.

What’s more, burnout is not just bad for doctors; it’s bad for patients and bad for business, according to interviews with more than 20 healthcare executives, doctors and burnout experts.

“This really isn’t just about exercise and getting enough sleep and having a life outside the hospital,” said Dr. Tait Shanafelt, a former Mayo Clinic researcher who became Stanford Medicine’s first chief physician wellness officer in September.

“It has at least as much or more to do with the environment in which these folks are practicing,” he said.

Shanafelt and other researchers have shown that burnout erodes job performance, increases medical errors and leads doctors to leave a profession they once loved.

For a graphic, click

Hospitals can ill afford these added expenses in an era of tight margins, costly nursing shortages and uncertainty over the fate of the Affordable Care Act, which has put capital projects and payment reform efforts on hold.

“Burnout decreases productivity and increases errors. It’s a big deal,” said Cleveland Clinic Chief Executive Dr. Toby Cosgrove, one of 10 U.S. healthcare CEOs who earlier this year declared physician burnout a public health crisis.


Hospitals are just beginning to recognize the toll of burnout on their operations.

Experts estimate, for example, that it can cost more than a $1 million to recruit and train a replacement for a doctor who leaves because of burnout.

But no broad calculation of burnout costs exists, Shanafelt said. Stanford, Harvard Business School, Mayo and the American Medical Association are working on that. They have put together a comprehensive estimate of the costs of burnout at the organizational and societal level, which has been submitted to a journal for review.

In July, the National Academy of Medicine (NAM) called on researchers to identify interventions that ease burnout. Meanwhile, some hospitals and health insurers are already trying to lighten the load.

Cleveland Clinic last year increased the number of nurse practitioners and other highly trained providers by 25 percent to 1,600 to handle more routine tasks for its 3,600 physicians. It hired eight pharmacists to help with prescription refills.

Atrius Health, Massachusetts’ largest independent physicians group, is diverting unnecessary email traffic away from doctors to other staffers and simplifying medical records, aiming to cut 1.5 million mouse “clicks” per year.

Insurer UnitedHealth Group, which operates physician practices for more than 20,000 doctors through its Optum subsidiary, launched a program to help doctors quickly determine whether drugs are covered by a patient’s insurance plan during the patient visit. It is also running a pilot program for Medicare plans in eight states to shrink the number of procedures that require prior authorization.

Similarly, Aetna Inc this year began a behavioral health program that eliminates prior authorization requirements for admission to some high-performing hospitals.


Experts define burnout as a syndrome marked by emotional exhaustion, cynicism and decreased effectiveness. Many burned out doctors cut back their hours to cope, and a disturbing number commit suicide.

A landmark 2015 Mayo Clinic study found that more than 7 percent of nearly 7,000 doctors had considered suicide within the prior 12 months, compared with 4 percent of other workers. About 400 a year go through with it.

Driving the burnout symptoms is the burden of data entry on clumsy electronic medical records systems that doctors must use to prove the quality of their care, said Dr. Christine Sinsky, vice president of professional satisfaction at the American Medical Association.

Sinsky recently conducted an experiment in her own internal medicine practice in Dubuque, Iowa. She asked a staff member how many mouse clicks it takes to order and record a single patient’s flu shot in their electronic medical record. The answer: 32.

She has visited some practices where a doctor had to record flu shots for more than 1,000 patients because only the doctor was allowed to enter the order.

Such mandates reflect an overly strict interpretation of federal health reforms designed to encourage doctors to use electronic medical records, such as the 2009 Health Information Technology for Economic and Clinical Health Act that required doctors to demonstrate “meaningful use” of the systems.

“We have to recognize the exacting toll that the first generation of electronic health records have had on physicians,” Sinsky said. “I would identify it as one of the most important drivers of physician burnout.”

Pre-approval requirements from health insurers for many services and quality metrics built into Obamacare have added to doctors’ administrative duties.

“We’ve got this measurement mania. We’ve got to back off of that,” said Dr. Paul Harkaway, chief accountable care officer for Michigan’s St. Joseph Mercy Health System, a part of Trinity Health, a national not-for-profit Catholic healthcare system.

As a result of these requirements, primary care physicians spend more than half of their 11.4 hour workday performing data entry and other tasks, according to a September AMA/University of Wisconsin study published in the Annals of Family Medicine.

To manage, doctors often finish work at home in the evening, a part of the day known as “pajama time.”


Doctors’ suffering can take a direct toll on patients. In a 2010 study, Shanafelt and colleagues found that the more burned out a surgeon was, the more likely he or she was to report a major medical error. Other studies have shown that burnout drives up rates of unnecessary testing, referrals to specialists and hospital admissions.

When doctors quit, it costs an estimated $800,000 to $1.3 million in recruitment, training and productivity costs, depending on the specialty.

Even when physicians don’t leave, they can contribute thousands of dollars in costs each year “just as a matter of inefficient functioning,” said Dr. Colin West of the Mayo Clinic.

The trend has medical malpractice experts concerned. CRICO, the malpractice carrier for Harvard University’s two dozen affiliated hospitals, recently had to settle a handful of cases because doctors were too burned out to fight, even though CRICO believed it could win.

“The clinician just wanted it to go away,” said Dr. Luke Sato, CRICO’s chief medical officer. Sato estimates that an average breast or colorectal cancer malpractice case might cost $750,000 to $1 million to settle.

The crisis has Harkaway worried for his colleagues in Michigan, and for his profession.

“Working with doctors every day, you see it,” he said. “They are just beat down.”

(Reporting by Julie Steenhuysen; Editing by Michele Gershberg and Editing by Edward Tobin)


Doctor Shortage? — Overwork taking a toll on Malaysian doctors — Public healthcare — Rising cost of living drives patients to seek cheaper treatment

August 20, 2017

Image may contain: 1 person, sitting and crowd

Klinik Kesihatan Kuala Lumpur, one of KL’s largest government clinics, which can treat up to 1,000 patients a day.PHOTO: BERNAMA

Public hospitals stretched as rising cost of living drives patients to seek cheaper treatment

As a paediatrician in training, Dr Nurul Huda Ahmad dreamed of making healthcare fun for children.

But her dream will never come true. The 33-year-old from Kuala Terengganu was driving home after working for 33 hours straight, with little rest, when she died in an accident on May 9.

In July last year, another young doctor, anaesthesiologist Afifah Mohd Ghazi, also died in similar tragic circumstances.

Worn out after a long shift, Dr Afifah lost control of her car and crashed into a tree, resulting in fatal injuries to her chest and brain. She was only 27.

Post-call fatigue is nothing new in the medical world, especially for doctors in the public health sector.

But the situation is worsening as more Malaysians switch to public hospitals to cope with the rising cost of living in recent years, especially since the 6 per cent goods and services tax (GST) was introduced on April 1, 2015.

The influx has added to doctors’ workloads and, in many instances, led to deadly consequences, according to anecdotal accounts from physicians and surveys by medical associations.

Dr Nurul Huda Ahmad also died in a crash after completing a 33-hour shift.
  • 55% Percentage of accidents that occurred after respondents had worked for 25 to 36 hours, according to a 2015 survey of 440 healthcare professionals.65% Percentage of respondents who admitted they suffered from post-accident psychological trauma.


We (doctors) are happy to be of service but I believe it is slowly taking a toll on us. A doctor at a public hospital sometimes has to take care of up to 500 patients. Imagine the exhaustion.

DR KUAN, on how the workloads of public hospital doctors have become heavier in recent years


Cost is definitely a factor because the prices of goods and services are steadily increasing. But another reason is that the waiting time (at public hospitals) is almost the same as at private hospitals.

MR MUHAMMAD NAJMI ABDULLAH, 36, an engineer, on how public hospitals are just as efficient as private ones.


When you have more people seeking treatment at public hospitals… it will also affect the doctors attending to them – they get overworked.

DR AZLAN HELMY ABD SAMAT, from the Islamic Medical Association of Malaysia, on how the rising cost of living has resulted in a higher number of patients going to public

Dr Rozaimi (not his real name), a 35-year-old doctor at a public hospital in Selangor, told The Straits Times that he and his peers suffer from chronic fatigue and high levels of stress. “There is no job without stress and fatigue, but I’ve lost count of how many times I’ve accidentally fallen asleep behind the wheel post-call,” said Dr Rozaimi.

“One incident will always stand out – I had just completed a 35-hour shift and was driving to my home in Shah Alam. I accidentally swerved into the fast lane when a car was already speeding along it. The loud honks (from the driver) saved me, I managed to swerve back into my lane.”

Dr Kuan (not his real name), 32, has also had his share of near-miss post-call experiences.

He said: “Although most of us (doctors) have adjusted to our hectic schedules, I can never forget an incident several years ago when I almost lost my life. I crashed into a divider and my car ended up in a drain. My injuries were minor but I could have drowned.

“After transferring to a research department two years ago, I no longer work more than 24 hours at a stretch. My quality of life has improved tremendously and I have not fallen asleep behind the wheel any more.

“We have all been guilty of falling asleep post-call while driving.”

Both Dr Rozaimi and Dr Kuan say their workloads have become heavier in recent years due to more patients going to public hospitals.

Dr Kuan said: “The number of patients has definitely doubled compared with several years ago. Most of the patients I have attended to have cited the higher cost of living as the reason they’re seeking treatment at public hospitals.

“We (doctors) are happy to be of service but I believe it is slowly taking a toll on us. A doctor at a public hospital sometimes has to take care of up to 500 patients. Imagine the exhaustion.”

In 2015, a survey of 440 healthcare professionals on the topic of post-call motor vehicle accidents was published by the Islamic Medical Association of Malaysia (Imam) and Pertubuhan Amal Perubatan Ibnu Sina Malaysia, a non-profit organisation.

Some 55 per cent of the accidents the respondents had been involved in occurred after they had worked for 25 to 36 hours.

Nearly 65 per cent of respondents also admitted they suffered from post-accident psychological trauma.

Imam’s Dr Munawwar Salim said that at the time, the survey highlighted the need for further investigations into the correlation between motor vehicle accidents and the preceding hours of duty.

After serving the standard 24 hours, most doctors have to work for a further four to 10 hours just to clear the backlog of work.

Sleep deprivation is one of the recognised factors contributing to motor vehicle accidents.

Research has shown that drivers who are suffering from fatigue are as cognitively impaired as drivers who are intoxicated.

The high cost of living has been cited as the top reason that more Malaysians are seeking treatment at public hospitals.

Last year, public hospitals saw 20 per cent more patients compared with the year before, according to the Health Ministry’s deputy director-general, Dr Jeyaindran Sinnadurai. He noted that even before 2016, the number had been increasing.

Restaurateur Rita Liyana Rahmat, 41, said she started going to government-funded hospitals and clinics after the GST kicked in.

“It’s already hard to cope with daily expenses these days. Forking out money for medical treatments at private medical institutions just doesn’t make sense to me,” she told The Straits Times.

Engineer Muhammad Najmi Abdullah, 36, said he prefers going to public hospitals, which he said are just as efficient as private ones.

“Cost is definitely a factor because the prices of goods and services are steadily increasing. But another reason is that the waiting time (at public hospitals) is almost the same as at private hospitals,” said Mr Najmi.

“Instead of using up my deposit – which always happens at private hospitals after I get discharged – I would rather get treated at or admitted to government hospitals.”

Dr Azlan Helmy Abd Samat from the medical association Imam said there is a definite link between the rising cost of living and the rising number of patients opting for public hospitals.

“When you have more people seeking treatment at public hospitals… it will also affect the doctors attending to them – they get overworked,” he said.

This shift also means that private outfits have seen a drop – of almost 30 per cent – in patient numbers, according to Association of Private Hospitals of Malaysia president Jacob Thomas.

He told The Malaysian Insight news site last month that patients are turning to public hospitals asthese hospitals are exempt from GST and treatment is almost fully subsidised by the government.

Dr Jacob urged the Health Ministry to collaborate with the private sector to reduce long waiting times for procedures such as magnetic resonance imaging, computerised tomography and positron emission tomography scans.

At some private hospitals, patients who have been referred by public hospitals are offered these services at reduced prices, he noted.

“We understand that 25 per cent of patients at public hospitals have access to private healthcare insurance. We can manage them in our private hospitals,” Dr Jacob was quoted as saying.

In May, government representatives from the Road Safety Department and the Health Ministry’s Occupational Health and Safety Unit, as well as medical associations, held a meeting to discuss ways to prevent doctors from getting into road accidents after exhausting shifts.

The meeting was held in response to concerns aired by a group of medical non-governmental organisations (NGOs) on May 13 about the number of medical professionals who were involved in road accidents after working long hours.

“Until today, we do not have data on this subject. This is the reason why we need to have our own research on this,” Dr Munawwar from Imam told The Straits Times.

For now, the NGOs are working to raise awareness of the problem through campaigns and engagements, he added.

They will also launch a discounted ride-hailing service for post-call doctors in collaboration with GrabMalaysia on Sept 16.




Doctors are not prescribing a drug to treat opioid addiction because they don’t want to be flooded with patient requests for it, study says

August 4, 2017

Suboxone buprenorphine/naloxone tablets 8mg 2mg

  • Doctors are hesitant to prescribe a drug that treats opioid addiction  
  • Buprenorphine can treat addiction if a doctor has a waiver to prescribe it
  • It is the less severe of only two drugs approved by the FDA to treat addiction
  • In the past few years there has been an uptick in opioid use in the United States
  • Doctors said they were hesitant to prescribe it because they don’t want a flood of new patients
  • Those that do prescribe it have said they don’t want to prescribe more because they can’t handle more patients 

Doctors are hesitant to prescribe a drug that treats opioid addiction and withdrawal, a new survey revealed.

One of the two drugs that treats opioid addiction is being under-prescribed, especially when taking into account the spike in numbers addicted.

Most doctors said they don’t want to prescribe the drug because they don’t want to be flooded with new patient requests according to the study at Johns Hopkins School of Medicine in Maryland.

And among the doctors that can prescribe it, a number didn’t want to give it to new people because they don’t feel they can take on new patients.

Doctors are hesitant to prescribe a drug that treats opioid addiction and withdrawal, a new survey revealed (stock image) 

Doctors are hesitant to prescribe a drug that treats opioid addiction and withdrawal, a new survey revealed (stock image)


‘Though it was widely believed that allowing physicians to prescribe this drug in a primary care setting would increase the number of patients receiving treatment, the number of physicians adopting this therapy has not kept pace with the magnitude of the opioid epidemic,’ lead author Dr Andrew Huhn explained.

In the past few years there has been an uptick in opioid addiction, with the most common being heroin and the powerful contaminant fetanyl.

Paul Wright shows a picture of himself in the hospital after a near fatal overdose in 2015, Thursday, June 15, 2017, at the Neil Kennedy Recovery Clinic in Youngstown, Ohio. (AP Photo/David Dermer)

Fentanyl, the drug responsible for the death of musician Prince last year, is a man-made opioid 100 times more powerful than morphine.

Opioid addiction impacts million of Americans, and withdrawal symptoms can be severe if a sufferer stops taking them.

Withdrawal can cause intense sweating, nausea, chills, diarrhea, shaking, depression, fatigue and severe pain.


Figures released in June by the New York Times revealed drug overdoses are now the leading cause of death in American adults under 50.

The data, published in a special report by the Times’ Josh Katz, lays bare the bleak state of America’s opioid addiction crisis fueled by deadly manufactured drugs like fentanyl.

The figures are based on preliminary data, which will form part of an official report by the CDC later this year.

Experts warn a key factor of the surge in deaths is fentanyl, which can be 50 times more powerful than heroin.

The Times said its data showed between 59,000 and 65,000 people could have died from overdoses in 2016, up from 52,404 in 2015, and double the death rate a decade ago.

In the past few years there has been an uptick in opioid addiction, with the most common being heroin and the powerful contaminant fetanyl.

Fentanyl, the drug responsible for the death of musician Prince last year, is a man-made opioid 100 times more powerful than morphine.

The two opioid replacement methods currently used to treat addiction are:

  • Methadone, which under federal law must be dispensed from authorized clinics
  • Buprenorphine can used to treat addiction in the privacy of a physician’s office so long as he or she has proper waivers to prescribe it

Buprenorphine was approved for treatment of opioid use disorder in 2002, but in order to prescribe it physicians must apply for a waiver from the Substance Abuse and Mental Health Services Administration.

It works similarly to methadone, but is less intense and therefore not as likely to be abused.

Both suppress addiction withdrawal symptoms with daily doses of the drug.

A physician who has a waiver to prescribe buprenorphine is allowed to treat up to 30 patients in the first year and 275 in each year following.

The team of researchers surveyed 558 English-speaking physicians in the United States over email during the spring and summer of 2016.

Each participant was asked a series of questions addressing drawbacks associating with prescribing the drug, possible resources that would make doctors more likely to get the waiver, and resources that would make those with the waiver accept new patients.

Only 74 said they did not have the waivers required to prescribe the drug. Of them, one-third said nothing would make them more willing to get a waiver.

The most common reasons for not having the waiver were not wanting to be inundated with new patient requests for the drug and concerns about people reselling it.

More than half of the people who said they had waivers and were not prescribing to capacity said nothing would make them more willing to prescribe at that level.

The most common reason for not prescribing at the maximum capacity were lack of time for new patients and insufficient reimbursement.

Participants in general said they would be more willing to either obtain the waivers or increase their number of patients if they received information about local counseling resources, were paired with an experienced provider and if there was more access to medical education courses on opioid use disorder.

An estimated 1.27 million people were hospitalized or went to the emergency room for opioid related issues in 2014. This was a 64 percent increase for in-patient care and a 99 percent increase for emergency room visits compared with 2005.

‘I think the two biggest takeaways from our research are that there are not enough physicians prescribing buprenorphine to meet patient demand, and access to counseling services for patients and mentoring services for physicians would make physicians more likely to take on new patients with opioid use disorder,’ Dr Huhn said.

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Doctors Leaving Venezuela During Unrest

June 13, 2017

Country’s loss of medical and other professional personnel is gain for places like remote Chilean island

Doctors Flee Desperate Venezuela to Work in Safer Places

© Juan Barreto, AFP | Opposition activists clash with the police during a demo in Caracas on June 7, 2017.


June 12, 2017 5:39 p.m. ET

ANCUD, Chile—On a recent day in this remote island town, Dr. Jhomar Yansen rushed to operate on a man who had been kicked in the gut by a sheep and was suffering severe internal bleeding.

The surgeon worked in his native Venezuela saving patients with gunshot and knife wounds until last year, when he fled the chaotic, impoverished country like thousands of other professionals. Now he finds himself as part of a cluster of Venezuelan physicians looking after fishermen and shepherds here on a green archipelago in the frigid Southern Pacific.

“This isn’t exactly where I thought I’d work,” said Dr. Yansen, who lives here with his wife, also a doctor, and their infant daughter. “But thank God I’m here. I didn’t want my daughter to grow up in such a hostile environment.”

Venezuelan physicians Eiko Desirée Urquiza  and Jhomar Yansen at the hospital where they work in Ancud, Chile.
Venezuelan physicians Eiko Desirée Urquiza and Jhomar Yansen at the hospital where they work in Ancud, Chile. PHOTO: RYAN DUBE/THE WALL STREET JOURNAL

Nearly 2 million Venezuelans have fled their country since the late strongman Hugo Chávez took office in 1999 and put his country on the path to socialist revolution, according to Tomás Páez, a sociologist at Venezuela’s Central University who wrote a book on the diaspora.

The numbers have accelerated since President Nicolás Maduro took over in 2013, Mr. Páez said, with businessmen, university professors, farmers and oil workers abandoning a country riven by authoritarian rule and protests. Venezuelans are flooding particularly into neighboring Colombia and Brazil. They have boarded boats bound for Caribbean islands. In the U.S., their asylum requests have surged, while the sight of them selling cornmeal cakes known as arepas has become a commonplace in the Peruvian capital, Lima.

The exodus of doctors is exacerbating the already serious strain on Venezuela’s once-vaunted public-health system, which has been crippled by dilapidated hospitals and shortages of medicine, supplies and equipment. Figures released last month by the country’s health ministry showed maternal mortality there increased by 66% last year; infant mortality, which rose by 30% last year, is now higher in Venezuela than in war-torn Syria. Malaria and diphtheria rates are soaring amid shortages of insect repellents, vaccinations, and public-health funding.

Fellow activists help an injured opposition demonstrator during clashes with riot police last month in Caracas.
Fellow activists help an injured opposition demonstrator during clashes with riot police last month in Caracas. PHOTO: FEDERICO PARRA/AGENCE FRANCE-PRESSE/GETTY IMAGES

The Venezuelan Federation of Doctors estimates that some 16,000 doctors have left in 12 years, moving as far away as Spain and Australia.

“If this wave of migration of doctors to other countries continues, a moment is going to arrive…when they aren’t going to have enough capacity to run hospitals,” said Juan Correa, the federation’s vice president. Calls to Venezuelan health authorities seeking comment weren’t returned.

Venezuela’s loss is helping places like Ancud on Chiloé, a tranquil island of green rolling hills, Humboldt penguins and wooden churches located 760 miles south of Santiago—and a world away from Venezuela’s strife.

“We’ve had, I would say, a blessing with doctors of such good technical quality,” said Luis Hernán Vallejos, a Chilean physician who runs the Ancud hospital’s emergency unit.

Venezuelans have arrived to Chile in droves, attracted to the political stability in Latin America’s most developed nation. Last year, nearly 23,000 Venezuelans received visas, up from 439 in 2006, with recent arrivals including many young, well-educated professionals, according to the head of Chile’s immigration office, Rodrigo Sandoval.

“Chile is kind of this California of the south,” said Cristián Doña, an immigration expert at the Diego Portales University in Santiago, referring to this country’s appeal to South American migrants.

Last year, 1,313 Venezuela-educated physicians, more than any other foreign group, took a test to work in Chile’s public-health system, up from just 16 in 2011, according to exam administrators. Most took jobs in areas that have an acute shortage of physicians, said Juan Carlos Riera, a urologist who created an association of Venezuelan doctors in Chile.

Many more could arrive. In 2016, 88% of medical students in their final year at four Venezuelan universities said they hoped to emigrate after graduation, according to research by Iván de la Vega, a Venezuelan sociologist.

The town of Ancud in southern Chile has become home for a cluster of Venezuelan doctors escaping their native country's crisis.
The town of Ancud in southern Chile has become home for a cluster of Venezuelan doctors escaping their native country’s crisis. PHOTO: RYAN DUBE/THE WALL STREET JOURNAL

Mario Castro, the first Venezuelan physician to settle in Ancud, fled with his family in late 2015 after a friend was kidnapped and a neighbor’s car was stolen with her baby in the back seat.

“In no way did I want my son to grow up in an environment with so much violence,” the fertility expert said.

In the last 18 months, about a dozen other Venezuelan doctors—including surgeons, gynecologists, and anesthesiologists—have found work in Ancud’s small 72-bed hospital.

The physicians recently saved a baby through an emergency caesarean section and operated on a man’s deeply cut forearm and wrist to avoid amputation. Angélica Velásquez, a 25-year-old woman Dr. Castro treated for difficulties conceiving a child, recently gave birth to twins.

“I’ve had an excellent experience,” she said. “His knowledge can help a lot of women like me.”

These Venezuelan exiles from a Caribbean climate have adjusted to the Chilean island’s cold nights by learning to split firewood to heat their houses. They have been rattled by powerful earthquakes and had to start thinking of where to flee in the case of a tsunami.

Venezuelan doctors Karina Castilla and Eduardo Arteaga at their home outside Ancud, Chile.
Venezuelan doctors Karina Castilla and Eduardo Arteaga at their home outside Ancud, Chile. PHOTO: RYAN DUBE/THE WALL STREET JOURNAL

Sometimes, they listen to Venezuela’s folk music, recalling memories of home.

“At times you want to cry,” said Karina Castilla, a gynecologist from Caracas. “You’re in a country that has welcomed you, but it isn’t your country and it will never be.”

Still, they don’t see a future back in Venezuela. Here there are no food shortages. Some doctors have opened businesses, and many are able to send remittances and medicines to family back home.

“I have no problem living here,” emergency-room physician Daniel Arocha said as he watched his daughter play in a park. “We found what we were looking for.”

Write to Ryan Dube at

Philippines: Doctor Shortage — Why Not Pay Tuitions With Government Funds To Get More Doctors? (Editorial)

March 20, 2017

Philippines: Doctor Shortage — Why Not Pay Tuitions With Government Funds To Get More Doctors? (Editorial)

Taxpayers spend P2.5 million over four years to produce a graduate of the Philippine Military Academy. Why not make the same investment in producing surgeons and other physicians?

The proposal was made by Senate President Pro Tempore Ralph Recto, who noted that the Department of Health already has an existing scholarship program for aspiring doctors. All that’s needed is to expand the program while at the same time making compensation and benefits more attractive for physicians working for the DOH.

Unless remuneration is improved, the nation may see its shortage of doctors worsen, especially in rural areas. Recto noted that of the 946 available slots in the government’s Doctor to the Barrios program from 2015 to 2016, only 320 were filled. The program is meant to provide at least one doctor in each low-income municipality, but there were few takers. Those 626 unfilled slots meant that millions were deprived of the services of a doctor in their communities.

The medical profession can pay handsomely – but only after many years of grueling studies and substantial financial investment in schooling and specialized training. The cost of medical textbooks alone can be beyond the reach of a low-income household.

Parents who have invested their life savings to send their child to medical school would naturally be reluctant to let the new doctor volunteer for a rural assignment that pays P56,000 a month, especially in conflict zones. The medical community is still waiting for justice for a Doctor to the Barrio volunteer, Dreyfuss Perlas, who was shot dead by still unknown assailants last March 1 while serving in Lanao del Norte.

If the government shoulders the schooling expenses of deserving medical scholars, the nation may be assured of a steady supply of physicians, even if the beneficiaries leave the DOH after a mandatory four-year service. The government may then have at least one doctor for every municipality, with the scholars encouraged to serve in their hometowns.

Health experts estimate that the country currently faces a shortage of 60,000 doctors. This means six out of every 10 Filipinos die without seeing a doctor. This need not be the case. The government is recruiting more police and military personnel. Why not boost resources to produce and recruit more doctors?

Junior doctors’ strike in Britain: All-out stoppage ‘a bleak day’

April 26, 2016


Junior doctors walked out of routine and emergency care at 08:00 BST.

The strike affects A&E, maternity and intensive care for the first time.

Health Secretary Jeremy Hunt expressed disappointment that the stoppage was taking place, but again said the government would not back down and halt the imposition of the new contract.

The walkout ends at 17:00 BST with further all-out action due to take place on Wednesday, between the same hours, in the protest against the imposition of the new contract from the summer.

Speaking to the BBC, Mr Hunt described it as a “very, very bleak day” for the NHS, but said no union had the right to stop a government trying to act on a manifesto promise.

“The reason this has happened is because the government has been unable to negotiate sensibly and reasonably with the BMA.”

Before the strike, government sources had indicated that they could not give in because the row had become political, with the BMA trying to topple the government, and other unions watching the dispute “like hawks”. The BMA described this as ridiculous.

During the stoppage, hospitals can request that junior doctors return to work if needed, but as yet, no NHS trust has raised the alarm.

There have been reports that hospitals may be quieter than normal with patients heeding warnings to stay away unless absolutely necessary.

NHS England said the situation was being monitored carefully, but “military level” contingency planning had ensured hospitals were as well prepared as they could be.

Steps taken include:

  • The postponement of nearly 13,000 routine operations and more than 100,000 appointments to free up staff
  • The cancellation of holidays and study leave
  • Redeployment of consultants, middle-grade doctors and nurses into emergency care
  • More GP appointments being kept free for last-minute requests
  • An increase in 111 staff on duty to allow the phone service to handle more calls

NHS England’s Anne Rainsberry said: “Clearly industrial action of this type can put significant pressure on the NHS. We have been working with all hospitals to make sure they have plans in place to provide urgent and emergency care.”

She said those plans were “robust” and hospitals were “confident” they could cope, but the situation would be kept under review.

There are more than 50,000 junior doctors in the NHS in England, representing about a third of the medical workforce.

Ipswich Hospital chief executive Nick Hulme said his trust had been coping well – and more doctors than expected had come into work, 23 out of 122, suggesting an all-out strike had been a “step too far” for some.

But he said both sides needed to come back together to resolve the dispute “quickly”, saying it was getting “really difficult” for the NHS to cope with the backlog of postponed operations.

A new poll by Ipsos MORI for the BBC showed the majority of the public still backed junior doctors, although support was not as high after it became an all-out stoppage.

Asked whether they supported junior doctors striking while not providing emergency cover, 57% said they did and 26% said they were opposed.

The last time the public was asked was ahead of the 48-hour walkout in March, when emergency cover was maintained. Then, 65% supported junior doctors.

The poll of more than 800 adults in England also found a growing number of people blaming both sides for the impasse. Some 35% said the government and junior doctors were at fault. The majority – 54% – still blamed the government.

The dispute is about working hours and pay, but a key sticking point is about payments for working on Saturdays.

Talks between the government and British Medical Association (BMA) broke down in January, prompting the government to announce in February that it would be imposing its contract in the summer.

How the dispute reached stalemate

A junior doctor

Image copyright PA
  • Talks broke down in January and after a final take-it-or-leave it offer from government was rejected by the BMA in February, ministers announced the contract would be imposed
  • It will reduce the amount paid for weekend work, but basic pay is being increased
  • The BMA wants a more generous weekend pay allowance and more investment for more seven-day services
  • Two legal challenges are being pursued by doctors against the imposition
  • Hospitals are pushing ahead with the new contract – offers are expected to go out in May
  • The government is refusing to reopen talks, arguing it made compromises earlier in the year but the BMA did not
  • The first four strikes in 2016 all involved emergency cover being provided, before the all-out stoppages on 26 and 27 April

Graphic showing the differences between junior doctors' current contracts and the government and BMA proposals

Image caption: The current rates for junior doctors and how the government position compares with the BMA’s

Junior doctors’ row: The dispute explained
The strike comes after last-minute pleas from medical leaders, patient groups and opposition MPs for both sides to get back round the negotiating table.

National Voices, a coalition of patient groups and charities, even offered to host talks. Chief executive Jeremy Taylor said: “Patients and the public are caught in the middle – and the harm is being felt by patients and their families.”

BMA junior doctor leader Dr Johann Malawana said if the government had scrapped his plan to impose the contract, the union would not have taken this action.

“No doctor wants to take any action. They want to be in work, treating patients, but by refusing to get back around the negotiating table the government has left them with no choice but to take short-term action to protect patient care in the long term.”

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Obama Administration Report Slams Digital Health Records

April 10, 2015

Report criticizes vendors for making it costly to share patient information

An Obama administration report cites complaints that some hospital systems make it difficult to transfer patient records to rival systems or physicians.  
An Obama administration report cites complaints that some hospital systems make it difficult to transfer patient records to rival systems or physicians. Photo: Fabrizio Costantini for the Wall Street Journal
By Melinda Beck
The Wall Street Journal

The Obama administration took vendors of electronic health records to task for making it costly and cumbersome to share patient information and frustrating a $30 billion push to use digital records to improve quality and cut costs.

The report, by the Office of the National Coordinator for Health Information Technology, listed a litany of complaints it has received about vendors allegedly charging hefty fees to set up connections and share patient records; requiring customers to use proprietary platforms; and making it prohibitively expensive to switch systems.

The report also cited complaints that some hospital systems make it difficult to transfer patient records to rival systems or physicians as a way to control referrals and enhance their market dominance.

The agency didn’t cite any companies by name, however, and said it couldn’t determine the extent of information-blocking—in part because contracts often forbid customers from discussing prices and other terms.

“This is our first deep dive, where we have taken the opportunity to describe the situation and identify practices that interfere with the flow of health information,” said ONC chief Karen DeSalvo. “We believe it will take an array of solutions and we look forward to working with Congress on this.”

Congress requested the report last December amid rising concerns that the government’s massive investment in digitizing health records has created a windfall for the information-technology industry, but left patient records largely stuck in silos.

Spurred by $28 billion in incentives to date, nearly 80% of doctors and 60% of hospitals have converted from paper files to electronic health records, known as EHRs since 2009. But only 20% to 30% of providers are able to share records with outside providers, according to government and industry surveys.

The Electronic Health Record Association, a trade group, said its members are committed to sharing patient records but building connections to the myriad systems used by hospitals, doctors, labs and others takes time and money. “Even if they were all using the same standards, there will always be costs for maintenance and upgrades and making sure the information goes to the right place,” said Sarah Corley, the group’s vice chairwoman and chief medical officer of NextGen Healthcare Information Systems Inc., an EHR vendor and part of Quality Systems Inc.

Some vendors say they aren’t relying on connection fees. As of last week, 25 EHR vendors—representing 70% of the acute-care market and 24% of the ambulatory-care market—had joined the CommonWell Health Alliance, which aims to create a network with low-cost connections so doctors can easily query patient records from anywhere in the system. Vendors build one interface to the network and can connect all their customers to it, and each other, rather than having to create many separate interfaces.

Athenahealth Inc. is offering the CommonWell connection free to the 62,000 physician using its cloud-based EHR systems. McKesson Corp. MCK 0.36 % plans to do the same for its hospital EHR users. Cerner Corp. says it will offer it to customers free for three years, after a small start-up fee.

To date, only 60 provider sites in 15 states are live on the CommonWell network, but the alliance hopes to be nationwide by the end of the year.

Epic Systems Corp., the privately held industry leader, has declined to participate in CommonWell—in part because it says its 315 large health-system clients can already exchange records with 2,000 hospitals and 25,000 clinics in its proprietary network. “Every system our customers have wanted to connect to so far, we’ve been able to make that happen,” said Epic spokesman Shawn Kiesau.

Connection fees have hit small physician practices especially hard, some observers say.

Farzad Mostashari, a former ONC director and now CEO of Aledade Inc., which helps doctors join together in integrated systems, said he has seen vendors charge small practices as much as $29,000 for an interface to send patient data to other providers, and as much as $1 a virtual page to transmit patient files, which can run thousands of pages.

The ONC report stressed that the agency cannot regulate prices and that most of the alleged actions don’t violate current laws.

ONC does set the criteria that EHR systems must meet for providers to qualify for Medicare incentive payments, or to avoid penalties starting this year. The agency has proposed increased surveillance of EHR systems and more upfront disclosure by vendors of any costs or limitations on data-sharing.

Theoretically, ONC could decertify EHR systems that deliberately block data-sharing, as some lawmakers have suggested, but the report says that would unduly penalize customers.

Micky Tripathi, CEO of the Massachusetts eHealth Collaborative and project manager for Argonaut Project, which aims to accelerate the adoption of open technology standards, predicts that patients will increasingly demand that competing networks work with each other to let their records flow freely. “I’m sure that when the telephone networks and electricity grids were forming, it felt the same way. It just takes a while to shake out,” he said.

Write to Melinda Beck at

VA hospitals and military hospitals criticized for lax care, reprisals against staff who point out problems

December 21, 2014

— Veterans and their families in Fayetteville on Friday got a chance to voice their complaints directly to the head of the director of the Fayetteville VA Medical Center, which has come under scrutiny in recent months for the long wait times patients have experienced.

Medical Center Director Elizabeth Goolsby held two town hall meetings to hear patients’ concerns and to offer immediate on-the-spot help filing claims.

One thing the hospital has done to try to alleviate long wait times has been opening a new VA clinic on Breezewood Drive and staffing it with three primary care teams, Goolsby said.

Earlier this week, the hospital held a ribbon cutting for a 10,000-square-foot trailer to provide mental health care.

Goolsby said the additions have decreased the amount of time veterans have to wait for care.

The New York Times

FAYETTEVILLE, N.C. — Beyond conducting their periodic evaluation of Womack Army Medical Center, one of the military’s busiest hospitals, the inspectors who came here to Fort Bragg last March had a special task. A medical technologist had complained of dangerous lapses in the prevention of infections. The inspectors planned to follow up.

But Teresa Gilbert, the technologist, said supervisors excluded her from meetings with the inspectors from the Joint Commission, an independent agency that accredits hospitals.

“I was told my opinions were not necessary, nor were they warranted,” said Gilbert, an infection-control specialist.

The review ended disastrously for Womack, one of 54 domestic and overseas military hospitals that serve more than 3 million active-duty service members, retirees and family members. The inspectors faulted infection prevention and many other aspects of care, putting the hospital’s accreditation under a cloud for months.

It was disastrous for Gilbert, too. She said she was reprimanded for being an obstructionist, reduced to part-time hours, investigated for what she called trumped-up charges and transferred to a clerk’s job.

The message to Womack workers, she said, was clear: “You don’t go against us. If you do, we will get you.”

At any hospital, patient safety and quality of care depend on the willingness of medical workers to identify problems. The goal is for medical workers to be free to speak bluntly to — and about — higher-ups without being ignored or, worse, punished.

In interviews and email exchanges, many doctors, nurses and other medical workers said military hospitals fall short of that objective.

During an examination of military hospitals this year, The New York Times asked readers to recount their experiences via a private electronic portal. Among more than 1,200 comments were dozens from medical workers about how the system thwarted efforts to deliver superior care.

Physicians and nurses described in follow-up interviews how they were brushed off, transferred, investigated, passed over for promotion or fired after they pointed out problems with care.

Senior military health officials said they were working aggressively to instill a culture where complaints are welcomed and addressed.

“We want people to come forward,” Lt. Gen. Patricia Horoho, the Army surgeon general, said in a statement to The Times. “We are committed to patient safety, we are committed to transparency, and there will be no compromise.”

“We want people to come forward. We are committed to patient safety, we are committed to transparency, and there will be NO COMPROMISE,” Lt. Gen. Patricia Horoho, the Army surgeon general, wrote in a statement. Credit Cliff Owen/Associated Press

But hospital workers, military and civilian, described compromise as routine. The nature of military medicine, they say, muddles the emphasis on patient safety and quality of care. The command structure is so rigid that a nurse can oversee a doctor because the nurse holds a higher military rank. Promotions often reward administrative deeds over medical performance. Legal accountability is diminished: Active-duty service members cannot sue for malpractice, and other patients can sue only the government, not individual doctors or nurses.

Read the rest:

Capt. Michael Schell, center, operating room nurse, and anesthesiologist Frank Wallace, right, assist Chief Warrant Officer Jonathan Grogan to his transfer beds after his spinal cord stimulation procedure in May 2009 at Womack Army Medical Center at Fort Bragg in North Carolina. A review found physicians and nurses at military hospitals were brushed off, transferred, investigated, passed over for promotion or fired after they pointed out problems with care.

ObamaCare’s Threat to Private Practice

December 8, 2014


By Scott Gottlieb
The Wall Street Journal

Here’s a dirty little secret about recent attempts to fix ObamaCare. The “reforms,” approved by Senate and House leaders this summer and set to advance in the next Congress, adopt many of the Medicare payment reforms already in the Affordable Care Act. Both favor the consolidation of previously independent doctors into salaried roles inside larger institutions, usually tied to a central hospital, in effect ending independent medical practices.

Republicans must embrace a different vision to this forced reorganization of how medicine is practiced in America if they want to offer an alternative to ObamaCare. The law’s defenders view this consolidation as a necessary step to enable payment provisions that shift the financial risk of delivering medical care onto providers and away from government programs like Medicare. The law’s architects believe that doctors, to better bear financial risk, need to be part of larger, and presumably better-capitalized institutions. Indeed, the law has already gone a long way in achieving that outcome.

A recent Physicians Foundation survey of some 20,000 U.S. doctors found that 35% described themselves as independent, down from 49% in 2012 and 62% in 2008. Once independent doctors become the exception rather than the rule, the continued advance of the ObamaCare agenda will become virtually unstoppable.

Local competition between providers, who vie to contract with health plans, is largely eliminated by these consolidated health systems. Since all health care is local, the lack of competition will soon make it much harder to implement a market-based alternative to ObamaCare. The resulting medical monopolies will make more regulation the most obvious solution to the inevitable cost and quality problems.

A true legislative alternative to ObamaCare would support physician ownership of independent medical practices, and preserve local competition between doctors and choice for patients.

First, Congress should remove the pervasive biases in ObamaCare that favor hospital ownership of medical practices. Payment reforms that create incentives for the coordinated delivery of medical care (like Accountable Care Organizations and payment “bundles”) all turn on arrangements where a single institution owns the doctors. They’re biased against less centralized engagements where independent doctors enter into contractual relationships among themselves.

These ObamaCare payment reforms are fashioned after 1990s-style health maintenance organizations, or HMOs, in which entities like hospitals would get a lump sum of money from Medicare (or now, ObamaCare) for taking on the risk of caring for a large pool of patients. But right now all of these payment schemes are tilted far in favor of having hospitals pool that risk, and not looser networks of doctors.

For one thing, providers who want to participate in the “reformed” physician payment plan must control their own IT infrastructure to comply, as opposed to collaborating freely across space rented in the cloud. This practical need can require IT infrastructure that costs millions of dollars. It makes participation absurdly expensive for anyone but a hospital that already has its own server hub.

Also, waivers of certain anti-kickback provisions (that prevent doctors from forming needed business partnerships) only apply when providers qualify as an Accountable Care Organization. Not surprisingly, ACA qualification is largely dependent on requirements that create the same need for physical infrastructure and bureaucratic overhead that is hard to replicate outside the hospital setting.

To implement real reform, Congress must give independent, private-practice doctors an equal footing. One legislative proposal would let a new class of “independent risk managers” act as third parties to help individual doctors analyze and share the risk of caring for these patient pools. This would make it possible for independent medical offices to band together and bid against hospitals for a pool of patients. Private companies specializing in analyzing and pricing medical risk could serve as brokers and help the doctors know what they’re getting into. But ObamaCare deliberately crowds out this sort of market innovation in favor of hospitals and their existing networks.

Individual, provider-owned medical practices also deserve equal footing when it comes to reimbursement. Right now, Medicare is paying much more for many procedures when performed in a hospital outpatient clinic rather than an independently owned medical office. Things as common as heart scans ($749 versus $503), colonoscopies ($876 versus $402) and even a 15-minute doctor visit ($124 versus $70) all pay more when done by a hospital-based doctor than a privately owned medical office. Obama officials know that hospitals are buying doctor practices to take advantage of this difference. But they favor hospital ownership of doctors and see it as a small cost to pay to drive that migration.

When I talk to physician colleagues, Republican or Democrat, a frequent refrain is that their professional strain would be the same regardless of what happens to ObamaCare. They are wrong. ObamaCare has accelerated many of the detrimental trends doctors see in their profession, and introduced new ones.

Reformers in Washington need to do a better job of explaining how market-based alternatives to ObamaCare are a better outcome for the structure and delivery of health care. And how they intend to preserve the entrepreneurship, autonomy and physician ownership that have long been the hallmark of American medicine.

Dr. Gottlieb, a physician and resident fellow at the American Enterprise Institute, is a member of the Health IT Policy Committee that advises the Department of Health and Human Services. He also invests in and advises health-care companies.

Some Cancer Experts See ‘Overdiagnosis,’ Question Emphasis on Early Detection

September 21, 2014

Debate Among Doctors Looks at Whether Zealous Screening Leads to Overtreatment

By Melinda Beck

The Wall Street Journal

Early detection has long been seen as a powerful weapon in the battle against cancer. But some experts now see it as double-edged sword.

While it’s clear that early-stage cancers are more treatable than late-stage ones, some leading cancer experts say that zealous screening and advanced diagnostic tools are finding ever-smaller abnormalities in prostate, breast, thyroid and other tissues. Many are being labeled cancer or precancer and treated aggressively, even though they may never have caused harm.

As a result, these experts say, many people may be undergoing surgery, radiation, chemotherapy and other treatments unnecessarily, sometimes with lifelong side effects.

Meanwhile, an estimated 586,000 Americans will die of cancer this year—many from very aggressive, fast-moving cancers that develop between screenings and spread too quickly to stop.

“We’re not finding enough of the really lethal cancers, and we’re finding too many of the slow-moving ones that probably don’t need to be found,” says Laura Esserman, a breast-cancer surgeon at the University of California, San Francisco.

Dr. Esserman chairs a National Cancer Institute advisory panel that is calling for major changes in how cancer is detected, treated and even talked about. Among its suggestions: devise new screening programs to target the deadliest cancers; create registries to track lower-risk cancers; and remove the term cancer from very slow-growing and precancerous tumors that are unlikely to progress. The panel suggests calling them “indolent lesions of epithelial origin,” or IDLEs, instead.

“Unfortunately, when patients hear the word cancer, most assume they have a disease that will progress, metastasize and cause death,” the group wrote in the journal Lancet Oncology in May. “Many physicians think so as well, and act or advise their patients accordingly.”


The new thinking could bring radical changes to the vast world of cancer care, which accounts for more than $100 billion in medical costs in the U.S. annually. It is being embraced by a growing number of medical associations and major journals.

“The harm of overdiagnosis to individuals and the cost to health systems is becoming ever clearer,” says Fiona Godlee, editor in chief of The BMJ, formerly the British Medical Journal, which is hosting a conference on the topic starting Monday at Oxford University.

The idea that not all cancers are deadly is already beginning to transform treatment for prostate cancer. As many as 60% of the tumors detected via screening grow so slowly that they pose little threat in a man’s lifetime, experts say, and treating them with surgery or radiation carries a substantial risk of impotence or incontinence. About 15% of patients now opt to monitor them instead—and some experts say more could probably do so safely.

Some urologists even propose calling prostate tumors with a Gleason score of 6 or below “benign lesions”—although others note that that would mean half of the men treated for prostate cancer in the past 20 years didn’t have cancer after all.

Overdiagnosis—the detection of tumors that aren’t likely to cause harm—is now a hot topic in other cancers as well. A growing volume of studies estimate that as many as 30% of invasive breast cancers, 18% of lung cancers and 90% of papillary thyroid cancers may not pose a lethal threat.

More than 2.5 million Americans are diagnosed with non-melanoma skin cancers each year—more than all other cancers combined. They are rarely fatal, and some experts say that removing the term “cancer” would encourage more doctors and patients to monitor the lesions rather than remove them surgically. A commentary in the Journal of the American Medical Association last week noted that more than 100,000 people are treated for basal-cell cancers annually even though they died of other causes within a year. “Clinicians need to take a step back from the microscope and take a look at the patient,” the authors wrote.

Not So Fast

But such calls to rethink the C-word and slow the relentless drive for more and earlier treatments remain highly controversial.

Officials from five major dermatology societies have blasted the idea of calling non-melanoma skin cancers IDLEs, saying that deaths from squamous-cell cancers are rising and basal-cell carcinomas can invade surrounding tissues if untreated. “Renaming a destructive and sometimes fatal disease—to make it sound harmless—is a disservice to our patients,” the doctors wrote in Lancet Oncology.

Brett Coldiron, president of the American Academy of Dermatology, says it’s often the patients who want their skin cancers removed—”and sometimes you get surprised. These things that look like a basal-cell are a melanoma.”

Dr. Esserman and other doctors warning about overdiagnosis have been harshly debated at cancer meetings and have received angry letters from people convinced that early detection saved their lives, or could have saved loved ones.


Some critics say that the whole premise that cancers are overdiagnosed comes from statistical guesses, based on old, flawed studies, and that even if some patients are treated unnecessarily, early detection still saves lives.

“There’s no question that periodic screening doesn’t catch fast-growing cancers, but you save lives by finding moderate and slow-growing cancers and finding them earlier,” says Daniel Kopans, a senior radiologist at Massachusetts General Hospital.

Even doctors who accept the idea of overdiagnosis say it poses a dilemma when it comes to treating individual patients.

“I am confident that somewhere between 10% and 30% of women with localized invasive breast cancer would be just fine if we just watched them,” says Otis Brawley, chief medical officer of the American Cancer Society. “But I cannot look into a patient’s eyes and say, ‘You’re one of the 10% to 30% that should not be treated.’ ”

The conflicting messages have left many patients bewildered. After years of educational campaigns saying that early detection saves lives, it’s no wonder that some people view recommendations to cut back on cancer screenings as dangerous, or veiled health-care rationing.

Bitter disputes still rage over a U.S. Preventive Services Task Force recommendation that men no longer use tests for prostate-specific antigen, or PSA, to screen for prostate cancer, and that women have mammograms every other year starting at age 50, rather than annually starting at 40, to reduce the likelihood of overdiagnosis. At Congress’s insistence, the federal health law requires insurers to fully cover annual mammograms starting at 40 as part of “essential health benefits.”

“Everyone says they’d be willing to be overtreated if it means not dying—but that’s a big fallacy,” says Dr. Esserman. “By treating 1,000 people who have low-risk disease, we’re not going to save the one person with aggressive disease.”

Sharks and Goldfish

What makes scientists think some cancers are indolent? One clue comes from autopsies that find a substantial number of breast, thyroid, lung and other tumors that never caused symptoms in people who died of other causes. Small, localized prostate cancers are so ubiquitous in older men that the risk is roughly equal to a man’s age: a 70-year-old has a 70% chance of harboring the disease. Yet the average lifetime risk of dying of prostate cancer is less than 3% according to the American Cancer Society.

Most of the evidence for overdiagnosis comes from statistical analyses of long-term cancer trends. Theoretically, as screening efforts find more early cancers, the death rate from those cancers should decline. Widespread use of colonoscopies and Pap smears has cut the death rate from colon and cervical cancers roughly in half since 1975.

But death rates from thyroid, kidney and skin cancers have stayed flat or increased, despite many more being diagnosed at early stages, leading researchers to conclude that many of those caught early would never have progressed.

Death rates from breast and prostate cancers have fallen by about 30% and about 40%, respectively, in the past 30 years. But experts disagree on whether that is due to the rise of screening mammograms and PSA tests or improved treatments.

“We have thrown the net very, very widely and eliminated some of the sharks,” says Ian Thompson, a urologist at University of Texas Health Science Center and co-chairman of the NCI advisory panel. “But we’ve also netted a lot of goldfish and assumed they’d behave the same way.”

The New War on Cancer

Part of the problem, says Dr. Brawley, is that modern medicine is using a definition of cancer that hasn’t changed since the 1850s, when German pathologists first described various types of the disease based on autopsy specimens. Tiny lesions that would never have been detected a few decades ago are now routinely biopsied and analyzed, he says, “and if it looks just like what killed that woman 160 years ago, we assume it will be deadly today.”

But assuming cells that look the same will behave the same way is the biological equivalent of “racial profiling,” Dr. Brawley adds. Many other factors—including the tumor’s genetic profile and the patient’s immune system, diet and overall health—could affect how fast those cancer cells grow, or conceivably regress. “We desperately need better tests to distinguish the things that will behave like traditional cancers versus the things that look like cancer but won’t,” Dr. Brawley says. “This is the beginning of the new war on cancer in the 21st century.”

Prodigious efforts are under way to devise such tests. The National Cancer Institute’s Early Detection Research Network is bringing together 300 investigators at 40 institutions to study how molecular patterns in screen-detected cancers differ from those that cause symptoms. Biotech firms and university labs are also racing to develop prognostic tools.

Much progress has been made in identifying subtypes of tumors and tailoring treatments to them. “It’s a fallacy to throw up our hands and say we have no idea which patients are low risk,” says breast surgeon Shelley Hwang at Duke University Medical Center, who is also on the NCI panel.

Tests such as Genomic Health Inc.’s Oncotype DX and Agendia Inc.’s MammaPrint analyze patterns of gene activity on breast tumors that have been removed and can help predict how likely the cancer is to recur and whether the patient would benefit from chemotherapy after surgery.

Several new gene tests for prostate cancer have hit the market in the past year. Oncotype DX has a test that works at the biopsy stage and can help doctors assess how aggressive a particular tumor might be.

But clinicians say much more research needs to be done before they can say for certain how any individual cancer will behave. “I think we will get there. I just don’t think we’re there yet,” says Clifford Hudis, chief of breast-cancer medicine at Memorial Sloan Kettering Cancer Center in New York and past president of the American Society of Clinical Oncology.

Peace of Mind

In the absence of certainty, many doctors and patients are opting for more aggressive treatment, not less.

In breast cancer, for example, nearly 20% of women with early-stage tumors now elect to have both breasts removed, up from 3% in 1998

“Patients do this for peace of mind, for symmetry—but there’s no survival benefit for most of them,” says Barbara Smith, director of the breast program at Massachusetts General Hospital.

About one-quarter of the breast cancers diagnosed each year aren’t technically cancers, but abnormal cells confined to milk ducts called “ductal carcinoma in situ” that were seldom noticed before mammography. Experts think only about 20% of DCIS lesions might eventually progress to become invasive cancer. But they don’t know for sure, because virtually all DCIS cases are treated as if they are stage-one cancers, with lumpectomy or mastectomy, often combined with radiation.

“We are picking up on these conditions way before we know whether they are dangerous or not,” says Duke’s Dr. Hwang. “In our ignorance, it’s safest to assume they are all dangerous, but we’re hurting some women in the process.”

Few doctors dare leave DCIS untreated, but Dr. Hwang is leading a multicenter study treating patients who have small, estrogen-positive DCIS lesions with hormone therapy for six months in hopes they can avoid surgery. She hopes to start another study next year offering DCIS patients the option of hormone therapy or active surveillance alone. “We may identity a group of patients we could treat with just a pill rather than mastectomy,” she says.

Risk-Based Screening

Dr. Esserman is embarking on a major study to test a new approach to breast-cancer screening. She hopes to enroll 100,000 women from all five University of California medical centers and Sanford Health in North Dakota. Those with average risk will have mammograms every other year, starting at age 50. Those at higher risk due to genetic variations, family history, dense breast tissue or other factors will be screened—with mammograms and other imaging tests—younger and more often.

“For some people, early detection does save lives—but we need to sort out who that might be,” says Dr. Esserman, who theorizes that after five years, such “risk-based screening” will have netted more high-risk cancers, fewer indolent ones and fewer false positives.

Any breast cancers that are diagnosed will be treated and tracked in registries shared among the universities; women with low-risk DCIS will be offered active surveillance, with or without hormone therapy, as well as surgical options. The risks and benefits will be discussed in depth, and individual choices will be honored.

“For a woman with DCIS who has 6-year-old twins and a mother who died of breast cancer, the right option might be radical bilateral mastectomy,” says Dr. Esserman. “For someone who is 86 years old and has multiple co-morbidities, surveillance may be.”

Some critics, including Dr. Kopans, warn that risk-based screening could be risky, since about 75% of women diagnosed with breast cancers had no known risk factors.

Says Dr. Esserman: “We need to start testing some of these ideas, rather than just fighting over them. People are afraid to do less. We want to figure out how to do less safely.”

Ms. Beck is a reporter and columnist for The Wall Street Journal in New York. Email:

Corrections & Amplifications

More than 90% of all skin cancers are basal-cell carcinomas that are slow-growing and unlikely to be fatal, according to commentaries in the Journal of the American Medical Association and Lancet Oncology. An earlier version of the Fatal Retraction graphic appearing with this article incorrectly identified the source as the American Academy of Dermatology. And an estimated 18% of lung cancers diagnosed with low-dose CT scans are unlikely to be fatal, according to research published in JAMA Internal Medicine. The graphic incorrectly suggested that the 18% figure referred to all lung cancers.