 Our next speaker is Dr. John Schumann. John is an associate professor in the Department of Internal Medicine at the University of Oklahoma School of Community Medicine, where he also directs the internal medicine residency program. He blogs and tweets at At Glass Hospital and writes for national publications including TheAtlantic.com and NPR's Health Blog. And last week, he had a publication at least online. I'm not sure if the actual issue has come out on JAMA about some work he's done about patients leaving against medical advice. The title of his talk today is The Non-Ethics of Direct-to-Consumer Screening Companies, A Call to Action. John? Thanks. Thank you. It is great to be here. I want to... the slide is Direct-to-Consumer Screening Companies. As Laney pointed out, there's a little bit of a typo there. But I want to thank Mark for having me back and for making this all happen. And this is number 25 of the conferences. I also want to give a special thanks to Laney. I'm delighted that she introduced me and that was very nice. Laney has been a sounding board and a mentor and continues to be so even as I am in absentia from Chicago. So I am greatly appreciative of her mentorship to me. Disclosures. I do two things that are, I guess, need to be disclosed. One is I consult for a group called twistle.com. It's an internet startup. You know, everyone wants to get on one of those. It's actually geared toward medical communication, doctor-to-doctor communication and doctor-patient communication. They develop an app and all I do for them is really give them advice because for a long time I've been e-mailing patients back and forth even though I've been instructed by my various institutions not to do that. And the other thing is Glass Hospital is the name of my blog. I've formed an LLC really to my burgeoning media empire as a blog and a proto-journalist. I do some public radio locally in Tulsa and so it was deemed necessary by my advisors to form a company so that public radio could pay me a dollar for my content that I deliver. So this is the call to action and this talk is really designed to get you to join in my call to action or I should say our call to action. This work is really the brainchild of a colleague of mine named Dr. Eric Wallace who's my associate program director and an internist in Tulsa and Dr. Steven Weinberger who many of you probably know who's the executive VP and CEO of the American College of Physicians. And our call to action says basically that healthcare organizations be they hospitals or medical centers and physicians who promote high value care should actively encourage, should be encouraged to cease and desist in supporting or sponsoring direct to consumer screening companies that offer low value testing and I will explain what I mean. So perhaps you've been at a shopping mall or a church or some other religious place and seen one of these buses pull up. This is the health fair screening bus and I'm not picking specifically on health fair as a company but there are many others. And what they do is they pull up and with the not only consent but the actual encouragement of be they the church leaders or the shopping mall opportunists they provide cash based screening tests to unwary consumers. And you'll see ads like this. These tests are quick, easy and painless. They're trusted. No insurance is of course required other than your, you know, hard earned US dollars and they often offer, sorry, bargain prices. So they basically mislead and offer advertising that's fear mongering saying things like can I help you stay stroke free or my doctor said I was a stroke waiting to happen and these come in the mail. These get put as newspaper inserts and there's heavy promotion and advertising and so the research and advocacy we've done is to essentially look and just see how prevalent this is. These are all privately held companies so data is very hard to come by in terms of the revenues, the advertising or the prevalence. So the call to action. What caught me is that good advocacy actually is underpinned by good research and that you have to actually build consensus. It doesn't do a lot of good. We've learned to just argue moral principles because we wind up disagreeing more than we agree as we heard this morning. So I try to educate my patients individually and a patient came into my office bearing this ad and said, hey doc, look at this. I can get all six of these tests. I don't know if you can see the slide for $179. Now this was an asymptomatic 64-year-old man and we know by national screening guidelines that there's actually no indication for any of these tests in someone who's asymptomatic non-smoker who actually exercises but he wanted those tests. So we went back to educate him individually. It took a long time. I had to try to in a sense talk him out of these tests or work with him and explain why it was. It was very hard for him to understand that. Other ways in which the call to action can be we can perform our advocacy writing op-eds, journal article, investigative journalism and I'll show you some examples of that. This was an op-ed that Eric Wallace and I wrote for the Tulsa world which I'm sure many of you get. You can now read it online actually. Most people don't read newspapers but this was caveat emptor, let the buyer beware. We basically saw so much of this in Tulsa and so many of our patients were coming to our office. The other insidious thing about it is not only do they use fear mongering to get you to come in and have these tests that you don't actually need or aren't indicated. They then, talking about the ethics of it they tell you, they give you a letter with your result and say, oh, go talk to your doctor. So there's no doctor-patient relationship implied with any of these companies. They're merely technocrats in the sense of the word. You pay them, they offer you a service and I'll get to the criticism in a minute. This is the academic article we did. This was in the Annals of Internal Medicine in March of last year on the ethics of commercial screening tests and it got a lot of interest and we got a lot of response including a response from, I'd have guessed, one of the chief medical officers of one of the screening companies. So this was the research part. We had a research assistant. This is a Google map display of churches in Tulsa. It's a very pretty religious place, a lot of fervor so there's lots of churches, lots of opportunities to go to church. So the blue dots are 49, sorry, the numbers. The denominator is about 400 churches we were able to find on public databases and of those 400 we were able to, we were able to go to those churches. 49, the blue dots were churches that actually reported they'd either had a screening fair or been contacted by a screening company to set up a screening fair. The red dots were churches that had not had any knowledge or had not been contacted but so of the sample size about half, more than half actually had been involved with these direct consumer screening companies. So is your life worth $87? It says the body, bag, body, the tag body and we use the lowest-dose CT scan available. I asked, so my program is basically a university but we partner with community hospitals. We don't actually have a university hospital in Tulsa. So one of the hospitals where my residence work has a cardiac CT scanner and they offer this to be fair is not from that ad but they run ads in the local paper and on local websites offering these discounted cardiac CTs for patients. So I went up to, we had a Grand Rounds from the young academic who did a fabulous Grand Rounds showing all of the research and all the data on coronary CTs and calcium scores and why this is a compelling test and why it's safe and why we should do it. I went up to him afterward and I said, what about these ads you run offering these tests to really to patients in whom they aren't indicated. And he sort of looked down and put his head in his hands and said I'm really embarrassed by that but I work here in this for-profit hospital we have to pay for the scanner. So this is sort of what I have to do. So this is kind of a startling admission. So our direct-to-consumer screening company Consent Decree. I'm stepping forward to what I want them to do. This is the end result, the goal I want. I want them to state openly. Keep in mind I'm not opposed to free enterprise. I certainly think patients, I'm all for patients who want to do it themselves. We have a profusion of Google and internet related things where people can learn. Obviously there's a lot of crap out there but they can learn reasonable things about healthcare. So I'm not in principle opposed to these companies but I do want them to treat patients fairly. So I want them to state openly for whom their screening tests are indicated which runs totally counter to their business model which is to get every single person in the door in the church or in the shopping mall into their scanners or into their ultrasound machines so that they can make money. So I want them to tell for whom the tests are indicated based on the current evidence-based guidelines. I want them to inform the customers that the screening tests, i.e. no screening test is foolproof, right? We know that. No test is perfect. The downside of testing, as you know there's a whole genre of both medical skepticism and overdiagnosis. My two favorite books in that genre are Gil Welch's Overdiagnosed and the notice Brawley's How We Do Harm. These are books that take this issue on tackle it straight on and essentially say that we are doing our patients a disservice or the medical community is by and large by turning by fear mongering. And so the problem of a non-indicated screening test is you take a well person and you turn them into a patient. So let's say the asymptomatic individual goes in and has a crowded ultrasound and they find out they have mild to moderate blockage of their coronary artery. What do they do with that information? Well first of all they get a letter that says go talk to your doctor so they come in to see me and they say doc look I have a blockage of my crowded artery. I'm going to have a stroke I'm going to die and I say well no this is a milder moderate blockage. You're going to be fine. You shouldn't have this test. You certainly should quit smoking and by the way that's one of the defenses that these companies use is that they will scare people straight essentially and actually the data runs counter to that by having these test patients are less likely to actually improve their behavior. And then lastly that medical organizations including hospitals, physicians should refrain from sponsoring these health screenings because it represents a clear conflict of interest and we have a little bit of investigative journalism data on that and I'll share that in a second. So this was a letter to from the annals piece thank you for your op-ed you call it an op-ed. The problem related is more widespread in my practice locale the local hospital is detailed as the sponsor of these screenings that are conducted at local churches. I have never really ever seen religion use more seductively to enhance unneeded testing at the heart center of the local not-for-profit hospital. Unfortunately your article will never be read by those in most of its message. So then there was an article last summer by Julie Appleby that ran on Kaiser Health News in partnership with the Washington Post and so she did a rather exhaustive looking at hospital relationships with these direct-to-consumer screening companies and so like Innova Fairfax in Virginia was this so you can find this on many different hospital websites here that here's the bus pulling up they're proud to announce this new quick affordable and convenient way to get a cardiovascular health screening and the issue really is that is a way for them to feed business into their health systems and it's a questionable certainly quite dubious ethical value but it's a questionable business value as well but hard times call for hard measures and drumming up business is probably more and more important in an era of health reform and tightened budgets. So these were some quotes actually from this is from the Jefferson Hospital website as I mentioned Dr. Weinberger who's at the ACP in Philadelphia we've been in partnership also with the consumer affairs group who publishes consumer reports so they're also looking at this issue the quote from the health fair which is one of the screen companies present we're proud to partner with a respected name in cardiovascular medicine presents a great opportunity to give even more people the peace of mind that comes from preventive health care very seductive come on what about the question that these tests potentially do harm by turning innocent asymptomatic people into patients well these tests don't do harm people are not exposed to radiation and that that claim is really about the ultrasonic screening test which is true in terms of ionizing radiation however when you turn someone into a patient or create anxiety and fear that they then live with realistically forever and wind up having to get subsequent follow-up tests that's more expense more anxiety more hassle you actually are doing harm so this was a letter from the chief medical officer of one of the companies to this was in the Washington Post article instead of debating the questionable points of this article I prefer to share a letter I received this week from a recently screened participant and he goes on to talk about how so many grateful patients have written in saying well life line screening saved my life health line health fair technicians found the blockage in my so-and-so artery and so there are all kinds of testimonials and so this is you know the plural of anecdote is not data they throw these anecdotes back at us when we criticize them and that's their that's the power of their seduction and their advertising similarly when we question the value and validity of their screening tests usually what they throw back at us is the quality of the technology we use the latest ultrasound tests and you know our tests cannot be called into question so they're really not even arguing back on the point they're really just it's really subterfuge instead of debating oh sorry I read that every year this is from the patient testimonial I visit the health fair screening bus and what the technicians found to absolutely save my life I already told you that okay so how do they drum up more business well so now they have you in their database they have found the mild to moderate artery and so they send you a letter a year later saying you need to be re-screened now to see if this has changed or progressed meanwhile if the patient has never had the test in the first place they certainly wouldn't need to be re-screened they certainly could go on about their lives you know you can argue on the merits of the medicine of if you know certainly if they're a smoker they need to stop smoking or if you know if there's going to be progression of their carotid plaque we would encourage you to take a screening test sorry we would not encourage you to take a screen test if you wouldn't benefit from it although we really want everyone in the shopping or everyone in the church to come in and have one and then regular screenings and help you live a fuller healthier life so again that call to action discourage hospitals from participating certainly discourage your religious institutions from participating under the guise that they're doing good work and then there's this sort of new area so I took this to the ethics committee at this local hospital it has this CT scanner because I sit on the ethics committee with my McLean credential and so I raised this and I said you know our hospital here is promoting these low value tests and we live in an area of high value cost-conscious care is this something we as an ethics committee want to write to or take to our hospital management and let me tell you there was a very dim view of my idea basically the ethics committee essentially wanted to wash their hands and say listen we're here for ethical conflict we're here for patient related matters this is really a business and a professional practice issue this is not something we want to touch however since you're from the university if you want to do something from the university side of things we would welcome that so that was my question and so one avenue in brainstorming about this was you guys going back to your own institutions bringing this up with your hospital ethics committees if not to shame sort of these companies into providing adequate disclaimers to at least get your hospitals not to participate in this low value activity education and media so I mentioned I'm a proto journalist so I'm trying to write news articles or spread the word that way and then lastly probably judicial or administrative action how about having for example the FTC or something come down on these folks for promulgating these basically false advertising claims so this is interesting so Thomas Jefferson actually stopped after their one-year deal with was it health line or health fair because basically out of 5000 screen patients they only got about 20 patients to come in and get additional help so in fact even as a business plan it didn't was not effective for them so there's lots of education out there about over diagnosis and I didn't have time in this talk to really take you on a tour of that but the high value curriculum is highly touted by both the American College of Physicians the American Board of Internal Medicine if you're in a different specialty I would encourage you that it's sort of broadly applicable there's lots of internal medicine examples but that principle applies to you know whatever specialty you're in they're really pushing this at the residency level the GME level they want us to promote the high value curriculum in our residency level at our program director meetings the British Medical Journal runs a section called over diagnosis where it's a recurring feature and then JAMA internal medicine which used to be the archives has a recurring series called less is more all about the phenomenon of over diagnosis really with a theme that sometimes doing less is actually the much better medicine private health screen.org is actually and I should tell you these screening companies are not just in the United States where we have free enterprise they're actually also in the UK and Europe and so there's a British physician a GP named Margaret McCartney who's who works in Glasgow and she has set up this whole website and as part of a network of national health service physicians who are decrying this overuse over testing over spending and then of course your various social media things so one last thing to share with you and my time is pretty much up there's a blogger who told me to use this story his name is Kenny Lynn he is at Georgetown and he's a family physician and he blogs at commonsense family doctor so he wrote a blog post about because he went to his own church where his own church was offering this test and he was called so he talked to his deacon about the low value nature of the this test and he asked he wanted his church not to participate in this anymore so he wrote a blog post about the experience it got about six times the traffic of any of his previous biggest posts and so he got a personal letter from the CEO of one of the screening companies in question and he shared this letter with me and said I could use it and so he said I'm writing in the hopes that we can quietly discuss our differences we believe in the right screenings of the right people for the right time I'm writing you privately to ask this to not be used as fodder well too bad so just say no