nov.dec.edits.indd A N NA L S O F FA M I LY M E D I C I N E ✦ W W W. A N N FA M M E D . O R G ✦ VO L . 1 0 , N O. 6 ✦ N OV E M B E R / D E C E M B E R 2 0 1 2 490 PRIMARY CARE WORKFORCE EXPANSION I n this issue, an analysis of the primary care work- force predicts that the United States will need 52,000 more primary care physicians by 2025.1 Population growth will be the single, most important driver, 10-fold more than expansion of insurance cov- erage—but insurance expansion will occur soonest and most abruptly. The new estimate recognizes that not all primary care physicians practice full time in the offi ce; it is based on the current average across all primary care physicians of 48 offi ce visits with patients per week (rather than 76 visits per week for a physician in full-time offi ce practice). CLINICALLY RELEVANT RESEARCH As a family physician, I am fascinated by the variety of clinically relevant articles in this issue. Because almost all of this research was conducted—and much of it generated—in primary care, it can directly help us to understand and improve what we do. • The systematic review and meta-analysis by John- son et al compares more- and less-effective ways to increase infl uenza and pneumococcal immuni- zation rates, which are currently below national targets.2 • A 12-country study reveals the prevalence of undiagnosed asthma or chronic obstructive pul- monary disease in unselected patients with acute cough.3 • A companion article shows a low yield of action- able incidental fi ndings on chest radiographs of patients with acute cough in primary care.4 • Systematically asking women’s pregnancy inten- tions and contraceptive method as a vital sign increases documentation.5 One goal is to pre- vent prescribing of teratogenic medications (eg, statins, angiotensin-converting enzyme inhibi- tors) to fertile women. Including men in this vital sign might further enhance the vital preventive effort to implement effective contraception for everyone who wants or needs it. • Karaca describes a method for treating ingrown toenails that prevents recurrences.6 The Annals editors thought that, were we to adopt this pro- cedure, we would probably substitute local anes- thetic without a vasoconstrictor, recognizing that it is common practice in the United States not to use epinephrine in digital blocks. • A placebo-controlled trial among vitamin D-defi - cient people found vitamin D helpful for nonspe- cifi c muscular aches and pains.7 Does this agree with your clinical experience? • A birthing center located in a rural family prac- tice serving Amish women offers childbirth care tailored to the community—and “an opportunity to look at the effects of local culture and prac- tices that support vaginal birth and [successful] TOLAC [trial of birth after cesarean].”8 These studies range from case series to random- ized controlled trials, with many different research techniques. To further develop research capacity, Peterson et al9 report that they have defi ned research architecture, processes, and requirements of software to support community practice-based translational research: eg, recruitment of participants, collection of aggregated anonymous data, and retrieval of identifi - able data from previously consented adults across hun- dreds of practices. PREVENTION ‘NUMERACY’ In this issue you will fi nd a research study,10 an essay,11 and a guest editorial12 on screening. In their essay Hoffman and colleagues caution guideline makers to “avoid distracting primary care clinicians from providing services with proven benefi t and value for EDITORIAL In This Issue: Through the Lens of a Clinician Louise S. Acheson, MD, MS, Associate Editor Department of Family Medicine and Community Health, Case Western Reserve University, Cleveland, Ohio Ann Fam Med 2012;10:490-491. doi:10.1370/afm.1456 A N NA L S O F FA M I LY M E D I C I N E ✦ W W W. A N N FA M M E D . O R G ✦ VO L . 1 0 , N O. 6 ✦ N OV E M B E R / D E C E M B E R 2 0 1 2 491 E D I T O R I A L S patients.”11 Indeed, many preventive interventions have proven benefi t. Yet Hudson et al present the quandary that many patients appear willing to undergo preven- tive care on the basis of “overly optimistic expectations of the benefi ts of preventive interventions and screen- ing.”10 Are they innumerate or overly optimistic? What about policy makers? What about clinicians? We hope you will share your thoughts about the articles in this issue. Join the discussion at http://www. AnnFamMed.org. References 1. Petterson SM, Liaw WR, Phillips RL Jr, Rabin DL, Meyers DS, Baze- more AW. Projecting US primary care physician workforce needs: 2010-2025. Ann Fam Med. 2012;10(6):503-509. 2. Lau D, Hu J, Majumdar SR, Storie DA, Rees SE, Johnson JA. Inter- ventions to improve infl uenza and pneumococcal vaccination rates among community-dwelling adults: a systematic review and meta- analysis. Ann Fam Med. 2012;10(6):538-546. 3. van Vugt S, Broekhuizen L, Zuithoff N, et al. Airway obstruction and bronchodilator responsiveness in adults with acute cough. Ann Fam Med. 2012;10(6):523-529. 4. van Vugt S, Broekhuizen L, Zuithoff N, et al. Incidental chest radio- graphic fi ndings in adult patients with acute cough. Ann Fam Med. 2012;10(6):510-515. 5. Schwarz EB, Parisi SM, Williams SL, Shevchik GJ, Hess R. Pro- moting safe prescribing in primary care with a contraceptive vital sign: a cluster-randomized controlled trial. Ann Fam Med. 2012;10(6):516-522. 6. Karaca N, Dereli T. Treatment of ingrown toenail with proximolat- eral matrix partial excision and matrix phenolization. Ann Fam Med. 2012;10(6):556-559. 7. Schreuder F, Bernsen RMD, van der Wouden JC. Vitamin D supple- mentation for nonspecifi c musculoskeletal pain in non-Western immigrants: a randomized controlled trial. Ann Fam Med. 2012; 10(6):547-555. 8. Deline J, Varnes-Epstein L, Dresang LT, Gideonsen M, Lynch L, Frey JJ III. Low primary cesarean rate and high VBAC rate with good outcomes in an Amish birthing center. Ann Fam Med. 2012;10(6): 530-537. 9. Peterson KA, Delaney BC, Arvanitis T, et al. A model for the elec- tronic support of practice-based research networks. Ann Fam Med. 2012;10(6):560-567. 10. Hudson B, Zarifeh A, Young L, Wells JE. Patients’ expectations of screening and preventive treatments. Ann Fam Med. 2012;10(6): 495-502. 11. Hoffman RM, Barry MJ, Roberts RG, Sox HC. Reconciling primary care and specialist perspectives on prostate cancer screening. Ann Fam Med. 2012;10(6):568-571. 12. Woolf SH. The price of false beliefs: unrealistic expectations as a contributor to the health care crisis. Ann Fam Med. 2012;10(6): 491-494. EDITORIAL The Price of False Beliefs: Unrealistic Expectations as a Contributor to the Health Care Crisis Steven H. Woolf, MD, MPH Department of Family Medicine, School of Medicine, Virginia Commonwealth University, Richmond, Virginia Ann Fam Med 2012;10:491-494. doi:10.1370/afm.1452. T he alarming rise in health care costs haunts our society. The United States now spends $2.6 trillion per year on health care,1 and the spiral- ing costs are placing unsustainable burdens on employ- ers and workers, Medicare and Medicaid, state and local governments, and American families. A growing proportion of Americans are now foregoing health care to pay for other household needs or are facing bank- ruptcy.2 A variety of strategies have been proposed to slow medical cost infl ation, such as realigning fi nancial incentives to discourage costly procedures, account- Confl icts of interest: none reported. CORRESPONDING ADDRESS Steven H. Woolf, MD, MPH Department of Family Medicine School of Medicine Virginia Commonwealth University 1200 East Broad St PO Box 980251 Richmond, VA 23298-0251 swoolf@vcu.edu A N NA L S O F FA M I LY M E D I C I N E ✦ W W W. A N N FA M M E D . O R G ✦ VO L . 1 0 , N O. 6 ✦ N OV E M B E R / D E C E M B E R 2 0 1 2 492 E D I T O R I A L S able care organizations, the patient-centered medical home, and malpractice reforms. Evidence that any of these ideas will bend the cost curve remains limited. A more basic but possibly neglected strategy for reducing demand for health services is to confront unrealistic beliefs about their benefi ts. Health care expenditures ultimately begin with a decision to use the service, a decision that may rest on false expecta- tions—among patients, clinicians, or both. Removing the need for the service by correcting such misper- ceptions is a potentially more effective way to curb costs than many current reforms can achieve. Financial incentives are important, but they are weak when pit- ted against core beliefs. If patients and clinicians widely hold that a procedure is life-saving and harmless, any reform is unlikely to curb demand until those miscon- ceptions are addressed. Studies suggest that patients, clinicians, and soci- ety often hold unrealistic expectations about the effectiveness of tests and treatments. Two articles in this issue add to that literature. In New Zealand, Hudson et al3 surveyed 977 primary care patients and found that many overestimated the benefi ts of cancer screening and chemopreventive medications. The min- imum benefi t from screening that respondents deemed acceptable was less than their known benefi t. The survey had a modest sample size and low response rate (36%), and its fi ndings might not be fully applicable to other countries, but US studies have reported a similar problem. For example, a variety of studies document Americans’ appetite for procedures of dubious effec- tiveness and their overestimation of benefi ts.4,5 Many Americans underestimate the probability of harms and are quite willing to receive false-positive results and unnecessary biopsies for the chance to detect can- cer.6,7 Public complacency about the safety of health care is only occasionally shaken, as when a conspicu- ous tragedy or disclosures of industry wrongdoing draw attention to specifi c dangers. Physicians are not immune to false beliefs about clinical effi cacy or complication rates.8 Correcting such misperceptions has always been part of the impe- tus for the evidence-based medicine movement and its promulgation of systematic evidence reviews, prac- tice guidelines, and other tools that present the facts on benefi ts, safety, and scientifi c uncertainties. Even these tools, however, can refl ect the misconceptions of those who produce them. The specialists who serve on expert panels derive much of their clinical case knowl- edge from the patients with advanced disease who fi ll their clinics. Having seen the worst of the worst, they are less sympathetic to expressions of concern about the potential harms of interventions or imperfections in effi cacy studies.9 Whereas epidemiologists consider the population denominator to put the numerator in perspective, the world of specialists is confi ned to the numerator, giving them a skewed basis for judging the population prevalence of diseases or benefi t-risk ratios. Were this not enough, the preeminent scientists who often serve on guideline panels bring additional biases, such as being the authors of key studies under review or having fi nancial ties to industry.10 Guideline panels composed of generalists tend to produce recommendations that are more conservative than those dominated by experts,11,12 in part because they are chosen for their skills in critical appraisal and because they have little to gain from the recommenda- tions. In an essay in this issue, Hoffman et al cite this phenomenon in explaining why guideline panels domi- nated by cancer specialists advocate prostate cancer screening beginning at age 40 years, despite evidence that the lifetime benefi t of an earlier starting age is 1 averted death per 1,000 men.13 Even guideline bodies harbor unrealistic expectations of effi cacy. A seemingly simple solution is to arm patients and clinicians with more realistic data, the very motive behind the production of evidence-based decision sup- port tools for clinicians and decision aids for patients. Large initiatives in comparative effectiveness research are now underway to assemble such data for patients,14 and research in decision science and risk communication is seeking the best formats and framing for explaining likely outcomes and scientifi c uncertainty.15 Information technology and innovative infographics are helping to address challenges with health and numeric literacy. These important efforts can help only to the extent that people make choices through the cognitive act of weighing benefi ts, risks, and scientifi c uncer- tainty. In real life, decisions are shaped by affective infl uences: beliefs and fears; vulnerability; faith and trust; long-standing routines; personal experiences; messages conveyed by advertising and media; and the advice, testimonials, and transmitted knowledge imparted by trusted sources. Patients’ explanatory models of illness may clash with scientifi c data but represent a form of “evidence” that must be respected. Fact sheets and bar charts exert marginal infl uence if they ignore this larger context. If people are widely convinced that a screening test or drug is benefi cial, confronting these beliefs can, if anything, engender suspicions about one’s veracity and motives. Whether the messenger is one’s physician, a health plan, or a government task force, attempts to set more realistic expectations about benefi ts, risks, and scientifi c validity are often taken as insensitivity to suffering, discrimination, or a pretext for cutting costs, rationing health care, or threatening personal autonomy. In today’s media environment, the political A N NA L S O F FA M I LY M E D I C I N E ✦ W W W. A N N FA M M E D . O R G ✦ VO L . 1 0 , N O. 6 ✦ N OV E M B E R / D E C E M B E R 2 0 1 2 493 E D I T O R I A L S narrative these ideas feed allows for viral dissemination of distorted characterizations by websites, talk shows, blogs, and social networks. Ours is an era of “death panel” debates in which facts are swept aside by politi- cal agendas and talking points. It is an increasingly dif- fi cult environment for the American public to receive, let alone absorb, undistorted scientifi c information from reputable bodies. Unrealistic expectations therefore persist, surviv- ing not only on misinformation but also by serving other purposes. For example, false beliefs meet the psychological needs of patients for hope and safety, as well as for action, agency, and a sense of control. They enable clinicians to feel they are making a differ- ence; even physicians who know better order unneces- sary tests to please their patients.16 False expectations fuel market demand for products, industries, and health delivery systems and can be fomented by mis- leading advertising. Confronting these expectations can not only dash hopes but potentially threaten prof- its, shareholders, clinical practices, industries, legisla- tion, and political careers. But good news on the horizon hints at a shift in societal attitudes. Increasingly, overutilization of medical services, overdiagnosis, and profl igate use of screening tests are being covered by major newspa- pers and magazines17-20 and are the subject of books in the popular press.21,22 The American Cancer Society has adopted more rigorous methods for developing screening guidelines, and in broadcast appearances its chief medical offi cer has openly discussed the limita- tions of screening.23,24 Although the US Preventive Services Task Force recommendations about the start- ing age for mammography sparked infamous outrage in 2009, the same group’s recommendations against prostate-specifi c antigen screening met with softer criticism when proposed in 2011, and its 2012 recom- mendation to delay the starting age and reduce the frequency of cervical cancer screening—fi rst issued by the American College of Obstetricians and Gyne- cologists25—raised no tempest. Equally encouraging is the Choosing Wisely Cam- paign, organized by the American Board of Internal Medicine Foundation.26 In April 2012, 9 medical specialty societies—from primary care to oncol- ogy and nuclear cardiology—each released a list of 5 tests or procedures that their specialists commonly use and “whose necessity should be questioned and discussed.”27 Consumer Reports and 11 other organi- zations are helping these medical groups relay these messages to large audiences in consumer-friendly language.28 For example, the material on antibiotics for sinusitis, cobranded by Consumer Reports and the American Academy of Family Physicians, uses plain-spoken headings: “the drugs usually don’t help,” “they can pose risks,” and “they’re usually a waste of money.”29 Organized medicine appears to be embrac- ing this movement: the foundation’s website now lists 25 specialty societies that have joined the initiative and will be releasing their own lists of questionable proce- dures in late 2012 or 2013. Time will tell whether such efforts succeed and whether the medical profession will emerge as the change agent that brings more realistic expectations to patient care. Regardless of whether physicians or other stakeholders ultimately take the lead, the power of this strategy should not be overlooked by government, businesses, or others who urgently seek solutions to the health care crisis. The best way to reduce wasteful spending is to convince the purchaser that the product is not worth buying. It is a straightforward economic argument, but it can also save lives. To read or post commentaries in response to this article, see it online at http://www.annfammed.org/content/10/6/491. Key words: decision making; diagnosis; screening Submitted September 16, 2012; accepted September 27, 2012. References 1. Martin AB, Lassman D, Washington B, Catlin A; National Health Expenditure Accounts Team. Growth in US health spending remained slow in 2010; health share of gross domestic product was unchanged from 2009. Health Aff (Millwood). 2012;31(1):208-219. 2. Cohen RA, Gindi RM, Kirzinger WK. Burden of medical care cost: early release of estimates from the National Health Interview Sur- vey, January–June 2011. National Center for Health Statistics. http:// www.cdc.gov/nchs/nhis/releases.htm. Accessed Jun 4, 2012. 3. Hudson B, Zarifeh A, Young L, Wells JE. Patients’ expecta- tions of screening and preventive treatments. Ann Fam Med. 2012;10(6):495-502. 4. Domenighetti G, D’Avanzo B, Egger M, et al. Women’s perception of the benefi ts of mammography screening: population-based sur- vey in four countries. Int J Epidemiol. 2003;32(5):816-821. 5. Herndon MB, Schwartz LM, Woloshin S, et al. Older patients per- ceptions of “unnecessary” tests and referrals: a national survey of Medicare benefi ciaries. J Gen Intern Med. 2008;23(10):1547-1554. Epub2008Jul1. 6. Schwartz LM, Woloshin S, Sox HC, Fischhoff B, Welch HG. US wom- en’s attitudes to false positive mammography results and detection of ductal carcinoma in situ: cross sectional survey. BMJ. 2000;320 (7250):1635-1640. 7. Schwartz LM, Woloshin S, Fowler FJ Jr, Welch HG. Enthusiasm for cancer screening in the United States. JAMA. 2004;291(1):71-78. 8. Wegwarth O, Schwartz LM, Woloshin S, Gaissmaier W, Gigerenzer G. Do physicians understand cancer screening statistics? A national survey of primary care physicians in the United States. Ann Intern Med. 2012;156(5):340-349. 9. Eccles MP, Grimshaw JM, Shekelle P, Schünemann HJ, Woolf S. Developing clinical practice guidelines: target audiences, identify- ing topics for guidelines, guideline group composition and func- tioning and confl icts of interest. Implement Sci. 2012 Jul 4;7(1):60. [Epub ahead of print]. A N NA L S O F FA M I LY M E D I C I N E ✦ W W W. A N N FA M M E D . O R G ✦ VO L . 1 0 , N O. 6 ✦ N OV E M B E R / D E C E M B E R 2 0 1 2 494 E D I T O R I A L S 10. Institute of Medicine. Clinical Practice Guidelines We Can Trust. Wash- ington, DC: National Academies Press; 2011. 11. Kahan JP, Park RE, Leape LL, et al. Variations by specialty in physi- cian ratings of the appropriateness and necessity of indications for procedures. Med Care. 1996;34(6):512-523. 12. Hutchings A, Raine R. A systematic review of factors affecting the judgments produced by formal consensus development methods in health care. J Health Serv Res Policy. 2006;11(3):172-179. 13. Hoffman RM, Barry MJ, Roberts RG, Sox HC. Reconciling primary care and specialist perspectives on prostate cancer screening. Ann Fam Med. 2012;10(6):568-571. 14. Selby JV, Beal AC, Frank L. The Patient-Centered Outcomes Research Institute (PCORI) national priorities for research and initial research agenda. JAMA. 2012;307(15):1583-1584. 15. Woloshin S, Schwartz LM. Communicating data about the ben- efi ts and harms of treatment: a randomized trial. Ann Intern Med. 2011;155(2):87-96. 16. Campbell EG, Regan S, Gruen RL, et al. Professionalism in medi- cine: results of a national survey of physicians. Ann Intern Med. 2007;147(11):795-802. 17. Jain M. “Are we relying too much on cancer screening?” Washington Post. November 1, 2011:E5. 18. Rosenthal E. “Let’s (not) get physicals.” New York Times Sunday Review. June 2, 2012. 19. “False promises on ovarian cancer” (editorial). New York Times, Sep- tember 11, 2012. 20. The business of healing hearts: cardiac care is a money-making machine that too often favors profi t over science. Consum Rep. 2011;76(9):26-36. 21. Brownlee S. Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer. New York, NY: Bloomsbury; 2007. 22. Brawley OW, Goldberg P. How We Do Harm: A Doctor Breaks Ranks About Being Sick in America. New York, NT: St. Martin’s Press; 2012. 23. Brawley O, Byers T, Chen A, et al. New American Cancer Society process for creating trustworthy cancer screening guidelines. JAMA. 2011;306(22):2495-2499. 24. Brawley OW. Prostate cancer screening may do more harm than good. CNN. http://www.cnn.com/2011/11/01/opinion/brawley- prostate-cancer-screening/index.html. Accessed Dec 27, 2011. 25. ACOG Committee on Practice Bulletins—Gynecology. ACOG Prac- tice Bulletin no. 109: Cervical cytology screening. Obstet Gynecol. 2009;114(6):1409-1420. 26. Cassel CK, Guest JA. Choosing wisely: helping physicians and patients make smart decisions about their care. JAMA. 2012;307(17): 1801-1802. 27. Brody H. Medicine’s ethical responsibility for health care reform— the top fi ve list. N Engl J Med. 2010;362(4):283-285. 28. When to say ‘Whoa!’ to doctors: a guide to common tests and treatments you probably don’t need. Consumer Reports Health, 2012. http://consumerhealthchoices.org/wp-content/uploads/2012/05/ ChoosingWiselyWhoaPkg.pdf. Accessed Sep 16, 2012. 29. Treating sinusitis: don’t rush to antibiotics. Consumer Reports Health, 2012. http://consumerhealthchoices.org/wp-content/ uploads/2012/04/ChoosingWiselySinusitisAAFP.pdf. Accessed Sep 16, 2012.