By Dr. Allen Frances
Two years ago, I wrote that the first "PREVENTING OVERDIAGNOSIS" conference was easily the most important meeting I had ever attended. http://m.huffpost.com/us/entry/3920844
Last week's third "PREVENTING OVERDIAGNOSIS" conference, held at the National Institutes of Health in Washington, DC was even better. The conference was sponsored by the National Cancer Institute in collaboration with Oxford University, the British Medical Journal, Consumer Reports, and Bond and Dartmouth Universities. Hundreds of presentations covered the causes, consequences, and cures of overdiagnosis from every conceivable angle and laid out an agenda for future action. The international audience of 350 was as bright a group as I have ever encountered in almost 50 years of attending medical meetings.
The topic is the highest priority public heath problem we face in the US and increasingly around the world. Medical mistakes are the third leading cause of death in the US- and are often occasioned by excessive testing and treatment delivered in an uncoordinated way by doctors who know lab tests, but don't know their patients.
Clearly, too much medicine can be very bad for your health. And it is also a disaster for the health of our economy. The US spends $3 trillion a year on heath care- more than the GDP's of all but four countries in the world. Because one third of this enormous investment is sheer waste, it is no surprise that we get lousy outcomes compared to countries that spend much less, but spend much more wisely.
The biggest culprit in overtreatment is over testing. We have developed sophisticated technology that discovers incidental 'diseases' that would have little or no impact on our lives and then treats them with disproportionately blunderbuss interventions that often cause more harm than good. Rates of breast, prostate, and thyroid cancer increased dramatically not because people are sicker, but because disease definition has been broadened to inflate diagnosis. Much of what is now called 'cancer' is not really cancer at all, or so slow growing that it is not really health or life threatening.
Aggressive treatments that are delivered for non-aggressive 'diseases' cause more problems than they solve. Our current excess of therapeutic zeal follows a long historical tradition of well intended, but overly exuberant, doctors harming their patients with really terrible treatments. Not so long ago, doctors routinely bled their patients, gave them emetics and cathartics, and poisoned them with heavy metals. Future observers of our current practice will find some of what we are doing now equally wrong headed and harmful.
Diagnostic inflation has also resulted in overtreatment of diabetes, hypertension, osteoporosis, attention deficit disorder, most problems that lead to orthopedic surgery, and lots more of what constitutes everyday medical practice.
Overtreatment is driven by many powerful and interacting forces and will be difficult to tame.
Most destructive has been the commercialization of medicine as a big business- healing art transformed into profitable cash cow. Perverse financial incentives encourage disease mongering, false advertising, over testing, quick diagnosis, and unnecessarily aggressive treatment.
Often the best medical decision is to cautiously watch and wait, but this is discouraged by reimbursement mechanisms that favor quickly jumping in with potentially harmful, very expensive, and often unnecessary treatments. The powerful medical-industrial complex will exert all its considerable financial and political might to protect its profits, even if this means compromising patient welfare and eating up the economy. The obvious solution here is to substitute capitation for crazy fee-for-service incentives that reward the health system for doing more.
Too much medicine has also been driven by a medical research enterprise that systematically rewards scientists, journals, and the media for hyping often-false positive findings. Negative findings that would encourage the public to have a healthy skepticism about exaggerated claims are buried.
The result: patients accept, and even clamor for, testing and treatment that is more likely to harm than help. People fear the risks of illness too much and fear risks of treatment far too little. A great deal of conference time was thus productively devoted to the communication tools necessary to help right this imbalance. Patients must become informed consumers to balance the benefits of treatment with its risks and protect themselves from a system pushing them to always want more than may be good for them.
Regulators of medical excess no longer regulate. Seven years ago, the Food and Drug Administration, approved only one third of drug applications. This year, it has approved 96%. And drug companies are increasingly winning the right to mislead both the public and physicians, with false advertising and pushing off-label prescription.
Quality Assurance programs also play an unwitting role. Historically, QA has focused on identifying the things that should have been done during the course of treatment, but were left out. As a result, nine tenths of QA measures tap errors of omission, only one-tenth errors of commission. Unless this imbalance is redressed, QA will continue to drive doctors to do too much, even in situations where less would be more.
Unless applied cautiously, 'Personalized' or 'Precision' medicine may make things worse, becoming the next slick advertising gimmick to justify the use of treatments that have failed to prove their effectiveness in large groups. A more precise medicine would offer much less, not more, treatment.
The battle to tame medical excess is classic David vs. Goliath. But, fortunately, David has some potentially effective pebbles and might sometimes does come from being in the right. Thirty years ago, Big Tobacco seemed as impregnable as the medical-industrial complex, but it was toppled by its obvious outrageousness, dedicated opposition, public and media awakening, and lawsuits. The same combination, along with the inevitable need for cost containment, will eventually tame the medical beast- the question is how long will this take and how much harm will be done to patients and the economy before we get back to patient-driven, rather than profit driven medicine.
The conference wasn't perfect. There was a preaching to the choir feeling. Future conferences should invite debate with leaders from the forces promoting overtreatment- e.g. the insurance industry, Pharma, hospital associations, physician specialty groups, and consumer advocacy. Government and employers wind up footing the lion's share of medical costs and need to hear how much of their expenditure is not only wasteful financially, but also bad for the people they are trying to help.
The conference was attended by about a dozen science writers interested in the topic, but it did not itself become the big media story it can and should be. More intense public relations could lead to numerous stories alerting the public about which specific tests and treatments are most overdone and most risky.
And there could have been more discussion about how best to unite the various groups fighting against medical excess and hype. 'Choosing Wisely'; the Lown Foundation's 'RightCare' initiatitive; the HeathNews Review; the British Medical Journal; Consumer's Reports; and the many researchers and educators engaged in the field are all individually wonderful, but might collectively be more effective if their efforts were better coordinated.
Bottom line: Medical marvels are oversold and overbought. Doctors need to be more humble and safety-conscious. We can't overstep our knowlege base without putting our patients at risk. Patients and doctors need to accept the uncertainty and limits of medicine. False certainty leads to terrible decisions.
We must not ignore the most important ethic in medicine laid out 2500 years ago by Hippocrates: First Do No Harm.
We are starting a new monthly column where you can get your special education and intervention questions answered by an expert. Parents, teachers, and administrators can receive valuable information. Please send your questions to email@example.com.
About the expert: After 30 years serving complex learners of all age groups as a special education teacher, reading specialist, school leader, and clinical learning specialist, Hollis Dannaham, M.Ed., now consults with schools to design intervention and special education programs, coaches teachers and administrators, and provides professional development workshops.
I am a middle school principal who is trying to implement a Response to Intervention program in my school. I am having a problem with scheduling since I can't pull student's from their classes. What can I do?
Well Intentioned in Westchester
Dear Well Intentioned,
You are not alone! Scheduling is one of the greatest challenges when implementing an RTI program. Try carving out an intervention period for each grade level. During this period the grade is broken into homogenous groups and all teachers are on deck. The RTI students get small group remediation from the specialists, students struggling in a content area get an extra period with that content teacher, and high achieving students are given extension projects to complete. All student benefit. Let me know how it works out!
In Service, Hollis
I am a parent of a 6 year old with Autism Spectrum Disorder. Every morning is a battle to get out of the house. I can't get my son to complete basic routines. What can I do?
Signed, Frustrated in New Jersey
Try creating a picture, morning routine chart. Take a piece of card stock, draw a line down the middle and on the top left write the words "To Do" and on the top right, put the word "Done." Then laminate it. Find pictures of each of the activities you want your child to complete. For example, get out of bed, brush your teeth, etc.. Keep the list to four items maximum. Place velcro hooks down both sides of the chart and velcro loops on the back of each picture. Have your child move the picture from the "To Do" side to the"Done" side after each task is completed. If all pictures are moved to "Done," then give your child a small reward. Good Luck!
In Service, Hollis
Urban schools mirror the communities they're in. Unfortunately, all too often that mean that violence and substance abuse make their way into our schools. Neither should be tolerated.
Most kids will pretty much do as the adults around them say provided the message is clear and consistent. And the message needs to be zero tolerance for violence. If there's a fight, all parties should be suspended, regardless of who started it. The message also needs to be no weapons allowed here, and not I don't want to see any weapons here. This implies active vigilance in weeding out those who carry knives, box cutters, and guns to school.
Restorative justice sounds nice, but from my experience, is rarely effective. It clouds the message for students, just as sending misbehavers to a "safe room" and serving them doughnuts. Given that so many of our youngsters are hungry, that alternative sounds too attractive and incites transgressions.
Not that suspensions need to separate students from their schools for very long. In fact, a suspension should be an excuse for a guidance conference with the kid and her family. The goal must be to return the student to her classes as quickly as possible.
These policies were in place during my 18 year tenure as the first Principal of The International High School at LaGuardia Community College. While there were a number of students each year who received a "Principal's Suspension," I am proud of the fact that during my nearly two decades at the school not a single student received the more serious and longer "Superintendent's Suspension."
Educators make a commitment to parent to serve in loco parentis; that is, in the place of a parent. As such, our primary responsibility is maintaining a safe environment for our students. When other students threaten that safety, the school needs to act decisively.
Professor of Practice in Educational Leadership & Director of the Summer Principals Academy, Teachers College Columbia University
Ahead of the International Day of Peace, which is marked each year on September 21, the U.S. Institute of Peace has created the Peace Day Challenge. We aim to raise the visibility of this day, to frame peace as an attainable alternative to the violence we see daily in the news, and to encourage individuals and communities across the U.S. and beyond to take an action for peace, to share it at #PeaceDayChallenge, and then to sustain it beyond the day. Learn more, and get involved at www.peacedaychallenge.org! Because Peace is Action, and it starts with You!
After living in the concrete jungle of Manhattan, it was a great opportunity to retreat to the green state of Maine where I spent my fourth summer at Camp Takajo. In Naples, Maine, you never hear honking horns, sirens screeching, and never get caught in traffic jams. As the buses rolled into camp, we were greeted by counselors who brought us to the cabins where we would be living for the next seven weeks.
Takajo offers many different activities ranging from soccer to sailing and lacrosse to photography. The counselors encourage you to try a wide variety of activities and as a result, get you to try new things. Before my first summer at Takajo, I had never tried sailing. Now, making my way down to the dock and hopping into a sailboat is my favorite activity at camp.
Although Takajo is a sports camp, it also offers many other activities such as canoeing, video, woodworking and photo. I had an amazing experience this past summer on a project I worked on in Photography. I took a panorama photo of the Takajo waterfront and started working. I spent the next several weeks laboring over my masterpiece, an enormous 5ft by 2ft collage. It was a fun experience and I was happy to tote it back to New York and hang it in my room.
After archery, lacrosse, laughing with my friends, movie night, and white water rafting, it was finally time to go back home. It will be difficult to return to the concrete jungle and to daily activities of homework and exams, and sitting in a classroom all day instead of being on a lake.
As cell phone usage rates increase each day, not many of us are aware of the harmful effects our gadgets may have on the body. Dr. Martin Blank from Columbia University explains in an informative video, found in the link below:
In August, a parent's thoughts turn to the new school year that will be starting all too soon, and what can be done to set up our kids to do their best and feel good about it. Knowing that kids are not all alike, we've been thinking about how to prime kids who have particular emotional or learning challenges for a strong start.
This week on childmind.org we kick off a series of specialized back-to-school tips with what we're calling our School Success Kit for Kids With Executive Functioning Issues. It's a list of supplies and strategies tailored to kids who are organizationally challenged. It's aimed at helping kids keep track of the things they're responsible for (from homework assignments to house keys), have less trouble getting out the door in the morning (Where did that other sneaker go?), and better manage their time (What was it I'm supposed to be doing?).
We'll follow this with lists for kids with anxiety, ADHD, sensory problems, selective mutism, and more, throughout the month of August. Check out our Facebook page to see when they're posted.
--Caroline Miller, Editorial Director
On Friday, at a joint press conference, the Secretary for Education and Attorney General announced the Obama administration's intention to explore the restoration of Pell grants for incarcerated Americans. Next month, the Department of Education will launch an "experimental site" program which restores Pell eligibility for three years, for a small group of participating programs which will be chosen in the months ahead.
This announcement is evidence that optimism is not unwarranted. After many years of things only getting worse, after so much work by so many, things can and will get better. If you haven't yet seen the recent New York Times' editorial lauding the announcement and describing BPI's work as "highly acclaimed" and "widely emulated," please read here.
At the same time, the scale of the intervention proposed is limited and reminds us - however far we've come - how much work remains to be done.
Nothing that we've accomplished at BPI over the past fifteen years would be possible without the generous support of individuals across the country who took a risk on us long before the cause was fashionable.
Please continue with us in the months and years ahead as we work to ensure the next generation of Americans will be better served by our systems of education and justice than the last one.
To celebrate this milestone, please join me in making a contribution to BPI here.
Recognized nationwide as a "top Fulbright producer," Hunter is proud to honor the College's 2015 Fulbright U.S. Student Award winners. Three members of the new graduating class are recipients of the prestigious government grant to spend the next academic year living, working and studying abroad. The Fulbright program's stated goal is for these young scholars to "interact with their hosts on a one-to-one basis in an atmosphere of openness, academic integrity, and intellectual freedom, thereby promoting mutual understanding."
Bianca Malhotra '15, an economics major at Hunter's Macaulay Honors College, will spend her Fulbright year teaching English to university students in Turkey. This is a return trip for Malhotra, who studied abroad in Istanbul during the 2014 spring semester.
Malhotra cites a "timely" course in the Human Rights Program at Roosevelt House, where she learned about Turkey's involvement in the Arab Spring, as the inspiration for her previous semester abroad. She devoted that semester not only to studying in Istanbul but also to teaching English to high school and middle school students in a village outside the city center. The experience was so fulfilling, she says, that "I knew I had to come back."
Born in Brooklyn, Malhotra moved in her teens to Long island, and in high school theater "found my community." While majoring in economics at Hunter, she attended theatrical performances throughout the city, and began observing how much a thriving artistic scene boosts local economic development. Her winning Fulbright proposal includes plans to invite her Turkish students to join a theater club, where they can "learn about American plays and practice the language skills learned in class."
Malhotra's proposal also states her intention to return to the U.S. after her Fulbright year and continue pursuing her interest in the arts and community development. One attractive option, she says, is to earn a dual master's degree at France's Paris Institute of Political Studies and Columbia University's School of International and Public Affairs. Her eventual goal is to work for the government or a global NGO.
Right now she is looking forward to a summer internship at Bloomberg Philanthropies, where she can make immediate use of what she learned writing her Honors College thesis on corporate social responsibility. She says that in her thesis work, as well as her successful Fulbright application and her other achievements at Hunter, she was supported by faculty and advisers "who are looking out for you, want to make sure you succeed, and will sit down and share all the insights they have."
Hugo Genes (IMA/MFA '15) a graduate student in Hunter's Integrated Media Arts Program, has won a Fulbright to create multimedia documentation of the lives, culture and customs of Brazil's Xavante indigenous people. He intends to create filmed records that the tribe's older generations can pass down to younger generations, detailing and reinforcing their people's proud history, identity, and commitment to live sustainably.
Genes spent his own childhood on the shores of a river with a notorious environmental history. He grew up on Roosevelt Island, and crossed the East River daily to attend high school at Brooklyn Tech before heading upstate to Cornell University. As an applied economics major, he was courted by Wall Street and saw many of his classmates opt for careers in finance. But Genes says he gradually realized that he didn't want to devote himself to the abstractions of financial markets, or to "contributing to greater inequality in the world." Through Nancy Flowers, a family friend and retired professor of anthropology at Hunter, he found his way to the Xavante.
"Nancy is in her 90s, and when my sister and I went to help her move, we saw the accumulation of a lifetime of work in her home. We wondered what would happen to it all," he says. Assisting the professor, he came to know some of her former colleagues, anthropologists who work with the Xavante, and started working with the tribe himself. He soon found the best way to contribute his efforts and talents.
"Growing up, I was always playing with cameras, making movies with friends," Genes says. To develop his craft, he enrolled at Hunter and pursued advanced studies in the creation of nonfiction media. At the same time, through further collaboration with Xavante tribe members and Brazilian anthropologists, he developed the proposal that won the Fulbright grant.
"I will take several trips through the year into the village Pimentel Barbosa, and work collaboratively to find the ideal ways for the Xavante to generate, store and access audiovisual documentation," his proposal states, offering specific travel and work plans before concluding, "I'm inspired by films that bring change in our society and environment."
Maggie Slavin (MSEd '15), a South Bronx middle-school teacher earning her master's in special education, successfully applied for a Fulbright post in Amman, Jordan. "I chose Jordan," her application stated, "because I have knowledge of the language and region, and because many of my current students are Arab American." She is looking forward to teaching English to Jordanian students at the high school or college level, and to spending her "free" time working with Jordan's fast-growing Syrian refugee community.
Slavin says that because she grew up in a semi-rural area outside Chicago and attended a very small high school, "I didn't know I had a passion for cultures and languages until college." At St. Mary's, the sister school to Notre Dame, an advisor encouraged her to take the college's first-ever Arabic course.
By her senior year, Slavin was a teaching assistant in an Arabic 101 class. She also taught English to adult learners in a nearby community of Iraqi refugees. After graduating, she joined the national service program AmeriCorps, serving as a language teacher for young children from Mexican families in Northern California.
When she came to New York to study for an ESL tutoring certificate, Slavin says, "I fell in love with the city and recognized the huge need for public school teachers here." She decided to pursue her master's at Hunter, and in the School of Education's Special Education program, found "some of the best professors I've ever come across and a very holistic approach to educating kids - one that completely transformed my approach to teaching." She adds, "Without my Hunter education, I would not have gotten the Fulbright."
After her Fulbright year, Slavin will return to the Bronx, where there is a growing community of Yemeni refugees and a great need for teachers proficient in Arabic.
BY KISA SCHELL
It's not often that you hear of a child raised in New York City longing to become a park ranger in Yellowstone National Park. Yet for Sean MacGuire Reinicke, a high school senior at Beekman High School, this dream is becoming a reality. Sean was born in Lithuania and brought to the United States at the age of four. Though Sean had difficulty grasping the English language at first, he quickly surmounted this challenge and has excelled in many endeavors, both scholastically and creatively. Currently, Sean is taking advanced English courses at his high school where he is inspired by an animated teacher, James Vescovi: "We do everything from "Romeo and Juliet" to James Hanley. We just read the book "The Dragon Can't Dance." My teacher is very wonderful. He's so nice and he's so lively and he's Italian- he just has this vibe where everyone in class just enjoys [the lesson] and we just come in and he has coffee waiting for us. No one does that and it's just amazing because we sit down and everyone talks to each other and it feels great and the vibes are amazing." Sean describes many of the teachers at Beekman as influential figures in his life: "They all helped influence me to follow my dreams and none of them said that I should focus on something that can make me more money." In a society where class and status are emphasized, it's not often that students are encouraged to pursue their dreams, no matter how unconventional they might be. The small class sizes and seminar-style settings have helped Sean feel at home and in an environment where people genuinely care about his interests and well-being. In the fall of 2015, Sean will be starting school at SUNY Cobleskill. With the motto: "Real Life. Real Learning," SUNY Cobleskill encourages students to immerse themselves in hands-on fieldwork and internships to help them secure employment after graduation. At Cobleskill, Sean plans to concentrate on courses that are related to nature, from zoology to botany to wetlands to biology. Sean is most looking forward to working in a fish hatchery, as well as study abroad opportunities that will bring him to Hawaii and the Galapagos Islands. He is also excited to be in a rural environment with likeminded peers who have had different backgrounds: "I've always been a kind of country kid. I've never really been interested in the city and I've always wanted to go out and see more of the countryside. I think that me, a city kid, going to college at Cobleskill will be very interesting because not a lot of kids from NYC go to college there. Not only can I tell my stories, but [the Cobleskill natives] can tell their stories to me about what their life is like." From Lithuania to New York City to Cobleskill, New York, Sean has had an interesting journey. His interests in nature and the outdoors have grounded him and pushed him to pursue the career of his dreams at a school that emphasizes education through experience. As the old (and very corny) adage says, if his future were any brighter, he would have to wear shades. #