Monthly Archives: September 2012

Choosing Well: Patient Challenges in Choosing a Physician in a Rapidly Changing World

Earlier this week the Wall Street Journal published an article describing challenges today’s patients face in choosing a primary care provider.  Primary care provides the backbone for our medical system and is an integral part of prevention–thus conferring a significant savings in healthcare dollars over the long run.  For most patients, finding the right provider can be a daunting task.  More and more patients are looking for new providers as physicians retire or modify current practice models.  Analysts predict that if the current iteration of government reform continues on its planned “phase in” schedule, there will be a significant shortage of primary care physicians by 2014.  It is important that patients are able to find the right physician to care for them and establish a care relationship now.

Primary care models are changing as the healthcare industry moves forward toward the currently legislated reform.  The system will soon be flooded with new patients and practicing physicians will have difficulty absorbing the expected large increases in volume.  Many physicians are leaving private practice to work for large hospital systems.  Others are starting “concierge” practices where patients pay premium prices for preferred “round the clock” cell phone access and house calls.  Still others are opting to move into employer based clinics and work to provide care to company employees.  These medical landscape changes have resulted in confusing and sometimes difficult choices for patients.
Historically, most patients find new physicians by “word of mouth” recommendations from friends, family, and colleagues.  Although this remains an integral part of the process, there are other considerations and other sources from which a potential patient can find a primary care provider.  In the digital age, online reviews of physicians are easily available.   However, these online reviews may be biased by disgruntled patients, former employees and competitors.  Most online review sites are not regulated and may not provide a clear picture of the skill and expertise of the provider.  Other online resources including websites of individual state medical boards can provide information regarding any pending actions or complaints against a particular physician or healthcare provider.  In addition, a google search of a particular physician can provide links to his or her website, scholarly articles, TV and radio appearances or other relevant press.

Choosing a physician is a lot like choosing a spouse.  The best medical care often results from a well established long term relationship.  Just as in a marriage, to be most effective, the physician and patient must be able to communicate, work together to achieve common goals and (at times) engage in difficult discussions.  The choice of the perfect physician match is not a new issue and was addressed in an article in the New York Times in 2008.  Many of the points made in the article remain relevant today as well and are included in the list below.  It should go without saying that the first step in physician selection is to determine which physicians are included in your insurance’s provider network.

So, what are some helpful hints for choosing the physician who is the best fit for you and your needs?

1. Determine what your goals are.  Do you have multiple medical problems and are you looking for frequent care and visits?  If so, you may consider larger practices that are owned by a hospital system with multiple providers that can accommodate same day visits.  Alternatively, are you relatively healthy and really only need a yearly physical exam and care when acute illness strikes?  Then a different system such as a small group private practice or concierge practice may be the right thing for you.

2. Determine what style of care you are looking for.  Questions to ask yourself include:  Do you want a physician who is very conservative or more aggressive?  Do you want a provider who orders frequent and multiple tests?  Do you want a physician who involves lots of specialists in your care or simply handles most concerns himself?

3.  Consider the importance of the location of facilities and hospitals.  It is important to understand where you will receive care.  The office should be in a convenient location.  Additionally, it is important to ask if the doctor who cares for you will be caring for you in the hospital as well.  Today, it is common for your primary care doctor to focus on outpatient care while turning you over to a hospitalist physician for times when you are admitted to the hospital.  Patients must also ask where they may be hospitalized if required.  It may not always be the closest and most convenient facility.  Many providers have relationships with particular hospital systems and patients may be directed in a particular pattern.

4. Evaluate the physician’s practice information processing and consider the ease of two-way communication.  It is important to understand how your physician handles medical information.  For some patients with multiple providers, it may be important that the primary care doctor is digitally connected with other specialists so that medical records, test results and referrals can be easily accessed and immediately available.  In addition, patients may prefer a particular way to communicate, schedule appointments and receive test results.  For example, there are some primary care practices that use email and internet portals to schedule appointments, deliver test results and communicate follow up information.

Healthcare is rapidly changing.  Primary care physicians (as well as specialists) are facing more challenges as healthcare reform evolves in the US.  Practice models are more diverse and healthcare delivery is becoming more technologically innovative.  For patients, choosing the right provider to meet their particular healthcare needs can prove challenging.  Outcomes are improved when providers and patients “connect” well.  Now, more than ever, it is important that patients are able to “choose wisely” and find a primary care provider with whom they can bond and develop a life-long relationship.  For many patients, navigating the current healthcare environment is akin to navigating a ship in rough seas.  A good primary care physician can make the difference between shipwreck and safe passage.

Medicine, CEOs and Twitter: To Tweet or Not to Tweet?

The use of social media is a tricky business. A recent Wall Street Journal article points out the challenges that CEOs and business leaders face when using Twitter. Many CEOs and other executives relate stories of personal attacks and cyber stalking from disgruntled customers, former employees or competitors. Some have opted out of the social media space due to specific legal concerns. Other very successful business leaders continue to embrace social media and have developed a knack for keeping their tweets and posts professional. It is clear that social media is here to stay and that it can be a very effective marketing tool.

In Medicine, social media can have far reaching effects. Twitter can allow a clinician to reach, educate and interact with a wide audience of patients, partners, and colleagues.   As I have mentioned in previous blog posts, social media is an effective tool for widespread communication and public relations. Nearly 50% of all Americans regularly use Facebook and almost 40% use Twitter. Often CEOs and other business leaders seem distant and unreachable; a social media presence turns icons into real people who are accessible to all. Interestingly, many executives fail to see the return on investment (ROI) from the use of twitter and other social media outlets. According to the WSJ and an article in CEO.com, 7 out of 10 leaders of fortune 500 companies have no social media presence whatsoever. However, there are real tangible benefits in both business and in medicine that can result from dedicated use of social media. An article online in April 2012 from INC.com suggests key reasons that CEOs should tweet and include connecting with employees, building relationships and connecting comfortably with the press. I believe that these applications are just the beginning. However, social media must be used responsibly and respectfully in order to be most effective.

Here are some guidelines that I like to follow when engaging professionally in social media:

1. Separate business and pleasure. A professional social media presence is just that- professional. Steer clear of posting personal items on twitter or facebook unless these are events that directly relate to or enhance your business or reputation. Certainly, it is important to help those who may follow you see you as a “real person” who is in touch with the “real world”. However, don’t cross the line.

2. Avoid polarizing topics unless the issue directly involves what you represent or stand for in your profession. For example, a discussion promoting healthcare reform or a “patient’s bill of rights” may be very appropriate for a physician to tweet or blog about. However, a physician should probably avoid posting religious or political views about abortion rights on twitter or facebook. Conversely, a CEO of an oil company may want to post about the benefits of offshore drilling even though it may be a very controversial topic. Social media allows you to tell your side of the story and can be a platform for you to provide data to support your opinion.

3. Respond to criticism in a respectful, thoughtful way. Not everyone is going to agree with you, your company or organization. Often, people feel free to express displeasure or disagreement very openly on twitter  (the internet allows people to hide behind a cyber curtain). Be careful to separate emotion from your response. Acknowledge alternative opinions and provide constructive comments.

4. Avoid saying bad things about others. Social media outlets are not the place to start a war of words. Make sure that you do not say anything about competitors, colleagues or others on twitter that you would not be comfortable saying directly to those individuals. Twitter is not the place to “air dirty laundry” or discuss private matters. Remember, twitter is a megaphone that broadcasts your message to millions of potential listeners.

5. Maintain a constant presence. Once you engage in social media, it is vital to remain regularly engaged. Developing a following and a dedicated readership requires effort. You must provide fresh, relevant content. Avoid periods of “radio silence”. For instance, provide twitter content daily–spread out tweets to different parts of the day. I typically tweet several newsworthy items early in the morning and then again in the afternoon and evening. The only rule is be consistent.

Social media is the future. Early adopters are willing to take risks, have long term vision and already are able to see the ROI. Twitter, facebook, and other outlets should be part of every leader’s job and executives should be held accountable for what is and is not posted. Social media provides opportunities in both medicine and business in general to educate, motivate and influence opinions. Careful attention to keeping posts professional and thoughtful will provide the best results. The world is getting smaller everyday. Twitter and social media outlets allow us to connect, interact and collaborate to accomplish common goals. Use your voice, be heard and Tweet Away!

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Addressing Medical Errors: Working to Improve Care and Reduce Costs

In the last week there have been two articles written addressing medical errors. In the Wall Street Journal, surgeon Dr Marty Makary discusses the alarming costs of medical errors and offers suggestions to improve the system. In medicine, particularly during the training years of residency and fellowship, young doctors are not given the opportunity or security to report shortcomings of their superiors. As discussed in the article, all of us have a memory of a particular surgeon or clinician who was not very proficient at his or her specialty but was allowed to continue practice due to perceived national or international academic prestige or reputation. (not to mention the dollars brought in to the University via grant funding, etc). Dr Makary offers up solutions that he believes will decrease error rates including: publishing hospital scorecards online, installing cameras for peer review, open notes and eliminating the culture of “gagging”.

As part of national training requirements, all teaching hospitals are required to have a regularly scheduled Morbidity and Mortality (M & M) conference for housestaff. These meetings typically consist of a case presentation by a trainee where the outcome of the hospitalization was suboptimal and the deficiencies in care are debated and discussed. The focus of the best conferences is always placed on the central question of “what could we have done differently to change the outcome?” Unfortunately, these conferences (although required attendance by the housestaff is standard) are not well attended by faculty. Much can be gained from actively discussing cases and learning from the experience of others. In practice, there are standardized peer review processes that are in place in hospitals today. These are very different from the M and M conferences from training. I have served on QI (or quality improvement) committees at numerous hospitals over the years. These committees are made up of very diverse specialists and primary care doctors. Unfortunately most of these committees stop short of dealing with real physician deficiencies. Often, letters are issued and cases are discussed with little or no penalty or constructive criticism provided. Most often, the QI committee responds to complaints about promptness and appropriateness of emergency on-call care–particularly after hours. Only once in my tenure on these committees has true competency and clinical skill been addressed. Many of the cases are brought to the committees attention by competing groups and the motivation for the reports can be called into question. Much of what these committees do is done so that the hospital can remain accredited and remain in compliance with government regulations.

In reality, physicians need to work together to improve care and reduce errors. Government regulation as suggested by the Obama administration’s creation of an error-reporting system for consumers and reported on in an article in the New York Times is NOT the answer. Many consumers may interpret poor outcomes as errors in care when in fact no error occurred. Many times, disease may “defeat” even the most skilled physicians. A national “reporting system” as described in the Times, may ultimately lead to increased liability concerns for both hospital systems and physicians alike. Certainly, lapses in care and medical errors must be tracked and addressed in order to save lives, health care dollars and improve overall quality. However, the practice of medicine is an honorable profession with a long tradition of excellence in the US. Most physicians see the practice of medicine as a privilege. As such, we must all take responsibility to maintain high quality care throughout our profession. Thorough, unbiased evaluations of care need to be undertaken in both teaching and non-teaching hospitals if we are to impact medical error rates and reduce healthcare costs. Dr Makary has several important suggestions–we must continue to hold medical professionals to high standards of care. Transparency of care and physician decision making is a must. Video critiques can serve as a great learning tool. As we did in the M &M conferences in residency, we must continue to discuss cases formally with colleagues and both give and receive feedback and constructive criticism. All physicians, no matter how well funded or respected, must be held accountable for the care that they provide. By working together as a team, we can all reduce errors and improve care. Ultimately, both patients and doctors will benefit.

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Build It Bigger? Maybe Not: Addressing Obesity in the US today

This week I came upon an article in the Wall Street Journal describing the challenges of producing a new “plus size MRI scanner“. Companies that manufacture imaging equipment such as MRI and CT scanners have been challenged in recent years to produce technology that will adequately image larger patients. There are several physical limitations beyond the actual size of the scanner in obtaining good images from obese patients including the fact that tissue absorbs x rays and limits the penetration needed to adequately image critical structures. According to Siemen’s chief executive, Americans account for the majority of the extra large imaging market due to increased average patient size. The CDC estimates that nearly 35% of all Americans are considered obese–as compared to 20% only 15 years ago. More than ⅓ of adults and almost 17% of children are considered obese. Some agencies estimate that obesity and obesity related illnesses costs the US healthcare system nearly 150 billion dollars annually. Even with efforts to contain costs, US hospitals will spend 40% more on imaging equipment that will accommodate larger patients. As I have mentioned in previous blogs, the US spends a disproportionate amount of money on healthcare as compared to other industrialized nations. Costs are skyrocketing out of control. It seems to me that the American way of “build it bigger” may not be the most effective strategy when it comes to managing larger patients. Instead we should approach the real issue–prevention and treatment of obesity.

The CDC defines obesity as a body mass index (BMI) of 30 or greater. The BMI is calculated by taking the weight in kg and dividing by the height in meters squared. A report released this week jointly by the Robert Wood Johnson Foundation and The Trust for America’s Health estimates that nearly 45% of Americans will be classified as obese by the year 2030 unless major public health changes are made. The report goes on to say that the numbers of cases of type II diabetes, coronary artery disease, stroke, and arthritis will grow by 10% between 2010 and 2020 and double again by 2030. These frightening statistics should provide ample evidence for addressing the obesity epidemic in the US today. By reducing obesity rates by 5%, we can save billions of dollars in healthcare costs and prevent numerous chronic diseases–in fact, we can reduce costs by nearly 7.5%.

How Can We Prevent Obesity?

In order to effect change in obesity rates in the US, we must individually take responsibility for our waistlines and our overall health. We must work to support out patients, our families and our colleagues. I have listed what I believe to be four key components to preventing obesity:
1. Set an example for today’s youth:

As parents and adults, we must demonstrate a culture of physical activity to today’s children. It is important to emphasize daily physical activity and smarter, healthier eating choices. Children mimic the behavior of their parents. Obesity prevention starts at home.

2. Move:

Physical activity and exercise is essential to the treatment and prevention of obesity. The CDC recommends 150 minutes of brisk exercise per week. This boils down to walking roughly 20 minutes each day. In addition, strength and resistance training such as lifting weights will provide increased bone strength and “jump start” metabolism. Increased metabolic rates result in increased calorie consumption and weight loss

3. Remember that Calories OUT must be more that Calories IN:

It is simple math. The more calories you consume, the more you must burn in order to maintain or lose weight. Calorie counting is essential to making good nutritional choices. Choose foods carefully and avoid, high fat, calorie dense foods. For example, a “fast food” lunch at a popular US chain can contain as many as 1500-1700 calories. For many of us, 2000 calories may be our ideal DAILY target for intake!

4. Set Goals/Get Support:

Obesity prevention and treatment requires support and sometimes even psychological counselling. By investing time and money in counseling and support the job of managing obesity can be made easier. Goal setting is an important part of obesity management and prevention. Goals must be reasonable but challenging. Goals are necessary so that we can hold ourselves and others accountable.

The Upshot:
As a nation, we have a choice to make. There are two clearly divergent paths for US health going forward. If we continue to gain weight, remain sedentary and “build it bigger”, we can expect obesity levels to approach 50% and obesity related disease to triple by 2030. If we begin to focus on treatment and prevention (even reducing obesity rates as little as 5%) we can save billions of dollars and millions of lives. This choice begins on the individual level–we must each take responsibility for our own health and set a positive example for the generations that are to follow.

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Dr. Campbell enjoying a coffee after a morning run on the beach

Workplace Stress and Heart Attack: Finding the proper Work-Play Balance

Americans are workaholics.  Most of us work 40+ hours a week, bring work home on the weekends and take as little as 2-4 weeks of vacation including holidays.   As cleverly addressed in an essay in the New Yorker in 2006, life in Europe is quite different; 7-8 weeks of vacation time is the norm.   Europeans seem to value leisure more whereas Americans tend to emphasize earning and spending.  Much has been written about how certain habits at work can harm our overall health.  In US News and World Report in July, seven habits that were considered to be health harmful were examined. Habits identified included eating at your desk, lack of exercise, all night work sessions just to name a few.  Now add excessive workplace stress to the list.

I was listening to NPR this weekend and was intrigued by a story from the Lancet on the relationship of on the job stress and increased risk of heart attack.  In this study, a meta analysis from 13 European cohort studies was performed and included nearly 200 thousand patients.  The study demonstrated a 23% increase in risk for cardiovascular events in patients whose jobs were considered stressful as compared to those who did not report workplace pressure.  Based on this report, reducing stress in the workplace could potentially reduce heart attacks by 3-4%.  Certainly, this potential for reduction is not really comparable to the 20-30% reduction in events that is conferred by smoking cessation but it is not insignificant.

Traditionally, stress has been thought to contribute to cardiovascular events by increasing sympathetic tone and causing the abundant release of stress hormones such as adrenaline and cortisol.  These stress hormones may cause increased lipid (cholesterol) levels, increased tendencies for blood to clot and they may also promote the formation of atherosclerotic plaques in the arteries with subsequent vascular damage.   Blood pressure and heart rate are all increased in this state, all leading to increased demands by the heart and potential for ischemia (lack of blood flow to the heart muscle).  Stress management techniques have been studied in the past and have been shown to result in decreased cardiovascular events.  A survey by the American Psychological Association (APA) in 2011 found that 36% of workers included in the study had experienced stress on the job.  Interestingly, the study participants cited lack of opportunities for advancement (43%), heavy workload (43%) unrealistic job expectations (40%) and long hours (39% ) as major stressors at work.

Much of the American worker’s self worth is measured by elite job titles, driving luxury cars and owning a large home in a prestigious community.  In Europe, the worker measures himself by having the ability to take extended holidays with friends and family.  In fact, US workers often fail to take allotted vacation time.   This may be due to the fear of losing traction towards advancement in the workplace or out of fear of being replaced by co-workers who did not take time away.  The US certainly remains the land of opportunity but many US workers have lost sight of the real American dream–the freedom to use our time as we see fit.  To enjoy family, friends and the lives we have worked so hard to build.

Much can be learned from the value that the Europeans place on leisure.  These workers make time away with family a priority.  Some studies of worker efficiency and productivity have shown superior performance and less burnout and depression in employees who take time for vacation and leisure.  Coronary artery disease and sudden cardiac death are one of the leading causes of death in the US today (behind all types of cancers combined).  Certainly we can impact disease by eliminating smoking, eating well and exercising but we can also reduce events through better management of workplace stress.  Take time for family.  Take time to relax.  Return to work refreshed, re-energized and renewed.  Although workplace stress is an unavoidable reality in the US today, we must find ways mitigate stressors and this will ultimately improve both our productivity and overall quality of life.

Grief and Loss in Medicine: The Role of Physicians in Helping Families Find Closure

This week I blogged about screening tests for potentially life threatening ovarian and prostate cancers. As I thought about the impact of screening for disease, I reflected on the potential for poor outcomes and how these outcomes may impact families and loved ones. Unfortunately, death and dying is part of medicine. Patients and families must cope with extraordinary circumstances as they face life aggressive cancers, traumatic injuries and deadly disease. As physicians, we must try to help patients and families navigate through difficult times.Today, while reading the New York Times, I came across a very moving article addressing closure after the death of a family member.   In the piece, author and oncologist Dr Mikkael Sekeres describes a recently widowed spouse and her young children meeting with him after their husband/father’s death in order to find closure after his long battle with leukemia. Dr Sekeres’s story illustrates an important part of our job as physicians–the care of the family and loved ones.   Disease and death can strike suddenly and end quickly but can also persist over agonizing days, months and years.   In either case, many families need to process these events and find closure to their journey with disease.   I recently blogged about the recent publications demonstrating increased rates of depression and suicide in spouses of heart attack and sudden cardiac death patients.   Families with young children have particularly difficult times finding closure after the untimely death of a parent and spouse.

Harvard Professor J. William Wordencreated his “Tasks of Mourning” and these principles can provide a framework in which we can better understand and help the families of our patients cope with and process grief.

1. To Accept the Reality of the Loss–The common initial reaction after the news of loss is delivered is protest and denial. This reaction can last for months, particularly if the death was sudden. As providers, we must help the families move beyond protest and denial so that they can begin to heal. Allowing families and children to be with the patient after death (before the patient is moved from the hospital room or bed) is a critical part to fostering acceptance of death.

2. To Work Through the Pain and Grief: Once the loss is accepted by the psyche, feelings of profound sadness and loss often occur. Sometimes these feelings can constitute clinical depression (situational). As I have stated in my previous blog on depression after sudden cardiac death it is critical that healthcare providers take time to meet with and assess the emotional health of loved ones after the death of a patient. Moving through grief may require counselling and discussions such as the one that Dr Sekere describes in the New York Times today are critical to this process. For many experiencing a significant loss, the first year following the loss is all about “learning to survive”.

3. To Adjust to An Environment Where the Deceased is Missing: Families have a difficult time adjusting to a world without a spouse or parent. Reminders are everywhere, and this can be good for the adjustment. Family members may have to take on new tasks (such as paying the bills or mowing the lawn) that were previously performed by the deceased family member. These practical transitions can be difficult. Talking about this adjustment with others–friends, support groups and physicians can be an important part of the process.

4. To Emotionally Relocate and Move On With Life: The process of emotionally relocating a loved one is a lifelong process. For families experiencing the loss of a spouse or parent (in the case of young children) time does not necessarily “heal all wounds”. This process may continue throughout life and things such as ritual and meaningful rememberances will certainly facilitate the process. For example, if dad always enjoyed putting particular decorations on the Christmas tree, it may be helpful to have a special night before Christmas where the children celebrate their dad’s life by hanging up those decorations and commemorating his life.

Closure is a difficult concept. The “Tasks of Mourning” involve learning to live with and adjust to the loss of a beloved family member. Although families may never completely adjust or emotionally relocate, it is important that they are able to learn to once again find hope and enjoyment in everyday life. As physicians, it is important to remember that we can help families dealing with loss by supporting, educating and coaching spouses and children through this process and prepare them to rekindle their desire to live life to its fullest.

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To Test or Not to Test: The Value of Screening Tests for Prostate and Ovarian Cancer in the US Today

Recently several commonly used diagnostic tests intended to screen for and detect early cancers have been called into question. Several articles in both the New York Times and Wall Street Journal have examined this issue in the last several weeks. There has been a great deal of controversy surrounding the use of the PSA test to screen for prostate cancer. Prostate cancer affects one in six men in their lifetimes and is often a slow growing indolent tumor. While the screening test or PSA can provide early detection, it also has a very high rate of false positives and results in many unnecessary procedures and biopsies. Recently in July, 2012 the US Preventative Services task force  recommended that PSA tests no longer be performed routinely in men who are asymptomatic. This week another article in the New York Times also questions the use two screening tests for ovarian cancer– a blood test called Ca-125 and the trans-vaginal ultrasound evaluation. Ovarian cancer is a very aggressive, often fatal, form of cancer and is often widespread and advanced by the time it is diagnosed. The same US Preventative Services Task Force just made these new recommendations public. The task force recommends continued screening in high risk populations but suggests that routine screening may lead to false positive results and unnecessary and risky major surgeries. Much of the recommendations made by the task force are based on data from larger clinical trials.

So, What is a good screening test?

There are four characteristics that are required for an effective screening test:

1. The disease must have a detectable preclinical period before it becomes clinically apparent and can be detected by the screening test–The time in which we can impact outcome

2. The detectable preclinical period must allow detection while cure is possible–if we detect cancer early, treatment options are available which can impact outcome

3. Treatment must be more effective if given earlier–there must be a significant difference in treatment early vs late in a particular disease state in order to impact outcome

4. The disease must be sufficiently common in the population–The disease must be something that is a public health threat to large enough numbers of people in order for widespread screening to reduce late detection, facilitate better therapies and impact outcome

A good screening test must also be sensitive and specific, be acceptable in terms of risk and patient tolerability and must be cost effective. The test must be feasible for broad based use. If a disease is in fact highly prevalent but a screening test is accessible to only a small proportion of the population, it has little public health value. However, if a test is easily administered, safe and inexpensive, it can be used to screen entire populations. With accurate screening using good screening tests, outcomes are improved and overall healthcare costs are reduced.

The Bottom Line:

In this age of health care cost containment we must use testing in a more judicious and a more effective way. We must choose tests that have a reasonable chance of detecting and impacting disease such that we can alter and improve outcomes. Unnecessary testing and testing that yields high false positive rates only serves to drive up costs and can actually harm patients
through the performance of unnecessary and sometimes life-altering procedures.

Unlike therapy for disease, screening tests are performed in an asymptomatic healthy population. Even for common cancers with a well studied, reliable and accurate screening test (such as colon cancer or breast cancer), the majority of people being screened will not benefit as they are unlikely to develop the condition in the first place. Therefore, any population wide screening test should have minimal risk; Everyone who undergoes the test will be at risk for whatever the complication may be and only a minority of patients who are screened will actually benefit by early detection and treatment.

Special note: Thanks to Dr Deborah Fisher, Asso Professor of Medicine, Department of Gastroenterology, Duke University Medical Center for her assistance with the content and preparation of this manuscript. Dr Fisher is an expert in the use of diagnostic testing in Gastroenterology and is a member of the AGA Guidelines Committee.

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