Drink more? Do more prostate cancer screening? I don't think so. But be careful about falls!

If the malignant lies and disinformation coming from HHS Secretary Robert F. Kennedy, Jr. (RFKJr) and his minions, whom he regularly replaces if they are too inclined to make decisions based on truth and science (see Susan Monarez, head of CDC for less than a month) were not enough, his psycho – but totally dangerous -- baloney regarding vaccines and other health issues provides cover for the re-emergence of other potentially dangerous “health” recommendations. This is par for the course for this administration, which is entirely focused on distracting us from important issues by focusing our attention on other things, brush fires (or sometimes major conflagrations). Trump is quite willing to arrest, brutalize, imprison, and deport people, to start wars across the globe, or whatever it takes to keep the Epstein files – which must contain truly damning information about him – from being made public. 

In the area of health this re-emergence has not been of the major blaze type, certainly nothing compared to the evil of RFKJr’s opposition to, discouragement of, and even blocking vaccines, but more of “well, we have an axe to grind and let’s bring it back out now that we have cover”. Who, after all will worry so much about the issues I address below when they can worry about the return of polio, measles, mumps, whooping cough, H. influenza, Covid, etc. And maybe even smallpox! But there have been several recent articles covering health issues which should be already settled. But, heck, if vaccines are not settled, why should these be?

On Sept 2, 2025, the NY Times Roni Caryn Rabin reports that Reduced Screening May Have Led to Rise in Advanced Prostate Cancer Diagnoses,  and follows that with the subhead “Changes in screening recommendations over a decade ago may have inadvertently resulted in later diagnosis of the most common cancer in men, a new study has found.” It sounds pretty scary, as it goes on to report that Black men are the least likely to be screened for prostate cancer and the most likely to die from it. Prostate cancer is being diagnosed at a later stage and the implication – no, the direct assertion in the article – is that it is because of a recommendation from the US Preventive Services Task Force (USPSTF) which in 2012 began discouraging the use of routine screening with PSA (Prostate-Specific Antigen). The Times article, and the article it is based on, from CA: A cancer journal for Clinicians, and the comments of the chief scientific officer of the American Cancer Society and one of the article’s authors, Bill Dahut, say “The pendulum may have swung too far in one direction, where we were afraid of overtreatment, and now we’re not finding these cancers early on, when they can be treated and are more curable, and we’re more likely to find metastatic disease that is not curable.” 

This conflates diagnosis of cancer at later stages with (implicitly) increase in death from prostate cancer. Well, doesn’t that make sense? Except that what makes sense is not always true. There is no data in the article that says more men are dying from prostate cancer, only that they are being diagnosed with further advanced cancer. Dr. Dahut says that finding the prostate cancer earlier would make it more curable, but if this were true, the decrease in screening would not only have led to cancers being diagnosed at a later stage, but in an increase in deaths from prostate cancer. How come it didn’t? There are basically two types of prostate cancer: the kind that kills you and the kind you die with, but not from. Medicine has yet to be able to find a test that can identify which kind you have. If diagnosing the kind that kills you earlier can make it curable, that’s great – but then we would see more deaths from prostate cancer as a result of not screening, and we don’t. What has historically happened is that the other, more indolent, kind has been treated and physicians have claimed “cures” – even though men don’t die from it without treatment. But they do suffer the morbidity of treatment (i.e., impotence, incontinence, radiation cystitis, etc.) This, along with the poor performance of PSA as a screening test for prostate cancer, is what led the USPSTF to recommend against screening. This issue has been addressed a number of times over the years on this blog (PSA Screening: What is the value?, March 21, 2009, PSA Screening: “One of Medicine's Great Success Stories"?, Oct 27, 2009,  PSA redux: The USPSTF finally recommends NOT getting it!, Oct 14, 2011, Prostate Screening and the Public’s Health, July 12, 2015, as well as other posts on the benefits – or not – of cancer screening), and essentially, nothing has changed. It is terrible that Black men die from prostate cancer. It is terrible that anyone dies from prostate cancer. If screening saved lives we should do it. But this article presents no new evidence that lives are being lost that could be saved.

A few days later (Sept 5, 2025) the Times had an article by the same reporter titled Federal Report on Drinking Is Withdrawn with the subhead “The upcoming U.S. Dietary Guidelines will instead be influenced by a competing study, favored by industry, which found that moderate alcohol consumption was healthy.” Yup. Favored by industry. Not only were the guidelines withdrawn by HHS and thus not, as planned, presented to Congress, but HHS promotes a “competing report” by a panel of the National Academies of Sciences, Engineering and Medicine that “came to a conclusion long supported by the industry: that moderate drinking is healthier than not drinking”. Yay for the alcohol industry! Of course, “Some panelists came under criticism for financial ties to alcohol makers,” but what the heck. It is perhaps surprising, as the article points out, that RFKJr’s MAHA (“Make America Healthy Again”) campaign does not include anything about the use of alcohol – or, even more amazingly, tobacco! When we don’t like the message, we kill the message (and sometimes the messenger), especially in the current administration. But despite the fact that “Science Over Bias, an industry-supported advocacy group, faulted the alcohol intake study for bias: “The Dietary Guidelines should be guided by a preponderance of sound science, not the personal ideologies of a handful of researchers,” it is the industry’s position that is based on bias rather than on evidence. With regard to physical health (not short-term mental health), there is no amount of alcohol that is good for you, and any amount is a little bad. No alcohol is better than moderate alcohol, except for the financial interests of the industry and the scientists on their payroll.

On a somewhat different issue regarding health, not about controversy (screen or do not screen for prostate cancer? Drink alcohol in moderation or not at all?), is the Times article from Sept 7 by Paula Span titled Why Are More Older People Dying After Falls? It doesn’t provide a definitive answer, but strongly implicates prescription drug use (“Some researchers suspect that rising prescription drug use may explain a disturbing trend.”) It’s important. Falls are a major cause of morbidity and mortality in older people. You can break your hip or your head, you can get a concussion or a brain bleed or die. No joke. The association with prescription medication is legitimate, especially certain ones, called FRIDs, or “fall risk increasing drugs”, that are more likely to cause falls though inducing drowsiness, dizziness, drops in blood pressure, etc. Older people are more likely to have more diseases and be on more medications to treat them, and they are also more sensitive to the side effects of these drugs. (Note that drugs do not know which of their effects are “side effects”; we define them as the ones we don’t like!) And they are more likely to suffer serious injuries from a fall. The take-away message is that physicians should carefully review the medications that their older patients (actually all patients) are on, make sure that there is a need for them, and that there is not another less risky (less FRID) drug that could be substituted. Psychoactive drugs “like benzodiazepines, opioids, antidepressants and gabapentin — that act on the central nervous system” should be especially assessed for need, with particular emphasis on the use of more than one drug with similar side effects that can lead to greater risk. The message should not be “stop taking my drugs because the pharmaceutical industry is greedy and trying to drug us all”. Sure, they ARE greedy, and we shouldn’t have to pay so much to them, but that is another issue. They also make drugs that are effective and in standardized doses (unlike “natural” herbs). And often it is the drugs that people like most (because they relieve pain and/or make them feel better) that are most likely to be FRIDs. Exercises to increase strength and balance are important. And, if the risks still cannot be significantly reduced, people may have to modify their lifestyles. For example, it may be necessary to stop walking a big dog.

These are 3 different issues. I included the first two, prostate cancer screening and alcohol use, because they represent efforts to peel back science-based policies that may have been deleterious to the profits of industry, which is like many of the policy changes across the administration over the last 8+ months. The falls issue is a little different; here the concern is to address the risks to the extent possible without overreacting and stopping all your medications!

Medicine and science are complex. But findings can be skewed to fit an agenda, and when that agenda is corporations making more money, a little skepticism is wise.

Conservative, Liberal, or Relevant Blood Pressure? We need studies that are really relevant...

The following is a guest post from Robert Bowman, MD

One set of guidelines says to loosen up blood pressure control to prevent consequences such as falls. Almost in reaction there appears a new study that indicates a need to, perhaps, tighten up control to reduce the potential for stroke or heart disease. When British GPs were paid more to address BP there did not seem to be gains, other than better pay for participating GPs. Time after time we seem to have cutting edge studies that are pro-intervention. They remain until longer and bigger studies come out years later indicating problems or limitations involving the once “cutting edge” pro-intervention studies.

The lives of millions of people can be impacted by hypertension guidelines. How can we best deal with blood pressure issues?

The answer is not likely to be found in guidelines, quality measures, reports, or the latest studies.

The answer is more about process and less about print.

The problem with guidelines that are too liberal or too conservative is the same – they are too distant from the real world. The real problem remains the failure to include many of those most important to the process.

The real world in health care is what is happening at home. What is the real world for elderly patients? What happens when you get up at night to go to the bathroom? Do you get up at night more because of your medications or because of how you take them? Do your physicians coordinate the addition and subtraction of medications – including drugs that impact blood pressure or fluid volumes? With more and more medications there are more potential interactions. What happens when you get up from a chair or sofa? When you lose 10 or 15 pounds, do your medications drop your blood pressure to dangerous levels? Do you even have contact with a health care professional to help look out for the problem of weight loss and medications that are suddenly too effective?

We know about the benefits of blood pressure control, but do we know about the consequences of too much control?

Sadly we know less about the risk of blood pressure that is kept too low, the risk that a fall that may belife or lifestyle ending will occur.For example, should our blood pressure goals be more aggressive in men or in those with proven bone stability while being less aggressive with those likely to suffer greater consequences becaue they have osteopenia, osteoporosis, or other conditions? We often assume linear increase in risk, but this may not be the case.

What Is Missing from “Guidelines?”

With control of BP or coagulation or other treatments that defeat how the body adjusts to change, the patient and family must have the best understanding regarding what the drugs do and how the drugs impact their particular body and situations.

Large scale studies can be helpful, but the studies need to be relevant. Studies should reflect the real world. After three hundred recent home visits, observations indicated a few with perhaps lax control that may, just may have problems in 1, 5, or 10 years. There are also a different few of the 300 who are having falls or symptoms that suggest the potential for falls - with the potential of immediate consequences. Many large studies examine only the outcome of interest to the researchers – such as the rate of strokes in people with uncontrolled blood pressure – rather than the overall rate of harm or death to the people involved. In addition, many studies exclude from participation people who have the risk factors most likely to cause them harm. Studies that do examine all outcomes (“all-cause morbidity and mortality”) are of more value, and we need to be sure that the people we are treating in the “real world” are similar to those studied.

And then there is the problem of getting reliable BP measurements at the office or at home. How many people do we overtreat based on office-only measurements when lower home BP measurements are more relevant? How do we best use ambulatory measurements? Are these accessed and priced in ways that can make a difference?

A final reflection may be more relevant. In the 5 or 6 minutes of face-to-face time that is often all that exists, given current payment design, how do we get to know our patients well enough in our office environment to optimize BP control while minimizing the consequences to them as they live in their world? How do we teach them enough to loosen up medication when necessary to help prevent falls?

Addressing Problems and Solutions

One thing is certain. As long as research is distant and irrelevant, guidelines will contribute to too much negative consequence and not enough gain.

Practice-based research could contribute. But the real potential involves home-based research. The irrelevance of the academic setting and even the office was suggested by the founders of family medicine. What matters most is far away from university hospitals and NIH researchers. Lest we forget, the home – and the community -- is where it all happens.

Follow up to come:

Why the Home is the Best Unit of Analysis for Research

Medicare, falls, families, and risk: "Qualifying" to be in a safe place

Older people are, like all people, a widely varied group. Some are healthy and independent and can live on their own until very old age, while others have diseases that make them infirm at chronologically much younger ages. Some live with family members or have family members living with them. Most of those are well cared for, but some are exploited or even abused. Some elders live in assisted living facilities or nursing homes. A lot more of them are women than men, a reflection of differences in life expectancy. And most of them will, sooner or later, have an adverse event occur that leads them to be hospitalized. Sometimes it is almost routine, getting admitted for a complication of an existing condition such as chronic lung disease or heart disease; sometimes it a surprise, as when a 90-year old who has lived alone and been healthy falls and breaks her hip. The first time something happens, I find myself often repeating to these people and their families, is always the first time, whether at 20 or 90.

Whenever I am the attending physician on our inpatient service, we have a number of such people admitted, but in the last two weeks the number of people admitted who were what my residents call “little old ladies” seemed especially high. They ranged in age from their late 60s to 104; some lived in nursing homes, some with family, and some lived alone (including the 104 year old!). Some were admitted to the hospital for the first time, while others were “frequent fliers”; some had families hover around and others seemed to be left alone even when their family lived in town. A lot of them had falls, sometimes with broken bones (most commonly hip fractures, but others as well), sometimes, fortunately without. Some had moderate to very severe dementia, from Alzheimer’s or other causes, and may know only who they are (or not even that); others are “sharp as a tack” – at least when we can fix the dehydration or whatever else has brought them in.

One characteristic shared by many of these people is that they are unlikely to be safe returning to their homes. If they have fallen, they are likely to fall again. If they avoided a hip fracture this time, they may not next time. We do tests to see if there is an “explanation” for why they fell that might be treatable. Did they have a stroke? Should they be on blood thinners that make another stroke less likely but make the possibility of a bleed into their brain much higher if they do fall and hit their head? Heart rhythm problems? Maybe a pacemaker. Low blood sugar? Are they taking too much insulin? Maybe they “just” tripped: on the cat, on the rug, on the hem of their pants (which might be because those pants are hanging low from the 40 lbs they have lost since they were last seen a year ago -- really? I have been eating. I never noticed I was losing weight!) But, while anyone can trip, if it happens more than a couple of times, they are at risk of something bad. Sometimes it is possible for a health worker or family member to the home and help get rid of clutter, area rugs, and such, but sometimes that isn’t enough.

No one wants to go to a nursing home, especially compared to some idealized vision of being better and functional at home. Few families want to send their parents or grandparents to a nursing home, feeling that it is abandonment, or undignified, or irresponsible. Occasionally, there are complicating social issues, as nursing homes will take the Social Security check that family members are living on or Medicaid will require the sale of the house that family members are living in. And nursing homes are not a panacea; some are better than others, and folks get sick enough to require admission back to the hospital even from the best. But often they are a safer option, even when the family is committed to care. A person may be hospitalized by the family for a minor change that makes the Alzheimer’s victim even harder to care for; the primary care doctors may have already discussed admission to a nursing home, and, as one put it, “their voices said ‘no’, but their eyes and body language said ‘yes’.”

Medicare will pay for a period of time in a “skilled nursing facility” (SNF), where a person who was hospitalized but no longer needs to be in an acute-care hospital can get time to recover, get physical therapy, get to the point where they in fact, often with home health and a supportive family, go home. It works for someone who just had surgery, or someone who broke a bone and either had it surgically repaired or not. But to get this “benefit” the person needs to spend 3 midnights in the acute care hospital. Whether they need acute care or not. Indeed, if they don’t “meet Medicare criteria” for an inpatient hospitalization, they are not even officially “admitted” but are in a fantasy world of “observation status” where they are in the hospital, but are officially outpatients. And those nights don’t count toward “qualifying” for a SNF. So if you (or your father, or grandmother), “just” tripped and hurt themselves, and didn’t break a hip this time (sometimes they have already had both hips repaired), and is “just” bruised, and may have a “little” disorientation but no new stroke, and a little difficulty caring for themselves, and could really benefit from a month of skilled nursing, you better be able to pay for it, because Medicare won’t because they didn’t have 3 nights of “qualifying”.

This is crazy. I am a huge fan of “Medicare for All” rather than the nonsense patchwork of often-inadequate private insurance plans (and people who are uninsured) that we currently have. But that Medicare for all – and right now, for those who are on it – needs to have a rational payment and benefit structure. I understand the financial challenges facing Medicare (and the whole health insurance system – it is not a “Medicare” problem, it is a medical care problem) and believe that we need to save money by spending it rationally. This means, perhaps, not paying for every drug that the FDA approves even when it is not better than an existing, cheaper drug. This means not doing fantastically expensive interventions on people whose quality and duration of life will be marginally affected. It does mean placing people in the settings in which they can get the most appropriate, cost-effective care, whether at home with or without home health, in a skilled nursing facility, in a long-term care facility or in an acute care hospital. It does not mean requiring that someone who would benefit from a stay in an SNF first have to “qualify” by being in an acute care hospital overnight.

My local paper recently had a big front-page article about the fantastic new technology being employed at our hospital using GPS to map the location on the heart where an abnormal rhythm is being generated, so that it might be able to be fixed. Congratulations to the cardiologists and engineers who have developed this, and to the PR department that got it in the paper. It might be a big help for a few people, and will almost certainly be very costly (and profitable for the hospital). But as we develop all these expensive new technologies that might help a few people a lot and might help a few more a little, it is insane if we save money by not providing what we already know is the right thing in prevention and intervention for the conditions that affect the many. Right now, Medicare is trying to save money by identifying “fraud”; they do this (this is absolutely true!) by contracting with bounty-hunter companies called “RAC”s to discover when a patient has been “admitted” when their condition didn’t technically qualify and they should have been on “observation” status. They should be saving money by not paying for expensive high-tech procedures which offer little benefit.

A rational health care system, as we have discussed before, means that people are getting the right care in the right setting; this is the ostensible promise of health-care integrated systems. But, just as we will never have enough primary care doctors doing prevention and early treatment as long as we pay them a fraction of what we pay those doing heroic (and often ineffective) intervention for far-advanced disease, we will not have a rational health care system if we pay for huge high-ticket items but not for people to be in the right setting for them to receive the care that they need.

Medicare can, and should take the lead. For seniors, it is our national health program. Others will follow.