November 19, 2008

The Art of Listening

I was reading an article in the Washington Post today about a medical mystery solved. Well, a headline with anything being solved definitely catches your eye. What was most surprising was that this mystery was solved by a doctor who listened.

Seems like such an easy concept. Listen to what is wrong with your patient and then try to figure out a way to help them. Listening is one of the first things we learn in school. So why is it so difficult for doctors? Well in this article, this woman had stomach like flu symptoms for 5 months; she did everything as instructed. She took her medications; saw a gastroenterologist; she even believed it was stress induced. Then after 5 months, she ended up seeing a different doctor because her regular one was out that day. This one listened and recognized the symptoms as a rare brain tumor.

If she never had seen a different doctor, the article said she would have been dead in 6 weeks. Maybe if her provider would have not assumed it was all in her head or the stress from finishing her MBA, she would have been spared the months of agony and years now of recovery. These things happen all the time- we are interrupted or we have a preconceived bias, but I know in my life, I rarely am harming the other person.

The more I research patient/physician relationships, the more I realize the mistakes that could have been avoided or misdiagnosis that could have been spared. I lose so much trust in this system. I’m not an expert, so what do you think? What can we do to fix this problem?

The full article can be read at: http://www.washingtonpost.com/wp-dyn/content/article/2008/11/14/AR2008111403005.html

November 13, 2008

Who do you trust?

The Internet is huge. Not only are more American online than ever before, but there is more information located online, especially health information. More Americans are going online to get second or third opinions about their health issues, instead of relying solely on their doctor.

I personally do not think this is necessarily a bad thing- I have found a lot of good health information online. But how do you separate the good from the bad? What do you risk more, trusting your doctor or trusting the Internet- where anyone can post things?

I am not really sure what the answer for this is except to educate more consumers on how to spot a reliable health information website. I also do not know if trusting our doctors will help either. But I am sure that if more physicians took the time to explain all the options before the choice was made, it wouldn’t hurt. If patients were given more than 20 minutes with their physician, maybe a trusted relationship could grow and have positive results on our healthcare.

The Education of the Patient

Today in my public health class, we had an interesting discussion on chronic illness adherence, which is the compliance of patients to follow “doctor’s orders? such as taking medications or making lifestyle changes according to the recommendations from a healthcare provider. We looked at several facts as to why patients may not follow the recommendations such as environmental and personal factors.

What I thought was most interesting was the question “is it the doctor’s responsibility to educate the patient?. This question referred to a nice chart that explained the progression of a virus, such as the HIV virus, if medication is not taken 12 hours apart like recommended. I wondered if maybe the education is what more patients need to follow “doctor’s orders?.

This discussion reminded me of a NPR report that discussed how many patients taking statins to control their cholesterol would stop taking the medication after a year. It was a small study conducted in Colorado, but it found 2 main reasons why patients stop their medication: “they lack a clear understanding of how the medicines work, and they don't trust their health care providers?.

This drives in the point that we need to mend that once trusted relationship between physicians and patients. Maybe more education and simple explanations are all that is needed.

Report can be found at: http://www.npr.org/templates/story/story.php?storyId=96928250

November 6, 2008

Media Influences Young

We constantly look at leaders in a community to teach young ones appropriate behavior. These leaders can range from parents to health care providers.

Primary care doctors, a specialty losing its lust and once popularity among medical students, would be a prime target to help control the behaviors of American teenagers. They would be the ones to help guide them and inform them about appropriate sexual relations and pregnancies (educators would also be good, but that’s not the focus of this blog). With new research linking promiscuity to television shows, I’m not sure how well we can rely on these community leaders.

Shows that highlight only the positive aspects of sexual behavior without the risks can lead teens to have unprotected sex "before they're ready to make responsible and informed decisions," lead author Anita Chandra said. Chandra said TV-watching was strongly connected with teen pregnancy even when other factors were considered, including grades, family structure and parents' education level.

I find it disturbing how well media can influence teenage behavior. Where have all the positive role models gone to? I’m not sure if seeing a primary care doctor annually would change any behavior among this age group.

Article can be found at: http://www.washingtonpost.com/wp-dyn/content/article/2008/11/03/AR2008110300753.html

November 4, 2008

Quantifying Patient Care

Many service industries in the US require surveys on consumer satisfaction. It is even becoming more commonplace for these surveys to be given to employees to help improve working conditions. However only recently have these surveys being used in the health care industry.

According to a new results in a study conducted by Dr. Ashish Jha, a Harvard health policy researcher, many hospitals fall short in the patient’s eye especially when managing pain, communications and clear discharge instructions. Overall patients were fine with their care, but there was plenty of room for improvements.

The data analyzed was collected by the federal government and was a required survey if hospitals wanted to get payment increases in Medicare rates. What is interesting is that this type of information collection was never done before.

I don’t think hospitals never cared before how their patient care was- I’m sure each hospital chain had its own internal survey, but they never made those numbers public. By having a required survey by the government opens up this system to standardization, ranking, and publicly known results.

All of these could help improve patient care.

Article can be found at: http://www.reuters.com/article/healthNews/idUSTRE49S8YF20081029

October 30, 2008

The Burnout in Medical School

So far in this exploration of doctor/patient relationships, I have only looked at the current issues or problems. What I have yet to explore is how these relationships develop. The only place I can think of where future doctors learn to handle their patients is in medical school.

In an opinion piece by Dr. Pauline Chen in the NY Times, she recounts the multiple issues a med student is dealing with. She says how difficult it was to balance the pressure to succeed, the enormous debt, the sleep deprivation, the hazing from more experienced doctors and the fact that patients continued to suffer despite her efforts.

The article continues with the results of a 2006 study by Dr. Liselotte Dyrbyre and her colleagues at the Mayo Clinic that “nearly half of the 545 medical students they surveyed suffered from burnout, which they defined as professional distress in three domains: emotional exhaustion, depersonalization and low sense of personal accomplishment?. After widening their scope, they found similar results from medical students across the country.

This burnout and exhaustion must have some effect on how these newly graduated doctors deal with their patients. Well in another study, the Mayo researchers found that in the beginning medical students level of empathy was similar to non medical peers. However as burnout increased, the empathy levels dropped.

These students obviously continue in a medical field because they want to help people, but that is not going to happen if we continue to overwork their minds and bodies thus building a barrier to positive doctor/patient relationships.

This article can be found at: http://www.nytimes.com/2008/10/31/health/chen10-30.html?_r=1&ref=health&oref=slogin

October 28, 2008

Politics in the Doctor's Office

Politics can ruin friendships, marriages… we all have heard the stories or experienced this first hand. But can politics have an affect on the doctor/patient relationship? Will disclosure of political views change the dynamic as to cause harm on the patient?

Dr. Manoj Jain thinks this information can have some effect on the delicate relationship. He writes in his article “Elective Surgery Is One Thing, Elective Politics Another?, published today in the Washington Post, that politics should stay out of the doctor’s office. He lists several reasons, but one of the most important is that doctors and patients need to work as a team and conflicting views can make it harder for either side, especially if both sides are very strong in their beliefs.

In the article Jain talked to some colleagues to hear their opinion and each had a different reason as why we need to keep politics out of the office. The reasons ranged from it can cause elevated stress levels to the fact that in less than 20 minutes there are more important things to discuss.

Jain also talked with some patients to hear their opinions. One patient “feared that patients would be hurt if the doctor did not agree with their views?. Another one wanted to be treated for his condition and not take up the doctor’s time.

I agree with this doctor that there is a time and place to discuss the candidates’ views on insurance, but not in the short time in the office. Politics is such a personal thing, and I rarely discuss it with my parents or friends unless they are willing to keep on open mind- of course we all know this almost never happens.

article can be read at: http://www.washingtonpost.com/wp-dyn/content/article/2008/10/24/AR2008102403082.html

October 25, 2008

The Prescribing of Placebos

A new study involving 679 American doctors reports that half of them prescribe placebos to patients according to a New York Times article http://www.nytimes.com/2008/10/24/health/24placebo.html?_r=1&ref=health&oref=slogin

In a way this helps with medical costs, but at the same time I think the ethics are a bit shaky. Is it really ok to deceive patients? That is a big ethical challenge, especially with so many unanswered questions. Such as in a clinical setting will the placebos work better? Will they have the same effect if the patient knows like when the 5 percent of doctors tell the patient what they are prescribing to them?

The American Medical Associaton states that “in the clinical setting, the use of a placebo without the patient’s knowledge may undermine trust, compromise the patient-physician relationship and result in medical harm to the patient.

This practice hurts our trust in our doctor and makes me a little more worried about the health care community. What do you think?

October 21, 2008

Can Financial conflicts hurt you?

One of the major issues affecting the decisions of most doctors is their financial tie with medical device companies or pharmaceutical companies. As funds from government organizations weaken, more researchers have to rely on corporate America for the funds to support their trials on new drugs and procedures. With these financial backings, comes the obligation to shine a positive light on the company.

Unfortunately not all doctors disclose this relationship, which can have a devastating effect on their patient. For example it has happened where a doctor has elected to use certain procedures or devices based on their financial interest or investment in a particular company.

These close relationships are nothing new. But the New York Times published last week an article, “Ties Between Doctors and Stent Makers Queried,? about a government inquiry on these relationships and how they are affecting healthcare.
http://www.nytimes.com/2008/10/17/business/17device.html?ref=health

What I find interesting is how little the American people know about these relationships and how they are affecting their care options. As a health communicator I want to know what I can do to expose these financial ties.

October 14, 2008

What Happen to Quality Face Time part 2

I have just read the most appalling article about our healthcare system. Located in the Washington Post today, “Equal Treatment for the Uninsured? Don't Count on It? is a doctor’s account of how most of the uninsured patients doctors see everyday are receiving unequal and below standard care. With 47 million Americans without insurance, that’s a lot of people who are not receiving adequate care.

How can any morally sound doctor who believes in the oath they took upon graduation, deny full service to any patient they see?

The article explains that the uninsured patient will receive care- the hospital can not turn any person away- but they will get less attention and detailed prognosis than insured or paying patients. The uninsured will receive less medicine, tests or time with the doctor.

Look at these numbers from a 2006 study of 25 primary care practices: in nearly 1 in 4 encounters a physician adjusted clinical management based on ability to pay and 90% admitted to these adjustments. For patients with no insurance, alterations occurred 43% of the time; and for the privately insured, just 19%. I cannot believe this inequality to quality healthcare is happening…

Article can be found at: http://www.washingtonpost.com/wpdyn/content/article/2008/10/10/AR2008101002679.html?referrer=emailarticlepg

October 12, 2008

What Happen to Quality Face Time

I hate it when I go into my doctor’s office and we talk for a quick 5 minutes before she is off to the next patient. I have no time to ask any questions before I’m putting my clothes back on. I have a better relationship with the nurses than my own doctor.

This is the situation for many Americans- so why am I complaining? As long as I have a clean bill of health, right? Well unfortunately it is not that simple- more and more Americans are electing to have expensive procedures, use brand name drugs over generic or choose their own drug plan because they are not engaging in quality time with their doctor.

Simply they do not understand their choices. And this where shared decision making comes into play- if I had known some of the harms and side affects of Gardasil from my doctor, maybe I would have chosen to not have the vaccine.

There are countless health stories out every week about this issue. At the end of September the Associated Press had an article on how more elderly are choosing name brand drugs over generic although their chemical make up is the same- costing the government more in Medicare spending. (http://news.yahoo.com/s/ap/20080925/ap_on_he_me/medicare_generic_drugs)

The New York times had an article on Friday on how a liver transplant patient decided to end her anti-rejection medications which lead to her death- maybe if a doctor had time to talk and understand her issues, one life could have been spared. (http://www.nytimes.com/2008/10/10/health/10chen.html?ref=health)

If doctors had more time to explain complicated procedures and why drugs are needed for recovery, possibly we can start to reverse this downward spiral of American healthcare

October 8, 2008

A New Style of Preventative Medicine

As election time rounds its ugly head into our mass media 24/7, we will be hearing from the candidates time and time again about what issues are most important: the economy, the war in Iraq, and Healthcare.

A big belief in our society is that early diagnosis is good-- the sooner the better. We all should go in for cancer screenings and annual test even if we are perfectly healthy. This belief has become the new method of preventative medicine and is largely supported by both presidential candidates.

Senator John McCain believes that we need to emphasize prevention and encourages early testing and screening. Senator Barack Obama echoes that strategy and believes this will help contain medical costs and improve American health. It is unfortunate that these two candidates don’t understand that extra screenings and annual checkups and tests will cost more money not lower the annual healthcare spending.

H. Gilbert Welch, MD, writes about the consequences of this new form of preventative medicine in the New York Times article Campaign Myth: Prevention as Cure-All. He explains that “early diagnosis may help some, but it undoubtedly leads others to be treated for “diseases? that would never have bothered them. That’s called overdiagnosis.?

These are the people who will be harmed from the extra medicine. For example a patient may have lived their whole life with a benign tumor. Once it’s found, the doctor feels obligated to remove it and therefore the patient is facing more risks than before the screening. This extra medicine cost Americans billions of dollars in health care that does nothing to improve our health.

October 3, 2008

Consequences of Doctor's Pay for Performance

Pay for Performance, P4P, is an initiative started by employers, insurance companies and supported by Medicare to reward doctors and hospitals for quality with extra bonuses for better care. However when does better care become a risk and cause more harm than good for the patient.

According to the Centers for Medicare & Medicaid Services, "the foundation of effective pay-for-performance initiatives is collaboration with providers and other stakeholders, to ensure that valid quality measures are used, that providers aren’t being pulled in conflicting directions, and that providers have support for achieving actual improvement".

So I understand they are trying to improve our healthcare system but is using monetary rewards the best course of action? Doesn't this add more pressure to doctors who already have so much to worry about? Can't more tests and antibiotics prescribed as preventative measures have detrimental effects on the patient- not only on their health but their wallet?

The New York Times article "The Pitfalls of Linking Doctors’ Pay to Performance" out early in September commented on one of these cases- an older male patient was receiving an intravenous antibiotic every day for the pneumonia he never had, which caused and infection and a 2 week hospital stay. Doctors want us to think that they were being cautious by diagnosing the pneumonia early on, but with P4P the hospital actually received a bonus for administering "antibiotics to pneumonia patients in a timely manner".

I am not saying that all doctors are selfish, greedy and want more money, but isn't all this over treatment another costly aspect of our already $2.1 trillion healthcare industry?