Holiday update

I am heading to the beautiful, green and rainy Pacific Northwest for the holidays, so this blog will likely be pretty quiet for the next week or so. But I will be back in the new year, ready to continue the discussion on improving communication in health care.

Merry Christmas!

A gift for your doctor?

The New York Times Health blog has an interesting post about the ethics of doctors accepting gifts from their patients. http://well.blogs.nytimes.com/2007/12/21/when-your-doctor-is-on-the-gift-list/. It is, or course, the holiday season, and many patients may want to give their physician a gift to show their appreciation. Small. homemade or food gifts rarely raise ethical dilemmas, but what about more extravagant gifts? Might they raise expectations of entitlement with regards to treatment?

I was encouraged by the guidelines proposed by Psychiatric Times. Among other issues such as the monetary value, doctors are encouraged to consider the impact of accepting or rejecting the gift on the relationship with the patient. Patient-physician relationships are built on trust, and the rejection of a gift may be construed as a betrayal of trust and a great harm to the relationship.

Patients are encouraged to put themselves in the physicians shoes, and keep gifts modest and perhaps consider a gift that can be enjoyed by the entire clinic staff.

I would add, the most valuable gift may be your heartfelt, genuine appreciation. And maybe some cookies.

A patient advocate in an increasingly complex system

The New York Times calls Frederic Riccardi an attack dog disguised as an insurance counselor for the Medicare Rights Center. Riccardi helps elderly patients navigate the complex Medicare system. He endures bureaucratic phone trees at the state and federal level, to make sure patients get the medication and medical care they need. It's a difficult, but important job. And this story shows the difference an advocate, who works to communicate directly with patients and not above them, can make in the lives of patients.

See the story here: http://www.nytimes.com/2007/12/18/health/18tren.html?ex=1355634000&en=513a31769b8713f0&ei=5124&partner=permalink&exprod=permalink

Update on Ransom Ads

The Wall Street Journal Health blog reports that the NYU Child Study Center is pulling the controversial "Ransom Notes" public awareness campaign. The intention of the campaign was to raise awareness of the problem of untreated mental health illnesses in children. But many protested that the campaign went too far.

The NYU Child Study Center says they will continue the dialogue on mental illness in the coming year. See the link to the study center statement here: http://www.aboutourkids.org/about_us/public_awareness##

Miss Evers' Boys

The Tuskegee syphilis study is a horrific example of medical researchers abusing participants in the name of science. The abuse is almost hard to fathom in the abstract: researchers allowing African American men to die from syphilis despite known effective treatment. The abuse becomes all the more real when you hear the individual stories of the men affected by the 40 year study. The stories come alive in the movie Miss Evers' Boys. No one advocated on behalf of these men. No one spoke up to protect them. Those who tried to speak up went unheard. Nurse Evers tried her best to care for the men and nurse them in their time of need, but even she was lead to believe that letting these men die was the best she could do for the future of science.

Jumping through institutional review board hoops can be aggravating at times, and may even seem to inhibit research. But these regulations are in place to protect real people. And protecting the rights and safety of research subjects needs to be as important as the data being collected.

Desperately seeking a kidney

The New York Times Magazine had an engaging story about a woman seeking a kidney donor on Sunday. You can find the story here: http://www.nytimes.com/2007/12/16/magazine/16kidney-t.html?ex=1355374800&en=23384ef453ea4cdb&ei=5124&partner=permalink&exprod=permalink.

There is a huge shortage of transplantable organs. And many believe living donors may be an answer to that shortage. But the donor takes on a tremendous psychological burden. Many potential donors end up backing out when the full weight of what they are considering sets in. And the person receiving the transplant takes on a potential burden of a lifetime of guilt as well. These are difficult questions and the author doesn't pretend to have all the answers. But they are important questions to consider when it comes to the future of organ donation.

Does this campaign go too far?

A campaign by the New York University Child Study Center to raise awareness of the silent public health epidemic of child mental health illness is getting people's attention and raising eyebrows. The campaign uses billboards and advertisements depict ominous threats about depression, autism, obsessive-compulsive disorder, Asperger's syndrome and bulimia. For example, the autism ad reads: "We have your son. We will make sure he will no longer be able to care for himself or interact socially as long as he lives." The idea is to raise awareness of how mental health illness "kidnaps" millions of children. See an article in The New York Times here: http://www.nytimes.com/2007/12/14/business/media/14adco.html?ex=1355374800&en=8bf0e7a608ccac2b&ei=5124&partner=permalink&exprod=permalink

But some are concerned that these ads go too far. Some worry that these ads only further stigmatize these illnesses. Others are concerned the ads cast the young people who live with these illnesses in a negative light, that these young people are trapped, when families spend so much time trying to emphasize the things people with these illnesses can achieve.

But these ads are getting people's attention and they are getting people talking about mental illness. Isn't that the idea? Or is this the wrong way to get people talking?

Giving is good for you

The New York Times ran an article and blog today about the psychological benefits of giving to others http://www.nytimes.com/2007/12/11/health/11well.html?ex=1355115600&en=8759bebe20b79539&ei=5124&partner=permalink&exprod=permalink and http://well.blogs.nytimes.com/2007/12/11/are-you-a-grinch-or-a-giver/.

It's easy to rail against the materialism of the holiday season. The materialism does after all take the focus away from the true purpose of the season, that is the celebration of the birth of the Messiah. And I have my own cache of holiday nightmare stories this season. But I do love the joy and apparent psychological high of giving a great gift to someone I care about and love. I especially love giving special handmade gifts. So when the craziness of the season threatens to steal your joy, the answer may be to find the nearest Salvation Army bell ringer and get a little high from giving.

a little bit of looney fun

The Wall Street Journal Health blog had a little fun this morning http://blogs.wsj.com/health/2007/12/07/hospital-casting-call-st-looney-tunes/. The blog points readers to another health blog Aggravated DocSurg who has a little fun casting the usual characters found in a hospital as Looney Tunes characters. http://docsurg.blogspot.com/. Sometimes the best thing you can do is have a sense of humor.

For the record, I am not a doctor, but I feel like Sylvester at the Looney Tune hospital.

research safety and efficiency

Research safety and efficiency? Does that seem like an odd combination? Might someone even say impossible? Well I don't know about that, but I do know some of the mechanisms in place to keep research safe and to protect the rights of participants can seemingly bog down the research experience, not to mention increase the cost. The Wall Street Journal Health blog reports on an effort by Duke University and the FDA to improve the nation's clinical trial process http://blogs.wsj.com/health/2007/11/20/duke-fda-put-clinical-trials-on-the-examining-table/.

No matter the changes to the clinical trial process, patient safety must remain paramount. Every regulation has a face behind it. The regulations are in place because there has been terrible abuse among research participants. But efficiency is also a worthwhile goal. And an efficient clinical trials process may mean that drugs get approved sooner, at less cost, but are still properly examined for safety and efficacy.

Reforming the clinical trials process will be an arduous task. But it is a process that will only succeed if the parties involved keep their eye on the goal of safe and efficient clinical trials and not exclusively on the fiscal bottom line.

doctors and professionalism

The New York Times Health blog posted an article about a recent Annals of Internal Medicine survey about doctors and professionalism http://well.blogs.nytimes.com/2007/12/03/how-professional-is-your-doctor/.

Especially concerning is the number of physicians who are aware of and do not report medical errors. But there is a larger, systematic issue at play here. We cannot expect physicians to report medical errors when the system is stacked against them. There is a huge professional liability to reporting errors, whether your own or a colleague's. And while we can hope that a physician's ethical beliefs would cause him or her to rise above this, we cannot depend on it. I'm not saying that there are no situations in which the doctor should be held liable. But health systems have to work on a way that encourages doctors to report risks and errors without a constant fear of legal implications.

a public face on a misunderstood disease

OK, I'll admit it. I've occasionally watched America's Next Top Model (not regularly, just when I need background noise when working on a craft project). Well this exceedingly shallow show proved to be a launching pad for one young woman, and I'm not talking about launching her modeling career. Heather Kuzmich, one of the contestants, has the neurological disorder known as Asperger’s syndrome. Asperger's is considered a form of autism and can manifest itself in social awkwardness and trouble making eye contact. And now this young woman has found herself as a spokeswoman of sorts for the cause. Audiences have seen the awkward manifestations of the disease in Heather's behavior on the show. And this has given her a platform for raising awareness. http://www.nytimes.com/2007/12/04/health/04well.html?ex=1354510800&en=43391992a37eb3ac&ei=5124&partner=permalink&exprod=permalink.

Other public figures have put a face on poorly understood or socially stigmatizing diseases by their disclosure of living with the disease: Betty Ford and breast cancer, Magic Johnson and AIDS. If anything, these public persons open the door to creating dialogue about these diseases. And whether or not they sought the spotlight or were thrust into it, these people may in some ways find it empowering to tell their story. And they might just help others find their voice along the way.

Health care and the movies

'Tis the season for serious award-seeking movies. And it seems the health care industry is playing a starring role in several movies this season. And these aren't just your usual doctor as a character in a love story or even your run-of-the-mill good old hospital drama. These movies are taking on issues such as living with paralysis and the terror of waking in the middle of a medical procedure. You can see the blog on this topic on the Wall Street Journal Health blog and links to reviews of the movies here: http://blogs.wsj.com/health/2007/11/30/health-care-now-playing-at-a-theater-near-you/.

Personally, I'm not entirely surprised that health care is playing such a role at the movies. These are stories of life and death, stories of how we live and how our lives affect the lives of the people around us. That's compelling human drama.

Question of the week

The Wall Street Journal Health Blog's question of the week asks whether we can force people to make better health decisions by making the healthier option the default option. Some of the examples include making water the default drink on combo meals and automatically scheduling routine screenings such as colonoscopies, rather than waiting for patients to remember to schedule them. You can find the article and intriguing discussion here: http://blogs.wsj.com/health/2007/11/27/to-push-healthier-choices-reset-the-default/.

There is something in us, whether it be human nature or good old U.S. individualism, that rails against anyone telling us what to do. We don't like to be condescended. But at the same time, sometimes we're lazy and we just go with the default decision rather than putting the effort into making an alternative decision. Maybe making the healthy decision the default decision would do some good. After all, it is in the public interest if we can improve the health of the population. But what limits on our freedom to make unhealthy choices are we willing to implement? Is making the healthy choice the default choice even a limitation at all?

Text messaging for your health

I'm still catching up on articles from the Thanksgiving holiday, but this article from The Wall Street Journal caught my attention http://online.wsj.com/article/SB119551720462598532.html#. Drug companies and other health services are sending health information to patients by text message. Of course, there are limitations to what information you can convey in a brief text message. You can't get into the details of a diagnosis. But you can send a message to a patient to remind him to take his pills. Or a patient could ask a question and receive a text message answer about how to adjust insulin for eating at a party or what to do when a condom breaks. It is, above all, imperative that this information be accurate and understandable (especially in abbreviated text language). But as more people embrace text-messaging technology this may be another avenue to access health information and get quick and accurate answers to emerging health questions.

Dr. Drug Rep

I am still catching up on my reading after the holiday weekend, but one article garnering a great deal of attention is The New York Times article about the relationship between doctors and pharmaceutical companies in "Dr. Drug Rep" http://www.nytimes.com/2007/11/25/magazine/25memoir-t.html?ex=1353560400&en=5681ba7698e69709&ei=5124&partner=permalink&exprod=permalink.

Dr. Daniel Carlat, an assistant clinical professor of psychiatry at Tufts University School of Medicine, found himself intoxicated by the quick cash he was making as a paid speaker for Wyeth Pharmaceuticals. At first, he felt OK about the talks he was giving and even justified the talks as important education for primary care doctors. But as more research emerged, Carlat was less enthusiastic in his talks. And after a year and a talk in which he was more candid about potential side effects, Carlat gave up the gig. He now publishes The Carlat Psychiatry Report, "a medical-education newsletter for psychiatrists that is not financed by the pharmaceutical industry and that tries to critically assess drug research and marketing claims."

Money is a powerful incentive and it has the potential power to cloud a researcher's judgment. The story is an important reminder to place safeguards on research and research incentives.

Bonus post: 21st century snake oil

This is just an interesting story from The Seattle Times aboutthe 21st century snake oil http://seattletimes.nwsource.com/html/localnews/2004020598_miraclesplit18m.html

When the patient is a googler

Everyone seems to have an opinion about a Time magazine story "When the patient is a googler," found here http://www.time.com/time/health/article/0,8599,1681838,00.html. As usual, the comments on the New York Times Health section is busy http://well.blogs.nytimes.com/2007/11/19/a-doctors-disdain-for-medical-googlers/.

I can understand physicians frustrations with patients who use Google as their first source of medical information. But I think it is too easy to paint doctors as paternalistic jerks who just want their patients to be quiet and do as they are told. I have always contended that health and effective physician-patient communication is a two-way street. Yes it is important for doctors to be open, use understandable language and listen. It is important for doctors to be respectful and to help facilitate a patient's autonomy. But patients also have a responsibility to be honest about their symptoms, to be polite, to appreciate and respect their doctors expertise, and to not create a hostile communication environment. If you come in second-guessing every thing that comes out of the doctor's mouth and act like you have as much medical expertise just because you found a couple articles online, you can expect to be met with some annoyance, if not outright hostility. Not to say patients shouldn't come to the doctor's office prepared. To facilitate effective communication, I believe patients do have a responsibility to be prepared for their appointment by having a list of their medications and even preparing questions in advance, including perhaps questions about medical stories they saw online or on television. And patients should not be afraid to ask questions or seek a second opinion as necessary. But as with most things, patients and physicians must strike a balance. And sometimes the most important part of communication is politeness by all parties.

Every regulation has a face behind it

Today I attended the Association of Clinical Research Professionals Southern Wisconsin chapter Fall symposium. The most passionate and engaging speaker of the day was Barbara Davis of The Clinical Research Center of Northwest Florida, Inc. Her topic was the process of consent, a topic that is familiar territory for these types of conferences. But Barbara spoke with the kind of passion that can make any topic interesting. Her point was that informed consent should be a process and a conversation, not just a technical form. She was sincerely emotional when talking about the fact that every regulation we as research professionals have to go through has a face behind it. Every procedure for consent is because of some research atrocity that has happened in the past, whether Nazi doctors experiments on Jews and gypsies or American doctors in the 20th century withholding life-saving syphilis treatments from African American men in the name of research. She reminded the audience that it is the participants that take all the risks of medical research. We are in charge of protecting their rights.

It was refreshing to see the topic presented with such passion.

The power of stories

The New York Times runs occasional essays about patients living with diseases and doctors who dedicate a lifetime to treating a particular condition. The power of words makes the reality of the consequences of these illnesses tangible. And they allow patients and doctors to tell their stories, to have a voice. I found this story about a woman who has lived with sickle cell disease especially interesting http://www.nytimes.com/2007/10/09/health/09essa.html?ref=health. So many sickle cell patients are disrespected and discounted as drug seekers. Often times, doctors and nurses accuse these patients are faking the pain to get pills. But if you take the time to listen, you may see the pain they are living with and their desire to keep living.

This and other stories are archived in the Health section on the New York Times web site.

a child's right to privacy and public health

I've been passively following this developing story in Minnesota for a while because it hits close to our project at MCW. A growing group of privacy advocates in Minnesota is concerned about mandatory newborn genetic screening. They claim that the screening amounts to involuntary genetic testing with unknown future implications for employment and insurance. You can see the story here: http://www.startribune.com/1244/story/1541400.html.

It is a concern. From a public health perspective, you want to catch these deadly diseases and screening does do that. Newborn screening absolutely saves lives. But it means that the state has access to a child's personal genetic information, and as such has access to the family's genetic information. Of course, the state has access to all sorts of information about all of us, but when you throw genetic information into the mix, you inevitably raise concerns about the potential for genetic discrimination and eugenics.

Of course, the parents who have a child who is alive because of screening or lost a child because screening was not offered in their state, most passionately wants screening to be required. Privacy means very little to you when faced with the prospect of something that could save your child's life. Still others remain concerned about government intrusion on private lives, and the unknown future consequences. Check out more parent and citizens responses here: http://www.startribune.com/blogs/comments/?p=54#respond

The importance of communication and trust

I am still catching up on The New York Times Health section and I came across this article on clinical trial participants who never hear the results of the trials in which they have participated http://www.nytimes.com/2007/10/30/business/30device.html?ex=1351483200&en=168720f2e6ca47ba&ei=5124&partner=permalink&exprod=permalink. Congress recently passed a law requiring drug and device manufacturers to release the results of clinical trials for products that are on the market. But there is no requirement to release the information for drugs and devices that never make it to market. There are reasons for this of course, including not wanting to disclose results for products still in development for competitive reasons. But the failure to disclose results is particularly problematic for participants in device trials, who may end up with the device well beyond the duration of the trial. And if a participant develops complications and finds out other people had similar problems and the manufacturers and doctors involved in the research never disclosed such problems, it can breed mistrust among research participants. Communication is the key to making sure participants are fully informed about the risks and benefits of trial participation. Anything less than full disclosure opens the door to mistrust.

the cost of publishing

This afternoon I went to the Bioethics Grand Rounds at the Medical College of Wisconsin where the speaker was Dr. Doug Diekema of the University of Washington. Dr. Diekema was the ethics consultant on the "Ashley Case." In 2004, the parents of a severely disabled 6.5 year old girl approached doctors to slow Ashley's growth so that they could continue to care for her at home. The ethics committee at Children's Hospital and Regional Medical Center in Seattle was convened and the 20 member panel ultimately decided it was in Ashley's best interest to agree with the parents request. Here is the parents story http://ashleytreatment.spaces.live.com/blog/.

What struck me about Dr. Diekema's recounting of this story was the fact that there was no media attention, no pubic outcry, until after the story was published in the journal Archives of Pediatric and Adolescent Medicine. This was an important case. It needed to be shared with the medical community. So much of medical and scientific research is about collaboration and learning from what others have tried. But in doing so, the doctors opened themselves up to so much criticism and misunderstanding from the mass media, from disability advocacy groups, and from other doctors. When the story was picked up by the media, two years after Ashley's treatment, it absolutely changed the lives of the doctors involved, the parents, and the institution where this all took place. Sometimes medical research carries a very personal cost, even for the researchers.

Hey, I just said that

I was catching up with the New York Times Health section this afternoon and I saw this blog about portrayals of doctors and hospitals on television http://well.blogs.nytimes.com/2007/11/05/at-real-hospitals-less-traumaand-drama/. This blog was about a Stanford Medicine Magazine article http://stanmed.stanford.edu/2007fall/med-tv.html about doctors and medical students reactions to medical television shows. Many of the doctors interviewed are not so much concerned about the technical details as they are about the unrealistic portrayals of day-to-day life in these clinical settings. For example, the time from a patient arriving in the ER to the time that patient is having open heart surgery is unrealistically short. Of course, television condenses time for the sake of moving the story along. And there is a lot more sex going on in television hospitals than in real clinic settings. Real interns and residents do not have the time for leisurely lunches and casual sex as the doctors on Grey's Anatomy.

Of course, television is about entertainment and not necessarily realism. And as I mentioned in a post earlier last month, many professions feel the same way as doctors about how their respective professions are portrayed on television. Still, it's fun to listen to doctors play television critic.

doctors and coercion

OK, I'll admit it. I watch the melodramatic soap opera that is Grey's Anatomy. And something struck me while I watched last week's episode: coercion by doctors. In one scene, one of the doctors talked a young woman into the shoulder surgery she needed by telling her she would have a hunchback on her wedding day if she didn't have the surgery. In another scene, another doctor talked a patient into a risky heart surgery by telling the patient, an avid birdwatcher, i was the only way he could live to see a rare bird.

Of course, this screams coercion and doesn't even remotely resemble anything like informed consent or patient autonomy. But in both scenes, the doctors were looked highly upon by their colleagues and supervisors for talking the patients into the surgeries.

It makes me wonder, is this how people see doctors? It's not like this show is written by doctors. It is written by people who have interacted with the health care system as patients or as family members of patients. Do people see doctors as coercive and paternalistic? And no one on the show seemed outraged by this coercion. Do people think this paternalism is OK? Or do they not expect autonomy in medical decision-making because they have yet to truly experience it themselves?

Another cool blog

This one is from Jay Barnhardt, director of the National Center for Health Marketing at the U.S. Centers for Disease Control http://www.cdc.gov/healthmarketing/blog.htm.

Social marketing has the potential to be a powerful tool in health promotion and communicating health messages to the general public. Check it out.

small steps not enough?

The Ad Council is running a series of public service announcements encouraging people to take small steps to combat obesity. But at least one doctor from Center for Science in the Public Interest thinks the ads don't go far enough to address the serious consequences of obesity, especially compared to the gruesome anti-smoking ads that are now commonplace.



What do you think?

I first heard about this story from The Milwaukee Journal-Sentinel http://www.jsonline.com/story/index.aspx?id=679370

Grumpy old docs not quite as grumpy

That was the headline of a recent Wall Street Journal Health blog entry http://blogs.wsj.com/health/2007/10/26/grumpy-old-docs-not-quite-as-grumpy/. A survey asked doctors age 50-65 if practicing medicine was more or less satisfying than 5 years ago. In 2004, 74% of doctors said yes, practicing medicine is less satisfying than 5 years ago. In 2007, 52% answered yes. And while the title said grumpy old docs are less grump, the responses to the post leaned more towards grumpy than not. Make no mistake, medicine is a difficult, demanding profession. You have to be dedicated to spend that much time in school and training, and go into immense debt, to work in a system with less autonomy and falling reimbursements.

In all things, you have to love what you do. And physicians have to love what they do if they are going to make any effort to do it better.

What if they have no good examples?

Today I heard a presentation from Dr. Rachel Bonnema on teaching residents how to disclose medical errors. She is finishing a fellowship in internal medicine at the University of Pittsburgh in General Internal Medicine and Women's Health and was asked to develop a curriculum for the OB-GYN residents to teach them to disclose medical errors.

These are certainly high level communication skills. Numerous studies have found that patients want and expect physicians to disclose medical errors, but physicians rarely disclose such errors, for any number of reasons from fear of lawsuits to the belief that patients don't want to know.

So Dr. Bonnema set out to design an innovative curriculum, complete with standardized patients (trained actors who actually cry). It's an intense experience for the residents and Dr. Bonnema is planning to do follow-up research to see if the training sticks.

But one of the questions raised was how do you teach residents a skill that practicing physicians do such a poor job of themselves? The residents may have no mentors after which to model their communication skills. It is a difficult tide to turn. Once these physicians are in practice outside of the confines of residency, they can easily fall into the practices of the physicians around them. This is a question for all physician communication training programs conducted in medical school and residency. How do we get this training in effective communication to stick once these young doctors are in the working world, surrounded by doctors who may not be good examples? How do we inspire young doctors to turn the cultural tide?

The Wall Street Journal health blog posted this related blog on Wednesday http://blogs.wsj.com/health/2007/10/31/does-medical-liability-mean-never-saying-youre-sorry/

This is disturbing on multiple levels

Siemens Medical Solutions is running a shameless promotion to give away a free MRI machine to the hospital which creates the most popular web video http://www.winanmri.com/. On one level, it is entertaining to watch mostly small town hospital staffs create these videos promoting themselves. But it is a sad commentary on the state of the medical culture in this country that small hospitals can't keep up with the pace of medical equipment and that the culture demands expensive and state-of-the-art medical tests that may not always be necessary. Medical equipment is a lucrative business.

I read about this on the Wall Street Journal's Health blog, which covers a broad range of interesting health and health policy topics http://blogs.wsj.com/health/2007/10/24/hospitals-beg-for-mri-scanner-via-video/.

(My apologies for the previous error attributing this to the Washington Post.)

No one can use a laugh more than residents

With the exception of nurses, residents seem to be the most over-worked and under-appreciated members of the hospital staff. But you have to have a sense of humor about such things and that's what Dr. Jordan Safirstein brings in his web site stoppagingme.com. He started the web site when he was a resident and is now a fellow, so he is still championing the resident and student cause. Features include celebrity illness, hospital fashions, and my favorite, the top 5 list http://www.stoppagingme.com/top_five_list.php. Check it out.

Is it better to steal hope or give false hope?

This is a difficult question.

Often times, doctors find themselves faced with a distraught family who desperately wants to know what the prognosis is for their loved one. And the doctor may not know yet. It can take days for a doctor to know what the real prognosis is. So often times, the doctors find it easier to give the worse case scenario. They figure it is better to set expectations low, to brace people for the worst, and if the patient improves, everyone will be happy.

But as the blog from todays nytimes.com states, this isn't neccessarily the best answer http://well.blogs.nytimes.com/2007/10/22/when-doctors-steal-hope/. The family featured in the blog was given a terrible prognosis when their grandmother came in to the emergency room having a stroke. When the grandmother recovered, they felt like they couldn't be upset about the vitality she has lost because they felt they needed to be grateful that she survived. "But because the doctor initially said the woman would die, they feel like they are no longer entitled to grieve for her lost vibrancy — after all, she’s alive. And their premature grief has come with a cost, stealing away precious emotional energy they now need to help with a long recovery."

The better answer is for doctors to spend more time with the patients' families and offer the full range of possibilities of prognosis. Take the time to discuss what could happen and listen to the fmialies questions. Don't be afraid to express and explain uncertainty.

All of this, of course, requires something in short supply in most hospitals and that is time. But that little extra bit of time means everything in the world to the patients and families who have been given the greatest gift: hope in appropriate measure.

Dr. Jerome Groopman has written two enlightening books on the topic of doctors and how they interact with their patients: The Anatomy of Hope and most recently How Doctors Think. Both should be required reading for doctors.

ICCH Conference

A group of physicians at Ohio State University developed a series of videos featuring patients talking about the pain, fatigue and depression associated with chemotherapy. Ineffective communication is a barrer to effective management of the side effects of cancer treatment. These videos are given to new cancer patients to facilitate their own conversations about their symptoms.

Someone asked what the researchers did if a new patient didn't want to view the videos. The researcher said they usually gave the patient the video anyway because the they found the patients generally benefit from hearing from the patient advocates on the video, even if it is more information than they say they want.

This seems to fly in the face of the idea of patient autonomy. But it is probably true that the patients who are initially hesitant to watch these videos ultimately benefit from them. Is it ever OK or even neccessary to tell the patient more than they want to know?

A death in the funny pages

I promise to post more about the International Conference on Communication in Healthcare, but I wanted to post a link to this article from nytimes.com health blog "Well." The blog reports about cartoonist Tom Batiuk and his long-running comic strip "Funky Winkerbean." A recent story arc followed one character's struggle and ultimate death from breast cancer http://well.blogs.nytimes.com/2007/10/16/a-death-in-the-funny-pages-stirs-controversy/.

Reactions to the story arc have been widely varied. Some see this strip as inflicting pain in what is supposed to be a family-friendly section of the newspaper. Others express support for Batiuk and thank him for his beautiful portrayal of a very real part of life: death.

I have never really followed "Funky Winkerbean," but I always enjoy the work of authors who aren't afraid to tell a true story, no matter how painful.

ICCH conference day 2

On day 2 of the International Conference on Communication in Healthcare, I heard a presentation by Dr. Somnath Saha of Oregon Health and Science University. Dr. Saha presented his research on communication, trust and racial disparities in HIV care. One of the most provocative points he brought up was that African American patients report better commmunication with their doctors than white patients. But actual observations of patient-physician conversations show that white patients actually are the recipients of better communication; that is, their questions are answered and they are allowed more time to talk during the conversation. So what's happening? The most likely explanation is that African American patients have lower expectations of physician communication. On some level, many African American patients don't expect to be an active part of the conversation, where white patients are starting to expect better communication. As communication scholars seek to make physicians better communicators and help patients ask better questions, scholars also need to raise the level of expectations. All patients should expect their doctors to make an effort to be competent communicators. Our health depends on it.

Questions are the answer

One of the keynote speakers at the International Conference on Communication in Healthcare was Dr. Carolyn Clancy, director of the Agency for Healthcare Research Quality (AHRQ). She shared this Public Service Announcement created by AHRQ and the Ad Council encouraging people to get involved in their health care by asking questions. It's an entertaining spot and hopefully some people will get the message.

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International conference day one

On the first day of the International Conference on Communication in Healthcare I got some great feedback on my research on how nurses’ religious beliefs impact how they communicate with patients about end-of-life care. Here are some of the highlights of the comments and feedback I received:

• Maybe the intrinsically religious people are more prepared to have discussions with patients about end-of-life care. These people know how important religion is in there lives and are therefore prepared to ask about it in their patients lives.
• Some people were surprised by the result that intrinsically religious people are more willing to give patients control. The stereotype would be that very religious people would be more apt to push a certain set of religious beliefs. But there is a difference between dogma and deep intrinsic belief.
• Some people expressed concern about a social desirability bias on the empathy scale, especially among nurses. One way to control for this would be to conduct a study giving nurses the empathy scale and then video tape the nurses in real patient interactions and compare the results.
• The most curious responses seemed to come from my European colleagues. They did not seem to understand why end-of-life care was a religious issue. End-of-life care is certainly more comprehensive in Europe, and in places like the Netherlands, even euthanasia is discussed openly. Some colleagues suggested that religion seems to be more pervasive in American culture than in Europe. Still my European colleagues were very polite and interested in my research. Though one had to keep reminding me to slow down when I was talking, as English was not her first language.

All in all, there seemed to be a good amount of interest in my research and it has renewed my drive to try and get a paper on the topic published in a journal.

International conference on communication in healthcare

I am leaving tomorrow morning for the International Conference on Communication in Healthcare http://www.aachonline.org/programs/internationalconference/. I will try to post from the conference. Otherwise, I will post about all the exciting things I learn next weekend.

Playing doctor on television

I laughed when I saw this article from MSN and Forbes Magazine about how medical television shows get some of their details wrong http://health.msn.com/general/articlepage.aspx?cp-documentid=100171006&GT1=10514. I laughed because I have heard doctors more than once expressing their frustration with medical shows and the expectations they create for some patients. The doctors in my office especially seem to hate House, though I admit I watch it regularly.

Doctors aren't the only ones whose jobs are exaggerated for the sake of entertainment. Ask lawyers and police detectives how they feel about the Law and Order series. Ask a chef about the fabulous apartment Monica on Friends lives in. Ask a journalist about how they feel about the movie Anchorman.

Of course, none of these jobs create life-threatening expectations or fears about going to a hospital. An article in Health Communication and another in Clinical Transplantion in 2005 especially criticized the dearth of stolen kidney storylines, creating unfavorable views of organ donation. Donate Life Hollywood is a foundation trying to remove stolen kidney storylines from television and encourage more shows that show organ donation in a positive light.

The medical community certainly cannot distate how medical stories are portrayed on television, but it can serve as a resource for how to make these stories as compelling, entertaining and accurate as possible.

another newspaper letting a patient tell her story

A few weeks ago I told you about The Seattle Times and its series following Gloria, an 11 year old battling childhood cancer. This week, I came across a series on The Oregonian which was also allowing a patient to share her dying weeks. But this story was very different. The story followed Lovelle Svart, who had terminal lung cancer. But this was not a story about a woman dying from cancer. You see, Oregon is the only state in the United States that allows physician-assisted suicide. This was the chronicle of a patient going through the process to choose "death with dignity."

The link to the series is here http://next.oregonianextra.com/lovelle/about.

Lovelle's story is part of a series called Oregonian Next. Here's how they describe the series: "The Oregonian wants to offer an online home where we can give voice to people who are going through transitions in their lives. They can offer a gift of experiences and wisdom that we all can learn from, whatever comes next."

Like Gloria's series, this series allows a woman to share her thoughts and feelings in her final weeks, and perhaps teach others in the process. Sometimes the best thing we can offer someone in a time of illness is the chance to be heard.

lingering misconceptions

October is Breast Cancer Awareness month and the pink ribbons are everywhere and on everything. Despite the huge awareness campaigns and media coverage, breast cancer myths still abound. The National Breast Cancer Coalition recently published a survey of 1,000 women, asking them questions about breast cancer and risk. The New York Times mentioned the survey in its wellness blog "Well." http://well.blogs.nytimes.com/2007/10/01/despite-awareness-campaigns-breast-cancer-myths-linger/

But even more interesting than the blog, are the comments about the blog. Many posts accused the media of perpetuating myths and furthering confusion about risk and breast cancer. Many people struggle with issues of numeracy and risk perception.

Are the media making it worse?

Last Lecture

I came across a New York Times blog about a Washington Post article about Carengie Mellon Professor Randy Pausch. Earlier in September, he took part in the Last Lecture series, a series of lectures in which professors are asked to think deeply about the topics that most capture them and to give a hypothetical final speech about the topic. But for Professor Pausch, this isn't hypothetical. He is dying of pancreatic cancer. But he refuses to feel sorry for himself or let others feel sorry for him. He even did one-arm push-ups on stage. He took the stage to encourage others to pursue their dreams and to overcome roadblocks on the path to your dreams. He encouraged his colleagues and loved ones to continue to do great things without him.

Here's a link to a clip of the speech:
http://link.brightcove.com/services/link/bcpid452319854/bctid1199157902

Here's the full two hour lecture from Carnegie Mellon:
http://www.etc.cmu.edu/global_news/?q=node/42

Here's someone who is making sure he shares his final thoughts with those he loves and in doing so inspiring us all to go for our dreams.

Doctors on TV

Dr. Farrell was on Fox 6 Wake Up this morning, along with Angela Gill, a research associate who also has sickle cell disease. The intention, at least from our perspective, was to tell people about this event we are holding tomorrow to solicit community input on a new communication research project. We want to get community input on how they would want to hear about newborn screening results from their doctor, what information the patients would want to know.

Of course, talking about counseling isn't sexy. But talking about disease, and pain, and children having strokes, now that's good television. So the anchor steered it more towards the disease itself than we would have liked, rather than about the counseling process and the community event. But Dr. Farrell and Angela both managed to bring it back to the event, and we got a least one phone call about the event because of the appearance. And it was kind of entertaining. And apparently Dr. Farrell's three kids were thoroughly impressed that dad was on television. Not bad for a day's work.

Hear more about the research project I am on

Dr. Mike Farrell will be on Fox 6 Wake Up in Milwaukee on Monday October 2 to talk about his research project on improving physician counseling about newborn screening. So if you are in Milwaukee, and up at 6:50, tune in to channel 6 to learn more about this communication project. http://www.myfoxmilwaukee.com/

Empathy in communication

With physicians pressed for time, it can be difficult enough to effectively communicate with patients, let alone communicate with empathy. Most physicians realize it is important to speak empathetically, but many fail in their efforts.

One of the indicators of quality physician communication we are testing at MCW is empathy. One of the scales we looked at comes from Robert Smith, MD and his book The Patient's Story. Smith uses the mnemonic NURS to help physicians effectively empathize with patients.

Name the emotion: "That sounds sad for you."

Understand the patient's emotion: "I've never had this happen, but I can see how deeply it hurts."

Respect the patient's difficulties: "I like the way you've hung in there and kept fighting."

Support the patient and show this is a partnership: "I'm here to help any way I can. Together, you and I can get to the bottom of this."

Small steps can make a world of difference in making a patient feel confident in the words and actions of his or her physician.

Telling the patient's story

Jerry Brewer of The Seatttle Times has spent the last five months telling the story of an amazing little girl Gloria Strauss and her family. Gloria was fighting neuroblastoma, a vicious childhood cancer. The parents gave Jerry and The Seattle Times full access as they prayed for a miracle for their little girl. They wanted to tell their story. They wanted to share their faith that gave them strength, their hope, their love. Jerry Brewer kept a reporter's journal where he recorded his thoughts on telling this life-changing and career-changing story. http://seattletimes.nwsource.com/html/localnews/2003897807_gloria23.html

Brewer said, "I could have written this series many different ways. I could have focused on the medical side of this vexing disease. I could have focused on the suffering. I could have focused on how a father with a sick child, a wife with multiple sclerosis and six other children struggled as the family's only source of income.

But this had to be about faith.

If I had written about the experience any other way, I would have either ignored or de-emphasized the most pivotal part of the Strausses' lives."

Brewer captured what many families and patients want in their last days. They want their story told. They want to be heard with compassion.

And thanks to The Seattle Times and Jerry Brewer, we all got to share in Gloria's story.

I think I get it now

I have been in a number of health communication forums and seminars where the topic of conversation will come to public relations and the media. Many scientists and medical researchers have a contentious relationship with the media. They admire the idea of disseminating their research to the public, but they hate the way journalists oversimplify the significance of their findings. Journalists don't seem to appreciate nuance and degrees of change. Public relations officials don't fare much better. Medical schools and private foundations love to promote the life-altering research they fund, but the public relations people exaggerate and paint things in such a way to generate media buzz, and in the process lose the true meaning of the results found.

Given my own journalistic background, I always nodded sympathetically at these scientists' lament. But I tried to defend the journalists and p.r. professionals. "They are working with a limited amount of print space." "They have to get the readers attention." "Most newspapers aim for a sixth grade reading level."

But I think I get it now. I have been working on a community outreach event at the Medical College. Our goal is to bring community members in for an awareness event to get community leaders input on our upcoming project to improve communication with parents about newborn screening. But the p.r. hacks are more concerned about what we can do to get t.v. crews there. I don't really care about t.v. crews. I want to publicize the event to the public so that we can get some input and support from the people our project most affects. It's about the research effort and making a difference in the lives of patients. It's not about looking good for the camera.

I get the frustration now.

Why does a doctor need good communication skills?

One of the first things I did when I started my job at the Medical College was to check out the library's selection of books on communication. There were of course a selection of books on topics such health communication case studies and media campaigns as an important element of public health. But many of the communication books targeted at doctors make the argument that effective communication lowers the risk of malpractice lawsuits. It's true of course. People generally don't sue doctors they trust and people generally trust doctors who are effective and empathic communicators. But is that the reason we want and need doctors to be better communicators? Don't we want doctors to be better communicators so they will provide better care?

I imagine I am not the only communication scholar who feels conflicted about this. We know that many physicians are kind empathic people who want to do what is best for patients. And physicians want their patients to understand what they need to know to improve their own health. But let's face it, in this era of managed care and our litigious society, the best way to get a physician's attention is to say "Hey, do this, be a better communicator and you'll have less of a chance of getting sued!" Besides, these books do offer some practical tips, if a bit simplistic. Anything that gets physicians to think twice about their communication skills should be welcomed.

The next generation of doctors

Our Toastmaster's club was invited to give a presentation today to a group of medical students about improving your public speaking skills. The group that invited us to speak was the Asian Pacific American Medical Student Association, so we were expecting the crowd to be quite a few non-native English speakers, but we were impressed by how many American students were there. They seemed to realize that public speaking skills are important to their profession and that they need to build those skills and were willing to give up their lunch hour to learn more (though the fact that the club had food helps).

Ellen, a seasoned Toastmaster, started things off by talking about getting over the fear of public speaking. My assignment was to talk about impromptu speaking, which is relevant to these soon-to-be doctors because they will often find themselves in an impromptu speaking situation when a patient asks an unexpected question. I tried to integrate research about physician-patient communication into my talk, including the 1984 Annals of Internal Medicine study which found that doctors usually only wait on average 18 seconds before interrupting a patient who is talking (JAMA replicated the study in 1999 and they had improved to 23 seconds). The students seemed receptive and appreciative of the presentation. I even got a few brave souls to practice an impromptu speaking exercise.

When I told my boss what I was doing today, he said: "Tell them the two most important things are to think before you speak and to listen. Some students, and even some doctors, never seem to get that." It made me feel good to see that perhaps the next generation of doctors will keep trying to improve communication skills.

Making difficult decisions in the genetic age

A colleague at the Medical College told me about this article that ran in the Sunday New York Times about the difficult decisions patients sometimes are faced with in the era of genetics http://www.nytimes.com/2007/09/16/health/16gene.html?ex=1347681600&en=ead2468f0794dcd8&ei=5124&partner=permalink&exprod=permalink.

As researchers continue to identify the genes linked to particular diseases, ordinary people are left with some extremely difficult decisions. If you know you have a family history of a disease, do you get yourself tested for the gene? What will you do if you find out you do have the gene for a disease? Are you ready to subject yourself to life-altering surgery to prevent a disease you found out you have a 60 percent chance of developing in your lifetime? What if it was a 90 percent chance? What if you find out you carry the gene for a disease for which there is no cure? Then what?

The article also shows the family dynamics of a genetic disease. If someone finds out he or she is a carrier for a disease, it potentially impacts the members of his or her family, even if the family member never wanted to know. These lead to difficult family discussions as family members struggle to come to terms with their shared family history and how the decisions one family member makes can impact the whole family.

Presented with the option of knowing your risk for a disease makes it all the more important to have a doctor you feel comfortable talking to and asking questions. Having a doctor to answer your questions can help you make a well-informed decision and prepare you to face the consequences, whatever the results may be.

Numeracy in health care

Many scholars who study physician communication are concerned about the words physicians use and whether patients can understand those words. Indeed, words are important, but an often over-looked part of communication is how physicians use, and patients interpret, numbers.

One of the doctors in my department at the Medical College of Wisconsin has just received a grant from the NIH to develop a measure of health numeracy. Numeracy is one of the concepts the Institute of Health highlights in its definition of health literacy, but is often overlooked in traditional health literacy research. How patients interpret numbers is important in everything from understanding doses of medicine to the assessing riskiness of a surgical procedure. And I imagine, not many doctors stop and think about how the patients understand the numbers they hear in the course of a visit.

The topic reminded me of a pair of books by John Allen Paulos: Innumeracy: Mathematical Illiteracy and its Consequences and A Mathematician Reads the Newspaper. These are both great books to make you think about the consequences of a society that doesn't comprehend numbers. And it's not just about simple math, but being able to use and apply mathematics in situations such as risk and probability. It is an important alarm that we all need to sharpen our numeracy skills. And physicians need to take the time to make sure their patients are numerically literate.

Health news at the New York Times

Here's another web site aimed at the active health care consumer. The New York Times Health Section http://health.nytimes.com/.

Many patients are becoming more engaged in seeking health care information. And the Internet is filled with information, some, of course, of dubious quality. But the NYT section impressed me with its 3,000+ article archive of news stories about health topics, in a useful search database. It also offers stories on health care policy and health care financing, as one would expect from The New York Times.

Nothing can replace dialogue with a trusted physician, but it is always good to have an additional source of information.

The Mystery of Breathing

I was suprised to see a novel about a competitive neonatal physician at an elite academic hospital described as a "psychological thriller." But that is exactly what The Mystery of Breathing by Perri Klass is. The novel delves into the life of Dr. Maggie Claymore, a gifted neonatal physician in line for a coveted promotion, when an annonymous hate campaign threatens to derail her career. She works in a higly competitive world and the hate campaign not only causes her colleagues to quietly question her credentials, but the events shake Maggie's own deepest sense of her self.

The novel takes the reader between the events unfolding in Maggie's life to the defining events in Maggie's childhood and young adulthood that brought her to where she is. The author manages to articulate the combination of childhood events, adult ambitions and human emotions that mold our very being. And our ability to control who we are and how the world perceives us is fragile indeed.

I was not at all suprised to see that Perri Klass is a practicing pediatrician. You just can't make up the intricacies and oddities of academic medicine. Because of that insight, and the searing look into a women's ambition and soul, The Mystery of Breathing is indeed a gripping psychological thriller.

Distrust and communication in health care

It seems that at least some of the problems with communication in health care come down to distrust. Some people may not disclose information to their doctor because they feel like they can't trust their doctor. If the patient withholds information, the doctor may not have all the information they need to make a diagnosis. If a doctor senses a patient is not being being honest, he or she may be more guarded with the information he or she shares with the patient. And the communication problem perpetuates.

This is even a larger problem when it comes to medical research. Because of past medical research atrocities, such as the Tuskegee syphilis studies, many African Americans are inherently distrustful of medical research. I am now in the process of beginning some outreach efforts for our communication research project at MCW and because it involves sickle cell trait, we have to be even more deliberate in our efforts to reach out to the community. In the past, some have used sickle cell disease and even sickle cell trait as a reason to discriminate against African Americans for certain jobs, so it is easy to see why some people may potentially question our motives for wanting to talk to people about sickle cell disease.

This distrust of the medical establishment is ultimately one of the reasons why physician-patient communication research is so important. Better communication and better understanding can lead to greater trust between patients and physicians.

The Facebook/ MySpace of Health Care

From the same people who brought you Wikipedia, we have Wikidoc http://www.wikidoc.org/index.php/Main_Page. They call themselves the Facebook/ MySpace of Health Care.

When I was teaching I ranted at my students about the evils of Wikipedia, but I have since softened a bit. It is of course not a legitimate primary source, but Wikipedia and Wikidoc are powerful examples of the potential of the Internet as a portal for sharing information. And Wikidoc offers a compelling set of health information for those in the medical profession and lay people seeking information for their own health.

Wikidoc does have more stringent guidelines for editors than Wikipedia, requiring prospective editors to submit a CV. It will be interesting to watch how much they get in contributions, since doctors and academics are usually more worried about publishing in peer-reviewed journals than open-source web sites.

Talking with a white coat

For a lay audience, doctor-patient communication is not some abstract academic concept. It is real life. It is sitting in a stranger's office in a paper gown in an unladylike position and this stranger is using lots of big, unfamiliar words. Even the best-educated, most well-intended among us can get flustered in such a situation.

So for a recent speech at Toastmasters, I offered some tips for how to effectively talk to your doctor. The speech was well-received and I even won best speaker for the evening.

Talking with a white coat

At Toastmasters, we like to think we are all reasonably intelligent and articulate people. But even the most articulate person can be reduced to babbling when confronted with the prospect of talking to a doctor.

Let’s face it: the long wait times and embarrassing questions make many people dread having a one-on-one conversation with a virtual stranger about the most personal of issues: your own health and well-being.

Well no more. Today I will be sharing some strategies for how to successfully and effectively talk to you doctor so you can be an active partner in your care.

We’ll start with some strategies before you even get to the doctor, then some effective ideass for what to do and say once you get to the doctor’s office, and then we will talk about strategies for effective follow-up.

Your preparations for your doctor’s visit begin long before you arrive in the parking lot of your doctor’s office. To begin, make a list of all your questions and concerns. From that list, you are going to prioritize and then create a summary statement. This summary statement is a summary of your main, driving reason for coming the doctor’s office that day. You want to be able to state your primary concern in one or two sentences. Your statement should be specific, be clear, and be brief. For example, “Doctor, I am here today because I have has worsening heartburn over the last two weeks and over-the-counter medications do not seem to be helping.” The reason why it is important to be specific, clear and brief is because communication scholars have found that doctors, on average, usually only wait about 18-23 seconds before interrupting a patient who is talking. So you want to use that time wisely and make sure your primary concern is heard.

If you are going to you doctor to discuss a serious issue, consider bringing a family member or trusted friend with you. The reason for this is cognitive psychologists have found that people who are hearing stressful news may not actually hear everything that is being told to them. That’s why it can be helpful to have someone else also listening to the doctor with you who you can talk to again after the initial shock has worn off. If you do not have someone who can come with you, ask your doctor’s permission to use a personal tape recorder to record the conversation, so you can refer to the tape again later.

And of course, anytime you do to the doctor, you should always bring a list of all your medications and the doses, because if your doctor doesn’t have this information already, he or she is going to want it.

The day of the big doctor’s appointment arrives, and first things first, you need to follow the rules. Arrive on time, if not a little bit early. If you absolutely need to cancel you appointment, give your clinic 24 hours notice, or whatever the policy is for your clinic. The reason this is important is it conveys your respect to the doctor and shows you are serious about playing an active part in your medical care. Also, make sure you have everything you need for your visit, including your list of medications and your insurance cards or any forms you need you doctor to fill out.

Have realistic expectations of your doctor. Your doctor is not a miracle worker, and there is no magic pill to treat every ill. Sometimes it takes time to come to a diagnosis and effective treatment plan. So be patient and be realistic.

Don’t say things that set up barriers to communication, such as: “Doctors never listen” or “All you doctors are pill-pushers,” or “Those HMOs are just out to screw the little guy.” These kind of statements may just make your doctor defensive and will not encourage him or her to be open and honest with you and engage you as an active partner in you health care. He or she will just be in a bigger hurry to get you out of the office.

Be clear about your major concern – what is bringing you in today. Use your summary statement that you prepared ahead of time. Be brief and be clear. Remember the 23 second average; you may not have a lot of time, so you want to use it well.

When you doctor speaks, listen carefully. Taking notes may help. Cognitive psychologists have found that for some people, the act of writing information down can help people process information more than just listening. Plus, you will have a reference for later.

Repeat back key points that your doctor says to make sure you understand. For instance, you may say, “OK doctor, I’m hearing you say this…” If you are correct, the doctor will say so. If you do not repeat it back correctly, the doctor will correct you and perhaps rephrase the information so you can better understand what he or she is saying.

When your doctor asks questions, be honest. Your doctor needs as complete a picture of your health as possible. And to be an active and engaged partner in your health care, you need to be open and honest. While it may be tempting to be idealistic when it comes to questions such as how often you exercise or how many vegetables you eat or how much you drink, it is more important to be honest than idealistic.

Before you leave, make sure you understand what your doctor expects you to do next. If your doctor needs you to get lab tests, make sure you know when and where to get them. If you need a new prescription, make sure you understand the dose and when and how you should be taking it.

If you don’t think you can follow the regimen your doctor has prescribed, speak up before you leave. For example, if you don’t think you will be able to remember to take a medicine three times a day, say so. The doctor may be able to help you come up with another solution. It’s better to let your doctor know that you don’t think you will be able to follow through with a regimen than to just not do it, which can create barriers to the future of your relationship with your doctor.

After you get home from your doctor’s appointment, your work is not quite done yet. Review your notes or tape recording right away. If possible, review your notes with another person. Cognitive psychologists have found that teaching a piece of information to another person can help you retain and understand the information better.

Follow up with your doctor right away if there is something you don’t understand. Sometimes people are embarrassed to call so soon after their appointment. They don’t want to be seen as a nuisance or a bother. But you and your doctor are partners in achieving your best health, and you need to understand the information your doctor has given you if you are going to be an active partner in your care. When you call, often times, there is a nurse or doctor on call who may be able to answer your question over the phone. If not, they will be able to get a hold of your doctor, who can answer your question. So if you find something you do not understand or remember a question you forgot to ask, don’t hesitate to call.

So the next time you get a little reminder postcard in the mail reminding you it’s time to make a doctor’s appointment, or a change in your health you can’t ignore causes you to finally make the call to see your doctor, you don’t need to be intimidated about that conversation with the man or woman in the white coat. With proper preparation, a clear and brief summary of your health concerns, careful listening and immediate follow-up, you can speak effectively and confidently with your doctor, as you work together to achieve what you both want: your good health.

Patients and direct-to-consumer prescription drug advertising

In continuing with my introduction from last night, tonight I am sharing the abstract of a research project I conducted in 2004-05 while a graduate student at Marquette University. This paper won the faculty/MA student symposium best paper competition in 2005. http://www.marquette.edu/comm/grad/symposium_papers.shtml

Patients exerting control with their physician: Bringing direct-to-consumer prescription drug advertising into the conversation

Introduction - With the burgeoning of direct-to-consumer prescription drug advertising, patients can bring in more information from outside sources to the conversation with their physician than ever before. My study examines the potential impact of direct-to-consumer prescription drug advertising on the relationship between patients and physicians.

Theory - The study was guided by relational control theory, which says that conversation partners assert control through patterns of conversation. Relational control stems from the notion that interactional partners assert control through patterns of conversation indicating who is in charge.

Hypothesis - It is expected that patients who bring information about a specific drug to the conversation will exert more control during the conversation. It is expected that patients, who realize the advertisements are produced by the pharmaceutical companies and not government health agencies, will use that information as part of the conversation by asking more questions about their health care.

Data analysis - I examined my hypothesis by analyzing data from a 2001-02 Harvard Medical School survey on the public health impact of prescription drug advertising. I specifically examined responses that indicated that a prescription drug advertisement had caused a respondent to take some action and their satisfaction with the outcome.

Discussion – Patients are indeed asking their physicians questions based on prescription drug advertisements and those questions are not just limited to asking about a specific drug. Satisfaction with the interactions about a drug is relatively high and indicates that patients are satisfied with how their physicians handle their health concerns.

Nurse religiosity and relational control

As a means of introduction to my new blog, I am posting the abstract of the poster I will be presenting next month at the International Conference on Communication in Healthcare http://www.aachonline.org/programs/internationalconference/ I will try to post a pdf of the poster itself once it is finalized.

The impact of nurses’ religiosity on their willingness to relinquish relational control in conversations with patients about end-of-life care

Introduction - Nurses and physicians are taught to approach communication in the clinical setting in a task-oriented manner, but discussions about certain topics such as end-of-life care may bring up personal religious values. The study attempts to examine how religious beliefs may influence patterns of communication in the clinical environment. The study was grounded by relational control theory, which says that conversation partners assert control through patterns of conversation indicating who is in charge. Previous studies indicate it is helpful for patients to have some control of conversations, but medical providers do not always relinquish control.

Hypothesis – It is hypothesized that nurses that are higher in intrinsic religiosity will be more willing to relinquish control. Clinician empathy is expected to be an intervening variable, diminishing the impact of intrinsic religiosity on willingness to relinquish control.

Method – An online census survey was administered to the graduate students in the school of nursing at a Midwestern university. The survey was designed to measure: relational control, as measured by the subscales of dominance and task orientation in Burgoon and Hale’s scale of relational communication; clinician empathy, as measured by the Jefferson scale of clinician empathy; and intrinsic and extrinsic religiosity, whether religious views are held for deep personal reasons or social reasons, as measured by the Maltby and Lewis scale, designed for religious and non-religious samples. Data were analyzed using multiple regressions and one-way ANOVAs.

Results and Implications – Intrinsic religiosity and empathy were both associated with the willingness to relinquish relational control in certain contexts. Many clinicians with intrinsic religious beliefs are willing to let patients guide their own care. Some respondents struggled with the language used on the relational control scales, so future research should consider different methods and language sensitive to the clinical culture to measure relational control in clinician-patient interactions.