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.