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.