Researching and trusting your doctor

Dr. Pauline Chen wrote her column yesterday about Angie's List, an online community where participants can rank and review service providers, and now allows patients to rank their physicians. Dr. Chen observed how when reviewing service providers such as roofers, participants detailed the quality and competence of work, often giving details such as supplies used, quality of technique and even photos of finished products. But when ranking doctors, patients consistently ranked physicians higher for things such as attentiveness, and gave failing grades to physicians who were brusque and rushed. But the reviews of physicians said little about physician's actual medical skills. Dr. Chen then goes on to discuss the difficulties patients have in assessing and researching physician skill and competence, and why patients need to take an active part of their health care by researching and knowing about their physicians.

You can find the column here: http://www.nytimes.com/2008/12/19/health/18chen.html?partner=permalink&exprod=permalink

And the blog and comments here: http://well.blogs.nytimes.com/2008/12/18/in-doctors-we-trust/

What do you think? How should patients take a more active role in their health care? How can patients do this without putting physicians on the defensive?

More on the experience of prostate cancer

I wanted to include two more links with regards to the blog I posted yesterday about New York Times editor Dana Jennings and his articles about his experiences with prostate cancer.

You can find yesterday's Well Blog and comments here: http://well.blogs.nytimes.com/2008/12/15/prostate-cancer-in-the-flesh/

And all of Dana Jennings' articles about his experience with cancer are here: http://well.blogs.nytimes.com/tag/jennings/

Being treated for cancer

Dana Jennings, an editor at The New York Times has been undergoing treatment for prostate cancer. He has been writing occasional blogs for the Well blog and today offers his perspective in the Cases section. Today he write about how he feels that as a patient, he is reduced to an abstraction. But every once in a while, his case becomes real to someone.

It's compelling reading. You can find the article here: http://www.nytimes.com/2008/12/16/health/views/16case.html?partner=permalink&exprod=permalink.

physician disclosure rules

The Boston Herald has an interesting article today about proposed new disclosure requirement for Massachusetts physicians banning expensive meals and trips paid for by pharmaceutical companies and requiring disclosure of payments to physicians to promote certain drugs. The proposed laws are believed to be the toughest in the nation, but one group is still critical of the rule because of what it leaves out: physicians will not be required to disclose payments from pharmaceutical companies for clinical research. The proposal's creators said the exception was made to keep clinical trials in the state, but some activists want the state to do more to encourage physicians to disclose all possible financial interests.

You can find the article here: http://www.bostonherald.com/business/general/view/2008_12_11_Doctor-gift_regulations_loophole_hit:_Pay_for_research_stays_secret/srvc=business&position=recent_bullet

What do you think? Should doctors have to disclose payments from drug companies for medical research? What are the possible pitfalls?

Communication with under-age patients

There was an article in The New York Times today about the unique relationship and communication between pediatricians and pediatric patients. Confidentiality and trust are important in a physician-patient relationship, but what about when the patient is a minor, who asks the doctor not to tell Mom what he or she just said. Of course, it is a different matter when the child's safety is at risk, and there is more consideration given to confidentiality with an older teen. But what about a middle schooler? They are still young, but old enough to want autonomy, and old enough to know when their confidence has been betrayed. It is an interesting set of communication challenges.

You can find the article here: http://www.nytimes.com/2008/12/09/health/09klas.html?partner=permalink&exprod=permalink

What do you think? How can pediatricians approach these young patients?

doctors and sleep

The Institute of Medicine released recommendations last week regarding the amount of sleep doctors, specifically residents, should be required to get. The recommendations are in part, to protect patient safety, as sleep-deprived physicians may be more prone to errors.

But Dr. Pauline Chen raises some interesting questions about whether the recommendations may have unintended consequences by depriving young doctors with the ability to put in as many hours as it takes to learn medicine and also preventing doctors from establishing relationships with hospitalized patients because they have to fit so much into the limited number of hours they can be at the hospital that they sacrifice time at the patient bedside. There are also concerns about problems with hand-offs between doctors at the end and beginning of shifts.

So what do you think? How can we balance physician's education time with patient safety? How can we encourage hands-on learning, but guard against abusing residents with inordinate hours in the hospital? What are the benefits and drawbacks of regulating physician activities like the number of hours they can work?

You can find the article here: http://www.nytimes.com/2008/12/05/health/05chen.html?partner=permalink&exprod=permalink

And Dr. Chen's blog here: http://well.blogs.nytimes.com/2008/12/04/what-if-your-doctor-doesnt-want-to-nap/

Media bias in clinical trials reporting

The ACRP Wire published an article about a couple of journal articles discussing shortcomings in how mass media report on clinical trials. Among the shortcomings, the articles found that media articles failed to report investigators' financial conflicts of interest, information about dose and sample size and methods for randomized trials.

You can find the article here: http://newsmanager.commpartners.com/acrpwire/issues/2008-12-04/3.html

The mass media has the potential to be a great educator about the complex and fascinating world of clinical trials research. How do you think media could report on clinical trials in a better way?

Too much talk?

The New York Times published an article in today's paper about the "Six Habits of Highly Respectful Physicians" in addition to an article from yesterday which shot up to the top of the most e-mailed list: "Arrogant, Abusive and Disruptive -- and a Doctor." These articles about physician-patient relationships generate a lot of discussion. But sometimes the articles put physicians on the defensive. Doctors have a very difficult job, compounded by a difficult fiscal environment, and all the while patients and patient advocates criticize everything from their communication skills to how often they wash their hands. So does all this talk about physician-patient communication, and the brokenness of the health care system and how physicians can and should improve really help anyone? Or is it just complicating the relationship further by putting physicians on the defensiveness?

How can we make these conversations more constructive?

Learning from medical errors

Dr. Charles Bosk, author of Forgive and Remember Reflections on Physicians and Mistakes, spoke this afternoon at the Medical College of Wisconsin 3rd annual Medical Humanities lecture. One of Dr. Bosk's points in the lecture was that an environment that pressures medical staff to make absolutely zero mistakes ultimately harms the staff because it fosters an environment where staff will lie and cover up mistakes and staff will not be able to learn from those mistakes and develop better medical judgment.

So how do we encourage medical excellence and preventing the preventable medical errors, while still fostering a learning environment where medical staff grow and learn from their mistakes?

physician dissatisfation

The Physicians' Foundation released the results of its survey on physician satisfaction, or rather, physician dissatisfaction.

You can find a summary from the Foundation here: http://www.physiciansfoundations.org/news/news_show.htm?doc_id=728872

And an article and comments from the Wall Street Journal Health blog here: http://blogs.wsj.com/health/2008/11/18/doctors-feel-gloomy-financially-strapped/

Such high rates of dissatisfaction with the field raise questions about not only the future of the field and being able to retain enough physicians for society's health care needs, but it also raises questions about the quality of the relationship between physicians and patients today. If so many physicians are so dissatisfied with their jobs, does it make it that much harder for them to do their jobs well? Is it harder to forge a meaningful physician-patient relationship? Or is it the satisfaction of reaching out and helping patients that keeps physicians in medicine, despite all the paperwork and bureaucratic non-sense that takes up so many physicians' time?

A new ad campaign and a speedy response

I think what is perhaps most remarkable part of this story was the speed with which it became so huge.

Motrin released an ad on their web site about "baby-wearing," parents who wear their children in a sling or a wrap, and the ensuing back pain. However, some parents took offense to the insinuation that moms wear their babies because it is trendy and in particular, the lines that "Supposedly, it’s a real bonding experience" and "Plus, it totally makes me look like an official mom. And so if I look tired and crazy, people will understand why." The offended moms and dads took to their computers and responded swiftly and loudly through blogs, Twitter, and even responses on YouTube. The company reacted, though not quite as swiftly as the bloggers, by removing the ad from its web site. Of course, there are already magazine ads on the newsstands and the you can still find the video on YouTube:



I don't want to comment about whether the ad is offensive or not. I'm not a mom, I've never worn a baby sling, I have no opinion. What is fascinating is how quickly a group of people expressed their opinion, spread the message to others, who in turn expressed their opinions and in doing so created a voice loud enough to get a company to change course on a brand new advertising campaign.

You can find The New York Times article and comments here: http://parenting.blogs.nytimes.com/2008/11/17/moms-and-motrin/

What do you think?

This is cool!

So Google's foundation is using the power of its search engine to help in tracking flu data. Google is tracking and analyzing patterns of searches for flu symptoms to track where flu outbreaks may be occurring. It is thought that by tracking the number and location of people searching for terms such as flu symptoms, muscle aches, and chest congestion, they may be able to spot trends of flu outbreaks before health departments see such trends. Of course the data is still being analyzed and will be analyzed through the upcoming flu season, but if this does prove to be a useful tool in spotting flu outbreaks sooner, it would be a free source of important, emerging health information.

Check out the web site here: http://www.google.org/flutrends/

And the NY Times article here: http://www.nytimes.com/2008/11/12/technology/internet/12flu.html?partner=permalink&exprod=permalink

clinical hypnosis

This article is from last Monday but I just came across it today. The New York Times printed an article last week about clinic hypnosis, not the stuff of stage shows, but the hypnosis that can help patients reach health goals. Hypnosis doesn't work for everyone. And hypnosis can't make you do things you don't want to do. But hypnosis can empower some people to achieve goals such as to quit smoking or get over a fear of flying.

You can find the article here: http://www.nytimes.com/2008/11/04/health/04brody.html?partner=permalink&exprod=permalink

positive reinforcement in medical education

Dr. Pauline Chen writes in her column in today's New York Times about positive reinforcement in medical education. tI's easy for Dr. Chen and any other doctor to come up with stories of abuse and yelling and negative reinforcement directed at medical students and residents by attending physicians. Is the approach detrimental? Is it necessary? Medicals students are learning life and death procedures. And if someone is making a potentially deadly mistake, it certainly needs to be corrected immediately. But is there a better way correct mistakes and teach students along the way?

You can find the article here: http://www.nytimes.com/2008/11/07/health/chen11-06.html?partner=permalink&exprod=permalink

And the discussion here: http://well.blogs.nytimes.com/2008/11/06/no-praise-for-doctors-in-training/

the benefits of voting

I guess it's no surprise, given the historical nature of today's presidential election, that all stories seem to point to elections and voting. The New York Times included an interesting article about research on the psychology and psychological benefits of voting.

Check it out here: http://www.nytimes.com/2008/11/04/health/research/04mind.html?partner=permalink&exprod=permalink

Voting behavior is extremely difficult to predict. But there does seem to be some psychological benefit to making your voice heard.

So if you haven't done so, go vote.

burnout in medical education

The New York Times published an article yesterday about burnout and suicidal ideation among medical students. No one is surprised that medical school is hard. That’s perhaps an understatement. But combine the massive amount of information you are supposed to absorb with an ultra-competitive environment, and the thought that complete failure is just one slip-up away, and you have a group of students ripe for complete burnout or worse. The other implication of this is that such completely burned out students lose the ability or desire to empathize or effectively communicate with their patients. They are just trying to get through the day.

The question is whether anything can be done about this. Medical school is hard. There is a vast amount of information you simply have to learn in a limited period of time. Practicing medicine is hard. There are a million decision that need to be made, many of them a matter of life or death. There is nothing you can do to change that. But can or should medical school try to change or soften the environment in which the students learn?

The comments on this article were varied; everything from those who exhort students saying “Medical school is hard. Deal with it, quit whining, or find another profession,” to those who believe the model for how medical students and residents are educated must be completely turned on its head. Is it a matter of screening incoming medical students better to measure who will be able to handle the high-pressure environment or is it a matter of monitoring students mental health better before the stress gets dangerously high? But if such burnout impacts the students’ ability to ultimately practice medicine, most would agree that something needs to be done.

You can find the article here: http://www.nytimes.com/2008/10/31/health/chen10-30.html?partner=permalink&exprod=permalink

And the comments here: http://well.blogs.nytimes.com/2008/10/30/the-misery-of-the-med-student/

Health messages through song

The New York Times ran an article Saturday about Feliciano Dos Santos one of southern Africa's most popular singers, who writes and performs songs promoting sanitation and disease prevention. It is an interesting look at health promotion in a different culture and also examines the barriers to health promotion. Health promotion is about more than getting health messages to the people, but addressing the cultural and systematic barriers to changing behavior.

You can find the article here: http://www.nytimes.com/2008/10/25/world/africa/25santos.html?partner=permalink&exprod=permalink.

Literature and medicine

The New York Times published a compelling article today about the growing use of literature courses in medical school and residency programs. The courses are intended to help physicians grow and foster empathy for patients. And there is growing research that the programs work.

You can find the article here:http://www.nytimes.com/2008/10/24/health/chen10-23.html?partner=permalink&exprod=permalink

And the comments here: http://well.blogs.nytimes.com/2008/10/23/combining-literature-and-medicine/

One of the most compelling comments was that these courses are indeed valuable, but they should be taught by literature professors, not medical doctors. But some of the doctors who commented on the article disagreed, saying it was more important to emphasis the relevance to the patient narrative rather than literary technique. Like the literature professor, I have sometimes wondered about the fact that M.D.s rather than communication professors teach medical students communication skills. It is not just that literature professors or communication professors hold specialized knowledge about their topic, which they certainly do. It is about the fact that professors from outside the medical field bring a new perspective and push medical students to get beyond thinking like doctors and get them to think as members of the human community. Senior physicians can certainly guide young physicians in how to pull all they have learned together in the patient setting. It seems that if we want a doctor that is technically astute and also expressive and empathetic, there has to be many teachers and many different kinds of textbooks to make that happen.

Patients' stories in their own voice

While at the AACH conference, I heard about a great resource for patients, health care providers and researchers, organized by the DIPEx research group at University of Oxford. The web sites http://www.healthtalkonline.org/ and http://www.youthhealthtalk.org provide patient interview videos and transcripts of patients talking about the many facets and implications of living with a particular disease. Diseases are indexed so that a new patient or a physician seeking to better understand the patient experiences can seek stories by topic. Researchers can access the material as well to gain a broader look at living with a particular illness.

Patient stories provide a unique perspective, especially to new patients, by providing technical information as well as insight into the emotional toll of an illness. And the volume of stories on these two web sites offers a dramatic look at human element of health and illness in a way that you just can't capture in text.

Positive medical experiences

I had a chance to meet and chat with Dr. Shailia Jain, founder and moderator of http://www.thebedsidemanner.com at the AACH conference in Madison last weekend. She started the web site because she wanted a place where people could record their positive experiences interacting with physicians and other health care providers, as well as their hopes for how the provider-patient relationship could improve. With so many bad examples on the Internet and elsewhere, this web site seeks to give physicians a place to learn from good examples and aspire to do better. Check it out.

Counting words

The New York Times published an article earlier this week about Dr. James Pennebaker, a psychologist who counts and studies words and leads a resurgent interest in text analysis. It is a fascinating approach to studying communication, by looking at individual words and patterns among people who use particular words.

You can find the article here: http://www.nytimes.com/2008/10/14/science/14prof.html?partner=permalink&exprod=permalink

And speaking of innovative communication research, I am looking forward to heading to Madison tomorrow for the American Association on Communication in Healthcare Research and Teaching Forum http://www.aachonline.org/programs/aachforum. It should be a great conference and I'm sure I'll be bursting with ideas come Monday.

A book that is good for your help

The New York Times printed an article yesterday about a study out of Duke University. The study examined whether fiction books with health messages impact the health of the young girls who read them. There is some indication that the books with healthy messages certainly don't hurt and may even help.

You can find the article here: http://www.nytimes.com/2008/10/14/health/14well.html?partner=permalink&exprod=permalink

The article generated considerable discussion about the value of hiding messages in entertainment novels and other ways to influence children's health decisions. You can find the discussion here: http://well.blogs.nytimes.com/2008/10/13/books-for-girls-with-a-health-message/.

So what do you think of the approach? Is it just preaching that most girls will ignore? Is it potentially useful? What might work better?

The choices patients make

This article is from last Thursday, but I still wanted to point it out. Dr. Pauline Chen writes in The New York Times about the choices patients make and a new book called Sick Girl by Amy Silverstein. The book offers explores the patient's perspective of being chronically ill. While their lives may have been saved by life-saving procedures such as transplants, they still have to deal with being sick each and every day of their lives. This leads to mixed emotions of being grateful for life but frustrated by life at the same time. And many times, chronically ill patients feel like they cannot express the frustrations and anger about their illness because of expectations that they should be optimistic.

You can find the article here: http://www.nytimes.com/2008/10/10/health/10chen.html?partner=permalink&exprod=permalink

And the discussion here: http://well.blogs.nytimes.com/2008/10/09/the-choices-patients-make/

The power of language

The New York Times published an article about the power of language as it relates to elderly patients. A study to be published in The American Journal of Alzheimer's Disease and Other Dementias found that "elderspeak," belittling language directed toward the elderly, may cause psychological harm. Such language includes referring to elder patients as "sweetie" and "dear" rather than by a courtesy title or behaviors such as discussing the elder's health with an adult child rather than the elder. The psychological harms comes when people mutely accept the attitudes behind the language and develop a negative perception of aging. Those with a negative perception of aging have worse functional health over time.

You can find the article here: http://www.nytimes.com/2008/10/07/us/07aging.html?partner=permalink&exprod=permalink

And the discussion here: http://newoldage.blogs.nytimes.com/2008/10/06/how-not-to-offend-the-aging-a-primer/

The study raises interesting questions about the power of language and the responsibility to communicate with elderly patients in a respectful way. What do you think? Are there other communication relationships and behaviors that have the potential for psychological harm?

A new approach to recruiting healthy research subjects

The Dr. Susan Love Foundation and the Avon Foundation have partnered to take a new approach to recruiting healthy research subjects. They have launched a high profile campaign called the Army of Women to recruit 1 million healthy women to participate as healthy volunteers in breast cancer research. The foundations are also hopefully that more scientists will work on preventative breast cancer research with the available healthy volunteers. Interested women fill out a short profile on the web site and are notified by e-mail of studies in need of volunteers. The women who fill out the profile are not obligated to participate in any of the studies sent to them and the final decision to participate is still left to the individual.

This is an innovative new approach to recruiting healthy volunteers and the images and words on the web site certainly tap into the altruistic reasons that motivate some people to participate in research. In the process, it seems it may also educate more people about the clinical research process.

So check it out: http://www.armyofwomen.org/ The web site includes some current ongoing research, combined with some compelling stories and images.

What do you think of the approach?

Being a bad patient

CNN recently interviewed actor Evan Handler who says being a "bad patient" can save your life. Drawing from his own experiences, Handler says that patients should double check everything, ask questions, and be your own advocate, even at the risk of annoying your physicians and being labeled a "bad patient." Such vigilance can save your life.

You can find the article here: http://www.cnn.com/2008/HEALTH/10/02/ep.evan.handler.patient.advocate/index.html

So what do you think? What behaviors or actions do you think patients should take that may be perceived as "bad behavior" by physicians?

Deciphering medical studies

One of the articles in the Decoding your Health series that ran in The New York Times yesterday was an article about how to decipher medical studies. It does a great job of explaining the different types of medical trials and studies, and illustrates the differences using examples.

You can find the article here: http://www.nytimes.com/2008/09/30/health/30stud.html?partner=permalink&exprod=permalink

drowning in a sea of information

The New York Times published an interesting series of articles today called "Decoding Your Health" about the vast amounts of information that sick and healthy consumers face everyday. As we discussed on this blog yesterday, there is more medical information available to consumers than ever before. And it can be difficult for those of us without a medical background to wade through it all. As one of the authors of the series Tara Parker-Pope said. "Are patients swimming in a sea of health information? Or are they drowning in it?" The articles offer a variety of opinions and tips for wading through the information.

You can find one of the articles in the series here "You're Sick. Now What: Knowledge is Power", with links to the others: http://www.nytimes.com/2008/09/30/health/30pati.html?partner=permalink&exprod=permalink

And the discussion of the article is here: http://well.blogs.nytimes.com/2008/09/29/decoding-your-health/

What other tips would you add to wading through all the information available?

Seeking answers from doctors and the Internet

The New York Times had a first-person essay about the perils of seeking health information form the Internet, from physicians, and then from the Internet again. There is a lot of health information out there in all sorts of different forms - written, verbal, in-person, online and more- and it can be extremely difficult to wade through it all, especially if you do not have an established relationship with a health professional you trust.

You can find the article here: http://www.nytimes.com/2008/09/30/health/30seco.html?partner=permalink&exprod=permalink

So how do you wade through all the information? What can patients and physician do to wade through it all?

missed opportunities for empathy

The Washington Post printed an article today about a study published in The Archives of Internal Medicine about missed opportunities for physicians to express empathy for patients. The study was between lung cancer patients and their thoracic surgeons or oncologists. The relationship of a cancer patient and physician is complex, not only because of complex treatment plans, but because patients are also dealing with emotional issues such as the loss of identity and the fear of death. Patients reach out to physicians, but physicians may feel more comfortable talking about biomedical issues rather than emotional issues, which don't have an easy answer.

You can find the article here: http://www.washingtonpost.com/wp-dyn/content/article/2008/09/22/AR2008092201894.html

So what do you think? What steps can physicians take to better prepare for emotional encounters?

therapy by phone

The New York Times Well blog posted an interesting article about a new study on the benefits of therapy by phone, published by Clinical Psychology: Science and Practice. The phone offers a means for physicians to reach out to patients who can't or won't make it in for face-to-face visits.

You can find the article here: http://well.blogs.nytimes.com/2008/09/22/the-benefits-of-therapy-by-phone/.

Let's consider this from a communication perspective. What aspects of communication might be lost in therapy by phone rather than in person? Could there be benefits of phone conversations over in-person conversation?

Advertising medical devices

A Senate committee met today to discuss advertising of medical devices. While advertising for medical devices, such as replacement knees and heart stents, are a relatively small share of consumer medical advertising, some believe that because of the risks, extra precautions should be taken with such advertisements. Medical devices almost all require surgery and become a permanent part of the patient, and as such are riskier than a pill. But some are concerned that device advertisements aren't being clear enough about the risks.

You can see a New York Times article about the hearing here: http://www.nytimes.com/2008/09/17/business/17device.html?ex=1379390400&en=f81f16144c4b1d4a&ei=5124&partner=permalink&exprod=permalink.

In light of the article I posted yesterday, what do you think? Should medical device advertisements be more closely regulated?

Effects of direct-to-consumer prescription drug advertising

The ACRP Wire published an article last week about a recent journal article about the first randomized control trial of the effects of direct-to-consumer prescription drug advertising. The design of the study, published in the British Medical Journal, was an interesting twist. Direct-to-consumer prescription advertising is only legal in United States and New Zealand. The advertisements are ubiquitous in these countries, so how could you find a group who never saw such ads? The answer to finding a control group was Canada. Prescription advertising is illegal in Canada, but media from U.S. routinely spills over into border towns. So you had a group of English-speaking Canadians who see such advertising and a group of French-speaking Canadians who do not see such ads.

Consumer advertising for drugs is unlike other advertising, because it is not just a matter of motivating a person to buy a product. Drug advertising requires motivating a consumer to make an appointment with the doctor, keep the appointment, ask for the drug, get the physician to give a prescription, and then motivate the consumer to actually fill the prescription. That's a lot of steps between advertisement and sale of product. But for pharmaceutical companies, those steps lead to a potential for a lot of sales.

But does the advertising work? This study showed for some of the drugs there was little effect in prescription rates from the exposure to advertising and with others there was an initial spike in prescriptions that evened out over time. It is an interesting study that should contribute to the conversation in this country about whether such advertisements help or harm health consumers.

You can find additional information about the study procedures and results here: http://newsmanager.commpartners.com/acrpwire/issues/2008-09-11/5.html

Healing the gap between patient and physician

The New York Times is starting a new series of columns to be featured each Thursday dedicated to exploring the gap between patients and physicians. Dr. Pauline Chen will facilitate the conversation, as patients and physicians explore this complex relationship, which is increasingly marked by distrust. I am looking forward to the conversation that emerges.

You can find the first column here: http://www.nytimes.com/2008/09/11/health/chen9-11.html?ex=1378872000&en=0c9fe0a40d188c53&ei=5124&partner=permalink&exprod=permalink

You can find the discussion and comments here: http://well.blogs.nytimes.com/2008/09/11/doctors-and-patients-start-talking/

A nurse's perspective

I have had a soft spot for nurses since I did my Master's thesis on nurse communication behaviors. They provide a tremendous amount of clinical and emotional care in what can be very intense and stressful settings. And they are often overlooked.

The New York Times Cases section offered a rare nurse's perspective. Theresa Brown, an RN from Pennsylvania, who also happens to have a literary background, offers a moving reflection on witnessing death and the lessons for life.

You can find the article here: http://www.nytimes.com/2008/09/09/health/09case.html?ex=1378699200&en=05f3b38d7b5ff8f8&ei=5124&partner=permalink&exprod=permalink

A doctor's attire

The New York Times Health blog reported today about a new British National Health Service directive for physicians to wear clothing that allows for bare arms below the elbows and no longer wear neckties. The intention is to prevent infection transferred through the hems of loose or long clothing. The evidence of this practice is still emerging, and the U.S. has yet to institute such a policy.

Physicians across this country are encouraged to dress professionally, often including a long white coat. But clothing policies raise the questions of how clothes effect patients perceptions of a physician. Would you perceive your doctor differently if he or she was in short sleeves, without tie or white coat?

You can find the article here: http://well.blogs.nytimes.com/2008/09/08/do-you-really-want-to-see-your-doctors-elbows/

Insisting on a test a patient insists she doesn't need

This discussion is from last week's New York Times Well blog but I still think it is worth bringing up. The heated discussion was about physician's who consider women of child-bearing age to be "pre-pregnant," and as such insist on pregnancy tests before certain procedures, even when a woman insists there is no way she could be pregnant.

Of course, it is pertinent for a physician to know if a female patient is pregnant, as certain medications and x-rays are dangerous to an unborn child. And women do not always know when they are pregnant and some may lie about their sexual history and likelihood of being pregnant. But the frustration expressed by many women in the blog discussion shows that some physicians are not approaching this delicate discussion in the most constructive way.

You can find the discussion here:http://well.blogs.nytimes.com/2008/08/28/do-doctors-view-women-as-pre-pregnant/

So how could physicians and patients both approach this conversation in a more positive way?

pharmaceutical hype

My apologies for the prolonged absence. I have been busy preparing for the Association of Clinical Research Professionals clinical research coordinator certification exam coming up this Saturday(http://www.acrpnet.org/MainMenuCategory/Certification/GetCertified/CRCCertification.aspx).

I did want to take a minute to point out an interesting discussion of The New York Times Well blog about the media's role in promoting a new drug. It is a discussion about the HPV vaccine Gardasil, and the large media buzz that in effect promoted the drug when it was first made available to the public. Long-term efficacy data is still emerging about the vaccine causing some to wonder if the maker over-hyped its benefits. But a watchdog group is saying that media coverage when the vaccine was released contributed to the hype.

The report raises interesting questions about the role of media in reporting medical research. Are the media there to repeat what the pharmaceutical companies say about the product or should reporters and editors be doing more to present the meat of the research rather than the promised results?

You can find the Well blog here: http://well.blogs.nytimes.com/2008/08/29/blaming-the-media-for-gardasil-hype/

The life of an intern

The Wall Street Journal Health blog posted an interview with an intern in emergency medicine about the frantic first days of internship. It is extremely hard work, and even at that the intern didn't get a lot of sympathy from some of the commenters. It's hard to comprehend the frantic pace of the work environment, combined with the bombardment of new knowledge coming at you, and the pressure of living up to others' and your own expectations. In some sense, this interview doesn't even scratch the surface. But trying to understand and empathize with the other person's perspective can open the door, just crack, to better communication.

You can find the article here: http://blogs.wsj.com/health/2008/08/22/as-america-hits-the-beach-medical-residents-hit-the-wards/

Jargon use

Our study team at the Medical College recently had two journal articles published about our study of jargon usage among physicians. Jargon can significantly inhibit effective communication between physicians and patients. Our studies are finding that jargon use is frequent and explanations of jargon words are rare. This study in quantifying jargon is a first step in identifying where and how physicians can improve their communication skills.

You can find the abstract of the Pediatrics article here: http://pediatrics.aappublications.org/cgi/content/abstract/122/2/243

And the abstract for the Journal of General Internal Medicine article here: http://www.springerlink.com/content/q2420jr825320181/?p=f33f83aa889b4003aca940ee5bde457a&pi=9

Communicating at the end-of-life

The topic of communication between physicians and patients at the end-of-life is near to my heart, as it relates to my own Master's thesis. But the topic is near to us all because it reaches a primal complex fear: the fear of death.

The New York Times Cases section offers a perspective from a doctor reflecting on a missed opportunity to talk with a patient about her impending death. The physician perspective delves into the complexities of whether discussing impending death is hurtful or helpful and how it can be helpful instead of hurtful.

You can find the article here: http://www.nytimes.com/2008/08/19/health/views/19case.html?ex=1376884800&en=a5e4e3c907bdc83c&ei=5124&partner=permalink&exprod=permalink.

Cancer and Identity

The New York Times published a patient perspective back on Monday, but I wanted to be sure and point it out here. It's about a cancer patient who found herself using humor to create a new identity for herself as she went through cancer treatments. She goes on to tell a little bit about the uncertainty of her identity after the cancer treatments were over.

It's compelling reading. You can find the article here: http://www.nytimes.com/2008/08/12/health/12case.html?ex=1376280000&en=9116e05460b514ff&ei=5124&partner=permalink&exprod=permalink.

Six ways to be a better patient

Last week The New York Times health blog posted an article about six rules for doctors. This week, they posted an article about six ways to be a better patient.

You can find the article here: http://well.blogs.nytimes.com/2008/08/12/six-ways-to-be-a-better-patient/.

So what do you think? What guidelines would you add to be a better patient?

Communicating and healing through nature

My hometown newspaper, The Milwaukee Journal-Sentinel published an article today about healing gardens, green spaces at hospitals around the region and around the country, designed to give patients a place to reflect, meditate and heal. It paints a picture of how healing comes in many forms. Having a place to physically engage in the act of healing, by walking and taking in the sights, sounds and smells of the garden, can do wonders.

You can find the article here: http://www.jsonline.com/story/index.aspx?id=781180

rules for doctors

The New York Times Well blog published a post today about the rules doctors should follow to get along with their patients. You can see the article here: http://well.blogs.nytimes.com/2008/08/07/six-rules-doctors-need-to-know/.

What do you think? What rules do you think doctors should follow to build better relationships with their patients?

ethics of research in developing countries

An article in the New York Times today reports on an article from the Bulletin of the World Health Organization about the ethical questions that arise when conducting research in developing countries. Even with survey research special consideration of the customs, culture and ability to access health care must be considered. Especially relevant is the potential for coercion to participate as some community members may pressure others to participate to access free health care that would not otherwise be available.

You can find the NYT article here: http://www.nytimes.com/2008/08/05/health/research/05glob.html?ex=1375588800&en=f8c5f4265ff56c35&ei=5124&partner=permalink&exprod=permalink

And the WHO article here: http://www.who.int/bulletin/volumes/86/8/08-051037/en/index.html

Empathy and communication

The New York Times printed an interesting article about a new program to teach health care workers and others what its like to be elderly. Participants engage in a series of simple activities, but while wearing equipment that limits the range of movement, sight and touch, simulating the day-to-day life of an elderly person. It is hoped that the tangible experience of feeling what it is like to be elderly will foster sensitivity toward elderly patients, clients and customers. This improved empathy also has the potential to foster better communication between generations, as the younger generation can catch just a glimpse of the physical limitations that may inhibit their elders.

You can find the article here: http://www.nytimes.com/2008/08/03/us/03aging.html?ex=1375588800&en=d3b42e922a1c4746&ei=5124&partner=permalink&exprod=permalink

participating in clinical research

An article in the ACRP Wire caught my attention today. Many Americans recognize the value of medical research but many don't participate because they don't have time. But now more patient self-report studies are being conducted online, giving participants a convenient way to contribute to medical knowledge.

It is exciting to see any industry grow and adapt to new technologies. And the Internet holds much promise in gathering self-reported health information from people all over the world.

You can find the ACRP article here: http://newsmanager.commpartners.com/acrpwire/issues/2008-07-31/2.html

children and the media and sugary breakfast cereal

Nothing stirs passions among communication scholars quite as much as a conversation on children and the media. The influence of media on children has gotten the attention of public health officials, whose attention has turned to the makers of sugary cereals, greasy fast food and fizzy soda. The Federal Trade Commission released a report this week about the pervasiveness of such advertisements and a coalition of food companies released their own report on the progress made on self-regulation of advertising and increasing the nutritional value of foods marketed to children.

Whether the answer is government regulation or self-monitoring, the attention paid to this issue demonstrates the power of mass communication as an influence on children's health.

You can read more in the New York Times article here: http://www.nytimes.com/2008/07/30/business/media/30adco.html?ex=1375156800&en=18798a00c135aaf6&ei=5124&partner=permalink&exprod=permalink.

a rocky relationship

Well this is not news to anyone who works in health care or studies health care, but The New York Times published an article and accompanying blog today about the rocky, and in some cases deteriorating, relationship between physicians and patients.

There are many causes to blame for the deteriorating relationship and everything from the proliferation of health information on the Internet to declining reimbursements to short visit times get blamed.

I believe an effective physician-patient relationship is ultimately founded on effective communication based on mutual trust and respect. This requires open and honest communication in an environment where both parties feel safe. Of course, this is easier said than done in the current health care environment in this country. But it begins with taking a deep breath and trying not to enter the interaction with hostility, no matter how short the time you get with the doctor.

You can find the article here: http://www.nytimes.com/2008/07/29/health/29well.html?ex=1375070400&en=49ba4622b20ecda8&ei=5124&partner=permalink&exprod=permalink and the blog and discussion here: http://well.blogs.nytimes.com/2008/07/28/doctors-and-patients-a-rocky-relationship/.

cosmetic and medical procedures

The New York Times published a revealing article about a trend in dermatology practices across the country. Some dermatologists are devoting more of their clinic time, space and effort to cosmetic patients to the detriment of those seeking dermatology medical problems. And because the cosmetic patients pay top dollar out-of-pocket, these clinics are catering to them with nicer waiting rooms, immediate access to appointments, and longer visit times that those who are paying for medical procedures through insurance.

The article generated some interesting and heated discussion about the responsibilities of physicians, capitalism in medicine, and a two-class medical system in this country.

You can find the article here: http://www.nytimes.com/2008/07/28/us/28beauty.html?ex=1374984000&en=a17cc8b23e040a96&ei=5124&partner=permalink&exprod=permalink

The last lecture

Randy Pausch, the Carnegie Mellon Professor whose Last Lecture became a popular Internet video and later a best-selling book, died today. His lecture didn't focus on dying, but focused instead on living life and working to achieve your childhood dreams and helping others achieve their own dreams. You can now find the lecture at: http://www.thelastlecture.com.

The Wall Street Journal obituary is here: http://online.wsj.com/article/SB121699381188384657.html?mod=hpp_us_whats_news

Slowing down and respecting the moment.

Dr. Jennifer Israel wrote a moving article in the Cases section of the New York Times Health section yesterday about the need, as a doctor, to slow down. Physicians are busy and because they are so busy, they sometimes risk becoming desensitized to the beauty and pain of life and death. So they must make an effort to slow down and take in and respect the moments that make up their professional lives.

You can find the article here: http://www.nytimes.com/2008/07/22/health/views/22case.html?ex=1374465600&en=558e88206d6b356e&ei=5124&partner=permalink&exprod=permalink.

This article also reinforces my belief that it is useful to teach medical students the art of reflection, through study of the arts and humanities. Being able to write and reflect on the experiences of dealing with life and death gives physicians a coping mechanism for facing the particular stresses of their job. But ultimately, it is a lesson we can all learn: to slow down when life seems rushed and take in the moment.

altruism and research participation

A story on last night's NBC Nightly News touched on what of the motivators for participants in medical research that is sometimes not evident: altruism.

The story is about genetic research in Iceland, where most of the nation's population descended from Vikings and many have extensive knowledge of their family ancestry. This means that the people of Iceland offer a potential gold mine of genetic knowledge. Th research is voluntary and many are proud to volunteer for such as effort.

You can find the clip from last night's broadcast here:



The story continued this evening. You can find tonight's clip here:

Compassionate use

The New York Times published an article today that sheds insight into the complexities of medical research, desperate patients and investigational drugs. One mother fought hard to raise money and awareness for her son's disorder, thinking it would help get her son new treatments. But clinical research follows a set of strict protocols for who they enroll in trials with unproven medications. Those guidelines are both patient/research subject safety. But things get complicated when not everyone understands how and why medical research proceeds in certain ways.

It's compelling reading. You can find the article here: http://www.nytimes.com/2008/07/17/business/17dystrophy.html?ex=1373947200&en=9e58936b75dd9b17&ei=5124&partner=permalink&exprod=permalink.

Celebrity effect

Public figures who die from, or openly discuss their diagnosis of a particular illness, sometimes find themselves as the founder of an unintended effect. A celebrity face on an illness cloaked in shame or uncertainty can be the catalyst for the viewing public to get tested or at least raise public awareness. Perhaps the most well-known and studied celebrity effects are Betty Ford and breast cancer and Magic Johnson and HIV/AIDS. Now NBC Nightly News and other media outlets are reporting on the Tim Russert Effect, an increase in middle aged men seeking additional tests and more aggressive management of their heart health after the sudden death of NBC political analyst Tim Russert last month.

You can watch the video clip from Monday's newscast here:



Though the public does not know these public figures personally, many feel as though they can realte to these figures because they are so visible. When one of them gets sick, it may trigger some people who are watching to realize their own risk.

Your doctor and e-mail

Dr. Richard Friedman has an interesting article in the New York Times today about physicians, patients and e-mail. He offers a physician's perspective, from excitement about the time-saving possibilities of e-mail, to fear about possible harms when patients e-mail when they should be calling their doctor or 911. E-mail is great for rescheduling appointments or routine prescription refills. But it is problematic when a patient with suicidal thoughts e-mails his psychiatrist at 3 a.m. instead of calling or when a patient sees a delay in response as rejection.

He asks if e-mail should play a role in the therapeutic relationship?

And if e-mail can play a useful therapeutic role, what role, and how do you safeguard from potential abuse and harm?

You can find the article here: http://www.nytimes.com/2008/07/15/health/views/15mind.html?ex=1373774400&en=a13c40e0a6956439&ei=5124&partner=permalink&exprod=permalink.

Changing health by changing habits

The New York Times ran an interesting article about anthropologist Val Curtis, who wanted to find a way to encourage Africans to wash their hands with soap. When education campaigns failed, she turned to consumer market researchers. Market researchers study the psychology of habits, how habits are developed, and how habits can be manipulated to get consumers to exhibit a certain behavior. The method appears to be working for the hand-washing campaign. Reported hand-washing with soap is up dramatically.

Some people worry about the campaign's manipulative approach and would like to continue to focus on education effort. But where education efforts have failed, working to develop new habits is ultimately saving lives.

You can find the article here: http://www.nytimes.com/2008/07/13/business/13habit.html?ex=1373601600&en=e3072a7b2bc8ebf4&ei=5124&partner=permalink&exprod=permalink.

The power of the pen

No, I'm not speaking in a metaphorical sense. I'm speaking of free trinkets like coffee mugs, notepads, clipboards, and yes, pens, that pharmaceutical companies shower on physicians. The Pharmaceutical Research and Manufacturers of America, the trade association for pharmaceutical companies, has issued a new code of conduct for pharmaceutical companies discouraging companies from giving such trinkets to physicians and prescribers. The concern is that such gifts encourage over-prescribing or inappropriate prescribing of heavily advertised drugs, where older generics would suffice.

Some advocates are lauding this move, but others don't think it goes far enough. The guidelines say nothing about the large amount of money spent on consulting arrangements and speakers fees paid to physicians to advocate for a new drug. The guidelines take away the influences that patients see but do not address the pharmaceutical influences on physicians that patients do not see.

You can find a couple of articles here: http://www.nytimes.com/2008/07/10/business/10code.html?ex=1373428800&en=344e999790b6717d&ei=5124&partner=permalink&exprod=permalink and here: http://well.blogs.nytimes.com/2008/07/11/for-doctors-no-more-drug-company-trinkets/

The best prescription

Sometimes, the best prescription is simply to take a break.

So I'm going on vacation.

"A prescription for better communication" will be back online sometime after July 10.

Your doctor's secrets

The New York Times Health blog pointed to a Reader's Digest article "41 secrets your doctor would never share." And in typical Reader's Digest style, physicians of various specializations from across the country, shared short quotes and vignettes about the practice of medicine, the things that patients do that drive physicians crazy.

The introduction to the vignettes claimed the lessons offered "can help you be a better, smarter patient." But as I read the short quotes, I couldn't help but think many of the vignettes, without context, would cause more harm than good, and perpetuate the stereotype of the physician as hurried, uncaring, and paternalistic. Certainly it would be helpful to understand the frustrations that doctors encounter with patients. But the frustrations of medicine are certainly more complex than they are presented here. It's not just a matter of patient non-compliance, but also the changing context of HMOs, reimbursements, shorter visit times and increasing overhead and malpractice costs. And these quotes also often fail to take into consideration why these men and women went into medicine in the first place and many went into the profession for the noblest of reasons: to help people.

You can't boil effective physician-patient relationships to pithy, memorable quotes. Such working relationships take time and effort to build. Many of the "secrets" offered by RD just seem preachy. And seeing the naked frustrations of the practice of medicine, without context, won't help build the trust necessary to build quality working relationships between physicians and patients. But maybe it can help start a conversation.

You can find the NYT blog here: http://well.blogs.nytimes.com/2008/06/25/what-your-doctor-really-thinks/.

And the RD article here: http://www.rd.com/living-healthy/41-medical-secrets/article75920.html.

What it means to be well

Dr. Abigail Zugar compares and contrasts to doctors' books on health and wellness in today's New York Times. The two books offer close to an opposite approach to health; one advocating screening tests and careful monitoring of the body's systems and the other advocating that the over-medicating of relatively minor problems is causing more harm than good.

Dr. Zugar points out that the contrast points to a discussion about what exactly is wellness? Is wellness the complete removal of disease or is it learning to cope with illnesses without becoming a perpetual patient? What is the emotional toll of always thinking, or even worrying, about health and illness?

Thought-provoking reading: http://www.nytimes.com/2008/06/24/health/24book.html?ex=1372046400&en=8feef82ac9684dd2&ei=5124&partner=permalink&exprod=permalink.

Advice for doctors from a public relations expert

Larry Ragan, founder of founder of public relations firm Ragan Communications, wrote an article years ago about how to hospital staffs should treat patients. The article was originally printed in 1980, but reprinted this week. The sentiments still seem to ring true.

You can find the article here: http://www.ragan.com/ME2/Audiences/dirmod.asp?sid=&nm=&type=MultiPublishing&mod=PublishingTitles&mid=5AA50C55146B4C8C98F903986BC02C56&tier=4&id=40D18B17DD78463AB7E1110663AF898E&AudID=3FF14703FD8C4AE98B9B4365B978201A

I found about the article in the NYT health blog here: http://well.blogs.nytimes.com/2008/06/23/advice-for-doctors-from-a-patient-long-ago/.

Secret shoppers in the waiting room

The New York Times Health blog posted a story about an American Medical Association proposal, now tabled, to put secret shoppers in hospital and doctors' office waiting rooms to monitor how patients are treated by office staff. Though secret shoppers are already used in some individual clinics and health systems, the AMA has tabled the idea because they are afraid it will distract from the medical care of actual patients.

You can find the article here: http://well.blogs.nytimes.com/2008/06/18/should-undercover-patients-check-up-on-doctors/

This whole concepts set off a heated discussions about the ethics of using "secret shoppers" when they may distract from the needs of real patients. But the real point is this: You wouldn't need secret shoppers to tell you what it is like to be a patient in a waiting room if patients thought they could communicate honestly with their physicians. There is a substantial power differential between physicians and patients. Patients are often afraid to complain for fear of offending their physician, or even fear of getting fired from their physician's practice. So many patients don't speak up. I don't believe the answers is to put secret observers in waiting rooms to observe and report on conditions. I believe the answer is to continue to pursue open, honest and substantial communication between patients and physicians, built on a relationship of trust. This will solve more problems than any mystery shopper can.

Electronic health records

The New York Times technology section reported on some recent surveys about physicians and utilization of electronic medical records. Electronic medical records can be a great mechanism for improving quality-of-care and ultimately cost of care. Some especially useful features include warnings about drug interactions and reminder pop-ups for tests that should be done for a patient based on age and recorded conditions. The physicians who use such records are largely enthusiastic about them. But many doctors are still not using them, largely doctors in small and private practices. There are a number of reasons: the available software is largely geared toward, the initial start-up costs are very high, and the people who have to bear the costs, doctors, do not always see the cost savings, as in money saved from not having to repeat lost labs. Electronic records are something physicians want in order to be able to practice more efficient medicine, but the cost seems so incredibly daunting.

The answer may come, in part, in the form of government financial subsidies to help clinics transition to electronic medical records. Because if such systems improve quality and cost of care, everyone benefits.

You can find the NYT article here: http://www.nytimes.com/2008/06/19/technology/19patient.html?ex=1371528000&en=bc2c007f1a9df2b0&ei=5124&partner=permalink&exprod=permalink

the frustrations of primary care

Dr. Sandeep Jauhar writes an essay in today's New York Times about the growing frustrations of practicing medicine. With increased bureaucratic pressures, shorter patient visits, increasing malpractice costs, and lower reimbursements, a growing group of physicians are growing more fed up with the pressures of practicing medicine that have nothing to do with actual patient care. Some, even though they love patient care, are leaving medicine altogether.

The biggest threat to public health is the effect of these growing frustrations on primary care, which faces the biggest challenges and lowest reimbursements. Fewer physicians entering and staying in primary care creates a threat to the continuity of care for the patients who need it. This is a problem that drastically needs to be fixed.

You can find the essay here: http://www.nytimes.com/2008/06/17/health/views/17essa.html?ex=1371355200&en=505c2fbd5bfe4f7f&ei=5124&partner=permalink&exprod=permalink.

Monday round-up

Three interesting articles in the wide world of mass media that I just couldn't pass up. The first two are from my local newspaper, The Milwaukee Journal-Sentinel.

The first article is about a fourth grade teacher who took her own illness as a chance to teach her students about medicine. Their lessons included a trip the hospital and a surgical suite and visits from a surgeon, a nurse, an anesthesiologist and a surgical technician who explained their jobs and answered all their students questions. Students learned about robotic surgery techniques and all the hard work it takes to become a doctor. And in the process, the students also learned about the complexity of keeping people healthy.

You can find the first article here: http://www.jsonline.com/story/index.aspx?id=761844.

The second article from my hometown paper is about a program at the University of Wisconsin School of Medicine to help first year medical students learn about their future patients by partnering them to learn about and from older adults. Students learn that the realities of old age do not always fit the stereotypes and that health issues encompass far more than a list of symptoms. Everyone hopes the students will carry these lessons with them as they grow in their medical education and face the hard realities of ever-shortening visit times.

You can find the second article here: http://www.jsonline.com/story/index.aspx?id=761843.

And finally, in entertainment new, the American Medical Association is furious about the "gratuitous depictions of smoking" in the new movies The Incredible Hulk. Apparently the bad guy is almost never seen without a cigar in his mouth. The physicians' group is worried about a movie marketed toward children with any references to tobacco use.

You can find the final article here: http://www.nytimes.com/2008/06/16/business/media/16smoke.html?ex=1371268800&en=da83254074d41053&ei=5124&partner=permalink&exprod=permalink.

disparities in health care and cultural misunderstandings

The New York Times ran an article earlier this week about racial disparities in health care. One finding of the study was that racial disparities in care may not be so much the result of overt racism, but rather failing to take into consideration cultural contexts when making recommendations and treatment plans for patients. It is not a matter of patients being treated unequally, but of all patients being treated the same. One example given was that advising black or Latino diabetic patients to cut their carbohydrate intake may not be a realistic strategy if rice is a family food staple.

This finding that physicians sometimes fail to consider a patient's culture points to the necessity of open communication between physician and patient. In these cases, it may be necessary for the physician to take the initiative: ask questions, ask them more than once and in more than one way. Make the effort to learn about the patient's culture and social situation. Listening is an important aspect in providing quality health care. Clearly, cookie cutter medicine doesn't work for everyone.

You can find the NYT article here: http://www.nytimes.com/2008/06/10/health/10study.html?ex=1370836800&en=eba66169c1ce3fab&ei=5124&partner=permalink&exprod=permalink

Firing a patient

Things got heated today in The New York Times Health section with today's Cases article. Dr. Rahul Parikh discussed a case in which he decided to fire a patient from his practice. Well actually, his problem wasn't with the 14-year-old patient but the patient's mother. The case set off a prolonged discussion about physician responsabilities, patient responsabilities, and who and how and when a physician-patient relationship can and perhaps should be terminated.

Everyone can agree that a physician shouldn't put a patient's health at risk in terminating a relationship, and sufficient time should be allowed to find another physician. But what is a good reason to terminate a relationship? Is non-compliance a good reason? Is personality a good reason? Does the doctor have an obligation to probe deeper into why a patient is non-compliant? Or can a doctor just cut loose an annoying patient?

As with any relationship, the patient-physician patient is built on trust. If the doctor cannot trust the patient, is there any good reason to keep the relationship going? Could keeping a poor relationship going potentially put the patient at greater risk of harm?

You can find the case and discussion here: http://www.nytimes.com/2008/06/10/health/views/10case.html?ex=1370836800&en=3343f835511192ce&ei=5124&partner=permalink&exprod=permalink.

heatstroke and denial

OK, so this has nothing to do with health communication or physician-patient relationships, but this NYT Health blog was just interesting. It turns out that heatstroke may impair cognitive function. Which means, if you ask someone who you think is suffering from heatstroke if he is OK, he will probably say he is fine. Denial may be a symptom of a larger problem.

You can find the article here: http://well.blogs.nytimes.com/2008/06/09/a-common-symptom-of-heat-illness-denial/.

So if you think your weekend warrior is suffering from heatstroke, don't ask questions, just take charge and cool them off immediately.

One more word on Meredith and Derek and their clinical trial

A couple weeks ago, I mentioned the season finale of Grey's Anatomy and the unrealistic portrayal of clinical trials. Well, it turns out I'm not the only one who noticed. The Association of Clinical Research Professional June ACRPWIRE reprinted an editorial from the Coalition of Cancer Cooperative Groups expressing concern that the show equated cancer clinical trials with a death sentence.

You can find the article here: http://newsmanager.commpartners.com/acrpwire/issues/2008-06-05/1.html.

It can be potentially dangerous when television shows spread misconception about how medicine works. When a television show or other mass medium breeds potential mistrust of medical research, everybody suffers.

Another patient group's perspective

The Wall Street Journal Health blog pointed to an interesting web site for an often overlooked demographic group of cancer survivors: young adults. Young adults with cancer often struggle to find a voice when much of cancer treatment and research seems to be split between two disparate groups: very young children and elderly patients.

The web site is: http://www.imtooyoungforthis.org and is presented in a multimedia format familiar to its intended audience. It offers patient perspectives and resources for patients to be advocates for themselves.

The Wall Street Journal blog is here: http://blogs.wsj.com/health/2008/06/02/ad-man-sees-young-cancer-patients-as-consumer-bloc/.

The words and emotions of cancer

The New York Times ran an article and blog posting yesterday about the words and emotions of cancer. The most common metaphor for cancer is that patients are fighting a war on cancer. But a war metaphor may not be appropriate for the experience of all patients. The public is used to, and has come to expect, that famous cancer patients, such as Patrick Swayze and Senator Ted Kennedy, express optimism and bravado in the face of their cancer diagnosis. The expectation of stoicism, and even optimism, from cancer patients can make some patients believe they cannot express the pain, fear and sadness that a cancer diagnosis and treatment can bring. The desire to appear optimistic, to protect their friends and family, may keep them from expressing their own anxieties. Ultimately, this expectation of optimism may be a disservice to the patient, that only adds to his burden in a time of already great difficulty.

Ultimately, there is no cookie cutter answer to communication with cancer patients. Cliches are rarely effective in general, and while convenient, they are not helpful when talking with cancer patients. Genuine communication and sharing between two people takes more thought than the nearest cliche. It may be uncomfortable to talk about realities, but it's worth it if that is what the patient wants.

You can find the article here: http://www.nytimes.com/2008/06/01/health/01stoical.html?ex=1370145600&en=78723bd41cb12ce7&ei=5124&partner=permalink&exprod=permalink

And the blog and comments here: http://well.blogs.nytimes.com/2008/06/02/cancer-emotions-upbeat-stoic-or-just-scared/

Body Worlds!

I finally got a chance to check out Body Worlds, the touring exhibition of plastinized human bodies created by German anatomist Gunther von Hagens. It is a fascinating display of the human body, preserved through the process of plastination, and posed to reveal the intricacies of the human body, from muscles to nerves to bones. The exhibit gives the chance for people other than medical students and anatomists a chance to check out the beautiful complexity of the human body.

It is a hugely popular exhibit. The Milwaukee Public Museum kept the museum open for 63 straight hours to accommodate the many people who wanted to see the exhibit before it closed. It was great to see so many people so excited for a science exhibit. When we left the museum at 11 p.m. on Saturday there was still a steady stream of people waiting to get it. And the exhibit can cause a person to be reflective, about the complexity of life and death, in a way that an anatomy textbook just can't convey.

My own visit was influenced by my readings beforehand from the American Journal of Bioethics. Its April 2007 issue devoted several articles to the ethics of the exhibit. There is certainly an educational value to the project and its education is available to the masses. But the point that stood out to me was the idea of preserving the autonomy of the individuals who donated their bodies to the exhibit. The article reported that exhibits were presented with a title card, signed by von Hagen, presenting the exhibits as art, and in doing so taking away the identity of the person. There were no signature cards at the Milwaukee exhibit, though each had a title, year of creation, and a guide plaque naming the exposed muscles, bones and nerves. But I at least, did wonder a little bit about the people. They have been stripped of their skin and any ready identifiers. Though oddly enough, most still had their belly buttons. They are posed in a way which may or may not reflect who they were when they were living. Was the teacher really a teacher? Did the chess player ever play chess a day in his living life? What are their stories?

What we do know is this: Each of these people made a decision to take their shell of a body and donate it when they no longer needed it, so others may learn. Maybe that's all we need to know. But the residual journalist in me wants to know more.

Ethics of giving a child a placebo

This article is from earlier this week, but I still wanted to point it out. The New York Times ran an article on the ethics of giving a child a placebo to soothe the little ills that don't require medication. The article is a pretty thorough examination of the ethics of placebo use in general, as well as the possibly implications of giving placebos to children. The makers of the children's placebo says that conceivably this product could reduce the over-prescribing of antibiotics for childhood ills. But the effectiveness of placebos is pretty unpredictable. And for placebos to be effective, there has to be a certain level of deception. Is that OK? Plus, is it OK to teach children that there is a pill for every ill? It seems that somewhere along the line, children have to learn the body is pretty resilient and that a skinned knee repairs itself.

It is an intriguing read. You can find the article here: http://www.nytimes.com/2008/05/27/health/27plac.html?ex=1369627200&en=93794384172e0a50&ei=5124&partner=permalink&exprod=permalink

When hostility melts

I really appreciated the Cases article in today's New York Times Health section by Dr. Godfrey Onime. He described the very personal reaction he had to a patient's family that initially greeted him with hostility, but later realized the quality of care he provided and asked him to the patient's new primary care doctor. He described how it is hard to not take the hostility personally when patient families are advocating for their patient. But the hostility can be forgotten when the family and doctor come to see eye-to-eye.

You can find the article here: http://www.nytimes.com/2008/05/27/health/views/27case.html?ex=1369540800&en=0831cbb37433c8b6&ei=5124&partner=permalink&exprod=permalink.

I especially appreciated this since sometimes I am greeted with harsh or short words when I am trying to get physicians to participate in our study to improve communication. Most of the time, the hostility isn't at me, per se, but just at how busy the day is and having to answer yet another phone call. But often times the hostility melts when they realize I am interrupting their busy day for a good cause. And who am I to stay annoyed with the doctor who was a little short with me, if he or she decides to enroll in our study? It's all a part of a day's work.

Unrealistic portrayals of clinical research

First, I hate to admit I even watch Grey's Anatomy. It's such a soap opera. But I have had to laugh in recent weeks about the portrayal of Meredith and Derek's clinical trial. First of all, Meredith has some epiphany, makes some discovery in text book and just decides she wants to do a clinical trial. Of course, first, she has to find an attending to sign off. But Derek signs on and next week they are enrolling their first patient. HA! In the real world, that's not all she has to do. I guess it just isn't sexy showing the months and years of laboratory research, institutional review board applications, grant applications and reapplications and the months of waiting for IRB approval, and then several rounds of amended applications.

And then in this week's episode, the chief of surgery approached Meredith and said the institutional review board, the national review board that oversees clinical trials, is concerned because she has had 11 deaths and she has one more chance before midnight to enroll and treat a patient. What is this, Cinderella? First of all, the institutional review board is local, not national. There would be someone breathing down her neck right at her hospital. And there are no "one more chances in clinical research." If an IRB thinks a trial is dangerous, they are not afraid to shut a trial down immediately. But in Meredith's world, she sneaks in two more patients, one of them lives, the trial continues, and she even gets her man in the end.

I know, I know, television dramas have always had an unrealistic view of the practice of medicine and the medical profession. These shows are about entertainment, not education. But I believe the writers are selling their viewers short by speeding through the research process. There certainly is great drama and story in the less flashy parts of research. But maybe that's just the researcher in me talking.

Advice from a cancer patient

Hamilton Jordon, the former White House chief of staff for Jimmy Carter died this week of cancer. He had four different types of cancer in his lifetime and was a strong advocate for patients empowering themselves and being active in their own health care. In his 2001 memoir, “No Such Thing as a Bad Day,'’ Jordan outlined his “Top 10 Tips for Cancer Patients.'’ The New York Times Health sections reprinted an interview from webMD. com on those 10 tips. You can find the article here: http://well.blogs.nytimes.com/2008/05/21/one-mans-advice-from-four-cancer-battles/.

Of course not everyone agrees about the advice, as seen by the commenters on the NYT article. Especially No. 10: "Your attitude and beliefs are your most powerful weapon against cancer." But there is something reassuring about a patient sharing what he or she has learned with another patient. Sharing in this way gives both patients a voice.

Conducting social research in a biomedical world

My job title is clinical research coordinator. I enjoy my work on a number of studies to improve physician-patient communication and I like to think I do it well. I maintain regulatory documents, obtain informed consents, enroll subjects and write institutional review board applications. Given my background, I am also involved in conducting literature reviews, writing grant applications and preparing article for publication.

I am preparing to take the Association for Clinical Research Professionals certification exam for clinical research coordinators http://www.acrpnet.org/MainMenuCategory/Certification/GetCertified.aspx. I am looking forward to taking the exam and obtaining this professional credential. But I am a little concerned. I meet all the qualifications for their definition of a clinical research coordinator (CRC), but as I reviewed the materials, I got a stark reminder of how, while the research we do about physicians and communication is valuable, it is completely foreign to the world of biomedical research.

It is not the first time I have encountered this. Most of the continuing education offerings for research professionals are geared toward the biomedical end of the spectrum. The IRBs are set up to handle all sorts of biomedical scenarios, but the questions can be difficult to answer when you are conducting a survey. And every once in a while, I encounter a doctor that we try to enroll in our study who thinks psychosocial research is "a waste of time."

But I know the research we do is valuable, even if occasionally overlooked in the biomedical world. The only reason this concerns me at all is that the certification exam I am preparing to take assumes all clinical research coordinators work on clinical drug trials. And while I have picked up some clinical trial knowledge in continuing education seminars, it is not my primary day-to-day work. So over the summer I will be giving myself a crash course in clinical drug trials, so that I will be prepared to take the exam. And hopefully this certification will be a valuable assets as I continue to pursue communication research in medical contexts.

Saying "I'm sorry"

The New York Times ran an article this week about an experiment at the University of Michigan Health System, loosening the typical restrictions on doctors to apologize to their patients for medical errors. Malpractice lawyers and hospital legal departments generally discourage doctors from admitting mistakes to patients for fear of legal repercussions. But some health systems such as the one the University of Michigan are starting to questions whether this practice causes more harm than good. And a policy of honesty may actually benefit the bottom line, as well as benefit the mutual physician-patient relationship.

I have always contended that the key to communication in any relationship - physician-patient, professional colleagues, intimate partners - is mutual respect and trust. You cannot have an effective communication relationship without trust. And a doctor who stonewalls and does not admit to a medical error erodes the delicate balance of trust between doctor and patient. That doctor cannot expect that patient to ever be honest about his or her symptoms, health problems, or questions. Not admitting to an error telegraphs to the patient that the physician doesn't trust the patient and that the patient can't and shouldn't trust the physician. But a physician who trusts the patient enough to admit his or her mistake tells the patient that the physician is human, but that the physician values and trust the patient enough to allow him or her to see that. And that's how you build an effective patient-physician relationship where both parties play an active role in the patient's health care. I can only hope that more research like what is going on in Michigan will show physicians and health systems that honesty be a wise health and legal policy.

You can see the New York Times article here: http://www.nytimes.com/2008/05/18/us/18apology.html?ex=1368936000&en=c9496b7eb97e3235&ei=5124&partner=permalink&exprod=permalink

5 mistakes women make at the doctor

CNN.com ran an article about the mistakes women make at the doctor. Most of the mistakes tend to revolve around communication. But the mistakes reveal the complexity of the physician-patient relationship. One mistake is that women don't question their doctors. But another stated mistake is that women tend to over-research and in the process get overwhelmed. So they don't ask enough questions but they over-prepare for questions they ultimately don't ask. The author also said that women tend to interpret their symptoms for their doctor rather than give just the facts. See, it's complicated. So you have to be deliberate in your preparation for talking to your doctor, but don't overdo it on the Internet research. And trust your intuition.

You can find the article here: http://www.cnn.com/2008/HEALTH/05/14/ep.women.mistakes/index.html.

a parent's perspective

Time has gotten away from me, but I didn't want to let too much time pass without at least pointing you to another article that looks at advancing health from the patient's perspective. But here it is the parent's perspective. The New York Times Health section today writes about a little girl with a rare tumor and the risky procedure to treat it. You can feel what I am sure is only a tiny portion of the gut-wrenching pain and anxiety the parents experienced. The article also offers a glimpse into the surgical room as well. Definitely worth the read.

You can find the article here: http://www.nytimes.com/2008/05/13/health/13tumo.html?ex=1368417600&en=fd49d2e9a128fb83&ei=5124&partner=permalink&exprod=permalink

Blog as therapy

CNN.com had an interesting article today about how blogging can act as a type of group therapy. While of course blogging can't replace face-to-face counseling, it can allow people a venue to interact with people who have faced similar problems. Patients are finding blogging as a valuable venue too, both as a way to sort out their own feelings and to gain perspective from others.

You can find the article here: http://www.cnn.com/2008/LIVING/personal/05/07/blog.therapy/index.html

Redefining disease

The New York Times published an interesting article today about the field of nosology, or disease classification. Scientists are redefining classifications of disease by examining the genetic underpinnings of disease.

The article is far from my area of knowledge or expertise, but it is interesting to read how knowledge about medicine and disease is constantly changing . You can find the article here: http://www.nytimes.com/2008/05/06/health/research/06dise.html?ex=1367812800&en=b4a1fb3e0b65b4c2&ei=5124&partner=permalink&exprod=permalink.

Slow medicine

The New York Times published an article today about "slow medicine," an approach that advocates less aggressive care at end-of-life.

Slow medicine ultimately advocates giving patients a greater voice in what treatments they pursue, or even decline, at end-of-life. But as some of those interviewed and the article and some commenters pointed out, contemporary medicine does not build in a lot of time for heart-to-heart discussions between patients and physicians. The typical default is to take medical action, even drastic action, first and ask questions later. The assumption is that a physician should always pursue every medical avenue for every patient. But this slow medicine movement points to the value of seeking the patient's perspective. Even if it means slowing down to do it.

You can find the article here: http://www.nytimes.com/2008/05/05/health/05slow.html?ex=1367726400&en=1b4e1a08fd8b7247&ei=5124&partner=permalink&exprod=permalink

Doctors and quality of life

The Wall Street Journal reported a story today about how a new generation of doctors is seeking a greater work-life balance. Some physicians are rejecting jobs that require after-hours on-call, which has long been a staple of the physician's life. Hospitals and clinics are looking for new solutions, including shift work, to improve not only physicians quality-of-life by having a set hourly work week, but also patient safety.

You can find the article here: http://online.wsj.com/article/SB120942599600151137.html?mod=WSJBlog.

You can find blog opinions and comments, here: http://blogs.wsj.com/health/2008/04/29/call-of-medicine-gives-way-to-family-tug/?mod=WSJBlog and here: http://blogs.wsj.com/juggle/2008/04/29/not-on-call-young-doctors-want-workfamily-balance/?mod=WSJBlog.

Taking a hiatus

My best friend is getting married! So I'm off to primp and help with all the final details, and of course be by her side on her special day. So there won't be any updates from me for about a week or so. But I'll be back online sometime next week.

Emotion at the bedside

The New York Times published an essay today about physicians showing emotion at the bedside of their patients. Most patients want a physician who is empathetic and understanding, but physicians struggle with how and how much emotion they should show. The comments after the article are especially telling, as patients express a range of desires: from those who want an emotive physician and those who want a doctor who tells only the facts.

The article raises the importance of the individual relationship, that requires the physicians to fine-tune perceptions of patients and try to read the patient's desire for an emotive interactions.

You can find the article here: http://www.nytimes.com/2008/04/22/health/views/22essa.html?ex=1366603200&en=1078af22fd5fff5e&ei=5124&partner=permalink&exprod=permalink