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.