The pressures when the patient is a VIP

The New York Times Well blog had a guest column today exploring the potential problems and pressures when a patient is a VIP. A VIP patient may cause a physician to second guess their course of treatment or a VIP may insist on a treatment that the physician knows may cause harm. But if a physician fears losing the prestige or the monetary benefit of having a VIP patient, that fear may cloud the physician's sound medical judgement.

From a communication perspective, it demonstrates how extreme power imbalance in a relationship impairs effective and honest communication. When physicians hold all the power, patients have trouble finding this voice. When patients have the power in the relationship, physicians have the some trouble.

The lasting trauma of having a child in the NICU

I wanted to be sure and highlight The New York Times article today discussing the long-term potential trauma associated with having a child in the neonatal intensive care unit. These are the kind of underlying issues that physicians and nurses need to be aware of when speaking with patients and parents about treatment and health care decisions. Communication is not just about the current conversation, but all the previous conversations and experiences that color our perspective. And having a child in the NICU can make a lifelong impression.

Experiencing a patient's perspective firsthand

The New York Times featured an article today about an innovative geriatric education program, in which medical students have the opportunity to experience life in a nursing home. Medical students at the University of New England are given a diagnosis that an elderly patient might have and spend two weeks living as a patient with that diagnosis, including medical exams, being assisted in and out of bed, and passing the time with other nursing home residents. The goal of the program is that the two week experience better equips future geriatric doctors to interact with and understand their elderly patients. When clinicians can empathize with their patient's situation and actions, they will be better able to communicate with their patients about their medical and quality of life needs.

Talking about end-of-life care

A provision in the proposed health care reform legislation to reimburse physicians for discussions with patients about their wishes at the end of life has been misunderstood and even misinterpreted as government intervention to ration care to elderly patients near the end of life. The provision is gone now, but the provision has started conversations about end-of-life care in homes and doctors offices across the country. Conversations about what the kind of care patients want at the end of life should be ongoing, both with the patient's physician and the patient's family. But when a patient is near the end, often the person to have the difficult end-of-life conversation with the patient is a palliative care specialist. The New York Times had a compelling article today about palliative care doctors and how they approach their difficult job. I think the most important part of this article is the conversations that it is capable of generating, both online and in hospitals and physicians offices and homes across the country. The only way to assure that you or a loved one will reach the kind of end-of-life care you want at the end is to have ongoing, respectful and honest conversations.

Talking to your doctor about conflicts of interest

The Wall Street Journal Health blog pointed to an interesting article this morning in the Washington Post about potential physician conflict of interests and the difficulty patients have in asking their physicians about them. Patients don't want to ask questions that might alienate their physicians, but many express interest in knowing just how much influence pharmaceutical companies may have on their physician. There are some mechanisms for finding out this information on your own, such as physician and practice profiles online, especially if your physicians works for an academic medical center. And there is now proposed legislation to create greater transparency by disclosing all pharmaceutical company payments of more than $100. This transparency will equip patients to ask their physician more about their prescribing habits.

Of course, being able to find this information yourself is good, but it doesn't replace the real need for conversation between physicians and patients. Patients need to be able to express their concerns about potential physician conflicts of interest. Physicians need to know that their patients have concerns and perhaps help the patients gain insight into the physician's prescribing thought process. But the question is how to start these conversations between physicians and patients. Ideas?

Another great source for information on the health care debate

The Association of Healthcare Journalists offers a great resource page for finding facts of the health care policy debate. It's a great source for journalists and all citizens looking to get beyond the shouting.

Making sense of the health care reform debate

The New York Times has taken an extra step to help inform readers about the health care reform debate. The online edition has added a new blog in the Health section called "Prescriptions" devoted to the dissecting the health care debate. The writers are off to a fast start, filling the page with articles about the key players in the health care debate, criticisms of policy proposals, and even analysis of advertisements and public service announcements.

This kind of analysis is long overdue. There has been so much shouting and arguing over the possibility of health care reform that there has been little time devoted to what the actual proposals are and what changes may or may not occur. I especially like the informative graphic showing how the different proposals would affect Americans in different economic and marital situations. The availability of this kind of information probably won't stop the shouting and arguing, but it does give the rest of us a chance to consider the future of health care in this country.

How can physicians and patients find reliable information?

The New York Times had two articles in two different sections that together highlighted the problems both physicians and patients can encounter in accessing reliable health information. In the first article, the "Room for Debate" feature in the Opinion section, several contributors debated whether direct-to-consumer prescription drug advertising should be banned. The second article in the Health section examined the use of ghostwriters in medical journals, and the lack of disclosure when pharmaceutical companies sponsor journal articles.

Both articles, and the accompanying comments, demonstrate the desire and need for both physicians and patients to find reliable health information. But that task is often difficult. The argument often presented in favor of direct-to-consumer prescription drug ads is that they make information available and accessible to the patient. But that information is obviously one-sided, and some fear that the ads interfere with another important source of information: the patient's physician. Physicians on the other hand, turn to medical journals to find the latest in medical research. But when articles are influenced by pharmaceutical companies, with or without disclosure of that influence, it makes it all the harder for physicians to discern which new practices are best. Both articles demonstrate the need for transparent communication, whether it is transparency in advertising or transparency in research. But that transparency is easier said than achieved.

Doctors from Cuba starting over in the U.S.

The New York Times had a compelling article today about Cuban doctors who have defected to America and the struggles some go through to establish themselves in the medical field in their new country. Foreign trained doctors have to complete four rigorous exams and several years in residency training before being licensed to practice in the U.S. For many Cuban doctors, lack of proficiency in English and residency programs that favor younger physicians, means that the compelling dream of coming to America will require them to make the choice to take other jobs in the medical field, such as nursing or medical technicians.

It is difficult to think about what it must be like to make that decision - to devote years to retraining to pursue that profession you have already trained for in a new home or even to give up a profession you feel called to in order to pursue new opportunities and new freedoms. The compulsion to pursue medicine, to help others in their time of need, is strong. Even for those who cannot pursue medicine in the U.S., deep down still feel like the physicians they are called and trained to be.