Tag: doctor/ patient relationship

Let Doctors Be Doctors

Apr 22, 2014• 7

By Hans Duvefelt, MD

It’s a strange business we are in.

Doctors are spending less time seeing patients, and the nation declares a doctor shortage, best remedied by having more non-physicians delivering patient care while doctors do more and more non-doctor work.

Usually, in cases of limited resources, we start talking about conservation: Make cars more fuel efficient, reduce waste in manufacturing, etc.

Funny, then, that in health care there seems to be so little discussion about how a limited supply of doctors can best serve the needs of their patients.

One ~~hair-brained~~ novel idea making its way through the blogs and journals right now is to have pharmacists treat high blood pressure. That would have to mean sending them back to school to learn physical exam skills and enough physiology and pathology about heart disease and kidney disease, which are often interrelated with hypertension.

Not only would this cause fragmentation of care, but it would probably soon take up enough of our pharmacists’ time that we would end up with a serious shortage of pharmacists.

Within medical offices there are many more staff members who interact with patients about their health issues: case managers, health coaches, accountable care organization nurses, medical assistants and many others are assuming more responsibilities.

We call this “working to the top of their license.”

Doctors, on the other hand, are spending more time on data entry than thirty years ago, as servants of the Big Data funnels that the Government and insurance companies put in our offices to better control where “their” money (which we all paid them) ultimately goes.

In primary care we are also spending more time on public health issues, even though this has shown little success and is quite costly. We are treating patients one at a time for lifestyle-related conditions affecting large subgroups of the population: obesity, prediabetes, prehypertension and smoking, to name a few that would be more suitable for non-physician management than hard-core hypertension.

It is high time we have a serious national debate, not yet about how many doctors we need, but what we need our doctors to do. Only then can we talk numbers.

Hans Duvefelt, MD is a Swedish-born family physician in a small town in rural Maine. He blogs regularly at A Country Doctor Writes where this piece originally appeared.

Whose Cancer Is It, Anyway?

Apr 16, 2014• 19

By “Knot Telling”

I recently read a blog by Dr. Danielle Ofri in the New York Times “Well” blog about how as a physician she learned to respect the patient’s wishes even when they contradict her professional inclinations. It’s called Doctor Priorities vs Patient Priorities.”

She writes that the patient is looking through a “wide-angle lens” that takes in the whole of his life while the doctor’s lens is “narrowly focused on the disease that pose[s] the gravest and most immediate risk”. She saw her challenge as entering into dialogue with her patient in order better to understand the wider perspective of his whole life and to work with him to find the most acceptable way to deal with his disease.

If only Dr. Ofri were an oncologist. If only she were my oncologist. My last appointment with my onco, Dr. G, was a disaster. Not only have I not been back to her, I have not gone to any oncologist since then. Part of that is because I don’t want any treatment at this time; that’s still true.

But if I am going to be very honest, and I try to be that always, it is also because of that disastrous appointment with Dr. G.

First of all, she would not respect my decision not to have any more chemo and refused to order any scans unless I would a priori agree to chemo if she decided it was indicated. She also mocked me. It took a long time for me to tell that second bit. In fact, from that day in August 2013 until just recently—seven months!—I only told one or two other people about what happened.

The evening of that last appointment, Dr. G called me at home to continue the argument. I found myself apologizing for causing her distress. Yes, I know that’s ridiculous, but that is how I react to being bullied. Borrowing the words of a friend who really gets it, I apologize to others for their hurtful behavior and then I internalize it. I haven’t talked about Dr. G mocking me because I feel ashamed.

Open Notes: Is Sharing Mental Health Notes with Patients a Good Idea?

Apr 11, 2014• 13

By MICHAEL KAHN, MD

Would allowing patients to read their mental health notes provide more benefits than risks?

In a recent article in JAMA my colleagues and I argue that it would. While transparent medical records are gaining favor in primary care settings throughout the country through the OpenNotes initiative, there has been reluctance to allow patients to see what their treaters say about their mental health issues. While this reluctance is understandable and deserves careful consideration, we suggest that several benefits could result from patients reading their mental health notes.

First of all, accuracy would be enhanced by allowing patients to cross-check what their clinicians say about their symptoms, medication doses, and so forth. Second, allowing patients to review assessments and treatment decisions privately might help to promote a richer dialogue between patient and clinician. Third, patients might learn that their clinician sees them more as a complete person, rather than as a collection of symptoms.

Many patients silently fear that their treater “will think I’m crazy/whining/lazy/boring”; seeing in print that the treater does not see them that way—and in fact recognizes and documents their strengths—can be an enormous relief and might therefore enhance the therapeutic alliance.

Clinicians have their own worries about transparent mental health notes that must be considered. Will patients feel objectified by the medical language commonly used in documentation? Will they break off treatment if they don’t like what they read? Will too much time be spent wrangling over details of what has been documented? Will vulnerable patients be psychologically harmed by reading their notes? Although our article briefly addresses these issues, only a trial of transparent mental health notes will provide the data needed to assess them.

Such a trial has just begun at the Beth Israel Deaconess Medical Center in Boston. Culminating many months of careful planning by my colleagues in the ambulatory psychiatry clinic, the Social Work department, as well as the OpenNotes team, we began a pilot project of transparent notes in our psychiatry clinic on March 1. So far almost all clinicians have chosen to participate in the project, and have identified 10% of their caseloads to be included. It’s too early to gauge results yet, but we hope to more fully evaluate the effects of making mental health notes fully transparent to our patients.

Michael W. Kahn, MD is an assistant professor of psychiatry at Harvard Medical School and Harvard Medical Faculty Physician at Beth Israel Deaconess Medical Center (BIDMC).

The Problem of Pain: When Best Medical Advice Doesn’t Equal Patient Satisfaction

Apr 4, 2014• 23

By Karen S. Sibert, MD

The problem of pain, from the viewpoint of British novelist and theologian C. S. Lewis, is how to reconcile the reality of suffering with belief in a just and benevolent God.

The American physician’s problem with pain is less cosmic and more concrete. For physicians today in nearly every specialty, the problem of pain is how to treat it responsibly, stay on the good side of the Drug Enforcement Administration (DEA), and still score high marks in patient satisfaction surveys.

If a physician recommends conservative treatment measures for pain–such as ibuprofen and physical therapy–the patient may be unhappy with the treatment plan. If the physician prescribes controlled drugs too readily, he or she may come under fire for irresponsible prescription practices that addict patients to powerful pain medications such as Vicodin and OxyContin.

Consider this recent article in The New Republic: ”Drug Dealers Aren’t to Blame for the Heroin Boom. Doctors Are.” The writer, Graeme Wood, faults his dentist for prescribing hydrocodone to relieve pain after his wisdom tooth extraction.

As further evidence of her misdeeds, he says, first she “knocked me out with propofol–the same drug that killed Michael Jackson.” Wood uses his experience–which sounds as though it went smoothly, controlled his pain, and fixed his problem–to bolster his argument that doctors indiscriminately hand out pain medications and are entirely to blame for patient addiction.

But what happens to doctors who try not to prescribe narcotics for every complaint of pain, or antibiotics for every viral upper respiratory infection? They’re likely to run afoul of patient satisfaction surveys. Many hospitals and clinics now send a satisfaction questionnaire to every patient who sees a doctor, visits an emergency room, or is admitted to a hospital.

The results are often referred to as Press Ganey scores, named for the company that is the leading purveyor of patient satisfaction surveys. Today these scores wield alarming power over physician incentive pay, promotion, and contract renewal.

Now hospital payments are at risk too.

“You Doctors These Days Just Want Us To Go off and Die …”

Mar 9, 2014• 4

By JOHN MANDROLA, MD

A recent case taught me a lot about how people perceive their medicines.

I was trying to help a 92-year-old man get off some of his medicine. I can’t go into the details, but suffice to say, there was much opportunity to trim a long list of drugs, many of which were threatening his existence and impairing his quality of life.

As I was discussing stopping many of the meds, the patient said (with a quite sincere tone):

“You doctors these days just want us old people to go off and die.”

That was a zinger, a real punch in the gut. I was trying to do the opposite–allow him to live a longer and better life–but the patient perceived me as a mini-death panel.

I’ve been thinking a lot about this case. Why was this man “attached” to his meds? Why had he associated his longevity with chemicals that now threatened his existence?

The answer, I believe, is a knowledge gap. He, like many people, doctors included, fell into the trap of association and causation. He associated his health with his medicines; he overestimated their benefits. He thought the pills were keeping him alive. They were not. He lived despite his medicines.

What I tried to explain to this patient was that benefits from medicines do not continue indefinitely. Things change in the elderly, and, what is for younger patients may not be in the aged.

Take the case of preventing stroke in the elderly. Simple drugs, such as high blood pressure medicines and statins, may no longer offer a net benefit to the patient over the age of 80. Really. It is true.

Let me tell you about a recent commentary in the journal Evidence Based Medicine (from BMJ).

Dr Kit Byatt is a doctor in the UK who specializes in Geriatric Medicine. He wrote this refreshingly concise summaryoutlining four reasons why the medical community should reconsider its overenthusiastic views of stroke reduction in patients over the age of 80. In the title, Dr. Byatt asks whether we are being disingenuous to ourselves and to our elderly patients.

The answer is yes.

That Vitamin There Could Kill You

Feb 25, 2014• 20

By James Salwitz, MD

Once-upon-a-time, when a patient said they were taking a vitamin, most doctors would simply shrug their shoulders and say, “well, I guess its OK, it couldn’t hurt.” There was little research to judge the affect of vitamin supplements, so there was no reason to take a stand. That is no longer true.

Now we have published data on many vitamins and we can say that for most people they do not work. More importantly, there is increasing research that says manufactured, chemically synthesized nutriment compounds in a pill, can be deadly.

For this reason, I am likely to ask my patients if they are taking a vitamin and, if so, which fabricated additive and how much. Therefore, I asked Bill, while he was in the office receiving chemotherapy for Hodgkin’s disease, what alternative therapies he was using.

When he informed me that he swallowed a multivitamin (MVI), large doses of Vitamins C and E, as well as a B complex preparation, I advised him to stop.

To my astonishment he responded, “Well, you only want me to do that because you make a lot of money on chemotherapy, and vitamins might put you out of business.”

Bill’s response, he lack of trust in my advice, disturbs me at several levels. He fails to understand and does not wish to learn the present state of science regarding nutrition. In addition, there is a major problem regarding his perception of my motivations and therefore the veracity of my guidance.

Let us be clear; in the absence of malnutrition, malabsorption and a few uncommon medical conditions, there is absolutely no reason to take a multivitamin. They do not prevent or fix anything. Originally developed for starving populations and hungry soldiers during the Second World War, they have no place in a society with access to a broad range of foods.

More importantly, there is increasing data that people taking a multivitamin may become less healthy.

The Black Box at the Center of Health Economics

Jan 25, 2014• 11

By Richard Gunderman, MD

When Michael injured his knee, he did what any responsible person would do. He was not incapacitated, and though the knee was painful and swollen, he could get around pretty well on it. So he waited a few days to see if it would get better. When it didn’t, he saw his primary care physician, who examined it and quite reasonably referred him to an orthopedic surgeon. The orthopedic surgeon considered ordering an MRI of the knee but worried that insurance would not cover a substantial portion of the $1,500 price tag, so he suggested a less expensive alternative: a six-week course of physical therapy that would cost only $600 – a quite responsible course of action.

At the end of this period of time, Michael was still experiencing pain and intermittent swelling. The orthopedic surgeon made another quite responsible decision and ordered the MRI exam, which showed a torn meniscus. The orthopedic surgeon could have recommended arthroscopic surgery, which would have earned him a handsome fee and generated revenue for his physician-owned surgery center. Instead he again acted quite responsibly, advising Michael that the surgery would actually increase the pain and swelling for a time and probably not improve his long-term outcome. Based on this advice, Michael declined surgery.

Though everyone in this case proceeded responsibly, the ultimate outcome was inefficient and costly. Many factors contributed, but perhaps the most important was the fact that Michael’s physician outlined choices based on an inaccurate understanding of the costs associated with his recommendations. The orthopedic surgeon thought that the cost of six weeks of physical therapy was 60% less than the MRI. In fact, however, the actual payment for the MRI from the insurance company would be only $300, not the “retail” price of $1,500. What appeared to be the less expensive option was actually twice as expensive, and it delayed definitive diagnosis by six weeks.

This story is emblematic of a larger problem in contemporary healthcare. No one – not the patients, the physicians, the hospitals, or the payers – really understands in a thorough way the true costs of their decisions. After receiving care, patients routinely receive by mail multi-page “explanations of benefits” that show huge differences between list prices and actual payments. Most find it baffling to try to determine who is paying how much for what. Physician practices and hospitals get calls every day from panicked patients who believe that they are being billed for exorbitant costs, when in fact most or all of the charges will be paid by insurance at a huge discount.

Fee for Service vs. Fee for Serving

Jan 15, 2014• 15

By Robert McNutt, MD & Nortin Hadler, MD

In a previous blog we demonstrated how guidelines can compromise the care of individual patients when designed to serve the health care system.

Why should treating physicians defer to guideline committees at all, we asked? For decades medical students have been taught to read and understand information from published papers.

We are all trained in critical appraisal and can keep up with the clinically meaningful literature, the literature that is relevant and accurate enough to present to patients. Just because there are nearly 20,000 biomedical journals does not mean that any, let alone all are replete with meaningful information. We can discern the valuable from the not valuable; why do we need others to tell us?

In fact, we even argued in our last post that patients can and should judge the value of medical information. After all, they face the consequences of misinterpreting the likelihoods of benefit and of harm associated with various options for care.

No one remembers the numbers that describe the chances for benefit and harm or ask more questions about the veracity of information than a patient who must choose. The smartest information managers we have ever encountered are our patients; when informed, they quickly determine the validity of the information and apply their personal values to the estimations of the chances for benefit and harm.

Patient Empowerment

Take the example of a patient who recently entered into a therapeutic dialogue with one of us, RAM. This was not the traditional clinical interview. This patient had been diagnosed with prostate cancer and was scheduled for an approach to treatment that the diagnosing physician had offered as the most sensible. However, the decision did not rest easily.

The appointment with RAM was scheduled because the patient sought a dialogue that might offer a chance to reflect on the rationale for the approach he was about to initiate. Two hours into the dialogue, the patient, a 40ish year old African-American man accompanied by his wife, were mulling over the marginal benefits and harms of the options for treating an early stage prostate cancer.

The wife asked how many African-Americans were in the study under discussion. “None”. The husband perked up and then asked, “How many people in the study was my age?” “None”. They then asked if the difference in benefit was a certain, fixed amount? “No, it varies over this range.” – examining the descriptive statistics.

They then asked when the study was started and did it pertain to the present day. “It started over 15 years ago” and the stage of disease of the men in the study was generally more aggressive than in this particular case.

The Great Coronary Angioplasty Debate: Giving Patients the Right to Speak

Oct 19, 2013• 2

By Nortin Hadler, MD

Earlier this month, the editors of THCB saw fit to post my essay, “The End of the Era of Coronary Angioplasty.”

The comments posted on THCB in response to the essay, and those the editors and I have directly received, have been most gratifying. The essay is an exercise in informing medical decisions, which is my creed as a clinician and perspective as a clinical investigator.

I use the recent British federal guideline document as my object lesson. This Guideline examines the science that speaks to the efficacy of the last consensus indication for angioplasty, the setting of an acute ST-elevation myocardial infarction (STEMI). Clinical science has rendered all other indications, by consensus, relative at best. But in the case of STEMI, the British guideline panel supports the consensus and concludes that angioplasty should be “offered” in a timely fashion.

I will not repeat my original essay here since it is only a click away. The exercise I display is how I would take this last consensus statement into a trusting, empathic patient-physician discourse. This is a hypothetical exercise to the extent that little in the way of clear thinking can be expected of a patient in the throes of a STEMI, and not much more of the patient’s caring community.

So all of us, we the people regardless of our credentials, need to consider and value the putative efficacy of angioplasty (with or without stenting) a priori. For me, personally, there is no value to be had rushing me from the “door to the balloon” regardless of the speed. You may not share this value for yourself, but my essay speaks to the upper limits of benefit you are seeking in the race to the putative cure by dissecting and displaying the data upon which the British guideline is based.

There is an informative science, most of which cannot deduce any benefit and that which deduces benefit finds the likelihood too remote for me to consider it worth my attempt. A hundred or more patients with STEMI would have to be rushed to the catheterization lab to perhaps benefit one (and to harm more than one).

Should We Sacrifice Medicine’s Sacred COW?

Oct 14, 2013• 2

By Richard Gunderman, MD

Chicago Cubs fans of a certain vintage will never forget broadcaster Harry Carey’s signature line, “Holy cow!” Some have speculated that the exclamation may have originated in Hinduism, one of the world’s major religions, whose adherents worldwide number approximately one billion. Hindus regard cows as maternal, caring figures, symbols of selfless giving in the form of milk, curds, butter, and other important products.

One of the most important figures in the faith, Krishna, is said to have been a cowherd, and one of his names, Govinda, means protector of cows. In short, cows are sacred to Hindus, and their slaughter is banned in virtually all Indian states.

Medicine, too, has its sacred cows, which are well known to physicians, nurses, and patients visited by medical teams on their hospital rounds. In this case, the cow is not an animal but a machine. In particular, it is the computer on wheels, or COW, a contraption that usually consists of a laptop computer mounted on a height-adjustable pole with a rolling base. It is used to enter, store and retrieve medical information, including patients’ diagnoses, vital signs, medications, and laboratory results, as well as to record new orders.

As the team moves from room to room and floor to floor, the COW is pushed right along. The COW is often treated with a degree of deference seemingly bordering on reverence. For one thing, people in hallways and patients’ rooms are constantly making way for the COW. As an expensive and essential piece of equipment, it is handled gingerly. Often only the senior member of the medical team or his or her lieutenant touches the COW.

Others know that they have said something important when they see the chief keyboarding the information into the COW. Sometimes it plays an almost oracular role. When questions arise to which no one knows the answer, such as the date of a patient’s admission or the time course of a fever, they often consult the COW. Just as cows wandering the streets of Indian cities often obstruct traffic, so healthcare’s COWS can and often do get in the way of good medicine. Continue reading…