Medical Blog Grand Rounds – June 29, 2010 Edition

(Vol. 6, No. 40)

Learning about medicine is a lifelong endeavor whether you’re a patient, a doctor, a caregiver, a hospital administrator or, perhaps, even an insurance company executive. In today’s Grand Rounds, we’ve an array of eleven perspectives that, directly or indirectly, bear on the suggested theme of education.

If there’s a motif that emerged unsolicited this week, it’s empathy, a term highlighted in the titles of two submitted posts:

In Glass Hospital, Dr. John Schumann considers what motivates health care workers in a thoughtful post, Finding Empathy. Schumann, an internist and medical educator at the University of Chicago, suggests that doctors and nurses need to re-encounter and re-engage with empathy to continually find meaning in their work.

Bedside Manner, a blog out of Boston’s Kenneth B. Schwartz Center, offers an article on ‘Boosting’ Empathy through Continuing Medical Education. Here, director Julie Rosen writes on newly-published data on the value of post-graduate, interdisciplinary sessions where clinicians discuss psychosocial and emotional aspects of patient care.

Near empathy lies the concept of interpersonal connectedness. In that vein, several of this week’s essays consider the essential and sometimes close (or not-so-close) relationships that form between patients and their doctors, between physician-educators and doctors-in-training, and between scientists who study particular disorders and the public that depends on their work:

In How Can I Explain it to You? The Life of a Grad Student With Lupus, a young woman (20-something, as self-described) blogs anonymously about her experiences as a person with systemic lupus erythematosus. Her latest post, it’s supposed to be a ‘doctor-patient’ not ‘doctor-disease’ relationship bemoans the lack of attention given to empathy (yes, it’s here too!) and patients’ lives in medical education. “Don’t test only the science,” she recommends.

Dr. Kimberly Manning is a medical educator at Atlanta’s Grady Memorial Hospital. In the ACP Hospitalist she considers the transience of some relationships, and permanence of others, formed between faculty and junior doctors passing through that public hospital’s residency training program. Her post, “Life at Grady: A clinician-educator reflects” included some lovely verse. After reading those lines, I couldn’t resist trying to find out more on Aleksandra Lachut, a poet previously unfamiliar to me.

A recent Health Business Blog offering weighs in on the emotional and healing value of connectedness among patients. In a transcript of his Podcast interview with LaChance Publishing President Victor Starsia, HBB author David E. Williams reveals why Debra LaChance founded the Healing Project. This non-profit organization provides support and education for people with breast cancer and other chronic or life-threatening diseases. It encourages patients’ sharing of stories through a book series, Voices Of.

In his wrenching Medicine vs. Religion: My Brother’s Keeper Revisited, Dr. Alan Dappen considers the predicament of a severely anemic woman who refused treatment for many years based on her firmly-held religious views. Drawing on his own, personal experiences with a brother whose faith-based ideals led him to decline care, Dr. Dappen persuaded the patient to accept medical help. This and related posts by can be found on Better Health.

A scientific sort of connection is espoused by Walter Jessen, Ph.D., who edits and writes at Highlight Health. In his early-June post on The 2010 NF Conference – Connecting the Public with the Research, he anticipated the research presentations at a meeting on neurofibromatosis (NF) sponsored by the Children’s Tumor Foundation. Although conference attendance was restricted to researchers, the foundation decided to provide information and updates to the public through a video and blog. What I liked best was the video, in which Dr. Kim Hunter-Schaedle explains the significance of the NF conference theme: “Back to the Future.”

Moving on, toward a most practical aspect of medical education, the ever-anonymous and Happy Hospitalist tells us in Difficult Foley Catheter Insertion. I Got To Watch The Cath Man In Action how glad he was to absorb, first-hand, details on the intricacies of placing a Foley the right way. (As someone who’s, um, had quite a few surgeries and subsequent catheters, I cannot exaggerate the significance I assign to this type of specialized knowledge.)

Going further in a pragmatic direction, Louise Norris advises patients and doctors to “think twice” before CT scans in her post Radiation Exposure from Medical Testing. She and her husband own Insurance Shoppers Inc., provider of the Colorado Health Insurance Insider blog. Of interest, Norris advocates a radiation medical record that would track a patient’s total exposure to imaging radiation over a lifetime. Health insurance companies could help patients, she suggests, by reducing their risk through the approval review process for imaging studies. “If an ultrasound could be used instead of an x-ray, or an x-ray instead of a CT scan, we could be saving money as well as preventing future cancers,” she writes.

My favorite title of the week comes from InsureBlogs Bob Vineyard, CLU (that’s Chartered Life Underwriter, just in case you’re wondering as I was). In his Mission Accomplished! post, Vineyard rails on the consequences of Romneycare including a primary care physician shortage. One lesson from the Massachusetts experience is that there will be an even greater demand for primary care physicians under Obamacare. As he sees it, the question for today’s aspiring physicians is whether or not to take advantage of that opportunity.

Finally, and coming full circle, the ACP Internist submitted a post authored by none other than Glass Hospital’s Dr. Schumann. This one’s called Cholesterol: validation of the self. Here, he questions the merit of an established and perhaps over-valued concept in medicine, that of lowering cholesterol.

It seems to me, the notion of challenging old assumptions is a terrific lesson with which to end any catalog of essays on education.

Lots to think about –

Many thanks to all who contributed to this week’s Grand Rounds!

ES

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Follow-up on the Harlem Heart Tests

Last month I examined the serious case of the overlooked heart tests at Harlem Hospital, as told initially in the New York Times. Since then, Times journalist Anemona Hartocollis has followed-up on the disorder at the medical center.

The problem is older and wider in scope than first indicated. Another 1,000 echocardiograms, beyond the first 4,000 told, went without review by a cardiologist.  The situation dates back to 2005, rather than 2007.  An additional 2,000 exams were reviewed by doctors who didn’t complete or sign reports on those studies, taking the total number of missing reports to the range of 7,000.

Concern persists that the errors arose due to administrative decisions and a shortage of cardiologists at the hospital. According to the paper:

…After the backlog was discovered, some doctors at Harlem Hospital said they had complained of understaffing to the administration but had been ignored. At one point, they said, the hospital was down to one cardiologist, who could not possibly review all of the echocardiograms.

Last week the hospital finished an internal investigation. Approximately 200 of the patients who had echocardiograms died before their tests were analyzed. According to the Times, a hospital spokeswoman stated that 14 patients received an incorrect diagnosis because the tests were mishandled.

Upon further contemplation, I’ve upped my lessons learned from 2 to 3:

1. For hospital administrators:

When doctors complain that they’re overworked, so much so they can’t meet their clinical responsibilities, don’t dismiss their concerns. A stressed system – with fewer clerks, escort workers, nurses, phlebotomists, aides and other workers – is a setup for rushed or frankly skipped work. These kinds of errors (delayed reports) might apply to how physicians interpret other kinds of complex medical tests including CT and MRI scans, pathology reports, bone marrow findings and other specialized evaluations.

Most physicians I know work long days, weekends and nights. Many work putting out one fire and then the next; it seems unlikely that this problem is isolated to a single department in one hospital. Rather, it’s a flag.

With so much new emphasis by law on restricting resident physicians’ hours, perhaps there’s insufficient attention to the workload of senior (“attending”) physicians. Their responsibilities should be limited, too, such that they can accomplish their work in a careful manner in a reasonable number of hours per week.

2. For doctors:

If neither you nor the patient has sufficient reason or even the inclination to check a test result, don’t order it. As I’ve suggested previously, we might save a lot (billions?) of dollars, besides precious medical resources – personnel, transport workers, clerks, machines and patients’ valuable time – which are limited whether we acknowledge that or not, by thinking more carefully about the tests we order.

This is not just about heart tests. I’m thinking of urine examinations, routine chest x-rays, nerve conduction studies, pulmonary function tests, swallowing tests, etc.

3. For patients:

What happened at Harlem Hospital is, among other things, a lapse in communication between patients and their physicians. The responsibility is shared. So if you don’t understand the reason for a test, ask for a better explanation. If you need a translator, ask for one. Ask for results. Be persistent.

Aspire to be pro-active, not passive in the health care system which, otherwise, may treat you like an object. “Own” yourself!

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On People Who Receive Care From Physicians

This week’s medical blog Grand Rounds will focus on posts having to do with “customer service” in health care. A problematic concept, it seems to me.

As a physician I never considered my patients as buyers or consumers. People came to me as their doctor, or I visited them in the hospital, and I thought my job was to identify if something was wrong and, if so, to identify the exact nature of the problem and then take care of the person as best I could. I didn’t contemplate the situation with a business mind-set.

As a patient I don’t think in shopping terms when I visit my doctors or my physical therapist, although I do sometimes pay significant bills. Even for lab services, such as at Quest Diagnostics, I don’t feel as if I’m making a purchase. Sure, I’m annoyed when there’s a long wait or my results are inexplicably delayed. And I sometimes prefer one technician to another. I might mind the costs, and if there’s an error in my bill I’ll challenge that. Still, I don’t perceive myself as a health care customer.

In medical journals a patient typically is called a person, an individual, a subject in a clinical trial or (unfortunately) a case. But in some blogs and other sources I’ve been reading lately, most often having to do with health care delivery or IT, consumers pop up constantly. A good example occurs in a recent article in the journal Health Affairs, “Evidence That Consumers Are Skeptical About Evidence-Based Health Care.” This study generated a small brouhaha (in my opinion undeserved) about the public’s alleged blind faith in their personal physicians’ advice.

In reviewing that story, what most surprised me most about the paper was not so much the study’s findings (limited) or sponsorship (by the National Business Group on Health), but its language. The term “consumer” or “consumers” appears in the article’s title, no fewer than 5 times in the 125-word abstract and a noteworthy 39 times in the main paper excluding captions, tables, and references.

My point, which is really a question, is whether people who seek out or need health care should be referred to as consumers or customers. My gut feeling is that neither term is appropriate. But then again, I don’t believe that medicine can be or should be run as a business. Here’s why:

If physicians are in a position that they might be influenced by a profit motive, they’re less likely to make decisions based in evidence and are more likely to make recommendations that include income-generating procedures and treatments.

If people receive medical care from physicians who might generate greater income by recommending particular treatments, procedures or referrals, they may not receive the most appropriate care. What’s more, they are less likely to trust that their physicians are providing sound advice. The upshot is that when expensive medical care is needed – say, for the sake of this discussion, in the case of a young person with a curable leukemia – some individuals may be less trusting of physicians if they think they are motivated by money and may decline helpful and even life-saving treatments. So the profit motive, or even the appearance of a possible profit motive, has the potential to lessen the patient-doctor relationship and undermine good care.

What’s worse, though, and even more off-putting, is that in a financial transaction for medical care – in which a person with or without an illness is referred to as a “consumer” in a business called the health care industry – what’s really happening is that the illness, and maybe even the patient who has an illness, is rendered a commodity.

Ultimately this is the greatest downside of medicine as a business. No. I don’t think patients should be considered as customers or clients by any other name.

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Traveling

Information for Travelers

Dear Readers,

I’ve been on vacation for a few days, in Woods Hole and Boston, Massachusetts. I’m learning about my family.

Have a great weekend,

ES

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Mind over Matter? Don’t Kid Yourself (on Stress and BC)

I learned of a new study implicating stress in reduced breast cancer survival by Twitter. Three days ago, a line in my feed alerted me that CNN’s health blog, “Paging Dr. Gupta,” broke embargo on the soon-to-be-published paper in the journal Clinical Cancer Research. It seems the story – that women who undergo a stress relief program live longer after breast cancer recurrence – couldn’t wait.

“Less stress helps breast cancer patients” is the title of the rushed post. What the researchers, based at Ohio State’s Comprehensive Cancer Center, report is that psychological intervention helps to increase the quality of life and survival among women with recurrent breast cancer.

The intervention at issue is this: weekly, small-group meetings of BC patients for 4 months after their initial surgery and diagnosis. Led by clinical psychologists, the women met 18 times and discussed strategies to reduce stress, improve mood, strengthen social networks, eat better, exercise and adhere to medical treatments.

The current report is an extension of previous findings among an initially larger group of women at the time of BC diagnosis. Then, the researchers randomized 227 patients after surgery, all with stage II or III disease, either to receive the intervention, or not, after an initial psychological assessment and blood tests to check their immune function. The women were overwhelmingly Caucasian, mostly with stage II tumors, well-educated and, for the most part, had ER/PR+ tumors. What the researchers noted was that:

…As predicted, patients receiving the intervention showed significantlowering of anxiety, improvements in perceived social support,improved dietary habits, and reduction in smoking…

In 2008, the same Stress and Immunity Cancer Project investigators reported in the journal Cancer that the psychological intervention reduces BC recurrence and prolongs survival. Here’s where the results become both exciting and suspicious. In 2007, with a median follow-up of 11 years, 62 women (29%) in the initial study had recurrent disease. The proportion among those who’d received the intervention was indeed lower, confirming the authors’ hypothesis that the intervention would help prevent BC from coming back. But the p-value for this difference was 0.034, barely meeting the threshold for statistical significance. Similar results were observed for overall survival among the women who’d attended the group sessions: they had a reduced risk from death with a minimally-significant p-value (0.028) for the difference.

Now, the Ohio group reports on the 62 patients who relapsed. Before going further, I should say that it’s a bummer of a result from a medical perspective and from mine as a BC survivor out at seven years. Group support aside, 44 (71%, yikes!) of the patients with recurrent disease have died with a median time until death (after recurrence) of 2.8 years (range: 0.9 – 11.8 years).

What the authors conclude is that the psychological intervention improved survival after BC recurrence. How the data flowed is this: among the recurrences, there were 33 women who’d been randomized to the assessment only, “A” arm of the original trial and 29 who’d been randomized to the intervention, “I” arm. These numbers were whittled down to 18 patients who could be followed for continued study on the “A” arm and 23 women on the “I” arm. So the total number of women evaluated in this new report is small: just 41 women.

Among those, the women who received the psychological intervention were more likely to survive, with what’s called a hazards ratio of 0.41. Here again the p-value is valid but marginal (p= 0.014). The authors show a very limited amount of data regarding test-tube based studies of natural killer (NK) and T lymphocytes in the different patient groups, and suggest in the paper’s abstract that “immune indices were significantly higher for the intervention arm.”

What would have killed this paper (pardon the verb) had I been a reviewer is this: among the 41 women with recurrent disease, there was a major difference in the treatments they received. According to the “Patients and Methods” section of the paper, in the section on “adherence, chemotherapy dose intensity,” the authors indicate that just 6 of the “A” patients received chemo in the 12 months following the recurrence, while 13 of the “I” patients got chemo in the same period.

My math: only 6 of the 18, or 33 percent of the “A” group (assessment-only) patients received chemo, while 13 of the 23 (56 percent) of the “I” (intervention) patients got chemo in the year after recurrence. That’s a huge difference in medical treatment among a very small number of patients.

My point: the small difference in survival after recurrence among those women who received structured psychological support, years earlier, may be attributable to the prompt chemotherapy they received upon relapse of the cancer. This seems a more plausible explanation than that group therapy-type sessions make a difference in tumor biology or treatment resistance. (Neither outcome is proved by this study.) The difference may also derive from better overall health in the women who initially received the intervention that included advice and support regarding diet, exercise, smoking cessation and medication compliance.

My opinion:

I think there can be tremendous value in psychological support for people with illness of any kind, whether that’s provided casually by supportive families and friends, one-on-one psychotherapy, medication and/or group meetings. And it’s easy to envision that meetings in which women with similar disease situations and concerns get together and discuss coping mechanisms, how to stay healthy, eat better and exercise could have positive effects on overall survival.

But the immune benefits of stress relief, like those presented in David Servan-Schreiber’s like-minded Anti-Cancer, are bogus. There’s no scientific evidence that the sort of NK or T cell changes tested in this study help or hurt breast cancer growth. It’s possible that a revved-up, stress and steroid-driven immune system might help kill cancer cells, or might favor their expansion. It could go either way. The effects of stress steroids on tumors vary and are complex. Prednisone and similar steroids, for example, which resemble the body’s natural stress steroid cortisol, are well-established and effective components of most lymphoma treatment regimens and once were a mainstay of breast cancer treatment. My point is not that the immune system doesn’t affect tumor growth. (I think it can and does.) But the effects are complicated and differ among individuals and according to the specific tumor type.

On linking stress and breast cancer: this argument, which is all that it is in the absence of better data, is patronizing and demeaning to women. It’s the kind of advice we offer children, that if they think and do the right things the outcome will be favorable. Oncology doesn’t work that way. If a woman’s breast cancer comes back, it’s not because she didn’t go to support groups or relax sufficiently. Tumors grow due to inherent, malignant properties of the cancerous cells and other biological factors in the body, such as other illnesses that may, indeed, weaken the immune system or limit a person’s capacity to receive effective treatment.

I’m all for stress reduction, as an aim in itself. But it’s not a cure for cancer.

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A Tapestry, and Double-Dose of Magic (on Carole King and James Taylor, Troubadour and Breaking Addiction)

My plan for today was to write on evidence-based medicine. But that can wait, at least until the morning comes.

I came upon the most wonderful recording of a concert by Carole King and James Taylor played in November, 2007 at LA’s Troubadour Club, a place I’ve never been. PBS aired the video, about an hour long in its fuller form, for its June fund-raising drive. I have tickets to see the pair at Madison Square Garden in a few weeks, and had seen yesterday morning a heartening review of the old friends’ joint concert tour.

Sweet Baby James (1970)

Even within the limits of our old TV and nothing approaching a Dolby sound system in our living room, the images – the sounds and smiles generated by Taylor and King, fixtures of my childhood – made me tremble with joy. It was lovely beyond verbal expression and I felt, among other things, glad.

Here’s the medical lesson – a surprise for me was Taylor’s astonishingly well appearance, in a born-in-1948-and-still-strumming sort of way. I’m speaking as a doctor now, as someone who’s used to eying people for signs of ill health. He looked fit, comfortable and happy in jeans and a button-down blue collared shirt. He grinned broadly while he sang, surely taking none of this for granted.

I couldn’t help but reflect on his past. He seems to have made it out of the woods. And how dark those were – to a teenager listening and watching him from afar, circa 1973, it seemed like he might not pull through. For purposes of this post, I’ll stick with the parts of Taylor’s health history that fell into the public domain long before the Internet entered our homes and minds.

Taylor, the son of a Harvard-trained physician, struggled with depression and serious drug use, including heroin addiction, for years. In 1969 a motorcycle accident broke his hands and feet.  In the same decade as he offered fabulous ballads – anthems like “Fire and Rain” and King’s “You’ve Got a Friend,” familiar even to my parents’ generation – he ravaged his body and then his marriage.

Tapestry (1971)

King’s personal story is less known to me, but the lyrics to Tapestry are deeply ingrained. I know them as I know the red carpet, flowered wallpaper and stodgy furniture of my old bedroom. She looks beautiful now. Older and gray, for sure, but natural, lovely, lively and playing strong.

The two together, even on TV, deliver a double-dose like magic. They’d performed together, in 1970, at the Troubadour and now were doing it once again, with grace. The genuineness of the friendship between them, manifest in King’s glances over the piano toward Taylor and what might have been a few tears, and his beaming toward her, could not have been staged. They’ve had some difficult times, for sure, but this was beautiful.

I’m afraid I’m gushing romantic, but as a doctor I’ve seen so many patients who’ve suffered through hard times alone, physical and mental illnesses without anyone to turn to. You have to wonder, to what extent did Taylor’s support system – his dad, who reportedly drove to retrieve him from some tough spots – and his enduring friendships and his family, old and new, help him to recover.

Not all drug abuse stories end like this one. Our government reports, based on a large 2003 survey (which may underestimate use of an illegal substance), that nearly 120,000 Americans said they used heroin in the month before the survey and 314,000 took it the year prior. From 1995 through 2002, there were approximately 150,000 new heroin uses per year in the U.S. Most were over 18, male and addicted. As for depression, the numbers are huge and deaths, very real.

What I’m thinking is this – how lucky Taylor is to have had the friends, family, financial resources and courage to get the help he needed. The message he conveys is that it is possible, at least for some, to get through it, to get better and to move on.

And for me, how lucky I am to have those tickets. I can’t wait to see them in concert later this month, in person, live.

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