Informed Consent on Paper, but Not in Reality

Over the long weekend I caught up on some reading. One article* stands out. It’s on informed consent, and the stunning disconnect between physicians’ and patients’ understanding of a procedure’s value.

The study, published in the Sept 7 Annals of Internal Medicine, used survey methods to evaluate 153 cardiology patients’ understanding of the potential benefit of percutaneous coronary intervention (PCI, or angioplasty). The investigators, at Baystate Medical Center in Massachusetts, compared patients’ responses to those of cardiologists who obtained consent and who performed the procedure. As outlined in the article’s introduction, PCI reduces heart attacks in patients with acute coronary syndrome – a more unstable situation than is chronic stable angina, in which case PCI relieves pain and improves quality of life but has no benefit in terms of recurrent myocardial infarction (MI) or survival.

The main result was that, after discussing the procedure with a cardiologist and signing the form, 88% of the patients, who almost all had chronic stable angina, believed that PCI would reduce their personal risk for having a heart attack. Only 17% of the cardiologists, who completed surveys about these particular patients and the potential benefit of PCI for patients facing similar scenarios, indicated that PCI would reduce the likelihood of MI.

This striking difference in patients’ and doctors’ perceptions is all the more significant because 96% of the patients “felt that they knew why they might undergo PCI, and more than half stated that they were actively involved in the decision-making.”

What we have, here, is a study of informed consent, set up in a way that the doctors knew the study was ongoing – because they and their patients were participating, all in one division of one hospital – and, presumably, spent if anything more time and not less than usual talking with patients and answering questions about the procedure. (Note: this particular point is an assumption on my part, supported by the reported fact that 83% of the patients reported that their questions had been answered.)

The central finding is a failure of communication between doctors and patients about the potential benefit of the procedure: 88% of the patients, who’d signed consent, thought that PCI would prevent heart attacks and only 17% of the cardiologists at the same medical center thought the same. This matters, first, because over a million people in the U.S. undergo angioplasty each year and, more broadly, because it represents an everyday outgrowth of the  phenomenon of therapeutic misconception – when patients think a procedure has a greater potential benefit than it does.

The concept of therapeutic misconception, as was initially defined narrowly in the context of clinical trials, applies to all areas of medicine. In cancer treatment it’s a big deal but, in my experience, under-addressed. A common misconception among breast cancer patients, for example, concerns the benefit of adjuvant chemotherapy, which generally reduces the odds of recurrence by about a third. So if you have a stage II tumor with good molecular features and the odds of recurrence are somewhere around 15%, that comes down to around 10% with the treatment, which does bear significant side effects and risks. Another fairly common misunderstanding in oncology is in the area of Phase I clinical trials, in which the drugs are tested for toxic effects in humans, and to see how much people can withstand, and not for therapeutic effect.

This topic is worthy of lots more discussion than I can afford here. I do recommend reading the full article, including the methods about how the survey was done, and the editorial* in the Annals, which accompanied the paper, which like so many other provocative and significant reports in the medical literature, didn’t get much attention in the lay press.

One point the editorial considers is that, perhaps, the PCI consent form used by the study authors and said to be at a 12th grade reading level, should instead be provided at an 8th grade level, as some institutions recommend and require. I’m not so sure about this, because I think a lot of medical ideas and decisions simply cannot be communicated at a lower level without loss of content, i.e. nuanced information.

I’m eager for readers’ views on this – how often is it that doctors effectively convey why a procedure should be done or a treatment be given, and what might be done to improve the process?


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The Author Chooses Not to Go to the Emergency Room

Yesterday the author of ML wasn’t feeling too well. She had (and has) what’s probably a recurrent bout of diverticulitis, a condition when a little pouch stemming from the colon becomes inflamed and causes pain and fever. This can be serious if infection of the colon’s wall progresses, or catastrophic if the colon ruptures.

So I’m thankful, today, among other things that I’m feeling better with antibiotics, extra fluids by mouth and a good dose of rest. I’m glad, also, that I avoided the hospital for evaluation and treatment, as were de rigueur for this ailment 20 years ago. I’m lucky that, so far, I’m doing OK. And I’m reminded that illness is not a metaphor for anything.

Really it’s a crapshoot – hard to know sometimes when it’s worth going to the ER or staying home and enjoying Thanksgiving with your family, as I did.


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Engage with Grace: Talking About the Hard Stuff

When I practiced oncology, I relished time spent talking with patients and their loved ones about tough decisions – when an indolent condition accelerated and it seemed time to start treatment, or when a cancer stopped responding to therapy and it seemed right to shift gears and, perhaps, emphasize palliation instead of more chemo, and at every value-loaded decision checkpoint in between.

These conversations weren’t easy; speaking of levels of care, palliation and end-of-life wishes are discussions that many doctors, even oncologists, still avoid. But I, in what I hope was a healthy way, always enjoyed that part of my work. My thinking was that even if I couldn’t change the course of an aggressive tumor, I might make a difference in the quality of a person’s end of life.


At Thanksgiving, when family and old friends come together, we face similar choices in the topics we discuss: we can chat about the weather, or delve into relatively heated topics like global warming, politics or religion, but it’s rare that we get into the existential stuff, where my thoughts tend to wander, or into the most-avoided topics of all: what to do when our loved ones get really sick.

This weekend, Medical Lessons is participating in its first blog rally. I learned about this last year from Paul Levy, who’s Running a Hospital in Boston, and was reminded earlier today in an email from Dr. Christian Sinclair of Pallimed. The purpose of the rally is to draw attention to the Engage With Grace project, which is, ultimately, about communication in non-trivial health decisions.

From the Engage With Grace website:

  • 73% of Americans would prefer to die at home, but anywhere between 20-50% of Americans die in hospital settings.
  • More than 80% of Californians say their loved ones “know exactly” or have a “good idea” of what their wishes would be if they were in a persistent coma, but only 50% say they’ve talked to them about their preferences.
  • Eight out of ten people say it is “very” or “somewhat” important to write down EOL wishes, but only 36% actually have written instructions.

The project goal is to get the conversation started – to get families talking about values and medical decisions when they’re together over the Thanksgiving holiday, instead of waiting until there’s an emergency and they’re forced to make critical decisions under pressure and without clear directive.

I don’t mean to suggest that this is an ideal or even a good subject for conversation at the Thanksgiving table, or in a house filled with neighbors or casual acquaintances. (I don’t think it is.) But maybe when you’re washing dishes in the kitchen with your brother, or driving your mom to the airport, or sitting on the bus with your son…

There’s never a good time, or enough time, to talk about these kinds of things. But these matter a lot, especially if you or someone you love becomes really sick, which happens sooner or later to most mortals. PBS aired a special on this topic last night, on the kinds of tough decisions families face when someone is acutely ill, which is available on-line and I suggest to my readers.

For tomorrow, my recommendation is to enjoy the holiday, as I intend to do!, and to eat lots of fresh fruits and vegetables, and to connect with the people you care about and don’t see as often as you’d like or wish you could –

And maybe on Friday, or Saturday, some of you will begin that difficult conversation.

Happy Thanksgiving!


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The Transportation Safety Authority Screens Travelers Inside and Out

I’ll be staying near my home in Manhattan this week. But if I did have plans to travel by airplane for the holiday, I think I’d be apprehensive about the new screening procedures implemented by the Transportation Safety Authority (TSA).

My concern is not so much with the scanners. (For a detailed review of these machines, I recommend this article in Popular Mechanics.) There are two types of scanners in current use: millimeter wave machines, which use radio-frequency waves to generate 3-D images, and back-scatter units which, by design, use low doses of x-rays to visualize what’s inside a person being scanned.

Rather, I’m worried about screening errors – false positive and false negative results, and about harms – physical and/or emotional, that patients and people with disability may experience during the screening process.

In the context of travelers’ screening, a false positive occurs when an examiner thinks he or she sees or feels something abnormal – say a weird expression on a passenger’s face or when an initial, low-threshold alarm goes off somewhere in the system – but the person isn’t carrying any dangerous or contraband items. That early, false positive signal puts the traveler through extra procedures, possible embarrassment and/or stress.

A false negative happens when a screener misses an explosive device or other harmful material. A good example is the so-called Christmas bomber, who last year got through airport security and boarded a plane with explosives effectively hidden in his underwear. In that December 2009 instance, the examiners failed to identify a passenger who carried a potentially lethal weapon. The TSA’s goal should be to minimize the number of false negative screening tests. That’s because we wouldn’t want someone to get through screening and board a plane while carrying a weapon.

The problem is that it’s easy to imagine an imperfectly-trained, inexperienced or just plain tired screener missing an irregularity in someone’s 3-D or other kind of whole-body image, especially in the context of a steady stream of passengers rushing to catch flights. The operators might miss weapons despite the visual “information” available, right in front of their eyes.

So I don’t object to the new technology, which should increase the accuracy of the screeners’ function. Ultimately, though, we can’t get around the fact that TSA employees are human and some will be nearing the end of their shift; the scanners can reduce but not eliminate these kinds of errors.

My second concern is with the potential harm to patients and people with disabilities. People may be harmed physically if, for example, a screener mishandles a pump or other device. There’s been a lot of attention to one recent report, that of a 61 year old man with a history of bladder cancer whose urostomy bag ruptured during an airport pat-down. The man described his urine spilling, and his feeling humiliated.

This is a very understandable reaction; as someone who has implants after mastectomies, and who carries a lot of internal metal hardware in her spine and elsewhere, with scars galore, I know how damaging can be a stranger’s scrutiny. Unlike doctors and nurses, most TSA employees are not accustomed to seeing colostomy bags, stumps and other disfigurements usually hidden under a person’s clothing. Even an accidental, unkind expression in a look-over, or an insensitive pat-down, could make a person feel pretty bad about their ailment.

Of course we don’t have to travel on airplanes. I don’t see this as a civil rights issue; I don’t think there’s a right to board a public vehicle without full screening if the TSA deems it’s necessary for public safety. Rather, I accept that an aspect of having illnesses is that sometimes you have to put up with things other people don’t experience.

What would help, clearly, is better sensitivity and training of TSA staff, as was considered in response to the urostomy incident. But given the huge volume of travelers and enormousness of our complicated transportation system, it seems unlikely we’ll get a satisfactory solution among all staff at all airports, at least not in time for Thanksgiving.

From the patient’s perspective, there are some practical points that might help. Amy Tenderich, at Diabetes Mine, offers tips for individuals with insulin pumps. Trisha Torrey has an interesting piece on her Patient Empowerment blog (where she argues that this is not an empowerment issue) and recommends a simple, common-sense approach, which is to arrive early at the airport. As for me, I carry cards indicating the dates of my surgeries and the nature of my hardware. Now, I’ll add to those a note from my doctor.

Meanwhile I hope the screeners will use their new equipment to do a better job at detecting people carrying weapons. And that those individuals who plan to boycott the scanners with a National Opt-Out Day tomorrow, will change their minds. The TSA employees have enough on their hands already, without a demonstration; it’s in everyone’s interest that the screening be effective, hopefully 100 percent, in this holiday season.

minor rev: 11/23, 2PM

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Does Cathy Make the Right Cancer Treatment Decision in the Big C?

scene from season finale, The Big C

“I don’t want to get sicker trying to get better and then just end up dying anyway” – Cathy, the 42 year old protagonist with advanced melanoma, on the Big C.

ML’s incoming search data suggest that some people out there are very determined to know exactly what happens to Cathy in Showtime’s new series about a young-seeming, middle-aged woman with advanced, presumably stage IV, melanoma. In last week’s review I elected not to give it away. Now I’ve reconsidered. So here’s a spoiler alert: Don’t read this post if you don’t want to know what happens to Cathy at the end of the Big C‘s first season.

After months of unusual and comfort zone-breaking behavior, Cathy reconsiders her initial decision to forgo treatment. She, possibly influenced and clearly supported by her husband’s enthusiasm for her middle-aged life and continued existence, indicates that she’s willing and ready to try treatment with Interleukin-2. Cathy seems to know something about the FDA-approved drug, which is generally toxic and ineffective in most melanoma cases. At one point, she lists its putative side effects, according to the show: “burning scabs all over my body, constantly throwing up, fluid on the lungs, my veins could shut down, I could die on the table…”

Nonetheless she decides to accept treatment:

“I’m gonna hang on as long as I can. And I’m going out ugly,” says Cathy, played by the actress, Laura Linney.

“It will never be hard for me to look at you,” responds her supportive husband Paul, portrayed by the actor Oliver Platt.

At this point Cathy’s hoping the Interleukin-2 (“interlaken,” as her husband keeps calling it, perhaps metaphorically, subconsciously, or else just simply) will keep her alive for six months, when she might or might not be eligible for an experimental anti-melanoma drug in a clinical trial.

So she goes for it: in the final scene she’s in the hospital, her mind cloudy, and dreaming. You may wonder what I think of her decision.

As an oncologist I’m half-relieved. The patient will, undoubtedly, die too soon – within months or a year or, if she’s lucky, maybe two years or even longer – because you never really know for sure about these things, if she doesn’t take any treatment. Deaths from metastatic cancer can be unpleasant and painful. On the other hand, conventional therapy for stage IV melanoma rarely leads to complete remissions and, essentially, never cures the disease.

I admired that the patient, until this last episode, maintained such a no-nonsense approach to her condition. Her perspective seemed more mature than her oncologist’s. Despite her weird and nearly unraveling behavior, she’s clearer in her priorities than many patients I’ve known; she seems to understand that a treatment might give her a few additional months but is very unlikely to help her get well and, likely, would make her sick for the duration of her life.

Sometimes oncologists get carried away with hope. What I liked best about the story is that she, the patient, was realistic in this. She didn’t want to take toxic medications in desperation, without reason.

As a patient, my feelings are mixed, too. I respected Cathy lack of passivity in her decision. Accepting treatment initially would have been the easier, “normal” thing in our culture. In effect, so far, Cathy’s taken control of what happens to her body. At the same time, I couldn’t help wonder – what if she tried it? Maybe there is a cure in the pipeline, and she’d be eligible for an experimental agent in a few months, and that drug would help her, and she’d live beyond middle age, or at least until she’s 45 or 46.

Today is Monday, but there’s no new Big C episode because the season’s over. We won’t know how Cathy fares with the Interleukin-2 for a while. Even though she is just a cable TV character, she’s in a position to teach us about oncology and living with cancer.

Hopefully the show’s producers will provide insights into immune treatments, targeted agents, clinical trials, informed consent and palliative care. (I will consider Interleukin 2 and melanoma in a separate post, to follow.) But given the TV scenario, do you think Cathy’s made a sound decision?


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Lots of Excitement about Anacetrapib, a Cholesterol-Lowering Drug

I’m a bit puzzled by all the excitement about Merck’s new drug, Anacetrapib (MK-0859), that’s said to lower risk for cardiovascular disease by lowering bad cholesterol. Earlier this week at the annual meeting of the American Heart Association, researchers presented promising findings on the drug, including results from the phase III DEFINE (Determining the EFficacy and Tolerability of CETP INhibition with AnacEtrapib) trial. The list of disclosures for that abstract is long and fairly shocking. On Wednesday, the results were published on-line in the NEJM.*

The new drug interests me, as an oncologist, because it’s an enzyme inhibitor – in some ways like many new and in-the-pipeline cancer treatments. Anacetrapib raises high-density lipoprotein (HDL, a.k.a. “good cholesterol”) and lowers low-density lipoprotein (LDL, a.k.a. “bad cholesterol”) by interfering with a cholesterol enzyme transfer protein (CETP). The experimental medication is a pill that, based on earlier safety studies, is taken at 100 mg by mouth, once daily. So it’s convenient enough.

In some respects, the results of this randomized, placebo-controlled large trial are knock-your-socks-off impressive: patients on the drug had, an average, a more-than doubling of their serum HDL levels, from 41 to 101 mg per deciliter.** At the same time, the HDL shift was just 40 to 46 for patients assigned to the placebo (control). Conversely, LDL levels went down dramatically in patients taking Anacetrapib, from 81 to 45 mg per deciliter on average, and the corresponding drop seen among the control patients was only 82 to 77. These numbers are really terrific, and the results highly significant from a statistical perspective. The study lasted for 76 weeks, i.e. well over a year, and the drug was very-well tolerated according to all published reports.

What’s wrong here? Well, it’s that we don’t know for sure how this new drug affects heart disease and other vascular conditions. In this study, the plasma cholesterol levels were monitored as surrogate markers for risk of atherosclerotic events, but these laboratory parameters are not the same thing as direct measures of disease. It is uncertain if this drug has any impact on mortality, or even on heart attacks, strokes or other clinical endpoints.

In my opinion, we need a lot more information about this new drug before we prescribe it to thousands or millions of people who have hyperlipidemia. Fortunately, as pointed out by Dr. Harlan Krumholz, writing for Forbes, Merck is “doing the right thing” by testing the drug in additional studies now, with clinical endpoints in mind. Still, his enthusiasm for what amount to very favorable blood testing seems extreme in light of the previous experience to which he refers with Pfizer’s torcetrapib, a drug of the same class that turned out to have significant side effects, and Merck’s previous marketing of Zetia.

According to the New York Times, John Boris, an analyst at Citigroup, wrote in a note to investors on Wednesday that the drug could potentially have sales of more than $1 billion a year. Dr. Steven Nissen, a sometimes cautious leader in the field, found the results encouraging, according to widely-cited comments such as those appearing in the Dow Jones Newswires.

In a few years, we’ll see what Merck finds out with the ongoing trials, and if the drug really helps reduce heart attacks and deaths in people with hyperlipidemia.

Meanwhile, since my cholesterol’s crept up, just a bit above 200, I’ve started eating oatmeal and quinoa more often. I take only skim milk in my cereal at breakfast, cut out most cheese and pizza, and enjoy ice cream but occasionally. I don’t wish to ingest any experimental enzyme inhibitors that aren’t essential in the life-saving sense.

The NIH offers tips for therapeutic lifestyle changes that can help reduce hyperlipidemia in many patients.

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**cholesterol units: milligrams per deciliter

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Medical Lessons is One Year Old!

Today Medical Lessons is one year old. That’s an important milestone in any blog’s life, as I suppose it is in this author’s.

Why blog, a mother in medicine might ask me. I’m having fun with this project, for starters. Since November 17, 2009, I’ve taught myself how to use WordPress, learned the ins and outs of website hosting companies and faulty servers, experimented with Twitter – on which I’m now hooked and, best of all, engaged a growing on-line group of interesting people.

What I like best, I think, is the freedom of modern penmanship in this strange, new mode. “It’s my blog and I’ll write what I want” is my motto in this ongoing real life-segment. How cool is that?

Where ML is headed, I’m not entirely sure. It’s been picked up by the ACP Internist blog and, as of today, the Get Better Health network. I’m a firm believer in the concept that anything can happen. So far, so good!

So thank you everyone, for reading and subscribing to ML. And for those who’ve commented, double-thanks!

I’m headed to the gym,

– ES

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First Season Ending of the Big C

Last night I stayed up late to see the season finale of the Big C. For the first time in watching this series about a 42 year old woman with advanced melanoma, in a near-final scene involving the protagonist Cathy’s teenage son, I cried.

The storyline is moving, finally, in a real and not necessarily happy direction. I must admit I was disappointed overall with the program overall until lately. That’s not because Cathy behaved recklessly and irresponsibly upon receiving her Stage IV cancer diagnosis – her decisions are her personal business and a plus for my engagement. At least the program’s not too preachy.

My gripes are with the show’s other confused characters: her homeless brother, in a TV relationship with Cynthia Nixon’s spent, post-Sex in the City character, is so extreme in his strangeness, choosing not to shower for instance, he distracts from the narrative; her obese student, played by Gabourey Sidibe, seems like she’s stuck in the wrong program; her “oncologist” is so free with his time, and apparently has so little else to do (how about studying for his boards, if he still hasn’t any other patients besides Cathy?),  he comes across as a joke instead of as a credible and sensitive physician who’s completed his training.

The good news of course is Cathy, played fantastically well by Laura Linney. She’s amazing, perhaps more than ever, a good example of how women don’t have to be knock-out gorgeous to shine. Phyllis Somerville, as Cathy’s crotchety old neighbor Marlene, offers a revealing image of loneliness and dementia, with a bit of paranoia thrown in her mix. The two men in Cathy’s life – her husband and recent lover – provide a strange balance that somehow works around her: the lover is nice, supportive and easy-going; her husband is intense and devoted; his uber-love is persuasive. As for Cathy’s son, well, he’s grown on me over the past few months.

My favorite scene, easily, is Cathy dancing with a way-alternative cancer treatment provider, the Canadian “bee man” portrayed by actor Liam Neeson. How sad he must have felt, on the set, holding close a middle-aged woman in the role of someone facing death in slow-motion.

I don’t want to give the plot away, so I’ll just say that I will definitely keep watching the Big C. I can’t wait to see what happens with Cathy, if she’ll make it to the clinical trial that opens in six months and if she’ll be eligible for experimental therapy. This is no ordinary TV show.

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Links Add Value to On-Line Reading and Medical Blog Content

This post is intended mainly for medical bloggers, but it has applications elsewhere. It’s about links and uniform resource locators (URLs), terms that I didn’t fully appreciate until the last year or so. That’s because like most of my colleagues and readers, I grew up reading printed books, newspapers and magazines. Now, perhaps as much as 90 percent of the non-fiction I read is on-line.

The Web has a lot of advantages for readers – you can see multimedia presentations, or double-click to enlarge a graph of interest. What I think is best, though, is the third dimension of information that’s sometimes provided: supportive links.

Hyperlinks, which come as urls embedded in on-line text, provide immediate access to relevant ideas and sources. For example, any reader here should be aware that what prompted this mini-essay was a recent piece on the med-blog 33 Charts in which the author, Dr. Bryan Vartabedian, suggested that link over-use can detract from the reader’s experience. As he indicates, appropriately, his post was prompted by Phil Baumann, who wrote on the value of links, particularly for the purpose of author attribution.

I suppose that excessive links might distract a reader or might even be self-serving, especially if they lead to content for which the author has some ulterior motive to connect, such as a website where my book is for sale (a strictly theoretical concern, for now). Turns out that bloggers have debated the link-bait problem for years; some suggest we insert links to acquire Google Juice, i.e. connections that support search engine optimization (SEO) and blog rankings.

But I don’t care about that, at least not primarily. Rather, an author’s responsibility to credit someone whose ideas influenced her work overrides other concerns. Consider this: if at, an academic conference a lecturer draws upon another researcher’s data but doesn’t mention that person, for fear of seeming like a brown-noser or for not wanting to draw her listeners’ attention to that investigator’s work. The presentation would be considered sloppy, at best, and might border on plagiarism. Another “reason” for omission is laziness; it takes work to find an on-line reference or supporting data to justify a point you’re making. You might not remember exactly where or when you heard of an idea, so you just spell it out in a post and, over time, might even forget that you were influenced by another’s post, full-length article or even a book you read years ago.

From the reader’s perspective, links enhance an article’s utility by providing related articles and data. With appropriate connections, a reader can easily take at look and judge for herself what she thinks of whatever it is you’re talking about in a blog post. Take a real example, for instance: if I refer to the number of individuals in the U.S. who are diagnosed with cancer of the brain and nervous system, you could click and check that the National Cancer Institute estimates that would be around 22,000 for 2010. Without the link, you’d just have to take my word for it.

So I wish bloggers, and medical bloggers in particular, would provide more links to support what they write. Otherwise, what we say amounts to “I think X,” and nothing more.

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Hospital Fashion News from AARP and the Cleveland Clinic

The November AARP Bulletin highlights a promising development in hospital couture: trendsetter Diane von Furstenberg has designed new, unisex gowns ready for wearing in hospitals. The new gowns provide style and full coverage, with options for opening in front or back according to the bulletin. A trial is underway at the Cleveland Clinic.

Turns out Newsweek (which will soon marry Tina Brown’s Daily Beast, but I digress) ran a more detailed feature on the von Furstenberg hospital gowns last August. For those of you who missed the medical fashion story of last summer, here’s the scoop:

In May, 2010, the Cleveland Clinic held a Patient Experience Summit with a bifocal theme of “empathy and innovation.” There, on Day 2, the gowns were unveiled. Jeanne Ryan, a nurse who leads the redesign team, gave a presentation. In sum: the garments should be comfortable to wear, provide dignified coverage, allow ease of access for medical examination, and meet the needs of both ambulatory and bedbound patients. And cheap – the gowns cost about $9 each, according to Newsweek.

The magazine provides some history on hospital gown innovation:

… In 1999 the Hackensack University Medical Center in New Jersey redid its gowns with the help of designer Nicole Miller. In 2004 the Maine Medical Center in Portland introduced a floor-length option to accommodate the requests of female Muslim patients, and in 2009 the Robert Wood Johnson Foundation offered $236,110 to the College of Textiles to work on designing, producing, and marketing a new style of gown…

It’s not obvious to this reviewer what will be so much better with the new DvF wraps, but I’m encouraged by the Clinic’s efforts to get this right.

Initial feedback has been good, according to Some men find the print a bit feminine, so the team may change the color scheme. Also, because the fabric shrinks upon washing, the gowns may need lengthening.

The team painstakingly chose a fabric not too heavy so as to be warm or uncomfortable for patients lying in bed, but not so light as to be transparent. The gown incorporates the Cleveland Clinic’s diamond logo in a von Furstenberg signature, repetitive kind of pattern. There’s an elastic waistband, a wrap-around closure, and a wide V-neck. The gown is functional while preserving modesty. “Physicians can open the gown to expose the part they need to access without exposing the patient completely,” Ryan told Newsweek.

As someone who’s experienced one-size-fits-all including me and a basketball player, both, in pre-surgical outfits, and who’s spent weeks lying in hospital beds barely clad while all kinds of people came in and out without knocking, and who even in this year felt embarrassed in a revealing “gown” that was supposed to cover me as I walked down a hall to a room for an x-ray but didn’t, in front of other patients and sometimes former colleagues, I see this as definite progress, or at least a step in the right direction.

These gowns needn’t (and shouldn’t) be expensive, and I have some concerns about the V neck, which sounds too open for a post-mastectomy style and for frail patients who might catch cold, or pneumonia. (Will Diane design matching scarves?) But in general I think this is a favorable trend, or at least a start, that some hospitals are noticing how patients are treated – apart from the meds and procedures and strict nursing care – affects their experience and, potentially, their wellness.

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