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!


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Are Doctors Necessary?

Ten years ago, my colleagues and I squirmed in our swivel chairs when a few tech-savvy patients filed in bearing reams of articles they’d discovered, downloaded and printed for our perusal. Some of us accepted these informational “gifts” warily, half-curious about what was out there and half-loathing the prospect of more reading. Quite a few complained about the changing informational dynamic between patients and their physicians, threatened by a perceived and perhaps real loss of control.

How a decade can make a difference.

In 2000 the Pew Charitable Trusts initiated the “Internet & American Life Project” to explore how the Web affects families and communities in matters of daily life. Susannah Fox is an associate director of the Research Center project.

“It’s the ultimate information appliance” she says of the Internet. Now that it’s in most people’s homes, people use it as they choose.

And that’s quite often –

In 2008 over 140 million Americans, a majority of U.S. adults, looked for health information on-line, according to the Center’s 2009 report. Nearly 60 percent of those admit that a recent Internet search influenced a medical decision.

“Back in 2000, our data was used to prove the concept that people were going on-line to get heath care information,” she says. But that’s no longer the issue.

“With Facebook, MySpace and Twitter, there’s a new frontier” she states. “I think we’re at a new inflection point, and now is the time to have a very clear conversation on health care.

There’s been a significant shift on the physicians’ side, too.

“It’s become clear that increased communication and discussion can change care in a positive way” says Dr. Barron Lerner, a primary care physician and medical historian at Columbia University. His most recent book, When Illness Goes Public: Celebrity Patients and How We Look at Medicine, considers how ailments in the public realm can influence peoples’ perception of illness and inform their care choices.

“The Internet can be amazingly good to get people up and running” he considers. Lerner encourages his patients who have cancer to visit the National Cancer Institute (NCI) website.

“Why not go on, and explore,” he tells them. “Now as for how much they can absorb there, I don’t know,” he adds. “It’s a very hard website.”

Dr. Gretchen Berland is a primary care physician, videographer and former MacArthur Foundation fellow at the Yale University School of Medicine. She led an early study on the quality and accessibility of web-based medical information in that was published in the Journal of the American Medical Association in 2001.

“The Internet gives people a sense of control,” she says. “People use the Web to augment the information they’re given by their physicians, to look for a second opinion, and to search for clinical trials.”

But despite the wealth of information, and good quality of many sites, Berland sees limits in the Internet’s use, particularly for patients with complex, serious conditions like cancer. Even if online materials are comprehensive and accurate, they rely on people’s ability to find and understand them.

The Internet is not enough to help most people, she states.

Recently Berland searched on-line resources on behalf of a friend who had cancer surgery. When she looked at all the data, including material gleaned from some physician-oriented sites, there were gaps. “It wasn’t clear what he should do, despite how much information is out there.”

That’s the paradox of the Internet, she notes. “It’s hard to know what applies to a particular person’s unique and complex medical circumstances.

“One thing the Web doesn’t do is personalize the information,” she says. “That’s what physicians do.”

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A Note on Blogging and Medicine

Some of you may have noticed I’ve been quiet for a few days. That’s because I’ve been working on the elements of my new Medical Lessons site. Among the things I’ve learned since starting this project in mid-November, just 2.5 months ago, is this –

Blogging is like practicing medicine in some surprising ways:

1. You learn how to blog by doing it;

2. What you say, and how you say it, makes all the difference;

3. Some people will appreciate your style, others won’t;

4. You have to be careful, details can make things go right or wrong;

5. There’s never enough time in the day;

6. It’s fun, interesting and rewarding (largely in intangible ways);

7. You have to stay current to be good at it;

8. You get to interact with all sorts of people;

9. You’re constantly learning;

10. I love it.

As soon as the new site is ready, you’ll find the directions automatically.

Not to worry – I’ll be writing lots, then and there. Once the formatting’s done I’ll have more time to spend on ideas and information.

See you there!


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Moms Tweet About Blood and Cancer

This afternoon I found a Tweet from a colleague, a journalist who happens to be a mom in my community:

Tweet from SuSaw:

“RT @JenSinger: Hey, baby. What’s your blood type? Nothing against the Big Pink Machine…

As a trained hematologist (blood doc), oncologist and breast cancer survivor, I couldn’t resist checking this out. Here’s what I discovered:

The link traces to Turns out MammaBlogger Jen Singer counts herself among lymphoma survivors in remission. Another mom in remission, I might add –

Jen clues us in on a new breast cancer awareness campaign that migrated to Facebook but three days ago – breast cancer awareness ? I updated my Status with my Bra colour ? and, as of this moment, has over 57,000 fans. Her solidarity with breast cancer patients and their loved ones is very real. She’s at increased risk, among other reasons for her sensitivity to the issue.

Jen plugs for greater public consciousness of other malignancies including tumors that arise from blood cells – conditions like non-Hodgkin’s lymphoma, leukemia and myeloma. She’s particularly concerned about a young neighbor, a teenager with recurrent leukemia, who needs blood now.

In a post “O Positive is the New Pink” she writes:

“So, I ask you this: Please put your blood type in your Facebook status and ask your friends to do so, too, to raise awareness for lymphoma and leukemia. Mine is O+, a blood type…

I was blown away by this, and impressed. What social media might do for the practice of hematology!

With just a few clicks at the keyboard and some thousands of on-line connections, one lymphoma survivor has improved the chances that one girl with leukemia will get the platelets she needs. And, maybe thanks to the Facebook blood typing information campaign, more potential blood donors will connect with those who need cells in the future.

Last year, Phil Baumann listed 140 potential applications for Twitter in health care. I was curious but skeptical. Now I’m partly persuaded, at least.

Besides, just think what three moms can do. It takes a village…


More soon – on giving blood, blood types and blood cells.

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Information Overload

Americans are consuming unprecedented amounts of information. Some small fraction of that – what we read, hear and see on TV – relates to health and illness. Today’s sources might include a story on cell phones and cancer, an NPR feature on autism or a commercial in which Sally Fields recommends Boniva, a drug for osteoporosis.

Does knowing more help us lead better, healthier lives?

In Bits, a NY Times blog on business, innovation, technology and society, Nick Bilton recently described our voracious appetite for enlightenment: 34 Gigabytes or, depending on how you count, nearly 12 hours’ worth of data-gleaning per day from diverse channels like television, radio, the Web, text messages and video games.

The Bits piece links to the Global Information Industry Center‘s “How Much Information?” (HMI?) project that issued a December 2009 paper. The research center, based at the University of California in San Diego, dates to 1960, when the Internet was, if anything, theoretical, and the concept of sharing computer-based data a matter of defense.

As best I can tell, the topics of “health” and “cancer” don’t figure prominently in the recent analysis. Maybe we don’t want to know much more on these subjects than we find in our doctors’ offices. But long runs of TV shows like “Marcus Welby, M.D.,” “ER” and “Scrubs” suggest otherwise. Indeed, many tune in regularly for a peek into the medical world, at least when fed in bits and pieces by idealized or heart-throb fictitious physicians with complex, warm and sometimes hot personal lives.

Nearly two-thirds of U.S. adults seek health-related information on the Web, says Susannah Fox of the Pew Research Center’s Internet & American Life Project. The agency tracks how North Americans use the Internet for medical purposes and published an update, “The Social Life of Health Information” earlier this year.

Dr. Kevin Pho touched on the issue in a December 16 post on KevinMD:

To be sure, doctors and other health professionals don’t get everything right. But anyone can find information on the web, which can be of dubious accuracy.

Knowing what to do with that data can only come with experience and training.

Fox, of the Pew Research Center, commented:

…one of our key findings is that most people use on-line health resources to supplement advice they get from doctors and other health professionals. After 10 years of researching this field, we have no evidence that the internet is replacing traditional sources of medical advice. Yes, many people are gathering and sharing health information online, but they are also discussing it with friends, family, and health professionals.

I was considering the matter last week, it happens, when I received an email from a former patient. He has hemochromatosis, an inherited disposition to iron overload. His body is programmed to take in excessive amounts of iron, which then might deposit in the liver, glands, heart and skin. He offered holiday greetings and mentioned “some amazing videos on hematology and hemochromatosis and genetics” he’d discovered on YouTube.

This is the future of medicine, I realized. A patient accesses public databases, videos and other resources to learn about signs and symptoms of his illness, what foods to eat or best avoid, what medicines and treatments he might need and if his condition is likely to affect others in his family.

Whether physicians want their patients to search the Internet for medical advice is beside the point. We’re there already, whether or not it’s good for us and whether what we find there is true.

The current issue is not about limiting non-professionals’ access to facts or fiction. Rather, it’s about how we might sift through so much material – whether that’s a CNN segment we take in, passively, while running on a treadmill in the gym, or a detailed analysis of a new prostate cancer treatment provided straight from an oncologist – and digest it properly.

Perhaps information is a bit like iron, an essential nutrient that makes us stronger. To benefit from such a surplus, we’ve got to somehow identify, process and absorb what’s useful, what helps and doesn’t hurt.

Patients using internet health information without physician guidance

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Doctors Don’t Tweet

I didn’t know much about social media until the summer of 2008. Then, I entered Columbia University’s Graduate School of Journalism as a new student and attended an optional lunch-time session on Facebook, Gmail and Twitter.

My kids used Facebook, so I knew about that. Still, I hesitated to sign on to something so un-private, so revealing, so exposed. I asked the dean of students if joining Facebook was essential to my participation in the graduate program.

“Not exactly,” he said. “But if you want to be a journalist, you probably should.”

So I did. Over the course of 10 tough academically dense months, I saw streams of status updates, invitations to parties, news flashes and pix. Finding Facebook friends is easy, I learned, if you’re spending your days amongst people half my age.

Still, I wasn’t entirely comfortable. Physicians are professionals, reserved and careful.

Gradually a few of the moms I know from my kids’ school connected. Some of them are using Facebook for professional purposes, others maybe to assuage boredom. Some, I suspect, joined to monitor their teenagers’ lives. (I didn’t.) More recently, a bunch of my high school classmates reunited on-line. A few friends from college met up there, too.

But my physician friends – some 25 years’ worth since I entered med school – aren’t in sight.

The New England Journal of Medicine first approached this somewhat sensitive subject last summer in an article “Practicing Medicine in the Age of Facebook.”

I wonder when the Journal will talk on Twitter.

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