by KEVIN PHO, MD at KevinMD.com
The following column was published on November 10, 2011 inMedical Economics.
I recently saw two patients in my primary care clinic, each with new-onset hypertension.
The first, a middle-aged executive, brought printouts from the Internet and already had researched the various treatment options for high blood pressure. During the visit, we discussed this information, and I gave my thoughts on what to do next. He considered and appreciated my input but made it clear that the ultimate decision was his.
The second was an elderly gentleman in his 70s. Again, I discussed the various management approaches and then gave my opinion on what we should do. In contrast to the other patient, he said, “I want to do whatever you suggest. After all, you’re the doctor.”
As a publisher of a social media health Web site, I’ve observed closely the growth of the patient empowerment movement, facilitated by the Web making health information more accessible. According to the Pew Internet and American Life Project, 80% of Internet users go online to research their health, and this effort gives patients a greater voice in their care. Paternalistic decision making that traditionally drove the doctor-patient relationship slowly is being replaced by shared decisions. But not all patients embrace their new decision-making role.
In a recent study from the Journal of Medical Ethics, researchers interviewed more than 8,000 patients. Almost all wanted doctors to offer choices and help consider their options, but two-thirds preferred that the final medical decision to be left to the physician.
According to Farr A. Curlin, MD, an associate professor of medicine at the University of Chicago and one of the authors of the study, “the data [say] decisively that most patients don’t want to make these decisions on their own.”
There is a spectrum of how much physician involvement patients want. Some may want physicians only to suggest and inform but leave the ultimate decision to them. Others prefer doctors to have the final say.
The only way to know a patient’s preference is through a continuous relationship where that comfort level can be developed over time. After several encounters, a clinician should have a sense of how much, or how little, direction a patient needs.
Sadly, two factors in healthcare today work against such a sustained doctor-patient relationship. One is the fragmentation of medical care. More patients are seeing not only a primary care physician (PCP) in a clinic, but also a hospitalist when admitted to a hospital, along with an array of specialists both in the hospital and the clinic. According to a New England Journal of Medicine study, Medicare beneficiaries saw an average of two primary care physicians and five specialists working in four different practices. Without knowing the patient well, each provider may differ with his or her input in the medical decision process, which can frustrate patients who may have their own ideas of how much their doctors should be involved.
Next, consider the decay of primary care itself. There is a profound shortage of PCPs, with the American College of Physicians noting that “primary care, the backbone of the nation’s healthcare system, is at grave risk of collapse.” Patients who cannot schedule timely primary care appointments go to the emergency department, where they encounter clinicians they’ve never met before. The shortage is compounded by what is shown in the results of an Annals of Internal Medicine survey, which revealed that 30% of PCPs were likely to leave the field, citing burnout from time pressures, a chaotic work pace, and little control over their work. Both the shortage and attrition of primary care providers worsen the odds of forming long-term relationships with patients.
Having known my two patients with hypertension for years, I anticipated how much physician involvement they would need to make a treatment decision and was able to tailor my approach to meet their individual expectations. During this turbulent period of healthcare reform, we cannot lose sight of the importance of a continuous relationship between doctors and patients. Otherwise, our fragmented health system and deterioration of primary care will make it challenging to provide the proper amount of guidance for patient medical decisions.
- The Social Life of Health Information(Pew Internet Report)OVERVIEW
The internet has changed people’s relationships with information. Our data consistently show that doctors, nurses, and other health professionals continue to be the first choice for most people with health concerns, but online resources, including advice from peers, are a significant source of health information in the U.S.
- Predictors of hospitalised patients’ preferences for physician-directed medical decision-making (Journal of Medical Ethics, June 2011)
Background Although medical ethicists and educators emphasise patient-centred decision-making, previous studies suggest that patients often prefer their doctors to make the clinical decisions…Conclusions Almost all patients want doctors to offer them choices and to consider their opinions, but most prefer to leave medical decisions to the doctor. Patients who are male, less educated, more religious and healthier are more likely to want to leave decisions to their doctors, but effects are small.
- Choosing Wisely (an initiative of the ABIM Foundation)
- What Makes Patients Complex? Ask Their Primary Care Physicians (medicalnewstoday.com)
- What makes patients complex? Ask their primary care physicians (medicalxpress.com)
- Letting Doctors Make the Tough Decisions (jflahiff.wordpress)
- What makes patients complex? Ask their primary care physicians (eurekalert.org)
- Make an informed judgment on the abilities of your surgeon (kevinmd.com)
- Let physician assistants be part of the primary care answer (kevinmd.com)
- Patients eager to see doctor’s notes; physicians, not so much (seattletimes.nwsource.com)
- The primary care doc fix is in (kevinmd.com)
- Letting Doctors Make the Tough Decisions (New York Times)
As part of its ongoing efforts to ensure safe, effective and appropriate medical imaging, the American College of Radiology has joined the ABIM Foundation and eight other medical specialty societies in Choosing Wisely. The new campaign promotes wise choices by physicians and patients to improve health outcomes, avoid unnecessary interventions and make efficient use of healthcare dollars.
The ACR will develop a list of five things to reduce unnecessary imaging exams ordered by physicians and improve quality of care. The list names imaging exams whose necessity should be discussed before being ordered. The list also equips providers with steps to help ensure safe, appropriate use of scans.
“Medical imaging exams are a perfect fit for Choosing Wisely. Scans lower healthcare costs by replacing more invasive surgeries and allowing for shorter hospital stays. Although imaging use is down significantly since 2008 and Medicare spending on imaging is the same as in 2004, opportunities remain to ensure appropriate ordering of scans. As greater access to imaging is directly tied to increased life expectancy, ACR will identify areas where care can be improved without restricting patient access,” said John A. Patti, MD, FACR, chair of the ACR Board of Chancellors……
The ACR list, and those of other Choosing Wisely partners, will be released in April 2012. To learn more, visit ChoosingWisely.org.
This series of six video vignettes featuring physicians and patients emerged from research the ABIM Foundation conducted to better understand public and professional attitudes about stewardship of finite resources. Watch the videos.
- ACR in Choosing Wisely campaign to promote wise use of resources among physicians and patients (medicalxpress.com)
When we think about numbers, we mentally represent smaller numbers to the left and larger numbers to the right. The researchers surmised that leaning one way or the other – even imperceptibly – might therefore nudge people to estimate lower or higher. To test this hypothesis, study participants – 33 undergraduates – stood on a Wii Balance Board that imperceptibly manipulated their posture to tilt left or right or stay upright while they answered estimation questions appearing on a screen. The participants were told they probably didn’t know the answers and therefore would have to estimate; they were also instructed to stand upright throughout the trials. A representation on the screen, below the question, of the person’s posture showed it to be upright even when it was not. The participants answered the questions one by one verbally.
In the first experiment, the estimations were of different kinds of quantities – e.g., the height of the Eiffel Tower or percentage of alcohol in whiskey. In the second, the quantities were all of the same kind – How many grandchildren does Queen Beatrix of the Netherlands have? How many Number 1 hits did Michael Jackson have in the Netherlands? The answers were all between 1 and 10.
As expected, participants gave smaller estimations when leaning left than when either leaning right or standing upright. There was no difference in their estimates between right-leaning and upright postures.
- Posture Reveals All (studiowithoutwalls.org)
…..When it came to medical decisions, almost all the respondents wanted their doctors to offer choices and consider their opinions. But a majority of patients — two out of three — also preferred that their doctors make the final decisions regarding their medical care.
“The data says decisively that most patients don’t want to make these decisions on their own” said Dr. Farr A. Curlin, an associate professor of medicine at the University of Chicago and one of the authors of the study.
The challenges appear to arise not when the medical choices are obvious, but when the best option for a patient is uncertain. In these situations, when doctors pass the burden of decision-making to a patient or family, it can exacerbate an already stressful situation. “If a physician with all of his or her clinical experience is feeling that much uncertainty,” Dr. Curlin said, “imagine what kind of serious anxiety and confusion the patient and family may be feeling.”
Patients and their families also often don’t realize that their doctors may be grappling with their own set of worries. …
- Talking about faith increases hospital patients’ overall satisfaction (esciencenews.com)
- Do Patients Have the Toughest Job in Medicine? (well.blogs.nytimes.com)
- What this doctor learned when he was a patient (kevinmd.com)
- Why doctors should stop wearing ties (kevinmd.com)
- Patients want and need to take a greater role in their medical care (kevinmd.com)
Narcissists rise to the top. That’s because other people think their qualities – confidence, dominance, authority, and self-esteem – make them good leaders. Is that true? “Our research shows that the opposite seems to be true,” says Barbora Nevicka, a PhD candidate in organizational psychology, describing a new study she undertook with University of Amsterdam colleagues Femke Ten Velden, Annebel De Hoogh, and Annelies Van Vianen.
The study found that the narcissists’ preoccupation with their own brilliance inhibits a crucial element of successful group decision-making and performance: the free and creative exchange of information and ideas..
- When a Narcissist Becomes a Church Leader (dawnmarie4.wordpress.com)
- Is social networking turning teens into narcissists? (ctv.ca)
- Study: Narcissists Know What You Think of Them and They Don’t Give a Flying Fig (blogs.forbes.com)
- Bipolar or Narcissistic Personality Disorder? (everydayhealth.com)
- Facebook and Teens: Depressive, Narcissistic Consequences? (inquisitr.com)
The National Prevention Strategy includes actions that public and private partners can take to help Americans stay healthy and fit and improve our nation’s prosperity. The strategy outlines four strategic directions that, together, are fundamental to improving the nation’s health. Those four strategic directions are:
- Building Healthy and Safe Community Environments: Prevention of disease starts in our communities and at home; not just in the doctor’s office.
- Expanding Quality Preventive Services in Both Clinical and Community Settings: When people receive preventive care, such as immunizations and cancer screenings, they have better health and lower health care costs.
- Empowering People to Make Healthy Choices: When people have access to actionable and easy-to-understand information and resources, they are empowered to make healthier choices.
- Eliminating Health Disparities: By eliminating disparities in achieving and maintaining health, we can help improve quality of life for all Americans.
- National Prevention Strategy: America’s Plan for Better Health and Wellness (nlm.nih.gov)
- HHS Announces Plan to Reduce Health Disparities (nlm.nih.gov)
The production of health economic evaluations of pharmaceuticals is a multibillion dollar industry globally. Nevertheless, little is known about uptake by medical decision makers.
Dr. Sandra Erntoft has investigated whether there are differences in use across decision makers and to what extent these patterns can be explained by contextual factors?
The review – “Pharmaceutical priority setting and the use of health economic evaluations – A systematic literature review”, published in Value In Health identifies differences in the use between decision makers and contexts. Health Economic evaluations are not only used in order to inform decisions, but also serves the purpose of rationalize decisions, structuring the priority setting process or requesting additional budgets. Factors that seem to support an increased use of health economic evaluations are a general awareness and acceptance of limited health care resources, demands for an explicit priority setting process, the lack of budgetary responsibilities and the presence of health economic skills.
Dr. Sandra Erntoft, Research Director of the Swedish Institute for Health Economics says “When these preconditions are not in place, it is difficult for a decision maker to use health economic evaluations directly in medical decision making. In order to increase the use these cultural and institutional barriers need to be removed.”
- FDA could analyze public health consequences of its decisions better (medicalxpress.com)
Happy people are more likely to eat candy bars, whereas hopeful people choose fruit, according to a new study. That’s because when people feel hope, they’re thinking about the future. (Credit: © Andrea Berger / Fotolia)
ScienceDaily (Apr. 20, 2011) — Happy people are more likely to eat candy bars, whereas hopeful people choose fruit, according to a new study in theJournal of Consumer Research. That’s because when people feel hope, they’re thinking about the future.
Most of us are aware that we often fall victim to emotional eating, but how is it that we might choose unhealthy or healthy snacks when we’re feeling good?” write authors Karen Page Winterich (Pennsylvania State University) and Kelly L. Haws (Texas A&M University).
Because previous research has explored how feeling sad leads to eating bad, the authors focused on the complicated relationship between positive emotions and food consumption. “We demonstrate the importance of the time frame on which the positive emotion focuses and find that positive emotions focusing on the future decrease unhealthy food consumption in the present,” the authors write….
- Karen Page Winterich and Kelly L. Haws. Helpful Hopefulness: The Effect off Future Positive Emotions on Consumption. Journal of Consumer Research, October 2011 (published online March 18, 2011) DOI:10.1086/659873
Choosing the appropriate way to present risk statistics is key to helping people make well-informed decisions. A new Cochrane Systematic Review[abstract]*** found that health professionals and consumers may change their perceptions when the same risks and risk reductions are presented using alternative statistical formats.
Risk statistics can be used persuasively to present health interventions in different lights. The different ways of expressing risk can prove confusing and there has been much debate about how to improve the communication of health statistics.
For example, you could read that a drug cuts the risk of hip fracture over a three year period by 50%. At first sight, this would seem like an incredible breakthrough. In fact, what it might equally mean is that without taking the drug 1% of people have fractures, and with the drug only 0.5% do. Now the benefit seems to be much less. Another way of phrasing it would be that 200 people need to take the drug for three years to prevent one incidence of hip fracture. In this case, the drug could start to look a rather expensive option.
Statisticians have terms to describe each type of presentation. The statement of a 50% reduction is typically expressed as a Relative Risk Reduction (RRR). Saying that 0.5% fewer people will have broken hips is an Absolute Risk Reduction (ARR). Saying that 200 people need to be treated to prevent one occurrence is referred to as the Number Needed to Treat (NNT). Furthermore, these effects can be shown as a frequency, where the effect is expressed as 1 out of 200 people avoiding a hip fracture.
In the new study, Cochrane researchers reviewed data from 35 studies assessing understanding of risk statistics by health professionals and consumers. They found that participants in the studies understood frequencies better than probabilities. Relative risk reductions, as in “the drug cuts the risk by 50%”, were less well understood. Participants perceived risk reductions to be inappropriately greater compared to the same benefits presented using absolute risk or NNT.
“People perceive risk reductions to be larger and are more persuaded to adopt a health intervention when its effect is presented in relative terms,” said Elie Akl of the Department of Medicine, University at Buffalo, USA and first author on the review. “What we don’t know yet is whether doctors or policymakers might actually make different decisions based on the way health benefits are presented.”
Although the researchers say further studies are required to explore how different risk formats affect behaviour, they believe there are strong logical arguments for not reporting relative values alone. “Relative risk statistics do not allow a fair comparison of benefits and harms in the same way as absolute values do,” said lead researcher Holger Schünemann of the Department of Clinical Epidemiology and Biostatistics at McMaster University in Ontario, Canada. “If relative risk is to be used, then the absolute change in risk should also be given, as relative risk alone is likely to misinform decisions.”
Cochrane Reviews are “ systematic reviews of primary research in human health care and health policy. They investigate the effects of interventions (literally meaning to intervene to modify an outcome) for prevention, treatment and rehabilitation. They also assess the accuracy of a diagnostic test for a given condition in a specific patient group and setting.”
ScienceDaily (Mar. 3, 2011) — How well our brain functions is largely based on our family’s genetic makeup, according to a University of Melbourne led study. The study published in The Journal of Neuroscience provides the first evidence of a genetic effect on how ‘cost-efficient’ our brain network wiring is, shedding light on some of the brain’s make up.
Lead author Dr Alex Fornito from the Melbourne Neuropsychiatry Centre at the University of Melbourne said the findings have important implications for understanding why some people are better able to perform certain tasks than others and the genetic basis of mental illnesses and some neurological diseases….
…”We found that people differed greatly in terms of how cost-efficient the functioning of their brain networks were, and that over half of these differences could be explained by genes,” said Dr Fornito.
Across the entire brain, more than half (60%) of the differences between people could be explained by genes. Some of the strongest effects were observed for regions of the prefrontal cortex which play a vital role in planning, strategic thinking, decision-making and memory.
Previous work has shown that people with more efficient brain connections score higher on tests of intelligence, and that brain network cost-efficiency is reduced in people with schizophrenia, particularly in the prefrontal cortex.
“This exciting discovery opens up a whole new area of research focus for scientists around the world,” he said.
- Parts of Brain Can Switch Functions: In People Born Blind, Brain Regions That Usually Process Vision Can Tackle Language (jflahiff.wordpress.com)
- Study points to liver, not brain, as origin of Alzheimer’s plaques (physorg.com)
‘Gut Instinct’ May Stem From the Heart
Study probes what prompts people to make the decisions they do
From a January 6, 2011 Health Day news item by Robert Preidt
THURSDAY, Jan. 6 (HealthDay News) — Everyone feels gut instincts at one time or another: Marry that guy! Don’t take that job. Stay inside during this snowstorm! Now, a new study suggests there is indeed a link between your heartbeat and the decisions you make.
“These findings can help explain how we make key choices in life — for example, which house to buy, which job to go for — for better or for worse,” explained study author Barnaby D. Dunn, a clinical psychologist who works with the Medical Research Council Cognition and Brain Sciences Unit in Cambridge, England.
The findings don’t indicate that your heart is very good at giving you insight into what to do. And the research doesn’t point to any particular way to get better at decision making. Still, the study does manage to find evidence that there’s something to the idea of trusting your heart.
“I work as a clinical psychologist, and I have been struck in my therapy practice how clients often describe their emotions and decisions in terms of what is happening in their bodies — for example, feeling brokenhearted or following their gut instincts,” Dunn said. “I wanted to see if there was a scientific basis to the idea that what happens in our bodies shapes our minds.”
The researchers tried to find a link between heart and mind by first testing participants to see if they could estimate how fast their hearts were beating. “Participants are instructed to try to ‘feel’ their heart internally and not to directly measure their pulse with their fingers,” Dunn said. “Most people say they are guessing at the tracking task and are unconfident in their performance, and yet there are marked differences in how accurate their estimates are. Only around one-fifth of people show high levels of accuracy.”
Researchers then tried to elicit emotions from the participants by showing them photos of happy things (like a cute puppy) and not-so-happy things (a disgusting plate of food). They then tried to link people’s responses to their ability to monitor their heart rates.
“People’s arousal turned out to be related to changes in their heart rate,” Dunn said. “And this link was stronger in people who were more aware of their own heartbeat. So how people felt depended in part on how well they could sense the status of their own bodies.”
“This suggests that what happens in our bodies really does shape how we feel emotionally,” he said.
In a second experiment, the participants played a card game that emphasized intuition instead of strategy. “The quality of the advice that people’s bodies gave them varied,” Dunn said. “Some people’s gut feelings were spot on, meaning they mastered the card game quickly. Other people’s bodies told them exactly the wrong moves to make, so they learned slowly or never found a way to win. This link between gut feelings and intuitive decision making was stronger in people who were more aware of their own heartbeat.”
What’s the connection between the heart and brain? Dunn said one theory goes like this: “The ‘emotional’ parts of the brain generate the bodily response in the first place. The ‘rational’ parts of the brain then listen in to these bodily responses to find out what the ‘emotional’ parts of the brain are doing. This allows both logic and emotion to shape our choices.”
Dunn said better understanding of the link between the body and the mind might eventually help people who struggle with depression and anxiety.
“We know that anxious people are hyper-aware of the body, whereas those who are depressed are out of touch with the body,” he said. “Training the ability to tune in and out of the body may be beneficial for these individuals.”
The study was published in the December issue of Psychological Science.
SOURCES: Barnaby D. Dunn, Ph.D., clinical psychologist, Medical Research Council Cognition and Brain Sciences Unit, Cambridge, England; December 2010 Psychological Science
ICU communication study reveals complexities of family decision-making
While a much hailed communication intervention works for families making decisions for chronically-ill loved ones in medical intensive care units, Case Western Reserve University researchers found the intervention was less effective for surgical and neurological ICU patients.
Barbara Daly and Sara Douglas, the study’s lead researchers from the Frances Payne Bolton School of Nursing at Case Western Reserve, attribute the varied results to different types of patients served by the three types of ICUs and differences among ICU cultures.
“We found the same approach is not going to have the same results for everyone,” Daly said
With the number of ICU patients predicted at more than 600,000 patients annually by 2020, researchers search for ways to help families make critical decisions for their loved ones. This study contributes to those ICU practices involving complex communication issues.
The researchers repeated a study from a Boston hospital that resulted in shorter stays and less unneeded tests and treatments when families were routinely informed through a systemized communications intervention about their family member’s progress in a medical ICU. They compared the effect of the new communication system in 346 patients to usual practice in 135 patients.
The intervention involved a 30-minute communication meeting between the clinical staff and family, beginning five days after a patient requiring a ventilator was admitted to the ICU. The staff and family covered five components: medical update, preferences and goals for the patient, treatment plans, prognosis, and milestones (the markers that can tell whether a person is improving).
The meetings continued weekly until the patient was transferred to a regular hospital ward, to a long-term facility, went home or died.
According to Daly, the discussions are important because up to 40% of these ICU patients do not survive beyond two months if they have spent more than five days on a mechanical ventilator.
For survivors, the most likely outcome is for long-term care, which raises issues about the quality of life that the patient might want to have, she said.
Overall, the researchers found no significant differences between the control and intervention groups in length of stay in the ICU or in limitations of aggressive interventions.
“The Boston study had been the ideal situation where the director of the ICU was conducting the study and the ICU staff accepted the intervention as part of its routine practices, said Daly, professor of nursing and clinical ethics director at University Hospitals Case Medical Center. “We took the study into real-life situations.”
Daly attributes the varying effectiveness of the new communication system to different ages and needs of patients in the medical, compared to surgical units and to differences in clinical staff attitudes towards decisions to limit aggressive interventions, such as feeding tubes and tracheostomy.
In the medical units, the patients generally are older and chronically ill—many suffering several chronic illnesses. The other ICUs generally serve younger patients who are more likely to have suffered a sudden acute health crisis, such as an emergency surgery or trauma from a motor vehicle accident.
Daly said many treatments in the medical ICU will not sustain life, and families face complicated end-of-life decisions to stop or continue ineffective treatments.
The research group also tracked conversational interchanges between family members and doctors.
All families received medical updates. About 86% of the meetings covered treatment plans; 94%, prognosis; 78 percent, preferences and goals; and only 68%, milestones.
Daly said analyses of the types of conversations found that 98% of the time was spent relaying facts about the patient, and only 2% was spent on personal, emotional, or relationship conversation.
The researchers also found that on average, doctors asked families one question, which was: “Do you have any questions?”
The families asked an average of six.
“Better communications is needed. Overall the process is not working as well as we would like and there are missed opportunities to better support families in their decisions,” Daly concluded.
The full results of the National Institute for Nursing Research-funded study were published in the article, “Effectiveness Trial of an Intensive Communication Structure for Families of Long-Stay ICU Patients,” in the journal Chest.