I realize that my blog has been littered with depressing musings on healthcare lately, and so I thought I’d offer up one very positive and “actionable” suggestion for all you patients out there. In the midst of a broken system where your doctor is being pressured to spend more time with a computer than listening and examining you, where health insurance rates and co-pays are sky-rocketing, and where 1 in 5 patients have the wrong diagnosis… There is one “magic” question that you should be asking your physician(s):
“What else could this be?”
This very simple question about your condition/complaint can be extremely enlightening. Physicians are trained to develop extensive “differential diagnoses” (a list of all possible explanations for a set of signs and symptoms) but rarely have time to think past possibilities 1 through 3. That’s one of the reasons why so many patients have the wrong diagnosis – which is both costly in terms of medical bills, time, and pain and suffering.
There is a risk in asking this question – you don’t want to be over-tested for conditions that you are unlikely to have, of course. But I maintain that the cost/risk of living with the wrong diagnosis far exceeds the risk of additional testing to confirm the correct diagnosis. So my advice to patients is to keep this very important question in mind when you see your doctor for a new concern.
- Better tests needed to improve patient care, public health (medicalnewstoday.com)
- Mistakes even good doctors make (consumerreports.org)
- Hypochondriacs Rejoice: WebMD is Beefing Up Its Real-Life Doctor Support (betabeat.com)
- Admit when you fall short: The power of “I don’t know” (kevinmd.com)
From the 21 October 2013 KevinMD.com article by Kathy Neider, Physician
Over one year ago my office implemented an EHR (electronic health record). I’ve not done a note on paper since.
Last week, a Transition of Care (TOC) document was placed on my desk with a sticky note stating: “Dr. Nieder please fill out this form so we can bill a 99496 for your visit with Mrs. Jones yesterday.”
I pick up two sheets of paper with multiple questions including:
- discharge Medications: (list)
- present Medications: (list)
- diagnostic tests reviewed/disposition (list)
- disease/illness education (discussion documentation)
- home health/community services discussion/referrals: (list)
- establishment or re-establishment of referral orders for community resources: (list)
- discussion with other health care providers: (list)
- assessment and support of treatment regimen adherence: (discussion documentation)
- appointments coordinated with: (list)
- education for self-management, independent living and activities of daily living: (discussion documentation)
Please remember, I am now on an EHR. So I am expected to document electronically first then manually fill out forms. I have no discharge summary yet from the hospital. The medications when she left the hospital state “resume pre-admission meds.” In order for me to list what tests she had I log in to the hospital portal and look them all up. Some of them have been scanned into my EHR, some not. She had a straight forward admission for a small bowel obstruction. She declined to keep the surgeon’s appointment as she was told there was nothing he could do for her.
A TOC visit is paid at a higher rate than other visits if the patient does not return to the hospital in the following 30 days. Hence, we hold the billing until that time. My understanding of the purpose of this new code is to improve coordination of care as a patient transitions from the hospital to home. Coordination would imply that there are other individuals involved and thus there is improved communication between us.
However my staff and I bear the brunt of gathering information (which is what we normally do anyway, so I guess it’s nice because now we get paid for it).
At what point will it become incumbent upon the hospital to send me the necessary information for treating the patient now that he/she is home again? How does it follow that improving care means the primary care doctor fills out even more forms, ultimately reducing the time spent with the patient?
The form will not keep the patient out of the hospital. Communication can keep the patient out of the hospital. True coordination of care might keep the patient out of the hospital. More busy work for the patient’s primary care doctor will not. Since the order of the day is using hospitalists, it is imperative that we improve our communication systems at the time of discharge and before the patient is seen again in the primary care office. Systems must stop thinking that one more form is going to save the patient. Especially another form on my back.
Kathy Nieder is a family physician who blogs at Family Practice 2.0.
- How Can Reinventing Patient Experience Decrease Readmissions? (healthcareitstrategy.com)
- St. Elizabeth Hospital Helps Meet HIMSS Stage 7 Requirements, Improves Patient Care with Hosted Electronic Patient … (prweb.com)
- Electronic Health Records Benefits: An ePatient Story (healthcarereimagined.wordpress.com)
- Managing Unsolicited Health Information in the Electronic Health Record – AHIMA (healthcarereimagined.wordpress.com)
- Meaningful Use, Meaningful Results (medcitynews.com)
few weeks ago, I went for the first time to Stanford’s Medicine X conference. It’s billed as a conference that brings a “broad, academic approach to understanding emerging technologies with the potential to improve health and advance the practice of medicine.”
Well, I went, I saw, and I even briefly presented (in aworkshop on using patient-generated data).
And I am now writing to tell you about the most important innovations that I learned about at Medicine X (MedX).
They were not the new digital health technologies, even though we heard about many interesting new tools, systems, and apps at the conference, and I do believe that leveraging technology will result in remarkable changes in healthcare.
Nor were they related to social media, ehealth, or telehealth, even though all of these are rapidly growing and evolving, and will surely play important roles in the healthcare landscape of the future.
No. The most remarkable innovations at MedX related to the conference itself, which was unlike any other academic conference I’ve been to. Specifically, the most important innovations were:
- Patients present to tell their stories, both on stage and in more casual conversational settings such as meals.
- Patient participation in brainstorming healthcare solutions and in presenting new technologies. MedX also has an ePatient Advisors group to help with the overall conference planning.
These innovations, along with frequent use of storytelling techniques, video, and music, packed a powerful punch. It all kept me feeling engaged and inspired during the event, and left me wishing that more academic conferences were like this.
These innovations point the way to much better academic conferences. Here’s why:
The power of patient presence
I wasn’t surprised to see lots of patients at Medicine X, because I knew that the conference has an e-patient scholars program, and that many patients would be presenting. I also knew that the director of MedX, Dr. Larry Chu, is a member of theSociety of Participatory Medicine. (Disclosure: I’ve been a member of SPM since last December.)
I was, on the other hand, surprised by how powerful it was to have patients on stage telling their stories.
How could it make such a difference? I am, after all, a practicing physician who spends a lot of time thinking about the healthcare experience of older adults and their caregivers.
But it did make a difference. I found myself feeling more empathetic, and focused on the patient and family perspective. And I felt more inspired to do better as a physician and as a healthcare problem-solver.
In short, having patients tell their stories helped me engage with the conference presentations in a more attentive and meaningful way.
- Real patient engagement depends on defining it correctly (kevinmd.com)
- Reducing medical errors will require better reporting tools, engaged patients and – you guessed it – culture change (medcitynews.com)
Physicians love being liked. They also love doing their jobs well. With other incentives, such as monetary returns, dwindling, the elation we get from satisfying a patient as well as providing them good care is what still makes being a doctor special. But is keeping patients satisfied and delivering high-quality care the same thing? And more important, can patients tell if they are getting good care?
Policymakers certainly think so. In fact, under the Affordable Care Act, Medicare, and Medicaid hospital reimbursements are now being tied to patient satisfaction numbers.
But the association between patient satisfaction and the quality of care is far from straightforward, and its validity as a measure of quality is unclear.
In fact, a study published in April and conducted by surgeons at the Johns Hopkins School of Medicine showed that patient satisfaction was not related to the quality of surgical care. And a 2006 study found that patients’ perception of their care had no relationship to the actual technical quality of care they received. Furthermore, a 2012 UC Davis study found that patients with higher satisfaction scores are likely to have more physician visits, longer hospital stays and higher mortality. All this data may indicate that patients are equating more care with better care.
Although patients and their physicians generally have similar goals, that is not always the case. As a resident, who is not paid on a per-service basis, I have no incentive to order extra testing or additional procedures for my patients if they’re not warranted. But one study found that physicians who are paid on a fee-for-service basis and therefore have an incentive to deliver services — needed or not — are more likely to deliver these services (such as an MRI for routine back pain).
On top of that, as another study found, they also are more liked by their patients. It is no wonder then that the number of patients with back pain, one of the most common reasons for physician visits, are increasingly being overmanaged with MRIs and narcotic pain medications.
Consumer satisfaction is a metric that has been used extensively in other industries, and its increasing integration in healthcare may represent a desire to model medicine on industries that lead in efficiency, such as the technology, automobile or airline industries. But healthcare remains fundamentally different.
Consider Medicare’s initiative to have hospitals publicly report their patient outcomes and satisfaction data and have consumers compare them a la computers or SUVs. Of the 13 teaching hospitals within five miles of my apartment, the relationship between the quality of care and patient satisfaction was unclear. Within these hospitals, hospital mortality outcomes did not correlate with satisfaction ratings.
I’m a physician and I had difficulty making sense of the data, so how can we expect everyday people to use them in a meaningful way? Would they prefer a place where they or their relatives are likely to live longer, have a lower risk of readmission and have fewer infections, or a place where their pain would be better managed, their nurses more responsive and their bathrooms cleaner? Although ideally hospitals would score highly in both sets of measures, data suggest that is not necessarily always the case.
Patient visits can sometimes be like family dinners. They are probably not the best occasions to talk about Dad’s smoking habit or Mom’s Xanax addiction. But to maintain shared decision-making, clear and honest communication is vital. And in critical situations, most data suggests that patients want their physicians to be upfront about bleak issues such as life expectancy.
Yet a 2012 study by investigators in the Dana-Farber Cancer Institute found that patients who were better informed about the grim nature of their cancer and the goals of their treatment were less satisfied with their physicians. Such findings put a physician in a quandary: a more informed patient or a more satisfied one?
Emphasizing patient satisfaction and offering incentives to hospitals and physicians to keep their patients satisfied are laudable. But trying to transform patient satisfaction into a catch-all quality metric may not be the right approach. What is really needed is for physicians to take the time to help patients identify the things they need, not just what they want.
- ‘Common courtesy’ lacking among doctors-in-training (eurekalert.org)
- Study finds little correlation between patient satisfaction scores, quality of care in hospitals (medcitynews.com)
- Are Patient Views about Antibiotics Related to Clinician Perceptions, Management and Outcome? A Multi-Country Study in Outpatients with Acute Cough (plosone.org)
- Patient Satisfaction? In a Jail? (jailmedicine.com)
- Patient experience more of a priority for hospitals (chronicle.augusta.com)
- It’s Not You, Doctors Are Just Rude (healthland.time.com)
- Hospitals face whole new world under health law (usatoday.com)
Greetings from the National Library of Medicine and MedlinePlus.gov
Regards to all our listeners!
I’m Rob Logan, Ph.D. senior staff National Library of Medicine for Donald Lindberg, M.D, the Director of the U.S. National Library of Medicine.
The extent of caregivers’ assistance to patients — and suggested strategies for physicians to assist caregivers — are detailed in an interesting commentary recently published in the Journal of the American Medical Association.
The commentary’s author (who is a professor at Harvard Medical School) explains about 42 million Americans are caregivers and they assist patients for an average of 20 hours a week. Muriel Gillick M.D. reports the majority of caregivers are middle-aged women caring for aging parents.
Dr. Gillick notes caregivers often assist patients with daily living activities, such as shopping, cooking, bathing, and dressing. However, Dr. Gillick writes (and we quote) “Nearly half of all caregivers report responsibility for complex medical tasks that often are the province of a professional nurse or trained technician’ (end of quote).
Dr. Gillick finds caregivers report they are responsible for clinical activities including: diet adherence, wound care, treating pressure ulcers, providing medications and intravenous fluids, as well as operating medical equipment.
Dr. Gillick notes the recipients of caregiving are likely to be seniors in the last stages of their life. In the year before death, Dr. Gillick explains only 17 percent of Americans are without a disability while about 22 percent have a persistent severe disability. She reports the largest groups of caregiver-dependent adults include seniors who are frail or have advanced dementia. Dr. Gillick notes about 28 percent of Americans are frail and 14 percent have advanced dementia in their last year of life.
Dr. Gillick adds patients who are frail or have dementia often cannot participate in the management of their care, which necessitates a caregiver’s involvement. Dr. Gillick writes (and we quote): ‘If (end of life) medical care is to be patient centered, reflecting the values (patients) no longer have the cognitive capacity to articulate, clinicians must rely on surrogates to guide them. Yet, few programs caring for patients with dementia (or frailty) regularly incorporate caregivers in every phase of care’ (end of quote).
To improve assistance to caregivers, Dr. Gillick suggests physicians need to better explain a patient’s underlying health condition as well as work with caregivers to prioritize a patient’s health care goals.
Dr. Gillick adds caregivers should be encouraged to provide input about a patient’s surroundings as well as more fully participate in health care planning in a partnership with attending physicians.
Dr. Gillick notes caregivers are especially helpful in creating a continuity of patient care within different settings. She writes (and we quote): ‘In the complex US health care system, in which patients are cared for in the home, the physician’s office, the hospital, and the skilled nursing facility, the most carefully thought-out plan of care will prove useless unless its details can be transmitted across sites’ (end of quote).
Dr. Gillick concludes physicians as well as health care organizations need to provide more educational support to help caregivers.
Meanwhile, MedlinePlus.gov’s caregivers health topic page provides comprehensive information about caregiving’s medical and emotional challenges. For example, a helpful website from the American Academy of Family Physicians (available in the ‘start here’ section) helps caregivers maintain their health and wellness.
A similar website that addresses overcoming caregiver burnout (from the American Heart Association) can be found in the ‘coping’ section of MedlinePlus.gov’s caregivers health topic page.
In addition, there are special sections loaded with tips to provide caregiving to seniors as well as women and children within MedlinePlus.gov’s caregivers health topic page.
MedlinePlus.gov’s caregivers health topic page also provides links to the latest pertinent journal research articles, which are available in the ‘journal articles’ section. Links to clinical trials that may be occurring in your area are available in the ‘clinical trials’ section. You can sign up to receive updates about caregiving as they become available on MedlinePlus.gov.
To find MedlinePlus.gov’s caregivers health topic page, type ‘caregiver’ in the search box on MedlinePlus.gov’s home page. Then, click on ‘caregivers (National Library of Medicine).’ MedlinePlus.gov additionally features health topic pages on Alzheimer’s caregivers, child care, and home care services.
It is helpful to see JAMA address some caregiving issues. Let’s hope other medical journals will help educate caregivers and encourage more physician-caregiver communication.
Before I go, this reminder… MedlinePlus.gov is authoritative. It’s free. We do not accept advertising …and is written to help you.
To find MedlinePlus.gov, just type in ‘MedlinePlus.gov’ in any web browser, such as Firefox, Safari, Netscape, Chrome or Explorer. To find Mobile MedlinePlus.gov, just type ‘Mobile MedlinePlus’ in the same web browsers.
We encourage you to use MedlinePlus and please recommend it to your friends. MedlinePlus is available in English and Spanish. Some medical information is available in 43 other languages.
Your comments about this or any of our podcasts are always welcome. We welcome suggestions about future topics too!
Please email Dr. Lindberg anytime at: NLMDirector@nlm.nih.gov
That’s NLMDirector (one word) @nlm.nih.gov
A written transcript of recent podcasts is available by typing ‘Director’s comments’ in the search box on MedlinePlus.gov’s home page.
The National Library of Medicine is one of 27 institutes and centers within the National Institutes of Health. The National Institutes of Health is part of the U.S. Department of Health and Human Services.
A disclaimer — the information presented in this program should not replace the medical advice of your physician. You should not use this information to diagnose or treat any disease without first consulting with your physician or other health care provider.
It was nice to be with you. I look forward to meeting you here next week.
From the 31 July 2013 article at HealthPopuli
Most Americans are concerned about their ability to for medical bills, even when they have health insurance. As a result, most are comfortable asking their doctor about how much their medical treatment will cost. People are becoming savvier health care shoppers largely because they have to: 37% of people in the U.S. have an annual health insurance deductible over $2,000, according to the Spring/Summer 2013 Altarum Institute Survey of Consumer Health Care Opinion, published on 11th July 2013.
Many of the media stories coming out of the Altarum survey since its publication have been about people and their trust in doctors – or lack thereof.
But the other side of this coin is growing patient/consumer health empowerment.
It appears that people feel competent to take on a greater role in shared decision making, self-diagnosis or assessment of symptoms, and information collecting on conditions – even before seeing the doctor. Take a look at the table, which illustrates that most do “health homework” before going to see their doctor.
Altarum polled a survey sample of 2,357 U.S. consumers in May, 2013.
Health Populi’s Hot Points: The internet has truly become a go-to source for people and their health, every day. I grew up with a thick tome of a health guide on my parents’ living room bookshelf – I remember a dog-eared Mayo Clinic Guide to Health, as well as a Merck Manual my mom picked up from a library sale in the early 1970s and her nutrition bible, Adelle Davis’ Let’s Get Well.
Today’s 5-inch-thick guide to health isn’t a book at all; it’s WebMD, NIH.gov, FDA.gov, Yahoo! health groups, WEGO Health, PatientsLikeMe, CureTogether, DiabetesMine, TuDiabetes, Migraine.com – and to be sure, Paging Dr. Google. And, it’s also friends and neighbors, whose opinions 75% of Americans trust to choose a doctor – more than online rates on a doc’s bedside manner, office waiting times, or objective information on clinical quality, according to Altarum’s poll.
What Altarum finds is that people are preparing in advance of their doctor’s appointments – preparing questions, which means spending time thinking through symptoms, family histories, observations of daily living, and other factors that may feed into an acute situation or a question about how to stay well, fit, and out of the health system.
- Why is the health consumer always wrong? (doctorsbag.wordpress.com)
- Consumer Health Websites Could Be Sharing Your Personal Data With Third Parties (medicaldaily.com)
- Women Are Key to Improved Health Coverage, Say Health Advocates (publicnewsservice.org)
Admittedly everyone have the same feeling when they are compelled by physiologic abnormality to visit the doctor. Anxiety is the leading cause of why people delay seeing a doctor, they would tend to rationalize their illness until it interferes with their day to day living. Anxiety is a common feeling especially if you have no idea of what your illness is, could it be life threatening or just a minor glitch?
….An analysis of four years of Medicare prescription records shows that some doctors and other health professionals across the country prescribe large quantities of drugs that are potentially harmful, disorienting or addictive. Federal officials have done little to detect or deter these hazardous prescribing patterns.
Searches through hundreds of millions of records turned up physicians such as the Miami psychiatrist who has given hundreds of elderly dementia patients the same antipsychotic, despite the government’s most serious “black box” warning that it increases the risk of death. He believes he has no other options….
The data, obtained under the Freedom of Information Act, makes public for the first time the prescribing practices and identities of doctors and other health-care providers. The information does not include patient names or the reasons why doctors prescribed particular drugs, so reporters interviewed the physicians to learn their rationales.
Medicare has access to reams of data about its patients, their diagnoses and the medical services they received. It could analyze all of this information to determine whether patients are being prescribed appropriate drugs for their conditions.
But officials at the Centers for Medicare and Medicaid Services say the job of monitoring prescribing falls to the private health plans that administer the program, not the government. Congress never intended for CMS to second-guess doctors – and didn’t give it that authority, officials said.
“CMS’s payments don’t go to physicians, don’t go to pharmacies. They go to plans, which is how our oversight framework has been established,” Jonathan Blum, the agency’s director of Medicare, said in an interview. The philosophy “really has been to defer to physicians” about whether a drug is medically necessary, he said.
Asked repeatedly to cite which provision in the law limits their oversight of prescribers, CMS officials could not do so.
The Office of the Inspector General of the Department of Health and Human Serviceshas repeatedly criticized CMS for its failure to police the program, known as Part D. In report after report, the inspector general has advised CMS officials to be more vigilant. Yet the agency has rejected several key recommendations as unnecessary or overreaching.
Other experts in prescription drug monitoring also said Medicare should use its data to identify troubling prescribing patterns and take steps to investigate or restrict unsafe practitioners. That’s what state Medicaid programs for the poor routinely do.
“For Medicare to just turn a blind eye and refuse to look at data in front of them . . . it’s just beyond comprehension,” said John Eadie, director of the Prescription Drug Monitoring Program Center of Excellence at Brandeis University.
“They’re putting their patients at risk.”
The Part D records detail 1.1 billion claims in 2010 alone, including prescriptions and refills dispensed. ProPublica has created an online tool, Prescriber Checkup, to allow anyone to search for individual providers and see which drugs they prescribe.
Typically in Medicare, the government is responsible for contracting with doctors, reviewing claims for treatment and paying the bills.
But Part D is different: Patients get their drugs through stand-alone drug plans, which cover only drugs, or through Medicare HMOs that also cover medical services.
Medicare pays private insurers a set amount per enrollee to run the program and pay for the drugs. All the insurance plans are supposed to alert pharmacies to potentially harmful drug interactions, query doctors who prescribe high levels of narcotics to individual patients and be on the lookout for fraud, among other things.
Potential for Fraud
Since Part D was launched, the HHS inspector general and the Government Accountability Office have grown increasingly worried that it lacks adequate oversight.
Several reports have found that Part D is vulnerable to fraud. Insurers have paid for prescriptions from doctors who were barred by Medicare. Separately, in 2007 alone, the program covered $1.2 billion worth of drugs prescribed by providers whose identities were unknown to insurers or Medicare, according to a June 2010 report.
The inspector general even found fault with the contractors Medicare hired to dig out fraud: The contractors generated few of their own investigations, relying on outside complaints for direction.
Although many reports focus on fraud, analysts also have found that the program was vulnerable to inappropriate prescribing that put patients’ lives in danger.
A May 2011 report said Medicare has not ensured that Part D paid only for drugs prescribed for FDA-approved and widely accepted off-label indications as federal law requires. About half of the 1.4 million antipsychotic prescriptions made to nursing home patients in the first six months of 2007 “were not used for medically accepted indications,” the report said.
“There’s certainly room for improvement,” Robert Vito, a regional inspector general who has directed many of the reports, said in an interview.
Medicare should, for example, require that prescriptions include a patient’s diagnosis as a way to monitor how Part D drugs were being used, his agency said.
But Medicare officials told the inspector general that neither state boards of pharmacy nor private industry requires this practice, so neither would they.
CMS also has rejected proposals to require insurers to report suspicious prescribing to its fraud contractor. Such sharing is now voluntary.
Medicare’s safeguards lag well behind those of many state Medicaid programs.
Louisiana requires that doctors include diagnosis codes when they write prescriptions for painkillers and antipsychotics. Similar checks have proved effective in other states. Florida found that antipsychotics given to children younger than 6 dropped when specialists reviewed prescriptions.
Even some of Medicare’s top prescribers think the program should do more to research unusual or suspicious prescribing patterns.
Indiana physician Daniel J. Hurley led the country with more than 160,000 prescriptions under Part D in 2010, ProPublica’s analysis shows. In an interview, he said nursing home pharmacies had credited him with prescriptions by other health professionals in his practice, a quirk Medicare should want to address.
It’s unclear how often this might happen, and some nursing home doctors do write lots of prescriptions on their own. Medicare said it recently addressed this issue, but according to Medicare’s own numbers, Hurley’s prescriptions have dropped only slightly.
“Why wouldn’t they call us up and ask us?” Hurley said. “If you hustled, you couldn’t come anywhere near that number, nor should you.”
- Doctors’ Extreme Prescribing – Footprints of Medicare Fraud? (aarp.org)
- Top Medicare Official: ‘We Can and Should Do More’ to Oversee Drug Plan (gantdaily.com)
- A Rap Sheet For Medicare’s Prescription Drug Program (propublica.org)
- Inspector General Faults Medicare for Not Tracking ‘Extreme’ Prescribers (stateofglobe.com)
- Medicare Has Been Paying for Prescriptions Written by … Art Therapists (newser.com)
- Top Medicare Prescribers Rake In Speaking Fees From Drugmakers (wnyc.org)
- Over 700 US doctors suspected of harmful excessive prescription practices – report (rt.com)
From the 20 March 2013 post at Science Roll
I was very glad to see the new book authored by e-Patient Dave deBronkart, whose thoughts I describe to medical students as a part of the official curriculum at Semmelweis Medical School, just became available.
Medical professionals must let patients help and become equal partners in the treatment! A must-read book!
Concise reasons, tips & methods for making patient engagement effective.
Third book by e-Patient Dave, cancer beater, blogger, internationally known keynote speaker and advocate for patient engagement; co-founder and past co-chair of the Society for Participatory Medicine. Profile:http://www.ePatientDave.com/about-dave
- Let Patients Help: A New Book Authored by e-Patient Dave deBronkart (scienceroll.com)
- Project HealthDesign’s new video series: Conversations with e-PatientDave (projecthealthdesign.typepad.com)
- Part 1: Value of social media in healthcare is already outlined – just not realized (himss.org)
- The Multidimensional Role of Social Media in Healthcare (gumption.typepad.com)
- First Post: A Video About Patients Involvement in Their Own Healthcare (healthitoutlook.wordpress.com)
- The 7 Habits of Highly Patient Centric Providers (forbes.com)
- I’m an e-patient: equipped, enabled, empowered, engaged (worldofdtcmarketing.com)
The treatment of B12 deficiency, as has been established from studies done in the 1960s, is ORAL B12. That’s right. Pills. Injections of B12 are not necessary—oral supplements work well, even in pernicious anemia. They’re cheap and they work. I suppose a very rare patient, say one who has surgically lost most of their gut, could require injections. But the vast majority of people with genuine B12 deficiency can get all of the B12 they need through eating foods or swallowing supplements. No needles needed.
So why this fetish with injections? From the patient’s point of view, shots feel more like something important is going on. Placebos need rituals—with acupuncture, for instance, the elaborate ritual creates an illusion of effectiveness. And from the doctor’s point of view, injections reinforce dependence on the physician, creating visits and cash flow.
So: people seem to think they feel better with injections, and the doctor makes a little cash, and everyone’s happy. So what’s the harm in that?
I think it’s wrong to knowingly dispense placebos, even harmless ones. We doctors like to criticize the chiropractors and homeopaths. We point fingers. They’re the quacks. We’d better take a close look at what we’re doing, first. Our placebos are sometimes far more dangerous than theirs.
More importantly, people should be able to expect more from physicians…
This article reminds me of my days as a medical librarian.
If I did not carefully listen to a patron (customer) or ask the right questions, I gave the person the wrong information!
Minutes spent in listening and asking focused questions often saved an hour (or more!) of fruitless searching.
So, when I talk with a health care practitioner, I am mindful to give as much relevant information as possible to so the proper diagnosis and treatment can be given!
It is also necessary that we all do whatever we can so that health care practitioners are given the time they need to listen to patients.
Ultimately this will result in lower health care costs overall.
Before we can understand the high cost of not listening, we need to examine in detail the diagnostic process. I am limiting my discussion to patients with chronic or recurring symptoms lasting several months. I am not discussing acute illnesses. They fall into completely different category.
At the front line of medical care, at the first contact between a patient and a doctor, the patient describes physical symptom. Whatever the real underlying cause, a physical symptom is the required ticket to see a physician. The physician, on first contact, has no idea what the underlying nature of the patient’s chronic complaint really is. At the risk of oversimplifying, there are five broad categories of the causes for complaints.
1. There is a definable medical disease in one or more organs.
2. There is no definable medical disease but the patient is in contact with an unknown toxic substance causing the symptom (inhaled, ingested, or from skin contact).
3. The patient is in a stressful or toxic relationship at home or work producing physical symptoms or even a definable medical disease. (“What the mind cannot process is relegated to the body.” Dr. William Mundy, psychiatrist, personal communication. )
4. The patient or a companion is inflicting harm. Here, there are several categories:…
5. There is no definable medical disease but the patient has assumed a chronic illness role in life with multiple symptoms (i.e. hypochondriasis).
6. There is a sixth category; patients with psychosomatic disorders. Time and space does not permit a full discussion of this important and very common set of disorders. I suspect they represent more than fifty percent of patients seeking primary medical care. The book“The Divided Mind” explains and defines these disorders and the successful treatment applied to thousands of patients at NYU by Dr. Sorno and his colleagues. At present the medical profession denies the existence of this category. The epidemic emergence of pain clinics comes from lack of knowledge about psychosomatic disorders and their proper treatment.
Of course, the patient can have any of these, and also be suffering from a definable medical disease.
But my experience in primary care over the past 55 years — combined with studies in the medical literature —suggest that between 30 and 40 percent of first contact primary care visits are stress related or are psychological in nature (#3 and #6 in above list).
It should be obvious that the only way to sort out these causes of symptoms requires very careful listening to the narrative of the patient’s life. Some of these causes can be determined only by listening…..
1. There’s not strong data to support self-tracking. We can make some inferences about how self-tracking would work in a clinical setting by looking at the studies done on telemonitoring, which also generates a large volume of attribute-rich data. Some studies have shown benefit in outcomes, especially for diseases like diabetes, COPD, and hypertension. However, hard measures like mortality have not been improved by telemonitoring devices. Data on hospitalization and ED visits, especially in the elderly, have been mixed. People (especially the engineers who created these wonderful devices and apps) love to think that more data points are better. But to date, we just don’t have a robust set of well controlled studies telling us what self-tracking is useful for, what devices or apps to use, how to interpret the data, or how to integrate it into medical care.
2. Physicians may not want the data. Imagine that a 45-year old man who had just started exercising after years of inactivity gives their doctor all of their heart rate measurements from the past month. All 5000 measurements. There’s no way their physician is going to want to touch that data. Buried inside those data points will be erroneous and clinically meaningless measurements which, without review and context, will be fodder for trial lawyers when something bad happens. It’s data overload to the Nth degree, because let’s face it … anything can be tracked. Once data gets put into the medical record, it’s assumed the physician has reviewed the data and acted on it accordingly. No one wants something in the patient’s chart that not only has limited medical use but carries substantial legal risk.
Finally, we need to pay physicians to analyze and counsel about the data, similar to how we pay for EKG interpretation or reading an x-ray. Fee-for-service still rules the roost, and nothing gets done unless someone pays for it…
Simple intervention helps doctors communicate better when prescribing medications (5 basic facts to convey)
If the prescribing health care practitioner forgets, here they are
- the medication’s name
- its purpose
- the directions for its use
- the duration of use
- the potential side effects
- Doctors Prescribe, Pharmacists Dispense, Patients Suffer (medicine.com.my)
- Better care from doctors who are culturally aware (eurekalert.org)
- Pharmacists to prescribe medication (stuff.co.nz)
A nationwide survey ***of US adults finds that 1 in 3 of Americans say they have used the internet to help them diagnose a medical condition, either for themselves or someone else. But, when asked who they turned to for help with a serious health issue, either online or offline, the majority said they turned to a doctor or other health professional…
…when these “online diagnosers” were asked who they turned to for information, care or support the last time they had a serious health problem, either online or offline:
- 70% said they got it from a health professional,
- 60% turned to family and friends, and
- 24% said they got it from others with the same condition.
When the survey asked online diagnosers if the information they found online had led them to think they needed to see a doctor, 46% said yes, while 38% said they could take care of it themselves and 11% said it was a case of both or something in between.
- Internet Is First Stop for Many Ill People, Study Finds (mashable.com)
- 1 in 3 adults search online for medical diagnosis (cbc.ca)
- ‘Doctor Google’ Isn’t Replacing Actual Doctors Any Time Soon (betabeat.com)
***The full Pew Internet report Health Online 2013 may be found here
It is increasingly becoming the year of the Thrifty Patient. People are paying for more medical care and are more responsible for the costs of getting that care via higher deductibles and co-pays. Patients don’t have a choice but to be involved in their care. Though the recent 2008 recession saw a decrease in overall medical and health care utilization as a sign of better informed patients, I believe that was simply because people deferred needed care in order to keep their jobs. With the economy getting better, more people will begin to seek care again. The question is how can they save money on medical and health care costs?…..
- How and Where to Save Money on Health Care (dailyfinance.com)
- Better health care will reduce Medicare costs (mysanantonio.com)
- Spending More On Health Care Doesn’t Guarantee Better Treatment (thinkprogress.org)
For providers apprehensive about increasing demands for patient engagement, a small dose of email could get them on their way toward becoming comfortable with the idea as well as the practice. “For the organizations who’ve pushed patient portals the furthest into their patient base, email is always the place where things started,” argues Avado CEO Dave Chase in a recent contribution toForbes. According to Chase, email is the equivalent of a gateway drug in the context of patient engagement able of easing providers’ concerns about additional work and responsibility that they fear having to undertake by making themselves more available to their patients.
- DrFirst Launches Free Secure Clinical Messaging System to Help Healthcare Providers Close Gaps in Patient Care (virtual-strategy.com)
- Patient Portals – From Doctor to Patient (medcitynews.com)
- EMR and Patient Portal, Where’s the link? (medcitynews.com)
- Without patient participation, there is no patient engagement (kevinmd.com)
- Big Data, EHR Driving Healthcare IT Innovation (pcadvisor.co.uk)
- Patient Engagement, There are Reasons to it (medcitynews.com)
- Getting Personal: My patient experience – #2 (thielst.typepad.com)
Doctors are failing to really listen to patients’ views on how they want to be treated, suggests a study in the British Medical Journal.
The Dartmouth College research says working out a patient’s preferences is as important as an accurate medical diagnosis.
Involving patients in discussions about treatment could cut the cost of healthcare around the world, they say.
Doctors should follow a three-step approach to engaging patients.
The BMJ analysis, written by three healthcare experts from the Dartmouth Center for Health Care Delivery Science in New Hampshire, US, is based on a report written for the UK’s King’s Fund, a policy thinktank.
In it they argue that “preference misdiagnosis” – misinterpreting or ignoring the patient’s wishes – is a significant problem which is damaging to both doctors and patients.
The researchers say it can lead to, what they call, “silent” misdiagnoses – when doctors choose the wrong treatments because they fail to assess their patients’ preferences correctly.
These misdiagnoses are “silent” because they go largely unreported.
While doctors are taught to concentrate on diagnosing the medical problem, the authors point to evidence which suggests doctors are not as good at setting out all the treatment options and finding out how the patient feels about them.
In one study they looked at, doctors believed that 71% of patients with breast cancer rate keeping their breast as a top priority, but the figure reported by patients was just 7%.
In another study of dementia, patients placed substantially less importance than doctors believed on the continuation of life with severely declining brain function.
Evidence also shows that patients often choose different treatments after they become better informed about the risks and benefits, say the authors….
“More than 100 years ago student doctors were told to ‘listen to the patient, he is telling you the diagnosis’.
“Today, the rise in treatment options makes this even more critical, not only to reach a correct medical diagnosis but also to understand fully patients’ preferences – and reduce the huge waste in time and money that comes from the delivery of services that patients often neither want nor need.”
Anna Dixon, director of policy at the King’s Fund, said the research supported the idea that patients should be helped to make decisions about their care.
“Not only does it find that this results in more appropriate treatment than currently achieved but, rather counter-intuitively, it results in dramatically lower intervention rates.”
Dr Vivienne Nathanson, head of science and ethics at the British Medical Association said good medicine was about doctors using their knowledge and expertise to help patients make informed choices.
“Good decisions about treatment reflect both a patient’s preferences, and the relevant medical evidence. Doctors try to help patients express their preferences and are aware that these sometimes differ from those of the ‘average’ patient.
“Exploring how the patient’s preferences and values relate to the decision to be made requires a relationship of trust between patient and doctor.”
- Patient wishes ‘not listened to’ (bbc.co.uk)
- Doctors often miss patients’ treatment preferences (cbc.ca)
- Patient preferences often ignored in treatment decisions, warn experts (eurekalert.org)
- Doctors Often Misinterpret Patients’ Wishes, Study Says (newsday.com)
- A third of patients say their GPs are so rushed they are worried they will be misdiagnosed (thisismoney.co.uk)
The mobile healthcare industry has made significant strides within the healthcare provider community. Rock Health found 75% of small and medium size medical and dental offices will purchase tablets within the next year. And almost 40% of physicians use medical apps on a daily basis.
The digital healthcare field is also alleviating the costs of patientcare and increasing the scale at which doctors and nurses can help people. The healthcare industry is already strained, Ziegler says, and a shortage of primary care physicians in years to come will only exacerbate the problem. She says mobile apps can bridge that gap.
But patients have been slower to realize the impact apps could have, Ziegler says, potentially because the apps force people to take notice of their health.
“No one wants to actively track what they are always doing, so we really want to make the experience passive,” she told us, adding, they are working to make tech and apps that “provide incentives for people to manage health more efficiently.”
Consumers are also generally unaware of how quickly the space of mobile health is growing, David Tao, Chief Research Officer at Greatist, tells Mashable. He says once consumers realize the vast industry already accessible, more consumers will begin utilizing the products.
“Mobile health isn’t a replacement for healthcare, it’s a supplement,” Tao says. “These companies aren’t replacing doctors’ keen eye or experience, but the apps are just bettering communication between doctor and patient.”
- Health and Wellness Information and Tracking Apps (Flahiff’s Health/Medical Resources site)
- Health and Fitness Tracking Apps (Flahiff’s Health/Medical Resource site)
- And these may be helpful when selecting health apps
- How to Choose A Better Health App (by LEXANDER V. PROKHOROV, MD, PHD at KevinMD.com on August 8, 2011) contains advice in the following areas
- Set realistic expectations
- Avoid apps that promise too much
- Research the developers
- Choose apps that use techniques you’ve heard of
- See what other users say
- Test apps before committing
- iMedical apps has mobile medical app reviews and commentary by medical professionals. Most apps are about apps geared toward professionals and are not free.
- The iMedical app forum now includes a medical librarian corner, with some patient/consumer apps
- Evaluating Health/Medical Information
- The Penn State Medical Center Library has a great guide to evaluate health information on the Internet.
- The tips include
- Remember, anyone can publish information on the internet!
- If something sounds too good to be true, it probably is.
- If the Web site is primarily about selling a product, the information may be worth checking from another source.
- Look for who is publishing the information and their education, credentials, and if they are connected with a trusted coporation, university or agency.
- Check to see how current the information is.
- Check for accuracy. Does the Web site refer to specific studies or organizations?
- The Family Caregiver Alliance has a Web page entitled Evaluating Medical Research Findings and Clinical Trials Topics include
- General Guidelines for Evaluating Medical Research
- Getting Information from the Web
- Talking with your Health Care Provider
- Additional Resources
- Consumer’s Guide to Taking Charge of Health Information (Harvard Center for Risk Analysis)
- How to Evaluate Health Information on the Internet (US National Cancer Institute)9iiu9
- Quackwatch (a private corporation operated by Stephen Barrett, MD)
- And a Rumor Control site of Note (in addition to Quackwatch)
- National Council Against Health Fraud National Council Against Health Fraud is a nonprofit health agency fousing on health misinformation, fruad, and quackery as public health problems. Links to publications, position papers and more.
- Phones, tablets may become most popular tech devices for docs since the stethoscope (infographic) (medcitynews.com)
- Does smartphone = smart healthcare? (docmate.com.au)
- Mobile health apps: a new opportunity for healthcare marketers (worldofdtcmarketing.com)
- More Consumers Get Health Info On Mobile Devices (informationweek.com)
- INFOGRAPHIC: Smartphone = smarter healthcare? (mobile-ent.biz)
- How Smartphones Are Facilitating Better Health Care (thinkprogress.org)
- U.S. HealthWorks Adopts iTriage App to Connect with Patients (prweb.com)
- Who Do You Trust When it Comes to Healthcare Information? [INFOGRAPHIC] (mashable.com)
- How Smartphones Are Changing Health Care (iphonesavior.com)
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A push to treat chronic pain and financial disincentives for treating addiction may pressure clinicians into prescribing opioids for patients who are already addicted, a researcher suggested.
Over the past decade, there’s been a perfect storm of changing clinician attitudes toward pain treatment and patient attitudes towards suffering, combined with a lack of compensation for time-consuming clinic visits such as addiction counseling, Anna Lembke, MD, of Stanford University, wrote in a perspective in the New England Journal of Medicine.
That may be leading doctors to write scripts for pain pills even if they know those patients are abusing their medications, Lembke wrote.
“Treatment of pain is held up as the holy grail of compassionate medical care,” she wrote, and clinicians have, over the last decade, felt more compelled to deliver treatment.
They also have the additional pressure of consumer ratings sites, because patients who are dissatisfied may turn around and leave a less-than-favorable review online. Lembke cites the example of one colleague who will occasionally bite the bullet: “Sometimes I just have to do the right thing and refuse to prescribe them, even if I know they’re going to go on Yelp and give me a bad rating,” the colleague told her…
- Cochrane reviews for pain management (anesthesia and pain control)
More info about Cochrane reviews (systematic summaries of medical studies) at http://www.cochrane.org/cochrane-reviews
- MedlinePlus-Pain has links to resources on treatments, alternative therapy, research news, and more
- As new MaineCare opioid restrictions take effect, hospital program to help with withdrawal (bangordailynews.com)
- Many injured workers remain on opioids, study finds (jsonline.com)
- Narcotic Abuse (iamaddicted2.wordpress.com)
- Action Alert: Physicians for Responsible Opioid Prescribing (PROP) We must stop this Petition! (rsdadvisory.com)
- Experts to tackle prescription drug issues (news.com.au)
- Legal Barriers to Effective Pain Control (Part One) (lawprofessors.typepad.com)
Wow, am I the last person on earth sans smartphone?
Most patients I see are surprised to find out that there’s something they should have brought to their doctor’s visit. Granted, I’m an emergency physician, and many of my patients come to me in emergency situations that they can’t plan for. However, most people have some heads-up for going to their doctor. Certainly if you’re going to your annual check-up or a routine appointment, you should bring these items with you.
Keep this checklist readily accessible; even if you’re going to the hospital for an emergency appointment, aim to take the following 10 items with you:
1. A medical card. It would be ideal for every doctor to have a full list of your medical history, but our country is not even close to having a nationally accessible medical record system. To make sure your doctor has your information available, carry a card with you. You can find many cards that easily downloadable on the Internet where you list your medical problems, surgeries, doctor’s names, insurance, and allergies. Especially if you are seeing a coverage doctor or visiting the E.R., he or she may not have your medical record. This makes sure that your doctor can see your most critical medical information.
2. Changes to your medical record. If you have had recent test results since you last saw your doctor, bring these with you. Even if it was your doctor that you’re going to see who sent you to get the test, bringing the results will make sure that they are discussed during the visit.
3. Your medications.
[Read the entire article at http://www.kevinmd.com/blog/2012/10/preparing-doctors-visit-10-bring.html]
8. A family member or a friend. Having someone with you will give you support and company during the appointment. As importantly, they can help remind you of your questions and concerns, and is another measure to help ensure your doctor answers all the questions that you have.
9. A smartphone. Everyone seems to have some kind of smartphone device: an iPhone, a Blackberry, an iPad. There will downtime when you’re waiting. Use this time to look up what your doctor has told you. The smartphone also keeps you busy if your wait is particularly long!
10. Some snacks. Often, there are limited food options are the doctor’s office, and you may be waiting for some time. Unless you’re told not to eat, or have a complaint that you’re not sure how it will go, having something on hand can help make you feel better.
I hope this list is useful for you as you prepare for your next doctor’s visit.
- 5 Ways to Make the Most of Your Doctor’s Visit (sprighealth.com)
- Doctors open their notes to patients – and patients like what they see (washingtonpost.com)
- Think big about mobile health — going beyond medical records (blogs.computerworld.com)
- Benefits of online medical records outweigh the risks (larrysworld.com)
- Why electronic medical records are good for patients (whatsupatupstate.wordpress.com)
- Find out whether your medical record accurate (kevinmd.com)
The use of computers in everyday medical practice has finally reached the tipping point.
The HITECH Act, part of the 2009 federal stimulus bill, has been the final kick in the pants that U.S. health care has long needed to make the conversion to digital. The act states that, by employing electronic health records (EHRs) in a fashion known as meaningful use, doctors are individually eligible for Medicare subsidies of $44,000, paid out over five years. Before now, only early adopters and deep-pocketed institutions like hospitals and large medical groups could afford the investment to convert to EHRs.
In general, EHRs are secure digital repositories of patient information–doctors’ notes, lab and X-ray reports, and letters from specialist physicians. They are an electronic version of the paper chart. Newer, more advanced EHRs are integrated systems and allow doctors to order tests, generate bills, communicate with patients, and run analyses on aggregate patient data. In hospitals, nurses use EHRs to administer and record medication dosing and document other patient care activities.
Though medical practices have a high burden of proof to claim their bonus–the Department of Health and Human Services is still in the process of fully defining just what constitutes ‘meaningful use’–there is now conclusive evidence that the carrots are working. Recent data demonstrates that solo and two-doctor offices, which still comprise over half of all medical practices in the U.S., have seen the biggest jump in EHR adoption over the last six months. These small shops are reaching the conclusion that they must.. participate, as they risk being left behind technologically and financially…
No one describes this more elegantly than doctor and author Abraham Verghese, who has lamentedthe rise of the “iPatient.” For Verghese, the iPatient symbolizes the adoption of technology to a level that is eroding the foundational elements of the profession, like the physical examination. He decries trainees spending vastly more time at computer stations looking over their ‘virtual’ patient [the collection of progress notes plus lab and x-ray data, not an avatar] than giving face time to the sick person down the hall. Other commentators describe the sloppy habits of ” copy and paste” medicine, in which doctors (especially trainees) perpetuate the same patient histories from one hospital admission to the next without applying fresh thinking. [Human nature is no different among doctors: Where possible, we take the path of least resistance.]
Further, doctors and nurses are now tethered to computer appliances. To perform any basic hospital function (e.g. admission, lab test, x-ray, pill delivery, discharge), an order needs to be sent via the computer system. The good in this is that all doctors’ orders go through one standardized entry point: It eliminates issues with poor physician penmanship. However, the technology inhibits doctors and nurses from actually talking to one another…
There is hope, however. Bryan Vartabedian, a pediatric gastroenterologist and social media enthusiast in Texas, gives voice to the possibilities of doctor-patient collaboration using technology. In a blog post about his visit to an orthopedic surgeon for back problems, Vartabedian writes (italics mine):
…through the course of my visit he never touched me. We spent an extraordinary amount of time examining my MRI. Together in front of a large monitor we looked at every angle of my spine with me asking questions. I could see firsthand what had been keeping me up at night. I could understand why certain positions make me comfortable. What we drew from those images could never be determined with human hands. In my experience as a patient, I consider it one of my most thorough exams.
Vartabedian is describing a new paradigm, in which he plays the role of empowered patient and demands an explanation to his level of satisfaction. In the parable offered, the technology is the medium, not the message….
- EHRs: Fewer errors and better care are the end game, not increased fraud (medcitynews.com)
- 4 reasons why doctors need to drive health care technology (kevinmd.com)
- Essentials of telehealth and telemedicine, top Do’s and Don’ts, mHealth and other health IT advice (healthcareguy.com)
- Electronic health records improve quality of patient care, study says (bizjournals.com)
- Five Reasons Americans Should Want Electronic Health Records (thehealthcareblog.com)
- Survey: Clinicians believe EHRs will have positive impact on health care (eurekalert.org)
- Should medical students learn how to use an EHR in medical school? (kevinmd.com)
- PCPs may be distracted by adapting to EHRs (bhgstat.wordpress.com)
- Why we need to go from e-patient to i-patient(insurance savvy patient) (jflahiff.wordpress.com)
- e-patient Dave de Bronkart was successfully treated for kidney cancer at a very late stage. He credits his recovery to using the Internet to find trusted medical information as well as to get advice from patients via support groups.
His video Let Patients Help outlines how and why patients should empower themselves.
Some video highlights
- Patients are presently the most underutilized part of the health team
- The e-patient movement is at least partly based on hippie ideals of self-reliance and self-care (think Whole Earth Catalog)
- e-patients are empowered, engaged, equipped and enabled through finding information to use in discussions regarding treatment options with their health care providers
- Support groups often are useful in providing information not available at other sites (as which doctors specialize in certain treatments)
- Patients not only need quality information, but also access to their raw medical data
Patients with access to notes written by their doctors feel more in control of their care and report a better understanding of their medical issues, improved recall of their care plan and being more likely to take their medications as prescribed, a Beth Israel Deaconess Medical Center-led study has found…
“Open notes may both engage patients far more actively in their care and enhance safety when the patient reviews their records with a second set of eyes.”
“Perhaps most important clinically, a remarkable number of patients reported becoming more likely to take medications as prescribed,” adds Jan Walker, RN, MBA, co-first author and a Principal Associate in Medicine in the Division of General Medicine and Primary Care at BIDMC and Harvard Medical School. “And in contrast to the fears of many doctors, few patients reported being confused, worried or offended by what they read.”…
Of 5,391 patients who opened at least one note and returned surveys, between 77 and 87 percent reported open notes made them feel more in control of their care, with 60 to 78 percent reporting increased adherence to medications. Only 1 to 8 percent of patients reported worry, confusion or offense, three out of five felt they should be able to add comments to their doctors’ notes, and 86 percent agreed that availability of notes would influence their choice of providers in the future.
Among doctors, a maximum of 5 percent reported longer visits, and no more than 8 percent said they spent extra time addressing patients’ questions outside of visits. A maximum of 21 percent reported taking more time to write notes, while between 3 and 36 percent reported changing documentation content…
Walker suggests that so few patients were worried, confused or offended by the note because “fear or uncertainty of what’s in a doctor’s ‘black box’ may engender far more anxiety than what is actually written, and patients who are especially likely to react negatively to notes may self-select to not read them.”..
- Patients Like Reading Their Doctors’ Notes (nlm.nih.gov)
- Patients Feel More Control Of Their Health When Doctors Share Notes (yubanet.com)
- Doctors open their notes to patients – and patients like what they see (washingtonpost.com)
- Giving patients more control: share doctor’s notes (enterprisenews.com)
- OpenNotes: Great News for Patient Engagement (thehealthcareblog.com)
- Patients to View Doctors’ Notes Online (blogs.lawyers.com)
- OpenNotes: The Results Are In (thehealthcareblog.com)
When Patients Don’t Take Their Medicine What Role Do Doctors Play in Promoting Prescription Adherence?
About 10 years an area health care provider told me she did a study on prescription adherence.
The results included a shocking low percentage of folks taking their prescriptions as prescribed.
She said that no journal would publish the results, because the rates of adherence were so low. (This seemed odd to me, this reasoning).
I’ve been prescribed a cholesterol lowering drug, for being a bit over the HDL threshold. I decided to stop taking it, because after all I have read, I don’t really believe in either the tests, the thresholds, and the efficacy of the drug. No, I haven’t discussed this with my prescribing physician, but I think I’m going to catch hell on the next annual exam. For the past 5 years (age 58) I’ve only seen the doctor about once a year, just for the annual wellness.
Analyses indicated that although physicians uniformly felt responsible for assessing and promoting adherence to prescriptions, only a minority of them asked detailed questions about adherence.
“Medicine left in the bottle can’t help.”
— Yoruba proverb
Lack of adherence to prescriptions (that is, patients failing to take medicine either as instructed or at all) afflicts medical care in the United States. Nonadherence affects up to 40 percent of older adults, especially those with chronic conditions, and is associated with poor outcomes, more hospitalizations, and higher mortality. The health care cost of nonadherence is estimated at $290 billion per year. Prior RAND research has shown that some nonadherence is cost-related and can be addressed through insurance benefit designs that keep copayments low.
Physicians also play a key role in addressing nonadherence. Yet physician perspectives on their responsibility for nonadherence and strategies for promoting adherence are not well understood. A team from RAND; the University of California, Los Angeles; and the University of California, Davis, examined physicians’ views about their responsibility for medication adherence and explored how physicians and patients discuss nonadherence. The team conducted focus groups with physicians in New Jersey and Washington, D.C., and audiotaped primary care visits in Northern California doctors’ offices.
The results point to a contrast between what physicians believe and what they do:
- Although physicians uniformly felt responsible for assessing and promoting medication adherence, only a minority of them asked detailed questions about adherence.
- Although providers often checked which medications a patient was taking, they rarely explicitly assessed adherence to these medications.
- Many physicians expressed discomfort about intruding on patients’ privacy to detect nonadherence. In the office, they rarely asked about missed medication doses.
- Most cases of nonadherence detected during office visits were revealed through unprompted patient comments.
Physicians’ reluctance to intrude has important implications for the vast array of new information that is becoming available from pharmacy benefit plans, managed care plans, and other data repositories. In addition, the reluctance to inquire that the physicians described contrasts sharply with the physician role in the increasingly prominent concept of the medical home, where primary care doctors are envisioned as playing a central and active role in managing and coordinating care.
The authors conclude that addressing nonadherence will require a different approach than the one they observed in the study. Given the importance of patients’ shared responsibility, a new paradigm that clarifies joint provider-patient responsibility may be needed to better guide communication about medication adherence. In this context, developing new protocols to guide discussions of adherence is worth exploring.
- Monitoring Your Drug Use and Compliance through the Internet, with Electronic Smart Pills (engineeringevil.com)
- Three Reasons Why Doctors Need To Spend More Time Talking and Listening To Their Patients (healthecommunications.wordpress.com)
- Are Your Physicians Prescribing Mobile Apps? (thehealthcaremarketer.wordpress.com)
- Half of Heart Patients Don’t Take Their Meds; Probably a System Related Cause (labsoftnews.typepad.com)
- Put patients to work during their wait time (kevinmd.com)
- Things Your Doctor Should Tell You About Antidepressants (madinamerica.com)
- ACMT Studies Enhancement of Prescription Drug Monitoring Programs (prweb.com)
- “No.. Not Yet”:Answering the Patient’s Request for “Off Label Use” of a Drug (bioethicsdiscussion.blogspot.com)
- What Your Doctor Is Not Telling You: Why generic is better than name-brand (mothermiser.com)
- Drug czar to push for prescription monitoring program in Missouri, the last holdout (kansascity.com)
Some edits made, and new items added, late the same evening.
I’ve recently learned of some well-intentioned medical research that disturbs me so deeply that I think it’s time to get formal about teaching e-patients and their partners how to detect research that misses its target, even if it’s well intentioned.
Doing this responsibly requires a deep understanding of the purpose of research and its methods. So this is the start of a series in which I’ll lay out what I’ve learned so far, describe the problems and challenges and opportunities that I see, and invite dialog on where I’m wrong and your own experiences as patient or clinician or researcher.
If this succeeds we’ll have a new basis for considering questions of what to do and how to prioritize it, in this era of change in medicine – not just in research but in all of medicine, as we work on reducing our spend. My goal in the series will be to be as clear in my writing as I can, while being as verifiably accurate as I can, given that I’m no PhD or Pulitzer laureate. Critique and correction are welcome.
This first post is an introduction, with background reading.
Context: Patient Engagement
The context for this series is patient engagement: patients shifting from being “compliant” cars in a medical car wash to being responsible and engaged.
Empowered, engaged patients take responsibility for their health and their care. One aspect is being responsible for understanding, as best we can, the evidence that a recommended treatment is right for us. Sometimes it’s pretty simple, sometimes not; but the higher the stakes get, the more important it is.
With respect to research, there’s a big challenge: sometimes the published evidence sucks – even though it got through the peer review process and was approved by a big-name journal.
Of course not all evidence sucks. But if you’re considering whether to be cut open or eat chemicals (meds), you have a choice: trust blindly (“whatever you say, doc”) or take responsibility for understanding as much as you can.
As we’ll discuss, one big reason blind trust fails is that the evidence your doctor gets isn’t necessarily great, and most clinicians aren’t rigorously trained in how to scrutinize it. (They too are largely trained to trust the journal process.) So this is for them too.
- Patients and caregivers – the people on the receiving end of the treatment; the ones who make the decision to accept treatment.
- Clinicians, for two reasons:
- In a participatory relationship, the patient and clinician need to be on the same page regarding the basis for decisions, or one will think the other’s crazy
- As I said, in my experience most clinicians haven’t been rigorously schooled in the weakness of the info they were taught to trust. (This isn’t an insult; see homework below.)
- Health policy people (government and non-profits), because they need to be firmly grounded in reality, or they can’t possibly make policies that work in reality (eh?)
- Insurance companies (commonly euphemized as “care plans” or just “the plans”), who decide what will get paid for. (I know some insurance companies don’t mind paying for stuff that doesn’t work; they basically get a commission on all spending. But others do care what works and what doesn’t – some even have staff who help patients understand the options! They need to be well informed too.)
- Others, I’m sure.
This will make some people unhappy.
It’s the unhappiness that comes from realizing the world isn’t what you thought it was. And the unhappiness that comes from realizing you have to adjust.
But ladies and germs, disconnects like that are what keep a dysfunction in place and make problems intractable. So, comfortable or not, let’s get on with it. The unhappiness I anticipate:
- Some clinicians don’t welcome questions from their patients. (Others do.) In my personal experience most of the ones who object don’t realize how weak the evidence is.
- I hope they’ll remember what I learned in school: all science must be open to new information. (As SPM co-founder and ACOR founder Gilles Frydman said in 2010, “All knowledge is in constant beta.”)
- I know clinicians have many pressures including short appointments. This doesn’t have to be done by an MD; in my view of the future, every “medical home” will have coaches who can help assess published material.
- Some patients really don’t want to hear that the science they depend on – which has indeed produced miracles – has also produced crap sometimes. They especially don’t want to hear that clinicians – their clinicians, who they know are good people – aren’t perfect.
- In general, everyone wants certainty – doctors and patients alike – so it’s unsettling to know you can’t have it. (Even the best science has a chance of errors, and all science is subject to correction.)
Important: This is not a “we reject science” series.
- I love science. I personally am alive because of great medical research that created a harsh treatment delivered brilliantly by great clinicians at Beth Israel Deaconess in Boston. I love the training and clinical experience that made them able to save my life!
- It included great laparoscopic surgery and orthopedic surgery developed by great skilled scientists and delivered by skilled, adroit surgeons & teams. Hooray for science!
- But in the end, science knows that there is no certainty. They’re doing the best they can amid uncertainty. Heck, I myself live in uncertainty:
- The best evidence (which is not great) says there’s a 50% chance my cancer will return, which would likely kill me
- At diagnosis the evidence said I had 24 week median survival
- On the flip side, the treatment that did cure me usually doesn’t work.
Bottom line: There Is No Certainty.
The art of designing, conducting and reporting research includes dealing accurately with this issue.Whatever you read, there’s always a chance it’s wrong.
In my view, the ultimate responsible patient understands this, accepts the uncertainty (as best a human can), and responds by saying “Okay, what are the options? And what are the chances they’ll work?”
If you fully understand that much research is shaky and deserves questioning, you can skip to the end and wait for round 2. If not, read these past posts, because if you don’t realize there’s weakness, you have no reason to learn what comes next.
Here’s your homework.
Past posts establishing the need to be responsible for our decisions
These posts are from e-patients.net………
Click here for the rest of the post
- Is there hope for clinicians in the digital age? (guardian.co.uk)
- Martine Ehrenclou and “The Take-Charge Patient” (digitaldoorway.blogspot.com)
- Regular patient/clinician interaction can help increase follow-up cancer screening (medicalxpress.com)
- Helping Patients Communicate More Effectively About their Health (thielst.typepad.com)
Apply folk wisdom to your family practice patients (How to turn unsolicited advice into positive communication!)12
Great article on communication/relationship skills.
It shows how to show you value advice on your own terms.
This reminds me of a scene in Gone With the Wind. Rhett takes baby Bonnie for a walk in her baby carriage. He passes two older women and asks for their advice on breaking the child’s habit of thumb sucking. Although the advice does not seem good, Rhett smiles and thanks them profusely. After Rhett departs, the women talk amongst themselves what a wonderful father Rhett is.
Late in my family practice residency – and very early in my parenting career – I had mentioned the persistent and sometimes uncomfortably intrusive suggestions offered by my mother and mother-in-law. One of our faculty, a seasoned pediatrician and parent, made the suggestion that I call both sets of grandparents regularly and ask for advice. He pointed out that their motivation (to be helpful and involved) was beyond reproach and that they probably had valuable insights to offer, if I could just reframe it to protect my own need to be autonomous and masterful. It worked like magic. The unsolicited advice nearly disappeared – and I learned a great deal from our conversations. The grandparents felt needed. I benefitted. And so did my kids.
Over the years, I have found it a valuable life strategy, and it comes up fairly frequently in practice:
- I tell all new parents at my first opportunity that they should each call their in-laws regularly to discuss parenting concerns and ask for suggestions, pointing out that the investment in making them feel like a valued contributor will pay huge dividends over time, and making sure that they realize that asking for advice will make it easier to ignore it.
- I suggest to parents that they play various versions of the “what if” game with their kids, getting the kids to help decide how best to set rules, reward success, and punish transgressions.
- I tell young adults starting a marriage (or other long term relationship – times have changed) that they should make a point of asking their partner’s opinion and advice often and sincerely, to build a comfortable platform of sharing.
- I suggest proactive questions and requests for feedback when I see people with job stresses.
- When patients are diagnosed with a serious illness for which others will be directing their care (cancer, degenerative neurologic disease), I tell them we are going to be proactive rather than reactive, and schedule regular appointments to discuss their progress and concerns. This makes sure that they understand I want to remain involved, and I avoid having to deal with crises and questions in a vacuum. (Since we often have a long term relationship, I also find that they need to have me tell them the same things the specialist has said to understand it and believe it.)
- When patients reach an age and health status where they are declining and vulnerable, I suggest that we schedule regular visits to talk about how things have gone and what problems we might expect, rather than waiting to things to go wrong.
As a doctor, I appreciate that I am at an advantage when I seek medical care. Knowing terminology and basic medical principles helps a lot. In addition, when you’ve been practicing medicine for a while you get a feeling from how a doctor discusses options if the care seems valid or if a second opinion is in order. Other things I look for are board certification and a doctor who explains their treatment plan in the context of recommended guidelines.
Summarizing everything that combines to make good medical care is very hard. However, from time to time I take unfortunate histories from patients or hear stories of medical misadventures from friends and I just cringe. Actually, they make me want to shout, “Your doctor did/said what?!” These are red flags, because not only are these recommendations potentially harmful, but if your doctor recommends one thing that is so flagrantly bad, well, uh, um, how can you trust the rest of their care?
So, these are six red flags that would make me stop and not pass go. They would make me get up, get dressed, and say, “Thanks but no thanks,” and walk out the door looking for a second opinion:
1. A prescription for estrogen containing birth control (pills, patch, or ring) with no inquiry about migraines. Why? Migraines with aura are an absolute contraindication to estrogen containing birth control (do to an increased risk of stroke) and if your doctor were up to date on the WHO/CDC guidelines he/she would know that. I want my doctor to be up to date on guidelines, you know?
- 6 warning signs you’re seeing the wrong gyno (drjengunter.wordpress.com)
- Migraine 101: Menstural Migraine (somebodyhealme.dianalee.net)
- Prolonged Periods: A Cause for Concern? (everydayhealth.com)
Yesterday I reflagged an item about the Free UMSkinCheck Mobile App.
While these self check apps are wonderful consumer and patient tools, they are not without “problems”.
This KevinMD.com post outlines health app use challenges as folks gathering data without knowing what to do with and reimbursement issues (physician consultations outside of the office).
Article ends with statement “Until our system puts more value on avoiding unnecessary treatment and keeping people well we will be stuck in this struggle between patients who want to avoid seeing the doctor and doctors who can’t afford to let patients do that.”.
by ROB LAMBERTS, MD(KevinMD.com post, 17 July 2012)
Eric Topol wrote a post on The Health Care Blog where he looks to a future enabled by emerging technology: “Just as the little mobile wireless devices radically transformed our day-to-day lives, so will such devices have a seismic impact on the future of health care. It’s already taking off at a pace that parallels the explosion of another unanticipated digital force — social networks….
large number, if not the majority, of ear infections are undiagnosed and clear on their own at home without intervention. Now add to this a technology which gives us the ability to see all of those undiagnosed ear infections, and we have to muster even more willpower to resist the urge to treat them all. This is the same problem as we have encountered with PSA testing: be careful gathering data you don’t know how to handle.
But even without considering this important objection to improved data-gathering, there is another problem which stands in the way of this type of technology: reimbursement. It sounds great to enable people to avoid visits to the doctor’s office by having tools that previously were only accessible at an office visit. It sounds like a very good way to save money and wasted time spent in waiting rooms with outdated magazines. But this technology presumes that doctors will be willing to act on this information without seeing the patient in the office. It presumes we will be willing to offer free care. If the time I spend sifting through patient-collected data rises exponentially, the payment I get for that time cannot remain at the present level: zero.
If our goal (as it should be) is to spend less money on unnecessary care, we will get to it much faster if we somehow give proper incentive. Our encounter-based payment system stands in the way of any progress in this area. The only way most of us get paid is to see people and deal with problems. This makes doctors reluctant to offer any care outside of this setting, and puts undue pressure on intervention (to justify the encounter to the payors). Until our system puts more value on avoiding unnecessary treatment and keeping people well we will be stuck in this struggle between patients who want to avoid seeing the doctor and doctors who can’t afford to let patients do that….
Will Information Technology Squeeze Physicians Out Of Their Central Role In Health Care? (the healthcareblog.com, July 11, 2012)
“Turns out that while most of us (90%) would like be able to make a doctor’s appointment and check lab results online….85% of us also still want the option of be able to talk to our physician face-to-face. These are the finding from a recent 2012 study conducted by Accenture.”"
What is significant about the finding cited above is that patients at least get it. They understand the value of a having a relationship with a knowledgeable physician or similar health care provider. In spite of, and for some, because of the plethora of health information outlets on the web people want to know that they always have access to your family doc when the chips are down.”
“Here’s what I mean…based upon some 20+ years working in health care:
From the get go…going back to Hippocrates…health and health care delivery has been about the relationships between people starting with the physician-patient.relationship.
The most important diagnostic tool a physician has at their disposal is not a smart phone…but their ability to talk with and observe patients verbal and non-verbal behavior.
“Talk” is not only how physicians diagnose problems and recommend the appropriate treatments…talk is also how patients are able to engage in the health care. Perhaps the most overlooked aspect of talk (and touch) during the medical exam is the therapeutic benefits patients derive from being able to express heart-felt fears and concerns to someone who hopefully cares.”
- Now Your Smartphone Can Be Used To Diagnose Ear Infections At Home (singularityhub.com)
- Now Your Smartphone Can Be Used To Diagnose Ear Infections At Home (forbes.com)
- Back to the Future: Predicting the Future of Healthcare (Part I) (drchrono.com)
- Three mobile tools that could transform how cardiovascular disease is managed (medcitynews.com)
- Company developing #mhealth ECG device for iPhone, ipad raises $10.5M (medcitynews.com)
- Dr Topol to med students: “When I was in medical school, the term “digital” was reserved for the rectal examination” (casesblog.blogspot.com)
…Lead author Robert E. Gramling, M.D., Sc.D., associate professor of Family Medicine at URMC, and colleagues with a special interest in palliative care, made several key discoveries:
- In 93 percent of the conversations, prognosis was brought up and discussed by at least one person, with the palliative care team broaching the issue 65 percent of the time. Also, the prognosis information focused more often on quality of life rather than survival, and on the unique individual rather than the population in general. Researchers noted that prior studies support the link between open and honest discussions about prognosis to clinical benefits.
- Both patients/families and physicians/nurses on the palliative care team tended to frame prognosis with more pessimism than optimism. This was unexpected and different than the usual patterns of communication, where talk of a serious illness tends toward avoidance or unbalanced optimism, researchers said. However, emphasizing accuracy during the palliative care consultation usually leads to treatment decisions that match patient preferences.
- The substance and tone of the conversations varied, depending on whether the patient was present and actively participating. For example, prognosis conversations with family members alone were more pessimistic and contained more explicit information. It is possible, researchers said, this type of conversation takes place out of respect for the patient, who might be sicker in this scenario, or is someone who prefers to avoid information.
- The closer to death, the more likely the palliative care physician was to foretell or forecast events. This might seem logical – that doctors would guide patients and families in what to expect as death approached – but in reality this vulnerable and frightening time is when families often report a void in communication. The URMC data suggests that palliative care consultations respond to this need….
- Listening in, researchers learn about end-of-life communication (eurekalert.org)
- Palliative Care in Australia (blogs.abc.net.au)
- Some Facts On Palliative Care (georgevanantwerp.com)
- A nurse practitioner-driven palliative care intervention improves cancer patients’ quality of life (eurekalert.org)
- Honest talk eases end-of-life choices (futurity.org)
- A nurse practitioner-driven palliative care intervention improves cancer patients’ quality of life (medicalxpress.com)
- Nurses urged to discuss death with heart patients (yorkshirepost.co.uk)
- Improving Palliative Care For Heart Failure Patients (medicalnewstoday.com)
And don’t miss the lively discussion at the end of the article..
Some things in medicine are obvious. Despite the endless worship of ‘evidence-based’ medicine, and the constant barrage of studies on every conceivable topic, we do certain things because we know they just seem right. I take as evidence the fact that we daily try to save lives, devoting research time, untold gazillions of dollars and heroic clinical effort to our continued goal of staving off death. Why is this? Do we know that death is inherently worse than life? Well, since we can’t see beyond the grave, and can’t exactly engage in double-blind, placebo controlled studies about the after-life, the answer is “no.” But we assume that life is preferable to death, based on our feelings, our sense of the thing.
The same is true in our personal lives. No one can show me a scientific study that details why he or she married a particular person. No one can offer up a mole of affection for empiric analysis. And yet, we don’t doubt the existence of romance, or the reality of love.
And yet, medicine is filled with situations in which “self-evident truth” is systematically ignored, and those who believe in it intentionally and often viciously marginalized.
For example, after years of being told that physicians weren’t giving enough treatment for pain, and after years of clinicians saying, “yes we are, and too many people are addicted and abusing the system,” the data from CDC says that far too many are dying from prescription narcotics, far too many infants being born addicted, and far too many people, young and old, are using analgesics and other drugs not prescribed for them. To which many of us say, “duh!”
And then there’s the customer service model, the thing which causes clinicians to lose their jobs as satisfaction scores fall due to disgruntled patients (often upset over not receiving the drug they desired … see above paragraph). This is a darling of administrators. And it clearly has flaws…
- Will Evidence-Based Medicine Become Reality? (georgevanantwerp.com)
- A Rough Guide to Evidence-Based Medicine (jdc325.wordpress.com)
- This is not what the doctor ordered (thehindu.com)
- “How do you feel about Evidence-Based Medicine?” (sciencebasedmedicine.org)
- Scientific evidence (sixpointnineme.wordpress.com)
- Evidence based medicine (slideshare.net)
- Faux Evidence-Based Behavioral Medicine at Its Worst (Part I) (psychologytoday.com)
- Healthcare, a New Car, or Paying for College (georgevanantwerp.com)
The success of medical treatment might improve if the outcomes for persons with multiple conditions, severe disability, and short life expectancy were more based on a patient’s (rather than a health care provider’s) goals, suggests a stimulating commentary recently published in the New England Journal of Medicine.
The commentary’s two authors note the primary outcomes for patients with multiple conditions, severe disability, and short life expectancy often are based on medically-posited, condition-specific protocols. The authors add treatment success often is envisioned as meeting short and longer-term clinical indicators.
David Reuben M.D. and Mary Tinetti M.D. write (and we quote): ‘rather than asking what patients want, the culture has valued managing each disease as well as possible according to guidelines and population goals’ (end of quote).
However, the authors explain for patients with multiple conditions, severe disability, and short life expectancy (and we quote): ‘the overall quality of care depends on more than just disease-specific care processes’ (end of quote). As an alternative, the authors suggest a more patient-centered option should focus treatment on individual tailored goals, which might be quite different than what health care providers admirably hope to achieve.
The authors (who are from the University of California-Los Angeles and Yale University respectively) provide several hypothetical examples where a patient’s goals do not match the clinical indicators physicians seek and there may be differences in how physicians versus patients perceive the ultimate success of medical treatment….
Overall, underlying the commentary’s thought-provoking ideas is the foundational importance of good communication between doctors and patients, which is the focus of MedlinePlus.gov’s talking with your doctor health topic page.
MedlinePlus.gov’s talking with your doctor health topic page provides an array of links to help you improve interpersonal communication with a health care provider. One highly useful site (from the Agency on Healthcare Research and Quality) provides 10 basic questions to ask a clinician that cover a wide range of medical situations. This website is available within the ‘overviews’ section of MedlinePlus.gov’s talking with your doctor health topic page.
A website from Harvard Medical School (available in the ‘related issues’ section) supplements the former site with specific questions about 40+ diseases and conditions that you can take with you to a doctor. Let’s Talk … and Listen also in the ‘related issues’ section helps you establish more rapport and shared decision making with a physician.
MedlinePlus.gov’s talking with your doctor health topic page additionally contains updated research summaries, which are available within the ‘research’ section. Links to the latest pertinent journal research articles are available in the ‘journal articles’ section. Links to related clinical trials that may be occurring in your area are available in the ‘clinical trials’ section. From the talking with your doctor health topic page, you can sign up to receive email updates with links to new information as it becomes available on MedlinePlus….
- “Patient-centered care” vs. CAM in the New England Journal of Medicine (scienceblogs.com)
Robotic surgery has its place. However, robotic surgery is not superior to traditional surgery in every case or for every surgery candidate. It is best to discuss the pros and cons (and alternatives) of any surgical procedure with trusted health care professionals.
Discussion starters below under Related Resources.
Why I am posting this? Partly because a recent article in my local newspaper read more like an advertisement for robotic surgery than an unbiased news item. It seemed to have been written the surgeon interviewed (or at least had only one source of information — the surgeon who touted robotic devices). Am seriously considering a letter to the editor gently inquiring about their journalistic standards. I know they have a skeletal staff of reporters, and no longer have a staff librarian to do research. Still.
As of December 2011, 1548 surgical robots have been sold and installed in the United States as opposed to 16 in Canada.
The estimated population of the U.S is 313,388,000 and for Canada, 34,764, 600.
Canada has a population that is 11.1% of the U.S. population but Canada has only about 1% as many robots. Or put another way, Canada has 1 surgical robot for every 97 robots in the U.S….
The estimated population of the U.S is 313,388,000 and for Canada, 34,764, 600.
Canada has a population that is 11.1% of the U.S. population but Canada has only about 1% as many robots. Or put another way, Canada has 1 surgical robot for every 97 robots in the U.S.
California’s population is 37,691,912, which is about 3 million more than the population of Canada, but California, with 114 robots, has seven times as many robots as Canada..
Related Resources (will be adding resources included unbiased items about robotic surgery by the end of the week)
- Explore your treatment options: start the conversation (one of a series of great tips by the US Agency for Healthcare Reseearch and Quality (AHRQ) )
- Questions are the answer – your health care depends on good communication (AHRQ)
This Web site lets you make a list of questions that you can bring to your medical appointments and gives you tips on talking with your doctor.
- More assistance & helpful tips via AHRQ via the Patient/Consumer site
Related articles (Pros and Cons for informational purposes)
- [Reblog] How hospitals recoup the cost of buying robotic surgery systems (jflahiff.wordpress.com)
- Robotic surgery shouldn’t be universally dismissed (kevinmd.com)
- DistalMotion’s Surgical Tool Combines the Best of Robotic and Endoscopic Surgery (medgadget.com)
- Robot Performs Prostate Surgery (blogs.wsj.com)
- Intuitive Surgical Sued In New York Over Death of 24 Year Old Woman Arising from the Use of the daVinci Robot During a Hysterectomy (ducknetweb.blogspot.com)
- Could pricey surgical robots make their way into medium-sized hospitals? (medcitynews.com)
- Open-source Platform Aids Surgical Robotics Research (it4good.wordpress.com)
- Fewer deaths, complications with robotic bladder cancer surgery, but cost is higher (medicalxpress.com)
From Choosing Wisely – a Web site that aims to “aims to promote conversations between physicians and patients by helping patients choose care that is:
Supported by evidence
Not duplicative of other tests or procedures already received
Free from harm
Nine United States specialty societies representing 374,000 physicians developed lists of “Five Things Physicians and Patients Should Question” in recognition of the importance of physician and patient conversations to improve care and eliminate unnecessary tests and procedures.
These lists represent specific, evidence-based recommendations physicians and patients should discuss to help make wise decisions about the most appropriate care based on their individual situation. Each list provides information on when tests and procedures may be appropriate, as well as the methodology used in its creation.
What tests and procedures should patients and physicians talk about? Read the lists:
[Links at http://choosingwisely.org/?page_id=13]
American Academy of Allergy, Asthma & Immunology
American Academy of Family Physicians
American College of Cardiology
American College of Physicians
American College of Radiology
American Gastroenterological Association
American Society of Clinical Oncology
American Society of Nephrology
American Society of Nuclear Cardiology
- 5 Things Doctors And Patients Should Question (boston.cbslocal.com)
- Six Common Medical Procedures You Probably Don’t Need (businessinsider.com)
- Medical societies list unneeded tests to reduce healthcare costs (medcitynews.com)
- Physician Groups Call for Fewer Medical Tests (cherished79.wordpress.com)
- Physician Groups Call for Fewer Medical Tests (news.health.com)
- U.S. doctors advised to reduce routine tests, treatments (ctv.ca)
- Which Medical Tests Are Really Needed? (connecticut.cbslocal.com)
- Choosing Wisely, Continued… (rjwh617dotcom.wordpress.com)
- US doctors urge fewer tests‚ less costly treatments (thehimalayantimes.com)
- Doctor Panels recommend fewer tests for Patients (maryannebachia.wordpress.com)
…Bloch points to a growing body of research evidence showing the impact of financial struggle on the risk of a variety of diseases (this research is largely Canadian, so US statistics will differ, though the themes are likely similar):
Cardiovascular disease: there is a 17% higher rate of circulatory conditions among the lowest income quintile versus the average
Diabetes: prevalence among the lowest income quintile is more than double the rate in the highest income quintile
Mental Illness: the suicide-attempt rate of those living on social assistance is 18 times higher than higher-income individuals
Cancer: low-income women are less likely to access screening interventions like mammograms or Pap Smears
Development: infant mortality is 60% higher in the lowest income quintile neighborhoods
Regardless of this compelling evidence, why is there a need to screen for poverty? “Simply because we don’t know which patients live in poverty and if we don’t ask, we won’t find out,” says Dr. Bloch. Since the recession of 2008, many hard-working people have been squeezed out of the middle class. A November 2011 report by Wider Opportunities for Women entitled, “Living Below the Line,” highlighted the fact that nearly half of Americans struggle to make ends meet. …
NCAAM (National Center for Complementary and Alternative Medicine) recently published these pages/articlers
- Director’s Page – It’s Time to Talk (March 13, 2012)
Time to Talk is a recently launched NCAAM series which encourages folks to discuss complementary health practices with their health care providers
The director notes the following
- We know that nearly 40 percent of Americans use some kind of complementary health practice. But we also know that most patients do not proactively disclose use of complementary health practices to their health care providers. Likewise, most providers don’t initiate the discussion with their patients. As a physician, I strongly believe that patients and their health care providers need to talk openly about all of their health care practices to ensure safe, coordinated care. Talking not only allows fully integrated care, but it also minimizes risks of interactions with a patient’s conventional treatments.
- This month’s Time to Talk includes these tips
- List the complementary health practices you use on your patient history form. When completing the patient history form, be sure to include everything you use—from acupuncture to zinc. It’s important to give health care providers a full picture of what you do to manage your health.
- At each visit, be sure to tell your providers about what complementary health approaches you are using. Don’t forget to include over-the-counter and prescription medicines, as well as dietary and herbal supplements. Make a list in advance, or download and print this wallet card and take it with you. Some complementary health approaches can have an effect on conventional medicine, so your provider needs to know.
- If you are considering a new complementary health practice, ask questions. Ask your health care providers about its safety, effectiveness, and possible interactions with medications (both prescription and nonprescription).
Don’t wait for your providers to ask about any complementary health practice you are using. Be proactive. Start the conversation.
NCCAM TiwtterChate – Join us for monthly Twitter Chats that cover a variety of health topics and complementary approaches. Each month, a different topic will be selected. An expert in scientific and health issues will be available to answer your questions. Most chats will occur on the last Thursday of each month at 1 p.m. ET. Dates, times, and topics may change, and will be announced on this page and through Twitter and Facebook.
Find us on Twitter: @NCCAM. To participate, use the hashtag: #nccamchat.
Upcoming ChatsMarch 30, 2012 Time to Talk
Time to Talk Campaign—an educational campaign to encourage patients and their health care providers to openly discuss the use of complementary health practices.April 26, 2012 Asthma and Complementary ApproachesMay 31, 2012 Yoga
- Is it Time to Talk? (lynnawiensmd.com)
- The Holistic Nurse: What’s So Awful About the Placebo Effect? (makingsofanurse.com)
From the 25 January posting at Eye on FDA
Patients are changing. They are accessing medical information differently, they are storing it differently and they are consuming it more voraciously. This access to medical information and tools means that many patients are more medically conversant and knowledgeable than the patient of just five years ago. Medical literacy is likely on the rise.
It also changes the way physician and patient communicate. Five years ago, I never would have considered the need for email between my physician and myself, thinking it impractical. Today, I think a physician needs to have some portal of access for the exchange of data and information. Here are my readings – blood pressure, blood sugar, whatever… – for the week. The medical record will reflect information not just gathered at an exam in the office, but that gathered by my apps when I am not in the office. And when I’m diagnosed with a new condition, I fully expect either the physician or someone in his or her office to not only prescribe some medication, but to pull out an i-Pad to steer me to some good resources, including apps. If the condition is one where there are few treatment options and I’m expected to consider a clinical trial, the i-Pad should have a clinical trials app that lets us look at what’s available together….
- eHealth: patients are changing, but not (yet) the Physicians (scienceintelligence.wordpress.com)
- From Pinterest and Septris to the Patient of the Future (Science Blog)
“Are ePatients self diagnosing too much ? Too many people are not going to see their doctors on a regular basis and they need to be educated on why that is a bad idea. No printed or interactive forum can replace a trained medical professional. The Patient of the Future Like many “self-quanters,” Smarr wears a Fitbit to count his every step, a Zeo to track his sleep patterns, and a Polar WearLink that lets him regulate his maximum heart rate during exercise. Stanford University’s Septris app …”
Unnecessary reliance on screening tests and the underuse of personalized medicine are two major concerns I have with the present practice of medicine. Hence the selection of this article for a blog item.
Mayo’s Dr. Victor Montori and his team argue that medical intervention success is best be measured in holistic terms as death, quality of life, and ability to function. This is in direct opposition to current industry and professional guideline standards which emphasizes narrow (and often misleading) outcomes as blood pressure reduction, lipid levels, and glucose levels.
The team’s analysis with “10 commandments” for physicians is published in the 28 December 2011 article The idolatry of the Surrogate. The article, unfortunately, is only available through paid subscription through the BMJ (British Medical Journal – Helping Doctors Make Better Decisions).***
The commandments basically encourage physicians to be careful with statistical results from clinical trials, information from industry experts, and to treat and respect the patient as individual with treatment related statistics as guides.
On a related note, I am very impressed with folks who empower themselves in treatment decisions by keeping up with biomedical breakthroughs, new treatments, and new ways of looking at diseases. I have posted related blogs as ePatients: The hackers of the healthcare world and Meet e-patient Dave – a voice of patient engagement.
Here is the abstract of the article
Easier to measure surrogate outcomes are often used instead of patient important outcomes such as death, quality of life, or functional capacity when assessing treatments. John Yudkin, Kasia Lipska, and Victor Montori argue that our obsession with surrogates is damaging patient care
Diabetes care is largely driven by surrogates. The US Institute of Medicine defines surrogates as “biomarker[s] intended to substitute for a clinical endpoint [and] expected to predict clinical beneﬁt (or harm . . .) based on epidemiologic, therapeutic, pathophysiologic, or other scientiﬁc evidence.”1 In diabetes, concentrations of glycated haemoglobin (HbA1c) are used as a surrogate marker for outcomes that are important to patients, such as blindness or amputation. Other surrogates such as blood pressure, lipids, albumin excretion rates, and C reactive protein have been used to predict outcomes of cardiovascular disease and to guide clinical practice in people with or without diabetes. Much of the evidence for clinical interventions is based on their effect on surrogate outcomes rather than those that matter to patients such as quality of life or avoidance of vision loss or renal failure. Moreover, because these “hard” end points generally show much smaller responses to interventions than surrogate markers, many of the widely accepted strategies for diabetes may be based on artificially inflated expectations.
Recent studies have challenged the assumption that reliance on surrogates can accurately predict the effect of treatment on hard outcomes. There are the oral hypoglycaemic drugs that reduce HbA1c but increase the risk of cardiovascular events,2 antihypertensive drugs that do not reduce the risk of stroke,3 and drugs that improve cholesterol profiles but do not reduce cardiovascular events.4 Explanations for such phenomena include unwanted effects of the drug or an incomplete understanding of the pathophysiology of the disease.5 But why have …
Below are listed the the ten commandments**** with definitions and paraphrasing. I have forgotten much more than I have remembered from a college statistics class 30+ years ago! The “explanations” are a result of finding quality information on the Internet.
(For a great “translation” with less math, please go to the blog posting …Get Your Doctor to Treat You Right)
The New Therapeutics: Ten Commandments
- Thou shalt treat according to level of risk rather than level of risk factor.
Level of risk - these levels are experienced by everyone, not just those having the disease being treated [good summary of risk levels (minimal, less than minimal, greater than minimal) ]
Risk factor -anything that makes it more likely you will get a disease, either something you do (smoking)or something you have no control over (as being over 50 makes it more likely you will get colon cancer. People should be given treatments based on the risks associated with the treatment on anyone,not individual factors (age, blood pressure, other conditions)
- Thou shalt exercise caution when adding drugs to existing polypharmacy.
Polypharmacy - (poly is Greek for many) Whenever a person is taking a drug, any additional drugs may interact and cause bad reactions, including death.
- Thou shalt consider benefits of drugs as proven only by hard endpoint studies.
Endpoint study – research study involving humans where the outcomes (results) directly address the question. For example, if a drug was tested on how it reduced heart disease, the hard endpoint would be the reduction of heart disease. However, hard endpoint studies are usually not accomplished in short periods of time, because it takes time for diseases to develop. This paragraph sums up endpoint workarounds well.
From Deciphering Media stories on Diet (Harvard.edu)
4. Did the study look at real disease endpoints, like heart disease or osteoporosis? Chronic diseases,
like heart disease and osteoporosis, often take many decades to develop. To get around waiting that
long, researchers will sometimes look at markers for these diseases, like narrowing of the arteries or
bone density. These markers, though, don’t always develop into the disease.
- Thou shalt not bow down to surrogate endpoints, for these are but graven images.
Surrogate endpoint – a substitute endpoint in a clinical trial. It is not the item being measured directly (as heart disease), but an item related to what is being studied (as blood pressure). During the study these substitutes will be used to check on the health of the people in the clinical trial, the usefulness of the drug being treated, and if there are any complications. Surrogate endpoints are substitutes for (true) clinical endpoints (as survival for 5 years after the treatment). Surrogate endpoints don’t always guarantee a clinical endpoint (just because blood pressure goes down, heart disease may not be treated). However studies with good endpoints are expensive (require testing on many people) are take long periods of time. [Adapted from an eHow article with good references]
- Thou shalt not worship Treatment Targets, for these are but the creations of Committees.
Correlation doesn’t always meant causality!A treatment target is a goal of a treatment intervention. An example would be to reduce a specific protein in order to prevent a specific cancer (Potential New Treatment Target for Retinoblastoma, 13 January 2012 Medscape article) . The “cause/effect” relationship between something measurable (as a protein) and a disease may not truly exist. It is also possible that the presence of the protein and the onset of a disease may be due to other factors in a web of events.
- Thou shalt apply a pinch of salt to Relative Risk Reductions, regardless of P values, for the population of their provenance may bear little relationship to thy daily clientele.
Relative Risk - The number of times more likely (RR > 1) or less likely (RR < 1) an event is to happen in one group compared with another. [From the BMJ glossary] P value – a number used to show how a variable (as a drug treatment) has a different result thano variable (no treatments). So, a high P value would seem to point to an effective drug treatment.
- Thou shalt honour the Numbers Needed to Treat, for therein rest the clues to patient-relevant information and to treatment costs.
The Numbers Needed to Treat (NNT) tells how many patients need a specific treatment in order to prevent an additional bad outcome (as a heart attack or stroke). So if a drug has an NNT of 10, 10 people have to be treated with the drug in order to prevent one additional bad outcome.
For example, if a drug is found to reduce the risk of a bad outcome from 50% to 40%, the absolute risk .1 (the difference). And the NNT is the inverse of the absolute or 10. [From Numbers Needed to Treat (Patient.co.UK)
- Thou shalt not see detailmen, nor covet an Educational Symposium in a luxury setting.
Detailmen are pharmacy representatives who present doctors with their company's drug information with the aim of persuading the doctor to presribe their drugs. These representatives often sponsor educational talks (often "focusing" on conditions rather than drugs) at physician meetings. These "luxury settings" may included free buffets and hospitality rooms. [From Influencing Doctors :How Pharmaceutical Companies Use Enticement to 'Educate' Physicians (ABC News)]
- Thou shalt share decisions on treatment options with the patient in the light of estimates of the individual’s likely risks and benefits.
- Honour the elderly patient, for although this is where the greatest levels of risk reside, so do the greatest hazards of many treatments.
*** Click here for suggestions on how to get this article for free or at low cost.
In past blogs I have posted items on initiatives for the wider sharing of scientific articles to the public with subsidies, open access, etc.
****Richard Lehman’s Journal Review – 3 January 2012
amednews: Why patients are turning less to media and friends for health information :: Dec. 26, 2011 … American Medical News
Excerpts from the 26 December 2011 news item of the American Medical Association (AMA)
Consumers’ access to physicians and the quality of information available are affecting their level of interest in seeking outside guidance on their conditions.
By PAMELA LEWIS DOLAN, amednews staff. Posted Dec. 26, 2011.
As patient visits to physicians have declined, so has their interest in finding information relating to their health.
The waning interest in information-seeking as patient visits fall is what the Center for Studying Health System Change called a “surprising” conclusion to a survey of 17,000 patients released in November. Visits to physicians dropped 4% between 2007 and 2010. Meanwhile, the percentage of American adults seeking information about a personal health concern in the previous 12 months decreased from 55.5% to 50% in the same period, it said.
Analysts said there probably are multiple reasons for that. The trend could reflect that when patients are less able to see a physician, they are less likely to be engaged in their health. It could be that with physician visits down, patients have more time to spend with their doctor, meaning they have less of a need for outside sources of information.
And they said the decline could reflect that so much information is available — and so much of it conflicting — that some overwhelmed patients may be opting out altogether from researching their health.
For physicians, analysts said, the implication of the study is that when patients come into their offices, they are going to rely on them more than ever for help in managing their health.1 in 5 patients has delayed or canceled a doctor visit, medical test or procedure in the past year.
The sources of information the center studied were the Internet, print media, television and radio, and friends and relatives. Internet was the only source that went up, to 32.6% from 31.1%. But center researcher Ha T. Tu wrote that the growth failed to keep pace with a strong rise in residential broadband Internet access, which went up from 47% to 66% between 2007 and 2010….
- How much guidance do patients want with their medical decisions? (jflahiff.wordpress.com)
- Epatients: The hackers of the healthcare world [O'Reilly Radar] (jflahiff.wordpress.com)
[While I have some major concerns about this video, since it was at the blog item, I decided to add it anyway.
In my humble opinion the background music is too gloomy, the use of some declatatory statements seem to false imply "all", and it seems to foster an "us" versus "them" mentality that in the long term may be unhelpful...
Still, it does emphasize that people can be empowered through reputable information and interacting with other like-minded and similarly educated folks]
A quick reference for becoming an empowered patient
Excerpts from the blog item by Fred Trotter at O’Reilly Radar- Insights, Analysis, and Research about Emerging Technologies
help build open source software tools that patients can use to have greater control and influence over their own healthcare (like the Direct Project and Your Doctors Advice). As as result, I’ve become quite familiar with other tools that do the same sorts of things. There is a community of patients who are deeply interested in the ways in which they can become more engaged and how they can specifically use technology to achieve this. This community calls themselves epatients. The epatient community asked me to write a short collection of resources for “becoming an epatient.”
The “e” in epatient is intentionally obscure. The initial assumption is that the “e” stands for “electronic,” as it does in “email.” But in fact, the “e” stands for “engaged” or “empowered.” Nonetheless, reference to email is intentional: The epatient community recognizes that leveraging data is a critical part of empowering a person who happens to be sick. Patients must be “electronic” to become fully “engaged.” I think of epatients as the healthcare equivalent of makers and hackers. More importantly, they are the people I have in mind when I write software….
Let’s go over some simple concepts that the rest of my epatient advice and resources are based on:
- Your doctors are probably not managing your healthcare information. You should assume it is your responsibility. Otherwise, the people involved in your treatment process will often presume that this information simply does not exist.
- Other patients, with similar conditions to yours, can have better information about your health problem than your doctors have.
- Like the highway system, the healthcare system is generally beneficial, but there are dangers, and you need to learn to avoid them.
And here are two things you should keep in mind:
- Whenever I say “patient,” I actually mean “the patient/caregiver team.” Often, the patient will not have the energy to do what is necessary to be fully engaged. It is critical that when the patient cannot be an epatient, that at least the patient’s team be an epatient proxy.
- In regard to the “better information” I mentioned above, I don’t mean that your doctor is typically wrong and another patient is typically right about your diagnosis or treatment options. While that does happen on occasion, it is not the norm. Another patient’s information is “better” because your doctor typically does not have the visceral experience of being a patient. Your doctor doesn’t understand which lotion can make all of the difference or what position might let you get some sleep after a rough procedure. There is simply no substitute for experience. Sometimes that experience can make your life a little easier, and sometimes it can help you get the right treatments that literally will save your life. (This is the gist of epatient Dave deBronkart’s story.)
Read the entire blog item (including descriptions and links to epatient communities)
- The slow integration of community into health care (The Health Care Blog)
For a long time now patients have been meeting in online (and offline) communities, sharing experience, advice and more recently data and measurements. And the health care system–which knows that communities improve health–has done virtually nothing–other than some doctors having doctors answer questions on MedHelp. That is just starting to change. Last year Geisinger did a small trial with dLife that showed improvement in diabetics outcomes. More recently Aetna inked partnerships withMindBloom and OneRecovery, two communities focused on spirituality and addiction, and today Diabetic Connect (part of Alliance Health) announced a deeper integration with the Joslin Diabetes Center. It’s been a while, but the heart of Health 2.0 (communities) are starting to move towards the mainstream.
- Are you an ePatient? (enbloommedia.com)
- The Rise of the e-Patient: Slideshow (ScienceRoll)
“It’s always good to see the trends about the growing number and importance of e-patients. Lee Rainie, director of the Pew Internet Project, presented this wonderful overview of the Project’s health findings at Providence St. Joseph Medical Center in Burbank, CA, on January 12.”
- Why patients are turning less to media and friends for health information (jflahiff.wordpress.com)
- Can differential diagnosis be crowdsourced to Facebook Friends?(medgadget)
- ePatient Connections: A Patient Checks In. (sixuntilme.com)
- From E-patient Hackers to Health Games on Mobiles (scienceroll.com)
- The end of social – O’Reilly Radar (queuniversidade2.wordpress.com)
- Meet e-patient Dave – a voice of patient engagement (and related resources) (jflahiff.wordpress.com)
- 2020 Vision: The ePatient Evolution Over the Next 10 Years (prweb.com)
- ePatients Come Together to Brainstorm and Share (brassandivory.org)
- 6 P’s Of Social Health (socialmediaclub.org)
- The Rise of the ePatient – presentation by Pew Internet Project (casesblog.blogspot.com)
From the 5 January 2012 posting by PATRICIA SALBER, MD at KevinMD.com
I am a big fan of DIY (do-it-yourself) healthcare, at least for the bulk relatively minor issues that plague people. I think the days when doctors were needed to control, interpret and dole out health data and information are waning. There are simply too many ways, primarily via the internet, to get good, reliable, easy-to-understand information about our own health.
The Quantified Self (QS) people who use sensors, mobile apps, and other devices to collect data on themselves may be taking it to what some would consider extreme, but I think it is the wave of the future.
Now, no one would question who “owns” the data collected in this manner, but how about data collected via a medical laboratory? Is that somehow different and something we, the patients, should not be allowed direct access to lest we harm ourselves by misinterpretation. Interesting question!
The issue is explored in a commentary in the December 14, 2011 issue of the Journal of the American Medical Association.*** Traber Davis Giardina, MA, MSW and Hardeep Singh MD, MPH, ask the question: “Should patients get direct access to their laboratory test results?” They find that it is “an answer with many questions.”…
The reason to raise this question now is that there is a proposed rule by the Department of Health and Human Services in conjunction with the Centers for Medicare and Medicaid Services, the Centers for Disease Control and Prevention and the Office for Civil Rights, that would allow individuals the ability to access their test results directly from the laboratory by written or electronic request. …
There are a number of reasons why direct access is a good idea:
- Between 8 and 26% of abnormal test results, including those suspicious for cancer, are not followed up in a timely manner. Direct access could help reduce the number of times this occurs
Self-management, particularly of chronic illness has known benefits. Just like the QS people, many folks with chronic illness obtain and manage to self-acquired lab results every day via glucometers, home pulmonary function tests, blood pressure measurements, and so forth. Direct access to laboratory-acquired data, one could argue is a continuation of that personal responsibility…
The arguments against direct access discussed by Giardina and Singh include the following:
- Studies show that patients prefer their physicians contact them directly when they have abnormal test results, although the studies, published in 2005 and 2009, preceded the extraordinary use of the internet to access health information that exists today.
- There is concern over whether patients will know what to do when they receive the results – will they make erroneous interpretations or fail to contact their docs? …..
***Article available online to paid subscribers only.
- Should Patients Get Direct Access to Their Laboratory Test Results? An Answer With Many Questions (jflahiff.wordpress.com)
- Proposal on access to lab tests should be revised, doctors say (kboreilly.com)
- Progress Made on Direct Patient Access to Lab Results (projecthealthdesign.typepad.com)
- Getting Lab Results Directly to Patients (blogs.wsj.com)
- Becoming a master diagnostician – Step 3 – lab test interpretation (medrants.com)
- Dentists Could Screen 20 Million Americans For Chronic Physical Illnesses (medicalnewstoday.com)
- Support Your Right to Access Your Clinical Lab Results (spittoon.23andme.com)
- Docs Don’t Want Lab Results Going To Patients (informationweek.com)
- HHS wants to give patients test results straight from the lab (kboreilly.com)
- HHS Proposed Regs Would Give Patients Direct Access to Lab Results (physicianlaw.foxrothschild.com)
Do You Really Need a Yearly Checkup? | Yahoo! Health By Lisa Collier Cool
Typically, a routine visit with your primary care doctor involves a slew of tests and screenings. While patients are often told that all this poking and prodding is crucial to protect their health, is there any scientific evidence to support that? A decade ago, the US Preventative Services Task Force (USPSTF), an independent group of medical experts appointed by Congress, concluded that yearly physicals are unnecessary for healthy, symptom-free adults.
What’s more, a new study published in Archives of Internal Medicine*** reports that primary care doctors often order unnecessary and inappropriate tests, screenings and treatments, costing the healthcare system—and patients—$6.8 billion in 2009. The annual checkup is a prime culprit in needlessly driving up medical bills, the researchers found, with dubious or worthless tests ordered in up to 56 percent of these exams.
Instead of a yearly checkup, the new thinking is that healthy patients should “check in” with their doctors periodically, on a schedule tailored to their individual needs, to discuss any medical concerns and which tests truly are appropriate for their age, gender, and family history. Here’s a look at routine screenings that primary care doctors are most likely to use needlessly, according to analysis by the National Physicians Alliance (NPA)—and when these tests are worthwhile….
- How much guidance do patients want with their medical decisions? (jflahiff.wordpress.com)
- Top 5” Lists Top $5 Billion in Potential Savings (National Physicians Alliance)
- How much guidance do patients want with their medical decisions? (kevinmd.com)
- What Makes Patients Complex? Ask Their Primary Care Physicians (medicalnewstoday.com)
- What makes patients complex? Ask their primary care physicians (eurekalert.org)
- Let physician assistants be part of the primary care answer (kevinmd.com)
***The article, “Top 5″ Lists Top $5 Billion, is available online only through paid subscription.
Click here for suggestions on how to get this article (and other science/medicine articles) for free or at low cost
Minal S. Kale, MD; Tara F. Bishop, MD, MPH; Alex D. Federman, MD, MPH; Salomeh Keyhani, MD, MPH
Arch Intern Med. 2011;171(20):1856-1858. doi:10.1001/archinternmed.2011.501
Since this article does not have an abstract, we have provided the first 150 words of the full text and any section headings.
The Good Stewardship Working Group presented the top 5 overused clinical activities across 3 primary care specialties (pediatrics, internal medicine, and family medicine), as chosen by physician panel consensus.1 All activities were believed to be common in primary care but of little benefit to patients. We examined the frequency and associated costs of these activities using a national sample of ambulatory care visits.
We performed a cross-sectional analysis using data from the 2009 National Ambulatory Medical Care Survey (NAMCS) and the National Hospital Ambulatory Medical Care Survey (NHAMCS). The NAMCS and NHAMCS survey patient visits to physicians in non–federally funded, non–hospital-based offices and non–federally funded hospital outpatient departments, respectively.2
We limited our sample to visits by patients to their primary care physicians. Visits for each “top 5″ primary care activity were identified . . . [Full Text of this Article]
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)