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)