Monthly Archives: May 2012

Speak Up and Be Heard: Shared Decision Making Improves Outcomes

Yesterday, while reading the New York Times I stumbled upon an article by Pauline Chen addressing issues with doctor patient communication.  In the article, Dr Chen describes a highly educated, articulate patient who was unwilling to speak up and discuss care related issues with her doctor.  The reasons given for not wanting to speak up included not wanting to anger the physician and not giving the perception of questioning judgement.   I immediately began to reflect on one of my recent blog posts on patient compliance and outcomes.  During the course of researching that particular blog topic, I found much published that suggested that patient-doctor partnerships in care were key to positive outcomes. Certainly, if a well educated, academic patient like the one described in the New York Times is reluctant to discuss care related issues with her provider, what about the rest of the world’s patients?  Maybe this is the largest barrier to achieving more positive outcomes and better compliance.

First and foremost, providing high quality care means doing what is right for our patients.  We all learn in medical school and residency the “gold standard” diagnostic test and the first line therapy for many disorders.  However, there are often several options that are within the scope of standard of care. The option that we may choose for a patient may have a significant impact on therapy success (even when treatment options have data to support equivalent outcomes).  Moreover, how we go about choosing which option to utilize in a particular patient has a lot to do with how successful the therapy may be.  Involving patients in this type of choice and providing the patient with decision tool aids is critical to this process.

A recent review by Dr Michael Barry published in the J Ambulatory Care Management in 2012, explored this very issue.  The concept of Shared Decision Making is defined in the same journal in 2012 by Dr Angela Coulter as “a patient working together with clinicians to select appropriate treatments or management options”.  Shared decision making is an obvious approach when patients are facing major procedural decisions such as whether or not to have an ICD implanted.  In order to use this approach there must be more than one acceptable option with acceptable outcomes.  However, these options often have different types of side effects and patterns of therapeutic effects.  In addition shared decision making can be used when trying to decide about whether or not to use a particular screening test that may have far reaching implications (such as mammograms in younger women–often yielding false positive results and necessitating follow up breast biopsies).  As clinicians we must present the outcomes data for a particular test or intervention and help our patients decide (together, as a team) what is best for them and their overall situation.  

With these concepts in mind tools to aid in decision making have been designed specifically for certain diagnoses.  Decision making tools can be utilized to aid patients in making difficult treatment or testing decisions.  The International Patient Decision Aids Standards (IPDAS) provides quality standards for decision aids.  These decision making tools are designed for particular disease states and are created to provide information about options to patients.  They are NOT designed to promote one option over another nor are they designed to replace a consultation with a physician.  According to the IPDAS, “they are specifically designed  to prepare patients to make informed, value-based decisions with their practitioner.”  These tools are created to facilitate the shared decision making process.  They do NOT replace the communication process with the physician–they are created to enhance it.  

So, it is obvious that shared decision making requires communication.  We must find a way to remove barriers to communication.  As physicians, we must work to avoid giving our patients the perception that they are “questioning  judgement” or “bothering the busy doctor” when they ask questions during a routine office visit.  In fact, at every office visit, we should introduce a time for questions.  In my EP practice, before the patient leaves the room, I try to ask if there are any issues they would like to discuss and try to have them assess their progress.  By involving them in discussions at every visit, I hope that I am able to open the door for future patient-initiated discussion.  We know from numerous studies that patient engagement is key to successful outcomes.  Now we must make sure that our patients, regardless of education or socioeconomic status feel free to ask questions, challenge treatment plan decisions and discuss options for care.  We must strive to remove barriers to communication and facilitate shared decision making.  When patients are not afraid to speak up in the doctor’s office, care is exponentially improved.

Improving Patient Compliance and Outcomes : Communication is the Key

As Physicians, it is easy to become frustrated when we see patients in the office who have stopped taking a carefully crafted treatment regimen or have continued to engage in smoking or other self destructive habits.   A CHF patient may have spent a week in the hospital with IV diuretics, meticulous medication adjustments, dietary counselling and left on a “text book” perfect set of meds only to return to the ER a week later with decompensated CHF and on no meds.  This is certainly a significant public health issue that contributes to the rising cost of healthcare.  It is estimated that non compliance results in an estimated $100 billion dollars and 10% of hospital admissions in the US today.  Why does this happen?  What can we as healthcare providers do to impact this problem?
Patients and doctors today are confronted with enormous challenges when it comes to sticking to a treatment regimen.  Disease states are often complex and overlapping.  It is not uncommon to see patients in my EP clinic who are taking more than 10 different medications.  In addition to the 2 page medication list many patients also have a carefully prescribed diet, an exercise regimen and frequent doctor’s appointments.  Many of these patients are elderly and may live alone with minimal support.  Adherence to a complex set of treatment regimens becomes difficult if not impossible.  It is clear that as compliance decreases, the success of therapy decreases exponentially.  Lack of compliance results in readmission to the hospital, and progression of disease along with associated increases in morbidity and mortality.  

A manuscript by Mcdonald, et al published in JAMA in Dec 2002 reviewed all relevant published RCT of interventions to improve adherence to medications.  In the analysis 49% of the interventions resulted in increased medication adherence and only 17% resulted in improved treatment outcomes.  Many of the interventions to improve compliance involved phone calls, staff reminders and post-doctor visit counseling.  Thus, most interventions were labor intensive and were not terribly effective in changing outcomes.  In another review in Clinical Pharmacy and Therapeutics from 2001, Vermeire, et al found that factors related to poor compliance included psychiatric disorders, duration of treatment (longer duration results in decreased compliance), number of medications (and their cost) as well as the frequency of dosing.  Not surprisingly, the complexity of the regimen was shown to predict poor compliance and the doctor-patient relationship really seemed  to be an important variable in predicting higher adherence rates.  Traditionally, physicians have taken a very paternalistic approach to counseling patients about treatment plans.  Today, it is clear that there must be a shift to a “partnership” with shared responsibility between doctor and patient.

In this presidential election year, there is much discussion as to how best to reform healthcare in order to reduce cost and improve outcomes.  Politicians have recommended sweeping changes to our healthcare system at high cost to taxpayers.  Maybe more cost-effective changes to improve healthcare may be those that focus on improving compliance through strengthening the doctor-patient relationship. It is clear that lack of compliance results in poor outcomes, increased cost and lack of successful treatment.  As physicians, we must understand that the doctor-patient relationship is central to solving this problem.  We must involve patients in shared decision making and work to understand each individual patient’s perspective and circumstances that may impact adherence to a particular treatment plan.  We must treat the patient as a partner in care.  We must consider factors that may impede our ability to achieve high levels of adherence such as psychiatric illness, financial stress, family circumstances and support mechanisms.  Most importantly we must individualize treatment plans and foster two way communication in order to promote success.  

Just Because We Can…Doesn’t Mean We Should: The Use of Implantable Cardiac Devices in Elderly Patients

Our patients are sicker than ever. Obesity, diabetes, and cardiovascular disease is increasingly prevalent in the US today. Even with the challenges of an aging population, we are doing a much better job diagnosing and treating cardiovascular disease in the year 2012 as compared to decades ago. Life prolonging therapies are commonplace and death rates from CV disease are declining (particularly in men). Advanced technologies such as LVADs and ICDs have been developed specifically to prolong life. Healthcare costs have skyrocketed and healthcare reform is at the forefront of almost any political campaign.

As an EP physician, I am often asked by my colleagues to make difficult decisions about the implantation of life saving ICDs in an aging population. How do you decide how old is too old? Is this all about chronologic age or does so called “biologic age” play a role? Is this all about applying the data from multiple ICD trials (with a patient population that may not represent your patient exactly)? Should we as physicians be unofficially “rationing” healthcare?

These are difficult questions, and I think, only represent the tip of the iceberg in this debate. In my opinion, we must take a multifaceted approach to making these decisions. When asked to consult on a patient who is elderly and asked if the patient would benefit from an ICD, I do just that-I provide consultation. I provide a thoughtful consideration of the data supporting what we do, the patient’s age and overall condition (including co-morbidities) and, most importantly, the patient’s feelings about the risks and benefits of proceeding. Most device trials have excluded patients over 80 years old so we really have no specific data in this population. Despite this fact, national database registry information indicates that nearly one fifth of ICD or CRT devices are implanted in this age group. When we examine the guidelines, there are almost no absolute age-specific contraindications for ICD therapy but as the patient age advances very careful consideration of alternatives should be entertained and disclosed in discussions with patient and family.

In a article by Swindle, et al in Archives of Internal Medicine in 2010, the outcomes of ICD implantation in elderly patients was examined. In the study, the median age was 70 years old and almost 18% were more than 80. When the study cohort was compared to younger patients, those more than 80 years old were more likely to receive CRT pacing therapy without ICD. In hospital mortality increased from .7% to 1.2% in patients older than 80 and to 2.2% in patients older than 85. In another study by Panotopoulos et al published in JACC in 1997, the implantation of ICDs in patient older than 75 was examined and found that mortality rates in this pateint population was increased 3 fold as compared to younger cohorts. Data from studies involving mainly younger patients and ICDs may over estimate benefit in elderly populations and conversely studies involving a large population of elderly patients may under-estimate that benefit in younger cohorts.

Obviously there is no consensus at this time as how to best handle elderly patients meeting criteria for ICD or CRT therapy. Our best practice should involve a careful assessment of the patient, the disease and co-morbidities as well as a detailed discussion of risks and benefits with patient and family. There is no right answer in these cases. There is no well designed RCT in this age group to to guide our decision making. Certainly there are times and situations where I believe that CRT therapy without ICD is appropriate and have advocated this approach in many of my elderly patients. I have also implanted ICDs in many patients over the age of 80. In all cases, the most important factor in making this decision has been thoughtful discussion with the patient. Ultimately we must individualize care and help the patient make an informed decision that is best for their own personal situation and belief system. Certainly, just because we CAN, doesn’t mean we SHOULD.

Medical Conferences: What makes an Academic Meeting Great (Or Reflections on HRS 2012)

As my time at the Heart Rhythm Society’s annual meeting is coming to a close, I have begun to reflect on and evaluate this year’s event. Our time in Boston has been both productive and enjoyable. I have met with familiar faces from my medical training past and have collaborated with both new and old colleagues. We have shared opinions on disease and device management and even bickered over specific points related to the buzz surrounding the recent Riata lead recalls. I have had a great time in Boston and look forward to next year in Denver. With that in mind, I wanted to provide a few thoughts on what makes academic meetings great.

In 2006, a paper published in Nature Reviews Molecular Cell Biology addressed the question of what makes a good meeting. In that manuscript, Dr Petsko lists the 10 characteristics of exceptional meetings. I have listed a few of the most important ones below and then evaluated this year’s HRS on these points.

  1. Human Interaction. Often the best part of the HRS annual session is the academic exchange among members—both strangers and old friends. Larger auditorium sessions do not always promote this type of interaction but if an attendee makes an effort to catch a speaker after the talk is over, I find that most HRS members are willing to talk and discuss a point with another physician scientist. Sessions that involve debates, audience participation and response often provide the most benefit.
  1. Gender and Ethnic diversity among speakers. I believe that as an international society HRS does a reasonably good job of promoting diversity of lecturers. As a “younger generation” EP doctor (I am out of fellowship 9 years now), I do believe that our society is a bit “Top Heavy” with the same very senior members giving the same talks every year. As a society, we must begin to embrace the younger generation of thought leaders and cultivate their participation. In the not so distant future, we are going to need new society leadership. I am personally involved in committee work and hope that my “Young Gun” colleagues will do the same. I sincerely hope that HRS will continue to promote our involvement in more meaningful committees and push to use us as expert lecturers in future scientific meetings.
  1. Even Very Specialized Conferences Benefit from “Outside the Box” Sessions. I have been promoting new and unique sessions to add to HRS for quite some time. I think that the society has struggled in this area in the past but is now interested in moving towards including unique, thought provoking sessions in the future. For example, HRS leadership has been very gracious in meeting with me and other leaders in Social Media in EP to discuss inclusion of social media sessions at next year’s meeting.

In Summary, I have enjoyed my time at HRS this year. Highlights have included meeting the Blog-father Dr Wes and Dr John Mandrola as well as many others. I have reconnected with friends from training and have interacted with my mentors. I have learned from my colleagues, and hopefully someone has learned something from me. In the end, it is my hope that we have improved patient care in Electrophysiology. By coming together and sharing expertise and knowledge, we are able to go back to our individual practices with renewed energy and a few new tricks to add to our bag. Now, off to the convention center for one more dose!

Breaking Bad News: A Skill Set Gone Missing in Medical Education

As a cardiac electrophysiologist, I have had to discuss bad news with patients and families more times than I would like during my career.  How a physician goes about this process can make an enormous impact in the lives of those affected by the news that must be delivered.  Precious little time is devoted to teaching this essential communication skill in the training of physicians today.  I can remember back to the early days of my internship at the University of Virginia when I had my first patient death.  I had been a “real doctor” for less than a week.  I was caring for a gentleman in the CCU who had suffered an anterior MI and was in cardiogenic shock.  He was on multiple pressors and his BP remained dangerously low.  He had lots of tubes and lines and was supported by an intra-aortic balloon pump.  When my supervising attending and cardiology fellow went home that evening (leaving me in charge) they informed me that we had “done everything we could” and they did not expect the patient to live through the night.  Several hours later, the patient coded.  VF arrest, multiple electrical shocks, tons of drugs and ridiculous doses of Epinephrine were all to no avail.  The patient died.  I had to go and tell the family that their husband and father was not coming home.  Walking to the quiet family conference room, I tried to compose myself.  Be factual, be clear, be compassionate–I repeated to myself over and over again.  When I sat in front of the family, my eyes gave me away.  The family began to sob. I told them of the heroic efforts that were used in an attempt to save a life.  I told them that he had died.  As I recounted the insurmountable medical problems and the multiple interventions and attempts at treatment, I became tearful.  I cried with the family. I began to feel the pain that was so apparent and real to the folks who had known this man for a lifetime. 

Later that year, I received a call from my Chief Resident.  He had received a letter from the family of the patient who had died with cardiogenic shock.  They had written to express their appreciation for our care.  They commented on the fact that I had grieved with them and that I had helped them feel good about the care their loved one had received.  Even though I was ill-prepared to deliver bad news of such magnitude so early in my career, I defaulted to providing care and compassion and I allowed my emotions to be seen and felt by the family.   I was fortunate, sheer instinct (and Devine intervention) had allowed me to help the family through a difficult time.  However, blind luck aside, I wish that I had been provided formal training in communicating bad news during my medical education.  Most medical schools and post graduate residency programs still do not do an adequate job teaching emerging physicians this critical communication skill.  However, some programs are finally beginning to emphasize this aspect of training and creating seminars as part of the curriculum.  We must do more.  We must prepare doctors to be effective communicators-even when the news is bad.

Much has been written about how to deliver bad news in the medical literature.  Buckman et al from the University of Ontario is very well published in this area.  In his book published in 1989, Dr Buckman advocates a 6 step plan (SPIKES).  It involves the following process:

1. Setting-DO NOT give bad news over the phone.  Deliver bad news in person in a quiet place and always have the family member bring others with them.  When families are given bad news, they do not always “hear”.  An extra set of ears may be important.  Do not launch directly into the bad news.  LISTEN and develop a rapport. 

2. Perception-Get an idea of how much the family knows already so that when you discuss the pertinent facts, you are starting at the right place.  You must understand that some families may have absolutely no idea that the loved one is truly very sick and this may come as a huge surprise.  Conversely, others may have been preparing for the moment of bad news for months if not years. 

3. Invitation- Levels of medical sophistication and education vary widely among patients and families.  You must get an idea of where a particular family stands and how much detail the family may or may not want.  The ability to assess this level of detail comes with experience. 

4. Knowledge-As you begin discussions, give the family a warning of what is to come.  Attempt to prepare them for the news with statements such as “I wish I had better news… or Things have not gone very well…”  Take time revealing the news and provide the news in small bits.  Repeat and review througout the discussion.  Often, families may shut down and be unable to process the news if given too quickly.  Give families a chance to cry.  Take a break for tears. 

5. Empathy-Let the family know you care.  It is OK to cry with the family but make sure you have delivered the news clearly.  In my opinion, this is the most important step to developing effective communication when delivering bad news.

6. Summary and Strategy-Take a moment to ensure the family understands what you have told them.  Make sure they have a support system and a way to get back in touch with you for follow up questions and support.   

How we deliver bad news is critical to how families deal with grief and process loss.  As medical professionals we must accept death as a reality.  Unfortunately, we must help families to deal with this acceptance as well.  Successful communication and a structured process for delivering bad news must be mastered early in training.  It is essential that training programs teach these skills.  More importantly, physicians who are involved in training programs must model effective behaviors.  Promote a team based communication strategy and always involve trainees in family meetings and end of life discussions.  The “See one, do one, teach one principle” is important in learning effective communication skills just as it is in learning procedures. 

Most of all, remember it is ok to cry.  It is ok to feel pain and grieve with families experiencing loss.  Even though death often cannot be forestalled, effective communication during these events can help families begin to heal.