Monthly Archives: February 2013

Helping Patients Successfully Weigh Options: Effectively Discussing Risks and Benefits Prior to Procedures

Medicine is about balancing risk and benefit.  Certainly, as healthcare providers, we attempt to provide the best care for our patients based on available evidence.  Physicians often are seen as shepherds, helping to guide patients through disease and therapy.  As I have mentioned in previous blogs, ultimately medicine will be personalized and tailored to one’s particular genetic make-up.  However, the need for a clear discussion of treatment options with patients will remain a necessary and important part of the doctor patient relationship–even in the era of genomics.

Recently an article was published in the Archives of Internal Medicine that examined the way in which cardiologists communicated with patients prior to implantation of an Implantable Cardioverter Defibrillator (ICD).  As an Electrophysiologist who routinely performs ICD implantations, this particular study hit pretty close to home. The authors used patient focus groups to determine just how well each was informed prior to their respective procedures.  Researchers found that many patients felt inadequately prepared specifically for the emotional and psychological impacts of ICD therapy prior to proceeding with implantation.  Moreover, many patients felt that they did not fully understand the reason for the procedure or its possible complications.

For the most part, I think that procedurally based physicians do a fair job of explaining the technical aspects of the planned procedure and readily quote complication rates (as required by informed consent).  What we don’t do a great job of is making sure the patient actually understands the explanation or the risks.  Physicians who are procedurally focused often do not consider the long term emotional and psychological impacts that procedures such as ICD implants may have on the patient down the road.  As Electrophysiologists, we are aware that there is a growing body of evidence to support the significant psychosocial and emotional side effects for patients living with an ICD (mostly thanks to the outstanding work by colleagues such as Dr Sam Sears).  In the last decade, device recalls and lead failures have led to significant patient morbidity and mortality.  All of these complications come with a price–both physical and emotional.  

Clearly, we are not doing enough when discussing a potential procedure with a patient.  I do not believe this is in any way limited to Electrophysiologists who are implanting ICDs.  I think that this study brings up an important issue for every physician to consider.  The results of these patient focus groups should cause us all to pause and evaluate our ability to communicate with our patients.  In my practice, I make a conscious effort to carefully explain the procedure, why it is indicated and what the potential side effects are to both patient and family.  But, after reading the Archives piece, I am left wondering, do I do enough?

Given the shortcomings that are illustrated in ICD consents in this survey, Where do we go from here?  I think that we must reevaluate the way in which we discuss procedures with our patients.  Certainly the principles of informed consent must continue to be documented for the lawyers of the world.  However, we must go beyond basic informed consent and make sure that we are able to provide a reasonable explanation of possible long term emotional and psychological side effects (as well as the immediate impact on our patient’s lives).  We must also do more than simply discuss the statistics and the potential for risk vs. benefit.  We must provide the patient the opportunity to ask questions and to explore with our patients how the implant of an ICD may impact their lives–both positively and negatively.  Only then, can we feel as though we have truly served as a guide for those we are charged with caring for.  After all, one of our most important jobs is to communicate options in a way that allows our patients to make the best treatment decisions for themselves and for their families over the long haul.

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Suffering in Silence: When Doctors Fail to Ask The Right Questions

Let me start by saying that I am by no means an expert in Medical Oncology and I have great respect for what my colleagues in this field are able to do for their patients and their families.  From my earliest days of Internal Medicine training at the University of Virginia, I can remember the oncologists as being some of the most caring and compassionate physicians around.  However, recently I came across a remarkable article in the New York Times that gave me great pause.  Author Suleika Jaouad has been chronicling her battle with cancer in a regular blog.  In this particular entry, she describes her experience with dealing with the sexual and reproductive side effects of her cancer and its therapy.  Ms Jaouad brings to light the fact that often physicians fail to ask the right questions at the right time of the patient in their care.  It is not for lack of attention or concern but more often due to a laser-like focus on the task at hand–battling the disease.  In addition, in medicine today, most physicians (other than urologists and gynecologists) do a poor job of discussing sexuality and sexual side effects of diseases or treatments.  In her blog, Ms Jaouad remarks that she found it very difficult to discuss sexuality related issues with her doctors or staff–the subject never really came up.  Thankfully, she had a support group of peers to turn to.

As a specialty physician, I often find myself focused on one disease or one aspect of my patients’ health.  Sometimes, patients are crying out for help and we do not even hear them because we are wearing “blinders” as if we are thoroughbreds in the Kentucky derby. Too many times, we see the finish line of the race and forget to provide the necessary encouragement (and support) to the patient along the way.  Certainly there are guidelines and proven therapies for specific diseases–we all strive to provide the very best care.  But, as evidenced by Ms Jaouad’s blog, we sometimes fall short simply because we “forget to ask”. Or worse, we fail to pause and provide an environment conducive to TWO WAY communication when interacting with our patients.

So, what is the lesson here?  I think that for starters, it is imperative to LISTEN to our patients.  I have blogged many times about the importance of developing a positive and productive doctor patient relationship.  As we all know from our personal lives, one of the most important aspects of a relationship is effective two way communication.  This is not always easy–patients may be intimidated by their disease or by their doctor–Doctors may be so preoccupied with their agenda for the day that they forget to pause for questions.  Either way, the opportunity for questions and attending to the needs that are important at the moment to the patient are lost.  A patient with a chronic or debilitating illness may have concerns that may not seem relevant to the overall treatment plan or disease battle to us as caregivers.  However,  addressing these concerns may make an enormous difference in the long run to the human being suffering with the disease.  As physicians, we are now under increased pressures for productivity and are asked to do more with less time–But we must remember to take a deep breath, and focus on what really matters.  More than anything, our patients need our care, compassion and concern.

I think that as healthcare professionals we must make it part of our routine to spend some time each visit making sure that the patient feels comfortable asking questions.  In order to facilitate this type of interaction AND ensure that our treatment goals are also met for the visit, we must make a real effort to incorporate time for questions into every visit.  In addition, we must remember that sexuality and sexual side effects of diseases and the treatments we prescribe are real and can have significant negative impacts.  We must do a better job of educating ourselves about these side effects and make a concerted effort to discuss them with our patients during routine office visits.  Although initial discussions may be a bit awkward for doctor or patient, it is important to open the door and invite communication to improve the lives of our patients who suffer with chronic disease.

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Vacation Downtime….

Thanks to everyone who follows and reads my blogs throughout the year.  I am grateful that I am able to engage with you through my writing.  Typically I try to have 2-3 posts a week based on my writing inspiration at the time.  This week I am vacationing with my family and will try to unplug for a week.  There may not be a blog post this week –depending on internet service and on whether or not I can sneak out with my computer without my wife seeing me–

I will be recharged and ready to write when I return next week.  Hopefully the downtime will fill me with lots of inspiration for the blog…

Happy President’s Week to All!

Interpreting Physician Rating Websites: Garbage IN Equals Garbage OUT

In the past, learning about a good doctor or a pleasant hospital experience was a “word of mouth” phenomenon.  Today, more and more patients are going online for information about potential healthcare providers and hospital systems.  But exactly how accurate is the information they are accessing?  Recently, multiple surveys and research investigations have been published about the validity of online physician review sites.  Like most things that we find on the internet, the best advice is to take what you see there “with a grain of salt”.

A recent survey performed by the Pew Research Center asked participants a simple question.  “What percentage of adult internet users have consulted or posted online health reviews?”  The results are quite startling.  The minority of users actually post–but a fair number of users read and consult these reviews.

Source:  Pew Research Center “Health Online 2013”

So, as consumers of healthcare, how in the world do we interpret this data.  The fact that only 3% of the folks surveyed actually posted reviews suggests that the reviews are somehow biased–either good or bad.  This can certainly lead to misleading comments and ratings and can drastically change how a provider is perceived.  We must remember that these MD ratings sites are unregulated and not very well controlled or policed.  Typically, in any customer service industry, we find that most comments come from dissatisfied customers–it is rare in corporate America that someone takes the time to leave a positive comment.  There have been many published studies in the literature have shown that negative events are much more likely to elicit comments.

An article published in the New York Times in March 2012, discusses the neuropsychiatric basis for this very fact.  In the article, Stanford researcher Dr Clifford Nass states that the brain handles positive and negative events differently and in these events are even processed in separate locations within the cortex.  His research has demonstrated that we tend to process negative experiences more thoroughly and tend to ruminate about negative more than positive–in other words it takes many many positive experiences to overcome one negative interaction.  A recent study in the Journal of Urology evaluated the ratings of common sites such as Vitals.com, Healthgrades.com and RateMDs.com and found that from a random sample of 500 Urologists whose ratings were examined, the average number of evaluations for each was 2.4 ratings.  Many of the reviews focused more on the office experience (decor, wait times, etc) rather than the interaction with the physician or the providers knowledge or ability.  Obviously with very few respondents the results can be significantly skewed by either a remarkably high or a remarkably low rating.  The results suggest that physician rating sites are probably not the most effective way to evaluate your next  potential healthcare provider

What are some possible sources of bias in MD ratings?  The internet allows for anonymity and promotes the ability to say things that we normally may not say in a face to face interaction.  Disgruntled employees, angry family members or patients frustrated by their disease may provide unwarranted negative ratings to healthcare providers.  Conversely, family members and friends may also provide unwarranted high praise.  Altogether, these types of bias limit the utility of physician ratings sites.  Other options for choosing a provider include social media sites such as twitter.  There are disease specific tweet chats that promote interaction among patients.  Patients in the chat often recommend certain therapies, physicians and hospital systems.  These groups tend to be very well informed and the information is fairly reliable.  Ultimately, as an article on the NPR website last week suggests–we  may just have to go back to the prehistoric pre-digital era when it comes to rating and choosing physicians–we might just have to talk to one another!

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Policing The Internet: Physician Behavior In Cyberspace

In the last few weeks there have been several articles published examining the behavior of physicians and other healthcare providers on social media outlets.  Certainly, professionals must take care as to what is posted online–as I tell my 11 year old daughter–the internet is forever.  Social media is now commonplace and smartphones and tablet computers make for almost unlimited access.  Because of the ease of use and ubiquitous access to social media, these outlets can be a powerful tool for interacting with patients.  As you might imagine because of visibility, the internet and social media outlets in particular, are another enormous area for potential regulation.  Physicians are held to high standards for behavior both in and outside of the hospital (as they should be) and the cyberspace is no exception.

In spite of the potential pitfalls of social media, I believe that reaching out to patients and colleagues via cyberspace is the future of medicine and will positively impact our ability to provide healthcare in the future.A recent study published in Archives of Internal Medicine in January identified high risk online physician behaviors to be avoided.  As the authors state, there are no formal policies in place  to address physician online behavior in most state medical boards.  However, the intent of the Archives article was to identify behaviors that are likely to be considered violations of online professionalism.  Many of the behaviors identified are just simply common sense–Physicians should not post pictures of drunken debauchery or make inappropriate, sexist or racist comments on social media outlets.  In addition, physicians should never inaccurately present outcomes data, present false credentials, or post pictures without patient permission.  Most certainly, physicians should not engage in non professional relationships with patients in cyberspace.  A recent article on the NPR website published examples of tweets that are likely to get a physician in trouble with professional governing bodies.

Yesterday in the Wall Street Journal, author Anna Mathews explores the controversy associated with physician-patient relationships on Facebook.    In the world of social media, Facebook is the number one viewed website in the world.  It facilitates connections between old friends and fosters new interactions.  However, when physicians become active on Facebook, there is potential for both positive and negative impact.  In a survey in the Journal of General Internal Medicine, researchers found that nearly 85% of all medical students are involved in social media sites–this suggests that the next generation of physicians will become increasingly more active and engaged with each other and with patients via sites like Twitter and Facebook in the future.  Another survey found that while more than 80% of physicians who are active on Twitter and Facebook are likely to engage and interact with one another, less than 8% interact with patients via social media.  However, for those that do use Facebook and Twitter to interact with patients, there are significant legal and ethical questions that arise.  In an extreme example discussed in the WSJ article, one physician actually returns calls when contacted via his Facebook account.  I worry that universal and unrestricted access to healthcare providers may blur the line between one’s personal and professional lives.  In order to provide the highest quality care, physicians and other healthcare providers must also have some downtime–everyone needs to recharge and relax.  Moreover, once a provider sets a precedent for interacting via social media with active patients (and establishes a doctor-patient relationship) a legal obligation to continue to respond in the same manner may be created.  Just how deep does the rabbit hole go?

I am an active social media user.  I enjoy engaging other physicians and patients in cyberspace.  I believe that social media is a powerful tool that medicine and physicians must embrace.  However, I am careful in how I interact with patients and colleagues in the social media world.

Here are my thoughts:

Things to AVOID in Medical Social Media

1. Never share privileged information
2. Never identify patients or provide information that could be used to identify patients
3. Never, ever give specific medical advice to a patient (never ever engage in patient care and create a doctor-patient relationship)
4. Never misrepresent my credentials or my training and expertise
5. Never provide inaccurate outcomes data
6. Never post pictures or make statements that reflect poorly on my professional reputation

Things to DO EVERY DAY in Medical Social Media

1. Engage your audience with interesting posts–provide commentary on timely medical information as it is released in the press
2. Promote yourself and your abilities–let potential patients and other providers know what you do and how to reach you
3. Become a Key Opinion Leader–engage colleagues in discussions about current therapies, emerging technologies, etc4. Educate–Twitter, Facebook and Blogging are great ways to teach patients about health related topics of interest WITHOUT developing a doctor-patient relationship and giving patient specific device.  Patients frequently turn to the internet for medical information.

Social Media is the final frontier for the doctor-patient relationship.  As physicians and healthcare providers we are held to high behavioral standards.  In addition, legal considerations abound in medicine today and will continue to be an issue until our country addresses tort reform.  As a profession, we must develop standards for online behavior based on good judgement and common sense.  In addition, we must learn to embrace the power of social media and maximize its potential positive impacts on our patients and our profession.

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Genomics at your fingertips: DNA Sequencing in the Primary Care Office

Personalized medicine is on the horizon. Social media, wireless devices, mobile smartphones and emerging medical technologies have allowed us to track our own health indicators and monitor our bodies like never before. Genomics allows us to better understand why certain people are more susceptible to certain diseases and why disease may be more aggressive in particular individuals. Combining the power of data with the power of genomics will revolutionize the way in which we care for patients in the future–most likely this will occur in my lifetime.

Imagine a day in which you are given a prescription that is specifically made to target disease in YOUR body based on YOUR own genetic characteristics. The future of medicine is in genomics. Diseases that have been long thought incurable or untreatable may very well be cured and successfully treated through matching DNA and therapies. In the past genetic sequencing has been a tool of the research center and has been cost prohibitive for most–nearly $250,000 dollars per genome. Now, technology has improved significantly and sequencing is around $6000 dollars and is expected to drop even further.

This week in the New York Times, author Anne Eisenberg describes a new company that is marketing genomic sequencing machinery (cleverly called Knome)–currently these are being sold to academic and private research laboratories at about $125,000 dollars each. However, in the not so distant future, I can imagine a world in which a primary care physician has a sequencer like the Knome on-site and is able to analyze your DNA when you come into the practice as a new patient. Your personal physician can then utilize the information for choosing your therapies for years to come. If you move or transfer care to another provider, your genome sequencing would transfer with you–just like your medical records do now. I would also expect that ultimately we would have an encrypted national database of our personal genomes so that when you are travelling and need medical care, a provider in an Emergency Department in another part of the country can (with your permission of course) access your genome data when prescribing therapy.

Certainly, genomics has much promise. We are just beginning to see the potential that targeted therapies can have on treating particular forms of certain cancers. As our knowledge of genomics increases and the availability of DNA sequencing becomes more mainstream the archaic data driven population approaches to treatment of disease are likely to be abandoned for more efficient, more effective and more directed, patient specific approaches. The transition to the genomic based practice of medicine will not be without difficulty. As we approach a time when patient-specific genetic information will be commonplace, we must prepare for the inevitable administrative responsibilities and controversy that are sure to arrive at the same time. Protecting individual privacy (and you think HIPAA is bad now) and avoiding discrimination for “genetic predisposition” to particular disease come to mind as potential hot button issues. However, the potential impact on our ability to practice medicine is infinite. As Dr Eric Topol clearly articulates in his book The Creative Destruction of Medicine, doctors will be able to combine data obtained from personal technology with powerful genome sequencing tools to provide the BEST medical care where drug effects are predicted and diseases are treated with certainty as opposed to a trial and error approach. Ultimately, the digital revolution will improve healthcare and allow for new technology and tools such as genome sequencing to be quickly incorporated into everyday practice.

So, one day in the not so distant future, I expect all of us will know our own genetic sequences. A visit to the doctor will likely include a look in your ears, a look in your throat, a stethoscope on your chest AND a quick glance at your DNA….

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