Doctors and difficult patients

Many doctors get frustrated with patients whom they consider to be difficult – and some doctors have a harder time than others as they try to deal with these encounters, a study has found.

The article, and an accompanying editorial, appeared earlier this month in the Archives of Internal Medicine.

The researchers surveyed 426 physicians at 118 clinics in Wisconsin, Illinois and New York. Then they focused on the 113 doctors in the group who reported the highest number of difficult encounters with patients. Among the findings: Doctors who reported seeing many difficult patients were more likely to be younger and female, and they also were more likely to report feeling burned out.

It’s hard to know what to make of these conclusions and what they suggest about the complexity of the interaction between doctors and patients.

Do female doctors tend to react more personally when a patient frustrates or upsets them? Do difficult patients gravitate for some reason toward female doctors? Are women doctors more likely to experience sexism or subtle disrespect from patients? Are younger physicians more likely to see difficult patients because their older colleagues have learned how to successfully avoid these patients? Do younger doctors have fewer skills for managing patients they perceive as difficult? Did the doctors in the sample feel burned out because they saw larger numbers of difficult patients, or were the encounters difficult because the doctor was burned out? Perhaps the sample size – 113 doctors, after all – is simply too small to draw any meaningful conclusions.

What’s most intriguing about the study, however, is how common it is for doctors to deal with patients whom they would rather not see.

Physicians report that they secretly hope that their challenging patients will not return and find that, in general, difficult encounters are time-consuming and personally and professionally unsatisfying.

Other studies have estimated that about one out of every six patient visits will wind up being difficult.

Patients who are most often perceived as difficult include those with mental disorders, with long lists of complaints, with a past history of high use of health care services, or aggressive or abrasive personalities. Demanding individuals, such as those who insist on a particular test or prescription medication, also tended to test the doctor’s patience. So did patients who ignored the doctor’s advice and recommendations.

It’s an issue on both sides of the stethoscope, because the evidence suggests that when the relationship doesn’t go well, the patient is less likely to receive the best level of care.

The editorial in the Archives of Internal Medicine recommends better training for physicians in how to deal with challenging patients. This might mean addressing the patient’s expectations more clearly at the beginning of the visit, or taking more time to identify unmet needs.

It’s "all about how doctors and patients relate to one another," a family physician writes in an essay that appeared last year in Health Affairs. "And the problem with a difficult patient isn’t just the patient. It’s also the doctor. Difficult patients and their frustrated physicians fail each other."

Arthritis, heart disease pose double challenge to exercise

People with heart disease are supposed to be physically active to help manage their condition. The same is recommended for people with arthritis, so their joints can function better and help them stay more mobile.

Arthritis pain is often a barrier, however – and in fact a new study has found that people with both arthritis and heart disease are significantly more likely to be physically inactive than those with heart disease alone.

The study by the Centers for Disease Control and Prevention appears in the latest issue of the Morbidity and Mortality Weekly Report.

Data were collected via the Behavioral Risk Factor Surveillance System in 2005 and 2007. The authors found that the number of people with both arthritis and heart disease varied from state to state, but overall it was about 57 percent of adults.

In the study, about 29 percent of adults with arthritis and heart disease were inactive, compared to 21 percent of people with heart disease alone, 18 percent of those with arthritis alone, and 11 percent of those with neither.

It’s an issue because both conditions are very common. Heart disease affects about 14 million adults in the United States and arthritis affects more than 46 million. It’s particularly challenging for people who have both conditions, the study explains:

Both (heart disease) and arthritis can interfere with physical functioning, ability to work and ability to perform household tasks. These conditions also might interfere with efforts to become more physically active. Persons with arthritis face the same barriers to being more active as most adults, including lack of motivation and time, competing responsibilities, and difficulty finding an enjoyable activity. They also face additional barriers, such as concerns about aggravating arthritis pain and causing further joint damage, and they might be unsure about which types and amounts of activity are safe.

Low-impact activities such as swimming, walking or biking could benefit these individuals, the report notes. The study recommends greater integration of heart disease and arthritis management among people who live with the two conditions.

A rising tide of bacterial resistance

Minnesota health officials are seeing increasing evidence of antibiotic resistance across the state, prompting a new reminder this week to health care providers and patients about the importance of using antibiotics appropriately.

A report in this week’s New England Journal of Medicine details the finding by health officials in Minnesota, North Dakota and the U.S. Centers for Disease Control and Prevention of an antibiotic-resistant strain of bacterium, Neisseria meningitidis, that causes meningococcal disease. In a related occurrence, the Minnesota Department of Health on Tuesday sent out an alert about a resistant strain of Klebsiella pneumoniae bacteria.

The bacteria N. meningitidis can cause meningitis, sepsis, pneumonia and joint infections, in some cases life-threatening. The resistant strain was discovered during an investigation and follow-up of three cases of the disease in 2007. The cases – two in western Minnesota and one in North Dakota – were not related or linked. All three had the same strain of the bacterium and all proved to be resistant to ciprofloxacin, the antibiotic most often recommended for preventing infections among adults in close contact with infected persons. These were the first strains of this particular bacteria in North America found to be resistant to ciprofloxacin.

State health officials are concerned because ciprofloxacin resistance in a related bacteria, Neisseria gonorrhoeae, rose quickly within just a few years, and ciprofloxacin is now no longer recommended to treat this type of infection.

After discovery of the resistant strain that causes meningococcal disease, the state health departments in Minnesota and North Dakota advised health care providers in western Minnesota and eastern Minnesota to use different antibiotics as preventive treatment for people who might have been exposed to the three people who were sick. The CDC also has recommended increased nationwide surveillance for antibiotic-resistant meningococcal bacteria.

In another instance, a strain of Klebsiella pneumoniae that is resistant to nearly all classes of antibiotics was recently identified in Minnesota. State health officials are especially concerned because this type of resistance can spread to other similar bacteria, making them resistant as well.

Klebsiella pneumoniae has been responsible for hospital outbreaks in other parts of the U.S., but this is the first time it has been found in Minnesota.

The increased resistance of these two pathogens underscores the need to use antibiotics judiciously so their effectiveness can be preserved, health officials say.

What this means for the public: Patients should not insist on antibiotics unless this treatment is determined to be necessary. Many respiratory infections, such as influenza or acute bronchitis, are actually caused by viruses, not bacteria, and antibiotics are ineffective against them. Basic infection prevention measures, such as hand washing, covering your cough, staying home if you’re sick, and getting recommended vaccines also can help reduce the spread of potentially resistant germs.

If you do need antibiotics, it’s important to take every single dose as directed. Failing to complete a course of antibiotics can encourage more resistant types of bacteria to survive, and has been one of the contributing factors to the rising incidence of antibiotic resistance.

Understanding heart failure… from soup to nuts VII

Millions of Americans have heart disease, of which congestive heart failure can be the most challenging to manage. The topic of heart failure and how to live well with it is being explored in a series of guest columns this month by Aimee TeBrake. Aimee is a cardiovascular nurse specialist with Family Practice Medical Center in Willmar. This is the final installment in the series; to read the rest, check out Part I, Part II, Part III, Part IV, Part V and Part VI.

Many people with heart failure take four or more medications. Oftentimes when patients first are prescribed medications, lower doses are prescribed and gradually increased to the optimal dose by the prescribing provider. This can become confusing to patients. The tips below can help.

Keep track of medications.

– Order more medication when you still have 1-2 weeks supply of pills left. Pharmacies often will mail or deliver prescriptions if transportation is an issue. Allow extra time if using a mail order pharmacy. Do not assume if there are no refills left, your physician wants you to stop the medication.

– If traveling, always carry your medication with you (not in baggage). Take extra prescriptions with you when you travel, just in case.

– Always keep a list of all the medications you take in your wallet. Check out My Pill Box for an easy way to create, change, print your medication schedule without rewriting the whole list over every time. This is a helpful Web site for both patients and family members who set up medications.

– Fill all your prescriptions at one pharmacy. Your pharmacist then will know all your medications and can tell you which medications can cause problems when taken together.

– Read the warning labels on over-the-counter medications, herbs and supplements you take, or ask your physician or pharmacist. Some pain medications cause problems with some heart medications, including nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen and naproxen. Always specify you have a heart failure diagnosis when inquiring. Even "all natural" products can interact with each other and prescription medications.

– Use a pillbox that’s marked with the days of the week. Fill your pillboxes as part of your weekly routine. Pillboxes come in many different styles. Buy one that meets your needs.

– If you have difficulty remembering to take your medications, consider placing the pillboxes in a place where you do other routines. For instance: dining table, take meds with meals; cupboard with breakfast food/dishes, coffee pot, take meds at breakfast; or denture cup/toothbrush, take meds at bedtime.

– If you are experiencing unpleasant side effects, contact the prescribing physician  and they might be able to offer suggestions to help you tolerate the medication better. Oftentimes, the medication doesn’t need to be discontinued, the medication schedule just needs to be fine-tuned.

Cancer discoveries: learning from animals

When it comes to cancer research, there’s a lot to be learned from animals.

A new program at the University of Minnesota hopes to explore these similarities and ultimately improve and even prevent cancer in both animals and humans. The university announced this week that its College of Veterinary Medicine, in conjunction with the Masonic Cancer Center, is establishing an animal cancer care and research program.

It’s a unique collaboration that university officials hope will become a premier model for researching cancer and providing cancer treatment for companion animals.

Among older pets, cancer is the leading cause of death. Over the past few decades, cancer rates have risen steadily among companion animals. It’s thought that this is at least partly due to the fact that so many pets are living longer, and surviving to an age when – just as in humans – cancer tends to be more common. Veterinarians’ ability to detect and diagnose cancer in cats, dogs and other companion animals also has improved signficantly.

Are there certain aspects of cancer biology that are shared between animals and humans? It appears the answer might be yes. Researchers at the University of Minnesota have been making some intriguing discoveries – one of them being the finding that many cancers in dogs are caused by the same genetic abnormalities found in humans.

The animal cancer care and research program is part of the university’s comparative medicine signature program. It will draw its expertise primarily from scientists in the College of Veterinary Medicine and the Masonic Cancer Center, but researchers also will be working closely with the Medical School, School of Pharmacy and School of Public Health.

Researchers are currently working to define breed-specific and disease-specific "Achilles heels," or genetic vulnerabilities, in dogs. Golden retrievers, for instance, develop lymphoma at higher rates than other breeds of dogs; Rottweilers tend to be more vulnerable to bone cancer. These findings could then be translated into more effective and less toxic cancer treatments, with implications for the future of cancer treatment for humans.

Some of this knowledge is already being applied. Last August an experimental two-step therapy was tried for Batman, a shepherd mix with a potentially fatal form of brain cancer. The combination of gene therapy and vaccine, if it’s successful, could point the way toward new treatment options for humans with brain tumors.

Research teams also will be delving into the complexities of cancer prevention, stem cells, cell signaling, and how cancer cells spread, or metastasize, to distant sites in the body.

The president’s health care challenge

In his speech to Congress last night, President Obama said health care reform can’t wait.

Fixing what ails America’s health care system will be a huge challenge, however. The commentators are beginning to weigh in today, starting with the Room for Debate forum at the New York Times, where four experts were assembled to give their opinions.

What would they fix? Get rid of unnecessary care, says one. Shore up the system of primary care, opines a New Hampshire physician. Rein in spending, says someone else.

Political blogger Jeff Mapes of The Oregonian was impressed at how Obama "made his pitch for healthcare reform":

That by itself was no surprise. Everyone knows the system is in real trouble. What he did, though, was lay down the marker that, amid all of the country’s economic mess, he wants to tackle it now. As in this year.

Blogger Ezra Klein also reacts, and his commenters continue a lively discussion here.

Over at Managed Care Matters, Joe Paduda takes note of the sense of urgency conveyed by Obama – and how hard it’s going to be to reduce health care costs.

Debra Manlin isn’t a policy wonk; she’s a medical billing manager from Bethlehem, Pa., who was laid off from her job last month. She told the Allentown Morning Call that she’s pleased the president appears to be keeping his commitment to doing something about health care.

"Health care is a big issue," said Manlin, a Democrat who supported Hillary Clinton in the primary. "It is on everybody’s mind how expensive it is. If you are out of work, it is a major issue to afford to even find somebody who will cover you. It is good to hear he does want to address it as soon as possible."

The pain of eating disorders

Are you often preoccupied with the desire to be thin? Do you feel that food controls your life? Do you often have an impulse to vomit after eating?

If this sounds like you, or someone you know, you might be at risk for an eating disorder. You can find out by taking a free, anonymous online survey that’s being offered by the National Eating Disorders Screening Program this week in conjunction with Eating Disorders Awareness Week. More than 400 colleges are participating in the online screening, which is designed to help people assess whether they might benefit from a professional evaluation for an eating disorder.

Eating disorders are surprisingly prevalent. The National Eating Disorders Association places the number at 10 million women and 1 million men in the United States – higher than for Alzheimer’s disease. In fact, the organization believes the number of cases may be underreported, especially if disordered attitudes and behaviors about eating that fall into the subclinical range are taken into account.

Eating disorders may begin with a preoccupation with weight, but they often are about much more than appearance. They are usually complex conditions that arise from a combination of long-standing behavioral, emotional, psychological, interpersonal and social factors. It’s believed that more than one in three normal dieters progress to pathological dieting.

The peak onset is during adolescence and the late teen/early adult years. In some cases, however, disordered eating can show up as early as the kindergarten years – and it’s also occurring more frequently among middle-aged women.

Eating disorders are serious illnesses. The malnourishment of anorexia and bulimia can lead to hypoglycemia, inflammation of the pancreas, enlargement of the heart, heart attacks, congestive heart failure, permanent brain shrinkage, infertility and osteoporosis. Among the mental illnesses, anorexia nervosa has the highest rate of premature death.

For a compelling look at what it’s like to live with anorexia, check out Anorexia: a portrait. And take some time to also read "Stories of Hope" at the National Eating Disorders Association Web site.

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Understanding heart failure… from soup to nuts VI

Millions of Americans have heart disease, of which congestive heart failure can be the most challenging to manage. The topic of heart failure and how to live well with it is being explored in a series of guest columns this month by Aimee TeBrake. Aimee is a cardiovascular nurse specialist at Family Practice Medical Center in Willmar. Go here to read Part I, Part II, Part III, Part IV and Part V of her series.

Medications play a major role in treating heart failure. They can help you live better and longer. They can also stop it from getting worse. Your physician will prescribe medications for you based on the cause, type, and severity of your heart failure.

Although medication and treatment options for heart failure differ from one patient to another, all heart failure patients should get the following drugs unless there is some reason they cannot take the drug. These medications have been proven to slow the progression of heart failure.

ACE (antiotensin-converting enzyme) inhibitors. Lower blood pressure, helping your heart pump more easily and improves blood flow. They also help the heart muscle maintain its shape and function. Angiotensin II receptor blockers (ARBs) may be prescribed instead of ACE inhibitors.

Beta blockers. Lower heart rate and blood pressure. It does this by altering hormones (body chemicals) that are damaging the heart. Beta blockers may strengthen the heart’s pumping ability over time.

Other heart failure medications your physician might prescribe for you may be:

Diuretics (water pills). Helps body get rid of excess water, which decreases swelling and improves breathing. Less fluid to pump means less strain on the heart.

Aldosterone inhibitors. Blocks the hormone called aldosterone which causes the body to retain sodium and water. This decreases strain on the heart.

Digoxin. Makes the heart pump stronger. May also control irregular heartbeats.

Certain devices may help in some cases of heart failure. They help regulate slow or abnormal heart rhythms. This helps take additional strain off the heart.

Pacemaker. A small electronic device that treats a slow heartbeat. Some pacemakers stimulate only one side of the heart. Others (called bi-ventricular pacemakers) stimulate both sides of the heart and help the two different sides of the heart to work together better to improve blood flow to the body.

Defibrillator. Corrects fast heart rhythms when they become life-threatening.

Additional online resources:

Affairs of the Heart

Minneapolis Heart Institute

Climate change holds implications for health

Global climate change could mean longer, wetter summers in some parts of the world, and possibly increase the population of disease-carrying mosquitoes. Shifting weather patterns might lead to local crop failures and malnutrition, or to heavier rainfall and flooding.

These public health issues need more attention from the U.S. Climate Change Science Program, contends a group of medical, health and environmental experts.

Citing an under-emphasis on human health, the group called on the Climate Change Science Program to address "the important and growing gaps in knowledge and practice" as the program undergoes an internal reorganization under the Obama administration.

The memorandum was signed by 22 medical experts and 10 groups, including the American Academy of Pediatrics, American Nurses Association, American Public Health Association, Association of State and Territorial Health Officials, the National Association of County and City Health Officials, and the Environmental Defense Fund.

Organizations such as the Centers for Disease Control and Prevention are already trying to anticipate some of the potential challenges and to prepare for them. Weather disruptions, for instance, might mean more severe storms, droughts or long-lasting heat waves, with consequences for human health. Air pollution might increase. Flooding might become more frequent.

The issue is important enough for the American Journal of Preventive Medicine to devote an entire edition to it this past November.

Public health needs a stronger focus, however, argue the health groups who signed the memorandum this week. Among their recommendations:

– Make it an explicit goal of the U.S. Climate Change Science Program to prevent harm to human health due to climate change.

– Carry out monitoring and data collection to better analyze and track climate-sensitive health problems such as asthma and diseases carried by ticks and mosquitoes.

– Address the risk factors that might make certain socioeconomic or geographic populations more vulnerable to climate change.

– Develop and promote standard methods for assessing the national, regional and local health impact of climate change.

– Develop a research program and standard methods for assessing the health impact of strategies intended to reduce the effects of climate change or adapt to climate change. Decisions made by water agencies, for instance, might benefit crop production or the drinking water supply but could unintentionally alter the environmental balance in ways that are harmful.

– Provide better training for federal, state and local health departments on the human health risks and the public health response to climate change.

Flu tracker, week 6

What’s happening with influenza during week 6, the week of Feb. 8-14:

Levels of influenza continue to increase, according to the Centers for Disease Control and Prevention. Children have been hit especially hard; five pediatric deaths associated with flu have occurred between the end of January and mid-February.

Twenty-four states had widespread flu activity and 13 states had regional activity. Flu levels remained local in 11 states and the District of Columbia, and sporadic in two states and in Puerto Rico.

In Minnesota, influenza has reached regional levels, the Minnesota Department of Health reported. Outbreaks occurred in 28 schools and one long-term care facility during the week of Feb. 8-14. Although most of the circulating flu strains belong to the type A virus group, there has been a recent rise in type B viruses.

At the 30 health care provider sentinel sites for monitoring influenza in Minnesota, 2.18 percent of patients showed up with influenza-like illnesses during the second week in February.