An ode to doctors

Sometimes they nag us. Sometimes they hurt us. Sometimes, despite their best efforts, they can’t fix what ails us.

It’s the fashionable thing nowadays to bash doctors, but today, on National Doctors’ Day, it seems an appropriate occasion to recognize them for their skills, their dedication and their importance to their communities.

You didn’t know there’s a day set aside just for doctors? The day was first observed in as a local celebration in Georgia in 1933 and became a national day in 1990.

In their own words, several doctors tell us why they chose their profession and why it’s rewarding.

Here’s the story of a cardiovascular internist who has been a doctor for 30 years. Here’s a young intern who has chosen to train in emergency medicine in Australia. And here’s a wonderful collection of original stories and poems submitted last year for the Texas Academy of Internal Medicine’s annual student creative writing contest.

One of my favorites is from a Minnesota doctor. His beautiful and thoughtful essay, "Northwoods Elegy," was originally published in the Annals of Internal Medicine.

From the other side of the stethoscope, a mother describes how the right pediatrician helped make an enormous difference in her daughter’s life. A young patient writes about the doctor who is her hero.

When their son needed help, this Michigan family was grateful for the care of a neuro-ophthalmologist. A seriously ill teacher found many reasons to be thankful for the doctors who saved her life.

Do you have a story of your own you’d like to share? Leave it in the comment section below, or send an e-mail to healthbeat@wctrib.com.

Divided opinions on medical marijuana

West Central Tribune readers are weighing in on coverage of a medical marijuana bill making its way through the Minnesota Legislature. Judging from the responses, sentiments are similar to public opinion in the rest of the U.S.: Most people favor making the drug legal for medical use.

For anyone who’s interested in reading the entire bill, the House version can be found here and the Senate version here.

This issue has been on legislators’ radar screens for the past few years. This year it seems to be gaining considerable traction, probably due to a combination of public support and to lobbying efforts by groups such as the Marijuana Policy Project. Clearly there’s a lot of muscle behind this effort; tax statements indicate the MPP is at least a $4 million organization.

It’s also pretty hard to argue with firsthand stories from patients, such as this advertising video that was making the rounds last year.

Of particular note: The Obama administration has said it won’t aggressively enforce federal drug violations for medical marijuana use in states where such use is legal. This policy shift may be making medical marijuana laws more palatable – and possibly easier to pass – in states where medical marijuana proposals are under consideration.

Popular opinion notwithstanding, the scientific basis for using marijuana as medicine is not especially strong.

For a closer look at the medical application of marijuana, here’s a 2007 report prepared by the American Medical Association’s Council on Scientific Affairs. While it doesn’t take a stand one way or the other on legalization, it notes that there’s a shortage of sound data on the medical safety and effectiveness of marijuana, and calls for more research.

Perhaps the most in-depth study was conducted by the Institute of Medicine in the late 1990s. According to the authors,

The accumulated data indicate a potential therapeutic value for cannabinoid drugs, particularly for symptoms such as pain relief, control of nausea and vomiting, and appetite stimulation… The effects of cannabinoids on the symptoms studied are generally modest, and in most cases there are more effective medications. However, people vary in their responses to medications, and there will likely always be a subpopulation of patients who do not respond well to other medications.

The IOM’s recommendation was similar to that of the AMA: further study to determine clinical effectiveness and safety.

The staggering cost of a medical education

Medical students traded the classroom and the anatomy lab last week for the halls of power in Washington, D.C. Their mission: to issue a plea to Congress for help with the crushing financial burden that medical school has become.

You can hear a group of students discussing their lobbying efforts with MedPage Today in this video interview. And here’s the briefing from the American Medical Association on loan relief for medical students.

By the time they complete their training, American medical students are staggering under a debt load that would make most of us cringe.

A college education nowadays is expensive by any measure. But consider the medical student: four years of undergraduate study, then four years of medical school, then at least three years of residency. Someone who wants to specialize further or complete a fellowship can add several more years of training.

The costs mount quickly. At the University of Minnesota Medical School, for instance, tuition and fees alone are $18,000 to $20,000 per year, plus another $1,500 in annual registration fees and $1,400 for books.

And the university is relatively affordable compared to, for instance, Harvard Medical School, where students last year could expect to pay more than $60,000 in just the first year for their tuition, fees and housing.

Debt from medical school has been rising faster than the cost of inflation, a task force for the American Medical Association found in a review of data from the past 20 years. Of the students who graduated from medical school in 2007, the average debt load was close to $140,000. Three-fourths of graduates owed at least $100,000.

Most people among the general public probably give little thought to the issue - but they should, because the cost of medical school is an invisible undertow that’s threatening to drag down the health care system.

Increasingly, future doctors are being forced to factor their educational debt into career decisions. Why be a family doctor in rural Minnesota, where they’ll likely make less money, when they can be an urban radiologist and earn significantly more?

Medical school debt isn’t the only consideration, of course. Demographics and personal goals and characteristics also play a role, as does a physician payment structure that’s weighted heavily in favor of procedure-based specialties. All things being equal, however, it’s hard for many medical students to remain idealistic when they’re facing the reality of enormous loan payments, coupled with lengthy training that delays their entry into the work force and their ability to start earning a salary.

Here’s another question: Is medicine increasingly becoming a career option only for those who can afford it?

The sad story of Jade Goody

Sad; appalling; tragic. It’s hard to find the right words to describe the story of Jade Goody, a British reality TV celebrity who’s dying of cervical cancer at age 27 after ignoring test results because, as she confessed publicly, she was scared.

Most people on this side of the Atlantic have probably never heard of Jade Goody. In Britain, however, she has been tabloid and headline fodder ever since making her debut in 2002 in the reality show "Big Brother." Over the past seven years she has appeared in TV shows, released several exercise DVDs, written her autobiography and even launched a perfume. She’s gained a reputation for being brash and outrageous.

But she’s now more likely to be remembered for how her life is ending: with an aggressive form of cervical cancer. The cancer has spread to her liver, bowel and brain.

With only a few weeks left to live, she’s saying her goodbyes. More than 1 million people watched the televised special last week of her wedding Feb. 22 to boyfriend Jack Tweed.

Worldwide, cancer of the cervix is one of the leading causes of cancer deaths among women. Most of these fatalities occur in developing nations, where screening is less common. Survival rates are relatively high, however, in the United States and in other industrialized nations such as the United Kingdom. About 11,000 new cases occur in the U.S. each year, and about 3,800 women die from it. By comparison, more than 180,000 women in the U.S. are diagnosed with breast cancer each year and nearly 40,500 will die.

The Papanicolaou test, or the Pap smear, has been widely credited with reducing the cervical cancer death rate by detecting abnormal cells early, before they’ve had a chance to progress into full-blown cancer. Between the mid-1950s and the early 1990s, the death rate from cervical cancer fell by 74 percent in the U.S., largely as a result of the introduction of screening.

It would be easy to spin Jade Goody’s sad story as an example of what can happen when a woman doesn’t get screened – except this isn’t the whole story.

For one thing, it appears that Jade did undergo screening. Three times, in fact, during which abnormal cells were found and removed. After the fourth positive Pap screening, apparently, she was simply too frightened to go back for the procedure.

She said as much in an interview last August with Heat magazine: "They had sent a letter to me ages ago, telling that I needed to go in for an operation, but I had been too scared to do anything about it."

Did she have her head in the sand? Maybe not. After all, she’d already had pre-cancerous cells removed from her cervix three previous times, starting at age 16. In the same interview with Heat, she says that the first time "nearly traumatised me for life, it was so painful."

It begs the question: Could the outcome have been different if the cancer had been found sooner, before it had spread?

We’ll never know. But it does raise a lot of questions. Was there adequate followup when she didn’t return for care after her fourth suspicious Pap test? You’d think that after even two abnormal test results, let alone four, her case would have been flagged as high risk and received more intensive monitoring. By some accounts, she had been hospitalized more than once in the past four years for blood loss; were doctors aware of her previous history - and if not, did she think to tell them?

Did it even occur to anyone that she might have been scared?

Possibly Jade herself didn’t understand the importance of following through. One of her statements in the Heat interview – that she thought once the abnormal cells were removed, "they should not come back" – suggests she might not have known or understood she was still at risk.

It’s worth noting that not all cancers are created equal. Cervical cancer can be divided into at least four subtypes – squamous cell and adenocarcinoma, which are the most common, and small cell and neuroendocrine, which are more rare. Furthermore, although the majority of cervical cancers grow slowly, some do not. The relatively high survival rate for this cancer (and some other cancers as well) tends to obscure the fact that for a smaller number of people, it’s still fatal.

Jade Goody’s specific type of cancer hasn’t been publicly disclosed, but given the extent to which it has spread, some observers are speculating that it is more aggressive than most. Although much is still unknown about why cancer cells behave the way they do, a growing body of research suggests that this is often influenced at the molecular level; in other words, it’s coded into the cancer itself. This doesn’t mean that screening and early detection are useless, because for millions of people, they clearly have a benefit. But there are limits to what screening and early detection can accomplish, and increasing the cervical cancer screening rate in Britain, as many advocates have urged, may not be the solution that some think it is.

In the end, we are left with the story of one young woman whose life is ending far too soon. Perhaps saddest of all, the thing that should haunt us the most, is that she may be going to her death believing it’s her fault. To be sure, she made a bad decision not to seek followup care – but there are plenty of other contributing factors to go around, some of which were simply out of her control. And to put the blame on her shoulders alone is a burden no one should have to bear.

Patient advocacy: Do we expect too much?

Wrong-site surgery is relatively rare but it still happens, as I learned firsthand a few years ago.

I was scheduled to have two wisdom teeth removed from the right side of my mouth. On the day of the surgery, as the staff reviewed the X-ray to confirm the site, I noticed that one of the teeth that had been marked was on the wrong side. The situation was quickly clarified and the correct teeth were extracted without a hitch.

Ideally, this is how it’s supposed to work. Patients, or someone who can advocate for them, are supposed to be aware and informed and to speak up if something seems wrong.

But what would have happened if I’d never heard of wrong-site surgery? What if I hadn’t noticed the X-ray was incorrectly marked? I might have simply glanced at it and not registered the mistake. Most of us, after all, don’t have a ton of experience in knowing how to read an X-ray. I might have just assumed it was marked correctly because I was expecting it to be marked correctly. What if the patient in this case had been a child or an elderly person or someone with limited English-speaking skills? It’s entirely possible that the mistake wouldn’t have been caught until it was too late.

Herein lies the issue with patient advocacy. We expect people to be knowledgeable and to participate in their care. And many of them do so, quite successfully. But is this realistic for everyone in every situation? Because, at times, it seems like expecting too much.

To be sure, patients, or someone who can speak on their behalf, should be informed about what’s happening with the patient. The three most important questions, according to the Partnership for Clear Health Communication, are: What is my main problem? What do I need to do? Why is it important for me to do this?

At a minimum, patients should know their diagnosis and the plan for treatment. They should know what medications they’re taking, why the medication is needed, the dosage and the frequency. They should know their past medical history.

Above all, they should ask questions, particularly if something isn’t clear or hasn’t been resolved to their satisfaction.

For many people, though, this is far easier said than done. The knowledge gap, not to mention the imbalance in power, between the layperson and the health care professional is often enormous. What’s routine or obvious to the professional is not necessarily routine or obvious to the patient. Patients may not understand the terminology, nor do they understand how the system is supposed to work, especially if it’s a situation they’re encountering for the first time.

Health literacy has been identified as a serious barrier to engaging patients in their own care. 
But even someone who’s highly literate can find it difficult to advocate when he or she is stressed out, not feeling well, or is rushed through an appointment.

Above all, health care is extraordinarily complex. How is a patient supposed to recognize, for instance, a rare drug complication? How are patients supposed to know that the IV drug they’ve just been given is the wrong one, or is a 10-fold overdose? How much can patients be expected to know about the vulnerabilities in the system – for instance, the hand-off from hospital to outpatient clinic – and know what steps to take to smooth the transition and avoid a potential disaster? Even health care professionals, who know the system inside out, often struggle to get it right.

It’s not always enough for patients and families to just ask questions. The questions need to be the right questions. And to ask the right questions, you first need to know what the right questions are, and this takes a certain level of knowledge which many laypeople simply don’t have. As the saying goes: You don’t know what you don’t know.

There’s no clear set of directions for how to turn patients into better advocates for themselves. Maybe we can start by recognizing that everyone is at a different level. Many will welcome the participatory medicine movement and have the intellectual and technological wherewithal to embrace it. Others, for whatever reason, may never progress beyond the basics.

Maybe we need to recognize that people have varying levels of comfort with information. Some want to know all the details; others don’t, and this is a difference that perhaps needs to be respected more. For some people, not knowing every last detail is how they cope, how they keep the threat at a level that’s manageable for them.

We need to recognize that people often bring a lot of baggage into the health care encounter. Sometimes they don’t ask questions because they’re afraid of what they might hear, or they’re not ready yet to hear it. Maybe they’ve had a negative experience in the past with being shot down for asserting themselves, and they’re reluctant to risk having it happen again.

We need to be careful about blaming patients and families when something goes wrong. Although outcomes are usually better when patients can advocate for themselves, advocacy is not a magic silver bullet. Disasters can happen even when patients are speaking up and involved in their care.

The system has to be part of the solution too. In an online interview about literacy and patient safety that appears this month on the Agency for Healthcare Research and Quality Web site, Dr. Dean Schillinger calls it "a shared responsibility" and asks, "to what extent do we enable and prepare people to take on that responsibility?" Health care systems are often complicated and byzantine. Some patients learn how to successfully negotiate this maze, but others can’t.

Whatever the route for getting there, it seems that information and communication, preferably at the patient’s own comfort level, are key. Given these tools at the right time and in the right quantity, the majority of patients will likely be able rise to the occasion. More involvement in our health care and health decision-making is, after all, something that most of us want.

But it shouldn’t automatically make someone a bad patient for not measuring up to the standard. And above all, we need to tread carefully in how much responsibility is placed on the patient because, sometimes, it truly is too much to expect.

Circadian shock: adjusting to the spring forward

No matter what the time of year, my canary wakes with the sunrise and settles down to sleep at dusk. These days, he’s waking earlier and earlier as the daylight hours get longer. By 7 a.m. or shortly thereafter, he’s rustling around in his cage and uttering soft little chirps.

He doesn’t need a clock – but not so for we humans, whose circadian rhythms are about to get a jolt this weekend with the start of Daylight Saving Time. The clock officially jumps forward one hour at 2 a.m. Sunday.

Many people will experience daytime sleepiness, sleep disturbances and mood changes as they adjust to springing forward, says J. Todd Arnedt, a sleep specialist at the University of Michigan. Arnedt is an assistant professor and director of the university’s behavioral sleep medicine program.

You can hear Arnedt discuss sleep and the Daylight Saving Time transition in this video from the University of Michigan.

The spring adjustment, when the clock moves forward one hour, is harder for many people than in fall, when clocks are set back an hour. A Swedish study analyzed in the New England Journal of Medicine found that the risk of having a heart attack increased by 5 percent during the first three days after the time switch. The reasons aren’t clear, but the study’s co-author speculates that sleep deprivation may play a role.

Various studies also have documented a rise in traffic crashes during the first two days after the start of Daylight Saving Time.

Some tips from the experts: Adjust your sleep time gradually by going to bed half an hour earlier tonight, Saturday and Sunday. Alternately, you can try to catch some extra Zs for a few days after the Daylight Saving Time transition. Avoid taking naps during the weekend, and limit your caffeine and alcohol intake.

Grooming the next hospital CEO

A growing number of new health care presidents and CEOs are plucked from the ranks of non-CEO executives.

Witt/Kieffer, the Chicago-based firm who has been helping with the search for Rice Memorial Hospital’s next chief executive, conducted a survey last fall to look at the placements it made on behalf of its clients.

Fully 40 percent of the CEOs that the company placed in 2007 were not CEOs in their previous position. Among this group, half were chief operating officers and 22 percent were vice presidents of operations/administration. Fourteen percent were chief financial officers before being moved into the executive suite.

The survey wasn’t exclusive to health care executive placements. It also covered top-level placements in higher education, academic medicine and information technology. Overall, however, two-thirds of Witt/Kieffer’s placements in 2007 were in the health care field. Health system CEOs also earned the highest salaries, the survey found.

The American College of Healthcare Executives conducted its own study of health care executives and found that more women are becoming CEOs. The data, gathered from a questionnaire sent to members, had findings similar to the Witt/Kieffer survey: Many health care CEOs were promoted from positions as chief operating officer, senior vice president or associate administrator.

The women CEOs were more likely than their male counterparts to have some clinical experience. They also were more likely to have started their career at the department staff or department head level.

What about turnover rates? Data collected by the American College of Healthcare Executives found a turnover rate of 15 percent among U.S. hospital CEOs in 2007. Minnesota, with a turnover rate of 13 percent, was grouped among the 18 states that had medium turnover among its hospital chief executives.

The barrier of health literacy

It’s common for patients to be sent home from the hospital or clinic with perhaps a prescription, instructions for how to take care of themselves after surgery or an injury, or an appointment slip to come back for followup care.

Yet how many patients truly understand what’s expected of them and are capable of following through?

For years, health literacy was an under-recognized issue. Now, as patients increasingly are being asked to assume more responsibility for their own care, health literacy is gaining long-overdue attention.

The Partnership for Clear Health Communication, a project of the National Patient Safety Foundation, defines it as "the ability to read, understand and act on health information."

Staying healthy in tough times

In these bleak economic times, it’s a challenge to stay healthy. What do you do if your hours have been cut and your income has shrunk? What if you’re laid off and lose your health insurance? What if you’re forced to make hard decisions about household spending? How can you manage the stress so many people are facing right now?

It’s important for health care to remain a top priority, advises Dr. A. Mark Fendrick, a professor of internal medicine at the University of Michigan Medical School and professor of health management and policy at the University of Michigan School of Public Health.

Trying to economize, such as cutting back on prescription drugs or not following a doctor’s recommendation, can be a potentially dangerous move, Fendrick said.

"Cutting back on health care without consulting your clinician is a very risky decision. It may not only have an impact on your health, but also have a worsening economic consequence that will lead to greater costs down the road when minor health concerns become major health issues."

Dr. Rahul Parikh writes at Salon.com about a family trying to save on drug costs for their 12-year-old daughter with asthma, and making her sicker in the process:

This isn’t a poor family. They’re a typical middle-class one from Pleasant Hill, Calif., a nice suburb 25 minutes east of Oakland. But like a lot of other families, they’re under pressure and must decide whether healthcare takes precedence over paying the mortgage or buying food.

When the Kaiser Family Foundation conducted a poll last year before the November election, it found a growing number of people who said they skipped necessary health care because of the cost. About one-third said they postponed care, and three in seven said they decided not to obtain a recommended test or treatment. About 25 percent didn’t fill a prescription; slightly fewer said they cut pills in half or skipped doses.

Fendrick’s advice: Continue to follow up with recommended screenings and immunizations, and contact your health care provider before cutting back on health care.

If your medication is expensive, find out whether you can switch to a cheaper generic. Many pharmacy chains now offer $4 generics. Other resources, such as NeedyMeds and the Partnership for Prescription Assistance, can link patients with help paying for their medications.

Focusing on eating well and being more physically active can go a long way toward staving off illness and managing existing chronic conditions, experts say. And although it’s often easier said than done, finding ways to manage stress and anxiety also can help people stay well and feel better able to cope with challenging economic times.

Will hospital construction boom go bust?

Starting in 2000, hospitals around the United States started to expand. New facilities were built. Aging hospitals underwent renovation. New specialty hospitals sprang up.

This building boom could slow dramatically by the end of the year if the economy doesn’t improve, predicts a cover story in this week’s issue of Health Facilities Management magazine.

Hospitals enter this year in a state of financial uncertainty, made cautious by what economist Jim Haughey of Reed Construction Data/RSMeans warns is the prospect of "a couple of lean years ahead."

"Members are in a wait-and-see mode as to how things are going to play out in 2009," says Troy Martin, SASHE, president of ASHE and director of facilities services at Poudre Valley Health System in Fort Collins, Colo. "Everybody’s kind of saying ‘Whoa, time out. Let’s take a look at stuff, reprioritize and look at what we’re doing here.’"

It appears that for the most part, projects that already have financing or are under way will continue. At the start of the fourth quarter of 2008, $40.7 billion worth of hospital and clinic projects were taking place.

The rising cost of financing is slowing the pace, however. An industry survey last October found that 42 percent of the respondents said they were delaying or canceling construction projects because of financing costs. Large hospitals in cities and suburbs and small hospitals – those with fewer than 50 beds – in small towns and rural areas were most likely to be affected.

More hospitals also are cutting back on their capital spending, or freezing their capital spending altogether.

The industry survey found that cancer treatment hospitals were at the top of the list of new hospital construction, followed by children’s hospitals and heart hospitals. Among the addition and renovation projects under way, most were for emergency departments or for medical imaging services.

In 2008, Minnesota was one of the industry’s hot spots for hospital and clinic construction, with between $500 million and $1 billion worth of projects in the works.

Close to half of the hospitals and clinics that were building during the fourth quarter of 2008 were doing so because they had aging facilities.

Although construction may be slowing, it could be only temporary, the article says:

The fact that so many organizations still need to replace facilities built decades ago gives hospitals cause to hope the boom will resume once the economy has recovered.

The article also notes that as the baby boomers get older and require more health care, this demographic is likely to sustain the need for hospitals to continue building.