Social butterflies and the law of correlation

When it comes to interpreting the findings of health and lifestyle studies, there’s one axiom to keep firmly in mind: Correlation does not equal causation.

Got that? Correlation does not equal causation. In other words, just because two things appear to be associated with each other, it doesn’t necessarily mean one of them caused the other.

This principle leaped rather strongly to mind this week after reading a new study about the impact of social relationships on mortality. The study, which was published in the latest issue of PLoS Medicine, analyzed 148 previous studies that examined the effect of social relationships and whether people who were well integrated socially lived longer than those who were more isolated.

It’s an intriguing question to ask. As the study’s authors point out, there’s been a trend in industrialized nations for people to be less socially connected. It’s logical to wonder whether we’re headed in the wrong direction or whether increasing social isolation might translate into a negative effect on physical and mental health.

After analyzing a large collection of prior studies and calculating the “effect size” of social integration on mortality risk, the researchers concluded that people with what they termed “adequate social relationships” had a “50% greater likelihood of survival compared to those with poor or insufficient social relationships.” What’s more, the effect appeared to be comparable to quitting tobacco and was even stronger than well-established risk factors such as obesity and lack of activity.

The study describes the implications:

Physicians, health professionals, educators, and the public media take risk factors such as smoking, diet and exercise seriously; the data presented here make a compelling case for social relationship factors to be added to that list. With such recognition, medical evaluations and screenings could routinely include variables of social well-being; medical care could recommend if not outright promote enhanced social connections; hospitals and clinics could involve patient support networks in implementing and monitoring treatment regimens and compliance, etc.

The authors conclude: ”Social relationship-based interventions represent a major opportunity to enhance not only the quality of life but also survival.”

It’s all certainly very intriguing, but I’m not quite ready yet to run out and make 10 new friends just so I can tack on an extra few years of life. Despite all the data and the number-crunching, this study did not demonstrate conclusively that social integration in and of itself is a protective factor against early mortality. Sure, it showed an association – but this is not the same thing as proof.

In some ways, the study actually raised more questions than it answered. How should “adequate social integration” be defined? Are strong family relationships better for our health than friendships with peers? Are 10 friends better than two or three? Which is more protective – a large circle of casual acquaintances or a small handful of close friendships?

It’s entirely possible that people who are less socially integrated and die sooner are in poorer health to begin with – and that their poorer health status is the reason they aren’t as socially active. (The researchers said they controlled for this but it’s always tricky to draw conclusions from multiple studies, all of which might have been designed in different ways.) Or maybe there’s some other factor that hasn’t been accounted for, such as particular physical, emotional or behavioral characteristics that might influence someone’s likelihood of being both socially engaged and living longer. Perhaps social engagement is a surface expression of something deeper, such as a sense of personal belonging, purpose and meaning.

It’s also interesting to note the study’s implicit bias: the assumption that social integration is almost always beneficial and should be vigorously pursued for better health. American culture is fundamentally open and gregarious – we’re the ones who gave the world Facebook, after all – and extroversion has come to be viewed as the norm. When this is the case, people who are introverted and more comfortable with solitude can be seen as not quite right or somehow in need of fixing. Researchers might conclude we should all be more socially engaged because it’s good for us, but an introvert could well find this stressful and not particularly beneficial to his or her well-being. In fact, more than a few social observers have lamented that Americans, with their dependence on cell phones and 24/7 access to the Internet, are becoming too connected.

It all seems like an area ripe for further research. Just remember, though: If it appears that people who are more socially engaged tend to live longer, it doesn’t automatically follow that their social life is the reason for their longevity. Correlation does not equal causation.

West Central Tribune file photo by Bill Zimmer

Patients of size

To what extent are health care providers obligated to make special provisions for patients who are extremely obese?

My attention was caught last week by a lawsuit that has been filed against St. Joseph’s Hospital in St. Paul after a patient fell off a surgical table, sustained a head injury and later died. The family of Max DeVries, who weighed 300 pounds, maintains the fall could have been avoided if the table had been equipped with larger straps, and that the hospital was improperly equipped to provide safe care.

I’m not in possession of the facts, other than these, so I couldn’t begin to comment on the merits of this lawsuit, nor would it be appropriate. Moreover, it’s not entirely clear whether the issue is about safely accommodating larger patients or whether it’s about safe care, period.

It raises some interesting questions, though, about the responsibilities of health care providers toward patients of size.

From the Star Tribune article that reported the DeVries family’s lawsuit:

With growing obesity and about 30 percent of Americans obese, having adequate equipment for very heavy people has become an issue for hospitals and skilled nursing facilities.

In some cases, hospitals have bolted surgical tables to the floor to prevent heavy patients from tipping them over. How to care for overweight surgical patients has generated new operating-room products as well as medical journal articles and books in recent years.

There’s no denying that taking care of large patients has its challenges, as this case report from the U.S. Agency for Healthcare Research and Quality illustrates. Because of their size, they’re harder to transport in an ambulance or wheelchair. They often fit with difficulty, or not at all, in a CT or MRI scanner. It can be physically challenging to start an IV in one of these patients, or insert a chest tube or even conduct a basic exam.

Many health care organizations are trying to respond to these patients’ needs by purchasing sturdier equipment, developing procedures to lift and move them that are safer for health care workers as well as the patient, and training staff to be better prepared for treating obese patients.

Yes, it takes time and money to do this. The fact is, though, that health care organizations need to make an effort to provide safe, quality care to patients of size, whether providers like it or not.

Patients who are extremely obese are nothing new to the health care system. Human beings come in all shapes and sizes across the spectrum and at some point most will need health care services of some kind. In the past there may have been comparatively fewer patients who were in the 500-, 600- or 700-pound range. We’re noticing them now, and perhaps deeming them to be a problem, because there are more of them and because obesity has become so prominent on society’s collective radar screen. Health care also is much more interventional than it was a generation ago, making the mechanics of caring for very obese patients correspondingly more difficult.

Plenty of other patient populations pose some special difficulties too, however. It’s challenging to care for premature infants who are so tiny that they require specialized needles, tubes and surgical techniques. It’s challenging to care for patients who have disabilities or who are fragile and very elderly or who can’t communicate. Health care providers have accepted that many of these patients will have special needs that have to be addressed, and I’m not sure why extreme obesity should be any different.

Critics might argue that if you accommodate large patients, you in essence are condoning a so-called choice to be fat. The mechanisms that influence weight are complex, however, and lifestyle and calorie intake are often only one part of the equation. In any case, when a very obese patient presents at the emergency room or in the doctor’s office, it’s not a time to be moralizing or to insist the patient must shed 300 pounds before you’ll offer any kind of evaluation or treatment.

I suspect that over time, the health care community will probably develop more knowledge and technical skill for how to best meet the needs of large patients. But first there has to be a recognition that this is necessary and that it’s the right thing to do.

Photo: Wikimedia Commons

Technical update

Official word has arrived that this blog, and the other blogs on AreaVoices.com, will be migrating soon to the WordPress platform. I’m told that new domain names are being assigned, which will mean updating your bookmarks when the time comes. Those are all the details I know for now. Stay tuned.

Circle of friends

All you had to do was drive by the Willmar Middle School Friday afternoon or evening to see that something big was happening.

It’s hard not to catch the excitement as the Kandiyohi County Relay for Life takes visible shape: the tents, the signs, the volunteers, the paper luminaries lining the track, the party atmosphere. The goal of the American Cancer Society was to raise $150,000 at the event this year to support cancer research and services for patients.

Money is tangible. So are volunteers. You can see them and count them and measure their impact. Without them, the Relay for Life wouldn’t happen.

When you really think about it, though, the value of the Relay for Life can’t be quantified in numbers. More than any other event I can think of, it’s a way for diverse people to share the common experience of what it means to have cancer. I like how Kim Madsen, the local community relations director for the ACS, explains it: "For those people who have gone through the cancer journey, Relay for Life is a big healing process. You’re surrounded by people who understand that journey."

It’s one of those bonds that forms among people who’ve had to navigate the same emotional landscape. They get it without needing a lengthy explanation. The club has its own subcultures – children with cancer, women with breast cancer, young adults with cancer, men with prostate cancer, caregivers, short-term survivors, long-term survivors, the recently diagnosed, the currently in treatment – but they all still belong to the same society.

Dr. Bruce Campbell, a blogger and physician at the University of Wisconsin, recently witnessed this unspoken connection while attending a conference for cancer survivors:

The stillness in the meeting room was electric.

First, one panelist addressed the audience members who have never experienced a malignancy. She described the unique and powerful bond that exists between cancer survivors. She described how the brush with mortality forces each survivor to renegotiate terms with Life itself. She reminded everyone that the cancer care system too often lets down both cancer patients and survivors.

Then she addressed the cancer survivors. "As a fellow survivor, even if you and I have never met before, I would bet that we would find common ground within fifteen seconds." Other survivors in the room agreed with her immediately.

It’s invisible but it’s very real. The fundraising and the community awareness are important elements of the Relay for Life too, of course, but in the end it’s the shared experience that speaks the loudest and makes this event unlike any other. If you’ve never attended a Relay for Life, mark it on your calendar and be there next year.

West Central Tribune photo by Ron Adams

Something chronic

Until you know someone, or become someone, who has chronic disease, it’s hard to imagine what it’s like to have a life that revolves around bouts of illness, constant attention to managing symptoms, and frequent visits to the doctor.

Blogs such as A Chronic Dose, Chronic Babe and Somebody Heal Me offer a window into a world that many of us don’t inhabit, don’t understand and might not even want to know about. Imagine going to a friend’s wedding, as blogger Diana Lee describes at Somebody Heal Me, and being forced to vomit into a leaky plastic bag after getting hit with a migraine.

For as much time as these people often must spend at the doctor’s office, you’d think they’d develop strong relationships with the health care system and vice versa. The reality, though, is that the system often lets these patients down. And doctors, for their part, often feel frustrated and defeated when the patient at the other end of the stethoscope is someone with chronic disease.

“You scare doctors,” Dr. Rob Lamberts, who blogs at Musings of a Distractible Mind, confesses in an exceptionally candid and compelling “Letter to Patients with Chronic Disease.”

“You don’t get better, and it makes many of us frustrated, and it makes some of us mad at you,” he writes. Then he goes on to explain the physician’s perspective and offer some advice on how to make the most of the relationship. (Don’t come on too strong. Don’t use the ER unless absolutely necessary. Don’t put up with doctors who are jerks. Be forgiving.)

He concludes: ”I hope this helps, and I really hope you get the help you need.”

Talk about hitting a nerve. The last time I checked, there were more than 150 responses and counting. The post also has been linked by a number of bloggers and patient sites that focus on chronic disease. The whole issue of chronic disease and how it influences the relationship between the doctor and the patient apparently taps a deep well of emotion.

Commenters described their longing to have their chronic issues well managed and their frustration and vulnerability at feeling disbelieved, dismissed or written off by the doctor. One of them summed it up this way: ”One of the most difficult things about being chronically ill is living at the mercy of medical professionals.”

Here’s what someone else wrote:

At the very very very best, we get doctors who are sympathetic and well-researched and willing to treat our symptoms as aggressively as we wish to treat them. At the worst, we are bullied, ignored, screamed at, told one minute that the doctor will do anything to make us better and told the next that there is nothing anyone can ever do for us so we better get used to it, given bad recommendations to disability offices that deny us benefits we need,  and the list, as I’m sure you already know, goes on and on.

From someone else:

I know we aren’t easy to cope with and I will do my utmost to help a doctor who is honest about how difficult it is to handle a chronically ill or disabled patient, I however feel nothing but contempt for doctors who take advantage of their power to harm me because they don’t like how treating me makes them feel.

But others spoke of their gratitude at finding and developing a relationship with a doctor who understood them. It’s a two-way street, one person pointed out: “I expected too much from medicine, and now that my expectations are more realistic I’m happier, and I think my doctors are too.”

Patients and doctors are, quite frankly, often unhappy with each other. (If you don’t believe this, take a look at the many online health care discussions that so often deteriorate into insults and defensiveness on both sides.) Sometimes the frustration is over minor, transient issues that are easily resolved. Other times the dissatisfaction goes much deeper. But if you were to ask them how much effort they’ve invested in trying to understand and respect each other’s perspective, the answer most of the time would probably be: Not very much.

Although some of Dr. Rob’s commenters ripped on him for being, in the words of one critic, “condescending,” you have to give him credit for opening up this particular door and letting chronic-illness patients peek inside. And if we’re going to be fair about this, we also have to give credit to the people who responded to his post for being so honest and articulate about how they feel about living with chronic illness.

There’s rarely time in a face-to-face encounter in the exam room to explore or talk about this stuff. And even if there were, I don’t think there’s a billing code for “mutual rapport.” But maybe there should be.

Image: Wikimedia Commons

Opening up the medical record, redux

A year or so ago I blogged about the pros and cons of opening up the medical record so patients could read everything that was written about them, including the doctor’s notes.

Well, the initial results are in from OpenNotes, a demonstration project exploring the feasibility, benefits and pitfalls of allowing patients to see the doctor’s notes about their visit. The findings, reported this week in the Annals of Internal Medicine, suggest it’s not an easy practice to implement and that the implications “are broad and filled with uncertainty.”

The project involves more than 100 primary care physicians and 25,000 patients at selected practices in Massachusetts, Pennsylvania and Washington. Patients don’t have to read the doctor’s notes if they don’t want to; what’s noteworthy about this project is that instead of shielding this information, as physicians have traditionally done, it is voluntarily being shared with patients who ask to see it.

What exactly is the doctor’s note? Good question.

The visit notes often contain observations about the patient. Was he or she anxious? Well informed? Confused? Belligerent? The notes might outline the doctor’s train of thinking about a possible diagnosis for the patient or the need to rule out something serious. They might also sum up the plan of action – ordering a test, for instance, or watchful waiting to see if a problem resolves on its own.

Although the main purpose of the doctor’s note is to document the encounter for future reference, it’s also used in determining third-party payment, in tracking measures of clinical quality, and sometimes in settling questions or even lawsuits over the care received by the patient.

In other words, it’s a pretty crucial piece of the patient’s medical file. But is it helpful for patients when they have access to the doctor’s notes? Will it lead to a better understanding of their health and a better relationship with the doctor, or might it have some negative consequences? That’s what the OpenNotes project aims to find out. The study involves surveys of the participating doctors and patients both before and after the demonstration project, as well as a collection of personal stories about the process. The study authors also plan to evaluate whether health care utilization changes as a result of implementing OpenNotes.

You’d think it would be relatively simple for doctors to share their notes with their patients, but the OpenNotes project is finding that it’s not so straightforward. The Annals study reports that doctors worry about the impact on their time:

… They anticipated calls, letters and e-mails as patients seek clarification, disagree with statements, or correct what the doctors consider trivial errors of fact. Some felt they would have to compose scientifically imprecise notes that leave out important diagnostic and therapeutic considerations. Some were embarrassed by how they write. They talk about halting phrases as they hunt and peck on their keyboards, feared that the many typos that creep into notes will seem unprofessional, or were self-conscious about the impersonal appearance of notes generated by templates. Wondering how often phrases like “the patient denies…” or “the patient appears SOB [short of breath]” would evoke an angry response, some doctors anticipated spending considerable time editing notes. Several worried that apparent discrepancies between what they write and what actually happened in the encounter may jump out at the patient, whether real or simply reflecting imprecise patient recall.

They also worried patients might become frightened, angry or depressed as a result of what they read in their notes.

As for the patients, they have worries of their own:

Some clearly did not want to read what their doctors wrote because they were worried about discovering something they would rather not know, finding potential diagnoses that might make them anxious, or reading what their doctors really thought of them. Others feared reading something that would shake their trust in their doctors. Some felt that unfamiliar medical terminology would make them misinterpret what they read. They wondered how to learn to ask the right questions and who should teach them.

That’s the down side to note-sharing. Previous smaller studies have suggested, however, that there also can be significant benefits. These studies have found that when patients have more information, it often helps them become a better partner with the physician, and that the time factor hasn’t been as great as physicians fear.

I don’t know about anyone else, but I’m certainly intrigued by this study and what the eventual findings might show.

I can relate to physicians’ concerns about opening up their notes. I wouldn’t be keen either on sharing the contents of my reporter’s notebook with its scrawls, news lingo and idiosyncratic shorthand. (On the other hand, though, my sources don’t have to worry that other people will read my notes; no one sees them, and no one needs to see them, except me.)

I think there are also some very real concerns with finding a balance between Information Is Power vs. Ignorance Is Bliss. Where this line gets drawn is different for everyone. Sometimes physicians write pejorative or judgmental statements in their notes that can be upsetting to patients even when the statements are true (and especially when they’re not true, or when they’re based on a hasty 10-minute visit). Sometimes it can be too much for patients to know all the details of a surgery or a diagnosis.

It’s valid for physicians to wonder if they’ll be forced to self-edit their notes for fear of offending patients. On the other hand, a certain amount of accountability enters the equation when patients are allowed to review the doctor’s notes.

The Annals report sparked some interesting back-and-forth at the New York Times. “I want to read the notes,” one person wrote:

It is important to me. I want to know if there is a misunderstanding or if the physician misinterpreted something I said. I want to see the numbers on my test results, too. The notes can also give me a clue into the doctor’s attitude. If they indicate they don’t believe me, I can go find another doctor.

Someone else was emphatic that patients needed to know what the doctor says about them:The real issues are 1) outright medical errors or misstatements and 2) off-the-cuff characterizations of a patient’s psychological status that are 3) indelibly written in records that are passed on to other medical personnel, insurance companies, and so on.”

Physicians weighed in as well. Doctors make subjective observations of the patient for a reason, one physician wrote. “Please don’t judge our chart comments too harshly unless you know why we write what we write.” From another physician: ”Medical charts must be brutally honest. There’s no room for fluffy warm fuzzies there.”

(Brutally honest? How about just being… oh, I don’t know… honest without the brutality?)

If you want to check out the official OpenNotes website, it’s here. There’s also an online survey you can take.

Health care clearly is evolving in the direction of greater participation by patients. Many, although not all, patients want this and welcome it. It’s significant that some of the roadblocks are now being demolished, making it easier for patients to have access to information which, frankly, they deserve to have shared with them. The journey likely will be rough at times. Not everyone is going to agree on the process or the principles. I’d like to think, though, that the destination – more involvement by patients and more participatory relationships between patients and doctors – will make the trip worthwhile.

Update, July 22: Here’s another look at this issue by Dr. Pauline Chen, who writes the “Doctor and Patient” column for the New York Times. She raises some of the same questions but adds another point: Even though patients are legally entitled to see and obtain copies of the medical record, including the doctor’s notes, they face many bureaucratic obstacles, ranging from outrageous copying fees to administrative foot-dragging and uninformed or uncooperative staff.

Image: Kinross House, Kinross, Scotland. Courtesy of Wikimedia Commons.

Growing old in America

In recent years I’ve covered quite a few meetings that have addressed the issue of how to best care for older adults living in our communities. The general tenor has been that we need to do more, especially with millions of baby boomers on the brink of retirement.

A listening session in Willmar last week with Sen. Al Franken’s staff was no exception. The main message: This demographic is growing, the need for services is growing and the funding unfortunately is shrinking. There was another message, though, that I think is just as important: Cookie-cutter solutions aren’t necessarily the answer because every individual, and every community, is different.

We make a lot of assumptions about the old – how they should live, how they should behave, how they should receive their health care. (What should we call this age group, anyway? The elderly? Seniors? Retirees? Older adults? Golden agers? Nothing really seems to fit.)

There’s a tendency to view them as a monolith. Yet when you look more closely, this age group is just as diverse as middle-aged people, or young adults, or children. Not all older adults are frail, doddering and forgetful, just as not all older adults are, or want to be, vigorous mountain climbers and marathon runners. The very old are not at the same place in their lives as the younger old.

Chronological age is not a reliable predictor of what to expect. Many people remain hale and hearty into their 90s, while others begin declining in their 60s.

Why do we insist, then, on lumping them together in a category labeled as “old” and presuming what they need or want?

Consider just one example – how older adults are often treated in the health care setting.

Why is it assumed that because someone is in her 70s and takes seven or eight prescription drugs, she can’t keep them all straight and needs a nurse calling her each day to remind her?

Why is it assumed that older people are resistant to technology or too uncomfortable with it to ever use it in their health care?

Why do otherwise well-meaning caregivers dole out activities and socialization as if they were medicine?

Why do health care professionals call older patients “dear” or “gorgeous” and get away with it? (Something that seems to happen almost exclusively when the patient is an older woman, I’ve noticed.)

Why is there something unacceptable about an 85-year-old who wants chemotherapy for cancer or aggressive treatment for some other disease?

Why is the identity of older patients so often reduced to little more than a lengthy list of health problems?

Age + polypharmacy does not equal confusion. Just because someone fits this profile doesn’t automatically mean they need extra help.

It’s a generalization to assume older adults have no interest in exploring new technology. Many of them are open-minded and adventuresome and would welcome – and use – telehealth services.

Socialization and activities have value but they’re not something to be pushed on people as if they were spoonfuls of cod-liver oil. Whatever happened to the right of older adults to be left alone sometimes?

If you wouldn’t call a younger male patient “dear”, then don’t say it to an older person either.

Aggressive treatment may be neither helpful nor appropriate for patients who are in their 80s or 90s, but it’s unfair to dictate the health care choices we think they should make. The life force can burn just as strongly in an older person as in someone who’s younger. It’s a mistake to insist they should be ready and willing to forego treatment that would be considered acceptable in a young patient.

Health issues can mount as people age, but that doesn’t mean this should be the only prism through which they’re viewed. The older patient with coronary artery disease, hypertension, kidney disease, arthritis, osteoporosis and hyperlipidemia is more than just the sum total of the medical labels that have been pinned on him or her.

To be sure, aging is not for sissies. It’s worth asking, however, whether societal attitudes, beliefs and stereotypes have made it harder than it needs to be. Everyone is an individual, first and foremost, no matter how many birthdays they’ve had.

West Central Tribune file photo by Ron Adams

Rethinking the medical home

There’s a lot about the medical home concept that makes sense. Coordination and continuity of care, teamwork, more focus on preventive care and the management of chronic disease – what’s not to like?

Lately, though, I’ve been rethinking whether the medical home is truly going to improve the delivery of primary care. Apparently I’m not the only one; Dr. John Schumann, who blogs at GlassHospital, recently came right out and declared, “It’s never going to work.”

Dr. Schumann lays it on the line:

… While the PCMH sounds good conceptually, individual doctors and patients are finding it less lofty than its rhetoric. For one thing, the model presupposes the doctor as the center of a “care team,” consisting of nurses and “mid-levels” (i.e. nurse practitioners and physician assistants). Under the PCMH model, doctors would only see the “complex” patients, leaving the “simpler” issues (like sore throats, colds, sprains and urinary tract infections) to the rest of the team.

In theory, the doctor (really the doctor’s team) has the ability to handle many more patients, improving both practice revenue and efficiency (attributable to the new informatics tools and data pooling). The obvious problem with this is that the patient has to buy in to the model. Some folks are fine seeing the nurse practitioner for their acute complaint, but how does the Medical Home model improve the doctor-patient relationship, especially if you already have trouble seeing your actual doctor?

Worse yet, with all of this restructuring, the PCMH has yet to be shown to be cost effective. Reorganization costs money, as do the startup costs of the electronic tools. Integrated systems like Group Health in Seattle and Geisinger in Pennsylvania have shown cost savings when doctors are salaried, networked, and have a captive audience of insureds to analyze. Unfortunately, the vast majority of practicing doctors still operate outside of these networks. Encouraging them to transition their practices into “homes” will be disruptive to say the least; the real question is whether the disruption will be transformative toward the ideal or cause the destruction of individualized doctor-patient relationships.

I wouldn’t go so far as to say it won’t work (at least not yet). But I’m starting to doubt whether it’s the solution to primary care that many people think it is.

Last month I blogged here about the results of some early demonstration projects to implement the medical home concept. One of the lessons was that it’s incredibly hard work to adopt this model – much harder, in fact, than anyone realizes. Nor is there a great deal of evidence yet that medical homes do indeed save money, result in better care and are more satisfying for patients.

I hesitate to draw conclusions on the basis of first-generation data. It stands to reason that the learning curve will be steeper during the early stages of exploring any new model of medical care. Now that we know, for instance, that too much focus on implementing the information technology of the medical home can hurt patient satisfaction, other providers who want to adopt this model can try to avoid the same mistake.

There are a lot of assumptions, however, that the medical home model will somehow automatically make things better for patients, and I’m not convinced this is necessarily so.

If patient care is going to be coordinated by teams, good communication is critical. It’s one of the things in  health care, though, that’s notoriously difficult to do well. Are care teams prepared to step up their game? Or will the patient’s care become increasingly fragmented as he or she is handed off to a series of mid-level professionals? How many nuances of someone’s health will get overlooked or missed?

How clearly are the roles delineated? There are many things a mid-level professional can do better, or more efficiently, than a physician. But this isn’t appropriate in every situation, nor with every patient. Moreover, someone still needs to be the captain of the ship and have responsibility for the overall care of the patient.

There’s a very real concern that the adoption of the medical home model is more focused on meeting the requirements than on the actual provision of care that’s patient-centered. A clinic might have an electronic medical record (check!) but this doesn’t guarantee it’s being used in a meaningful way. Likewise, some practices might have a well-developed philosophy of teamwork and patient-centered care but not be able to document it so that it satisfies the bureaucratic standard.

Then there’s the patients themselves. What do they think about this?

Patients, in fact, seem to have been left out of the loop altogether, Dr. Pauline Chen contends in a thoughtful column this week in the New York Times:

Call it a P.R. issue, an information disconnect or simply an unfortunate choice of a name, but in all the discussions about patient-centered medical homes, one group of individuals has been conspicuously missing: the patients themselves. And it’s hard not to notice the irony; in a model of care premised on the strength of the patient-doctor relationship, few people other than doctors and experts are even sure what it is or how it affects their care.

Farther down in the column, she notes that many patients who participated in early demonstration projects were unhappy with the results:

Yes, they were getting into their doctors’ offices more quickly and were being followed more closely than ever before, but many patients reported feeling disoriented. Some felt displaced as they saw the old one-to-one doctor-patient interactions replaced with one-to-three or one-to-four relationships involving not only the doctor but also a whole host of other providers. As offices switched from paper-based to electronic medical records, other patients reacted to the distracted clinicians who seemed more focused on learning the new computer system than on listening to them. Satisfaction fell because, like my friend, few patients were cognizant of, much less involved in, the changes going on around them.

It’s worth noting that one of the online commenters who responded to the column was a participant in one of the medical home demonstration projects. Her reaction wasn’t positive:

During the 18-month period, I saw 7 different providers, only one was my primary care physician. For one medical issue, I saw 5 different providers. One of the PAs I saw failed to prescribe the appropriate treatment and for my return visit, I saw a different PA who suggested I needed another appointment with “my doctor” because I hadn’t seen “my doctor” for over a year.

On top of all this, she relates, all of these well-meaning professionals somehow completely missed a problem that required treatment.

Does this mean the model is flawed? Maybe this particular clinic was just floundering with how best to implement a medical home strategy. Maybe, given the passage of time coupled with feedback from patients, these processes could have been smoothed. Then again, maybe not.

On paper, the concept of a medical home still sounds good. But there are clearly issues with how it’s executed in real life, and it seems too soon to know whether these can be overcome. In the meantime, my opinion of the medical home has been cooled off with a healthy dose of skepticism.

Image: Wikimedia Commons

Blowing the whistle on bad doctors

I admit to some hesitation in using the term “bad” doctors in the title of this post. Physicians can fall short in many ways, often for reasons that are purely human and forgivable. It doesn’t necessarily mean they’re incompetent or that they are somehow bad for their patients.

Medicine is like any other profession, though. Sometimes a doctor is too impaired to safely take care of patients. In these circumstances, colleagues need to be willing to intervene, not only for the sake of maintaining professional standards but also to protect the public. But judging from a newly published study in the Journal of the American Medical Association, doctors are often very reluctant to blow the whistle.

The authors of the study surveyed 1,891 doctors and found a noticeable gap between what they professed to believe about dealing with impaired colleagues and what they actually did about it. The physicians who participated in the survey represented a variety of specialties, from family practice and pediatrics to surgery, anesthesiology and psychiatry. The majority, 64 percent, said they “agreed with the professional commitment to report physicians who are significantly impaired or otherwise incompetent to practice.”

Seventeen percent personally knew of a colleague who shouldn’t be practicing medicine. In more than two-thirds of these cases, the physicians in the survey said they reported it to the appropriate authority. But this still left close to 30 percent who did nothing. Reasons for failing to take action included a belief that someone else was taking care of it, a belief that nothing would be done about it, and fear of retribution.

These findings are actually not too surprising. It has long been known within inside circles that physicians tend to be reluctant to report a colleague. There’s a lot more under the surface than the arrogance of protecting one’s own, however. Medical Economics magazine explored some of the issues after conducting its own ethics study back in 2002, and found that many factors come into play.

There’s the question of how to deal appropriately and compassionately with addiction or physical or mental illness. Should a physician have his or her license yanked because of an addiction, or should the doctor first be urged to seek treatment? Does a mental health disorder automatically mean someone is unfit to practice medicine? If physicians believe they’ll be punished for having a disease or disability, might it not result in a reluctance to seek help and end up driving these problems underground?

A more challenging issue is when a physician has poor skills or chronically exhibits poor judgment or lapses in ethics. Clinical incompetence can be hard to discern, the article notes:

If you assist someone at surgery or some other highly visible activity, you may be in a position to evaluate his competence. But how do you know whether what someone does in his office meets the standard of care, especially if he’s in a different specialty?

Some outcomes information is becoming available in areas like cardiac surgery. But most doctors don’t use that data in deciding on a referral; in fact, they rarely even check publicly available information on sanctions by state medical boards. So their knowledge of whether a consultant is competent comes mainly from patient feedback, hunches, and hearsay.

Truth to tell, it can also be extraordinarily difficult to rat out one of your own – particularly if you don’t have proof or even if you simply empathize with the colleague whose office is next door to yours. Many physicians, says Medical Economics, might wonder how they would feel if the tables were turned:

Craig Wax can testify to that. When he got out of family practice residency two years ago, he would have been inclined to report any physician he suspected of being impaired. But since then, with both group and solo practice under his belt, he’s decided it would be better to approach an impaired physician privately.

“I’d be afraid of ruining the other doctor’s reputation. I’d also be concerned about earning a reputation as a whistle-blower, he says. “Other doctors may think I’m overreacting and say, ‘Oh, it’s just Charley. He’s always done that, and he’s always managed it. It’s silly to report him.’”

In the Medical Economics survey, 4 percent of the respondents said they would do nothing if they became aware of a colleague whose performance was impaired by drugs, alcohol or a physical or mental illness. Thirty-one percent said they would talk to their colleague privately and 65 percent said they would report the physician to the appropriate authorities.

Ideally, there would be systems in place to monitor physician performance so problems are detected sooner and addressed more quickly. But these can be inadequate or dysfunctional; indeed, they can end up being a case of the fox guarding the henhouse, as Dr. Robert Wachter points out in his incisive analysis of a scandal earlier this year involving a Baltimore cardiologist who placed more than 500 unnecessary stents in patients.

Where was the peer review? Dr. Wachter wonders. And did hospital politics allow the cardiologist a free pass, as long as he kept generating revenue?

Cases like this one are terribly troubling, not just because they harm individual patients but because they do violence to the trust that is so fundamental to the physician-patient relationship. Part of the solution must be more robust oversight procedures, such as mandatory second readings of randomly selected cath films.

But these cases also force us to consider the kind of culture that could allow such a fraud to take root and go on for years – a culture that likely prized the hospitals’ and physicians’ financial health over the clinical health of their patients. If the allegations are true, the penalties should be severe, not only for Dr. Midei but also for leaders who knew – or should have known – what was going on, yet remained silent.

Left unsaid in all of this is what patients are supposed to do if they suspect their doctor is impaired or incompetent, or is engaging in unethical behavior. Is there any reason to think patients don’t face some of the same issues about reporting someone? Patients might fear being wrong, or that the authorities will do nothing about their complaint. They might also fear being labeled a troublemaker, or possibly even dismissed from someone’s practice for registering concern about the physician’s competence.

That fact that most of the physicians in the JAMA survey – more than 80 percent – didn’t personally know of an impaired colleague suggests the majority of doctors are indeed competent. The gaps in the profession’s ability to police and regulate itself are troubling, however. It’s not reasonable to think the public is better equipped to be the enforcers, and turning the responsibility over to government opens up a whole new, and probably undesirable, can of worms. If the medical profession wants to do better, it needs to confront these issues itself.

A new wrinkle in the war on teen smoking

Back when I was in high school, one of the hottest issues on many high school campuses was whether to provide students with a smoking lounge.

Then as now, school officials, and society in general, didn’t approve of teen tobacco use. There seemed to be an unspoken level of tolerance, however. It was commonplace for kids who smoked to light up in the school building or on school property. As I recall, the bathrooms across the hall from the principal’s office were where the smokers at my high school always hung out. The air reeked so strongly of cigarette smoke that the rest of the students wouldn’t set foot inside.

Give the kids their own smoking lounge and they can smoke to their heart’s content without bothering their classmates, or so the thinking went.

It would be hard to imagine any high school nowadays even contemplating such a thing. Policies are much more stringent about tobacco use on high school campuses, and teen smoking rates are down significantly compared to even 15 years ago.

It’s a constantly moving target, though. And one of the latest wrinkles comes from a direction I’m not sure anyone would have anticipated: In the push to curb youth obesity, we may be unwittingly shifting the focus away from youth tobacco prevention.

That’s one of the premises, at least, of a couple of intriguing articles that appeared late last week in the New York Times. The U.S. has fallen short of its goal to lower the number of high school-aged youths who smoke, the first article notes:

"People are getting the image that it’s cool to use nicotine as a drug," Terry F. Pechacek of the Centers for Disease Control and Prevention said in an interview. "We need to bring back our voice, our antismoking mass media campaign."

The popularity of hookah bars and smokeless nicotine products, Mr. Pechecek said, are the modern equivalent of the banned Joe Camel cartoon in their appeal to youths. And some experts worry that the new health campaign against obesity – spearheaded by Michelle Obama from the White House – may be hampering donations to antitobacco campaigns as public health issues shift in emphasis and compete for funds.

A second article poses the question more bluntly: "If you had to choose one public health problem to attack, which would it be: teenage smoking or childhood obesity?"

When the scientific evidence is weighed, the benefits of youth tobacco prevention are more firmly established, the article points out. For one thing, contrary to what many among the public might believe, the death toll from obesity has been difficult to accurately pin down. The death toll from tobacco, on the other hand, has been relatively well documented.

For another thing, the article points out, intervention strategies and their long-term benefits are harder to measure for childhood obesity prevention than for tobacco prevention:

Even if it were possible to calculate the lifetime health risks a fat child faces, combating obesity is not so easy. Jeffrey Friedman, an obesity researcher at Rockefeller University, notes that there are many assumptions about what will work – more healthful foods in schools, a soda tax, getting children to be more active. Yet no interventions, when tested in large studies, have caused a big difference in children’s or teenagers’ weights.

There’s the addiction component as well. There can be many reasons why children are obese, and so-called food addiction is only one – and probably not even the most prevalent. Few could argue with any scientific validity, however, that nicotine is not addictive; indeed, it’s one of the factors that makes the habit so hard to quit for so many people.

It all makes you wonder why it has to be either-or. Should ramping up the war against childhood obesity have to be at the expense of youth tobacco prevention? Why can’t there be room in the prevention tent for both?

To the extent that we no longer talk about smoking lounges for high school students, there has been measurable change in how teen tobacco use is regarded. But if the fact that close to 20 percent of American teens still smoke is any indication, there’s room for improvement yet. On the front lines of youth tobacco prevention, it seems we can ill afford to become complacent or distracted.

West Central Tribune file photo