The expert patient


If you’re ever diagnosed with a chronic condition – diabetes, for instance, or Crohn’s disease – you’ll probably learn more than you ever thought possible about your disease and how to manage it. You might even become almost as knowledgeable as your doctor.

Is there such a thing as an expert patient? I know people whose diagnosis motivated them to read everything they could lay their hands on about their condition. They’re active participants in their health care. They avidly follow the latest research. Some of them have their own website and/or blog.

It’s hard to argue with the level of knowledge these patients command. After all, they often invest far more time and energy in learning all there is to know about their condition – or, in some cases, their child’s condition – than can a busy physician with hundreds of other patients.

Judging from a guest post this week at Kevin MD, though, the medical world is rather ambivalent about the whole concept of expert patients. Dr. Martin Young writes that he has a problem with it – “not because I don’t think patients should have access to knowledge or know a lot about their own disease, but because knowing one pattern of pathology, i.e. your own, does not make you an expert.”

So what does make an expert? The word “expert” suggests “knowing everything there is to know about something,” Dr. Young writes.

There may be expert patients out there, but I believe that denotation demands explanation, and e-Patient advocates and their blogs need to make sure that their information carries disclaimers that they do not have medical training or qualifications, and that the contents thereof are opinions, not medical advice.

It seems we don’t quite have a common definition of what constitutes patient expertise. Physicians tend to equate it with the knowhow that’s conferred by medical training and years of practice. But for patients, being expert often has much more to do with the physical and emotional terrain of living daily with a chronic or long-term health condition. From these people’s perspective, the expert patient is one who’s not only knowledgeable about his or her condition but also is highly competent at managing it. A broader definition might include knowing how to find the right resources and how to effectively navigate the health care system.

A similar discussion has been taking place in Great Britain, where the National Health Service offers an Expert Patients Programme whose goal is to educate people with chronic, long-term conditions and enable them to participate in their care. When the British Medical Journal published an opinion piece pondering whether the expert patient concept was good or bad, responses fell into two camps.

Patient expertise is welcome, as long as patients understand the limits of their knowledge, wrote one person:

Searching the internet or going through several medical magazines by the patient can never replace the comprehensive understanding of the subject by a doctor. The patient may find out a lot about his/her medical problem and may make suggestions about how to treat it but the doctor is the one who is aware of all the different aspects involved, be it the interactions of different drugs with each other or the suitability of a specific patient to undergo any of the several treatment options available.

It’s hard enough for health care professionals, let alone the average layperson, to keep up with all the latest knowledge, someone else wrote. “Would a patient be so expert to unravel all these issues in order to autonomously decide the best for his/her health?” he wrote.

The patients who responded, however, took a slightly different view of their role. One woman who participated in the Expert Patients Programme expressed dismay that it might have relegated her “to the ‘heart-sink’ category” with some physicians. “We were a mixed group of all ages and various conditions, but, without exception, all of us wanted to learn to manage our conditions better and to establish good therapeutic partnerships with those trying to help us,” she explains.

Another patient was emphatic that she’s not trying to replace the expertise of a doctor:

I think it must be infuriating for someone who has spent many years in medical training, and even more gaining experience, to find that an untrained patient has notions of how they want to be treated! But if someone came to me in my own professional field and told me of new research that I hadn’t yet encountered, I hope – I do hope – I would be able to accept that they had the time and motivation to find out things I didn’t know, and I hope – I do hope – I would be able to assess this new information impartially, without feeling that my expertise was being threatened.

The debate over expert patients seems to be about multiple issues. On one level, it’s about the terminology that should be used to describe people who are knowledgeable, motivated and participatory in their care. Is “expert” the right word? Maybe it’s not quite accurate, or maybe it’s too strong a word. On the other hand, it’s worth keeping in mind that the expression is “expert patient,” not “expert co-physician.”

But on another level, the discussion is about whether it’s even possible for patients to be experts. If it is indeed possible for a patient to be an expert, to what extent should this expertise be allowed to help shape his or her care?

Knowledge is power, and the increasing availability of medical information for the layperson is altering the balance of power between doctors and patients in ways that are dynamic, unaccustomed and frequently uncomfortable. The discussion about expert patients reveals one of the fault lines along which this shift is taking place. There’s sure to be more upheaval and disagreement before the ground starts to settle.

Photo: Wikimedia Commons

How to dissect a study

Who remembers the mammography study that was issued last year, and the firestorm that ensued over its conclusion that mammography for women in their 40s should be an individual decision between women and their doctor, rather than a blanket recommendation for all women in this age group?

There were cries that this was tantamount to rationing care. There were protestations that it would be taking away a valuable screening tool for breast cancer.

But if people went back and read the original study by the U.S. Preventive Services Task Force, they would have seen this wasn’t what the study was about. The study didn’t conclude that mammography was useless and that it should be scrapped. Nor did it address the cost-effectiveness of mammography; it was primarily an epidemiological study designed to measure the clinical benefits of mammography in reducing breast cancer deaths across the population of women in the U.S. And yes, it wasn’t without its limitations.

If there’s going to be an argument over a study, shouldn’t it at least address what the study actually says?

American readers these days seem to be awash in studies. Hardly a day goes by without coming across reports of new or better drugs and treatments, or a new recommendation on how to live a more healthful life. But as the USPSTF report on mammography demonstrates, it often takes careful reading and a critical eye to analyze the findings from a study and, more importantly, to be able to understand what the study is about – as well as what it’s not about.

When it comes right down to it, the ability to dissect a study is mostly a learned skill. It’s a matter of knowing what to look for and what questions to ask.

For starters, there’s the size of the study. Did it involve 100 participants or 1,000? Was it conducted in multiple settings or at a single large institution? Numbers aren’t everything, of course; a small, well-designed study can be just as valid – perhaps even more so – than a large study that’s poorly designed. Nevertheless, when a study is small or limited in scope, caution is called for when it comes to interpreting the results. It can be hard to reliably extrapolate the findings from these studies because there’s always a chance they won’t apply in a larger, more diverse setting. A good example is this study that measured patient preferences for seeing a doctor vs. a mid-level provider. The study was conducted among emergency room patients at three urban teaching hospitals – a reasonably good sample but not large enough to indicate whether patients in a non-emergency setting or in a rural setting might feel the same way.

Study longitude, or duration, is another consideration. One of the best examples of a long-term study is the Framingham Heart Study, which began in 1948 and has yielded much of what we currently know about heart health and heart disease risk factors in the United States. This study carries considerable heft for both its size and longitude. The majority of studies, however, are fairly short-term, and it can become correspondingly more difficult to draw conclusions, especially when the study involves a disease or an intervention with long-term implications. This is the weakness of many weight-loss studies, which might track how well the participants are able to lose weight over the course of, say, one year, yet fall short in evaluating how well they’re able to maintain their weight loss beyond the one-year mark.

How were the participants recruited? I blogged last month about a study conducted at Mayo Clinic to evaluate the feasibility and use of online patient care. It was an interesting study but it had one major drawback: The participants were specifically recruited, rather than being randomly selected. Most of them also were Mayo Clinic employees, which might have made them more savvy or more sensitive than the general population about using online care.

How was the information for the study collected? Did it come from medical records? Interviews? Patient or clinician surveys? Many studies are based on survey responses or some form of self-reporting, such as asking participants to keep a food diary. Survey data can sometimes be skewed, both by the questions that were asked and how they were worded. Surveys that rely on the participants to fill out and return a questionnaire tend to get responses from people who are highly motivated to participate, and might not reflect the attitude of the general public. Surveys that rely on self-reporting also can be tricky because self-reporting isn’t always accurate.

Computer modeling has become an increasingly common research tool. It can be valuable for analyzing large amounts of data and drawing conclusions that might otherwise be difficult to measure. These types of studies are highly reliant on number-crunching and mathematical formulas, however, and formulas can sometimes be flawed.

How were the terms and parameters of the study defined? The definitions are important because they help ensure that apples are being compared to apples. If you’re going to evaluate a type of treatment for heart disease, for instance, you might decide to focus your study on participants who haven’t yet had a heart attack so you can ensure some uniformity in the population that’s being studied. Sometimes, though, the terms can be too exclusionary – and this can end up being reflected in the study’s findings. Here’s an example: A study is undertaken to measure physical activity in a community and the authors decide to define “physical activity” as time spent at a gym or fitness center. This can unintentionally introduce a class bias against individuals who can’t afford to join a gym, or those who work in physically demanding occupations who don’t necessarily need to go to a gym to stay active.

In any study, bias is an ever-present risk. Study authors can be biased, sometimes unintentionally so and sometimes because of overt conflicts of interest. The premise or hypothesis of a study can be crafted in such a way as to make the conclusion a foregone certainty. Selection bias can come into play in defining the terms of the study and recruiting the participants. Data dredges, which involve collecting and analyzing large numbers of similar studies, can unwittingly engage in cherrypicking.

The best way to understand a study and how it was conducted is to go straight to the source – the study itself. This isn’t always feasible, though, and many studies also quite frankly are difficult/boring/incomprehensible for the average reader to slog through. Many folks end up relying on news stories which might not be complete or might misinterpret the study’s findings altogether. When reading any news account of a study, there are several additional caveats to keep in mind: Does the language fit the evidence? Does the story hype a theory that’s unproven or premature?

Every study has some limitations – some more than others. This doesn’t necessarily mean it’s a bad study or that no study can be trusted. Studies, after all, are the backbone for much of what we know in medicine – which treatments work in which patients, which screenings are the most effective, which models seem to be the best for patient care, and so on. They can help reinforce theories. Often they inject much-needed facts into the discussion.

Each study, though, needs to be understood within the context of its scope, methods and findings. Studies might offer up information that’s valuable, or controversial, or inconclusive, or preliminary, but they rarely can capture more than one fragment of a very large and often fuzzy picture. And none can contain the final, authoritative word.

Photo: Wikimedia Commons

An extra pair of ears

If we’ve heard it once, we’ve all heard it a million times: Bring an advocate with you to doctor’s appointments so you can have someone else to help you ask questions and remember what the doctor said.

The latest voice to join this chorus is that of Diana Lee, who has chronic migraines and blogs at “Somebody Heal Me.” In a recent guest post at KevinMD, she explores the issue of having a friend or family member at your side during an appointment with the doctor – but she also raises an important point that frankly doesn’t always get recognized: How much, really, does it help to be accompanied by someone else?

It’s something I’ve always wondered myself. You know what reporters are like. We question everything.

Generally speaking, it’s good advice to have a companion who can be another set of ears. People don’t necessarily hear and remember every detail of the conversation with the doctor, especially when the information involves a serious diagnosis or a complicated plan of treatment. It can be extremely valuable to have someone else’s perspective. Two heads also can be better than one when it comes to asking questions.

But the standard advice to “bring someone along” often glibly ignores the many practical considerations.

In the first place, not everyone has someone who can accompany them. They might not have a spouse, or their children might live far away. Bring a friend or neighbor? Well, maybe – but this assumes there’s a friend or neighbor available who’s a) willing to do this; and b) has the necessary skills.

The assumption that family should naturally be able to fill this role also can be a fallacy. Just because someone is related to the patient doesn’t mean he or she knows how to be a good advocate. And there are times when their emotional involvement can make family members not very effective during a conversation in the exam room or during a procedure.

Then there are those who simply don’t want someone else present and might even regard it as an intrusion.

Some of the commenters who responded to Diana Lee’s post thought that having a friend or family member in the exam room has the potential for disrupting the dynamics of the encounter. A family physician explains:

I have absolutely no problem with family or friends in the room (it is called family practice after all).

However, many times this friend/family member interjects their own issues, ie squeezing in a question about their own health.

Also, be there to assist your friend; don’t play “advocate”. True examples: a friend telling the patient how unpleasant her colonoscopy was, right after I recommended one. Or saying how painful mammograms are. Or how the flu shot made them sick once. Or saying how traditional medicine should not be trusted. Or telling a patient that they need to go to “the city” for further care. All of these, and then some, have occurred during my years of practice.

Here’s another thing: Despite how common it is to advise patients to bring a family member or friend to their appointments, some doctors apparently think this is, well, strange. A commenter named Lisa, who has metastatic cancer, brings her husband to her appointments so he can get to know her oncologists. “I think a few of my doctors have found this odd,” she writes. “They’ve later made remarks suggesting that my husband was being amusingly overprotective by coming with me.”

Expectations also seem to vary from one practice to the next. One physician commenter said he doesn’t allow family or friends to be present while the patient is undergoing a procedure. “Patients who insist differently are asked to find another doctor,” he huffs.

What’s the best way to handle all of this? Diana Lee offers some good pointers:

Obviously, you need to make sure you pick the right kind of person to come with you. Don’t choose someone who is known to interrupt people or talk over them. Don’t choose someone who might be combative or difficult to deal with. Choose someone who understands his or her role in being there and is willing and able to fulfill that role.

I still think it’s good advice to have another set of ears when you visit the doctor. But carrying out this advice effectively is, as is so often the case, easier said than done.

Photo: Wikimedia Commons

Into the tunnel

So far, I’ve managed to make it through life without needing to undergo a magnetic resonance imaging scan.

I’ve heard the experience can be rather, uh, claustrophobic. Although I’m usually OK with confined spaces, I’m not sure I’d like the sensation of being enclosed in the noisy metal tunnel of the MRI machine.

Multiply the “not like” factor by 10 times or so and you might have an experience like this one described by Dr. Allen Roberts, an ex-Marine, emergency room doctor and blogger from Texas who goes by the name of GruntDoc.

Dr. Roberts recently needed an MRI of his shoulder. He didn’t think the scan was going to be a big deal. He was even rather amused when the technologists “gave me a little black bulb ‘to squeeze if there’s a problem.'”

Then came the trip into the tunnel:

…The first thing I thought of, looking at the fiberglass tunnel lining with two light strips embedded in it was HAL from 2001, which is weird. Then I realized my heart rate was up, my hands and feet were sweating.

“Wow, this isn’t going to happen to me, is it?” was the higher-brain function; “get me the heck outta here” was what my midbrain was yelling. I’m a rational guy, so I can think my way through this.

Just by putting my chin on my chest I can clearly see I’m out of the tunnel from the knees down, I can see the control room windows, I could relatively easily wriggle out. “Not. Having. It,” sayeth the midbrain, and by this time the lower functions have decided to side with the midbrain, now I’m starting to hyperventilate, a little, and the upper brain had a realization that’s never happened before: “You’re not going to reason yourself through this, and you’re going to have a full on panic attack if you don’t get out of this tunnel.”

The techs quickly slide him out, he apologizes, declines a chance to try the procedure again and goes home humiliated. He writes: “I’m a middle aged man, a doctor, I knew what this would be like, and it went almost as poorly as it possibly could.”

There there, Dr. Roberts. Welcome to the club.

Medical care, let’s face it, often involves exposing patients to sights, sounds and experiences that can be unsettling and even trigger panic. Take MRI claustrophobia and anxiety, which are thought to occur among somewhere between 1 percent and 5 percent of patients. Some patients get so anxious that, like Dr. Roberts, they have to be removed from the machine before the scan is completed.

When I blogged last year about needle phobia, I heard from someone who can’t tolerate needle procedures unless she’s fully sedated.

And what about fear of blood? Or dental procedures? Or anesthesia? It’s not always clear how prevalent these phobias are because these people, understandably, tend to avoid settings that can trigger their fears. Their reluctance to see a doctor or dentist can sometimes be exacerbated by clinicians who are impatient or dismissive of them for being “irrational.” The woman with needle phobia probably speaks for many of them:

 I try to negotiate with medical providers on alternatives, but somehow they think if they reject my reasonable accommodations, I will agree. I won’t. I will forgo treatment or diagnostic procedures if they involve a needle unless I am sedated. Fact is, most of the medical profession has no clue that people like me (and there are lots of us) exist since their close-mindedness has resulted in our avoiding even presenting ourselves for medical advice. My hope is that – somehow – those like me can connect and speak with a unified voice in favor of revised protocols that accommodate our condition. Otherwise, most of us are destined to shortened lives due to lack of medical care.

GruntDoc’s experience prompted several of his blog visitors to relate similar stories about their own encounters with the MRI machine. One person had a few flashes of panic, “though not enough to pull me out of the tube.” From someone else: “Didn’t have a clue that I was claustrophic and laughed at the possibility. Never even got started. Freaked out all the way home.”

There are ways, of course, to make an MRI scan more tolerable. Sedation can help; so can placing the patient in a prone position, or lying face down, if this is feasible. Ear plugs, music and sleep masks also can help distract the patient and make him or her feel slightly less trapped in the MRI tunnel.

As for Dr. Roberts, his brief trip into MRI land was eye-opening. “I now have more empathy for those who tell me they’re claustrophobic in the MRI tunnel (I have ordered sedation liberally before, and will continue to),” he writes. “But, I always thought, in the back of my head, ‘what’s up with that?’, and now I know. In spades.”

Image: “The Scream,” Edvard Munch,  from a series of paintings and prints, 1893-1910

Raising girls

You’d think Katherine Schwarzenegger, the 20-year-old daughter of California Gov. Arnold Schwarzenegger and Maria Shriver, would have every advantage: glamorous parents, sophisticated lifestyle and financial security.

But none of this stopped her from developing major insecurity in the fourth grade about feeling fat and ugly. In a story this week in USA Today, she relates her body-image crisis:

“It was the first time I was aware of my body and compared what I looked like to what other girls looked like. It freaked me out,” she says.

Her parents reassured her that she was beautiful and intelligent, but she wasn’t convinced. Her preoccupation with her appearance continued in seventh grade, and it wasn’t until later that she realized she was going through the same roller coaster of emotions other girls experience.

Katherine tells her story in a new book she wrote, “Rock What You’ve Got: Secrets to Loving Your Inner and Outer Beauty From Someone Who’s Been There and Back.” As she explains to USA Today, “I want to let girls know they are not alone with the changes and doubts about their body.”

It’s not easy growing up female. This isn’t to say that boys don’t have challenges of their own, because they do. But for girls, the issues often are pervasive and can have repercussions long into adulthood. When the Women’s Foundation of Minnesota put together a new report earlier this year on the status of women and girls, it concluded that females are still shortchanged on many fronts, from wage inequities to underrepresentation in power and leadership positions.

The report pulls together data from a number of sources, such as the Minnesota Student Survey, Minnesota Department of Health and the Minnesota Legislative Office on the Economic Status of Women. Among some of its findings on women’s and girls’ health:

– Minnesota girls are less likely than boys to be physically active or participate in school sports. Exercise by girls to help control their weight also is on the decline, especially among girls of color.

– Minnesota women of color are more likely to lack health insurance. According to the report, 25 percent of Latina women are uninsured. Across the board, the rate of being uninsured is highest among women in the 19-to-25-year-old age bracket.

– Teen birth rates are highest among girls of color. Among white girls in Minnesota, the teen birth rate is highest in rural areas.

– Risky behaviors appear to be on the rise for teen girls who are sexually active, and they’re contributing to a rather alarming increase in the incidence of sexually transmitted infections, especially chlamydia.

– In the most recent Minnesota Student Survey, in 2007, almost twice as many girls reported suicidal thoughts or attempted suicide as boys.

Although gender profiling has its drawbacks, it’s hard to ignore some of the differences that exist. On a national basis, for instance, girls are more likely than boys to develop an eating disorder. Depression seems to occur among females at a higher rate than among males.

The take-home message here is that one size does not fit all, and that when girls and women are shortchanged, it can be to their detriment.

That’s why I like what the Women’s Fund of the Willmar Area Community Foundation is doing: building up an endowment to support local programs that benefit girls and women. This fund is still relatively new but it has already awarded four grants and will be announcing two more grant awards Thursday at “Time for  Women, Time for Tea,” an event to raise money and promote wider community awareness and support for what the Women’s Fund is doing.

Because it’s a local fund directed by a steering committee of local women, it’s in a better position than most to recognize community needs and respond to them. The fund’s current emphasis on programs that support teenaged girls is filling a gap that hasn’t always been recognized.

I don’t think it’s just my imagination that girls these days are growing up under far more pressure than previous generations ever did. Even when they appear to have everything going for them, they’re often surprisingly vulnerable. So why not help girls now, while they negotiate the challenging pre-teen and adolescent years? This is one investment that can come with long-lasting dividends.

Photo: Wikimedia Commons

Lost in translation

What the doctor says, and what the patient hears and understands, are sometimes not the same thing at all.

A new study, published in the Annals of Internal Medicine, examines this communication gap by focusing on a specific procedure: percutaneous coronary intervention for stable coronary artery disease – or, in layperson’s terms, threading a catheter and stent into one or more of the major blood vessels of the heart to reduce blockage.

It’s a fairly common procedure for people with heart disease. Often it can reduce the chest pain that’s associated with angina – but it doesn’t necessarily reduce the risk of a future heart attack, and it’s no guarantee the patient won’t have a fatal heart attack at some point. These last points aren’t always grasped by patients, however, according to the authors of the Annals study.

The authors surveyed 153 patients who had consented to undergoing percutaneous coronary intervention if other tests showed blocked blood vessels. They also surveyed 27 cardiologists who had either referred the patient or performed the procedure.

What they found was that 88 percent of the patients mistakenly thought the procedure would reduce their risk of heart attack, and 82 percent thought it would reduce their risk of dying from a heart attack. Among the cardiologists, however, the majority believed these patients would only see relief from angina.

It’s hard to draw any firm conclusions from this study. It was quite small, involving a single hospital, fewer than 30 cardiologists and only slightly more than 150 patients. The researchers didn’t have access to the amount or quality of the discussion the cardiologists had with their patients before the procedure, nor did they measure what the patients’ beliefs may have been before and after the discussion to give informed consent.

Nevertheless, it’s an interesting study for how it reveals the differences in perception that often exist between patients and clinicians. There could be two possible ways of looking at the findings: Either doctors aren’t very good communicators, or patients aren’t very good at listening or understanding what they’re told, or some combination of all three. I suspect, however, that what this study has uncovered is more subtle than this.

There’s an inevitable knowledge gap between patients and physicians. Sometimes it leads physicians to assume that what’s obvious to them – in this case, that PCI has little if any effect on heart attack risk – is equally obvious to the patient. It’s not a safe assumption to make, but it often goes unchallenged. It might not even occur to the doctor to ask patients to clarify their understanding of the benefits of the procedure they’re about to undergo. And sometimes, of course, patients hear what they want to hear, even when what they think they heard isn’t what was actually said.

The other issue is the high expectations to which we in the United States are acculturated. The public frequently overestimates what medicine can deliver. I’d be one of the first to admit the media have often been complicit in this by playing up the benefits and not being clear enough about the limitations. Physicians are usually much more realistic but it’s not always a message that’s heard.

A companion piece to the Annals study makes another important point: The informed consent process usually focuses on the risks of a prescription drug or medical procedure or treatment. Perhaps the process also needs to focus more on the benefits so patients’ expectations are better aligned with reality.

Communication is always a tricky thing but never more so than in health care, where the stakes are high and the information is complex. All too often, even when both parties are doing their best, the message can easily get lost in translation.

Photo: Wikimedia Commons

It’s a wonderful blogworld


I’ve probably said this before but I’ll say it again: I enjoy blogging. And now that Forum Communications Co. has upgraded its AreaVoices platform, I enjoy belonging to this online community even more.

The West Central Tribune is looking for new voices to join the AreaVoices blogging community. You can read more here about blogging, about AreaVoices and, most importantly, how to sign up and get started.

If you’d like to get a flavor for the variety of blogs and blogging voices that belong to AreaVoices, check them out here, at the West Central Tribune website. How cool would it be to see yours among them?

The price of educating health professionals

At one time you could find dozens of small programs for training nurses, laboratory technologists, radiologic technologists and other health care professionals. But one by one, they began to disappear.

One of the last of these programs in the region, the School of Radiologic Technology at Rice Memorial Hospital here in Willmar, became the most recent casualty this week, when the hospital announced the program will be discontinued after the final class graduates in 2012. The reason: The hospital simply couldn’t afford the cost anymore of supporting the two-year training program.

Increasingly, the education and training of future health care professionals is becoming an expensive proposition. Part of this is due to the growing volume of skills, competencies and knowledge that would-be professionals are required to master, whether they plan to become a dental hygienist, nurse, physician assistant or doctor. They’re simply expected to learn more, period, and it takes resources to adequately prepare them for a professional career.

The other, and singular, piece of the equation, however, is the cost of clinical training. Health care professionals cannot acquire all their skills in the classroom. At some point they must gain real-life experience with real patients. The only way to become a good surgeon, after all, is to do actual surgery. The only way to become a good radiologic technologist is to learn how to administer actual X-rays and CT scans.

It’s a cost that tends to be hidden, especially from the public. It means finding clinics and hospitals willing to become training sites. It means investing time, energy and staff resources in supervising students and providing them with constant feedback. And although using trainees to deliver direct patient care might sound like a money-saving bargain, it often isn’t. Students typically are slower. They need to have their work double-checked. For organizations that agree to be training sites, it can come at the cost of lower productivity and lost revenue.

Rural facilities are especially at a disadvantage. Although rural training experiences are a valuable, and proven, way to recruit these health care professionals to rural practice, offering these opportunities can be a significant stretch for small clinics and hospitals where resources are already spread thin.

Policymakers have tried to offset the burden by allocating public money to help subsidize the expense of educating the state’s future health care professionals. In Minnesota, the Medical Education and Research Costs program, or MERC for short, has distributed more than $450 million over the last decade or so to hospitals, clinics and other sites that host clinical training. In recent years, though, the size of the fund has diminished. Once the bulk of the money is distributed to the state’s main teaching hospitals in the Twin Cities and Rochester, there’s little left over. In fact, 75 percent of the MERC funds in 2009 went to the 20 largest sites, while the majority of small community sites received less than $20,000. Many received nothing.

It should be noted that eligibility for MERC grants also is limited to certain types of training programs, primarily those that prepare students in medicine, dentistry, advanced-practice nursing, pharmacy, chiropractic and physician assistants.

An obvious solution to the rising cost of training health care professionals is to shift the financial burden onto students by charging higher tuition. To some extent this has already happened. At a certain point, though, it can become unsustainable. Probably the best example is medical school: The average student now graduates from medical school with $156,456 in educational debt, according to the American Medical Association. The main reason? Rising tuition costs. Not only is it burdensome for students but there’s also some evidence that their loan obligations are influencing many students’ career choices when they complete their training, driving them toward higher-paying specialties at the expense of primary care. The daunting costs also can discourage bright young people from even considering a career in health care.

It’s not clear what the solution should be. What’s obvious, though, is that many clinics and hospitals are continuing to offer training opportunities and hands-on experiences for students in the health professions. They do it because they’re committed to helping develop a health care workforce that’s skilled and competent and can carry their communities forward into the future. They’re certainly not doing it for the money.

Photo: A University of Minnesota dentistry student gains skills in cleaning teeth and working with children while participating in a rural training rotation at the Rice Regional Dental Clinic in Willmar. West Central Tribune file photo.

Nobody’s perfect

For health care professionals, there are few worse moments than the horrible, sinking realization of having made a mistake that harms a patient.

It’s not just the psychic pain that comes with hurting someone whom you intended to help. It’s also worry about the fallout. Will you be blamed? Will you be punished? Will there be an ugly confrontation with the patient and family?

Finally, there’s the lingering self-doubt: Does making a mistake mean you aren’t competent?

It has been extraordinarily difficult for the health care world to admit to being less than perfect, especially when it comes to individual performance. All things considered, this isn’t too surprising. Health care culture has historically been demanding of excellence, and punitive toward those who fall short of the standard.

When you ask patients and families, though, many of them are far more understanding when things go wrong than they’re often given credit for. A recent post at Paul Levy’s “Running a Hospital” blog asks the question: Do patients want to punish? Levy, the CEO at Beth Israel Deaconess Medical Center in Boston, concludes that most of the time the answer is no:

The literature on the topic of disclosure and apology suggests that patients and families are not interested in having the doctor or nurse be punished when a medical error occurs, if (and this is an important if) the clinician makes clear that he or she is clearly regretful about the error, is empathetic with the patient, and if the clinician and hospital show that they plan to learn from the error to help avoid repeats with other patients.

Studies that explore how patients and families respond when something goes wrong with their care are still relatively sparse. To date, though, they’ve been remarkably consistent in their findings: Patients and families don’t necessarily expect health care providers to be perfect. What they really want after an error is accountability. The most recent of these studies appeared just last month in the Annals of Internal Medicine. The authors analyzed data from the University of Michigan Health System before and after the establishment of a program to disclose errors to patients and offer them compensation when appropriate. What they found was that the number of claims and lawsuits went down, as did the hospital’s liability costs. Moreover, claims were resolved more swiftly.

Are patients and families upset and perhaps distraught over being harmed by their care? Of course they are, says Linda Kenney, the founder of Medically Induced Trauma Support Services, a Massachusetts program that educates and supports families and health care professionals who have been involved in a medical injury. All too often, though, there’s a lack of knowledge about how patients and families feel and it can be automatically assumed they’re looking for someone to blame, Kenney writes in a response to Levy on his blog:

We don’t give staff the information about the emotional impact and the stages for the patients/families. If we did, they would know that even if a patient/family doesn’t want punishment, ANGER is a normal part of the healing process. We need to start addressing the impact to staff as well. If they can recognize it in themselves, they will be able to recognize the emotional impact to the patients as well.

Jim Conway, who’s a national leader in patient safety, offers this insight: “Errors don’t necessarily erode trust, it’s the way we act after them that can.”

There is a big difference, of course, between accepting that nobody’s perfect vs. using “nobody’s perfect” as a rationalization for the most careless or reckless of errors. Health care is still struggling with how to achieve a just culture, one that recognizes the role of faulty systems in contributing to error yet holds individuals accountable for their own role in providing safe care. There’s a balance here, and I’m not sure the industry has found it yet.

It all begs the question: When health care providers talk about the expectation of being perfect, are they talking about the public or are they talking about their own expectations of themselves? And when they talk about the need to forgive and to recognize that no one is perfect, who is it, really, who needs to forgive whom?

Photo: Wikimedia Commons

Extreme, baby! Carrots.

The new website at is so extreme that my current version of Flash can’t handle it.

Yes, you read that correctly: baby carrots.

The crunchy, innocuous little orange vegetables are taking a walk on the edgy side with a new advertising campaign designed to give them the same coolness factor as junk food. Yes, you read that correctly: junk food.

The Associated Press reports:

A group of 50 producers hopes the “Eat ‘Em Like Junk Food” effort starting [this] week will double the $1 billion market in two or three years.

The goal is to get people to think of baby carrots as a brand they can get excited about – not just a plain, old vegetable. A website,, features metal music and deep male voices chanting, “Baby. Carrots. Extreme.” On social networking site Twitter, the campaign’s account suggests people eat them “like there’s no tomorrow (maybe there won’t be…)”

“This campaign is about turning baby carrots into a brand,” said Jeff Dunn, CEO of Bolthouse Farms, the nation’s top baby carrot producer with 50 percent of the market, and the most to gain if the market grows. “We think ultimately long-term here we’re going to turn it into a very vital brand in the mind of consumers.”

Who knew? I’ve always thought baby carrots were sorta cute, when all along it seems they’ve been yearning to unleash their inner badness.

The $25 million ad campaign, we’re told, will include billboards with the message “Our crunch can beat up your crunch” and colorful crinkly packaging that resembles potato-chip bags. A recently launched page on Facebook already has nearly 1,000 fans and invites the rest of the world, “You already love baby carrots; the only thing left to do now is like us.”

OK, so it’s an advertising campaign whose ultimate goal is to sell more baby carrots. But you have to admit it’s inspired, if not outright ingenious, in the way it taps into American attitudes about food. I mean, think about it: Maybe our subliminal messages with food have been completely wrong. Part of the appeal of junk food, after all, is how it’s packaged and marketed as something that’s fun and exciting to consume. When’s the last time you saw the words “fun” and “exciting” in the same sentence with the word “vegetable”? We’re urged to eat vegetables mainly because they’re good for us. Reverse psychology being what it is, how can vegetables be expected to compete when they’re seen as boringly healthful?

It’ll be interesting to see whether this campaign is successful in transforming the image of baby carrots into something cool and desirable. Perhaps a similar approach could be taken with some of the duller members of the vegetable family – beets, for instance, or cabbage. Eat ’em like junk food; they’re good for you.

Photo courtesy of Crispin Porter + Bogusky