Monthly Archives: October 2010

Linkworthy 2.3: Halloween edition

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 A roundup of some tricks ‘n’ treats (mostly treats) encountered lately while browsing the Internet.

- Here’s a sweet opener: The New York Times has a conversation with the writer behind the Candy Professor blog and tries to answer the question: Is candy evil or just misunderstood? The opening paragraphs give you an idea of the extreme attitudes Americans can harbor about candy:

For Samira Kawash, a writer who lives in Brooklyn, the Jelly Bean Incident provided the spark.

Five years ago, her daughter, then 3, was invited to play at the home of a new friend. At snack time, having noted the presence of sugar (in the form of juice boxes and cookies) in the kitchen, Dr. Kawash, then a Rutgers professor, brought out a few jelly beans.

The mother froze. Her child had never tasted candy, she explained, but perhaps it would be all right just this once. Then the father weighed in from the other room, shouting that they might as well give the child crack cocaine.

Read the rest. It’s definitely a treat.

- Some treats are a little more complex and not particularly sweet: As the month-long pink ribbon campaign winds down, here’s a thoughtful, and thought-provoking, dual look at how we perceive breast cancer. From the New York Times (again) comes a review of two books. One, “Promise Me,” is the story behind the Susan G. Komen Foundation, arguably the most vocal and well-funded breast cancer advocacy group in the United States, if not the world. The other can be summed up by its title: “Pink Ribbon Blues.” It’s an exploration of the tyranny of positive thinking, the breast cancer marketplace and the scientific uncertainties surrounding screening and treatment for the disease.

The contrast turns on a dime, from inspirational to in-your-face. Dr. Abigail Zuger suggests that both points of view have validity: “The inspirational and the actual, the wish-it-were and the how-it-is; don’t read one without the other.”

- Here’s more food for thought: A nurse practitioner explains why she no longer believes in routine mammograms. I first encountered Veneta Masson’s essay a few weeks ago in the Health Affairs journal and wanted to blog about it. But I got busy and then other bloggers beat me to it. An excerpt from Masson’s essay was even published in the Washington Post, where it was tweeted extensively.

Masson writes, “I shock friends when I admit that I’m no longer a member of the mammogram club.” But far from being heretical, she’s reasoned and articulate – in short, an example of a woman who has weighed the evidence and made a choice. Whether you agree with her or not, this is a treat worth reading.

- Time for a trick, and this is an unsavory one: a compilation of 10 of the worst recent patient privacy violations. (You have to click through a whole bunch of super-annoying links to read about each one, so be patient.) I didn’t have to decide which of these was the worst because the Hospital Impact blog did it for me: health care workers who “shared photos of a dying, nearly decapitated patient in the ER on Facebook for all of their friends – and the world – to see.”

There is a tendency to blame technology for patient privacy breaches, but what about the person who’s using the technology? The real issue here, it seems, is employees who are clueless or unprofessional or immature or venal or all of the above, and can’t (or don’t want to) understand the meaning of patient privacy. I call that scary.

- Is the bad taste gone from your mouth? If so, let’s move on to a final treat. This moving story, about one of the lowliest of hospital employees and the power of human connection, comes from the Notes of an Anesthesioboist blog, written by an anonymous doctor who is an anesthesiologist, mother and ardent oboe player. Her blog was a finalist for the best literary medical blog of 2008. “The Cleaning Guy” was first posted several months ago but it’s a story that’s timeless. Most definitely a treat.

West Central Tribune file photo

Addicted to tobacco

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Society sometimes has little empathy for smokers who are trying to quit their tobacco habit. ”Can’t quit? Try harder. And why did you even start in the first place?” tends to be the common attitude.

Well, after viewing a couple of online clips from a new public television documentary, I see this issue in an entirely different light. “Tobacco Addiction: The Unfiltered Truth” was produced by Twin Cities Public Television and ClearWay Minnesota and premieres on Sunday. Additional air dates and times are planned over the next few weeks.

The filmmakers have taken an unusually compelling approach by seeking out firsthand stories from people who have struggled with nicotine addiction.

These aren’t individuals you would necessarily associate with a tobacco habit. For instance, there’s Brad Piepkorn, who has asthma yet started smoking when he was 17 and hasn’t been able to successfully quit. Brad is an articulate, clean-cut college graduate. Other people, including his boss, see him as an unlikely candidate for tobacco addiction. But as Brad explains, “Anyone can fall victim.”

Then there’s Pamela Gold, a businesswoman and grandmother who managed to quit after 35 years of smoking. Like any other addiction, tobacco can take control and smokers often don’t even realize the extent to which they’re hooked, “because it is a part of our lives,” she says.

Tobacco use, addiction and cessation have been extensively studied. It’s safe to say we know far more than we did 20 years ago or even 10 years ago.

Here’s some of what has been learned:

- The vast majority of smokers start when they’re in their teens, an age when many kids can be rebellious, experimental and vulnerable to peer pressure, or believe it’ll be easy for them to set aside the cigarettes once they reach adulthood.

- Smoking during adolescence has been linked with a far greater likelihood of addiction, possibly due to psychological or pathophysiological factors associated with this stage of human development. Although it’s possible for people to pick up the tobacco habit later in life, it’s much less common.

- Environment seems to matter. Children who grow up in households where at least one adult is a smoker are at greater risk of becoming a smoker too. In the policy arena, smoke-free policies appear to help prevent and reduce tobacco use and motivate smokers to try to quit.

- Youth prevention has the greatest and most long-term impact on reducing tobacco use in the United States. Some of the most successful strategies involve making it more difficult for kids to obtain tobacco, such as raising the cost of cigarettes or placing all tobacco products behind store counters.

- Nicotine dependence often makes it extremely difficult for many smokers to quit. Although the addiction is partly physical, it also contains psychological components. Smokers can find themselves as dependent on their smoking rituals – lighting up the first cigarette of the day, for instance, or their daily smoke break with their coworkers - as they are on the nicotine.

- Failure to quit the first time doesn’t necessarily signal complete failure. Many tobacco users make multiple attempts before they’re able to successfully quit.

- Although some smokers manage to quit by going cold turkey, many need more than this and will probably require some medical help in order to quit.

- Readiness is important. Not everyone wants to quit, and of those who do, not all of them are ready for it. Nor is there a one-size-fits-all strategy for cessation; what works for one person may be less effective for someone else.

There’s an enormous public debate in the United States about health, lifestyle choices and individual control. Many Americans believe it all comes down to individual responsibility but it isn’t always this simple. Perhaps “The Unfiltered Truth,” with its stories of tobacco use and addiction, will add a human, personal and necessary perspective to the discussion.

Photo: Wikimedia Commons

Time crunch

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Good communication can be challenging, especially in the hectic world of health care. And I’m not only talking about the patient’s perspective of feeling rushed through an appointment; it’s hard for physicians too.

What are doctors up against in the typical 10 or 20 minutes allotted to see a patient? Getting patients to understand a diagnosis, for starters. Getting patients motivated to follow through with treatment or lifestyle changes. Not having enough time to really talk to the patient or foster a relationship. Difficulty connecting with the patient. Not having enough time. Difficulty getting an accurate health history from the patient. And did I mention not having enough time?

The latest issue of the Journal of Participatory Medicine contains an interesting study that identifies some of the main barriers standing in the way of shared understanding and shared decision-making between doctors and patients. The authors put together a list of 18 issues and sent out a survey to about 275 doctors in the Canadian province of Manitoba, asking them to rank each item according to how serious a barrier it posed.

The top two? Patients who don’t follow through with treatment or lifestyle changes ranked first, followed by – you guessed it – insufficient time.

When the study’s authors broke the results down further, the greatest individual barrier to shared understanding was having a patient with too many health issues to address. The greatest individual barrier to shared decision-making was having a patient who didn’t trust the physician.

Because the study was conducted in Canada, where the health system is nationalized, it’s not clear if the same results would apply in the United States, although it’s reasonable to think many of the communication challenges are similar. There may also have been other barriers that either weren’t identified or were left off the list.

What leaps out, however, is the extent to which the time factor underlies, or contributes to, many of the communication difficulties doctors have with their patients. If a patient has multiple health issues, it can take more than a 10-minute or even a 20-minute appointment to sort through it all. If the patient presents a rambling and disorganized story about his or her symptoms, it can take time to elicit the highlights. If patients don’t buy into the treatment plan, it might be because they don’t feel they’ve been given enough information or had a chance to ask questions.

As for the whole trust thing, it’s one of the fundamental and necessary qualities for motivating patients to participate in their care, and it’s not something that happens overnight, the study’s authors write: “Trusting relationships are more likely to succeed when developed over time and when they are in the context of a continuous relationship with the provider.”

The authors also have this to say:

Taking sufficient time to discuss the ramifications of the treatment plan in a nonjudgmental way may help to minimize potential risks and facilitate optimum patient wellbeing. Physicians who spend more time with patients tend to have communication styles that result in a greater degree of shared decision making. In contrast, physicians having higher volumes of patients who spend less time with them tended to be less participatory. Both patients and physicians agree that time pressure is a significant barrier to shared decision making.

It’s interesting to speculate on how all of this might be related. Are physicians who spend more time with patients simply better to begin with at communicating and encouraging shared decision-making? If the care is less participatory when the doctor spends less time with the patient, how much of this might be due to the time factor and how much might be due to the physician’s own personality or attitude toward patient involvement?

Longer appointments don’t necessarily guarantee patients will participate more in their care. The quality of the time spent in the exam room or hospital room matters too. But a fair amount of evidence suggests that care is generally enhanced when physicians and patients have more, rather than less, time for discussion, questions and answers. You can’t always hurry health care and expect to get good results.

Photo: Wikimedia Commons

Flu shot refuseniks

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Got your flu shot yet?

Many people have probably already gone through the annual ritual of being vaccinated against influenza, or plan to do so soon. (I got mine today.) Every year, though, there are folks who skip the whole routine.

Their reasons are varied. Many of them don’t think they need a flu shot. Sometimes they’re skeptical about whether the vaccine is all that safe or effective. Maybe they hate needles or don’t like the idea of vaccines, period. And sometimes they have good intentions but it isn’t high on their list of priorities.

Face it, there are a lot of myths about the influenza vaccine, who should receive it and why it’s helpful. The two I hear most often are: 1) “I never get the flu so I don’t need to be vaccinated”; and 2) “I don’t want a flu shot because the last time I had one, it gave me the flu.”

These would both be entirely logical reasons to abstain from the flu vaccine, except for one thing: They’re based on misinformation.

The U.S. Centers for Disease Control and Prevention lays out the facts in an informative Q and A addressing many of the most common misconceptions, starting with the vaccine itself. No, flu shots don’t cause influenza, the CDC explains: “The influenza viruses contained in a flu shot are inactivated (killed), which means they cannot cause infection.”

Yes, people sometimes develop flu-like symptoms after being vaccinated, but the vast majority of the time it isn’t because of the vaccine, the CDC says. Sometimes it’s because someone was already exposed to influenza before being vaccinated, or they were exposed shortly after receiving a flu shot, before the vaccine had a chance to take full effect. Sometimes those flu-like symptoms aren’t influenza at all but are caused by a different respiratory virus not covered by the flu vaccine. And sometimes the three flu strains included in the annual vaccine formula simply aren’t a good match to whatever strains of the virus happen to be circulating.

Like all vaccines, flu shots aren’t 100 percent guaranteed to be effective. Some people, primarily the elderly and those whose immune systems have been compromised, can’t mount a strong immune response and therefore can end up getting sick with influenza, even when they’ve been vaccinated. And in some cases, people can react to a flu shot with fever, muscle pain and weakness – but, according to the CDC, this isn’t common.

There’s one exception, sort of, to the flu-shot-doesn’t-give-you-flu dictum: FluMist, the intranasal version of the vaccine which is approved for use among healthy individuals ages 2 to 49. This form of the vaccine does contain live flu viruses, which is why it’s recommended only for younger people without chronic conditions. The viruses are weakened, however, and pose little risk of causing infection anywhere other than in the relatively cool environment of the nose.

None of this matters, of course, if your reason for skipping a flu shot is because you just don’t think you need to be vaccinated. I’ll let the folks at WebMD’s Cold and Flu Center respond to this one:

First of all, we should all get the seasonal flu vaccine. Sure, if you’re in good health, you’ll probably recover from the seasonal flu just fine. But why suffer through the flu if you can avoid it? Second, protecting yourself isn’t the only reason to get vaccinated.

“Healthy adults forget that while they themselves might be at low risk for getting serious flu complications, other people in their family might not,” says Dr. Christine Hay, assistant professor at the University of Rochester Medical Center. If you have a small child at home, or an older parent, your failure to get yourself vaccinated could endanger them.

And that’s true on a larger, societal level. People with the weakest defenses, like children under 6 months, can’t get the flu vaccine. Their safety depends on the rest of us getting immunized.

It’s more than a little startling that many health care workers don’t seem to buy into the necessity of getting an annual flu shot to protect both themselves and the vulnerable patients with whom they come into contact. From what I’m told, the immunization rate among health care workers here in Willmar is very high, probably because leaders at Affiliated Community Medical Centers, Family Practice Medical Center and Rice Memorial Hospital have made a point of pushing it aggressively. Nationally, though, the rate is only about 44 percent, for many of the same reasons the rest of the public declines to get a flu shot – concerns about effectiveness, misplaced worry about getting sick from the vaccine, and plain old procrastination.

No one should be forced to get immunized for influenza if they genuinely don’t want to. It’s dismaying, however, that this decision often seems to be made on the basis of incomplete or inaccurate information. When the Consumer Reports National Research Center recently conducted a poll among a nationally representative sample of 1,500 adults, fewer than half of the respondents with a medical condition placing them at greater risk of flu-related complications actually considered themselves to be at risk. About one-third of those over age 65 didn’t see themselves at higher risk due to their age. And “even among those who consider themselves at risk for complications, only 56 percent said they’d definitely get vaccinated this year,” the pollsters reported.

If you’re going to be a refusenik, don’t you at least want it to be an informed choice?

West Central Tribune file photo

The burden of low health literacy

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The patient, age 84, was supposed to take daily aspirin and Plavix after having a stent inserted in one of his coronary arteries. Two months later he shows up at the hospital with chest pain. The cardiologist suspects the new stent has become blocked. The patient hasn’t been taking his aspirin. He still has his prescription for Plavix but he never had it filled.

How did this situation happen? A health care professional might draw one (or more) of the following conclusions about this patient: He’s stubborn. He won’t do what he’s told. He’s in denial. He’s lazy. He’s confused. He doesn’t care about his health. He can’t afford the cost of his medications.

The real answer: none of the above, as Julie Rosen, executive director of the Kenneth B. Schwartz Center, relates at the Bedside Manner blog, where she shares this real-life story from a colleague who’s a nurse:

When I offered my patient the newspaper yesterday, he declined. When a patient does not want the newspaper, I see red flags. I began to assess his literacy level. He can write his name. He can write the dates. He recognized the name of the paper but could not read the headlines. I asked him how he keeps track of his medications. He told me one of the staff members at his primary care physician’s office puts his medication in a pill organizer so he knows which ones to take when. Our hospital cardiac nurse educator gave him a booklet (everyone gets the same booklet). It uses the following terms “angina, triglycerides, sodium.” It is printed in Times New Roman, in 11-point font and it uses pictures, but the pictures are not in any context. He handed the booklet back to me saying, “I can’t use this.”

How often have patients been labeled nonadherent or uncooperative when the real issue is that they can’t read well? The incidence would probably be eye-opening; nationally, it’s estimated that 43 percent of the adult population in the U.S. has some difficulty with literacy. This translates into millions of adults – all of them potential patients – who don’t read well enough to comprehend written or online information beyond the most basic level.

Low literacy tends to be an invisible issue. People often hide it or have figured out how to compensate with strategies such as Rosen’s story describes: learning to recognize what the Boston Globe looks like, for instance, even if they can’t decipher the headlines, or using visual reminders to keep track of their daily medication. Their inadequate reading skills don’t necessarily imply they’re unintelligent. Sometimes their schooling has been interrupted, or they have an undiagnosed learning disability. Many youngsters fall behind early in their school career and simply never catch up. Often low literacy is entwined with poverty, mental health issues and language barriers.

Consider, then, how challenging it would be for someone with low literacy to try to navigate the health care system, and to be able to understand and appropriately act on health information in all its complexity.

The stakes are very real. Education and income have long been recognized as key determinants of health status, and literacy is one of the critical factors. Those with lower literacy don’t tend to fare as well, a finding that has been reinforced in numerous studies. The U.S. Agency for Healthcare Research and Quality sums it up in a review of the evidence: “Low literacy may impair functioning in the health care environment, affect patient-physician communication dynamics, and inadvertently lead to substandard medical care. It is associated with poor understanding of written or spoken medical advice, adverse health outcomes, and negative effects on the health of the population.”

Although awareness of health literacy is growing, it’s not clear how well this awareness is filtering into day-to-day patient care. Do physicians, nurses, physical therapists and other clinicians know which of their patients have low literacy? Do they know how to recognize when a patient might lack literacy?

Many providers have made a point of offering educational material in languages other than English, but do they offer printed information that’s designed for lower-literacy readers as well? Do they assess how well the patient understands what the doctor is saying – explaining a diagnosis or a new medication regimen, for instance – or do they just assume the patient comprehends? Are they able and willing to reach out to low-literacy patients with communication strategies that are better suited to help this population, or do they cling to a one-size-fits-all approach?

This is all easier said than done, of course, a lesson that Dr. Hilary Seligman, a physician who works in the areas of health literacy, food insecurity and chronic disease management, reflects on in “Confessions of a Health Literacy Expert.” Literacy is a social issue that’s larger than health care, she writes:

We have to start thinking about health literacy in a broader framework. We cannot approach health literacy in isolation, because rarely do we encounter limited health literacy in isolation. We see limited health literacy in the context of poverty, or dementia, or limited English proficiency, or depression. So our clinical responses to health literacy must be similarly broad.

Unfortunately it’s often not perceived as a very glamorous issue, so the fact that October is National Health Literacy Month seems to be escaping much of the public’s notice. It’s too bad, because it’s an issue that deserves far more attention than this.

Photo: Wikimedia Commons

Not your father’s binge drinking

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Over the past 15 years, an enormous amount of time, money and resources has been poured into the effort to lower the rate of binge drinking in the United States. You’d think it would have made a difference by now – but according to a new report from the U.S. Centers for Disease Control and Prevention, binge drinking remains almost as prevalent as it was in the mid-1990s.

The report, which appeared earlier this month in the CDC’s Morbidity and Mortality Weekly Review, found that binge drinking is common among high school students and adults in the U.S. and that prevention has made few inroads. The study used data from the 2009 Behavioral Risk Factor Surveillance System of 412,000 adults and the National Youth Risk Behavior Survey, involving about 16,400 youths.

Among some of the key findings: About 15 percent of the adults reported binge drinking, defined as four or more drinks on one occasion for women and five or more drinks on one occasion for men during the 30 days preceding the survey. The rate was highest among the 18- to 24-year-old age group.

Nearly one-fourth of the high school students reported binge drinking, defined as five or more drinks within a couple of hours on at least one day during the 30 days preceding the survey. Girls were almost as likely as boys to engage in binge drinking, and the behavior also was more common among students who reported overall alcohol use.

For some reason, binge drinking often doesn’t grab society’s attention to the same extent as other risky behaviors. Nor is it necessarily even seen as risky. When the federal Substance Abuse and Mental Health Services Administration queried nearly 45,000 adolescents about their risk perceptions, the majority of youths saw cigarettes, cocaine and heroin as more risky than binge drinking.

It’s not clear why this is the case. Part of the explanation may lie in community or cultural norms and what’s considered typical adolescent behavior. If the surveys are any indication, the majority of young people in fact do not engage in binge drinking. But many adults have the attitude that “everyone does it, we binged when we were that age and it didn’t hurt us, so what’s the big deal?”

Middle-aged parents can sometimes romanticize their youthful binge drinking days as an adolescent rite of passage. What a lot of them don’t realize is the intensity that’s often associated these days with binge drinking, and the popularity of games such as sloshball and Edward Winey Hands that incite young people to drink far more than they realize or perhaps intend. Debate over what constitutes binge drinking may have further blurred the issue by suggesting that four or five drinks in a row is actually normal college drinking behavior.

There’s a strong consensus in the research that binge drinking is a serious public health issue with implications both for individuals and for society. Multiple studies have shown that people who binge drink are more likely to drive after drinking, have unplanned sex or sustain some type of injury. Students also were more likely to miss class or fall behind in their schoolwork when they engaged in binge drinking. I suspect the same thing happened a generation ago, but the stakes seem much higher now, with many more opportunities for kids to get into serious trouble. In recent years several college students in the upper Midwest have died after leaving parties where they drank too much.

We know much more about brain development than we did even 20 years ago. It’s now known that the human brain doesn’t reach full maturity until we’re in our mid-20s, and that exposure to alcohol, particularly the high levels associated with binge drinking, can have long-term repercussions.

Given all of this, condoning youthful binge drinking as “kids will be kids” doesn’t really cut it anymore.

Photo: Wikimedia Commons

The e-mail barrier

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If you ask consumers whether they’d like to be able to communicate with their doctor by e-mail, the majority would probably say yes. But if you added up the number of doctors who actually offer this option to their patients, it would be very few.

Despite the pervasive presence of e-mail in how we live, work, shop and keep in touch with family and friends, the medical community has been remarkably slow to adopt this form of technology to communicate with patients.

A new national study by the Center for Studying Health System Change attempts to put some numbers on this issue – and to explain the barriers that may be preventing physicians from using e-mail more fully.

Some of the findings were frankly rather startling. For instance, a 2008 survey of more than 4,200 physicians in the U.S. found that barely one-third of these physician practices even had the information technology to e-mail their patients – and among those who did, fewer than one in five actually used e-mail routinely to communicate with their patients.

Granted, these data are two years old. A more current survey might show the numbers have shifted upwards.

Nevertheless, compared to the rest of the world, there has clearly been a significant lag in the adoption of e-mail in medical practice. The health tracking physician survey conducted by the Center for Studying Health System Change found the use of information technology was highest for viewing lab, radiology and other diagnostic test results. Nearly half of the doctors who responded to the survey also used information technology to access parts of the patient record, such as notes or medication lists. About one-third used IT for writing prescriptions.

E-mail came in dead last in the survey, both in its availability and its use.

Some factors seem to predict how likely a physician will be to use e-mail. Practices that are still entirely paper-based, for instance, have the lowest rate of e-mail use. Smaller practices and rural practices also are less likely to use e-mail, as are physicians who are older. How the physician was paid seemed to make a difference as well; physicians who received a fixed salary used e-mail with their patients more often, perhaps because they faced fewer productivity pressures.

Although it’s easy to criticize physicians for being behind the times, the public shouldn’t underestimate how formidable the barriers can be. The HSC report lists the many challenges:

Physician concerns about increased workload without reimbursement, uncertainty about impacts on quality of care, and challenges related to data privacy and security and medical liability have hindered adoption and use of e-mail to communicate with patients.

The survey notes that doctors aren’t necessarily averse to the overall use of e-mail. The survey participants were much more likely to communicate via e-mail when the communication was with another clinician. Also, the survey didn’t look at the extent to which e-mail communication might be delegated to other practice staff. If e-mail with patients is being handled by nurses or other staff, the study might have underestimated how broadly e-mail is used by the practice as a whole, the study’s authors wrote.

It’s clearly going to take some policy change at the federal level to make e-mail a more attractive communication option between doctors and patients. Doctors aren’t going to use it if they’re worried about their liability, and they certainly aren’t going to use it if their clinic doesn’t even have up-to-date information technology. The release this past July of the final rules for Medicare and Medicaid incentive payments linked to “meaningful use” of the electronic medical record may help speed the adoption of paperless systems and foster an increase in e-mail communication. The HSC study’s authors also note that “formal protocols governing message triaging, turnaround time, appropriate use and documentation can help to address physicians’ liability concerns.”

The impact on the doctor’s time is a separate question. Although other studies suggest that allowing patients to e-mail their doctor doesn’t generally result in opening the floodgates (there’s even some evidence it can cut down on telephone calls), physicians are reluctant to add yet another task to their already busy day – especially if they aren’t going to get paid for it. Health plans need to recognize that 21st-century communication isn’t what it used to be, and that innovation and open-mindedness are called for here. Consumers might have to be more open-minded too in their willingness to perhaps pay a little extra to be able to e-mail their doctor.

The big question, of course, is whether e-mail between doctors and patients truly does improve patient care. If it doesn’t, or if the benefit is only marginal, then all of the effort to develop this will have been for naught. Deep down, however, I can’t imagine that e-mail won’t help facilitate and improve the dialogue. Good communication lies at the core of effective, quality health care. Giving doctors and patients another tool for talking to each other can’t help but enhance their ability to provide and receive good care.

Photo: Wikimedia Commons

The healthy Internet

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How often do you turn to the Internet to find health information? If you’re like me, it’s normally the first resource you seek out.

According to some interesting new data from Google, this is far from unusual. Mary Ann Belliveau, Google’s health industry director, recently guest-blogged at CNN about the rise of health information-seeking on the Internet. Among the statistics she shared:

- Health information is “one of the web’s most popular topics.”

- A Google-commissioned study by the research and consulting firm OTX found high use of the Internet among people who researched their conditions online before talking with their doctor. I’ve been unable to find any data on the actual size of this survey or how it was conducted, so the findings are somewhat vague. Here are a couple of key data points, though: The proportion of respondents who looked for information online before seeing their doctor was 75 percent, and 70 percent of the respondents also researched online afterwards to learn more.

- Online search engines were the tool most people turned to first.

- 37 percent of the respondents said they did health-related Internet searches at least once a week.

What information do people most want to find? Belliveau writes: “The No. 1 thing we hear from patients and caregivers is a desire to hear from people in situations similar to their own.”

If the study results are any indication, people aren’t passive about how they use the information they find online. Belliveau writes that 55 percent said they changed their lifestyle or behavior, 52 percent made a self-diagnosis, 49 percent started an over-the-counter treatment, and 46 percent told a doctor about a symptom they or someone else had.

This interest in health-related information also extends to social media. According to the survey, the health category on YouTube was more popular than sports, food or celebrities.

A couple of thoughts come to mind: First, although physicians often gripe about patients who get their health information on the Internet, it’s a phenomenon that’s widespread and won’t go away any time soon. If anything, it likely will become the standard, default behavior among a younger generation that has grown up taking Google and the Internet for granted. Rather than fighting it, health care professionals need to learn to live with it and figure out how they can incorporate it in a way that’s constructive.

Second, the Internet is a bottomless pit when it comes to health information – some of it accurate and worthwhile information but some of it unhelpful, misleading, or overly generalized. Some websites purport to offer health information but in reality are thinly disguised marketing ploys. And sometimes the information that can be found online has no basis in science whatsoever and might be downright harmful.

Some consumers can separate the wheat from the chaff and navigate all of this on their own. Others need help learning how to judge a website’s credibility and what questions to ask. And there’s a whole contingent of consumers who probably just want to be pointed toward one or two of the best websites that contain the information they need.

The Google consumer survey underscores another critical issue: People can and do take action based solely on what they read on the Internet. Reputable providers of online health information need to understand this and make every effort to be accurate and transparent.

No one seems to have clearly defined what the role of medical providers should be in steering consumers toward reliable online resources or helping them understand what they read online. Nor has there been any clear delineation of the responsibility consumers ought to bear for using online information wisely. Maybe it’s a conversation we need to have, sooner rather than later.

HealthBeat photo by Anne Polta

Pink passion

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If it’s October, the color must be pink.

It would be hard to think of a public awareness campaign that has been more successful than the signature pink ribbon of breast cancer. From burly football players to the cartoon artists of the Sunday comics section, everyone is doing the pink thing. The pink ribbon has become one of the most iconic symbols in American culture.

Clearly we’ve come a long way from the era 40 or 50 years ago when breast cancer was rarely spoken of in public and women faced stark choices in their treatment options. But is there such a thing as overdoing the pink message? An increasingly loud chorus of dissent suggests many people are feeling oversaturated, jaded, cynical and resentful.

And the critics certainly have plenty of ammunition. For starters, there’s the blatant commercialism. I’ve learned to get used to the pink foil lids on Yoplait’s yogurt containers, but the fresh mushrooms I saw last week at the store, packaged in a pink carton with a pink-ribbon logo on the label, seemed rather over the top. Does enticing consumers to spend money on pink-themed products actually help promote awareness of breast cancer, or does it mainly line someone’s corporate pockets? How much more awareness do we need, anyway? Does the sale of pinked-up trinkets, T-shirts and other merchandise benefit research? Does it directly support programs and services for screening or treatment for breast cancer? Does it do anything for women who are uninsured or underserved?

Consumers would do well to ask questions before buying into the pink-ribbon marketing, urges Think Before You Pink, a San Francisco-based organization that calls on companies to be more transparent and more accountable in their fund-raising on behalf of breast cancer. In other words, buying pink doesn’t automatically mean your money is well spent.

It’s not just about the hucksterism, though, or the girly feel-good pinkness that threatens to trivialize what is, after all, a serious health issue. The pink tsunami is skewing our perceptions of risk, disease and the populations that are deserving of our attention, writes Mary Elizabeth Williams in an article for Salon magazine titled “The Smug Morality of Breast Cancer Month”:

For over 25 years now, thanks to the efforts of organizations like the Susan G. Komen Foundation  and the Avon Foundation for Women, one of the most pervasive — and deadliest — diseases to strike women has become an important topic for research, detection and public awareness. No doubt all that advocacy has played a part in the sharp decline in breast cancer rates over the past decade, an encouraging sign for all of us who possess breasts — and for our daughters. But as breast cancer awareness becomes an increasingly pervasive branding opportunity, perhaps it’s time to consider what the glut of pink says about our attitudes about the meritocracy of disease, and the ways in which we dispense compassion.

Plenty of other deadly diseases – HIV, alcoholism, melanoma, throat cancer – affect thousands of Americans yet don’t receive the same focus as breast cancer, perhaps because it’s easy to blame these people for their disease, Williams writes. She wonders: “What if we had even a measure of the same generous, unconditional support we give this month to women with breast cancer for those living with less morally unambiguous conditions? What if October wasn’t just pink? Imagine how much suffering we could eliminate.”

The message that the pink-ribbon promoting has perhaps gone too far is not an easy one to convey. Many people simply don’t want to hear it. When a commenter at a NESN sports blog said he thought it was “a little overboard” for NFL football players to wear pink this month, he was told to “shut up.”

Still, there seems to be a groundswell of discussion at a thoughtful level we haven’t really seen before. The New York Times reflected Monday on “pink ribbon fatigue,” observing that in spite of all the awareness and visibility, the battle against breast cancer hasn’t progressed to the degree we think it has. Guest columnist Dr. Barron Lerner writes:

Over 40,000 women still die from breast cancer annually in the United States, and strategies for preventing the disease have received inadequate attention and funding.

It is great to celebrate one’s survivorship from breast cancer, but it would be better to not have to be a survivor in the first place.

A number of readers responded with comments about their own pink ribbon fatigue – comments that were frank in a way we might not have seen even five years ago. One person wrote that she boycotts pink products “because I feel they are nothing more than a marketing gimmick. Companies are playing on the emotion of the ‘pink’ in order to get people to buy their products, which is a sleazy manipulation tactic and belittles those who do have cancer – of all kinds.”

Someone else wrote, ”It’s to the point where I want to say to these perpetrators of the Pink Ribbon culture, “What? Breast cancer? Never heard of it before! Glad you are making me AWARE!”

From another commenter who works for a breast cancer research project:

Sometimes I experience what I call pink ribbon guilt. People pour money into breast cancer organizations, snapping up every processed food and made-in-China tchotchke they come across. All the while the cancers that kill people faster and with more certainty get very little attention in popular media, and therefore get very little funding. The worst pink-ribbon-guilt moment was hearing a melanoma patient relate the story of how she couldn’t get a chair massage at her chemo appointment [because] they were for breast cancer patients only.

It’s ironic that in the span of little more than a generation, we’ve gone from speaking in whispers about breast cancer to creating a din that’s so loud and so chaotic, it’s in danger of stampeding off the cliff.

Passion is an incredible force. It can move mountains. When it’s harnessed in the right way it can change how we think and perceive and behave about health. It would be a bitter injustice if the pink ribbon turned into an empty symbol, and all because we didn’t know how to say “enough.”

Photo: Associated Press

Doc around the clock

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If you’ve ever spent a weekend in the hospital, you couldn’t fail to notice how quiet it was. No surgeries, other than those that are urgent. Fewer tests being scheduled. Fewer staff in the building. The underlying mood that we’ve-all-throttled-back-because-it’s-the-weekend-and-we’ll-get-back-to-normal-on-Monday.

But what if hospitals were ramped up around the clock, instead of concentrating most of their activity during traditional hours? This concept is the focus of an intriguing opinion piece that appeared this past week in the New York Times. The author, Peter Orszag, may be familiar to readers as the previous director of the White House Office of Management and Budget.

It’s been well established that weekends aren’t an optimal time for patients to receive care, Orszag writes:

It’s never good to be hospitalized, but you really don’t want to be hospitalized on a weekend. There are fewer doctors around, and people admitted on Saturdays and Sundays fare relatively poorly.

One study in 2007 found, for example, that for every 1,000 patients suffering heart attacks who were admitted to the hospital on a weekend, there were 9 to 10 more deaths than in a comparable group of patients admitted on a weekday. The weekend patients were less likely to quickly receive the invasive procedures they needed – like coronary artery bypass grafts or cardiac catheterization.

If patient safety is one of the weekend hazards, cost and efficiency are the others. Orszag calls it the “the economics of a $750 billion-a-year industry letting its capacity sit idle a quarter or more of the time.”

“If hospitals were in constant use, costs would fall as expensive assets like operating rooms and imaging equipment were used more fully,” he writes. “And if the workflow at existing hospitals was spread more evenly over the entire week, patients could more often enjoy the privacy of a single-bed room.”

This isn’t just idle speculation. Orszag describes what’s happening at one institution, New York University Langone Medical Center, to provide more care on weekends. At Langone, magnetic resonance imaging and elective cardiac surgery are now available on weekends. The facility’s radiologists read medical imaging studies seven days a week. The cancer center provides some treatments during the weekend. Women planning to undergo an elective Caesarean delivery can now schedule it on a Saturday.

Information being tracked at NYU Langone has uncovered some hitherto-unnoticed issues with how the hospital deploys its resources, Orszag writes.

The dashboard data revealed, for instance, that on any given day a disproportionately small number of eligible patients were discharged before noon, so that many people were kept in the hospital longer than necessary. Further analysis revealed a key reason: several routine procedures that some patients need before leaving, like the insertion of central catheters, were not performed in the morning. The medical center has since begun to offer the procedures earlier, and the percentage of discharges before noon has increased significantly.

Reaction around the blogosphere to Orszag’s column has been, uh, interesting. Many people have seized on Orszag’s opening comments, which in essence said doctors should suck it up and work more weekends, as the equivalent of endorsing involuntary servitude. The response, at least from more than a few health care professionals, could probably be summed up by a blog commenter who said, “My first thought was, yeah, good luck with that.”

I can feel a twinge of sympathy. I’ve worked evenings, weekends and holidays my entire adult life. In the news industry it just comes with the territory and I’ve learned to live with it. This doesn’t mean I always like it, though, and I suspect most people would rather not work evenings and weekends if they can possibly help it. I don’t think this was Orszag’s main point, however.

It’s true there’s idle capacity in health care, particularly among hospitals, and that the normal 8-to-5 schedule doesn’t always match patient need. How many of us have wished we could make a doctor’s appointment in the evening so we wouldn’t have to take time off work? There’s a certain irony in telling consumers to call their doctor for non-urgent problems rather than seek expensive emergency-room care – yet giving them no other option if something crops up when the doctor’s office is closed for the day or for the weekend. There’s a certain irony in advising people to try to avoid being hospitalized on a weekend, yet ignoring the fact that illnesses and injuries don’t happen solely during daytime hours Monday through Friday.

Whether this is enough to justify a shakeup of the industry model is a whole ‘nother question, though. Do hospitals and clinics have the wherewithal to expand their hours into the weekend? How feasible is it, in terms of both workforce and financial resources? Would patients use a weekend service? Would it actually improve patient care and outcomes?

On the other hand, it should be troubling to all of us that patients who are hospitalized on a weekend might not receive the same level of care as on a weekday. And the many little overlooked inefficiencies in the system – such as having no one available to insert central catheters until after lunchtime – are frustrating and frankly make little sense, either for patient care or for the financial bottom line.

Maybe some discussion on these issues has been long overdue. Access to care on evenings and weekends isn’t a new problem that only recently sprang up. There has been a long-standing gap in how care is provided outside traditional hours, and solutions such as urgent care clinics and nurse hotlines, even when they do fill some of the need, are not the total answer. Critics might not like what Peter Orszag is saying but he’s nailed an issue that seems to merit further consideration.