Boys and body image

Is Michael “The Situation” Sorrentino and his fabulous abs really all that? Maybe not, according to the teenage boys who were interviewed extensively for a newly published study on young men and male body images in popular culture.

What the teens in the study mostly wanted was a normal-looking physique – not too tall, not too short, not too heavy, not too skinny, not too muscular and not too scrawny.

Not all boys aspire to the lean, muscular body that’s idealized in so much of popular culture, study author Moss E. Norman said in an accompanying news release.

“In many cases, boys who took part in our study were staunchly critical of idealized male images,” he said. “They found it problematic, feminine or vain to be overly concerned with appearances. Sculpted bodies were seen as unnatural, the products of steroids or zealous weight-lifting.”

The study appears in the current issue of the Men and Masculinities journal. It involved 32 boys, ages 13 to 15, who were recruited from a community center and private school in the Toronto area. Although this is a very small sample group which limits the ability to draw any broad or sweeping conclusions, it may have made up in depth for what it lacked in breadth. The study took place over nine months and consisted of four in-depth interviews and 19 focus groups.

Topics of discussion ranged from health to diet and physical activity. The participants were asked to comment on male images from popular culture, such as Homer Simpson, the shirtless models who appear in ads for Bowflex home gym equipment, and athletes from Ultimate Fighting Championships.

Interestingly, the boys in the study clearly noticed how other guys look, and they had opinions about it. They reported feeling pressure to be physically fit, and they viewed being overweight as undesirable.

They also saw sports as an acceptable way to achieve the “right” kind of male body. “They felt sports could naturally produce a healthier, fitter and more attractive man,” said Norman, a professor at the University of Manitoba. “Sports are used to deflect, obscure and erase their bodily anxieties and desires.”

In other words, they wanted to look fit and attractive – but without the appearance of working too hard at it or caring too much.

Body image among adolescent girls has been extensively studied. It’s only in recent years that more attention has been focused on how boys deal with issues related to their physical appearance. Boys may talk about it less than girls do, but as the interviews with the participants in Norman’s study demonstrate, they do think about body image, and the study adds another layer to what’s being learned. Where teen boys and body image are concerned, looking buff doesn’t seem to matter as much as simply looking normal and fit.

Photo: Wikimedia Commons

Scrimping on health care

More Americans are skipping doctor visits and scrimping on prescription drugs to save money, a new survey has found.

The survey, released today by the Consumer Reports National Research Center, found that the percentage of people who reported cutting corners on their health care rose from 39 percent to 48 percent over the past three years. The poll was conducted this past June and involved a representative sample of 1,200 adults.

The findings reinforce what many observers have been saying all along: Consumers are pressured by health care costs and some of them are opting to delay or forego care, perhaps unwisely.

– 21 percent of the survey participants said they had delayed seeing a doctor because of the cost.

– 16 percent didn’t fill a prescription.

– 12 percent skipped a scheduled dose without first discussing it with their doctor or pharmacist. (The poll unfortunately wasn’t designed to examine whether those who reported skimping on care ended up with health consequences down the road.)

– Survey respondents in lower income brackets were more likely to cut corners than those who earned more.

– Although generic drugs are cheaper than name-brand versions and their use is widespread, 41 percent of the respondents said their doctor only sometimes – or never – recommended a generic. The survey also uncovered misconceptions about generic drugs; nearly 40 percent of the participants expressed concerns about the safety and effectiveness of generic drugs, suggesting a need for more education on this front.

– In most cases, the cost of prescription drugs was not discussed during the visit with the doctor. Two-thirds of the survey respondents didn’t know what their medication would cost until they picked it up at the pharmacy.

– The majority of those surveyed said they were concerned about the influence of the drug industry on physicians’ likelihood to issue prescriptions – but it appears patients also can be swayed by drug advertising. Eighteen percent of the respondents said they had asked their doctor to prescribe a drug they saw advertised, and the majority of the time they received it.

What can patients do to ensure they’re spending wisely on prescription medications? Consumer Reports offers some advice: If you’re concerned about the cost, bring it up with the doctor, especially if it involves a medication you’ll need to take long term. In many cases you might be able to substitute with a generic. Pharmacies also can help with discounts, or help connect you with programs that offer lower-cost prescription medications.

The Consumer Reports survey doesn’t let clinicians off the hook either, noting that they need to be more aware of the financial impact of their decisions. Some studies in fact suggest that nine out of every 10 health care dollars spent in the United States is ultimately determined by health care providers rather than by patients.

Although this survey underscores how cost-conscious many people are when it comes to health care, it makes another point that’s subtle but important: When consumers pay more out of pocket for health care, it might force them to think twice before spending the money but it doesn’t guarantee they’ll be smarter or more well-informed, or that they’ll make better choices. Furthermore, what looks like a short-term cost saving could turn out to be more expensive in the long run, particularly if people are skipping medications they truly need. If the Consumer Reports poll is any indication, there’s still considerable work to be done on how we approach the entire monster issue of health care costs.

Better access to the lab report

Raise your hand if you’ve ever waited a really long time to receive the results of lab tests and then were told only that the results were “normal.”

Under a proposal within the federal health care reform law, all patients could soon have direct electronic access to their lab results – without first having to go through their doctor. The proposed new rules were announced last week by the U.S. Department of Health and Human Services.

Essentially, they’d replace a confusing patchwork of privacy regulations that vary from state to state, and strengthen the patient’s right to see their laboratory test results, numbers and all.

When it comes to health care, “information is power,” HHS Secretary Kathleen Sebelius said last week, speaking at a national information technology summit where the rules proposal was unveiled. “When patients have their lab results, they are more likely to ask the right questions, make better decisions and receive better care.”

Talk about a major shift in how information is shared with patients. A handful of states* currently allow direct access to lab results, but it’s safe to say most consumers usually have to leap hurdles to get their test results, especially if they want actual numbers instead of a vague, all-purpose “fine” or “normal.”

Donna Cryer, who blogs at DCPatient, wrote this week about her surprise at receiving a phone call from the doctor’s office within three days of undergoing some tests. “I say surprising because normally I have to beg, plead, call or at least charm a nurse to get my results at all,” she writes.

The caller announced that the results were “fine.” Now in 27 years with a chronic disease “fine” is not a word I usually heard in conjunction with my blood work, so I asked if I could see them. (note: every patient should do this) “OK” was the quick answer. I could fax or email them to you. Yee Haw!! Now we were getting somewhere.

Patients are continually being told that if they want to receive better care, they need to be more engaged. But it’s hard to see how patients can develop an effective partnership with their doctor when they don’t have access to information as basic as lab test results, or when the only way to obtain it is through the filtered version they receive from the doctor’s office.

Of course, having the information isn’t the same as knowing what it means or what to do with it. Many doctors are ambivalent about sharing the full lab report, often out of a belief the patient doesn’t need to know all the numbers or won’t be capable of understanding them.

Dr. Marya Zilberberg, writing for The Health Care Blog, says that all in all, she’s “looking forward to the liberation of my lab data. What I worry about is all the calls I will be getting from friends and family to help them understand them.”

Some physicians have already raised objections to the proposed new HHS rule. One of them is Dr. J. Fred Ralston, former president of the American College of Physicians, who told InformationWeek magazine, “Lab results often contain a lot of information. A patient downloading many raw lab results over the Internet may be overwhelmed by lots of tiny insignificant tiny abnormalities that could each demand an individual explanation – and cause significant worry until those concerns are dealt with.”

But is this a valid reason to withhold the data?

Although there might be some initial confusion, many patients want to learn more about what their lab results mean and they’re eager to become educated. Overall, the trend is clearly in favor of more rather than less access, with polls and studies suggesting that online viewing of lab results, online scheduling and the ability to email their doctor are increasingly important to consumers, especially those who are younger.

If lab reports are difficult for the average layperson to understand, perhaps this is because they’ve historically been designed with clinicians in mind. One spin-off of improving patient access to lab results might be the development of formats that are more user-friendly to patients.

Allowing patients direct access to their test results also could help put an end to the unsafe practice of “if you don’t hear from us, you can assume all your results were fine.” It’s thought that as many as 20 percent of lab results fall through the cracks because of faulty systems for following up. Sometimes, as in this case or this one, the consequences can be fatal. Opening up the lab report to patients is no guarantee that oversights won’t still take place, but it’s one more backstop that might help reduce lapses in communication.

Who owns the lab results, anyway? The responsibility for ordering and interpreting lab tests still rests with the clinician. But no one has more ownership than the patient and it’s becoming increasingly difficult to justify all the barriers between patients and their lab results.

What do readers think? What experiences or difficulties have you had in trying to obtain lab results? Would you take advantage of direct access to your test results if it were available? Please share your comments in the discussion section.

*Delaware, Maryland, Nevada, New Hampshire, New Jersey, Oregon, West Virginia, Puerto Rico, District of Columbia.

Photo: Wikimedia Commons

Getting practical with medication adherence

If patients aren’t taking their prescription medications properly, maybe the problem doesn’t rest entirely with their level of health literacy or motivation. Maybe what they really need is more help incorporating their pill regimen in their daily routine.

This is the premise of a newly published article in the Nursing Clinics of North America journal, which examines potential strategies for getting people to take their medication correctly.

Medication adherence is a significant issue. Those who study it have estimated that 30 to 50 percent of Americans take their prescription drugs incorrectly, resulting in billions of dollars each year in additional health care costs to treat the consequences. Although it’s a problem that can occur at any age, it tends to be more prevalent among older adults who are more likely to be taking multiple prescription drugs.

Researchers at the University of Missouri examined a collection of previous studies and concluded that much of the effort to improve medication adherence has focused on things such as the patient’s knowledge, motivation and cognitive abilities – and that this approach hasn’t always worked very well.

What they call for instead is a “personal systems approach” – that is, giving people practical ways that help ensure they take their medication correctly.

This could include strategies such as “putting pills next to the coffee maker as a reminder to take them each morning or using technology like cell phones and computers to set reminders to take medications,” Cynthia Russell, an associate professor of nursing at the University of Missouri, explained in an accompanying news release.

The researchers make several concrete suggestions. One of them is creating a routine that encourages and reinforces adherence. Another is involving a supportive family member or caregiver. Monitoring techniques, such as pill-bottle caps with embedded computer chips that record each time the bottle is opened, might also help people stay on track.

There are many, many reasons, of course, for why people don’t take their medication correctly. Sometimes they don’t think they need medication, or don’t want yet another daily pill. Sometimes they’re reluctant to accept the side effects. And sometimes they just can’t afford to fill the prescription.

If you think of this as a continuum, though, these issues tend to cluster at the front end, when the medication is first prescribed. Once the patient has agreed to try the medication, fills the prescription and brings the pills home, a whole different set of challenges arises – namely, the day-to-day routine of remembering to take the medication and taking it as directed.

I’m not a forgetter. I’m very motivated to take my medication, it’s part of the daily routine and over the past six years, I think I might have forgotten only once. (I’m not quite so adherent with veterinary medications, although the issue here isn’t my memory; it’s the prospect of forcing a pill down the throat of a hissing, protesting, unhappy cat.)

For many people, though, forgetfulness and inconsistent routines are significant reasons for falling off the medication wagon. In a study published earlier this year, researchers queried more than 8,000 people who had been prescribed medication for high blood pressure but weren’t complying. The chief findings: “forgetfulness” and “being too busy” topped the list of reasons for non-adherence.

The researchers make a telling observation:

Our findings indicate that events interfering with daily routine had a significant impact on adherence. Medication adherence appears to be a patterned behavior established through the creation of a routine and a reminder system for taking the medication. Providers should assess patients’ daily schedules and medication-taking competency to develop and promote a medication routine.

All of the clinician’s careful work to explain why a medication is needed and how it should be taken can be completely undone if the patient goes home and then forgets, or can’t stick to a routine. When it comes to medication adherence, the practical things really do seem to matter.

Photo: Wikimedia Commons

Gimme my antibiotics!

Dr. Emily Gibson calls it the “Z-pack pas de deux.”

Dr. Gibson, who blogs at Barnstorming, describes the dance this way:

I’m really miserable and need that 5-day antibiotic to get better faster.

Ninety-eight percent of the time it is a viral infection and will resolve without antibiotics.

But I can’t breathe and I can’t sleep.

You can use salt water rinses and decongestant nose sprays.

But my face feels like there is a blown up balloon inside.

Try applying a warm towel to your face.

And so on and so on, until the patient finally complains, “That’s all you can offer?” and leaves Dr. Gibson’s office to go find “a real doctor” who presumably will do what the patient wants and prescribe that Z-pack.

There are many issues on which doctors and patients can clash, and the use of antibiotics is surely one of these flashpoints. Growing concern about overuse and the development of antibiotic resistance has only sharpened the potential for conflict.

But who’s the villain here – patients for being unreasonable and demanding? Doctors for caving in and whipping out the prescription pad? As it turns out, it’s a little more complicated than this.

Although a number of studies suggest that inappropriate use of antibiotics is mostly driven by patient demand, there’s evidence this might not be the driving force everyone assumes it is.

Take this study, which appeared in the Archives of Family Medicine more than a decade ago and involved a survey of parents and adult patients at three Minneapolis clinics who sought relief for symptoms of a cold. Barely half of the adults and only 30 percent of the parents wanted a prescription for antibiotics – and when they did, it was often because their symptoms were more severe and they were worried about coming down with something more serious.

The researchers also uncovered a couple of interesting facts: The adult patients who expected antibiotics were more likely to have been prescribed antibiotics in the past to treat a cold, and many of them were unaware of the rising concerns over antibiotic misuse. This suggests that past experience, coupled with a lack of current information, may be an important factor in patients’ attitudes – perhaps more so than “demand”. “Clinicians incorporating a discussion of the patient’s previous cold-related medical management and drug resistance into the educational component of the visit might preserve a positive doctor-patient relationship while reducing antibiotic prescriptions,” the researchers wrote.

Another study, carried out in Belgium, found that teens and adults who visited the doctor for a sore throat often were in search of pain relief rather than antibiotics per se.

Other studies have found that physicians are more likely to prescribe antibiotics when they perceive the patient wants them – but that these perceptions are often inaccurate. As for the doctor’s fear that patients might complain or become upset at not receiving antibiotics, most of these studies determined that the quality of the time spent with the doctor was the most important predictor of patient satisfaction.

A review in Emergency Medicine News a few years ago sums it up this way:

The preponderance of evidence strongly suggests that physicians should not attempt to base their antibiotic prescribing practices on perceived patient expectations. Not only is this a bad way to practice medicine, but we do a lousy job of guessing what the patient wants. Furthermore, contrary to our assumptions, receipt of an antibiotic (whether expected or not) is not a significant factor in determining whether the patient will be happy with his visit and his doctor.

When to appropriately prescribe and when not to prescribe isn’t always clear-cut, however. The patient’s bronchitis is most likely viral, but what if it’s among the 5 to 10 percent of cases that are bacterial? What if the doctor sends the patient home without antibiotics and the patient gets worse? Are there subgroups of patients who are more at risk – and if so, how should they be identified? Should every patient with bronchitis be tested first to weed out the viral infections and ensure antibiotics are only being prescribed to those who truly need them?

These aren’t easy questions to answer. Guidelines have been emerging to help make more rational, evidence-based decisions, but patients don’t always fit neatly into one-size-fits-all formulas. Clinicians sometimes just have to use their best judgment, and sometimes this means falling back on the familiar habit of issuing a prescription.

Has the increased focus on appropriate antibiotic usage made a difference? Earlier this month the CDC reported on a national sample of antibiotic prescriptions issued in doctors’ offices for children 14 and younger and noted several trends: From 1993 to 2008, the overall number of antibiotics for children in this age group fell by 24 percent. The largest decrease was for sore throats, 26 percent, and colds, 19 percent. Unfortunately there was little significant change in the number of antibiotic prescriptions that continue to be written for children with ear and sinus infections and bronchitis.

The CDC’s rather dispiriting conclusion: This is still “inappropriately high” and indicates that more work is needed to reduce the overprescription of antibiotics to children.

What can the public do? First, it’s helpful to understand the difference between viral and bacterial infections. Antibiotics are designed to knock out bacteria and have little, if any, effect on the viruses responsible for colds, sore throats and other common respiratory ailments. Second, patients can ask more questions in the doctor’s office. If the doctor prescribes an antibiotic, is it necessary or is the physician doing this out of habit? Finally, antibiotics should be taken as directed for the full course of the prescription – no quitting while there are still five pills left, no hoarding for future needs, no sharing with others in the household. Although overprescribing has been one of the major contributors to the worrisome antibiotic resistance spreading across the globe, improper use is a significant factor as well. Hard as it may be, old habits need to change.

A toxic place to work?

Talk about ironic: A new survey suggests that many hospital employees don’t practice what they preach when it comes to staying healthy.

The survey, conducted by the Thomson Reuters consulting group and released this week, found that health care spending for hospital workers was 10 percent greater than for the U.S. workforce as a whole. Hospital employees also were more likely to have chronic medical conditions such as asthma, diabetes, high blood pressure and congestive heart failure.

The report is based on an analysis of health care costs and utilization by 1.1 million hospital employees and their dependents who had employer-based coverage.

I’m not sure what to think of these findings. Are people who work in hospitals really less healthy than everyone else? Or is the real issue that hospitals often are stressful, unhealthy places for people to work?

I once spent a day shadowing a registered nurse. She was on her feet almost all day and barely even had time for lunch.

Multiple studies have documented the occupational stress nurses face every day and the toll it takes on them. Many observers believe the stress is only increasing as the work load intensifies, putting nurses at greater risk of burnout and chronic disease.

But it’s not just nurses who work in stressful conditions. It would be hard to find a hospital employee anywhere these days, from the kitchen to the intensive care unit, who isn’t feeling the pressure to do more with less, to be more efficient and deliver safe, quality services while reimbursement continues to be ratcheted down.

Despite a mounting body of evidence that 12-hour and rotating shifts are associated with fatigue, decreased physical and mental functioning and even lower life expectancy, these schedules are still commonplace at many U.S. hospitals.

Fast meals, often grabbed on the go from a vending machine, can become the norm during a busy day. Even eating in a hospital cafeteria isn’t necessarily the better option, especially when menus are designed to appeal to visitors rather than the workers who eat there every day.

Put it all together and it should no longer be surprising that hospital employees statistically comprise one of the least healthy occupational groups.

When the University of Michigan tackled an initiative in 2002 to develop a wellness program at Allegiance Health in Jackson, Mich., the researchers’ baseline assessment found some of the unhealthiest workers they’d ever seen. Only half of the employees who underwent the assessment were considered low risk; 19 percent were classified high risk.

All of this is to say that it’s usually not enough to tell people they should shape up. The environment must support this as well.

I had the opportunity recently to visit with a couple of local employers about some of the changes they’ve adopted to encourage better food choices and more physical activity among their workforce during the work day. They haven’t been draconian about it; employees can still get a candy bar from the vending machine if they’re really craving a Milky Way. But both these organizations – Affiliated Community Medical Centers and West Central Industries – have become more intentional in their policies and practices: smaller portions for catered meals, more low-fat entrees and fresh fruit and vegetables in the cafeteria, fewer high-calorie snacks in the vending machines, walking programs that encourage employees to log some exercise time each day.

Studies to date have shown mixed results on the benefits of employee health initiatives. The payoff – healthier workers and lower health care costs – generally isn’t immediate; in fact, costs can rise in the short term as issues such as high blood pressure are identified and treated. Corporate wellness initiatives seem to work best when they target the workforce as a whole, not just those who are deemed at risk. They can also be counterproductive if workplace hazards and other environmental barriers aren’t dealt with first.

The lesson here, it seems, is that wellness doesn’t begin and end at home. If we want hospital workers to be healthier, part of the solution will have to come from their employers.

Photo: Wikimedia Commons

The right to fail

It’s the kind of story that probably makes most clinicians grit their teeth in frustration: An 80-something patient doesn’t want medication for her high blood pressure, refuses to follow the doctor’s advice and ends up on the operating table with a life-threatening aortic dissection.

“Oh, if only her stubbornness hadn’t gotten in the way prior to her surgery,” laments Sharon Bahrych, a physician’s assistant who blogs at A PA View on Medicine and recently related her tale at Kevin, MD.

The patient may very well have been stubborn, or unwilling to listen, or skeptical of the benefits of prescription drugs. But what if she just didn’t want to be on medication and was willing to accept whatever negative consequences might ensue?

The discussion about health behavior is generally couched in terms of what’s best for patients and for their health. The assumption is that patients ought to – nay, must – do everything they can to stay healthy – if not for themselves, then for the good of society. Anything less is considered a failure.

But there’s an interesting ethical question here, and it’s one that often gets overlooked: Do patients in fact have the right to fail?

Most ethicists would say they do. In the United States we value autonomy and the right of patients to make their own decisions, even if those decisions have a negative impact on their health.

This principle can clash painfully with the medical imperative to do what’s in the patient’s best interests. What do you do, for instance, if your patient – a homeless man who’s had a small heart attack and needs a second angioplasty – won’t cooperate?

Dr. Sandeep Jauhar writes about this ethical predicament in a case study that appeared some years back in the New York Times:

He had lost faith in his doctors, and that was all he seemed to care about at that moment. He understood that he had a serious heart ailment, that there were treatment options and that he could die if he left the hospital.

I implored him to reconsider but his mind was made up.

Dr. Jauhar wonders: “How far should a doctor go to make a patient do the right thing?”

If you believe in autonomy, the answer is clear: Even the most caring, well-intentioned doctor cannot “make” a competent adult “do the right thing,” especially if the patient and doctor have differing definitions for what the right thing should be.

It’s not always easy to tell when advocacy on behalf of the patient morphs into medical paternalism. Nor is it easy to know where the line ought to be drawn between respecting patients’ wishes and allowing them to walk off a cliff. Online readers debated this question last year at GeriPal, a geriatrics and palliative care blog, in response to an essay in the Journal of the American Medical Association about the elderly patient’s right to self-determination.

“There perhaps is a case that we sometimes take autonomy too far,” reflected one of the commenters. “On the other hand there are probably cases where we are too quick to label a patient’s decision as irrational, because their tolerance for risk is much higher than ours.”

How important is it to preserve someone’s autonomy when others might be affected – for example, a 90-year-old who doesn’t want to go to a nursing home, even though this may be unsafe and will put a considerable burden on the rest of the family?

And who gets to define what’s “best” for the patient, anyway? A few years ago I attended a community meeting about health care costs and chronic disease management. A couple of the clinicians who spoke were frustrated: They’d developed a diabetes education program that patients could attend for a small out-of-pocket fee and learn more about managing their disease. But instead of taking advantage of the opportunity, many patients didn’t even sign up.

You could view this as a failure of personal responsibility to take care of one’s health. But you could also view it as a choice these folks made to invest their time and money in something else that, to them, was perhaps more important.

There’s an uneasy intersection between autonomy and responsibility, between helping patients make wise decisions and dictating what those decisions should be. I suspect the whole right-to-fail issue will continue to be debated for many years to come.

The not-so-clean workplace

I’ve never cultured my newsroom desk or keyboard to see what kinds of creepy microbes might be lurking there. But for all I know, these work surfaces could be crawling with enough pathogens to make me sick.

A recent new survey by the American Dietetic Association and the Home Food Safety program at ConAgra Foods, involving a random online sample of 2,191 adults, produced some interesting findings about germs in the office environment and workers’ behavior:

– A majority of the respondents said they ate lunch and snacked throughout the day at their desk, usually to save time and/or money. But only about one in three said they cleaned their work areas – desk, keyboard and mouse – once a week. Nearly 65 percent cleaned their work areas once a month or less.

– Nearly half of the men and 30 percent of the women admitted to rarely or never cleaning their work area.

– It gets worse: Half of the survey participants failed to wash their hands each time before eating lunch at work.

– And worse yet: Although almost all the workplaces included in the survey were equipped with a refrigerator, the refrigerator was cleaned once a week only about 25 percent of the time. Forty percent of the survey respondents either didn’t know how often the office refrigerator was cleaned or said it was cleaned rarely or never.

– Many of the respondents failed to keep perishable lunch items in the refrigerator or in a cooler; 49 percent said they sometimes left perishable food at room temperature for three hours or longer.

I wash my hands often at work and I keep a bottle of hand sanitizer next to the phone. But I confess to not cleaning the desk surface very often. My excuse reason is practical: Most of the space is covered with towering piles of stuff and it’s too much work to rearrange it.

Research findings from the University of Arizona give me pause, however. Dr. Charles Gerba, a microbiologist, collected a series of bacteria samples at offices in four cities in 2001 and found that the five most heavily contaminated sites were, in descending order: phone, desktop, water fountain handle, microwave door handle and keyboard.

In fact, the average desktop harbored 400 times more bacteria than the office toilet seat, which actually turned out to be one of the most germ-free surfaces, comparatively speaking. Although you’d expect common surfaces such as elevator buttons and photocopiers to be the germiest, Dr. Gerba’s study found that people’s personal space – phones, desks, computer keyboards and so on – was the prime culprit.

In a followup study in 2007, Dr. Gerba made another discovery: Women have three to four more times bacteria on and around their work space as men do, most likely because they so often have food and makeup in their desks. Men didn’t get off scot-free though: Their wallets contained more germs than women’s purses, and their office space also was more likely to test positive for staphylococcus bacteria.

Still want to eat off your desk? Me neither, at least not without cleaning it first with a disinfecting wipe. If good habits help reduce the risk of getting sick from germs in the home, they’re good enough to reduce the risk in the workplace too.

Photo: Wikimedia Commons

This encounter is being recorded

Better not bring your smartphone or pocket-size digital recorder to Dr. David Troxel’s office – and don’t even think about recording your conversation with the doctor so you can remember the details later.

In a guest entry last week at Kevin MD, Dr. Troxel, the chief medical officer for a physician liability insurer, took issue with the practice of bringing a recorder into the doctor’s office:

It is understandably tempting for patients to record consent discussions, medication and follow-up instructions, and other physician and staff interactions.

Recording a medical discussion via video or audio is no proxy, however, for paying attention, and the practice puts you and your office at significant risk.

Video or audio recording should not be allowed in the office setting. It breaches the confidentiality rights of the other patients and infringes on the privacy rights of the physician and employees.

His recommendation to medical practices: Post a sign prohibiting the use of recorders and urge patients to take written notes instead.

It seems to be only a matter of time before someone records a scene in the waiting room or a visit with the doctor or nurse practitioner and posts it on YouTube for the whole world to see. To some extent this is already happening with videos of labor and delivery (and creating a whole set of questions about ethics and patient safety, but that’s a topic for another day). In this sense, the privacy issues wrought by technology are very real.

But not allowing patients to tape their encounter with the doctor to help them remember afterwards?

Many experts in the field of patient advocacy see recordings as a very useful tool for prompting the patient’s memory and helping them recall details of the conversation they may have missed. Most people do not in fact absorb everything that’s said during the encounter, especially if they’re anxious, stressed or have just received a life-changing diagnosis.

Numerous studies over the years have examined the patient’s ability to recall what was said during the visit, and most of these studies have found significant gaps – both in how much patients remembered and how accurately they remembered it. One study, published earlier this year in the Family Medicine journal, found that one-third of the patients in a sample group who received a new prescription during an outpatient visit forgot at least some of the information the doctor gave them.

Conversely, in a Scottish study last year on the quality of informed consent for patients about to undergo heart surgery, patients who received an audiotape of the consultation with the heart surgeon had a better understanding of the procedure and felt more in control.

And check out the feedback on a project being undertaken at the Oliver Center for Patient Safety and Quality Healthcare, at the University of Texas Medical Branch in Galveston, to provide patients with tape recorders to use during office visits: “I forget a lot so this has been really good for me.” “This is helpful since my hearing is poor and my wife’s memory is bad.” “Makes my kids feel involved.”

There’s nothing wrong with inviting patients to take notes the old-fashioned way, via paper and pen. But many people don’t have good note-taking skills, and some patients may not be literate enough to take adequate notes during a doctor visit. A recording can address all these issues in one fell swoop.

The down side is that, like any other technology, the use of recorders in the doctor’s office can create problems of its own. Their presence sometimes has a way of inhibiting the conversation, which may not be in the patient’s best interests. Nor does it guarantee the patient will be more informed or receive better care; this still depends to a great extent on the quality of the encounter itself.

What about the privacy issue, which seemed to be Dr. Troxel’s main concern? As long as one party has consented, audio recording is considered legal in most states. It seems to be generally agreed, however, that if patients want to record their doctor visit, they should do so openly and ask for permission first.

Which brings us back to where we started: how best to use a technology that clearly benefits patients but also might be misused. It seems there’s a deeper issue here and it isn’t merely about the technology; it’s about doctor-patient trust and how this is helped or hindered by allowing patients to record their visit with the doctor. If Dr. Troxel believes patients can’t be trusted to use the technology appropriately, what does that say about his attitude toward patients in general? And if patients feel they need to surreptitiously record their visit with the doctor, what does that say about the relationship?

There may be times when recording isn’t appropriate, but on the whole it seems far better to err on the side of openness than to yank away the usefulness that audio recording can bring to the encounter.

What do readers think? Should recording the doctor visit be encouraged or should it be banned? Have you ever recorded a doctor visit – and if so, was it helpful?

Photo: Wikimedia Commons

An ocean of soda

My reaction to a new report this week that found 50 percent of Americans over the age of 2 consume at least one sugar-laden soda daily: You mean only half of us drink soda every day? In light of the soft-drink cans, mega-liter bottles and Big Gulp containers that seem to be everywhere these days, I thought it would be way more than this.

The report, issued by the National Center for Health Statistics of the CDC, is based on data collected through the National Health and Nutrition Examination Survey from 2005 to 2008. It shows a steady increase in soda consumption among both children and adults over the past 30 years.

The fact that so many Americans consume sugary soft drinks should come as no surprise. The anecdotal evidence is obvious.

What’s revealing about the CDC report is how the statistics break down by age, gender and socioeconomics. Across the board, adolescents and young adults are far more likely to drink sugared soft drinks than senior citizens are. Teenage boys drink the most of all; women over age 60 drink the least.

Consumption of soda (or “pop,” if you prefer) also is concentrated among lower-income individuals.

A few thoughts come to mind:

– If consumption of sugared soft drinks declines with age, perhaps this simply reflects a change in people’s preferences as they get older. On the other hand, the statistics could well be documenting the rise of the Coca-Cola generation – that is, we now have an entire cohort of younger adults who grew up drinking soda and for whom it’s a habit, unlike older adults who came of age when sugared soft drinks were far less prevalent.

It begs the question: As the current crop of 20- and 30-somethings reaches 50 and beyond, will they continue consuming soft drinks at the same rate as they do now? And if so, what might be the consequences for their health as they age?

– That 70 percent of boys ages 2 to 19 drink soda at least once a day isn’t all that surprising. But as is so often the case with statistics, the “why” is harder to pin down than the “what”. Is it peer behavior? Is it somehow related to sports participation? Perhaps it’s simply a guy thing; milk or water just don’t seem to be the beverages of choice among young males.

– Of the many reasons why people in lower socioeconomic groups consume more sugared soft drinks, one might be that these drinks are the easiest to obtain in their neighborhoods. Studies elsewhere have documented the lack of supermarkets in poor neighborhoods. When people don’t have access to fresh food and milk at a grocery store, they turn to convenience stores or discount stores instead, where the beverage selection often is concentrated on soft drinks.

Soda has a long shelf life and doesn’t spoil as quickly as milk – something that matters both to shopkeepers and consumers. Refrigerators in lower-income housing also can be somewhat unreliable, creating further disincentives for families to stock up on perishable milk instead of pop. When a study earlier this summer found that minority parents were more likely than white parents to give their children bottled water, the response of the Minnesota Department of Health’s director of the office of minority and multicultural health was this: Many of these parents may live in housing where the water is rusty or tastes bad. Even though bottled water is more expensive, for these families it’s better than water from the tap. Socioeconomic details can matter a great deal when it comes to health behaviors.

– Efforts to make sugared soft drinks less available in schools and day care have apparently paid off. The survey found that the vast majority of soft drinks being consumed are bought from stores or at restaurants and fast-food establishments. Only a tiny sliver – 1.4 percent – comes from school or day care settings.

There are two ways to look at this. One is that school policies, although helpful at curtailing the availability of soda in schools, have only a limited effect because soda is so widely available from other sources. The other is that school policies might indeed make an overall difference but the effects are subtle and long-term and may not be visible yet.

There’s nothing wrong with a sugared soft drink from time to time. What’s worrisome is the increasing trend toward soda as the beverage of choice, from adults all the way down to 2- and 3-year-old children. The risk of obesity is talked about most frequently but there also are consequences for people’s oral health and risk of tooth decay.

Moreover, when soda replaces milk, kids may not be getting enough calcium for optimal bone strength. Some orthopedic surgeons are beginning to predict an onslaught of fractures when the current younger generation ages into the high-risk years for osteoporosis.

Given how entrenched soda has become in daily life, however, it’s hard to see American drinking habits changing anytime soon.

HealthBeat photo by  Anne Polta