Their cup runneth over

Young adults have never been known for moderation in their drinking habits, but a new study by British researchers suggests there may be more to their behavior than mere youthful recklessness.

When researchers surveyed a group of secondary and university students to assess their knowledge and beliefs about alcohol consumption, fewer than half were able to give correct answers. Most of them didn’t do much better when asked to demonstrate what a “usual” drink should be; they consistently poured more than government guidelines recommend for daily consumption of alcohol.

The findings suggest many young drinkers don’t really know what constitutes sensible drinking behavior, concluded Richard de Visser of the University of Sussex, the lead author of the study. “There may be a need for more and/or different alcohol education in schools and the media,” he said in a news release accompanying the study.

The study appears in the March issue of the Drug and Alcohol Review journal and provides some interesting insight into the ability of young drinkers to estimate the size of a drink.

For instance, university students who participated in a drink-pouring exercise underestimated the size of the drink 65 percent of the time; secondary school students underestimated 52 percent of the time. In many cases, they poured more than the recommended daily guideline but were unable to recognize this. Overall, university students were more accurate in their estimates than the younger students – but even so, they were within 10 percent of the drink’s actual size only 25 percent of the time.

The questionnaire portion of the study also revealed that many of the participants didn’t know the guidelines for safe alcohol consumption and weren’t knowledgeable about how much alcohol is contained in a drink.

This was a small study, involving 309 secondary students and 125 university students, so the findings are limited. It’s also hard to know whether similar findings would apply in the United States, where the drinking culture is different from that in Great Britain.

It’s a little eye-opening to realize, however, the disconnect between what young drinkers see as a standard drink and what a standard drink actually is. If we want young adults to drink moderately, perhaps we need better techniques to help them understand what “moderate” means, the researchers concluded.

Hearts by the numbers

What’s in a blood pressure number?

As I paged through the Parade magazine that arrived with my newspaper this past weekend, my attention was grabbed by Dr. Oz’s health column on page 7, specifically this statement about heart health:

Blood pressure is the largest driver of heart disease; ideally it should be 115/70.

I confess to doing a bit of a doubletake. 115 over 70? What happened to the standard yardstick of 120/80?

It’s not an idle question. High blood pressure is one of the most common cardiovascular conditions, so where the threshold is set is a matter of importance to millions of Americans.

As it turns out, the answer isn’t all that straightforward. Once upon a time, optimal blood pressure was determined by adding your age to a baseline of 100 – a method that wasn’t particularly evidence-based or useful. As researchers tracked large populations to see how they fared over the course of many years, a consensus emerged: People were less likely to have a stroke or heart attack if their blood pressure was maintained at 140/90 or  lower.

This became the goal to which patients and their doctors aspired. But with more research came more nuances. In 2003 the National Institutes of Health identified a new, and lower, “normal”: 120/80. The guidelines also created a category known as prehypertension, defined as systolic readings of 120 to 139 and diastolic readings of 80 to 89, a range previously considered “high normal” but now thought to elevate the risk of heart disease

As a result, 120/80 or lower became the gold standard for successfully managing high blood pressure.

(For an easy-to-read breakdown of the stages of hypertension, check out this chart from the American Heart Association, or this one from the Mayo Clinic.)

So where does 115/70 fit in? Has the threshold for risk been ratcheted down even further, and are we headed for trouble if we don’t achieve these numbers?

Maybe not. Nowhere does this appear to be a new official guideline – not by the American Heart Association, the American Society of Hypertension, the Heart, Lung and Blood Institute, nor the U.S. Preventive Services Task Force, which evaluates the scientific evidence and makes recommendations for clinical practice in everything from pain management for arthritis to the best use of antidepressants.

In fact, there appears to be no such thing as an “ideal” blood pressure value, although there’s certainly a range that’s considered optimal; 120/80 obviously is better for overall health than, say, 160/100. I had to do some online digging but finally came up with the apparent basis for the numbers cited by Dr. Oz: 115/70 appears to be the cut-off point at which researchers have seen no evidence of increased risk for cardiovascular disease.

Is this a number we all should strive for, then? Well, I don’t know. Most American adults – especially those middle-aged and older – are unlikely to achieve that target without serious lifestyle changes, prescription medications or both. What’s more, a too-aggressive approach to lowering blood pressure comes with risks of its own, such as increased likelihood of dizziness and falls, not to mention the increased costs of all those drugs.

To complicate the picture further, evidence has emerged that suggests even prehypertension doesn’t necessarily raise the risk of dying from a stroke or heart attack. A study published last year in the Journal of General Internal Medicine analyzed data from the National Health and Nutrition Examination Survey and concluded that people with prehypertension were no more likely to die prematurely of heart disease than those whose blood pressure was categorized as “normal.” What seemed to matter were the individual systolic and diastolic numbers and the person’s age. Systolic readings consistently over 140 were associated with higher risk among people 50 and older, whereas it was the diastolic number that was more predictive among those younger than 50.

This particular study looked only at mortality and did not attempt to quantify the risk of non-fatal heart attacks and strokes among people with elevated blood pressure. Meanwhile, the state of knowledge is continuing to evolve. The last time the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure revised its guidelines was back in 2003; an update is in the works and scheduled to be released this year, possibly refining our understanding of the picture even further.

It would probably be safe to say that there’s more to blood pressure management than achieving a simple, standard set of numbers. While Dr. Oz’s benchmark of 115/70 might not have been wrong, technically speaking, it’s not the whole story. We’d do well to ask ourselves what these numbers really mean and whether there’s all that much to be gained before adopting this as a new goal.

Afraid to err

There was dispiriting news this week from the patient safety front: Despite efforts by hospitals to create a culture that encourages employees to report their mistakes, many still fear they’ll be punished for doing so.

The U.S. Agency for Healthcare Research and Quality issued a report this month on the state of safety culture in U.S. hospitals. It’s the second such report in five years, and the results show minimal progress in developing non-punitive responses to medical errors.

Survey information was collected from nearly 600,000 workers at 1,110 hospitals across the U.S. Half said they felt their mistakes were held against them, and 54 percent said that when an adverse event was reported, it felt “like the person is being written up, not the problem.”

Two-thirds worried that their mistakes were kept in their personnel file. Less than half were comfortable speaking up and questioning the actions of someone in authority.

Some of the survey findings were downright scary. Nearly 40 percent of the survey respondents said it was only by chance that more mistakes didn’t happen at their hospital. About the same number believed hospital management is only interested in patient safety when there’s an adverse event.

Is this perception or is it reality? It’s a little hard to pin down why so many hospital workers responded to the survey the way they did. Even if their attitudes are based on belief rather than fact, however, the outcome is the same: People don’t speak up if their perception, rightly or wrongly, is that they’ll be punished for it.

It’s not enough for hospitals to say they won’t take the shame-and-blame approach to mistakes – they need to show that they mean it, Brian Sexton told American Medical News in an article published this week.

“They say all politics is local. Well, all culture is local. That’s why it is that we say this is so important and yet we don’t see a lot of traction,” said Sexton, a medical psychologist and director of the Duke University Health System Patient Safety Center in Durham, N.C.

“We’ve given more rhetoric than we have resources to this problem in health care.”

Health care isn’t unique in taking a hard approach to human mistakes, but many observers say blame and punishment seem to be especially entrenched in the culture of hospitals and, to a lesser extent, medical clinics. This isn’t necessarily surprising; after all, the stakes are enormous. Patients can be killed or permanently disabled when things go wrong.

Moreover, many who work in health care expect a lot of themselves and those around them. Maybe the health professions are somewhat self-selecting for people who tend to seek control and perfection; maybe some of these attitudes are born out of rigorous training environments. Whatever the case, they can result in merciless condemnation when the inevitable mistake gets made. Fear of being sued and/or ripped apart by the media adds to the pressure even more.

Consider the anonymous nurse in an online nursing forum who was summoned to a case review after a patient was found unresponsive during her shift. She was quickly exonerated of any misjudgment but the process was agonizing, she wrote. “…This feeling of being a horrible cruel person is not what I ever thought would have happened… to me.”

It’s no wonder people are afraid to report their errors.

But here’s an important question: How much of patient safety is about safe systems and how much of it is about safe practices by individuals? In promoting a blame-free culture in hospitals, is there a risk of going too far in the opposite direction and doing away with accountability for reckless or careless behavior?

A nurse responded to Fierce Healthcare’s coverage of the AHRQ survey with this comment:

What is not mentioned in the study is for how many of the respondents, was this the fifth, sixth or seventh error? Where is the line drawn between reporting errors and a negligent practitioner?

A good review process that everyone participates in, is the way to distinguish between the inadvertent error, perhaps based upon bad process or other mitigating circumstances and the negligent practitioner. That’s the environment that needs to be fostered.

Some balance seems to be demanded – hospital cultures that are neither heavy-handed nor permissive, that encourage openness about their failures yet take responsibility when things go wrong.

Making this happen isn’t easy but it needs to be done, Sara Singer, an assistant professor at the Harvard School of Public Health, told American Medical News. “I don’t think you should give hospitals a free pass on this. Yes, it’s hard – and it’s critically important that they do it anyway.”

A new breed of doctor

Most people probably skipped right over the announcement late last week, but for anyone thinking about going to medical school, it was pretty big news. For the first time in 20 years, the Medical College Admission Test, or MCAT, has been revised.

Starting in 2015, students who aspire to become doctors will be tested on more than just their knowledge of the sciences. They’ll also need to have a good understanding of psychology, sociology and biology and how these forces help shape individual health and behavior.

How best to educate future doctors has long been a subject for debate. Should students be accepted into medical school on the basis of their grades and test scores alone, or should other factors be considered as well? How important is it for pre-med students to have a grounding in non-science disciplines such as psychology or the humanities? Who’s likely to make a better doctor – someone who’s outstanding in science but mediocre in people skills, or someone who’s merely good in science but excellent in people skills?

The MCAT matters because it’s one of the major determinants for who gets into medical school and who doesn’t – and, ultimately, what the future physician workforce will look like.

The revisions to the exam have been brewing for many months and reflect an ever-broadening definition of what it takes to be a good doctor. It’s no longer enough to be a science nerd with a solid background in organic chemistry. As Dr. Darrell D. Kirch, president and CEO of the Association of American Medical Colleges put it, “it also requires an understanding of people.”

The new version of the MCAT adds two sections: one on the psychological, social and biological foundations of behavior, and one on critical analysis and reasoning skills. A writing section has been dropped but the rigor of the science sections remains unchanged, and the test will still be a marathon. It’ll take students about six and a half hours to complete the whole thing, versus the four and a half hours it takes now.

I checked out an online preview guide for the test. Make no mistake, it’s very difficult. Here’s a sample question from the new section on the psychological, social and biological foundations of health: “How does cognitive dissonance explain the occurrence of persistent conformity? Memories change to reduce discomfort resulting from providing answers that differ from: A. answers identified as correct. B. memories of others. C. previously provided answers. D. original memories.” (The answer is D.)

Curious to know what pre-medical students think of these changes in the MCAT, I visited an online student doctors forum, where most of the reaction can be summed up in one word: “Brutal.”

“I think we lucked out not having to take this,” one pre-med student commented.

MedPage Today interviewed an aspiring doctor who had a different perspective. Adam Gardner, 29, earned a master’s degree in international affairs, then decided he wanted to become a doctor. He’s currently loading up on science prerequisites in preparation for taking the MCAT in June.

He said that while he appreciates the idea behind trying to create a more well-rounded doctor who can interact on a deeper level with patients, he worries that the additional test sections may require students like him who decide later in life to go to medical school, to take a greater number of classes in order to prepare for the test.

“Adding these new things to the test could drag this out even longer for people who want to get it done,” he said.

But then again, Gardner said having a knowledge of social sciences would lead to a better doctor-patient relationship.

“I’ve met a lot of doctors … and some of them are pretty cool people,” he said. “But a lot of them are not terribly social and easy to get along with, and I think having a more rounded background will create doctors who can deal with patients better.”

Critics didn’t waste any time weighing in with their reaction to the newly revised MCAT. One of the objections being voiced most frequently is that the heightened emphasis on psychology, sociology and critical thinking skills is too “touchy-feely” and will have the effect of dumbing down the test, thereby lowering the bar for who gets admitted to medical school.

It’s a valid concern. You could just as easily argue, however, that a medical school admissions process that’s structured in favor of the sciences can end up unfairly excluding students who are well-rounded, hard-working, took all the right pre-med college courses, earned good grades, have all the makings of becoming a good doctor but simply didn’t do as well on a science-oriented test.

It comes back to the original question: What are the most important qualities for doctors to have? Knowledge of the sciences will always be critical, but is there room for training programs to also emphasize analytical thought, the social sciences and the underpinnings of human behavior? The new version of the MCAT suggests that indeed there is. In 20 years or so, we’ll find out whether it’s made a difference.

The view from the sidewalk

Way back in the day, I used to bike to work during the summer. The distance wasn’t far and traffic was light. I could leave my bike at a convenient bike rack near the newsroom.

It was a great addition to my daily routine. I saved a ton of money on gas. Better than that, I was in the best physical shape of my life ever.

Nowadays I wouldn’t even contemplate riding a bike to work. Even if city sprawl hadn’t made it too time-consuming to be practical, the traffic is simply unsafe.

City sprawl, you say? Unsafe traffic? In rural west central Minnesota?

Believe it. A new report by the Rails-to-Trails Conservancy challenges the notion that only cities need to think about bicycling and pedestrian infrastructure. In fact, the authors of the report found that in some smaller communities, the number of people who frequently walk or bike is higher than that in cities and suburbs. Moreover, many rural residents see a real need for communities to be bike- and pedestrian-friendly.

In the words of Kevin Mills, vice president of policy and trail development for the Rails-to-Trails Conservancy and one of the report’s authors, “Small communities need safe and convenient walking and bicycling facilities just as much as big cities.”

The full report, “Active Transportation Beyond Urban Centers,” can be found here.

Several statistics leaped out at me. For instance, people who live in towns with a population between 2,500 to 10,000 ride a bicycle to work at twice the rate of those in urban centers. They also are just as likely to walk to work as residents of urban cores. Residents of towns in the 10,000 to 50,000 population range walk to work at a rate almost identical to urban core communities.

Rural Americans care about bike- and pedestrian-friendly infrastructure too. When asked to choose their priorities from a list that included major roads and long-distance travel, they picked sidewalks more than any other need.

The report comes at a time of growing national recognition of the shortcomings of our built environment: All too often, the communities we live in are designed to subtly sabotage our best efforts to be physically active.

About a year ago I joined a group of local public health and law enforcement folks for a “walking audit” of the Willmar Middle School and immediate neighborhood. It’s pretty surprising what you start noticing from a sidewalk’s-eye view: Wide four-lane streets with busy traffic and few pedestrian crossings. No bike lanes or paths. Neighborhood streets with no sidewalks. Pedestrians ignoring the crosswalks. Speeding drivers.

Should it be any surprise that more kids don’t walk to school, or more adults don’t bike or walk to work?

Although we’d like to think that incorporating more physical activity in our daily routines is a matter of choice, the reality is more complicated than this. I’d love to dust off my bike, fix the flat tires and start pedaling to work once again – but I have to weigh this against heavy traffic, the absence of bike lanes and the very real possibility of being crushed by someone’s SUV, and it doesn’t seem worth the risk.

Reducing these barriers in the environment won’t be easy. Infrastructure is costly, and bike lanes and sidewalks face fierce competition for transportation dollars. And how do you retrain two generations of bikers, pedestrians and motorists who aren’t accustomed to safely sharing the road.

It’s therefore encouraging to see these issues being studied and talked about in ways that weren’t happening 10 years ago. Maybe there’s a glimmer of hope for change after all.

Patient satisfaction: Deadly to your health?

Do patients truly benefit when health care providers pay attention to the patient experience?

A rather startling new study suggests otherwise. In fact, researchers found that the patients who were the most satisfied with their care also had higher prescription drug expenditures, were more likely to be hospitalized and more likely to die.

How can this be?

Predictably, many in health care are saying “I told you so.” The increasing emphasis on patient satisfaction as a measure of quality care has never sat well with some clinicians – for instance, the anonymous doctor who offered this online reaction to the study’s findings: “Now that the ‘patient satisfaction’ industry has taken root, we will continue to waste billions and billions of dollars on this each year, money that could have gone towards providing genuine health care.”

It’s a valid question to ask. Intuitively, you’d think that when patients are happier with the care they receive, they’re more likely to have a good relationship with providers, more likely to be engaged in their care, ask questions, follow directions and have better outcomes. But whether this is actually the case hasn’t really been tested rigorously enough to prove it; it’s gut instinct, not science.

Let’s back up for a minute and see what the study says. It was published this week in the Archives of Internal Medicine and involved data on cost, health care utilization and patient satisfaction scores for 51,946 adult U.S. patients.

Among the key findings:

- Patients who reported the highest satisfaction with their care were more likely to be hospitalized than patients who were less satisfied.

- Higher patient satisfaction was associated with higher prescription drug costs and higher overall use of health care services, but lower use of emergency rooms.

- Patients who were the most satisfied had a 26 percent higher mortality risk, even after the study’s authors excluded patients who had three or more chronic conditions and who had self-rated their health as poor.

The authors offer several possible explanations for their findings. Patients often expect – and demand – unnecessary drugs and tests, and they’re more satisfied when doctors cave in and give them what they want, even if this amounts to inappropriate or possibly harmful care, the researchers suggested.

Or maybe patients who received more care also were more reliant on their doctors and hence reported higher satisfaction, although the study’s authors note this doesn’t really explain the apparent connection between higher utilization and more patient satisfaction.

I’m not sure what to make of all this. But with all due respect to folks like uberblogger Dr. Kevin Pho, whose headline this week proclaimed, “How patient satisfaction can kill,” I don’t think this study offers proof that efforts by the health care industry to be more customer-centered are bad for patient care.

Patient satisfaction and clinical outcomes are not the same thing. Although there may be a link between the two, this is a far cry from establishing cause and effect.

Perhaps the real issue is that patient satisfaction, at least in some people’s eyes, has somehow become conflated with giving patients whatever they want. Would patients themselves define it this way? I’m not sure they would; they’re often more likely to use words such as “caring,” “compassionate,” “respectful,” “understanding” and “listens to me” when they describe what makes them satisfied.

Perhaps clinicians are judging on the basis of a different scale. Patients can be surprisingly tolerant of a less than stellar outcome – in other words, more satisfied – as long as they feel they’ve been treated like a human being. Clinicians, on the other hand, might be more apt to see a negative outcome as a failure, period.

Maybe we’re simply not very good yet at measuring patient satisfaction, or we’re using indicators that aren’t particularly meaningful. (Who’s selected to fill out those patient satisfaction surveys anyway? I have never, ever been asked to fill one out.)

If health care leaders focus on patient satisfaction to the exclusion of all else, then yes, it has the potential to be detrimental and even harmful. And clinicians who order drugs and procedures in the belief this is what’s needed to make patients happy (and keep their own satisfaction scores high) are not doing any favors for patient care.

But let’s not allow this study to persuade us to throw out the baby with the bathwater. The collective gut feeling of patients like me is that, on some level, caring about patient satisfaction truly does matter.

What if health care…?

What if health care… was different?

What if health care… was better? What if it was designed to help patients do their best and clinicians do their best?

I regret that I stumbled too late last week upon a Twitter chat, #whatifhc, that started as an impromptu discussion and quickly morphed into an online flash mob of ideas for health care. It would have been fascinating to see the discussion unfold in real time.

@BrianSMcGowan: What if we learned from the best areas of healthcare to improve the worst areas of healthcare?

@Kaylan Baban: #whatifhc wasn’t political?

@Prometheus100: #whatifhc adopted free market traits, such as allowing customers [to] know how much something costs prior to treatment?

@DanBrostek: #whatifhc could embrace digital so my health record wasn’t the manila folder version of George Costanza’s wallet

@produceconsume: #Whatifhc was focused on health, not just on care?

@MeredithGould: #whatifhc Used a common clear language that would help patients & providers communicate challenges, problems & solutions.

There’s more here and here.

You didn’t have to be an expert to join the discussion, and that’s one of the things that perhaps helped make it so lively. What if health care engaged regular folks more often and sought out their ideas?

In the fast-moving world of Twitter, a tweetchat two weeks ago might as well have taken place in the era of quills and parchment. If it’s not too late, though, here’s what I might have tweeted:

- #whatifhc respected what the patient knows?

- #whatifhc allowed patients to help define what the patient experience should be?

-#whatifhc didn’t cost so darn much?

- #whatifhc policy was developed and tested in the real world?

Readers, what would you like to add?

Is the doctor too old?

Here’s a dilemma: The doctor is 83 years old and still seeing patients. There’ve been no complaints – so far – about the quality of his care, yet hospital leaders sense it’s only a matter of time before a patient is harmed.

How do you transition an aging physician out of patient care in a way that’s both dignified and safe? Dr. Kenneth H. Cohn recently asked this question on the Hospital Impact blog, triggering an interesting online discussion about the difficult balance between protecting patient safety and respecting an aging doctor’s skills and knowledge.

It’s not an idle question. Americans are getting older and this includes doctors. “This challenge of guiding aging physicians will come up with increasing frequency over the next decade,” Cohn notes.

Look no further than here in Minnesota, where nearly one-third of all the state’s practicing physicians in 2008 were 55 or older. Slightly more than 7 percent were over the age of 65.

A report produced by the Minnesota Department of Health on the physician workforce notes these statistics about older doctors: 19 percent of doctors who were actively practicing in Minnesota in 2008 (this was the most recent year in which workforce information was collected) said they planned to retire in the next five years and more than 40 percent expected to retire within the next 10 years. But of even more note, 10 percent of the doctors older than 65 planned to work for at least another decade.

American society is starting to redefine what it means to retire, and I suspect we’ll be seeing an increasing trend of doctors continuing to practice medicine well into their 70s and possibly even 80s. The recession also has caused many doctors to rethink their retirement plans and decide to work longer.

It’s not unreasonable to wonder whether older doctors can continue to keep up and still provide quality care.

Consider a New York Times article published a year ago that explores this challenge. It outlines the case of a 78-year-old vascular surgeon whose skills were called into question after a patient died. He remained in practice for another four years until a competency assessment was finally ordered, revealing serious cognitive deficits. The surgeon was asked to surrender his license.

The article cites a 2005 study that found doctors who’d been out of medical school for 40 years were more likely to face disciplinary action than doctors practicing for only 10 years.

Just because a doctor is getting old doesn’t mean he or she is no longer fit for medicine, the article notes. “But physicians are hardly immune to dementia, Parkinson’s disease, stroke and other ills of aging. And some experts warn that there are too few safeguards to protect patients against those who should no longer be practicing.”

The generation gap isn’t a new issue in medicine. I blogged awhile back about the differences between old and young doctors. Which is better – youth, energy and the latest knowledge or skills acquired and refined through years of experience? How do you help aging doctors recognize their fallibility without selling them short?

Cohn asks this question on his blog and got some thoughtful responses. One physician wrote: “I consider [m]andatory [r]etirement blatant age discrimination that opens up the possibilities of legal suits and rests on the premise that after a certain age, a different standard is arbitrarily applied in the physician credentialing process.”

Perhaps physicians past a certain age could be required to undergo a cognitive assessment to ensure they’re still able to practice skillfully and safely, someone else suggested – but neurocognitive tests aren’t always reliable, plus there’s the issue of who would pay for it, he wrote.

Another commenter offered a different perspective. He wrote that he has a neighbor who’s a doctor and is about to turn 90. “He volunteers at a nearby free clinic 2-3 days a week. They use his considerable experience effectively and they have a dialogue regarding limitations of practice. It is rewarding for my neighbor and provides a real and needed service to our community.”

Rather than putting older doctors out to pasture, we should find ways to make meaningful use of their skills and experience, urged another commenter. Helping them stay productive would benefit society and allow aging doctors “to ride into their sunsets with graceful dignity and a sense of fulfillment.”

Regardless of age, most doctors want “meaningful work that makes a difference in patients’ lives, a sense of community, and regular and reliable feedback that affirms their value,” Cohn concluded. But as they get older, it’s a good time to think about how they want to be remembered, he suggested. “Legacy becomes increasingly important when the marginal value of seeing one more patient diminishes.”

Worrying ourselves sick

You have a headache that won’t go away. In search of more information, you Google your symptoms and discover you might have eyestrain or tension. Or food allergies. Or meningitis. Possibly even a brain tumor.

How can the average person make sense of all the health information available on the Internet?

Often they can’t, and it may be to their detriment, suggests an American Medical News article outlining the increased anxiety some doctors are seeing among patients who research their symptoms online.

From the article:

The increase in using the Internet to self-diagnose comes at a time when many physicians are encouraging patients to be more involved in their medical care to help improve health outcomes, particularly for chronic illnesses. Some health professionals say researching medical concerns on reputable websites can be a positive step for patients, because it helps them become more educated about their health. In doing so, patients sometimes accurately diagnose themselves, particularly when it involves common illnesses, such as appendicitis and strep throat, doctors said.

More often, though, the large number of health websites, some of which are unreliable, mislead patients into thinking they have a medical problem, say health professionals. They say the outcome frequently is heightened patient anxiety and unnecessary screening tests that can result in medical complications. Cyberchondria also demands that physicians spend more time in office visits as they discuss why the individual thinks he or she has a particular disease, educate the patient on why that diagnosis is unlikely and then determine the true cause of the symptoms.

I can attest to some of this firsthand. For the past decade I’ve belonged to an online lymphoma discussion group. Lymphoma is one of those cancers whose symptoms are often vague. It isn’t easy for the layperson to distinguish between fevers and enlarged lymph nodes that might be a sign of lymphoma vs. fevers and enlarged lymph nodes that are a sign of something more benign, such as an infection.

On a regular basis, people join the group who haven’t been diagnosed with lymphoma (often they haven’t even had a biopsy yet) but are worried sick they might have it because of what they read on the Internet. Most of the time their fears turn out to be unfounded. In fact, some of the staunch old-timers in the group have started issuing a standard line of advice to these folks: Get off the Internet until you’ve had a chance to talk to your doctor and/or have a formal diagnosis. Some are reassured by this but others aren’t, and their distress can be painful to see.

A little bit of worried-well behavior is not necessarily bad. Sometimes it can prompt people to take necessary action. Sometimes the patient even turns out to be right. At what point, however, does it cross the line?

A question worth asking is whether cyberchondria is just another form of the classic hypochondria, amplified by easy access to online health information. Academic studies on cyberchondria seem to be few and far between. (When I conducted a search via the U.S. National Library of Medicine and National Institutes of Health, I found exactly five published reports.)

The most recent study appeared last month in the Journal of Anxiety Disorders. It explored whether health anxiety is linked to the online use of health information and concluded that yes, there’s an association and that individuals who already have underlying anxiety about their health can become worse the more time they spend researching health information online.

Perhaps this is at least partly a matter of degree. It’s one thing to worry; it’s quite another for the anxiety to escalate into full-blown hypochondria, which can become so obsessive as to interfere with careers, relationships and quality of life.

Among those interviewed by American Medical News was Dr. Rahul Khare, an assistant professor in the Department of Emergency Medicine at Northwestern University Feinberg School of Medicine in Chicago. Dr. Khare said he’s seeing an increase in cyberchondria, especially among young adults who show up in the emergency room after researching their symptoms online.

Patients are “way more knowledgeable” than they used to be, he noted. “But too much information without proper guidance can cause anxiety or fear.”

I don’t think we’d want to return to an era when patients were told a minimum of information and paternally advised not to worry. The challenge these days is just the opposite: learning how to sift through vast amounts of data and figuring out which pieces are relevant and which aren’t. It gives me a whole new respect for what it takes to learn how to think like a doctor.

When the patient complains

She was having surgery the next day and the instructions from the hospital said someone would call the night before to tell her exactly what time the surgery would be. Kristin Baird, a national consultant with the Baird Group on the patient experience and customer satisfaction in health care, waited by the phone that evening… and waited… and waited.

She called the hospital, got cut off, called again, was told to call another number, called and listened to the phone ring over and over before being disconnected. Finally, after half an hour of trying, she reached a live person who took her number and promised to call back.

On her blog this week, Baird describes her frustration: “At that point, I was not only irritated, but I had lost trust in the organization. After all, if it couldn’t answer a simple question, or even answer the phone number I was told to call, how reliable could its staff be in cutting me open and doing the right procedure on the right body part?”

What should the patient do in this situation – complain to someone in charge or keep quiet?

Chances are, most people would say nothing, even when there are valid grounds for complaining. Researchers in Sweden who randomly surveyed 1,500 adults found that fewer than 3 percent filed a formal complaint after something went wrong with their care – but among those who didn’t complain, 18.5 percent felt they had good cause to do so.

The study was published last week in BMJ Open and demonstrates what the authors called “the tip of the iceberg” when it comes to dissatisfied patients: that formal gripes represent only a small portion of the problems and frustrations patients may encounter with their care.

To those in health care, it can seem as though every patient is a volcano waiting to explode at the slightest provocation. When I did a Google search of “unhappy patients,” I found hundreds of articles, many of them written by doctors for other doctors and often conveying the message that, gosh, patients these days are so demanding and unrealistic that no one can ever hope to keep them happy.

To be sure, there are patients who are impossible to please. But this mindset overlooks an inconvenient truth: When patients complain, it’s often a reliable sign that a health care organization is falling short in some area. If patients are consistently unhappy with their surgery results, are they too demanding or has the surgeon been unclear about what the expectation should be? When patients complain that the office staff is rude, are they just being touchy or is there a genuine customer service problem? If a complaint goes unvoiced, should health care providers breathe a sigh of relief or should they see it as a lost chance to build trust with the patient and provide better care?

There’s been an interesting shift in the past decade or so – away from viewing patient satisfaction as nice but optional and toward seeing it one of the essential ingredients in quality health care.

Nowadays we can find people like Mary Pat Whaley, a medical practice management consultant, proclaiming she “can’t wait to hear patient complaints.” Why? Because, Whaley explains, “complaints are the only opportunity managers have to understand the patient’s experience and hear in their own words what went wrong for them.”

Her blog posting on the topic last fall sparked similar sentiments from other medical practice managers. “Clinics should LOVE feedback,” one person wrote. “Otherwise you’re completely at a loss for what the practice’s weak spots are (and every practice has one or more).”

Someone who used to be “terrified” of patient complaints wrote that she now sees them for what they are: “an incredible opportunity to see things through the patient’s eyes and make improvements.”

Whether these positive attitudes are being conveyed to patients isn’t clear, though. Even allowing for cultural differences, the Swedish study suggests that many patients simply don’t, or won’t, complain. The authors uncovered several reasons: People didn’t have the energy, didn’t think it would make a difference, or didn’t know whom to approach with a complaint. In some cases, patients didn’t complain because they were afraid of reprisals. The study also found that when patients had grounds for complaining, those who reported positive health care experiences in the past were more likely to file a complaint than those whose experiences were negative – possibly because they were more confident there would be a response.

Not surprisingly, bad experiences led to less overall trust, setting the stage for poor relationships between patients and clinicians and making patients less likely to agree with or follow recommendations for their care.

Baird eventually did receive a call from a hospital department manager who apologized for the mix-up and told her when to arrive for her surgery. The nurse who admitted her knew there had been a problem and apologized too. The surgery, Baird wrote, “went well and the staff was thorough and confident.”

But trust is fragile and easily broken, she wrote. “… It reminded me that a patient experience is only as strong as the weakest link. Everything about the experience must be safeguarded in order to earn patient trust.”