Who’s old? Not I

To someone in their teens or early 20s, anyone over 30 is old. When you’re in your 40s, the 70s seem impossibly ancient. And when you’re 70-something? Well, then it’s the octogenarians who are old.

We think we know what it means to get old, yet our perceptions often are fueled by stereotypes about older adults – and as with most stereotypes, it can end up doing more harm than good.

The down side of pigeonholing older adults was astutely explored in a recent entry at the Covering Health blog. Although it was aimed primarily at reporters, it contains a larger message about what can happen when we categorize older adults as “old” instead of seeing them for what they are: a highly diverse population with diverse needs and in diverse states of health.

For starters, older adults themselves often don’t perceive themselves as old, writes Judith Graham, topic leader on aging for the Association of Health Care Journalists.

She cites a 2009 study by the Pew Research Center that reveals some interesting insights about aging. Here’s one: Of the adults over age 65 who participated in the poll, 60 percent said they felt younger than their actual age, and many said they felt 10 to 20 years younger than they actually were.

Here’s another: There’s a measurable gap between what younger adults expect their lives to be like as they get old – negatives such as memory loss, loneliness, depression – and what older adults report as their own experience.

In other words, despite the stereotypes, aging often isn’t the burden younger adults think it is.

So why do we persist in viewing the elderly as, well, elderly – and, more to the point, what are the consequences of doing so? Some provocative studies have suggested that when older adults internalize the widespread cultural stereotype that to get old means to become frail and diminished, they are more likely to be in poor health and less likely to take care of themselves, Graham writes.

In response, there has been a push to rewrite the script on aging to portray it in more positive terms, she writes. But beware making too many assumptions in this direction, Graham warns:

The danger here is that efforts to create a new narrative focused on the positive aspects of aging – one that centers on activity, wellness, encore careers, volunteering, and having more time to spend with friends, family – risks marginalizing older people who aren’t especially healthy or well off financially.

I’d add that it also risks sending the message that older adults who aren’t as healthy are somehow doing it wrong and are in need of being “corrected.”

To be sure, efforts to create a better, more healthy old age are beneficial, not only to individuals but to the communities they live in as well.The key, points out Graham, is to view older adults as individuals, each with his or her own life story, challenges and desires. When she advises that “there’s no substitute for face-to-face interactions,” she could be talking about the setting of the medical exam room, the hospital room or the skilled nursing facility.

It may take time to encourage older adults to talk about themselves, Graham says. “But I suspect you’ll be surprised by what older people will tell you, if you take the time, suspend judgment and truly listen.”

‘Questions are the answer’

The consensus is virtually unanimous: If they want better care, patients need to speak up. But for many, this is easier said than done.

If three decades’ worth of research on patient engagement is any indication, most people tend to suddenly become silent in the doctor’s office. Some studies put the average number of questions asked during the appointment at only two.

How to change this?

Encouraging people to ask more questions and giving them some tools to get started with question-asking behavior is the focus of a newly launched campaign by the U.S. Agency for Healthcare Research and Quality, It’s called “Questions Are the Answer,” and it’s based on a solid body of evidence that when it comes to safe, effective health care, communication matters – not only communication by the doctor but by the patient as well.

The AHRQ campaign is the latest in a widening national effort to better equip patients to become active partners in their care.

What can happen when patients are too passive about asking questions? They could have the experience of Alastair McGregor, whose story appears on the AHRQ website in a collection of videos featuring patients and clinicians. McGregor’s heart rate was excellent but he had high blood pressure, so his doctor prescribed medication to lower it. Unfortunately the medication led to an increasingly irregular heart rhythm – which McGregor didn’t report to the doctor until he wound up in an emergency room.

Lesson learned: If there’s a problem, bring it up, McGregor tells viewers. “This is not a question of just taking my car in to have the oil changed, and sitting there while it’s being done,” he says. “This is me. I happen to be the car.”

The AHRQ campaign makes another key point: These days, good clinicians want their patients to ask questions. The health care team can’t address the patient’s concerns or provide appropriate care if the patient doesn’t speak up, the website points out.

Because it’s all too common for patients to be unsure of what to ask, the AHRQ website offers a list of 10 “starter” questions: What is this test for? When will I get the results? How do you spell the name of that drug? What are the potential side effects?

There’s a cool Question Builder tool that helps patients prepare for a doctor’s appointment by identifying and prioritizing the questions they want to ask. There also are tips for questions to ask during the appointment itself and for following up afterwards.

It would perhaps be unrealistic to think the “Questions Are the Answer” campaign will be, well, the total answer to getting more patients involved in their care. There are plenty of other reasons why patients are reluctant to speak up – feeling rushed through their appointment, not wanting to “bother” the doctor, fearful of looking stupid or having their question ignored or trivialized. Sometimes patients don’t ask because they’re afraid the answer will be something they aren’t yet ready to hear. Sometimes it comes down to health care culture and the openness (or not) of individual clinicians to listening to what their patients have to say. Language and literacy barriers are additional obstacles that aren’t easily overcome.

Instilling confidence in people that their questions are expected – welcomed, even – seems like a major first step, however.

If more proof is needed of the importance of asking questions, consider this: Studies clearly demonstrate that when there’s good communication between doctor and patient, health outcomes are generally better. Exactly how this works isn’t entirely understood, but researchers have measured greater trust, more agreement on the plan for the patient’s care, higher-quality medical decisions, increased adherence and greater shared understanding than when communication is lacking. Moreover, asking questions is considered one of the hallmarks of positive information-seeking behavior by patients.

The only truly dumb question? It’s the one the patient wants answered but fails to ask.

Undermining the patient

The way some people tell it, most patients are ignorant, unmotivated consumers of health care who’d rather seek the opinion of a doughnut vendor in the hospital lobby than do the actual research it takes to find a qualified doctor.

Harsh words? They come from Dr. Jon Cohen, a vascular surgeon and chief medical officer at Quest Diagnostics, who spoke last week at the annual TEDMED conference in Washington, D.C.

Among some of the excerpts from his talk: The average American spends more time deciding which TV to buy than choosing a physician. Consumers are more likely to judge the quality of their health care on the basis of service – whether the parking was convenient and how long they spent in the waiting room – than on the basis of the actual care they received and whether it was clinically appropriate and effective.

Finally, most people just aren’t motivated enough to be good consumers of health care, Dr. Cohen concluded. “Consumer-driven health care doesn’t work because people don’t want health care.”

Ouch.

There’s some truth to this. But in saying it, Dr. Cohen has unwittingly exposed the gulf that often lies between patients and health care professionals – namely, that they approach the patient experience from entirely different perspectives and an entirely different fund of knowledge. And it’s a mistake to write off the patient’s behavior as uninformed or unmotivated or unconsumer-like without considering the validity of the health care experience from their point of view.

The TEDMED folks unfortunately haven’t yet posted a video of Dr. Cohen’s speech, so I’m relying here on secondhand reports of what he said. I’m going to give him the benefit of the doubt by assuming he meant to give his audience some food for thought rather than bashing on consumers.

But the whole tenor of his talk raises some pretty interesting questions: If it’s so hard to get Americans to think like well-informed, thoughtful health care consumers, whose fault is it (if, indeed, “fault” is the word we want to use)? If people aren’t better health care consumers, is it because they don’t want to be, or is it because they’re being held back by how the current system functions? If patients make decisions on the basis of different values and beliefs than clinicians, does this invariably make them wrong?

A glimpse of the online reaction that emerged this weekend in response to the TEDMED conference suggests people feel rather strongly about the issue. A commenter at the Wall Street Journal called it “a typical paternalistic surgeon perspective. Everybody is dumber than they are, and nobody can make a decision as well as they do.”

“Let’s get real here,” opined someone else. “If the consumer had transparency into key drivers like, quality, cost, access and could have a ‘real’ discussion with care providers then maybe the average consumer could become a good health care consumer… The insurance companies, pharma companies and the provider communities need to check their ego at the door and actual[ly] SERVE their patients as CONSUMERS.”

Bunk, argued another commenter. Patients don’t behave like consumers because their health insurance cushions them from the cost of their care and they have no financial incentive to shop around for quality or cost-effectiveness.

The mHealth Insight blog has another point of view: “I don’t think we should be blaming the key stakeholders (patients) for the way they make choices but focusing on the failure of healthcare providers to bring transparency to the services they offer.”

For what it’s worth, I suspect a lot of people want to become more informed as patients and health care consumers. No, wait, make that: I know a lot of people want to become better patients and health care consumers. But the system doesn’t make it easy for them, and I think Dr. Cohen is dead wrong in his assertion that “intense desire trumps all barriers” to becoming good health care consumers.

Whenever the topic turns to patient empowerment, it seems to stumble into a double bind: Patients are told they should be more engaged and involved in their care, yet they’re given few tools for doing so. They’re lectured for not doing more yet the expectations are often set woefully low on the assumption they’re not smart enough to get it anyway (the assertion that most people don’t really want to be good health consumers being a case in point). One minute they’re exhorted; the next, they’re undermined.

Could patients do more to educate and advocate for themselves? Of course they can, and should. Sheer desire isn’t always enough, however, to overcome systemic barriers and the weight of a health care culture that’s still of two minds whether to accept that patients are indeed capable of becoming more involved partners in their care. If patients are falling short at being good health care consumers, it would seem there’s plenty of blame to spread around.

Photo: Wikimedia Commons

When families clash during the doctor visit

Family togetherness is usually a good thing but sometimes it’s a source of conflict, and new research suggests doctors can be slow to recognize when families disagree about the best course of care.

A small-scale study involving patients with advanced lung cancer, their oncologists and caregivers found that the doctors didn’t always notice differences of opinion between patients and families.

In interviews conducted separately with the participants, the researchers found that most of the time, patients and families did agree on important care decisions such as extra tests or options for hospice care. And most of the time, the doctors correctly perceived there were no conflicts between the patient and caregiver.

But in seven cases in which a patient reported conflict with a family caregiver, the doctor picked up on only two of them. Of the 17 cases in which a caregiver reported conflict, five of them were recognized by the doctor. And in the 15 instances in which both the patient and caregiver separately reported some kind of conflict, only two of them were recognized by the doctor.

This was a very small study but the implications are intriguing.

Do the findings mean doctors are often obtuse about what’s going on between patients and caregivers? Sometimes they are, perhaps. “This is not something that oncologists regularly explore with patients,” Laura Siminoff, of the Virginia Commonwealth University School of Medicine and one of the researchers, told Reuters News.

But it’s equally likely that patients and families often hide their disagreements when they’re in the presence of the doctor. Maybe patients are uncomfortable bringing it up, especially if a family member is in the exam room with them, or maybe they don’t want to bother the doctor with something they perceive as trivial, Siminoff suggested.

There’s a bigger question here, though: Does family involvement help or hinder patient care?

Experts in patient advocacy are unanimous in believing patients fare better when they have a family member or caregiver who’s committed to helping them manage their health and who can advocate for care that’s in their best interests. There’s been considerably less focus on how to deal with families who disagree or don’t function well together.

American Medical News recently explored this topic and what it means for the clinician who’s sometimes caught in the middle:

Even as the push toward the patient-centered medical home stresses the invaluable role that families can play in improving compliance and health outcomes, the presence of a relative raises a host of complicated issues for physicians to navigate.

“Now you’ve got potentially two patients in the room,” says Jason Karlawish, MD, professor of medicine and medical ethics at the University of Pennsylvania School of Medicine. “You even have a kind of third patient, which is the relationship between the family member and the patient. If you ignore that, you ignore it at your own peril.”

Some examples of how the dynamics can get complicated: The patient might not want the family member in the room but is too polite or too intimidated to say so. Family members might have an agenda that conflicts with that of the patient. Relatives who are distrustful might second-guess or undermine the doctor’s assessment and recommendations.

The visit doesn’t have to get adversarial to be difficult, noted the physicians interviewed by American Medical News. Sometimes well-meaning family members simply take over the discussion, talking on behalf of a patient who’s perfectly competent to speak for himself or herself. Or they might appeal to the doctor to take sides in a family dispute over health behaviors, such as a spouse who doesn’t want to stop smoking or an aging parent who doesn’t want to take a medication.

The biggest mistake that can be made, according to Dr. Yul Ejnes, an internist in Cranston, R.I., is “to forget that the patient is the boss.”

Conflict can be magnified a thousandfold in high-stakes situations, such as when end-of-life decisions need to be made. The study involving the lung cancer patients and their caregivers and oncologists didn’t look at whether disagreements – and the doctor’s lack of awareness of them – had an impact on care, but Reuters Health spoke to experts who said the discord often raises the family’s stress level and can complicate the process of making treatment decisions.

Dr. Anthony Back, an oncologist at the Seattle Cancer Care Alliance, said it’s important for oncologists to notice the cues and to call in a social worker or therapist to help resolve family differences. “Sometimes those things are beyond the purview of the oncologist,” he said. “But when (patients and caregivers) have some major issues, they need to figure it out and we have other resources for them.”

Primary care’s bad rap

Primary care’s often-negative reputation as stressful and unrewarding apparently starts early in the medical education process – possibly before students even enter medical school, a recent study has found.

The study appeared earlier this year in the Family Medicine journal. More recently, the findings and their implications for family practice medicine were explored in an interview by the American Academy of Family Practice with one of the study’s authors, Dr. Julie Phillips. an assistant professor of family medicine at Michigan State University College of Human Medicine.

Primary care has struggled for several years with perceptions that it’s boring, stressful, demanding, low-paying and hemmed in with constraints on everything from insurer requirements to time pressures in the exam room. Whether this is perception or reality, it has had an impact: Fewer students who enter medical school are choosing a career in primary care.

The authors of the study wanted to learn more about how primary care is perceived by medical students and whether their perceptions are changed by what they experience during their training.

Surveys were conducted among 983 medical students at three medical schools between 2006 and 2008. The students were asked to rate statements such as “primary care physicians have too much administrative work to do” and “time pressures keep primary care physicians from developing good patient relationships.” Similar questions were posed about the students’ perception of specialty physicians.

Perhaps the most eye-opening conclusion of the study is this: Negative views of the daily routine of primary care were already present in many of the students at the beginning of their training. What’s more, these views didn’t really change as students progressed through medical school, even after they had a chance to directly observe and participate in patient care.

What to make of these findings? It’s clear that “contemporary physicians struggle to meet the high expectations set by patients and their profession with limited time and resources,” the authors wrote. “Our date demonstrate that students are paying attention to the struggle.”

The results were “kind of discouraging,” Phillips told AAFP News Now. She said she also was surprised that the students’ perceptions were formed so early. “That makes me think that some of their views of what it’s like to be a doctor actually don’t come from medical school but from the larger cultural perception of what physician work is like – and especially what primary care is like.”

There were some glimmers of hope. Students who completed a primary care clerkship (typically during the third year of medical school) and had seen real-life primary care in action were more positive about the ability of primary care doctors to develop good relationships with their patients, in spite of the time constraints in the exam room. “It may be that actually spending time observing physicians helps to break some negative stereotypes,” the study’s authors noted.

The researchers also learned that some students will choose primary care regardless of their perceptions about the daily grind. This suggests that individual values and goals play an important role in the career choices of medical students, the authors wrote. “The study reinforces the importance of admitting students with primary care-oriented values and primary care interest and reinforcing those values over the course of medical school, if we are to produce greater numbers of primary care physicians.”

We’ve come a long way from the romanticized ideal of the family doctor that prevailed a generation or two ago. But did the ideal ever really match the reality? If you talk to physicians privately, some of them will admit there’s a great deal of grumbling about the profession and not enough focus on what makes it rewarding. To be sure, there are all too many reasons for doctors to be frustrated and exhausted and discouraged, but at what point do the negatives start to drown out everything else?

Phillips challenged the medical profession to become more involved in supporting new models of care, such as the patient-centered medical home, that can breathe new life into primary care and make it a better career choice. Family doctors also should try to share what’s good about their specialty, she said. “Students listen to what we say. We should try to be positive about the great things in our everyday work, because there are many wonderful things about being a family physician.”

Doctor, heal thyself

Do doctors who are carrying a few extra pounds shy away from advising overweight patients to lose weight? Are they less likely to counsel patients about making lifestyle changes – eating broccoli, being physically active – if they don’t follow the same advice in their own lives?

An interesting new survey presented last month at a meeting of the American Heart Association suggests that physician health plays a role in how they talk to their patients about a healthful lifestyle – and that when doctors don’t practice what they preach, it might be to the detriment of their patients’ health.

The survey was carried out among 1,000 primary care doctors. Among the findings: 27 percent said they exercised at least five days a week and 39 percent reported eating the recommended five servings of fruits and vegetables per day. Only 4 percent said they were smokers.

The survey comes on the heels of a study earlier this year, published in the Obesity journal, that found doctors who were overweight or obese were less likely to talk to their patients about weight loss than doctors with a normal body mass index. A similar study that appeared in 2010 in Preventive Cardiology reached the same conclusion: Doctors who exercised regularly and were at a healthy weight were the most comfortable discussing lifestyle behaviors with patients.

American Medical News spoke recently about this issue with Dr. Jo Marie Reilly, a family physician and associate professor at the Keck School of Medicine at the University of Southern California. Her take: “Practicing what we preach is important. Physicians are just more aware and better able to counsel patients if they take care of themselves.”

There’s certainly something to be said for being a good role model, and that includes health care organizations as well as individuals. It doesn’t send the right kind of message when the hospital cafeteria menu is loaded with high-fat, high-calorie food, or when patients can glimpse the staff at the medical clinic clustered in the loading dock for a smoke break.

The doctors in the Obesity journal study seemed to sense that “do as I say, not as I do” can create problems in caring for patients. Physicians of normal body mass index who participated in the survey had higher confidence in their ability to offer lifestyle counseling. They also were more likely to think that patients wouldn’t trust weight-loss advice coming from an overweight doctor.

One conclusion that might be drawn is that patients with less-than-ideal lifestyle behaviors tend to get a free pass from doctors whose own behavior doesn’t match the ideal and who are thus reluctant to bring up the subject in the exam room. In other words, they don’t want to appear hypocritical, even if remaining silent isn’t in the patient’s best interests.

But there’s another way to look at this. Perhaps doctors who struggle in their own lives with weight, nutrition and activity are more sensitized to how patients might feel about lifestyle advice, and more apt to be accepting when patients fall short.

Although the studies didn’t examine how patients perceived normal-weight vs. overweight doctors, it raises the question: Do patients truly resent it when an overweight doctor tells them to lose weight? Some of them surely do, but others might feel an overweight doctor is better able to identify with and understand the difficulty of making lifestyle changes.

One also has to wonder where to draw the line. Should a physician who has depression (and, sadly, the incidence of depression is higher among doctors than the population at large) counsel patients about their mental health? If the doctor drinks, is it hypocritical to talk to patients about problem alcohol use? Is it OK for a doctor to refuse a flu shot? To be seen in public eating a burger and fries? By these measures, everyone in the medical profession has probably been a hypocrite at one time or another. It doesn’t necessarily make them bad doctors; it makes them human beings susceptible to the same struggles that confront every other mortal.

What seems to matter is how the conversation is framed, suggests Dr. Reilly. Even when doctors aren’t perfect, they can still help patients by talking about their own struggles with weight or other issues. And they can take the time to have the discussion about lifestyle habits if that’s what patients need, she told American Medical News. “It’s really important that we take that time to counsel patients about how their health habits influence their lives at every visit, and that we look at that as important as any medication,” she said.

‘The patient is on fire!’

December 2011: A 29-year-old woman is undergoing minor facial surgery at an outpatient center in Florida when a flash fire erupts. She sustains burns to the face and neck and is airlifted to a burn center.

October 2011: A 68-year-old California woman’s oxygen tube catches fire while a surgeon is cauterizing a wound in her neck. Five months later, she’s still recovering.

September 2009: A woman from Illinois, age 65, dies six days after being severely burned in a flash fire during a biopsy. The hospital subsequently revises its safety policies and puts mandatory training in place for all surgery staff.

Of all the things that can go wrong in patient care, surgical fires are among the most horrifying – so much so that the U.S. Food and Drug Administration recently launched a prevention initiative to educate health care organizations about the causes of surgical fires and provide them with risk reduction strategies. The initiative includes a number of prominent partners: the Anesthesia Patient Safety Foundation, the Institute for Safe Medication Practices, the Joint Commission, the Veterans Affairs National Center for Patient Safety, the American Academy of Orthopaedic Surgeons, the American Society of Anesthesiologists and the American Society of Nurse Anesthetists, among others.

Surgical fires are thought to be rare. Some estimates put the number of surgical fires  at 600 to 650 a year out of millions of surgical procedures performed in the U.S. Other studies have suggested they’re much less common, citing fewer than 100 a year. But because many states don’t require hospitals and surgery centers to report them, the true incidence is unknown, and surgical fires in the U.S. likely are significantly underreported.

What’s more, most patients and families are unaware of the risk. Ann Grice, the mother of the Florida woman whose face was burned last December, told the Crestview (Fla.) News Bulletin in an interview shortly afterwards, “I am in shock. This is not what happens with a routine outpatient surgery.”

After the death of her mother in 2004 following a surgical fire and subsequent severe complications, Cathy Reuter Lake founded SurgicalFire.org, a nonprofit organization dedicated to raising awareness and providing information about this underrecognized risk.

“While many people have never heard of a surgical fire inside a patient, it happens more frequently than you might think,” Lake writes on her website. “Exact statistics are hard to uncover due to under-reporting and efforts to cover up surgical fires for fear of malpractice suits.”

Regardless of how often they occur, fires that break out in operating rooms are frightening, both for staff and for the patient – the more so since the consequences can be so deadly. Surgical fires also can injure the staff in the OR, damage or destroy expensive equipment and put a surgery suite out of commission due to smoke or water damage or worse.

ORs present a uniquely hazardous environment for triggering flash fires. They contain numerous instruments capable of touching off a fire: surgical lasers, electrocautery units, heated probes, fiberoptic light sources, drills, defibrillators and so on. They contain fuels such as surgical drapes, sheets, mattresses, bandages, alcohol skin preps and breathing circuits. Finally, they’re typically rich in oxygen, which makes it easier for a fire to break out and causes the flames to spread faster and burn hotter.

Based on data collected and analyzed by the FDA, the Joint Commission and the ECRI private research group, the majority of surgical fires have several things in common. Electrosurgical equipment and lasers account for the most frequent ignition sources, and an oxygen-enriched atmosphere was a contributing factor in nearly three-fourths of the cases that were studied. Burns to the patient were most likely to involve the airway, head or face.

The most critical conclusion: With proper precautions, surgical fires are almost 100 percent preventable.

One of the outcomes of the FDA initiative has been the development of a series of recommendations to reduce the risk of surgical fire. Surgery teams are advised to be judicious in their use of supplemental oxygen and to avoid allowing oxygen to accumulate around the surgery site. After alcohol-based skin preparations are applied, the patient’s skin should be allowed to dry before being draped and starting the procedure. Surgery teams should exercise caution in how they wield electrocautery devices, lasers and other tools and how they place them when not in use. Finally, the OR should have a plan for what to do if a surgical fire does break out.

None of this might be very reassuring to patients – and indeed, it’s exceedingly difficult to patients to advocate for safety in the OR when they’re under anesthesia. Nevertheless, there are a handful of things patients can do ahead of time, starting with awareness of the risks and the knowledge that these types of fires are almost entirely preventable.

The Empowered Patient Coalition suggests asking questions: Is the OR team at the hospital or surgery center trained in preventing, recognizing and putting out surgical fires? What precautions do they use to protect patients? Are water and carbon dioxide fire extinguishers readily available in the OR? Vague or unsatisfactory answers may mean the patient is better off choosing somewhere else to go for surgery.