Category Archives: ethics

Doctor, heal thyself

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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.

Is the doctor too old?

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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.”

Fessing up to tobacco use

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It’s a question many of us are routinely asked during a visit to the doctor: Do you smoke or use tobacco?

Ideally, nothing less than the truth should suffice – but according to a newly released poll, about one in 10 people opt to conceal their smoking status from their health provider.

The survey, which involved 3,146 American adults who were either current or former smokers and was conducted by Legacy, a national public health organization, offers some interesting insight into the evolving social attitudes surrounding tobacco use – namely, a stigma that seems to be making it harder for some smokers to confess their habit to a doctor. About 13 percent of those who participated in the poll said they didn’t tell their doctor that they smoked.

According to the survey findings, smokers had a variety of reasons for concealing their tobacco use. Some were ashamed; others didn’t want to be nagged or lectured. But what’s especially noteworthy is this: The more stigmatized they felt, the less likely they were to disclose their smoking status.

The poll uncovered another interesting fact: Although the majority of smokers said they were honest with their doctor about whether they smoked, 25 percent did not seek help from a doctor or nurse during their most recent attempt to quit – and hence may have missed out on an important source of support.

Public health policy in the United States is strongly focused on reducing tobacco use. One of the key strategies has been to make it so uncomfortable to smoke – via higher cigarette taxes, smoke-free restaurants, higher health insurance premiums and so on – that people are either motivated to quit or discouraged from taking up the habit in the first place.

There’s evidence that it all contributes to making a difference. According to the most recent figures available from the U.S. Centers for Disease Control and Prevention, the number of American adults who smoke declined from 20.9 percent in 2005 to 19.3 percent in 2010.

It’s worth asking, though, whether efforts to make smoking socially unacceptable might reach a point of diminishing returns. In an accompanying news release, Cheryl Healton, president and CEO of Legacy, notes there’s been “a significant shift in the social climate” surrounding tobacco use in the U.S. in recent years.

“As an unintended result of higher prices of cigarettes, increased measures to ban smoking in public places, and create smoke-free workplaces, many smokers may feel marginalized and less compelled to discuss smoking with their physicians and other providers,” she said.

And when smokers don’t want to disclose their habit for fear of being judged, “it becomes a missed public health opportunity” to connect them with resources that might help them quit, Healton said.

The findings from the survey prompted Legacy to put together a guide that helps clinicians discuss tobacco use with their patients in ways that are sensitive and appropriate rather than stigmatizing. Although it’s ultimately up to smokers to decide to quit, how health providers approach the issue clearly does seem to matter.

Photo: Wikimedia Commons

Fat kids: the blame and shame game?

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Who knew an ad campaign promoting a healthy weight for kids could become the target of so much controversy?

The campaign, called Strong4Life, was rolled out last summer by Children’s Healthcare of Atlanta, Ga., prompted by concern for the future health of overweight children and data suggesting many parents fail to recognize when their child is overweight. Its newest addition is a series of billboards and ads containing photos of fat children, the word “warning” in red letters and messages such as “Fat kids become fat adults,” “It’s hard to be a little girl if you’re not,” and “Big bones didn’t make me this way. Big meals did.”

Public reaction has been swift, to say the least. It’s being blogged and talked about coast to coast this week.

Organizers of the campaign have said the shock tactics are deliberate. “We felt like we needed a very arresting, abrupt campaign that said: ‘Hey, Georgia! Wake up! This is a problem,’” Linda Matzigkeit, a senior vice president at Children’s Healthcare, told the Atlanta Journal-Constitution.

Few would argue we should all just look the other way when it comes to overweight children. But is an in-your-face approach appropriate? More to the point, does it work?

This campaign has drawn a lot of criticism, much of it well placed. (Read more here, here and here.) Public health experts who’ve weighed in say there’s little evidence that shaming is effective in getting either kids or adults to change their behavior. Some worry the harshness of the ads could make children and parents even more reluctant to seek help in losing weight. Others point to the complex influences on children’s weight – family income levels and lifestyle, food availability, the community environment, even the national school lunch policy – and the difficulty of applying simplistic solutions to childhood obesity.

But score at least a couple of successes for this campaign. It has highlighted, rather painfully, the fine line between attacking the problem vs. attacking the person who has the problem. It also has highlighted how difficult it is to have a national conversation about obesity without descending into shrill self-righteousness on one side and angry defensiveness on the other.

The firestorm surrounding the Georgia campaign actually is nothing new. Some years ago, a local medical clinic had to revamp its advertising for a pediatric weight loss program after hearing complaints from parents who objected to the imagery – a sad-looking child sitting alone while his peers played together in the background.

It’s not easy to know how to convey the message in a way that’s constructive. And make no mistake, “constructive” should be the operative concept here.

Since the goal of the Georgia campaign ostensibly is to prod parents of overweight children into taking action, it seems fair to ask: Are these parents genuinely in denial? There’ve been a number of studies examining parents’ perceptions of their child’s weight and most have found that families aren’t very good at recognizing when a child crosses the threshold for being overweight.

I had to look it up online: Among kids ages 2-19, overweight is defined as having a body mass index between the 85th and 95th percentile on the growth chart for children of the same age and gender. Obesity is defined as a BMI above the 95th percentile. I suspect many parents don’t know this formula off the top of their heads. Moreover, they may have trouble accurately applying it, especially for a child who’s actively growing.

Even when parents do recognize their child is overweight, they can be reluctant to add the obesity label (or any label, for that matter) to his or her medical record early in life. There also seems to be a persistent amount of misinformation about childhood obesity, one of the myths being that most kids eventually outgrow it.

It would seem that helpfulness and better information are called for here, rather than judgment or scare tactics.

And let’s not overlook another important fact: The medical community traditionally has had little to offer overweight children and their families other than the standard advice to eat less and be more active. Nor is there much evidence yet that interventions for adults, such as weight-loss surgery, are safe or effective for kids.

For the record, I dislike the Georgia campaign. Kids who are fat already know they’re fat; their peers are telling them so every single day. Harping on it may highlight the symptom but it does little to address the deeper causes. And if the ad campaign is meant to galvanize parents into taking action, why manipulate kids into the position of being a shameful symbol of parental failure?

If we’re going to recognize that the people who designed this campaign were motivated by concern for kids’ health, let’s also recognize that those who object to the ads are motivated too by concern for what’s best for kids. How about dialing down the rhetoric and meeting somewhere in the middle?

Image: Children’s Healthcare of Atlanta

No touchy, no feely

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Trapped in the broccoli aisle at the supermarket, Dr. Kate Scannell listened as a former patient complained about his new doctor’s uncaring demeanor. A grocery clerk chimed in with “Tell me about it. I don’t think mine has touched me in – gosh, years, actually.”

In an essay that recently appeared in the Contra Costa (Calif.) Times, Dr. Scannell wonders: Can you be a doctor without ever touching a patient?

Once upon a time, the laying on of hands was an important clinical skill, she laments. “Hearts were heard, skin was inspected, pulses were palpated, livers were percussed. Physicians literally ‘had a hand’ in keeping you healthy.”

But no longer. Nowadays, the knowledge gained through touch has largely been replaced with medical tests and technology. “Most of us doctors probably touch a computer keyboard at least a thousand times more often than we touch a patient throughout the course of a workday,” Dr. Scannell writes.

And because of this, the doctor-patient relationship has lost something valuable, she writes:

Lack of relatedness and trust translates into poorer medical outcomes, patient dissatisfaction, treatment noncompliance, doctor shopping, pursuit of non-beneficial treatments, lawsuits, physician burnout, and greater reliance upon costly arbiters of health care like medical specialists and technology.

Steve Wilkins, a former hospital executive and consumer health behavior researcher who blogs about doctor-patient communication at Mind the Gap, has been reflecting recently too on the power of touch. Touch often can help convey feelings and emotions more accurately than facial expressions, gestures or even words, Wilkins writes. He cites research findings on the ability of touch to reduce cortisol, a hormone produced by the body when it’s under stress.

“I suspect we could use a whole lot more touching… not less as is the trend,” Wilkins concludes.

There doesn’t seem to have been much research on the role of touch in the clinical setting. Many of the studies, at least to date, focus on therapeutic touch within the context of complementary medicine. There’s also considerable evidence that babies benefit, both physically and emotionally, from being touched, held and cuddled early in life, and fail to thrive without it. But when it comes to adult patients in the hospital or doctor’s office, the studies register a gap.

Perhaps it’s not surprising. This is an area that can be a minefield for everyone involved. When Wilkins’s blog entry was crossposted this week at Kevin, MD, some of the commenters pointed out that many patients dislike being touched and the familiarity this implies.

“I don’t particularly enjoy being touched by anyone other than people who are very close to me, like my husband, or siblings,” one person wrote. “It’s unpleasant when my employees and acquaintances hug me, and I really dislike people who invade my personal space or touch me in any way other than a business-like handshake. Being touched is highly stressful.”

“Touch is not therapeutic unless the patient perceives it that way,” someone else commented.

On many levels, it’s hard to blame clinicians for keeping their distance. How are they supposed to know how an individual patient will respond to a pat on the shoulder or a hug? A gesture that’s misunderstood could lead to accusations of impropriety and sully someone’s reputation for life, even when the clinician isn’t at fault. Far better for everyone to keep their hands to themselves.

It’s a fine line, admitted one of the commenters at Kevin, MD. “I have one doctor who puts his hand on my shoulder when he leaves the room. To me it’s a comforting gesture that the visit went well. I suppose some might view this as unwanted familiarity.”

To be sure, there’s a difference between clinical touch that’s necessary for a physical exam or to carry out a procedure, and personal touch such as a hug or handshake that belongs to the relationship aspect of the doctor-patient encounter. Overall, though, there seems to be less touching, period. Is it out of line to wonder whether this might be one of the factors contributing to the alienation many people sense between doctors and patients? Even when they don’t like being touched too often, most people notice when touch is absent. In this, we are all human.

Porcupine photo: Wikimedia Commons

Scary tactics

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The Kandiyohi County Drug-Free Communities Coalition is in the midst of surveying students about their perceptions and priorities, and a rather interesting preliminary finding has emerged: Many of the kids believe scare tactics are an important – perhaps even necessary - strategy for discouraging young people from tobacco and alcohol use.

But are tricks really better than treats? There’s in fact mixed evidence on whether scare tactics truly are successful at getting people to change their health-related behavior.

Look no further than the FDA’s new cigarette label warnings, which go into effect in September 2012. Unlike the current warnings, which are text only, the new ones are larger and more graphic – one of them features a photo of a corpse.

Will they be effective? There’s some international research suggesting that blunt, scary tobacco warnings can result in an increase in the number of smokers who want to quit. For other people, though, it’s likely to be a turn-off.

Repeated exposure to frightmeister messages often dulls the impact, Jonathan Whiteson, director of the Cardiac and Pulmonary Wellness and Rehabilitation Program at New York University’s Langone Medical Center told USA Today earlier this year. “We become immune to the negative warnings over time. The more graphic the image, the more likely the message will become marginalized.”

Another drawback to fear-mongering is that the effects often aren’t very long-lasting. After a health scare, for instance, people tend to have trouble sustaining their motivation to live better. When Truth on Call conducted a text message poll for MSNBC.com on this issue, 47 percent of the 100 family physicians who were surveyed said their patients’ good intentions lasted for only a few weeks. A depressing 2 percent of the poll respondents said patients went back to their old ways within one day.

There seems to be some recognition in the health care world that browbeating patients with scare tactics has a way of backfiring. When the Clinical Diabetes journal published an overview in 2007 of best practices for encouraging patient adherence with diabetes management, it included a list of what not to do: “do not establish rapport; tell patients what to do; take control away from patients; misjudge patients’ sense of the importance of behavior change and their confidence in achieving change; overestimate their readiness to change; argue with patients; blame them for not taking better care of themselves; and use scare tactics.”

Unfortunately the dividing line isn’t always clear between what constitutes enough information and what’s too much. What’s the difference between scare tactics vs. fully informed consent? Are scare tactics more acceptable in public health campaigns than in the doctor-patient encounter? Do they work better among adolescents than among adults?

Ultimately, some of this seems to boil down to individual preferences and how the message is delivered.

When researchers interviewed obese African American patients for a study published two years ago in the Journal of General Internal Medicine, they uncovered some interesting nuances about how these patients perceived the use of weight-loss scare tactics. “I like to be scared. Scare me with all the bad things that can happen if I don’t lose weight,” one of the patients told the researchers. But others didn’t like it and even found it intimidating. “I look at it as a threat. The only thing the doctor should do is encourage,” was the response from one patient.

The upshot? Scare tactics seem to work sometimes, but they don’t work all the time and with many patients they’re counterproductive. Clinicians would do well to tailor their message, the researchers wrote. “Providers must be cautious when employing scare tactics as a means to promote lifestyle change to achieve weight reduction as not all patients respond well to this technique.”

West Central Tribune file photo

The right to fail

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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.

This encounter is being recorded

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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

Little white lies

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 I’m tempted to buy a copy of Dr. Michelle Au’s new book for the title alone: “This Won’t Hurt a Bit (and Other White Lies): My Education in Medicine and Motherhood.”

Aha! Someone in health care actually is publicly admitting they’re not always truthful with patients.

The practice of fudging the truth seems to have a rather long history in medicine. Once upon a time it wasn’t unusual to sugarcoat or withhold bad news – not telling a patient of a cancer diagnosis, for instance, or characterizing the cancer as a “growth” rather than a malignancy.

When health care professionals have done this, it has generally been with good intentions. Often it’s because they don’t want to unduly frighten or discourage the patient. Sometimes they simply don’t want to overwhelm a layperson with too much information or complexity.

And sometimes, let’s face it, a little white lie or two just makes it easier to manage the patient. We’ve all heard the fibs, and I would guess most of us haven’t been fooled by them:

- “The doctor will be with you shortly.” Translation: “Find a good magazine to read because it’s going to be awhile.”

- “This may sting a little.” Translation: “This is definitely going to sting a whole lot.”

- “I’ve never had a patient vomit/pass out/die from this procedure.” Translation: “None of the above has happened to me yet but there’s a first time for everything.”

- “I don’t want to alarm you.” Translation: “Be alarmed. Be very, very alarmed.”

Is it ever OK to be not entirely truthful with patients, even in a minor situation? Even if a little dishonesty seems to be in the patient’s best interests?

Ethicists have debated this issue extensively. While it’s generally agreed that truth-telling belongs at the heart of the patient-clinician relationship, there are a lot of gray areas. One example: smoothing over the truth to help an elderly patient avoid becoming overly upset or exposed to information they don’t need to know. There’s actually a name for this – the “geriatric fiblet” – and it can be deployed in a variety of situations, such as concealing information from an older person at the request of their adult children.

What about some of the deeper ethical complexities? How truthful can clinicians be in the face of medical uncertainty? What if the patient explicitly says he or she doesn’t want to know certain information?

The right thing to do can sometimes depend on the circumstances. In general, though, the foremost principle should be to preserve the patient’s autonomy, explains an article published last month by the Center for Health Ethics at the University of Missouri School of Medicine:

Ordinarily physicians and other providers are considered to be bound by obligations to the patient of respect for patient autonomy, acting for the benefit of the patient, and refraining from anything that would harm the patient. Truth-telling or honesty is seen as a basic moral principle, rule, or value. Withholding information or otherwise deceiving the patient would seem to at least disrespect patient autonomy and potentially harm the patient. Respecting patient autonomy means allowing patients to make their own decisions about whether to have certain tests, procedures, or treatments, or other interventions recommended by the healthcare provider. It means allowing patients to be in control of their lives to the extent possible. But no one can be in control of their healthcare decisions and lives if the choices are being made on the basis of significantly incomplete information or outright deception.

Here’s something else to consider: When clinicians tell little white lies, are they also more likely to fib when it comes to larger issues?

Since we’re talking about honesty, there definitely are times in health care when patients would probably rather not hear the blunt truth.

Several years ago I had to undergo a throat swab for what later turned out to be strep throat. The swab in the lab technician’s hand looked like it was a mile long. I was not thrilled about it, and I could feel my gag reflex getting ready to activate. “Is this going to make me vomit?” I blurted out.

The tech could have told a white lie – “Oh, no, you’re going to be just fine” – but she stuck to the truth: “You might” was her reply.

At the moment, it wasn’t exactly a reassuring response. On the other hand, at least I had a realistic idea of what to expect and was ready for it. And guess what? I appreciated that she was straightforward with me. (The throat swab went fine, in case anyone is wondering.) A little honesty, even in the small things, can go a long way.

How do readers feel about white lies told by health care providers? Do you think they’re OK in certain circumstances, or would you rather have total honesty? Please share your thoughts in the comment section.

Money on the table

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For patients and their families, it’s bad enough to have something go wrong with their care. It often adds insult to injury when they’re expected to bear the cost of fixing it.

But from the health care organization’s point of view, the reasoning can go something like this: We fixed it. We said we were sorry. What more do they want from us – money?

Yet there’s a growing body of evidence that in order for patients to truly be made whole after an adverse event, the package needs to include compensation, along with accountability and an apology.

It’s a component of the process that’s often missing when hospitals, insurers and medical practices put together policies on what to do when things go wrong and a patient is harmed, writes Doug Wojcieszak, the founder of Sorry Works!, a pioneering organization in the field of disclosure advocacy and training.

Why should this matter? Wojcieszak explains in a recent edition of the Sorry Works! newsletter:

Apologies without compensation are often hollow and meaningless. Critics will say, “It’s always about the damm money,” but, who are we kidding? Patients and families need to be fairly reimbursed for lost time, expenses, pain and suffering, and, yes, crippling injuries or even death. However, we always tell people when you apologize the money stuff gets a lot less scary because the anger is dissipated and you can have a rational adult discussion with patients and/or families to learn their needs – and sometimes it has nothing to do with money!

Wojcieszak hopes to bring this perspective to a revision of one of the landmark documents in the disclosure movement, a white paper on “Respectful Management of Serious Clinical Adverse Events,” released last year by the Massachusetts-based Institute for Healthcare Improvement.

The paper is slated to be discussed in October at the annual meeting of the American Society of Healthcare Risk Management. The authors are looking for ideas and suggestions on how to improve or update it, along with real-life examples of how the paper has been used.

“Respectful Management of Serious Clinical Adverse Events” essentially is a blueprint for how health care organizations can develop a crisis management plan ahead of time, rather than scrambling after something bad has taken place and possibly making poor decisions. The paper makes a case for prioritizing the needs of the patient, family, staff and organization and responding in ways that build empathy, learning and improvement. When health care organizations fail to do this, the result can be a loss of trust and the risk of lawsuits and negative publicity. More to the point, a failure to learn from what went wrong can doom the organization to repeating the same mistakes and endangering future patients.

Inserting the money issue into the discussion can be sensitive, but Wojcieszak, whose family sued when his brother died of a heart attack after a series of diagnostic missteps, argues that it needs to be part of the process of fixing what wrong. “Simply saying sorry and hoping you don’t get sued because the patient/family seems placated is unacceptable,” he writes:

If you want to truly restore your ethical reputation as well as learn from the mistake (i.e. improve quality) you have to fix the problems you create. And, yes, this means sometimes offering things to patients and families they might not otherwise think to ask for. The truth of the matter is many patients and families are emotionally traumatized post-adverse event and have no idea what they need or can ask for… you need to help in a fair and honest way.

Sometimes this might entail waiving a bill or offering a gift card, Wojcieszak writes. Other times it might take more than this, especially if a serious injury or death is involved. When organizations put restitution squarely on the table, it often helps defuse some of the patient’s and family’s anger and paves the way for everyone to start healing, he writes.

It’s hard to know how many health care organizations might be willing to take this approach. After all, the industry still struggles with the concept of honesty in the wake of an adverse event. Although the Joint Commission, the main accrediting body for hospitals in the U.S., now requires its member hospitals to have a disclosure policy, it’s not clear whether organizations are actually putting this into practice or how well it’s enforced. And although most health care leaders and physicians would probably say patients and families deserve fair compensation when something goes wrong, to date there’s little evidence of any widespread movement in this direction.

Yet when organizations have been bold enough to try it, they’ve gotten results. One of the most widely cited examples is that of Veterans Affairs Medical Center in Lexington, Ky., which saw payouts decrease dramatically after adopting a policy of transparency and compensation. From 1990 to 1996, the Lexington VA had 88 malpractice claims and paid an average of $15,622 per claim. For the VA system as a whole, claims during the same period averaged $720,000 for court judgements and $205,000 for out-of-court settlements.

In an article published in 2007 in Proto magazine, Dr. Steven Kraman, former chief of staff at the Lexington VA, said, “We settled almost every case at the hospital, and patients were usually willing to negotiate on the basis of real financial losses rather than out of a desire for revenge.”

The Proto article offers another example of how this can work:

In a closely watched experiment that began in 2000, COPIC Insurance Company, which insures 7,000 private-practice doctors in Colorado and Nebraska, gives physicians the chance to stay in the good graces of patients with an offer of as much as $30,000 to compensate for hardships caused by an adverse outcome. Physicians are encouraged to communicate openly, and if appropriate, apologize. And because patients don’t make a formal written demand for compensation or waive their right to sue later (after they accept the check), doctors avoid having their errors reported to the National Practitioner Data Bank and the state licensing board.

Some patients and families undoubtedly will sue regardless. But the evidence suggests that when organizations are proactive about confronting the money question, it can help ease a bad situation. The evidence also suggests that patients and families often are far more willing to be reasonable than they’re given credit for.

What do patients want when something goes wrong? What they want, says Wojcieszak, is full disclosure about what happened, a sincere apology, a promise to fix the systems involved in the error, and a timely offer of compensation. If the hospital where his brother died had offered these four things, “what would we have sued over? Nothing,” he said. “If you treat us with respect, we don’t want to own your hospital, your speedboat or your kids’ college fund. We just want what’s fair so we can move on with our lives.”