5 health messages from Angelina Jolie

Posted on May 31, 2013 by Anne Polta

It’s been more than two weeks since actress Angelina Jolie revealed the bombshell story of her preventive double mastectomy, and I’m still trying to wrap my head around the implications.

This was a news item that was hard to miss, given the reaction and commentary it ignited. For those who’ve been out of the loop, here’s the story in a nutshell: Jolie went public with a New York Times essay on May 14, telling her story of recently undergoing a double mastectomy to lower her risk of developing breast cancer. Her mother died at age 56 of ovarian cancer and Jolie herself has the BRCA1 gene, heightening her chances of someday being diagnosed with breast and/or ovarian cancer.

“Once I knew that this was my reality, I decided to be proactive and to minimize the risk as much as I could,” Jolie wrote.

She explained that although the decision wasn’t easy, “I feel empowered that I made a strong choice that in no way diminishes my femininity.”

It’s a compelling personal story but the ensuing reactions made it clear there was much more to it than one woman’s choice. After a lot of reading, I saw these main issues that kept rising to the surface:

1. Genetic testing – helpful or not? Jolie urged women to get tested for the BRCA gene, especially if there’s a family history of breast and/or ovarian cancer. What’s left unsaid is that only about 1 percent of women in the U.S. have the BRCA1 or BRCA2 gene. To be sure, genetic testing could help these women weigh their options, but it may not be useful to the population as a whole. For women who test negative for the gene, it might even create a false sense of security, since the vast majority of breast and ovarian cancers are not tied to any obvious risk factors.

Nor is it enough to simply have access to genetic information; people also need guidance to help them make sense of the information and make decisions based on their own values and tolerance of risk.

2. Risk isn’t always perceived accurately. By undergoing a preventive mastectomy, Jolie was able to lower her risk of breast cancer from 87 percent to under 5 percent. But these numbers seem to mostly reflect the odds ratio, i.e. overall likelihood given a specific set of circumstances. They don’t necessarily indicate actual risk. Moreover, even a drastic measure such as a preventive bilateral mastectomy does not lower the risk to zero, nor does it lower the risk of developing other types of cancer.

3. Be careful of the anecdote. Personal stories resonate with people. Jolie put a human face on the ordeal of learning you have the BRCA gene and pre-emptively having both breasts removed. But this is one person’s story; the experience may be quite different for someone else.

Jolie writes that her surgery and breast reconstruction were complication-free. “The results can be beautiful,” she says. No doubt this is the case for some people but it glosses over the possibility of scarring, infection, repeat surgeries and all the other things that can make these procedures anything but beautiful.

4. Surgery to remove healthy body parts, even when heightened risk is present, is a drastic measure. Maybe this speaks to how Americans have been conditioned to fear breast cancer. Some of this fear may be justified. In spite of massive investment in research, treatment options remain limited for metastatic, or widespread, breast cancer. The fact remains, however, that it’s a very aggressive way to try to prevent disease.

Interestingly, studies going back at least a decade indicate that most women who undergo a preventive mastectomy are happy with their decision and feel less anxious about their risk for cancer. Unfortunately some of the public discussion about Jolie’s story has become muddled over the distinction between preventive mastectomy and mastectomy once cancer is diagnosed. These are two different things that cannot accurately be weighed on the same scale.

5. Individual medical decisions are exactly that – individual choices. I wouldn’t judge Angelina Jolie for her choice. Only she can determine what level of risk she’s willing to live with and what she’s willing to do to reduce that risk. For someone else, the decision might be entirely different.

The crux seems to be whether patients have accurate, realistic information and a good understanding of their personal values and preferences – a principal that applies in countless other health decisions, from whether to take a prescription drug to making end-of-life decisions. Maybe by sharing her story, Jolie has contributed to moving along a complicated conversation that needs to happen.

The ethics of medical job shadowing: Who benefits?

Posted on March 13, 2013 by Anne Polta

The patient was about to undergo surgery when the surgeon came into the hospital room with “a clan of about six ‘student doctors’.”

It was uncomfortable and embarrassing:

As the young students craned their necks to get better views of my condition, I remember feeling so overwhelmed and self-conscious that I didn’t voice any of the several concerns I had outlined to discuss with my surgeon. I’m ashamed to admit it, but I remained quiet as my surgeon prattled on about what he was going to do.

Now imagine the student doctors are high school or college-aged students who aren’t even in medical school yet but are job-shadowing a physician mentor to learn more about a possible career in medicine.

Does the discomfort level ratchet up even more?

Some intense online discussion erupted recently over the ethics of allowing students to observe patient care as part of the career exploration process.

Job shadowing is a time-honored way for teens and young adults to gain a firsthand look at what medicine is like so they can make informed, realistic choices about pursuing it as their life’s work, writes Dr. Elizabeth Kitsis, director of bioethics education and assistant professor of medicine at Albert Einstein College of Medicine in New York.

But she admits to feeling uneasy about its impact on patients and on their care.

She wonders: Do patients know the “student” observer in the exam room might actually be a high school student? Are they allowed to ask the student to stay out of the room? What if they don’t want a student present but are too shy or intimidated to say so?

More to the point, does the presence of a high school or college student inhibit the discussion of sensitive medical issues? Maybe the patient won’t bring up worries about having contracted a sexually transmitted infection, or might give less than honest answers about alcohol consumption, Dr. Kitsis writes.

She asks: “Are these concerns outweighed by the benefit derived by premed students from being in the room? I suspect that students would respond in the affirmative. But I am not sure what patients would say.”

To help answer some of these questions, Dr. Kitsis and a colleague turned to the research to conduct a study of their own. What they found was a dearth of information on best practices in medical job shadowing, how to measure the effectiveness of such programs and how to address the ethical and practical considerations.

She and Dr. Michelle Goldsammler concluded that more research is needed, and they suggest the development of guidelines and a code of conduct for premedical students who want to shadow a practicing physician.

Judging from the online conversation, most medical students find it valuable indeed to shadow an experienced physician to gain an understanding of a career they’re seriously considering.

Jimmy Tam Huy Pham, a medical student, shadowed in several different settings before entering medical school. Most patients were OK with having him in the room, although many others declined, he wrote.

“The bottom line is: exposure to any aspects of medicine (and as much of it as possible) is crucial for an individual who is about to spend the next 8-11 years of their life (subsequent to high school) in a profession where repetitive exposure and practice to procedures and patient interaction are keys to learn,” he wrote.

“Patients were always asked whether or not they were happy to have me present and, of course, their wishes always respected,” someone else wrote. “Personally, I feel that shadowing was invaluable in helping me to decide that I do truly want to pursue a career in medicine.”

Several people pointed out that shadowing experience is an unofficial entrance requirement at many medical schools in both the U.S. and the U.K.

Many of the patients who joined the online discussion had a different perspective, though.

“A curious teenager in my exam room? Never,” was one person’s response.

Someone else wrote that she did not want “some kid who has nothing to do with my care tagging along with my doctor.” Nor did she want to be in the position of having to say yes or no to allowing a student in the room, she wrote. “Why should patients have to go through that? It’s not the patient’s responsibility to help young people figure out if they want to be doctors.”

Previous studies have found that a majority of patients are willing to accept the involvement of medical students in their care – and that many in fact find it rewarding to help contribute to a student’s education. But most of these studies concentrated on students who have already entered medical school and are able to bring training and commitment to their encounters with patients. Does it – or should it – make a difference when the student is still in the career exploration phase?

Society holds a stake in the training of future health care professionals. After all, today’s student is tomorrow’s doctor, nurse, physical therapist or physician assistant. But do patients have a moral obligation to participate in this process? And when they do participate, what can be done to help ensure it doesn’t compromise their care or their privacy? It would seem these are questions that need to be examined and satisfactorily answered.

Movember: just another gimmick?

Posted on November 19, 2012 by Anne Polta

Take a look at the guys around you this month and count how many of them are displaying more facial hair than usual.

Chalk it up to Movember, a global charity event that invites men to grow mustaches during November to raise awareness and money for men’s health. According to the website, the initiative had more than 854,000 participants – they’re known as “Mo Bros” – worldwide last year and raised $126 million on behalf of prostate and testicular cancer.

Well, fair enough. After all, the entire month of October is devoted to breast cancer awareness and fundraising and all things pink. Maybe it’s time men had their own health month.

But the critics are cautioning: Don’t be too quick to get behind this health campaign without asking more questions about what’s really being accomplished.

What is the substance behind the “awareness” the Movember campaign says it promotes? Take a look at the list of Movember health tips, which include a recommendation to get an annual physical: “Getting annual checkups, preventative screening tests and immunizations are among the most important things you can do to stay healthy.” Nary a mention is made of the debate surrounding the value of the yearly physical exam. Nor is there discussion about the risks vs. the benefits of prostate cancer screening, an issue that’s of considerable controversy amongst the medical and scientific community, or how men can weigh the evidence to make appropriate, informed decisions.

Another health checklist on the website advises men 40 and older to talk to their doctor about the use of aspirin and statins to lower their risk of heart disease, even though the preventive benefit of these two therapies has not been clearly established in people who don’t have existing heart disease.

Most would agree men are well served by education that gives them accurate, realistic information about their health. Are they served as well by information that’s overly simplified or that fails to adequately convey evidence-based pros and cons? Or by messages that confuse screening with prevention?

Perhaps the bigger issue is whether Movember, which started out with good intentions, is turning into a gimmick that allows people to feel good about a cause merely by growing a mustache and donating a few dollars.

Blogger Ashley Ashbee calls it “a type of slacktivism.”

“Does your moustache share information about the importance of screening, or where to get screened?” she wrote last year. “Does it tell you how you can prevent prostate cancer (if you even can)? Does it tell you the symptoms? Does it tell you who’s affected?”

Moreover, critics say one of the flaws of catchy public awareness campaigns, whether they’re exemplified by mustaches or by pink ribbons, is that they can skew the public’s perspective about risk and disease and lead to inaccurate or exaggerated beliefs that sometimes spill over into health-related behaviors. Although prostate cancer is far and away the most commonly diagnosed type of cancer among men in the United States, it’s actually lung cancer that is responsible for the most cancer deaths in men. Heart disease continues to be a significant health risk for men and, many would say, is the leading male health issue. Men also outnumber women when it comes to alcoholism, fatal traffic crashes and suicide.

To their credit, the Movember organizers added men’s mental health this year to their list of causes. But whether this helps improve the public’s understanding about male health remains to be seen.

The Toronto Globe and Mail spoke last week to medical ethicist Kerry Bowman of the University of Toronto, who lamented, “There’s not a direct relationship between the diseases we hear most about and either their occurrence in society or the lethality and the amount of suffering they create.”

Ideally, there should be a form of “ethical triage” that helps the public be better informed about the most widespread and urgent health care needs before donating their money to a cause, Bowman said. But for most fundraising campaigns, this kind of analysis is “very much lost,” he said.

A cancer hero, fallen from grace

Posted on October 19, 2012 by Anne Polta

Two days after the news of Lance Armstrong’s fall from grace, I’m still not sure what my reaction should be. Disappointment? Disgust? Outrage?

Probably all three.

Not because he cheated his way to the top of the competitive cycling world, all the while steadfastly denying the doping allegations that dogged him – first in whispers, then in shouts – for years. Bad enough as this was, the real moral offense lies elsewhere: in leading everyone to believe in his amazing recovery from cancer, in accomplishing victories that inspired so many of his fellow survivors, when apparently all along his feats were artificially enhanced.

Were those Tour de France performances the real Lance Armstrong, the guy who battled back from testicular cancer that had spread to his abdomen, lungs, lymph nodes and brain, the guy who at one point was given only a 40 percent chance of survival? Or was his incredible comeback helped along by performance-enhancing drugs?

We’ll never know for sure. And in all honesty, I feel sort of betrayed by one of my own, because Armstrong and I belong to the same tribe: young adults who were diagnosed with cancer (in fact Armstrong’s diagnosis came a year after I completed treatment for lymphoma), beat the disease and returned to normal life.

The difference is that I didn’t cheat to do it while pretending to the rest of the world that my recovery was entirely the product of my own motivation and endurance. If anything, my life – like that of all too many other cancer survivors – has never gone back to what it used to be.

Truth be told, Armstrong has been a bit polarizing among some within the cancer community – not because of the long-standing doubts about whether he was doping but because he set the recovery bar so high.

This isn’t meant to diminish his accomplishments. Even without winning seven Tour de France races in a row, Armstrong would have been inspiring for his post-cancer career as a world-class cyclist – not to mention the founding of Livestrong, his charitable foundation that has done so much to offer help, hope and community to people with cancer.

Many survivors don’t fare as well as Armstrong, however. That cancer and the treatments for it are often accompanied by long-lasting and even permanent effects is one of the dirty little secrets of CancerWorld. It has only been within the last decade or so that the health community has begun recognizing this and trying to address it.

How people recover seems to be, at least to some extent, an individual outcome. Armstrong may have been better equipped than most, due to his training, physical and mental conditioning and perhaps even a genetic edge, as some research has suggested. Other survivors might not; does it mean they’re doing it wrong or not trying hard enough if they fall short of Armstrong’s level?

Perhaps the real issue has nothing to do with alleged doping and everything to do with the hero narrative. Armstrong gave us a shining example of overcoming adversity that turned out to be flawed. Maybe the correct response here isn’t outrage but forgiveness for placing the unreasonably high expectation on him of being everyone’s perfect cancer survivor superhero.

Why can’t the heroes be the survivors quietly showing up every day, working, going to school, raising families and being part of their community? Why can’t it be heroic enough to simply persevere through chemo brain, fatigue, nerve damage and the rest of the long-term cancer baggage?

For what it’s worth, it comes as somewhat of a relief that Lance Armstrong may be fading as the image to aspire to. Maybe now we can go back to more realistic expectations that embrace the still-rich human potential of life after cancer while remaining honest about the limitations.

Going public with disease: How much is too much?

Posted on September 27, 2012 by Anne Polta

I’m rooting for Robin Roberts. As if breast cancer in her 40s wasn’t enough, the warm, sparkly co-anchor of Good Morning America is now dealing with myelodysplastic syndrome, a rare bone marrow disorder that may have been caused by the chemotherapy she underwent five years ago.

Robin, 51, underwent a bone marrow transplant last week and her colleagues from ABC were there on the spot, cameras and all, capturing the moment. Described in news accounts as “visibly spent”, she nevertheless recorded a message from her hospital bed, telling viewers she could “feel the love” from her legions of fans.

She has been open about her medical situation and exceedingly gracious about sharing this challenging journey with the public. No one could possibly wish her anything but the best.

But there’s a troubling side to this story: When does going public with a disease become too much?

ABC has begun taking heat from critics who think the network has gone overboard. Some have leveled accusations that the story is being exploited to gain better ratings. ”It’s a fine line between educating the audience and bringing them up to date, and crossing over and turning that into a ratings booster or an audience grabber,” Arthur Caplan, director of medical ethics at the New York University Langone Medical Center, told the Associated Press.

(You be the judge; the video is here.)

ABC has denied engaging in hype, saying viewers care about Robin and genuinely want to know how she’s doing. There’s value in the emotional support she’s receiving from her many fans.

Nevertheless it ought to make us feel a little uneasy, and not only because of the ethical issues it raises about newsroom decision-making.

At what point does our collective love of a feel-good story trump what’s best for the subject of that story?

It’s not hard for me to put myself in Robin’s place. Regular readers of this blog know I had non-Hodgkin’s lymphoma when I was in my 30s. I’ve done chemotherapy, I’ve done radiation, I’ve done time in an inpatient oncology unit. I know the physical and emotional toll exacted by cancer treatment. I’m all too aware of the potential for serious long-term and late complications such as the myelodysplastic syndrome Robin is being treated for, and the limited options for reducing the risk of late treatment-related toxicity – an angle of Robin’s story that most people unfortunately don’t seem to have picked up on.

So it was rather disconcerting to see Diane Sawyer, Sam Champion and presumably at least one television camera operator crowd into the hospital room with Robin and her family while new bone marrow cells were infused into her. Sure, Robin is a colleague and has many friends at ABC who wish her well. Sure, everyone was appropriately gloved and masked and (I hope) mindful of the infection risk.

But first and foremost this is a patient. Moreover, this is a patient with virtually no immune system, someone who’s highly vulnerable and undergoing a very challenging medical procedure. Even a seemingly minor infection can be a serious threat. Is it truly in her best interest to expose her to the extra risk for the sake of a heart-warming TV moment?

One can only hope it didn’t inadvertently send a message that the immune suppression that accompanies bone marrow transplants, not to mention many standard chemotherapy regimens, is not a big deal. People whose immune system is compromised depend on the community around them to exercise good judgment and avoid the unnecessary spread of germs.

Finally, there’s the emotional aspect to consider. ABC has said that everything being broadcast is with Robin’s permission, and I believe them. Even when there’s consent, though, media coverage of these kinds of stories can exert subtle pressure on the subjects to go along with it. Sometimes the story takes on a life of its own and it becomes difficult to tell the cameras and reporters, “Not now”, especially when someone is sick and perhaps not able to think clearly or be assertive. Sometimes the story stops being about the patient and becomes more about tugging at heartstrings or manipulating the emotions of the audience.

“At a certain point, Robin needs to heal,” Shelley Ross, former executive producer of Good Morning America, told the Associated Press.

Exactly. Although it’s generous for sick people to share their experience with the public, they don’t owe it to us. Rather, we have a responsibility to protect them at a vulnerable time. What’s in their best interest, physically and emotionally, ought to come first always.

Lessons in Professionalism 101

Posted on September 5, 2012 by Anne Polta

A couple of years ago there was an online flap over a MedPage Today blog post about a group of medical students and a vending machine that dispensed beer.

Writer Charles Bankhead was attending a cardiology conference and was on his way to a breakfast meeting when he encountered the young doctors-in-training gathered enthusiastically around the beer machine. He writes:

As they drained the cans and vowed to return often to worship at this altar, something told me this wasn’t the first time they had consumed beer before breakfast.

And then a thought occurred to me. One day I might have to entrust my heart to the care of these young men.

I found the thought unsettling.

He goes on to muse about medical students these days and their behavior, both bad and good, and winds up with some uplifting observations about the medical trainees who helped staff street-corner clinics in New Orleans, ministering to the many needs in the days and weeks after Hurricane Katrina.

“I hope I can remind myself of that the next time I see a group of young doctors gathered around a beer machine,” he concludes.

Students have rarely been known for maturity or prim behavior, but when it comes to medical students, should there be a higher standard?

Bankhead’s blog entry was reposted at Kevin, MD, where the reaction was decidedly mixed. What’s the big deal? wondered several commenters. One person’s assessment: “Honestly, if you get heart palpitations from the idea of late 20s male doctors finding the idea of a beer dispenser awesome, I don’t want you as my patient any more than you want me as your doctor.”

Not so fast, cautioned another commenter, who observed that “it has been my experience that this type of ‘childish’ behavior (getting excited about a beer machine and drinking DURING a conference) generally does spill over into practice.” These are the future doctors who make fun of patients, ogle the nurses and talk more about their extracurricular activities than the business at hand, the commenter wrote.

So who’s right?

As medical students head back to school this fall and the new crop of residents that began training in July gains some seasoning, it’s an opportune time to consider one of the more intangible lessons of medical school: teaching students how to be professional.

There doesn’t seem to be any formal curriculum for Professionalism 101. Yet it would be hard to find a U.S. medical school that doesn’t value professionalism or create expectations for how students should conduct themselves around each other, the staff and their future patients.

A paper published in 2010 in the International Journal of Medical Education attempted to pin down the teaching of professionalism. Is it shaped by medical school coursework? By being selective about who gains entrance to medical school? By strong role models on the faculty?

The researchers reviewed about three dozen previously published studies and came up with some interesting findings. One of the things that seemed to matter most was the learning environment – whether it was supportive and whether students had a variety of opportunities to gain experience and insight into what it means to practice professionally. The researchers found it was also important to have faculty and staff who set a positive example.

There’s been some debate over the role of the medical school admissions process in selecting students with the right qualities. But as the authors of the review note, it can be difficult to determine at the outset of a medical student’s career whether he or she is capable of learning professionalism. Furthermore, there don’t seem to be any reliable tools for identifying candidates who might not measure up.

Finally, assessment and feedback mattered. The researchers wrote that it’s especially important to monitor medical students for unprofessional or disruptive behavior and to have policies for dealing with problem behavior.

Judging from the online discussions at some of the student doctor forums, most medical students are keenly aware of the professional expectations placed upon them. A student who was ticketed for illegally netting crabs at the seashore fretted that the infraction might result in a rejected application for a residency training program. Some students had bigger problems: a DWI arrest, an assault charge, poor academic performance.

We expect a lot of doctors; perhaps we expect too much. Should a certain amount of partying or immature behavior be acceptable among medical students? Or should even an indiscreet Facebook post be grounds for disciplinary action? Some years back I had a conversation with a medical school instructor who spoke of the challenge of curing young medical students of casual terminology such as the word “butt.” Professionalism seems to be a many-layered creature that extends to language and demeanor, especially around patients, yet it’s not always easy to know where (and when) the line should be drawn.

Here’s a bit of evidence, though, that students who grasp the concept of professionalism might also be better able to practice it: In a study that appeared a few years ago in the New England Journal of Medicine, researchers found that doctors who were disciplined by the state medical board often showed warning signs of problem behavior back in medical school. Indeed, problem behavior in medical school was among the strongest risk factors for disciplinary action later in the physician’s career. Other studies, though, have found only a weak association between medical school behavior and future professionalism.

It points to a need for defining more clearly what is meant, exactly, by medical professionalism. Most future doctors do in fact measure up; it’s a minority who don’t, and a reason why the public has some stake too in the education that helps shape medical students into good doctors.

Fire all the fat patients

Posted on August 29, 2012 by Anne Polta

Ida Davidson, of Shrewsbury, Mass., started seeing a new primary care doctor but on the second visit, she was told by Dr. Helen Carter that she needed to find another doctor. The reason? Davidson weighs 246 pounds, give or take the occasional fluctuation, and Dr. Carter’s policy is to turn away any new patient who weighs 200 pounds or more.

Discriminatory? Davidson certainly isn’t happy about it. “I have never heard anything so ridiculous in my life,” she told WCVB-TV of Boston last week.

Policies such as Dr. Carter’s might not be common but they’re not unheard of. When the Miami Sun Sentinel conducted a survey earlier this year among obstetrics-gynecology practices in South Florida, 15 of the 105 clinics that responded said they refuse to take new patients who weigh too much.

It seems to be completely legal. After all, there’s nothing that obligates physicians in private practice to see any and all patients who come through the door.

But as stories like these pop up from time to time, medical ethicists have expressed uneasiness over such policies. At the very least, it violates the spirit of the medical profession, some ob-gyns told the Sun Sentinel.

“No doctor should be unable to treat patients just because they are heavy” was the assessment of Dr. Bruce Zafran of Coral Springs, Fla.

Medical ethicist Dr. Arthur Caplan said doctors have a duty to provide care regardless of the patient’s health issues. “Simply saying ‘I’m not gonna take someone who’s obese,’ is, I think, not the way to approach the whole challenge of obesity, either for that person or for any American,” he told WCVB-TV.

Doctors who set weight limits for the patients whom they’ll accept into their practice say they have reasons for their policies. Some of the Florida ob-gyns told the Sun Sentinel that heavy female patients are more likely to have complications and are too much of a liability. According to news accounts, Dr. Carter decided to stop seeing patients like Davidson because three of her staff were injured while caring for obese patients. She also felt other facilities were better able to meet the needs of these patients.

Fair enough, but it makes one wonder where the line should be drawn. People who are aging or have higher-risk medical conditions also can be more prone to complications; should physicians stop seeing them? If it’s too much trouble for a medical practice to accommodate the special needs of overweight patients, should they also stop accommodating patients who are frail, who use crutches or wheelchairs, who don’t see well, who have low literacy or don’t speak English as their first language?

Although back injuries are a very real occupational risk for those who work in health care, proper training and equipment can go a long way toward making it safer to handle overweight or obese patients. And to simply dismiss overweight patients without first attempting to assess their willingness or ability to lose weight seems unfair (as well as an inaccurate generalization that these people couldn’t possibly have health issues or health-related goals other than their weight).

Sadly, numerous studies have documented that anti-fat bias is as prevalent among health care professionals as among the rest of the public. The typical medical school training also tends to be woefully short on education about nutrition and physical activity, with the result that many doctors are ill-equipped to effectively help their overweight patients.

So what – if any – should be the physician’s role in working with this population? A consensus report issued in May by the Institute of Medicine tackles this question and concludes that although policy and environment are significant areas that need to be addressed, doctors also play a key part in reducing and preventing obesity.

The report calls on doctors to be more systematic in assessing body mass index in their patients and talking to them about nutrition and physical activity. It recommends focusing on the patient’s overall health goals, not just weight loss, and providing advice and support to help patients meet their goals.

It doesn’t say anything about refusing to see these patients or delegating them to someone else’s responsibility.

Ethics aside, if doctors profess to be serious about reducing the incidence of American obesity, it’s hard to see how the “it’s not my problem” approach would meet this goal. An opportunity to forge a doctor-patient relationship with Ida Davidson and help her take care of her health was squandered here, and nothing positive was accomplished.

What price for peace of mind?

Posted on July 3, 2012 by Anne Polta

The patient is eight years out from treatment for breast cancer and is doing well, but four times a year she insists on a blood test to check her inflammation levels.

The test is pointless and has nothing to do with cancer or its possible recurrence. But what happens when the patient makes the request to the doctor?

“To my shame, I must admit, I order it every time,” writes her oncologist, Dr. James Salwitz (if you haven’t yet discovered his excellent blog, Sunrise Rounds, head over there and check it out).

The test may provide temporary reassurance for the patient. At $18, it isn’t expensive, and it’s considerably less harmful or invasive than other tests. But all the same, it’s useless, and it prompts Dr. Salwitz to ask: What can health care do to stem the practice of tests, procedures and other interventions that have no real benefit to the patient?

He writes:

Medicine is full of better-known examples of useless and wasteful testing. PSA and CA125 cancer markers that fail as screening tests. Analysis indicates they cause more harm than benefit. MRIs for muscular back pain, which will go away by itself. Unneeded EKGs, stress tests and cardiac catheterizations, instead of thoughtful conservative medical management. CT scans often take the place of sound clinical analysis and judgment. A 15-year study of 30.9 million radiology imaging exams published recently shows a tripling in the last 15 years.

These unneeded tests do more than waste dollars. If a test is not necessary and has no medical benefit, it can only cause harm. The test itself can cause problems such as excess radiation exposure, allergic reactions and discomfort. In addition, tests find false positive results, which lead to further useless testing or unneeded treatment.

It’s been rather remarkable to witness the pulling-away from excess tests and treatment that has taken place in American medicine in the past few years. There’s a growing recognition that there’s such a thing as too much intervention and that intervention is not automatically good for patients.

Moreover, we’re becoming more willing to talk openly about the tradeoff of benefit vs. harm. Not all that long ago, it was considered heresy to even suggest that women in their 40s didn’t absolutely need a mammogram every single year. The thinking on this is beginning to change as the evidence accumulates of mammography’s limited benefits for younger, low-risk women, and it’s showing up in patient decisions; a recent study by the Mayo Clinic found a 6 percent decline last year in the number of 40-something women who opted to have a mammogram.

It’s easy to oversimplify this issue, and indeed, it’s not always as straightforward as it seems. Interventions sometimes don’t look useless until they’re viewed afterwards through the retrospectoscope. At the time, in the heat of battle, they may seem necessary and justified. Nor do patients fit neatly into little diagnostic boxes; what may be unnecessary for one might make sense for someone else.

There’s a larger question, though, that we sometimes fail to ask: If something is medically useless, does it still have value if it gives the patient (and perhaps the clinician as well) some peace of mind?

To many patients, this is no small thing. It’s an emotional need that’s not easily met by science-based rational discussion about the studies and the actual evidence for the pros and cons. Unfortunately it’s also often abetted by consumer marketing that plays up the peace-of-mind aspect of certain tests while remaining silent about the limited benefit, the possible risk and the clinical complexity that may be part of the larger picture. The message can be sent that it’s OK as long as it provides the patient with some reassurance, and who’s to say this is entirely wrong?

Should clinicians be tougher about just saying no, then? It may be easier to give in, but does this constitute quality care? An interesting ethics case by the Virtual Mentor program of the American Medical Association explores some of the issues that make this so challenging: the responsibility of the physician to make recommendations and decisions that are clinically appropriate, the importance of respecting the patient’s autonomy and values, the balance between patient preferences and wise use of limited health care resources.

You could argue that patients should be allowed to obtain unnecessary care as long as they pay for it themselves, but does this really address the larger question of resources? Regardless of who’s paying the bill, unnecessary care comes with a cost. The blood test requested by Dr. Salwitz’s patient, for instance, likely would involve the use of equipment such as a disposable needle and lab supplies, staff time to draw the blood, analyze the sample, record the results, report them to the doctor and patient, enter them in the medical record and generate a bill (and I may have skipped a few steps).

Yet it’s not always easy to make this case to patients when what they’re really looking for is that elusive creature known as peace of mind.

Dr. Salwitz writes that he’ll be seeing his patient again soon and will try once again to persuade her that the test she’s asking for has no medical benefit for her. “I will try to replace this test crutch with knowledge, reassurance and hope,” he writes. “Maybe it will help us to understand each other a little better.”

Patient privacy vs. the urge to snoop

Posted on June 8, 2012 by Anne Polta

When nearly a dozen teens and young adults were hospitalized last year after overdosing on a designer drug at a party in the Minneapolis suburb of Blaine, some hospital employees apparently couldn’t resist the urge to peek at their medical records – a clear violation of patient data privacy regulations.

In one of the largest such cases on record in Minnesota, 32 workers were subsequently fired for accessing medical records they weren’t authorized to see.

What does it say about a health care organization – and the people who work there – when patients find out someone has been prying into their medical record out of sheer curiosity?

It’s undoubtedly embarrassing and damaging, and a recent survey by the Ponemon Institute confirms that it often leads to less trust among patients.

The survey involved 700 people whose patient information had been stolen or misused. Six out of 10 said they lost confidence in the organization because of the incident. Fifteen percent said they would end their relationship, or already had ended the relationship, with the health care facility, and another 40 percent said they would consider doing so.

Not surprisingly, eight out of 10 said they felt organizations that fail to protect personal patient information are not trustworthy.

For all the resources that have been poured into HIPAA compliance – passwords, data encryption, secure servers, staff training and the like – many data breaches seem to be less about technology and more about basic human nature: in other words, the urge to snoop and the lapses in judgment that lead health care workers into this less-than-ethical behavior.

Although theft and hacking are usually regarded as the biggest threat to the security of patient information, it’s unauthorized access or disclosure that consistently ranks as one of the leading issues. A single incident might not be as large or noticeable as, say, the theft of a laptop containing private data on 25,000 patients. But what snooping lacks in scope, it more than makes up for in frequency. According to the most recent federal report on HIPAA breaches under investigation, unauthorized access is second only to theft.

A survey last year found that 70 percent of the organizations in the study had experienced a privacy breach in the previous 12 months that involved unauthorized access to patient records. Most of it was insider abuse rather than theft or hacking from outside. In about one-third of these cases, the target was the medical records of coworkers. Just under one in three involved snooping into patient information belonging to relatives and friends.

You might argue that some of these breaches are accidental rather than a case of deliberate snooping. But it’s disconcerting to note how many of them involve high-profile patients or medical cases that may be more likely to tempt someone’s curiosity.

For instance, there was the employee at Catskill Regional Medical Center in Harris, N.Y., who was fired last November after helping herself to the medical records of friends and coworkers. She apparently accessed more than 400 records in all, even though she had no legitimate reason to look at them. Hospital officials characterized her actions this way: “She was nosy.”

Consider the 16 people who were terminated at Ben Taub General Hospital in Houston, Texas, for allegedly snooping into the medical record of a physician who was on the staff and was hospitalized there after being shot during an attempted robbery. Among those fired were doctors, supervisors and nurses.

Then there were the four people who were fired after looking at the medical records of the victims in the high-profile Tucson supermarket shooting last year. Six people died in that shooting and 13 were wounded, including Arizona Rep. Gabrielle Giffords.

Celebrities who’ve had their medical records breached include Britney Spears, Tom Hanks, Tom Cruise, Drew Barrymore and the late Farrah Fawcett. Last year UCLA Health System paid an $865,000 penalty for multiple allegations that employees accessed patient information belonging to celebrity patients. An investigation by the Office of Civil Rights of the U.S. Department of Health and Human Services found that between 2005 and 2008, employees repeatedly looked at protected health information they weren’t authorized to see.

Although no one likes to acknowledge it, snooping has probably taken place in health care for a very long time. These days, though, the temptations seem to be greater and electronic medical records have made it easier to indulge one’s curiosity. Not only is an electronic record easier to peek at than a paper record, but it also takes a matter of seconds to download, print and/or copy.

On the other hand, auditing tools are getting better at tracking who’s supposed to have access to someone’s patient information and who’s been looking at it. Health care workers who engage in this kind of behavior sooner or later risk being caught, and health care organizations that don’t monitor and enforce internal practices risk earning a bad reputation when someone blows the whistle.

Doctor, heal thyself

Posted on April 6, 2012 by Anne Polta

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.