The problem of clinician overload

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At the 45-bed hospital in rural Alaska where Dr. Janice Boughton is a hospitalist, her shift starts at 7:30 a.m. Here’s what greeted her when she arrived one recent morning:

The night shift doc told me about the 13 patients who I needed to take care of that day. Seven of the patients were new to me, admitted the night before. For those patients, I needed to review their medical histories in the computerized medical record and get to know them, with a focused physical exam and an interview to determine what needed to be accomplished in the hospitalization. For all of the 13 patients, I needed to review all of the lab tests completed in the last day and all of the radiological studies and check their vital signs and review the nurses’ notes about what had happened in the previous 24 hours. Each person had an average of about 30 blood test values and some of them also had microbiological results that needed to be reviewed.

And the day had barely even started.

For the next 12 hours she saw patients, reviewed tests and medications, dictated notes, updated medical charts, admitted two new patients from the emergency room, transferred two patients out of intensive care, answered the phone, did five bedside ultrasounds, talked to patients and families about end-of-life care, discharged patients who were ready to go home, discussed patient care with referring physicians and tried to track down incomplete test results from a pathologist.

No wonder doctors become frazzled by the amount of multitasking they’re required to do. “I love every little part of my day, but I don’t necessarily love trying to do all of it at the same time,” Dr. Boughton writes.

Patient care has always been demanding. But if you listen to clinicians when they talk about what their days are like, it’s clear there’s a rising tide of frustration with the overload.

Perhaps it’s no coincidence that around the same time Dr. Boughton wrote about her hectic day in the hospital, JAMA Internal Medicine published a survey that uncovered serious, quantifiable issues with the workload that many hospitalists experience.

Just over 500 hospitalists from across the U.S. took part in the survey, which was conducted online. Among the findings:

- 40 percent of the respondents said their patient load exceeded safe levels at least once a month, and 36 percent said this happened weekly.

- One in four reported that the excess workload often resulted in being unable to fully discuss treatment options with patients and families or answer their questions.

- About 25 percent said their workload affected patient care.

- 19 percent felt the heavy workload was detrimental to patient satisfaction.

The overload isn’t limited to hospital medicine. Nurses worry about high patient-to-staff ratios and the impact this has on patient care and safety. A study that looked at pharmacy workloads found that when pharmacists were overloaded, there was increased potential for error.

And when researchers tracked the workload at a private internal medicine practice in Philadelphia a few years ago, they found some startling statistics on how the physicians spent their day. Each of the five doctors saw an average of 18 patients per day, made 23.7 phone calls, received 16.8 emails, processed 12.1 prescription refills, and reviewed 19.5 laboratory reports, 11.1 imaging reports and 13.9 consultation reports.

It’s a recipe for harried providers, frustration, mistakes and ultimately professional burnout.

None of this is good news for patients who increasingly are having to make do with a smaller slice of the doctor’s time and attention.

Patients can help reduce some of the overload by being organized and focused when they talk to the doctor. They can help by knowing their health history and what medications they’re taking. They can quietly grit their teeth and be patient when a phone call isn’t promptly returned. They can show up on time to their appointment, because even though doctors are often late, the schedule gets further clogged when patients arrive late too.

This is only a fraction of the solution, however. Moreover, there’s a limit to how much should be expected of patients to help reduce the doctor’s workload. There are times, after all, when someone genuinely needs the extra attention.

No, the real problem lies with the system itself. Perhaps even more than cost or quality, clinician overload is a major – and often ignored – issue that threatens to swamp the progress toward better, safer care. And the near future doesn’t seem to hold many fixes.

The primary care doctor: someone who knows you

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Fans of Downton Abbey were stunned this week at one of the more shocking plot developments in the show’s three-year history: the death of young Lady Sybil Branson, who developed eclampsia after giving birth to her first child.

Besides the drama, the episode contained multiple health messages. One was the danger of preeclampsia,  less common today than in the 1920s setting of “Downton Abbey” but still a serious and sometimes fatal threat to pregnant women and sometimes to the infant as well.

Another was “VIP syndrome,” the tendency for doctors to defer to wealthy and/or important patients and their families, perhaps at the cost of exercising sound judgment. If Sir Philip Tapsell, the eminent obstetrician hired by Sybil’s father, Lord Grantham, hadn’t been so busy ingratiating himself with the aristocracy, would he have paid closer attention to the patient’s condition and heeded her husband’s pleas to get her to a hospital?

Finally there’s Dr. Richard Clarkson, the country doctor who has known Sybil all her life but whose urging for an emergency C-section is brushed aside – with fatal consequences, as it turns out.

Do patients truly fare better with a doctor who knows them well? This is one lesson from “Downton Abbey” that’s grounded in evidence: Having an ongoing relationship with a primary care doctor is seen as one of the best things people can do to ensure their health needs are understood, met and coordinated.

Here, for example, is how the Palo Alto Medical Foundation explains the importance of choosing, and staying with, a primary care doctor:

One of the best ways to make sure you’re getting excellent health care is to have a primary care physician (PCP) with whom you can build a long-term relationship – someone who knows your medical background and understands what’s important to you.

… When you have a physician you know and trust, you feel comfortable talking about anything. And, all your basic care – including routine exams, preventive care and treatment for illnesses and injuries – goes more smoothly and easily. Your PCP also knows when it’s best to refer you to a specialist.

Doctors themselves reinforced this in a survey carried out a couple of years ago by Consumer Reports. Of the 660 primary care doctors who participated in the survey, three out of four said a long-term relationship with a primary care doctor was one of the most important things their patients could do to obtain better medical care.

Here’s more of the evidence surrounding the benefits of primary care:

- In studies carried out in the 1990s, regions of the United States with an adequate supply of primary care doctors had lower rates of premature death from cancer, heart disease and stroke, even after controlling for lifestyle and demographic factors. Later studies also linked the primary care doctor supply to longer life expectancy and decreased incidence of low birth weight.

- Researchers have documented better outcomes for patients who have a primary care doctor as their regular source of care. This seems to hold true regardless of age, health status or whether the patient has insurance.

- People who had a usual source of care were more likely to receive treatment for high blood pressure and elevated cholesterol levels – both risk factors for heart disease – than those who lacked a usual source of care, according to a 2010 study in the American Heart Journal.

- A usual source of care, such as a community health center, also appears to help reduce the effect of disparities such as income, education and environment and improve health for these populations.

Specialists are needed too. Primary care cannot fix everything that ails the patient, after all. But many bereft “Downton Abbey” fans are probably wondering whether one of their favorite characters might have been saved if the doctor who had known her all her life had been allowed to make the decision.

The awkwardness of open notes

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Do patients really need to know what the doctor is thinking? The potential awkwardness of sharing the doctor’s notes, especially with older patients, was explored this week at The Health Care Blog, where it generated some interesting discussion about the pros and cons of how much information patients should be allowed to have.

It’s not that she’s against transparency or believes patients shouldn’t be engaged and have open access to their medical record, Dr. Leslie Kernisan writes. “It’s because in my own VA practice caring for WWII vets, I used to frequently document certain concerns that would’ve been a bit, shall we say, awkward for the patient to see. Reading about these concerns would’ve quite possibly infuriated the patient, or the caregivers, or both.”

She lists the sensitive areas: Possible cognitive impairment. Possible substance abuse, especially alcohol. Possible prescription misuse or diversion. Possible elder mistreatment. Concerns about ability to live safely at home or safely drive. Concerns voiced by family or caregivers.

Many of these can be issues regardless of the patient’s age. But they’re of particular importance in caring for geriatric patients, and they have a history of being under-recognized and under-addressed in the clinic setting, Dr. Kernisan writes.

It’s delicate to talk to a patient and family about the possibility of Alzheimer’s disease, or to suggest that an elderly person might no longer be able to manage independently at home or drive a car, she writes. It can get even more complicated when caregivers and family members are involved. Do the doctor’s private observations and speculations about what’s happening with the patient belong in an open medical record?

Dr. Kernisan wonders: “I’m not sure what I’d do if I were told tomorrow that all my patients (and whichever caregivers the patients give access to) would be able to read everything I write about them. For the most part, it would be fine, but I’d certainly have to work out an approach for handling the awkward issues I describe above.”

Complete open access to the medical record – including the doctor’s notes – is still fairly new, and there’s considerable learning yet to be done on how doctors adapt to it, how patients react to it and whether it has an effect, positive or negative, on the doctor-patient relationship.

OpenNotes, the largest project to date that has implemented and studied open access to the doctor’s notes, may have eased some of the early concerns about sharing more of the doctor’s thought processes with patients. According to the results so far, it hasn’t been more time-consuming for doctors or upsetting for patients to incorporate open notes in patient care. Most of the participants in fact have given it glowing reviews, and it seems to be fostering more patient engagement.

As Dr. Kernisan points out, however, the patient population in the OpenNotes study is middle-aged on average; what about elderly patients who may be dealing with dementia, vulnerability, loss of independence and other difficult issues unique to their stage of life?

The responses to Dr. Kernisan’s blog have been rather revealing in terms of who’s saying what.

A physician commenter felt it could be too anxiety-inducing for patients to read the entire contents of their medical record, doctor’s notes and all. “It’s not so much that I put things in patients’ notes that I don’t want them to see, it’s that some of the things they see they don’t have the knowledge to interpret,” she wrote.

There may be benefits to “limited access,” she wrote, “but only if the doctor is available and compensated for making sense of it to their patients.”

A biomedical and computer scientist with a Ph.D. suggested that sensitive notes be kept  in a “vest pocket” section of the record, inaccessible to patients.

Not surprisingly, laypeople saw it differently. One person wrote:

If you’re my doctor, I want you to discuss your concerns with me. If you’re wondering about cognitive impairment, it’s very likely that I already worry about that. Writing it in your notes without telling me seems… Well, you’d have to explain your rationale.

The reaction from someone else: “Sensitivity is not secrecy – it is learning to say the whole truth with tact and with a compassionate understanding of how the knowledge will be applied.”

Although it was left unsaid, the entire debate raises the question: If sharing the doctor’s notes can lead to moments of awkwardness, for whom is it most awkward – the doctor or the patient?

Here’s another question: Should there be different standards of openness depending on the patient’s age?

Many people want to be able to exercise more preference over how much information they receive. Some may only want limited information and would probably make little use of open notes if they were available. But others want more and are willing to accept the anxiety, the uncertainty and whatever other negative emotions might arise as a result of reading their medical record.

As the ongoing open-notes debate shows, however, doctors have reservations about whether this is always best for the patient. Is there any way these two perspectives can be brought closer together?

Update, Jan. 28: Two of the pioneers in the OpenNotes initiative respond on The Health Care Blog with some observations on their own experiences with open notes and on the conversations they’ve had with other providers.

Blog break

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This blog is taking an extended break while I concentrate on other priorities. Blogging will resume (hopefully) at some yet-to-be-determined time in the future.

In the meantime, since influenza is in all the headlines right now, here’s a selection of past entries about flu and flu vaccine:

- We all know someone who’s been sick with the flu. But is it really influenza, or is something else? Read more here about Influenza’s identity crisis.

- Remember the H1N1 flu virus? Was it all Much ado about nothing, or was the public health community simply being prudent about a potentially serious disease threat?

- By now, many of us have heard that flu shots aren’t as effective as they could be, and it’s fueling a certain amount of skepticism over the value of annual flu shots. In defense of the flu vaccine explores some of the research on attitudes and beliefs about the flu vaccine.

- Does age have anything to do with how we view influenza? Read about what happened during the H1N1 outbreak when Generation X met the flu.

- Swine flu, avian flu, H1N1… Even when it’s a new type of influenza, the lessons are invariably the same.

- If you didn’t get a flu shot this past fall and plan to do so now, here’s a rundown of the vaccination options that may be available (ask your health provider which one is best for you).

- Finally, we could all do with a gentle reminder about the low-tech but effective practice of washing our hands.

Despite taking a break from blogging, I may not be able to resist posting new entries from time to time. Readers are invited to check for updates.

Out with the old

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Purging the bad stuff of 2012 so the new year can start with a clean slate has become something of a tradition in New York City’s Times Square, where the Times Square Alliance hosted its sixth annual Good Riddance Day last week.

A Dumpster and giant shredder were hauled in so people could trash all their worst memories – tax records, insurance forms and painful reminders of Hurricane Sandy, unemployment and cheating ex-boyfriends.

Catharsis is supposed to be a good thing, so here’s some health-related baggage we’d like to see consigned to the shredder before the year is over:

- The politicizing of health.

- Public messages that hype or oversimplify health issues.

- Health scare tactics.

- The demonizing of obesity.

- The urge to pathologize a condition in order to sell a product or service (“You aren’t coming down with a cold; you have a pre-cold!”)

- Cluelessness by health organizations about the patient experience.

- Automated phone systems that strand patients in voice-mail no-man’s-land.

- Pill bottle caps that are complicated and difficult to open.

- The scale at the doctor’s office.

Into the Dumpster with all of them! Here’s to a fresh start in 2013.

How sweet it isn’t?

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First it was fats, then carbohydrates. Now sugar has joined the ranks of nutritional villainy.

With Christmas approaching on a tidal wave of candy canes and gingerbread, one can’t help wondering: Is it OK to indulge in a little sweetness, or is sugar entirely bad?

There’s no denying a certain amount of hysteria when it comes to sugar. Critics claim sugar causes everything from hyperactivity to premature aging. A common – and inaccurate – belief about cancer is that cancer cells feed on sugar.

Some of this is hyperbole but there’s also a considerable amount of science that has examined the effects, both good and bad, of sugar consumption. Sugar has been linked, for instance, to increased risk of weight gain, diabetes and heart disease. Earlier this year, some U.S. health experts went so far as to declare that sugar is as addictive and dangerous as alcohol or tobacco and should be regulated accordingly.

Unfortunately it’s not always clear whether sugar itself is the culprit or whether something more complex is going on.

At least part of the reason why higher sugar consumption is linked to weight gain may simply be the extra calories. One of the issues with sugar-sweetened sodas and other beverages isn’t just that they contain lots of sugar, it’s that they often end up replacing water or milk in someone’s diet. Processed foods high in sugar also can be higher in fat and sodium, which are associated with negative health effects of their own.

A certain amount of sugar is necessary in order for the human body to function, but moderation seems to be called for here. Consuming large quantities of sugar each day also tends to be a marker for an overall diet that may not be optimal for health.

This brings us to the real vexation: the proverbial sweet tooth. Why do so many people love sugar and why can it be so hard to consume less of it?

I admit to not totally understanding the whole sweet tooth thing. If you were to invite me to your holiday buffet, I would go directly to the spinach dip and the shrimp cocktail. Cookies and candy, not so much. But this wouldn’t necessarily be the case for other guests.

There’s debate about whether so-called sugar addiction is real or imagined. Some studies have found clinical similarities between food cravings and drug dependence. A study published this year in the Journal of Psychoactive Drugs found, for instance, that when people binge on sugar-dense foods, it increases the amount of extracellular dopamine in their brain which has the potential to lead to addiction.

The authors wrote, “There appear to be several biological and psychological similarities between food addiction and drug dependence, including craving and loss of control.” They also note that for some people, consuming these foods is comforting and therefore might be regarded as a form of self-medication.

So far, however, the sugar addiction theory has mostly been tested on rats and mice, with implications for human behavior that are unclear at best. A 2010 review in the Clinical Nutrition journal examined the evidence and concluded there’s nothing yet in the literature suggesting that humans can become addicted to sugar or that sugar addiction plays a role in obesity or eating disorders.

The bottom line is that when it comes to “sugar addiction,” the jury still seems to be out.

In the meantime, here’s some guidance. The U.S. Department of Agriculture’s 2010 dietary guidelines recommend limiting consumption of added sugars and solid fats to somewhere between 5 and 15 percent of total daily calories. The American Heart Association suggests no more than 100 calories a day of added sugar for most women and no more than 150 calories a day for most men. That’s about 6 teaspoons for women and 9 for men.

Here’s something else to keep in mind. For most Americans, the main source of the sugar they consume isn’t in that spoonful they dump into their coffee, or a homemade dessert or even a Christmas cookie. Most of our dietary sugar comes in the form of added sugar – sugars and sugar-based syrups that are added to food during processing. Although the tendency is to single out highly sugared products, such as sodas, as the problem, added sugar can show up in a variety that may not be readily recognized – chicken nuggets, for instance, or ketchup or children’s breakfast cereals, all of which are often surprisingly high in sugar.

So go ahead and have that reindeer-shaped holiday cookie if you want. If you’re worried about the sugar, just take one.

The looming shortage of doctors

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Not too long ago, the American Association of Medical Colleges unveiled a new print ad depicting a patient sitting alone and distressed in an exam room. The stark message: “By the time you notice America’s doctor shortage, it will be too late.”

A new round of ads released this month warns, “Careful what you cut.”

What many rural communities have known for years is increasingly catching up with everyone else: The supply of doctors won’t be enough to meet future demand.

The AAMC’s workforce estimates aren’t encouraging. By 2020, the U.S. is projected to have a shortfall of 90,000 doctors, according to data collected and analyzed by the AAMC Center for Workforce Studies.

Part of the shortage is on the demand side. As the baby-boom generation ages, there will be a dramatic increase in the number of Americans older than 65 – precisely the population that tends to use health care services the most. Easier access to health insurance, the result of the federal health care reform law, also is expected to bring millions of formerly uninsured patients into the system, many of them with pent-up health needs that will need addressing.

But the absolute number of doctors is also anticipated to decline in future years. Although at least half of the projected shortage is among primary care doctors, the other half will be among specialties not customarily thought of as being in short supply – surgeons, oncologists, endocrinologists and more.

In practical terms, what it means for patients is the likelihood of longer waits in the future to see a doctor, more difficulty obtaining timely appointments, and possibly delays in care that could have long-term health consequences.

This is obviously a vastly oversimplified picture of what’s happening in the U.S. physician workforce right now. It doesn’t even touch on the many other issues churning alongside the basic math of supply vs. demand – the number of physicians who will be retiring in the next decade, for instance, or the tendency for physicians to gravitate toward non-rural practice, or the soaring cost of a medical education, or the staggering educational debt that students accumulate and its impact on their choice of specialty.

There’s another factor, though, that much of the public may be less aware of: Federal funding for residency training, which all physicians go through after completing four years of medical school, has not increased to meet current demands. The result is a bottleneck that has reduced U.S. capacity to get physicians fully trained and into the workforce.

Physicians – and indeed all the health professions – have unique training needs. Although much of their initial learning takes place in the classroom, at some point they must be unleashed on actual, live patients to hone their skills. Without this hands-on experience, there’s no other way to become familiar with health and illness and the variety of ways these manifest themselves across the spectrum of patients. There’s no other way to become proficient at diagnosing, treating, prescribing and performing procedures.

It takes time, money and resources to provide the necessary programs and supervision at teaching hospitals where residency training takes place – which is why outside funding is so critical.

The Association of American Medical Colleges has ramped up its lobbying effort with Congress this year to eliminate a freeze on Medicare funding for residency training. The freeze has been in place since 1997 – a full 15 years. Even a relatively modest 15 percent increase would be enough for teaching hospitals to prepare 4,000 additional doctors per year, the AAMC argues. The AAMC estimates that 10,000 more doctors need to be trained annually to completely address the pending shortage.

Certainly there are other sources of residency funding – state governments, private businesses and the teaching hospitals themselves, to name a few. The number of residents in training in the U.S. in fact has grown despite the Medicare cap. State governments and cash-strapped hospitals may not be able to sustain this indefinitely, however, nor does a fragmented approach necessarily ensure that the right types and amounts of primary care doctors and specialists are being trained.

Redesigning the health care delivery system to make it more team-centered could help blunt some of the growing shortfall in the physician workforce, yet this is unlikely to be the total answer. Patient care will still demand the skills and training of a doctor.

Considering the success that physician practices here in rural central Minnesota have had in hiring new doctors the last couple of years, it may seem there’s no real urgency to address a looming shortage of doctors.

But what’s critical to keep in mind is that the pipeline from medical student to full-fledged physician is long – seven years at a minimum, and usually longer for subspecialists. Is it OK to delay action until the problem becomes more painfully evident? The AAMC says no: “The United States cannot afford to wait until the physician shortage takes full effect because by then, it will be too late.”

Too stoic for antidepressants

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Should people who are depressed take antidepressant medication, or should they just tough it out?

There’s often a stigma surrounding the use of antidepressants, and it may be preventing people from getting the treatment they need, college student Leah Lancaster wrote this week in an insightful opinion piece for the Minnesota Daily.

Lancaster writes that she has been taking antidepressants since she was 15 years old – and that without them, she most likely would not have gone to college. “Yet, when the topic comes up, I often find myself defending my decision against accusations that I’m ‘numbing myself’ or ‘taking the easy way out,’” she writes. “Supposedly, if I did yoga, ate healthier and took a more ‘natural’ approach, I wouldn’t need to contaminate my mind and body with toxic pills.”

Some of the stigma surrounding depression itself seems to have eased in the last couple of decades. But when it comes to antidepressants, it can still be hard for the public to accept that for many people, medication may be necessary to help them feel better.

It’s hard to measure how widespread this attitude might be. It clearly exists, however, and one of the consequences is untreated depression. A study that appeared last year in the Annals of Family Medicine found that patients often don’t tell their primary care doctor that they’re experiencing depression. The No. 1 reason for this lack of disclosure? They feared being prescribed an antidepressant.

Even in the medical setting, patients often are reluctant to report that they take prescription medication for depression or anxiety, writes Mag Inzire, a physician assistant at a community hospital in New York.

The patients she encounters rarely worry about disclosing a history of diabetes or high blood pressure, she wrote. “Yet when it comes to depression or anxiety, there is some uncertainty in their response. And it always seems to follow by some long, drawn-out explanation as if to justify the diagnosis.”

Depression in fact is relatively common. In any given year, about 6.5 percent of the
American population will experience depression. Across a lifetime, about 16.2 percent of the population will have depression at some point. Stigma or not, antidepressants are one of the most frequently prescribed drug categories in the United States.

How antidepressants work in the brain, and whether they’re truly effective, is a matter for some debate. At one time it was thought that low levels of serotonin, a mood-enhancing chemical, were a trigger for depression, and that drugs such as Prozac, which raise the level of serotonin in the brain, would correct this. This theory has been called into question, though, and if continuing neuroscience study is any indication, the role of antidepressants is considerably more complex than this.

Why, for instance, does medication seem to be more effective for severe depression but less so for mild or moderate depression? Why do some antidepressant medications cause a worsening of depression in some people?

Studies have found that people with mild depression often do well with talk therapy alone. Other studies have found that a combination of medication and talk therapy is often most effective for mild to moderate depression. What does this mean for the role of talk therapy in treating some forms of depression?

Of the millions of antidepressant pills dispensed in the U.S. each year, some likely have been overprescribed to those who don’t really need them. “The reality is that many psychiatrists do give out pills too freely, and many patients start taking medications without properly researching them beforehand,” Lancaster writes.

But in her own case, antidepressant medication has made the difference between being able to function vs. withdrawing from life, she wrote.

Medication hasn’t been a cure for her. “No pills can do that,” she wrote. “What they can do is give you some energy and focus so you can make it through the day without feeling lethargic, irritable or just downright horrible.”

And she notes a double standard, at least in college-campus culture, of peers who view binge drinking, smoking, unprotected sex and “study drugs” as socially acceptable but believe antidepressants are “dangerous and mind numbing.”

“Like any medicine, antidepressants aren’t perfect,” she wrote. “But to make the sweeping generalization that all of them are bad is dangerous and prevents many from getting the help they need.”

Does online patient access = better care?

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When patients have online access to their medical record and the ability to email their doctor, does it lead to better care?

In theory, patient portals are supposed to improve communication between patients and clinicians and encourage patients to become more engaged in their care, thereby producing better outcomes. There has also been a belief that if patients can view test results online and have non-urgent concerns resolved via email, it would help cut down on in-person use of health care services and allow the system to function more efficiently.

But a new study, carried out by Kaiser Permanente and published last month in the Journal of the American Medical Association, has found that the case for efficiency might be wishful thinking.

Previous studies that have examined patient use of health information technology have mostly been small. This study was a large one, involving about 44,000 Kaiser Colorado members who had online access to their medical record and 44,000 who did not. Both groups were followed before and after the introduction of an online patient portal.

The results were surprising. Contrary to what the researchers expected, patient use of the portal was associated with more, rather than fewer, office visits and telephone calls. The researchers found an 8 percent increase in the volume of phone calls from these patients and a 16 percent increase in office visits.

Patients who had access to the online portal also made more visits to the clinic after hours, went to the emergency room more often and were hospitalized more often than those who weren’t signed up for the portal.

Is there a connection between online access to medical information and care-seeking behavior by patients? The study wasn’t designed to explore this, although Dr. Ted Palen, the lead author, speculated in an accompanying audio interview that patients who anticipated needing more care may have been more likely to sign up for the portal in the first place.

It’s an intriguing study because there’s still much that isn’t clear about how health information technology is shaping patient behavior and the impact this has on the delivery of health care. Which patients are more likely to use online access to their doctor and their medical record? Do patient portals foster more engagement? Are outcomes better for these patients? When a medical practice decides to offer an online patient portal, does it promote more efficient communication or does it create an extra burden?

This last point is important. An 8 percent increase in phone calls or a 16 percent increase in office visits might not sound like much, but when it’s applied across a system  with thousands of patients, it can add up to a significant impact, Dr. Palen points out.

Health systems considering the use of patient portals need to ask themselves whether they have the capacity to absorb a potential increase in utilization, he said. “You’d better plan for that.”

The findings from the study could further dampen the enthusiasm for online patient portals, which the health care system has been slow to adopt anyway. What we don’t know, however, is whether the additional office visits and phone calls were actually beneficial in some way to patient health, or whether there was a fundamental difference between the patients who signed up for the portal and those who didn’t.

The increased utilization may in fact have been “a good thing” if it led to better outcomes and health status in the long run, Dr. Palen said. But it seems far more study and analysis are needed to truly sort out the impact of patient-centered information technology and how to use it wisely, appropriately and effectively.

Grief for the holidays

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It’s hard to look at the calendar and not be reminded that Christmas Eve will mark exactly four months since my dad’s funeral. There’s going to be an enormous gap in the family holiday celebration this year, and in fact every year from now on.

But for what it’s worth, we are far from alone in having grief as an uninvited guest for the holidays.

Although the cultural expectation is that this is supposed to be a joyful time of the year, the reality is otherwise for anyone dealing with death, illness, financial difficulties, divorce, homelessness, or other forms of loss.

We shouldn’t need to be reminded of this, but somehow we often do anyway. And it seems many of us need outside advice on how to cope – or, for those who aren’t anticipating that their own holidays might be difficult, advice on how to be sensitive toward family and friends who are.

My email inbox has been filling up since October with suggestions on everything from getting through the holidays while undergoing cancer treatment to coping after a natural disaster. A half-hour on the Internet  turned up even more advice and insight, much of it from experts on grief.

If there’s one message to be gleaned from all this information, it would perhaps be this: Expect your emotions to be near the surface and expect that it will be hard at times, but concentrate on how you can make the holidays both manageable and meaningful in spite of what you’re dealing with.

Caroline Flohr, who lives in suburban Seattle and recently published “Heaven’s Child,” a memoir about the sudden death of her 16-year-old daughter, Sarah, has this to say: “Through the web of pain, I have been amazed by the power of family, love and faith in  healing.”

Have faith in your own inner strength and be appreciative of what you have, she writes.

From a grief counselor: Try to avoid comparing your situation with that of other people who are together and enjoying the holidays; no family gathering is perfect or stress-free.

Alan Wolfelt, the founder of the Center for Loss and Life Transition in Fort Collins, Colo., and a noted author and counselor, suggests that rather than allowing well-meaning friends and family to prescribe how they think you should spend the holiday, focus instead on what would be meaningful to you.

What about the thousands of people for whom health challenges will be an unavoidable part of the holidays? Deborah Cornwall, a leadership volunteer for the American Cancer Society and author of a new book, “Things I Wish I’d Known: Cancer Caregivers Speak Out,” sums it up this way: “Keep it festive. Keep it simple. Keep it social. Keep it positive.”

Having cancer or being a caregiver for someone with cancer (or any other major or chronic disease, for that matter) is often overwhelming, so look for normalcy, she advises. This might mean focusing on a few traditional activities, such as baking and decorating cookies, that are most important to you and skipping the rest. Make togetherness the priority – and find time to laugh, Cornwall suggests.

Those who haven’t yet experienced grief or illness or hardship during the holidays may want to be helpful but don’t know what to say or do.

Again, the experts come to the rescue with some important tips: Don’t judge. Don’t give advice that hasn’t been asked for. Be present and listen. Rather than waiting to be asked or making vague offers of help, take the initiative and offer to help in ways that are specific and practical, such as bringing over dinner or shoveling snow off the sidewalk.

In the days and weeks after Dad died, it was often the little things that mattered most – the cards, the phone calls, the neighbors who brought food, the people who took the time to share their memories of him.

Studies on coping with grief and adversity mostly point to the same conclusion: Support from other people matters, and an essential part of the recovery process is the construction of meaning out of loss. Even though the holidays are often a serious test of people’s emotional fortitude, at the same time it can be an opportunity for the sick, the struggling and the bereaved to become more resilient.