Saturday, April 17, 2010

Is Marriage Good for Your Health? -

In 1858, a British epidemiologist named William Farr set out to study what he called the "conjugal condition" of the people of France. He divided the adult population into three distinct categories: the "married," consisting of husbands and wives; the "celibate," defined as the bachelors and spinsters who had never married; and finally the "widowed," those who had experienced the death of a spouse. Using birth, death and marriage records, Farr analyzed the relative mortality rates of the three groups at various ages. The work, a groundbreaking study that helped establish the field of medical statistics, showed that the unmarried died from disease "in undue proportion" to their married counterparts. And the widowed, Farr found, fared worst of all.

Farr's was among the first scholarly works to suggest that there is a health advantage to marriage and to identify marital loss as a significant risk factor for poor health. Married people, the data seemed to show, lived longer, healthier lives. "Marriage is a healthy estate," Farr concluded. "The single individual is more likely to be wrecked on his voyage than the lives joined together in matrimony."

When Nursing Is a Team Sport -

Day shift had just started and a patient down the hall was having a
problem. I asked the nurse, Lisa, what was going on.

Jeff Swensen for The New York Times Theresa Brown, R.N.
"Not my patient," she said hurriedly as she carried a portable
defibrillator into the room, helping out until the patient's nurse
got there. One of the doctors shouted a question, and the nurse
quickly looked it up on the computer. The patient had a low magnesium
level and was experiencing P.V.C.'s, or premature ventricular
contractions, irregular heart beats that on their own are usually
harmless but can lead to dangerous cardiac arrhythmias when magnesium
levels drop.

I jumped in and called the pharmacy. Soon, the pharmacist arrived and
tossed me the bag of I.V. magnesium, which I quick walked down the
hall and gave to Mary, the patient's nurse. The doctor was in the
room by now and approved the magnesium order. I waited to see if I
was needed for anything else. "I think we're good," Mary said,
hanging the drug.

In his new book "The Checklist Manifesto: How to Get Things Right,"
Dr. Atul Gawande argues that health care has evolved to be much more
of a team, rather than an individual, effort. In fact, the book is as
much about the importance of teamwork as it is about checklists, and
he explains near the end, "In a world in which success now requires
large enterprises, teams of clinicians, high-risk technologies, and
knowledge that outstrips any one person's abilities, individual
autonomy hardly seems the ideal we should aim for."

He's completely right about how inpatient care is now provided. In
teaching hospitals, every patient's care is managed by a medical team
that can include doctors-in-training, nurse practitioners, physician
assistants, attending M.D.'s and doctors from other medical
specialties. Every team also includes the patient's nurse, who tries
to coordinate the work of the team members. Ancillary staff who often
go unremarked are also members of the team: pharmacists, occupational
and physical therapists, behavioral medicine specialists, social
workers, dietary experts and respiratory therapists. And often,
doctors, nurses and other workers who aren't assigned to the patient
must jump in when needed.

At the end of shift that day, we needed a team effort once again. I
was talking over the morning's events with Mary when a family member
of one of my new patients came to ask for help. "She's having trouble
breathing," the family member said.

This patient had only one lung and was already on oxygen, so hearing
that she was having a hard time breathing was worrisome. I hopped off
my chair and at the same time Mary sprang into action to help me.

I headed into the patient's room while Mary hurried to the nurses'
station, calling, "I'll grab a pulse-ox," the small machines we have
that check blood-oxygen levels.

In the room I learned that, in an effort to be kind, her family
members had removed her oxygen equipment so that she could put on a
nightgown she especially liked. I understood their impulse, but in
that situation it just wasn't a good idea. "How about we get her
stable and then worry about the nightgown," I gently suggested, and
they all agreed.

I put the oxygen back on the patient, and Mary brought me a pulse-ox
machine. As the patient breathed in, her oxygen level increased, but
she was still struggling.

"What about breathing treatments?" Mary asked. She left the room to
page a respiratory therapist who could administer a bronchodilator, a
drug that would open the lung passages, making breathing easier.

The respiratory therapist showed up, and we discussed the patient's
climbing heart rate, which was now much too fast. The drug usually
prescribed in a situation like this could have caused it to increase
even more, so the therapist chose a different drug. After it was
administered, another nurse, Sara, checked in to see if she was
needed. By then the patient's breathing was no longer labored, her
oxygen level was normal and her heart rate had not gone up. Relieved,
I told Sara we were fine.

In some ways it was a hard day — the action was virtually nonstop and
stressful as we focused on crisis situations that put our patients at
risk. But the truth is, I loved that day at work because we met the
ideal. Working as a team may be the model, but in reality we often
fall short. People are stressed or tired, egos get in the way,
someone needs to be two places at once and can't be, opinions about
the best course of action differ aggressively.

But on that rare day I got to bask in the feeling of all of us
working together, without conceit and without rancor, to do what we
strive every day to do best: take care of all our patients.

Living Wills Do Make a Difference at the End of Life -

 Tomorrow is Health Care Decisions Day, part of a national campaign to encourage Americans to complete their advance directives or living wills and document their desires regarding medical treatment at the end of life.

I will spend the day thinking about my father-in-law and how the wishes outlined in his advance directives continue to affect our family a month after his death.

My father-in-law was a lifelong educator, a gentle Latin scholar and former school head. That he also possessed cinematic-grade good looks seemed irrelevant to him. Instead, his greatest delights were, in descending order, his family and friends, word games and reeling off a good story, the quality of which could be judged by the wryness of the final one-liner. Even as he suffered from dementia, my father-in-law retained his ability to deliver the unexpected zinger.

Earlier this year at his skilled nursing facility, after joining one of two teams involved in a spelling bee, a staff member asked him what he wanted to name his team. He looked up at his elderly, slightly glassy-eyed comrades, then surveyed his opponents.

"The Winners," he answered, with a slight smile. "Our name is 'The Winners.' "

But there were no witty quips that morning four weeks ago when he woke up with a cold left arm. Later, in the hospital, surgeons would tell us that he had a clot in the arm's main artery, as well as multiple clots in other arteries. With these pathways for oxygenated blood obstructed, my father-in-law's arm, part of his spleen and a small segment of intestine were dying. Without multiple surgical interventions, the dying organs would soon release a torrent of toxins into his bloodstream. The tingling, numbness and slight discomfort he was complaining about would eventually give way to excruciating pain.

Even with my experience of having cared for patients in similar situations, I wanted at first to believe, against all odds, that my father-in-law's course might be different. It seemed easier that morning to take the responsibility of deciding to do something, to proceed with an operation, than it was deciding not to intervene.

But was it right to count on the small chance that he might survive such an operation, when in fact it was more likely that our interventions would leave him languishing in an intensive care unit and returning over and over again to the operating room?

As it turned out, none of his family had to brood over the decision for long. In his gentle, understated way, my father-in-law had lifted the burden of that choice from his family's shoulders years earlier. In the folder of papers that he carried with him to the hospital were the advance directives that spelled out how he wanted to live and that recapitulated conversations he had had with his children years ago about the inevitable end of his life.

My father-in-law completed those documents with the hope but not the assurance that they would actually influence the end of his life. In fact, not even experts in end-of-life care could have assured him or predicted whether his living will would have made any difference. While advance directives have been around for almost 40 years and have been federally mandated in all Medicare-certified institutions for two decades, there has been no research to show that patients with living wills actually end up dying in a way that is consistent with their wishes.

Now we have the evidence that advance directives do make a difference.

Researchers at the University of Michigan in Ann Arbor combed through the records of over 4,000 individuals over age 60 and found that almost a third of these patients would eventually become too incapacitated to make the necessary decisions regarding medical treatment at the end of life. But among them, nearly all of those with a living will requesting limited or comfort care only ultimately did receive such care at the end of their lives. And those patients who specified all care possible were far more likely to receive aggressive care than those who did not request it.

"We need to take the initiative to document decisions seriously," said Dr. Maria J. Silveira, lead author of the study and an assistant professor of internal medicine at the University of Michigan. "Every person who comes through the door at age 60 or above has a significant chance of losing decisional capacity."

The number of individuals with living wills has increased steadily over the years; still, fewer than half of the patients in the study had one. Without such documents, patients remain vulnerable even if they have already had end-of-life care conversations with a physician. "We live in a time where care is very fragmented," Dr. Silveira said. "You can't be sure that the doctor who has the conversation with the patient is the same doctor who will care for the patient in the hospital or in the nursing home."

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Tuesday, April 13, 2010

In Reporting Symptoms, Don’t Patients Know Best? -

About six years ago, my doctor gave me some samples of a drug to treat pain from an injury. I took it for a few days and then woke up one morning with a big red blister on my tongue. I'd never had anything like it before, and I wondered if the pills might be to blame. They weren't helping much anyway, so I quit taking them. The blister went away. I mentioned it the next time I saw the doctor, but he said it must have been a coincidence.

Not long after, the drug, Bextra, was taken off the market in the United States. It had been linked to heart attacks and also to a dangerous condition called Stevens-Johnson syndrome — which can cause mouth blisters, among other things.

There's no way to know if Bextra caused my problem, but it seemed like a reasonable idea, and I never understood why my doctor was so quick to dismiss it.

The episode came to mind when I read an article in the March 11 New England Journal of Medicine by Dr. Ethan Basch, an oncologist who treats men with prostate cancer and does research at Memorial Sloan-Kettering Cancer Center in New York. He argues that doctors, researchers, drug makers and regulators should pay more attention to patients' firsthand reports of their symptoms while they take medicines, because their information could help to guide treatment and research, and uncover safety problems.

Direct reports from patients are rarely used during drug approval or in clinical trials, Dr. Basch says. If patients' comments are sought at all, they are usually filtered through doctors and nurses, who write their own impressions of what the patients are feeling.

In addition, he writes, doctors and nurses "systematically downgrade the severity of patients' symptoms" and sometimes miss side effects altogether. One result is "preventable adverse events" — for instance, suicidal thoughts in young people taking antidepressants, or severe constipation in people taking a drug for irritable bowel syndrome, both of which might have been detected earlier if symptoms had been systematically tracked.

Dr. Basch, 42, said he first became interested in this subject around 2003, when he attended a presentation of the results from a study of a new cancer drug. The researchers had not found fatigue to be much of a problem, but other doctors in the audience said their patients had suffered terribly from it while on the drug, so much that some had to quit taking it. Somehow, the study had completely missed that finding.

Intrigued, Dr. Basch began to study people receiving chemotherapy, and to compare symptom reports by patients with those from doctors and nurses. The differences were striking. For every problem — fatigue, nausea, appetite loss, vomiting, diarrhea, constipation — patients reported it earlier and more often than did doctors and nurses.

Why does this happen so often? There's no simple answer.

"There is a sensibility among some old-school clinicians that they have a better sense of their patients' experience than patients do themselves," Dr. Basch said. "But doctors and nurses bring their own biases to the evaluation. They might say, 'Mrs. Smith always exaggerates her fatigue — she says 9, but I rate it a 6.' "

Three clinicians asked to rate the same patient's nausea will often give three different scores, he said.

The tendency to downgrade symptoms may be based on the doctor's knowledge that a patient is in the early stages of an illness and could be much worse. Or the doctor may be making mental comparisons with other patients who are sicker: "You think your nausea is bad, you should have seen the patient I saw this morning, let me tell you," as Dr. Basch put it.

Sometimes, he said, the downgrading may reflect wishful thinking by doctors, who may think that a certain drug will help patients and don't want to take them off it.

Another reason, Dr. Basch said, is that "we live in a litigious society." Describing a problem in a chart creates a record that the doctor may have to act on. "There may be a defensive lack of documentation," he said.

But he went on, "Increasingly, scientifically, we believe that whatever Mrs. Smith says is what Mrs. Smith is experiencing, and it's important to know how patients themselves feel about how they're doing."

But the doctor's perspective is important, too, he said, and he suggested that symptoms be rated the way the Web site Metacritic rates movies: it posts two types of score, one from the public and one from professional critics.

"I want both," Dr. Basch said.

Sometimes the information is lost altogether, when doctors and patients, distracted by test results and treatment plans, forget to discuss symptoms. "This is where a checklist could help," he said.

Mistakes and distortions in reporting symptoms can be compounded in studies, where one researcher collects the information, another retrieves it from the chart and enters it into the study record, and still others evaluate it. The results can be like playing telephone.

"There are multiple steps of transcription and information filtering," Dr. Basch said. "We know there are omissions and misinterpretations at every step of data transmission. We know information gets lost."

Patients may also tell doctors one thing and then write another in their own reports, Dr. Basch said; most say their written accounts are closer to reality.

The idea of not telling doctors the whole truth struck a guilty chord with me. Growing up, I got weekly hay fever shots that I don't think helped me at all. But I kept hoping they would, and the doctor was very kind, so whenever he asked if I was feeling better, I said yes, even though I actually spent most of August and September sneezing my brains out. This charade went on for years. Would I have been more honest in a diary? Maybe.

The Food and Drug Administration does have a system, Medwatch, that lets doctors and patients report problems that they think are adverse events from drugs already on the market. But it's a passive system that waits for reports instead of actively surveying patients. Many people don't know about it, and it has failed to catch some important adverse events, Dr. Basch said.

A better approach, he says, would be to have large numbers of patients filling out questionnaires before and after drugs are marketed. In an e-mail message, he said, "For example, in the postmarket setting we could ask 5,000 selected patients starting Bextra to report monthly (you would have reported the mouth sore without knowing if relevant or not, and this would then be pieced together with other reports)."

If patients had been asked to report their symptoms while the drug was still being tested, he added, problems might have been detected before it was even approved.

Gathering the patients' information would cost money, but not much compared with the overall cost of drug development and clinical trials, Dr. Basch said, adding that it would also save money by heading off potentially expensive problems.

Dr. Basch said he was surprised to find drug companies enthusiastic about his research.

"You'd think it would not be appealing to them, because you're generating more adverse events," he said. "But the grade of the data is superior. You catch a lot of baseline symptoms before people start the drug, so you can understand what's probably related to the drug versus what's related to the patient's arthritis or whatever they had before the trial."

Although the regular reporting may sound like a nuisance for patients, researchers find that many people are eager to have their say. In one study, Dr. Basch said, subjects "typed volumes" into a small online text box, even though they couldn't see what they were typing after the first few sentences.

"We'd get two pages of stream of consciousness," Dr. Basch said. "The clinicians became overwhelmed."

The challenge is to create surveys that focus on what's relevant — and yet still provide a way to describe symptoms the researchers hadn't anticipated. Dr. Basch is working on it, for the National Cancer Institute.

"Patients have a lot to say," Dr. Basch said.

We're just waiting for someone to listen.

U.S. Faces Shortage of Doctors -

The new federal health-care law has raised the stakes for hospitals and schools already scrambling to train more doctors.

Experts warn there won't be enough doctors to treat the millions of people newly insured under the law. At current graduation and training rates, the nation could face a shortage of as many as 150,000 doctors in the next 15 years, according to the Association of American Medical Colleges.

That shortfall is predicted despite a push by teaching hospitals and medical schools to boost the number of U.S. doctors, which now totals about 954,000.

The greatest demand will be for primary-care physicians. These general practitioners, internists, family physicians and pediatricians will have a larger role under the new law, coordinating care for each patient.

The U.S. has 352,908 primary-care doctors now, and the college association estimates that 45,000 more will be needed by 2020. But the number of medical-school students entering family medicine fell more than a quarter between 2002 and 2007.

A shortage of primary-care and other physicians could mean more-limited access to health care and longer wait times for patients.

Proponents of the new health-care law say it does attempt to address the physician shortage. The law offers sweeteners to encourage more people to enter medical professions, and a 10% Medicare pay boost for primary-care doctors.

Meanwhile, a number of new medical schools have opened around the country recently. As of last October, four new medical schools enrolled a total of about 190 students, and 12 medical schools raised the enrollment of first-year students by a total of 150 slots, according to the AAMC. Some 18,000 students entered U.S. medical schools in the fall of 2009, the AAMC says.

But medical colleges and hospitals warn that these efforts will hit a big bottleneck: There is a shortage of medical resident positions. The residency is the minimum three-year period when medical-school graduates train in hospitals and clinics.

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