Friday, May 7, 2010

Diagnosis - Pregnant and Pained -

Even sitting quietly in the hospital bed, the young woman looked out of breath. The muscles of her neck were pulled tight, and she lifted her shoulders as she inhaled, as if simply taking in air required work. According to the chart that Dr. Roxanne Wadia had glanced through, the patient was five months pregnant. But her arms and legs were thin and wasted-looking, and she had only a tiny hint of the expected baby bump. Her eyes were sunken, and her skin was sallow. Looking at her new patient, Wadia, a resident in her second year of training at Tufts Medical Center in Boston, felt her own heart quicken. The patient was clearly sick. The doctor gave her patient oxygen and then sat down to take a history.

The troubles started when she became pregnant, the patient told her. She had barely missed her period when she started throwing up. She was hungry, but even the thought of food made her stomach heave. She could hardly get herself out of bed. Her OB-GYN gave her all kinds of medicines, but none of them worked. Finally, she had lost so much weight that her doctor put her on intravenous feedings. She put the weight back on and then a little more, but she still felt sick. "Even now," she said, "I can hardly eat a thing without vomiting."

But that wasn't why she was here now, she told the young doctor. No sooner had she got the vomiting under control than she developed a terrible cough. She didn't have a fever, but the racking cough made her body ache all over. Her husband said it sounded as if she were coughing up a lung. Her OB said it was probably a virus. Whatever it was, it didn't go away. Over the next several days, the cough became almost constant, and with every cough came pain — a pain that felt like a gigantic claw squeezing her chest and back. Finally her husband called the OB, who sent her to the hospital. After much discussion about the risks of radiation during pregnancy, a chest X-ray was done. The lower third of her right lung was filled with fluffy white where it should appear almost solid black. Pneumonia, they told her. She was admitted to her local hospital in Cape Cod, and she started on antibiotics. But she still didn't get better. The next day her fever spiked to 101.5. The day after that she started coughing up blood. The doctors switched to other antibiotics. When that didn't help, they sent her to Boston.

On exam, the patient had no fever, but her heart was beating rapidly. Her breathing slowed somewhat after she was given oxygen but was still faster than expected. When Wadia put her stethoscope on the patient's back to listen to her breath, she heard another sound as well — a sound like crisp paper being crumpled. But it was distant, as if it were in another room. The rest of the exam was unremarkable.

Wadia settled down with the stack of papers that traveled with the patient from the last hospital. She was impressed with the doctors' thoughtful approach to this complicated patient. The patient had been admitted with what looked like a run-of-the-mill pneumonia caused by a run-of-the-mill bacterium. When the infection didn't respond to antibiotics, they considered other possibilities. Could she have a pulmonary embolus — a clot from somewhere in the body that traveled and became wedged in the arteries of her lungs? That could certainly cause a cough and shortness of breath. It could even cause the bloody sputum and the fever. And a pregnant woman was at higher risk for a pulmonary embolism because the hormones of pregnancy made the blood thicker and more prone to clot. Spending so much time in bed because of nausea also increased her risk of a clot. Her doctors had looked in several different ways but hadn't seen one.

Was the problem related to her heart? That could cause the cough, the shortness of breath and the crinkly noise in her chest. This patient had no history of heart abnormality, but sometimes a new problem can develop or an old problem can be unmasked during pregnancy. But an echocardiogram, an ultrasound of the heart, was normal. If it wasn't a clot or a problem with her heart, maybe itwas an infection, but not one caused by a common bug. Could it be tuberculosis or H.I.V.? Could it be a fungus? None of those would respond to the antibiotics she'd been given. At a bigger hospital, like Tufts, doctors would be able to put a camera, known as a bronchoscope, into her lungs to look for evidence of some of the more unusual causes of pneumonia.

Late in the evening Roxanne Wadia called Dr. Geraldine Finlay, the attending physician in charge of this patient's care and the doctor who would perform the "bronch." Finlay, a pulmonologist, listened as the resident laid out the patient's story. When Finlay heard that the young woman had gotten worse on antibiotics and begun coughing up blood, she immediately suspected that this wasn't an infection but a blood clot in the lungs — a pulmonary embolus.

A common error in medicine is the assumption that tests provide definitive answers. In the math and science classes doctors take leading up to medical school, we work through a problem, come up with an answer and then check the back of the book to see if we got it right. We treat medical tests as if they provide these back-of-the-book answers. They don't. A medical test is simply another clue in the puzzle.

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Thursday, May 6, 2010

Do Women Make Better Doctors? -

Recently, one of my patients, an elderly man, stopped me as I got up from my stool to leave his room. I had just finished examining him, offering my assessment and plan, and apologizing for his long wait since I had been running late that day. He listened patiently then hopped down from the exam table just as I turned toward the door, the ties of his flimsy hospital gown flapping around his thin legs.

"Doctor," he said, "No need to apologize for being late." He smiled affably and added, "Truth be told, I prefer you lady doctors. You spend more time with patients. It's like you just know how to be a mother."

I smiled. My patient was satisfied and believed I had listened to him well. But, truth be told, I left his room somewhat taken aback, despite his good intentions. Did being a woman necessarily mean I gave better care? And was that care necessarily more patient-centered?

For two decades, spurred on by the rising number of women going to medical school (women currently make up almost half of each entering medical school class), researchers have been studying the influence of gender on physician style. While many of these investigators initially assumed that the long training process completed in lockstep with male peers would diminish gender differences, their findings over the years have indicated otherwise. Several studies have shown that female doctors tend to be more encouraging and reassuring, use shared decision-making, ask more psychosocial questions and spend more time — up to 10 percent more — with patients than male doctors do.

But research over the last few years has also found that the patient's gender determines how patients feel about their doctors, as much if not more than the physician's.

Gender is important in the patient-doctor relationship, but its influence can't be reduced to a simple statement like, "Women doctors are more sympathetic."

In one study, for example, Swiss and American researchers found that patients, depending on their gender, evaluated their male and female physicians' displays of concern for their patients differently. While male patients tended to be content regardless of physician gender and communication style, female patients were much more specific when it came to assessing their doctors. The female patients were most satisfied with their women doctors if those doctors expressed great concern and empathy and were extremely reassuring. But if the doctors were male, the female patients were dissatisfied with overt displays of caring and actually preferred less empathy and reassurance from the doctors.

"In any field that women have moved into as executives or managers, there's a Catch-22, double-blind ambivalence about how people are expected to behave," said Judith A. Hall, one of the study authors and a professor of psychology at Northeastern University in Boston. "We are just now uncovering how true it is in medicine."

Findings from other studies have also revealed that patients, regardless of gender, tend to be more assertive with women doctors, interrupting them and asking questions more frequently. While some experts have construed these interruptions as a sign of decreased respect, others contend that they in fact reflect a greater sense of comfort on the part of the patient. "Interruptions are not necessarily bad," Dr. Hall observed. "They can be a sign of empowerment and of participation. Patients feel like they are really talking."

But while the female doctor in the exam room tends to ignite such interactive conversations, it is the presence of a female patient that keeps those discussions going. According to another study published last year in The Journal of Women's Health, women patients were more likely to have discussions with doctors that focused on their illness experience and personal factors, regardless of the physician's gender.

"You can't necessarily say that women are better doctors," said Dr. Klea D. Bertakis, lead author of that study and a professor of family and community medicine at the University of California, Davis. "It's a matter of gender behaviors in the course of an encounter. Patients, as well as physicians, are bringing their specific backgrounds and experiences to that encounter; and we need to be aware of that."

Perhaps the most interesting finding in these studies of gender in the patient-doctor relationship involves male doctors who practice obstetrics and gynecology. While this group of male physicians has been shown to be significantly better than their female colleagues at showing empathy and talking to patients about their emotional concerns, many of their patients continue to have a strong preference for female doctors.

Patient-centered communication styles, it seems, may not be the only, nor even the most important, determinant of patient satisfaction.

But, as the obstetrics and gynecology example reveals, and contrary to my elderly patient's belief, the ability to have more patient-centered discussions is not limited to one sex. Or to those who might be mothers. Physician communication skills can be shaped with training; and medical schools across the country have taken advantage of that fact. More and more schools are offering courses that teach young doctors how to offer better counseling and prevention, provide shared decision-making and pay increased attention to how an illness and its treatment are affecting a patient, skills found in studies to be present more often in female physicians.

"But it's not about trying to become a woman," Dr. Bertakis reflected. "It's about learning behaviors."

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Monday, May 3, 2010

The Medpedia Project

The Medpedia Project is a long-term, worldwide project to evolve a new model for sharing and advancing knowledge about health, medicine and the body among medical professionals and the general public. This model is founded on providing a free online technology platform that is collaborative, interdisciplinary and transparent. Read more about the model.

Users of the platform include physicians, consumers, medical and scientific journals, medical schools, research institutes, medical associations, hospitals, for-profit and non-profit organizations, expert patients, policy makers, students, non-professionals taking care of loved ones, individual medical professionals, scientists, etc.

As Medpedia grows over the next few years, it will become a repository of up-to-date unbiased medical information, contributed and maintained by health experts around the world, and freely available to everyone. The information in this clearinghouse will be easy to discover and navigate, and the technology platform will expand as the community invents more uses for it.

Sunday, May 2, 2010

The Ethicist - A Doctor and His Imaging -

A specialist recommended that my wife get a CT scan and suggested that she use a lab in which, we later discovered, he has an interest. She wasn't required to use that lab, and there was no reason to question its quality or his calling for a scan. I'm O.K. with this lab — I say you either trust the specialist or you don't — but my wife is not so sure. What do you say? PETER THORNE, GLEN HEAD, N.Y.

I say it's more complicated than trust or don't trust. And so does Katie Watson, an assistant professor in the Medical Humanities and Bioethics Program at the Feinberg School of Medicine at Northwestern University: "I trust my physicians not to be criminals who intentionally order unnecessary tests to feed their yacht habits. I also trust them to be human beings, which means they're vulnerable to subconscious influences and incentives just like the rest of us."

That your wife's physician is trustworthy does not immunize him to conflicts of interest that can skew referrals. That's why a physician should not send patients to facilities in which he has a financial interest. It is neither prudent health policy nor good medical ethics to put a doctor or a patient in such a position.

Worse still, apparently your wife's physician was cagey about owning a piece of the action. You "later discovered" it. Here, too, Watson shares my discomfort, e-mailing me, "At minimum I believe physicians are ethically required to disclose their ownership interest and to direct patients to alternate service providers as well." The doctrine of informed consent compels physicians to give patients all pertinent information about their care. Because some patients might regard the ownership question as significant — your wife certainly does — her physician should have disclosed it.

Incidentally, the physician most likely broke no laws in keeping silent about his empire of diagnostic facilities and whether he owns a piece of that casino in Vegas where he suggested your wife go to recuperate. Watson again: "The laws regulating physician ownership of diagnostic and therapeutic services are complex. Much ownership is prohibited, but federal law has exceptions allowing ownership of some services (including imaging)." State laws vary, she adds, and some do require physicians to disclose ownership of certain facilities. But even where the law allows physicians to own imaging facilities, ethics does not.