Studies suggest more Americans are turning to generic drugs to cut costs, but perhaps we've taken it too far.
Nearly 50 percent of Americans take prescription drugs, with the number of people taking more than five drugs rising 70 percent between 2000 and 2008.
Doctors write prescriptions, often with incentives from drug companies, even though most drugs work for only 30 to 50 percent of patients, according to Allen Roses, an academic geneticist from Duke University.
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Ramos walked to the medical station, where he was given an injection in his right arm and told to return for another after his leave. As compensation, Ramos's commanding officer gave him a few coins to spend on prostitutes. The same thing happened several times during the early months of Ramos's two years of military service. He believes that the doctors were deliberately infecting him with venereal disease.
Now 87 years old, Ramos says that he has suffered for most of his life from the effects of those injections. After leaving the army, he returned to his family's remote village, on a steep mountain slope northeast of Guatemala City. Even today, Las Escaleras has no electricity or easy access to medical attention. It wasn't until he was 40, nearly two decades after the injections, that Ramos saw a doctor and was diagnosed with syphilis and gonorrhoea. He couldn't pay for medication.
"For a lack of resources, I was here, trying to cure myself," says Ramos. "Thanks to God, I would feel some relief one year, but it would come back." Over the decades, he has endured bouts of pain and bleeding while urinating, and he passed the infection onto his wife and his children, he told Nature last month in an interview at his home.
Ramos's son, Benjamin, says that he has endured lifelong symptoms, such as irritation in his genitals, and that his sister was born with cankers on her head, which led to hair loss. Ramos and his children blame the United States for their decades of suffering from venereal disease. "This was an American experiment to see if it caused harm to human beings," says Benjamin.
Ramos is one of a handful of survivors from US experiments on ways to control sexually transmitted diseases (STDs) that ran in semi-secrecy in Guatemala from July 1946 to December 1948. US government researchers and their Guatemalan colleagues experimented without consent on more than 5,000 Guatemalan soldiers, prisoners, people with psychiatric disorders, orphans and prostitutes. The investigators exposed 1,308 adults to syphilis, gonorrhoea or chancroid, in some cases using prostitutes to infect prisoners and soldiers. After the experiments were uncovered in 2010, Ramos and others sued the US government, and US President Barack Obama issued a formal apology. Obama also asked a panel of bioethics advisers to investigate, and to determine whether current standards adequately protect participants in clinical research supported by the US government.
When details of the Guatemalan experiments came to light, US health officials condemned them as 'repugnant' and 'abhorrent'. Last September, the Presidential Commission for the Study of Bioethical Issues went further, concluding in its report1, that "the Guatemala experiments involved unconscionable violations of ethics, even as judged against the researchers' own understanding of the practices and requirements of medical ethics of the day" (see 'Evolving ethics').
Yet that report and documents written by the researchers involved in the Guatemalan work paint a more complex picture. John Cutler, the young investigator who led the Guatemalan experiments, had the full backing of US health officials, including the surgeon general.
"Cutler thought that what he was doing was really important, and he wasn't some lone gunman," says Susan Reverby, a historian at Wellesley College in Massachusetts, whose discovery of Cutler's unpublished reports on the experiments led to the public disclosure of the research2.
Cutler and his superiors knew that some parts of society would not approve. But they viewed the studies as ethically defensible because they believed that the results would have widespread benefits and help Guatemala to improve its public-health system. Those rationalizations serve as a warning about the potential for medical abuses today, as Western clinical trials increasingly move to developing countries to take advantage of lower costs and large populations of people with untreated disease. Bioethicists worry that laxer regulations and looser ethical standards in some countries allow researchers to conduct trials that would not be allowed at home. "The strongest lesson should be that the same rules, same principles, same ethics should apply no matter where you are," says Christine Grady, acting chief of the Department of Bioethics at the National Institutes of Health (NIH) Clinical Center in Bethesda, Maryland, and a member of the bioethics commission.
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http://www.nature.com/news/human-experiments-first-do-harm-1.9980
Overweight for much of his youth, the patient developed diabetes in his early 30s, then high blood pressure a few years later. By the time he was in his 40s, he had become so debilitated by a heart attack, congestive heart failure, peripheral vascular disease, arthritic joint pains and his ever-increasing weight that he could no longer work.
He was in his 50s now, and, his forays outside his home were limited to doctors' offices or the hospital, where he would show up with out-of-control blood sugars, chest pains, an infection attacking his legs or feet or, as it was this time, shortness of breath.
Many other observers, including myself, might have jumped to the same conclusion.
My colleague stood up, bracing himself. "I hate to say it, but I feel like he's done this to himself," he said. He said the patient seemed to ignore all medical advice and had no interest in learning about his diseases. "If he were even a little bit interested in his own care, he wouldn't be where he is."
It's easy to do what my colleague did and hold patients responsible for their own health. By taking an active role in their care, patients could be healthier, clinicians would feel more gratified, and even health care costs would decrease, as there would presumably be less need for additional services outside the doctor's office.
But like everything in medicine, carrying out this "cure" takes work, as an interesting collaboration between researchers and a nonprofit health care system is revealing.
For almost two years, Fairview Health Services, with more than 40 primary-care clinics in the Minneapolis area, has been giving patients a survey developed by researchers at the University of Oregon in Eugene to measure how actively involved they are in their heath care. Known as the Patient Activation Measure, the survey includes just 13 questions and takes only a few minutes to complete, with patients responding to statements like, "I know what my prescribed medications do," "I am confident I can tell my health care provider concerns I have even when he or she does not ask," "and "I am confident that I can maintain lifestyle changes like diet and exercise even during times of stress." Patients are then placed into one of four categories depending on how likely they are to understand their health care issues and how much confidence and skill they have to take care of themselves.
Not long ago, the researchers examined the survey results of over 25,000 Fairview Health patients and compared those results with various objective measures of wellness like blood pressure, body mass index, blood sugar and cholesterol levels, emergency department use and hospitalizations.
Although not all the differences were dramatic, patients who were more involved in their health were less likely to smoke, be obese, get hospitalized or go to the emergency room than those who were less engaged. And while more affluent patients tended to be healthier than those who were poorer, patients who were more active in their own care tended to be in better health than their socioeconomic peers, regardless of income.
With these findings in hand, Fairview Health has been trying to find ways to use patients' activation survey results and encourage their participation. Recently, the health care system tried offering a two-day seminar for clinicians on techniques to motivate patients. Instead of simply offering generic advice, lectures, laboratory tests or prescriptions, the clinicians learned to encourage and respect individual patients' involvement levels by allowing them to come up with their own solutions to wellness issues, an approach that showed some promise. But it also posed challenges. For at least a few patients, for example, the most effective personal strategy for remembering to take a pill first thing in the morning meant placing the medication next to a pack of cigarettes.
In another Fairview Health initiative, hospital teams have tried using the results of the surveys to plan patient support after hospital discharge. If a patient was hospitalized for complications of diabetes, for example, and showed low "activation" levels on her survey because she had difficulty regularly monitoring her blood sugar levels at home, the hospital might schedule more frequent home visits and telephone calls by visiting nurses. The patient would also get a timely follow-up appointment in the doctor's office.
While it's still too early to know if these initiatives and others are actually encouraging patients and having an impact on their health, both the clinicians and the researchers remain committed to continuing their work in this area. Fairview Health plans to continue administering the activation survey to patients and expand its motivational seminar program, and the University of Oregon researchers hope to further explore how clinicians can best encourage patients.
Referring to the current health care system, Valerie Overton, an advance practice nurse and vice president of quality and innovation at Fairview, said, "There comes a time when we have to realize that there's not much more to squeeze out of this old turnip.
"Patient engagement is a way to get us to the next level of quality of care, but it's not an easy journey."
http://well.blogs.nytimes.com/2012/01/12/getting-patients-to-take-charge-of-their-health/
Slender, in her 60s and possessing the stoicism of someone who had single-handedly raised children in the toughest section of the city, our patient faced a difficult challenge of the medical kind. She had diabetes and such severe peripheral vascular disease that even the strongest antibiotics could not heal a long-standing foot infection. She needed an operation.
This grandmother who regularly held court in her hospital room with her extended brood also suffered from high blood pressure and heart disease, and all of us on the surgical team knew that operating would be no easy feat. We could amputate her infected foot, a relatively quick operation that would carry few risks, but she would never walk again. Or we could do an arterial bypass, a more complex operation that would save her leg but that might disable or even kill her before her surgical scars ever healed.
The final decision hinged on our assessment of her likely course, or prognosis. If she was unlikely to live long, we would amputate, because it wouldn't make sense to put her at risk of other life-threatening complications just to save her leg. But to throw out some ballpark figure, an actual number of the weeks, months or years this woman we had grown to care about had left to live, meant shouldering the responsibility none of us were eager to be reminded of – that is, our potential role in hastening her death because of poor clinical decisions based on the wrong prognosis.
A week after her bypass operation, our patient died of a heart attack. The prognosis of her senior surgeon and our entire team — that she would tolerate the surgery and survive long enough to walk again — had been incorrect.
While not all assessments of how long someone has to live result in life-or-death clinical decisions, addressing prognosis remains a challenge for most doctors. And after struggling for several years with determining their own patients' prognoses, a group of physicians at the University of California in San Francisco set out to collect and study all the research that had been done on so-called prognostic indexes, tools that help with determining general prognosis in older patients.
Given the growing use of age-based treatment and preventive care guidelines, the doctors assumed there would be plenty of data to help decide whether, for example, an 80-year-old patient might live long enough to benefit from a colonoscopy, a cancer screening procedure that can have its own set of complications.
But they found little.
Prognosis was rarely, if ever, alluded to in the most popular medical textbooks and on clinical Web sites used by practicing physicians. Even the widely used medical database PubMed, maintained by the National Library of Medicine, had no specific indexing category for prognosis, making finding any published study on the subject like searching for a book in a library before the Dewey Decimal System.
While the researchers were finally able to single out 16 indexes that hold promise in helping doctors predict how long a patient might live, there was"insufficient evidence at this time" to recommend any of them for widespread clinical use. None of the indexes had been tried with groups of individuals other than the initial test group to confirm reliability, and every single one had a potential source of bias. Some studies were never able to follow up on the final outcomes of a substantial subset of patients; others used researchers intimately involved with the development of the prognostic tool, and not impartial observers, to validate findings.
"There's a need for much more research in this area," said Dr. Eric W. Widera, one of the authors of the study, which appeared in The Journal of the American Medical Association. "Compared to diagnosis and treatment, prognosis is like the unloved stepchild of medicine."
A century ago, predicting a patient's life expectancy was an essential part of doctoring. Details relating to the art and science of "prognosticating" occupied a prominent position in textbooks, journals and conversations with patients. That emphasis began to shift as technology advanced, with doctors focusing more and more of their time on treatment and diagnosis.
Economic forces reinforced this new emphasis, as it became clear that while the ability to predict the timing of a patient's death was useful, the tools to treat and diagnose were profitable.
Perhaps even more important, prognosis has now become a potent symbol of the limits of medicine. With a growing array of successful treatments at hand, doctors often have the power to forestall death. But thinking about prognoses means recognizing not only fallibility but also possible culpability.
"Even in the privacy of their own minds, doctors don't like to think about prognosis," said Dr. Nicholas A. Christakis, a professor of medicine and medical sociology at Harvard Medical School and author of "Death Foretold"(University of Chicago Press, 2001), a book on the sociocultural issues of prognosis.
With so little research on how to predict how long a patient might live and few resources to turn to, physicians often end up relying on intuition. But studies have shown that these "guesstimates" can be wildly inaccurate, and that inaccuracy can adversely affect an older patient's quality of life and care. Doctors who are too optimistic may prescribe unnecessary and painful procedures and treatments; those who are too pessimistic may neglect to offer adequate care.
Most current clinical guidelines sidestep considerations about prognosis by relying on simple age-based cutoffs. The United States Preventive Services Task Force, for example, uses 75 as the age to stop routine colon cancer screening. "But age is an incredibly blunt tool," Dr. Widera noted. "We all know of 65-year-olds who are much sicker than some 95-year-olds."
While the authors of the study have created a Web site, www.eprognosis.org, to help physicians and patients access available prognostic tools, they are quick to acknowledge that this interactive tool is only a small part of what doctors and patients need. More work and resources must be devoted to creating accurate assessment tools, testing the reliability of those that exist and teaching doctors once again the art and science of determining, and talking about, prognoses.
Drug companies are by no means the only players in this drama. Through the work of investigative journalists, we have learned how informal alliances of pharmaceutical corporations, public relations companies, doctors' groups, and patient advocates promote these ideas to the public and policymakers—often using mass media to push a certain view of a particular health problem. While these different stakeholders may come to these alliances with different motives, there is often a confluence of interests—resulting in health problems routinely being framed as widespread, severe, and treatable with pills, as has happened recently with social anxiety disorder [5]. Currently, these alliances are working with the media to popularize little-known conditions, such as restless legs syndrome [6] and female sexual dysfunction [7], in each case lending credence to inflated prevalence estimates. In the case of female sexual dysfunction, there has been a serious, though heavily contested, attempt to convince the public in the United States that 43% of women live with this condition (see pp. 175–195 in [2]). This is happening at a time when pharmaceutical companies perceive a need to build and maintain markets for their big-selling products and when pipelines for new and genuinely innovative medicines are perceived as being weak.
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http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.0030191
It began suddenly a little over 10 years ago. With impressive fluency, friends, family members and patients started asking me about random medications, the odd syncopations of those invented, polysyllabic pharmaceutical brand names – Viagra, Lipitor — rolling perfectly off their tongues.
The questions they asked about those drugs did not reflect breaking news or the results of scientific studies. Rather, they were a reflection of sound bites, advertisements and the draw of celebrities who endorsed them, all part of carefully conceived marketing schemes.
There's no question that Americans like their prescription medications. We spend nearly twice as much per person on pharmaceuticals as patients in other developed countries do, and we account for nearly half of all sales worldwide. But in 1997, when the Food and Drug Administration loosened its regulations and the United States became one of only four countries to allow direct-to-consumer advertising (the others are New Zealand, Bangladesh and South Korea), we entered a new era in pharmaceutical consumerism.
Players in the drug industry began aiming their advertisements at patients, and their goal was to define in the minds of patients not only the beneficial effects of the drugs but also the diseases they were designed to treat.
As Vince Parry, a well-known marketing expert, counseled his colleagues, "If you can define a particular condition and its associated symptoms in the minds of physicians and patients, you can also predicate the best treatment for that condition."
The phenomenon is sometimes referred to as "disease mongering," redefining what is normal and abnormal in a way that widens potential markets for those who sell treatments. And, as detailed in a recent study in the journal Social Science & Medicine, one marketing strategy has accomplished more in this regard than any other by using what has come to be the very symbol of quality and reliability for doctors and patients everywhere: the checklist.
Placed on Web sites, on downloadable apps and in pamphlets in doctors' offices, these checklists of symptoms have become a critical part of every major pharmaceutical marketing campaign. What makes them so attractive is that they make it easy for patients to diagnose their own ailments, to take some control over their own health.
What makes the checklists so powerful is their ability to influence patient preferences.
The makers of Yaz, a birth control pill, for example, used a checklist to help promote the use of their drug as a treatment for premenstrual dysphoric disorder, a controversial diagnosis said to affect up to 10 percent of women. Alongside links to articles on fashion, makeup, hair and celebrity news, Yaz's Web site offered a "Body Diary" checklist to help patients determine whether they suffer from the disorder.
Taking its cues from the Diagnostic and Statistical Manual of Mental Disorders, or D.S.M., which mental health professionals use to diagnose disease, the checklist offered watered-down and potentially more inclusive descriptions. A symptom described in the D.S.M. as "persistent and marked anger or irritability or increased interpersonal conflicts" appeared in the Yaz questionnaire as "Felt angry, or irritable." "Marked change in appetite, overeating, or specific food cravings" became "Had increased appetite or overate; or had cravings for specific foods." The printable results that patients could then take to their doctors (the site has since been taken down) were on a form emblazoned with the birth control brand.
"The whole point of tools like this one is to confine people's experiences into these categories in order to make a diagnosis in line with the branded drug," said the author of the study, Mary Ebeling, an assistant professor of sociology at Drexel University in Philadelphia who got interested in the use of checklists while doing research at a marketing firm. "I became really intrigued when I saw a group of marketers sitting around a table in Midtown Manhattan and coming up with symptoms."
Some symptom checklists are clearly branded, so patients and clinicians can easily discern the pharmaceutical interests involved. But many are less obvious or are used as part of advocacy groups' materials or awareness events. For example, National Depression Screening Day, held annually at college campuses, military sites and community centers across the country, uses a symptom checklist called the Patient Health Questionnaire, or PHQ-9. The nine questions are based on a well-known anxiety screening tool, but its copyright is held by Pfizer, maker of the antidepressant Zoloft.
It's difficult to ascertain whether efforts aimed directly at consumers ultimately translate into real sales. A recent marketing study found that fewer than 3 percent of patients mentioned a marketed drug by name and less than 1 percent asked for a prescription. However, a separate study comparing patients in Canada, where direct-to-consumer marketing is illegal, with those in the United States found that American patients were more than twice as likely to request advertised medications.
But sales may not be the only measure of success for these campaigns. "The whole point of this marketing and branding is that the name ends up in the minds of the consumers," Dr. Ebeling said.
While the Obama administration is looking to force pharmaceutical companies to disclose any payments to doctors that might influence their treatment decision, marketing efforts directed at patients are likely to continue to grow. And with those efforts comes a widening, not shrinking, circle of interests that can influence their care.
"There are pharmaceutical marketers, medical device makers, health insurers and whoever is involved in the health industry sitting in the exam room, not just the doctor and patient," Dr. Ebeling said.
She added, "I find that disturbing, because it's our health and the quality of our lives that are at stake."
Siri, the iPhone's smart guide, can tell you what's on your calendar today. But not if the event is an episode of depression, nor can it tell you what to do about it.
A new program for smartphones in the pockets of people with major depression can do both. The software, developed by researchers at Northwestern University, combines data gathered by phone sensors with reports of mood to predict events likely to trigger an emotional plunge. Then the phone suggests ways to ward off the blues. In a small preliminary trial, patients who scored high on a test for major depression didn't even meet the criteria for the disorder after two months.
"I don't want to make huge claims, but we're encouraged," says David C. Mohr, the psychologist who headed the team that developed the program, Mobilyze. In a few weeks he will begin testing an enhanced version of the program, with a larger trial planned for this summer, backed by part of a $5-million grant from the National Institutes of Health. He and others think the program could fill a major health-services gap.
"Health data show that 60 million people in this country have problems that should be treated by a mental-health specialist. Obviously they aren't," because of insurance problems, lack of counselors, and other barriers to access, says Mr. Mohr, a professor of preventive medicine at Northwestern's medical school. "So this technology has the potential of extending treatment to people who are underserved and undertreated."
His is just one of several new attempts to expand treatment for mental illness using smartphones. Others target bipolar disorder and post-traumatic stress disorder. But there are cautions. "You need long-term adherence to these things," says Colin A. Depp, an assistant professor of psychology at the University of California at San Diego who did the work with bipolar patients. "We saw a decrease in symptoms, but none of us have done long trials, or used comparison groups to see if similar patients would get better anyway."
"I am, though, very excited about the potential here," he says. The work at Northwestern, he adds, "is a new frontier because of the way it uses the phone sensors. And ultimately it is automatic and doesn't require the patient to enter any information in order to get help."
Mobilyze starts by asking a little bit of the patient, who keeps a mood diary on the phone, noting when he or she feels high and low. At the same time, the smartphone's 40-odd sensors—GPS and wireless network finders to determine location, accelerometers to detect motion, light sensors, Bluetooth detection of other devices, and more—collect a lot of information. And then they connect the data to the mood ratings, and come up with a predictive model so the patient doesn't have to enter any more information.
"If the system sees that you've been sitting at home for four hours on Saturday morning, it knows that, historically, this leads to depressed feelings later in the day," Mr. Mohr says. "Then it will send you a text message with that observation, and perhaps suggest that you call a friend."
The key points here are that the interventions are customized for each patient, and drawn from a recognized effective therapy technique called behavioral activation. They may sound simple or hokey, but in the initial trial of seven patients, which lasted for eight weeks, scores on several standard depression surveys dropped by more than 50 percent, as did anxiety scores. The computer predictions of mood triggers, like location or social contacts, also proved to be pretty accurate.
The program isn't totally automated. Patients got a weekly call from a counselor to discuss issues. "We're not trying to replace therapists, but augment them," Mr. Mohr says. Mr. Depp adds that "if you embed the program, like the reminders, with language that people wrote themselves, it's a lot more personal."
Mia L. A. Lustria, an associate professor of communication and informatics at Florida State University who studies Internet-based health treatments, also thinks this work shows a lot of promise. But she points to some potential downsides. "If you provide seriously depressed patients with these tools, are they in a position to use them? Do they have the energy and motivation?" Mr. Mohr admits that since he recruited the people in his study, they were likely to be more curious and motivated than the typical depressed patient is.
Mr. Depp also cautions that short-term trials might not reveal device fatigue: People get excited when they are given a new phone with a new program, but after a few weeks the novelty wears off and they may stop using it.
He also notes some advantages, though. "We heard from our participants," he says, "that getting advice from a phone is more benign than, say, getting advice from their mother."
I recently read through a study published in The Journal of General Internal Medicine on the different ways that African-American and white doctors communicate nonverbally with older patients, and I was reminded of a former colleague, a specialist in brain tumors who stood out from the rest of us young doctors for two reasons.
First, though a relative newcomer to the hospital, he had diagnostic skills equal to those of physicians many years his senior. Second, and not unusual for over a decade ago, he was one of the few African-American physicians there.
One day I asked him to see one of my patients who had recently been given a cancer diagnosis. The patient, who was older and white, was sitting upright in his bed, surrounded by his wife and children, when we entered the room. But by the time we left, the patient, along with his relatives, was doing exactly what I was — leaning over and politely straining to hear what my colleague was saying.
This brilliant doctor's soft baritone voice was rendered even less comprehensible because he tilted his head down and spoke not toward us but at the door. Every so often he looked up and shared a radiant, even reassuring smile. But then he would look down again, shift his weight and continue speaking too softly to be intelligible.
What puzzled me was that I didn't normally think of this colleague as being that self-effacing. But when I described his visit a couple of days later to another colleague, a mutual friend, she immediately recounted a similar episode. "It's weird, isn't it?" she said. "He's the smartest doctor in the hospital, but when he starts talking to some patients, it's like he's trying to disappear."
For nearly two decades, teaching good communication skills has beenmandatory for medical schools because of research showing that good patient-doctor communication can lead to improved patient satisfaction and better health care outcomes. To this end, medical educators have developed a host of communication courses and workshops that combine lectures, self-assessments, video recordings and "standardized patients," or actors in the role of patients.
More recently, many schools have broadened their courses to include "cultural competency," or the ability to communicate with those from different racial, ethnic and social backgrounds. Studies have shown that while a patient's race and ethnicity can be linked to sharply different treatment courses and quality, better communication between doctors and patients of different backgrounds can reduce the disparities.
Despite these tremendous efforts, there is one area of communication to which few schools have devoted significant time or resources: body language and facial expressions.
Now a small but growing body of research is revealing that the nonverbal component of the patient-doctor interaction — the subtle gestures, body positions, eye contact, touch and expressions that pass between individuals — is as critical a part of communication as verbal expressions. And nonverbal cues may, in fact, be more reflective of the biases faced by doctors and patients.
In this recent study, for example, a group of medical sociologists analyzed the interactions between 30 primary care doctors and more than 200 patients over age 65 and found that white physicians tended to treat older patients similarly, regardless of race. Black physicians, on the other hand, often gave white patients contradictory signals, mixing positive nonverbal behaviors, like prolonged smiling or eye contact, with negative ones, like creating physical barriers by crossing the arms or legs.
The finding was reminiscent of earlier studies on interactions between female doctors and male patients, in which the doctors tended to give the patients conflicting nonverbal cues, combining, for example, smiles with a negative or anxious tone of voice. These mixed signals, said Irena Stepanikova, the lead author of the recent study and an assistant professor of sociology at the University of South Carolina in Columbia, are a result of dealing with "a status in our society that is devalued." Rather than being expressed explicitly, biases regarding race and gender tend to be expressed "in behaviors not consciously controlled," she said.
The researchers also found that despite the contradictory cues, the black doctors were generally more skillful in using positive nonverbal behaviors than their white colleagues. They were, for example, better able to use prolonged eye contact, more open body positions, facial expressions and even light touch to encourage patients and convey respect, understanding, availability and attention. "Patients feel vulnerable and search for nonverbal cues," Dr. Stepanikova noted. "If the doctor nods when the patient is talking but keeps looking at the chart, the patient will wonder if the doctor is really taking her seriously."
Dr. Stepanikova and her colleagues believe that greater emphasis on nonverbal communication can help medical educators address some of the social biases that affect patient care. But they acknowledge that the process will be challenging. Research in this area is still relatively sparse, and few medical educators are well versed in this topic. Moreover, even experts like Dr. Stepanikova, who needed to devote several hours to analyzing just portions of a single patient-doctor visit, are unsure of how researchers and educators can measure the nuances and complexities of nonverbal communication accurately, consistently and efficiently.
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Despite wide acceptance of a professional code that endorses openness and honesty with patients, a 2009 survey of 1,891 doctors published in the February edition of Health Affairs found gaps between those standards and how they actually practice.
A vast majority of physicians said they embraced the American Board of Internal Medicine Foundation's Charter on Medical Professionalism which calls for fully informing patients about the risks and benefits of interventions. But more than a third said they did not completely agree it was necessary to disclose "all serious medical errors to affected patients." Even more striking, one in five acknowledged they had not fully disclosed an error to a patient in the previous year because they feared a lawsuit.
"This survey raises a caution about the extent to which physicians are currently prepared to provide the kind of information that patients really need to fully be informed about their care," said Dr. Lisa Iezzoni, the study's lead author and director of the Mongan Institute for Health Policy at Massachusetts General Hospital in Boston. "Both patients and physicians need to have a better partnership around patient care," Iezzoni said.
More than 55 percent of physicians reported they often or sometimes described a patient's prognosis in a more positive manner than the facts might support. Meanwhile, 11 percent of respondents said they had told patients something untrue in the previous year, and 17 percent did not completely agree that physicians should never tell a patient something untrue. The authors point out that their estimates may be low because of the tendency to respond to questions in a way others regard favorably. Significant barriers also exist for physicians in talking about their relationships with drug and device manufacturers. More than a third of doctors did not completely agree that they should disclose their financial relationships with drug and device companies to patients.
Author Eric G. Campbell, an associate professor at Harvard Medical School and director of research at the Mongan Institute for Health Policy, said those attitudes could lead to uncomfortable conversations when industry relationships become publicly available in 2013 through a requirement in the health care law.
The survey also found notable variations correlated with race, gender and physician specialty. For instance, women and minorities were significantly more likely to follow standards for honest communication compared to white male doctors, which the authors suggest may be due to greater vigilance about the code on the part of newcomers to the profession. General surgeons also were significantly more likely to report telling patients the truth than doctors in other specialties.
"If you put people from different specialties together and they have fundamentally different attitudes, it's going to potentially create problems," Campbell said. "Think about the sports analogy – imagine a quarterback in a huddle, lying to the offensive line man about when he wanted the ball. It's just not going to work," Campbell said.
The authors said the survey raised questions for subsequent inquiry about why physicians withheld and misrepresented information. Iezzoni speculated they may do so to keep their patients from worrying or they may lack the training to have difficult conversations, she said. She noted that research suggests patients want to know the truth about their prognosis, even if it is dire, so they can make better-informed decisions.
"I think it's just really important for patients to tell their doctors how much truth they want to know, to be very, very clear about the extent to which they want the physician to be completely clear about their prognosis," Iezzoni said.
Bernard Lo, a physician and professor emeritus of medicine and director emeritus of the medical ethics program at the University of California San Francisco, said that doctors should have more on-the-job training about how to talk to patients about difficult issues such as life-threatening illnesses.
"It's very enlightening when you actually talk to the doctor and the patient after they had a conversation, and ask for their perspectives because they often don't coincide on key issues," Lo said. "Knowing the different perspectives is an important starting point."
The Center for Survey Research at the University of Massachusetts, Boston, administered the eight-page survey in May 2009 to 3,500 physicians drawn from seven specialties. Almost two-thirds, or 1,891 completed the survey.
A leading child health expert at the National Institutes of Health has lent his support to an effort to end a controversial anti-child obesity campaign that includes such taglines as "Chubby isn't cute if it leads to type two diabetes."
In a letter to the activist leading the counter-campaign, NIH's Alan Guttmacher said that the ads carry "a great risk of increasing stigma" around childhood obesity and, as a result, pose "risks to the psychological health" of obese adolescents.
The ads in question (two of which are pictured below) come from Georgia-based Strong4Life, which is run by Children's Healthcare of Atlanta. The group began putting up billboards in the Atlanta area this past August that couple stark black-and-white images of overweight children with warnings of health risks linked to obesity. The posters are accompanied by messages such as: "Being fat takes the fun out of being a kid," and "Fat prevention begins at home. And the buffet line." The group has also put out similarly-themed videos, which can be viewed here.
The aggressive campaign has sparked its fare share of debate, with online activists urging the group to take the ads down. As part of its counter-push, one of the activists reached out to a number of health experts to solicit their opinions, including Guttmacher, whose response was passed along to the BBC.
Strong4Life contends that the ads were meant to be controversial as a means of sparking debate, and were modeled after a recent anti-methamphetamine campaign deemed successful. Most of the billboards have been taken down as the anti-obesity campaign moves into its next phase, although the group says that some still remain in neighborhoods with particularly high child obesity rates.
Georgia has the second-highest child obesity rate in the nation. Mississippi, the southern state's western neighbor, nabs the top spot.
Last week in my cello lesson, I spent an hour and a half on a single line of music. It was a snarly line, and I botched it heroically for 90 solid minutes. My teacher was patient, but uncompromising; I was met with blunt feedback at every step and left feeling wholly dispirited.
At home I plowed through that line for the next week, painstakingly dissecting each infuriating dotted-sixteenth note and every nasty double-sharp. On my teacher's advice, I recorded each attempt, then listened back to repair my errors. It was excruciating for me (to say nothing of the suffering of innocent household bystanders).
There was no eureka moment, but slowly, grindingly, the dissonant cacophony coalesced into a recognizable melody. It was only one measly line, but I'd successfully navigated it. I was one tiny step better than I'd been before.
It made me think about an unusual essay in The Annals of Internal Medicine called "Music Lessons: What Musicians Can Teach Doctors." The author, Dr. Frank Davidoff, an internist and former editor of the Annals, makes the interesting point that although medicine is learned over many years, the actual practice of clinical medicine is a performance, "in the best and deepest sense of the word."
Doctors spend much of their energy keeping up with the vast medical knowledge, but scant attention is paid to how this knowledge is dispensed in actual practice, or what Dr. Davidoff would call the performing of medicine.
Musicians, on the other hand, focus intensely on the performing of music. My experience was but a snippet of what musicians spend a lifetime doing — relentlessly practicing, constantly bathed in critical feedback from teachers, audiences, critics and their own ears.
Dr. Davidoff points out that the greatest music teachers are coaches, not lecturers. In contrast, most of our teachers in medicine are lecturers, and information is simply shoveled at the student.
In a recent piece in The New Yorker called "Personal Best," Dr. Atul Gawande probed the idea of coaches for physicians who would observe doctors in the process of practicing medicine, then give detailed feedback, much like my cello teacher did with me.
The midcareer plateau Dr. Gawande wrote about resonates with me. At this point, I feel comfortable treating most of what crosses my desk, but I'm not really learning much. This is in contrast to the exponential learning I experience as an amateur musician. The exhilaration — even with its implacable frustrations — pulls me to practice cello with a vigor that can't quite be mustered when I read my weekly medical journals.
This exhilaration, in fact, recalls what I felt as a beginning medical student. The loss of this excitement may be a large component of burnout and plateaus in midcareer doctors.
In music, plateaus are flatly unaccepted. When complacency creeps into my cello practice, my teacher exhorts me, "If you aren't improving, you are getting worse!" Could a medical coach bring back the intellectual vibrancy from medical school days, spur that constant growth?
Dr. Gawande decided to try, and invited an esteemed surgeon to observe him and give blunt feedback. There were many uncomfortable moments of feeling awkward under observation, of worrying what his colleague would think of him. These are all familiar emotions to me from my cello lessons, where I present the fruits of each week's practice to my teacher. There is always that painfully long moment after I put down the bow, the deep breath in which my teacher searches for a charitable way to catalog my blunders. Criticism, no matter how softly couched or solidly constructive, is always hard to take. But without fail, I improve after these critiques, once I've scraped my battered ego off the floor.
Would doctors actually want a coach observing their work and offering critiques? It's not a comfortable experience, for sure, but if done in a spirit of self-improvement, without the threats and penalties of the current quality-measures movement, many might be open to it. I surely would. I'm probably a "good enough" doctor now, but it would be hubris to think that I couldn't be better.
Picking the right coach is paramount. I initially tried several cello teachers. All were excellent, but when I took a lesson with the last one, I knew immediately that I'd found the right mentor. The combination of exacting standards — whether for Suzuki's "Twinkle Twinkle" or Bach's suites — and unflinchingly honest criticism, laced with an unfailing optimism that I would succeed if I kept at it, is perfect for me. We've been sweating it out together for six years. It's the hardest, most sustained, most gratifying work I've done in the last decade; nothing I've done in medicine in these same years comes close.
The main stumbling block, honestly, is time. As I read through Dr. Gawande's experience — detailed discussions, reviewing videos, observing other doctors — I kept waiting for him to reveal where that time came from. Was it his own free time? Or did the hospital exempt him from some clinical duties (that is, take a revenue loss)?
If doctors are told that coaching is a fabulous idea — go ahead and squeeze it into your schedule! — there will be very few takers. But if we allot some resources (as we do for continuing medical education) and ensure that this will not be used punitively, many doctors would be eager for an experienced clinician to offer feedback. The next step would be to incorporate suggestions from patients. Then the orchestration might really get interesting.
Danielle Ofri is the author of three books, including "Medicine in Translation: Journeys With My Patients." She is an associate professor of medicine at New York University School of Medicine and editor in chief of the Bellevue Literary Review.
EVERY sphere of life, it seems, can be turned into a game — including the way physicians offer medical advice and build a public reputation. HealthTap, a start-up based in Palo Alto, Calif., has brought the vocabulary and mechanics of games to medicine.
At the company's Web site, users post questions and doctors post brief answers. The service is free, and the doctors aren't paid. Instead, they engage in gamelike competitions, earning points and climbing numbered levels. They can also receive nonmonetary awards — many of them whimsically named, like the "It's Not Brain Surgery" prize, earned for answering 21 questions at the site.
Fellow physicians can show that they concur with the advice offered by clicking "Agree," and users can show their appreciation with a "Thank" button. These clicks bring recognition to the contributors, too. Receiving 25 thanks gives a doctor a "Doogie Howser Award"; for 50, it's a "Dr. Heathcliff Huxtable Award."
Here's an example of a question on HealthTap: "What does it mean when ur right side of ur body goes num?" The top-rated answer last week was as follows: "Stroke is likely. If that occurs at any time, anywhere, immediate emergency room evaluation should be done and the person should get there by ambulance. The earlier the intervention the better the result." Five other doctors agreed.
By participating, doctors who want to attract new patients have a chance to gain visibility. When searching for answers to a particular question, users can add a geographic filter, narrowing the search to doctors who are nearby. But doctors who already have busy practices and can't accept new patients are less likely to be interested in participating on the site.
HealthTap started its Web site last May. It says that it has signed up more than 9,000 physicians and that it is adding 100 a day. The site does not carry advertising, and the company declines to comment about how it plans to generate revenue.
Aside from the badgelike awards, the site offers some social network features. Users can follow particular doctors and topics of interest; new answers related to these are displayed in an "activity feed" shown when users log on to the site.
"Twitter, Facebook, Quora and Zynga have invented social and game mechanics for broad markets," says Tim Chang, a managing director at the Mayfield Fund, one of HealthTap's venture capital backers. "If you can take the best of those mechanics and apply them to a single vertical, that can be very powerful."
The site offers a peer-based reputation system of its own devising. Next to each answer, users see the number of doctors who agree; with a click, they can see who the approving doctors are, as well as something that HealthTap calls a "reputation level," which is built by accumulating HealthTap awards, "Agrees" from fellow physicians and other measurable activities at the site.
Neither the doctors' specialties nor the levels are displayed next to doctors' answers, but by clicking, the curious user can see that one answer was submitted, say, by a psychiatrist listed as "Level 7 Leading" and a dissenting one from an internist who had reached "Level 14 Distinguished."
Ron Gutman, the chief executive of HealthTap, says this of its system: "In academic or big hospitals, a physician's reputation is known only to fellow physicians. At HealthTap, professional reputation is transparent to patients as well as to peers."
But patients have long been able to check on one part of their doctors' background: whether they are board-certified. That certification, administered by physician peers, requires continuing education after one collects a medical degree and license and passes a famously difficult board exam. The American Board of Medical Specialties works with 24 member boards, covering internal medicine, family medicine and specialties. It offers a Web page that makes it easy for patients to learn a particular physician's certification status.
HealthTap requires only that its physicians be licensed in the United States and in good standing — that is, not accused of malfeasance. Lamentably, it does not use board certification to establish a floor for qualifications required for physicians to participate. The company says it does not require board certification because this "is not required in the U.S. to see and care for patients."
Another worrisome aspect is the breeziness of HealthTap's answers, which are limited to 400 characters, a length hardly well-suited for providing nuanced answers to some medical questions.
A disclaimer at the foot of every page says that the site "does not provide medical advice, diagnosis or treatment."
DR. PETER W. CARMEL, president of the American Medical Association, says he is concerned about the use of online medical information, which should "complement, not replace, the communication between a patient and their physician," he wrote in an e-mail.
With online health information sites, "a medical history is not taken, a physical exam does not occur and any suggested treatment is not monitored or assessed," he said. "Using this information in isolation could pose a threat to patients."
In response, Mr. Gutman said, "We respect the A.M.A. and would welcome collaboration with them and any other forward-thinking medical organizations looking to improve the quality of care."
Many doctors just out of medical school, like other people in their 20s, are accustomed to texting as a primary mode of communication, so they may embrace HealthTap's exchange of bare-bones information. But other physicians may find the context-free, short-question, short-answer approach problematic. The Doogie Howser Award will go to others.