Wednesday, January 15, 2014

Researchers tackle weight bias in the health-care system | University Affairs

Canadian researchers are finding that obese people often encounter bias, discrimination and stigmatization when dealing with health professionals, many of whom seem to believe that excessive weight is the obese person's own fault.

"This bias often means delays in treatment or lack of care, which can be life-threatening," said Mary Forhan, an assistant professor in the faculty of rehabilitation medicine at the University of Alberta who recently co-authored a research review of weight bias in health care. "It's getting better but it's almost as if there's a resistance [by care givers] to see beyond the weight, which means obese people often don't seek preventative care because they've been blamed for overeating or not exercising."

Research shows that health-care providers understand the implications of too much weight, said Dr. Forhan, but they often lack the time, resources or knowledge of specialized treatment, and so develop an oversimplified, stereotypical attitude that such patients are lazy, unmotivated or simply overeat.

Dr. Forhan and her team are working to change attitudes among health-care students at the university, as well as among allied health professionals such as first responders. One of the tools at their disposal is a specialized bariatric care suite on campus that's used to train health professionals. She believes occupational therapists like her can play a role in obesity treatment. "There's a resistance to suggesting equipment like long-handled shoehorns or hand-held reachers or other specialized equipment that could make everyday life easier. We wouldn't withhold assistive devices from a spinal cord patient but we seem to from the obese patient."

Obesity on stage
Atlantic Canada has one of the highest rates of obesity in the country. Researchers from Dalhousie University decided to turn their recent Nova Scotia research into a live drama as part of a "Balancing the Scales" workshop for health-care students at selected universities in the region. Their paper looked at the multi-faceted problems involved in weight management within a health system that, it says, has built-in biases and barriers.

"Obesity is such a complex issue," said Sheri Price, one of the authors and an assistant professor of nursing at Dalhousie. "Research papers often sit on a shelf, so we wanted to take our findings to students in a way that disseminated how patients and professionals feel."

All the spoken words are taken from transcripts of obese people, policy makers and health professionals who were interviewed by the Dal researchers. On stage, the setting is a clinic where an overweight patient spends time in the waiting room and then sees the doctor. Although the actors talk and interact with each other, they also turn to face the audience with their thoughts, frustrations and emotional feelings about caring for and living with obesity.

The play opens with an overweight actress entering the waiting room, wondering if she will be humiliated again by being weighed in view of others. Eventually she struggles to sit in the only empty seat – a narrow chair with arms.

"Everyone just watched me stuff myself into this chair like a sausage." The actress shifts uncomfortably. "I hate when people look at me like that," she continues. "I know what they're thinking: 'Look at how fat and lazy she is.'"

The workshops include a mix of students from various disciplines like nursing, nutrition, diagnostic imaging, and respiratory and radiation therapy. "The ideal workshop number is around 30 but the response has been so great that we have been forced to limit it to a hundred and then we break into three groups after the play to discuss and to rewrite it," said Dr. Price.

She said the feedback has been overwhelmingly positive, with students affirming that they'll apply the information in their careers. Among the student comments were: "Made me think of patients as people with real struggles, not just statistics" and "There are situations in X-ray when we have no equipment that can image a very obese patient. We need to find solutions to this – communicate restrictions with doctors so they are referred in a way that they are not set-up for failure."

A small dissemination grant from the Canadian Institutes of Health Research has allowed them to take the actors to UPEI, UNB, Memorial and Dalhousie for the workshops. Currently, the Dalhousie researchers are discussing whether to go national with their workshop but say funding is the main hurdle.

Tuesday, January 14, 2014

What Patients Don't Tell Their Doctors -

A patient's wife was on the phone, her voice hesitant, unhappy. She didn't bother with small talk. "I need to talk to you about Tom's drinking," she said.
Only the pure shock of the moment justifies the first words out of my mouth. "Tom? You're kidding me," said I.
Every family has a tortured soul in a closet whose door doesn't quite close. The demons inside are all too visible to friends and family, neighbors and doormen, even the staff of the emergency room. To the outside world, though, not a hint of a problem displays, and that includes colleagues, clients and always, especially, the doctor.
It is an extraordinary phenomenon, this saving of face in the doctor's office, amusing and distressing in equal parts, spilling into every kind of medical evaluation. At its most basic, it is the patient recovering from the flu who announces — we must hear it once a day — "I was so sick last week, I didn't know what to do." So where were you? "Oh, I didn't want you to see me like that."
The same instinct lies behind the heartbreaking valor of the demented as they struggle to conceal every lost thought; the dying, who determinedly focus the conversation on any subject but mortality; the substance users, who jump through hoops to avoid medical help for their medical problem.
There are some tools to trap the elusive user, but not nearly enough. The standard implements of the trade sometimes come through: A physical exam can turn up the needle user's track marks or the alcoholic's swollen salivary glands. Routine lab work occasionally yields clues, as can studiedly casual chat ("What are you up to this weekend?"). A variety of more pointed questions ("Do you ever need a drink to get going in the morning?") have been scientifically validated to pick up many serious problems.
But even good tools are useless when nobody bothers to use them. A new analysis from the Centers for Disease Control and Prevention estimates that of the 38 million problem drinkers in the country, only one in six have come clean to a health professional. Doctors are often just not in the mood for a long, fraught investigation. They may feel too much empathy and respect for a patient who is clearly a pillar of the community. They may be up to their armpits in the patient's other problems (as I was with Tom's), predictably forgetting, as studies have demonstrated, that addiction can be the source of most of those problems.
Then, suddenly, an unfamiliar voice is on the phone, and everything becomes crystal clear — clear but, alas, certainly no easier, as evidenced by my next words to Tom's wife: "I'm so sorry. I can't talk to you about that."
Three separate considerations canceled our conversation before it began.
First, discussions behind an adult patient's back are always a terrible idea. No matter how well intentioned, they instantly deform the connection between doctor and patient, transforming one into a pediatrician and the other into a child. Of course, since neither is either, this new relationship seldom works out, and the nonchild heads right out and finds a new doctor.
Ethical standards also hold that most aspects of the adult patient's health are private, not to be discussed, even with a loving spouse, without specific permission. This mandate lapses only when patients are confused or comatose and urgent medical decisions have to be made.
A clear, imminent danger to the concerned party can also justify a breach. If Tom's wife was a nondriver and he was planning to take her on a long cross-country road trip, weaving down Interstate 80 with a quart of vodka in his lap, then a lengthy conversation might be in order. Absent this kind of danger, Tom's business remains his own.
And finally, the law is now involved. With the Health Insurance Portability and Accountability Act of 1996, or Hipaa, the federal government weighed in on patient privacy, to everyone's great confusion. The convolutions of this legislation are often misinterpreted to affirm that no one can talk to anyone about anyone else's health without written consent. In fact, most ordinary conversations are legitimate as long as the patient is consulted first and has no objections. Still, the law makes everyone just a little more cautious.
I told Tom's wife I'd get back to her.
At his next appointment, I told Tom she had called. I didn't say about what.
"Mind if I talk to her? Or maybe she can come to your next appointment with you." And Tom, firmly and politely, said absolutely not.
So that's where it ended. I never met his wife, never heard that sad voice on the phone again. But Tom suddenly found our health conversations heading in an entirely new direction. It turns out that even when moral, legal and professional considerations all forbade me to say a single word, nothing stopped me from listening and nothing made me forget.

Monday, January 13, 2014

Heroic Measures -

LISA BONCHEK ADAMS has spent the last seven years in a fierce and very public cage fight with death. Since a mammogram detected the first toxic seeds of cancer in her left breast when she was 37, she has blogged and tweeted copiously about her contest with the advancing disease. She has tweeted through morphine haze and radiation burn. Even by contemporary standards of social-media self-disclosure, she is a phenomenon. (Last week she tweeted her 165,000th tweet.) A rapt audience of several thousand follows her unsparing narrative of mastectomy, chemotherapy, radiation, biopsies and scans, pumps and drains and catheters, grueling drug trials and grim side effects, along with her posts on how to tell the children, potshots at the breast cancer lobby, poetry and resolute calls to "persevere."

In the last month or two, her broadcasts have changed tone slightly; her optimism has become a little less unassailable. As 2013 ended, the cancer that had colonized her lymph nodes, liver, lungs and bones had established a beachhead in her spine, the pathway to her (so far tumor-free) brain. She was deemed too sick to qualify for the latest drug trial. She is bedridden at New York's Memorial Sloan-Kettering Cancer Center, which has embraced her as a research subject and proselytizer for the institution.

Lisa Adams is still alive, still blogging, and insists she is not dying, but the blog has become less about prolonging her survival and more about managing her excruciating pain. Her poetry has become darker.

"The words of disease become words my brain gravitates to," she pecked the other day after a blast of radiation. "The ebb and flow of cancer, Of life. And so too, Inevitably, Of death."

In October 2012 I wrote about my father-in-law's death from cancer in a British hospital. There, more routinely than in the United States, patients are offered the option of being unplugged from everything except pain killers and allowed to slip peacefully from life. His death seemed to me a humane and honorable alternative to the frantic medical trench warfare that often makes an expensive misery of death in America.

Among doctors here, there is a growing appreciation of palliative care that favors the quality of the remaining life rather than endless "heroic measures" that may or may not prolong life but assure the final days are clamorous, tense and painful. (And they often leave survivors bankrupt.) What Britain and other countries know, and my country is learning, is that every cancer need not be Verdun, a war of attrition waged regardless of the cost or the casualties. It seemed to me, and still does, that there is something enviable about going gently. One intriguing lung cancer studyeven suggests that patients given early palliative care instead of the most aggressive chemotherapy not only have a better quality of life, they actually live a bit longer.

When my wife, who had her own brush with cancer and who has writtenabout Lisa Adams's case for The Guardian, introduced me to the cancer blog, my first thought was of my father-in-law's calm death. Lisa Adams's choice is in a sense the opposite. Her aim was to buy as much time as possible to watch her three children grow up. So she is all about heroic measures. She is constantly engaged in battlefield strategy with her medical team. There is always the prospect of another research trial to excite her hopes. She responds defiantly to any suggestion that the end is approaching.

"I am not on my deathbed," she told me in an email from the hospital. "Periods of cancer progression and stability are part of the natural course of this disease. I will be tweeting about my life and diagnosis for some time to come," she predicted, and I hope she's right. In any case, I cannot imagine Lisa Adams reaching a point where resistance gives way to acceptance. That is entirely her choice, and deserving of our respect. But her decision to live her cancer onstage invites us to think about it, debate it, learn from it.

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A Busy Doctor’s Right Hand, Ever Ready to Type -

Amid the controlled chaos that defines an average afternoon in an urban emergency department, Dr. Marian Bednar, an emergency room physician in Dallas, entered the exam room of an older woman who had fallen while walking her dog. Like any doctor, she asked questions, conducted an exam and gave a diagnosis — in this case, a fractured hand — while also doing something many physicians in today's computerized world are no longer free to do: She gave the patient her full attention.

Standing a few feet away, tapping quickly and quietly at a laptop computer cradled in the crook of her left arm, was Amanda Nieto, 27, Dr. Bednar's scribe and constant shadow. While Ms. Nieto updated the patient's electronic chart, Dr. Bednar spoke to the woman, losing eye contact only to focus on the injured hand.

"With a scribe, I can think medically instead of clerically," said Dr. Bednar, 40, who works at Texas Health Presbyterian Hospital Dallas.

Without much fanfare or planning, scribes have entered the scene in hundreds of clinics and emergency rooms. Physicians who use them say they feel liberated from the constant note-taking that modern electronic health records systems demand. Indeed, many of those doctors say that scribes have helped restore joy in the practice of medicine, which has been transformed — for good and for bad — by digital record-keeping.

"Having the scribe has been life-changing," said Dr. Jennifer Sewing, a family medicine practitioner in St. Louis, who used to spend late nights at her computer finishing electronic patient charts. Now, she can relax with her family or go to bed instead.

Dr. Michael Murphy, the chief executive of ScribeAmerica, a company based in Aventura, Fla., that supplies scribes to hospitals and medical practices, estimates that there are nearly 10,000 scribes working in hospitals and medical practices around the country, with demand rising quickly. At his company alone, the number of scribes deployed to clinics and emergency departments has risen to 3,500 from 1,000 in the past three years. Many of them are people like Ms. Nieto, who works for PhysAssist, a company based in Fort Worth. Training typically takes between 15 and 21 days, and is done by the companies themselves. She plans to enter a master's program to become a physician assistant.

For decades, physicians pinned their hopes on computers to help them manage the overwhelming demands of office visits. Instead, electronic health records have become a disease in need of a cure, as physicians do their best to diagnose and treat patients while continuously feeding the data-hungry computer. Five years ago, only 10 percent of hospitals and doctors' offices used electronic health records. But now the adoption rate is nearly 70 percent, thanks to tens of billions of dollars of federal incentive payments. And on the heels of electronic records has come the growing popularity of scribes.

A study published jointly in October by the American Medical Association and RAND Corporation found that electronic health records were a major contributor to physician dissatisfaction, as doctors negotiate a cranky truce between talking to and examining the patient, and the ceaseless demands of the computer. And a recent article in the journal Health Affairs concluded that two-thirds of a primary care physician's day was spent on clerical work that could be done by someone else; among the recommended solutions was the hiring of scribes.

"Making physicians into secretaries is not a winning proposition," said Dr. Christine Sinsky, a primary care physician at Medical Associates Clinic and Health Plans, in Dubuque, Iowa, who also researches physician dissatisfaction.

Dr. Sinsky, who was an author of the article in Health Affairs, has visited more than 50 primary care practices over the past five years, in the course of studying ways to stem high rates of physician burnout. She has found that physicians who use scribes are more satisfied with their work and choice of careers.   

The inconsistency isn't lost on health care experts. In most industries, automation leads to increased efficiency, even employee layoffs. In health care, it seems, the computer has created the need for an extra human in the exam room.

The scribes, Dr. Sinsky said, offer "a triple win."

"The patients get undivided attention from the physicians," she said. "The scribes are continuously learning while making an important contribution, and the physician gets the satisfaction of doing the work they went into medicine for in the first place."

Not everyone is sold. Some physicians are concerned about the privacy implications of introducing a third person to the examining room. According to one study of scribes in clinical settings, roughly 10 percent of patients were uncomfortable with having the scribe present.

The cost of hiring a scribe, borne largely by the physicians themselves, is also a concern. Companies typically charge $20 to $25 per hour for scribes, who in turn are paid $8 to $16 per hour. Yet physicians who use scribes say they come out even, or ahead, financially, as they can see up to four extra patients a day.

Medical transcriptionists are not new. Since the 1960s, physicians have dictated their notes into a tape recorder and given them to transcriptionists to convert into written reports, interpreting medical terminology and abbreviations as they worked. The notes appeared on paper charts hours, sometimes even days, later. Scribes simply speed up the process, entering data as it is gathered so that records can be viewed and assessed instantly. Dr. David Reuben, a geriatrician at the University of California, Los Angeles, uses "physician partners," who do the work of scribes, with expanded responsibilities such as scheduling appointments, filling out test requisitions and completing the checkout process. Preliminary results from a six-month study Dr. Reuben conducted of geriatricians and general internists suggest that the physicians saved an average of three minutes per visit by using the scribes. Just as important, the physician partners or scribes dramatically reduced the amount of work for the doctor to do at the end of the day. And a vast majority of patients said they thought the assistants helped the visit run smoothly.

Dr. Reuben said that working with physician partners had transformed his work. "Do it once, and you're hooked," he said. 

Dr. Sewing, 42, feels the same way. It used to be that every night, following a long day at work, after seeing to dinner, homework and baths for her two children, she would return to the computer for several hours to finish up electronic patient charts. Chronically exhausted and feeling enslaved to the computer, she began to wonder why she had entered medicine in the first place.

But since she started working with scribes two years ago, Dr. Sewing has found that she can focus on patients instead of the machine. In her practice of five physicians, she and another doctor use scribes full-time, with a third now using a scribe one day a week. As for the two holdouts, she said, "I wonder how long that's going to last."