Saturday, September 27, 2008

Do Doctors Have Time to Be Empathetic?

“But I also did not want to open the floodgates of emotion on an afternoon when the waiting room was overflowing. ”

One of the statements by Dr. Pauline Chen in her new column Doctor and Patient in the NY Times. The inspiration for the article was from a recent piece in the Annals of Internal Medicine which found that doctors missed the chance to give an empathetic statement the vast majority of time.

What Dr. Chen illustrates with her comment is the fear that the vast majority of doctors have and that is by being compassionate and empathetic that not only will it take too much time, but frankly is too uncomfortable for doctors to dare open the door. The reality is it doesn’t take much time and in fact may take less time. As Dr. Chen notes, when patients don’t get the feeling of a connection, they unconsciously fill this void some other way and lengthen the visit.

The issue isn’t whether doctors have enough time to be empathetic, which was suggested as the reason for doctors to miss 90 percent of the opportunities to provide a empathetic comment. The issue is whether medical students are trained adequately to be compassionate and thoughtful doctors.

It’s our training that fails us. It’s not the clock. The good news is like all other skills we developed in medical school, all doctors have the potential of becoming more empathetic with some simple behavioral interventions.

Until we as a profession realize that, it is no wonder patients feel increasingly alone when they access the healthcare system.

Tuesday, September 23, 2008

Micropractice Model Not the Answer to Primary Care Crisis

Medical Economics published my letter to the editor in their September 5th issue. The contents of the letter follows:

For primary care to attract more medical students, it will need to transform the delivery of care to improve the doctor-patient relationship, as well as professional satisfaction. While I applaud the efforts of the solo practitioners who follow the micropractice model ["The one-person show," June 20, 2008], this evolution won't save our specialties of internal medicine or family medicine.

Current graduates are flocking toward radiology, ophthalmology, anesthesiology, and dermatology because they offer a more predictable lifestyle with relatively good compensation.
Micropractice practitioners not only take a substantial pay cut, but also are wedded to their practice by being a sole proprietor.

Despite some erroneous assumptions, many patients find their primary care doctors in large group practices particularly satisfying and personal. These innovative groups practice the medical home touted by the AAFP and the ACP as the future for primary care.
With the use of electronic medical records, same-day access for appointments, the ability to communicate via e-mail, and improved revenue generation, patients and doctors are finding this model of delivery far superior to what has been practiced in the past.

Unless medical students and current practitioners see and join practices where primary care doctors have rewarding professional lives and are compensated well, the numbers of primary care doctors will dwindle rapidly, which will result in a complete collapse of the health-care system in the near future.

Tuesday, September 16, 2008

Primary Care Crisis Will Doom Universal Coverage and You

While it made the news all too briefly recently, a report in JAMA found that there still continues to be a primary care crisis. Even Dr. Dean Ornish commented on the problem in a recent Newsweek piece.

This is a big problem. Fewer US medical students wish to do internal medicine or family medicine because of the administrative hassles, decreasing compensation, and increasingly demanding workloads. It isn't necessarily because they are lazier or more money hungry than previous generations because doctors currently in primary care are retiring, leaving medicine entirely, or doing something else like hospital medicine or urgent care. Students are opting for fields that offer work-life balance which include radiology and dermatology. And why not? The way the healthcare system is structured, the more procedures you do the more you are compensated which isn't always in your best interest. Doctors, who are paid to be more cognitive, like primary care, as a result can spend much more time with a patient and prevent complications from happening, but because the specialty isn't procedurally based, they have continued to watch their income decrease. With increasing medical student loans, it shouldn't surprise anyone that the crisis is at hand.

Why is this a problem for you? It is expected that with the baby boomers that the nation will need to increase the number of internists by 38 percent or roughly add 2000 internists per year. As a nation, we only train about 1000 internists that will go on to do primary care and that number is falling rapidly. With a shortage of primary care doctors, it means you are more likely to get worse care, pay more, and wait longer. Research consistently shows that patients with a primary care doctor do far better healthwise and financially than those that don't.

Adding more stress is the goal of the nation to address the 47 million uninsured. While Senator Obama and Senator McCain both have healthcare plans, neither actually address universal coverage, which may be years away because if everyone is covered, not everyone can access the healthcare system. We don't have enough doctors. Take the Massachusetts experience where health insurance in mandatory. Although the state has more primary care doctors per capita than any other state in the union, the newly insured now are either unable to find an accepting doctor or need to wait an average of seven weeks to see one. Though legislators want to increase the number of students trained, the fact is students won't go into the field until the issues that are causing those to leave are addressed.

The problem is that no one is willing to address the fundamental problems anytime soon. To do so, specialists would have to give up some of their income. After all, we spend a lot as a nation and it is unlikely we can increase the total amount spend to make up for the deficiency, but will need to re-distribute some of the income. This is why it won't happen.

Get ready to get more fragmented uncoordinated care, increased costs and frustration, and worsening health outcomes. If you still have a primary care doctor, then give him or her a hug because they are disappearing rapidly and frankly their skills and expertise are priceless.

Friday, September 12, 2008

MRI After Breast Cancer Diagnosis Increases Mastectomy Rate and Delays Care

A recent study presented at the 2008 American Society of Clinical Oncologists (ASCO) Breast Cancer Symposium questioned the need for breast MRI on patients recently diagnosed with breast cancer. The abstract “the influence of routine pretreatment MRI on time to treatment, mastectomy rate, and positive margins” was headed by Dr. Richard J. Bleicher, a breast cancer surgeon at Fox Chase Cancer Center, and tried to determine if having an MRI would be helpful for breast cancer patients. Increasingly more women seem to be getting them after the diagnosis.
Basically, is using the latest imaging technology helpful? Already, the American Cancer Society recommends that women at high risk of developing breast cancer, those with a family history or personal history of breast biopsy for example, get screening MRI in addition to mammography. Whether MRI can and should be used as a tool before breast surgery was the reason for the research. The study looked at 577 women, who were referred to the breast cancer clinic between July 2004 and December 2006. The average age of a woman in the group was 57 years old. Nearly 23% of the women had MRI. Women who received MRI were younger (52 years old) than those who did not (59 years old).
Researchers found that having a MRI appeared to delay treatment by nearly 25 days after the initial doctor evaluation. Patients who had a MRI were two times more likely to have a mastectomy rather than breast conserving therapy (BCT). Interestingly, the women who received MRI were not considered at high risk for breast cancer (family history of breast cancer or ovarian cancer) or for recurrence based on tumor size, staging, or pathology. It wasn’t clear to researchers why some women received MRI and why others didn’t.
Perhaps MRI was ordered to help surgeons prepare their plan for surgery. An ideal pre-surgical tool would help the surgeons and patients make better decisions prior any surgery so that an operation is only done one time. So, how did MRI do for breast cancer surgery? Having a MRI before breast cancer surgery made no difference in the likelihood another excision would be needed because the biopsy margins weren’t free of tumor and it didn’t decrease the chance that a lumpectomy would be needed to be converted to a mastectomy. In other words, MRI made no difference, even though intuitively you would think it would. After all, isn’t more information better?
The study concludes that, “our findings suggest that MRI should not be a routine part of patient evaluation for BCT. Greater efforts to define the limitations and appropriate use of breast MRI are needed.”
What does this mean for you? MRI for breast cancer surgery planning is not the standard of care, there is currently no evidence that it makes surgical outcomes better than without it, trying to obtain one can delay treatment by 25 days, and it can also increase your chances of having a mastectomy. Understand that the findings should be limited to those patients in their fifties and probably older. It is difficult to say whether the findings are applicable to younger women in their twenties and thirties as MRI has been found to be somewhat helpful in breast cancer screening and could possibly have a role in pre-surgical planning.
As has been demonstrated many times in medicine, don’t fall into the trap of always assuming the latest technology or test is any better than traditional therapies. As this study suggests, newer methods may actually delay care and result in more surgery (mastectomy) than initially intended. Always try to demand treatments and therapies that are evidence-based.
Read more from the abstract.

Sunday, September 7, 2008

Fountain of Youth - Exercise

Fascinating article from Men's Health, not talking about the fountain of youth per se, but about the feeling among researchers that people were born to run. Titled, "Yes, You Were Born to Run" it speaks about the evolutionary adaptations that people have that provides proof we were meant to be running - a strong nuchal ligament to keep our head straight and focused when hunting prey (evidently pigs can't do that), a large number of long leg tendons which provide bounce so we can run (chimpanzees have short and few leg tendons which are fine for climbing trees), and the ability to perspire when running continuously (which provides the advantage of hunting speedy prey like a kudu which although faster than a human is unable to sweat and therefore needs to stop and therefore can be run down). More from the article:

  • According to a controversial body of research, is that our passion for running is natural. A small group of biologists, doctors, and anthropologists say our bodies look and function as they do because our survival once depended on endurance running, whether for long-distance hunts like the one Liebenberg witnessed or for racing the competition across the African savanna to scavenge a kill.
  • In his book Why We Run, the biologist and runner Bernd Heinrich, Ph.D., argues that something exists in all of us that still needs to be out chasing antelopes, or at least dreaming of antelopes. Without that instinct, "we become what a lapdog is to a wolf. And we are inherently more like wolves than lapdogs, because the communal chase is part of our biological makeup."
  • Anyone who has put in some miles knows how good running can feel, once it stops feeling bad. But beyond the way it feels, medical evidence also suggests that humans are built for endurance exercise. In response to a good training program, for instance, the left ventricular chamber of the heart can increase as much as 20 percent in volume. The chamber walls thicken, too. So the heart fills up faster and pumps more blood to the rest of the body. The coronary arteries also change, dilating more rapidly to meet the body's demand for oxygen. Endurance exercise won't make anyone live forever. But it seems to make the cardiovascular system function the way the owner's manual intended.
  • In the skeletal muscles, increased blood pressure causes new capillaries to emerge. The mitochondrial engines of the cells ramp up to consume energy more efficiently, helped along by an increase in the production of various antioxidants. These changes in the heart and extremities together typically boost the maximum amount of oxygen the body can consume each minute by 10 to 20 percent. For men who used to become short of breath slouching to the fridge for a beer, VO2 max can increase even more. Lapdogs start to function like wolves.
  • More surprisingly, the brain responds as if it was built for endurance exercise, too. researchers have discovered lately that exercise affects the function of 33 different genes in the hippocampus, which plays a key role in mood, memory, and learning. By stimulating growth factors, exercise also produces new brain cells, new and enhanced connections between existing cells, new blood vessels for energy supply, and increased production of enzymes for putting glucose and other nutrients to work.
  • People who exercise regularly perform better on some cognitive tests: Run more, think better, hunt smarter, eat better. Exercise also seems to buffer the brain against neurological damage, reducing the effects of stress and delaying the onset of Alzheimer's and other diseases. Most significant, exercise helps prevent and alleviate depression, which afflicts one in six Americans and costs $83 billion a year.

Not advocating everyone start running, you might need to check with your doctor first before doing any vigorous exercise, but what is clear is that people were built to move. In our American 21st century society where everything is built on convenience and relatively little work -- cars allow us to travel distances without walking / running, grocery stores and restaurants provide us food without us actually laboring in the fields to grow, harvest, and then prepare food, entertainment is becoming more sedentary with internet, video games, television, movies, instead of us actually participating in activity, and finally that for many of us work isn't as laborious as the past -- perhaps it isn't surprising as a nation we are getting fatter and less healthy than a generation before even though we understand more about health and illness.

It appears we were born to run or be active. Our society makes our bodies more like lapdogs rather than the wolves that our anecestors evolved to be to survive. The fountain of youth is very much staying active whether dancing, swimming, walking, running, biking, or whatever. It affects our bodies and our minds. Unlike any machine that exists, our body is dynamic and adapts to the challenges ahead, regardless of your age or whatever happened (or didn't happen) in the past. So even lapdogs have the potential to slowly become wolves again with increased activity. So start getting active!


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