You’re Sick. Now What? Knowledge Is Power.

By TARA PARKER-POPE

Are patients swimming in a sea of health information? Or are they drowning in it?

13 april 2009--The rise of the Internet, along with thousands of health-oriented Web sites, medical blogs and even doctor-based television and radio programs, means that today’s patients have more opportunities than ever to take charge of their medical care. Technological advances have vastly increased doctors’ diagnostic tools and treatments, and have exponentially expanded the amount of information on just about every known disease.

The daily bombardment of news reports and drug advertising offers little guidance on how to make sense of self-proclaimed medical breakthroughs and claims of worrisome risks. And doctors, the people best equipped to guide us through these murky waters, are finding themselves with less time to spend with their patients.

But patients have more than ever to gain by decoding the latest health news and researching their own medical care.

“I don’t think people have a choice — it’s mandatory,” said Dr. Marisa Weiss, a breast oncologist in Pennsylvania who founded the Web site breastcancer.org. “The time you have with your doctor is getting progressively shorter, yet there’s so much more to talk about. You have to prepare for this important meeting.”

Whether you are trying to make sense of the latest health news or you have a diagnosis of a serious illness, the basic rules of health research are the same. From interviews with doctors and patients, here are the most important steps to take in a search for medical answers.

Determine your information personality.

Information gives some people a sense of control. For others, it’s overwhelming. An acquaintance of this reporter, a New York father coping with his infant son’s heart problem, knew he would be paralyzed with indecision if his research led to too many choices. So he focused on finding the area’s best pediatric cardiologist and left the decisions to the experts.

Others, like Amy Haberland, 50, a breast cancer patient in Arlington, Mass., pore through medical journals, looking not just for answers but also for better questions to ask their doctors.

“Knowledge is power,” Ms. Haberland said. “I think knowing the reality of the risks of my cancer makes me more comfortable undergoing my treatment.”

Dr. Michael Fisch, interim chairman of general oncology for the University of Texas M. D. Anderson Cancer Center, says that before patients embark on a quest for information, they need to think about their goals and how they might react to information overload.

“Just like with medicine, you have to ask yourself what dose you can take,” he said. “For some people, more information makes them wackier, while others get more relaxed and feel more empowered.”

The goal is to find an M.D., not become one.

Often patients begin a medical search hoping to discover a breakthrough medical study or a cure buried on the Internet. But even the best medical searches don’t always give you the answers. Instead, they lead you to doctors who can provide you with even more information.

“It’s probably the most important thing in your cancer care that you believe someone has your best interests at heart,” said Dr. Anna Pavlick, director of the melanoma program at the New York University Cancer Institute. “In an area where there are no right answers, you’re going to get a different opinion with every doctor you see. You’ve got to find a doctor you feel most comfortable with, the one you most trust.”

Keep statistics in perspective.

Patients researching their health often come across frightening statistics. Statistics can give you a sense of overall risk, but they shouldn’t be the deciding factor in your care.

Jolanta Stettler, 39, of Denver, was told she had less than six months to live after getting a diagnosis of ocular melanoma, a rare cancer of the eye that had spread to her liver.

“I was told there is absolutely nothing they could help me with, no treatment,” said Ms. Stettler, a mother of three. “I was left on my own.”

Ms. Stettler and her husband, a truck driver, began searching the Internet. She found Dr. Charles Nutting, an interventional radiologist at Swedish Medical Center in Englewood, Colo., who was just beginning to study a treatment that involves injecting tiny beads that emit small amounts of radiation. That appeared to help for about 18 months.

When her disease progressed again, Ms. Stettler searched for clinical trials of treatments for advanced ocular melanoma, and found a National Institutes of Health study of “isolated hepatic perfusion,” which delivers concentrated chemotherapy to patients with liver metastases. After the first treatment, Ms. Stettler’s tumors had shrunk by half.

“I don’t like statistics,” she said. “If this study stops working for me, I’ll go find another study. Each type of treatment I have is stretching out my life. It gives me more time, and it gives more time to the people who are working really hard to come up with a treatment for this cancer.”

Don’t limit yourself to the Web.

There’s more to decoding your health than the Web. Along with your doctor, your family, other patients and support groups can be resources. So can the library. When she found out she had Type 2 diabetes in 2006, Barbara Johnson, 53, of Chanhassen, Minn., spent time on the Internet, but also took nutrition classes and read books to study up on the disease.

“I was blindsided — I didn’t know anybody who had it,” said Ms. Johnson, who told her story on the American Heart Association’s Web site, IKnowDiabetes.org. “But this is a disease you have to manage yourself.”

Tell your doctor about your research.

Often patients begin a health search because their own doctors don’t seem to have the right answers. All her life, Lynne Kaiser, 44, of Plano, Tex., suffered from leg pain and poor sleep; her gynecologist told her she had “extreme PMS.” But by searching the medical literature for “adult growing pains,” she learned about restless legs syndrome and a doctor who had studied it.

“I had gone to the doctors too many times and gotten no help and no results,” said Ms. Kaiser, who is now a volunteer patient advocate for the Web site WhatIsRLS.org. The new doctor she found “really pushed me to educate myself further and pushed me to look for support.”

Although some doctors may discourage patients from doing their own research, many say they want to be included in the process.

Dr. Fisch of M. D. Anderson recalls a patient with advanced pancreatic cancer who decided against conventional chemotherapy, opting for clinical trials and alternative treatments. But instead of sending her away, Dr. Fisch said he kept her in the “loop of care.” He even had his colleagues use a mass spectroscopy machine to evaluate a blue scorpion venom treatment the patient had stumbled on. It turned out to be just blue water.

“We monitored no therapy like we would anything else, by watching her and staying open to her choices,” Dr. Fisch said. “She lived about a year from the time of diagnosis, and she had a high quality of life.”

Dr. Shalom Kalnicki, chairman of Radiation Oncology at the Montefiore-Einstein Cancer Center, says he tries to guide his patients, explaining the importance of peer-reviewed information to help them filter out less reliable advice. He also encourages them to call or e-mail him with questions as they “study their own case.”

“We need to help them sort through it, not discourage the use of information,” he said. “We have to acknowledge that patients do this research. It’s important that instead of fighting against it, that we join them and become their coaches in the process.”

The Importance of Knowing What the Doctor Is Talking About

By JANE E. BRODY

13 april 2009--How often have you left a doctor’s office wondering just what you were told about your health, or what exactly you were supposed to be doing to relieve or prevent a problem? If you are a typical patient, you remember less than half of what your doctor tries to explain.

Whether you left school at 16 or have a doctorate; whether your annual income is in four figures or six; whether you are black, white, Hispanic, Asian or American Indian, chances are there have been many medical encounters that left you with less than optimal understanding about how you can improve or protect your health.

National studies have found that “health literacy” is remarkably low, with more than 90 million Americans unable to adequately understand basic health information. The studies show that this obstacle “affects people of all ages, races, income and education levels,” Dr. Richard H. Carmona, the United States surgeon general, wrote in the August issue of The Journal of General Internal Medicine, which was devoted to health literacy.

The fallout is anything but trivial. Researchers have found that poor health literacy, which is especially prevalent among the elderly, results in poor adherence to prescription instructions, infrequent use of preventive medical services, increased hospitalizations and visits to the emergency room and worse control of chronic diseases.

The consequences are poorer health and greater medical costs. All because doctors fail to speak to patients in plain English (or Spanish or Chinese or any other language) and fail to make sure that patients understand what they are told and what they are supposed to do and why.

In a study published in the internal medicine journal, conducted among 2,512 elderly men and women living on their own in Memphis and Pittsburgh, those with limited health literacy were nearly twice as likely to die in a five-year period as were those with adequate health literacy. That held true even when age, race, socioeconomic factors, current health conditions, health care access and health-related behaviors were taken into account.

Another study in the journal among 175 adult asthma patients treated by Cornell University doctors found that “less health literacy was associated with worse quality of life, worse physical function and more emergency department utilization for asthma over two years.”

Among the many problems resulting from limited health literacy are misinterpretations of warning labels on prescription drugs. For example, among 251 adults attending a primary care clinic in Shreveport, La., those with low literacy were three times more likely to misunderstand warnings than the more literate.

When the warning label read “Do Not Chew or Crush, Swallow Whole,” misinterpretations included “Chew it up, so it will dissolve” and “Don’t swallow whole or you might choke.”

When the warning read “Medication Should Be Taken With Plenty of Water,” the mistakes included “Don’t take when wet” and “Don’t drink hot water.”

When the warning was “For External Use Only,” the mistakes included “Medicine will make you feel dizzy” and “Use extreme caution in how you take it.”

Better Communication

Despite major reports on the need to improve health literacy issued in the last decade by organizations including the American Medical Association and the National Academy’s Institute of Medicine, little improvement has been noted in how much patients understand and remember about encounters with health care practitioners.

A main obstacle has been the decreased time patients can spend with their doctors, dictated largely by managed care and other medical reimbursement plans.

A second hurdle is the embarrassment that patients with limited health literacy experience when they do not understand what the doctor has said. And, of course, asking for clarification is seriously impeded by the imbalance in power between the white-coated physician and the paper-wrapped patient. Even when conversations are conducted in the doctor’s office with a fully clothed patient, patients are often reluctant to ask questions.

The tools for repairing this problem lie mainly within the realms of medical education and clinical practice. More medical schools, residency programs and continuing education programs for practicing physicians need to include training in clinical communication skills.

Dr. Sunil Kripalani of the Emory University School of Medicine in Atlanta and Dr. Barry D. Weiss of the University of Arizona College of Medicine in Tucson suggest these strategies:

¶Doctors should assess the patient’s baseline understanding before providing extensive information: “Before we go on, could you tell me what you already know about high blood pressure?”

¶Doctors should use plain language, not medical jargon, vague terms and words that may have different meanings to a lay person. They should say chest pain instead of angina, hamburger instead of red meat and, “You don’t have H.I.V.” instead of “Your H.I.V. test was negative.”

¶To encourage patients to ask questions, doctors should ask, “What questions do you have?” rather than, “Do you have any questions?”

¶Doctors should confirm the patient’s understanding by saying, “I always ask my patients to repeat things back to make sure I have explained them clearly.” Or, if a new skill like using an inhaler was taught, the doctor should have the patient demonstrate the action.

¶Then, as fail-safe measures, the doctor should provide written instructions and educational material for the patient and family to review at home.

Dr. Kripalani and Dr. Weiss say none of this should take more than a few minutes. And by tailoring information to a patient’s individual needs and limiting it to the most important points, the process can save time in the long run, result in better control of chronic illness and lead to shorter and less frequent office visits.

Experts on health literacy also encourage doctors to assess patients’ health literacy by asking them to read aloud a list of 66 medical terms, each within 5 seconds. Patients are scored on how many words they pronounce correctly.

Taking the Lead

Do not wait until doctors become better at communicating. If you want the best medical care, you have to take the initiative. If the doctor says something you do not understand, ask that it be repeated in simpler language. If you are given a new set of instructions, repeat them back to the doctor to confirm your understanding. If you are given a new device to use, demonstrate how you think you are to use it.

Insist that conversations about serious medical matters take place when you are dressed and in the doctor’s office. Take notes or take along an advocate who can take notes for you. Better yet, tape-record the conversation to replay it at home for you and your family or another doctor.

If you have received a diagnosis of a new problem and want to explore it further on the Internet, be sure to look up reputable sites. Two that can be relied on are www.nlm.nih.gov, produced by the National Library of Medicine, and www.healthfinder.gov, produced by the United States Department of Health and Human Services. Many major medical centers also provide useful, accurate information online.

Avoid anecdotal information posted by patients or patients’ relatives, as well as write-ups by commercial organizations that overtly or covertly sell products.

Patients 'Connected' to a Specific Physician More Likely to Receive Recommended Care

04 mar 2009--Patients who use a single primary care physician are more likely to receive guideline-consistent care, reports Annals of Internal Medicine.

Researchers assessed whether some 156,000 adults seen at 13 practices in a primary care network were considered "connected" to a particular physician, and then examined whether connectedness was associated with quality of care. (Connectedness was determined using an algorithm that predicted the likelihood that a physician would identify a patient as "my patient.")

In adjusted analyses, patients who were connected to a specific physician were significantly more likely to receive guideline-recommended cancer screenings and chronic disease management, compared with those connected to only a practice.

An editorialist says the findings "make a strong case" that a personal physician improves quality — which has important implications for promoting a "patient-centered medical home" approach to primary care.

LINK(S):

Annals of Internal Medicine article (Free abstract; full text requires subscription)

Annals of Internal Medicine editorial (Subscription required)

How a Patient Can Help a Doctor Give the Best Care

By JANE E. BRODY
01 oct 2008--As primary care doctors become increasingly pressed for time, here are 10 tips to help maximize the benefits you get from modern medical care.
1. Write down your questions before calling or seeing the doctor. Don’t wait until the end of a visit to mention a pressing health concern.
2. Keep a diary of your symptoms and the circumstances under which they occur, and bring it with you to the appointment.
3. Maintain an up-to-date list of all the medications and over-the-counter drugs and supplements you take and their dosages. Bring that with you.
4. Write down what the doctor says about your condition and how to treat it.
5. Know your personal and family medical history, including illnesses and operations you had and diseases or causes of death of your parents, grandparents and siblings.
6. Be honest about your lifestyle. If you smoke, drink alcohol or take recreational drugs, reveal how often or how much.
7. Be willing to see a physician’s assistant or nurse practitioner for routine care like wellness checkups and immunizations.
8. Ask if the doctor uses e-mail and checks it daily. If so, use e-mail messages to discuss nonurgent matters or lingering concerns, to clarify treatment instructions and to report an improvement in symptoms. But call immediately if your symptoms fail to improve as expected or suddenly get worse.
9. If you call about a worrisome symptom and the doctor tells you to go to the emergency room, don’t wait. If you are told to go by ambulance, do it; you’ll be seen right away, which could make a life-or-death difference.
10. Get an independent second opinion if you are told that you have a life-threatening condition or that surgery is needed to correct a problem, or if you are doubtful about the quality of tests that were done.

Taking Time for Empathy

By PAULINE W. CHEN, M.D.
27 sept 2008--I would like to believe that I am a compassionate doctor. But when I must convey bad news to a patient, one of the first things I worry about is time.
One of the most challenging, and potentially rewarding, aspects of being a doctor is responding and acknowledging patients’ fear, anger, frustration and sadness. But I have always believed that it takes more time to listen and answer empathetically — time that is hard to ignore when you know there are other patients who have been waiting a long time outside to see you.
A paper this week in a medical journal, though, has made me think a little differently about time and empathy. The study, in The Archives of Internal Medicine, found that physicians overwhelmingly miss opportunities to express empathy to their patients.
Listening to transcripts and recordings of 20 conversations between men with lung cancer and their doctors, Dr. Diane Morse of the University of Rochester School of Medicine and her colleagues identified 384 “empathic opportunities” in the discussions — moments when a doctor might respond with a few words to address patient concerns ranging from fear of illness and death, to mistrust about care and the health care system, to confusion about treatment.
They found that the physicians missed 90 percent of opportunities to respond empathetically to their patients.
One of the reasons for this staggering statistic, the investigators suggest, is lack of time. “In a busy clinic,” the authors wrote, “physicians may believe that there is no time for empathic responses.”
As I read the paper, I remembered one particular afternoon in clinic spent with a man in his late 50s who had liver cancer.
The man, wiry and stooped, had immigrated some 30 years earlier and had worked in restaurants in the Los Angeles area. Accompanying him was his daughter, a radiant 20-something graduate student who spoke comfortably, confidently, in the English that was her first language.
She had researched her father’s diagnosis on the Internet and had arranged to have him seen in our clinic. She wanted to know if we could take out her father’s tumor.
After examining her father, I stepped out of the room to join the other surgeons viewing his CAT scans. As we crowded around the pictures, the tumor emerged — a dark circle in the middle of the man’s liver. View after view, the circle seemed only to widen, an ominous black hole that threatened to swallow what little normal liver was left.
I wanted to scream for the man and his daughter. Instead, I whispered a series of expletives directed at the tumor, then stepped back into the examining room, bracing myself for what would be a hard and, I believed, long conversation. I had to tell this family that the tumor was inoperable.
I had had these kinds of conversations in the past and could only imagine how difficult it would be for this patient and his daughter. I wanted to be compassionate with them, to take the time to listen and to acknowledge their fears and concerns.
But I also did not want to open the floodgates of emotion on an afternoon when the waiting room was overflowing.
In the end, I decided to take the time to listen to the man and his daughter, to ignore for a few moments the clock on the wall.
What surprises me, reflecting back on that interaction, is that despite all the questions and moments of deep emotion that came up during our conversation, the entire visit did not take nearly as long as I had imagined it would. And clinic that afternoon did not run any later than usual.
It did not take more time to be open to the man and his daughter’s emotional needs and to acknowledge them with a few words.
The results of Dr. Morse’s study have already made their way onto the Internet. “For Some Doctors, Empathy Is in Short Supply,” the headlines read.
But the statistic about doctors’ missed empathic opportunities is not, I believe, what is so intriguing about her study.
What is most interesting — and, I believe, most important — about this study is that empathy, expressed throughout a patient-doctor encounter, may actually help to alleviate problems with time.
Or at least not exacerbate them to the extent that many doctors, including myself, fear.
Dr. Morse and her colleagues found that while patients brought up important emotional issues throughout a visit, their doctors tended to express the bulk of their empathy toward the end of that visit.
When doctors did not respond to initial opportunities to be empathetic, patients would try repeatedly, throughout the rest of the visit, to elicit that support in some way.
In other words, too little empathy, or empathy expressed too late in an encounter, may actually result in longer visits.
When the doctors did respond in a way that explicitly recognized patient emotions, patient responses were not long, as some of us might imagine. Instead, patients usually responded with one or two words, or a single sentence.
There is, then, no floodgate.
Not long after I spoke to that man with liver cancer in clinic, I received a note from his daughter:
I just wanted to say thank you deeply for all your assistance and care regarding my father. Finding out my father has cancer has consumed me and my family emotionally and physically. Meeting you and the entire team calmed my heart more than you can know.
We had finished our visit in time, and it was, I believe, worth every minute.

The Tyranny of Diagnosis

By PAULINE W. CHEN
21 sept 2008--Not long ago, while surfing online for one disease, I got sidetracked by another: cryptogenic cirrhosis.
I have cared for patients with cryptogenic cirrhosis. It is a common cause of liver-related illness and death in the United States, and symptoms can range from jaundice, bleeding and confusion to life-threatening hemorrhage, coma and death.
The cause of the disease, as the name implies (from the Greek “krypt,” or hidden, and “genesis,” or origin), has long been unknown. Every one of my patients with cryptogenic cirrhosis has heard the same thing from their doctors, including myself: “We have no idea why you are so sick.”
For these patients, cryptogenic cirrhosis is not a diagnosis but a non-diagnosis.
Non-diagnoses like cryptogenic cirrhosis pose particular challenges for doctors. While I feel comfortable predicting the post-transplant course and clinical reactions of patients with, for example, hepatitis or liver cancer, I can never be sure with patients who have cryptogenic cirrhosis.
And patients with non-diagnoses face even greater challenges, challenges that go beyond knowing what exactly is wrong or getting treatments.
For several years of my childhood, my mother suffered from an illness that could not be diagnosed. I have memories of her weakness, of days spent whispering so that she could sleep, and of living with the constant darkness of her bedroom and of her suffering.
Debilitated, my mother went from doctor to doctor, clinician to clinician. Despite their rapt attention to the details of her symptoms, she eventually heard from them what her surgeon-daughter would someday tell others: “We have no idea why you are so sick.”
As I read up on cyptogenic cirrhosis, I was reminded of those words again. Over the last few years, medical researchers have made tremendous advances in our understanding of this illness; it is not quite so cryptogenic anymore, and those suffering from the disease may soon have specific drugs for treatment.
That’s good news for patients, I thought as I scanned the Web sites. But also not-so-good news.
As comforting as it may be to have a real diagnosis, those diagnoses also carry powerful assumptions about our bodies and our place in the world, which can in turn influence our health care.
Charles Rosenberg, a Harvard historian, writes about the power of diagnoses in his book “Our Present Complaint: American Medicine, Then and Now” (Johns Hopkins University Press, 2007). He refers to it as the “tyranny of diagnosis.”
The concept of disease, Professor Rosenberg writes, has historically focused on the individual — a single person’s experience, story and sense of meaning.
Over the last century and a half, however, medicine has increasingly decoupled disease from the individual. This decoupling has given rise to the concept of precise, objective and quantifiable diagnoses, diagnoses so separate from patients that they seem in many ways to take on a life of their own.
Diagnoses cluster together by specific physiologic mechanisms, signs and symptoms, pathologic findings. They have insinuated themselves into health care economics as DRG’s, or Diagnosis-Related Groups, which drive physician compensation. They have inspired whole subspecialty training programs and huge advances in how we understand and treat them. Think of heart failure, cancer and my own specialty, liver transplantation.
This greater understanding and improved treatment are important and good news for all, no doubt.
Yet along with these great clinical strides, diagnoses have also fomented their own cultural revolution. Diagnoses have changed the way we approach individuals.
Diagnosing a patient requires placing that single person’s narrative against the larger predetermined trajectory of a diagnosis. When the individual’s story fits into the diagnosis’s trajectory, there is some relief for all of us. We know what is wrong.
But when we know what is wrong, we sometimes stop paying such close attention to those patient experiences that seem to have little relevance to the diagnosis at hand. We focus less on the individual and more on the diagnosis.
When the diagnosis trajectory and patient picture don’t match, we are left with an “atypical,” “complicated,” “idiopathic” or “undiagnosable” case. One of the risks for these patients, in addition to prolonged physical discomfort or suffering, is that without a diagnosis, their experience may lose meaning and relevance in the eyes of others.
My mother has been well for a few decades now, though her doctors still are not entirely sure of what made her so sick years ago. But the diagnoses they have considered, and her own search for one, have influenced how others — both doctors and non-doctors — have treated and listened to her.
When my mother had no diagnosis, her family and friends, clinicians, and others at first listened intently, sifting her narratives for every possible clue. But then most of us eventually lost interest, as if her experience could not really exist if it had no name.
But each time my mother got close to the relief of having a diagnosis, many of us stopped listening, too, choosing to hear only what seemed important to the diagnosis.
That, I now fear, is the not-so-good news for people with diseases like cryptogenic cirrhosis. We seem unable to harness the power of diagnoses and give full weight to the meaning of an individual’s illness experience.
I recently asked Professor Rosenberg about the power that diagnoses have over how all of us view illness and health care. “Some people would call it progress, some people would call it reductionism, some people would call it bureaucracy,” he told me. “But it’s all of those things.”

When the Patient Is a Googler

08, nov, 2007--By Scott Haig
We had never met, but as we talked on the phone I knew she was Googling me. The way she drew out her conjunctions, just a little, that was the tip off — stalling for time as new pages loaded. It was barely audible, but the soft click-click of the keyboard in the background confirmed it. Oh, well, it's the information age. Normally, she'd have to go through my staff first, but I gave her an appointment.
Susan was well spoken and in good shape, an attractive woman in her mid-40s. She had brought her three-year-old to my office, but was ignoring the little monster as he ripped up magazines, threw fish crackers and Cheerios, and stomped them into my rug. I tried to ignore him too, which was hard as he dribbled chocolate milk from his sippy cup all over my upholstered chairs. Eventually his screeching made conversation impossible.
"This is not an acceptable form of behavior, not acceptable at all," was Susan's excruciatingly well-enunciated and perfunctory response to Junior's screaming. The toddler's defiant delight signaled that he understood just enough to ignore her back. Meanwhile, Mom launched into me with a barrage of excruciatingly well-informed questions. I soon felt like throwing Cheerios at her too.
Susan had chosen me because she had researched my education, read a paper I had written, determined my university affiliation and knew where I lived. It was a little too much — as if she knew how stinky and snorey I was last Sunday morning. Yes, she was simply researching important aspects of her own health care. Yes, who your surgeon is certainly affects what your surgeon does. But I was unnerved by how she brandished her information, too personal and just too rude on our first meeting.
Every doctor knows patients like this. They're called "brainsuckers." By the time they come in, they've visited many other docs already — somehow unable to stick with any of them. They have many complaints, which rarely translate to hard findings on any objective tests. They talk a lot. I often wonder, while waiting for them to pause, if there are patients like this in poor, war-torn countries where the need for doctors is more dire.
Susan got me thinking about patients. Nurses are my favorites — they know our language and they're used to putting their trust in doctors. And they laugh at my jokes. But engineers, as a class, are possibly the best patients. They're logical and they're accustomed to the concept of consultation — they're interested in how the doctor thinks about their problem. They know how to use experts. If your orthopedist thinks about arthritis, for instance, in terms of friction between roughened joint surfaces, you should try to think about it, generally, in the same way. There is little use coming to him or her for help if you insist your arthritis is due to an imbalance between yin and yang, an interruption of some imaginary force field or a dietary deficiency of molybdenum. There's so much information (as well as misinformation) in medicine — and, yes, a lot of it can be Googled — that one major responsibility of an expert is to know what to ignore.
Susan had neither the trust of a nurse nor the teachability of an engineer. She would ignore no theory of any culture or any quack, regarding her very common brand of knee pain. On and on she went as I retreated further within. I marveled, sitting there silenced by her diatribe. Hers was such a fully orbed and vigorous self-concern that it possessed virtue in its own right. Her complete and utter selfishness was nearly a thing of beauty.
When to punt is not a topic taught in medical school. There is but one observation that I can offer: Patients like Susan, as self-absorbed as they are, know it immediately. They can tell when you're about to punt.
I knew full well what was wrong with this woman, and I could treat her, probably as well as anyone. But treating her condition, which was chronic patellofemoral pain, would test the mettle of patient and surgeon. What we have doesn't work very well nor very quickly. The swelling takes months to go down, the muscles take even longer to strengthen. Good patients often complain, "It was better before we started," in desperation or anger, before they see improvement. But with plenty of therapy, braces, exercises and one or two operations, this knee does improve. It's often tough going, though, and patients have to stick with you. I like to be straight — "It gets worse before it gets better" is what I tell them. Susan's style, her history and, somehow, most telling, the way she treated her son said she was not going to make it through this. Not with me, anyway.
A seasoned doc gets good at sizing up what kind of patient he's got and how to adjust his communicative style accordingly. Some patients are non-compliant Bozos who won't read anything longer than a headline. They don't want to know what's wrong with them, they don't know what medicines they're taking, they don't even seem to care what kind of operation you're planning to do on them. "Just get me better, doc," is all they say.
At the other end of our spectrum are patients like Susan: They're often suspicious and distrustful, their pressured sentences burst with misused, mispronounced words and half-baked ideas. Unfortunately, both types of patients get sick with roughly the same frequency.
I knew Susan was a Googler — queen, perhaps, of all Googlers. But I couldn't dance with this one. I couldn't even get a word in edgewise. So, I cut her off. I punted. I told her there was nothing I could do differently than her last three orthopedists, but I could refer her to another who might be able to help. A certain Dr. Brown, whom I'd known as a resident, had been particularly interested in her type of knee problem.
Disappointed and annoyed, Susan stopped for a beat.
"You mean Larry Brown on Central Avenue?"
"Uh, yes —" I started.
"I have an appointment with him on Friday. And, Dr. Haig?" she said, pulling Junior by the arm out my office door, "Watch out on your drive home tonight. There was an accident near your exit."
Dr. Scott Haig is an Assistant Clinical Professor of Orthopedic Surgery at Columbia University College of Physicians and Surgeons. He has a private practice in the New York City area.Thursday, Nov. 08, 2007 By Scott Haig
We had never met, but as we talked on the phone I knew she was Googling me. The way she drew out her conjunctions, just a little, that was the tip off — stalling for time as new pages loaded. It was barely audible, but the soft click-click of the keyboard in the background confirmed it. Oh, well, it's the information age. Normally, she'd have to go through my staff first, but I gave her an appointment.
Susan was well spoken and in good shape, an attractive woman in her mid-40s. She had brought her three-year-old to my office, but was ignoring the little monster as he ripped up magazines, threw fish crackers and Cheerios, and stomped them into my rug. I tried to ignore him too, which was hard as he dribbled chocolate milk from his sippy cup all over my upholstered chairs. Eventually his screeching made conversation impossible.
"This is not an acceptable form of behavior, not acceptable at all," was Susan's excruciatingly well-enunciated and perfunctory response to Junior's screaming. The toddler's defiant delight signaled that he understood just enough to ignore her back. Meanwhile, Mom launched into me with a barrage of excruciatingly well-informed questions. I soon felt like throwing Cheerios at her too.
Susan had chosen me because she had researched my education, read a paper I had written, determined my university affiliation and knew where I lived. It was a little too much — as if she knew how stinky and snorey I was last Sunday morning. Yes, she was simply researching important aspects of her own health care. Yes, who your surgeon is certainly affects what your surgeon does. But I was unnerved by how she brandished her information, too personal and just too rude on our first meeting.
Every doctor knows patients like this. They're called "brainsuckers." By the time they come in, they've visited many other docs already — somehow unable to stick with any of them. They have many complaints, which rarely translate to hard findings on any objective tests. They talk a lot. I often wonder, while waiting for them to pause, if there are patients like this in poor, war-torn countries where the need for doctors is more dire.
Susan got me thinking about patients. Nurses are my favorites — they know our language and they're used to putting their trust in doctors. And they laugh at my jokes. But engineers, as a class, are possibly the best patients. They're logical and they're accustomed to the concept of consultation — they're interested in how the doctor thinks about their problem. They know how to use experts. If your orthopedist thinks about arthritis, for instance, in terms of friction between roughened joint surfaces, you should try to think about it, generally, in the same way. There is little use coming to him or her for help if you insist your arthritis is due to an imbalance between yin and yang, an interruption of some imaginary force field or a dietary deficiency of molybdenum. There's so much information (as well as misinformation) in medicine — and, yes, a lot of it can be Googled — that one major responsibility of an expert is to know what to ignore.
Susan had neither the trust of a nurse nor the teachability of an engineer. She would ignore no theory of any culture or any quack, regarding her very common brand of knee pain. On and on she went as I retreated further within. I marveled, sitting there silenced by her diatribe. Hers was such a fully orbed and vigorous self-concern that it possessed virtue in its own right. Her complete and utter selfishness was nearly a thing of beauty.
When to punt is not a topic taught in medical school. There is but one observation that I can offer: Patients like Susan, as self-absorbed as they are, know it immediately. They can tell when you're about to punt.
I knew full well what was wrong with this woman, and I could treat her, probably as well as anyone. But treating her condition, which was chronic patellofemoral pain, would test the mettle of patient and surgeon. What we have doesn't work very well nor very quickly. The swelling takes months to go down, the muscles take even longer to strengthen. Good patients often complain, "It was better before we started," in desperation or anger, before they see improvement. But with plenty of therapy, braces, exercises and one or two operations, this knee does improve. It's often tough going, though, and patients have to stick with you. I like to be straight — "It gets worse before it gets better" is what I tell them. Susan's style, her history and, somehow, most telling, the way she treated her son said she was not going to make it through this. Not with me, anyway.
A seasoned doc gets good at sizing up what kind of patient he's got and how to adjust his communicative style accordingly. Some patients are non-compliant Bozos who won't read anything longer than a headline. They don't want to know what's wrong with them, they don't know what medicines they're taking, they don't even seem to care what kind of operation you're planning to do on them. "Just get me better, doc," is all they say.
At the other end of our spectrum are patients like Susan: They're often suspicious and distrustful, their pressured sentences burst with misused, mispronounced words and half-baked ideas. Unfortunately, both types of patients get sick with roughly the same frequency.
I knew Susan was a Googler — queen, perhaps, of all Googlers. But I couldn't dance with this one. I couldn't even get a word in edgewise. So, I cut her off. I punted. I told her there was nothing I could do differently than her last three orthopedists, but I could refer her to another who might be able to help. A certain Dr. Brown, whom I'd known as a resident, had been particularly interested in her type of knee problem.
Disappointed and annoyed, Susan stopped for a beat.
"You mean Larry Brown on Central Avenue?"
"Uh, yes —" I started.
"I have an appointment with him on Friday. And, Dr. Haig?" she said, pulling Junior by the arm out my office door, "Watch out on your drive home tonight. There was an accident near your exit."
Dr. Scott Haig is an Assistant Clinical Professor of Orthopedic Surgery at Columbia University College of Physicians and Surgeons. He has a private practice in the New York City area.08, nov,2007 By Scott Haig
We had never met, but as we talked on the phone I knew she was Googling me. The way she drew out her conjunctions, just a little, that was the tip off — stalling for time as new pages loaded. It was barely audible, but the soft click-click of the keyboard in the background confirmed it. Oh, well, it's the information age. Normally, she'd have to go through my staff first, but I gave her an appointment.
Susan was well spoken and in good shape, an attractive woman in her mid-40s. She had brought her three-year-old to my office, but was ignoring the little monster as he ripped up magazines, threw fish crackers and Cheerios, and stomped them into my rug. I tried to ignore him too, which was hard as he dribbled chocolate milk from his sippy cup all over my upholstered chairs. Eventually his screeching made conversation impossible.
"This is not an acceptable form of behavior, not acceptable at all," was Susan's excruciatingly well-enunciated and perfunctory response to Junior's screaming. The toddler's defiant delight signaled that he understood just enough to ignore her back. Meanwhile, Mom launched into me with a barrage of excruciatingly well-informed questions. I soon felt like throwing Cheerios at her too.
Susan had chosen me because she had researched my education, read a paper I had written, determined my university affiliation and knew where I lived. It was a little too much — as if she knew how stinky and snorey I was last Sunday morning. Yes, she was simply researching important aspects of her own health care. Yes, who your surgeon is certainly affects what your surgeon does. But I was unnerved by how she brandished her information, too personal and just too rude on our first meeting.
Every doctor knows patients like this. They're called "brainsuckers." By the time they come in, they've visited many other docs already — somehow unable to stick with any of them. They have many complaints, which rarely translate to hard findings on any objective tests. They talk a lot. I often wonder, while waiting for them to pause, if there are patients like this in poor, war-torn countries where the need for doctors is more dire.
Susan got me thinking about patients. Nurses are my favorites — they know our language and they're used to putting their trust in doctors. And they laugh at my jokes. But engineers, as a class, are possibly the best patients. They're logical and they're accustomed to the concept of consultation — they're interested in how the doctor thinks about their problem. They know how to use experts. If your orthopedist thinks about arthritis, for instance, in terms of friction between roughened joint surfaces, you should try to think about it, generally, in the same way. There is little use coming to him or her for help if you insist your arthritis is due to an imbalance between yin and yang, an interruption of some imaginary force field or a dietary deficiency of molybdenum. There's so much information (as well as misinformation) in medicine — and, yes, a lot of it can be Googled — that one major responsibility of an expert is to know what to ignore.
Susan had neither the trust of a nurse nor the teachability of an engineer. She would ignore no theory of any culture or any quack, regarding her very common brand of knee pain. On and on she went as I retreated further within. I marveled, sitting there silenced by her diatribe. Hers was such a fully orbed and vigorous self-concern that it possessed virtue in its own right. Her complete and utter selfishness was nearly a thing of beauty.
When to punt is not a topic taught in medical school. There is but one observation that I can offer: Patients like Susan, as self-absorbed as they are, know it immediately. They can tell when you're about to punt.
I knew full well what was wrong with this woman, and I could treat her, probably as well as anyone. But treating her condition, which was chronic patellofemoral pain, would test the mettle of patient and surgeon. What we have doesn't work very well nor very quickly. The swelling takes months to go down, the muscles take even longer to strengthen. Good patients often complain, "It was better before we started," in desperation or anger, before they see improvement. But with plenty of therapy, braces, exercises and one or two operations, this knee does improve. It's often tough going, though, and patients have to stick with you. I like to be straight — "It gets worse before it gets better" is what I tell them. Susan's style, her history and, somehow, most telling, the way she treated her son said she was not going to make it through this. Not with me, anyway.
A seasoned doc gets good at sizing up what kind of patient he's got and how to adjust his communicative style accordingly. Some patients are non-compliant Bozos who won't read anything longer than a headline. They don't want to know what's wrong with them, they don't know what medicines they're taking, they don't even seem to care what kind of operation you're planning to do on them. "Just get me better, doc," is all they say.
At the other end of our spectrum are patients like Susan: They're often suspicious and distrustful, their pressured sentences burst with misused, mispronounced words and half-baked ideas. Unfortunately, both types of patients get sick with roughly the same frequency.
I knew Susan was a Googler — queen, perhaps, of all Googlers. But I couldn't dance with this one. I couldn't even get a word in edgewise. So, I cut her off. I punted. I told her there was nothing I could do differently than her last three orthopedists, but I could refer her to another who might be able to help. A certain Dr. Brown, whom I'd known as a resident, had been particularly interested in her type of knee problem.
Disappointed and annoyed, Susan stopped for a beat.
"You mean Larry Brown on Central Avenue?"
"Uh, yes —" I started.
"I have an appointment with him on Friday. And, Dr. Haig?" she said, pulling Junior by the arm out my office door, "Watch out on your drive home tonight. There was an accident near your exit."
Dr. Scott Haig is an Assistant Clinical Professor of Orthopedic Surgery at Columbia University College of Physicians and Surgeons. He has a private practice in the New York City area.We had never met, but as we talked on the phone I knew she was Googling me. The way she drew out her conjunctions, just a little, that was the tip off — stalling for time as new pages loaded. It was barely audible, but the soft click-click of the keyboard in the background confirmed it. Oh, well, it's the information age. Normally, she'd have to go through my staff first, but I gave her an appointment.
Susan was well spoken and in good shape, an attractive woman in her mid-40s. She had brought her three-year-old to my office, but was ignoring the little monster as he ripped up magazines, threw fish crackers and Cheerios, and stomped them into my rug. I tried to ignore him too, which was hard as he dribbled chocolate milk from his sippy cup all over my upholstered chairs. Eventually his screeching made conversation impossible.
"This is not an acceptable form of behavior, not acceptable at all," was Susan's excruciatingly well-enunciated and perfunctory response to Junior's screaming. The toddler's defiant delight signaled that he understood just enough to ignore her back. Meanwhile, Mom launched into me with a barrage of excruciatingly well-informed questions. I soon felt like throwing Cheerios at her too.
Susan had chosen me because she had researched my education, read a paper I had written, determined my university affiliation and knew where I lived. It was a little too much — as if she knew how stinky and snorey I was last Sunday morning. Yes, she was simply researching important aspects of her own health care. Yes, who your surgeon is certainly affects what your surgeon does. But I was unnerved by how she brandished her information, too personal and just too rude on our first meeting.
Every doctor knows patients like this. They're called "brainsuckers." By the time they come in, they've visited many other docs already — somehow unable to stick with any of them. They have many complaints, which rarely translate to hard findings on any objective tests. They talk a lot. I often wonder, while waiting for them to pause, if there are patients like this in poor, war-torn countries where the need for doctors is more dire.
Susan got me thinking about patients. Nurses are my favorites — they know our language and they're used to putting their trust in doctors. And they laugh at my jokes. But engineers, as a class, are possibly the best patients. They're logical and they're accustomed to the concept of consultation — they're interested in how the doctor thinks about their problem. They know how to use experts. If your orthopedist thinks about arthritis, for instance, in terms of friction between roughened joint surfaces, you should try to think about it, generally, in the same way. There is little use coming to him or her for help if you insist your arthritis is due to an imbalance between yin and yang, an interruption of some imaginary force field or a dietary deficiency of molybdenum. There's so much information (as well as misinformation) in medicine — and, yes, a lot of it can be Googled — that one major responsibility of an expert is to know what to ignore.
Susan had neither the trust of a nurse nor the teachability of an engineer. She would ignore no theory of any culture or any quack, regarding her very common brand of knee pain. On and on she went as I retreated further within. I marveled, sitting there silenced by her diatribe. Hers was such a fully orbed and vigorous self-concern that it possessed virtue in its own right. Her complete and utter selfishness was nearly a thing of beauty.
When to punt is not a topic taught in medical school. There is but one observation that I can offer: Patients like Susan, as self-absorbed as they are, know it immediately. They can tell when you're about to punt.
I knew full well what was wrong with this woman, and I could treat her, probably as well as anyone. But treating her condition, which was chronic patellofemoral pain, would test the mettle of patient and surgeon. What we have doesn't work very well nor very quickly. The swelling takes months to go down, the muscles take even longer to strengthen. Good patients often complain, "It was better before we started," in desperation or anger, before they see improvement. But with plenty of therapy, braces, exercises and one or two operations, this knee does improve. It's often tough going, though, and patients have to stick with you. I like to be straight — "It gets worse before it gets better" is what I tell them. Susan's style, her history and, somehow, most telling, the way she treated her son said she was not going to make it through this. Not with me, anyway.
A seasoned doc gets good at sizing up what kind of patient he's got and how to adjust his communicative style accordingly. Some patients are non-compliant Bozos who won't read anything longer than a headline. They don't want to know what's wrong with them, they don't know what medicines they're taking, they don't even seem to care what kind of operation you're planning to do on them. "Just get me better, doc," is all they say.
At the other end of our spectrum are patients like Susan: They're often suspicious and distrustful, their pressured sentences burst with misused, mispronounced words and half-baked ideas. Unfortunately, both types of patients get sick with roughly the same frequency.
I knew Susan was a Googler — queen, perhaps, of all Googlers. But I couldn't dance with this one. I couldn't even get a word in edgewise. So, I cut her off. I punted. I told her there was nothing I could do differently than her last three orthopedists, but I could refer her to another who might be able to help. A certain Dr. Brown, whom I'd known as a resident, had been particularly interested in her type of knee problem.
Disappointed and annoyed, Susan stopped for a beat.
"You mean Larry Brown on Central Avenue?"
"Uh, yes —" I started.
"I have an appointment with him on Friday. And, Dr. Haig?" she said, pulling Junior by the arm out my office door, "Watch out on your drive home tonight. There was an accident near your exit."
Dr. Scott Haig is an Assistant Clinical Professor of Orthopedic Surgery at Columbia University College of Physicians and Surgeons. He has a private practice in the New York City area.

HOW TO BE A GOOD PATIENT

We ask that you read the list below and do your best to abide by these suggestions:
Do not apologize for your symptoms – It is a very self-conscious thing to be sitting on the exam table. You can fill kind of stupid at times when your symptoms don’t seem to make sense. But if you had these symptoms, then please tell us what they are. It is not your fault that they don’t make sense.
Wear many layers of clothing – We generally have no idea if our office will be hot or cold. Some mysterious person controls that and we have yet to locate them. Hence, you should come prepared for a freezing cold room or a furnace.
Kids are sometimes not perfect – Since we take care of many children, we have come upon the great truth: kids are not always sedate and obedient. This may be a shock for some parents (who the rest of us resent), but we do realize that your children may misbehave sometimes. We don’t think you are a horrible parent because your child is not “seen but not heard.”
Earwax is not embarrassing – It is a mystery why people always apologize about earwax. It is not a moral defect that brought the wax to your ears, and we won’t go home and tell our families about the wax we see in your ear. It’s OK to have wax. Honest!
We believe you – When your child has had a fever for 5 days and then that fever disappears the moment you step into the office, we don’t think you made the fever up. And please, if your body fluids are a different color that normal; do not bring in a sample for us to see. Just tell us what it looked like. Please!
“No news is good news” is a lie – If a reasonable amount of time has passed and you have not heard the results of a test, please contact us. We have a better system than most offices at keeping track of things, but things can be lost, ignored, or forgotten.
The most precious thing you can give us is trust - You should never put your life into someone’s hands that you don’t trust. That does not mean you can’t question us (please do!), but it does mean that if you don’t trust our judgment, then it is probably time to find another doctor. We are happy to say that this does not happen very often.
Stinky diapers smell bad – Please don’t stick them in the trash can. There is nothing subtle about that smell. We have special bags for that kind of thing.
There is no such thing as a dumb question – except for one you should have asked, but did not. If you are confused about something you have been told, please ask someone to clarify it.
Don’t save the most important thing for the “oh by the way” question at the end of your visit – It may be an uncomfortable thing you want to ask, or you may be scared you have a horrible disease, but if something is really worrying you, please ask it early in your visit.

Before firing bad patients, doctors turn to lawyers

by Lisa van der Pool
A patient is unhappy with her cosmetic surgery results and begins to bombard her physician with voice mails and e-mails demanding a refund; her doctor ponders a restraining order.
A physician has proof that his patient is "doctor shopping" to procure extra pain pills to feed a drug addiction.
A psychiatric patient threatens his doctor with physical violence.
Each of these real Massachusetts cases, while radically different, had the common effect of prompting a doctor to do the unthinkable: fire a patient.
But before those doctors prescribed pink slips, they call to their lawyers.
A lack of standardized policies and an increasingly litigious culture have combined to make doctors wary of abandonment claims and medical malpractice lawsuits, according to local health care lawyers, who say that in recent years they have fielded more inquiries from doctors and health care organizations about the best way to terminate a doctor-patient relationship.
Pressures to see more patients in a shorter period of time, mountains of paper work and the oppressive managed-care culture has created a harried environment in which clinicians must practice their trade, according to Dr. John Fromson, chairman of the department of psychiatry at the MetroWest Medical Center in Natick and assistant clinical professor of psychiatry at Harvard Medical School.
"The system has engendered much greater uncertainty, particularly with the insertion of the third party into the otherwise sacrosanct relationship of a doctor and patient," said Fromson. "The system is increasingly complex and it engenders concern about legal ramifications."
Statistics on patient firings are difficult to track down, although anecdotally local practitioners say the numbers are trending upward.
When a patient-physician relationship begins, the doctor is under ethical and legal obligations to provide medical services for as long as the patient wants, according to the American Medical Association. For a doctor to cut off that relationship and not be successfully sued with an abandonment claim, a laundry list of steps needs to be taken.
First, there has to be a legitimate reason, which could include everything from a patient refusing treatment and repeatedly missing appointments to threats of violence. Next, a letter should be sent to the patient via certified mail with a detailed explanation of the termination and a note that services will be continued for 30 days, to allow the patient to find another doctor.
Statements like "I cannot provide effective care for you" should be avoided.
The doctor should offer to transfer medical records, cost free, to the patient's new physician. Because every case is different, most practices deal with situations individually, according to legal experts.
Dianne J. Bourque, a health care attorney at Mintz Levin Cohn Ferris Glovsky & Popeo PC in Boston has gotten more calls of late about patient terminations, which she says often involve threatening, violent or drug-seeking behavior.
"It's amazing the lengths that patients will go to and how devious they're getting to get prescription drugs," said Bourque. About 7 million Americans abuse prescription drugs, up from 3.8 million in 2000, according to the U.S. Drug Enforcement Administration.
Bourque has also dealt with terminations that resulted from overbearing family members.
"That's one of the hardest reasons. You have this poor patient sitting there and you have these buffoons you can't get rid of who are incredibly disruptive," said Bourque. "It gets delicate ... if you have someone who's a wingnut and you deliver this letter. There can be a period of anxiety associated with that."
In a situation where there's a chance to modify patient behavior and avoid a termination, some doctors will use a "behavioral contract" detailing how a patient needs to alter their behavior in order to stay with their doctor, such as not swearing or yelling at the doctor, according to Jennifer Gallop, a health care attorney at Krokidas & Bluestein LLP in Boston.
"That's a first step if you think it's possible to work out and there's nothing dangerous" about the situation, said Gallop.
Christine G. Solt, head of the health care practice at Choate Hall & Stewart LLP in Boston, attributes the uptick in patient-termination requests to reasons including aggressive parents pushing for more tests and treatments; drug-seeking patients; and patients who habitually miss appointments.
"The bottom line is you want to give patients the best care you can and if you don't have a good relationship, you can't do that," said Solt. "It's okay to acknowledge that the relationship isn't working."
Still, there are no guarantees of a complaint-free future for doctors who consult lawyers and insurance companies before firing a patients.
"Even if one communicates with the patient, you can never say you're not going to get sued," said Dr. Michael Grodin, a professor of bioethics at the Boston University School of Public Health. "The issue is that you will not be successfully sued."

How Doctors Tell Patients They're Dying
Important to Give Hope, Sense of Security, Docs Say

By EMILY FRIEDMAN
Telling patients they're going to die is less dramatic than one might think, and contrary to popular belief, most doctors refuse to estimate how many weeks or months patients have left to live.
While initial reports of Patrick Swayze's pancreatic cancer diagnosis came with predictions that the star would have only five weeks to live, the actor's doctor quickly released a statement refuting the rumors.
"Patrick has a very limited amount of disease, and he appears to be responding well to treatment thus far," Dr. George Fisher, Swayze's physician, said in the statement. "All the reports stating the time frame of his prognosis and his physical side effects are absolutely untrue. We are considerably more optimistic."
Putting a time stamp on someone's life, several doctors told ABCNEWS.com, is something that few doctors are willing to do. Instead, they employ much more methodical and caring techniques of breaking the news to terminally ill patients.
"It's not [a doctor's] job to take away hope but to try to provide support and be realistic as possible," said Dr. Michael Grodin, the director of medical ethics at Boston University School of Medicine and Public Health. "We are notoriously bad at predicting how much time a patient has left.
"You can obviously say that if someone has metastatic cancer that it's unlikely they're going to live for years," said Grodin, who said that it's always "very tough" to tell a patient he is dying. "But then again I've seen time and time again patients living much longer [than predicted] or dying much sooner."
How Do You Tell Someone They're Going to Die?
Many patients fear abandonment, Grodin said, so doctors must be sure to take the time to remind their terminally ill patients that even though a cure might be out of the question, their health is still important to them.
"Once they're diagnosed as terminal they worry that because we have nothing to do for them [in terms of a cure], we'll desert them," Grodin said. "So we must tell them that 'we have many wonderful things to do for you so that you don't have the pain and the suffering.'"
Grodin, who trains residents on how to tell patients they're dying, told ABCNEWS.com that doctors must be as straightforward as possible when delivering the news.
"Don't use euphemisms," said Grodin, who teaches his students to say "died" and never "passed away" in situations of emergency room traumas. "You have to use the words 'terminal illness' and explain it's quite serious."
But what about those patients who want to know how long they have to live and would prefer a more precise answer from their doctors? Dr. Nick Christakis, a professor of medical sociology at Harvard Medical School, said doctors should cater to that individual's needs and be as honest as possible.
"Some patients say they don't want to know anything, and others say, 'Give it to me straight, doc,'" Christakis said. "Once you've established what kind of patient you're dealing with, you should be as willing to be as specific as science allows."
Even then, though, reminding patients that there are always exceptions to a doctor's prognosis is important, Christakis added.
With Only Months to Live, How Do Patients Cope?
While telling patients they're going to die is arguably one of the hardest parts of being a doctor, being on the receiving end of the news is certainly not easy, either.
"There's an overall pattern of how humans deal with forthcoming death," said Sherri McCarthy, a professor of psychology and a grief counselor at Northern Arizona University. "Shock or denial is a pretty universal first reaction. Patients say 'it's not me' or 'I'll go to a different doctor.'"
Eventually, these feelings usually transform into depression or anger, McCarthy said, and then later into "bargaining," a term used to describe when patients try to rationalize the situation and convince themselves they can do certain things to prevent their death.
And when they've finally accepted their illness, what happens next depends largely on the individual patient, McCarthy said.
"With people who have the freedom to [quit their jobs], it's common to see redirection," McCarthy said. "They're likely to think that they only have a limited time and say, 'I only have so much time to do the things I really want to do.'"
Dr. Ken Doka, a senior consultant to the Hospice Foundation of America, said that everyone copes differently, and often people deal with death similar to the way they deal with other aspects of life.
"We die as we live," Doka said. "If we're an angry person, then we tend to get angry at this. Some will cope by ignoring it and going on about their life as best they can, others will frantically look to do everything they can to try to beat it."
Said Boston University's Grodin, "We deal with death and dying daily as doctors. But most other people don't. There's this assumption that people know how to do it.
"There are as many people as there are ways people die," Grodin said. "You must take each case as unique and separate."

Is It Time To Fire Your Doctor?

Allison Van Dusen
Most executives know when it's time to fire an employee. Whether he or she constantly misses deadlines, doesn't take responsibility for mistakes or just isn't up to the job, the signs are usually pretty obvious.
But evaluating your doctor's performance can be a little more difficult.
That's partly because people don't tend to treat doctors' visits like business relationships. Whether you're going for a physical or treatment for a specific condition, instead of focusing on how to get the most out of an appointment, you're probably tense--maybe even intimidated.
Checklist: 10 Signs It's Time To Fire Your Doc
There's something about playing the role of a patient that can make the most powerful CEO, stripped of his Dior Homme suit and told to put on a skimpy cotton gown, feel vulnerable. Whether it's because you're nearly naked or afraid of what the doctor might say, you suddenly may not be able to clearly explain your symptoms, ask the list of questions you brought or decipher all of those medical terms, let alone tell if your doctor is doing a good job.
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If a person behind the counter at a retail store doesn't have the right attitude, you'll probably confidently walk away with your business, says Dr. Phyllis Hollenbeck, a Seattle-based fellow of the American Academy of Family Physicians and author of the new book Sacred Trust: The 10 Rules of Life, Death and Medicine.
"But," says Hollenbeck, "you lose that sense of being connected to your gut in the doctor's office."
Putting up with poor patient-doctor relationships can have consequences ranging from potentially billions of dollars squandered nationwide on unnecessary medical tests each year to outright substandard care. It also can be, quite simply, frustrating.
Top TipsIf you want to know whether it's time to give your doctor his walking papers, health experts suggest getting started by evaluating his or her communication skills.
"If your doctor communicates with you, explains why he is or why he's not doing certain things--that's critical," says Dr. Holly Atkinson, medical editor in chief of EverydayHealth.com, a Web site that specializes in consumer medical information.
Atkinson says she constantly hears from patients who are confused, for instance, about why a physician did or didn't order a test. Without an explanation, a woman who had chest pains, wanted a computed tomography (CT scan) coronary angiography and didn't get it might feel short-changed, not realizing her physician felt the resulting radiation exposure would have been too high. When doctors don't share how they're making important decisions, they not only leave their patients in the dark but they also fail to build trust, Atkinson says.
Likewise, you might want to think about moving on if your physician has a habit of barking commands at you. If you've just been diagnosed with diabetes and the doctor rambles off a list of sweets you have to give up, you're less likely to follow through than if he or she had taken a few minutes to work with you, identify some of your weaknesses and create an action plan, Atkinson says.
What do you wish your doctor would do differently? Weigh in. Add your thoughts in the Reader Comments section below.
It's also worth considering whether you and your doctor have personalities that clash, says Taylor Grant, founder of the health advocacy company Taylor Your Health and author of the book Health Matters: Eight Steps That Can Save Your Life--and Your Family's Health.
Patients who bury their heads in the sand and hope for good health need doctors who will keep on them to make appointments and offer support. On the other hand, if you wouldn't dream of going to your doctor's office without a few pages of medical information you printed off the Internet, you need a doctor who won't easily be bowled over and can listen, Grant says.
How To Get The Most Out Of Your VisitThe next time you see a new doctor, try thinking of the visit as you would a date, Hollenbeck suggests. Tap into your instincts during the first 45 to 60 seconds of your appointment and figure out whether you feel comfortable. You don't have to make a final decision right away, but don't ignore your initial response.
And before you do fire a doctor, be a good executive and at least tell him or her what's wrong. Doctors don't always realize they're not hitting the mark, and sometimes they just have bad days.
"Patients can be very helpful in helping doctors run their practices and make their practices better--if they let them know what isn't working," Atkinson says. "Doctors need feedback too."

Drug Companies Advertise and Americans Listen

By Peggy Peck
BOSTON, March 6 -- Direct-to-consumer advertising of prescription drugs has had a major impact on how patients deal with their doctors, confirmed a nationally representative a survey of American adults.
The survey found that 91% of the patients said they have heard or seen the ads, and 32% said they discussed the advertised drugs with their doctors.
And physicians apparently listened to what patients were saying, the survey found. Forty-four percent of those who talked to their doctors about an advertised drug were given a prescription for that drug, and 54% said their doctor gave them another prescription. The net result: 82% said they received a prescription when they brought up a drug ad.
The survey, which was conducted by the Harvard School of Public Health, Kaiser Family Foundation, and USA Today, also found that 80% of Americans think prescription drugs cost too much and 16% said paying for prescription drugs was a serious problem.
Not surprisingly, 52% of those who said they had difficulty paying for prescription drugs, or sometimes didn't fill prescriptions because of the cost, or cut pills in half to stretch out supplies, said they didn't have prescription drug insurance coverage. Likewise 54% of low-income people and 59% of people who said they took at least four prescription drugs regularly had the same complaint.
The nationally representative telephone survey was conducted between Jan. 3 and Jan. 23 among 1,695 adults ages 18 and older, and has a margin of sampling error of plus or minus three percentage points.
Seven in every 10 adults surveyed said pharmaceutical companies were "too concerned about making profits and not concerned enough about helping people," according to a press release issued by the Harvard School of Public Health and the Kaiser Family Foundation.
Other findings:
Nearly 60% said insurers should only pay for new drugs that are safe and more effective than existing ones.
78% said they thought drugs sold in the U.S. were safe --although only about 25% said they were very confident that drugs were safe.
47% said FDA regulations were adequate to ensure safety, but 44% said there should be more regulation, and 8% said there should be less regulation.
About half of Americans said the pharmaceutical industry had the right level of input into the drug approval process, and close to 40% said industry had too much influence on the process.
52% said government moved too slowly on drug approvals.
Overall, the public has mixed opinions of pharmaceutical companies, with 47% viewing the industry favorably and 44% unfavorably. Drug companies are viewed slightly more favorably than health insurers (40% favorable), but significantly less than doctors (81% favorable).

How To Give Bad News

A good stepwise process, for future reference in residency, from a lecture today in Family Medicine. This applies to both deaths and bad news in terms of studies, lab results, etc. (It’s also often a good idea to have the social worker or chaplain with you if you can.)

Make a setting. Don’t do it in a hallway, go find a private, quiet place to sit and talk.
Introduce yourself. Often the family has seen a number of different people caring for their loved one–doctors, nurses, techs, etc–so reiterate who you are, especially to the significant other.
Ask what they know already. It gives you a sense of their knowledge level, what they might be expecting, what they’re worried about, so you don’t repeat anything or speak above or below their level of understanding and medical knowledge.
Make a “preperatory statement.” This readies and focuses the loved ones for what they’re about to hear. A good suggestion from the lecturer: Don’t say “I have some bad news.” Try, “I have something very important I need to tell you right now.”
Deliver the news. Be brief, direct, and succinct, 25 words or less.
Pause, wait for a response. Be there and be present.
Arrange a follow-up for later. A phone call, a card–it doesn’t have to take extraordinary effort.
Take care of yourself. It’s emotionally trying and exhausting to do this, so allow yourself to grieve however you may express that, too.

10 Questions You Must Ask Your Doctor

By Trevor Thieme, Best Life
Best Life
1. Do I really need this test?
"Doctors often adhere to a better-safe-than-sorry philosophy, ordering tests just to protect themselves in the event of a lawsuit," says David Sandmire, MD, co-author of Medical Tests That Can Save Your Life.
A full 16 percent of prostate-cancer screenings, for example, are unnecessary, say Harvard researchers. Since 80 percent of PSA results are false positives, thousands of men undergo needless biopsies each year. Another overused procedure: CT scans. The radiation from these tests causes an estimated 5,695 cancer cases a year, say British researchers.
2. Where would you send your spouse or children?
Like our tax code and the judicial system, medicine is supposed to treat everyone equally, but it's clear that some people receive better treatment than others. "General practitioners who work within a particular system routinely refer patients to specialists within that health-care system," says Kevin Soden, MD, co-author of Special Treatment: How to Get the Same High-Quality Health Care Your Doctor Gets. "However, oftentimes the best surgeon is in a completely different facility on the other side of town, and you can bet that's where your doctor would send his family."
3. How many surgeries do you perform each year?
Nowhere is the saying "practice makes perfect" more applicable than in the operating room. Urologists who perform more than 40 prostatectomies a year, for example, experience 50 percent fewer complications than those who perform fewer than 40. The same goes for hospitals performing more than 200 coronary bypass surgeries a year, according to a report in the journal Circulation. Bottom line: Your health hinges on your surgeon's experience.
4. Can I schedule my surgery for the morning?
Arrive early and you'll get the undivided attention of an alert medical staff. A recent study of 90,000 surgeries by researchers at Duke University found that patients who had operations in the morning were four times less likely to have anesthesia complications — nausea, post-op pain, fluctuating blood pressure — than those who had them in the afternoon.
5. If I get sick, will you see me in the hospital?
In the past 10 years, the number of hospitalists, a new breed of physicians who specialize in inpatient care, has grown from a few hundred to nearly 20,000. "So if you require hospitalization, odds are your primary-care physician won't be at your bedside," says Evan Scott Levine, MD, author of What Your Doctor Won't (or Can't Tell You). "You'll be dealing with a new doctor who doesn't know you or your medical history." Make sure your GP makes hospital calls.
6. Do you earn bonuses based on performance?
Before you schedule a surgery, check the hospital's physician reward system. Insurance companies reimburse hospitals based on the type of treatment provided, not the length of your stay. As a result, "Many hospitals pay their physicians bonuses based on how quickly they move patients out the door," says Dr. Levine. "Quality of care is sacrificed in the interest of increasing patient turnover."
7. When did you graduate from medical school?
In an analysis of 62 studies, researchers at Harvard Medical School discovered that doctors who have been out of medical school for more than 20 years were up to 48 percent less likely to stay up-to-date on developments in their fields. They are equally likely to be unaware of current treatment guidelines, such as prescribing aspirin to treat angina (chest pain caused by decreased blood flow to the heart). If you don't want to ask your doctor directly, check out how long it has been since he graduated at healthgrades.com.
8. What the hell does that say?
No doctor would prescribe Zoloft for high cholesterol, but that's what you might end up with if your pharmacist can't read Zocor in your doctor's chicken scratch. Poor penmanship isn't just an old stereotype; it's responsible for up to 61 percent of medication errors and more than 1.5 million patient injuries per year, according to a recent report from the National Academies of Sciences' Institute of Medicine. "If you can't read a prescription, chances are your pharmacist can't either," says Dr. Soden. "Get your doctor to print out the name of the medication."
9. Will you remove that wedding ring?
When scientists at Rush University Medical Center, in Chicago, analyzed the hands of 66 nurses, they found that those with wedding rings had 10 times more bacteria than those without. "Bacterial infections are the leading cause of death in American hospitals; about 98,000 people die from them each year," says Dr. Soden. "That means you can contract a secondary infection at the hospital."
10. What else can I do to treat my condition?
Recent studies suggest that diet and exercise are essential for treating and preventing everything from heart attacks to prostate cancer, yet only one in six doctors discusses how to use nutrition to prevent disease, according to a study in the American Journal of Clinical Nutrition. Researchers in Colorado, meanwhile, found that only 28 percent of doctors mention exercise to their patients. Many primary-care physicians work with dietitians and trainers who can help treat patients with lifestyle-influenced health problems, such as type 2 diabetes. So even if your doctor doesn't have answers regarding nutrition and exercise, he likely knows someone who does.

Consumers and Physicians Online for Health

Testimonials from real patients and physicians on how the Internet has helped them with their health care treatment and delivery.

http://www.youtube.com/watch?v=PuNhxPCu2aY

Doctor’s Gender May Be Factor in Heart Diagnoses

By NICHOLAS BAKALAR
Conventional wisdom holds that coronary heart disease is an illness of older men, and that may be why doctors have difficulty diagnosing it in women. But do female doctors at least do a better job than male doctors? Apparently not, a new study finds.
The study, published online on Aug. 30 in Sociology of Health and Illness, did find significant differences in the ways male and female doctors diagnosed the illness. It reported that male doctors might be less biased by the gender and age of the patient being examined.
“We’re not trying to say that one group of doctors is better than another,” John B. McKinlay, the principal investigator said. “What we’re trying to do is for the first time describe and explain how much variability there is in doctors’ behavior when they look at exactly the same clinical presentation in different patients.”
The scientists videotaped professional actors portraying patients of varying gender, age, race and socioeconomic status who all had medically apparent symptoms of heart disease.
Then 112 male and female primary care doctors, half in Massachusetts and the rest in Britain, watched the videos. The physicians were asked to think of the patient as one of their own, make a diagnosis and suggest a treatment plan. Finally, they were asked to describe what factors they considered in arriving at their decisions.
Both male and female doctors picked up more psychological cues from female patients than from male patients. A characterization like “seemed very low" or “very depressed” was more likely to be made about a female patient than a male one.
Comments about a patient’s self-presentation like, “He doesn’t give a very cogent history,” or, “She’s a passive victim,” were more common among female doctors, and they made significantly more such observations of female patients.
Male doctors noticed fewer such cues in general, and only slightly more from male than female patients. This suggests that doctors, and especially female doctors, may be more sensitive to such information in patients of their own gender.
Even though older age is a significant risk factor for heart disease in both men and women, female doctors paid significantly less attention to female patients’ ages than those of males.
Dr. Alexandra J. Lansky, an associate professor of clinical medicine in cardiology at the Columbia University Medical Center who was not involved in the study, found the paper revealing.
“The old statement that female docs are better prepared to take care of female patients does not stand,” Dr. Lansky said. “Female docs are missing one big point that the male docs don’t miss, and that’s the age-related factor.”
Not all experts found the report convincing. “This study clearly says that female and male doctors approach the patient interview differently,” said Dr. Elizabeth A. Jackson, an assistant professor of medicine at the University of Michigan. “But they appear to have a similar knowledge base. This was not a real-life situation, and you can’t take conclusions from one study in isolation. I’d like to see if these results can be replicated.”
Dr. McKinlay, who is head of the New England Research Institutes in Watertown, Mass., said the study offered a new way to look at the disparities between men and women in treating coronary heart disease.
“A lot of the time,” he said, “health disparities have been explained by characteristics of the patient — race or economics, women versus men, older versus younger. But here the variability is explained by characteristics of the doctor.”