Category Archives: Clinician-Patient Relationships

Literacy, Communications and Star Trek – Cores for Reforming Healthcare

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In talking to people about the problems with the US healthcare system, two fundamental truths have become apparent.

First, people really want the type of healthcare that is envisioned in science fiction such as Star Trek, where almost any ailment is treated with a single injection or pill, or a few waves of a healing wand. Unfortunately, medical science hasn’t accomplished that, except in a few instances – antibiotics for a bacterial infection, or perhaps relocating a dislocated finger or shoulder (and those still require weeks to heal and therapy to regain strength and mobility).

And second, the ongoing problem of healthcare literacy and communications may be getting worse as the complexity of medical treatments increases.  Literacy and communications problems impair good healthcare when patients don’t understand what their doctors are telling them, how to take their medicines, or what disease they have.  When this happens  patients have much greater difficulty properly taking care of themselves.  A few examples and data:

  • The American Academy of Family Physicians has a Literacy Toolkit which they promote with the twin facts that only 50% of “patients take medications as directed,” and “nearly 90 million American adults have difficulty understanding and using health information.”
  • A July 9th ABC news story reported about an Annals of Emergency Medicine article showing that 78% of Emergency Room patients had some misunderstanding of their doctor’s instructions, but only 20% realized that they didn’t fully understand the instructions.
  • More patients are misusing medicines in dangerous ways. The actor Heath Ledger’s accidental overdose was the most recent high profile example of this. And CNN reported Monday about an Archives of Internal Medicine study showing that deaths of this type have increased 700% in 20 years.

Star Trek directly addressed communications challenges in a Next Generation episode, (Darmok and Jilad at Tanagra), where the crew of the Enterprise encounters an alien race whose words are understandable, but none of it makes any sense. It turns out that the alien’s language is based upon metaphors, and since the Enterprise’s crew doesn’t understand the context for the metaphors – the mythology and stories behind the metaphors – communications is nearly impossible….. until of course Captain Picard figures it all out in 60 TV minutes.

Unfortunately clinicians and patients aren’t able to resolve communications challenges like TV characters. When clinicians use words and concepts that their patients don’t understand, patients can’t correctly follow their instructions, and end up relying on what they think they heard or understand.

A classic example of this is that many people think taking antibiotics makes them resistant to antibiotics.  While it is true that antibiotic resistance is an issue of concern, it is the bacteria that become resistant to the medicines – not the patients. But patients who believe that they will become resistant may not take the full dosages of their antibiotics, or for as long as the doctor has prescribed – inactions that can actually increase the rate of bacterial resistance and not adequately treat the patient’s infection – bad outcomes for both society and the individual.

This is just one example of how misunderstanding a disease or a treatment can produce adverse consequences. Similar misunderstandings about diseases like diabetes and high blood pressure also lead to inadequate treatments and poor outcomes. For example, many patients believe they can tell when their blood pressure is high – and only then do they take their medicine. But high blood pressure (or hypertension) is called the “silent killer” because people can’t feel high blood pressure – except sometimes when it is dangerously high.

Which brings us back to Star Trek. One of the great things about the one-dose cure is that the patient doesn’t have to understand their disease or remember to take their medicines for the treatment to be effective, so literacy and communications problems are less of an issue for quality of care.

Lessons for Healthcare Reform
The lessons here for health reform are twofold: First, producing one-shot cures will require a lot more research and development – which needs to occur at the same time as we are improving the healthcare delivery system. And second, a fundamental area for improving healthcare delivery is communications and literacy. If patients don’t understand their disease, how to take their medicines, or modify their lifestyle, etc., then that is not their fault – that is the fault of the healthcare delivery system, and we should be able to find ways to fix it because this is not a new problem.

Vacations – Poker – Diagnostic and Research Skills

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What’s the point of vacations?  As a consultant that’s something I often ask myself since with the internet, cell phones, etc., it seems almost impossible to really “get away” and not be connected to work.

So what’s the value of vacations?  I think I’ve found the answer at the poker table.  As Ricky Ricardo used to tell Lucy, “Lemme splain!”

The point of vacations is to recharge by being in a different environment that presents a new context for viewing our normal “reality.”  A great practitioner of this principle was Teddy Roosevelt.  He would travel to the wildest and most dangerous parts of the world, and hunt the largest of animals. After these experiences he probably came back to Washington DC and the political world, and said to himself, “Hey, this jungle and these animals really aren’t so bad or ferocious.”

As a consultant, I often find my vacations are pieced together days, (or pieces of days), that often include work “time-outs.”  For example during a recent 5 day trip to visit family in Seattle, aside from the many emails, I had two 8 am conference calls, and a 6 am telephone presentation.  Trips like this have forced me to schedule “vacation” time like I schedule exercise time – in 2-6 hour chunks.  The challenge is making these mini intra-day vacations count.

Which brings me to the poker table.  I had gone with some friends to play at a local casino a few months back, and we all had a good time.  I also found that while playing I could completely focus on the game, and not keep drifting back to ongoing work projects.  I later realized that this was a mini-vacation which provided a refreshing break from the work mindset – a cranial reset if you will.

But there is more to it than just a diversion, because a good movie provides that same 2 hours of alternative focus.  What the poker table provides is an intellectual and rather fast-paced set of interpersonal interactions.  This is when I realized the two connections between poker and clinical medicine:

First, playing cards for many years has helped me learn how to read people – an essential skill in poker, and very useful in clinical medicine where non-verbal communications are a big part of the clinician-patient relationship.  This is similar to teaching medical students about art as a way to improve their observational-diagnostic skills.

And second, while playing poker I get the most gratification not from winning a hand, but from tossing down a hand I had started to play but then decided was probably not going to win.  This latter “skill” is essential to playing good poker, and is also related to good diagnostic skills.  Lemme splain.

In clinical medicine, the diagnostic process starts with gathering the first round of information – by talking to the patient, reviewing their chart, and doing a physical exam.  (This is like looking at the first cards you are dealt.)  Then, as more testing and inquiry are done, you and the patient learn more about their medical problem.  (In poker this information comes in the additional cards in the hand.) And then, as the patient tries different treatments, even more is learned about their condition and how best to treat them.  (This is similar to what happens with the betting in poker – each bet tells you something about the other players and their cards.)

Thus, by seeing the cards as they are dealt and the other players’ bets, (and their responses to my bets), I learn about how my cards stack up against theirs.  And with this additional information I can make a better diagnosis – and decide whether or not my cards are likely to win.  By correctly folding my cards in the middle of a hand, I have in essence made the right diagnosis – which is the ultimate goal of any clinician.  It is an essential step for helping patients – and at the poker table, for limiting losses from that hand.  Conversely, winning or losing a hand – no matter how big the pot – doesn’t carry the same thrill since the intellectual options have been exhausted and all that’s left is to get ready for the next hand – or get back to work.

The clinical analogy to staying in until the end of the hand is that the patient has no more options; every test has been done and treatment considered, and either a treatable or controllable condition has been diagnosed – or not. Medical research strives to expand these options by providing patients and clinicians with more and better diagnostic tests and treatments.  Successful research gives patients the opportunity to draw more cards and play more hands.  And just to come full circle here, medical research is very much like poker in that the skill to correctly fold research spending on an experimental compound or diagnostic test is very valuable – hundreds of millions of dollars valuable.

E-Prescribing – Good? E-Dispensing Bad!!

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With two notable government actions in the last couple of weeks there has been significant movement towards increasing the use of e-prescribing.

DEA Proposed Rule
The Drug Enforcement Agency (DEA), proposed regulations on June 27th that would make it possible for controlled substances to be prescribed electronically. Interestingly, this was released right after a National Journal article on this topic.

The DEA’s proposed rule is very important, because while it is appropriate to place stronger safeguards on medicines that are likely to be abused (which is the criteria for being a DEA scheduled medicine), having controlled medicines prescribed by pen and paper while all other medicines are e-prescribed would be a logistical problem and obviate many of the potential benefits of e-prescribing.  And technologically, if banks and others can provide secure login systems and other security measures, I would think that e-prescribing systems could be similarly secure to make sure that unauthorized people aren’t electronically writing themselves prescriptions for thousands of narcotics pills using a legitimate doctor’s DEA number.  (See more about this in the e-quackery section below.)

Medicare Bill Contains Carrots and Sticks for E-Prescribing
The Medicare bill which passed Congress yesterday included a provision to increase the incentives for physicians to use e-prescribing technologies.  These incentives are a small percentage add-on to allowed Medicare charges for physicians who are e-prescribing starting in 2009, and a cut to payments for allowed Medicare charges starting in 2011 for physicians who are not e-prescribing.

Movement in a Good Direction
Together these actions move the US healthcare system towards greater e-prescribing, something that if done right, should increase efficiency (with lower administrative costs), and improve quality of care and patient safety by creating a better system for detecting and preventing adverse drug reactions from known drug allergies and drug-drug interactions.  The use of computerized prescription order systems for patients in hospitals has been shown to accomplish both of these improvements, but how e-prescribing will work in the outpatient world remains to be seen.

Challenges to Making E-Prescribing Increase Efficiency and Improve Quality
There are many challenges for e-prescribing in clinicians’ offices.  Like electronic medical records, they have to buy and install the systems, learn how to use them, and then keep them updated – since new prescriptions keep getting approved etc.  Because of these challenges, it is estimated that only about 6-7% of physicians’ offices are currently using e-prescribing systems.

Optimally e-prescribing systems should be an integrated part of the office’s electronic medical records system so that it could identify potential problems with drug allergies, or the need to alter dosages for patients with impaired kidney or liver function.  And at a minimum, a free standing e-prescribing system should be able to keep track of each patient’s prescriptions to flag drug-drug interactions, otherwise it may become nothing more than a sophisticated fax machine – which some could argue (but I wouldn’t) is a rudimentary form of e-prescribing.

While, e-prescribing systems should provide alerts about drug-drug interactions,  potential allergic reactions, and the need for dosing adjustments, systems that constantly flash up reminders for such things when they’re not relevant, leads users to ignore them altogether. I take a lesson about this hazard from my brother who works on designing aircraft information systems. Clearly pilots need to know certain things at the right time, but I doubt any pilot would fly better or more safely if they kept getting an alert about it being unsafe to land the airplane because the wheels were up – even with the plane at 30,000 feet.  OK – that may be a bit of an extreme example, but if the e-prescribing system doesn’t know anything about the patient, it may send similarly useless alerts and lead those using it to ignore all alerts – which could be worse than having no alerts at all, since it having them pop-up and be ignored could provide a false sense of security.

This illustrates what most people involved with healthcare reform recognize – improving the quality and efficiency of healthcare in the US requires making the systems work better since our practitioners are generally already pretty good.  But giving these good people flawed systems won’t help them, their patients (i.e. us), or our overall healthcare system.

This brings me to one last point.  How many e-prescribing systems will each clinician’s office need?  I certainly hope that every pharmacy chain/group won’t require their own version of an e-prescribing system, nor will each payer, insurer or regulator require a different electronic or paper output of the prescription information for reimbursement or quality auditing purposes.  If that becomes the case, then e-prescribing will face even greater hurdles.

Since they do good work in this area, I also want to include the eHealth Initiative’s  summary of the challenges for e-prescribing systems:

  • Financial burdens – Physician practices face varying financial burdens related to e-prescribing, including covering the implementation, training and maintenance costs.
  • Workflow changes and change management – Although e-prescribing efficiencies and time savings are gained in the long run, introducing e-prescribing, and electronic health records (EHRs), can be difficult, time consuming, and requires adequate planning, training, and support, particularly in the beginning.
  • Continued needs for greater connectivity – The infrastructure exists for connectivity among pharmacies, physician practices, payers and pharmacy benefit managers (PBMs), but some pharmacies, payers/PBMs and mail order pharmacies are not yet connected.
  • Medication history – Although e-prescribing is an improvement over relying on paper medical records and patients’ memories, the information that is available may not always be comprehensive or accurate and therefore tools to adequately reconcile medication histories from multiple sources are needed.

E-Dispensing – Bad!!  And E-Quackery – Bad Too!!!
One of the other challenges for e-prescribing may be the practical and policy interactions between physicians’ e-prescribing and internet sites that sell medicines directly to a patient without a prescription.  While e-prescribing potentially can improve efficiency and quality, e-dispensing can lead to bad fiscal and clinical outcomes from patients getting fake, adulterated or dangerous pills and potions.

Information on the worst examples of e-dispensing is in a recent report from Columbia’s National Center on Addiction and Substance Abuse (CASA).  Their recent annual report found that the number of web-sites selling controlled medicines without a prescription has decreased from the start of 2007 to the start of 2008 – from 581 to 365.  The CASA report also found, “Of those sites not requiring prescriptions, 42 percent explicitly stated that no prescription was needed, 45 percent offered an “online consultation,” and 13 percent made no mention of a prescription.”

I’m not sure if anyone knows what the total number of patients using these sites is, or the number of prescriptions they are filling, so it’s unclear if this reduction represents a real decline in the “industry,” or just its consolidation and maturation.  What CASA also found – and that I find especially worrisome – is “an emerging practice of Internet sites selling prescriptions for controlled drugs that can be filled at local pharmacies. The report also found sites selling online “medical consultations” which enable Internet users to get controlled drugs online without a proper prescription.”  I call this e-quackery, because this is physicians acting inappropriately, or non-physicians acting in the role of a physician and practicing medicine without a license by writing prescriptions.

Other notable findings from the CASA report include:

  • Of the few sites that require prescriptions, half permit the prescription to be faxed, allowing significant opportunity for fraud.
  • Benzodiazepines (like Xanax and Valium) continue to be the most frequently offered drugs for sale with 90 percent of sites selling them; followed by opioids (like Vicodin and OxyContin) at 57 percent of sites, and stimulants (like Ritalin and Adderall) at 27 percent of sites.
  • According to DEA estimates, in 2007 eleven percent of prescriptions filled by traditional pharmacies were for controlled substances compared to 80 percent of prescriptions filled by Internet pharmacies.
  • There are no controls blocking access to these sites by children and teens.

Conclusions
Just to bring things full circle – clearly e-dispensing and e-quackery are bad, so perhaps the greater use of legitimate and appropriate e-prescribing will help to clamp down on these illegal and dangerous activities.  And from a personal perspective, I can also only hope that it will reduce the ongoing flow of spam emails for on-line medicines – and the similar onslaught of spam blog comments to this blog that you never see because I delete them, but which like spam emails, just chew up time from every day.

p.s. Sorry about the long post – but this is an important and complicated topic.

Updates on Vitamin D

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Since I wrote about the importance of Vitaim D a few weeks ago, some new information has come out.

A report was released this week from researchers in Australia about Vitamin D reducing the risk of all causes of death.  The study was in the Archives of Internal Medicine, about their evaluation of 3,258 men and women scheduled to have a angiogram of their heart arteries.  They found that the people who had below average Vitamin D levels had about twice the risks of dying than those with levels in the highest 25% of the group.

While looking for the report of the Austrlian study, I found another study from a group of reserachers in Boston, that looked at 18,225 men who had no diagnosed heart disease.  This study found that during 10 years of follow-up, the men who were deficient in Vitamin D (?15 ng/mL) were about twice as likely to have a heart attack as those considered to have sufficient levels of Vitamin D (?30 ng/mL).

It may be coincidence that both studies found a 2:1 effect from high/normal v. low levels of Vitamin D, but there seems to be growing interest and consensus that Vitamin D is important for overall health.  What do you think?

Cracking Down on Fake Cancer Cures

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The FDA announced today that they have sent letters to 25 companies to stop selling fake cancer cures. That is, things that the companies claim cure cancer, but have never been tested, or approved by the FDA. The FDA has a web-site with more information about this, and a sub-page that lists 125 Fake Cancer Cures.

I know the FDA gets lots of flack for not doing enough – and not doing it fast enough – I applaud the FDA for taking this action, and encourage them to do more because I have found the advertisement and selling of these non-medicines troubling for a long time.

Cancers are serious diseases by anyones definition, and real medical science is making great strides in developing better treatments and cures, and in overall improving the lives of people living with cancer – both through traditional drugs and biologics, as well as with complementary therapies. But those profiting from selling fake medicines are selling false hope.

I would like the FDA go after more of these people who are profiting from selling fake medicines marketed as cures for other diseases and conditions – particularly ones that may be for symptoms of serious conditions. For example, every time I see the plastic-faced grinning guy on TV hawking a non-FDA approved “natural male enhancement” product, I wonder about all the men who may still be too embarrassed to talk to their physician about their erectile dysfunction problem – which unknown to them is being caused by a serious medical problem, like cancer. And of course for men who are buying this stuff who don’t have ED, then it would be nice if they could talk to their physician about therapy to address the route causes of their feelings of sexual inadequacy.

But of course, the FDA currently has insufficient resources to cover all of it’s multiple priorities – which is why Congress and the Administration are discussing how to provide more funding. Until that happens, I hope the FDA continues being vigilant and stops as many of these purveyors of false hope as they can – at least so these people don’t get the idea that because the FDA’s resources are stretched a bit thin, that the FDA won’t bother them.

Nature v. Nurture – Smoking and Other Complex Problems

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A long-standing debate in the life sciences has been the role of nature versus nurture in determining individual characteristics. For example, how much of an individual’s height is determined by their genes and how much by their nutrition – both in childhood and prenatally?

In the last few decades advances in our understanding of genetics has shifted this dichotomy to describe it in terms of genetics versus environmental factors, and expanded our appreciation for the role nature/genetics play in causing all manner of human diseases. For example, it was discovered that genetically determined slow serotonin transporters in the brain can predispose individuals to developing depression. However, the more we learn about genetics, similarly exciting discoveries are being made into how environmental factors influence the activity of genes, and thus affect an individual’s health.

Thus – like many things with multifactorial causes – the pendulum swings one way and then the other, i.e. between nature/genetics and nurture/environment.

Pendulum

But what has also become clear is that genetics and environmental influences are not  separable – they interact in important ways, and both can cause health problems and be routes to solutions too.

What recently caught my eye in the nature versus nurture debate were two studies about smoking cessation that came out in the last couple of weeks. The first, by Nicholas Christakis published in the New England Journal of Medicine (and reported in the May 22nd New York Times) describes the importance of social factors for people trying to quit smoking. This study demonstrates how an individual’s social environment plays a dramatic role in their ability to stop smoking, and how people can help each other stop smoking as a collective activity.

On the nature side of the equation, NIH researcher George Uhl led a study that shows how genetic markers can predict which of two smoking cessation treatments will be more likely to work for an individual. From these two studies it is also possible to postulate that individuals may have genetic predispositions that effect the ability of social networks to help them to stop smoking – or possibly to start smoking in the first place. (Didn’t we call this peer-pressure in junior high?)

I find both these studies very interesting because for years smoking has often been described in terms of individual choice (or weakness), and as such something that is completely separate from genetic or environmental factors. These studies refute that popular myth, and more generally illustrate the fundamental point that most illnesses and healthcare problems are complex, and that the solutions to these problems need to be similarly sophisticated. This also reminds me why I cringe a bit when someone says to fix a healthcare problem, “all we need to do is…….”

What are your favorite examples of interacting genetic and environmental factors, or where simple solutions have gone awry when used for complex problems?

Baseline and Goals of Treatment

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While watching the Red Sox-Milwaukee baseball game on TV last Saturday, the announcers were discussing Julio Lugo, the Red Sox shortstop who had missed 5 games with a concussion. One of them noted that the team had done baseline neuroimaging testing on all the players so if they had a concussion during the season they would have a baseline to compare to their post-concussion tests. I assume that they also did non-imaging neurological testing, such as reflexes and memory, etc., and this was an extension of all the other evaluations the players went through.

The reason I found this interesting is that it highlights the importance of having an understanding of both a patient’s baseline and their goals. For example, the ability of someone to play the piano after a hand injury is healed depends upon whether or not they could play the piano before the injury. (Sorry – that’s from a very old joke.)

Obviously after a professional baseball player has a concussion, the important factors include reflexes and visual focus since hitting a 90+mph fastball and catching a rocketed ground ball requires precise physical abilities. But for the rest of us – and overall healthcare quality – baseline functioning and goals are important because they are different for every patient, and should be a crucial component of the conversation between a patient and their clinical team. Only when the clinician understands what the patient’s abilities were before the illness or injury, can they work with the patient to develop a treatment plan that they hope will get the patient to their goals.

This may all sound silly or simplistic, but too often I have heard stories about patients who complain that their physician has given them the treatment plan without considering their desires or perspectives – as in “this is what where going to do.” Unfortunately, physicians sometimes only see one reasonable treatment course. But patients are as different as baseball parks – and I mean globally from sandlots to Yankee stadium – and their perspectives, concerns and treatment goals really are just as diverse.

I’m ready for blasts from physicians and others on this one, so let me know what you think.

End of Life Issues: Clinical and Cost Considerations

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At a policy related forum for medical residents at the Massachusetts General Hospital last week, one of the questions was about end of life care. The other panelists and I answered from a clinical perspective – and I also put a plug in for the Kenneth B. Schwartz Center which does educational programs for clinicians about strengthening patient-caregiver relationships and communications.

However, during the informal discussion after the panel, a number of the residents raised questions about how much of our healthcare spending goes for treating people at the end of life. In talking with them about this, I recalled three things having looked at this issue several years ago: First, there is a lot of public misunderstanding and misrepresentation of information about this topic. For example, percentages of Medicare spending turning into percentage of total healthcare dollars, or spending in the last year of life being reported as spending in the last month of life. Second, the percentage of healthcare spending in the last 6 months of life has not changed in decades. And third, people agree that if a patient’s life expectancy was clear, then it would be easy to reduce spending at the end of life. This last point was one of the reasons for hospice care, which attempts to both improve clinical care and reduce costs. Hospice has been a big clinical success since – unlike hospitals and general home care services – it is designed to fit the needs of the patient and their family.

So what about costs at the end of life? I did a quick (and admittedly non-comprehensive) search for more information, and found that:

  • As of the late 1990s, care in the last year of life consumed about 27% of Medicare’s spending and this percentage hadn’t changed in 20 years. These costs represent 10-12% of total healthcare costs, and 30-40% of this spending occur in the last month of life.
  • There is great variability of costs incurred during the last 6 months of life across the country – with up to a 250% difference. But this might also reflect the overall variability in healthcare costs by location.
  • A 2007 study found that hospice use reduced Medicare’s costs in the last year of life by 23%, but a 2004 study found that savings from hospice were only with younger patients with cancer, and that overall, hospice enrollment cost Medicare more money.
  • A great 2002 article reviews the literature and the issues about end of life care – including how Medicare financial incentives may contribute to more intensive care and higher costs.

So what are my conclusions? Any focus on reducing spending on end of life care as the solution for our rising health care costs is misplaced. These costs are significant, but they are only part of the problem since their growth reflects the overall rise in healthcare spending. And Buntin and Huskamp’s conclusion in their 2002 article, that we have “critical gaps in our knowledge about how to design a better end-of-life care system for Medicare beneficiaries,” is right on target.

What are your thoughts about end of life care, hospices, and educational organizations for clinicians like the Schwartz Center?

People in Clinical Trials: Patients or Subjects?

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Are people who participate in clinical trials patients or subjects? This may seem like a minor rhetorical difference, but I believe it has tremendous implications for health and biomedical research policy. Let me explain why –

Clinical trials are experiments to discover new knowledge. Their intent is to see if a new way of treating a specific disease or condition is better than, the same as, or worse than, another option – either a placebo or an established treatment. Therefore, when people agree to participate in a clinical trial they are participating in this experiment, and their fundamental goal for participating should be to help future patients by expanding biomedical and/or clinical knowledge. As part of their participation, they may receive some benefit – IF the experimental therapy does prove to be beneficial. Therefore, they are not patients; they are subjects within the clinical trial.

I often see phrases like “clinical trial patients” or “patients in clinical trials,” and I understand what they are talking about, since for many patients with serious conditions that lack good treatment options, clinical trials offer some hope. However, I think that the term muddles the distinction, and can lead to conflicting responsibilities for the clinician-investigators conducting the trials and the patient’s primary physicians. This is one reason that I believe that patients who elect to participate in clinical trials should maintain a relationship with their primary care physician during the clinical trial – even if the researcher in charge of the clinical trial is responsible for all their clinical care. This also means that the clinical investigator and the primary care physicians for the subjects in the clinical trial need to have regular communications – both before and during the person’s participation in the clinical trial.

When the person’s primary care physician is also the clinical investigator in the clinical trial, these lines are easily blurred, and this can lead to problems – something that all clinician-investigators struggle with. This is why clinical trials have protocols that are pre-approved by at least one Institutional Review Board (IRB) that is charged with protecting the rights and welfare of subjects in the clinical trial. (IRBs are also involved with monitoring the clinical trials and modifying the protocols as needed during the course of the trial.)

I was reminded about this issue by an article in the May 1st issue of American Family Physician that discusses when and how it is OK to use a placebo in clinical practice, i.e. for patients rather than clinical trial subjects. The article lays out a bright line for physicians – “do not lie” – as well as referencing an older article* that lists five conditions that should be met before giving a placebo to a patient:

  1. There is a well-established, durable physician-patient relationship
  2. There is a concrete diagnosis that does not mandate or support the use of other “active” interventions
  3. The patient specifically requests that the physician provide some form of intervention
  4. The use of such agents is a consideration of last resort
  5. The use of such agents does not substitute for, or interfere with, diagnostic and therapeutic diligence

The distinction here is between using a placebo clinically, and using it in a clinical trial. For someone to become a subject in a clinical trial, they need to first give their informed consent so they are aware of the risks involved with their participation. Having a physician give such informed consent in clinical practice when using a placebo might actually undermine the placebo effect, and thus remove any benefit the patient might receive from the placebo. The AFP article specifically counsels that if a patient asks about a recommended treatment that is a placebo, that an appropriate response from their physicians should be something like – this may not directly affect your condition, “but it may turn on other mechanisms that might be important for your health and make you feel better.”

Any additional thoughts on this issue?

* Bok, S., “The ethics of giving placebos,” Sci. Am. 1974; 231 (5): 17-23

The Stressed and Strained Health Care Workforce

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The Institute of Medicine put out a report yesterday titled “Retooling for an Aging America: Building the Health Care Workforce.” The report discusses how the aging of the baby-boom generation will create greater needs for health care providers (of all types) who are trained in caring for the elderly with chronic conditions. The report’s recommendations fall into three categories: training, system transformation and financing. Like many reports about health system improvement, their recommendations all make sense – particularly within the context of the three categories. However, like many IOM reports, the writing by Committee process is a bit evident in that, (at least from the Executive Summary), it doesn’t seem to describe a complete plan, nor does it prioritize any of its recommendations – either in terms of funding or which actions should be done first.

In addition, while the report recognizes that the elderly in the coming decades will be healthier than those of 20 or 30 years ago, it doesn’t seem to fully address how this will change the healthcare services needed by the future elderly.

It seems to me, that one of the major challenges facing the healthcare system of the future is how to better manage chronic conditions – regardless of the patient’s age. Thus, rather than retrain clinicians (or train more caregivers) in geriatrics, there needs to be more across the board efforts in chronic care management and coordination among all levels of caregivers. This would benefit the growing elderly population – many, but not all of whom will have multiple chronic conditions – as well as the non-elderly with chronic diseases like diabetes, and the many neuromuscular degenerative diseases like MS or rheumatoid arthritis. This type of system-wide transformation seems like a better use of resources than segmental/specialized retraining and recruitment.

What are your thoughts?