Tag Archives: patient-centered medicine

Friday News Dump: Wonkbites

by Karan Chhabra

Health news doesn’t stop for oppressive heat, Memorial Day Weekend, or the French Open, and neither will Wonkbites:

  1. Look Ma, No Bankruptcy: Obamacare’s under-26 coverage provision has cut the amount of uninsured young adults showing up at emergency departments, according to a new study in the New England Journal of Medicine. One of the ACA’s most popular provisions, it allows adults to stay on their parents’ insurance plans until they’re 26. To put some numbers around it, in 2011, this meant an increase of $147 million in emergency department costs that were covered by insurance.
  2. Party poopersClostridium difficile (“C. diff”) is a life-threatening infection that can happen to any patient when antibiotics wipe out the normal bugs in their gut. You might’ve heard that fecal transplants are being used experimentally to cure them. What you might not know is that those poop swaps have shown a higher success rate than vancomycin (the heavy-duty antibiotic currently used for C. diff), and that nonetheless the FDA is introducing regulations to make them much more difficult for doctors to provide. The FDA cites safety and quality control as its concerns—but doctors are refusing to provide the procedure and delaying potentially lifesaving care in the process.
  3. Is there magic to the map? Wonks have had a lively debate on a study aiming to debunk research that, according to Jordan Rau, has “influenced a generation of health policy thinking.” The new research attacks a premise advanced by the Dartmouth Institute for Health Policy and Clinical Practice—specifically that arbitrary geographic variation explains much of our healthcare cost burden. Instead, this new work says that Dartmouth’s geographic cost variations were driven primarily by those regions’ underlying health status.
  4. Have it your way—and pay more? A recent study, according to many, has shown that shared decision-making increases healthcare costs. I have to interject with a few reactions:
    1) If you read the methodology, you’d find out what it actually says is that patients who responded to a survey saying they prefer more of a role in their healthcare turned out to have higher lifetime healthcare costs. Cause-and-effect could run the opposite way—those who’ve dealt more with the healthcare system end up preferring more of an active role.
    2) If someone used a stronger methodology to demonstrate that shared decision-making cost more, I’d still support it. Healthcare should provide what patients and families want, not what providers want—and if that costs more, so be it.
    3) That said, conventional wisdom is that more healthcare is better. If more patient-centered care means more healthcare, perhaps the medical establishment and media need to do a better job of showing that more is sometimes better, but not always.
  5. The more you know: Righty? You’re more likely to use your cell phone on your right ear. Lefty? The opposite. Why? Science.

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Karan is a student at Robert Wood Johnson Medical School and Duke graduate who previously worked in strategic research for hospital executives.

Follow him on Twitter @KRChhabra or subscribe to the blog.

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Today’s the Last Day to Make Sure Family Docs Learn about Contraception

by Karan Chhabra

I was pretty alarmed to read news today that training in contraception may be made optional for family medicine doctors-in-training:

The proposed new rules, they say, drop existing requirements that family medicine residents be required to undergo training in contraception and counseling women with unintended pregnancies.

Essentially, the board that oversees residency training (required for doctors to become board-certified) concluded that its educational standards needed more flexibility, and identified contraception education as one of those areas where it could lay off a little bit. Religiously-affiliated medical centers appear most likely to take advantage of this flexibility. But let’s be clear: this is a proposed change, not yet final, and it’s about training–not about whether reproductive health services can be provided. It’s also possible that trainees could learn a good deal about contraception through FOAM. So the sky isn’t falling, but I have serious misgivings about the precedent this sets.

A few months ago I offered my thoughts on the birth control debate as a whole:

The national conversation on birth control should look a lot more like ours on aspirin. When we talk about aspirin, we talk about about whether it’s right for you. When we talk about birth control, we get one-size-fits-all generalizations, political chaos, and name-calling. Something is wrong. These are individual, medical questions that demand individual, medical answers. Ethics have a place in medicine; faceless bickering and moralism do not.

I wrote those thoughts amid the debate on insurance coverage for contraception–a question that boils down to whether members of an employer-sponosred insurance plan ought to cross-subsidize people’s birth control expenses. In short, it’s thorny. Today’s question is different: should primary care doctors-in-training be required to learn how to provide services related to reproductive health? Should they be qualified to answer those individual, medical questions? To that, my answer is yes.

Family doctors are patients’ first line of trusted healthcare. In many parts of the country, they’re patients only line; not everyone can go to an ob/gyn for routine concerns like birth control. But we already have evidence that family doctors’ understanding of the research on birth control is inconsistent. Why make it worse? More importantly, though, what makes it okay to privilege certain types of medicine over others? Why is family planning any less a part of primary care than say, heart disease? If in fact it is, why can’t religiously-affiliated programs apply the same segregative logic to patients suffering from addiction or contemplating suicide, just because they disagree with it?

Medical education is about preparation. We go through medical school, residency, and all the rest to make sure that we can handle whatever our patients ask of us (within, of course, one’s specialty). Medical education should not be about judgment, about right or wrong, or about politics. It was one thing when the nation asked whether religiously-affiliated employers should pay for birth control. I believe it’s quite another thing when we ask whether our primary care doctors need to know about it. When authorities accept willful ignorance because of concerns that are at their core political, they attack the heart of a profession built on nonjudgmental service, and the patients who rely on it.

Today, April 25, is the last day for comment on this proposal. If you have something to say, do so in this form (courtesy of Reproductive Health Watch) and email it to familymedicine@acgme.org.

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Karan is a first-year student at Robert Wood Johnson Medical School and Duke graduate who previously worked in strategic research for hospital executives.

Follow him on Twitter @KRChhabra or subscribe to the blog.

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Helping Your Doctor Help You (Part II of II)

by Karan Chhabra

Ubel critical_decisions_cover

This is the second in a two-part interview with Dr. Peter Ubel, a physician, behavioral scientist, and author of the book Critical Decisions: How You and Your Doctor Can Make the Right Medical Choices TogetherMissed Part I? It’s right here

KARAN: You referred to patient education earlier, not just in terms of treatment information but also the types of questions to be asking. But what about the former? Our generation is definitely comfortable using technology to look up health information, and we get a ton of information through news, magazines, and the general media. But not all of it’s good. So how do you recommend people sift through the good and bad information out there, when they’re trying to inform themselves before a visit to the doctor.

DR. UBEL: Of course, the education system should help people learn how to objectively look at things and help them when things go over their heads.

But the other thing I’d say is, print out and bring in the stuff that you see online, show it to your doctor, and let them tell you what’s right or wrong about it. Then they’ll know what you care about more than they did before, which is really valuable. Your doctor shouldn’t be threatened when you bring these materials in; they should be happy that you’re helping focus the visit on the topics you care about. If you’ve got misconceptions that are affecting the way you’re behaving, like what pills you’re taking or not taking, the doctor should be happy to have a chance to address those misconceptions.

So: print it out; bring it in.

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Helping Your Doctor Help You (Part I of II)

by Karan Chhabra

Ubel critical_decisions_cover

Dr. Peter Ubel is a physician and behavioral scientist at Duke, as well as an author and personal mentor/hero. I recently read his latest book, Critical Decisions: How You and Your Doctor Can Make the Right Medical Choices Together, and recommend it highly to anyone interested in making the right medical decisions—either as a patient or a practitioner. I spent a lot of time with the topic when I wrote my Honors thesis, but Dr. Ubel‘s book beats everything else I’ve read at dissecting the psychological and historical quirks that make decision-making such a complicated issue. In addition, it offers a lot of concrete advice on how to do the decision-making dance better.

Dr. Ubel and I had this interview to elaborate on how his book applies to the Millennial generation and our unique medical needs. Because the conversation was so chock-full of decision-making goodness, we had to split it up into two parts—the second half can be found here.

KARAN: Though I hope our readers all read your book, for those who haven’t just yet, I want to start with an example that touches on the issues it discusses. I recently got a bad ankle sprain. The following week, I went to a local orthopedic surgeon for it. He was a very old-school doctor; before even talking about treatment options at all, he was getting his stuff out to give me a cortisone shot for my ankle. I was still trying to give him my history and symptoms and I had to stop to ask what he was doing. It was a little scary; I had no desire to get a shot, and from whatever little I know, I think cortisone might’ve even hurt more than it helped. But I’m obviously not residency-trained in orthopedic surgery, so I didn’t feel right questioning his opinion. So while I have seen how the patient autonomy movement has affected the way doctors are ethically trained, which you discuss in your book, I still think there are a lot of doctors who fit the old mold. As a patient, especially a young and inexperienced patient, it’s difficult sometimes to know how to respond.

DR. UBEL: I don’t think this is an old/young issue. If anything, people tend to think their older patients are more deferential than the younger ones. Most people in their 20s are more into the “consumer” mindset than older people who grew up in the “doctor knows best” era. But when you are young, the age difference between you and the doctor is bigger, so that could make it harder to be assertive when interacting with your doctor. But patients ought to feel they can assert themselves because, even for mundane issues, any time there’s more than one way to go about it, the patient deserves to know what their alternatives are and to be a partner in the decision. So what happened to you is not the best possible medical care. Whether the doctor made the right choice, that’s one thing. But if he didn’t say “One thing we could do is this, but you should know, there are other alternative. For example, if you don’t want to get a shot, we could just give it time, etc.” If the physician didn’t speak to you that way, that’s a problem.

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The Code of the White Coat

by Karan Chhabra

white coats

Inhalation. Exhalation. Perspiration. Equivocation. Self-Abnegation. Devastation. Urination.

The list of things I’ve endured in the name of getting to medical school could go on, and I doubt it’s any different from my classmates’. But we’re here, finally, freshly white-coated and already racing just to stay on track.

The White Coat Ceremony was a timely, though sometimes tearful reminder of what we did to get here, why we did it, and what we’re in for as medical students and physicians. It’s worth noting, though, that it is a young part of medicine’s long history—the first ever took place in 1993. The goal was—and has been—to inject a bolus of humanism into students right as they stumble into the start of their medical training.

Most of us students have read articles and heard admonitions about how medical students’ empathy declines precipitously as they enter their third year and start seeing patients full-time. In fact, when I worked at Columbia’s Program in Narrative Medicine and founded a Working Group on Patient-Centered Medicine, empathy erosion in medical school came up about as often as what was for lunch that day—which is to say, pretty often. I even wrote my undergraduate thesis on physician-patient communication, in hopes that it would make me (and others) a more humanistic and effective clinician.

Despite all that, after reading The Soul of a Doctor (a collection of medical student essays), I feel energized but utterly unprepared to handle the constant trauma of two years on the wards while maintaining the attentiveness and empathy that each patient deserves. Continue reading

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