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by Alex Smith, MD Words have power. Language has power. The words we use may comfort or shock, allay or provoke, sooth or batter. Words often imply layers of meaning that are not explicitly articulated, yet rest beneath the surface: “I worry that time is short for you” (You are dying) (I care about you) “I wish we could have done more” (Nothing would have changed her death) (I am on your side) “I hope with you that you’ll get better, but I think we should prepare in case things don’t go as we hope” (You are not getting better) (I support your hope)
I can think of no situation in which there is greater variation in how our choice of words varies than how we explain cardiopulmonary resuscitation (CPR). Many people, including me, vary the language we use depending on our recommendation for treatment. Some use more drastic language than others. Here are some examples I have encountered, again with possible implied meanings in parentheses: “Would you like us to restart your heart if it stopped beating?” (Please say yes) (I’m just asking as a formality) “Would you like to allow us to let you to die naturally?” (Saying no goes against nature) (We have an unnatural power over life and death) “Would you like us, in what would naturally be your final moments, to press on your chest and break your ribs, shove a tube down your throat and poke you with needles in lots of places in a chaotic attempt that has a very small chance of giving you more time to be technically alive but unlikely to ever return to meaningful communication with others?” (Please say no) (CPR is horrific) (I don’t want to have to do this to you) “Do not punctuate the end of your life with a senseless act of brutality!” (You’re crazy if you say you want CPR) Using persuasion to argue for something we believe is in a patient’s best interest is ethically permissible. Coercion – the use of force or threats – is not. Guy Micco, a physician ethicist in the East Bay, talked with a philosopher who preferred the terms “influence” and “undue influence.” “Influence” is, of course, permissible – the line not to cross is the “undue” one. Where do you see the line with these statements? What language do you use? Do you find yourself varying the language you use based on your recommendation for or against CPR? Does “unbiased” language exist? Alex Smith is an Assistant Professor of Medicine, Department of Medicine, Division of Geriatrics at the University of California, San Francisco who blogs at GeriPal. Submit a guest post and be heard. Posted at KevinMD.com. Stay updated and subscribe, follow me on Twitter, or connect on Facebook. Related posts:
Bill Davenhill asks, “Can your health depend on where you live?” From TEDMED 2009. Posted at KevinMD.com. Stay updated and subscribe, follow me on Twitter, or connect on Facebook. Related posts:
Originally published in MedPage Today by John Gever, MedPage Today Senior Editor A Massachusetts anesthesiologist accused of fabricating data in studies of pain drugs will plead guilty to federal criminal charges under an agreement with prosecutors.
Early last year, the hospital announced that an internal audit had revealed that Reuben had made up research data out of whole cloth, affecting at least 21 published studies over a 15-year period. The criminal charge arose from one of those studies, funded by Pfizer and published in Anesthesia & Analgesia in 2007. According to the U.S. Attorney’s office in Boston, Pfizer had given some $74,000 to Reuben for a placebo-controlled study of celecoxib (Celebrex) as part of a “multimodal” painkiller regimen for outpatient knee ligament surgery. The study was to enroll 100 patients. Reuben subsequently reported to Pfizer and in the journal article that 200 patients entered the trial and that the celecoxib regimen was effective. “In fact, Reuben had not enrolled any patients into that study, and the results reported both to Pfizer and to Anesthesia & Analgesia and, in turn, to the public were wholly made up by Reuben and therefore false,” prosecutors wrote in a court filing. Reuben could receive up to 10 years of jail time, to be followed by three years of supervised release and a $250,000 fine, but prosecutors agreed in the plea deal to recommend penalties at the low end of the range allowed in sentencing guidelines. The agreement also requires Reuben to pay a total of about $362,000 in restitution to Pfizer and other pharmaceutical companies, plus $55,000 in fines and forfeitures. Last year, after Baystate announced its findings on Reuben, the 21 articles it identified as tainted were retracted by the journals publishing them. The National Library of Medicine’s PubMed system lists more than 70 articles published since 1991 with Reuben as an author. The 21 retracted articles all listed Reuben as first author. The editor of one journal that had published Reuben’s research, Regional Anesthesia and Pain Medicine, contacted other investigators on six studies in which Reuben was a secondary author. They all attested to the truthfulness of the reported data, according to the journal editor, Joseph M. Neal, MD. The journal ended up retracting only the one paper which had Reuben as lead author. Reuben’s contract with Baystate was terminated last March, at which time he reportedly also agreed with the state’s medical board to voluntarily withdraw from practice. Visit MedPageToday.com for more ethics news. Posted at KevinMD.com. Stay updated and subscribe, follow me on Twitter, or connect on Facebook. Related posts:
The common thought among health reformers is that we spend too much on care, and the additional care patients receive doesn’t necessarily help them. What inevitably follows is a discussion on how to streamline care, yet maintain quality. To that end, most hospitals and emergency rooms are using algorithm-based care based on the best available evidence. Where doctors actually had to hand write admission orders, they are now checked off – like a menu at a restaurant. But sometimes diagnosis requires more nuance. How do you know, for instance, that the patient really has pneumonia as you’re running down the pneumonia checklist? That’s a question that Stanford physician Abraham Verghese asks as well:
But in a difficult financial environment, hospitals are making business decisions to emphasize efficiency and cut costs. And that sometimes impedes diagnosis, like a decision to move a microbiology lab off-site. So let’s slow down before completely embracing algorithm-based medicine, or as Dr. Verghese writes, “Let’s give ourselves a chance at precise diagnosis before we treat. That means good specimens, hand carried, examined by the people who care for the patient.” Indeed. Posted at KevinMD.com. Stay updated and subscribe, follow me on Twitter, or connect on Facebook. Related posts:
Originally published in MedPage Today by John Gever, MedPage Today Senior Editor Another study has found that hypertension may contribute to increased risk of dementia, this time with evidence of actual brain abnormalities.
Along with earlier studies linking blood pressure to clinical dementia, the evidence “supports tight control of blood pressure levels, especially beginning at younger and middle age as a possible and perhaps only way to prevent dementia,” Kuller and colleagues concluded online in the Journal of Clinical Hypertension.
One study reported in 2006 found that successful hypertension control reduced the risk of dementia, while another reported the following year indicated that uncontrolled high blood pressure increased the risk. Kuller and colleagues analyzed data collected from 1,424 participants in the Women’s Health Initiative who agreed to undergo MRI scans performed an average of eight years after starting the trial. Blood pressure was measured at baseline and annually throughout the trial. About half the women had been assigned to placebo in the trial, which primarily was designed to test two hormone replacement regimens. Some 436 received a combination of conjugated equine estrogen and medroxyprogesterone acetate, while the remainder received the equine estrogen alone. Kuller and colleagues found significant relationships between baseline systolic blood pressure and abnormal white matter lesion volumes as measured with MRI. Among participants not taking blood pressure medications, the lesion volume averaged 4.07 cm3 for those with baseline pressure of less than 100 mm Hg, compared with 5.20 cm3among those with systolic pressure of 140 mm Hg or higher (P=0.0044 for trend). A similar but weaker relationship was seen for lesion volumes according to systolic pressure at the last available measurement (P=0.03) among subjects who were not on antihypertensive therapy. Baseline systolic pressure was also significantly correlated with lesion volumes in women taking blood pressure drugs, Kuller and colleagues reported. Women with baseline pressure below 100 mm Hg had lesion volumes averaging 5.56 cm3 whereas those with pressures of 140 mm Hg or higher at baseline had average lesion volume of 6.09 mm Hg (P=0.002 for trend). There was a nonsignificant trend toward higher lesion volumes with increasing systolic pressure at the last measurement. After adjusting for age, race, treatment assignment, total cranial volume, clinical site, and time from study termination to MRI scan, the researchers found that women with normal blood pressure (<140/90 mm Hg) had lower lesion volumes, not only in their white matter but also in the basal ganglia, than participants with high blood pressure. The finding held both for baseline blood pressure measurements and for pressure at the last available evaluation (P<0.0001 for all comparisons). High baseline blood pressure, though not later measurements, was also significantly correlated with the number of brain regions containing abnormal white matter lesions (P=0.035). Regions in which high blood pressure seemed to promote abnormal lesions most strongly included frontal, parietal, and temporal lobes in both hemispheres. The frontal lobes in particular have been associated with vascular dementia and abnormal performance on cognition tests. Occipital lobes and the corpus callosum did not appear significantly affected, the MRI data indicated. “The association of blood pressure levels with white matter abnormalities years before the MRI is consistent with a long incubation period for the development of the white matter abnormalities,” Kuller and colleagues wrote. They said their findings are also consistent with earlier observations that midlife blood pressure is more strongly related to dementia later on than is blood pressure measured at older ages. Kuller and colleagues cautioned that it remained uncertain whether blood pressure treatment can prevent development of white matter abnormalities. Nor is it clear what the most appropriate blood pressure targets should be, or what type of treatment may be best. “We have only suggestive evidence that the progression of white matter lesions can be slowed by blood pressure-lowering therapy,” they wrote, calling for more clinical trials to clear up these issues. Nevertheless, they concluded, “a prudent clinical approach at present would encourage maintaining as low a blood pressure as possible, especially beginning in young and middle ages, in order to possibly prevent dementia as well as stroke. There are no other potentially effective preventive therapies.” Study limitations included a lack of MRI data on brain infarcts, no corroborating clinical data on cognitive performance, and, of course, the trial’s restriction to women. Visit MedPageToday.com for more hypertension news. Posted at KevinMD.com. Stay updated and subscribe, follow me on Twitter, or connect on Facebook. Related posts:
by Wendy S. Harpham, MD, FACP A patient learns about a treatment for his condition. So he goes to his physician to suggest the treatment as an option. Is there anything wrong with that? It depends on how his “suggestion” is presented. In today’s age of patient advocacy and direct-to-patient marketing of pharmaceuticals, a new phenomenon is flourishing in doctors’ offices: patients asking for specific diagnostic tests or therapies.
I think it’s terrific if you bring information and ideas to your physicians. In fact, it can be a red flag if your physicians refuse to listen to any of your ideas about your evaluation or treatment. But you only hurt yourself if you expect your physician to follow your orders [no matter how well-trained you are in the condition(s) being treated]. Problems can arise if you just appear to be trying to drive your own care. This is especially true in new physician-patient relationships, where you and your physician are just getting to know each other. If you find a test or treatment that interests you, instead of saying to your physicians, “I’d like to suggest this treatment,” try something along the lines of “This is what I’ve learned about the treatment and why I think it might be useful. What do you think about it in my case?” You and your physician are a team with a shared mission: getting you better, if possible. You benefit most when you can depend on and trust your physician’s judgment and expertise in your care. Wendy S. Harpham is an internal medicine physician who blogs at Dr. Wendy Harpham on Health Survivorship. Submit a guest post and be heard. Posted at KevinMD.com. Stay updated and subscribe, follow me on Twitter, or connect on Facebook. Related posts:
Originally published in MedPage Today by John Gever, MedPage Today Senior Editor More than 85% of American military medical evacuations from the Middle East were not the direct result of enemy action, but the result of non-battle injuries and disease, researchers said.
The most common reasons for medical evacuation were non-battle related musculoskeletal and connective tissue disorders, accounting for 24% of evacuations, the researchers wrote in the Jan. 23 issue of The Lancet. Combat injuries were the second most common, followed by neurological disorders (10%) and psychiatric illnesses (9%). “Non-battle related injuries continue to be the leading cause of medical evacuation in modern warfare, and medical officers should be prepared for this burden in subsequent conflicts,” Cohen and colleagues wrote. “To reduce the number of evacuees, preventive medicine programmes and educational initiatives need to target health-care providers, non-commissioned officers, and combat soldiers.” They also warned that “the burden of psychiatric illness” will increase with the duration of conflict and reliance on reserve units. Cohen and colleagues obtained data kept by the U.S. military on all medical evacuations from Iraq and Afghanistan spanning 2004 to 2007. In addition to describing the medical reasons for evacuation, the data included the individuals’ ranks, service affiliations, active-duty or reserve status, and whether personnel returned to duty. Any injury sustained during combat missions, including those not caused directly by enemy fire such as back strains, was counted as battle-related. The number of evacuations each year fell from 2004 to 2006 — from 10,290 to 6,778 — but abruptly rose in 2007 to 8,444 with the Iraq surge and the reinvigorated Afghan Taliban resistance. Not surprisingly, as these conflicts evolved over time, the balance of combat and non-combat injuries and illnesses changed and the characteristics of evacuated soldiers changed as well. The proportion of evacuations related to combat injuries climbed steadily in Afghanistan, from 10% in 2004 to 19% in 2007. Injuries from combat also increased over time in Iraq but not as much: from 24% of evacuations to 28% during the study period. But by 2007, combat wounds had become only the fourth most common reason for evacuation in both regions. Musculoskeletal and connective tissue disorders held steadily as the number one reason throughout the study period, ranging from 21% to 28%. But non-combat neurological and psychiatric disorders both increased substantially, especially the latter. Evacuations for psychiatric conditions soared from 5% to 6% of the total in 2004 to about 13% in 2007. Neurological disorders accounted for about 10% of evacuations early in the conflicts, rising to more than 12% in 2007. These figures did not differ substantially between Iraq and Afghanistan. Most of the evacuees did not return to duty: about 80% of those shipped from Iraq and 75% from Afghanistan. Although overall return-to-duty rates changed little with time, evacuations for some types of illness did increase or decrease. Personnel evacuated because of infectious disease became more likely to see service again — 37% returned to active duty in 2007, compared with 8% in 2004. Cohen and colleagues identified better control of leishmaniasis as at least partly responsible for the increase. More significantly, the researchers indicated, return-to-duty rates declined progressively after 2004 for psychiatric evacuees, Cohen and colleagues reported. By 2007, only 7% of psychiatric evacuees from Iraq and 4% of those from Afghanistan were returning to duty. The researchers also found that, among particular types of psychiatric illness, personnel with stress reactions, depression, and bipolar disorder were least likely to return to duty. They also found that individuals with back pain were also more unlikely than most evacuees to return to duty. In their report, Cohen and colleagues said these latter trends were potentially related. “The parallels between emotional distress and spinal pain are intriguing. Findings from several studies in patients presenting with back or neck pain have established that the major risk factors for disability and persistence are psychosocial (e.g., anxiety, depression, poor coping skills, and low job satisfaction),” they wrote. “As survival rates of combat injuries increase, and the burden of non-battle-related injuries and psychiatric disorders continues to soar, society must be prepared to deal with the aftermath of these injuries,” Cohen and colleagues concluded. In an accompanying commentary, J. Don Richardson, MD, of St. Joseph’s Health Care in London, Ontario, and colleagues also found the results on psychiatric evacuees most striking in the study. “The low rate of return to duty in service personnel evacuated for psychiatric conditions warrants further study, and [the] article points out the importance of cumulative stress in repeated deployments and the physical and mental demands on the military member and their family,” Richardson and colleagues wrote. “The low rate of return to duty might be related to the nature of the combat operation for which military commanders might be reluctant to deploy an individual with a psychiatric diagnosis to a combat zone,” they speculated. “Early intervention becomes crucial to help promote recovery because military members often experience substantial stigma disclosing symptoms of PTSD and other psychiatric problems,” Richardson and colleagues added. They also suggested that military doctors “should have a high index of suspicion” for PTSD when soldiers present with spinal pain or other somatic complaints, “especially if there is a physical injury.” Visit MedPageToday.com for more military medicine news. Posted at KevinMD.com. Stay updated and subscribe, follow me on Twitter, or connect on Facebook. Related posts:
by Danielle Ofri, MD, PhD There is a veritable epidemic of doctor-writers out there. What is going on? Are doctors suddenly in the kiss-and-tell mode? What about confidentiality? Professionalism? HIPAA? As one of the aforementioned doctor-writers, I look upon this trend with both awe and trepidation. I suspect that that this flourishing literary phenomenon relates to the public’s fascination and fear about all things medical. It also relates to the falling away of previous, pedestal-like images of doctors and doctoring. Lastly, it may have occurred to the medical profession—and this has taken a few centuries, it seems—that doctors have profound emotional reactions to the work we do, and that exploring these reactions may offer benefit to both patient and doctor. Whatever the reason, this literary genre appears to be here to stay, and it is worth considering the ethical implications. Legally, there doesn’t appear to be much beyond protecting identity and avoiding libel. But physicians clearly need to work with a higher bar. For starters, patients speak to doctors with an expectation of confidentiality. This is vastly different from an ordinary citizen speaking to a journalist. This confidentiality needs to be preserved. Unless a patient indicates otherwise, a doctor-writer must change the name and identifying characteristics. My rule of thumb is that the description must be different enough that it would be tough for anyone other than that person or a close associate to recognize them. This, of course, brings up an issue of reliability. We’re trafficking in nonfiction, not fiction. When I write, I try to ensure that the aspects I change are not the crucial ones in the story. When talking about the intricacies of an illness, it probably doesn’t matter whether the hair is blond or brown, or the country of origin is Trinidad rather than Jamaica. If these minor things mask the patient’s identity without altering the key aspects of the story, then I think it is a reasonable trade-off. But most importantly, there is the consideration that patients come to us for our help. They are in a particularly vulnerable situation and doctors have an ethical obligation to put that first. If, at some later time, this seems like a story that might edify the current discourse, the doctor might think about writing it up. It is helpful to let some time pass, so that the situation is no longer “active.” If it’s possible to obtain consent, we should do so. If I can’t obtain consent, then I need to ask myself whether I feel the patient might be hurt by the publication of the story. If there’s any thought that this person would be uncomfortable or embarrassed or pained, then the story stays in the drawer, no matter how amazing it is. (I have one powerful story—about a patient lied to me, and the implications of that lie—but I suspect that my patient would be unhappy if he ever saw the story, so I’ve never pursued publication.) Ultimately, I want to give a respectful rendering of my patient’s story, one that I hope would honor them and what they’ve endured. Of course this is necessarily a subjective decision, but it is the only internal ethic that I can live with. My patients have entrusted me with their stories, and I need to respect that. If a particular story can edify future doctors, or educate the public, there might be value in publishing it. I choose these stories very carefully. I obtain consent when possible—patients almost always have a positive reaction. I let time pass. I try my best to write a story that honors them, and show a draft to them if circumstances permit. Ultimately, doctor-writers have to treat patients’ stories as we treat our patients, realizing that we are in a privilege position, and taking care not to abuse that. Danielle Ofri is writer and practicing internist at New York City’s Bellevue Hospital who blogs at Medicine In Translation. She is the editor-in-chief of the Bellevue Literary Review. Her newest book is Medicine in Translation: Journeys with my Patients. Submit a guest post and be heard. Posted at KevinMD.com. Stay updated and subscribe, follow me on Twitter, or connect on Facebook. Related posts:
by Martin Young, MBChB, FCS(SA) Early in my training as a glider pilot my instructor showed me an excellent but simple analogy for ensuring my safe performance as a pilot. I have always remembered this lesson, which he called the ‘accident slope’, and have tried to apply it to my method of practicing medicine, as well as the other ‘dangerous’ activities for which I have an affinity. “Accidents and mistakes are seldom the result of one single error” he said, “ but more commonly the combination of a multitude of mishaps – each of which on its own may seem minor, but when superimposed, spin with increasing speed towards tragedy.” “Think of anything you do as if you were a mountaineer moving along a mountain ridge from your point of origin to your destination. The top of the ridge is perfectly flat, but falls away gradually to your side, becoming vertical. The covering is snow and ice, safe to walk on when level, but slippery on the slope.” “The perfectly safe route would be along the top of the mountain, where there is no gradient and very little chance of slipping. This represents the safe and well prepared route. Anything that affects you negatively moves you away from this flat route to where the gradient is steeper. Some of those things may be your own condition or unpreparedness, or may be external factors such as the weather.” “It is much harder walking along a gradient, particularly when it is slippery. The more things that are wrong before you start, the further down the slope you are, and the more critical your position, and the harder it is to get back onto the level route. You may find yourself so far down the slope that an unexpected factor beyond your control pushes you to a level where slipping and falling becomes inevitable.” “It all depends on where you start. Start too far down the slope, and you are an accident just waiting to happen.” I know from experience, both in flying and in medicine, that his analogy is correct. I think of all the times I have worked when I am exhausted, demoralized, angry or frustrated; when I have had to fight with insurance companies who will not authorize the operation for my patient already in the hospital; when my particular choice of drugs is not available, or the prosthesis I need has not been ordered. I know at those times I am at higher risk of making a mistake. And this time, in terms of the analogy, I have not just my route along the slippery slope to worry about, but also the health and welfare of my patient, the person I carry on my back. Martin Young is founder and CEO of ConsentCare. Submit a guest post and be heard. Posted at KevinMD.com. Stay updated and subscribe, follow me on Twitter, or connect on Facebook. Related posts:
Craig Venter talks genetics and bringing synthetic life to reality. From TEDMED 2009. Posted at KevinMD.com. Stay updated and subscribe, follow me on Twitter, or connect on Facebook. Related posts:
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Scott Reuben, MD, a well-known pain researcher at Baystate Medical Center in Springfield, Mass., was charged with one count of healthcare fraud.