How can patients and doctors talk about risk?

Check out this presentation (based on other people's research) that I'm giving tomorrow at the meeting of the Mid-Atlantic branch of the Society of General Internal Medicine. The Power Point version, prettier in its Microsoft way, is here.

What bridges the gap between evidence-based medicine and the patient?

Under the withering barrage of recent guideline changes, doctors and patients alike have raised their hands in surrender. It seems like guideline group after group have changed their recommendations to say (more or less) the same thing: "[name of screening test here] should be discussed with the patient according to their risk profile."

We used to think that population studies ("big-E epidemiology") would provide us with the tools to fix health care. The drill of empirical science would become the Swiss Army knife of evidence-based medicine.

But something got in the way: inconveniently enough, that something is the patient.

A patient is not a population, but a unique individual with a one-of-a-kind combination of characteristics. So how to apply the population findings (or even the evidence-based recommendations) to the individual? As Karla Kerlikowske says in the latest issue of the Annals of Internal Medicine ("Evidence-Based Breast Cancer Prevention: The Importance of Individual RIsk"): "We urgently need risk models with better discriminatory accuracy . . . that can accurately identify individuals at all levels of risk."

So that's one way of bridging the gap. But there's another way which is just as central: making sure the patient is informed enough (about their own desires, even - about their own priorities) to make them a partner in decision-making. Because how can evidence-based medicine leap the gap from the journal to the bedside without the patient taking hold of it themselves?

Does stress cause hypertension? A view from the real world

If you ask a doctor, they'll say that stress doesn't cause hypertension ~ or, at least, they will analyze "stress" in biomedical terms (catecholamines and what not). But every clinician has had the experience of patients who are sure that they know when they have high blood pressure: it's when they get stressed.

In a thought-provoking talk at the International Conference of Communication in Healthcare (which I return from tonight), Barbara Bokhour (from Boston) et al. helped reframe my experience with their analyses of interviews done with patients with uncontrolled hypertension. Patients have their own models for hypertension (psychological stress playing an important role in these) and they take action to self-treat, by trying to reduce their stress.

Among the researchers' interesting findings was that patients might be etymologizing hypertension into "hyper" + "tension": if you have high blood pressure you must be really tense.

I had two thoughts about this. 1. Why not co-opt these patient models, telling them that anti-hypertensives reduce stress (on the heart)? Not entirely deceptive. 2. What if we just started calling it "high blood pressure"?

I don't know why I'm in the hospital!

Continuing to tweak my thoughts about doctor-patient diagnostic discordance (i.e. doctor says: she's in the hospital for X; patient says: my doctor told me I'm in the hospital for Y), this time for the International Conference on Communication in Healthcare to be held Oct 4-7 in Miami Beach. I will be heading to the sukkah, not to the surf (I'm arriving 10/5 if anyone wants to look me up), but I am looking forward to it nonetheless.

I'm also working on an application for an AHRQ grant on the same topic so I can reproduce my Bellevue pilot study at the Johns Hopkins Hospital.

"This is Dr. Berger. He is visiting Australia to see what a modern medical system looks like."

I spent the day enjoyably. I gave a talk this morning to the folks at VMA General Practice Training, one of a number of provider training centers throughout Australia. (Recently - within the past decade or so - the Australian government has decentralized the training of general practitioners, formerly under the College of General Practitioners, in order to promote competition.) I had a feeling of being at home among people like those at the primary care program I just graduated from. Now, primary care doctors in the US are (with the addition of philosophical self-consciousness and their own advocacy organization) just like internists, while their equivalent in Australia is the GP. Australia is civilized because about half their practitioners are GPs. What struck me was how little difference there seems to be, on a brief first glance, in outlook and sensibility.

Then this afternoon and evening I have been shadowing the clinicians at Parkridge Medical Centre in Melbourne. Besides the obvious differences (namely, that Australia has a "modern medical system" with universal healthcare coverage) I noted, again anecdotally, a relative reluctance to spring first for the pharmaceutical solution, something I know I did as a resident (mere weeks ago!).

She doesn't know why she's in the hospital?

I'm still thinking about an all-too-common hospital situation: doctor and patient don't agree on the reason why the doctors put the patient in the hospital. I'm giving a revised talk about it on Wednesday to my primary care colleagues. Comments welcome!

How could someone not know why they're in the hospital?

As it happens, I gave a talk on that topic today. It involves some ongoing research of mine. Have a look!

Thinking about thinking about medicine
Rx: Think better.

I recently had the opportunity to interview Jerome Groopman for the Forward on the occasion of his new book, How Doctors Think. I hope the Q&A will appear soon. Meanwhile, enjoy this discussion in Slate which is rather less polite and chummy than ours was. Perhaps I should have said to Dr. Groopman what I was thinking, which is: Research on the patient-doctor interview has been accumulating for the past twenty-five years; why are mainstream MDs discovering it only now? (It's also interesting that the Slate discussion does not touch on doctor-patient communication at all. Groopman: doctors need to be trained better! Sanghavi: systems need to be more effective! But, guys, getting the patient to tell the doctor what the problem is? This is simple? This is done to perfection inside the office?)