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"?
БЕЛОЕ НА БЕЛОМ
Хлеб с толстыми ломтями света.
Роженица расцарапывает кожу
От зуда.
Из чёрной раны
Вытанцовывает кость.
At the Health Care Blog, George Lundberg picks the following sources of savings, where comparative effectiveness research can help save money while guiding us to the most effective treatment. His confidence that screening mammography doesn't improve mortality seems misplaced (the data isn't clear, and the studies are difficult), and his jab at oncologists is impolitic, but otherwise this is a worthwhile list.
I would never pray with a patient at the bedside. What doctor has time to talk about God? And who knows whether a patient will find the suggestion of prayer offensive, helpful, or rapport-building? Most of us doctors, when we think about prayer at all, keep it as far from our work as possible. I am an observant Jew, yarmulke wearing and Sabbath observing, and I pray three times a day. But never would I mention to my colleagues a word about my daily spiritual practice. We are practitioners of our own esoteric art, which we like to pretend is uncontaminated by outside influence, and our white coats are not cassocks. Even when an appreciation of religion might be of some use, we make an extra effort to keep it at a distance. When patients are about to die, or when our care is serving only to prolong suffering, we delegate the hard questions to highly trained ethicists sharing our worldview. When there's nothing left but to commend a patient's soul to its maker, we murmur something about "medical futility."
Thus the small but growing scientific literature linking prayer to health is discussed by nobody in my circles. It's in the same category as "alternative" medicine (acupuncture, Chinese therapies, ayurvedic medicine, and the like) or, for that matter, most of psychology - areas worth dabbling in but never imagined by orthodox practitioners as primary to the profession. Once organic causes have been thoroughly "worked up" (through appropriate technologies and laboratory tests), then we are free to speculate about the psychological and spiritual realms, usually with a cocked eyebrow or an eye on the clock.
What would it mean for prayer to help the sick? It's a question linked to others great philosophers have plumbed and foundered on: the existence of evil, God's relationship to prayer, the necessity of any belief in God at all when one prays. One might think that the scientific literature shouldn't find the problem as difficult as the philosophers - just find an objective measure of "prayer" and "help." But objective measures of prayer are precisely what are lacking, as psychologists Kevin Masters and Glen Spielmans explained in a review published in the Journal of Behavioral Medicine in 2007: what the field needs are "experimental studies based on conceptual models that include precise operationally defined constructs [and] longitudinal investigations with proper measure of control variables." In other words, we're back to the same issues: what is prayer? And how do we tell what is the effect of prayer, and not merely the nonspecific warmth of human companionship?
God is most relevant to me at work for different reasons. I'm a medical resident in his final year whose routine usually involves others' tragedy. Religion in my practice is usually evident only as a wedge between what I want and what patients - and, more often, patients' families - want. Enveloped by a medical culture which is difficult to step outside, I often catch myself assuming with an unquestioning certainty exactly what should happen in a given case: this person over here is worth treating (from a "medical" perspective - that is, from the perspective of my guild), there is progress to be made here, and we should try to convince the patient and family of this; or, conversely, there is "nothing to treat here," and any protestations to the contrary are due to delusion, illusion, or "cultural differences," a common euphemism which includes religion. Often it happens that religious patients and their families want more care than we doctors want. This is frustrating for me as a religious person: what's the point of all the spiritualism if it only blocks lines of communication between doctor and patient?
As in the case of prayer and health, the issue of end-of-life care for religious patients (and their families) can be illuminated through empirical research where otherwise we might get lost in philosophical byways. In a recent issue of the Journal of the American Medical Association, Holly Prigerson at the Harvard Medical School Center for Palliative Care, together with her colleagues, published a rigorous study of patients who use religious faith to cope with a diagnosis of advanced cancer. Even after controlling for other variables, these patients with "positive religious coping" request and receive more intensive life-prolonging care at the end of life.
In an on-line interview, the authors declined to make recommendations to clinicians based on this conclusion. In the article, however, they observe "because aggressive end-of-life cancer care has been associated with poor quality of death and caregiver bereavement adjustment, intensive end-of-life care might represent a negative outcome for religious copers." This would certainlly justify doctors' bewilderment when dealing with religiously intransigent families. Such families are arguing their loved ones into more days in the ICU and a death entangled in wires and tubes.
Thinking it about it in another way, though - trying as hard as I can to think like the spiritual person I occasionally manage to be outside of work - a scrabbling after every scrap of life, even as it seems to slip inexorably away, is a perfectly religious path. For many religious people, sick or well, the question is not "Does prayer help?" but "How can I manage to pray?" Prayer has no point; its existence is enough. Similarly, I would not be surprised if many religious families viewed the question of "negative outcomes" as just another barrier thrown up to the achievement of transcendence. Life is life. Clinging on to it has no point; the clinging is enough. These days our art of medicine is always accompanied by debates about the evidence, what it is and how one introduces it into practice. While God and God's adherents frustrate me no end while I am trying to get work done in the hospital, I am vivified by those whose attachment to life is circumscribed by something other than evidence.
Lower Copay and Oral Administration: Predictors of First-Fill Adherence to New Asthma Prescriptions
Background: Nonadherence to asthma medications is associated with increased emergency department visits and hospitalizations. If adherence is to be improved, first-fill adherence is thefirst goal to meet after the physician and patient have decided to begin treatment. Little is known about first-fill adherence with asthma medications and the factors for no-fill.
Objective: The goal of the study was to examine the proportion of patients who fill a new prescription for an asthma medication and analyze characteristics associated with this first-fill.
Methods: This retrospective cohort study linked electronic health records with pharmacy claims. The cohort was comprised of 2023 patients aged 18 years or older who sought care from the Geisinger Clinic, had Geisinger Health Plan pharmacy benefits, and were prescribed an asthma medication for the first time between 2002 and 2006. The primary outcome of interest was first-time prescription filled by the patient within 30 days of the prescription order date. Covariates examined included factors related to the patient (ie, age, sex, and ethnicity), comorbidities and utilization (ie, Charlson comorbidity index, number of office visits, number of additional medications), asthma treatment (ie, delivery route, pharmacologic class), and pharmacy co-pay amount. A logistic-regression model was used to determine covariates associated with first-fill.Results: The overall first-fill rate for new asthma medications was 78%. First-fill rate was lower for patients with a copay above the mean of $12 (odds ratio = 0.76; 95% confidence interval, 0.58-0.99) and higher for patients prescribed oral plus inhaled medications (versus inhaled only, odds ratio = 3.91; 95% confidence interval, 2.15-7.11).
Conclusions: Several factors associated with failing to fill an initial prescription for asthma can be addressed through simple interventions: screening for difficulties a patient may have in filling prescriptions, avoiding nonformulary medications, and recognizing the barrier that high copays present. In addition, for employers and policymakers, decreasing copay may improve adherence and, therefore, asthma control.
are readily apparent in EBM’s clear allegiance to experimental methods of inquiry that set aside past habitual thinking in favor of purely empirical investigation. Indeed, EBM’s promise of “the application of the best research evidence to medical decision-making” (EBMWG 1992) could have been achieved by strictly pragmatic scientific methodology.
[The] objectivist ontology,where the evidence “speaks” and reliable knowledge follows, presents an occupational hazard to (actual) medical practice. Subjective content muddies up even the most rigorous evidence-based practice by the inescapable layers of interpretation and sociocultural influence that enter in the setting of research agendas (including what projects get funded and why), the production of evidence in primary research, and the selection of which evidence is chosen to inform policy and practice.
From a pragmatist perspective, the problem is not so much that the gold standard status is tenuous, but that the RCT’s placement of at the top of the hierarchy is so insistently maintained. It is largely in the interest of avoiding dogmatic theoretical commitments that pragmatists endorse a bottom-up approach to theory construction, where localized beliefs must pass the test of experience in order to be elevated to generalizable knowledge claims.There are numerous experimental scenarios in health research where the RCT would not be the methodology of choice,which suggests that the hierarchy of evidence would not pass the rigors of the bottom-up approach to theory building.
In the interest of better science, I propose that EBM’s pragmatic features are worth keeping. By this, I mean that the open-ended critical inquiry should be encouraged, as should comparative clinical research and problem-specific methodology (which may include uncontrolled methods and even reliance on clinical judgment).The rigid hierarchy of evidence, as we have seen, leads to considerable problems for EBM and should be dismantled.The EBM critics,writing from the post-positivist philosophy of science tradition, have amply demonstrated these problems. But the constructive project of revisioning or perhaps recasting the evidence-based approach to medicine requires that the worthwhile aspects of EBM not be discarded along with its flawed features.
The truth is that we Chasidim haven't been so impressed by the swine flu from the beginning. Yes, it's gotten to South America, Europe, and even Israel. But that sort of thing usually doesn't interest a Chasid too much, and a "God have mercy"or a "it shouldn't happen to us!" can take care of it. So folks in New York have gotten it too? I assume you're familiar with the verse "and all the children of Israel had light in their dwellings"! And which cheder pupil doesn't know about the plague of blood when the Egyptians bought water from the Jews - so what's the difference here? ...They said about AIDS that it would eat up the whole world, but like the lice in Egypt it stopped at the Chasidic zip codes. Just like the miracle of the shemittah farmers who clearly see their blessings compared to their neighbors, all the maladies I visited upon Egypt are not seen or found among those who are meticulous in their observance of commandments both major and minor. So much the more so in this case because we don't eat the flesh of pigs - their hoof is cloven but the cud they do not chew - and we're in the month of Iyar, which stands for I, God, am your healer.
The catastrophe is though that - whether it's really true or they're just saying it - two yeshiva students from Mir got it. Oh my teachers and rabbis, death has risen to our windows, come to our palaces and the Angel of Death is attracted to white shirts and black hats too. Now it's a tragedy. I know the experts say that it's easier to get infected on the train than it is from a Chasid's achoo on the other side of the Mediterranean, but what do the experts know? They say the world's getting warm but the kutchme sellers aren't yelling for a bailout. When Chasidic young men get it it's a whole other story. It's our concern now, so we need to get in touch with the Chasidic doctors and move mountains.
Nevertheless, as they say, in all labor there is profit, or as the goyim say, every cloud has a silver lining. A truly God-fearing Jew feels a spiritual satisfaction, a feeling that we're not left out, we're on the guest list too. Leave it to the Jews: if there's something to pick up in the world you can bet that we won't be left behind. We might look different but there's nothing we don't have. We'll get there. We won't just get there, we'll make the whole business our own by giving it a name. Make a mishebeirach, change pig to Mexico, and confuse the devil just like we do on the eve of Rosh Hashanah... from a swine's flu you can make a silk purse, or a shtreimel.
If one eschews the skilled and repeated examination of the real patient, then simpl diagnoses and new developments are overlooked, while tests, consultations, and procedures that might not be needed are ordered.
Younger physicians often argue that physical signs lack an "evidence base." Clearly some signs are helpful, some are not, and we need continued study in this area. But recognizing erythema nodosum or decreased breath sounds and dullness over a larg pleural effusion is worthwhile in and of itself.
We teach that physical findings should be considered biomarkers, phenotypic markers. ... An enlarged spleen, Roth's spots, a Virchow's node, and jugular venous distention are all biomarkers that should be factored in with the high calcium level, the abnormal MRI, and other data to arrive at a true picture of the patient. Failure to recognize these biomarkers is an oversight akin to not seeing a key laboratory value in the chart.
The House and Senate negotiators also agreed to scale back spending intended to help provide health insurance to the unemployed. The House originally proposed that the government subsidize 65 percent of private insurance, under a law known as Cobra, for one year after the loss of a job. The final deal calls for a 60 percent subsidy, and for only nine months. The House had also wanted to let states offer temporary Medicaid coverage to jobless individuals who did not qualify for Cobra coverage. That proposal was eliminated entirely.
Throughout health care, the spending crisis requires a comprehensive search for ways to shift spending from services of dubious economic value to those with high cost-effectiveness or net savings. Whether those services are preventive or otherwise is not the point; what matters is prioritizing services that produce the greatest health benefits for the dollars spent. ... As a matter of economic security and ethics, it is inappropriate to debate the economic value of prevention while excusing the rest of medical care from such scrutiny.
Here's a call to action (read: e-mail petitioning) from the Society for General Internal Medicine. Unfortunately, I don't know explicit criteria for judging the stimulativeness of any given line item, but I would hope curing sick folks (some of whom work and make things!) would rank somewhere pretty high.
Later this week, a joint House-Senate conference committee will meet to reach a compromise on a massive economic stimulus bill. The House version of that bill includes $600 million for primary care health professions training, diversity and nurse education programs. This would double the current level of funding, a long needed beginning to healthcare reform.Unfortunately, the Senate version of the economic stimulus bill does not include funds for these Title VII primary care training programs.
Please contact your two senators and your representative today! Lawmakers need to be convinced that the compromise bill they send to President Obama must include $600 million to help ensure the supply of primary health care providers, namely internal medicine, family medicine, pediatricians, dentists and nurses.
Here are the creatures I think about:
Stammerers that like to kiss,
Poets dead a century,
Prophets.
I run headlong into pigeons
To catch them lifting up
As if they are lifted.
An aged hand might be the closely stamped card
Of a worn library book.
It's easy not to think
Of the elephant. I just imagine
What you want and go do it.
Hot tea,
Sweetened with fake sugar.
The name mentioned most often in the November issue was not Obama but Hashem. This is Binah, "the weekly magazine for the Jewish woman."
By the fourth sentence of the preface to The Silent World of Doctor and Patient, Jay Katz has quietly issued a startling challenge to a fundamental principle of the doctor-patient relationship. He writes:--Michael Millenson at the Health Affairs Blog. Times obituary of Jay Katz here.It took time before I appreciated fully the oddity of physicians’ insistence that patients follow doctors’ orders. During my socialization as a physician I had been taught to accept the idea of doctors’ Aesculapian authority over patients. When I began to doubt this authority, that was the moment when the book began to take shape in my mind.
“The oddity of physicians’ insistence that patients follow doctors’ orders” – the phrase brings you to an abrupt halt. Jay Katz, who wrote those words in his landmark book published nearly a quarter of a century ago, died in late November at the age of 86.
Ultimately, because of vast historical and social forces, physicians by and large remain oriented towards an unattainable and inappropriate positivist ideal, and thereby severely compromise the deeper values of their own moral agenda. This choice—encouraged by the professionalization process—largely explains why medical ethics serves such a minor role in medical education; why complaints of medicine’s dehumanization are rampant; and why myriad studies, surveys, and testimonies attest to the lack of physician empathy. Indeed, if medicine aspires to an objective ideal at the expense of its unique value-laden agenda, the profession will be hounded by complaints that it has forsaken its ancient calling for a Faustian pact.--Alfred I. Tauber, Medicine and the Call for a Moral Epistemology, Part II: Constructing a Synthesis of Values. Perspectives in Biology & Medicine Summer 2008; 51(3).A self-conscious moral epistemology—an epistemology that remains aware of its ongoing negotiation of competing values and construction of its interpretative knowledge—provides a philosophy of medicine for the doctor’s diverse roles and activities. On this view, a philosophy for medicine must acknowledge the multidimensional character of medical thinking that utilizes values spanning the ideals of laboratory science to the empathetic response of humane care. But more, this philosophy must recognize a fundamental difference between the scientist’s search for the real and the physician’s pursuit of the therapeutic.
Medicine requires more than “true” outcomes (as in scientific truth-seeking); physicians embrace “best” results for the care of their patients. While seeking the “true,” patients and their caregivers are often satisfied with something else (for example, the effective intervention may be a sham treatment or a placebo). “Truth” directs clinical science, and clinical science directs itself to good outcomes, but in the hierarchy of medicine’s philosophy, it is ethics of care that directs the physician’s science and ultimately determines clinical choices.
Surgical residents may someday soon have to prepare themselves to halt an operation and announce that it's nap time.Solomont doesn't know that surgeons often must hand off care during a long procedure (colectomies can last forever)?
Define quality for me. Then show me a system in which there won't be as many winners as losers--how else do you save 30%? Then I will show you a real health care policy debate and we will see how much consensus we have.Wellness? Wellness programs today look an awful lot like the voluntary education oriented wellness programs we were selling in 1988 and things are far worse. Prevention? Most of the commonsense steps in prevention were available to us years ago.We have been avoiding the heavy lifting in health care reform for 16 years. For me, all of these new ideas aren't so much new ideas as one more "Ground Hog day" in the long-running health care debate.
Among Cubans, “intoxicado” is kind of an all encompassing word that means there’s something wrong with you because of something you ate or drank. I ate something and now I have hives or an allergic reaction to the food or I’m nauseous. On the day Willie’s intracerebellar bleed began, he had lunch at a fast food restaurant, the newly opened Wendy’s. His mother and his girlfriend’s mother assumed that the severe headache he experienced that night was related to eating a bad hamburger at Wendy’s - that Willie was “intoxicado.”More at the Health Affairs Blog about a terrible linguistic misunderstanding. "Neither the ER doctor nor the family requested a professional medical interpreter because each side believed they were communicating adequately."
I was at Hopkins last week giving a talk as a recipient of one of the GIM Housestaff Research Awards. The other awardees were impressive. I wish they were as blogorrheic as I am, so I could provide links to their life & work. In any case, among the presentations wereWe need to train more primary care doctors. I heard only 2 percent of last year's doctors were primary care, because the money wasn't there. We need more medical homes, a more holistic approach to care. There must be a greater role for primary care then there is in America today, and this bill has incentives to do that.
