“The oddity of physicians’ insistence that patients follow doctors’ orders”

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:

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.

--Michael Millenson at the Health Affairs Blog. Times obituary of Jay Katz here.

Ill-Suited for Rapidity

Today's hospitals are all about the Rapid Response Teams.

But I was born a member of the Languid Deliberation League.

The Times Again Re-Discovers Yiddish

A whole article in the Times about Yankl Ejdelman without mentioning Yugntruf. Still and all, it's a positive piece.

But I can't help myself. Why is Yiddish a "venerable tongue" in the headline? Surely the language is no older than English? And why is it called "the 1,000-year-old amalgam of Hebrew, German and assorted European dialects that was once the lingua franca of Europe’s Jews"?

Amalgam? (You mean, perhaps "language"?) Assorted European dialects? (Maybe "languages"?) Lingua franca? (Rather, "first language"?)

It's almost as if the reporter knew nothing about the topic she was writing on!

Naw.

A conversation on the Lower East Side

[regarding me, between two Jews]

"Iz er a yid?" (Is he Jewish?)

"Avade iz er a yid." (Of course he's Jewish.)

What was next said, as I first heard it:
"Er kikt oys vi a narisher." (He looks like an idiot.)

I said "Vos?" (What?)

"Ir kikt oys vi an arisher." (You look like an Aryan[?].)

"Vos?"

"Vi an arisher!"

"Ah!"

Oh! I get it. Like an "ayrisher" ("Irisher" in non-"YIVO" Yiddish, Irlender in standard Yiddish), in the speaker's pronunciation - "arisher."

Thus was I saved from getting in a fight with two older men on the Lower East Side (probably avoiding a beating in the process).

Dr. Faust, meet Dr. Dewey: constructing a philosophy of medicine for the 21st century

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.

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.

--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).

Of minimal interest

I updated my literary CV. Where can I tell people that if not on my blog?

Lay down your scalpel, it's nap time!

E.B. Solomont (formerly of the Forward, as it happens), writing critically in Slate about the Institute of Medicine's work hour report, observes hyperbolically

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)?

The Royal College of Surgeons (one of the organizations named by Solomont as opposing stricter work-hour regulations) provides a summary of their recommendations regarding training modifications. After a thorough review of work patterns in the context of impending regulations (or after they had already been instituted; it's not clear to me), the following findings became (magically?) apparent:

• a significant reduction in the need for acute surgical intervention (except for life- or limb-threatening conditions) between 22.00 and 08.00
• the majority of work undertaken by surgical staff during this period relates to the management of medical co-morbidities

Do you think that these shocking facts would have made themselves known without the threat of regulatory penalty?

The report also mentions a number of possible solutions. Leaving off for a snooze during the middle of a heart bypass is not mentioned, but scheduling innovations are.

Surgery and medicine training programs are naturally going to squawk at work hour regulations, and it's a tradeoff between continuity of care and well-rested residents. But it's also a myth that every hour of time spent at the hospital means another hour spent in quality medical education. Hiring physician extenders doesn't mean depriving housestaff of the opportunity to see interesting patients and learn necessary procedures. Often just the opposite is the case.

Speaking of naps, many sleepless surgeons have already taken a few - but in the OR, browning out over the field, not at home. Which would Solomont prefer?

Greed vs. Greens, or In Which Righteous Quasitarian Anger is Cooled by Spicy-Hot Chili Sauce on Falafel

I hope you're happy, landlord. You gouged Zen Palate Union Square out of business and you don't have another renter yet.


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A pity that Google Maps' streetview is not festooned with the For Rent banners I saw today on the building at 34 Union Square East. I didn't take a photo, since I was stunned simultaneously with grief, schadenfreude, schaden-anger [Schadenzorn?], and...

...the happy thought that Maoz Vegetarian is just down the block.


View Larger Map

Yummy, and much cheaper than Zen Palate Usq ever was. Maybe I'm not so mad after all.

My talk in Philadelphia today

It's lacking something without the talk, but here's a silent Power Point.

Resident work hours in the Times and the "Journal"

The Well blog at the New York Times talked about the new Institute of Medicine study, Resident Duty Hours: Enhancing Sleep, Supervision, and Safety. I'm not likely to read it, but the IOM "asserts that revisions to medical residents' workloads and duty hours are necessary" to protect patients against errors and improve the educational environment.

The comments at the Times blog are to be avoided, as most comments are. Try this New England Journal article instead for a take on the tricky balance between work hours and handoffs. The fewer hours, the more handoffs. And fewer hours, with today's sicker patients, don't mean less work.

"What we do in improving quality can also help us address costs"?

That's what Neera Tanden, a member of Obama's transition team, had to say in this morning's conference call organized by Doctors for Obama, which had over a thousand people listening in.* I wish it were true. 

As I expected, the focus of the call was on outreach and recruitment. Tom Daschle (Obama's pick for HHS Secretary) spent some time talking about the transition team's Change.gov and the umpteen zillion comments that have been offered up there about needed healthcare reform, all of this by way of example of the transparency Obama emphasized during the campaign. "He wants the administration to change the way people interact with their government," said Daschle, "and this is especially true when it comes to healthcare." "We have to have better transparency," he said later - "we can't understand problems until we see them effectively."

The more interesting part of the call was policy, though Daschle averred that no decisions were being made yet: "That's not the role of the transition team, we're working to prepare the president-elect about healthcare options." 

To a question about prevention: "The new paradigm has to be a recognition that prevention has to be a central feature of a new healthcare delivery mechanism. ... But there are serious problems about whether we have the infrastructure to deal with the opportunities that an attention to health and wellness can bring. There need to be more roles for nurse practitioners and physician assistants. We need to make sure we incent people to become general practitioners and family physicians." 

Daschle also talked about improving healthcare delivery ("We have 21st-century operating rooms and 19th-century administrative rooms. The solution to that is electronic medical records and health IT") and quality ("we see an extraordinary lack of best practices and quality of care implemented in procedural ways across the country"). 

To his credit, he did not make the explicit claim (as has been done by others) that improving quality, emphasizing prevention, and implementing efficient delivery of care will reduce health care costs. (I think this claim is difficult to believe.) Nira Tannen made the claim, though: "Making sure our people are healthy will lower long-term costs for everyone and in the meantime ensure that everyone is covered."

To quote Bob Laszewski of the Health Care Policy and Marketplace Blog:

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.

I believe Laszewski over Tannen, though I wish I didn't. The stronger argument for universal care (and perhaps truer to the facts) is to say that covering everyone will cost more money, at the very least in the short term, but (a) it's the right thing to do, because healthcare has become as much a public as a private good; and (b) it's a stimulus to economic growth that people who understand the economy (not me!) say is necessary in times like these.

I should say I was encouraged by the speakers' attention to workforce issues. More primary care physicians, please. But we need more fundamental (re-)thinking about changing healthcare delivery.

*All quotes paraphrased.

an activity of the imagination

set the answer face to face
with its question.
awkward encounter
till the match fails.
who are you to set them up?

"Intoxicado" Does Not Mean "Drunk"

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."

Presenting the presenters!

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 were

• a discussion by Matt DeCamp of intellectual property rights and distributive justice, and their interdependence
  
• Lee Jennings' study of osteoporosis treatment in the hospital (per guidelines: calcium, vitamin D, and anti-resorptive/bone-forming agents). Two percent of patients got recommended treatment in-house!
• a sobering fact about residents' physical examinations of women (Rosette Chakkalakal): they don't listen to the heart like they should (is it because they respect too much their patients' modesty? or they're uncomfortable with moving their breast out of the way?)
• a study by Nitin Kapur of interpartner violence and sexually transmitted infections among Indian women (with a 1-month prevalence of IPV of around 20%, if I remember correctly; related link)

• Last but not least, my study about factors associated with patients' failure to fill new asthma prescriptions [Google version above not yet re-edited to account for Power Point - Google incompatibility].

"Drug-seeking"

Imagine you're in the hospital and in pain. You would like some medicine to treat that pain. Ipso facto presto chango- you are looking for drugs. Hence drug seeking. Voila! A reason not to give pain meds.

The Raucous Baucus Caucus

I skimmed the Baucus policy paper, which is (like the Health Care Policy and Marketplace Blog says) a plan, not a proposal for legislation, with a whole bunch of possibilities that Baucus doesn't really distinguish among. Also, it is a zillion (or 96) pages long. A couple of observations:

Baucus talks a lot about pay for performance plans but never really describes which he prefers, how the current stakeholders will be assuaged, or whether P4P is meant to be the basis for a new payment model - not just a worthy experiment. He also doesn't mention that outcomes improvement via P4P isn't supported by the literature. Then again I didn't expect him to say that. (But maybe he doesn't know that? Senator, a Dr. Berger on the line.)

[edited]

Right on, Max Baucus!

From today's press conference:

We 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.

Spelling Hope in Hebrew

From TNR it looks like Yediot Acharonot have chosen to spell Obama with two alefs, and Maariv - with one. Which spelling wins?

The Google, please:
אובאמה
versus
אובמה

I suppose it makes more sense to analyze the word as following normal Israeli Hebrew phonetics, than as a foreign word which needs to be spelled with another alef.

The Emanuels Take Over, 2

Which Emanuel brother are you? (Warning: extreme snark.)

Statins in patients with high C-Reactive Protein "cut the risk of heart disease in half"?

Shorter New England Journal on the JUPITER study
(a corrective to reports like this one)

1. We knew statins helped lower the risk of heart disease anyway.
2. Now we have an industry-funded study to tell us that statins help in people with high CRP.
3. They cut the risk of cardiovascular events from 1.8% (per year) to 0.9%. Yes - a relative risk reduction of 0.5. But 1.8% and 0.9% are both low numbers. Do you have patients who would think this difference meaningful?
4. The study excluded basically everyone we meet in the real world: folks with high cholesterol, diabetes, and kidney disease.
5. We still don't know if CRP risk stratification helps improve outcomes.
6. We're not buying it.