Patient Safety Blog

Many doctors believe that the recent sharp increase in drug advertising has altered the doctor-patient relationship for the worse.

From the article:

Like many doctors, Ron Ben-Ari thinks ads on TV for prescription drugs frequently go too far in touting a particular pill's benefits without adequately presenting the risks.

But Ben-Ari, who has a practice at USC's Health Sciences Campus in East L.A., accepts that the ads have fundamentally altered the doctor-patient relationship. He's found that it can be fruitless to try to talk a patient out of seeking some name-brand medication, even when a cheaper alternative is available.

"If it's an appropriate medicine for the person, I'd probably prescribe it," said Ben-Ari, who also teaches at County-USC Medical Center. "We're in an era of information. We have to evolve with it."

This highlights the fact that a little information can be a dangerous thing, since a little information is often incomplete information. If patients come into a doctor's office wanting a certain drug because they're aware of cherry-picked facts gleaned from ads designed to put a drug in the best light, and refuse to be talked out of it, then their health will obviously suffer.

It's good for patients to be informed about drugs even before they walk into a doctor's office, but that information needs to come from reliable sources. If a drug looks good to you based on what you see in an advertisement, it's a wise idea to do some independent research and ask your doctor's opinion before becoming set on it.

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Posted In: Communication

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Pain is a tricky medical problem because it's impossible to measure or adequately communicate to another person. Tara Parker-Pope discusses how patients in pain use art to describe what they're going through:

Sacramento resident Mark Collen, 47, is a former insurance salesman who suffers from chronic back pain. After his regular doctor retired due to illness, Mr. Collen was struggling to find a way to communicate his pain to a new doctor. Although he has no artistic training, he decided to create a piece of artwork to express his pain to the physician. “It was only when I started doing art about pain, and physicians saw the art, that they understood what I was going through,” Mr. Collen said. “Words are limiting, but art elicits an emotional response.'’ Mr. Collen wrote to pain doctors around the world to solicit examples of art from pain patients....

...Finding ways to communicate pain is essential to patients who are suffering, many of whom don’t receive adequate treatment from doctors. In January, Virtual Mentor, the American Medical Association Journal of Ethics, reported that certain groups are less likely to receive adequate pain care. Hispanics are half as likely as whites to receive pain medications in emergency rooms for the same injuries; older women of color have the highest likelihood of being undertreated for cancer pain; and being uneducated is a risk factor for poor pain care in AIDS patients, the journal reported.

The subjective nature of pain means that doctors often feel inclined to dismiss it, or assume that the patient is lying or exaggerating, especially if it fits in with the doctor's preconceived stereotypical beliefs. It is therefore vital that doctors respect what patients say about their pain. If you are a patient, there is no need to feel shy about insisting forcefully that you are in pain: that is an area within your expertise, not the doctor's.

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Posted In: Communication

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A new project, conceived of by Google and the Cleveland Clinic, will try to give patients the ability to access and control their health information.

This project would hopefully enable patients to give their information quickly and easily to multiple physicians and pharmacies. Such a thing would be beneficial because, as we have discussed often on this blog, lack of communication between physicians is a frequent cause of medical error. Patients might assume that doctors would automatically share relevant facts with each other in their medical histories, and this is indeed what is supposed to happen, but too often it does not. This new project would give the patient some control over making sure that doctors know important details.

The New York Times also has some comments on this, quoting Dr. John Halamka on the importance of "consumer-oriented health care."

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Posted In: Communication , Disclosure

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Most scientists are extremely unwilling to part with the raw data of the studies they perform on cancer and other life-threatening illnesses.

The author of the article speculates that this reluctance is due to convenience and careerism, specifically the fear of having others (especially layfolk) analyze their work and possibly find flaws in it. This may be an uncharitable speculation but it is difficult to disagree with, especially when one considers the pathetic reasons scientists cite for hiding their data. From the article:

Dr John Kirwan, a rheumatologist from the University of Bristol in England, has studied researchers’ attitudes on sharing data from clinical trials. He found that three-quarters of researchers he surveyed, as well as a major industry group, opposed making original trial data available. It is worth restating this finding: most scientists doing research on how best to help those in pain, or at risk of death, want to keep their data a secret.

Dr. Kirwan went on to ask his subjects why. Their reasons were entirely trivial: one cited the difficult of putting together a data set (wouldn’t this have to be done anyway in order to publish a paper?); another was concerned that the data might be analyzed using invalid methods (surely a judgment for the scientific community as a whole). This is something of a clue that the real issue here has more to do with status and career than with any loftier considerations. Scientists don’t want to be scooped by their own data, or have someone else challenge their conclusions with a new analysis.

As the author points out, however, new analyses are exactly what cancer patients (and patients in general) need. We all need all the information available that pertains to our health, so we can look at it and think about it and use it to safeguard ourselves. This reluctance to part with information is contrary to the spirit of scientific openness and inquiry. It is also unsafe and unfair to patients.

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Posted In: Cancer , Communication , Disclosure

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Guilt, fear, and further isolation plague families of victims of medical error, says the New England Journal of Medicine.

Why guilt? Because families feel like they should have kept a closer watch on their loved one, and regret the trust they placed in the health care institution or its workers. This guilt persists even if the family took reasonable precautions--for instance, the authors of the article discuss a case where a patient was given morphine and died of kidney failure despite the fact that his family repeatedly told doctors and nurses that he had sickle cell anemia. The family often feels inadequate for being unable to watch the patient twenty-four hours a day.

They also feel fear: fear of retribution, fear that health care workers will neglect or compromise their loved one's care if they make some sort of formal complaint. This is particularly true of people in disadvantaged and disempowered sections of society.

Their emotional turmoil is often compounded by the reactions of the health care workers, who will often isolate the patient's family after realizing their error. This leads to further pain and may even lead to further medical mistakes:

Guilt persists in the daughter of a woman who died after a series of errors culminating in a missed case of pneumonia. Although the daughter is a nurse, she could not gain entry into her mother's circle of clinicians, who closed ranks after the errors occurred. "The nurses were ruder to me than you can ever imagine, and the doctors wouldn't tell me anything," she said. "They looked at me like I was a dumb little girl. I became so addled that I couldn't act decisively and get her out of there to another hospital. I'll never get over my guilt."

This isolation comes at a time when, as the authors point out, patients most need someone to communicate with them on a personal and human level. They suggest that honest, direct communication--without condescension, buck-passing or hedging around to avoid lawsuits--is the best way to keep the patient safe as well as feeling satisfied with the care he or she has received.

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Posted In: Communication , Medical Error

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Critical thinking, communication and honest working relationships between doctors and nurses leads to better patient care. This sounds like common sense, but it is also the result of an analysis done by Dr. Barbara Loeb and RNs Mary Sue Dailey and Cheryl Peterman.

In brief, the three main areas that need improvement and hold potential for better patient care are:

1) Critical thinking--focusing on solving problems rather than blaming, analyzing root causes, looking at issues in different lights

2) Communication--doctors and nurses being open with each other about their concerns and sharing vital information, rather than assuming that important information is already known to everybody

3) Collaboration and collegiality--mutual respect and positive interactions between doctors, nurses and other healthcare providers.

As we have discussed before, communication and teamwork are an essential aspect of good medical care.

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Posted In: Communication

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An article in the New Yorker by Atul Gawande highlights the simple ways in which hospitals can be made less dangerous places for their patients. A checklist to make sure intensive care doctors and nurses handle catheters correctly has been proven to dramatically reduce the risk of deadly infections. Gawande focuses on the work of Peter Pronovost, MD, an intensive care specialist at Johns Hopkins Hospital who consults with hospitals around the country to spread his gospel of routinizing simple procedures. For example, on catheter infections, Pronovost's work was first published in December 2006 in the New England Journal of Medicine. In 108 ICU's across Michigan, they were able to virtually wipe out catheter-based infection by enforcing a required checklist of five interventions: hand-washing before handling a catheter, full-body draping when inserting a central venous catheter, scrubbing the skin with chlorhexidine, avoiding catheters in the groin, and removing unneeded catheters as soon as possible. All hospitals should implement these simple ideas which can prevent deadly infections and save lives. Dr. Pronovost is a pioneer in patient safety research.

Posted by Patrick A. Malone | Permalink | Email This Post

Posted In: Communication , Infections , Standard of Care--Hospitals

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This may fall into the category of stating the obvious, but a study published on Tuesday September 4th founds that doctors who graduate medical school with poor communication skills are more likely to get complaints from patients down the road in their careers.

The researchers tested and scored medical school graduates, who knew that they were being watched and graded (and who still often communicated poorly), and then tracked them and the complaints made against them. Lower scores correlated strongly with a greater number of complaints.

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Posted In: Communication

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