Breaking The Bad News

On the TV show House, House’s oncologist pal Wilson was reputed to be so humane and caring when giving patients bad news about their condition that, when he was done, patients actually thanked him.  Studies indicate, however, that there aren’t a lot of Wilsons out there in the medical profession.  Instead, many doctors botch one of the most important parts of their job — giving patients truthful information about their medical condition when the diagnosis is grim.

photo-hospital-doorwayTelling patients that they have untreatable cancer, or some other fatal disease, clearly is one of the toughest parts of a doctor’s job — and research indicates that doctors just aren’t very good at it.  Some doctors will break the bad news indirectly or use medical jargon that leaves the patient confused, others will do it with brutal directness, and still others will sugarcoat the news with treatment options.  As a result, many cancer patients aren’t well informed about their actual condition, and their prospects. A 2016 study found that only five percent of cancer patients understood their prognoses well enough to make informed decisions about their care.

Why are doctors so inept at giving patients bad news about their condition?  Of course, it’s incredibly hard to be the bearer of bad tidings, especially when the bad news is about a fatal illness, but there’s more to it than that.  Communications skills apparently aren’t emphasized at medical schools, and many doctors see a diagnosis of an incurable disease as a kind of personal failure on their part.

It’s interesting that, in a profession so associated with the phrase “bedside manner,” so many doctors regularly mishandle what is arguably the most important part of their job and so few medical schools make sure that their graduates are equipped to handle that task in a genuine, caring, and understandable way.  I hope I never receive a devastating diagnosis, but if I do I hope it comes from a doctor who knows how to break the bad news.

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“Burn-out” As A Medical Condition

Every few years, the World Health Organization produces a new version of the International Classification of Diseases, a catalog of acknowledged medical conditions that is used as a diagnostic guide by health care providers.  With every new version of the ICD, there seems to be some controversy about whether or not a particular ailment or complaint should be recognized.

burnoutThis year, the “should it be included or not” controversy swirls around “burn-out.”  Apparently there has been a long, ongoing debate about whether “burn-out” should be recognized as a medical condition, and the WHO has now weighed in with a “yes”:  the ICD-11 lists “burn-out” and defines it as “a syndrome conceptualised as resulting from chronic workplace stress that has not been successfully managed.”  According to the WHO, “burn-out” syndrome is characterized by “1) feelings of energy depletion or exhaustion; 2) increased mental distance from one’s job, or feelings of negativism or cynicism related to one’s job; and 3) reduced professional efficacy.”  Notably, the ICD-11 tries to draw a kind of line in the sand by stating that “burn-out” “refers specifically to phenomena in the occupational context and should not be applied to describe experiences in other areas of life.”

My guess is that many — if not all — workers have, at some particular point or another in their careers, experienced “burn-out” as defined by the WHO.  Jobs typically involve stress, and it’s almost inevitable that there will be periods where multiple obligations pile on top of each other, leaving the worker feeling overwhelmed, exhausted, and dissatisfied.  But . . . should “burn-out” be viewed as a medical condition?  What, exactly, is a doctor supposed to do for a patient who presents with classic “burn-out” symptoms — prescribe a three-month vacation, or a new job, or new job responsibilities, or a change in the patient’s workplace manager?  Will employers be required to allow leaves of absence, beyond their designated vacation periods, for employees whose doctors diagnose them with “burn-out,” and will health insurers be required to pay for vacations as a form of treatment?  By classifying “burn-out” as a diagnosable health condition, aren’t we really going far down the road of “medicalizing” common aspects of our daily lives?

And can “burn-out” really be limited to the “occupational context,” as the ICD-11 instructs, or will the same concepts underlying workplace “burn-out” ultimately be recognized in other areas, like family or marital or college “burn-out”?  Here’s a possible answer to that question:  the ICD-11 now recognizes video gaming, with cocaine, and alcohol, and gambling, as a potential source of addiction.

Guns, Doctors, Patients, And Medical Privacy

Yesterday the Obama Administration announced some new gun control measures.  Because President Obama issued executive orders, rather than proposing legislation to be debated and approved by Congress, most of the attention was on whether the President overstepped his authority and violated the intended constitutional balance of powers between the executive and legislative branches.

I’d like to focus on a different, substantive element of the changes announced yesterday:  namely, changes to a federal law protecting the privacy of certain health information to allow reporting of individuals who would fall within the mental health prohibitions of the federal gun background check law.  Politico reports that the new rule “enables health care providers to report the names of mentally ill patients to an FBI firearms background check system.”  Diagnostic information about the nature of the mental health condition being treated, however, would still be subject to privacy restrictions.

handgun_collectionThe announcement of the new rule by the Department of Health and Human Services uses the kind of dense, acronym-filled administrative jargon that makes ordinary people scratch their heads and throw up their hands, and it is not entirely clear the extent to which it applies to doctors — although the HHS announcement acknowledges that a number of comments it received about the rule expressed concerns about how the reporting issue would affect the “patient-provider treatment relationship and individuals’ willingness to seek needed mental health care.”

This is a difficult issue, because we’ve seen, over and over again, the carnage that can ensue when a mentally disturbed person builds an arsenal and then acts out their disturbed fantasies.  We want to keep those people from buying guns.  At the same time, however, notions of doctor-patient confidentiality are important — most states have laws or rules of evidence that protect such confidentiality — and exist precisely to encourage people to see a doctor and, in this example, seek treatment for their mental health issues.  New rules, even permissive ones, that could interfere with that confidentiality raise a legitimate concern, because if people who might otherwise seek treatment understand that by doing so they risk being disclosed to a federal database as mentally unfit, they may decline to seek treatment in the first place.  And if physician reporting of information that would disqualify a patient under the gun purchase laws is permissive, and a physician chooses not to report a patient who fits such criteria and the patient then acts on their fantasies, can the physician be sued for failing to report?  And, if the answer to that question is yes, won’t reporting become routine — and therefore the prospect of discouraging people from receiving treatment in the first place become even more likely?

No one wants to see mentally unbalanced people get their hands on guns, and we’ll have to see how these new rules play out, but this is a very sensitive area.  If the new regulations have the effect of discouraging people from seeking needed mental health treatment, they may unintentionally compound the problem.

 

A Nurse In The Family

Grandma Webner always said that she wanted to have a doctor in the family.  Alas, none of her sons or grandsons were able to fulfill her wishes — and the lawyers in the family just didn’t have the same cachet as an honest-to-goodness M.D.

Today Grandma Webner would be happy camper because our family has added the next best thing to a doctor — a nurse.  Our niece Brittany Hartnett learned that she has passed all of her boards and is now officially a nurse.

It’s great news for Brittany and her family, and it’s also nice to see the good things that can happen when someone follows their dream and works very hard to see that dream realized.  Becoming a nurse takes a lot of effort and dedication and stamina, to say nothing of a strong stomach and an enormous reservoir of patience and goodwill toward humanity.  There’s a chronic shortage of nurses in the United States, and it’s reassuring to know that talented young people like Brittany are stepping up to answer the call and fill that important need.

Congratulations, Britt!

What We Don’t Know

The Friendly Doc Next Door, who knows I’ve been following a low-carb regimen, sent along an email that he received from the American Medical Association this week.  It was a news summary called AMA Morning Rounds, and the lead story was about a new study that showed that low-carb diets are better than low-fat diets for reducing the risk of heart disease.

It’s 20140905-062424-23064638.jpggreat to have a thoughtful doctor in the neighborhood — especially one who keeps his yard in tip-top shape — to keep us abreast of the latest health news.  And the study mentioned in the AMA email, which was funded by the National Institutes of Health, is significant.  It concludes that people who follow a low-carb diet lose more weight and have fewer cardiovascular risks than people who follow the low-fat diets doctors have been recommending for decades.

Whoo-hoo!  I win!  Of course, not really.  What this new study really tells us is that there is an awful lot we don’t know — but we don’t really want to acknowledge that fact.  For decades doctors were confidently telling patients that the low-fat diet was the way to go, and the patients accepted that.  Now a new study says something different.  What’s a dutiful patient supposed to do?

I like the low-carb approach because it’s easy to remember when mealtime comes and I like meat and cheeses, anyway.  I feel like it’s working for me.  But I also can see that people who don’t really like eating meat will groan if low-carb now becomes the new low-fat and is prescribed for everyone who wants to lose weight.

My guess is that there are many ways to lose weight, provided you reduce your intake and make sure you get exercise.  What this latest study really tells us is that confident conclusions about health — like the decades of focus on low-fat diets — are often wrong.  That is useful information to remember.

The Network Issue

Another area in which the Affordable Care Act will have an impact on health care in America is beginning to get some attention.  It has to do with the “provider networks” — that is, the collection of doctors, hospitals, and other health care facilities and personnel being offered by some of the new insurance plans.

The Affordable Care Act posed some difficult challenges for insurers.  Under the statute, they were required to include a number of new, mandatory forms of coverage in their health care plans.  That requirement, obviously, limited the ability of insurers to control the costs of particular plans by tailoring the kinds of care covered by those plans.  But the insurers still need to figure out a way to control costs, because their plans need to be competitively priced.

There aren’t a lot of remaining cost-control options. One is to tinker with things like co-payments and deductibles and increase the non-premium payments that the insureds must make when they use health care.  Another is to limit the networks to particular health care providers who, due to location or contractual agreement or some other consideration, are offering health care at lower prices than their competitors.

That’s the gist of an article in the Wall Street Journal by a cancer patient whose existing policy has been canceled and who can’t find a substitute policy that includes all of the providers that have given her the unique combination of care that has allowed her to beat the odds and survive.  It’s an indication of the kind of long-term effects that will play out over time, as the Affordable Care Act reshapes the health care market.  In the individual market, at least, Americans who are used to going to whichever doctor and hospital they choose may need to change their habits — and they probably won’t be very happy about it.

The Arugula Initiative

Every year, when I go to the doctor for my annual physical, I hear the same thing:  you need to change your diet.  Consume less red meat, try to eat more fish, and — especially — eat more vegetables.  So, as the date of my annual physical nears, I always find myself trying to choke down some green, leafy item so that I can tell my doctor, in good faith, that I’m trying.  I’m like the kid who hopes to make up for months of complete inattention to dental hygiene by brushing and flossing diligently on the morning of his dentist’s appointment.

IMG_4810The doctor isn’t fooled by this charade, and I feel bad that I am not more compliant with his instructions.  He’s a doctor, after all, and has gone through years of education and training that allow him to say, with absolute conviction and sincerity, that I should eat more vegetables.  The problem is that I just don’t like vegetables!  At a restaurant, I’ll always order soup rather than salad — or if the soup options are of the gazpacho variety, I’ll just eat bread until my steak, medium rare, is brought to the table.

Fortunately, my lovely wife has come up with a solution to this problem.  It’s called arugula.  When she first asked if I liked arugula, I thought she was referring to that part of the human body that hangs down from the roof of your mouth at the back of your throat.  Instead, it is a leafy vegetable that looks like a weed from your garden and has a spicy taste.  Who knew?  It turns out that if you apply some tart vinaigrette dressing and add some parmesan cheese and blueberries or nuts to a bowl of arugula, it is reasonably edible.

So, we’ve been eating arugula lately, to the point where we must be mindful of arugula fatigue.  Arugula farmers the world over are celebrating the arrival of another convert to arugulaism.  And, when I go in to see my doctor for my check-up in a few weeks, I’ll be able to tell him I’ve been eating more vegetables — and for once my statement will have the incidental merit of being true.