1. It shouldn't be a surprise
2. You should have some idea of the answer before you ask the questions
3. It is not how you start the conversation.
4. Don't consult social work, ask yourself!
It's interesting to me how intimidating it is for doctors/residents/med students to bring up hospice (for a variety of reasons) and for patients/families to have it brought up or to bring it up. So to make thing simpler, I've come up with this analogy that I think applies for at least these 4 reasons.
Wednesday, June 20, 2012
Tuesday, June 5, 2012
Why it is difficult to collaborate with your physician
Recently I read two articles in the NYTimes (1, 2), stating how doctor's and patients fail to communicate or collaborate meaningfully and why that is necessary. I recently wrote about what questions I would ask a doctor when a doctor proposes a medical intervention whether that is a surgery, a medication or a test.
Here is the problem: doctor's don't have the answers to these questions readily available and even if they did, they don't have the time to explain the answers to those questions.
1. Guidelines and review articles often fail to present data in a clinically relevant way. It is up to the individual physician to go through the studies in detail to translate the info into a clinically meaningful way. Most docs don't have access to articles or time to do things like this.
2. It takes me a good half hour to explain the proper use of Aricept for example or the role of cholesterol medications or when to do prostate cancer screening. It takes time. I don't have that time.
Good intentions are nice but the data as presented currently and the structure of the office visit as constrained by financial pressures makes collaborating more of a pipe dream.
Here is the problem: doctor's don't have the answers to these questions readily available and even if they did, they don't have the time to explain the answers to those questions.
1. Guidelines and review articles often fail to present data in a clinically relevant way. It is up to the individual physician to go through the studies in detail to translate the info into a clinically meaningful way. Most docs don't have access to articles or time to do things like this.
2. It takes me a good half hour to explain the proper use of Aricept for example or the role of cholesterol medications or when to do prostate cancer screening. It takes time. I don't have that time.
Good intentions are nice but the data as presented currently and the structure of the office visit as constrained by financial pressures makes collaborating more of a pipe dream.
Wednesday, May 23, 2012
Trusting your doctor
One of the main things I do is to work with patients and families in education and making decisions. It can be the most rewarding thing I do and the most frustrating.
I've learned something about the frustrating times-at some point, people have to trust other people. Life works better that way. Many times, patients and families don't trust their health care team (which is understandable-really). But the way they compensate for that is by thinking they can learn the expertise to oversee the health care team and direct the health care team. I get that as a sentiment. It is intuitive, but impossible to carry out.
I'll give you a simple example, whether or not to take aspirin to prevent a first heart attack or stroke. There are a handful of studies over the last 20 years that have gone into making the USPSTF guidelines. There are newer studies coming out (1, 2, 3). All have methodological/epidemiological issues (internal validity-is the study well done). They all have external validity issues (application to a particular patient/population in the real world). They attempt to communicate risk and benefit by using things like relative risk, Number Needed to Treat, absolute risk reduction, 10 year risk, risk calculators etc.
It takes a lot of thought to digest this info and then it has to be balanced against the evidence for blood pressure reduction, cholesterol reduction, healthy lifestyle, diet, smoking, other blood thinners like plavix etc. To fully appreciate whether taking aspirin is "worth it" or not, a person would have to understand study design, statistical analysis and have a pretty comprehensive view of the literature and then be able to make rational sense of outcomes. This is not easy to do and in fact I would argue for a lay person (or even a physician of the wrong specialty), this would be impossible to do for the simple question of whether someone should take aspirin.
Other questions that come up: should I start a treatment, should I get a diagnostic test, how do I navigate the health system etc are all very difficult questions with very nuanced, subtle, yet vital issues involved.
At some point, patients/families have to trust that the recommendation they are getting from their physician is a good one. If they don't feel that it is, then they need to switch physicians because the solution of trying to know as much as the physician isn't realistic (or any more realistic than me understanding fully a legal issue or real estate issue or a car mechanic issue).
Too many times I've seen people make decisions badly when they are trying to be their own expert. I suppose this is in response to many patients experience that the advice they receive from physicians can be worthless. I get that. It is hard to find a good physician. But the solution to a lack of trust is to find someone to trust or to rebuild trust, not to create the facade of being one's own expert.
I've learned something about the frustrating times-at some point, people have to trust other people. Life works better that way. Many times, patients and families don't trust their health care team (which is understandable-really). But the way they compensate for that is by thinking they can learn the expertise to oversee the health care team and direct the health care team. I get that as a sentiment. It is intuitive, but impossible to carry out.
I'll give you a simple example, whether or not to take aspirin to prevent a first heart attack or stroke. There are a handful of studies over the last 20 years that have gone into making the USPSTF guidelines. There are newer studies coming out (1, 2, 3). All have methodological/epidemiological issues (internal validity-is the study well done). They all have external validity issues (application to a particular patient/population in the real world). They attempt to communicate risk and benefit by using things like relative risk, Number Needed to Treat, absolute risk reduction, 10 year risk, risk calculators etc.
It takes a lot of thought to digest this info and then it has to be balanced against the evidence for blood pressure reduction, cholesterol reduction, healthy lifestyle, diet, smoking, other blood thinners like plavix etc. To fully appreciate whether taking aspirin is "worth it" or not, a person would have to understand study design, statistical analysis and have a pretty comprehensive view of the literature and then be able to make rational sense of outcomes. This is not easy to do and in fact I would argue for a lay person (or even a physician of the wrong specialty), this would be impossible to do for the simple question of whether someone should take aspirin.
Other questions that come up: should I start a treatment, should I get a diagnostic test, how do I navigate the health system etc are all very difficult questions with very nuanced, subtle, yet vital issues involved.
At some point, patients/families have to trust that the recommendation they are getting from their physician is a good one. If they don't feel that it is, then they need to switch physicians because the solution of trying to know as much as the physician isn't realistic (or any more realistic than me understanding fully a legal issue or real estate issue or a car mechanic issue).
Too many times I've seen people make decisions badly when they are trying to be their own expert. I suppose this is in response to many patients experience that the advice they receive from physicians can be worthless. I get that. It is hard to find a good physician. But the solution to a lack of trust is to find someone to trust or to rebuild trust, not to create the facade of being one's own expert.
Tuesday, May 1, 2012
What Questions Should I Ask My Doctor?
One thing I do on a regular basis is help patients and caregivers make medical decisions. I watch my colleagues in other specialties give information and guide patients in decision making and I am often left with a fairly dissatisfied feeling that the conversation didn't quite hit the spot when I see the decisions are made and the regret that many families have afterwards. Decisions to start dialysis, transition to hospice, place someone in a nursing home, proceed with an amputation, put in a feeding tube or a defibrillator, start chemo, send someone to the emergency room, put someone on a ventilator are all decisions that are very complicated. Even starting or stopping a statin for cholesterol is not an easy decision. When discussing code status (DNR/DNI), all simplicity goes out the window. The way the medical community is supposed to help families is through a process called informed consent. This has been determined by the court system and ethicists as the minimal amount of information a doctor is obligated to give a patient and family before asking for a decision.
From the AMA's website on informed consent
In the communications process, you, as the physician providing or performing the treatment and/or procedure (not a delegated representative), should disclose and discuss with your patient:
1. The patient's diagnosis, if known;
2. The nature and purpose of a proposed treatment or procedure;
3. The risks and benefits of a proposed treatment or procedure;
4. Alternatives (regardless of their cost or the extent to which the treatment options are covered by health insurance);
5. The risks and benefits of the alternative treatment or procedure; and
6. The risks and benefits of not receiving or undergoing a treatment or procedure.
In turn, your patient should have an opportunity to ask questions to elicit a better understanding of the treatment or procedure, so that he or she can make an informed decision to proceed or to refuse a particular course of medical intervention.
It has taken me a while to figure out what I don't like about the informed consent process. Informed consent has it all wrong! The problem with this model is that it spends all the time talking about the procedure/alternatives and not enough time emphasizing how it is contextualized to the patient. I suppose under risks and benefits it could be assumed that a doctor would let a patient know how a given intervention will impact their life, but the way informed consent is done, it often stops with the immediate physiological benefit (you will not have a blocked bowel, your heart will restart, it will fight the cancer, your blood pressure will be lower).
There are two problems
1. No matter how detailed the information, there is simply no way for a patient and family to truly understand the above 6 points without understanding the full medical literature combined with personal clinical experience. It is one thing to say a patient may suffer or that a procedure may succeed, but what does that look like exactly? Not being an oncologist, no matter how much education I get on chemotherapy, I will never really understand how one regiment is better than another without looking at the literature and seeing how patients are affected in real life. Informed consent is a facade that makes doctors, patients and families think that the patient/family is making the decision autonomously where in reality it is like picking a dish at a new restaurant: you can read the description but you don't really know how it will turn out. To put it another way, I have a very low illiteracy when it comes to cars. No matter how many times someone explains to me different types of catalytic converters, a-I don't really care and b-I don't get it, just fix it or put a new one in and make my car go...which brings me to my second point
2. The most important part of the decision making is figuring out how the options fit in with a patient's goals of care, not the ins and outs of the medical procedure, the literature and the clinical experience and the science. For example, patients need to have some sense of whether a procedure will help them live longer, cause pain, be more independent, enjoy life, suffer less. I think giving patients/families the best information we can about goal directed outcomes will allow them to make much more relevant choices.
Here is my schematic
These are the four areas I think about when helping a family make decisions. Too many times the conversation takes place completely in the top right circle of the medical science and technicalities of the intervention itself. Too often how it would impact a patient's goals gets ignored. I would argue that if a conversation regarding a medical decision took place completely in the top left circle, bottom left circle, it would be a much more complete and accurate way to make a decision that will reflect the patient's best interest and will produce the least regret.
One thing I worry about is when doctor's tell patients what their goal should be and patients tell doctors what procedure/treatments they want. That gets things backwards. Ideally a patient would state a goal and the doctor would tell them the best way to achieve that goal. So for example, a physician may say, I know your goal is to live as long as possible with your wife at home, let's do hormonal therapy for prostate cancer because it will maximize your chances of surviving while minimizing the toxicity of treatment. Or he may say, I know your goal is to live as long as possible and you are okay with taking risks, let's do surgery and chemotherapy as your best chance for living as long as possible even though it is riskier.
At
When it comes to informed consent, I usually don't like how it is done anyway even putting the goal issue aside. Here is what I would want discussed:
1. Is it even effective in an older adult?
2. Is it effective for a clinical endpoint that the patient cares about?
From the AMA's website on informed consent
In the communications process, you, as the physician providing or performing the treatment and/or procedure (not a delegated representative), should disclose and discuss with your patient:
1. The patient's diagnosis, if known;
2. The nature and purpose of a proposed treatment or procedure;
3. The risks and benefits of a proposed treatment or procedure;
4. Alternatives (regardless of their cost or the extent to which the treatment options are covered by health insurance);
5. The risks and benefits of the alternative treatment or procedure; and
6. The risks and benefits of not receiving or undergoing a treatment or procedure.
In turn, your patient should have an opportunity to ask questions to elicit a better understanding of the treatment or procedure, so that he or she can make an informed decision to proceed or to refuse a particular course of medical intervention.
It has taken me a while to figure out what I don't like about the informed consent process. Informed consent has it all wrong! The problem with this model is that it spends all the time talking about the procedure/alternatives and not enough time emphasizing how it is contextualized to the patient. I suppose under risks and benefits it could be assumed that a doctor would let a patient know how a given intervention will impact their life, but the way informed consent is done, it often stops with the immediate physiological benefit (you will not have a blocked bowel, your heart will restart, it will fight the cancer, your blood pressure will be lower).
There are two problems
1. No matter how detailed the information, there is simply no way for a patient and family to truly understand the above 6 points without understanding the full medical literature combined with personal clinical experience. It is one thing to say a patient may suffer or that a procedure may succeed, but what does that look like exactly? Not being an oncologist, no matter how much education I get on chemotherapy, I will never really understand how one regiment is better than another without looking at the literature and seeing how patients are affected in real life. Informed consent is a facade that makes doctors, patients and families think that the patient/family is making the decision autonomously where in reality it is like picking a dish at a new restaurant: you can read the description but you don't really know how it will turn out. To put it another way, I have a very low illiteracy when it comes to cars. No matter how many times someone explains to me different types of catalytic converters, a-I don't really care and b-I don't get it, just fix it or put a new one in and make my car go...which brings me to my second point
2. The most important part of the decision making is figuring out how the options fit in with a patient's goals of care, not the ins and outs of the medical procedure, the literature and the clinical experience and the science. For example, patients need to have some sense of whether a procedure will help them live longer, cause pain, be more independent, enjoy life, suffer less. I think giving patients/families the best information we can about goal directed outcomes will allow them to make much more relevant choices.
Here is my schematic
One thing I worry about is when doctor's tell patients what their goal should be and patients tell doctors what procedure/treatments they want. That gets things backwards. Ideally a patient would state a goal and the doctor would tell them the best way to achieve that goal. So for example, a physician may say, I know your goal is to live as long as possible with your wife at home, let's do hormonal therapy for prostate cancer because it will maximize your chances of surviving while minimizing the toxicity of treatment. Or he may say, I know your goal is to live as long as possible and you are okay with taking risks, let's do surgery and chemotherapy as your best chance for living as long as possible even though it is riskier.
At
When it comes to informed consent, I usually don't like how it is done anyway even putting the goal issue aside. Here is what I would want discussed:
1. Is it even effective in an older adult?
2. Is it effective for a clinical endpoint that the patient cares about?
3. What is the time frame for efficacy (over long term/short term)
A. Will the patient outlive the usefulness of the intervention?
B. Will they achieve it within their life expectancy?
4. What is the likelihood of achieving benefit (i.e. NNT)?
Is that worth it to the person?
5. Is it worth the risk of side effects?
Is it worth the risk of failure
6. Will it achieve their QOL goal?
7. Is it a priority among all the person’s medical problems?
At the end of the day, contextualizing a decision in a patient's goal is far more important to me than discussing the ins and outs of the science of a medical intervention. Unless it is translated to a goal, the information is useless. And I would argue that a translated decision into a goal without the discussion of the ins and outs of the intervention would still lead to a pretty accurate choice that reflects the patient and minimizes the chances of making a wrong decision or guilt.
Tuesday, November 8, 2011
Do I need an Implantable cardioverter-defibrillator (ICD)?
What is an Implantable cardioverter-defibrillator anyway? Can I get it shut off? These are the type of questions I get. (BTW I tend to blog in spurts).
So here is the context: A 92 year old male patient of mine with metastatic melanoma, end stage (class 3, stage d) heart failure, recent fall with (a minor) hip fracture came to see me in the office. He had just had an ICD placed in July. This guy's main complaints were: he wants ear wax out so he can hear, he wants to stop urinating at night, he wants to sleep better at night, he wanted to be less short of breath, and stay at home with his wife. He had been hospitalized 5 times in 4 months for CHF and Oncology decided that his melanoma was only treatable with chemotherapy.
Question: What good is an ICD for this guy? This guy wants to avoid surgeries, being debilitated, lingering in pain and ICU's. He does not want aggressive care. If he could choose a way to die, he would like to die peacefully in his sleep. He wants to die in the hospital to avoid stressing out his family but does not want to end up in the ICU.
So what does an ICD do? Well just as a person is about to die peacefully in their sleep, or about to faint, lose consciousness and die painlessly, a large electrical shock wakes them up painfully and restarts their heart. Well for me, I would love that because I have no desire to die in my sleep. But for an older patient that is looking at dying from cancer vs heart failure vs consequences of immobility vs dying peacefully in his sleep, it's easy to see why he picked dying in his sleep painlessly, without being short of breath as his preferred way of dying. BUT an ICD is designed to prevent that specific way of dying.
The other thing to note is that the ICD often has false electrical shocks (of which this guy has had one), does not prevent death in all circumstances (asystole or when the heart stops altogether) and if you were to calculate a NNT (number needed to treat) it would likely be in the teens to 20's somewhere. In other words, it does not help the majority of people, and in those it helps, it likely delays death by months instead of preventing it altogether (kinda obvious but needs to be stated anyway), and it works by preventing what is likely the most peaceful way of dying.
Again, if you are a 45 year old person with a passion for life, a tolerance for medical procedures, then go for it. If you are looking at several ways of dying from various medical problems, many of which would cause suffering, then one needs to carefully consider not having an ICD placed which is designed to prevent the most peaceful way of dying I can think of.
So here is the context: A 92 year old male patient of mine with metastatic melanoma, end stage (class 3, stage d) heart failure, recent fall with (a minor) hip fracture came to see me in the office. He had just had an ICD placed in July. This guy's main complaints were: he wants ear wax out so he can hear, he wants to stop urinating at night, he wants to sleep better at night, he wanted to be less short of breath, and stay at home with his wife. He had been hospitalized 5 times in 4 months for CHF and Oncology decided that his melanoma was only treatable with chemotherapy.
Question: What good is an ICD for this guy? This guy wants to avoid surgeries, being debilitated, lingering in pain and ICU's. He does not want aggressive care. If he could choose a way to die, he would like to die peacefully in his sleep. He wants to die in the hospital to avoid stressing out his family but does not want to end up in the ICU.
So what does an ICD do? Well just as a person is about to die peacefully in their sleep, or about to faint, lose consciousness and die painlessly, a large electrical shock wakes them up painfully and restarts their heart. Well for me, I would love that because I have no desire to die in my sleep. But for an older patient that is looking at dying from cancer vs heart failure vs consequences of immobility vs dying peacefully in his sleep, it's easy to see why he picked dying in his sleep painlessly, without being short of breath as his preferred way of dying. BUT an ICD is designed to prevent that specific way of dying.
The other thing to note is that the ICD often has false electrical shocks (of which this guy has had one), does not prevent death in all circumstances (asystole or when the heart stops altogether) and if you were to calculate a NNT (number needed to treat) it would likely be in the teens to 20's somewhere. In other words, it does not help the majority of people, and in those it helps, it likely delays death by months instead of preventing it altogether (kinda obvious but needs to be stated anyway), and it works by preventing what is likely the most peaceful way of dying.
Again, if you are a 45 year old person with a passion for life, a tolerance for medical procedures, then go for it. If you are looking at several ways of dying from various medical problems, many of which would cause suffering, then one needs to carefully consider not having an ICD placed which is designed to prevent the most peaceful way of dying I can think of.
Tuesday, August 2, 2011
Communicating to physicians goals of care
Goals of care worksheet.
In geriatrics, there are so many issues to consider before deciding what is best for a patient. Nothing is more important than the goals that a patient defines for himself. While the effectiveness of treatments change as a person ages, and social situations and other medical problems can affect what is best, achieving a patient's goals should be the primary aim of a medical plan. The goals may vary based on what type of medical interventions a patient can tolerate, whether they want to live longer vs more comfortably.
The link is to a worksheet that I wrote that I hope will help people communicate goals to their physicians. The concern is that physicians can look at an older person and make two really wrong assumptions: that a older person is too old for certain interventions or that they should be treated like a 45 year old. Neither is right. A person should receive a treatment that is appropriate and that largely depends on what they want and their goals.
Edit:
Two things missing that have been suggested: spiritual beliefs and some sort of question about where a person, ideally, would like to spend their last days.
In geriatrics, there are so many issues to consider before deciding what is best for a patient. Nothing is more important than the goals that a patient defines for himself. While the effectiveness of treatments change as a person ages, and social situations and other medical problems can affect what is best, achieving a patient's goals should be the primary aim of a medical plan. The goals may vary based on what type of medical interventions a patient can tolerate, whether they want to live longer vs more comfortably.
The link is to a worksheet that I wrote that I hope will help people communicate goals to their physicians. The concern is that physicians can look at an older person and make two really wrong assumptions: that a older person is too old for certain interventions or that they should be treated like a 45 year old. Neither is right. A person should receive a treatment that is appropriate and that largely depends on what they want and their goals.
Edit:
Two things missing that have been suggested: spiritual beliefs and some sort of question about where a person, ideally, would like to spend their last days.
Sunday, July 3, 2011
So what does it mean to "be a doctor."
Edit:Please read the first part too!
Continuing with my last post on some non geriatric thoughts, the author of the NYtimes commentary told a medical student that if she wanted to be a doctor, she should just "be a doctor" implying that caring about a family life may not be compatible with being a doctor. Or at least her image of being a doctor. So it got me thinking, how would this author define "being a doctor?" I think her commentary raises more questions than answer.
My main question is what is the metric of a "being a doctor." How does one know that he is "a doctor."
1. Is it the number of hours per week? Is it 20, 30, 40, 60, 80, 120? Clearly for the author, 20 is not being a real doctor. But how does she draw the line?
2. Is it how many nights per week one takes call? She thinks you have to risk some interruption. How much is enough? Once a week, every night or something inbetween?
3. How many patients per hour does it take to be a real doctor? Apparently in her opinion, you have to see as many as men do. But why is that the metric? Is it 4 patients per hour or 12?
4. Other questions: Does a real doctor have to teach? Do research? Publish? Go to conferences?
At what point does caring about your personal life make you cease being a real doctor? Does she set no limits at all? If she does, how does she define herself as being a real doctor?
5. How many years should a real doctor work? In a medical school setting, we've all met docs in their 80's who have no desire to retire. Is that what real doctors do? (WWRDD-what would real doctor do?). Is it wrong for someone in their thirties decide to be doctor if their careers are shorter? How about in their 40's or 50's even?
6. How much vacation can a doctor take? As you can see, the questions become one of bravado: I work harder than you, that makes me more of a real doctor? Which specialties are real doctors? If you are a pathologist and never take call, are you a real doctor?
At the end of the day, I think the crux of the matter is that if by putting your personal life first, and by doing so you practice medicine in such a way to put patients at risk of bad outcomes, or you don't even care about the quality of medicine you are practicing as long as it fits your lifestyle, then you need to consider stopping the practice of medicine. That's unfair to patients. But if you take your job seriously, make sure your patient are well taken care of, your patients are satisfied and you practice good quality medicine, then you are "a doctor."
Continuing with my last post on some non geriatric thoughts, the author of the NYtimes commentary told a medical student that if she wanted to be a doctor, she should just "be a doctor" implying that caring about a family life may not be compatible with being a doctor. Or at least her image of being a doctor. So it got me thinking, how would this author define "being a doctor?" I think her commentary raises more questions than answer.
My main question is what is the metric of a "being a doctor." How does one know that he is "a doctor."
1. Is it the number of hours per week? Is it 20, 30, 40, 60, 80, 120? Clearly for the author, 20 is not being a real doctor. But how does she draw the line?
2. Is it how many nights per week one takes call? She thinks you have to risk some interruption. How much is enough? Once a week, every night or something inbetween?
3. How many patients per hour does it take to be a real doctor? Apparently in her opinion, you have to see as many as men do. But why is that the metric? Is it 4 patients per hour or 12?
4. Other questions: Does a real doctor have to teach? Do research? Publish? Go to conferences?
At what point does caring about your personal life make you cease being a real doctor? Does she set no limits at all? If she does, how does she define herself as being a real doctor?
5. How many years should a real doctor work? In a medical school setting, we've all met docs in their 80's who have no desire to retire. Is that what real doctors do? (WWRDD-what would real doctor do?). Is it wrong for someone in their thirties decide to be doctor if their careers are shorter? How about in their 40's or 50's even?
6. How much vacation can a doctor take? As you can see, the questions become one of bravado: I work harder than you, that makes me more of a real doctor? Which specialties are real doctors? If you are a pathologist and never take call, are you a real doctor?
At the end of the day, I think the crux of the matter is that if by putting your personal life first, and by doing so you practice medicine in such a way to put patients at risk of bad outcomes, or you don't even care about the quality of medicine you are practicing as long as it fits your lifestyle, then you need to consider stopping the practice of medicine. That's unfair to patients. But if you take your job seriously, make sure your patient are well taken care of, your patients are satisfied and you practice good quality medicine, then you are "a doctor."
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