Saturday, August 18, 2012

Why social media will work in medicine: Storytelling


Michael Wilson says it best in his book Redirect: The surprising new science of psychological change. It's the stories that motivate behavioral change, not data, because true behavioral change requires an emotional hook that can only come from people we know or identify with.

Meeting our doctor, presented before us in a white uniform, ourselves undressed, in a sterile unadorned room, makes emotional connection difficult at best.

When patients are told to change the way they eat, to add thirty minutes of exercise to their lives daily, to take pills that, if nothing else, tell us they're sick, and to stop drinking and stop smoking, these recommendations are useless if there is no emotional hook, if there is no story.

Social media provides a story. If patients were linked by social media with both their care providers and similar patients, then the stories of why and how behavior change supports health can flow. With social media comes the emotional hook to live better through healthy behavior that struggles to survive in the aseptic office.

I can see the heads shaking in disapproval, that tools like Facebook and Twitter don't belong in medicine, that even if health information could be protected, it'd be a massive waste of time.

I humbly ask, how much time is wasted making negligible inroads into staggering issues like smoking cessation or obesity? How much time is wasted investing in chemotherapy and diabetes treatments rather than prevention? Might it not be worthwhile to at least try the storytelling capacity of social media?

Sunday, July 15, 2012

The Storyteller: Best of Times, Worst of Times

Image from Jemimus


The storyteller is in an odd place today.

On one hand, a compelling story commands less authority than it used to. For information to be useful, for it to gain the deepest traction and the widest influence, it must be able to be turned into an app, to find its utility among the ubiquitous mobile devices currently trolling the information landscape in service to its user.

Stories aren't easily extracted, they don't fall into this paradigm of utility.

As such, the storyteller of yore is left behind. As the wise man or woman waxes on, appending one penetrating insight after another on top of anecdotes where the n is charmingly one, generation Y is staring at their phone looking to see where their friends are meeting up after.

And yet, as these mobile devices proliferate (some say metastasize), the storyteller's audience grows ever larger and ever more accessible. Never before has penetrating insight been so easily distributed.


I think the storytellers have lost the battle, but they've won the war. Sure, the audiences within earshot are staring head down at their phones. But. The world is inundated with information, deluged with data, and crying out for someone to make sense of it all. And sense of it all is analogous to insight.

Data is nice, but insight is priceless. Keep on truckin' you storytellers. Take a look at the data, information, knowledge, wisdom pyramid and take heart that we need your insight and wisdom at the top. You just need to get out there (on the interwebs), and be extra careful not to make stuff up. (Your authoritative tone used to win over audienes within earshot, but it doesn't work on the interwebs. Instead, just link it up and show us that you thought it through.)

Saturday, June 23, 2012

Social Media for Medical Students Part III: Stages of Engagement


Image by Sean MacEntee


This is an excerpt from a complete, downloadable policy found here.

Introduction:
If medical schools are going to encourage students to engage social media, students should do so gradually and at a pace that poses minimal risk to themselves, the patients they serve, and their home institution. The Levels of Engagement are designed to offer a stepwise introduction that starts from the most removed, and therefore safest, level of engagement, and progresses toward increasing involvement.

Since most, but not all, medical students enter training with some social media experience (Facebook and reading/writing blog entries), several of these levels may seem unnecessary. However, as noted above, incoming students are not yet familiar with the differences between casual social media use and that of a physician in training. Therefore, an effective system offers recommendations accessible to members at any stage of social media facility.



46 Angles: Legal, Ethical and Professional Obligations to Patients, Institutions, and Self


Image by eldh

This is an excerpt from my complete, downloadable policy here.

Introduction:
Medical students are unique users of social networking tools like Facebook and Twitter, among others. In brief, I describe five reasons for this: 1) The information that medical students steward is particularly sensitive, the privacy of which is protected by federal legislation (HIPAA). 2) Sharing patient information is central to both the practice and culture of medicine. 3) Medical students have a lot to lose, both in terms of resources invested and future career ramifications, if found in violation of privacy rules. 4) Having matured entirely in the internet age, most today’s medical students have deeply ingrained information sharing habits that are incommensurate with the traditions of their profession. 5) There is a growing body of MD’s, healthcare workers, pharmaceutical representatives, information technology firms, and others, many with unclear motivation, who encourage medical students to engage with social media without adequately preparing them to be responsible.      

In hopes of addressing these risks, this document discusses separately the means to protect students themselves, their patients, and their home institutions (medical schools, hospitals, and clinics), organized into 46 distinct points that deserve a thorough inspection and understanding.

Protecting Patients:
While upholding the legal responsibilities of patient information is of primary importance, students must understand that they have ethical and professional obligations above and beyond the requirements of HIPAA legislation. These three areas are addressed separately.

Legal Obligations:
1- Students may not share any “‘individually identifiable health information’… that relates to the individual’s past, present or future physical or mental health or condition… for which there is a reasonable basis to believe it can be used to identify the individual.”1 (Appendix A)

2- In addition, any shared information must be expunged of 18 identifiers, the most common of which are the following: (See appendix A for complete list)
           
            - Name
            - Location: All subdivisions smaller than state (street, city, county, zip code, etc.)
            - Date: Birth dates, admission/discharge dates, encounter dates, surgery dates, etc.
            - Images: Full face photographic images and any comparable images
            - Age if Above 90 Years
3- Since the specifics of a case are protected, general comments about the uniqueness or other interesting features of a presentation are unacceptable.
            Examples:
                        “I saw my first case of Guillain-Barre syndrome today.”
                        “I got to assist in the repair of a total anomalous pulmonary venous return!”
                        “This lady had a birthmark that looked like China.”
                        “I saw a guy with a tattoo of Gandhi.”

4- Since location is protected, no information about patients may be shared on services that are location-aware, such as a Facebook profile that includes the student’s city, or tweets that are geo-tagged.

5- Since dates are protected, no postings may be referred to by time, including use of the word “today,” as in, “I participated in my first birth today!”

6- Pictures, even if not including faces or any other identifying information, are unacceptable if they relate to unique features.

7- Since age above 90 is protected, one must describe encountering a 92 year-old as “a patient over 90 years old.”

Ethical Obligations:
Even if the patient information has been de-identified and is therefore lawful to share, it may still be unethical or unprofessional. A student should have an adequate grasp of the special ethical issues surrounding patient care before engaging in any online discussion of experiences. The following guidelines are addressed for each major ethical principle.2

Dignity- Student doctors should empathize with patients as individuals capable of making choices based on their particular values. Patients are vulnerable by definition, and especially vulnerable when being discussed in public without the ability to represent themselves.
       
8- Display empathy with shared feelings rather than pronouncing judgments.

9- Don’t objectify patients as disease states; use “patient with diabetes” rather than “diabetic.” Be especially careful to avoid derisive terminology, for example “cabbage patch,” a term sometimes used in the cardiac critical care unit.

10- Don’t demean choices that patients make or the values that drive those choices. For example, never judge the cause of a patient’s obesity or motivations for smoking.

Compassion- Student doctors should demonstrate sympathy for suffering and misfortune and efforts to provide relief, without prejudice. Casually discussing experiences in the day-to-day jargon common among physicians demonstrates a lack of compassion to those patients and their families, to others suffering with those same conditions, and to all those in the caring community who empathize.
11- Don’t trivialize suffering by speaking casually about a patient experience. Comments about an operation being “cool” or showing excitement at seeing an exotic condition are inappropriate in public.

12- Even if de-identified, publicly sharing the gory details of a case, including pictures, show a lack of concern for suffering.

13- Avoid including unnecessary details (demographics, ethnicity, etc.) in support of stereotypes of certain conditions.
       
Confidentiality- Although confidentiality is protected by law, doctors must still pro-actively assure patients of this. A student doctor maintaining an online presence gives cause for doubt, which may discourage patients from seeking treatment and from being open about sensitive details. Therefore, such practitioners should take the extra effort to assure that their online behavior can’t be perceived as violating confidentiality.

14- Don’t make jokes or other comments that may be misinterpreted as a lapse in confidentiality.

15- Only share powerful, intimate experiences to make a powerful point for an upright cause.

16- Be extra careful to identify when you have been given permission to share information.

Honesty- Doctors are knowledge workers, and their service to society depends on trust. It is important to maintain a consistent message in the office and in public, including online.

17- Never write something that you are not confident is true. Do not promote anything that you do not truly support. Do not publish partial truths that may mislead. Do not make promises you cannot keep. When possible, offer references.

Act in the Best Interest of Patients.

18- Don’t be selfish- Online content about patients should only be shared for their ultimate benefit. As in all walks of medical life, you should always ask yourself if and how this serves patient interests before posting.

19- Don’t post details in order to impress, to achieve credibility or gravitas, to entertain, to shock, or to ridicule.

20- Be open about conflicts of interest.
     
21- Competence- Only offer services that you can safely and effectively provide. Do not try to offer interventions online if you lack the means to competently follow through.

22- Do not attempt to establish a therapeutic relationship online. Instead, wait until guidelines for “best practices” are established.

23- A special note on “friending”- There is no reason, at least for a student doctor, to establish a close relationship with select patients (i.e. friending on Facebook), unless you previously know the person in a personal context outside of patient care. If so, you should not discuss that patient’s care in any way.

Professional Obligations:
Unlike other industries, doctors have a contract with society wherein they agree to provide services in their patients’ best interests, superseding doctors’ own gains, financial or otherwise. Doctors have a fiduciary responsibility not only to provide care at the bedside, but to advocate for patients in the public space on social justice issues like access to care and fairness of distribution and allocation of healthcare resources. This translates to several obligations in the online space.
           
24- Social Justice: Student doctors must develop an understanding of healthcare issues and work toward becoming comfortable in advocating for their position. Online comments about public policy should be restricted until this comfort has been reached, lest impulsive opinions both mar the discourse and come back to haunt the student later in their career.

25- Discipline: Just as society relies on the medical profession to regulate itself, student doctors should take action when they see others behave inappropriately online. When doing so, students should be mindful to communicate only with those directly involved, in private, and with great discretion. Additionally, students must recognize that they may be taking online content out of context and should therefore approach their colleagues delicately.

Protecting Institutions:
Medical schools and hospitals have special relationships with their communities, forged on years of intense experience, sacrifice, dedication, volunteerism, and shared community identity. As a member of such an institution, a medical student represents a variety of groups, some obvious and others less so. Since perception is reality online, students may easily find themselves unintentionally speaking on behalf of groups in inappropriate ways.

Referent Groups that student doctors implicitly represent:

Medical School: Student’s class, entire student body, faculty and staff, administration, and alumni.
Hospital: Patients—both current and past, staff, volunteers, administration, and donors.
Community: All community members who identify with the hospital and medical school as part of the place wherein they live.
The future: Since online text never dies, your comments also represent the future members of each of these groups—future students, faculty, community members, etc.—for untold years and amid shifting contexts.

26- Be familiar with your institution’s online presence and refer comments with direct links to those sources (homepage, Facebook page, etc.).

27- Check with the marketing department before conducting online activities for a group within the institution. Make sure that the presentation is in-line with the institution’s public face.

28- Refrain from any comments that you are not entirely comfortable making on behalf of the referent groups listed above.

29- Be particularly respectful when referencing your institutions. Since you are speaking in a mixed audience on behalf of a mixed audience, always reflect on how each group that you represent could interpret your comments.

30- Be polite. Address people formally, avoid casual and inappropriate language, especially when offering disagreement.

31- Be serious. Avoid spam or other off-topic content.

32- Be supportive. Avoid self-promotion for its own sake. Avoid cynicism. Be aware of your institution’s values and standards.

33- Be responsible. Avoid posting private material about any group members, including pictures or stories. Complaining about members of your provider team on Facebook is a particularly common transgression.

34- Be accurate. Make sure your statements are in accordance with actual facts and refrain from speculation. If you are not particularly knowledgeable, do not comment. If you make a mistake, address it quickly, honestly, and openly.

35- Offer content that is high quality and unique to your particular area of experience or expertise.

36- Be clear. Explicitly state that you speak only for yourself, as in “opinions are my own.” If you do weigh in on a topic related to the institution, state your role and relationship with that institution. Do use your institution’s email address for within-group correspondence so your identity is clear. Otherwise, use your personal email address.

37- If dissatisfied with an institution’s policy or action, discuss it first only with the people or representatives responsible.

Protecting Students Themselves:
All content posted online must be considered permanent, searchable, and traceable. Additionally, comments on third party services like Twitter and Facebook must be considered someone else’s intellectual property, and they are free to distribute it or otherwise utilize it as they please.

38- First and foremost, to protect yourself and your reputation, you must adhere to the above recommendations, particularly patient privacy.

39- Establishing a robust, quality online presence can create a visibility buffer, where positive content about you rises to the top of search results.

40- Do not offer medical advice, or anything that could be interpreted as medical advice.

42- Do not solicit, or interact in a way that could be interpreted as soliciting, protected health information.

43- Reflect before you post. Think about the different ways your content may be misconstrued. One mistake may be sufficient to terminate an entire career.

44- As a future physician, impulsive and uninformed comments made during training may be considered to represent you at any point later in your career.

45- Comments on topics unrelated to medicine may be considered reflective of your medical judgment and trustworthiness.

46- Comments left on other people’s content, such as blog posts, may be attached to the sentiment of those posts, even if you are expressing disagreement.



Social Media for Medical Students Part I: Why Engage?


Image by Rosaura Ochoa

This post is an excerpt from my complete, downloadable guide published here.

Part I: Social Media Strategy for Medical Students

Introduction:
Budding physicians are coming to recognize the power of a few good apps. Consider the following situation: your patient with right upper quadrant pain and abdominal distension needs a paracentesis today. Your senior resident is familiar with the procedure, but won’t be by to supervise the intern for a few minutes, during which time the intern is asked to prepare the patient for the procedure. The intern is almost as unfamiliar with the procedure as you are. Typically, you would witness the ongoing display of feigned competence, nursing frustration, and patient agitation. Later, during some down time or at home, you would reference paracentesis on the web so that you would be spared the embarrassment you had witnessed. Or, you could use an app.

Medscape is a mobile app designed for doctors that has a little known feature—a procedures tab that includes, among others, paracentesis. There, it describes the indications, preparation, technique, and interpretation of results, all supported with references. More substantive than Wikipedia, more available and too-the-point than UpToDate, you could soon be telling your intern how to prepare, assuring the nursing staff why the procedure is necessary, and explaining to the patient what he can expect when the procedure is finished.

Staying ahead of the information curve is a growing challenge. While medical school trains students to stay current with developments in the clinical and basic sciences, little attention is devoted to the latest point-of-care smartphone, tablet, and web applications. Until medical school curricula effectively modernize from its early 20th century roots, it is unlikely that they will provide guidance for staying abreast of the latest apps. Until that time, your best source will be social networking sites like Twitter, Facebook, blogs, Google+, and any other of the rapidly emerging two-way communication platforms.

A particularly effective method to stay up-to-date on these helpful new tools that are rarely incorporated into traditional medical education is to use Twitter. As of this writing, a useful source is  @iMedicalApps, the Twitter feed for the website iMedicalApps.com. In the form of once or twice daily short messages, or tweets, that include a web link, @iMedicalApps offers continual brief updates that are easy to peruse or search. The @iMedicalApps Twitter feed consists of very brief descriptions with a link, like this:

             “The top 20 free iPhone apps for medical professionals: http://bit.ly/fcGDLe.”

On Twitter, @iMedicalApps is just one of many great resources. The best sources are often an individual physician from a student’s area of interest who can comment on an app’s value from the perspective of an experienced clinician.

What sounds like a time-consuming process is actually more efficient than traditional use of web surfing or email to stay current. Several time-saving features bear mentioning. 1- The content is “pushed” to one place, your Twitter feed, obviating the need to regularly check in on websites and scan through irrelevant material. 2- Since the service is social, particularly useful tweets get highlighted by people in your network who share your interests. If you are interested in primary care, your attention is appropriately drawn when a prominent family physician recommends an interesting patient management app. 3- As a social service, it is also quick and easy to communicate directly with information sources. 4- Unlike email, tweets don’t demand your attention. Instead, they’re simply available for use if you want them.

The purpose of this document is to introduce the value of social media in medicine, particularly for medical students. Contrary to perception, appropriate use of social media supports several requirements of genuine, sound medicine. By adopting tools like Twitter, Facebook, blogging, and a whole host of other interfaces, a medical student can advance their studies and understanding of central aspects of the medical profession. The following are several strategic areas for applying social media tools.

Staying up to date:
People whose career interests match your own and are active in social media tend to share relevant news and updates. By tuning in, you can save yourself much of the effort required to actively hunt up this information. Instead, you can create your own network of interesting sources. Topics can span the massive diversity of relevant medical topics, from basic and clinical developments to changes in policy or technology, only a few of which are genuinely supported by medical curricula. With the accelerating pace of innovation, the sheer volume of “new stuff” can be efficiently filtered with social media.
Example: The Institute of Medicine’s updated its vitamin D recommendations in late 2010. While these guidelines would take months or years to reach medical curricula, social media tools can easily catch these updates on the day they were released. More than that, the social nature allows access to the developing controversy about what the guidelines mean, a controversy and discussion that grows stale with time.

Mentoring and Advice:
Social media services offer a simple way to connect with people who share your interests, to network, and to gain advice. By sharing what others post and commenting on their content, students have a method to casually develop relationships.

Example: The process of students meeting mentors, and ultimately collaborators and letter writers, has already begun with Twitter. On scenario began with the offer of guest lecturing after the would-be mentor noticed his tweets were being shared by an engaged medical student.

Networking:
Social media is a powerful tool to stay in touch with old colleagues. While email exchanges can become burdensome, they often trail off when people separate. Facebook and Twitter offer quick contact with minimal time obligations.

Professionalism:
Being a member of a profession, rather than simply an independent service provider, means engaging with the broader issues of healthcare, both as an individual and as a member of a physicians’ organization.

Example: There are a number of physician-commentators who maintain blogs and post their writings on Twitter. By finding a few compelling voices, one can both keep tabs on developments like healthcare legislation and new provider models, as well as offer comments and share opinions.

Business of Medicine:
Medical schools and residency programs are notorious for releasing their trainees with little preparation for the business realities of managing a practice. Social media offers a way to gain insight into these realities in the absence of classroom content.

Example: New and innovative care models, like direct primary care, do not find their way into medical curricula until they are sufficiently established. However, such cutting-edge techniques often access social media channels to publicize their progress. By gaining exposure to these ideas long before residency, fellowship, and practice, savvy students can have a better idea of opportunities early on in their career planning.

Teaching:
Tools like Facebook or Yammer are excellent resources with which to ask and answer the vast number of questions arising in medical education. Rather than requiring a faculty member to answer individual questions repeatedly by email, open groups enable such answers to be visible to everyone logging in. Such interactive tools both improve feedback and leverage student answers, promoting active learning.

Example: The use of a Facebook group is very well received in a first-year basic science course at SUNY Upstate.

Clinical Applications (in the future):
Although this is largely uncharted territory, there are several examples of doctors who use patient relationships over social media tools to improve scheduling and to affect behavior change. By getting involved earlier, students can establish an understanding of social media tools so that they may become pioneers of these developments.

Thursday, June 14, 2012

Disease-ification: How a person becomes a pathology




"Every patient is the only patient."- Arthur Berarducci

"Each person in need brings to us a unique set of qualities that require unique responses." -Don Berwick, Escape Fire 1999


Disease-ify Verb
      To generalize and then classify a unique person's health complaint in order to match them with an effective remedy that ends to encounter; often done out of convenience, expedience, or for profit.

Unique is a funny word. Every time I come across it, I am reminded of my high school English teacher's admonition that qualifying the word--very unique, kind of unique--is inappropriate. Things are either unique, one of a kind, or not.

Although Dr. Berwick did not have my English teacher, I think he would agree that each patient's presentation is unique in this sense; it is one of a kind. Even the most mundane complaint is buried in a rich social and genetic context that simply cannot be reduced to a chief complaint.

As a moral enterprise, medicine seeks to serve patient interests, and few interests supersede the need to be treated as the unique identities that we are. Therefore, to disease-ify must be seen for what it is: a capacity to cause harm in a profession that professes to do none.

Disease-ification is an important cause of the well-documented harms of overtreatment. In order to serve his or her role in each patient encounter, the assumption is that a physician needs to identify a disease and then match it with a remedy. To do otherwise is to dither.

To Practice Medicine Verb
      To generalize and classify a unique person's health complaint in order to match them with an effective remedy, all the while acknowledging and preserving their uniqueness, in order to heal.

In his inspirational 1999 speech Escape Fire, Dr. Berwick states that "we are not finished--we have not achieved excellence--until each individual is well served according to his or her needs, not ours." Interaction with patients is not "the price of care; it is care, itself." A patient's question is "an opportunity, not a burden."

As I begin my internship next week, I hope to live up to Dr. Berwick's aspirations, to learn how to practice medicine, and resist the urge to just disease-ify.


Thursday, May 17, 2012

Social Media for Medical Students

Image by Marc Smith


Social media use by medical students poses special opportunities and special risks. Although the need for an effective social media policy among students is widely recognized, few have developed a sufficiently robust approach that both encourages appropriate use and outlines the subtle risks.

In this document, Social Media for Medical Students, I have attempted to do both. In particular, I have outlined a basic strategy for using social media to become a better doctor and to plan a career. I have also organized the legal, ethical, and professional responsibilities students have to patients, institutions, and self.

All rights to this document are reserved, with plans for publication.
Social Media for Medical Students

Thursday, May 10, 2012

Do No Harm in the Third Age of Medicine

The Doctor- Luke Fildes 1891

We are in the third age of medicine.

The first age ended in the 1930's with the development of antibiotics. Before then, the best doctors took Hippocrates's dictum to heart with the understanding that the profession really did not have much to offer the sick. Their principle tools were 1) First, do no harm--making sure their limited efforts, however well-meaning, weren't part of the problem. 2) Prognostication--explaining the course of disease and so enabling effective planning, estate management for the rich, choosing who will pick up the chores for the poor. 3) Relief--doctors could amputate and dress a shattered leg, as well as provide opiates to relieve pain. Though not cures, they were quite helpful. 4) Comfort--As a profession dedicated to the sick, often they were the only ones whose job description included tenderness and care.

The second age of medicine began with the advent of antibiotics in World War II. Suddenly, doctors actually had treatments to offer, a few cures that beat back some true scourges of mankind. Beyond vanquishing the streptococcus, antibiotics swept aside the sordid record of patent medicines to prove the concept that chemicals could be empirically be marshaled against any threat to health. In this second age of medicine, doctors were able to offer more and more treatments that actually worked against disease. Their jobs of prognostication, relief, and comfort were downsized. Instead, doctors's proper course was to stop doing house calls and set up clinics to efficiently distribute these treatments.

It's not clear when the third age began, but I will date it to 1997 when the FDA essentially green-lighted direct to consumer advertising of pharmaceuticals. Since then, drug companies have set the standard that is defining the age, and the standard is this: Broaden the market for your intervention by convincing people that they have a disease in need of your therapy. This is done explicitly by Big Pharma as they medicalize the slings and arrows of fortune, outrageous or otherwise, by creating diseases through multibillion dollar advertising and lobbying campaigns. It may also be done implicitly by well-meaning providers who conveniently conflate treatments and revenue streams. In this third age were face the paradox of witnessing the genius of modern medicine from our living rooms, illustrated with the best computer animation and doctors smiling serenely in their crisp white coats, while being told that our nation's health is second rate and threatening to bankrupt the leader of the free world. With the cost of unnecessary care estimated at $700 billion, this third age could be called the age of overtreatment.

What is the physicians' proper course of action in this third age?

Oddly enough, it is a lot like that of the first age: First, do no harm. The great challenge to physicians is to shield their patients from unnecessary treatments. They must stay up to date on which treatments don't help patients (PSA testing doesn't reduce prostate cancer deaths, coronary stenting doesn't prevent heart attacks better than medicines), and they must make sure their patients don't receive them. Doing so involves avoiding the tests (PSA) as much as the interventions (an elevated PSA in the chart can lead a different physician to perform the harmful biopsy and surgery).

Perhaps more startling in this age of overtreatment is the presence of undertreatment. In a heart disease center of excellence, patients are in fact more likely to get a stent and less likely to get aspirin, even though aspirin actually has the strongest track record of preventing heart attacks. Unfortunately, unlike drug-eluting stents, we've been using willow bark (from which aspirin derives) for quite some time, and no one makes money off a glossy commercial highlighting its effectiveness.

In the third age of medicine, doctors must recapitulate the first age: 1) First, do no harm by making sure we aren't a $700 billion part of the problem by shielding patients from private interests, and make sure they get the care, and ONLY that care, that they truly need. 2) Prognosticate so that patients can make informed choices, abjuring the rabbit hole of tests and treatments that may only be helping someone else's bottom line. 3) Never substitute tests and procedures for the provision of relief and comfort, which are timeless interventions that never age.



For more on this issue, see www.avoidablecare.org

Saturday, May 5, 2012

The myth of defensive medicine: Part I



It's been a truism of the last four years of medical school- when in doubt, order some more tests so that you'll have more ammo in court when this patient sues you, commonly expressed: "sues your ass." Politely termed "defensive medicine," it's known on the floors as CYA, "covering your ass." It's no coincidence that this crass thinking is supported with crass dialog.

Doctors who are so keen to avoid lawsuits would probably be very interested to read this Archives of Internal Medicine commentary, which states:

"Ironically, some of these protective steps, far from reducing legal risk, may actually increase it."
This research is not at all new--it's been known since the 1990's that not all patients with even a bona-fide gripe sue, and that the primary reason for lawsuits is poor communication. A vast amount of research boils down to a simple point:
Listen more, get sued less.
But how many times on rounds have I been privy to a discussion where the attending physician justifies another CAT scan by saying:
"We have to cover our asses here: let's order a CAT scan."
If these physicians were so concerned about litigation, their warning should have gone:
"We have to cover our asses here: let's get in there and talk to this patient, share our uncertainties honestly, and listen to their concerns."


Thursday, May 3, 2012

A "First, do no harm" campaign to change culture in medical school


                                                                                                                                                                                                                   Aaron Stupple 5/2/12
Introduction:                                                                                                                         
First, do no harm has a curious place in medicine and culture. On the one hand, it is widely recognized, and sometimes celebrated as “the cardinal ethical principle sacred to medicine.”1 Simultaneously, it is often rejected by bioethicists as “inadequate”, “confounding”, and serviceable only by “inert nostrums.”2,3,4 Clearly, the phrase’s utility depends on its interpretation.

Do no harm can be interpreted in a way that is especially valuable to the Avoiding Avoidable Care movement. This document introduces five points of supportive interpretation, and then offers a proposal to use do no harm to influence medical school culture.

1- It is a moral injunction to listen. Primum is alternately translated as “first” and “above all else.” Notions of primacy have been interpreted as invoking medicine as a “moral enterprise”. 5 Since the basic morality of medicine is to serve patient interests above those of the doctor, a moral physician cannot serve, and therefore may harm, a patient’s interests if he or she does not actively determine what those interests are. Rather than actively sought, these interests are often simply assumed at best, and dismissed, even compromised, at worst. Quite simply, if a physician does not know their patient’s interests, First, do no harm invokes an image of an unhurried physician who begins with the patient’s interests well before embarking down the road of testing, diagnosis, and treatment. Such a physician recognizes the temptation for even simple tests to turn into painful and expensive treatments that the patient never had, or even wanted investigated. Such a physician thereby adheres to the principles, if not the techniques, of shared decision-making and its concomitant reductions in overtreatment.6 In addition, as explicated by Bernard Lown,7 listening clarifies the motives behind this service of patient interest, thereby engendering trust. Essential to the enterprise of medicine, trusting patients are more likely to adhere to their medications, return for follow-up, persevere with physical therapy, pass up alternative healers, and prefer the advice of their doctor over the speculation of Google, all consistent with reducing overtreatment. Further, patient trust is essential for doctors to successfully resist the common perceptions that drive treatment: doing is better than not doing, knowledge is power, certainty is strength, and errors of commission are preferred to errors of omission.

2- It emphasizes avoiding harm. Abjuring carelessness and malice, or the principle of non-maleficence, is so obvious that saying so is not saying much at all. However, there are several subtle implications of the specific need to avoid harm that are specifically related to overtreatment and that may be lost if not they are not stated. Drivers include physicians’ lack of evidence about which treatments and devices are truly effective, as well as a common inability to appraise existing evidence. Another is the fear of medical malpractice suits that spurs defensive medicine. According to Shannon Brownlee, the most powerful cause of overtreatment is that doctors are paid according to the amount of care they provide.8 Crucially, this last point illustrates the value of harm avoidance language rather than care promotion. On a simple reading, “providing care” can readily be used to rationalize overtreatment, and its attendant revenue. Pharmaceutical and device companies routinely disguise their profit motives behind a veneer of care, but rarely invoke an avoidance of harm in any way similar to Bernard Lown’s dictum: “Foremost, we did as much for the patient, and as little to the patient as possible.

3- It addresses the culture. Conveniently, do no harm is a cultural fixture that can be used to address another cultural fixture, namely, the belief among well-meaning physicians that more care is better care. According to Steven Smith, such beliefs are so pervasive, so deeply embedded within our ethic of caring and duty to patients that they become “the air we breathe,” and paradoxically easy to miss. Do no harm, unlike duty to treat or even serve the interests of my patients, includes a specific reminder that almost all care has risks. The phrase may be uniquely suited to identifying such a fundamental assumption. As well-meaning doctors begin to root out this subtle cause of overtreatment, then more overt profit-driven causes will become all the more evident.

4- It unifies the profession. Do no harm is notable for its widespread recognition among physicians. Regardless of its origin and interpretation, Primum non nocere is to medicine what Semper fidelis is to the marines and Be prepared is to the Boy Scouts. Accordingly, the phrase has value to the extent that it strengthens the unity of a profession widely perceived to be under siege. At a time when cynicism among the ranks is growing, when forces of government and corporations are encroaching on physician autonomy, and when public trust is waning, physicians are abandoning professional societies like the American Medical Association just when they most need to organize and collaborate.9 Do no harm can become a rallying cry, attracting both physicians in training and established doctors who pursued medicine from a moral calling, but may have since lost faith. By offering a core value, one that harkens back to the roots of medicine, as a remedy for today’s dire health care situation may re-engage members with the profession’s mission.

5- It renews public trust. Since do no harm is so widely recognized by the public, using it to brand the avoidable care movement may be an effective strategy to counter the vast marketing machine of pharmaceutical companies, hospitals, and other health care corporations as they triumphantly tout the latest and greatest treatments. The phrase’s humble tone rebrands the mindful physician who listens and restrains inappropriate treatment as a paragon of trustworthiness, all the while carrying an attendant rejection of trust that is based on action. Finally, since very few market mechanisms are incentivized to promote the mission of avoiding avoidable care, co-opting the most famous line in medicine is an effective way to get the word out.

Proposal: Avoiding Avoidable Care, as a movement, co-opts First, do no harm and outlines an interpretation of the phrase’s meaning specific to the aims of the movement, a condensed version of the above. It then approaches the Arthur P. Gold Foundation, sponsor of the Gold Humanism Society and the White Coat Ceremony, in which almost every medical student participates at the start of medical school. The movement requests the inclusion of a First, do no harm campaign within the Gold Humanism Society’s White Coat Ceremony. Since oath taking is a requirement of this ceremony, including do no harm is consistent. The movement could also create a pin, similar in fashion to the Gold Foundation pin that is distributed at the White Coat Ceremony. Students would affix this do no harm pin to their lapels, as a sign of their mindfulness of overtreatment. Central to this campaign would be an emphasis on listening. Specifically, students would be encouraged to query patients about their interests and goals as something akin to the fifth vital sign, whereby it is sought from every encounter. By affixing a moral spotlight on listening, students would be charged to advocate and innovate methods to increase the length and effectiveness of patient encounters. Thereby, as the Movement develops guidelines and best practices for avoiding avoidable care, this charge can become a hook with which to publicize these developments to students themselves, thereby obviating the need to negotiate with the medical schools to incorporate this material into curricula.

Conclusion: Do no harm does not specifically speak to all aspects of Avoiding Avoidable Care. Specifically, interpreting it to comment on the need in some cases to perform care that is being neglected is tenuous. However, the phrases near universal recognition, moral invocation, negative language, and humbling spirit outshine its liabilities in interpretation and comprehensiveness. Admittedly, co-opting the phrase is more about leveraging its spirit than in creating the ideal slogan or tag line. However, an essential role of any movement is to capture the hearts and minds of participants. Do no harm is already in their minds, and by showcasing it at formative periods in physician training, it can capture their hearts. Since much has been made of the limitations and failures of medical training to address overtreatment, do no harm offers an easy way to redress the dwindling patient focus in medical schools and residencies.

References:
1- McGarrv L, Chodoff P. The ethics of involuntary hospitalization. In: Bloch S, Chodoff P, eds.
Psychiatric Ethics. Oxford: Oxford University Press, 1981:217.
2- Smith C. Origin and Uses of Primum Non Nocere−−Above All, Do No Harm! Journal if Clinical Pharmacology. 2005 45: 371
3- Caelleigh AS. Cover note: medicines and poisons. Academic Medicine. 1998;73:842.
4- Lasagna L. The Therapist and the Researcher. Science. 1967;158:246-247
5- Jonsen A. Do No Harm. Annals of Internal Medicine. 88:827-832. 1978.
6- Joosten E, DeFuentes-Merillas L, et al. Systematic Review of the Effects of Shared Decision-Making on Patient Satisfaction, Treatment Adherence and Health Status. Psychotherapy Psychosomatics 2008;77:219–226
7. Lown, B. Social Responsibility of Physicians. Address presented at Avoiding Avoidable Care Conference, Cambridge, MA. April 26, 2012.
8. Brownlee, S. Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer. Bloomsbury USA.
9. Wynia M. The Short History and Tenuous Future of Medical Professionalism: The Erosion of Medicine’s Social Contract. Perspectives in Biology and Medicine. Volume 51, Number 4, 2008

Tuesday, April 17, 2012

A Case for Medical Diversity




Diversity trumps ability.

As described by Scott Page in his compelling book The Difference, the thinking is rather straightforward. Good problem solvers in a field are similar, so a collection of them rarely outperforms any one of them by themselves. However, a diverse group of intelligent people is far more effective, so long as they bring difference perspectives and different methods to bear on the problem.

I considered it a powerful argument for doctors to explore social media: to harness diversity. Specifically, it's an argument for physicians as managers of diverse patient care teams, including nurses, dietitians, and social workers, as well as the patient's family, friends, and other patients like them.

Page outlines four conditions necessary for diversity to trump ability. For each of these, I consider how they relate to healthcare.

The problem must be difficult. Good health is famously difficult, and you need only look at the Dartmouth Atlas to see how they vary.

Individuals must know about the problem. There are a great many people, not just doctors, who know a whole lot about not just the health issue in question (the disease and treatment), but also the patient's habits and values

Incremental improvements must be suggestible by the group. Much of health, particularly for chronic conditions like diabetes and heart disease, are about continual optimizations that could be gathered by diverse suggestions.

The group must be large and genuinely diverse. Many patients, particularly those with chronic conditions, interact with a growing number of healthcare providers.

Tuesday, April 10, 2012

Reasons for Optimism About Tech in Medicine

The DIKW Hierarchy

In David Weinberger's fascinating Too Big to Know, he taught me about the Data, Information, Knowledge, Wisdom hierarchy, which apparently is so commonly referred to that it is better known by it's acronym, DIKW. It's one of those ideas whose power derives from its staggering simplicity. Stated briefly (or, if you prefer, extensively on wikipedia), the idea is that information is more valuable, and more scarce, than raw data, and the same goes for knowledge and wisdom.


The hierarchy says a lot about the perfectly valid concern that the influx of modern technology in medicine is ultimately dehumanizing.


As someone who has could be accused as proselytizing med tech, the hierarchy gave me pause at first. Our fancy gadgets stand to create a data deluge that leaves little room for knowledge and wisdom, which are the stock and trade of medicine. A wealth of information certainly is no substitute for knowing what to do with the information, when, and to what purpose. Those who wonder if more technology is really the answer for medicine must not be casually dismissed as narrow-minded Luddites.


But there is a less obvious application of technology, and this is nicely illustrated with the DIKW hierarchy. Some of our new tools not only collect and dispense more data and information, but transform these into knowledge, any maybe one day, wisdom.


An example is IBM's Jeopardy master computer, Watson, currently being engineered to assist physicians. This tool is interesting because it turns information into knowledge. Far from overwhelming doctors with information, and even farther from attempting to replace doctors, Watson aims to help doctors by reducing the information they're faced with by converting it to knowledge. Ideally, a doctor working with Watson can spend more time turning knowledge into wisdom, and spend less time calculating information from data, or synthesizing knowledge from information.


My guess is that patients would prefer to have their doctor impart wisdom rather than manage data. To the extent that our tools promote this end, we should be optimistic about the future of tech in medicine.


Disclaimer: I receive no compensation from promoting books on this site or anywhere else.

Monday, April 2, 2012

Doctor Digitus: Recipe to Retake a Profession

Published in 1982, relevant in 2012.


In The Social Transformation of American Medicine, Pulitzer Prize winner Paul Starr outlines a medical history wherein doctors were exemplars of professional sovereignty: authoritative, powerful, "unambiguously important to their clients," nourishing their "thirst for reassurance."

Mastery of their profession was easy when doctors' heads were the sole repository of medical information, when medical error rates were not measured or published, and when a doctor's reputation was respected a priori, rather than questioned a Google. Patients had to come to them, in person. With no conceivable alternative, they had to bestow upon them their trust.

Unfortunately, that trust has eroded. Is there a way for physicians to retake their profession?

Simply put, professional mastery tracks with information mastery. In the 1980's, the two cohered: a doctor could master books and journals in a way patients couldn't dream, and control of the profession was unquestioned. Today, the digital explosion has left doctors playing catch-up, with patients arriving at the office with their own list of Web-derived diagnoses.

To retake the profession is to regain information mastery, which is to attain digital dominance: Doctor digitus.


In The Creative Destruction of Medicine, Eric Topol writes about Homo digitus, where the bright future of healthcare is a convergence of patients' digital and bodily selves. For Topol and others, the future of health is digital. Digital digital digital.*


What can Doctor digitorus do?

1- Outperform Google by giving patients the background information on their diagnosis, treatment, and prognosis from good, clear sources created by doctors and/or vetted by doctors.

2- Outperform alternative medicine by connecting with, communicating with, and supporting patients' need to feel empowered and in control of their health future.

3- Outperform scorecard medicine in magazines and online, where reputations hang on the caprices of frustration and marketing, by establishing a robust online presence that drowns out healthgrades.com.

4- Outperform distractions by creating engaging apps and other tools that encourage patients to maintain healthy behavior patterns, from diet and exercise to adhering to treatment regimens.

5- Outperform voter apathy and discontent by using modern media to promote the mission of medicine.

6- Outperform the past with quality improvement tools that measure and highlight avenues to decrease medical errors and avoid avoidable care.

7- Outperform the pace of knowledge-creation with tools that curate valid medical breakthroughs that matter clinically.

8- Outperform traditional medical education by teaching with digital tools.


Every one of these steps involves mastery of digital tools. Which have I left out?



*Don't take it from me, check out some of my favorites