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

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
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.

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