Dr. Malia Reckons

A patient sent me a link to a blog about psychological research discussing how patients recover more quickly from the common cold when the doctor they see is more attentive and empathic. Interestingly, the patients who judged the doctors as most empathic and attentive, not only improved quicker, but also demonstrated a stronger immune response on blood testing.

You can check it out here http://bps-research-digest.blogspot.com/2009/11/patients-with-empathic-attentive.html

Good information for me to read on a Sunday evening. Maybe I'll take the lesson to heart and be a better doctor this week by being more attentive and empathic for my patients.

Just as my earlier blog noted regarding compassion ( http://drmaliareckons.posterous.com/compassionate-caregiver-words-from-award-winn ), too bad there is no insurance billing code for empathy! But at least I'll know in my heart I may have really helped my patients beyond the standard therapies.

So much of "good care" goes beyond factors that can be measured or tracked. The magic of medicine is in the subjective, the factors that can not be counted as simple data, and hopefully you know it in your heart when you see it.

--Timothy Malia, MD

This week's hullabaloo about the latest recommendations for breast cancer screening from the USPSTF (U.S. Preventive Services Task Force) has been equally interesting and distressing for me.The recommendations can be found at http://www.ahrq.gov/clinic/USpstf/uspsbrca.htm and the three main points that have caused an uproar are:

(1) women without special risk are not advised to start screening for breast cancer before age 50,

(2) women between 50 and 75 years old can screen with mammogram every two years, and

(3) doctors should not teach breast self-examination (BSE).

I wish to use this opportunity to explain a few important concepts in health care as well as offer my professional perspective about the recommendations and the Task Force itself.

I will post a series of pieces over the next few days related to these subjects. Please follow along. I hope this is enlightening and interesting, and I look forward to feedback about the series and comments related to the topic.

These blogposts will cover a few issues, including:

• My thoughts on the USPSTF,
• Discussion of cancer screening and early detection,
• The breast cancer screening recommendations themselves, and
  
• Relating the new recommendations with three phrases I use regularly with my patients:
  • "We have not yet caught up with Mother Nature."
  • "Everything we do has risks."
  • "Every test tells us something. But no test tells us everything."

First, regarding the USPSTF, I have been startled by some of the comments in the media suggesting the Task Force's recommendations are politically-motivated, based on cost-savings or misogynistic.

Frankly, the USPSTF is, without a doubt, my favorite source for recommendations about preventive services I should be discussing with and offering my patients. Why? Because it has consistently been objective in its analysis and clear in explaining how strongly the research supports recommendations. Perhaps more importantly, the Task Force is a neutral party and regularly reviews and updates its recommendations as new research is published and expert opinion changes.

Please see the USPSTF website at http://www.ahrq.gov/clinic/uspstfab.htm and note that the Task Force is assigned the task of conducting "scientific evidence reviews of a broad array of clinical preventive services, develop recommendations for the health care community, and provide ongoing administrative, research, technical, and dissemination support" and has been doing that since 1989 and the first publication of The Guide to Clinical Preventive Services.

That first Guide to Clinical Preventive Services had a massive influence on how I think about health care and practice medicine. I found that Guide one night at my medical school library. Taking a study break, I was stretching my legs and perusing the reference texts on the first floor. Standing there, likely with my mouth gaping as I read the analysis of the research and the recommendations on a great variety of health services, I had a semi-epiphany about health care and my first taste of "evidence-based medicine,"  the use of objective assessment of treatments and practices to help decide the best ways to work and where to focus our energies.

Since that first Guide to Clinical Preventive Services there was a second, in 1996, and for about the last ten years the Task Force recommendations have been available on-line with review and updates every few years and new topics/issues being added from time to time.

The USPSTF makes recommendations about many health issues which cover a good part of primary care medicine. Understand that trying to review all salient research and claims about health issues and preventive medicine is impossible for a single person, especially a medical provider spending the day seeing patients. The USPSTF judges the quality of research and explains well the practical lessons for the actual practice of medicine. Topics are broad, and include whether to screen for cancers; counsel about exercise; suggest patients take aspirin to prevent health problems; screen for anemia, family violence, depression, dementia, childhood thyroid disease, and countless other conditions.

The members of the Task Force are not political appointees. It was established in a way so it was somewhat guarded from politics and is within the Department of Health and Human Services (HHS), and they do not have any direct control of policies. They only comment on the strength of research for health care matters. According the website:

The USPSTF comprises primary care clinicians (e.g., internists, pediatricians, family physicians, gynecologists/obstetricians, and nurses). Individual members' interests include: decision modeling and evaluation; effectiveness in clinical preventive medicine; clinical epidemiology; the prevention of high-risk behaviors in adolescents; geriatrics; and the prevention of disability in the elderly. Current members of the Task Force ...  have recognized expertise in prevention, evidence-based medicine, and primary care.

I am not surprised that politics has been thrown into the mix for the discussion about the new recommendations because of the current national debate on health insurance reform. That is typical, though regrettable, and the Task Force has been charged with playing politics in the past with some recommendations. But, in time, their recommendations more often than not do hold water, and other groups often move toward them as research and patient well-being is considered. In total, I would say it is obvious the Task Force does not include politics in making its decisions. I would say, however, that I am surprised at the Task Force members' public relations naivete as they reportedly did not anticipate the hub-bub about the breast cancer screening recommendation change and how the timing was less-than-optimal as has been reported http://www.nytimes.com/2009/11/20/health/20prevent.html?hpw

Suggestions that the Task Force's recommendations are part of on-going disregard for women's health issues sadden me. The USPSTF makes recommendations on a large number of services, all of which can be found at http://www.ahrq.gov/clinic/uspstf/uspstopics.htm and among those is the recommendation that doctors not screen for testicular cancer in asymptomatic men http://www.ahrq.gov/clinic/uspstf/uspstest.htm and a statement that the evidence is inadequate to assess the possible risks and benefits of screening men under age 75 for prostate cancer http://www.ahrq.gov/clinic/USpstf/uspsprca.htm. Those two male-health conditions kill about the same number of people each year as breast cancer. Just like the breast cancer screening recommendations, the statements are about the quality of the tests we have available and whether the research is showing them to adequately save lives and not cause excessive harm to patients, and are not commentary on the importance of the health problems themselves.

The Task Force currently has seven women (out of seventeen members), including the vice-chair who led the revision of the breast cancer screening recommendations. To claim they are anti-women's health borders on slander. In truth, over the years, the Task Force recommendations have been a powerful help in guaranteeing general support and insurance coverage for appropriate care and services while helping health care limit potential harm to patients with testing. I consider the Task Force not only not misogynistic, but also one of the best supporters of all patients' well-being.

My next blog post will consider two related topics: what does "screening" mean and what is early detection for cancer. I think patients, and society as a whole, need to understand those issues better than they might at this point. After that I will take a closer look at the actual breast cancer recommendations.

Please follow along. Any thoughts or feedback, if offered civilly, are appreciated.

-- Timothy Malia, MD

Just read some great insight into health care and how primary care needs to be considered in a new light. Dr. Amy Ship, a physician in Boston, MA, received an annual award for compassionate caregiving. A report about her award can be found here http://www.bidmc.org/News/AroundBIDMC/2009/November/AmyShip.aspx  and includes her touching personal story, stirring professional story, and some poignant comments. Here are a few which struck me:

I look out tonight at a room filled with people who have the minds, energy and position to change medicine, and I want to make it clear that primary care needs saving.

Those who practice it need to be given the time to do it right. Primary care can literally save lives, but it can not be done well in the tiny 15-minute visits to which we are held. There is no ICD-9 Insurance Code for compassion.

Connecting with patients means looking for what is not immediately visible, listening for the hole in another’s heart.

I encourage you to go to the link and see the whole report. We all need reminding there are still physicians like her, with a keen understanding of how health care should relate to everyone's hearts and souls as much as their bodies.

A colleague's blog at http://idealmedicalpractices.typepad.com/ideal_medical_practices/2009/11/running-a-hospital-there-is-no-billing-code-for-compassion.html had noted another blogpost, by Paul Levy, the President and CEO of Beth Israel Deaconess Medical Center in Boston, who writes about "hospitals, medicine and health care issues" and had discussed Dr. Ship's award. That post is http://runningahospital.blogspot.com/2009/11/there-is-no-billing-code-for-compassion.html

According the report, the organization giving the award, the Schwartz Center, was "established in 1996, is an autonomous, not-for-profit organization, which supports compassionate health care and seeks to strengthen the relationship between patients and caregivers." Their website is http://www.theschwartzcenter.org/

Dr. Ship's words keep running in my head ... "no insurance code for compassion" ... "primary care needs saving" ... "need to be given the time to do it right" ... pass the word, for changes that integrate those ideas really will bring health care reform, for the better!

-- Timothy Malia, MD

Just overheard a news report on the radio in my office's front room about an increase of Tamiflu-resistant H1N1 virus and transmission from patient-to-patient in a hospital.

Minutes ago I was on the phone with a patient discussing why I would hold off giving Tamiflu to them since they do not have symptoms even though their child was just in the hospital with possible infection (viral culture is still pending, but rapid test was negative).

Here is a news report from BBC about the Tamiflu resistance and spread in a hospital http://news.bbc.co.uk/2/hi/health/8370859.stm

Ironic, the timing of the call and the radio news report. But it speaks to the need to be somewhat selective in using Tamiflu, and using it for patients most at risk -- those who are severely ill or with high-risk of severe infection when H1N1 infection is suspected, especially patients with chronic conditions (heart disease, asthma, kidney disease, weakened immune system). Overuse would increase the potential of more resistance.

Patients and doctors all should be working together to give the best treatment possible while also using reasonable care to not over-use the treatment so it stays effective in the future. Other anti-viral medicines we previously used for influenza are often inneffective now because of resistance that developed. Let us hope Tamiflu is not moving in the same direction, but remains a useful treatment to help patients who most need it.

--Timothy Malia, MD

Saw a patient who can not use nasal decongestants and antihistamines because of a heart condition. Poor thing currently has a sinus infection and congestion. She had heard of a neti pot but did not know much about it. A quick Google search brought up this video which I think is pretty nicely done -- down-to-earth fellow, clear presentation of neti pot "how-to," and good music in the background.

Personally, I have not used a neti pot. But I do have patients who swear by it now as a means to control allergies and/or decrease sinusitis frequency. The potential risks seem minimal. From what I hear, once one gets beyond initial hesitancy, it is easier to tolerate than expected.

Reportedly, the practice of nasal flushing with neti pots goes back hundreds, and perhaps thousands, of years in India and Asia. So we can consider it a relatively innocuous treatment with a proven track record, and, perhaps best of all, there are no big corporate pharmaceutical profits being made off of it!

Please share you thoughts and experiences with the neti pot or other nasal flushing methods.

--Timothy Malia, MD

What an interesting week in health! My office is very busy with flu infections, pneumonias, ear infections, etc, plus questions about flu shots and the new H1N1 shots. Now I see in the news that a major medical task force is suggesting a change in mammogram screening frequency, and I saw a headline that pharmaceutical companies have continued to raise the prices of name-brand medicines. A cornucopia of interesting and relevant stuff to ponder and discuss!

But, of course, my priority has to be the office, so I will keep this simple, and I promise to post about those other issues later -- some of which deserve more than a little thought.

I have mentioned before that I often enjoy the Well Blog by Tara Parker-Pope in the NYTimes and how often she comments on useful and interesting health information. Yesterday was not unlike many other days as one of the blog posts was about Vitamin D and research that found an association of higher blood levels with less heart disease. The piece, actually authored by Roni Caryn Rabin for the blog, can be found here -- http://well.blogs.nytimes.com/2009/11/16/vitamin-d-shows-heart-benefits-in-study/?em

Almost two years ago, a very good, and succinct, review of Vitamin D and its possible health benefits, authored by Jane Brody, was in the NYTimes and can be found here -- http://www.nytimes.com/2008/02/19/health/19brod.html

Over the twenty years I have been in the medical field, many nutrients have surfaced as potentially healthful beyond anyone's prior imagination. Most fade after further research does not replicate the association, or proves the original theory wrong outright.

But Vitamin D seems different. Over the last five or ten years research has continued to point to its benefits. Because the current report only points to a possible association we can not say yet that more Vitamin D decreases heart disease. Additional research is needed to find possible cause and effect, and to study if increasing the Vitamin D in patients with low levels will lessen their heart disease risk later. But the current report, added to all the others, only bolsters the apparent positive benefits of getting sufficient Vitamin D.

For me personally, thinking about Vitamin D reminds me of the spring of my first year of residency and diagnosing a one-year old child with rickets. The African-American toddler was being admitted overnight for some other issue, but on exam I noticed her rickets rosary, small bumps on her ribs, which pointed me to her diagnosis -- as a young doctor at the time, the physical exam finding and diagnosis was a proud moment, and a step forward in my training as well as in the health of the patient. Interestingly, in northern climes, like here in Rochester, after long winters, children can have rickets due to lack of sunshine on the skin if they are not supplementing Vitamin D well enough. To me it was astounding as I thought rickets was a condition only from long ago, but there I was, in modern America, in a high-tech hospital, with a small child suffering from a preventable nutritional deficit. The experience has affected how I approach health and nutrition, though the questions and uncertainty remain in many areas of the subject.

Considering my patients today, I currently recommend adults get at least 800 IU (international units) of Vitamin D daily, and I would not be surprised if that minimum suggestion goes up in the future. Generally we suggest that calcium and vitamin D be taken with a meal. Interestingly, a patient's comment recently helped improve my recommendation on how to take the Vitamin D (I learn something new everyday, and, frequently enough, it comes from my patients): the Vitamin D should be taken with a fat/oil source as well. So, if taking it with a meal, be sure the food has some kind of fat or oil in it, and not be a low-fat meal. Or, take the Vitamin D in a capsule form in an oil base. Or take a Vitamin D tablet with an oil-based supplement such as fish oil capsules. Your skin also makes Vitamin D with exposure to the ultraviolet rays of the sun, but since I am writing this from upstate New York as the winter approaches and we are all covered head-to-toe, I want people to think about the oral supplementation options as those may be more applicable to many of us.

I will leave it at that for now. Keep watching for news about Vitamin D's benefits. Keep trying to get sufficient Vitamin D supplementation. If using the sun to make your own Vitamin D in your skin, please be careful about possible sun damage and skin cancer.

And please watch for later posts about many interesting, and relevant, issues worthy of discussion this week.

--Timothy Malia, MD

"Sometimes your joy is the source of your smile, but sometimes your smile can be the source of your joy." 

-- Thich Nhat Hanh

We are all hearing about H1N1 (swine) flu and the need for behaviors and efforts to limit the spread. And we see ads on billboards and on TV about the need to stop smoking. Now perhaps we should consider a public health effort to increase happiness.  I just read a nice piece in the NYTimes  by Olivia Judson in which she touches upon how all of our behaviors affect each other and our health. http://judson.blogs.nytimes.com/2009/11/10/social-medicine/?ref=science

Our influence on others, and their influence on us (always remember that "social networking effects" flow two ways), includes our eating habits, weight control, smoking, etc.  But, not just that, it also includes our happiness. And research has shown that happiness relates to health, including having a stronger immune system -- so, perhaps efforts to improve happiness should be part of our H1N1 flu health efforts.

Judson's piece alludes to possible public health efforts in helping improve these "social networking health issues," if you will. But I, as a family physician, wonder about how primary care medicine can help, one patient, and one family, at a time.

I find it interesting how discussion frequently focuses on the large, public health aspects of medical care and efforts, but often overlooks the small, face-to-face encounters of primary care medicine. Should not we be focusing on improving the power of the primary care doctors in the effort to improve health in every way possible, including happiness?

Currently, however, the system supports efforts by doctors to see more and more patients and focus on the objective measures of medical care, such as the lab values and blood pressure readings and percentage of patients having completed recommended tests and screenings. But I encourage all of us to consider the subjective measures of good care. They may be harder to measure and quantify, but I suspect you will know if your doctor is measuring up.

Do you leave your doctor's office with a smile on your face and your heart a little bit warmer than before you got there? Do you sometimes get to laugh or chuckle with your physician? Do you feel your doctor appreciates seeing you and spending time with you? If not, than why not? And don't you think you deserve better for your health?

I propose an effort for primary care doctors to help in this effort to improve our patients' happiness by connecting to patients in ways that can not be measured easily. We should ask about life issues that are not related to medical problems, and tell jokes and listen to a few. We should relate to our patients, somewhat, as friends who are over for a visit and to "catch up" if you will.

One great aspect of primary care medicine that is too often overlooked is the continuity of care over time, often over many years. I like to say that each appointment with a patient is just one part of an on-going conversation that stretches back to previous visits and stretches on into the future. It is the one aspect of care that no hospital, emergency room or urgent care center providers can ever offer.

And with that, I as a family physician have another weapon in my armatorium to support health and battle disease -- friendship and a social network to encourage healthful living and wellness, including the promotion of happiness.

Did you have any idea your primary care doc actually had such power?!

Take a look at Judson's article and consider your own life. Realize that you and your lifestyle affect other people. You have power. And be sensible in who you let in your life since they will affect you too (very important for the teens and college students who might be reading this, and for parents who should be teaching them). And, finally, consider how you feel at your doctor appointments, and whether your relationship with him or her is improving your health and happiness.

Finally, I will end by pointing to the quote at the start of this post from the world-famous Vietnamese Buddhist monk, Thich Nhat Hanh, who has often spoken of smiling as "facial yoga" and encourages us to wear a smile because it will stir our soul in positive ways, just as the quote suggests, but also because it can have a positive influence on everyone around us. That idea fits beautifully with the Judson article.

Maybe it should also fit with your doctor visits.

-- Timothy Malia, MD.

One of my patients with anxiety simply can not wait for things that are scheduled. Therefore, when planning most any kind of medical appointment she demands that she have the first appointment of the day. As an aside, I am proud to say that she does not maintain this requirement for me since I guarantee seeing my patients within 15 minutes of the scheduled appointment time, or I give a $5 gift card to Starbucks. But I digress.

My patient actually has had some conflicts with surgeons and their staff when she made her demand for the first scheduled operating room time in the morning so she would not have to wait an un-anticipated amount of time. Once she entirely switched surgeon and went through a whole other evaluation because she felt the first doctor and staff had been so disrespectful of her anxiety and wishes.

This morning, however, I learned my patient may be benefiting from her demand in other ways. Not only is she controlling her anxiety, she may be improving the quality of care she receives. Recent research about colonoscopies suggests that, yes, doctors are human, can fatigue, and may not do as good a job later in the day than early.  This observation is very important as we consider health care reform and design medical practices and how systems work.

The report in the NYTimes today -- http://www.nytimes.com/2009/11/17/health/research/17colon.html?ref=health -- notes that early morning colonoscopies were more likely to find polyps than ones done later in the day. Interestingly, the latest the studies were done was 1pm, so the difference in this case was early morning vs late morning essentially.

A colonoscopy involves sedating a patient and then inserting a flexible scope (tube with a camera and light) into the anus/rectum and coursing it through the whole length of the colon. Air is put into the colon to open its volume so the walls are flatter and more easily seen. After reaching the whole length of the colon, the doctor slowly withdraws the scope and carefully examines the colon tissue for signs of cancer and polyps (small growths that are potentially pre-cancerous).

Prior studies have suggested that the speed a doctor does a colonoscopy is important, and that a slower withdrawal may allow for a better inspection and better quality colonoscopy -- http://www.medscape.com/viewarticle/545105 -- which, I feel, makes perfect sense.

But today's report adds to the import of human fatigue affecting quality of medical care. Studies done earlier in the day, by just a few hours, even though done by the same doctors and teams, in the same facilities, seem to be better quality and to find more polyps.

For a better quality health care system, we all need to keep this in mind. At the center of our system are doctors and nurses who are human. We all can be fatigued, both physically and emotionally, and therefore we must always consider how medical system designs might strain us. If lower payments are being made to providers, will they simply increase the number of patients they see each day leading to more fatigue and possibly worse care? All indications are that is what has been happening as doctors and clinics run through "hamster-wheel" care in their offices day-after-day. Is that what we need or want?

Personally, I do not want that. And, for that reason, I have gone to great lengths to try to change the basic shape of my office. It still is not perfect, sometimes, by my own measures, far from it, but it is ever-changing and ever-improving. And it is my attempt to design a system that lessens the chance of problems, for patient and doctor alike, while increasing the chance of excellent care being given.

We need a system that is not wearing down the doctors, because they are human. But, until that system is in place, I think I will suggest my patients do as my anxious patient does and demand an early-day procedure even if it means waiting some time to book it. I know that is what I will do for myself.

-- Timothy Malia, MD

It has been a busy 6-8 weeks in the office, so the blog was on the back burner. This week, two patients were in for their appointments and commented that they had checked the blog and noticed nothing new recently. That felt good! So I promised myself to get something new up by the end of the week.

I guess the point is that my patients can get me to do important things. And, that is my segue to tonight's issue -- patients have power, and should use it to improve the medical care they receive.

The Consumer Reports Health.org website has an interesting piece noting how important it is for doctors and nurses to clean their hands with either soap & water or with the alcohol gels. ( http://www.consumerreports.org/health/doctors-hospitals/hospitals/wash-up-doc/hospitals-and-nurses-wash-up-doc.htm ) And, it notes, if the nurse or doctor does not clean hands in front of you, ASK THEM TO!

My favorite part of the piece was that they asked doctors and nurses how patients should speak up about the hand cleaning. All the ones they listed were fine, but not quite what I would suggest. Check out the piece and see if you agree.

I encourage patients to take this advise to heart and speak up. There are many health-related issues one should speak up about. But, the hand washing is so important, for your health as well as the health of the doctors, nurses, and other patients, it is a great one to focus on.

Finally, for the record, I suggest a patient make the comment light-hearted and fun by saying, with a slight chuckle, something like: "OK, doc, I'm sure you already cleaned your hands outside, but help me with my paranoia and let me see you do it again!"

How would you tell a doctor or nurse you would like to see them clean their hands before providing you care?

I am sorry to say this, and I need to move beyond the emotion, but right now, I feel bitter.

This year, I have not been able to get a small order of 150 influenza shots. In past years I have had a couple flu clinics for my own patients on Saturdays and Sundays when I gave out about half my shots. The other half was given during appointments with high-risk patients, those I scheduled in October and early November with diabetes, heart disease, lung disease, chronic kidney disease, etc. Anticipating the flu shots, and trying to help them get better value from one appointment and not waste time and energy, I plan such appointments many months ahead of time.

Now, in an effort to get the influenza vaccine to high risk populations early, before the H1N1 flu vaccine is more available, and lessening the risk of confusing the two, the seasonal flu shots were sent from manufacturers directly to companies that run community outreach programs and large pharmacies.

That, by itself, would not be a problem if I also could get a supply to offer my patients in my own office. But, this year is incredibly frustrating, and I, like many, many other primary care docs around the country, am not getting an order of flu shots.

Adding insult to injury, at least one pharmacy is letting patients schedule times for flu shots but they do not yet have a formal protocol for giving them and therefore have to get a formal approval from me to give the shots. I'm spending time every day explaining to patients about the hassles I have had trying to get flu shots, encouraging them to get the shots, and then asking them to find the community outreach programs and pharmacies where the shots are available.

Like so often happens in primary care, this is a situation where I am trying to work for the benefit of my patients but then others in the system are getting paid while I'm left empty handed. It is a business model with fundamental flaws.

Consider this: for my own patients, with whom I have long, on-going relationships, and for whose care I maintain malpractice insurance, I spend time and energy getting them to go to a pharmacist (a pharmacist!) of a large corporation to get a flu shot. And, I must wonder, what happens to my patients if they have severe reactions? A post-vaccination reaction will be dealt with by whom? The pharmacist? Or me? Who gets the phone call if there are questions after the vaccination?

I am bitter, but not proud of it. I can not get flu shots, but large corporations can. I have to encourage my patients to get the flu shots, but then someone else in healthcare will profit from my efforts.

Watch for other blog posts later about this, but here I present a major problem in the American system and primary care. Society has two trump cards that get thrown at primary docs depending on the situation and on what the powers-that-be need at one time or another. Either docs are told: "this health care stuff costs a lot of money, so you better run a good business model and focus on value for the patients," OR, when it serves other needs, we are told: "but doctor, don't you have a moral obligation for the welfare of your patients and to not think of care as a business?"

In the end, the system is making doctors who can't maintain the business model and are so burnt out they can't maintain the proper moral tone. In discussion groups among doctors working hard to make primary care better, I see this feeling again, and again. And I fear the general public does not understand the situation or what the doctors are feeling.

I'm sorry, but, right now, I'm bitter.

--Timothy Malia, MD