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Thursday, February 18, 2010

Doctor, Patient, Friend: Blurring the Boundaries

“I would be careful,” a fellow physician cautioned, as I told of my plans to attend a patient’s birthday party. In my 12 years of clinical practice I have lived in the community in which I practice, less than two miles from my office. I encounter patients daily in the supermarket, at soccer games, swim meets and school events. I have had conversations with patients at parties, on the street, and while half-dressed in the locker room. With my foray into social networking, beginning with participation in Facebook in 2008, I have “friended” my patients in cyberspace. As such, I have allowed patients to know details of my personal life and beliefs. They inquire about my family and are aware of my hobbies and interests. Perhaps against my better judgment, we have talked politics and health reform. But what are the appropriate boundaries?

Clearly the doctor-patient relationship is a highly privileged one, in which private and confidential information is exchanged. The communication that occurs within this context is subject to unique rules, ethical, and legal boundaries, as described by the Health Insurance Portability and Accountability Act (HIPAA). Patients share information with their doctors that they would not share with a friend, a neighbor, a fellow school committee member or another soccer parent. Should a doctor back away from a blurring of these boundaries?

Online social networking has introduced new aspects to this old question. Dr. Sachin Jain expresses it well in a New England Journal of Medicine Perspective piece: “The anxiety I felt about crossing boundaries is an old problem in clinical medicine, but it has taken a different shape as it has migrated to this new medium.” Whether or not physicians should engage in relationships with patients within the context of sites such as Facebook or Twitter is a matter of ongoing discussion.

One blogger, Dr. Bryan Vartabedian, suggested that physicians might take the following precautionary measures to avoid trouble:

1. Have an offline discussion with patients who contact you via social networking regarding the confidentiality and privacy issues inherent in communicating in this manner.
2. Discuss with patients the need to document doctor-patient communication in the medical record.
3. Develop a personal social media policy to govern your interactions with patients via the internet and social networking sites.

These measures seem prudent to me.

Others have advocated that physician-users of Facebook have two pages, one personal and one professional. Those same physicians might hesitate to have coffee or dinner with a patient. Clearly Facebook and Twitter are never appropriate sites for discussing the details of an individual’s health or other information that could possibly be privileged and identifiable. Patients need to be aware that tweets show up on Google searches. Does this mean I shouldn’t enjoy seeing pictures of a patient and her family, or getting to know her better through her status updates, sense of humor, likes and dislikes? In contrast, I believe that through this type of sharing the doctor-patient bond can be strengthened and trust enhanced. My view is that allowing some blending of doctor-patient-friend roles is likely to enhance the individualized advice that I am able to give my patients about their health problems.

With proposed changes to our primary care delivery model, “The Patient-Centered Medical Home,” we are looking at using electronic systems to care for populations of patients in part to compensate for inadequate numbers of primary care physicians. The proposed model would enlist care teams, including a single physician, to provide care for up to 5,000 patients (most primary care physicians currently care for two to three thousand). A system of automatic reminders, feedback on quality indicators, and decision support tools would ensure high quality care in this idealized model. But what happens to the doctor-patient relationship? So I say, lets not be so stymied by legalism that we are afraid to befriend our patients.

Monday, February 8, 2010

End-of-Life Care: A Discussion that Stirs Emotions in Both Patients and Their Physicians

A recent blog post and series of responses on the KevinMD weblog aroused my interest. Dr. Kevin Pho posed the question: Why are doctors so reluctant to discuss end-of-life care? Responders, including patients, doctors, nurses, and even a veterinarian highlighted the stress inherent in this discussion for patients and for medical professionals alike. To me the real issue is not whether the discussion should occur, because clearly it should, but when and how? The topic can be very sensitive for a patient who may perceive that their physician is "giving up" on him or her, or that the physician believes that death is imminent.

What constitutes a discussion of end of life care? Though there are many facets to this discussion, amongst health care professionals it most commonly refers to a discussion about an advance directive, a written document stating patient preferences for treatment and designating a surrogate decision-maker, should the patient become incapacitated and unable to communicate. The two primary components are also known as living will and durable power of attorney for health care. In 2007 Georgia enacted legislation replacing Living Will and Durable Power of Attorney for Health Care with the Georgia Advance Directive for Health Care, which combines elements of these two previous documents.

I admit that in my own practice I often do not broach this topic, particularly with young and middle-aged patients, because of my personal biases, believing that most healthy people, when asked, would want (as I would) to be offered all life-sustaining treatments unless there was no chance of meaningful recovery. But admittedly this thinking is likely flawed. Certainly there are healthy people who would want surrogate decision-makers other than their next of kin, thus the discussion becomes important.

What is meaningful recovery? Can this really be spelled out in the form of an advance directive? I am somewhat skeptical. I believe that one has to know a person really well in order to understand that person's concept of meaningful recovery. I personally feel that the surrogate decision-maker part of the directive is much more meaningful in clinical practice than is the living will portion. That being said, I am a strong proponent of encouraging patients to discuss these issues with their family members, who are the ones who will likely need to come to consensus in times of question regarding the direction of end-of-life care. If filling out an advance directive document facilitates this discussion with your family and your physician then the process in itself is as beneficial as the document.

Can doctors be taught to talk to patients about end-of-life issues? I was fortunate to participate in a medical school curriculum for this at Emory University, published by Dr. Alexia Torke and Dr. William T. Branch in the Journal of General Internal Medicine. Workshops with role-playing exercises may be helpful in teaching medical students strategies to ease these discussions.

As with many aspects of medical communication physicians should be culturally sensitive when discussing death and dying with patients. One study of impoverished African-American patients at the end-of-life highlighted the importance of understanding spirituality to grasp this population's view of death and dying.

The whole concept of "advanced directive" seems a very American notion, accepted especially by those of higher socioeconomic status, but not well understood by those of other cultures, who may feel it's up to the doctor to make recommendations, or who may have deeply spiritual beliefs about the nature of death and one's ability to orchestrate it.

So I take it back to both doctor and patient. Doctors, assess your patients' views about end-of-life of care and provide them with information about advance directives; and patients, think about these concepts on your own and with your families and surrogate decision-makers so that when the time comes we are all on the same page.

Friday, February 5, 2010

What's on the Table for Health Care in Georgia?

Yesterday I had the opportunity to attend Legislative Day at the Capitol with other Georgia physicians representing the Patient-Centered Physicians Coalition of Georgia. As an advocate for the American College of Physicians (ACP) I acted as a lobbyist for key health legislation in our state.

Highlights are as follows:

1. The Governor has proposed a 1.98% cut to Medicaid within the 2011 budget.
2. The Governor has also proposed a 1.6 percent premium tax on hospitals as a source of revenue.
3. The House has proposed a $1.00 tax, or “user’s fee,” on tobacco products as a source of revenue (House Bill 39).
4. Comprehensive tort reform (Senate Bill 3) was passed in Georgia in 2005. This included caps on non-economic damages for medical malpractice cases. This is under Supreme Court appeal and is likely to be back on the table.
5. Prompt Pay (House Bill 321, House Bill 342 and Senate Bill 62) reform is proposed, requiring prompt pay (15 days) by third party payors who now often delay payment up to 90 days.

In the state of Georgia Medicaid reimburses about 48% of what private payors reimburse. A cut to Medicaid would mean a 16% cut to current provider reimbursement for Medicaid patients. Poor payment by Medicaid has led many practices to drop Medicaid, limiting access to health care for Medicaid patients. Patients who are unable to access physicians use the emergency room for care and have worse health outcomes, leading to increased expense. Inadequate reimbursement will lead medical practices with a high percentage of Medicaid to have inadequate revenue to meet operating expense.

However, the reality is that the Georgia state budget projections for 2011 and 2012 are daunting: . Global cuts—including education and teacher furloughs are occurring. I spoke with my district representative, Mary Oliver (D), who sees few choices given the current economic climate.

As a source of revenue, the Tobacco Tax is opposed by many congressional republicans, who are in general opposed to any additional taxes. They voice concern that it would primarily impact those of lower economic means. Those in favor, including The ACP, point out the 400 million in additional revenue it would generate for the state, and the positive impact it would have on public health, particularly youth smoking prevalence.

Georgia passed comprehensive tort reform in 2005 limiting non-economic damages to $350,000 in medical liability lawsuits. Medical groups point out that since this time malpractice insurance rates have stabilized and decreased. However this is currently under Supreme Court appeal. Just yesterday Illinois overturned tort reform legislation it passed in 2005. Opponents of tort reform, including representative Stacy Abrams (D) feel that tort reform is a “red herring,” not truly accountable for increased health cost within our system. Consumer advocate group Georgia Watch supports this view:
The Patient-Centered Physicians Coalition of Georgia supports protection of tort reform in our state.

Where do you stand on these issues?

With all of the focus on the national debate I urge readers to understand what’s on the agenda for health care in your state, contact your representative, and let your voice be heard.

Monday, February 1, 2010

Is Exercise the Fountain of Youth?

For my kick off blog I have chosen discuss exercise. As an avid runner, or so I label myself, I've run 15 to 30 miles a week for over twenty years. I pride myself on remaining injury-free throughout those twenty years and attribute that to a combination of moderation, cross-training and good luck.

The 2008 Physical Activity Guidelines for Americans were developed by the Department of Health and Human Services and are endorsed by the CDC citing the substantial evidence for the health benefits of regular physical activity.

These recommendations suggest the following minimum requirements for adults:

1. Exercise of moderate-intensity (i.e., brisk walking) for 30 minutes on most days of the week for a total of 150 minutes per week.
2. Exercise of vigorous intensity (i.e., running) for shorter duration three to four days a week, for a total of 75 minutes a week.
3. Strength training on two non-consecutive days of the week using all major muscle groups.

Furthermore, there is evidence that more exercise of higher intensity is better, and that some exercise is better than none, particularly in elderly adults with chronic illness who are limited physically. Despite popular trends, stretching has not yet made it into the formal guidelines for physical activity.

Sunday's New York Times Magazine reported an interesting study, finding that middle-aged adults who exercise vigorously (ran 50 miles a week) were youthful at a cellular level. The study looked at telomeres, an intracellular marker for cell age. With age telomeres become shorter, and eventually cell death occurs. Middle-aged exercisers had telomeres that were significantly longer than their sedentary counterparts and only slightly shorter than those of exercising younger study subjects.

The January 25th issue of the Archives of Internal Medicine published several more studies demonstrating the benefits of physical activity in middle-aged and elderly adults. One reported on the cognitive benefits of strength training (compared with balance and tone training) in the elderly. The other reported on a cohort from the Nurse's Health Study demonstrating a positive correlation of exercise in mid-life with "successful" living at age 70 and beyond (defined as being free of chronic illness).

I am heartened to see many vigorous older adults at my local YMCA. They are clearly engaged and having fun. To me, the psychological benefits of physical activity have always been paramount and equal in importance to its physical effects.

Is physical activity the panacea of old age? Is there reason to be skeptical? How much is enough, and what should we be recommending?