Saturday, July 24, 2010

WHOSE RECORDS ARE THEY ANYWAY?


I often peruse the NY Times Well Blog (http://well.blogs.nytimes.com/), where columnist Tara Parker-Pope presents for discussion meaty issues in the healthcare field. On July 22 the piece was by Dr. Pauline Chen, on a movement to assure patients access to their medical records. Most patients never develop any interest in seeing their records, but those who do often find their way obstructed by healthcare professionals for a number of reasons.
Of course, I support people’s full access to their medical records, so I had to write this response to Dr. Chen’s article:

Controversy over patients’ access to their medical records begs a more fundamental question: how is it some physicians have come to fear their patients?
As Dr. Chen wrote, the Health Insurance Portability and Accountability Act (HIPAA) assures patients access to their medical records. It also increases the privacy of those records, restricting entities who shouldn’t have full access. Not one of us docs in a hundred has read the law, so please excuse our misinterpretations, which understandably tend toward our own legal protection. We’ll get in less trouble if we withhold information the patient ought to have than if we furnish info we shouldn’t have. That is, an appreciable quantum of fear has butted into the examining room.
Fear doesn't enhance relationships, as malpractice attorneys will testify. The source of most litigation doesn’t lie in medical mayhem as much as in a poor doctor-patient relationship. If you love your doc you’re more likely to excuse a mistake than if your doc strikes you as a clammy, greedy oaf. One gauge of your relationship with your doctor—or with your patient—is the level of fear you sense in yourself. As a patient, how suspicious are you that your doc might harm you, or hide something horrible in your medical records? As a physician, how much emotional distance do you place between you and your patient?
Dr. Chen quotes Dr. Sara Fazio describing the medical note as a story. I agree: it is indeed a story. The patient, reading the note, might disagree with or even be disturbed by the doc’s version of the story. Indeed, that can happen, but so what? Within a healthy doctor-patient relationship, the patient will inform the doc of his or her perspective, and now the doc knows more about the patient. This sort of give-and-take isn’t any arcane or revolutionary practice. It’s the definition of effective communication.

Tuesday, July 20, 2010

TESTOSTERONE POISONING SYNDROME: THE SILENT EPIDEMIC



Above is the headline for the following piece, published last weekend by Associated Press…

Considering he sits at the defendant's bench accused of murder, Armand Tetzlaff wears a curiously confident expression. He fondles the bracelet on his right wrist as though its inscription predicts his acquittal. The bracelet is engraved with the words, “Testosterone Poisoning Syndrome.” Indeed, his affliction—“TPS,” as it's known in medical circles—is his legal defense.
       
Tetzlaff does not contest the charge of homicide. He freely admits shooting Ohio school principal Howard Boyington in the spring of 2004. The school's custodian at the time, Tetzlaff was known to stock his barn with a veritable armory of guns and ammunition, and to haul a deadly selection in the cab of his pickup truck. Police could not, however, determine that he had violated any laws, at least not until the morning he sauntered into Boyington's office and, without a word, blew off Boyington's head with a soft-nosed slug from a .357 magnum.

Tetzlaff would be just another homicidal maniac had not a suspicious physician at the Cuyahoga County Jail sent a blood specimen to a clinic that specializes in Testosterone Poisoning Syndrome. The Clinic—the Sonoma Hormone Research Center in Santa Rosa, California—confirmed that Tetzlaff was indeed a TPS victim.

Its medical director, Dr. Harold Peterson, a graying, mild-mannered diplomate of the American College of Endocrinology, defines TPS as intensely exaggerated effects of the male hormone, testosterone.
  
“Those afflicted,” he explains, “suffer persistent feelings of tightness, constipation, and preoccupation with strength and dominance. TPS victims typically fear women, fear other men, wear baseball caps to bed, and are drawn to violent televised sports. What we're talking about here,” he continues, “is the ‘strong, silent type’ who explodes unpredictably after a minor provocation.”

Cuyahoga County Deputy District Attorney Marvin Goldstein offers a blunt reply: “Rubbish! There's no such thing as Testosterone Poisoning Syndrome. If you can say your hormones made you do it, then the next defense down the pike will be the tooth fairy or even Twinkies.”

Oblivious to the opinions of Ohio prosecutors, Dr. Peterson goes on to describe the history of this strange condition. “I first considered the possibility of TPS in 1968, when I heard a fascinating remark by one of the Presidential candidates’ physicians. He said women shouldn’t run for the presidency because their hormonal tides might trigger catastrophe. Bluntly—to paraphrase him—‘Who wants a premenstrual finger on the doomsday button?’

“So I began to wonder whether there might be an analog in men. As you know, women run a monthly cycle, the regularity of which gives them a perspective on their ups and downs. But men run their cycle just once, from adolescence to senility: a quick peak, a long plateau, and a gradual decline. Without the regular contrast women experience, we men confuse our hormone load with our personality.

“Now, knowing that, would we rather have the doomsday button under the finger of a woman who’s crabby a few days a month or a man who’s belligerent fifty years straight? In fact, which hormones built the button in the first place?”

The man at the defendant’s bench, the man screaming at the light heavyweights, the man now arming his car bomb, and the man in the Oval Office all have one thing in common: testosterone. Can their own hormones actually lead them into antisocial behavior?

“Only time will tell," concludes Dr. Peterson. “All I’m sure of is that we need more research."
*
What do you think about TPS, and, for that matter, Pathologic Niceness Disorder? Postmature Birth Syndrome? Will we soon have available a vaccine against human error? Will we grow human clones in labs for their organs? How much “medical news” do you believe?

Friday, July 9, 2010

SPEED-DATING YOUR DOCTOR


The AARP Bulletin’s July-August edition features an article on patient-doctor “speed-dating.”

Yup, you read that right. At the Texas Health Harris Methodist Hospital, twenty patients recently paired off serially with physicians in five-minute sessions to assess compatibility.

That may sound a little crazy, but it’s on the right track. Patients need to consider their choice of physicians seriously. The relationship is, after all, a crucially intimate one, often involving life-and-death issues.

I can’t say I’d feel confident doing this in a hectic five-minute setting, but a more leisurely interview with a prospective doctor can be revealing. I encourage patients to request such a visit, offering to pay cash for fifteen minutes of the doc’s time. In my experience, most physicians welcome this opportunity. An added benefit is that patients can rule out those who decline interviews without spending a nickel.

What do you ask in this visit? Content doesn’t really matter. The task is to gauge how well you get along. Is the doc personable, and interested in you? Does he or she have good eye contact? Does the doc touch you (and is that a positive?) Is he or she fully present, or quaking to get on to the next patient? Does it seem like the doc takes good care of himself/herself? 
 
Having secured a physician in this way, believe me, he or she will treat you permanently like the unique individual you are.

Thursday, July 8, 2010

COMMUNICATING A CANCER DIAGNOSIS

More than twenty percent of patients are told of their cancer diagnosis in an impersonal manner, according to a study related by Shari Roan in the Los Angeles Times July 6. 

Researchers at the National Cancer Institute and Columbia University gave a questionnaire to 437 patients who had received a cancer diagnosis. Fifty-four percent had been told their diagnosis in person in the doctor's office. 28% got the news while in the hospital and 18% by phone. 

Patients who heard their diagnosis in person had much higher satisfaction scores than those who received the diagnosis over the phone. Subsequent conversations in the doctor’s office were rated higher by patients than talks that took place in an impersonal setting such as a recovery room or radiology suite. 

Only a small percentage of patients reported very poor communication and lack of trust in their doctor. One patient described a message her doctor left on her answering machine: “…he called me on Valentine’s day to say I had a lesion in my chest…”

Leaving news of cancer on someone’s answering machine astounds me, considering what that message can mean to the listener. (Two people told me of this happening to them, both on a Friday afternoon, leaving them to stew over a long, long weekend before they could contact the doctor and ask questions.)

Sometimes it might be appropriate to inform patients via a phone call, but in any case an ensuing conversation is absolutely essential. In this study, 45% of the patients reported discussions of 10 minutes or less. Treatment options were not discussed in 31% of the conversations. In 39% of the cases, the patient had no other person -- such as spouse, sibling or child -- present when they received the news. 

A study conclusion was that “…too many physicians are either unaware of or not practicing good communication skills in such bad news circumstances.”

All this suggests that in many cases, neither patients nor doctors are prepared to discuss the issues that decorate a serious diagnosis. Since virtually anyone can suddenly hear they have cancer or some other serious disease (or, really, any bad news), it’s worthwhile to read the National Cancer Institute’s excellent post-diagnosis guide, at http://www.cancer.gov/cancertopics/takingtime/page2.