Fred N. Pelzman, MedPage Today

In general, I think that good data is a good thing. But is bad data of any use, and is it better than no data at all?

In our lives as healthcare providers, we encounter enormous amounts of data. All day long we are brushed by and inundated with data points, be they individual things like the number of patients on our schedules, or the number of times our patients’ hearts beat as we lay our fingers gently on the wrist to measure their pulses, or listen with our stethoscope to the number of breaths per minute.

Our inboxes and the electronic health record are filled with data, labs that indicate health or illness, or variations about the mean. Is this one dangerous? Is that one bad? Do I need to do something about this? Is this just a fluke?

Due to some internal restructuring, there are an enormous number of new efforts being built or overhauled that look at quality — since this reflects on patient safety — and also for the purpose of regulatory requirements and reporting.

At one meeting this week, we saw data on patient feedback on how our practices are doing, including such items as “Provider listens carefully to you,” “Clerk treats you with courtesy and respect,” and “Phone during office hours answers same day.” (Really, same day? Shouldn’t the goal be one ring or two?) full article

Danielle Ofri, The New York Times

Every doctor I know has been complaining about the growing burden of electronic busywork generated by the E.M.R., the electronic medical record. And it’s not just in our imaginations.

The hard data have been rolling in now at a steady pace. A recent study in the Annals of Family Medicine used the E.M.R. to examine the work of 142 family medicine physicians over three years. These doctors spent more than half of their time — six hours of their average 11-hour day — on the E.M.R., of which nearly an hour and a half took place after the clinic closed.

Another study, in Health Affairs, tracked the activities of 471 primary care doctors over a three-year period, and also found that E.M.R. time edged out face-to-face time with patients. full articles

Trisha Greenhalgh and Brian Hurwitz National Library of Medicine National Institute of Health

One day when Pooh Bear had nothing else to do, he thought he would do something, so he went round to Piglet’s house to see what Piglet was doing. It was snowing as he stumped over the white forest track, and he expected to find Piglet warming his toes in front of the fire, but to his surprise he saw that the door was open, and the more he looked inside the more Piglet wasn’t there.

This excerpt from the opening chapter of a well known children’s story illustrates a number of features of narrative as a linguistic form. Firstly, it has a finite and longitudinal time sequence—that is, it has a beginning, a series of unfolding events, and (we anticipate) an ending. Secondly, it presupposes both a narrator and a listener whose different viewpoints affect how the story is told. Thirdly, the narrative is concerned with individuals; rather than simply reporting what they do or what is done to them it concerns how those individuals feel and how people feel about them. Both Pooh Bear, trudging hopefully through the snow, and Piglet, mysteriously absent from his usual place beside the fire, are already characters in the story rather than merely objects in the tale.

The narrative also provides information that does not pertain simply or directly to the unfolding events. The same sequence of events told by another person to another audience might be presented differently without being any less “true.” This is an important point. In contrast with a list of measurements or a description of the outcome of an experiment, there is no self evident definition of what is relevant or what is irrelevant in a particular narrative. The choice of what to tell and what to omit lies entirely with the narrator and can be modified, at his or her discretion, by the questions of the listener. full article

Articolo di Michael Kruse su Huffington Post

How other medics have dealt in similar situations, for example, or the decisions they have made in rare or unique circumstances help me prepare for future challenges. It has struck me recently that even more than these obvious examples, storytelling has a direct impact on not only how we understand disease but the process of healing itself — from the perception and expectations of the patient to the diagnosis and treatment by the physician.

Our brains are wired to tell stories. “A story,” as Life-hack blogger Leo Widrich says in this post about brains and storytelling, “if broken down into the simplest form is a connection of cause and effect.”

We spend most of our day telling stories. We lay out our short-term goals, put events in the context of our own experience of the world, and let the people around us in on those experiences by relaying these stories to them.

This process is not just cultural in nature; it is how our brains are wired. In a 2001 paper by neurologist Jeffery Savor and English Professor Kay Young they make the point that narrative, central to our lived experience, takes place in many parts of the brain, and damage to any part impairs our ability to create our narrative and tell others our story.

What is even more striking is that our brain regularly makes stuff up to fill in the gaps and make sense of the world. The split brain experiments described here by Michael Gazzaniga in his book “Who’s In Charge? Free Will and the Science of the Brain” illustrate this property of the brain to confabulate a story to explain an otherwise inexplicable event. continua a leggere

A Milano, il 24 Maggio, presso l’Istituto di Ricerche Farmacologiche Mario Negri si terrà il convegno sulla promozione della salute dedicato a chi si occupa di comunicazione in sanità.

In collaborazione con Fondazione Pubblicità Progresso e realizzato grazie al sostengo di Healthware International e Digital Narrative Medicine.

Il programma esplorerà l’importanza delle nuove forme di comunicazione per promuovere l’informazione sanitaria e la partecipazione del cittadino. Osserverà come e quanto i nuovi media incidono sulle relazioni e sul modo di vivere e condividere la salute e valuterà quanto conta oggi essere social per le Istituzioni.

Il programma:

Gli esperti chiamati ad intervenire: Silvio Garattini, Eugenio Santoro, Maurizio Bonati, Paola Mosconi, Daniela Rodorigo, Roberta Siliquini, Luca De Fiore, Cristina Masella, Andrea Farinet, Isabella Cecchini, Walter Quattrociocchi, Cristina Cenci, Alberto Contri, Guendalina Graffigna, Roberto Ascione, Alessandro Lovari, Mirella Taranto.

L’evento si potrà seguire e commentare su Twitter usando l’hashtag #salutesocial

La partecipazione è gratuita e l’iscrizione obbligatoria scaricando la scheda qui di seguito allegata da inviare compilata a c.dondini@pubblicitaprogresso.org o al fax 0258307430.

Scarica il programma dell’evento.

Scarica la Scheda iscrizione.

Articolo di Noam Scheiber sul New York Times

Early in the morning on Aug. 12, 2015, a 68-year-old man named Barry turned up at PeaceHealth Sacred Heart Medical Center in Springfield, Ore., confused and feverish.

The case was not a candidate for even a minor subplot on “House.” The admitting doctor stopped one of the patient’s medications and inserted an IV to deliver fluids, and by late the next morning, he had largely recovered.

Still, Dr. Rajeev Alexander, the hospitalist who took over his care, was determined to make an accurate diagnosis.

For nearly half an hour, Dr. Alexander, a perpetually rumpled man, chatted with Barry and Linda, his sister, about the events that had landed him in the hospital, the food processing plant where he once worked, the stroke that had impaired his mind. “It was a very scary night last night,” Linda, his caretaker, said. “He was just sitting on the floor, like you would sit a 6-month-old when they haven’t got their balance.”

Dr. Alexander considers it proper technique to review each mundane detail with a patient. He is full of scorn for the eureka style of medical diagnosis depicted on television, and by his own admission, he reads a CT scan with the sophistication of a barber.

Eventually, Dr. Alexander would discard the more exotic theories that had crossed his mind — meningitis, or possibly a condition known as serotonin syndrome — and settle on a far simpler malady: dehydration, which aggravated a chronic kidney problem.

He was nonetheless unapologetic about the time he had invested.

“Real life is all about the narrative,” he said. “It’s sitting down and talking about bowel movements with a 79-year-old woman for 45 minutes. It’s not that interesting, but that’s where it happens.”

Dr. Alexander’s method is at the center of an emotional debate in medicine, in which the imperative to increase efficiency in a high-cost health care system is often at odds with the deference traditionally accorded to doctors. continua a leggere

Articolo di BioMed Central

Over the past fifty years the study of literature has become a generally accepted aspect of medical education. As thoughtful scholars have recently considered how to teach professionalism effectively and meaningfully, questions have arisen about the role of stories, essays, first-person narratives, and poetry in facilitating the professional identity formation of medical students. Those who argue affirmatively imply that exposing students to literature will inculcate professionalism virtues and attributes [1]. Those who disagree assert that the study of literature has goals and purposes unrelated to professionalism [2]. In this article, we investigate definitions of medical professionalism, and frame its inclusion in the competency framework as an effort to anchor its abstract virtues in behavioral specificity. Next we consider how literature can advance our understanding of medical professionalism through a different kind of singularity grounded in the literary method of close reading. Ultimately, we contend that the development of medical professionalism will benefit from the critical and interrogative methods of literature.

This article is a result of the Project to Rebalance and Integrate Medical Education (PRIME), sponsored by the Patrick and Edna Romanell Foundation. PRIME focused on how medical ethics and humanities education are prerequisite to professionalism formation in medical school and residency training [3, 4]. PRIME, in turn, resulted in the creation of the Academy for Professionalism in Health Care as an organization devoted to professionalism education [5].

Are you “battling” heart disease”? Have you “beaten” cancer? Are you “fighting”a chronic illness?

Articolo di Carolyn Thomas su MyHeartSisters.org

These wartime references are metaphors as described by Dr. Jack Coulehan, a physician, an award-winning poet, and editor of the 5th edition of The Medical Interview: Mastering Skills for Clinical Practice, a best-selling textbook on the doctor-patient relationship. Dr. C explains that there are several basic metaphors used in medicine that to a large extent generate the vocabulary of doctor-patient communication – but can also unintentionally objectify and dehumanize the patient.

Here are three of the most prominent metaphors you’re likely to encounter in health care:

Parental (paternalistic) metaphor

Disease is a threat or danger  (“She’s too sick to know the truth”)

Physician is a loving parent/ patient is a child  (“We don’t want him to lose hope”)

Engineering metaphor

Disease is malfunction   (“He’s in for a tune-up”)

Physician is an engineer or technician  (“Something’s wrong, doc – you fix it”)

Patient is a machine  (“We need to ream out your plumbing”)

War metaphor

Disease is the enemy  (“I treat all my patients aggressively”)

Physician is a warrior captain  (“She’s a good fighter”)

Patient is a battleground  (“The war on cancer”)

Dr. Coulehan believes that contemporary medicine has now largely abandoned the parental (or paternalistic) metaphor, perhaps the most prevalent way of thinking about the patient-physician relationship in the good old days.

But try breaking that news to the Emergency Department physician who misdiagnosed me despite my textbook heart attack symptoms in 2008, and – just as alarming! – the ER nurse who returned to my bedside and sternly warned me after the doc had left my cubicle:

“You’ll have to stop questioning the doctor. He is a very good doctor and he does not like to be questioned.” continua a leggere

Articolo di David Lee Scher su KevinMD

Online communities are now becoming a rich source of information gleaned from their discussions.  This information will be increasingly used for both clinical and commercial purposes. I will touch on themes which are universal to online health communities.  For a discussion citing specific examples, I would refer you to an excellent post by David Shaywitz.  Physicians have expressed concerns about online communities.  If appropriately conducted, like social media in general, I don’t believe these are barriers to acceptance or participation.

1.  OPCs provide education.  While surveys show that most people still prefer to go to a physician to receive a diagnosis for signs or symptoms, many seek a diagnosis online.  One should follow some helpful hints about seeking information online.  One interesting study found that it is the information seeking effectiveness rather than the social support which affects patient’s perceived empathy in online health communities run by healthcare organizations.  One might think that a similar study conducted on social media sites would have the opposite result (see below).  While confidentiality and accuracy of information are legitimate concerns, as long as the participant is aware of these issues, useful information can be provided via OPCs, especially if physicians and other providers are members.

2.  OPCs provide emotional support.  Although OPCs have been touted as providing emotional support, few studies have been conducted in this arena.  One study of 528 patients with breast cancer, arthritis, and fibromyalgia who participated in OPCs demonstrated patient empowerment The empowering outcomes that were experienced to the strongest degree were “being better informed” and “enhanced social well-being.” No significant differences in empowering outcomes between diagnostic groups were found.  Another study, utilizing sentiment analysis and natural language processing techniques is being conducted to determine the various strength of emotions in online discussions and to compare emotional status of men vs women, patients vs caregivers and inquirer vs responders.

3.  OPCs provide other resources.  OPCs whether affiliated or not with healthcare systems or non-profit organizations often (and should if they are good) provide links to commercial, governmental, health and other support services. In addition, community members themselves might offer even more accurate and appropriate first-hand advice regarding these resources.  Logistical (living arrangements, medical and surgical equipment), financial, communication, legal, and other advocacy concerns are commonly addressed in OPC discussions and websites. continua a leggere

In 2000, Charon founded the Program in Narrative Medicine at the Columbia University College of Physicians and Surgeons to teach future doctors how to elicit, interpret, and act upon the stories of their patients. The skills came through rigorous training in close reading, attentive listening, and reflective writing on stories of illness. By studying how narratives work, doctors could build trust, develop empathy, and foster a sense of shared responsibility in a patient’s health. An article in the March 2011 issue of Academic Medicine described an experiment that followed 891 diabetic patients for three years to see if their health outcomes related to their physicians’ empathy levels, which was measured in part by “an understanding of the patient’s experiences, concerns, and perspectives.” The results showed “the likelihood of good control [of diabetes] was significantly greater in the patients of physicians with high empathy scores than in the patients of physicians with low scores.”

“Stories are complicated things. They do not relinquish their meanings easily,” Charon says. “By teaching clinicians how stories work, what happens to their tellers and listeners, and where stories hide their news—in form, in metaphor, in mood, in time and space—we enable them to enter the narrative worlds described by their patients. So clinicians can receive what their patients reveal about their lives and health, leading to accurate clinical diagnoses and personal recognition. They hear in depth what their colleagues report about their patients. They even come to be more forcefully aware of their own interior voices in self-awareness.”

Since receiving $185,000 from NEH in 2003, Charon and a group of multidisciplinary scholars and clinicians wrote a textbook in narrative medicine published by Oxford University Press, and have influenced medical education and clinical practices across the United States and around the world. Narrative medicine curricula and projects can now be found in the United States, Canada, Europe, Latin America, the Middle East, and Australia. Going beyond physician training, workshops regularly attract nurses, social workers, mental health professionals, chaplains, and academics. In 2009, to fulfill demand for training, Columbia inaugurated a Master of Science in Narrative Medicine. To reach those who cannot move to New York for a year, an online Certification of Professional Achievement in Narrative Medicine is in the pipeline.

Charon acknowledges time with patients is often limited, making narrative medicine training a vital component. “The clinician has to be expertly trained to hear and register and interpret accurately everything that a patient might say. We cannot afford to squander one word or one piece of evidence. Narrative medicine training strengthens the listener’s capacity and speed and accuracy in receiving what their patients want them to know.”

National Endowment for the Humanities