Better Health’s Grand Rounds is hosted this week by Dr. Ed Pullen, a board certified family physician practicing in Puyallup, WA. His medical blog provides an experienced family physician’s viewpoint on medical news as well as giving interesting and helpful information to help patients be informed. For this week’s collection of health care blog posts, Ed drew clever sketches to give you an idea of the mood of each writer..as usual it’s an eclectic batch of posts from diverse perspectives. You can check out this week’s Grand Rounds here.
Archive for the ‘Grand Rounds’ Category
Check out this week’s Grand Rounds at DrPullen.com
CFAH StaffTuesday, August 16th, 2011
Better Health’s Grand Rounds Volume 7, Number 44
CFAH StaffTuesday, July 26th, 2011
Welcome to Better Health’s Grand Rounds Volume 7, Number 44! This is our second time hosting Grand Rounds and we’re excited about sharing the posts we received. The theme of this week’s collection came from a recent Health Affairs blog post by CFAH president, Jessie Gruman, Patient Advocates: Flies In The Ointment Of Evidence-Based Care, which addresses a few of the many challenges of basing health care practices, policies, and decisions on evidence of effectiveness.
We have posts that wrestle with conflicts of interest in reporting on evidence, obstacles to the delivery of evidence-based care, using evidence in practice and care decisions, and providing patient-centered care. We believe this topic is important to all those involved in health care, from patients and doctors to hospital administrators and policy makers. Thank you to everyone who submitted a post. We hope you enjoy this week’s collection.
Consider the Source
Evidence of clinical effectiveness/harm is revealed over time by additional “white-coat” research and via the real-life experiences of patients and clinicians. Identifying how and by whom evidence is revealed is an important part of evaluating its reliability and accuracy…and towards following the winding path towards effectively applying evidence to practice.
Elaine Schattner, in her post on Medical Lessons, Patients Words, Unfiltered, Medical Journalism and Evidence, shares her concerns that: 1) journalists often select patients’ voices to support pre-determined points of view; 2) making rational decisions based on data is often more complicated than surface appearances; and while 3) evidence should be the foundation of care…we also must acknowledge that outliers exist.
In Direct-to-Consumer Advertising and the Role of Advocacy Organizations: Two Threats to Evidence Based Testing, Josh Freeman, from Medicine and Social Justice, reviews two recent JAMA “commentaries” that addressed challenges to the implementation of evidence-based practice guidelines from two very different but very powerful forces. The marketing of health care technology and treatment directly to consumers and patient activists present both obstacles and opportunities to advance the delivery of evidence-based care.
How did this Heart Drug get Approved in the First Place?, asks Carolyn Thomas, in her post on The Ethical Nag: Marketing Ethics for the Easily Swayed, referring to the drug Nesiritide. A heart attack survivor, 
Carolyn “figured the purpose of the drug approval process is to ensure that testing the effects of new drugs on patient outcomes has already been done before approval is granted.” Pat Salber, of The Doctor Weighs In, also tackles this in her post: Niseritide, the “Lost Decade”, and the Pinto.
Obstacles to Delivering Evidence-based Care
One challenge to the delivery of evidence-based care is the interpretation and application of evidence by individual clinicians. A Country Doctor, in his post, Patient Centered or Evidence Based Medicine – Can we really have both?, notes that every physician has to evaluate the evidence and determine how to apply it to each patient’s unique situation.
From Joel M. Topf, of Precious Body Fluids, comes, The Problem with Numbers, the Curse of Intermediate End-points, expressing his concern that medical interventions are increasingly oriented around improving the “numbers” – what he defines as intermediate endpoints – rather than real goals of preventing morbidity and mortality in addition to effectively addressing patient concerns and symptoms. He worries that medications “are pursued and approved only for their ability to fix the numbers.”
The frenzied pace of many medical practices can also be a barrier to providing optimal care, says Steve Wilkins, of Mind the Gap, in Lack of Time and Reimbursement—Is That Why Physicians Don’t Do a Better Job Communicating With Patients? Steve points out that although doctors claim that there is not enough time for patient education, evidence shows that such conversations improve patient outcomes.
InsureBlog‘s Kelley Beloff makes a similar argument in Wait Times in the Medical Office, proposing that patients should consider why doctors run late before making judgments or feeling frustrated. Kelley writes, “The standard patient appointment time is 15 minutes. How many of us could do our entire job in 15 minute increments, 25 to 28 times a day?”
Are We Using Evidence Effectively?
Val Jones of Better Health tells us Why She’s Afraid For Anyone to Enter the Healthcare System…Ever. Val’s post offers resources for patients, caregivers and health care professionals to ensure they are “on the right diagnostic pathway, getting the most appropriate care that suits their needs and preferences, and protecting them from errors and missteps.”
Rheumatologist Irwin Lim, in One Fracture, Two Fracture, Three Fracture…Enough! writes about the need for targeted interventions for high-risk groups…especially patients with osteoporotic fractures that “are getting a surgical fix or a cast, but not assessed and therefore, not treated for osteoporosis…this causes pain, suffering, disability and loss of independence. It also costs….a lot of…money.”
Harold Pollack at Kaiser Health News says in, It’s Not Just About the Money: Cost Control in Cancer Care, that providing evidence-based care is greatly impacted by incentives promoting aggressive care. He writes that “We all must face these issues to control costs…We can treat our loved ones, and ultimately ourselves, more effectively, more efficiently, and more decently than we often do.”
Family physician Ed Pullen at DrPullen.com struggles with how to best reduce morbidity risks when facing contradictory recommendations for care. For example, he wonders how to weigh concerns about PSA screening asking “Is there more morbidity related to treating cancer long before symptoms develop, or is there more morbidity from treating cancer after symptoms appear?”
On Pizaazz, Glenn Laffel argues that while no one would dispute screening and prevention as potentially useful tools in the effort to improve the quality of care and reduce unnecessary costs, not all such programs actually work. Screening for prostate cancer, spiral CT screening for lung cancer, colonoscopies, and ECG screening for high school students, to name a few. He says, “Some screening and prevention programs are not effective at all. Others are effective, but prohibitively expensive.”
Gary Schwitzer, of HealthNewsReview, in two posts about using robotics for surgical procedures, raises questions about its use despite many questions about its benefits, harms, and increased costs. Gary asks, “How are patients to make informed health care decisions and weigh evidence fairly if the information presented is not whole?”
Alexander Friedman adds in his post, My Patient Needed to be Delivered, that cesarean section rates are on the rise due to standard use of fetal heart monitors. Friedman says that although it’s an “appallingly poor test,” nearly all American mothers are monitored during labor. Yet, in his experience, almost every time he performs a C-section based on the warnings of distress from the monitor, the baby is delivered “pink, healthy, and a little bit angry…our medical culture prizes technology and tests, even if they don’t work and can cause harm.”
With several recent deaths in Oregon from attempting at-home breech deliveries, Jonie Dawning, an experienced midwife, believes that too many midwives are unaware of the potential risks involved. In her letter to the Oregon State Legislature, she makes the case for an evidence-based care and policy approach.
Wilderness medicine expert Paul S. Auerbach acknowledges that antibiotics are overused to treat childhood ear infections. But when in an outdoor or wilderness setting, where there is no medical professional to help make the decision, he advises that it is certainly reasonable to administer antibiotics.
Using Evidence for End of Life Care Decisions
In response to a recent NYTimes piece on rising Medicare hospice costs and the role of fraud in the phenomenon, Chris Langston, of The John A. Hartford Foundation HealthAGEnda blog, offers a primer on hospice in the first of a two-part series. With the current budget-cutting environment, Langston “worries that we will make a mistake that will deprive people at the end of their lives of valuable services and that we could even unintentionally increase total health care costs while trying to lower them.”
On GeriPal, Eric Widera shares that “despite a lack of evidence to show any benefits to prevent aspiration pneumonias or pressure ulcers, improving comfort, or prolonging life, feeding tubes are still inserted in patients with advanced dementia.” Widera wonders if family members have unreasonable expectations about the benefits of feeding tubes and specifically if they know that “40 percent of tube fed individuals must be restrained to keep feeding tubes in place.”
Ryan DuBosar, on ACP Hospitalist blog, highlights a recent report from the Center to Advance Palliative Care, noting that nearly two-thirds of all hospitals now have a palliative care program and larger hospitals have even more access. These palliative care teams can help patients and their caregivers when facing a serious illness and making difficult choices.
Receiving Patient-Centered Care…Not Always as Expected
Clinicians, family members and sometimes even strangers can all play a role in providing patient-centered care. Sometimes you get the support you need…at other times, there is a gap between what you need and what you receive.
Amy Berman, of the John A Hartford Foundation HealthAGEnda blog, shares her experience with what she believes was an overly aggressive treatment recommendation in Can Good Care Produce Bad Health?. She says, “It doesn’t matter if care is cutting-edge and technologically advanced; if it doesn’t take the patient’s goals into account, it may not be worth doing.”
Posting a sick kid’s photo on Facebook led to the swift diagnosis of a dangerous, fast-moving illness. David E. Williams, in the Health Business Blog, explores the role of social media and crowd-sourcing in his post, Diagnosing an Illness with Facebook.
Beth L. Gainer, of Calling the Shots, recognizes the compassion and support she received from unexpected sources after she received her breast cancer diagnosis and during her treatment in her post, Heroic Moments.
We hope you enjoyed this week’s Grand Rounds. It was wonderful to read so many posts related to such an important and lasting issue. Thank you to everyone who submitted a post and to those whose posts we happened upon and included above. Please be sure to check out next week’s host, James Logan, MD at http://jamesloganmd.com.
We’re Hosting Grand Rounds for Better Health on Tuesday, July 26th
CFAH StaffWednesday, July 20th, 2011
We’re hosting Grand Rounds for Better Health on Tuesday, July 26th. Grand Rounds is a collection of top recent health care blog posts.
Recently, the Health Affairs Blog hosted CFAH President and Founder, Jessie Gruman’s piece: Patient Advocates: Flies in the Ointment of Evidence-based Care.
We would like to build on this theme by showcasing posts that address the challenges of basing health care practices/policy on evidence of effectiveness, providing patient-centered/individualized care, making informed patient/caregiver choices, weighing risks/benefits, etc.
Please submit any blog contributions for the July 26th Grand Rounds to grandrounds@cfah.org by Sunday, July 24th.
We look forward to hearing from you, and be sure to check out our collection for Grand Rounds here on the Prepared Patient Forum, What It Takes, blog on July 26th.
Better Health’s Grand Rounds Volume 7 #34
CFAH StaffTuesday, May 17th, 2011
We received more than 40 contributions for this week’s collection of health care blogs and columns. Patients, clinicians, policy wonks and interesting folks with opinions submitted original posts that are sure to expand your thinking and perspectives.
Patient Perspectives
Patient perspectives come from the front line of personal diagnosis. Those who are ill, are in recovery, or who cope with chronic conditions have special insight about health care experiences and managing their care.
On Calling the Shots, Beth Gainer takes issue with using terms such as “sexy” and “sassy” to describe the experience of having breast cancer. As a breast cancer survivor, Beth understands the reality of the diagnosis, treatment and aftermath that left her feeling anything but sexy or sassy. In The Treatment of a Lifetime of Pain, Cynthia Lott Vogel tries “to give you an idea of some of what a chronic pain patient may go through.” She explores the numerous difficulties someone bearing the diagnosis of chronic pain faces in their search for help. Marc Stecker, aka Wheelchair Kamikaze, is no stranger to the difficulties of living in a world designed by and for able-bodied people. For the disabled, the world can seem foreign and unintuitive. The Accidental Alien takes a unique approach to this situation by creating a world constructed solely for the disabled. If you ask Jennifer Jaff, she’ll tell you that it’s possible to make those who are ill feel a little less alien in this world. How? By making the invisible visible. She advises that simple acts can change the world of the chronically ill.
To make sure she could take her medications as directed, Warm Socks has tried numerous systems: the cross-your-fingers-and-hope-for-the-best system, the dancing-bottles system, the list/highlighter system and – finally – the pill-organizer. Her piece explores just one part of living with a chronic condition: managing multiple medications. How well prepared is the health care community to seek out these stories and use them to design care that’s better, safer, more efficient and more responsive to patients’ needs? Telling the Patient’s Story, by Anne Polta, reflects on why it’s important to allow patient stories to be part of this process.
Another responsibility that falls on patients is the need to be informed about their condition and the research relating to it. This aspect of patienthood can be burdensome for those who are ill.
Many patients rely on clinical trials to produce treatments that will help them. RA Warrior Kelly Young wonders if and why some rheumatoid arthritis trials seem to target a specific group of patients who respond better to treatment than average patients do. When it comes to personal research, About.com’s Trisha Torrey has a word to the wise, suggesting that patients explore why their doctors seem resistant to discussing information that patients find online.
Once you’ve recovered from a serious illness or are terminally ill…there are still more decisions to be made.
Should survivors of illness and those who are terminally ill make a bucket list? Carolyn Thomas’ post humorously addresses the existential question: “When you’ve somehow survived what many do not, should you now create a list of exciting life-affirming adventures to complete before you head off to that great Coronary Care Unit in the sky?” And finally, Allison Blass, in a letter to her first diabetes doctor, notes all that has changed in the diabetes world and how much she appreciated his care. We can all aspire to have this kind of relationship with our health care providers.
From the Sidelines…
Patient advocates, policy wonks and watchdogs sound off with close-up perspectives ranging from rating patient experiences to evaluating the latest news stories and health information technology (HIT) innovations.
In what seems like a rare event these days, Steven Wilkins gives a firsthand account about how a meeting with a new physician turned into a wonderful patient experience. Stories of personal interactions are the foundation for the evaluation tools that Julie Rosen supports in her blog. She writes about her support for evaluating patient satisfaction and providing hospital bonuses based on favorable patient satisfaction outcomes. Marya Zilberberg provides us with a reminder to look carefully at the evaluation tools used to promote new technologies and always look at the denominator.
Gary Schwitzer’s HealthNewsReview Blog, warns patients with three examples (in one week) of PR companies using objectionable techniques to promote pharmaceutical products to journalists.
HIT continues to evolve and change the way that patients and doctors interact and communicate. Lindsey Hoggle from Informatics for Consumer Health suggests a third player, the government, to participate through technological advances and is encouraged by the Draft Federal Health IT Strategic Plan (2011-2015) in her post In Concert. Mary Pat Whaley sends out a call to medical professionals to utilize technology as a way to be transparent about medical costs, so that patients can make informed decisions and communicate more effectively with their providers. Susannah Fox, of the Pew Internet & American Life Project, gives us data, data and more data about how Americans are gathering, sharing and creating health information in her speech at the Mobile Health conference at Stanford University.
Inside Health Care
Physicians, medical students, nurses, and other health care professionals shared posts covering a wide range of topics.
It begins in medical school…
Fourth-year medical student Christopher Bayne tells us how we can improve medical education. His ultimate hope is that “Technology will free overhead and liberate human energy.” On OB Cookie, resident in training Elizabeth Breuer, offers advice to new interns. Her final tip? “Work hard, keep your head down, take care of your patients and take responsibility for your actions.” In Short White Coat, fifth-year medical student Ishani Ganguli reflects on a New York Times piece on hospital bullying. She recommends training in communication and team building between medical students similar to what is needed for good doctor-patient skills.
Social Media is more than a buzzword in the health care world. Here, physicians talk about what it means to them.
Dr. Glenn Laffel says “the genie is out of the bottle.” He believes that all professionals should aggressively adopt social media. However, he also notes that it can blur professional and personal boundaries, risk patient confidentiality and threaten the careers of those who misuse it. For doctors who are just starting to use social media, Dr. Ves Dimov provides advice and a list of the top Twitter doctors by specialty. And with so many patients and doctors going online, Dr. Irwin Lim wonders if patients get better information online than from their doctor. After he started blogging, he discovered that patient blogs have much to offer both doctors and patients by demystifying conditions.
Blogging also provides clinicians with a venue to discuss the latest research/practice.
Dr. Ed Pullen takes a skeptical look at why labor and delivery units are adopting the use of nitrous oxide for labor pain relief considering that its effects on the fetus have not been studied. In a similar vein, Peggy Polaneczky critiques a Wall Street Journal article, saying it is filled with speculation, misinformation and generalizations about birth control and sexual attraction in humans…because the study was conducted on lemurs! For more reputable information, president and CEO of Better Health, Dr. Val Jones offers evidence-based weight loss and fitness tips to ABC News. And for allergy sufferers, Dr. Ves Dimov offers findings from a small, randomized controlled pilot study (results should be considered preliminary) on birch pollen-rich honey allergies. And Inside Surgery provides the American Association for the Study of Trauma classifications of pancreatic injuries on its blog.
Providing care is a doctor’s job, but so much affects how that care is administered.
Dr. Michael Kirsch discusses the ‘under-the-radar’ factors that affect patient referrals. He says, “In my experience, availability trumps clinical acumen for many referring physicians who want their patients seen expeditiously.” Second, manners and personality can affect the quality of care a patient receives, says Elaine Schattner. She reflects on a recent post by Dr. Wes and says, “It’s the professional’s job to see beyond the smile or anger” of the patient in order to provide good care. The Happy Hospitalist couldn’t agree more. He says it’s the physician’s responsibility to provide quality care at an affordable price. To back this up, ACPHospitalist highlights a report from American Family Physician that as family practitioners in a community increase, hospital readmissions rates decrease.
John Henning Schumann on GlassHospital finds that very little gets done in a hospital on the weekends. Ultrasounds, radiology tests, physical therapy, biopsies and elective surgeries all slow down. Does this jibe with how technological and “efficient” health care is supposed to be? Dr. Juliet Kottak Mavromatis reflects on privacy, ethics of informed consent and health literacy after reading The Immortal Life of Henrietta Lacks. And should you ever need to know, Dr. Paul Auerbach shares a Brief Introduction to Search and Rescue followed by recommendations on How to Avoid Needing Search and Rescue Services.
Counseling psychologist Will Meek says, “Many of my clients struggle with being ‘off time’ for major life decisions or anxious when their life course take an unexpected new turn.” Following the Path is aimed at helping people accept, adjust, and take ownership for these surprises. On Shrink Rap, Dr. Dinah Miller recounts an interview on NPR’s “Talk of the Nation” in which she and her colleague, Dr. Steven Roy Daviss discuss emergency room care.
Them’s Fighting Words
Passions, beliefs and opposing positions are well represented in this week’s GR submissions. Given the current backdrop of political divisiveness, some posts took a look at current politicians and policies and – not surprisingly – came out with diverse perspectives.
Bunny Ellerin, of Ellerin HealthMedia, shares a recent study, Online Health: Untangling the Web, which shows how people in 12 countries are using online health information. She warns that the consequences of poor-quality health information can be serious. While Jacqueline, of Laika’s MedLibLog, calls out one specific U.S. online resource for what she calls its “lack of credibility and transparency.” At InsureBlog, Bob Vineyard shares some of his concerns about electronic medical records: online patient privacy/security, physician accountability for HIPAA violations, and costly upgrades and changes in software that cause disruptions in busy physician practices.
Michael Millenson, in a Kaiser Health News guest column, opines on Newt and the Health Wonks: A Tale of Lust and Power. David Williams, of the Health Business Blog, believes that while imperfect, the Quality Adjusted Life Year (QALY ) “is an improvement over simply measuring life expectancy.” Carolyn Roy-Bornstein wonders about First Amendment Rights and Child Safety in her post about the recent debate in the Florida legislature over pediatricians routinely asking parents/caregivers during well- child visits “if there is a gun in your home and if so, how is it stored?”
Greg Vigdor with Washington Health Foundation, supporter of the Healthiest State in the Nation Campaign, asks and answers with a resounding “YES” in Can “We the People” Fix American Health Care? But Louise Norris, of the Colorado Health Insurance Insider, wonders in her post if it’s even possible for patients to be consumers.
We hope you enjoyed this week’s collection of posts. Thanks so much to all who contributed. Next week, Better Health’s Grand Rounds will be traveling to medGadget.
Aftershock:
The Center for Advancing Health is funded by