Doug Farrago, creator of the Placebo Journal, presents his latest episode of Placebo Television.

• Placebo Television returns with episode #16
• Placebo Television gives another take on President Obama’s address to the AMA
• Medscape op-ed on how to help today’s tense, frustrated doctors

by Danielle Ofri, MD, PhD

When I make rounds with my students and interns, I always try to sneak in a poem at the end. I think poetry is important because it helps convey the parts of the medical experience that don’t make it into textbooks. It’s important because it teaches creative thinking—something of immense value to doctors.

It’s important because interpreting metaphors is a critical clinical skill in diagnosis; patients’ symptoms often present in metaphorical manners and we doctors need to know how to interpret our patients’ metaphors. Last but not least, there is a therapeutic value to introducing beauty into a situation that is not commonly associated with aesthetics.

I’ve been giving poetry to my medical team for a few years now, but I’ve always wanted to give poetry to my patients. Unfortunately, English is not the first language for most of the patients in my hospital, so this has been challenging.

But there is one set of patients that seems to consistently speak English—the alcoholics. The Bowery-type alcoholics aren’t necessarily the favorite patients of the interns. These patients are frequent fliers, they are clinically “uninteresting,” they are often malodorous, and their illness is perceived as self-inflicted. But they do speak English.

So one morning on rounds, our team went to examine a new alcohol-withdrawal admission. His condition was standard: alcohol-on-breath, speech slurred, fingers trembling, hair and beard disheveled, body odor a mix of unwashed socks and cheap beer. He was cranky, and impatient with the detailed questions we asked.

As the team was finishing up, I whipped out some papers from my pocket—Jack Coulehan’s poem “I’m Gonna Slap Those Doctors. I gave a copy to the patient and distributed the rest to the resident, interns, and medical students. Asking their forbearance for this slight divergence from medical protocol, I plowed onward and read the poem aloud.

I’m Gonna Slap Those Doctors

Because the rosy condition
makes my nose bumpy and big,
and I give them the crap they deserve,
they write me off as a boozer
and snow me with drugs. Like I’m gonna
go wild and green bugs are gonna
crawl on me and I’m gonna tear out
their goddamn precious IV.
I haven’t had a drink in a year
but those slick bastards cross their arms
and talk about sodium. They come
with their noses crunched up like my room
is purgatory and they’re the
goddamn angels doing a bit
of social work. Listen, I might not
have much of a body left,
but I’ve got good arms — the polio
left me that — and the skin on my hands
is about an inch thick. And when I used
to drink I could hit with the best
in Braddock. Listen, one more shot
of the crap that makes my tongue stop
and they’ll have something on their hands
they didn’t know existed. They’ll have time
on their hands. They’ll be spinning around
drunk as skunks, heads screwed on backwards,
and then Doctor Big Nose is gonna smell
their breaths, wrinkle his forehead, and spin
down the hall in his wheelchair
on the way to the goddamn heavenly choir.

(from Medicine Stone, 2002. © Jack Coulehan)

As I read the poem, I could feel the atmosphere in the room changing, ever so slightly. The focus shifted from the patient to the poem, and everyone was an equal neophyte with this particular poem.

When I finished reading, some of the medical team looked uncomfortable, but the patient was smiling broadly. “This is great,” he said. “I love it!” With his pronouncements, everyone relaxed a bit.

“You know,” the patient continued, seemingly happy to have an audience, “ I used to read some books, back in the day.” He sat up in bed, more animated now. “I like history stuff—ancient Greeks, ancient Romans. Real characters, those guys.”

We ended up having a conversation about his childhood in small-town New Jersey, how he cut classes in high school to putter around on the beach.

We left the room feeling awkward but also somehow lighter. Suddenly our patient wasn’t just another alcoholic drying out on the ward. He was a real person, someone who stood out in our minds.

The poem certainly didn’t change the course of his devastating disease of alcoholism. It didn’t offer him the epiphany to suddenly quit drinking or to reconnect with his estranged family. His liver enzymes didn’t miraculously normalize. His platelets didn’t bound back to health. But it gave all of us a sense of human connection.

Throughout his four-day stay in the hospital, the patient was much more pleasant to the team. I noticed that the students and interns wandered in more frequently to say hello. We all felt just a bit more connected.

Rx: Take two sonnets and call me in the morning.

Danielle Ofri is writer and practicing internist at New York City’s Bellevue Hospital who blogs at Medicine In Translation. She is the editor-in-chief of the Bellevue Literary Review. Her newest book is Medicine in Translation: Journeys with my Patients.

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• Why doctors skip medical interpreters, and how that damages physician-patient communication
• Should the best and brightest really become doctors?
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by Jeffrey Knuppel, MD

Many non-correctional health care providers will also treat inmates from time to time. This may occur in the office or hospital. How can one best approach the challenges of working with the incarcerated in order to deliver the best possible care while simultaneously managing risk?

1. Treat the patient with respect. Not submissive respect, but mutual respect — the way we all want to be treated. I believe that this principle alone goes a long way towards helping one to establish a therapeutic alliance and to minimize interpersonal conflict and hostility. Inmates are people, too. Those who do not agree with this statement should steer clear of treating them.

2. Listen attentively. It may be tempting to get this shackled person (who you may secretly be embarrassed to have in your office) out as expediently as possible. Squelch that temptation, and listen actively as you would to any patient. All patients want their concerns taken seriously. Inmates are no exception. I believe you minimize problems for yourself in the long run (and provide better care) if you ensure that patients’ concerns are heard, especially if they seem to have more challenging personality styles.

3. Be honest. If there is a particular reason why you think something the patient is requesting is inappropriate, then politely tell them so. If you believe they have a particular diagnosis, psychiatric or not, then respectively inform them of your opinion. For some reason, I’ve gotten the impression that clinicians are more likely to be dishonest with inmates than with other patients. I don’t know why. Whatever you do, never lie to an inmate.

4. Maintain appropriate boundaries. While you may briefly mention something about your family or personal life to your long-term patients (depending on your specialty), never do so with offenders. Stick to the task at hand, and don’t answer personal questions. You want a professional, not a personal, relationship with them.

5. Avoid the defensive medicine temptation. Inmates sue doctors at a higher rate than does the rest of the population. Understandably, some physicians will believe they must practice more defensively to protect themselves. Despite such fears, do not order more tests, procedures, or medications for the incarcerated than you would order for other patients. Thorough documentation and caring are, in my opinion, your best defenses in these situations (see #7 below). Remember that your goal is to provide appropriate health care, not placation.

6. Focus on what you can do for them, not on what you cannot do. It’s always better to be positive. If you and the patient are having trouble reaching a mutually agreeable workup or treatment for their complaints, emphasize what you are willing to do to help them and why. Emphasizing the limits you want to set with them will only fuel animosity.

7. Document, document, document. Generally speaking, medical care documentation for inmates does not need to be different than that for non-inmates. However, it is crucial to be extra-thorough if you believe the inmate is in any way disappointed or angry about their medical encounter with you. Document not only your thorough history and physical but also your interpersonal interaction with the inmate, the fact that they were dissatisfied, and then justify your treatment plan as though it is being reviewed in court. If something frivolous is filed against you, it will be much easier for a judge to quickly dismiss before it goes anywhere if you have clearly demonstrated your thoughtfulness in providing care.

Jeffrey Knuppel is a psychiatrist who blogs at Lockup Doc.

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No words are needed in this graphic, high-impact public health ad.

(via Street Anatomy, where you can find other shocking public health ads)

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Originally published in MedPage Today

by Chris Emery, MedPage Today Contributing Writer

Nearly a third of children with special healthcare needs are underinsured, and where a child lives strongly influences whether he or she will have adequate healthcare coverage, a new study found.

The unadjusted proportion of underinsured special-needs children varied strongly by state, ranging from 24% in Hawaii (standard error=1.75) to 38% in Illinois (SE=2.13), found the study published online March 8 in Pediatrics. After adjusting for factors such as age, race, and poverty level, the proportion of children without adequate healthcare coverage ranged from 23% (SE=1.89) in Hawaii to 38% in New Jersey (SE=2.21).

“Our results indicate that where a child lives is strongly related to the likelihood that his or her health insurance is adequate,” Michael D. Kogan, PhD, of the Health Resources and Services Administration, and colleagues wrote. “Moreover, only a small part of that association is explained by the underlying demographic and health characteristics of children. These findings suggest that current efforts to add coverage incrementally for the uninsured, although important, will do little to address the problems of the underinsured or the state disparities demonstrated here.”

While considerable attention has recently focused on providing health insurance coverage for children who have none, much less attention has focused on the problem of underinsurance, according to the authors. In particular, they wrote, little attention has been given to children with special healthcare needs, who have chronic physical, developmental, behavioral, or emotional conditions — or are at high risk of these conditions — and require special services beyond what is normally required. Previous research has found that although 14% of children in the U.S. have special healthcare needs, they account for 42% of the medical expenditures for children.

The authors noted that focusing on underinsured children is useful for several reasons. First, “states are being called on to play a larger role in insuring their populations since the inception of the State Children’s Health Insurance Program (SCHIP) and the continuing shift away from employer-based health insurance.” In addition, “gaining additional understanding of the large state variations could lead to more effective interventions aimed at reducing disparities,” and “the best performing states can serve as benchmarks for what might be achieved by others.”

To determine the proportion of special needs children in each state, Kogan and colleagues analyzed data from the 2005-2006 National Survey of Children with Special Health Care Needs (NS-CSHCN), a nationally representative study of more than 40,000 children. Children were considered underinsured if a parent reported that the child’s insurance did not usually or always cover needed services and providers, or if the insurance did not reasonably cover costs.

Of the parents of special-needs children who responded to the survey, 12.7% reported that insurance did not offer benefits or cover services that met the child’s needs, 28.0% reported that the costs that were not covered by insurance were not reasonable, and 9.3% reported that the insurance did not allow the child to see the healthcare providers that he or she needed.

“Although there is perennial interest in the Census Bureau’s periodic reports on the number of uninsured individuals in the U.S., our analysis of the NS-CSHCN suggests that underinsurance affects far more children than does lack of insurance, at least among children with special healthcare needs,” the authors wrote.

Generally speaking, children living in Midwest states tended to have better coverage, while those living the Southwest had less coverage. Children with coverage from private insurers were more likely to be underinsured (33.5%) than those with public coverage (30.9%).

Children were also more likely to be underinsured if their parents had to cut back or stop working due to their condition, if they were between the ages 6 to 17 years, if they were poor, and if they lived in non–English-speaking households.

The authors cautioned that the study relied on parents’ assessment of their children’s healthcare status, which may have introduced recall bias into the findings, and that the study excluded children who were homeless or living in institutions.

“Also, because the focus of this study was underinsurance, states that provide less comprehensive public coverage to more children will seem to be ‘lower performing’ than states that provide more comprehensive public coverage to fewer children, because uninsured children were not considered ‘underinsured’ and were excluded from the analyses,” the researchers wrote.

Despite these limitations, the authors concluded that underinsurance is an large problem that remains to be addressed. “If policymakers are interested in ensuring equitable treatment in the healthcare system for children with special healthcare needs, then policy initiatives aimed at reducing underinsurance and increasing uniformity of coverage across states are also needed,” they wrote.

Visit MedPageToday.com for more pediatrics news.

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Mammogram screening for breast cancer continues to simmer in the news.

The recent USPSTF guidelines, no longer recommending a routine mammogram for women between the ages of 40 and 49, continue to stir controversy between physicians and their patients.

In a recent survey from the Annals of Internal Medicine, it looks like the debate between doctors and patients will continue for the foreseeable future:

. . . a divide has emerged between doctors and patients — with the doctors more inclined to accept the new recommendations and the patients wanting to stick to early and annual screening . . . Most of the 345 doctors who responded said they would stop offering routine mammograms to women in their 40s, and most said they would advise women 50 to 74 to have mammograms only every other year . . .

. . . most of the 241 patients who responded said they did not believe in giving up routine mammograms in one’s 40s — even if the doctor recommended a change — and were not likely to switch to an every-other-year routine.

This is entirely unsurprising. There continues to be a perception among patients that more screening and tests equate to better health care — despite the evidence that says otherwise. False positives that arise from more aggressive screening can lead to more harm than good.

The media firestorm caused by mammogram screening is a good first step to educate the public that there indeed can be such a thing as “too much” medicine.

Policy experts and health reformers tend to blame the medical profession for American’s embrace of expensive and unnecessary tests. Instead, they should help find ways to help doctors educate patients and reduce the demand for these studies.

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The following is part of a series of original guest columns by the American Medical Association.

by J. James Rohack, MD

Physicians in nearly every area of the country face a David and Goliath scenario when negotiating with entrenched health insurance companies. This is clearly illustrated by a new AMA study showing that competition in the health insurance industry is disappearing as more markets across the country are dominated by one or two insurers.

Most alarmingly, in 24 of the 43 states reported in the new AMA study, the two largest insurers had a combined market share of 70 percent or more in 2007. The year before, just 18 of 42 states had two insurers with a combined market share of 70 percent or more. The AMA study also found that 99 percent of metropolitan markets are “highly concentrated” according to federal merger guidelines – up from 94 percent of metropolitan markets the year before.

The near total collapse of competition in health insurance markets occurred as insurers amassed dominant market power through years of unrestrained mergers. Between 1996 and 2008, there were more than 500 mergers involving managed care insurers, but federal antitrust regulators challenged only three.

While the health insurance industry is the most consolidated sector in the health care system, nearly half of the nation’s patient care physicians are in small or solo practices (1 to 4 physicians). This imbalance allows the largest health insurers to flex their market power and substitute corporate policy for a physician’s best medical judgment.

The physician role as patient advocate is being undermined as insurers gain leverage over patient care decisions. Conditions in most markets are now heavily tilted toward insurers, giving them an unprecedented advantage in determining the scope, coverage and quality of health care.

Patients have not benefited from the virtual unlimited power insurers have over health care. Health insurers have posted historically high profits, even during times of economic slowdown. The premiums they charge have soared without an expansion of patient benefits. Average insurance premiums for family coverage have risen 131 percent in ten years to $13,375.

Despite the fact that only health plan executives and shareholders appear to be benefiting from the profitable absence of competition, health insurance companies have recently proposed amazingly high premium increases. For instance, Anthem Blue Cross of California proposed a 39 percent premium increase to cover “rising medical costs.”

Anthem’s proposed 39 percent premium hike is out of step with the latest figures showing that increases in U.S. health care spending slowed to 4.4 percent, the slowest rate of growth in nearly 50 years. Spending for physician and clinical services grew 5 percent, the slowest rate of growth since 1996. While insurers propose double-digit price increases, the latest figures show prices for physician services increased by only 2.7 percent. In fact, inflation adjusted physician fees decreased by 25 percent between 1996 and 2006.

Huge premium hikes in the face of record low health care spending figures demonstrate that insurance companies cannot promise that bigger is better. More oversight is needed to make certain that insurers are not funding their multi-billion dollar merger and acquisition strategies on the backs of patients, physicians and employers.

There are steps that can be taken right now to restore a competitive balance to health insurance markets. One is a renewed commitment by federal and state agencies to enforce antitrust laws that prohibit harmful mergers. The AMA has urged the Department of Justice to consider additional steps:

* Perform a retrospective study of health insurance mergers similar to that performed by the Federal Trade Commission on hospital mergers;
* Commission new research to identify causes and consequences of health insurer market power;
* Create a system for predicting the effects health insurer mergers will have on consumer and provider markets.

We are also urging federal regulators to relax the current rigid antitrust policies that discourage small and solo physician practices from joint arrangements that would improve the efficiency and coordination of patient care. This crucial step would level the playing field and allow physicians to negotiate contract terms with large insurers, ensuring that patients and their physicians make health care decisions, not insurers.

We hope our new study on health insurance competition will renew the long overdue dialogue among regulators, policymakers, lawmakers, and others about the imbalance in health care, and lead toward a better, more open and competitive marketplace to benefit patients and the physicians who care for them.

J. James Rohack is President of the American Medical Association.

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• Primary care doctors need financial independence
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• How ideology is shaping health care reform

by Matthew Mintz, MD

There are certain actions we take even though we know that ultimately we will not be successful. Sometimes we do this out of hope for a better tomorrow (like playing the lottery) or because we are taking a moral stand (like supporting a candidate that has no chance of winning).

Supporting health care reform is probably a little of both.

Even if any of the currently proposed health care reform plans pass, it will make little impact on our crumbling health care system. That said, you MUST support health care reform now.

Why?

1. The current system is worse then broken. You probably know about the over 40 million Americans that lack health care coverage, and the fact that we pay more than any other country for health care, but have poorer health than most other countries. However, non-health related facts may be even more important.

The most common reason for bankruptcy in the US is medical bills. In addition, our nation’s industries can not compete in a global market because of health care costs. GM spends more on health care for its employees then the metal in the cars they make. The health care system is not only broken, it is crippling our entire company.

2. If we don’t act now, reform may never happen. Congress goes into recess at the end of the month. By mid-April, our representatives will start to focus on the mid-term elections. Thus, it is likely that nothing substantial will get done this spring, summer and fall until after November, 2010. If this is the case, regardless of the outcomes of the upcoming elections, no politician will want to tackle health care any time soon.

3. We are so close. We have never before had health care bills that have been passed in both the House and Senate. This is historic. We can’t stop now, because we may never get this close again.

4. There are actually some good things that will happen if reform is passed. Even if we don’t cover all the uninsured, any bill that covers millions more has to be worthwhile. Both side also seen to agree on eliminating pre-existing conditions and closing the Medicare Part D donut hole will be a major help to many of our seniors.

But the current health care reform proposals aren’t perfect.  Here’s why.

1. Coverage is not enough. There are four major problems with our current health care system: lack of coverage (uninsured, underinsured, pre-existing conditions), escalating health care costs, a poor delivery system including a primary care shortage, and an unhealthy population.

The other issue, of course, is how to pay for any fixes. Current proposals pay lip service to all four, but really only address coverage. All are inter-related, so without addressing the others, your can’t fix the system. Massachusetts is a perfect example. After expanding coverage to all residents, the state found that there weren’t enough primary care doctors to see everyone. These newly insured patients ended up going to the ER, leading to dramatically increased costs for the state.

I believe we should have first addressed rising costs and our delivery system. Fixes include malpractice reform and restructuring our payment system which pays for tests and procedures over prevention and counselling.

2. You are probably not affected. If you are reading this, you are doing so a work (you have a job) or at home (you probably have a job if you can afford shelter with a computer and Internet connection). This means that you likely have health insurance that is provided by your employer, like most Americans between 21-65. Similarly, you are likely not happy about your escalating health insurance premiums and possibly frustrated by longer and longer waits for shorter and shorter appointments with your doctor.

However, you likely want to keep your doctor, are thankful you have coverage, and though you feel bad for the uninsured, you are more fearful of what substantial reform might mean for you. The good news is that whatever passes will likely not affect you. The bad news is that we will likely not get any real change until things get so bad that most Americans demand change.

3. Things are bound to get worse. Though our dysfunctional system and plans for reform may not affect you now, things will get worse. Without addressing costs, premiums will continue to go up and even more patients will lack the ability to afford health care coverage. Without addressing the bureaucracy of insurance paperwork and they pay disparity between specialists and primary care physicians, students will continue to go into non-primary care fields and current primary care doctors will retire. In addition, our nation is only getting older and fatter, and thus sicker and more expensive.

Bottom Line: Our health care system needs massive changes. This can’t be done quickly, so one piece of legislation will not fix it. It will take many years and many pieces of legislation just to start moving in the right direction. However, we have to start somewhere. Though the current proposals will not work, they are a first step. In addition, a millions of Americans will get coverage and we may get a few needed fixes. Yet, if we fail to take this first step, and don’t pass something soon, it may be a decade before health care reform is discussed again.

Matthew Mintz is an internal medicine physician and blogs at Dr. Mintz’ Blog.

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• Can universal health coverage be sustained long-term?
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Originally published in MedPage Today

by Chris Emery, MedPage Today Contributing Writer

The symptoms of autism tend to emerge in children after six months of age, with a loss of social and communications skills that is more common and more subtle than previously thought, according to a new study that questions previous assumptions about the progression of the condition.

At six months, children with autism spectrum disorder demonstrated behavior similar to other children, gazing at faces, sharing smiles, and vocalizing with similar frequency, researchers reported online in the Journal of the American Academy of Child & Adolescent Psychiatry.

However, autistic children displayed fewer of these behaviors as as they got older, and from six months to 18 months the loss of social communication and skills typically became clear.

While doctors typically caught early signs of autism, the declines were more subtle than previously suggested and most parents (83%) did not report regression in the social behaviors and skills.

“These findings lead us to two major conclusions,” Sally Ozonoff, PhD, of University of California Davis Health System in Sacramento, and colleagues wrote.

“First, the behavioral symptoms of autism spectrum disorder appear to emerge over time, beginning in the second half of the first year of life and continuing to develop for several years.

“Second, our most widely used and recommended practice for gathering information about symptom onset, parent-provided developmental history, does not provide a valid assessment of the slow decline in social communication that can be observed prospectively.”

Autism is thought to emerge in two ways: an early onset pattern and a regressive pattern.

A majority of autistic children are thought to experience the early onset pattern, showing clear signs of the disease in the second year of life but in some cases showing signs before the first birthday.

Those with the regressive pattern are thought to develop normally for the first year of life, then begin losing communications and social skills.

However, most previous studies have been retrospective in design, and some children don’t appear to fit either of the typical patterns, bringing into question the validity of this two-pronged model of onset.

More recently, a third category has been suggested, in which children develop normally and then seem to hit a developmental plateau, but not regress.

In an accompanying editorial, Tony Charman, PhD, of the Institute of Education in London, wrote that the design of the new study heralds a new wave of descriptive developmental studies of autism, or features of autism, in infants and toddlers.

“Previously, the only source of information we had about infancy and toddlerhood of children with autism was retrospective reports from parents at the age of diagnosis (often years after the onset),” he wrote.

“Parental report of early history and development still is an important component of the autism diagnostic evaluation. However, the retrospective parental informant biases, particularly through the lens of autism, might lead both to over- and underestimation of atypical features.”

Ozonoff and colleagues conducted a long-term prospective study that compared 25 high-risk infants later diagnosed with an autism spectrum disorder with 25 gender-matched, low-risk children later determined to have typical development.

The children were recruited for the study at University of California Davis and University of California Los Angeles. The high-risk children were identified based on having a sibling who had already developed autism.

The children were evaluated at 6, 12, 18, 24 and 36 months of age for frequencies of gaze to faces, social smiles, and directed vocalizations, which were were coded from video and rated by examiners.

“The results of the current prospective study suggest that the traditionally defined categories of early onset and regressive autism do not portray accurately how symptoms emerge, nor does the newer-onset category involving a developmental plateau,” the authors wrote.

They found that specific social communicative behaviors clearly decreased, rather than failing to progress, as previously thought, with losses especially dramatic between 6 and 18 months.

They concluded that this suggests onset of autism spectrum disorder, marked by loss of social communication behaviors, occurs much more often than has been recognized using parent report methods.

However, rather than the rapid and marked losses typically reported, they saw relatively subtle and gradual declines, which were often preceded by earlier parental concerns and often followed by failures to progress in other areas.

“We urge professionals to refer to intervention any infant or toddler who displays a sustained reduction in social responsivity over time,” they wrote.

“Given the gradual course of symptom emergence and the paucity of diagnostic tools for infants and toddlers with suspected autism, the diagnostic process can be quite protracted and intervention may be needlessly delayed.”

Visit MedPageToday.com for more pediatrics news.

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With health reform possibly passing within the next few months, attention now turns to the primary care doctor shortage.

Regular readers of this blog know that there are not enough primary care doctors currently; it’s frightening to think what would happen if an additional 40+ million newly insured patients start looking for care.

A recent piece from Newsweek nicely encapsulates the problem. It’s a good piece, elucidating the myriad of reasons why new medical students shy away from the field:

The close relationships that general practitioners once had with patients drew many idealistic students into the field. Now recruiters face an extra-tough sell: they have to convince bright young would-be docs to pursue a career that won’t pay very well and won’t be as emotionally fulfilling as it once was.

There are some who believe that primary care offices don’t necessarily need to be staffed by physicians; nurse practitioners and physician assistants can help reduce the shortages. And by the way, replacing doctors would be a great way to cut costs.

The problem is both nurse practitioners and physician assistants aren’t immune to the financial incentives swaying doctors away from primary care:

The problem with taking this approach nationwide is that nurses and PAs are subject to the same economic forces that drive medical students. Almost half of current nurse practitioners and physician assistants work in specialty practices, where the money is. Then there’s the fact that the country already has a nursing shortage. How are nurses going to replace doctors if there aren’t enough nurses to begin with?

Spending more money on primary care — and according to the American Academy of Family Physicians, we’re talking at least 25% more — is the best way to get the attention of not only medical students,  but also aspiring primary care nurse practitioners and physician assistants.

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