How doctors deliver the news: It's cancer

Anyone who has undergone a biopsy or other test to detect cancer knows the agony of waiting for the test results. Doctors face the dilemma of how to divulge the bad news to their patients. Call the minute you receive the results and let the patient know? Schedule a face-to-face office visit and explain the findings there?

A new study suggests that doctors should usually disclose a cancer diagnosis in a personal setting, taking plenty of time to discuss what the diagnosis means and explain treatment options. The study involved a questionnaire given to 437 patients who received a cancer diagnosis. The researchers, From the National Cancer Institute and Columbia University, found that 54% of patients were told their diagnosis in person in the doctor's office while 18% got the news by phone and 28% while in the hospital.

Perhaps more surprising, 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.

When asked how satisfied they were with the way the cancer diagnosis was delivered, the average score on a scale from 0 to 100 (the most satisfied) was 73.5. Having another person present when the diagnosis was given did not seem to matter to most patients. However, where and how the news was delivered did matter. Patients who heard their diagnosis in person had much higher satisfaction scores than those who received the diagnosis over the phone. Conversations that took place 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. There were a few horror stories. "...my doctor at the time called me on Valentine's day to say I had a lesion in my chest.... He left this message on my home answering machine."

Some situations may warrant using the telephone to divulge a cancer diagnosis, the authors wrote, such as when the patient already knows that cancer is suspected and has been waiting for several days to learn the test results. But, in general, a cancer diagnosis should be made in-person in a hospital room or doctor's office with sufficient time available to discuss prognosis and treatment. "...having more than 20% of patients told their diagnosis in an impersonal manner suggests too many physicians are either unaware of or not practicing good communication skills in such bad news circumstances," the authors wrote. The study was released Tuesday in the Journal of Clinical Oncology.

Here's some good information from the National Cancer Institute on what to do when you learn you have cancer.

-- Shari Roan

Photo credit: Spencer Weiner  /  Los Angeles Times

To heck with negative publicity! Doctors still dig those drug-company freebies

The public may have begun to raise a collective eyebrow at the largesse offered to doctors from drug makers and medical device manufacturers. Even the companies themselves have started to acknowledge the potential conflict of interest, or the perception of it. Medical schools too have begun to take a harder line on the matter. But individual doctors? They still kind of like this whole gift-giving, or rather, gift-getting practice.

Researchers at Mount Sinai School of Medicine surveyed doctors and medical students there to assess their opinions of industry interactions, gifts and the appropriateness of such things. True, the results are a reflection only of doctors and medical students at that institution, but the data offer a snapshot of how perspectives can vary, by specialty, by training level, by type of gift.

Overall, surgeons were fairly enthusiastic about relationships with drug and device manufacturers; pediatricians ... not so much. Here's the full doctors-and-gifts study.

The researchers write in their conclusion:

"Our overall finding of favorable physician attitudes toward industry suggests that individual physicians may be out of synch with trends among medical schools and public opinion and even industry itself. Although the evidence that physician-industry marketing relationships result in patient harm is inconclusive, US medical schools have increasingly adopted restrictive policies toward industry interactions, and there is widespread public concern that financial relationships between physicians and industry lead to conflicts of interest."

Here are two stories that provide a fuller examination of the broad issue: Doctor, Just a Little Something for You and And Now, There's a Growing Push for Reform.

Plus, a look at what medical schools are doing, A Pox on Drug Maker Freebies, Say Some Doctors, and the beginning of drug company pullback, Eli Lilly to Disclose Payments to Doctors.

Of note, this new survey found that most respondents believed other doctors were more likely to be swayed by such gifts than they themselves were.

-- Tami Dennis

Photo illustration credit: Myung J. Chun

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Quick! Name the U.S. surgeon general!

Can't pluck the name of "America's doctor" out of your mental hat? Don't beat yourself up. Few Americans probably can. (No, it's not C. Everett Koop.) But ask us to name a celebrity doc and the names just seem to roll off the tongue: Dr. Oz, Andrew Weil, Dr. Phil...

Writer Marni Jameson takes a look at this phenomenon in the most recent Los Angeles Times Health section. She notes:

"Fame alone seems enough to make many Americans trust their health and relationships to men and women they've never met. Unlike just a decade ago, when television and books were the only way these media doctors reached us, we now have multiple channels of media serving them up — there's no avoiding them. And our growing appetite for health and wellness information fuels our addiction to their advice." Read the full story: The cult of celebrity doctors

Sure, they're articulate and, appearances would suggest, wise and trustworthy. But our trust in them might say more about us -- and today's society -- than it does about the docs.

The current surgeon general is Dr. Regina Benjamin, by the way. (This L.A. Times story of a couple years back offers a bit of background on the job: Why the surgeon general wears a spiffy uniform -- and more)

We won't even bother with the "name the secretary of the U.S. Department of Health and Human Services" challenge. It's Kathleen Sebelius.

-- Tami Dennis

Photo: Dr. Regina Benjamin, known by some Americans as the U.S. surgeon general.

Credit: EPA

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Best medical schools don't produce the most-needed doctors

The nation has too few doctors, especially primary-care or family physicians and those who care for underprivileged populations, according to many studies. But don't look to the leading institutions for much help with this, say the authors of a new study. Researchers scored all U.S. medical schools on their ability to produce doctors who will work in primary care and in underserved communities.

Most of the schools with the finest reputations scored abysmally on the "social mission" criteria. That's not terribly surprising considering that the schools that rank as the best are often those that put a priority on research science. The survey, published Monday in the Annals of Internal Medicine, found that schools with substantial research funding from the National Institutes of Health did poorly in producing the most-needed type of doctors, as did private medical schools. Historically black schools, such as Morehouse College and Meharry Medical College, scored the highest in social mission rankings. The surveys were based on 60,000 doctors in active practice who graduated from medical school between 1999 and 2002.

Here are some details:

• The highest-ranking schools in social-mission scores were: Morehouse, Meharry, Howard University, Wright State University, University of Kansas, Michigan State University, East Carolina University, University of South Alabama, University of Iowa and Oregon Health & Science University.
• The top 10 lowest-scoring were: Johns Hopkins University, Stanford University, Duke University, Texas A&M University, Columbia University, Albany Medical College, Medical College of Wisconsin, University of Pennsylvania, Loyola University and Boston University.
• Osteopathic schools placed more graduates into primary care.
• Among California schools, UC Irvine ranked 138th among 141 schools in social mission. However, UC San Diego was among the few schools that received a large amount of government research funds while also producing a higher number of primary-care doctors.

Medical schools will be expanding enrollments for the first time in 30 years to meet the growing demand for health care. Perhaps the schools that turn out the most-needed types of doctors should receive the most financial support for expansion.

"Some schools may choose other priorities, but in this time of national reconsideration, it seems appropriate that all schools examine their educational commitment regarding the service needs of their states and the nation," the authors wrote.

-- Shari Roan

Photo: UCI Medical students at a student-run free clinic at the Orange County Rescue Mission's Village of Hope on Feb. 21, 2009. A survey found, however, that the school ranks low on promoting a "social mission" in medicine. Credit: Irfan Khan  /  Los Angeles Times.
 

And now, medical images for your weekend browsing pleasure

Remember those oddities we promised -- as in "Booster Shots: Oddities, musings and news from the health world"? The venerable New England Journal of Medicine is here to help.

The journal doesn't call them "oddities," of course. The journal calls them "featured images in clinical medicine," and it offers one up every week.

This week's offering is cutis marmorata in decompression sickness. It's interesting enough, but perhaps not what nonspecialists would consider odd. To most people, mottled-looking skin is mottled-looking skin.

But the Diphylloborthrium latum found during a colonoscopy? Fascinating. Absolutely fascinating. And the video...

-- Tami Dennis

Photo: If these walls could talk...

Credit: Los Angeles Times

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CPR in lingerie: It's never naughty to save a life!

We share because we care, dear readers. So, when a video clip begins to circulate among physicians on one of the proliferating medblogs out there, and it deals with an important subject such as cardiopulmonary resuscitation, you know I'm going to share it with you.

Afterall, who told you about doing CPR in perfect rhythm to the disco hit "Stayin' Alive"?

This one might be more memorable still. In his medblog, RangelMD.com, a physician practicing internal medicine in Texas, shares his thoughts about important thoughts such as medical ethics, primary care, the dangers of long-term use of new antacid medicines and on treating patients whose cholesterol is normal.

But recently he shared this video of two very fit young women demonstrating CPR -- clad only in lacy skivvies. Their technique is above reproach, however, and many will find the refresher course most helpful. Dr. Rangel's post was in turn picked up by KevinMD, one of the Web's best-read medblogs, so it's a good bet your physician has seen it too.

"Take home point: To be effective, CPR is best done in lingerie," Dr. Rangel comments.

--Melissa Healy 

A cautionary tale: Smart people and addiction

Rationalization and denial are key concepts in addiction treatment. To recover, addicts admit they have rationalized their habit ("I use so much less than my friends.") and denied they have a problem ("I can handle it. It's not affecting my job.") Here's another barrier to recovery from addiction: "I'm too smart for this to become a problem."

This week's Journal of the American Medical Assn., contains a sad essay from a medical researcher who made headlines last year when his fiancee, also a medical researcher, died after the two injected themselves with what they thought was the narcotic buprenorphine for kicks. The author of the essay, Clinton B. McCracken, a former pharmacologist at the University of Maryland, describes how he became a user of marijuana and intravenous opioids (morphine and oxycodone) over a decade while building his career as a successful neuroscientist who studied the effects of drugs on the brain.

He notes that people who work in medicine have addiction rates that are equal to, if not higher than, rates among the public. Drugs are easier to get, McCracken said. But he said an attitude of arrogance led him, as a medical professional, to believe that he could enjoy dangerous drugs and avoid serious consequences. For example, he was careful to schedule his opioid use to prove to himself that he did not need it to get through the day, made sure he was tending to his responsibilities at work and reviewed the criteria for drug dependence to assure himself that he was not an addict.

"By intellectually addressing the official criteria for abuse and dependence, I provided myself with the illusion of total control over the situation and was able to confidently tell myself that no problems existed," he wrote in the essay.

His world came crashing down last fall when his fiancee died while injecting drugs with him. When the police arrived, they discovered McCracken's marijuana plants. He was arrested and jailed, and he later agreed to a plea bargain to avoid more serious charges. Besides losing his girlfriend, he has since lost his career, his reputation and, as a citizen of Canada and convicted felon, he expects to be deported.

Addiction may look different in different people, but it seems that, in the end, everyone, no matter the level of intelligence, looks the same -- ruined.

"The transition from my drug use having no apparent negative consequences, to both my personal and professional life being damaged possibly beyond repair, was so fast as to be instantaneous, highlighting the fact that when it comes to drug use, the perception of control is really nothing more than an illusion," he wrote.

-- Shari Roan

Photo credit: Adam Gault / Getty Images / OJO Images

Physician rating websites mainly sing doctors' praises, study finds

Many doctors were considerably worried when websites began to pop up allowing consumers to rate their doctors. They feared disgruntled patients would harm their reputations and ruin their practices. Some even ask their patients to sign a "gag order" prohibiting them from expressing their opinions of the doctor on the Internet.

But a new study urges doctors to remain calm. The study, published online this week in the Journal of General Internal Medicine, found that the websites haven't caught on in any big way with consumers. Additionally, many of the reviews posted online are positive.

Dr. Tara Lagu, of Tufts University School of Medicine in Boston, and Baystate Medical Center in Springfield, and her colleagues examined 33 physician rating sites that contained 190 reviews for 81 doctors. They found 88% of the reviews were positive, 6% negative and 6% neutral. General practitioners and specialists did not differ in the types of reviews they received.

Patients just don't appear too interested in providing feedback on their doctors, the authors noted, despite the fact that consumers generally love and use ratings systems. In contrast to the scarcity of doctor reviews, a search of restaurants in Boston's Beacon Hill area "turned up 38 narrative reviews for a single Lebanese restaurant," the authors pointed out

The American Medical Assn. has expressed concerns about such websites, saying that doctors wouldn't be able to respond to negative patient reviews because of patient confidentiality requirements. But the study found that many of the negative comments were about things like the lack of parking and waiting too long in the waiting room -- issues that can be addressed without violating patient confidentiality.

Ratings sites, of course, are subject to manipulation. Perhaps the most obvious tinkering found in the study was that several "narrative reviews" appeared to be written by the doctors themselves. The doctor rating websites overall were found to be "neither user-friendly nor patient-centered," the authors noted. Searching for information is cumbersome, information is incomplete and advertising is prevalent.

The sites have the potential to empower patients. And, to be sure, consumers today are encouraged to be smarter and more discriminating shoppers of healthcare services and products in order to reduce costs. But this is one Internet function that doesn't seem to do patients much good or doctors much harm.

-- Shari Roan

Photo credit: Ken Hively / Los Angeles Times

When incentive payments to doctors end, quality of medical care declines

One of the best ways to improve the quality of medical care is to give doctors a financial stake in their health of their patients. Studies show that targeted monetary incentives prompt doctors to focus on specific clinical outcomes. But what happens when those incentives are removed?

British researchers wanted to know, since the government there is scheduled to stop making incentive payments based on eight indicators of clinical quality next year. So they teamed up with researchers from Kaiser Permanente to see what happened in Northern California when the health giant stopped rewarding doctors who screened patients for diabetic retinopathy and cervical cancer.

Between 1999 and 2003, when Kaiser physicians were rewarded for screening diabetic patients for diabetic retinopathy -- a complication that can cause severe vision loss, including blindness -- the screening rate rose from 84.9% to 88.1%. Then the incentive payments stopped, and the screening rate dropped to 80.5% four years later.

In the case of cervical cancer, screening rates ticked up from 77.4% to 78% between 1999 and 2000, when financial incentives were in place. Kaiser stopped the payments from 2001 through 2005, and during that time, the screening rate fell to 74.3%. That apparently caused Kaiser to reinstate the incentive payments, and the trend reversed over the next two years.

The study is being published online Wednesday by the British Medical Journal.

The results showed that doctors needed to find ways to maintain quality care for patients when financial incentives stopped, the researchers said. But that might be tricky, since it has been shown that once people get paid to do something, they’re less likely to do it for free.

-- Karen Kaplan

Photo: Targeted financial incentives help doctors focus on specific health problems -- and that focus wanes when payments stop, according to a new study. Credit: Barbara Davidson / Los Angeles Times

Many doctors don't discuss diet with obese patients

With the nation's high rates of obesity and the low odds of weight loss, perhaps weary doctors are just giving up. National statistics show that only about half of obese Americans were advised by their doctors to cut down on fatty foods. The rate, from a 2006 survey, has not changed from a survey taken in 2002.

The data, from the recently released 2009 National Healthcare Disparities Report, found that doctors discussed food choices with 52% of their obese white patients compared to 45% of obese blacks and 42% of obese Latinos.

Poor adults and less-educated people were less likely to be told to cut down on high-fat and high-cholesterol foods. The report notes that any obese person would likely benefit from counseling about diet and exercise. It would be interesting to see a survey of doctors on why they would choose not to discuss diet with an obese patient. Do they feel it's useless?

-- Shari Roan

Photo credit: Robert Sullivan / AFP / Getty Images