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Life after Death?

life after death

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How I Became a Fan of One of My Fans

Photo credit: pogophysio.com

Photo credit: pogophysio.com

A number of years ago, I wrote a book – You’re Stronger Than You Think – which explores the surprising resilience of people with chronic illness and disability. I’ve done a bunch of research on the topic, but in the book I wrote not only about such research, but also about real people, who overcame seriously adverse circumstances.

The book was a disappointment at the box office, but every once in a while I hear back from someone who says the book has had a good impact on their lives. I received one such email recently from Oliver Johnston, a competitive long-distance runner who got into a horrific automobile accident and was told he would never run again. He said the book really resonated with his experience:

“Much of what you wrote chimed closely with my own experiences.”

He talked about the surprising strength many of us find we have within ourselves, when faced with unexpected adversity:

“I have often said to people that while I would not wish my experience and situation on anybody, not everybody has the privilege to test themselves personally in the most terrible of circumstances and learning that they have the strength and power to pass the test, as the case studies in your book likewise so inspirationally did.” And much more importantly, he sent me a link to a video he made about his experience, one he said I was welcome to pass along to all of you. Please check this out – it’s amazing!

He might have liked my book. I loved his video!

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Here’s How a Great Doctor Helps Her Patient Make a Cost-Conscious Treatment Decision

Photo Credit: Consumer Reports

Photo Credit: Consumer Reports

Sometimes in my research on physician/patient communication, I come across a doctor who is so good with her patients, I have to share their bedside manner with you. The most recent example is a (to remain unnamed) oncologist in the Northeastern United States who practically gave a primer on shared decision making when caring for a patient with metastatic cancer.

The patient (I’ll call her Jennifer Decker) had stage 4 breast cancer, which had metastasized to liver and bone, the latter leaving her with substantial pain. Worse yet, a PET scan she received a week before her clinical appointment showed that the cancer had progressed significantly since her last test. “So we need to think about what to do next,” her oncologist explained.

A great statement, the idea of “we” – both doctor and patient – making a medical decision together. That’s a paradigm known as shared decision making, and is one that in my research I find is rarely achieved. Many doctors say they want to partner with patients in making healthcare choices, but most do not know how to accomplish this goal. Instead, they often earnestly overwhelm patients with well-intentioned information, at which point patients ask “what should I do?,” and the doctors point them towards treatments, even though they have done little to discuss what patients think about the pros and cons of their alternatives.

This oncologist, on the other hand, partnered like a pro. He explained that the first big choice Decker had to make was whether or not to have chemotherapy, to try to slow the spread of the cancer: “The biggest decision we’ve got to make right now is chemotherapy or not. Now chemo, thankfully, comes in a huge variety. There are probably a dozen drugs that work for breast cancer like yours. And you can use them one at a time. You don’t have to use two, three, or four.”

He explained some of the main differences between available treatments, the main one being that some treatments were given intravenously, meaning she would have to come into the clinic for treatment. But one treatment, Xeloda, could be taken as a pill, “and it’s not less chemo than any other product,” he assured her. He added, “if it doesn’t work, we have tons of other options you can switch to, but they are intravenous, so you have to come here and get an infusion.”

Decker asked a few questions and then told him she wanted to try one of the treatments: “I got to do what I need to do.”

The visit was already a p rimer on shared decision making, with the oncologist clearly and patiently explaining the patient’s treatment choices, simplifying the decision to its first branch point – chemo or not chemo – rather than overwhelming her with in-depth information on all her treatment options. Then, when he moved to the next branch of the decision tree, things got even more spectacular.

(To read the rest of the article, please visit Forbes.)

Posted in Medical Decision Making | Tagged , , ,

More Coverage of Our Research on Out-Of-Pocket Cost Conversations

Take one Per Day as Affordable.Here is a nice summary of our research, published by an excellent reporter at The American Journal of Managed Care:

A new qualitative study of clinical meetings between physicians and patients pointed out certain behavioral concerns that stand in the way of helping patients navigate out-of-pocket spending. The study, published in Health Affairs and led by Peter A. Ubel, MD, with fellow researchers, found that for optimum utilization of consumer healthcare markets, physicians need to be prepared to help patients navigate out-of-pocket expenses during clinical encounters.Most of the failures resulted from systemic barriers to healthcare spending conversations, such as a lack of price transparency. Some behaviors reflected a failure to fully engage with patients’ financial concerns—from never acknowledging such concerns to dismissing them too quickly. Other behaviors reflected a failure to resolve uncertainty about out-of-pocket expenses or reliance on temporary solutions without making long-term plans to reduce spending.Study Method and Results
For the study, the researchers analyzed patient-physician interactions for breast cancer, depression, and rheumatoid arthritis. Only these 3 medical conditions were chosen for the study because they often involve expensive healthcare interventions that could lead to high out-of-pocket expenses.

Excluded were visits conducted by primary care physicians, nurse practitioners, and nurses; visits conducted outside of United States; and visits involving patients younger than 18 years. The final sample consisted of 1755 visits: 677 breast oncology, 656 rheumatoid arthritis and 422 psychiatry. All visits occurred between May 2010 and February 2014.

The physician behaviors that led to missed opportunities to reduce out-of- pocket expenses were divided into 2 broad categories:

  • The physician’s failure to address the patient’s financial concerns, meaning they didn’t make an explicit effort to acknowledge the seriousness of the patient’s concerns
  • Instances where physicians did make explicit efforts to deal with patients’ financial concerns but failed to resolve them satisfactorily

Sometimes, patients explicitly mentioned their financial troubles, but physicians failed to give it complete attention because of clinical distractions. Many physicians get too involved in entering data into electronic medical records or examining patients that they tend to overlook unexpected and observational issues such as patient financial concerns. In other cases, when physicians do understand the patients’ money problems, they dismiss the possibility of solving it for the patients. – See more at: http://www.ajmc.com/newsroom/poor-physician-patient-communication-leads-to-higher-out-of-pocket-spending#sthash.TjgriRFV.dpuf

A new qualitative study of clinical meetings between physicians and patients pointed out certain behavioral concerns that stand in the way of helping patients navigate out-of-pocket spending. The study, published in Health Affairs and led by Peter A. Ubel, MD, with fellow researchers, found that for optimum utilization of consumer healthcare markets, physicians need to be prepared to help patients navigate out-of-pocket expenses during clinical encounters.Most of the failures resulted from systemic barriers to healthcare spending conversations, such as a lack of price transparency. Some behaviors reflected a failure to fully engage with patients’ financial concerns—from never acknowledging such concerns to dismissing them too quickly. Other behaviors reflected a failure to resolve uncertainty about out-of-pocket expenses or reliance on temporary solutions without making long-term plans to reduce spending.Study Method and Results
For the study, the researchers analyzed patient-physician interactions for breast cancer, depression, and rheumatoid arthritis. Only these 3 medical conditions were chosen for the study because they often involve expensive healthcare interventions that could lead to high out-of-pocket expenses.

Excluded were visits conducted by primary care physicians, nurse practitioners, and nurses; visits conducted outside of United States; and visits involving patients younger than 18 years. The final sample consisted of 1755 visits: 677 breast oncology, 656 rheumatoid arthritis and 422 psychiatry. All visits occurred between May 2010 and February 2014.

The physician behaviors that led to missed opportunities to reduce out-of- pocket expenses were divided into 2 broad categories:

  • The physician’s failure to address the patient’s financial concerns, meaning they didn’t make an explicit effort to acknowledge the seriousness of the patient’s concerns
  • Instances where physicians did make explicit efforts to deal with patients’ financial concerns but failed to resolve them satisfactorily

Sometimes, patients explicitly mentioned their financial troubles, but physicians failed to give it complete attention because of clinical distractions. Many physicians get too involved in entering data into electronic medical records or examining patients that they tend to overlook unexpected and observational issues such as patient financial concerns. In other cases, when physicians do understand the patients’ money problems, they dismiss the possibility of solving it for the patients. – See more at: http://www.ajmc.com/newsroom/poor-physician-patient-communication-leads-to-higher-out-of-pocket-spending#sthash.TjgriRFV.dpuf

A new qualitative study of clinical meetings between physicians and patients pointed out certain behavioral concerns that stand in the way of helping patients navigate out-of-pocket spending. The study, published in Health Affairs and led by Peter A. Ubel, MD, with fellow researchers, found that for optimum utilization of consumer healthcare markets, physicians need to be prepared to help patients navigate out-of-pocket expenses during clinical encounters.Most of the failures resulted from systemic barriers to healthcare spending conversations, such as a lack of price transparency. Some behaviors reflected a failure to fully engage with patients’ financial concerns—from never acknowledging such concerns to dismissing them too quickly. Other behaviors reflected a failure to resolve uncertainty about out-of-pocket expenses or reliance on temporary solutions without making long-term plans to reduce spending.Study Method and Results
For the study, the researchers analyzed patient-physician interactions for breast cancer, depression, and rheumatoid arthritis. Only these 3 medical conditions were chosen for the study because they often involve expensive healthcare interventions that could lead to high out-of-pocket expenses.Excluded were visits conducted by primary care physicians, nurse practitioners, and nurses; visits conducted outside of United States; and visits involving patients younger than 18 years. The final sample consisted of 1755 visits: 677 breast oncology, 656 rheumatoid arthritis and 422 psychiatry. All visits occurred between May 2010 and February 2014.

The physician behaviors that led to missed opportunities to reduce out-of- pocket expenses were divided into 2 broad categories:

  • The physician’s failure to address the patient’s financial concerns, meaning they didn’t make an explicit effort to acknowledge the seriousness of the patient’s concerns
  • Instances where physicians did make explicit efforts to deal with patients’ financial concerns but failed to resolve them satisfactorily

Sometimes, patients explicitly mentioned their financial troubles, but physicians failed to give it complete attention because of clinical distractions. – See more at: http://www.ajmc.com/newsroom/poor-physician-patient-communication-leads-to-higher-out-of-pocket-spending#sthash.TjgriRFV.dpuf

A new qualitative study of clinical meetings between physicians and patients pointed out certain behavioral concerns that stand in the way of helping patients navigate out-of-pocket spending. The study, published in Health Affairs and led by Peter A. Ubel, MD, with fellow researchers, found that for optimum utilization of consumer healthcare markets, physicians need to be prepared to help patients navigate out-of-pocket expenses during clinical encounters.Most of the failures resulted from systemic barriers to healthcare spending conversations, such as a lack of price transparency. Some behaviors reflected a failure to fully engage with patients’ financial concerns—from never acknowledging such concerns to dismissing them too quickly. Other behaviors reflected a failure to resolve uncertainty about out-of-pocket expenses or reliance on temporary solutions without making long-term plans to reduce spending.Study Method and Results
For the study, the researchers analyzed patient-physician interactions for breast cancer, depression, and rheumatoid arthritis. Only these 3 medical conditions were chosen for the study because they often involve expensive healthcare interventions that could lead to high out-of-pocket expenses.Excluded were visits conducted by primary care physicians, nurse practitioners, and nurses; visits conducted outside of United States; and visits involving patients younger than 18 years. The final sample consisted of 1755 visits: 677 breast oncology, 656 rheumatoid arthritis and 422 psychiatry. All visits occurred between May 2010 and February 2014.

The physician behaviors that led to missed opportunities to reduce out-of- pocket expenses were divided into 2 broad categories:

  • The physician’s failure to address the patient’s financial concerns, meaning they didn’t make an explicit effort to acknowledge the seriousness of the patient’s concerns
  • Instances where physicians did make explicit efforts to deal with patients’ financial concerns but failed to resolve them satisfactorily

Sometimes, patients explicitly mentioned their financial troubles, but physicians failed to give it complete attention because of clinical distractions. – See more at: http://www.ajmc.com/newsroom/poor-physician-patient-communication-leads-to-higher-out-of-pocket-spending#sthash.TjgriRFV.dpuf

A new qualitative study of clinical meetings between physicians and patients pointed out certain behavioral concerns that stand in the way of helping patients navigate out-of-pocket spending. The study, published in Health Affairs and led by Peter A. Ubel, MD, with fellow researchers, found that for optimum utilization of consumer healthcare markets, physicians need to be prepared to help patients navigate out-of-pocket expenses during clinical encounters.Most of the failures resulted from systemic barriers to healthcare spending conversations, such as a lack of price transparency. Some behaviors reflected a failure to fully engage with patients’ financial concerns—from never acknowledging such concerns to dismissing them too quickly. Other behaviors reflected a failure to resolve uncertainty about out-of-pocket expenses or reliance on temporary solutions without making long-term plans to reduce spending.Study Method and Results
For the study, the researchers analyzed patient-physician interactions for breast cancer, depression, and rheumatoid arthritis. Only these 3 medical conditions were chosen for the study because they often involve expensive healthcare interventions that could lead to high out-of-pocket expenses.Excluded were visits conducted by primary care physicians, nurse practitioners, and nurses; visits conducted outside of United States; and visits involving patients younger than 18 years. The final sample consisted of 1755 visits: 677 breast oncology, 656 rheumatoid arthritis and 422 psychiatry. All visits occurred between May 2010 and February 2014.

The physician behaviors that led to missed opportunities to reduce out-of- pocket expenses were divided into 2 broad categories:

  • The physician’s failure to address the patient’s financial concerns, meaning they didn’t make an explicit effort to acknowledge the seriousness of the patient’s concerns
  • Instances where physicians did make explicit efforts to deal with patients’ financial concerns but failed to resolve them satisfactorily

Sometimes, patients explicitly mentioned their financial troubles, but physicians failed to give it complete attention because of clinical distractions. – See more at: http://www.ajmc.com/newsroom/poor-physician-patient-communication-leads-to-higher-out-of-pocket-spending#sthash.TjgriRFV.dpuf

A new qualitative study of clinical meetings between physicians and patients pointed out certain behavioral concerns that stand in the way of helping patients navigate out-of-pocket spending. The study, published in Health Affairs and led by Peter A. Ubel, MD, with fellow researchers, found that for optimum utilization of consumer healthcare markets, physicians need to be prepared to help patients navigate out-of-pocket expenses during clinical encounters.Most of the failures resulted from systemic barriers to healthcare spending conversations, such as a lack of price transparency. Some behaviors reflected a failure to fully engage with patients’ financial concerns—from never acknowledging such concerns to dismissing them too quickly. Other behaviors reflected a failure to resolve uncertainty about out-of-pocket expenses or reliance on temporary solutions without making long-term plans to reduce spending.Study Method and Results
For the study, the researchers analyzed patient-physician interactions for breast cancer, depression, and rheumatoid arthritis. Only these 3 medical conditions were chosen for the study because they often involve expensive healthcare interventions that could lead to high out-of-pocket expenses.Excluded were visits conducted by primary care physicians, nurse practitioners, and nurses; visits conducted outside of United States; and visits involving patients younger than 18 years. The final sample consisted of 1755 visits: 677 breast oncology, 656 rheumatoid arthritis and 422 psychiatry. All visits occurred between May 2010 and February 2014.

The physician behaviors that led to missed opportunities to reduce out-of- pocket expenses were divided into 2 broad categories:

  • The physician’s failure to address the patient’s financial concerns, meaning they didn’t make an explicit effort to acknowledge the seriousness of the patient’s concerns
  • Instances where physicians did make explicit efforts to deal with patients’ financial concerns but failed to resolve them satisfactorily

Sometimes, patients explicitly mentioned their financial troubles, but physicians failed to give it complete attention because of clinical distractions. – See more at: http://www.ajmc.com/newsroom/poor-physician-patient-communication-leads-to-higher-out-of-pocket-spending#sthash.TjgriRFV.dpuf

A new qualitative study of clinical meetings between physicians and patients pointed out certain behavioral concerns that stand in the way of helping patients navigate out-of-pocket spending. The study, published in Health Affairs and led by Peter A. Ubel, MD, with fellow researchers, found that for optimum utilization of consumer healthcare markets, physicians need to be prepared to help patients navigate out-of-pocket expenses during clinical encounters.

Most of the failures resulted from systemic barriers to healthcare spending conversations, such as a lack of price transparency. Some behaviors reflected a failure to fully engage with patients’ financial concerns—from never acknowledging such concerns to dismissing them too quickly. Other behaviors reflected a failure to resolve uncertainty about out-of-pocket expenses or reliance on temporary solutions without making long-term plans to reduce spending.

Study Method and Results

For the study, the researchers analyzed patient-physician interactions for breast cancer, depression, and rheumatoid arthritis. Only these 3 medical conditions were chosen for the study because they often involve expensive healthcare interventions that could lead to high out-of-pocket expenses.

Excluded were visits conducted by primary care physicians, nurse practitioners, and nurses; visits conducted outside of United States; and visits involving patients younger than 18 years. The final sample consisted of 1755 visits: 677 breast oncology, 656 rheumatoid arthritis and 422 psychiatry. All visits occurred between May 2010 and February 2014.

The physician behaviors that led to missed opportunities to reduce out-of- pocket expenses were divided into 2 broad categories:

  •     The physician’s failure to address the patient’s financial concerns, meaning they didn’t make an explicit effort to acknowledge the seriousness of the patient’s concerns
  •     Instances where physicians did make explicit efforts to deal with patients’ financial concerns but failed to resolve them satisfactorily

Sometimes, patients explicitly mentioned their financial troubles, but physicians failed to give it complete attention because of clinical distractions. Many physicians get too involved in entering data into electronic medical records or examining patients that they tend to overlook unexpected and observational issues such as patient financial concerns. In other cases, when physicians do understand the patients’ money problems, they dismiss the possibility of solving it for the patients.

To read the rest of this story, please visit The American Journal of Managed Care.

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Physicians Can’t Stop Overtreating Diabetes And Hypertension

Photo Credit: FRED TANNEAU/AFP/Getty Images

Photo Credit: FRED TANNEAU/AFP/Getty Images

Aggressive control of blood pressure has saved millions of lives, and has prevented millions of people from experiencing heart attacks, strokes and kidney failure, among other things. Admittedly, controlling blood pressure is not the sexy part of medical care, but when primary care doctors like me help people get their blood pressure under control, we do just as much good as any of our colleagues who practice as cardiovascular surgeons. (No offense to those surgeons, of course, who do worlds of good for their patients!)

But blood pressure reduction can be too much of a good thing. For example, when patients with diabetes receive overly aggressive blood pressure treatment, the harms of that treatment–the side effects of low blood pressure–loom larger than the potential benefits. And I’m not talking just side effects like feeling a little bit fatigued from taking the pill. Aggressive blood pressure treatment can increase the risk of hazardous falls, for example. Consequently, physicians sometimes need to take their foot off the gas, and reduce the intensity of patients’ blood pressure medications. Unfortunately, a study from JAMA Internal Medicine shows that doctors frequently have difficulty backing off. The study looked at diabetes patients and assessed whether doctors reduced the intensity of hypertension treatments when people’s blood pressure dropped below recognized thresholds. They also looked at whether doctors reduced the intensity of patients’ diabetes medications, when their blood sugar levels–their A1C results–got worrisomely low. In looking at how aggressively doctors treated patients, the researchers also estimated how long patients had to live, based on their age and how sick they were. They estimated this because someone in the last, say, five years of his life is not going to get much benefit from aggressive blood pressure or diabetes control, because of the benefits of such control (versus more moderate control) accrue over many years, while the harms, the side effects, happen much more quickly.

The researchers discovered that physicians had a hard time backing off on, “de-intensifying,” aggressive treatment. (To read the rest of this article, please visit Forbes.)

 

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Watch Out for Those Deductibles!

Photo Credit: Cancer Today Magazine

Photo Credit: Cancer Today Magazine

Lots of folks in the U.S. are finding themselves with health insurance coverage that requires them to pay lots of money, in their deductible, before insurance kicks in. Here is a nice piece in Cancer Today Magazine on the topic:

Tammy Pope had already exceeded her health insurance plan’s $5,000 deductible for 2015 by August. She was still facing a double mastectomy for stage III breast cancer when she got into a debate with her oncologist over whether she could skip a magnetic resonance imaging (MRI) test of her brain. The doctor had recommended the MRI because Pope had been falling down, episodes she blamed on her cancer medications.

But the doctor insisted on the scan, saying the malignancy had already proved unexpectedly aggressive, with 23 positive lymph nodes removed during Pope’s lumpectomy. “She said, ‘We don’t know for sure if it has spread, and it does love going to the brain,’ ” as Pope recalls the conversation. “Of course,” Pope adds, “when they put it like that, you’re going to do it.”

Pope, a retail worker in Louisville, Kentucky, was already fielding bills she couldn’t pay for tests that had led to her triple-negative breast cancer diagnosis, as well as the chemotherapy that treated her cancer but left her with severe neuropathy in her hands and feet. And while the MRI showed no signs of brain metastasis, the bills kept multiplying: slightly more than $600 for her portion of the MRI’s cost, roughly $6,500 for various tests that led to her diagnosis, and at least $20,000 for her share of the cost of chemotherapy. (Even after Pope met her $5,000 deductible, she had to pay a percentage of each bill under the terms of her insurance policy.) Discussing those figures in early December 2015, a day before her double mastectomy, the 52-year-old noted that come January 1, 2016, her deductible would kick in again.

High-deductible plans, once a rarity in health insurance, have become more common. Nearly half of Americans on employer-provided insurance, 46 percent, were required to meet an individual deductible of at least $1,000 in 2015, compared with 10 percent in 2006, according to a Kaiser Family Foundation/Health Research & Educational Trust annual survey. In addition, the average deductible has increased, from $917 for individual coverage in 2010 to $1,318 in 2015.

Because high-deductible plans are relatively new, individuals might not understand the out-of-pocket ramifications unless they get a serious diagnosis, says Peter Ubel, a physician and behavioral scientist who studies health care decision-making. But signs of strain are starting to emerge, says Michael Diaz, an oncologist in St. Petersburg, Florida, and director of patient advocacy for a practice with 200 oncologists. “It’s causing problems because they [the high-deductible plans] are interfering with what we [doctors] would normally routinely want to do,” says Diaz, referring to delayed diagnoses or patients pushing for different treatment because of high-deductible worries.

Diaz described a middle-aged woman seen at the practice who had put off getting a lesion growing on her head checked out because of the out-of-pocket cost. By the time she reached an oncologist’s office, the squamous cell lesion was large enough that she needed to undergo radiation in an effort to reduce its size before surgery could even be considered, Diaz says. Another patient, a man in his 60s diagnosed with advanced prostate cancer, asked that chemotherapy be postponed for two months until the following January. The patient’s rationale: He’d only max out his $5,000-plus deductible in a single year rather than in two consecutive years. But, says Diaz, “he’s delaying what would be considered optimal therapy.”

Deductibles: A High Hurdle

With the exception of some preventive measures like flu shots or screening mammograms, patients on high-deductible plans typically must pay for all doctor visits, lab work and other medical care until the deductible is met. Along with becoming more common through employer-provided insurance, high deductibles also are a feature on many plans sold through the Affordable Care Act health exchanges. And that’s just part of the burden for many patients. Plans vary in the amount they will pay once the deductible is met, with some covering everything and others just a percentage.

Because high-deductible plans are relatively new, individuals might not understand the out-of-pocket ramifications 
unless they get a serious diagnosis.

A Kaiser Family Foundation analysis reveals how daunting high deductibles can become if serious illness strikes. Overall, 63 percent of adults under age 65 have enough financial resources on hand—via bank accounts, certificates of deposit, nonretirement mutual funds and stocks, among other assets—to meet a $1,200 deductible for an individual and $2,400 for a family. For the higher deductible—defined as $2,500 for an individual and $5,000 for a family—51 percent have sufficient funds, according to the analysis, published in 2015.

Another study, conducted by the nonprofit organization Families USA, looked at nonemployer health insurance coverage in 2014 and found that adults with a high deductible were more likely to skip care. Nearly 30 percent of adults with a deductible of at least $1,500 reported forgoing care versus 19.6 percent of those with a lower deductible.

To some users, high-deductible plans can feel like scant protection, says Ubel, based at Duke University in Durham, North Carolina. “You think that you’ve bought health care insurance,” he says. “And what you’ve really bought is insurance that will eventually kick in when you need a heck of a lot of health care.”

To read the rest of this story, please visit Cancer Today Magazine.

 

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More Coverage of Our Out-Of-Pocket Expenses Research

Healio

My colleagues and I have been doing lots of research lately on how physicians and patients discuss out-of-pocket expenses during clinic encounters. One of our recent publications has been getting lots of attention, with this being the latest example. I thought I would share it with you:

Recent qualitative findings published in Health Affairs showed that physicians struggled to help patients factor out-of-pocket expenses into their medical decisions.

“Health care consumers cannot expect to make savvy financial decisions if their doctors do not engage with them in productive conversations about the pros and cons of their health care alternatives, including the financial costs,”Peter A. Ubel, MD, professor in the Sanford School of Public Policy at Duke University, told Healio Internal Medicine. “Some physicians say they are reluctant to do so because money talk would contaminate the doctor-patient relationship.”

In 2014, one in three Americans was reported to have difficulty paying health care bills, the researchers wrote. In a previous study, Ubel and colleagues found that patients and physicians discussed strategies to reduce health care expenses about 44% of the time when these topics arose. They also determined, however, that these discussions did not always allow patients to navigate out-of-pocket expenses.

“Many more physicians, I expect, would like to hold such conversations, but struggle to do so because there is no easy way to figure out how much patients will be required to pay out-of-pocket for their medical care,” Ubel said.

In the current study he and his colleagues performed a qualitative study by analyzing physician-patient interactions taken from the Verilogue Point-of-Practice database. They used 677 interactions in breast oncology, 656 in rheumatoid arthritis and 422 in psychiatry that occurred from May 2010 to February 2014 at private practices nationwide.

The researchers found that two broad categories of behaviors led to missed opportunities that could trim out-of-pocket expenses. The first was the physician not acknowledging the seriousness of the patient’s concerns. The second was the physician failing to fully resolve a patient’s financial concerns.

For the first behavior, the researchers cited examples of how physicians missed opportunities to address patient concerns.

To read the rest of this story, please visit Healio.

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Is It Rational for Breast Cancer Patients to Have Bilateral Mastectomies?

Runners take part in the 10 km Odyssea foot race in Bayonne on April 17, 2016.The participants, all clothed in pink, run to help fight against breast cancer in this charity foot race. / AFP / IROZ GAIZKA (Photo credit should read IROZ GAIZKA/AFP/Getty Images

Runners take part in the 10 km Odyssea foot race in Bayonne on April 17, 2016.The participants, all clothed in pink, run to help fight against breast cancer in this charity foot race. / AFP / IROZ GAIZKA (Photo credit should read IROZ GAIZKA/AFP/Getty Images

Warning: I am not writing about Angelina Jolie. I am not asking whether women like Jolie, with a strong family histories of breast cancer and known genetic mutations, should consider having bilateral mastectomies. Women like Jolie face extremely high lifetime risks of breast cancer, and thus must make difficult decisions about whether to receive prophylactic mastectomies – surgical removal of healthy breasts in an effort to prevent them from harboring future cancers. I’m not writing about people like that.

Instead, I am writing about women who actually have been diagnosed with breast cancer, but who do not have any known genetic mutation predisposing them to such tumors. I’m wondering in these cases: Is it rational for women to ask their doctors to not only remove the affected breast, but also to perform a contralateral prophylactic mastectomy (hereon: CPM) – a procedure to remove the unaffected breast?

I will tell you my answer right now, so I can walk you through my reasoning without misleading you as to my intentions. I think the decision whether to receive CPM is a very difficult one. Unfortunately, many women make this decision even though they are poorly informed about the pros and cons of the procedure. Given what they believe about CPM, it is totally rational to receive that procedure. But if they were better informed? Then, honestly, I’m not sure so many women would receive that procedure.

But I might be wrong. I expect that CPM decisions, like many decisions most of us make in our lives, are often influenced by highly intuitive thought processes, ones often not influenced by informational campaigns. In short, I refuse to call this decision rational or irrational. Instead, I see it as a really hard call. But it’s a hard call we need to understand, because of what it tells us about the challenges of making good medical decisions.

Let’s start with the information that, plausibly, ought to guide such decisions. When women without genetic mutations (hereon: non-carriers) experience cancer in one breast, their risk of experiencing a cancer in the other breast is usually not dramatically different from the general population risk. To put a number on that: studies put the 10 year risk of contralateral cancer at about 5%. And with new breast cancer treatments, that risk has declined even further. So we are talking about an annual risk of less than a half a percent per year.

A second fact of note: there is no evidence, none, that CPM reduces a woman’s chance of dying of breast cancer. With such a low risk of a contralateral cancer arising, and such aggressive monitoring of such cancer in women with breast cancer histories, most such cancers are found at very early and very treatable stages.

This last fact is important to keep in mind when we look at why women choose CPM. According to a recent study in The Annals of Internal Medicine, more than 90% of women who receive CPM say they did so to increase their chance of long-term survival. Indeed, the majority of non-carriers who receive CPM significantly overestimate the impact the procedure will have on their risk of breast cancer recurrence, and on their chance of long-term survival.

In other words, many CPM decisions are either uninformed, or are being influenced by misperceptions. This finding is concerning given the dramatic rise in CPM rates in recent years. Back in the 90s, less than 5% of non-carriers received CPM after breast cancer diagnoses. Today, that figure is approaching 25% in many cancer centers.

I am in no way prepared to say that women who receive CPM are making poor choices. (To read the rest of this article, please visit Forbes.)

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Thoughts on Shared Decision Making

Photo Credit: Cancer Therapy Advisor

Photo Credit: Cancer Therapy Advisor

I recently gave a talk about shared decision making at the annual conference for the National Comprehensive Cancer Network. Here is a nice write-up of that talk. For those of you silly enough not to travel to Florida to hear me pontificate!

After listening to the treatment alternatives—surveillance, or active treatment with surgery and radiation—a patient just diagnosed with prostate cancer asks you, “what would you recommend?”

How would you respond?

As a clinician, your responsibility is to find out what the patient is actually asking, and to provide a recommendation that reflects his or her preferences, Peter A. Ubel, MD, told attendees at the NCCN 21st Annual Conference.

One answer might be “I might make a different choice than you because I might have different preferences,” said Dr Ubel, the Madge and Dennis T. McLawhorn University Professor of Business, Public Policy, and Medicine at Duke University in Durham, NC.

Such a reply “is what should trigger the true shared decision-making conversation,” he added. Far too often, however, patients are inundated with information they either do not understand or find overwhelming in its sheer volume.

The “right” choice, he outlined, depends on how the patient weighs the trade-off between the anxiety of living with cancer and the side effects of the active treatments.

“To really empower patients to be partners in decisions where their preferences are important in determining what the right course of action is, we have to communicate better,” he said. “We have to understand decision psychology better than we do, and we have to make sure we know the difference between a medical fact and a value judgment.”

Dr Ubel, with the Duke-Margolis Center for Health Policy, provided an example of an urologist explaining a Gleason score to a patient: “low risk is Gleason 6, intermediate is usually 7s, with 3 + 4 or 4 + 3, depending on how it looks under the microscope. And then 8, 9, and 10 are all high risk. So it’s in the middle. It was 3 + 3 and 3 + 4, so just enough of the atypical cells of the grade 4 to make it 3 + 4, which means you’re intermediate risk.”

Although this represents an earnest explanatory effort, what the clinician is trying to say is, “you do not have the kind of cancer that will kill you, maybe never, but certainly not in the next 10 or 15 years. We have months to decide what to do about this. We found it early enough and we can take care of this.”

“That’s what the patient needed to understand, and instead, what ends up, is the doctor kind of forgets that the patient doesn’t speak medicalese,” he said.

Informed consent also plays a role, in that clinicians may feel the need “to inform the heck out of patients with all the medical detail [they] believe is necessary to understand the decision, instead of a translation of that medical detail into terms a patient can understand.”

One challenge with shared decision-making is that thorough communication is “not always good communication,” and “good communication takes time, to acknowledge and deal with emotion, to absorb and reflect on information,” he said. This includes the ability to take the patient’s perspective into account, with recommendations often evolving.

Dr Ubel outlined 3 approaches he believed clinicians “can do better to promote shared decision-making.”

“First off, we need to use a simple technique called ‘teach back.’ When you give people information about their treatment alternatives, don’t assume they understand it because they are nodding,” he said. “Find out if they understand it by asking them to tell you in their own words.” For example, “‘Can you tell me what you think you understand the alternatives mean?’”

“You will learn so much in hearing patients translate back to you what you just said to them. I guarantee you, you do that a dozen times…and by the time you get to that 12th patient, your spiel—because we all have spiels to describe information—your spiel will probably be half as long as it used to be and twice as good because you’ll realize, early on, that patients are not hearing most of what you say.”

Secondly, even if patients say they do not want to be full partners in the decision and want to be told what to do, clinicians need to get to know patients well enough to help them make the right choices.

“When a patient asks what you would recommend,” try to find out something about the patient first. “That is critical to giving good advice.”

Finally, what’s needed are “recommendations that are based on an understanding of patient preferences,” he said.

Dr Ubel concluded by noting that “we also should be careful about how much information we give people. People can be harmed by receiving too much information. Too much information makes it hard to comprehend, regardless of whether there’s jargon. You give too much information loaded with jargon and understanding is going to be very poor”—thus making choices more difficult.

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The Bills People Struggle to Pay

I post pretty regularly on out-of-pocket medical expenses, a topic I’ve been conducting research on, and one that will fit centrally into the new book I’m writing. Most often when people think about paying for medical care, they think about medications. But as this figure from the Kaiser Family Foundation shows, don’t forget about the cost of doctor visits, x-rays, blood tests and, of course, trips to the emergency room:

Photo Credit: Kaiser Family Foundation

Photo Credit: Kaiser Family Foundation

 

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