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Sexual Harassment in the Medical Profession

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Here is a report from a study I collaborated on, led by the amazing Reshma Jagsi, a physician at the University of Michigan. It reveals just how common it is for female academic physicians to report experiencing sexual harassment in the workplace. Important but disturbing news:

“This is a sobering reminder that our society has a long way to go before we achieve gender equity,” says study author Reshma Jagsi, M.D., D.Phil., associate professor and deputy chair of radiation oncology at the University of Michigan Medical School.

Researchers surveyed 1,066 men and women who had received a career development award between 2006-2009 from the National Institutes of Health. These awards are given to promising physician-scientists to develop their career as independent investigators. The physicians are now mid-career; average age when surveyed was 43.

Physicians were asked a number of questions about their career experiences, including questions about gender bias, gender advantage and sexual harassment.

Women were more likely than men to report both perceptions and experiences with gender bias: 70 percent of women vs. 22 percent of men perceived gender bias, and 66 percent of women vs. 10 percent of men said they experienced gender bias.

In addition, 30 percent of women compared to 4 percent of men said they had experienced sexual harassment in their professional careers.

To read the rest of this article, please visit Science Daily.

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Here’s Why Insulin Is So Expensive, And How To Reduce Its Price

She drew the life-saving medication into the syringe, just 10cc of colorless fluid for the everyday low price of, gulp, several hundred dollars. Was that a new chemotherapy, specially designed for her tumor? Was it a “specialty drug,” to treat her multiple sclerosis? Nope. It was insulin, a drug that has been around for decades.

The price of many drugs has been on the rise of late, not just new drugs but many that have been in use for many years. Even the price of some generic drugs is on the rise. In some cases, prices are rising because the number of companies making specific drugs has declined, until there is only one manufacturer left in the market, leading to monopolistic pricing. In other cases, companies have run into problems with their manufacturing processes, causing unexpected shortages. And in infamous cases, greedy CEOs have hiked prices figuring that desperate patients would have little choice but to purchase their products.

Then there’s the case of insulin. No monopoly issue here – three companies manufacturer insulin in the U.S., not a robust marketplace, but one, it would seem, that should put pressure on producers. No major manufacturing problems, either. There has been a steady supply of insulin on the market for more than a half century. And there haven’t been any insulin company executives I know of who have been hustled in front of grand juries lately.

Yet insulin prices are rising to dizzying heights. In 1991, according to a recent study inJAMA, state Medicaid programs typically paid less than $4 for a unit of rapid acting insulin. After accounting for inflation, that price has quintupled in the meantime.

What explains the gravity-defying cost of insulin? I am not an expert on pharmaceutical pricing, but a few factors go a long way to explaining insulin prices. First, the insulin marketplace has been characterized by continual product upgrades. You see, there’s not just one chemical that makes up all insulin products. Instead, insulin treatments are a family of products, each with slightly different chemical makeup that influences things like how quickly the medicine is absorbed into the blood stream. Manufacturers have been toying with insulin molecules since at least 1936, when the manufacturer added protamine to insulin molecules to extend the duration of the chemical’s activity. In the 1960s, companies began synthesizing insulin, rather than harvesting it from pancreatic tissue. In the late 70s, they began producing insulin through genetic engineering.

So when I said that the price of insulin had quintupled over the decades, we have to keep in mind that today’s insulin is not the same as yesterday’s.

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

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See Mom, I CAN Teach!

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I got a really nice email the other day, from one of the provosts at my university. Here is the highlight:

“During the 2015 fall semester, in the categories of Quality of Course and/or Intellectual Stimulation, your course evaluations were among the top 5% of all undergraduate instructors at Duke.”

Which just leaves one question: Was it the quality of the course or the intellectual stimulation? Given the intellectual depths to which I normally climb, I’m betting on course quality!

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Should You Want a Robot to Do Your Surgery?

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Karen Scherr, an MD PhD student working with me, just published a paper showing that physicians don’t always give patients objective advice about the pros and cons of robotic surgery. Here is a news story on her work:

Duke University research found that doctors are more enthusiastic about treatments that are readily available, calling into question whether the doctors are recommending the best treatment, or just the one more readily available.

“Patients need accurate and unbiased information about their treatment choices, regardless of what is available where their appointment is taking place,” said Fuqua School of Business Professor Peter Ubel. “It’s the only way they can make fully informed decisions.”

Ubel’s research, published in the journal Health Communications found that robotic surgery was described in more positive terms to prostate cancer patients at hospitals where it was available than at facilities where it was not.

Importantly, the research looked at four Veterans Affairs medical centers. Because VA physicians are salaried employees, the researchers could rule out financial incentives as a factor in how the treatments were described. Other research has linked surgeons with procedures on which they could gain financially, so ruling that out bolsters the findings.

Although researchers found a correlation, they didn’t immediately draw a conclusion of nefarious activity among doctors. Instead, they drew a different conclusion.

“We found that physicians describe robotic prostatectomy more positively when it’s available,” said Karen Scherr, a Duke M.D./Ph.D. student who helped with the research. “Importantly, this seems to be happening because of concern about patients’ emotions when they find robotic surgery isn’t available. I don’t think physicians are doing this for any malicious reason. It’s just very difficult to tell people about something good if it’s not available, and if it is available you want to tell people it’s good.”

To read the full article, please visit the Triangle Business Journal.

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The Majority of Doctors in the Majority of Specialties – Are Experiencing Burnout

And the problem is getting worse with time!

The Majority of Doctors in the Majority of Specialties Are Experiencing Burnout

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Doctor Knows Best?

Peter Ubel Sport Coat

Photo Credit: NIH

Here is a write-up of a talk I recently gave at the NIH. The topic is a good one, about doctors and decision making and all that crap. But the real importance of linking you to the story is to find out if you hate my sport coat as much as my wife does. It is the only one I own now, and I’ve had it for 25+ years. Time for a new one?

Does doctor always know best? Patients often ask their doctor: “What would you do in my situation?” But as the doctor explains the risks and benefits of treatment options and imparts advice, it’s important to remember there’s a human behind that medical chart, a patient with unique values, opinions and personal preferences.

A doctor’s recommendation often influences a patient’s treatment choice, so the clinician has a huge moral responsibility to recommend well, said Dr. Peter Ubel, a physician and behavioral scientist who teaches public policy and business at Duke University. He led an animated, thought-provoking discussion about shared decision-making among doctors and patients at a bioethics lecture Mar. 22 in Lipsett Amphitheater.

“People want to be heard and understood. That, to me, is what shared decision-making is; that’s what partnership is,” said Ubel, who helps prepare business students for jobs in health care. “What we need to do as clinicians is to get better at eliciting those patient preferences. [Clinicians should tell patients]:‘I’m the expert on medical facts, but you’re the expert on you.’”

Ubel used the example of a patient with low-grade prostate cancer who was trying to decide between surveillance or surgery and radiation. Whether he chose the passive or active approach, the survival rate was the same. But with waiting comes anxiety, and with the medical procedures, he’d run the risk of incontinence and erectile dysfunction.

In this case, how worried was the patient about those side effects? What were his life goals? Asking these kinds of questions can help determine the best course of action. In a similar case, a patient said he preferred the watch-and-wait approach, that he could more easily pursue active treatment after he retired in a couple of years.

“All else equal, the treatment people receive should have something to do with what they care about and these baseline preferences,” said Ubel.

The doctor also should consider the patient’s reaction when delivering the diagnosis, said Ubel. In a urology office, a doctor told a patient he had slow-growing cancer, then tossed out a lot of convoluted, vague information. The doctor may think it’s not an aggressive case so it’s not bad news, but the patient probably only heard, “you’ve got cancer” and tuned out the rest.

People need time to recover from bad news before making an informed decision. Ubel warned that information overload reduces comprehension and retention, and ultimately affects the patient’s choice.

“I think in part because of the way we’re taught in medical school about informed consent and patient autonomy, there’s this big emphasis on information,” said Ubel. “We inform the hell out of patients in jargon they can’t understand at a time when they’re not ready to take on complex information.”

If we have too many choices and too much information to process, Ubel said, people disengage. And patients might just ask for the doctor’s advice without really understanding the diagnosis and treatment alternatives.

“One of the problems with shared decision-making and promoting patient autonomy is that thorough communication is not always good communication,” he said. “Good communication takes time; it takes time to deliver it well and it takes time for the patient to absorb the information.”

In one survey, urologists said they only dispensed advice after gauging which way the patient was leaning. The urologists usually asked whether the patient had normal sexual function, but only 12 percent asked whether sexual function was important to the patient. And, astoundingly, only 13 percent said this preference should factor into deciding the right treatment. Look beyond age and test results, said Ubel; consider what patients care about.

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


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Marketing 101

Brilliant graphic, courtesy of @Brilliant_Ads

Photo Credit: Brilliant Ads

Photo Credit: Brilliant Ads

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Life after Death?

life after death

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How I Became a Fan of One of My Fans

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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.)

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