How to Tell Grandpa He Is Too Old for Another Colonoscopy


Cancer screening can save lives: Mammographies reduce the chance women will die of breast cancer; and colonoscopies reduce the chance people will die of colon cancer.
But should my 93-year-old father receive a screening colonoscopy? The test is uncomfortable, carries risks, and costs money. Even more importantly, my dad probably won’t live long enough to benefit from the test. That’s why most medical experts think people like my dad—people unlikely to live another decade—should not receive cancer screening tests like colonoscopies. But how in the heck is my dad’s doctor supposed to deliver this news to him?
My father’s primary care doctor could tell him: “I have good news for you. You don’t need a colonoscopy—you’ll probably die of something else before colon cancer gets you!” But according to recent research, that message isn’t likely to go over well with its audience. The study, out of Johns Hopkins, convened senior citizens and asked them what they thought about conducting screening tests in patients of advanced age. The people told researchers that they understood the concept of stopping testing when people get too old to benefit. But they did not like the thought of doctors telling them that their impending mortality is the reason they will no longer receive such testing. “You’re too old to benefit” is a harsh message.
So what should physicians do?
(To read the rest of this article, please visit Forbes.)

Don't Let Your Physician Tell You What To Do Without Finding Out Your Goals


A recent study of men with early-stage prostate cancer found no difference in 10-year death rates, regardless of whether their doctors actively monitored the cancers for signs of growth or eradicated the men’s cancers with surgery or radiation.
What does this study mean for patients? Based on research we have conducted on prostate cancer decision-making, the implications are clear: Patients need to find physicians who will interact with them the way a good financial counselor would, taking the time to understand them well enough to help them find the treatment that fits their goals.
Imagine a couple in their 40s who ask a financial counselor for advice on retirement planning, and the counselor tells them how much to invest in domestic and foreign stocks versus bonds versus real estate without asking them about their goals. A good counselor would find out what ages the couple wishes to retire at, what kind of retirement income they hope to live off of, how much risk they are willing to take to achieve their goals, and how devastated they would be if their high return investments go south, forcing them to delay retirement or reduce their retirement spending.
Far too often in medical care, physicians don’t behave like good financial counselors–they give treatment recommendations without taking the time to understand their patients’ goals. Consider early-stage prostate cancer, a typically slow-growing tumor that is not fatal for the vast majority of patients who receive the diagnosis. In some men, the tumor lies indolent for decades.
For that reason, men sometimes choose to monitor their cancers–have their doctors conduct regular blood tests or biopsies to see if the tumor is beginning to spread. Such monitoring has the advantage of being relatively noninvasive, but it can create anxiety for patients who wonder, every six months, whether their next checkup will bring bad news.
For that reason, some men prefer active treatments like surgery or radiation that eradicate their cancers and therefore reduce cancer-related anxiety. But these more active treatments have their own downsides–each treatment is relatively arduous, and they can cause both erectile dysfunction and urinary incontinence.
The choice between active treatment and active monitoring depends on a patient’s goals–on how they view the trade-off between outcomes like cancer-related anxiety and erectile dysfunction. When counseling patients with early-stage prostate cancer, physicians need to help patients focus on these trade-offs.
(To read the rest of this article, please visit Forbes.)

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.)

Reducing Healthcare Waste: Don’t Expect Patients To Take The Lead

Lena Wright’s best friend was hunched over like a character from a French novel, with spinal bones so thin they would fracture with a fit of sneezing. Determined to avoid that fate, Wright (a pseudonym) asked her primary care doctor to test her for osteoporosis with a DEXA scan, also known as Dual Energy X-ray Absorption. The scan would send two X-ray beams through her bones, one high energy and the other low. The difference in how much energy passes through her bones would somehow (the wonders of physics!) allow her doctors to calculate the thickness of her skeleton.
If you need to figure out whether you have osteoporosis, a DEXA scan is a good idea. But if you don’t need such a scan, you end up exposing yourself to harmful radiation and, of course, to an unnecessary healthcare expense. According to the American Academy of Family Physicians, most people do not need the test, because they do not have risk factors for osteoporosis. Lena Wright, for example, harbored no family history of osteoporosis, had exercised regularly her whole life, didn’t smoke or drink and, very importantly, had received the test five years earlier at age 65, which showed her to have normal bone density at the time. In the best judgement of medical experts, a DEXA scan would bring Wright more harm than benefit.
But she was worried. So her doctor, to ease her anxieties, ordered another scan.
What, if anything, can we do to reduce unnecessary and potentially harmful medical testing?
We can start by trying to reduce patient demand for such services. That is an approach taken by the Choosing Wisely campaign, a voluntary effort by medical professionals to reduce wasteful medical care. As part of this effort, professional societies like the American Academy of Family Physicians put together “top 5” lists of wasteful services. Then, in partnership with organizations like Consumer Reports, they’ve tried to educate the general public about why they should be happy to avoid such services.
I am a huge fan of educating the general public and think that Consumer Reports does as fine a job at this as anyone in the business. But I also recognize that their reach – their ability to get the word out to the masses – is limited. (To read the rest of this article, please visit Forbes.)

The Wrong Way To React When Terminally Ill Patients Cry

Photo Credit:
Photo Credit:

Just three weeks earlier, she had noticed something strange about one of her breasts. An irregular shape. Her daughter brought her to the doctor, and soon the patient, I’ll call her Amanda, was diagnosed with breast cancer, stage “to be determined.” In fact, she was now in an oncologist’s office, learning what tests she would receive to determine the extent of her tumor. And sitting between her and the doctor was a tape recorder, capturing their conversation.
A dozen minutes into the appointment, Amanda would break down crying. And the physician’s response, which I will lay out for you in a bit, is unfortunately not uncommon. When patients express negative emotion, many oncologists do not respond with empathy. As I’ll explain later, this is an enormous problem, but also one we can fix.
Amanda was 60 years old at the time of the appointment, quite frail for her age, requiring help climbing up onto the exam table because of a recent stroke. She needed to wear adult diapers. She also suffered from diabetes and tremors, although it was unclear whether those non-spontaneous movements were from Parkinson’s or some milder disorder. In other words, her health was already fragile and a breast cancer diagnosis wasn’t going to make things better.
Which may be why she was so distraught about her situation.
The oncologist described how he would evaluate her problem: “Now I am going to order a scan, a CT scan. It’s like an x-ray but she needs to lie down,” he explained to Amanda’s brother. “After that, we will check her blood. After we’ve done the blood test and the scan, I will meet you in one week and we will discuss this, and I will advise accordingly.”

Then, perhaps noticing the look on Amanda’s face, he advised her: “Don’t be scared, please. We will wait for the scan and blood results and see you in one week. So next week, [turning to the brother] please come with your children [one of whom was Amanda’s caregiver] and I can discuss this further.” Amanda’s brother agreed with the plan, but Amanda started crying: “So difficult,” she said.
Her brother tried to intervene. “Stop crying,” he said. The oncologist also stepped into the uncomfortable situation: “Amanda, don’t be scared, please. We don’t know for sure [how bad your cancer is], so let us check first. OK?”
“Doctor will do the best for you,” continued her brother, “so don’t cry. OK?” The physician continued, almost a tag team now with the brother. “Today we can do the blood test. You don’t have to wait after doing that and can go home thereafter.”
“You have a lot of work, right?” she said, apologizing for letting her emotions take up so much of the doctor’s time. He tried to ease her mind. “No,” said the doctor, denying that he was too busy to address her concerns. But he immediately muddled his message. “I mean, you can do your blood tests today.”
A heartbreaking episode, heartbreaking in large part because of the awful situation poor Amanda was in, with so many things she could no longer do because of health problems and now with advanced cancer. Tragic, truly tragic. But compounding this tragedy was a veritable tragicomedy of miscommunication. Amanda breaks down crying and what message does she hear from her brother and doctor?
Stop crying.
Neither brother nor doctor acknowledged that, given her situation, she had a right to be scared, that it would in fact be abnormal not to be frightened. Neither realized that when people start crying, telling them to “stop crying” can actually make patients feel worse. I am sure I have made this same mistake scores of times in my own clinical practice. When a patient cries, our natural instinct as doctors, as humans, is to relieve their suffering, to say something that will stop their crying. It is perfectly normal, even compassionate, to reach out to soothe someone who is crying, to gently tell them not to cry, that everything will be okay.
(To read the rest of this article, please visit Forbes.)

Are Doctors Ready to Talk about Health Care Costs with Patients?

While I was on vacation, I spoke with reporter about a topic near and dear to my heart – importance of getting clinicians to talk about health care costs with their patients. The reporter put together a very nice piece on the topic, which I thought I would share with you:
Doctors Aren’t Grasping For Cost Transparency Tools
By Richard Mark Kirkner
In health care’s bad old days, doctors were often woefully ignorant of the costs to patients of the services they recommended. Today, with the industry striving to achieve cost transparency and physicians still the key influence on patient decision making, evidence suggests that in too many cases the bad old days are still here.
As health plans develop and refine tools to give members detailed information about how much they will pay for tests, procedures, and hospitalizations, members are taking that information to providers. Many of those providers, though well equipped to discuss the need for a test or procedure, are clueless about its cost — or where to get a more reasonably priced alternative.
That’s although physicians have a key role to play in helping payers and patients realize the savings the new cost transparency tools have been designed to yield. Despite their influence, doctors may be the last on board the cost-containment train as it prepares to leave the station…
(Continue reading here)

How To Tell Someone That She Is Dying

Doctors-AdviceElizabeth’s breast cancer had already spread to her bones and was now invading lymph nodes in her right armpit, causing painful swelling that kept her up at night. Today, however, as she walked into her oncologist’s office, Elizabeth felt like things were under control.
“All right, so how is your arm?” the oncologist asked.
“Actually, it’s better than it was,” she replied. “I mean, it still hurts. It’s still very swollen.”
The oncologist could see that her arm was getting worse. “I think those lymph nodes have gotten a little bigger, haven’t they?” he asked.

“I don’t think so. Well, I don’t know.”
“I think they’re bigger,” he said, as he placed his stethoscope on her chest. “A couple of breaths. Again.”
She exhaled one more time and made her position clear: “I’m still not in favor of chemo. Sorry. I’m not.”
“I thought about it and … I feel like I would never go back to work. I feel like it would just do me in.”
Frustrated by the denials, the oncologist let his emotions get the best of him. “How about if this sucker is going to go and do you in?” he asked. “That’s going to happen, too. That’s the problem. It’s going to grow and kill you.”
This clinical encounter was audio recorded, in 2012, by a company called Verilogue, which conducts marketing research for the pharmaceutical industry. The conversation struck me as emblematic of the challenge that physicians face practicing medicine in an era of empowered patients. As recently as the nineteen-seventies, medical decision-making in the United States was largely a doctor-knows-best endeavor…
(Continue reading on The New Yorker)

If Costs Are Unknown, Can Doctors Still Talk About Them?

don't talk about moneyI have been writing a bit lately on the need for healthcare providers to talk with their patients about healthcare costs, if for no other reason than to enable patients to determine whether they can afford to pay for the healthcare that their doctors are recommending them to receive.  I have been criticized for this position, on the grounds that I am rationing care from people with less money and connections than I have, a criticism that I have explained as being misguided.
But I have faced another more reasonable criticism too, one I want to write about today.  I have been reminded that doctors and other healthcare providers cannot easily discuss healthcare costs with patients because those costs are often unknown. Lisa Rosenbaum made this point in an excellent New Yorker essay:

“The first problem with financial disclosure from doctor to patient is a practical one. Doctors rarely know how much their patients actually pay. Patients are covered by a variety of insurers, all of whom offer several plans, for which any individual patient has a different copayment and deductible, which he may or may not have met.”

In this post, I will lay out a fuller version of this criticism and then explain why I still think doctors need to hold these conversations, and also why I think these conversations will become much more common in the near future… (Read more and view comments)

New Review of Critical Decisions

My heart was warmed by a new, and very positive, review of a Critical Decisions. I always find myself agreeing with people who liked my book. Funny thing. Anyway, here is the review:
“This is a very belated review. And I mean that as a compliment.
As soon as I finished reading Peter Ubel’s Critical Decisions, I immediately leant it out to a colleague as a very enjoyable “must-read.” She devoured it and passed it along to yet another colleague – and that was literally the last I saw of my copy, which I hope to eventually get back in some kind of battered but well-read condition.
Yes, we’ve ordered more copies. But I think everyone keeps passing it on because Critical Decisions provides a wealth of history and information about medical decision making, and how doctors and patients each think about decisions. Perhaps most importantly, it shows the author confronting the reality of how medical decision making actually plays out in the real world.
It starts by tracing the history of medical decisions. Yes, we’ve come a long way from the days where even a U.S. president wouldn’t question a physician’s recommendation for his wife to get something as life-changing as a mastectomy without even discussing the biopsy results, to a world where individuals and families have more opportunity to participate in and make decisions about their care.
But on both the patient and the clinician side, so many factors influence and bias us, and we’re often unaware of it.
First, as Ubel points out, decisions are also a burden. And when decisions get even a little tough we often look for ways not to decide. Yep, we defer. A common instinct is to ask our doctor what they would do if they were the patient. But it’s a problematic request, because our judgment changes when we’re actually responsible for the decision.
Even if we don’t defer, we often base decisions on a friend or family member’s good or bad experience with a drug or treatment, which may or may not be the norm. We also underestimate our own resilience and can’t imagine getting used to things like self-injecting insulin. And when words like “cancer” are introduced, we inflate risks, thinking they’re more likely. Clearly, it’s hard to give our brains space for calm deliberation. And, as Ubel writes:
Good decision making is not merely a matter of comprehension. Understanding doesn’t necessarily lead people toward making rational choices. Decision making is often as much about feeling as it is about thinking. And the way people use risk information… is often influenced less by their understanding of the magnitude of these risks than by subtle psychological cues that change the way these risks feel. (p. 137)… (Read more)”
(Click here to view comments)

Want narcotics just ask for them?

oxycontin-prescriptionA very disturbing new study was just published, in which physicians viewed a video of a patient with back pain asking for OxyContin. Twenty percent of docs said they would prescribe that med under that circumstance:

…Too often, doctors prescribe potentially dangerous medications to patients who shouldn’t be getting them, and what they prescribe is influenced by the pills patients ask for.
The study found that patient requests for certain medications — such as the powerful narcotic oxycodone — “substantially affected physician-prescribing decisions, despite the drawbacks of the requested medications.” The results suggested that even a gentle request from a patient could convince a doctor to prescribe potent, potentially dangerous narcotics — even when they’re not the best-practice treatment for the patient’s condition…(Read more about the study here)

(Click to view comments)