Blogging Fatigue (Friday Links)

Blogging can be an exhausting thing~ Doctor D is pretty familiar with exhaustion these days between doctoring, husbanding, fathering, and blogging.

Don't worry, this isn't one of those hiatus posts. AskAnMD is still going strong, but one of the web's favorite medbloggers Dr. Rob decided to throw in the towel this week. He was always an interesting read and will be much missed. Also D will now never be able to figure out that dudes odd obsession with lamas.

Blogs don't last forever, although there is always the hope Rob's blog will have a resurrection like Nurse K's and Ella the Med Student's have.

Fortunately amazing new bloggers are always appearing:

The new link this week is Medical Moments in 55 words! Word Doc is an internist who tells medical stories in short 55 word posts. The stories are both funny and poignant, and best of all they take less than a minute to read. So go check out Word Doc. Doctor D guarantees you won't be disappointed!

I'm really impressed with the brevity of Word Doc's posts. The shortness doesn't take any power at all from her stories. Should Doctor D try to answer your questions in 55 words for a while?

What Are My Chances, Doc?

As you may recall from the last post, if Doctor D suspects you might be facing a lethal illness he'll let you know straight up. He brings it up gently, pointing out that any doctor's guess has a lot of uncertainty.

You do, of course, have the right to ask, "How certain are you, doc?"

But here's the secret: MDs hate answering this because we often don't know how certain we are. I'm usually pretty good at predicting what will kill a patient. How good? Results may vary...

In a few diseases there is solid data: 80% of people diagnosed with pancreatic cancer will be dead one year later. Usually, however, the situation is too complex and there isn't any research data to answer the question. Then Doctor D whips out a gut guess.

I once had patient with curable but advanced colon cancer develop urosepsis and then have a heart attack from the septic shock. His family wanted a percentage for his chances. I made one up, "Maybe a 40% chance of surviving the next 24 hours." He survived and went home.

As I said, I'm not perfect.

Percentage numbers don't really mean that much when I'm guessing, but people just like something that sounds mathematical rather than “almost certainly dying” “could die” or “maybe dying but probably not.”

Predicting death is a risky business. Doctor D once had to dodge a fist when D told a dude his dad probably wouldn't make it. (Fortunately crying people can't pull off a good sucker punch!) Doctors also don't like mentioning death because most people don't like to discuss about their own mortality. We vaguely acknowledge we all die sometime, but you don't expect "sometime" anytime soon. Then Doctor D sits you down and says, “Now might be your time.” It's never an easy talk, and it's almost always based on an educated guess.

Doctor D still thinks it is worth letting you know, even if his estimations aren't perfect. Most patients want to prepare themselves and their families if death is a real possibility. I only withhold such information if a patient told me ahead of time they don't want hear any discussion of death.

What do you think? Do you want your doctor to tell you your chances? Even if it is only an educated guess?

Some old MDs never mention the word “death” because “they don't want to take away hope.” Obviously, Doctor D takes the opposite approach. Which would you prefer? For yourself? For your family?

Recognizing Death

A reader with a bad illness writes:

I would prefer that my doctors give me any bad news straight up. I'm not confident they will. No one is saying anything definitive. I've asked two of them about my prognosis. One said, "I can't tell you that." I don't really think anyone knows, but I wonder if they just don't want to tell me bad news?

Predicting the end of life is very difficult even for the most knowledgeable doctor. People with certain conditions are obviously closer to their death, but estimating how and when a person will die is extraordinarily difficult. With some illnesses (like common cancers) we can say what percentage of people will be dead in a year, but a percentage from a study doesn't tell you with certainty how long one individual will live. And most life-ending situations don't have good percentage studies. Still, experienced doctors become pretty good at recognizing when a person's body is declining and fighting a war that it won't win.

One thing that frustrates Doctor D is that MDs often talk amongst themselves about a person's prognosis without frankly mentioning it to the patient. They discuss the disease process in such techno-medical jargon that you don't recognize they are saying you will probably die. The confusion is intentional. They don't want you to hear the word "die" because they are often afraid to discuss with you it themselves.

Death is hard to discuss. No one likes to give bad news. You are telling a person about the end of their life. It is a heavy conversation. Since all they have to offer are educated guesses, doctors often busy themselves and the patient with the technicalities of treatments and tests—until the end is obvious and undeniable. Only then do we frankly discus dying. By then, death is sometimes so close patients have almost no time to prepare themselves and their families.

Your doctor is technically correct. A doctor cannot tell you exactly how and when you will die. But your doc may have a good guess as to where things are headed.

Give your doctor permission to guess. Let the doc know you won't be angry if they cannot win against the disease. Only then are you likely to get a straightforward estimate.

Doctor D has a policy of not hiding his guesses from patients. If I think a person may have a life-ending illness I won't keep it a secret. I point out that I am not certain, but I need to let them know my suspicions. It is hard to discuss someone's mortality, but I believe it is one of the most important duties of a physician with a patient facing a potentially fatal illness.

Of course the next question everyone asks is "What are my chances?" and "How long do I have?" These are also difficult questions to answer, so I will save them for a later post.

All of us will eventually die, but today you have your life and the lives of those around you to be thankful for. So today forget about shopping and tell someone that you love them. See you next week!

No Friday Links Today

Sorry! Doctor D spent the holiday with family and friends and didn't read any blogs. No Friday links today, but I have an answer to a reader's question I'll be posting later today.

Mammogram Madness

The U.S. Preventive Services Task Force recently advised that most women don't need mammograms as early or often as previously believed. Now you can't turn on a TV without some reporter telling us how angry Americans are about this.

What is Doctor D's take on the new guidelines?

As a working clinician I trust the USPSTF. They have no agenda-axe to grind and spend a lot of time studying mountains of data. These experts meticulously examine the thousands of studies that I just don't have time to read. They crunch numbers and come up with carefully considered recommendations.

While I can understand all the public concern, I am irritated that many doctors seem eager to jump on the irrational bandwagon.

What no one seems to comprehend is that even relatively safe tests and treatments can still be deadly. Doctor D has hurt some very nice people with the "right" treatment because all medical interventions have risks.

Men can also get Breast Cancer, just less often. Men die of this disease. Would screening every male "save lives" by catching some early cases? Probably. Would there be lots of false positives? Absolutely. Would the number of men we maim or kill with work-ups and treatments outnumber the lives saved? Almost certainly. Hence the need for evidence-based guidelines.

Breast Cancer is a horrible disease, so it was worth a try to screen women in their 40's. But now we have years of data indicating that we hurt more low-risk women than we helped. Uh-oh! It's one thing to hurt people with what we hope will be the right intervention, but when we hurt people by doing something we know doesn't work it's shameful. The same thing happened with prostate screening for men. We don't need to keep doing things that don't work.

We have a natural bias towards doing something rather than doing nothing. People expect doctors to "do something!" Doctors like to do things for patients. Hence over-testing and over-treatment run rampant in all fields of healthcare. Sometimes we make educated guesses at interventions and hope they work, but when we have evidence showing we aren't helping people, it's time to acknowledge that doing nothing is safer and wiser.

The trouble is that the guidelines are based on mountains of studies that the public, politicians, and many doctors are unequipped to evaluate for themselves. So we go for next best thing: anecdotal evidence. We base our opinions on heart-wrenching stories of women in their 40's that died of Breast Cancer. All the evidence in the world is no competition for a really moving story.

What the USPSTF needs to do is come up with a convincing narrative. Stop referring to data that nobody understands and give your arguments a human face! Parade the widowers of and orphan kids of women that died as the result of a workups for false-positive mammograms in front of every TV camera you can find. Get doctors up on stage and have us apologize, "Sorry, we did what we thought was best, but now we know we were wrong. We'll do better in the future."

Doctor D realizes he'll probably loose some readers over this post, but somebody had to defend the USPSTF against this crayzee smear campaign.

Feel free to post your thoughts, but please don't accuse me of "not caring about women's lives." I follow the recommendations because I care about women, and I've been saying the same thing about PSA in men for a while.

Psycho-Analysis (Friday Links)

It's Friday and Doctor D has a fun semi-medical blog for your reading pleasure:

The Last Psychiatrist

This very enjoyable blog is the product of an academic psychiatrist. Unlike most MD bloggers he doesn't discuss his patients or his practice much at all. Instead he caustically analyzes cultural phenomena from parenting to medical bullshit, teenagers to television (for all you Don Draper fans).

Despite the long posts and the obtrusive presence of Happiesque ads, Doctor D has been reading Last Psychiatrist most of the night, and this guy never gets dull! He diagnoses nearly everyone with Narcissism and warns about the danger, but never has a self-righteous Jeremiad against selfishness been so much fun! Seriously, this dude ranks 8 of 10 on a blog funscale (with Dr. Grumpy as a 9 and Nurse K as perfect 10)!

A taste of Last Psychiatrist:

Pop culture controls you even if you think you're separate from it. It is everywhere, from the clothes you wear to the language you use to the way you think. It is a viral pandemic that masks infection by pretending to be part of you. There's no cure.

"No way, I'm not getting infected, I'm not exposing myself to all that trash. I'm going to think for myself."

That's the virus talking.

Is the Last Psychiatrist a brilliant modern prophet or perhaps a closet narcissist himself who gets off on critiquing his readers? Doctor D isn't sure yet and isn't sure if he cares. Right now I'm just enjoying the ride.

Take a look at Last Psychiatrist and let me know what you think: Is this blogger a genius or a mad psychiatrist?

Why Not Call? (Exhaustion and Economics of Phone Calls)

A reader writes:

Why do I have to take time off of work and make an appointment for my doctor to explain test results? Wouldn't it be much easier to do over the telephone?

It would be easier to discuss this over the phone, and cheaper. Your doctor isn't paid for talking to you over the phone. Getting info over the phone is always a win for patients and a loss for doctors.

Primary Care Doctors (like Doctor D) for whom much of the job is educating you about your health are making a less and less every year (we're the green line) and we started out as the lowest paid physicians. Primary Care clinics are just barely scraping by, so when it comes to discussing your labs they can either do it over the phone for free, taking time away from seeing patients, or bring you in and get paid by your insurance to have the same discussion. The economic solution usually beats the common sense solution.

Now, I don't want this to sound like one of those Happy Hospitalist I-don't-get-reimbursed-for-all-I-do posts. Primary Care is still a good job and Doctor D doesn't have to worry about keeping food on the table.

But when Doctor D worked at Crayzee Clinic he spent many hours every day getting patients results, refills, and forms without pay. He did his best to call patients when he could, but if he knew it was going to be a long talk he usually had you come to the office. Doctor D had to keep some work during office hours—as it was he barely saw his wife or son while working primary care. Of course, some docs avoid phone calls because of greed, but most in primary care are just exhausted having to see more patients faster and faster while doing more paperwork in the evenings. An appointment to follow up tests was usually pleasant and easy, and didn't keep Doctor D in the office later at night after office hours.

But for the patient, it sucks! You have to get off work and drive to the doctor's office, just to get information you could have gotten over the phone. You can and should ask if your doc can call you the results without an appointment. Your heathcare is already too costly without extra visits. But please realize that this is harder on you doc, so don't abuse it. If you are the sort that needs to ask lots of follow up questions please schedule a visit instead of tying up your doc on the phone for 20 minutes!

Okay, after a long blog post about money and reimbursement Doctor D feels dirty and must go bathe the Happyishness off of himself.

This is one of those annoying situations that forces either you or your doc into a financially frustrating situation. The solution proposed on most doctor blogs is billing for phone calls.

What do you think? Would you be comfortable being billed for phone calls? It would save you costlier office visits. Or do you want to keep phone contact free?