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?

Should I Get A Medical Alert Bracelet? (Upselling Healthcare)

A question from WarmSocks:

When should someone wear a medical alert bracelet? Nobody has ever recommended that I should consider it, but my med list seems awfully long so I'm wondering if it would be appropriate?

The purpose of the alert bracelet is two-fold:

1. To provide vital information in an anticipated emergency.
2. To make money off of people with illnesses.

Should I wear a bracelet? Do you have a condition likely to cause you to be found unconscious, and have something about you that would make your care different than the average unconscious person? You should probably carry a brief list of your medical conditions and medicines, but most of those things don't require a bracelet.

These bracelets are marketed to people with things like insulin-dependent diabetes or heart rhythm problems. The bracelet basically says, "This is likely the reason I'm unconscious and this is what to do!" I've seen a lot of diabetics and heart patients with such bracelets, but I've never seen these bracelets make much difference. Paramedics always check blood sugar and heart rhythm as soon as they find you in such situations, so in my experience people with and without these bracelets get about the same care.

The best reason I can see for a bracelet is a rare condition that rescuers aren't going to be thinking about. Diabetics need not worry—we check a sugar on everybody that's unconscious, bracelet or not. (Other reasonable situations to have a bracelet would include: severe anaphylactic reactions to medicines or if you don't want to be resuscitated if your heart stops. )

The second reason for bracelets is to stimulate the economy. The healthcare industry is massive and you—the patient—are the cash cow. If you stop consuming all the medical accessories and extras then the Healthcare economy might shrink! Proven, effective care can be a narrow margin business, but all the physical and pharmaceutical accessories that you see marketed keep the Healthcare Business healthy even in lean times.

If you call a bracelet company they will say that your daily aspirin or history of ankle sprains should definitely qualify you for a bracelet. "Let's bill your insurance, and for a bit more you can get a stylish 14 K gold band for it!"

Your doc should be able to tell you if your condition really needs a bracelet or not.

But be careful if you doc is offering bracelets or any other "value added" products in their office for your convenience! With Primary Care profit margins razor thin, a lot of doctors are going over to the darkside and letting corporations talk them into adding "secondary income streams" to their practice. If your doctor is selling something (bracelets, supplements, skin rejuvenation, etc.) other than medical care you should run the other direction. Your doctor should be an advocate for you, not the spokesperson for some product line.

Is Doctor D may be alone in his righteous anger about MDs who sell extras in their practices? D was highly offended when Little D's doctor was selling vitamin products at the clinic. Mrs. D told Doc D to quit being a pinko Commie and accept that capitalism works this way. Do you mind if your doctor makes extra by selling products?

The Best of D (Friday Links)

This blog has grown so much recently that Doctor D's big doctor ego deemed we should link to all the fun and informative older posts buried in the archives. So if you will direct your attention to the right side of the screen you will notice AskAnMD's new feature:

Doctor D's Best Answers

Of course, if you've been visiting Doctor D's virtual clinic as long as WarmSocks you've already read it all, but if you are new here you can go check it out for loads of doctor-patient enjoyment.

Yes I realize that it is sort of cheating to count a "best of" page as this week's Friday Links, but D is suffering from an acute case of laziness today. Sorry. I will be back on my game next week.