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Maybe health insurance is part of the problem

As much as the nation bemoans the lack of people with health insurance, few realize just how much influence such companies have on health care decisions. And I mean in ways beyond just what procedure the company will pay for.

Chapter 5 helps bring the notion frighteningly home.

Groopman paints a picture of "gatekeepers," those medical professionals who help steer patients in other directions, whether that's a specialist or a trip to the sofa, such as pediatricians and family practice folks. What really comes through, though, is how the patient loads needed to make a living as a physician can lead to oversights while the insurance companies that have come to dominate payment structures can demand changes in those thought processes. Groopman uses a great analogy of those caseloads, comparnig them to a passing train "Imagine watching a train go by. You are looking for one face in the window. Car after car passes. If you become distracted or inattentive, you risk missing the person. Or, if the train picks up too much speed, the faces begin to blur and you can't see the one you are seekin. 'That's what primary care medicine is like,' Victoria Rogers McEvoy told me."

The good doctor also gives good insight on how far the insurance pull is. Take this nugget on how a pay rate got established:

Many primary care physicians find their practices taking on a similar frenetic quality, and for similar reasons. Insurance companies seriously underreimburse doctors for primary care, a legacy of the period when surgeons headed the medical societies that negotiated with insurers about what was a "customary" payment for services. A specialist who performs a procedure -- a brochoscopy, say, or a surgical operation -- gets a substantial payment form the insurance carrier. But if a pediatrician or another primary care provider, a general practitioner or internist, spends an hour with a complex set of medical problems trying to arrive at a diagnosis, or probing the emotional fallout from an illnes or its treatment, the payment is meager. For this reason, many general pediatricians 'feel like they are running up a hill of sand,' McEvoy said.

Scarier still, here's a look at insurance companies' sway:

Not long ago, one of my neighbors told me that she had returned from a visit to her internist, who is a member of a large practice in a Boston hospital. I know the internist, and he recounted to me that he had recently been instructed by the practice's administrator to cut thirty-minute visits for follow-up to fifteen minutes, and sixty-minute appointments for new patients down to forty. When the doctor protested, the administrator told him that there was an electronic solution to make this all possible -- a template would be on his computer screen. As he spoke with a patient, he would fill in the form. This would help, the administrator added, not only in economizing his time but also maximizing his revenue, since it would make it easier for the billing office to submit invoices to insurance companies based on his template documentation of the history, physical exam and treatment recommendations.

Eric Cassell expands on the danger that clinical care is being squeezed by the efficiencies of the marketplace: "In healthcare planning, it is natural that each service might be seen as a commodity or product. The calculus involved in determining the cost of providing the service, the factors affecting reimbursement, the required number of such services, and other factors all promote the commodity view ... Medical care -- in all of medicine, not just primary care -- is a human interaction between patient and doctor within a context and in a social system. As such it is not a commodity."

Then it comes back to haunt folks in pediatric settings

In the course of a day, a full-time pediatrician may see two dozen or more children

In fact, a recent study showed that over the past decade, taking inflation into account, the incomes of physicians like pediatricians have fallen. Many doctors have reacted by truncating visits to ten to fifteen minutes and increasing the volume of patients they see in a given day. This speeds up the train and fosters the kinds of errors that Pat Croskerry and Harrison Alter fear when the ER doctor is spinning plates. Working in haste can not only increase cognitive mistakes but impair the communication of even the most basic information about treatment. A study of 45 doctors caring for 909 patients found that two thirds of the physicians did not tell the patient how long to take a new medication or what side effects it might cause. Nearly half of the doctors failed to specify the dose of the medication and how often it should be taken."

I've always been quite happy with the health coverage offered by the paper (the big joke with a co-worker is that the insurance is the real reason my wife married me since she has three kiddoes from a previous marriage), but in the big scheme of things, the fiscal control such companies wield over health care may be at the root of some of the problems.

Posted by Michael Hines at 08:33 AM | Permalink | Comments (0) | TrackBacks (0)

Insight into hospital operation is a bit unsettling

Groopman does a great job of peering beyond the press releases and television shows on how healthcare organizations operate. He knows the tricks

[H]e recites the ABCs he learned during his training ... "A stands for airway, meaning that the mouth, throat, trachea, and bronchi are all open; B is breathing, that the patient's lungs are able to get enough oxygen and pass it into the bloodstream; C is circulation, that the heart is pumping, the blood pressue is adequte for the blood to reach vital organs like the liver, kidneys and brain..."

And he knows the pressures

"I'm coming up with nothing," Croskerry told the triage nurse. Nonetheless, he said he was sending off blood and urine tests. This was met by considerable resistance. "Why are you doing this?" the nurse asked. "She's already been worked up." Croskerry told me he felt "palpable" pressure because it was hectic in the emergency department and the nurse needed Maxine's bed for another patient. But he insisted. About an hour later, her test results were in hand, all normal. "I reassured her that this seemed to be her irritable bowel acting up," Croskerry said. "I went over again issues about proper diet and stress management. I also emphasized to her not to be reluctant to come back." Croskerry has learned from experience never to discourage patients from seeking follow-up care.

"She broke into tears, crying that no one believed her, that no one was able to come to a diagnosis," he recalled. "She kept saying that the pain was getting worse, that it was much worse than it had been even a week before." ... He sent he home. A short time later, she was rushed by ambulance back to the ER. "She collasped while walking home," Croskerry said. She was bleeding internally and on the verge of shock. She was rushed to the OR, where a surgeon found that Maxine had a ruptured ectopic pregnancy. "It had been missed three times. I was the third miss," Croskerry told me.

And he knows the pettiness (here, I wrote a note to myself that just said I'm shocked anyone survives being in a hospital with this kind of thing)

The ecology of an emergency department includes not only patients, their families, and, of course, nurses, but also other doctors. At Highland Hospital not long ago, Alter was the attending physician when a resident in training evaluated a man in his thirties complaining of a sore throat. "It's an open-and-shut case of strep," the resident told Alter -- an "uncomplicated" patient. Alter had the sense that the resident wanted to move quickly to his next patient. Alter asked for details. "He has an exudative pharyngitis, pus near the tonsils, and painful lymph nodes," the resident siad. Alter insisted that he wanted to meet the man himself. The resident sighed in frustration.

Alter peered into the patient's throat and saw no signs of pus. He ran his fingers along the sides of the man's neck and felt small, soft lymph nodes tha were not tender. Alter pressed more firmly on them. Still no reaction from the patient. The resident had already given him a large dose of antibiotic and a prescription for more.

Alter led the resident into the corridor and told him that it didn't at all look like strep, that it was most certainly a virus causing the sore throat, and that prescribing antibiotics unnecessarily could have serious consequences. ...

A short time later, another man came in with a sore throat. "Go to room 23 and start with the patient," Alter instructed the resident. After Alter had sutured the arm of a man with a knife wound, he made his way back to room 23. "he's fine," the resident said curtly. "Another one of your favorite viruses."

Alter didn't just sign off on the resident's assessment. As he interviewed the patient, he saw that he was restless, moving around on the examining table, unable to find a confortable position to rest his head. When Alter peered into his mouth, he saw nothing abnormal. The man was breathing easily, and there was no stridor, no harsh sounds suggesting an obstruction in the upper airway. But Alter was concerned about the patient's restlessness and his fever of 101 degrees F. He lingered awhile, thinking.

"Like I said, it's a viral pharyngitis, and at Highland Hospital we don't give these people antibiotics," the resident said with dripping sarcasm. Alter ignored the baiting tone. He again moved his fingers down the sides of the man's neck, marching meticulously, this time pressing inch by inch. When he was about halfway down, the man winced in pain.

"I want a CT scan of his neck," Alter told the resident. For a long moment the juniotr doctor said nothing, but then he left and ordered the scan. The call later from the radiologist did not surprise Alter: the man had an abscess in his neck. "This is the kind of infection that can kill you," Alter said. "If it's not treated quickly with intravenous antibiotics, it can block the upper airway and you'll suffocate."

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Chapter 3 shows importance of doing homework

Sorry about the unexpectedly long Memorial Day hiatus. Let's hop back into things.

Chapter 3 more than anything reinforces the importance of an informed patient, and not so much because people should know so much about their ailments so they can relay a lot of insight to their caregivers (though that's a good idea, too). No, what really sticks with me in this chapter is just how often someone had the guts to stick to their guns and not back down from wanting procedures despite the grumblings of their doctors. Some folks are born with that skill, but it's something everyone can develop once they have a little knowledge in them.

What Chapter 3 really looks at the way doctors and hospital operations can actually interfere with how healthcare gets delivered. The mental shortcuts doctors use can be skewed.

For one thing, there's the fault of "availibility" error, in which physicians "the tendency to judge the likelihood of an event by the ease with which relevent examples come to mind." So, if the area has a lot of allergies, then doctors maybe more apt to say an ailment is an allergy just because so many have come through the office. Then come tricks called "confirmation bias" and "anchoring," essentially selectively accepting facts that backup a hunch while downplaying contradictory notions and then hitching a diagnostic to a single hypothesis without considering other ideas. It adds up to situations in which misdiagnosis occur.

Battling against such problems comes from not being timid. Groopman offers some good advice on this front:

If the physician is distracted, frequently interrupted by other doctors, nurses, social workers, or the administrative staff as he interviews or examines you, the steady flow of his thinking may be diverted in the wrong direction. There is similar cause for concern if the physician seems rushed or breaks in as you answer a question, so that you feel he is not letting you tell him everything about your symptoms ...So a fair question to ask an ER physician is: What's the worst thing this can be? The question is not a sign of neurosis or hypochondria; in fact, residents are trained to keep it in mind with each patient they see.

Plus

Another way that laypeople can focus a doctor's attention is to ask: What body parts are near where I am having my symptom? This sounds elementary, but this query can help avoid "yin-yang out" errors

The yin-yang thang refers to doctors thinking every procedure that should be done has been done without making sure some new avenure gets explored. And finally

"No one -- no doctor, no patient -- should ever accept, as a first answer to a serious event, 'We see this sometimes,'" Alter said. "When you hear that sentence, reply, Let's keep looking until we figure out what is wrong or know the problem has passed."

Patients have to be on the look out because so much stuff can steal the focus they need from their providers.

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Advice for patients and just neat stuff

Groopman gives some good advice for patients about fending off stereotyping docs.

Rather, Delgado believes, patients and their families should be aware that a doctor relies on pattern recognition in his work and, understandably, draws on stereotypes to make decisions. With that knowledge, they can help him avoid attribution errors.

"It's not easy for laypeople to do," Delgado said, "because patients and their families are especially reluctant to question a doctor's thinking when their questioning suggests his thinking is colored by personal prejudice or bias." Still, Delgado thinks laypeople can diplomatically direct a doctor's attention to his reliance on stereotypes, because on of her patiets had done this with her.

That brings us to the neat stuff, namely just how fascinatingly weird the human body is. The patient that talked to Delgado was Ellen Barnett.

Ellen Barnett had already consulted five physicians and felt all five had shunned her. "I'm having what I call explosions, feeling hot all over, which make my skin crawl. I mean really crawl, like ants all over, and sometimes they come with terrible headaches," she told Delgado. "Really, it's like a bomb going off in my body. I know I am in menopause, and all five doctors told me that that's the cause of my problems. And two told me that I'm crazy. And, frankly, I am a little crazy."

That kind of candor helped the doc overlook the obvious menopause diagnosis and uncover the neat biology:

"I evaluated her very extensively," Delgado said, "and it turned out that, yes, she was menopausal, and yes, she was a strange person with lots of weird ideas, but what turned up in her urine was not from menopause or being kooky. Her catecholamine levels were through the roof. A CT scan showed a pheochromocytoma above her left kidney."

A pheochromocytoma is a relatively rare endocrine tumor that produces catecholamine, chemicals like adrenaline that can cause wild swings in blood flow and blood pressure. The changes in circulation may mimic menopausal hot flashes and precipitate severe migraine-like headaches. The catecholamines can also cause psychological symptoms such as anxiety, despair and even aggression. If untreated, the patient may have a stroke or heart or kidney failure.

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Folks depending on indigent care seem at greatest risk

How Doctors Think has really gotten me thinking about the problems faced by those depending on indigent care programs or charity care. Consider this:

More commonly, doctors make what are called attribution errors when patients fit a negative stereotype. Dr. donald Redelmeier of the University of Toronto, who ... studies physician cognition, told me about a case he had recently seen on rounds. Charles Carver was in his seventies, retired from the merchant mrine and living by himself in a small apartment. Over the past months, he had felt fatigued and his belly had begun to swell. When Carver came into the ER, the intern noticed alcohol on his breath, and Carver readily told him that he enjoyed a glass of rum each evening. His legs and feet, as well as his abdomen, were swollen. Carver was unshaven; his clothes were old and frayed. The intern wondered to himself how many days it had been since he bathed. ...

"The intern's plan was to have this boozer sleep it off, give him some mild diuretics, and send him home as quickly as possible."

The guy turned out to have an inherited disease.

More than anything, though, it makes me worry about how folks with little income and likely not living the best of lives can fare in such medical environments. Not that all folks on indigent rolls are slobs, but getting on such programs demand a person have little means. That can easily translate into looking more like the bum bilking the system than the patient needing the best care possible.

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Author's narrative taking too technical a turn

I've enjoyed How Doctors Think for the most part so far, but there's been a creeping increase in the use of clinical writing that's starting to turn me off of the tome. Author Jerome Groopman has done a superb job conveying how hospitals and physicians work and face challenges, but too often the prose goes into a set pattern. This wouldn't be a big deal if the book were meant for other doctors, but Groopman claims the book is meant for laypeople.

For instance, Groopman always seems to start a new topic with an almost rote descriptive style:

Ever since he was a little boy, Brad Miller loved to run.

Antecdotes are nice ways to introduce topics, but each new subject seems to start with that kind of one-line hook followed by a description of the person and elaborating on their background. It's a very newspaper-esque, featurey style that just drags at times. He could start with describing the physiology of a disease, its history, focusing on a particular characteristic of the person's physicality, just anything to break the monotone. I just wish he'd break out of the box some.

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Physicians aren't immune from putting people into categories

Man, covering trials just takes a whole lot outta ya.

Anywho, back to the book (and some insights from my first look at the text. If nothing else, I’ve learned that blog messages should be a bit shorter. Meh, I got excited and just went with it. Read to Achieve, you know?)

Chapter two boils down to understanding how prejudice and stereotyping exist even despite the best intentions and sometimes because of those intentions. It’s good to recognize that thinking, especially in light of how deep such bias may play in our culture. Groopman gives the term a more sterile phrase (part of a trend in the book that starts to make his writing less reader-friendly as it goes along), but the implications remain just as important.

Groopman provides insights into what he calls “representative," "attribution,” and “affective" errors. The first means a doc's thinking gets guided by a prototype and contradictory evidence get overlooked. In the book's example, a guy who looked fit and athletic wasn't thought to have heart problems, though he did. Attribution error is a lot more in line with stereotyping, in which folks who fit certain characteristics get short shrift, like this guy:

Charles Carver was in his seventies, retired from the merchant mrine and living by himself in a small apartment. Over the past months, he had felt fatigued and his belly had begun to swell. When Carver came into the ER, the intern noticed alcohol on his breath, and Carver readily told him that he enjoyed a glass of rum each evening. His legs and feet, as well as his abdomen, were swollen. Carver was unshaven; his clothes were old and frayed. The intern wondered to himself how many days it had been since he bathed.

The intern labeled the guy a drunk. Turns out Carver had Wilson's disease.

What Groopman really helps to get across is why such thinking can become such a big deal. For one thing, mental, medical and social ills can all look alike:

A young man was brought to the emergency ward of the hospital in the wee hours. The police had found him sleeping on the steps of a local art museum. He was unshaven, his clothes were dirty, and he was uncooperative, unwilling to rouse himself and respond with any clarity to the triage nurse's questions. Dr. Delgado was busy that night attending to other patients, so she "eyeballed" him and decided that he could stay on a gurney in the corridor, another homeless hippie who would be given breakfast in the morning and returned to the streets. Some hours later, she felt a nurse tugging at her sleeve. "I really want you to go back and examine that guy," the nurse said. ...

"His blood sugar was sky-high," Delgado told me. The young man was on the brink of a diabetic coma. He had fallen asleep near the art museum because he was weak and lethargic and unable to make it back to his apartment. ... His difficulties giving the police and the triage nurse information reflected the metabolic changes that typify out-of-control diabetes.

For another thing, technology won’t be the savior of mankind. For instance, Groopman explains that about half of anginas don't show up on EKG scans.

What helps all of these points is Groopman’s attention to details and frankness in his own shortcomings:

I examined his eyes, ears, nose and throat, and found nothing of note except some small ulcers on his inner cheeks and under his tongue, side effects of his treatment. Brad worked hard to take deep breaths when I examined his lungs -- they were clear -- and his heart sounds were strong, without a "gallop" indicating heart failure. His abdomen was soft, and there was no tenderness over his bladder.

"Enough for today," I said. Brad looked so peaked that it seemed wise to let him rest. He nodded his thanks.

Later that day, I was in the hematology lab, looking at the bone marrow biopsy of a patiet with leukemia, when my beeper went off with a stat page. "Brad Miller has no blood pressure," the resident reported when I called. "His temperature is up to 104, and we're moving him to the ICU."

Septic shock. When bacteria spread through the bloodstream, they can shut down the circulation. This can be fatal even in people who are otherwise healthy, but patients with impaired immunity, like Brad, whose white blood cell count has been lowered by chemotherapy, often die.

"Do we have a source?" I asked

"He has what looks like an abscess in his left buttock," the resident said.

Patients who lack the white cells to fight bacteria are prone to infections at sites that are routinely soiled, like the area between the buttocks.

I fell silent as I replayed in my mind the scene on rounds with Brad that morning. The abscess had certainly been there a few hours before. "Enough for today," I had said. Not enough at all. I had failed to ask him to roll over so I could examine his buttocks and rectum.

"We repeated his cultures and began broad-spectrum antibiotics," the resident said. "The ICU team will take over."

"Okay. Good job," As I hung up the phone, I berated myself further. Bad job. Sloppy job.

My heart had ached for Brad, and that deep feeling had caused me to break discipline [this is what Groopman calls affective error, or lulling oneself into thinking that what we want is what will happen because the scant info available confirms that hope] ... I hd not wanted to add further to Brad's discomfort. I left the bedsheets on him. That could prove to be a fatal mistake.

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Off to a trial, so it may be a bit for the latest from How Doctors Think

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Interesting insights from How Doctors Think

From Pg. 17:

They have shown that how a doctor asks questions and how he responds to his patient's emotions are both key to what they term "patient activation and engagement." The idea...is "to wake someone up" so that the patient feels free, if not eager, to speak and participate in a dialogue. That freedom of patient speech is necessary if the doctor is to get clues about the medical enigma before him. If the patient is inhibited, or cut off prematurely, or constrained into one path of discussion, then the doctor may not be told something vital.

----

Observers have noted that, on average, physicians interrupt patients within eighteen seconds of when they begin telling their story.

From Pg. 19

Hall discovered that the sickest patients are the least liked by doctors, and that very sick people sense this disaffection. Overall, doctors tend to like healthier people more. Why is this? ...Many doctors have deep feelings of failure when dealing with diseases that resist even the best therapy; in such cases they become frustrated, because all their hard work seems in vain. So they stop trying.

From Pg. 21

During my training, I met a cardiologist who had a deserved reputation as one of the best in his field, not only a storehouse of knowledge but also a clinician with excellent judgment. He kep a log of all the mistakes he knew he had made over the decades, and at times revisited this compendium when trying to figure out a particularly difficult case.

From Pg. 24

Experts studying misguided care have recently concluded that the majority of errors are due to flaws in physician thinking, not technical mistakes. In one study of misdiagnoses that caused serious harm to patients, some 80 percent could be accounted for by a cascade of cognitive errors ... Another study of one hundred incorrect diagnoses found that inadequate medical knowledge was the reason for error in only four instances. The doctors didn't stumble because of their ignorance of clinical facts; rather, they missed diagnoses because they fell into cognitive traps. Such errors produce a distressingly high rate of misdiagnoses. As many as 15 percent of all diagnoses are inaccurate, according to a 1995 report... These findings match classical research, based on autopsies, which show that 10 percent to 15 percent of all diagnoses are wrong.

From Pg. 34

Studies show that while it usually takes twenty to thirty minutes in a didactic exercise for the senior doctor and students to arrive at a working diagnosis, an expert clinician typically forms a notion of what is wrong with the patient within twenty seconds.

From Pg. 35

Research shows that most doctors quickly come up with two or three possible diagnoses from the outset of meeting a patient -- a few talented ones can juggle four or five in their minds.

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Opening chapters paint a sobering picture

Let’s just get into it.

How Doctors Think (Houghton Mifflin Company, $26) takes a gander at the myriad pressures and shortcuts physicians take to handle the mounting caseloads, dwindling time and shrinking insurance reimbursements that’s transforming medical care.

The Introduction outlines the book and underscores the importance of communication through the story of Anne Dodge. The 30-something Massachusetts native spent 15 years taking antidepressants and being treated by doctors who believed she was anorexic-bulimic. Turns out she was allergic to gluten (scary considering how common that type of thing is getting to be). It took a doctor willing to listen to her and not be biased against the eating disorder to figure things out.

The big theme of the book gets pointed out as well, that being physicians’ reliance on patterns of behavior to quickly diagnose and deal with patients. While such approaches seem to work for the most part, they can lead to erroneous and disastrous conclusions.

Chapter 1 recounts the first intern days of author Jerome Groopman, a physician at Harvard Medical School who is also a writer for the New Yorker. It also looks at how the emotions of doctors can cloud and influence their medical decisions.

Lot of good stuff in these introductory chapters.

The main issue for the book are "heuristics," or shortcuts for making decisions. Groopman describes them in Chapter 1: "[H]euristics flourish when a physician assesses unfamiliar patients, or when he must work quickly, or when his technological resources are limited. Shortcuts are the doctor's response to the uncertainty and demands of the situation. They are the essential working tools of clinical medicine, where a doctor must combine thought and action ... the core of flesh-and-blood decision-making. ... The problem is that medical schools do not teach shortcuts. In fact, you are discouraged from using them."

What I'm liking about the book is its frankness. Groopman isn't knocking you over the head with a bunch of fancy words and melodrama, but he isn't dishing out a lot of dry clinical reports either. He provides a pretty concise, clear picture of things, like here:

She had been expecting him to concentrate on her abdomen, to poke and prod her liver and spleen, to have her take deep breaths, and to look for any areas of tenderness. Instead, he looked carefully at her skin and then at her palms. Falchuk intently inspected the creases in her hands, as though he were a foretuneteller reading her lifelines and future. Anne felt a bit perplexed but didn't ask him why he was doing this. Nor did she question why he spent such a long while looking in her mouth with a flashlight, inspecting not only her tongue and palate but her gums and the glistenin tissue behind her lips as well. He also spent a long time examining her nails, on both her hands and her feet. ...

He also seemed to fix on the little loose stool that remained in her rectum. She told him she had had an early breakfast, and diarrhea before the care ride to Boston.

Or this from Chapter 1:

I was about to say goodbye when Mr. Morgan shot upright in bed. His eyes widened. His jaw fell slack. His chest began to heave violently.

"What's wrong, Mr. Morgan?"

He shook his head, unable to speak, desperately taking in breaths.

I tried to think but couldn't. The encyclopedia had vanished. My palms became moist, my throat dry. I couldn't move. My feet felt as if they were fixed to the floor.

Groopman is great at details and giving telling insights into how physicians work. Things can get a little yucky but never for the sake of shock value, just to show how thorough and involved medical work is when people escape their ER picture of things.

For patients (i.e., potentially all of us), these first couple of chapters provide ample reason to educate ourselves about our health and maladies. Groopman explains "Every doctor makes mistakes in diagnosis and treatment. But the frequency of those mistakes, and their severity, can be reduced by understanding how a doctor thinks and how he or she can think better. This book was written with that goal in mind. It is primarily intended for laymen ... because doctors desperately need patients and their families and friends to help them think."

Patients need to find ways to connect and trust their physicians so that communication can be honest and comprehensive. Without that, the psycological baggage that docs bring to the table may interfere with better care. Too often, though, patients don't aim for that professionalism.

Despite research showing that most patients pick up on the physician's negativity, few of them understand its effect on their medical care and rarely change doctors because of it. Rather, they blame themselves for complaining and taxing the doctor's patience. Instead, patients should politely but freely broach the issue with their doctor ... But when I asked other physicians what they would do if they, as patients, perceived a negative attitude from their doctor, each one flatly said he or she would find another doctor.

The other thing I enjoyed was having my own reporting be put into perspective. I write so much about the various issues in the medical community that the big picture can get obscured. Some insights from the tome helped. Stuff like patient satisfaction surveys mean a great deal to United Regional Health Care System, but they don't also seem like compelling news. Then you read something like this

How a doctor thinks can first be discerned by how he speaks and how he listens. In addition to words spoken and heard, there is nonverbal communication, his attention to the body language of his patients as well as his own body languange -- his expressions, his posture, his gestures.

But beyond me as a reporter and us as potential patients, the book at times really sounds directed to practicing doctors. Groopman stresses the need for physicians to ask open-ended questions that can let patients best explain their conditions and to be aware of the compatibility between patient and doctor. The sobering part is how that doesn't happen.

Most errors are mistakes in thinking. And part of what causes these cognitive errors is our inner feelings, feelings we do not readily admit to and often don't even recognize.

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Teenage Mutant Ninja Turtle tryout?

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My book finally arrives--!

From Library Journal

A quarter of a century after an invasion by the deadly alien plants known as triffids blinded most of the world's human population and caused the collapse of civilization, only a small colony of survivors on the Isle of Wight continues to preserve what they can of society and culture. When a new phenomenon arises, resulting in the darkening of the atmosphere, pilot David Masen, the son of the colony's founder, sets out to discover the source of the problem-and encounters a new group of technologically advanced survivors from across the Atlantic. Continuing the classic tale of alien invasion begun 25 years ago in John Wyndham's The Day of the Triffids, Clark envisions a world poised to fight back against their invaders. Winner of the 2002 British Fantasy Award for Best Novel, he retains a feel for sf pulp horror in an action-filled tale that captures the spirit of the original story. Recommended for most sf collections.

And what does it have to do with medicine, health, fitness or anything?

Absosmurfing nothing!

This book came after watching 28 Days Later and getting interested in what had prompted such a tale.

Amazon.com's two-day delivery appears to be letting me down. The day's not over, so my copy of How Doctors Think may still arrive.

But man, what a let down.

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Making a list of books, checking it twice

My first book for my blog should arrive Friday, so I'm pretty stoked. In the interim, I'm perusing the New York Times best-seller list to see what other tomes might pique my interest. So far, I like "Better", "On the Night You Were Born", "The Year of Magical Thinking", and from the Editor's Choice section, "Rethinking Thin".

If you're reading anything with a medical/health bent -- or if you're already delved into the aforementioned and have an opinion on if they're worth peeking into -- lemme know.

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I'm going to get this blogging thing down. Really. No, really.

This blog stuff hasn't been nearly as easy as I'd thought.

I've been plagued trying to find something worth writing about on a daily basis, and my television effort quickly tanked. I don't watch enough medical tv outside of Scrubs, and things took a strange twist this weekend when I left a message for the United Regional Health Care System's spokeswoman about the parallels of the Rage virus in 28 Days Later and the concerns real-life medical personnel face in light of emerging pandemics.

My problem is that while I'm enthusiastic about the medium, I haven't found a subject that won't make the glee flee.

Until now.

I like to read. Right now, I'm actively reading three tomes (Bartimaeus Trilogy Part Three: Ptolemy's Gate; Masks of God: Occidental Mythology; and Of Water and the Spirit: Ritual, Magic and Initiation in the Life of an African) and have another nine or 10 in line. My wife has forbidden any more book purchases (we'll see how that works out...). I was driving around yesterday when I heard on Newshour with Jim Lerher this discussion about How Doctors Think, and I thought "I should read that. Heck, lots of people should probably read that ... maybe I could read it for them!"

I have weird thoughts.

Anyway, a blog, ideally, was born.

My plan is to read a book a week or two (depending on the length) and summarize the chapters and share the insights, maybe even talk to an author or two. And feel free to join in and speak up on your thoughts and questions. Should be fun.

Posted by Michael Hines at 10:47 AM | Permalink | Comments (0) | TrackBacks (0)

Effort to curb youth smoking should be used to combat prescription drug abuse

As much as those commercials encouraging parents to help keep their kids from smoking annoy me with their cheesiness, I can't help but admit to their effectiveness (someone even blogs about these things).

It also makes me wish this kind of movement was aiming for the growing numbers of kids gulping down prescription medication like Red Bulls.

The benefit of the anti-smoking campaign comes to light with the Monitoring the Future survey that shows to steady stumble in the level of youths picking up cancer sticks.

The latest stats point to 9 percent of 8th graders and less than a quarter of 10th and 12th graders having lit up in the previous month, compared to 1996's 21 percent for 8th-graders and more than 30 percent for 10th and 12th graders.

What's more, all the data about how bad cigs are has gotten through the Brittany Spears and Smosh - Hardcore Max crowding young minds and made an impression. In 2005, nearly eight out of 10 12th graders didn't think smoking one or more packs of cigarettes per day was a good idea.

So kids have gotten the message that the Marlboro Man has no kids for a reason.

Parents still need to know the dangers posed by their own medicine cabinets.

The levels of kids abusing prescriptions is certainly dwarfed by the numbers abusing illegal drugs, but the trend is the trouble. Illicit drug use is falling while medication abuse continues climbing. So, while just under 3 percent of 8th graders reported abusing OxyContin in 2006, that was still double the number of 2002. Tenth- and 12th-grader levels stayed stable but high, according to the NIH.

But those tiny numbers aren't a reason to ignore the issue. In fact, they are the reason some commercial campaign like the smoking work should be implemented. Now's the time to head off problems before it reaches epidemic levels.

Posted by Michael Hines at 10:01 AM | Permalink | Comments (0) | TrackBacks (0)

Local resident vigilant in checking out scary locales

It's not exactly X-Files, but it's not as far off as you'd think.

Jason A. Kimbro is a student at Midwestern State University and a fellow journalist with The Wichitan. But that's just the day job. He's been freelancing as a kind of spook snoop, checking out supposedly haunted areas in the community as part of StrangeUSA.com

The 29-year-old father of three just gets a kick out of it.

"It was fun to be in these areas that were supposed to be haunted. I have been with friends who claim to have seen things while I was there but I never saw a thing," he said in an e-mail. "Some of the places, on the other hand, are definately creepy and I get a thrill, sort of an adrenaline pump, whenever I go there."

The dogged Scooby-Doo imitation got started with some buddies.

"I had some friends in the past that were overly involved in paranormal phenomenon but they were able to get me beyond curious," he said. "They told me about their supposed experiences involving spirits and ghosts and I had a hard time believing them. I would go with them on outings doing what they called "spelunking." Why they tagged it with a title for the sport of cave exploring I haven't a clue."

The terms may be weird, but his approach isn't.

"When it comes to the actual "investigation" I just go there and use my senses. One of my majors as an undergrad was psychology and I use this to undermine and psychological effects my brain may be suggesting ( i.e. the feeling of chills which is a common description of a "haunting.")," he said. "I wish I could afford some of the equipment that they sell, even though I am fairly certain they are about as genuine as the time machine on "Napoleon Dynamite."

Despite the terminology, the physiology seems to be a blast.

"I have looked up several websites to find locales in the area that are supposed to be haunted," he said. "Mostly its the rush from being there I enjoy. It's fun to do and it gets me out of the house."

Posted by Michael Hines at 10:05 AM | Permalink | Comments (0) | TrackBacks (0)

NBA game proves fear of HIV still rooted in ignorance of the disease

Geez, you'd think there's nothing else to Wichita Falls aside from Ice Harvest and Pat Methany. My original blog idea focused on finding neat stuff related to the Falls on the Web.

It crashed faster than Paris could hire the schmuck who got her locked up .

I looked and looked and came up with a lot of bumpkiss. So, I'm heading in a different direction (the name of the blog is set to change, too, in coming days). As I come across interesting tidbits, I'll let you know. But now I'm focusing on the medical community, as spun through the media. Just stuff that makes me giggle and think.

First up, b-ball.

Tonight's the big Game 2 of the 2007 NBA Western Conference semifinals between the San Antonio Spurs and the Phoenix Suns. I've been a San Antonio Spurs fan since my first internship made me a Missouri resident and the Spurs were the only Texas connection that helped sooth my homesickness.

And speaking of connection, there was quite a big one toward the end of the first game Spurs point guard Tony Parker and Suns guard Steve Nash.

Geez, that's nasty.

Nash's nose was a vampire's dream, which meant he couldn't get back into the game because of the NBA's rule against allowing bleeding players into games. Later that night, after the Spurs pulled out the 111-106 victory (Go Spurs Go!), many fans wondered about the need for the rule and how it really spoke volumes about the latent public ignorance regarding HIV.

DeWayne Robertson, HIV program manager with the Wichita Falls-Wichita County Public Health District, tends to agree.

He stressed that he could only give his personal opinion on the matter, but that opinion leans against the chance of contracting the disease.

"Is it a possibility? Yes. Is it likely? Not really," he said. "I don't think the rule is there so much for protection as a fear rule ... It still shows our own fear and ignorance."

I'd honestly never given the rule a second thought, but when I did, it did seem a bit silly.

At least one nation boasts blood-safety, but the pathogens it aims at have little chance at infection.

"The chances are real slim," Robertson said. "Under those conditions, the diseases aren't going to last too long outside the body."

No other US sport features this kind of rule, as far as I know, despite the loads of contact that goes on in rugby, soccer and football.

There's no denying the dangers of HIV, but it's precisely this kind of antiquated reaction that makes the stigma so much worse.

Posted by Michael Hines at 10:42 AM | Permalink | Comments (0) | TrackBacks (0)