Grocery Store Tour

Okay, so I guess it's been a little while since I last posted.  I've been a little busy trying to get into the driver's seat myself as a patient.  In order to try to achieve a healthier weight, and a cheaper life insurance premium, I've been running (a lot) and trying to improve my diet.  I've also been tracking my weight a lot more closely using my Withings Scale and using a Stiiv pedometer.

But despite running 4 marathons, and thinking I had improved my diet, I still had a BMI of 27 and my fitness age was greater than my chronological age.

So tonight I decided to really try address the final frontier so that the six pack that I know is there and is dying to show itself can hopefully land me that elusive water slide modeling contract I have long dreamed of.  That's another way of saying that I went around the grocery store with a registered dietician who gave me some helpful feedback on the food choices that I've been making.

Although I already had a sneaking suspicion that I was eating too much sugar, I had come up with many ways to rationalize my food choices so I could continue this pattern.  Erin Dubich, RD convinced me that the price I was paying for the sugar I was consuming in massive amounts coming from salad dressings, peanut butter, and that oh so good vanilla chai tea was too high to continue this pattern, and as of this writing, I have not had any of these since the tour!

If you are finding not sure what to eat, or not motivated to eat the foods you suspect you should be eating, consider taking a grocery store tour with a dietician.

“If we could give every individual the right amount of nourishment and exercise, not too little and not too much, we would have found the safest way to health.”  


(stated by a Greek physician who lived 460 years BC and whose pithy statements have survived the test of a long time)  


Have modern physicians missed the boat in terms of prescribing exercise and dietary changes to patients in an effective manner?  


Has exercise and diet been one of the ways you used to optimize your health, despite a chronic medical condition like diabetes or hypertension?  


Did your doctor point you in the right direction about how much exercise to pursue, how often, and how intense?


I would greatly appreciate it if you could weigh in on these questions!

Do mandated disclosure forms like (informed consent, Truth in Lending Act etc) work?

Watch this video, and you might think that helping patients better understand if a coronary stent is going to benefit them might be best accomplished by mandating a better informed consent process.

The use of patient specific, tailored informed consent forms might indeed improve the process of helping patients making treatment decisions that are better aligned with their preferences.

But before you write your congressman requesting that the informed consent process be improved, you might want to consider this interesting paper  from University of Chicago that explains what the informed consent process shares with the Truth in Lending act (hint--mandated disclosures frequently fail miserably to achieve their intended purpose, and have many unintended adverse consequences).

How to address this problem today, if you are having to make a treatment decision?  The DSP blog still thinks this approach is not a bad place to start.

Friends don't let friends consent for a stent uninformed

The DSP blog was saddened when it read this study which asked a simple question:  do patients about to undergo a stent for stable angina correctly understand the expected benefits.  The key finding of this study:  88% of the patients that were getting a stent thought that the stent would "reduce their risk for MI" (myocardial infarction).  Why is this a problem?  Why is the DSP blog exhibiting grinch-like behavior by blogging about this so close to Christmas?  It is a problem because of what this study told doctors about the benefits of stents for stable angina:  the COURAGE trial demonstrated that stents do not reduce the chance of MI compared to medical therapy.

In the DSP's humble opinion, this discrepancy between what is known about the benefits of stents for elective angina, and what patients who are going to get a stent think the benefits are--this is the proverbial canary in the coal mine warning.  If the current system does not facilitate patients arriving at a correct understanding about how a stent for elective angina will and won't do for them, this really signifies a major problem in doctor patient communication.

The DSP blog's recommendation:  Besides reading the DSP blog, if you are pursuing any elective procedure, you better know enough to ask, and ask enough to know.  Asking the right doctors the right questions (see related post on this blog) is a good place to start.

Is this the future of medicine? Is this the future of doctors?

The DSP's daily commute has been pure bliss this past week because I have been listening to A Whole New Mind.  In a nutshell, Mr Pink asserts that you better figure out how to use both your left brain (analytical, sequential) and your right brain (synthesizes big picture, sees things in patterns).  If you only use your left brain, you are in jeopardy of being replaced by either a computer, or somebody able and willing to do your left brain job for 1/5 of the compensation you require.

What does this have to do with a patient getting in the driver's seat?  Admittedly, it is only tangentially related (I am trying to exercise my right brain here).  But I'll give it a shot:

1)  Skin Scan is an app that analyzes skin lesions before you go to the doctor's office (at this point, it is not intended to replace the physician's visit) going to replace some of the left brain tasks that doctors are doing eventually.  (Consider that TurboTax has likely replaced a lot of accountants.)  This may be a glimpse into the future of medicine.  If Skin Scan disagreed with your doctor's assessment of your lesion, would you seek a second opinion?

2)  It is easier to be a patient if you have a job, and so if you think you are currently only using your left brain in your career, you would benefit from reading (or listening to, if you are an audio learner like me) A Whole New Mind, as it has a primer for developing your right brain.

3 magical questions

The DSP blog has recommended patients consider the Ask Me 3 approach when at the doctor (Ask Me 3). But I think those three questions (1. What is my main problem?  2. What do I need to do?  3. Why is it important for me to do this?) might stifle the discussion a bit.


While I hate to admit this, because it apparently has originated from England, I think some researchers at Cardiff and the Vale University Board (whatever that is) might have come up with 3 better questions:  


1.  What are my options?  
2.  What are the possible benefits and risks of those options?  
3.  How likely are the benefits and risks of each option to occur?


Are you going to the doctor soon and at risk for a prostate exam?  Ask your doctor these questions about your options re prostate screening, and tell me how well they work.    

Friends don't let friends have a prostate exam uninformed

While I definitely would not let this "doctor"  examine my prostate, I applaud CBS for this educational video for several reasons:  it is almost as funny as this doctor (does anybody know if he's still taking new patients) and is as accurate as this guy (talk about doctors who only use their left side of their brain) without being such a bore.

Dr Schloffengut's message essentially boils down to this: if you're a man over 50, talk to your doctor about whether or not you need a prostate exam.   Is Dr Schloffengut recommending talk therapy for the prostate?  Hardly.  He is recommending that men talk to their doctor before diving into a prostate exam (does that sound wrong), not only because it is always a good idea to talk to letting any doctor plunge a finger into any of your orifices, but because the decision to try to screen for prostate cancer simply isn't a slam dunk.

In a nutshell:  some men may benefit from prostate cancer screening, and some may be harmed by prostate cancer screening, and it is not entirely easy to sort it all out.  Consequently--before men consent to this graceless experience (unless Lou Rawls is your doctor), they deserve to partake in a discussion and share in the decision about whether this will benefit them.  

His recommendation is consistent with that from the United States Preventive Services Task Force recommendation.

Who is the Driver's Ed teacher?

In this study, primary care physicians were asked, "How important do you feel it is for patients to be well informed when making decisions about managing chronic conditions?  89% of the doctors felt it was very important.  At the same time, they felt only 15% of patients were well informed when making decisions about managing chronic conditions.  They felt 31% were not well informed.

To keep it real, what does the DSP blog think it for a diabetic to get an A?  In a nutshell, diabetics would need to know:  a) their goal A1C (typically <7%); b) their goal bp (typically <130/80); c) their goal LDL (depends, typically < 70 or <100); d) why they need to get a dilated eye exam once a year; e) why they need to have their kidneys checked for protein once / year.  That's pretty much it.  It seems pretty basic.  And yet the DSP blog would be concerned that most diabetics would not know theses answers.

This begs the obvious question--why so many driver's ed students getting low grades?  Who is responsible for how few patients get an A in this subject,  and how almost 1/3 are getting a D or F?

Obviously, this is a complicated question, and even though the DSP blog completely knows the answer, due to limited space here and the need for me to go to work, it will have to posit some thoughts to get the conversation started (at least that's the idea--come on, people, can you start pushing the comment button a few more times?):

1)  If being well informed translates into better outcomes (and that is a big if--driver's ed students have to be motivated to actually stop at the stop signs, stay within some approximation of the speed limit, for driver's ed to have much of an effect--then the DSP blog thinks driver's ed schools represent quite an opportunity for several key players affected by the high costs of poorly informed drivers.

2)  The DSP blog feels that doctors must take at least some of the blame for the low grades.  Some obviously seem to take a greater role playing driver's ed instructor than others.   The DSP blog is thinking about trying to find one of those kinds for itself.

3)  Patients deserve at least some of the blame for their low grades.  Perhaps Dr Google isn't the most effective way to learn how to drive.

The Blob that Ate America

When doctors were asked:  "When patients come to you with information they have gathered on their own, are they generally more likely or less likely to end up getting screenings, treatments, or interventions they don’t really need?"


63% said such patients were MORE LIKELY to get unneeded screenings, treatments, or interventions they really DON'T NEED.


Aside from the fact that there are risks to medical treatments and screenings, and that in medicine, "the more you do, the more you do," (quoting one of my best teachers ever--lives in Ann Arbor, MI), there are much greater concerns here:  Patients pursuing unneeded treatments increase traffic on the road, are unable to be perusing the DSP blog, and are missing time in their backyard looking at the birds while listening to the DSP show.


However, the DSP blog was briefly encouraged when it realized a benefit to patients pursuing unneeded treatments--what better way to simplify one's life?  For if you are going down the path of unneeded treatments, your life consists of one of two things, a) arming yourself with info that will lead to unneeded treatment; or b) pursuing the unneeded treatment; or c) talking about it or blogging about it.  I suspect most of the time would be spent in category b, driving all over the kingdom in order to get forms filled out, blood drawn, unneeded surgery performed, resulting in back pain from all the driving around, which would lead to category a...


Because the DSP blog suspects some reading this may be "serious readers" (the DSP blog acknowledges the disturbing possibility that serious readers who stumbled across this blog's clip of Sarah Palin interview may have unfairly put it in the category of total buffoon and decided not to return), it offers the following:


1)  One health care expert, Jack Wennberg, (whom, by the way, the DSP blog met when he visited its professor's house in Champaign, IL, where the DSP blog learned that pistachios are best eaten after the shell has been removed (somehow, I had missed that memo, and had to learn this lesson by putting a handful of these disgusting things into my mouth, and then trying not to appear uncouth while amongst many learned professorial types), and also had the unpleasant experience of eating one of said professor's mom's cookies in front of the professor, only to realize, while it was in my mouth, that some of said professor's mom's hair had been baked into the cookie), has suggested that for many medical decisions, there is no clear winner re the "right treatment". 


A perfect example would be prostate specific antigen screening, which the USPTF suggests it is just not clear whether this test should be pursued.  This could result in a situation where a patient gathers information on his ("or her" clearly unnecessary here) own and decides to get the PSA test, which the doctor feels is unneeded.  In this type of case, the DSP blog thinks this is not a horrible outcome at all--in these cases where the right strategy is unclear, if the patient should decides to pursue an intervention that the doctor thinks is unnecessary, does it really matter?  The only truly horrific outcome in this scenario would be the exam accompanying this screening test (the DSP blog formally apologizes for that image now running through your mind).


But alas, the above suggests that the DSP blog has clearly slipped back into its pollyannish ways (except for the part about the exam).


2)  To the extent that "informed patients" increase their doctors' fear of malpractice is driving unneeded pursuit of screening tests or interventions--this is bad and sad, and because I lost an hour last night due to daylight savings time, I don't have the emotional capacity to deal with that right now.


3)  If you just take it at face value--and the DSP blog thinks this might be the best approach--that doctors think (?correctly) that patients are informing themselves into unneeded interventions, then really the biggest take home point is this:


At this current time, patients in the driver's seat (in general) are seemingly looking at the wrong manuals and/or interacting with the doctor in the passenger seat in such a way that they are getting their oil changed too often, getting diagnostic testing they don't need, seeing mechanics they don't need to see, and in the end, this is causing them to spend too much time and money in the car and/or in waiting rooms talking to others about their adventures taking care of their car....

Does getting in the driver's seat affect your care?

It has long been known that there is widespread/geographic variation in rates of treatment for conditions like back surgery, breast cancer, prostate cancer. As this report suggests, the variation may be due to variation in how physicians practice and influence their patients. More is not always better. When treatment for a condition is proposed, ask questions such as, "Is this considered standard of care, or are there other acceptable alternatives?" If the proposed treatment is surgical, ask, "Do you perform the other alternatives?"

The ultimate goal is to get the right physician in the passenger seat, one that is competent, listens to you, and both of you like each other, and to collaborate with the physician to determine the destination and route that make the most sense for you. Probably wouldn't hurt if he's board certified as well. It's a bonus if the guy you get in the passenger seat shares the same tastes in music and/or talk shows.

Driver's seat patient who failed driver's ed

Although much more could be said, the Driver's Seat Patients blog thinks this video poignantly illustrates a) how patients and doctors are bumbling their way from a paternalistic doctor-patient relationship to one of shared decision making; b) why puppets should never use iphones; c) what happens when doctors pursue puppetry; d) some puppets who might benefit from a plastic surgeon's groupon deal.

The Too Informed Patient from Marketplace on Vimeo.

Getting in the driver's seat of your bank

The DSP blog is stumped and would appreciate your input:

1)  why are the maps to put us in the driver's seat of our money seemingly so much superior than those maps for us in the driver's seat of our health?  (Take a look at Mint.com--it is simply incredible!  and it is leaves health sites in the dust).

2)  of all of the sites you know, which health site comes the closest to Mint.com

Doctors inviting customers, I mean, patients, via Groupon

Still not convinced that doctors see you as a customer?  One plastic surgery group in Boston used Groupon to get the word out that Groupon ?patients could get laser hair removal for less than 25% of the normal $800 price.  Despite the DSP blog spouse's unfair comments about the ever increasing amount of hair on the DSP blog's back, the DSP blog was not in need of the hair removal offer.  However, it was disappointed that it could no longer by the cellulite treatment ($249 value) for its sisters (deal has expired).

The DSP blog anticipates the situations like this will increasingly force patients to make customer-like decisions with greater frequency.  Those who know best how to evaluate these ads placed under their windshield wiper will best be able to know which ones they should throw away and which ones they should pursue.

Even if you don't subscribe to Groupon, those reading this sentence may finish reading it for 50% off, today only.

Like it or not, you're being thrust into the driver's seat

Should patients be viewed as customers?  Is it appropriate to suggest that patients get in the driver's seat?  If billboards are advertising joint replacement, lap band specials can be found on the internet, and you can find out if you're at increased risk for experiencing muscle pain while taking statins, and you can directly access these services without going through a gatekeeper, then I would suggest that to a large extent, you are at the very least being viewed as a customer by many health care manufacturers, doctors, and hospitals.

If so, who do you turn to know whether you should pursue any of these flyers left under your windshield wiper while you're getting the groceries?  Or do you just throw them away?  Wouldn't it be nice if there was a "consumer reports" to turn to?   Interestingly, there is.  Not only that, it helps you sift through the small print that you might have otherwise missed, like the part about what percentage of patients that pursue lap band surgery love it so much that they have the band removed.  (about 1/3 need revision or removal of the band according to this reputable source).

Although Consumer Reports is great,  let's see it for what it is--a great map to have in your glove compartment.  But to figure out the best destination, make sure you have a primary care physician in the passenger seat that you enjoy talking to and will help you figure out which destination makes the most sense.

Sarah Palin talks about Driver's Seat Patients Blog in embarrassing interview

Okay, so I am engaging in some self-promotional behavior. I was, yeah, just a little surprised, and I must admit, somewhat flattered, when Sarah Palin mentioned this young blog, admittedly during what must have been a somewhat embarrassing situation for her, so, yeah.

Today's radio show guest: her condition would have stumped House, MD

On today's show, we had the pleasure of learning from Lisa Hall, who talked about her experience navigating her way on a ten year journey to the correct diagnosis and treatment.  Along the way, she was diagnosed with a variety of conditions, including being conflicted about her status as a Southern woman.  Now I'm no psychiatrist, but I'm pretty sure that diagnosis was a bit off.  She talks about how crucial her relationship was with one doctor, and she discusses questions you might consider if you are in the midst of a confusing diagnostic workup.

In addition, some intellectual firepower was brought to the show by cohost Michael, aka, the neighbor.

The DSP blog is indebted to both Lisa and Michael for this great show.

Tomorrow's show

0800 central standard time

Where to go to listen:  here

Call in number:  323-784-3632

Topic:  getting to the right diagnosis, with Lisa Hall

Co-host:  Michael, representing the patient side

Do doctors really want patients to question them?

Dr. Groopman does, and his stories illustrate why.  Short post here, because the value here is in this link.  For a treat, go to link and listen to interview with author of "How Doctors Think".  My hunch is that doctors will welcome the nature of questions Dr Groopman suggests.  The DSP blog is very interested in your thoughts and experiences in this arena!

The Art of War and Patients in the Driver's Seat

SSSShhhh.  Listen very carefully.  Did you hear that.  No, not Robin Williams.  No, if you listen carefully, you'll hear Sun Tzu, from the 6th century BC?   Sun Tzu, the military strategist and author of The Art of War, wrote:  Strategy without tactics is the slowest route to victory.  Tactics without strategy is the noise before defeat.  


I am quite confident that he was addressing diabetics when he said this.  Why?  What he was saying to diabetics was this:  You must know what your overall strategic goal is (i.e. achieve an A1C of <7%), or you will have no idea if all of the tactics you are employing (diet/exercise/medications) are effective and/or need to be modified.

This applies to any chronic disease:  first step, driver, is to know your strategic goals.

Help your doctor take better care of you by asking this one question