Your Medical Mindset? Dr. Groopman Suggests You Define It

Your Medical Mindset? Dr. Groopman Suggests You Define It

Posted on Friday, March 15th, 2013 at 4:02 pm by Life Matters Media

Dr. Jerome Groopman says when it comes to making medical decisions, he is a “maximalist,” a “technologist” and a “believer.” These qualities color his own choices and advice to patients, and he says they emerged directly from his Jewish upbringing.

Dr. Groopman

Dr. Groopman

We all have a medical mindset, Groopman argues, and it can be easily pinned down and translated for more effective communication in health care. It accompanies us from early childhood through the end of life, whether we are in the role of patient, physician or caregiver. The Harvard University oncologist and author discussed his own mindset and how we can determine ours at the Association of Health Care Journalists Conference this week in Boston, MA.

Culture and upbringing are perhaps the greatest shapers of a medical mindset. Groopman is the son of eastern European immigrants who put physicians “on a pedestal,” he says, and any natural medical intervention apart from the latest technology was viewed “as a throwback to village life.” His oncological training at the advent of bone marrow transplantation reinforced his faith in intense intervention.

When medical decisions must be made, Groopman advises patients to evaluate both their own mindset and that of their doctor. Having the vocabulary to describe mindsets is crucial, and Groopman suggests that anyone involved in such decisions should consider assigning oneself with the following labels. (Select one word from the following three pairs). 

1) Maximalist- “A maximalist is someone ahead of the curve,” Groopman says. They typically favor medication as a first-resort, whether or not there is a proven benefit. Maximalists often choose surgical intervention,aggressive chemotherapy and intensive care.

Minimalist- “A minimalist is someone for whom less is more,” Groopman says. Minimalists do not jump at the chance to take medication, and are far more likely to hold off on any invasive medical intervention. They often believe in “waiting it out.”

2) Believers- “Believers are certain there is a good solution to their problem,” Groopman says. Believers have faith that when they take a pill, they are on their way to better heath. They are generally trusting of physicians and the medical system.

Doubters- Doubters often worry that any treatment may be worse than the disease itself. They delay medication and therapy until absolutely necessary.

3) Technologists- With such a mindset comes a faith in prescription drugs, invasive
therapies and hospital stays.

Naturalists- Naturalists would rather take a vitamin or herbal supplement than any
drug.

Groopman says patients are able to better communicate with their physicians and better assess their end of life preferences if they identify their mindsets. Surrogates are better able to act on behalf of patients if medical mindsets are considered and discussed.

Pamela Hartzband, M.D., Groopman’s wife and an assistant professor and attending physician in the Division of Endocrinology at Beth Israel Deaconess Medical Center, says she agrees with her husband on the importance of evaluating one’s medical mindset. Hartzband and Groopman received similar medical educations, are on staff at the same medical institution, and are married, but her mindset still differs from his.

Hartzband says she is a “minimalist” and a “doubter,” and she hopes to help implement training on medical mindsets in medical schools, as mindsets are often set by young adulthood. The language Groopman outlined has proven beneficial to her as both a patient and a physician. “The language has helped us in our own clinical interactions, and when used, patients have expounded on it,” Hartzband says.


Organ Transplants: Who Should Receive Them?

Posted on Wednesday, January 9th, 2013 at 2:27 pm by Life Matters Media

The growing population of healthier older Americans is changing the way some medical centers choose recipients of organ donations. Debates are now brewing about who should receive vital organs and if age is a legitimate factor.

Many experts say these trends cannot be ignored. The graying population and revised policies determining who gets priority for donated organs have led to a rising proportion of older adults receiving transplants, The New York Times reports.

Joe Gammalo, 66, had been struggling with pulmonary fibrosis for more than a decade when he came to the Cleveland Clinic seeking a transplant four years ago. “It had gotten to the point where I was on oxygen all the time and in a wheelchair,” he told the Times‘ Paula Span. “I didn’t expect to live.”

Although lung transplants are  difficult, often involving lifelong use of immunosuppressive drugs with high rates of side effects, the Clinic successfully performed the procedure. “It’s not like taking out an appendix,” said Dr. Marie Budev, the medical director of the Clinic’s lung transplant program.

Only about half of all lung recipients live for five years, she said, and most still die of their disease. The only treatment for pulmonary fibrosis, however, is a new set of lungs.

Some medical centers would have turned Gammalo away due to his age. Because survival rates are lower for the elderly, Span reports, “guidelines from the International Society for Heart and Lung Transplantation caution against lung transplants for those over 65, though they set no age limit.”

Still, the Society advises: “recognizing that advancing age alone in an otherwise acceptable candidate with few co-morbidities does not necessarily compromise successful transplant outcomes.”

Similarly, Judith Graham reported last April on the emerging trends associated with heart transplants. “Just a decade ago, people 65 and older were routinely rejected for heart transplants at all but a few institutions,” she wrote. But in 2006, the International Society for Heart and Lung Transplantation issued guidelines advising heart failure patients should be considered for transplants even up to age 70.

The new guidelines did not substantially increase the number of patients receiving heart transplants, however. Data from the Organ Procurement and Transplantation Network shows that in 2006, 243 patients ages 65 and older received new hearts. By 2011, there were 332 transplants.

Last year in the U.S., almost 16,000 kidney transplants, 6,000 liver transplants, 2,000 heart transplants and 2,000 lung transplants were performed. The majority going to individuals 50 to 64 years old. However, more than 1,500 individuals remained on the waiting list for lung transplants. Almost 3,000 adults were awaiting heart transplants.

So who should receive these rare organs? Some physicians, like Dr. Jeffrey Punch, chief of transplantation surgery at the University of Michigan, argue that the young should get priority.

“Personally, I think we should transplant 18 and younger and then address this issue of the young versus the old, taking care not to exclude older people but making sure that we put more emphasis on transplanting younger people,” he said.

Dr. Mandeep Mehra, executive director of the Center for Advanced Heart Disease at Brigham and Women’s Hospital, disagrees. “Many of these older patients can transition to an even older age while maintaining a very good quality of life. Why would we deny someone that opportunity?”

Dr. Kevin Chan, transplant program medical director at the University of Michigan, posed this hypothetical: “What if there’s a 35-year-old on a ventilator who needs the lung just as much?” he asked. “Why should a 72-year-old possibly take away a lung from a 35-year-old?” But, he admits, “it’s easy to look at the statistics and say, ‘Give the lungs to younger patients.’ At the bedside, when you meet this patient and family, it’s a lot different.”

It is not as easy to receive an organ in the U.S. if you are 65 or older. Older individuals undergo physical and health screenings before being deemed eligible. They must have no chronic illness and the strength to complete post- surgery regimens. Then, they wait.

Differences between older and younger heart transplant patients are smaller when recipients are carefully chosen, according to researchers at Johns Hopkins University School of Medicine. After one year, 84 percent of heart transplant patients ages 60 and above survive, compared with 87 percent of younger patients. At five years, 69 percent of older patients survive, compared to the 75 percent of younger patients. The researchers suggest heart transplants not be restricted from patients based on age- so long as these encouraging statistics continue.


Hospice Enrollment Policies Contribute To Underuse Of Care

Posted on Sunday, January 6th, 2013 at 1:59 pm by Life Matters Media

Hospice enrollment policies contribute to the underuse of hospice care in the U.S., according to new findings published in the journal Health Affairs. Findings from the first national survey on hospice enrollment policies found 78 percent had at least one policy restricting care access for high-cost patients.

Although almost all Americans live within close proximity to a hospice, more than half of patients eligible for the care die without it. There are more than 3,500 hospice providers in the U.S.

Some 600 hospices were studied, and according to researchers, “patients with potentially high-cost medical care needs, such as chemotherapy or total parenteral nutrition,” had a greater likelihood of facing the restrictions. Limited enrollment policies were identified in both for-profit and nonprofit hospices. These restrictive policies include not receiving chemotherapy, total parenteral nutrition, blood transfusions, an intrathecal catheter, radiation therapy, tube feedings or requiring a primary caregiver at home.

“It represents a barrier to people who want hospice care but can’t receive it,” said lead author Melissa Aldridge Carlson, a palliative care researcher at the Mount Sinai School of Medicine.

The aim of hospice care is to manage the pain and symptoms of the terminally ill so that their last days are spent with dignity. The care is not intended to treat the disease. Hospice is most often used when curative treatment is no longer effective, and a terminal patient is expected to live about six months or less. Medicare states that to elect the Medicare hospice benefit, an individual “waives the right to receive all other Medicare covered services for the terminal illness and related conditions.”

Hospices may restrict access because of current Medicare reimbursements, which account for more than 80 percent of hospice revenue. The reimbursements do not cover treatments related to a patient’s terminal illness, so a hospice must pay for it. As Carlson points out, the average per diem reimbursement is only $140 per day.

The researchers explain, “many patients with terminal illnesses can benefit from using oral chemotherapy for palliative rather than curative purposes; radiation; or blood transfusions for treatment- or disease-related low blood cell counts.” Any one of these treatments can cost more than $10,000 a month.

Open access policies allow enrollment of those who are not yet eligible for the Medicare hospice benefit, anticipating that they will remain with the hospice when they do become eligible. Patients receive the medical comfort and social support available through hospice while simultaneously retaining access to medical treatments for their disease.  Such patients may be covered by private insurance plans or pay for the care out of pocket.  However, initial reports indicate that the cost of caring for patients enrolled through open access policies is generally absorbed by the hospice provider.

The authors conclude that increasing the hospice per diem rate for patients who require complex palliative treatments and removing the Medicare hospice benefit limitation on concurrent care may enable more hospices to expand their enrollment to patients who need and want it.  Providing hospice services in a cost effective manner for those whose treatment plans include concurrent life-extending and palliative care is the subject of the a pilot project funded by section 3131 of the Affordable Care Act, although results for this pilot project are years from completion.


Palliative Medicine, Hospice Care?

Posted on Tuesday, December 4th, 2012 at 7:50 pm by Life Matters Media

Despite its growing popularity in hospitals, most Americans remain unaware of the comfort and benefits palliative care can provide some terminally ill patients.

“There is a clear need to inform consumers about palliative care and provide consumers with a definition of palliative care,” researchers commissioned by the Center to Advance Palliative Care advise. According to Public Opinion Research on Palliative Care, seventy percent of the general population doesn’t know anything about palliative care, and 14 percent were “somewhat knowledgeable.”

The researchers also found that it is difficult to inform physicians about palliative care, because they often wrongly equate it with hospice or end of life care.

Public Opinion Strategies

Palliative care becoming more popular

Palliative care is treatment that enhances comfort and improves the quality of life for patients in life’s last phase. No therapy is excluded from consideration, according to the National Hospice and Palliative Care Organization (NHPCO).

Palliative care is becoming increasingly widespread. There are more than 1,600 hospitals that have palliative care programs in the U.S., according to Dr. Diane Meier, director of the Center to Advance Palliative Care at Mount Sinai School of Medicine. Some 85 percent of large hospitals have a palliative care team. Sixty-seven percent of small hospitals have programs.

Dr. William H. Frist, a heart transplant surgeon and former U.S. Senate Majority Leader, recommends palliative care. “[A] brand new field in medicine is making chronic, agonizing, and even terminal illnesses much more manageable… palliative care has emerged as the best solution for those facing serious, painful diseases, and introduces the very real possibility… that we can now live with these diseases for a long time,” he wrote recently for The Week.

Public Opinion Strategies

Palliative care also costs much less than aggressive end of life regimens. Patients who receive palliative care services cost hospitals between $1,700 and $5,000 less per admission, according to findings published in the Archives of Internal Medicine.

Hospice care remains overlooked

Hospice care is different from palliative care; its aim is to manage symptoms so that a person’s last days are spent with dignity and quality. The care is not intended to treat the disease but the person, according to the American Cancer Society.

Hospice is most often used when curative treatment is no longer effective, and a terminal patient is expected to live about six months or less.

“Many people believe that hospice is only for people who have cancer. This may be due to the fact that many of the patients cared for in the early days of hospice were cancer patients,” Becky Hillier, public relations director for Rocky Mountain Hospice, wrote for the Montana Standard. Less than 25 percent of hospice patients admitted to the hospice are cancer patients.

The NHPCO reports that 36 percent of hospice patients die or are discharged within seven days of treatment. Many terminally ill suffer more than they need to because they wait to enroll in a hospice program.

“We continue to see more dying Americans opting for hospice care at the end of their lives, yet far too many receive care for a week or less,” said the NCPCO’s J. Donald Schumacher. “We need to reach patients earlier in the course of their illness to ensure they receive the full benefits that hospice and palliative care can offer.”

One reason the terminally ill wait for hospice, he said, is due to the misconception that hospice means giving up.


Occupational Stress: Doctors Suffer When Unable To Save Lives

Posted on Thursday, November 29th, 2012 at 1:03 pm by Life Matters Media

Physicians who treat the terminally ill may suffer from emotional stress when unable to save patients’ lives. Burnout and compassion fatigue are two serious forms of occupational stress physicians may suffer, according to research by Michael Kearney, M.D.

Kearney, a palliative care physician at Santa Barbara Cottage Hospital in California, describes burnout as “the end stage of stresses between the individual and the work environment.” Compassion fatigue is “secondary post-traumatic stress disorder, or vicarious traumatization — trauma suffered when someone close to you is suffering.”

Health care journalist Jane Brody addresses the stress and anxiety oncologists struggle with in a new article for The New York Times. Brody writes, “A doctor with compassion fatigue may avoid thoughts and feelings associated with a patient’s misery, become irritable and easily angered, and face physical and emotional distress when reminded of work with the dying.” Compassion fatigue may lead to burnout.

Up to 60 percent of practicing physicians report symptoms of burnout.

According to Brody: “Patients and families may not realize it, but doctors who care for people with incurable illness, and especially the terminally ill, often suffer with their patients. Unable to cope with their own feelings of frustration, failure and helplessness, doctors may react with anger, abruptness and avoidance.”

Physician suicide linked to occupational stress

According to Crystal Phend, senior staff writer for MedPage Today, “Suicide among physicians appears to follow a different profile than in the general population, with a greater role played by job stress and mental health problems.”

Phend cites a study by Katherine J. Gold, M.D., of the University of Michigan in Ann Arbor, who found that problems with work were three times more likely to have contributed to a physician’s suicide than a nonphysician’s. Mental illness was also 34 percent more common before a suicide among physicians.

Up to 60 percent of practicing physicians report symptoms of burnout

“The results of this study paint a picture of the typical physician suicide victim that is substantially different from that of the nonphysician suicide victim in several important ways,” Gold wrote for General Hospital Psychiatry. “Inadequate treatment and increased problems related to job stress may be potentially modifiable risk factors to reduce suicidal death among physicians.”

Although physicians have more access to health care, they may be reluctant to seek help. “I think stigma about mental health is a huge part of the story. There is a belief that physicians should be able to avoid depression or just ‘get over it’ by themselves,” Gold wrote.

More than 200 of the 31,636 suicide victims reported in the National Violent Death Reporting System from 2003 to 2008 were physicians.

Meditation may help physicians

A 2008 study published by the Journal of Palliative Medicine, in which researchers studied 18 oncologists, found that physicians who viewed their work with patients as both biomedical and psychosocial found end of life more satisfying than those with a more biomedical perspective.

“Physicians, who viewed their physician role as encompassing both biomedical and psychosocial aspects of care, reported a clear method of communication about end of life care, and an ability to positively influence patient and family coping with and acceptance of the dying process,” the researchers concluded.

“In contrast, participants who described primarily a biomedical role reported a more distant relationship with the patient, a sense of failure at not being able to alter the course of the disease, and an absence of collegial support.”

Kearney recommends “mindfulness meditation,” a Buddhist-influenced practice for physicians suffering from stress. “The doctor is able to recognize he’s being stressed, and it prevents him from invoking the survival defense mechanisms of fight (‘Let’s do another course of chemotherapy’), flight (‘There’s nothing more I can do for you — I’ll go get the chaplain’) and freeze (the doctor goes blank and does nothing).” He claims that even 8-10 minutes a day of “mindfulness meditation” can help.