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Joel Howell was honored by the American College of Physicians (ACP) at its annual convocation ceremony in April. Howell was named a new Master of the American College of Physicians for 2017-2018. Each year, a select group of these Fellows are chosen from among the nominees for Mastership by the ACP Awards Committee and approved by the ACP Board of Regents.

Sorry, Doc, that doesn't fit my schedule (Feb-04)

Patients sometimes skip treatments because they just feel too busy. What should physicians do when their patients ignore their recommendations?

Imagine you are a businessperson who works long hours and you are on your way up to having a successful and lucrative career. You have a major business deal that will consume nearly all of your time over the upcoming month and your boss is relying on you to make sure the deal goes through. This is your chance to really make your mark and show your corporation that you are the kind of person that can handle deals as big as this one. Also suppose you have been smoking on and off for 25 years. You know it's a bad habit that could destroy your lungs, but you just can't quite kick it. Lately, you have been feeling tired, you have been experiencing chest pains when you are really busy at work and when you exercise, and you have had trouble breathing when climbing a flight of stairs. The chest pains are usually relieved by a little rest, but you decide it's time to get this examined by a doctor.

One day after work, you go to see Dr. Coral, who gives you a stress test and determines that you'll need an appointment for an angiogram to better evaluate your coronary arteries. Fortunately, you find one free day right before things get hectic at work, so you schedule the angiogram. Now imagine you have just had the angiogram and you are recovering in a paper gown waiting for Dr. Coral to come back with the results. Dr. Coral enters the room to speak with you and he has a serious look on his face. He says,

"I have both good and bad news for you. The angiogram shows that your 3 main coronary arteries are all severely blocked. The good news is that we caught this before you had a major heart attack."

"The bad news is that I am recommending you have triple bypass surgery as soon as possible. Your heart is working overtime, and it is just a matter of time until it gives out."

The news is shocking, but in addition to your health concerns, you also have the business deal to worry about. This deal is an opportunity to make a name for yourself, and your boss has been very vocal that he was counting on you, trusting that you'd be the one for the job. You find yourself having to weigh your work ambitions against the recommendation from Dr. Coral because if you get surgery, there is no way you'd be able to take on your current work responsibility.
 
Which of the following decisions would you be most likely to make?
 
  • I would put aside Dr. Coral's recommendation and instead take responsibility at work for the current deal. I'll wait to have surgery in about a month.
  • I would follow Dr. Coral's recommendation by having surgery immediately, even though this forfeits the current opportunity at work.

A little feedback on what you chose.

It's not that physician's don't care about your other values, but they are primarily concerned about your health, and you might not even have lived long enough to finish the business deal if you didn't have this surgery immediately. This does, however, bring up an important fact: patient's do sometimes reject their physician's medical judgment, and it can be at a great cost to their health.
 
Why should a patient be part of the decision-making process?
 
Why shouldn't Dr. Coral just tell you that you need surgery and leave no alternative? Efforts to share decision-making with patients are important because they acknowledge patients' rights to hold views, to make choices, and to take actions based on personal values and beliefs. In addition to being ethically-sound, this shared decision-making process also leads to improved patient health outcomes.
 
What can a physician do to help the patient choose surgery?
 
To answer this question, first it needs to be emphasized that in order for a patient to be able to participate in the decision-making process, the patient must be able to soundly make decisions. This sounds abstract and subjective, but it can be broken down into something a little more concrete. Decision-making capacity (DMC) is based on four guidelines:
 
The patient is able to:
 
  • understand the information about the condition and the choices available;
  • make a judgment about the information in keeping with his or her personal values and beliefs;
  • understand the potential outcomes or consequences of different choices; and
  • freely communicate his or her wishes
Based on these four elements, it is possible to see what a physician can do to help facilitate a "good" health decision. In order to make sure a patient fully understands the situation, a physician can ask him or her to state their understanding of the problem and of the treatment options. Also, a physician should use clear and unambiguous language with the patient at all times. Although a report might be quite clear from a physician's perspective, a patient might not be as clear about all the details. In the situation you were asked to imagine, Dr. Coral should tell you that you will die without this surgery and that waiting is not a safe option.
Also, there might be other factors keeping a patient from following a physician's recommendation. Again, in your hypothetical situation, your boss was putting a lot of pressure on you not to let him down. Also, this decision would potentially have an effect on your advancement at work. You might not have felt free to elect surgery even if you knew it was the only good decision for your health. By directly acknowledging and addressing a patients' concerns, physicians may facilitate a decision for the surgery.
 
In conclusion, if a physician feels that a patient is not able to fulfill one or more of the elements of DMC then his or her ability to make that decision should be brought into question and surrogate decision makers should be sought. For more serious decisions, the standards for DMC should be higher than for less important decisions or those with less significant outcome differences among the choices.
 
For more information see:

 

What is the price of life? (Aug-03)

Do you think that your life is worth more than the amount that the government usually uses as the maximum to spend to provide one year of life?

Imagine that you are a member of a government panel that is trying to decide how cost-effective a medical treatment must be in order for the government to cover the costs of the treatment. Suppose that a certain treatment could provide one additional year of life to an otherwise healthy person. What is the highest amount the government should be willing to pay per person for this treatment?

How do your answers compare?

For the past twenty years, the figure most often used as the maximum amount to spend to provide one year of life has been $50,000. This figure was originally proposed since it was the cost of a year of kidney dialysis, a lifesaving treatment that the U.S. government funds in Medicare.

Should the number be higher or lower than the current standard?

Conventional wisdom would suggest that the number be higher to take into account the inflation that has occurred in the years since the standard was developed. Current practices such as annual Pap smear screening for women with low risk for cervical cancer, which has a cost of $700,000 per year of life gained, also suggest that society is willing to pay more than the current standard for a year of life. The authors of the cited article recommend, based on current treatment practices and surveys of the general public, that the cost-effectiveness threshold should be revised to be around $200,000.

Should the number increase, decrease, or stay the same over time?

Again, it seems that the threshold amount should increase over time due to inflation. However, other factors come in to play that affect the value.

Since new technologies are emerging all the time, some of which will be deemed cost-effective, there will be more and more treatments to be offered in the future. Also, the rate of use of treatments is an important consideration, because even if a new treatment is more cost-effective than an old one, if it is used more often it will end up costing more to society overall. With more treatments becoming available and more people being given treatments, the threshold cost will probably have to decrease so that insurance companies and the government can keep up with the increasing availability and demand.

Why is this important?

Insurance companies and government health care entities face a continuing struggle when trying to determine which medical treatments to cover. Health care costs are increasing rapidly, so these groups will be facing even tougher decisions in the future. Establishing cost-effectiveness guidelines would be extremely helpful as an aid to making the decisions about treatment coverage. Evidence shows that the current threshold is probably not an accurate reflection of the desires of society or actual prescribing practices. It needs to be adjusted to become useful once again, and must be reevaluated periodically to make sure the value keeps up with trends in the health care market, rather than being left alone without question for two decades as is the current situation.

For more information see:

Ubel PA, Hirth RA, Chernew ME, Fendrick AM. What is the price of life and why doesn't it increase at the rate of inflation? Archives of Internal Medicine. 163:1637-1641, 2003.

Tue, January 10, 2017

Jeffrey Kullgren was recently featured in the Michigan Medicine article, "What do health plan deductibles really mean for people with chronic illness? New study takes a look." Dr. Kullgren co-authored a JAMA Internal Medicine Research Letter, which reports that even “low” deductible plans can mean high out-of-pocket costs for many Americans.

CBSSM Seminar: Twitter/Social Media

Thu, January 12, 2017, 3:00pm
Location: 
NCRC, Building 16, Room 266C

Twitter/Social Media Seminar “How to Promote Your Research, Yourself, and Make Connections using Social Media"

This seminar will be geared to all levels of social media/Twitter familiarity—if you are a newbie OR have an unused/dormant account, OR use it a lot, but want to be more efficient/effective, this seminar is for you! We also welcome experienced users to attend and offer their advice based on their experience!

 

CBSSM Seminar: Dina Hafez Griauzde, MD

Wed, January 18, 2017, 3:00pm
Location: 
NCRC, Building 16, Room 266C

Dina Hafez Griauzde, MD
Robert Wood Johnson Foundation Clinical Scholar
VA Special Fellow, Ann Arbor Veterans’ Affairs Medical Center
Clinical Lecturer, Internal Medicine

Abstract: Greater purpose in life (measured using a validated scale)  is associated with lower rates of certain chronic conditions such as cardiovascular disease and stroke.  In this seminar, we will discuss the role of purpose in life in the development of prediabetes and type 2 diabetes as well as the potential to augment ongoing type 2 diabetes prevention efforts with strategies that promote greater purpose in life.

Raymond De Vries is involved in a new research study led by Akbar Waljee, MD, MSc, which will develop a risk-based strategy to help providers tailor timing of treatments among CHC Veterans to ensure that those who most need urgent therapy get it as quickly as possible.

Using democratic deliberation, Dr. De Vries will engage Veterans to learn their thoughts and preferences about such a strategy, which will help with its implementation in a clinical setting.

Click here for more details.

Mon, January 30, 2017

Brian Zikmund-Fisher's The Conversation piece on raw cookie dough was cited in the Popular Science Health article, "The Chemicals In Burnt Toast And Crispy Fries Won't Kill You, But The Calories Might."

Mon, January 30, 2017

Kayte Spector-Bagdady has a new commentary out in The Conversation about the law and ethics of research with human biospecimens. It focuses on the recently published revisions to the human subjects research regulations, highlights the debate that ensued from a draft version over its proposal to include nonidentified biospecimens in its definition of "human subject," and summarizes where the final rule landed and possible steps going forward.

Research Topics: 
Wed, February 01, 2017

Raymond De Vries' commentary, "Giving (Bits of) Your Self to Medicine" was recently published in Medicine at Michigan. He and his colleague, Tom Tomlinson (MSU), published national survey data in JAMA that showed that while most Americans are willing to donate to biobanks, they have serious concerns about how we ask for their consent and about how their donations may be used in future research.

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