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Mythbusting, “demanding patient” edition

We’d bet good money that anyone who identifies as an e-patient has been led to believe that their desire to participate actively in their medical care marks them as a “demanding patient.” The perception of demanding patients is that they’re behaving like spoiled divas at a medi-spa, with their demands driving up incidence of unnecessary or inappropriate care.

That myth is now officially busted, in no less a method than a study published in JAMA Oncology. In an accompanying op-ed, Dr. Anthony L. Back says:

“In this issue of JAMA Oncology, Gogineni and colleagues report on their empirical inquiry into patient demands, a nemesis that proves to be more mythical than real. The study hypothesis—that patient demands for treatments and scans drove unnecessary costs—was spectacularly unconfirmed when using data collected from physicians themselves. Only 8% of the patient-physician encounters at 3 cancer centers in Philadelphia involved a patient “demand,” and the majority of those “demands” were viewed by the physician as “clinically appropriate.” Suddenly, the demanding cancer patient looks less like a budget buster and more like an urban myth.”

On his Healthcare Triage YouTube channel, Incidental Economist blogger Dr. Aaron Carroll offers up a great analysis of just how very busted that myth is. Click here to view it.

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NLM Director Donald Lindberg is retiring. Speak up: what’s next for the Library?

Donald LindbergDr. Donald Lindberg, long-time director of the National Library of Medicine, is surely the single most-quoted authority from “Doc Tom” Ferguson’s e-Patient White Paper. In almost every speech I’ve given in the past five years I’ve used Doc Tom’s quote of Dr. Lindberg in the White Paper:

“If I read and memorized two medical journal articles every night, by the end of a year I’d be 400 years behind.”

It’s a hoot to see people’s faces as this sinks in: “Holy crap, it’s not realistic to expect doctors to know everything!” The power of this realization is that if a patient shows up with an article the doc hasn’t seen, it’s no insult to the clinician. Instead, the door becomes open to partnership – to participatory medicine.

To have this statement come from a highly respected member of the establishment has been of transformational importance in our work. Now, Dr. Lindberg is retiring at the end of March, and the Library has issued a call for public comment:

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OpenNotes in the BMJ: the message goes global, adoption is international

Screen capture of BMJ OpenNotes article

Click to go to the BMJ article

OpenNotes logoOur Society for Participatory Medicine is all about effective patient-clinician partnerships, and to us that simply requires patient access to all information about the case. As SPM co-founder Dr. Danny Sands often says in his speeches, “How can patients participate if they can’t see what I see??”

So, naturally, this blog has been one of the biggest, loudest boosters of the OpenNotes project. (Our many posts are listed here, especially the first one and the results post.) There are many, many stories of how healthcare works better – happier patients, better outcomes – when patients are empowered to collaborate by not being kept apart from what their “hired experts” (docs) have written.

But in my travels I’ve often heard people talk about the cultural and policy differences between US healthcare and other countries, so I’m thrilled that in the big Patient Centred Care supplement that the BMJ published yesterday (see our post with the list of articles), they included a major (2300 word) article on the US experience.

OpenNotes adoption map feb 2015

Click to visit OpenNotes adoption map page

Prepping for this post, lead author Jan Walker told me, “Transparency is a worldwide concept” – the article adds to previous OpenNotes publications, citing similar initiatives in other countries! Estonia, Sweden, and even parts of the UK. (While in London to record the podcast that’s in the issue, I got to meet Dr. Amir Hannan, who’s been sharing notes with his patients for years. He too was in the podcast.)

So when you tell friends about OpenNotes – or when you ask your care providers to give you OpenNotes – let them know:

  • It’s no longer a fringe thing – over 4.8 million Americans in many health systems have access to their records
  • It’s no longer just in America.
  • Now it’s got the endorsement of the editors of the BMJ
  • It works. Nobody who’s implemented it has said “Those findings in the articles are not happening here.”

The founder of our movement, “Doc Tom” Ferguson, was fond of citing futurist and science fiction author William Gibson, who famously said “The future is already here – it’s just not evenly distributed yet.” Be bold – change the world – ask for it, and point to the evidence.

 

 

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Big BMJ supplement on Patient Centred Care – with many SPM and MedX voices


This is a great week for SPM, for our colleagues at the Stanford Medicine X conference, and for everyone else who’s been working for years to shift medicine’s thinking about the role of the patient: Yesterday the BMJ (formerly British Medical Journal) released a big, 21 article “Spotlight” supplement on “patient centred care.” The print edition is due out tomorrow, Feb. 12. The list of articles in the Spotlight is below.  Important: they’re all open-access – no subscription required.

If I’m correct, this is by far the biggest boost (and acknowledgment!) our movement has seen so far. It brings a rich diversity of voices, patients and clinicians alike, from at least eight countries, all talking about patient-physician collaboration, in one of the most credible medical journals in the world.

I want to specifically call out the SPM members who contributed or are mentioned in it.  Here’s my list so far:

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on the complexity of problems and ePatients as innovators

One of our Society’s best kept secrets is the composition of our membership. And lately, some of my best collaborations are coming out of conversations with fellow members. Last week, as I frenetically packed for a trip, I was chatting on the phone with our own e-Patient Dave. We were talking about the Movement, some of its key players and the nature of problems.

Specifically, we were discussing some pioneering work to help end hunger in the 1970s. According to Dave, one leader of that movement —I trust he’ll pipe up in the comments and fill in some of these details —described problems as having three phases: deceptively simple, overwhelmingly complex, and then, profoundly simple. That construct struck me as feeling incredibly familiar, even though I was hearing it for the first time.

When I talk to people who aren’t as familiar with the movement —patient muggles? —I often describe ePatients as existing on a continuum. Many become ePatients out of necessity; they seek information on a new diagnosis. Those who continue along the continuum feel value in connecting with others and then as serving as guides for those just beginning their journey.

Along the way, virtually every ePatient, participatory provider, and advocate finds some sticky wicket, some problem which seems remarkably simple. My doctor is always late and makes me wait! If they were [insert any number of ideas here: more considerate, on time, technically literate…] then this wouldn’t happen. I don’t have to wait to see my dog’s vet! Sound familiar? Or sometimes its more like: giving me access to my records is a right. I deserve the same real-time access to information about me that my doctor sees. All the hospital has to do is flip a switch. I’m picking some pretty simple examples, but bear with me.

In these examples, both the problems and the solutions seem pretty simple, right? Doctor is late…text me before I leave the house so I don’t have to wait in the waiting room…problem solved. And, to make no bones about it, that’s a pretty clever solution to a nagging problem. So what happens next? ePatients, advocates, our fellow Society members speak up, addressing their own challenges and proposing simple solutions. The problems are real, and the solutions are smart, so they get invited into the tent. We speak at conferences, we write blogs, we tweet.

And once we’re in the belly of the beast, we see it all. Holy cow this is complex! What do you mean the doctor doesn’t work for the hospital? Why does the lawyer say they can’t text us? And what’s the deal with this EMR being so technologically opaque? And so we sigh. We throw up our hands. We call the entire system a broken mess. Perhaps you’ve heard colleagues, including yours truly, say something like: “we should blow the whole system up and start over.” Or sometimes it’s: “the real disruption is going to come from outside the system.” Again, like our problems above, the sense of overwhelming frustration and the hands-in-the-air-hopelessness are completely rational. Maybe, too, the ideas of starting fresh or looking outside the industry are valid.

Then something happens. As ePatients, advocates, and participatory providers continue on their journey, a zen-like simplicity emerges. They see problems differently. And because they are seeing them differently, the solutions are also different. They are simple. Only this time, they are profoundly simple. My doctor runs late, so I now take care of myself and don’t go to the doctor. Consider the #WeAreNotWaiting community, the group using existing technology to build an open source artificial pancreas system. In a recent talk, one of the community’s leaders, Dana Lewis, was asked if she told her doctor about her artificial pancreas. Dana’s answer: “why would I?” Pretty simple solution, become your own doctor. And with a virtually flat line blood glucose graph, who would argue her approach?

These two intersecting models —the nature of problems and the ePatient journey —tie together perfectly. Further they are the recipe for innovation in healthcare. Being able to clearly see a problem and reframe it is a hallmark of the the design process and that’s exactly what happens when ePatients go from deceptively simple to overwhelmingly complex to profoundly simple. ePatients who unravel problems and find profoundly simple solutions are both aided by and then advanced along their own journey. By being able to see problems and propose solutions they are invited into the discussion. Once inside, the overwhelming complexity fuels a burning need to simplify and solve problems differently. What results are more elegant, simple solutions, the creation of which moves the ePatient further along their journey. And that’s a pretty neat thing.

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ePatient efforts on “precision medicine” #LCSM edition

SPM member Janet Freeman-Daily, who’s an active voice in the #MedX and #LCSM communities, alerted us to a petition on Change.org that speaks directly to the principles of precision medicine – called for by the President in a White House event attended by our own Nick Dawson – and keeping the regulatory environment from standing in the way of actually delivering that precision medicine.

Quoting from the petition:

The FDA’s proposed “Framework for Regulatory Oversight of Laboratory Developed Tests (LDTs)” attempts to regulate LDTs as if they were self-contained devices (such as stents) or commercial test kits.  This won’t work.  Getting the best diagnostic and treatment outcomes from available specimens relies of the practice of medicine, which the FDA is not supposed to regulate.

The proposed regulations state that once a companion test kit obtains FDA approval, any modification to the test components or any change in specimen type requires separate FDA approval before the LDT can be offered to patients.  If no companion test exists for an oncogene, an LDT may offered to patients without obtaining FDA approval IF it is offered ONLY to patients in the same healthcare system as the laboratory that performs the test.

The proposed regulations require laboratories to submit all cancer-related LDTs for registration and listing.  In addition, LDTs for which a cleared or approved companion diagnostic exists (like BRAF-driven melanoma and ALK-driven NSCLC) must be submitted for financially prohibitive and lengthy premarket review.  Many labs, including those in major cancer centers (which currently offer hundreds of LDTs), might not have the deep pockets or other resources to seek FDA approval for their LDTs and would have to pull LDTs from their list of patient services, or even have to close.  This would impede not only access to potentially life-saving diagnostics, but impede innovation as well.

Hit the link in the first graf, head over to the Change.org site, and read the entire petition for yourself. Sign it, if you’re in favor of its principles.

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Join @HurtBlogger’s 48-hour “live tweet my chronic life”

HurtBlogger screen shotLADIES AND GENTS, YOUR ATTENTION PLEASE.

The famous @HurtBlogger, chronic pain patient Britt Johnson, has announced that she will LIVE TWEET 48 hours of “her chronic life,” MONDAY AND TUESDAY, Feb. 2-3. She has no idea what will happen – might be ordinary, might be nasty. (Long ago the radical group The Last Poets sang “The revolution will not be televised … it will be LIVE.”)

Britt is one of the “e-patient advisors” at our cousin event Stanford Medicine X (as are SPM members Nick Dawson, Hugo Campos, Jamia Crockett, Sarah Kucharski (@AfternoonNapper).) (Well, we’re not formally cousins, but obviously we have a lot of overlap in our “e-patient DNA.”)

Follow her twitter feed – details in that blog post.

Britt’s in the Pacific time zone. Her last tweet at bedtime Sunday:

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A landmark day in the movement: Patients in the Front Row

2015-01-30 11.18.59

Photo by Nick Dawson on Flickr


        

Last Friday, 200 patients, advocates, scientists, doctors and researchers gathered at the White House to hear President Obama’s launch of the Precision Medicine Initiative. According to the President, precision medicine aims to tailor treatments to each individual. President Obama likened precision medicine to how we match blood transfusions to blood type – only now we should aim to match a wide range of treatments to a wide range of varying genetic and biounique markers.

The initiative begins with a budget request for $215 Million in new funds. The funds will be used, mainly at the NIH, to:

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The movement gets real: one of Doc Tom’s sightings gets $28 million with Iora Health

Iora Health logoThere are times in a movement when value is revealed and recognized, and you know something real is happening. In the engaged-patient movement, the first I noticed was when Amy Tenderich’s Diabetes Mine blog (and its community) was acquired several years ago. That takes it from what some people might view as “clubby” to tangible significance. (Oh, and they just got picked up again (amid a flurry of press releases) by Healthline.)

Rushika at Wired health conf Nov 2013This post is going to be pretty enthusiastic so I’ll say at the start that I have no connection with Iora Health. I believe in what they’re doing, but that’s all – I’ve never visited or even talked to them, though I’ve met CEO Rushika Fernandopulle (left).

I first read about him, seven years ago this week, for what he was doing back then.

Twenty years ago the founder of our movement, “Doc Tom” Ferguson, predicted that the internet would turn healthcare on its head: see Steal These Slides, which cites CNN as calling Tom “the George Washington of patient empowerment.” He then started spotting various people doing things differently because of the internet, including SPM founders Gilles Frydman, Alan & Cheryl Greene of DrGreene.com, Dr. Danny Sands, Joe & Terry Graedon of PeoplesPharmacy.com, etc.

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From OpenNotes to OurNotes: New project heads toward *real* participatory medicine

OpenNotes logoI’m beyond thrilled. Way beyond thrilled. This is going to take some figuring out, but is this what we’ve been striving toward, or what??

For years we’ve written here about the OpenNotes study (MyOpenNotes.org), funded by the Robert Wood Johnson Foundation, which established that when patients can read their doctors’ unedited visit notes – the hairy detailed medicalese – the world does not fall apart, the sky does not fall; to the contrary, things overall work better and patients like it so much that 85% said from now on access to their notes would be a factor in their choice of provider!  (For full study results see here.)

Today over five million patients have access to their notes, at such world-class institutions as M.D. Anderson, Geisinger, Kaiser Permanente, and many more. (See the list here.)
Commonwealth Fund logo

Well, yesterday a big next step was announced:

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Opening the ICU doors to family: report from Virginia Mason

Screen capture of article top

Click to view article PDF (open access)

Cross-posted from my personal blog yesterday

On Twitter Friday night I learned from Dr. Sachin Jain of a November article that should be of interest to all of us who want to work toward full patient and family engagement in all aspects of medicine. To be sure, the changes we’d like are not always simple, and one example is expanding family access to the ICU.

Virginia Mason Medical Center (VMMC) is widely known for being far far more patient-centered and quality-oriented than most medical institutions – including, in this case, even the really challenging parts.  I hope I don’t get in copyright trouble for pasting too much in here, but the whole article is Open Access (no charge) so have a look, under the heading “Problem: Despite tradition, genuine need to open doors”:

Over time we became more aware that this traditional model was badly disconnected from the needs of our patients. The Institute of Medicine emphasized that families serve as a healing influence by providing comfort, connectedness, energy, self-esteem and wisdom; there is little or no evidence to indicate that the practice of family member presence is detrimental to the patient, the family or the health care team. Indeed family member presence during invasive procedures or resuscitation should be offered as an option to appropriate family members.

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