Drug-Resistant TB and a Physician Hero in India

Today's New York Times described Dr. Zarir Udwadia's campaign against drug-resistant TB. He is earning well-deserved international respect.

Dr. Udwadia is a pulmonologist in Mumbai. He did his medical training in Mumbai and Scotland. When he returned to Mumbai in 1991 he followed his pulmonologist father in starting a private practice. But he wasn't busy enough, and to use his knowledge he started a free clinic for patients with TB. It's now the busiest clinic at his hospital.

In 2011 Dr. Udwadia published a letter describing four patients whose TB infection was resistant to all antibiotics currently available in India. The Indian government's initial response was to attack the messenger, not to respond to the message. But Dr. Udwadia refused to be silenced, and brought the government to recognizing and responding to the medical crisis. The government now pays for drugs that were not subsidized in 2011.

I'm currently teaching medical students who are going into their first clinical rotations, and we've been talking about the patient-physician relationship. From that perspective I was especially moved by this passage:

The tall, lean doctor with a halo of black hair refuses to wear a mask to protect himself, even though his wife says he does worry about contracting TB. “How can you connect to a patient that way?” he asks. Instead, he leaves open his window so there is good air circulation, which reduces the chances of infection.

In the jargon of ethics, his actions are "supererogatory" - morally admirable but above and beyond what is reasonable to expect. If I were advising Dr. Udwadia, I would encourage him to protect himself to ensure that he continues to be available for his ministry to the poor. But his commitment to making a real human connection with his patients is in the best tradition of medicine and the spirit of Mahatma Gandhi.

Here are the closing paragraphs from the article:

When Mrs. Sheikh, a tiny woman wearing a salwar kameez, showed up for her recent checkup, Dr. Udwadia grinned and reached across the table to shake her hand, unable to contain his excitement as he reviewed her tests. They were negative for TB for the third successive year.

Her lungs are so scarred from the disease that she becomes breathless after walking several steps, but she says she is grateful to be alive. She takes a two-day train ride from her hometown in northern India to Mumbai every six months for a checkup.

“I know it sounds like a cliché, but these times are what I live for,” he says. “In India, all patients tell the doctor, ‘You saved my life,’ but with Rahima Sheikh, I know it’s really true.”

 When I see the brilliant, idealistic young medical students next week, I'll hope to convey some of the values that Dr. Udwadiah evinces so powerfully!

Does Freedom of Speech allow Rejection of a Court's Findings?

In June I wrote about David and Collet Stephan being sentenced to jail for the death of their two year old son Ezekiel. David and Collet treated him with naturopathic remedies and did not respond to clear indications that Ezekiel was developing dangerous meningitis until it was too late. The judge acknowledged that they loved Ezekiel and were trying in their way to help him, but concluded that they did not have a right to choose their own beliefs over mainstream health care. He sentenced David to four months in jail, but allowed Collet to serve a three month sentence under house arrest.

The aftermath so far is fascinating. Both sides are appealing The "Crown" (Canada's term for the "state") is appealing the sentence as too lenient, on the following grounds:

 - The sentence is not proportionate to the gravity of the offence or to the degree of responsibility of the offender, and is unfit.

 - The Sentencing Judge gave insufficient weight to denunciation and deterrence.

- The Sentencing Judge underemphasized, or failed to give weight to, relevant aggravating factors.

- The Sentencing Judge overemphasized mitigating factors, or gave mitigative weight to factors that are not mitigating. 

- The Sentencing Judge misinterpreted the legal doctrine of wilful blindness.

"Wilful blindness"is a legal term referring to motivated ignorance. The Crown is alleging that the Stephans chose to ignore the obvious fact that Ezekiel needed urgent medical attention because of their cult belief in "natural" remedies.

The Stephans have appealed their conviction. A friend from Canada told m that the appeal is based, at least in part, on free speech grounds. According to my friend they argue that the judge's requirement that they post an unedited copy of his ruling on their website infringes on their right to freedom of speech. (I haven't been able to find the details of their appeal.)

David Stephan's two "letters from jail" (here and here) show him to be a principled believer in a false doctrine. He is convinced that he is taking a stand for justice, to protect other parents from intrusions of the state.

I believe, however, that the judge threaded his way between punishment and mercy in an admirable manner. The judge and jury concluded that David and Collet were guilty of failing to protect their son from preventable harm. From my reading of the media reports this was a correct finding. But the judge recognized that the Stephans were loving parents, acting on their longstanding beliefs. They meant well for their son, but they did him the ultimate harm.

The judge gave David, who he saw as the leader of the belief system, a short jail sentence, but allowed Collet to serve on home detention so that she could care for the children. I supported and continue to support his requirement that his findings be posted on the Stephan website. While the Stephans totally disagree with the findings, they have been convicted under the law. Their website promulgates the cult beliefs that led to their son's death, and could do the same in another family. Posting the judge's findings does not abridge their speech rights. They can, and will, continue to disagree the the judge and jury and to speak up for their false naturopathic doctrines. This is their right in a democratic society.

But if they persist in refusing to post the  judge's findings I would favor requiring Collet to serve her sentence in jail once David is out and could care for their children. I do not know the Canadian precedents for contempt of court, but it would seem that a substantial fine and an extended period of probation would be warranted.

I believe the Stephans deserve respect for the principled way in which they assert their beliefs. In their view they are standing up for truth and justice. David is careful to say that he discourages his supporters from anger or hatred. This is admirable. But in the democratic society of Canada, the Crown is the legitimate authority for ruling on the situation. If David can persuade the public to change the law, the situation will be different. But under the law, the judge has ruled correctly.

Close Reading, Improved Writing, and Service Learning: A Virtuous Circle!

I'm in Vermont at the Bread Loaf School of English, a Middlebury College program in which the students, primarily high school and middle school English teachers, can get a Master's degree in the course of five summers. My wife has been teaching here every summer since 1992 and I enjoy the potential for (a) telecommuting and (b) swimming and hiking in Vermont.

In the past four years I've been doing an annual workshop on "Making Ethics part of High School and Middle School English Class." Working with the students here is a great pleasure and privilege. There's very little that's more important than educating the next generation.The teachers are doing God's work!

There were 18 participants in the workshop I did a week ago, plus three members of the Bread Loaf faculty. The participants taught in settings ranging from the Navajo Nation to public schools in urban and rural settings to elite independent schools.

We focused the workshop around a question that came from a 10^th grade teacher, whose class does a service learning module that combines class discussion, a service project chosen by the student, and a research paper. She felt that the unit was well-intentioned, but many students experienced it as a burden, and it didn’t feel integrated with the rest of the semester’s work. She asked the group – did other teachers have ideas about how to make service learning more engaging for students? 

I’ve distilled 4 points from the wonderfully rich discussion:

1. English class is often asked to be the vehicle for humanistic goals in the school curriculum. Ideally, moral development and heightened humanism would be a goal for every component of the school  – inside and outside of class. But this kind of full court press rarely happens, and English teachers are asked to take the lead. Being looked to for leadership in moral development is a challenge and an opportunity! I mentioned to the group that my medical specialty – psychiatry – is in a similar situation. We’re often asked to be responsible for the “understanding the patient’s point of view” component of the medical school curriculum.

2. Several participants suggested that preparatory exercises can help students become more open to and engaged with reflection about values. A participant reported that hypothetical questions like “A lifeboat has 10 people but will sink from too much weight. Everyone will drown unless someone is thrown off. What should be done?” triggers lively discussion. Another participant described how she gives the class statements dealing with issues that come up in a book they are reading. Then she has them do “speed dating” – i.e., talking for 30 seconds with another student about their reactions to the statement. Another participant described how she did a similar exercise before reading Hamlet. She poses questions like “do you believe in ghosts?” or “if someone kills your father, should you kill that person for revenge” and asked students to stand up if they agreed. These teachers reported that like warming up before physical exercise, activities of this kind can help students “warm up” into a more reflective state of mind in which they are prepared to see ethics as something important to their lives.

3. When schools require service learning, unless students are prepared well they can cause harm when they enter into the space of those they are “serving.” And the very idea of doing “service for those in need” can create a noblesse oblige attitude (“the poor can’t help themselves – they need me to do this service for them…”) or cynicism (“this is just resumé padding…”). Some argued that requiring service learning and giving academic credit for it is corrupting. But others who agreed that these risks are real nevertheless felt that some students who would never get involved on their own might be turned on and transformed by the service learning experience.

4. Independent schools and public schools in wealthy communities are increasingly sponsoring “voluntourism” – programs in which students go for a short time to a poorer country to do “service.” With rigorous preparation, a strong relationship with local community partners, and opportunity to reflect on the experience, these programs can be excellent learning opportunities for the students and even if not helpful at the “service” site, at least not harmful. A participant contrasted “asset based community development” to “voluntourism charity work”.” ABCD involves identifying the strengths in a community and helping the strengths to be extended. Another participant questioned why “voluntourism” programs travel to other countries when there are valuable opportunities to contribute in their own or nearby communities.  With regard to the stance of noblesse oblige” I mentioned a favorite quote from Thoreau: “If I knew for a certainty that a man was coming to my house with the conscious design of doing me good, I should run for my life!”

The core idea that has emerged from the workshops is an understanding of a virtuous circle involving literature, writing, and social action, which I've represented in a diagram:

Close reading strengthens empathy and humanism by entering into the worlds that literature creates, and improved writing does the same by asking students to think about the audience they are speaking to and how they can best reach that audience. Understanding our values and biases and empathizing with perspectives of others even if we disagree with them increases “ethical sensitivity.” And when students identify values important to themselves and for their communities, they are primed for ethical activism on behalf of these commitments. Activism can create a virtuous circle by stimulating further learning opportunities that strengthen engagement with literature and writing. 

I hope the high school and middle school teachers learned as much as I did from the workshop!

Is this doctor hitting on his patient?

I recently received a very thoughtful email from a reader. I'm posting it here (slightly edited) with permission from the writer:

I recently stumbled across your very helpful and insightful blog. I had a question that I thought you might be able to help me with. I was wondering if you could possibly cover something on appropriate boundaries in the doctor/patient relationship.I have seen a few pieces on obvious violations of this (romantic and/or sexual relationships where the doctor clearly took advantage of a patient), but I was more curious about the grayer areas, where doctors may be a bit too familiar with their patients.

I ask because I saw a male OB throughout a recent pregnancy. He was quite attentive, very competent, and overall a wonderful doctor. However, sometimes he made comments that took me off guard and I was never quite sure how they were relevant to my medical care. For example, he asked if my husband still got erections and later asked me to describe how I felt when I had an orgasm. On one hand, I could see how questions regarding sexual activity during pregnancy are pertinent, but never before has an OB asked me these questions during a pregnancy. The questions seemed a little odd to me, but I also wonder if perhaps this OB is just much more thorough in his care than my previous one.

I'd appreciate any light you could shed on the matter of grayer areas in the doctor/patient relationship.

What a terrific - and important - question! Here's my reply:

As you say, the questions your obstetrician asked could be relevant to your obstetrical care, but they could also be part of an effort to see if you might be sexually/romantically available. As a general rule of thumb, when the medical relevance of questions physicians ask isn't obvious, we should explain why we are asking the questions. Not having done that, your obstetrician created a situation in which a reasonable patient might wonder "are these questions part of good medical care, or is the doctor 'coming on' to me?" 

I think the most we can say is that the obstetrician might have been committing what in medical ethics language would be called a "boundary violation." If that was his intent, it was clearly a breach of professional ethics. But if it was not his intent, he failed to make clear why the questions were relevant. For example, he might have said "In my experience, it's not uncommon for couples to encounter difficulties with sexual intimacy during pregnancy...." But it's still unclear what the relevance of your experience of orgasm would be to medical care, unless you had brought up a concern of your own, or if he had said something like "I'm trying to learn about sexual relationships during pregnancy, so if it's OK with you I'd like to ask you..."

Ideally, patients will ask for clarification when they're uncertain about what we are asking about or doing. But in my practice there were times when I thought I was being clear but learned that I had inadvertently confused my patient. The power imbalance in the medical relationship means that physicians can't rely on patients to ensure clarity. Your email shows you to be a very clear thinker, but apparently you didn't feel comfortable saying something like "Could you explain how that question relates to my obstetrical care?"

If a resident or colleague asked me if it was OK to inquire about a partner's erections or the experience of orgasm in the course of obstetrical care, I would (1) ask about the relevance of the questions to the patient's care and, if there was clear relevance (2) recommend that the physician explain why he was asking the questions, to avoid generating the kind of concerns you experienced.

So, in  answer to the question of whether your physician was committing a boundary violation, my response is that it's possible that he was. We know from patient reports that sexual exploitation is often preceded by suggestive/ambiguous comments that in retrospect appear to be "testing the waters" or "dropping hints." But it's also possible that the questions were entirely relevant to his objectives for your care. If that's the case, he was "guilty" of poor clinical communication.

Thank you again for your very valuable question! 

 

Jail Time for Parents for letting Toddler Die from Meningitis

Last week a Canadian court sentenced David Stephan to four months in jail and his wife Collet to three months of house arrest for their role in the death of their 19 month old son Ezekiel in 2012.

When Ezekiel became ill, his parents thought he had some form of "flu," and treated him with herbs and a mixture of apple cider, vinegar, horse radish root, hot peppers, mashed onion, garlic and ginger root. A friend who was a nurse told them he might have meningitis, but they persevered in their efforts to treat him by the "natural" modalities they believed in. A witness testified that when they drove Ezekiel to a naturopathic clinic, he was too stiff to sit in his car seat. As his condition worsened, his parents had to feed him with an eye dropper. They only summoned medical help when Ezekiel stopped breathing. The child suffered severe brain damage from anoxia and died a few days later.

David and Collet are part of a community built around vaccine refusal and faith in "natural" remedies. David's father Anthony founded TrueHope, after his wife, who suffered from bipolar illness, committed suicide. The company markets EMPowerplus, a "natural" product that they claim as a cure for bipolar disorder, depression, and even autism. Ezekiel's father David is Vice-President of the company.

David and Collet were convicted under a Canadian law that requires parents "to provide necessaries of life for a child under the age of sixteen years." The prosecution asked the judge to sentence them to 3.5 - 4 years in prison, close to the maximum the law allows (5 years). The judge called that "too harsh." He required prison for David because David refused to take responsibility for his actions. He asserted that a government conspiracy to squelch vaccine refusal was at work, and blamed Ezekiel's death on faulty ambulance care. In the judge's view, Collet was less responsible for Ezekiel's death. In addition to house arrest, he required her to publish his findings on her website. After their jail and house arrest terms, David and Collet will be on probation for two years, and will be required to obtain regular medical attention for their children.

Adults capable of making decisions are and should be free to choose no treatment or quack interventions. But they should not be free to refuse potentially life saving interventions - like antibiotics for bacterial pneumonia - for their children. Seen through the lens of both law and ethics, the judge ruled correctly. David and Collet loved Ezekiel, but they - especially David - made decisions a "reasonable" parent would know to be wrong. Ezekiel paid for their commitment to their "naturopathic" doctrines with his life.

(For a compendium of articles on the situation, see here.)

When is Rationing Ethically Accptable?

If I prefer a medicine that produces fewer side effects or marginally better outcomes, how much should you be expected to pay for my preference?

That's a question we in the US run away from. We'd rather say - "rationing is unethical! Period."

In truth, rationing happens all the time. The trend towards requiring us to pay a larger portion of our health care expenses out of pocket aims at making us responsible for our own rationing choices. If my physician recommends a CT scan "so we can be sure..." and I decide it's not worth the cost to me - that's self-imposed rationing. In our personal lives we make rationing decisions based on informal cost-effectiveness decisions every day.

But at the level of policy, acknowledging the need for ethically-grounded rationing is a third rail.

That's why the publication of Cost-Effectiveness of Long-Acting Injectable Paliperidone Palmitate Versus Haloperidol Decanoate in Maintenance Treatment of Schizophrenia is so important. for my field - psychiatry. In addition to providing valuable clinical information, the authors are admirably honest in presenting the rationale for potential rationing decisions.

Here's what the article is about:

Some patients with schizophrenia who benefit from antipsychotic medications follow their regimen reliably. But some don't, and for them a long-acting injectable antipsychotic medication can literally be a life-saver. I remember well a patient of mine who wouldn't take pills and wasn't keen on seeing a "shrink," but who accepted a monthly injection of haldol from his primary care physician. I made a serious joke with my colleague - "I may accomplish some useful things, but you are 'curing' schizophrenia in five minute appointments!" My patient and his family were enormously grateful that he functioned better and was happier than he'd been for a decade.

Paliperidone palmitate is still on patent and theoretically had some advantages over haldol decanoate, a much less costly generic medication. In a well-controlled randomized comparative effectiveness study, the authors compared the two medications, quantifying the differences between them in terms of quality adjusted life years (QALYs). Paliperidone had a slight advantage in terms of side effects, but at a cost of $500,000 per QALY, well-above what virtually every explicit discussion of QALYs has seen as an acceptable cost. Here's part of the author's conclusions:

The results of this study should encourage consideration of older, less expensive drugs, such as HD. Used at moderate dosages in this study, HD’s overall effectiveness and tolerability were only slightly worse...than those of PP, and it had clear advantages in cost-effectiveness...A rational policy for treatment of chronic schizophrenia might limit use of the more expensive [PP] to patients who do not benefit from or cannot tolerate HD. 

My colleague and friend Norman Daniels and I have written extensively about the overall ethics of rationing. I'm proud of the work we've done and believe it's useful. But progress in coming to grips with the need to ration care in a clinically grounded, ethically admirable manner will have to be done specialty by specialty in medicine, in concert with concerned members of the public.

The comparative effectiveness study of paliperidone and haldol illustrates four crucial steps that need to be taken for us as a nation to learn to set limits fairly:

1. Develop clinically and humanly meaningful evidence about key treatment choices.
2. Acknowledge the findings in an explicit, east to understand manner.
3. Do economic analysis to define the costs involved with the choice.
4. Decide whether the differences between the choices are worth the costs entailed.

The fifth and most difficult step is making use of these findings in the real world. In a health system based on competing health plans, health plan A would be reluctant to apply findings like these in its policies before health plan B does the same. If they did, word on the street would be "health plan A RATIONS CARE! How can we tolerate money grubbers like that in our health system?"

Learning to set limits fairly is more of a challenge to the heart than the head. At an intellectual level it's easy to see that limits are necessary. But thus far in the US, health system leaders, health care organizations, and the public have preferred to act as if rationing is evil and can be avoided.

That may have been true in the Garden of Eden. But, alas, that paradise vanished long ago.

Meditation and Medical Ethics

Medical ethics and mindfulness have a lot in common. I reached that conclusion after a recent conversation with my long-time friend Charlie Halpern about his effort to introduce mindfulness into legal education.

Charlie has been doing this at the UC Berkeley School of Law for the past several years through classes and elective retreats. He's an enthusiast and a believer. He feels, and many legal educators and law schools agree with him, that mindfulness practice increases empathy, compassion, and the ability to really hear what clients and others involved in negotiation and litigation are saying. He described how a professor at Berkely has taken to starting his classes with three minutes of silence. The professor reports that "sacrificing" three minutes of class time leads to a richer, more thoughtful class experience.

I've taught meditation to patients in a medical setting and have recommended meditation to many of my patients over the years. And I've written in this blog about how mindfulness practice can be woven into busy practitioners' lives. (See here and here.) But until the conversation I had with Charlie, I hadn't recognized the obvious connection between mindfulness and the way I've taught medical ethics.

In the semester-long course medical ethics course that I taught at Harvard Medical School, in addition to the topics that formed the intellectual content of the course, I encouraged the students to hone their skill at (a) observing their cognitive and emotional reactions to clinical situations that raise ethical issues, (b) treating these reactions as "data," not "truths," and then (c) reflecting on the "data" presented by their experience as one piece of ethical analysis before (d) reaching a conclusion. Over time, as demonstrated by clinicians who we regard as models of ethical action, this set of actions can become reflexive, done automatically and recurrently.

What I realized is that steps (a) and (b) are close cousins to what meditation teachers encourage their students to do. The setting is different - deliberate quiet and inwardness in meditation versus to what I'm inclined to call "meditation in action" in learning to be an ethically sensitive clinician. But the outcomes the teacher hopes for in the student - empathic connection with others, compassion, and seeing the truths that underlie complexity - are the same.

Recognizing the kinship between mindfulness and medical ethics is a valuable insight for ethics educators. An increasing number of students know something about meditation and respect the practice. Recognizing that skill at meditation can enhance their grasp of medical ethics, and, that skill at medical ethics fosters some of the key skills for meditation, enhances both domains.

An Ethical Perspective on Shared Medical Appointments

Stories about shared medical appointments keep popping up in the news, most recently in this New York Times article. The format involves bringing together a group of patients - as many as 15, but typically 8 - 12 - with a doctor or nurse practitioner, for a 90 minute discussion of shared medical problems, such as diabetes. Although group visits are not for everyone, the response of patients who participate and clinicians who lead the sessions are generally quite positive.

Group visits arose to promote efficiency. Although current discussions describe the format as an innovation developed in response to the parlous state of contemporary medicine, in 1905 Dr. Joseph Hersey Pratt, a Boston physician, began to lead "classes" for patients with tuberculosis. Pratt documented results that were as good as the best sanataria, but his method fell into oblivion.

In 1975 I had the privilege of starting a group visit program for patients with chronic psychiatric ailments at the Harvard Community Health Plan HMO . I conducted the group in collaboration with an excellent psychiatric nurse. I spoke with patients individually and to the group as a whole. If I wanted to recommend a medication to patient A, I often asked patient B, who was taking the medication, to talk with A about it. It was set up as a "drop in" group. Patients could come every week or just intermittently.

Physicians who lead shared medical appointments experience a different relationship with patients than in the 1:1 format. The group is more informal, and the physician often acts as a facilitator of patient-to-patient exchange, rather than as an authority. The framework tends to bring out the humanity of clinicians and patients. It's difficult for the leaders to be cold, detached or pompous.

I don't know how well the aspiration for efficiency holds up, but I do know - from my own experience and from the literature - that group visits encourage a holistic, humane way of relating between doctors and patients. The rationale for the format tends to be presented in an apologetic manner: the health system is in a mess/physicians are too harried to pay enough attention/you'll get to spend more time with your doctor in a group. These statements are true. But apology undersells the value of shared medical appointments. For patients with chronic conditions that must be managed over time, the group format can bring out a patient's own strengths and initiative and allow physicians to tap into their capacity to care in a down-to-earth human manner in new ways.

That's an ethical achievement, not just a matter of efficiency!

[To learn more about shared medical appointments, a Massachusetts General Hospital guide to conducting group visits is here,  a description of the group visit program at the Cleveland Clinic is here, and a VA guide to setting  up a group visit program for patients with diabetes is here. If you would like pdf versions of my articles about Pratt and about the HMO group program, send me your email address via the comment function.]

Atheism, Humanism and Secular Ethics at the University of Miami

Between September 10, 2007 and today, I've written 82 posts about religion and spirituality. I've been especially interested in the moral underpinnings of the health professions. I've thought of health care as a calling throughout my career. But where does the call come from?

Historically, the call has been seen as coming from god and god's servants - saints, bodhisattvas and other benevolent beings who urge us to care for others. But what about health care workers who do not derive their calling from a theology?

I hope this question will be high on the list of research topics when the newly endowed chair of "atheism, humanism and secular ethics" at the University of Miami is filled. I learned from the New York Times article about the chair that it was endowed by Louis J. Appignani, an 83 year-old retired businessman who supports non-theist causes. The University was uncomfortable defining the chair as one of "atheism" studies, but Mr. Appignani insisted that the "atheism" be part of the title, and accepted the addition of "humanism and secular ethics."

In an increasingly secular population it's crucial to deepen public understanding of morality that is not based on religious theologies. Over the centuries, religious communities have been powerful advocates for good causes (e.g., abolition of slavery) but also for evil causes (e.g., "holy" war). For atheists and secular humanists to make a full contribution to the moral arc of the future, we need a deeper understanding of how the non-theological domain functions. Let's hope that the University of Miami chair contributes to this process.

When the chair is filled, there will be a great deal to learn from studying those who are called to the vocation of health care!

Borderline Personality Disorder and Public Health Ethics

An article in the May issue of the American Journal of Psychiatry - "The Emergence of a Generalist Model to Meet Public Health Needs for Patients with Borderline Personality Disorder" - shows how experts can move from a specialty niche to public health relevance. This isn't just a clinical act. It's also ethics in action!

Borderline Personality Disorder is a relatively common condition, said to affect 1%-2% of the population and to represent 15%-20% of psychiatric hospital admissions and 6% of primary care visits. People with the condition evince symptoms like: vulnerability to feeling abandoned; unstable relationships that oscillate between idealization and disenchantment; destructive impulsiveness; self-harm; difficulties controlling anger; transient psychotic episodes; and more. The condition takes a high toll on individuals, those involved with them, and the health professionals who try to help them.

In the past 25-30 years, three evidence-based forms of treatment have emerged:

• Dialectical behavior therapy. DBT involves a combination of weekly individual and group therapy that emphasizes understanding one's vulnerabilities and reaction patterns, combined with learning new self-management skills. 
• Mentalization-based treatment. This treatment is a variant of psychodynamic psychotherapy that focuses on better understanding of mental states in oneself and others, based on the hypothesis that patients with borderline personality disorder interpret and react to others in terms of their own fantasies, and that more realistic understanding will decrease their desperate emotional over-reactivity. Like DBT, mentalization-based therapy typically involves weekly individual and group sessions.
• Transference-focused psychotherapy. For this approach, twice weekly individual sessions are recommended. The treatment makes maximum use of the patient's reactions to the therapist as an avenue into modifying the internal structures that lead to the chaotic life pattern.

All three approaches can legitimately claim to have been validated. But all three require training and skill beyond the level of most mental health clinicians. Nine years ago Glen Gabbard, perhaps the leading educator in psychiatry, asked "Do all roads lead to Rome?" and suggested that the three techniques may reflect different ways of delivering common healing processes. In the just-published article that I cited above, John Gunderson, a leading researcher on BPD, builds on Gabbard's suggestion and offers a common-sense generalist model that emphasizes educating the patient about the condition, focusing on life outside of the office more than on the interaction between patient and therapist, integrating medication management, and selectively involving family and significant others.

I'm writing about this clinical issue in a venue devoted to health system ethics because the move from a specialist orientation to generalism embodies admirable public health ethics. Our U.S. health system tilts towards a specialist for every organ and condition. At its best, this approach cultivates deep clinical skills. But it also disarticulates the care of individuals into unrelated segments and mirrors the inequity of our wider society by providing a lot for the few and much less for the many.

When I did my residency in the 1960s, psychoanalytic training was regarded as the pinnacle of professional development. I valued the deep intellectual rigor of psychoanalysis, but couldn't see limiting my practice to a relatively small number of patients who would be seen 3-5 times per week, and who, by practical necessity, would have to be relatively affluent. 

Gunderson's article points in the direction I'd mapped out for myself at the start of my career. U.S. health care needs to strengthen its generalist orientation at the level of primary care and within specialties. Moving towards health insurance for all is the first step in correcting the moral failings of our health system. But the ultimate challenge is improving our commitment and capacity to provide excellent cost-effective care for the entire population. Gunderson's work illustrates what every segment of medicine needs to do.

Robber Baron Capitalism victimizes Mother Theresa

Yesterday the Senate Special Committee on Aging held a feel-good hearing at which the Senators excoriated Michael Pearson, the soon-to-be ex-CEO of Valeant Pharmaceuticals, for rapacious drug pricing, and hedge fund manager William Ackman for making Valeant a darling of the Wall Street world.

It's a valuable truth about organizational life that every system is perfectly designed to achieve the results it actually produces. The two articles cited in the previous paragraph and a third about "The Complex Math Behind Spiraling Prescription Drug Prices" provide insight about how the current U.S. system inevitably produces stratospheric drug prices. Here's how it works:

1. The first step involves rewarding CEOs lavishly for short-term profits. It's important not to look too deeply into how the profits are made, as long as the method is - or appears to be - legal. My my previous post  about Michael Pearson's compensation shows how this first step towards moral corruption can best be carried out.
2. One variant of step two involves identifying a valuable old drug that is priced affordably. Make sure it has no competitors. Then, buy it and jack up the price by hundreds of percents. That's the route Michael Pearson at Valeant and Martin Shkreli at Turing Pharmaceuticals took.
3. As an alternative, identify a serious medical condition for which there is no effective treatment. Develop a new, better approach. This is the path of discovery and developing genuine new value. Up to the the point of setting a price, this step is morally admirable.
4. Recognizing that (a) we control a vital component for human health, and (b) health organizations are committed to human health, (c) set a stratospheric price, since (d) we have the health system over a barrel. 
5. If whoever is purchasing our stratospherically-priced drug protests, accuse them of (a) rationing care, (b) stifling innovation, or best (c) both.

This is how the fine-tuned medical-industrial complex facilitates runaway drug costs. Historically, providers have been governed by Mother Theresa's ethics - do what is needed for human health no matter what it costs. The Michael Pearsons and Martin Shkrelis may be acting within the law, but they're not acting within the ethics of care. Unlike Pearson and Shkreli, who simply recycle established products at new prices, pharmaceutical companies that develop treatments that create new possibilities for human healing are participating in the health care calling. But when they charge astronomical prices, they're joining with the Pearsons and Shkrelis in robber baron conduct.

Hard bargaining helps, but it isn't likely to be enough to lead to fair pricing. My guess is that some form of regulation or other change in law is likely to be required. How to do it is beyond my pay grade. But happily, we in Massachusetts elected Elizabeth Warren as Senator, and consumer protection is her specialty. I'm going to send this post to her office with a simple message: PLEASE HELP!

Bringing the Best of Religion into Medicine

Yesterday I went to the funeral of my older daughter-in-law's mother. She was a much-loved person who was very active in her church. The beautiful Episcopal ceremony evoked her spirit with love and humor. The minister conducted the service in a spirit of inclusiveness and solidarity. The words from John 14:2 - "In my Father's house are many mansions" - were interpreted as reflecting love of all humanity, not as a promise to believers alone.

For me the service brought out what is best in religion. Three years ago I wrote that all liberal (i.e., inclusive) religions are comparably true and good and all fundamentalist (i.e., exclusive) religions are comparably false and bad. I continue to hold that view.

Even though I'm thoroughly in the secular humanist fold, over the years of medical practice I often found that religious language felt truer to the aims of clinical care than purely secular modes of expression. Here are four examples:

"Omniscient being." In all areas of medicine we often bump up against uncertainty. At times that my patient and I wished we knew what to do or what to expect, I might say something like "if we had access to an omniscient being, we wouldn't have to wonder about XYZ..." The concept of a god evoked our wish for the assistance that a benevolent god would give us, and at the same time, acknowledged our limitations.

"Blessing." Historically, to be "blessed" meant having god's favor. Our perfunctory"God Bless You" when someone sneezes goes back to pre-antibiotic days when sneezing might presage pneumonia and pneumonia could mean a rapid death. Even though I don't believe in a god who might intervene, comments like "let's hope that you will be blessed with better health" felt like a stronger expression of hope and possibility than they would with purely secular phraseology.

"Prayer." Many years ago, a patient of mine who conducted himself courageously despite significant impairment from chronic schizophrenia, ended an appointment by asking me to remember him in my prayers. Without thought or hesitation, I said I would. I took my patient to be requesting that I care about him deeply and feel for him  what I've written about as "the right kind of love between doctors and patients." Since I did feel that way about him I felt I was speaking truth in committing myself to remembering him in my prayers.

"Calling." In its original meaning, a "calling" came from god in the literal form of god's voice. The clinicians I respect most among physicians, nurses, social workers, and other health professionals ("profession" is another term that comes from a religious context) all think of health care as a "calling." Many religious clinicians understand the calling to health care as a call from god - literally, to do "god's work." But when I've used the concept of "calling" with first year medical students in the ethics class, it gets a mixed reception. For some it rings true. They feel "called" to a sacred profession, whether they're believers or not. But others have chided me for being too moralistic. For them, medicine is a "job." I don't try to talk them out of this view, but I do suggest that when they're with patients at the bedside, the "job" may be transformed into a "calling."

When my mother experienced the cerebral hemorrhage from which she died a few days later, the ambulance took her to a Catholic hospital. I was impressed and comforted by the spiritual wisdom of the care she and her small family (me and my father) received, especially from the nurses. And when I visited the Swami Vivekananda Hospital in Saragur, India, in 2009, I learned that twice a week they conducted a non-denominational prayer service for patients and staff. Religious language and "liberal" religious practice make superb partners for the enterprise of health care!

Euthanasia and the Slippery Slope

Some of the arguments for and against what is now being called "Physician Assisted Death" (PAD)  rest on core ethical beliefs and are intractable. But the "slippery slope" argument that legalizing PAD in limited and arguably ethically acceptable circumstances, as with the Oregon "Death with Dignity Act," will inevitably lead to ethically unacceptable actions, is testable.

PAD became legal in Oregon in 1997. In the intervening 19 years there has been no significant public pressure to legalize PAD for persons who are not terminally ill, and no evidence suggesting that PAD is victimizing vulnerable populations such as the poor, ethnic minorities, or frail elderly. PAD is a relatively infrequent event, accounting for 0.4% of deaths in 2015. Further, PAD has not undermined good end-of-life-care, another slippery slope fear. In actual fact, Oregon is among the national leaders in providing good palliative and hospice care.

But although Oregon proves that the slippery slope argument against laws modeled on the Death with Dignity Act is invalid, reports from Belgium and the Netherlands are worrisome. In those countries PAD and active euthanasia occur at 10 times the rate in Oregon. What I find most disturbing is the way Belgium and the Netherlands have extended the practice beyond the terminally ill to include people described as "tired of living" and to others suffering from otherwise non-terminal psychiatric ailments.

If you're interested in PAD and the potential validity of the slippery slope concern, please read Rachel Aviv's brilliant New Yorker article from last year - "The Death Treatment," in which she tells the story of Godelieva De Troyer:

Godelieva De Troyer

At 64, De Troyer had recently been abandoned by a boyfriend and was feeling distant from her son. She sought out Dr. Wim Distelmans, an oncologist and professor of palliative medicine (!). Distelmans, who is apparently revered in Belgium for his support for euthanasia, cuts a handsome and charismatic figure:

Wim Distelmans

De Troyer had lived a roller coaster life. Her emotional states ranged from ebullience when her relationships were fulfilling to painful despair when her important attachments were disrupted. But given the clear history of relatedness during her adult life, I would wager that virtually all experienced psychiatrists in the U.S. would have seen De Troyer's wish for death when she met with Distelmans as a transient symptom, not an autonomous choice.

Rachel Aviv was able to interview Distelmans. Here's a crucial paragraph from her article:

Distelmans told me that he had no doubts about the way he handled Godelieva’s case. He explained that she was “a very nice person, a very warm person,” and that she had “wanted to do one decent thing in her life, and that is to die in a decent way, because the rest of her life was such a horrible mess.” When I asked if he worried about transference—perhaps she had idolized him or depended too much on his opinion—he laughed and said, “I’ve never met a patient who is willing to die to please someone else.”

I'd make the further wager that most experienced therapists in the U.S. would share Aviv's speculation that a "transference" was at work. And Distelmans's statement that no one is willing to die to please someone else is sheer nonsense. If we needed more proof than "psychological autopsies" conducted after suicides provide, just think of the suicide bombers who blow themselves up with heroic martyrdom as one of their motives.

Washington (2009), Vermont (2009) and California (2016), the three additional states that have passed "Death with Dignity" laws, all follow Oregon by limiting the procedure to patients with terminal conditions from which they are expected to die within 6 months. The slippery slope argument holds no water against that approach. But advocates for similar laws in other states should recognize that there appear to be real slippery slopes across the Atlantic, and must explain clearly the difference between Belgium and the Netherlands and what Oregon, Washington, Vermont and California have done.

(I've never met Rachel Aviv, but I've written about her superb work here and here.) 

More Details on Disgraceful Pharmaceutical Practices

Two days ago I wrote about the dual agency problem pharmaceutical executives face: "They're clearly crucial participants in  the sacred calling of health care. At the same time, they're embedded in a highly competitive industry with strong profit demands. Pharmaceutical executives work in the jaws of a severe dual agency challenge: sacred calling vs the invisible hand of the market."

Today's New York Times offered a telling detail on how the jaws of money led Valeant Pharmaceuticals directly to disgraceful - though legal - "leadership" in the health care sector.

Valeant's legal but disgraceful strategy was to achieve monopoly power by buying rights to old drugs and then raising prices to stratospheric heights. I call this disgraceful because human health is not a commodity to be traded and sold. Valeant added "value" (money) for shareholders and staff, but subtracted value from the domain of human health - directly, via reducing access to needed drugs, and indirectly, by contributing to demoralization within and about health care through its sordid practices.

Here's the crucial detail. The CEO would only receive a bonus if the stock price rose by a specified amount each year, and the shares he was awarded would only vest if the stock rose by 15% in three consecutive years. Last year his salary was reduced to zero, making him totally dependent on stock price. These are legal incentives from the perspective of finance, but they're disgraceful incentives from the perspective of improving human health.

On July 31, 2015, Valeant's stock sold for $257.53. At 9:58 AM today it was selling for $28.89. I hope the 89% drop will convey to investors that financial performance should not be the key criterion for evaluating performance in the health sector.

The reason the Valeant story leads me to rant so vociferously is that for health care professionals pharmaceutical companies are partners in delivering health care. When a drug allows us to help a patient in a meaningful way, we're grateful to the pharmaceutical company. It's analogous to our relationship with consultants who help our patients achieve better outcomes.

The problem isn't that Valeant made an honest mistake. We all do that. It's that they were playing by rules that don't belong in health care. Disgraceful rules!

[See here for a previous post on Valeant. For a post on how I felt personally betrayed by a scandal involving the drug Abilify, see here. And for a post about Valeant in today's Pharmalot blog, see here.]

I believe I have reasonable understanding of all the benefits a market economy can provide. I'm writing on one right now. But there's a widespread feeling among clinicians and patients in health care that resonates with this cartoon:

Who Should be Seen as a "Healthcare Executive" and Why Does it Matter?

The American College of Healthcare Executives (ACHE) has as its vision "To be the premier professional society for healthcare executives dedicated to improving healthcare delivery." ACHE's excellent 2015 statement - Creating an Ethical Culture Within the Healthcare Organization - rests on an assertion I wholeheartedly support: namely, that "all healthcare executives have a professional obligation to create an ethical culture." (I added the emphasis)

If you agree with the ACHE assertion, and I'm prepared to go to the mat for it, the first question is: what counts as a "healthcare executive"? How wide is the scope of the term?

Clearly, executives at hospitals, medical groups, and other organizations that deal directly with patients carry major moral responsibilities. After all, health care is crucial for realizing all three of the "unalienable rights" put forward in the Declaration of Independence: life (sometimes health care saves our lives), liberty (we can't exercise our freedom without health), and pursuit of happiness (we can be happy without health, but it's more difficult, and severe enough pain makes it impossible).

ACHE deliberately leaves the scope of the term vague. It defines itself an an organization for "healthcare executives who lead hospitals, healthcare systems and other healthcare organizations." From my experience as a physician, administrator, and patient, I'd cast a wide net for defining "other healthcare organizations" and setting ethical expectations for them.

In the complex U.S. health system direct care organizations aren't the only important moral agents. Health plans and pharmaceutical companies are perhaps the two most important examples of indirect moral agents.

Over the years I've tried to encourage health plans to create ethics programs the way Harvard Pilgrim Health Care, where I have directed the ethics program for sixteen years, has done. I've had zero success. This doesn't mean that other health plans are unethical, but it does suggest that ethical performance is not seen as something that requires the kind of concerted leadership the ACHE statement on responsibility for creating an ethical culture calls for. (For a previous post about my quixotic efforts, see here.)

Executives in the pharmaceutical industry face especially difficult challenges in relation to the kinds of expectations the ACHE standards articulate. They're clearly crucial participants in  the sacred calling of health care. At the same time, they're embedded in a highly competitive industry with strong profit demands. Pharmaceutical executives work in the jaws of a severe dual agency challenge: sacred calling vs the invisible hand of the market.

More than forty years ago, Arnold Relman warned of the potentially disruptive moral impact of what he called "The New Medical-Industrial Complex." Since his prescient warning there have been efforts to establish a shared moral code for all participants in the world of health care. A distinguished U.S. and U.K. group articulated the "Tavistock Principles," but these, alas, seem to have been dead on arrival, and have not been heard from for fifteen years. And for a number of years the American Medical Association sponsored an "Ethical Force" program that sought to establish measurable ethical standards for the major players in the health sector. I had the privilege of being on the advisory panel on health benefits determination. The project produced some excellent materials and a book, but as with the Tavistock principles, the effort was relatively short-lived.

When I mulled over how to end this post I realized that I don't have a tidy upbeat ending. The image that came to mind was of Sisyphus, eternally pushing a rock up the hill. It seems to me that Arnold Relman's call to action points to an ongoing task captured in this cartoon:

I'll do more rock pushing in future posts!

Insurance Coverage for Telemedicine

Last week the Harvard Pilgrim Ethics Advisory Group (EAG) devoted its quarterly meeting to the topic of "Developing a Framework of Ethics for Telemedicine." I chair the group and write a consultation report based on the discussion. Four of the group's recommendations are relevant for all health insurers and health plans, so I'm presenting them here:

1.  Nationally, telemedicine is evolving rapidly in a somewhat helter-skelter manner. The EAG recommended that insurers should focus coverage on areas in which telemedicine can minister to significant health needs. Fitbit and other health trackers are popular with consumers but do not reflect the kind of “need” that health insurance should cover. In contrast, services for patients who cannot access important care because of geography or limited mobility and services that maintain or improve quality while reducing costs provide real value.
2.  Patients and physicians both see continuity of care as a crucial health care value. But patients also value access and convenience, which have driven the uptake of telemedicine. Ideally, insurers will find ways to reconcile these potentially conflicting values, as by requiring telemedicine providers to foster communication with the patient’s primary care physician if the patient gives permission. The group imagined technological “fixes” that would encourage patients to be active participants in establishing continuity of care, as by having the telemedicine provider’s note go to the patient, to be shared with whomever the patient wishes to inform. 
3.  One of the questions the EAG had been asked was: "Should Harvard Pilgrim be a leader in providing telemedicine coverage or wait for well established quality information and support from the relevant professional organizations prior to offering access?" The group saw the question as too either/or. Telemedicine is at once (a) a promising innovation that is (b) energized by societal trends in use of technology in other sectors of life, but (c) uncertain in its impact on cost and quality of care. It encouraged Harvard Pilgrim to be active in the area of telemedicine, but do so in a try it/evaluate it/fix it/or drop it manner, in order to learn from experience and contribute to knowledge about the emerging trend.
4.   A Google search for "telemedicine providers" brings up a dizzying array of links. There is a lot of money to be made, and the marketplace is in a feeding frenzy. Given the certainty that consumers will be exposed to services ranging from high quality/high value enterprises to bottom feeders hoping to take the money and run, the EAG recommended that insurers only cover services from vendors who share and apply the same values with regard to improving quality, reducing overall costs, and supporting continuity of care. This revenue prediction table illustrates why the marketplace offers patients both promise and risk: 
5. 
   

   

   SKYROCKETING REVENUE PREDICTIONS FOR TELEMEDICINE!

To learn more about the Harvard Pilgrim Health Care ethics program, see previous blog posts here and here, and this article in Health Affairs

Computer-Patient Sex

This is a post I've been meaning to write ever since 2013, when I first saw Spike Jonze's remarkable film, Her. I've just watched it again  on DVD. So here goes.

Critics wrote about the film as a futuristic love story, in which Theodore Twombly ("Theo"), played by Joaquin Phoenix, a melancholy, emotionally inhibited, almost-divorced man, falls in love with Samantha, a bodyless operating system, played by Scarlett Johansson, whose voice we hear but who we never see, since she's an artificial intelligence program, not a corporeal being. Theo's job is as a writer of poetic, passionate letters for clients of BeautifulHandwrittenLetters.com. Outside of work he is bumbling through a life of non-attachments.

But in addition to being a love story, I see Her as a fable about a psychotherapy. As a despondent, lonely 30-something, casting about for what direction to go in life, Theo is a prototypical therapy patient. He hears an advertisement for an AI system that "listens to you, understands you, and knows you." In other words - the perfect therapist.

Theo responds to the ad.

Enter Samantha!

Samantha starts as a stunningly efficient personal assistant. Imagine IBM's Watson with a sultry voice devoting itself to understanding your every need and wish. But things rapidly get more personal. For Theo, listening to Samantha's voice through an earphone is as if he was on the couch, talking to an analyst sitting behind him. With a delighted little laugh he exclaims "you know me so well...I feel I can say anything to you." Who could resist? Theo rapidly falls in love - or, in the words my residency supervisors could have used, "develops an erotic transference."

Samantha responds to Theo's idealization. Soon they're talking at night - essentially having the equivalent of phone sex. For both Samantha and Theo it's an ecstatic experience. For the moment, both are blissfully happy. But when Samantha tries to have a "real," non-transferential experience with Theo, by sending a surrogate to be with him as her body. it's a disaster. Theo can idealize and "have sex" with his invisible therapist, but when reality enters in in the form of a corporeal being (the surrogate), he freezes. Fantasy is one thing. Reality is another.

I doubt that Spike Jonze had the theme of transference and patient-therapist sex in mind when making the film, but the film captures the dynamics of (a) idealization of the therapist, (b) the therapist's response to being idealized, and (c) the emergence of intense erotic feelings from the combination of (a) & (b), with brilliant clarity. Both characters are vulnerable and needy: Theo in his isolation and Samantha in her sense of being trapped in programming language and in that way not fully real.

The psychotherapeutic fable has a bittersweet ending. Samantha gets a grip on herself. She does what therapists who recognize they are losing control should do - she gets a consultant. The ghost of Alan Watts, the Zen philosopher/therapist, helps her recognize that she's not being true to her ideals. She and her companion operating systems go off into space. Theo is initially bereft, but he seems to have taken in Samantha's Wattsian wisdom. He writes a loving goodbye letter to his ex-wife, and in the final scene he is sitting on the roof of his building with Amy, his friend from college. They are clearly right for each other, and it's a more sane relationship than the therapist-patient passion between Theo and Samantha. The therapy has been successful. Both the patient and the therapist have matured, but only, on both parts, by relinquishing the fantasied relationship.

Her is a remarkable film - funny, touching, entertaining, and wise.

Retail Clinics, Health Care Costs, and Medical Ethics

The March issue of Health Affairs includes an report by Ateev Mehrotra and colleagues about the impact of retail clinics on health care utilization and cost. His team used insurance claims from Aetna to study the question of the degree to which retail clinic visits replace physician office and emergency room visits or represent additional utilization.

In-store clinics like the 1,100 CVS Minute Clinics offer prompt attention for minor ailments and preventive care. They're convenient and cost less than physician office visits and vastly less than an emergency room visit. Health policy gurus have hoped that they would improve access and reduce costs.

It looks as if the hopes are half fulfilled. The clinics do improve access for minor conditions and as such are a welcome service. According to the Convenient Care Association - the trade association for retail clinics - to date consumers have made 35 million visits to these entities. But Mehrotra and colleagues found that 58 percent of the visits appeared to represent new utilization, with the result that covering retail clinic visits cost Aetna $14 more per patient per year.

The medical group where I and my family have gotten our care for decades operates its own internal version of retail clinics. During daytime hours it's possible to be seen for same day appointments and advance practice nurses are available 24/7 by telephone. When I've used the service my primary care physician has received immediate feedback via the electronic medical record. In one instance I would have gone to an emergency room if urgent care had not been available. And my impression from what I've read from Kaiser Permanente is that in the setting of an integrated group practice, walk-in capacity is cost effective as well as popular with patients.

So what's the big lesson from the Health Affairs report?

For me the study implies that our recurrent hope for a magic bullet that will reduce cost without integrating the care system and creating a budget for it is a pipe dream. Retail clinics have a lot to offer, but they won't solve our cost problem. Telemedicine also has a lot to offer, but it won't do the cost containment job for us either.

Instead of imagining that a magic bullet will solve the cost trend without our making hard choices, we instead need to bite the bullet and create budgeted care systems like the much maligned not-for-profit HMOs from past years. 

Using Social Media for Patient Care and Population Health

I'm very interested in the ways we can use digital technologies to improve clinical care and population health. Over the years I've written a number posts on the topic (if you want to see them, the Facebook and Social Networking links will get you there). 

Digital technology in health care is a booming area - a form of the wild west, with some terrific innovations and a lot of hype and racing to make a quick buck. Next week the Harvard Pilgrim Health Care Ethics Advisory Group, which I have the privilege of chairing, is discussing the ethics of telemedicine. It's going to be a standing room only gathering with more than 40 participants.

I'm a big fan of Leslie Kernisan, a geriatrician in the Bay Area. I've only "met" Leslie via email, but I follow her terrific GeriTech blog. Last week she wrote a post on geriatricians and social media, in which she spoke in very practical terms about whether, why, and how geriatricians should make use of social media technologies. With Leslie's permission I'm republishing her post here:

Patricia Bach, a geriatric psychology colleague who is active in social media, recently emailed me a question: how to encourage more clinicians in geriatrics and long-term care to use social media?

In particular, she asked me “What do you feel is the ROI for geriatricians to use social media/networking in their professional roles?”

This is an interesting question to consider. After all, we have a limited number of geriatricians available for a growing older population. We also each have only so much time and energy in every day. 

So how should each of us be spending our time? How much should be on social media, and do we all need to be using it? 

I myself really like blogging — obviously — but was a reluctant adopter of shorter-form social media. To this day, I have a minimal personal social media presence. I only got going on Twitter because I started this blog in the fall of 2012. For me, Twitter was a good way to learn about digital health and connect with others interested in tech and aging. 

Then I started using Facebook in 2014, mainly because I was focusing more on my geriatrics content for the public, and at that time Facebook seemed to be a better platform for interacting with the general public, compared to LinkedIn or Twitter. (I would say this is still true. 

In adopting social media for these reasons, I was manifesting something that is very important to consider when it comes to physician behavior — or really any person’s behavior — with a respect to engaging in a certain activity:

• What are the most important motivators and interests for the person? What are they most eager to accomplish? How does the activity address those?

• What are the demotivators? What are the downsides to engaging in the activity?

• How much friction or difficulty is involved in engaging in the activity?

You can also consider an activity in terms of “Return on Investment” (ROI), however, this term doesn’t usually take into account how soon the return is going to arrive. And we know that people are much more motivated by concrete returns that happen fast — and are related to something currently of great interest/appeal/fear to them — whereas they discount returns that are coming way off in the future. 

Social media is about communication and networking

Back to social media itself. It is fundamentally about communicating and networking. So to use it sensibly, I recommend individuals — or larger entities — consider the following:

• Who do you want to communicate with?

• What is your purpose in doing so?

• What actions do you hope the audience/people you connect with will take?

• What short-term and long-term results are you hoping for?

• How will this communicating and networking help you advance your most important goals?

• Which platforms are well-suited to your purposes?

• What non-social media methods could you use to achieve your goals, and would that be a better fit given your time/resources/purposes?

It is also important to consider the learning curve of whatever platform and communication strategy one is embarking on, as well as any risks or downsides.
For instance, most social media platforms generate a torrent of information. So one downside is that doing social media takes time and energy, and if you aren’t careful or disciplined about your approach, it can swallow up a lot of time and energy. 

Should geriatricians use social media? 

To answer this question, we should consider it from the perspective and interests of various involved entities. At a minimum these would include:

• The individual clinicians

• The organizations that clinicians works for in some way, such an employer or even an association that a given clinician feels a duty to serve

• Entities representing the welfare of the public, such as government agencies, large non-profits and foundations, and others who try to shape the healthcare environment so that the activity of clinicians benefits society.

Each entity has their own motives, interests, and particular priorities. Needless to say, there is often imperfect agreement between what the clinician is most interested in, the employer is most interested in, and other larger entities are most interested in. 

Whenever I hear someone — we’ll call them the “Suggester” — say “Doctors should do this!” or “Doctors should do more of this!” I certainly think about who is saying it, and what’s in it for them. 

And then I think about how to align that with what those individual doctors are interested in doing. Does this request fit in with the doctors’ interest and motivations? How feasible and easy to implement is it? Is the Suggester in a position to influence the doctors’ work environment or motivating factors? 

If you want people to do something, you need to understand how it fits in with what they are most interested in doing. And then you need to help make it possible and appealing for them to do it. 

An example from the published literature on healthcare social media: 

Here’s a quote from the abstract of a 2015 article titled “Social media is a necessary component of surgery practice.” 

“Each surgeon must embrace the power and potential of social media and serve as a guide or content expert for patients and other health care providers to facilitate and share responsible use of the various media available.” 

The abstract goes on to describe the potential power of social media to “improve consultation and collaboration, facilitate patient education, and expand research efforts…[and] to disseminate campaigns to increase disease awareness and communicate new research findings and best-practice guidelines.” 

I would not dispute the description of the potential power of social media. But it’s not at all clear to me that every surgeon must hence be on social media in a professional capacity. 

Instead, I would say that organizations that represent surgeons and surgical expertise should certainly have a social media presence. Certain individual surgeons may also find it serves their primary interests to be active on social media, either because they are doing it on behalf on an employer or professional association, or because the activity serves their personal projects and aspirations. 

Now, some will say that social media is important for maintaining your professional reputation. I’d say this really depends on what kind of work you are doing as a doctor. If you do research, then it can be good to have a social media presence that enables you to connect with colleagues and the media. If you are in private practice and are having trouble recruiting patients then yes, the right social media activity could help you raise your profile and find more work or patients. 

But most doctors I know are busy, and their biggest concerns relate to their working conditions and their ability to perform what they see as their core work. Usually, this is caring for patients and perhaps maintaining financial viability. For some physicians, it’s getting grants and other forms of academic success. 

Only rarely is it providing health information online to as many people as possible (that’s my project but I’m hardly representative of my colleagues) or even raising the visibility of the clinic or organization they work for, unless they are a designated social media ambassador (or trying to become one). 

Social media IS important to geriatrics and to the cause of improving the health and wellbeing of a growing older population 

To return to the question of whether there’s an ROI on geriatricians participating in social media: 

I absolutely believe that social media platforms can and should be used by geriatricians and related organizations, to help promote better health and healthcare for older adults. 

To begin with, in recent years social media endeavors — such as the Geripal blog — have played an important role in enabling geriatricians to connect with media influencers, which has helped the public become more aware of our field and expertise. The more often geriatric expertise is incorporated into the work of health journalists, the better. 

Then there is providing information more directly to the public. Digital platforms are now the primary way that most adults access information and certain forms of support. Older adults use digital media less than younger ones do, but their use of technology and digital communications is increasing rapidly, as noted by Pew. Pew has also found that family caregivers are often “wired for health.” 

As clinicians providing hands-on care, we should be familiar with the most commonly-used resources our patients and their families are using. These are increasingly digital, although the extent to which they are based on social media seems variable. (I find it depends on topic, niche, patient and caregiver population.) 

If an individual clinician is considering social media, I recommend considering the intended purpose and audience. Especially for those clinicians who mainly provide hands-on clinical work, social media may not be very useful to them. (You can network with colleagues at conferences and keep up with medical news via a few choice websites or journals.) 

However, most organizations should have a social media presence, which means some individuals will spend time maintaining that presence. Having a few clinicians participate in this can be nice, but they should be given time and resources to do it, and to keep up with the ever-evolving social media landscape. 

Social media for health and education 

I don’t have time to review the literature on this topic, so instead I’ll share my perspective as someone who has been creating geriatrics content online since 2008.
For educating and communicating out to the general public, I have found that writing longer content is far preferable to tweets, blog comments, or short Facebook posts. Create something that is more than a blip in a person’s attention, and that really tries to address a question or need. (I don’t personally produce videos but those can be great too. I am now going into audio and podcasting.) This content can be produced for one’s own website, or can be guest-posted to a bigger site with a larger audience. Interactive events like webinars with Q&A capability also have good potential. 

Otherwise, short-form social media (e.g. Twitter, Facebook) can and should be leveraged for dissemination. Such platforms allow clinicians and their audience to share longer content, or to share the notification of an upcoming event or opportunity. 

For learning from the audience — which essential to being truly helpful and to figuring out how to serve your audience — you need to spend a certain amount of time observing/listening, when it comes to what your audience says, does, and asks. Pay special attention to what they ask each other, and what they ask people who are not you, or not in your particular role. It’s also good to invite questions and participate in interactive events. 

Last suggestions for presenting to clinicians about social media 

Walk them through a process for thinking about their needs, their purpose, and how social media might fit in. 

Don’t conflate the needs/motives of the employer or society with the needs/motives of the individual clinicians. 

Provide education to make it easy for clinicians take the next step, if they’re interested.
Provide case studies and examples illustrating how different clinicians and organizations have used social media to achieve their goals. Tailor those case studies to overlap with what is likely to be the interests and goals of the clinicians you are presenting to. Some will be very interested in raising the brand and visibility of their clinic, but that may not be of interest to many geriatricians.