Oncologists are notoriously bad at predicting survival, and none of us wants to be known as “the doctor who told me I would be dead by now,” the doctor who made a prediction of imminent demise, sending a family into a terrifying tailspin of goodbyes, only to be proven wrong and subsequently mocked for years to come. One of my patients, upon being told by another doctor that she had two months to live, held Christmas in April so she could spend one last holiday with her grandchildren. She survived to see two more Christmases.

At the same time, we need to be truthful and give guidance to people who want time to prepare, time to write wills and pay off debts, to say goodbyes and to leave instructions, to tie up the loose ends of a life now heavy with meaning.

We try to provide hope, but not false hope.

So we give ranges, starting with the best estimate of survival, because my patients have told me they shut down after they hear the worst estimate. We talk about setting goals, about maximizing quality of life, because we don’t have much leverage with quantity of life. We emphasize spending as much time as possible with family and friends, and as little time as possible with people wearing white coats. We tell them we’re not going to give up if they don’t give up.

But the truth is, we don’t know.

More.

Longer shifts make nurses more likely to experience burnout and job dissatisfaction and also make patients more likely to be dissatisfied with care, according to a study.

In what was described as the first study to examine the relationship between nurse shift length and patients’ assessment of care, researchers from the University of Pennsylvania School of Nursing reported that nurses working shifts of 10 hours or longer were up to 2.5 times more likely than nurses working shorter shifts to experience burnout and job dissatisfaction.

When shifts of 12 hours or longer "are combined with overtime, shifts that rotate between day and night duty and consecutive shifts, nurses are at risk for fatigue and burnout, which may compromise patient care," Amy Witkoski Stimpfel, RN, PhD, a post-doctoral fellow at Penn Nursing’s Center for Health Outcomes and Policy Research, said in a news release.

Nearly 23,000 RNs took part in the study over a three-year period in California, Florida, New Jersey and Pennsylvania, states that represent about 25% population and 20% of annual hospitalizations in the U.S.

Survey data showed more than 80% of the nurses were satisfied with scheduling practices at their hospitals. However, as the proportion of hospital nurses working shifts of more than 13 hours increased, patients’ dissatisfaction with care increased.

The percentages of nurses who reported burnout and intention to leave their job increased incrementally as shift length increased, the researchers wrote. In hospitals with higher proportions of nurses working longer shifts, higher percentages of patients reported that nurses sometimes or never communicated well, pain was sometimes or never well controlled, and they sometimes or never received help as soon as they wanted.

Witkoski Stimpfel and co-authors recommend restricting the number of consecutive hours worked. They also said state boards of nursing should consider whether restrictions on nurse shift length and voluntary overtime are advisable, and nurse management should monitor nurses’ hours worked, including second jobs.

More.

The nursing profession should harness the power of the video-sharing website YouTube to promote a positive image of nurses, said study authors who investigated the portrayal of nurses on some of the most popular videos.

The researchers examined the YouTube database to find the most viewed videos for "nurses" and "nursing" as of July 2010. They included 96 videos after preliminary analysis of the first 50 hits for each word. They analyzed the top 10 hits, attracting between 61,695 and 901,439 views, in greater detail.

"Our study found that nurses were depicted in three main ways — as a skilled knower and doer, a sexual plaything and a witless incompetent," coauthor Gerard Fealy, PhD, from the School of Nursing, Midwifery and Health Systems at University College Dublin in Ireland, said in a news release.

Key findings of the study, which appears in the August issue of the Journal of Advanced Nursing, included:

• The 10 most viewed videos reflected a variety of media, including promotional videos, advertising, excerpts from a TV situation comedy and a cartoon. Some texts dramatized, caricatured and parodied nurse-patient and interprofessional encounters.

• Four of the 10 clips were posted by nurses and presented images of them as educated, smart and technically skilled. They included nurses being interviewed, dancing and performing a rap song, all of which portrayed nursing as a valuable and rewarding career. The nurses were shown as a distinct professional group working in busy clinical hospitals, where their knowledge and skills counted.

• Nurses were portrayed as sexual playthings in media-generated video clips from the sitcom Frasier, a Virgin Mobile commercial set in a hospital, a lingerie advertisement and a "soft news" item on an Internet videocast. All showed the nurses as provocatively dressed objects of male sexual fantasies and willing accomplices in their advances.

More.

Doctors were told last month that we should stop doing so many screenings for prostate cancer with the prostate-specific antigen test. We learned that sigmoidoscopy is a cheaper, easier and effective alternative to colonoscopy for colon cancer screening. And a study I led turned up strong evidence that routine lung cancer screenings are justified only for people at high risk because of heavy smoking in the past.

Regular mammograms aren’t necessary for women in their 40s and are needed only every two years for women ages 50 to 74, the United States Preventive Services Task Force has decided. For many women, Pap smears are required only every three years, not every year, the group also says now.

This deluge of do-less recommendations results from research into tests and procedures that have been arguably overused. You’d think these pronouncements would bring a sea change in the way patients are treated in this country. But my guess is that little will change. Many doctors, maybe most, will ignore these findings and keep doing what they have been doing all along.

The PSA test will still be ordered as a matter of routine, not selectively administered after careful discussion with patients. Colonoscopy will remain the accepted primary method for colon cancer screening. Radiology centers will continue to offer lung cancer screening to people who are unlikely to get lung cancer.

Why? Health care critics are quick to point to the profit motive. And it’s true that gastroenterologists, radiologists, urologists and physicians of all stripes make money from procedures that may not be necessary. But the real obstacle is not money. It’s the culture of doctors, and that will be very hard to change.

In medical school, I was given textbooks and made to memorize long lists of obscure facts, most of which have never come up in practice. Then I sat at the knee of master doctors. I followed them around. I learned to emulate what they did and how they thought. Over the years, I gained some approximation of their mastery. At times, I’ve even found myself mirroring how they stood and leafed through a patient’s chart.

Subtly, and then overtly, I learned that as long as I trusted my instincts, I was probably going to be right. Because doctors know best.

Ours is a comfortable hegemony, particularly if you do not question it. It has teeth, too. A strong defense to a malpractice lawsuit is that you did what other doctors in your community would have done — the “community standard” test. Citing anodyne research written by faraway experts to back up your actions is a less preferable strategy.

More.

For over a generation now, efforts to make health care more patient-friendly have focused on getting patients and doctors to work together to make decisions about care and treatment. Numerous research papers, conferences and advocacy organizations have been devoted to this topic of “shared decision-making,” and even politicians have clambered aboard the train, devoting several provisions in the Affordable Care Act to “preference-sensitive care.”

But one thing has been missing in nearly all of these earnest efforts to encourage doctors to share the decision-making process. That is, ironically, the patient’s perspective.

Now a study published in the most recent issue of Health Affairs has begun to uncover some of that perspective, and the news is not good. In our enthusiasm for all things patient-centered, we seem to have, as the saying goes, taken the thought of including patient preferences for the deed.

The researchers conducted several focus groups with 48 patients from five primary care physicians in the San Francisco Bay area. First, they showed the patient participants a short video on several equally effective but very different treatment approaches for a heart ailment. Then, they asked them questions about what they did with their own doctors when faced with a choice among several treatment options that might be equally effective but could differ in lifestyle effects, cost or range of complications. Finally, the researchers asked the participants if they were comfortable asking doctors about different treatments, discussing their values and preferences or disagreeing with their doctors’ recommendations.

The participants responded that they felt limited, almost trapped into certain ways of speaking with their doctors. They said they wanted to collaborate in decisions about their care but felt they couldn’t because doctors often acted authoritarian, rather than authoritative. A large number worried about upsetting or angering their doctors and believed that they were best served by acting as “supplicants” toward the doctor “who knows best.” Many also believed that they could depend only on themselves for getting more information about treatments or diseases. Some even said they feared retribution by doctors who could ultimately affect their care and how they did.

The findings fly in the face of previous optimistic assumptions about shared decision-making that were based mostly on studies that examined physicians’ intent, but not patient perceptions. “Many physicians say they are already doing shared decision-making,” said Dominick L. Frosch, lead author of the new study and an associate investigator in the Department of Health Services Research at the Palo Alto Medical Foundation Research Institute in California. “But patients still aren’t perceiving the relationship as a partnership.”

Interestingly, most participants in this study were over 50, lived in affluent areas and had either attended or completed graduate school. “It’s hard to think that people from more disadvantaged backgrounds would find it any easier to question doctors,” Dr. Frosch said.

More.

For patients, navigating the medical system is a struggle — even when they are relatively well. It’s worse when they’re sick, such as patients with complex medical problems requiring urgent attention, like work-ups for cancer. Simply trying to coordinate appointments between specialists can be incredibly frustrating and time-consuming. And because specialists often work in individual silos, they don’t communicate with one another, leaving hapless patients and their families to shuffle themselves and their reams of information from one specialist to the next.

A recent survey commissioned by ZocDoc, which is trying to apply an OpenTable-style online scheduling model to health care, found that young adults are especially frustrated with the current health-care infrastructure. More than half of 2,000 18-to-34-year-olds surveyed said they delayed getting medical care because the process is a “pain.” More than 60% of these tech-savvy Gen Yers — who are accustomed to scheduling their lives with the touch of a screen — said they felt they were at the mercy of their doctor’s receptionist just to make an appointment.

More.

Kyle Gospodarek expected to feel nervous about seeing a dead body up close on his first day of anatomy lab. He steeled himself for the smell — a pungent blend of latex, embalming fluid and something indescribable whose odor would cling to his clothes for days — but he never imagined he would have to get in touch with the cadaver’s family. "I’ll be honest: when I first heard about what we were doing, I was weirded out," he says. "I didn’t know what to say to them."

At Indiana University Northwest, an IU branch campus located in Gary, Ind., anatomy professor Ernest Talarico instructs his medical students to probe beyond the nerves and muscles of the bodies lying on their examination tables and think of the cadavers as their "first patients." "We ask students to use the name of the patient out of respect and to acknowledge that this was a person," he says. His students also typically exchange letters with family members to glean more information about their patients’ medical histories, hobbies and interests. They may even meet the family in person at the conclusion of the course during a memorial service held in the laboratory.

The annals of medical school training are filled with sordid tales of students taking glam shots with corpses or assigning unflattering nicknames to cadavers. When Talarico was in medical school, he remembers his classmates calling one cadaver "Salty" because of the tattoo of the naked woman on his chest. "These people had lives and names," he says, "and to use other names disrespects them."

Talarico believes his approach not only helps students be more respectful of the individuals who have given their bodies to science but also prepares them to act as empathetic clinicians when they’re faced with the cold, hard medical decisions they’ll have to make in their careers. He has no formal data to prove his approach gets better results, but anecdotally, the students say they feel better prepared to address patients as individuals and consider their feelings. As one student, Adam Harker, explains: "I think it translates into better post-op care and compliance."

While Talarico has won praise from many of the individuals involved in the program, he’s also raised concerns among critics who question the ethics of his teaching technique. When donated bodies are passed on to medical schools, the institutions are usually only given the basics — the donor’s name, gender, age and immediate cause of death. The name of the donor is typically not shared with students, and students do not usually interact with the donor’s next of kin.

More.

People with higher levels of education and higher income have lower rates of many chronic diseases compared with those with less education and lower income levels, according to "Health, United States, 2011," the government’s 35th annual report on Americans’ health.

The report was prepared by the CDC’s National Center for Health Statistics and includes a compilation of health data through 2010 from various sources within the federal government and in the private sector. This year’s edition features a special section on socioeconomic status and health, with several key findings.

Head of household: In 2007-10, higher levels of education among the head of household resulted in lower rates of obesity among boys and girls ages 2 to 19. In households where the head had less than a high school education, 24% of boys and 22% of girls were obese. In households where the head had a bachelor’s degree or higher, obesity prevalence was 11% for boys and 7% for girls.

Adult women: In 2007-10, women 25 and older with less than a bachelor’s degree were more likely to be obese (39%-43%) than those with a bachelor’s degree or higher (25%). Obesity prevalence among adult males did not vary consistently with level of education.

Smoking: In 2010, 31% of adults ages 25 to 64 with a high school diploma or less were smokers, compared with 24% of adults with some college and 9% of adults with a bachelor’s degree or higher. Overall, 19% of U.S. adults ages 18 and older smoked cigarettes, a decline from 21% in 2009.

Life expectancy: Between 1996 and 2006, the gap in life expectancy at age 25 between those with less than a high school education and those with a bachelor’s degree or higher increased by 1.9 years for men and 2.8 years for women. In 2006, 25-year-old men without a high school diploma had an average life expectancy of 9.3 years fewer than those with a bachelor’s degree or higher. Women without a high school diploma had a life expectancy of 8.6 years fewer than those with a bachelor’s degree or higher.

Healthcare coverage: Between 2000 and 2010, the number of children with a family income below 200% of poverty level who were uninsured decreased from 22% to between 11% and 13%. The number with a family income at 200% to 399% of the poverty level who were uninsured decreased from 9% to 7%, while the number with a family income at 400% of the poverty level who were uninsured decreased from 3% to 2%.

More.

Studies have shown in recent years that the quality of data in many electronic medical records is often not very good. According to Peter Witonsky, president and chief sales officer at iSirona, this is largely due to simple inaccuracies that occur more often than we think.

"A lot of these fall into the same category, in my mind, but it's different ways of getting to that category," said said Witonsky. "That latency of data is terrible. We have customers, prior to us, with eight to 10 hours in latency of data, and that's not uncommon. It's not the end of the world, but there are tons and tons of examples of what latency of data will do to decision making on the other side."

Witonsky highlights five reasons why data inaccuracies occur in EMRs.

1.Simple miskeying. Although it may be easy and "quite common," said Witonsky, the main way data inaccuracies tend to occur is because of simple miskeying. "If you look at any nurse of any floor, there's about 1,000 or over 1,000 data elements a shift that person is responsible for," he said. "So if you're an ICU nurse, and you're taking vitals and other critical information every 15 minutes, or if you're a low acuity nurse and you have for patients to be responsible for, it seems to average out just north of 1,000 data elements." And to expect a nurse to key in those elements with 100 percent accuracy isn't a realistic goal, Witonsky said. "The idea any person [can do that] is ludicrous," he said. 

2.Miscommunication from the patient. Bad information or miscommunication from the patient is another all-too-common way these inaccuracies can occur, said Witonsky. And this can include the patient not telling which drugs they're on, not knowing the name of the drug or the dosage or even the patient lying about his or her weight. "So it's sort of a garbage in, garbage out theory," said Witonsky. "If you don't tell me that you're allergic [to a drug] and I give you Penicillin and it's a bad result, again, that's bad data in the EMR." It's for that reason, he pointed out, that most of today's EMRs have allergies highlighted at the top of every patient screen.

3.Wrong entry or lack of entering device data. Looking back to simple miskeying, said Witonsky, 1,000 data elements, over time, is "an awful lot of work," he said. "So you have something called smoothing, [which is] a long practice of smoothing data where a nurse of physician is expecting to see normal [results], and they put in normal regardless of what the device is telling you." These generic readings tend to bring out inconsistencies in data, he continued, which wouldn't occur if the person inputting data took the actual information from the device. "That's not intended to be a knock," he said. "That's intended to say, in performing the hardest job on the planet, if they knew [a patient] was healthy, they leave all the vitals on the machine and may choose to put [the patient] in as a normal patient, as opposed to the exact answers."

More.

Hospital patients waiting in an emergency room or convalescing after surgery are being confronted by an unexpected visitor: a debt collector at bedside.

This and other aggressive tactics by one of the nation’s largest collectors of medical debts, Accretive Health, were revealed on Tuesday by the Minnesota attorney general, raising concerns that such practices have become common at hospitals across the country.

The tactics, like embedding debt collectors as employees in emergency rooms and demanding that patients pay before receiving treatment, were outlined in hundreds of company documents released by the attorney general. And they cast a spotlight on the increasingly desperate strategies among hospitals to recoup payments as their unpaid debts mount.

To patients, the debt collectors may look indistinguishable from hospital employees, may demand they pay outstanding bills and may discourage them from seeking emergency care at all, even using scripts like those in collection boiler rooms, according to the documents and employees interviewed by The New York Times.

In some cases, the company’s workers had access to health information while persuading patients to pay overdue bills, possibly in violation of federal privacy laws, the documents indicate.

The attorney general, Lori Swanson, also said that Accretive employees may have broken the law by not clearly identifying themselves as debt collectors.

Accretive Health has contracts not only with two hospitals cited in Minnesota but also with some of the largest hospital systems in the country, including Henry Ford Health System in Michigan and Intermountain Healthcare in Utah. Company executives declined to comment on Tuesday.

More.