Friday, May 16, 2008

All about bedside manner

This will likely be my last post for a while as my 2nd boy is due to be born in a few days. I'll be back in time however to mark the beginning of Pallimed's 4th year in the 2nd half of June. Yikes.

Christian has been working overtime on an up & coming expansion of the Pallimed 'family' too, which he will likely be announced while I'm away, & I just wanted to take this moment to acknowledge Christian's efforts and vision.

On to bedside manner.... (or is it bed-side manner?)

NEJM has a perspective piece on 'etiquette based medicine' (free full-text available). It's a brief article about teaching bedside manners & etiquette and engages in a discussion of whether it's better to encourage doctors to be more 'humane' and compassionate or, simply, to be polite and attentive. I think this is a very reasonable proposal and is often what I teach trainees. I'd love it if all doctors were genuinely empathetic and compassionate, and cared about their patients' suffering and lived-experience of their illness. However, you can do that and not have good bedside manner, and, as I opined on the blog earlier, having too much (or the wrong kind) of emotional response to our patients' suffering does not necessarily make one a better physician or help our patients.

In short, I think we should teach young doctors to fake it (although that should occur concurrently with mentoring in and role-modeling in genuine compassion) and I tend to tell trainees to 1) pretend you have all the time in the world (fake it!) - sit down, appear relaxed and confident, make a tiny amount of general small talk 'how's your day going?' etc, 2) ask directly about and listen attentively for emotional/existential components of a patient's experience and reflect back to them what you've heard, and 3) give an outward display of being calm, in control, and confident (fake it!) in your ability to meet a patient's needs (not that you know everything but that you know what you know, know what you don't know, know where to turn to get your patient's needs met, and know what is unknowable so at least you can confidently tell a patient that). Of course you have to 'care enough' to do this but frankly you could do all this out of pure self-interest (in the long run it's time saving and your patients will like you more which makes everything easier) and I think the fundamental message we should be sending to trainees is that they should give 'good care' (which includes faking this stuff) and get less caught up in trying to be 'caring.' A quote:

Training for an etiquette-based approach to patient care would complement, rather than replace, efforts to train physicians to be more humane. Pedagogically, an argument could be made for etiquette-based medicine to take priority over compassion-based medicine. The finer points of patient care should be built on a base of good manners. Beginning pianists don't take courses in musicianship and artistic sensibility; they learn how to have proper posture at the piano and how to play scales and are expected to develop those higher-level skills through a lifetime of study and practice. I may or may not be able to teach students or residents to be curious about the world, to see things through the patient's eyes, or to tolerate suffering. I think I can, however, train them to shake a patient's hand, sit down during a conversation, and pay attention. Such behavior provides the necessary — if not always sufficient — foundation for the patient to have a satisfying experience.
(Thanks to Dr. Sean Marks for alerting me to this.)

On a related note BMJ published a randomized controlled trial of the placebo-effect. (I love the cover they created for this issue.) It involved ~260 patients with irritable bowel syndrome who were randomized to observation (a waiting list), sham acupuncture performed in a cold, perfunctory way (the practitioners would tell the patient that this was a scientific study and that they weren't to talk with the patients), or sham acupuncture performed by practitioners who were deliberately kind, caring, warm, etc. As you'd expect, everyone's symptoms improved but did so in a step-wise manner (which the authors somewhat cheekily describe as a dose-response curve of the placebo effect): cold sham acupuncture did better than observation and warm/friendly sham acupuncture did best of all.

Their intentions with the study were to delineate and measure different potential components of the placebo effect (e.g. the effect of a sham procedure vs. the effect of interactions with warm, caring clinicians - it would have made an even more interesting study if they had had a caring practitioner-only arm) - and while that's an interesting topic what's more interesting to me is the observation that the bed-side manner of the clinicians improved the subjects' symptoms. This is of course not at all surprising but, heck, what's wrong with a little 'data' to back up our claims that warmth, listening, etc. are therapeutic in and of themselves. One also wonders if it's appropriate to even call this the placebo-effect (which, accurate or not, has a connotation that it's from a patient's mind being 'tricked' into a therapeutic response) as opposed to something else (a 'therapeutic demeanor,' 'therapeutic listening' etc. etc.).

There were several accompanying editorials which are worth reading as well. One about the research ethics of studying placebo effects. And a quote from another one:

That this study chose to evaluate placebo effects associated with an unconventional treatment raises further interesting questions. It is already widely assumed by sceptics that most if not all of the benefit of "alternative" or integrative medicine comes from the placebo effect. It is then assumed that demonstration of a powerful placebo effect, without proving a specific effect, is enough to consign the treatment to the realm of quackery. But what if we asked a different question? Is it possible that the alternative medical community has tended historically to understand something important about the experience of illness and the ritual of doctor-patient interactions that the rest of medicine might do well to hear? Many people may be drawn to alternative practitioners because of the holistic concern for their wellbeing they are likely to experience, and many may also experience appreciable placebo responses. Why shouldn’t we try to understand what alternative practitioners know and do, as this may help explain why so many patients are prepared to pay to be treated by them, even when many of the treatments are unproven?

And a futile attempt to clean out my 'to-blog' pile prior to my leave (and yes the pile is messy, sorry):
  • Critical Care Medicine has a paper looking at the appropriateness of using data from chart reviews to determine the quality of care of the dying in an ICU (whether certain data gleanable from a chart review can reliably predict quality of death).
  • JCO has a validation study of a prognostic model for colorectal cancer which includes WBC count, alkaline phosphatase, and patient self-reported social functioning.
  • JCO also has a systematic review of the treatment of dyspnea in 'terminally ill' cancer patients. The most interesting aspect of it, for me, was its review of trials for non-pharmacologic measures, most of which were nursing psychosocial and educational interventions (they seemed to work). Acupuncture didn't seem to work, but perhaps the practitioners' bed-side manner wasn't that good.
  • Annals of Internal Medicine has a narrative review of office buprenorphine for treating opioid-dependence.
  • JAMA has a clinical review about chronic low back pain. A reasonable addition to the teaching file. Mentions opioids and the controversies about their role for CLBP.
  • Supportive Care in Cancer has a case series looking at the natural history of patients who receive implanted peritoneal drainage catheters for malignant ascites. This is certainly a well-described practice, but this is the first study that I've seen which tries to measure how a group of these patients fared after catheter placement (which was OK - mean survival was 39 days which is not surprising given that they had refractory malignant ascites; relatively few complications from the catheter; and the majority of patients reported benefit from catheter placement).
  • Journal of Pain has a rat study looking at oxycodone plus ultra-low-dose naltrexone & the pathophysiology of neuropathic pain and hyperalgesia. Not that this study is practice changing but it's part of a growing body of mostly pre-clinical data about the possible analgesic benefits of opioid receptor antagonists (like naloxone and naltrexone) which I find interesting and am impatient for some human studies (case reports like this one are tantalizing - I'm very curious if anyone actually has any clinical experience with this).
  • J Pain also has a placebo controlled trial of marijuana cigarettes for neuropathic pain. Somewhat helpful, but 'neuropsychiatric' side effects (aka 'feeling stoned') were significant.
  • Archives of Internal Medicine has a narrative review of studies trying to define 'quality of dying.' Some interesting comments from its conclusion (personally I don't think I'm about to start using the term 'least undesirable death'):

    Second, good death is subjectively determined and, therefore, attempts to ascertain the objective "truth" of the end-of-life experience may be futile. We must, instead, acknowledge and accept the subjectivity inherent in all accounts, whether provided by patients, family, or health care professionals, and determine how to make use of these multiple perspectives. More research is needed to understand factors that influence end-of-life preferences and experiences, including sociodemographic factors, individual psychology, religious and cultural background, and social and health care context. Third, emphasis on good death could lead to ways of dying being normalized or pathologized. Both commonality and diversity of opinion were identified in the reviewed studies, which justifies caution regarding the assumption that there is a singular good death. Because a good death may be an unachievable or euphemistic goal, several authors have suggested terms such as good enough, appropriate, or least undesirable death. A focus on an acceptable, if not ideal, death may have the advantage of being a less prescriptive, less value-laden, and more realistic framework for end-of-life care.

  • And for those of you interested in the 'open-access' movement in scientific and medical publishing, Scientific American has a lengthy article discussing this, its pros and cons, and new trends which are emerging beyond just open access to published articles (like making your entire data-set freely available online). (Thanks to my brother, Luke, for alerting me to this.)

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