Wednesday, October 15, 2008

Magnesium Citrate #1: Empathy, Massage, fMRIs, More

I have reached some sort of critical-mass of articles-to-blog, so much so that I am developing a feeling of paralysis as I've realized I've been sitting on some papers for over a month. I've decided it's time for some Magnesium Citrate, if you know what I mean, and so plan on a few disorganized Pall-pourri-type posts to get some things out there that are worth a look, albeit without much commentary - sorry.

Archives of Internal Medicine has a look at missed opportunities for empathy in clinical encounters with lung cancer patients. The study involves analyzing clinic visit audio recordings between physicians and lung cancer patients in a Veterans Administration hospital - looking at emotional content, physician responses, etc. They don't specify explicitly where in their disease the patients were but the methods section implies these were patients being seen near the time of diagnosis or even prior to formal diagnosis as they were being evaluated in a thoracic oncology clinic. Can you guess the results? Patients made frequent remarks involving emotional needs or other concerns throughout the visit (median of 18 times/visit) and physicians made empathetic statements about twice a visit - mostly stacked toward the end although patients made 'empathy-worthy' comments throughout. Surgeons were less likely to be empathetic than oncologists, and the most common themes which physicians responded empathetically to were concerns about the health care system (presumably troubles with clinic waiting times, drug co-pays, etc.) not 'actual' medical concerns about the cancer, prognosis, treatment, etc.

This sort of research (research which closely analyzes the specific content of patient encounters) is fascinating but it's not the sort of thing one should make any conclusions about - it's purely descriptive at this point, but one hopes as this evolves that will change....

Annals of Internal Medicine has a research paper comparing simple touch to massage therapy for pain in advance cancer patients. The study involved randomizing ~300 advanced cancer patients (either receiving hospice care or from a single academic cancer center) who had pain at least 4/10 to 6, 30 minute sessions over 2 weeks of either massage (given by certified massage therapists - they described in detail in the study what they did) vs. simple touch as a control. While obviously unblinded they really tried controlling for factors such as attention, time spent with the patient, etc:
We designed the control exposure, simple touch, to control for the time, attention, touch, and healing intent components of the intervention. The control consisted of placement of both hands on the participant for 3 minutes at each of the following locations bilaterally: base of neck, shoulder blades, lower back, calves, heels, clavicles, lower arms, hands, patellae, and feet. Pressure was light and consistent, with no side-to-sidehand movement. Control therapy providers interrupted conscious healing intention by silently counting backward from 100 by 7, reciting nursery rhymes, or planning their day's activities. The control treatments were provided by individuals with no past body or energy work experience.
Essentially they found both interventions led to immediate improvements in pain, massage more so: 2 point improvement overall compared to 1 point improvement with simple touch on an 11-point scale. There were no differences however in sustained pain relief (baseline pain at 1, 2, and 3 weeks after the initation of the trial (both groups had a slight diminishement in pain). So: massage is helpful, albeit only on a short time frame. Besides that finding, this is study is notable because 1) it involved a lot of hospice patients, traditionally thought of as a 'tough-to-study' population, 2) it was a pretty big study overall given the context (symptom management in advanced cancer), and 3) it is an example of next-generation, well-designed, controlled trials of 'alternative medicine' therapies.

Lancet Neurology has a study suggesting that patients in the 'minimally conscious state' experience pain. It's based on comparing healthy controls with MCS and persistent vegetative state patients in how they responsed to noxious stimuli when they were in an fMRI. Essentially MCS patients responded (had similar fMRI findings) to pain similarly to healthy controls (PVS patients didn't respond much). This suggests 1) PVS and MCS really are different - some have argued this point, and 2) MCS patients should be given analgesics. I had no conception that #2 was even a question, but the way the discussion is phrased it suggests someone thought that was a question worth investigating (they talk about the need to give MCS patients analgesics when invasive procedures are done, etc.). Yikes. Previous posts about the wild and crazy world of interpeting fMRIs and speculating on the meaning of consciousness and self-hood are here. (Actually I'd suggest reading this from Salon - you have to sit through a site-pass commercial however).

Transdermal granisetron has been approved in the US for chemotherapy induced nausea and vomiting prevention. I'm reluctant to link to drug company sites, and Medscape, which is where I heard about this, requires an annoying registration, and so I am going to link to the only research I could readily find on it which are these poster abstracts (it's a pdf, scroll down to the 2nd page). I can't find pricing cost - anyone know?

JAMA recently had an editorial about emotional intelligence and graduate medical education. It is mostly a theoretical piece, arguing that the scientific concept of EI (they deliberately distance themselves from the popular books on EI) may be helpful for conceptualizing, assessing, and teaching interpersonal and communication skills. I read it with interest, as someone who observes a lot of doctor-patient interactions, and who tries to teach young doctors how to do it better, but found that overall the editorial was too vague/theoretical to actually inform anything I do. It may (this was, after all, published in JAMA) portend future scrutiny from the Powers That Be (e.g. the ACGME) about how communication skills are taught and assessed....

I've had some correspondence with Dr. Holly Prigerson the PI for the Coping with Cancer study that I recently blogged about. She clarified a few things about the study and promises there are many more analyses and publications forthcoming. I edited some of her comments to me and put them in the comments for that post: click here and scroll to the bottom to read. Thanks Holly.

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