How to address patients with "alternative" views

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i think it is odd that it is called "firing"
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CatFactorial said:
A relevant and interesting article:

http://www.economist.com/node/21552554

I disagree with the notion that we have to keep patients well. It's their job to live their lives, our jobs to try and fix them when they are sick.
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That's fine in an acute setting. But as a PCP, your goal is to maintain health. It's more of a PITA to resolve an acute issue d/t exacerbation of medical conditions than to prevent it in the first place.
 
Bacchus said:
That's fine in an acute setting. But as a PCP, your goal is to maintain health. It's more of a PITA to resolve an acute issue d/t exacerbation of medical conditions than to prevent it in the first place.
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true. But this is a "shoulda/woulda/coulda" sort of statement. the reality may be that PCPs are glorified babysitters in many contexts, but that is not necessarily how it should be. if I somehow end up in primary care I'm pretty sure my pirnter paper will all have the "ya dont say!" guy as a water mark.
 
Tatiana3325 said:
Also happened at Lahey Clinic in MA over cardiac stents (sp?). Surgeon had a problem with less effective ones being used that were equal price to the more effective ones. Fired.
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I think it's actually a problem inherent to the fill-in-the-blank Clinics.

Those are all organizations run by physicians (Mayo, Cleveland, and i believe Lahey too), so the incentives get a bit skewed for the guys at the top.
 
Bacchus said:
That's fine in an acute setting. But as a PCP, your goal is to maintain health. It's more of a PITA to resolve an acute issue d/t exacerbation of medical conditions than to prevent it in the first place.
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Yes, prevention is laudable. If in primary care, I will certainly educate them on the merits of a healthy lifestyle, but it's up to them to adhere to such a regimen.

If they choose not to embrace it, I'll treat them however I can, but I won't lose any sleep over their stupid decisions.
 
CatFactorial said:
Yes, prevention is laudable. If in primary care, I will certainly educate them on the merits of a healthy lifestyle, but it's up to them to adhere to such a regimen.

If they choose not to embrace it, I'll treat them however I can, but I won't lose any sleep over their stupid decisions.
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Obviously, but leg work to try and prevent the issues is better than having to deal with more serious issues later on that cost more time and money.
 
That came up in a small group today. Someone suggested insurance paying for healthy cooking classes.
 
CatFactorial said:
I hope that was slapped down, with vigor.
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It's probably not an effective intervention, but if there were a way to get everyone to stop drinking, smoking, and start eating properly, it would make sense for insurance companies to pay for it (hell, most pay for gym memberships).
 
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johnnydrama said:
It's probably not an effective intervention, but if there were a way to get everyone to stop drinking, smoking, and start eating properly, it would make sense for insurance companies to pay for it (hell, most pay for gym memberships).
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Providing "education" about something is a far cry from getting patients to follow the advice. Sinking money into the "education" because the intentions are good is a horrible idea, and would only add to the continuously rising cost of health care. Show me something that is effective enough to actually reduce the costs of long-term unhealthy living, and I would agree that it should be covered. Healthy eating classes are almost certain to cost more than they would save; heck, even free primary care doesn't ensure compliance by patients in management of their potential and actual chronic conditions.
 
theseeker4 said:
Providing "education" about something is a far cry from getting patients to follow the advice. Sinking money into the "education" because the intentions are good is a horrible idea, and would only add to the continuously rising cost of health care. Show me something that is effective enough to actually reduce the costs of long-term unhealthy living, and I would agree that it should be covered. Healthy eating classes are almost certain to cost more than they would save; heck, even free primary care doesn't ensure compliance by patients in management of their potential and actual chronic conditions.
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Yes, but I'm also sure they cost less than the incentives insurance provides for gym membership, and I'd be shocked if those are any more effective (considering the percentage of people who actually go to the gym).
 
SpecterGT260 said:
:thumbup:

as long as I am not the one paying for babysitting for the average american I don't really care.
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Haha, some babysitting might actually save us money.

If we did more to discourage tobacco and alcohol use, we'd probably save billions in Medicare fees (albeit some of the savings might take a few decades).

I think there should be some kind of calorie tax too, although that could get complicated.
 
johnnydrama said:
Haha, some babysitting might actually save us money.

If we did more to discourage tobacco and alcohol use, we'd probably save billions in Medicare fees (albeit some of the savings might take a few decades).

I think there should be some kind of calorie tax too, although that could get complicated.
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Im not agreeing with the idea here. I just don't think it is the right idea for people to profit off of making poor decisions (i.e. free cooking lessions comped by the gov to learn how to cook like a non-fatass). These feel like rewards for doing what you should be doing anyways.... I am a bigger fan of consequences rather than rewards in these settings. Someone mentioned in another thread - Nothing but out-of-pocket for smokers. Harsh, but I see no reason why everyone else should be paying for other peoples dumb decisions.

Prevention good. Expecting the government to pay for common-sense things bad.

for the cooking class thing I mentioned that it is equally reasonable for health insurance to cover internet connections as pt education is an important healthcare issue. But more to the point - there is no guarantee that giving someone free lessons will make them use that info down the road....


and as much as I hate babysitting patients, I do understand that it will save money. I just dont want to be the one paying for it ;) If they want to be paid to be babysat then by all means. (many do, btw... I cant get over the # of patients who come in only to get advice they should have known in kindergarten)
 
SpecterGT260 said:
Im not agreeing with the idea here. I just don't think it is the right idea for people to profit off of making poor decisions (i.e. free cooking lessions comped by the gov to learn how to cook like a non-fatass). These feel like rewards for doing what you should be doing anyways.... I am a bigger fan of consequences rather than rewards in these settings. Someone mentioned in another thread - Nothing but out-of-pocket for smokers. Harsh, but I see no reason why everyone else should be paying for other peoples dumb decisions.

Prevention good. Expecting the government to pay for common-sense things bad.

for the cooking class thing I mentioned that it is equally reasonable for health insurance to cover internet connections as pt education is an important healthcare issue. But more to the point - there is no guarantee that giving someone free lessons will make them use that info down the road....


and as much as I hate babysitting patients, I do understand that it will save money. I just dont want to be the one paying for it ;) If they want to be paid to be babysat then by all means. (many do, btw... I cant get over the # of patients who come in only to get advice they should have known in kindergarten)
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Well, there's always the flipside.

If not the carrot, the stick. Come up with an easy way to tax people for eating junk. Then we make $$$ off their vices instead of paying $$$ to try to make them be good.

We could also pay for the health classes with a tax on non-diet soda. Carrot and stick together! :p
 
johnnydrama said:
Well, there's always the flipside.

If not the carrot, the stick. Come up with an easy way to tax people for eating junk. Then we make $$$ off their vices instead of paying $$$ to try to make them be good.

We could also pay for the health classes with a tax on non-diet soda. Carrot and stick together! :p
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I actually dont mind these sorts of suggestions. Making people pay up front is just insurance when they cant pay after :thumbup:
 
johnnydrama said:
Yes, but I'm also sure they cost less than the incentives insurance provides for gym membership, and I'd be shocked if those are any more effective (considering the percentage of people who actually go to the gym).
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I'm actually almost positive that private industry has been incentivizing healthy living decisions for at least a couple years now (e.g., rewarding people for joining the gym, getting regular physicals, keeping their BP/cholesterol/etc. in check). No clue what the research shows in terms of effectiveness, but I'd be surprised if it isn't reducing costs for those companies.

Increasing motivation and finding ways to make education more effective (both cost- and outcome-wise) is an area seeing huge growth in health psychology as well.
 
So let's talk ethics... The vaccine thing keeps coming up and a buddy sent me www.vran.org (tread carefully.... The crazies are out).

So since adjuvants are in the crosshairs, is there some ethical dilemma behind injecting kids with a dummy vaccine? I feel like we could put this to bed pretty easily. A butt load of kids get a real vaccine, a buttload get adjuvant only, and a buttload get a saline injection. Bake on high for 12 months, and determine how many in each group can read calculus but can't handle loud noises
 
SpecterGT260 said:
So let's talk ethics... The vaccine thing keeps coming up and a buddy sent me www.vran.org (tread carefully.... The crazies are out).

So since adjuvants are in the crosshairs, is there some ethical dilemma behind injecting kids with a dummy vaccine? I feel like we could put this to bed pretty easily. A butt load of kids get a real vaccine, a buttload get adjuvant only, and a buttload get a saline injection. Bake on high for 12 months, and determine how many in each group can read calculus but can't handle loud noises
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You think that will put anything to bed? Since when have scientific data and logic ever put any type of conspiracy theory to rest? Assuming there is no difference between each group, the crazies will just say the study was fixed by doctors and their big-pharma masters, and the real result is being covered up.
 
SpecterGT260 said:
So let's talk ethics... The vaccine thing keeps coming up and a buddy sent me www.vran.org (tread carefully.... The crazies are out).

So since adjuvants are in the crosshairs, is there some ethical dilemma behind injecting kids with a dummy vaccine? I feel like we could put this to bed pretty easily. A butt load of kids get a real vaccine, a buttload get adjuvant only, and a buttload get a saline injection. Bake on high for 12 months, and determine how many in each group can read calculus but can't handle loud noises
Click to expand...

There have already been plenty of studies proving the efficacy of vaccines.

Most of the outrage is over events that (if they happen at all) happen so rarely it would be impossible to study them prospectively, at least with a reasonable budget and in an ethical manner.

Here's the thing that I always find interesting from a game theory perspective:

The best individual strategy is to be non-vaccinated in a vaccinated population (all benefit, no risk), but that's an unstable strategy since the more people who accept it, the less effective it is.

If a disease is truly rare though, we are vaccinating people against their individual best interests (albeit for the common good). So in those cases, we can't really claim any benefit to vaccination since the risks of disease are outweighed by the risks of side effects, but if we stopped giving the vaccine the disease would reappear and people would need it again.

I guess you could hold a lottery and only vaccinate enough to get sufficient herd immunity, but that would be even more of a ridiculous endeavor. It would have to be evenly distributed too, and I believe vaccine deniers tend to be clustered.

Anyway, that was enough rambling. :D

(For clarification, 100% pro-vaccine, just engaging in mental master something...)
 
Id be interested to see actual figures on the side effects.... I feel like, even in the worst of cases, the chances of side effects are about equal to the benefits of vaccinations.... And the ratio just improves from there.
 
johnnydrama said:
Here's the thing that I always find interesting from a game theory perspective:

The best individual strategy is to be non-vaccinated in a vaccinated population (all benefit, no risk), but that's an unstable strategy since the more people who accept it, the less effective it is.
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Exactly. But let's take the logic one step further. Your best option would be to be non-vaccinated in a population where everyone is vaccinated, but as you point out, that's not possible, because other people will follow the same strategy. Consider that vaccines are not 100% effective, and that every person will at some points in their life be susceptible to vaccinable diseases (as a very young child, when you're old and your immune system is waning, if you're every immunosuppressed for some reason, etc). So being vaccinated in an unvaccinated population is still not as good as being vaccinated in a vaccinated population. So your second-best strategy is to live in a population that has binding rules requiring everyone to be vaccinated, including you and your family.

Given that mandatory vaccines is possible, while you and your family free-riding on everyone else is not, mandatory vaccines actually _is_ the best strategy. The other one is wishful thinking on the part of amoral people.
 
Perrotfish said:
Theoretically: You politely, and non-confrontationally, educate them about what the literature says and say that their alternative treatment is not supported by the evidence. If their alternative treatment has inherent risks you advise them of it. If they're threatening to follow the alternative plan of care exclusively, rather than in addition to your plan, then you advise them of the risks of non-compliance. If they persist in their opinion your respect them and move one, while making it clear that you are always available for further questions. You never turn the situation into a confrontation, but at the same time you never validate a non-scientific plan of treatment just for the sake of improving your physician-patient relationship. If a patient is completely non-compliant with YOUR plan of care (which is not the same as just adding on some CAM) then you can fire them to make room for a compliant patient, but that is a last ditch option.
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Of course, this requires you to be familiar with the relevant literature.
 
But it's the best individual strategy, not a stable one without a threat of punishment from the community.

Just like with the prisoner's dilemma, the best outcome is for both sides to tell the police nothing, but no rational person would ever follow that strategy (without repeated games, threats of repercussions, etc etc).
 
SpecterGT260 said:
Id be interested to see actual figures on the side effects.... I feel like, even in the worst of cases, the chances of side effects are about equal to the benefits of vaccinations.... And the ratio just improves from there.
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Definitely not true for all of them, e.g. the smallpox vaccine (although personally I'd want to get that, although I know it's not rational).
 
johnnydrama said:
But it's the best individual strategy, not a stable one without a threat of punishment from the community.

Just like with the prisoner's dilemma, the best outcome is for both sides to tell the police nothing, but no rational person would ever follow that strategy (without repeated games, threats of repercussions, etc etc).
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A rational person would set up an organization amongst the prisoners whereby they could set rules for how to deal with each other. If they come up with some means of enforcing said rules, then they are all better off, because the rules let them work together cooperatively instead of constantly vying for a better opportunity to stab the other guy in the back without themselves being stabbed. Everyone wins.

You could call it, I dunno, a government.
 
phltz said:
A rational person would set up an organization amongst the prisoners whereby they could set rules for how to deal with each other. If they come up with some means of enforcing said rules, then they are all better off, because the rules let them work together cooperatively instead of constantly vying for a better opportunity to stab the other guy in the back without themselves being stabbed. Everyone wins.

You could call it, I dunno, a government.
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Haha, for the prisoner's dilemma, the more appropriate name for what you're describing is organized crime.

It actually is used - prisoners who squeal often don't make it out of prison alive. I'm betting that changes the relative individual utility of the different options.

I agree though, but what that means is we need even more stringent vaccination rules and need to stop pretending the patient has full autonomy over these kinda of choices. Maybe we don't need to go quite as far as shivving them in the rec yard, but something more forceful than saying, "please".

Just like we can lock up someone with MDR TB and basically throw away the key, we should do the same with Jenny McCarthy.

(Obviously joking, more along the lines of denying access to public schools, additional taxes, etc etc. I think some things like this are already in place.)
 
johnnydrama said:
Definitely not true for all of them, e.g. the smallpox vaccine (although personally I'd want to get that, although I know it's not rational).
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I dont think you understood my language.... even with smallpox the benefit to the vaccine (or the benefit at the time) outweighed any side effect. Similarly with polio... and once polio numbers dropped we started giving an inactivated instead of live attenuated vaccine on the off chance we inoculate someone who is immuno compromised. but still - the benefits are outweighing the side effects.

I cannot come up with any instances where the downside is worse than the disease would have been in the first place.
 
Assuming that you wouldn't be liable in hurting somebody with "alternative" beliefs,

Explain to that person that his/her proposition has been long established in the scientific literature and in the medical community; you would highly recommend the idea.

This approach has one of two possible outcomes:
(1) They feel guilty about defending the establishment and look for an alternative, which likely leads them (subconsciously, albeit) back to science.

OR
(2) They, backed by your reinforcement, pursue their hemlock therapy or what have you, win a Darwin Award, produce no progeny, and bother you never more.

Realistically though, you could explain to them that Steve Jobs would likely be alive had he been a bit more trusting of the mainstream, or, if it's not hurting anyone, that their idea sounds compelling and deserves some investigation.

I saw the Dalai Lama speak once, and some schmuck asked if he would recommend alternative medicine in the stead of "failing" western medicine. The Lama giggled and told him to go to a real doctor if he gets sick. True story, bro.
 
SpecterGT260 said:
I dont think you understood my language.... even with smallpox the benefit to the vaccine (or the benefit at the time) outweighed any side effect. Similarly with polio... and once polio numbers dropped we started giving an inactivated instead of live attenuated vaccine on the off chance we inoculate someone who is immuno compromised. but still - the benefits are outweighing the side effects.

I cannot come up with any instances where the downside is worse than the disease would have been in the first place.
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Oh, the disease is always worse.

That's the wrong question though.

Is the vaccine better than the disease * the odds of getting the disease?

For small pox, outside of a secret bioweapons facility in Russia or the USA, the answer is (I hope) no.
 
johnnydrama said:
Oh, the disease is always worse.

That's the wrong question though.

Is the vaccine better than the disease * the odds of getting the disease?

For small pox, outside of a secret bioweapons facility in Russia or the USA, the answer is (I hope) no.
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I am unfamiliar with small pox vaccine side effects (honestly... I feel like I am sarcastic enough on here that I have to say so in this case :laugh:) so.... why?
 
SpecterGT260 said:
I am unfamiliar with small pox vaccine side effects (honestly... I feel like I am sarcastic enough on here that I have to say so in this case :laugh:) so.... why?
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The main point is that officially smallpox no longer exists, so if it has any side effects (and it does), that makes it more dangerous than the disease.

The vaccine hasn't been improved much since the first vaccinia one - it's a live vaccine and there's no good way to test a safer version since the disease is essentially gone.

On the plus side though, it may convey some resistance to HIV (apparently there's a theory that the HIV outbreak was accelerated by decreasing rates of immunity to smallpox, learn something new every day)...
 
johnnydrama said:
The main point is that officially smallpox no longer exists, so if it has any side effects (and it does), that makes it more dangerous than the disease.

The vaccine hasn't been improved much since the first vaccinia one - it's a live vaccine and there's no good way to test a safer version since the disease is essentially gone.

On the plus side though, it may convey some resistance to HIV (apparently there's a theory that the HIV outbreak was accelerated by decreasing rates of immunity to smallpox, learn something new every day)...
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Yes. And as such the vaccine is no longer given. All I am saying is that the current medical establishment is on top of this.we do not give a vaccine that I am aware of that has a side effect that I wouldn't gladly take in exchange for the disease at the odds we are currently faced with. Just like polio, the vaccine efficacy and risk is modulated with disease risk
 
johnnydrama said:
The main point is that officially smallpox no longer exists, so if it has any side effects (and it does), that makes it more dangerous than the disease.

The vaccine hasn't been improved much since the first vaccinia one - it's a live vaccine and there's no good way to test a safer version since the disease is essentially gone.

On the plus side though, it may convey some resistance to HIV (apparently there's a theory that the HIV outbreak was accelerated by decreasing rates of immunity to smallpox, learn something new every day)...
Click to expand...

Improved smallpox vaccines do exist. Modified Vaccinia Ankara has been passaged through chick embryos until the virus has lost large fractions of its genome. It can no longer reproduce in mammalian cells, and is considered safe for almost everyone.

The problem is that there were large existing stores of the old Dryvax vaccine, so until recently everyone just used that because they already had it laying around. And for some reason the military now uses ACAM2000, which is still fairly dangerous.

The government still wants there to be a certain core of immunized health care workers and other first responders, so that in the event of an outbreak, there'd be people who could respond to it. It's certainly not worth the risk to vaccinate the whole population, but I think it's a good idea to have a few immunized first responders around.
 
The answer is simple - if they don't want to get the treatment because of their belief in some sort of alternative treatment and they are fully competent and capable of making decisions for themselves, they have EVERY right to do so as long as you document it.

I remember I was in a clinic where a guy came in diagnosed with prostate cancer, and after giving him the diagnosis, we offered him a variety of therapies including, of course, radical prostatectomy. He went on a spiel stating that he wanted to try a herbal concoction because "the drug companies are suppressing the real cures so they can make more money from us". We politely and professionally acknowledged his opinion, tried to convince him otherwise, and he didn't budge; he had full understanding and capacity about his condition. We documented it, and he'll likely live several more years with his slow growing prostate cancer untreated. Who knows, he might even change his mind later on. But they can't come back to sue us, because we have it on record.

One thing you'll also find is that people tend to be either a) hypocrites or b) more willing to try conventional medical therapy when they suddenly become symptomatic. I remember a cancer patient I had who didn't agree to systemic chemo/RT until his cancer was suddenly metastatic and causing cord compression, because until that time he wanted to try "modifying his electrical fields". Same with abortion clinics - I can't even begin to count the number of times I've heard of young women who are active pro-life supporters who come into these clinics because their boyfriend was having unprotected sex with them since condoms are forbidden in their religion. People are surprisingly huge hypocrites in general when they are faced with the condition they've rallied against for such a long time.
 
ArcGurren said:
The answer is simple - if they don't want to get the treatment because of their belief in some sort of alternative treatment and they are fully competent and capable of making decisions for themselves, they have EVERY right to do so as long as you document it.

I remember I was in a clinic where a guy came in diagnosed with prostate cancer, and after giving him the diagnosis, we offered him a variety of therapies including, of course, radical prostatectomy. He went on a spiel stating that he wanted to try a herbal concoction because "the drug companies are suppressing the real cures so they can make more money from us". We politely and professionally acknowledged his opinion, tried to convince him otherwise, and he didn't budge; he had full understanding and capacity about his condition. We documented it, and he'll likely live several more years with his slow growing prostate cancer untreated. Who knows, he might even change his mind later on. But they can't come back to sue us, because we have it on record.

One thing you'll also find is that people tend to be either a) hypocrites or b) more willing to try conventional medical therapy when they suddenly become symptomatic. I remember a cancer patient I had who didn't agree to systemic chemo/RT until his cancer was suddenly metastatic and causing cord compression, because until that time he wanted to try "modifying his electrical fields". Same with abortion clinics - I can't even begin to count the number of times I've heard of young women who are active pro-life supporters who come into these clinics because their boyfriend was having unprotected sex with them since condoms are forbidden in their religion. People are surprisingly huge hypocrites in general when they are faced with the condition they've rallied against for such a long time.
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This :thumbup:

this is pretty much what I was getting at. But to johnny's point, by that time those patients are going to cost us a lot more money. This whole thread was really just in response to the soft-science lectures we get about being a good "clinician" and the incoherence between the EBM and sound science we use in practice and the opposing view of total acceptance of what makes each patient unique.

I just find it frustrating at times that we are urged and pressured to work with such patients for the n=1 success story, but then we end up humoring bad ideas which lends validity to some of these bad ideas for a potential n>1 harm down the road.
 
Just as an aside, re: vaccines, many of us in the pediatrics community outright refuse to follow patients in clinic if the parents are anti-vaccine. Remember that parents and patients can choose to have alternative views, but we as physicians also have the right to tell them to hit the road too.
 
jcu said:
Just as an aside, re: vaccines, many of us in the pediatrics community outright refuse to follow patients in clinic if the parents are anti-vaccine. Remember that parents and patients can choose to have alternative views, but we as physicians also have the right to tell them to hit the road too.
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A physician should absolutely not stop seeing a patient because of their views, be they alternative or mainstream, whether the physician agree with them or not.

A physician may stop seeing a patient if said patient's presence in the clinic is a hazard to the other patients.

This is a very important distinction, which you'd do well to think about.
 
phltz said:
A physician should absolutely not stop seeing a patient because of their views, be they alternative or mainstream, whether the physician agree with them or not.

A physician may stop seeing a patient if said patient's presence in the clinic is a hazard to the other patients.

This is a very important distinction, which you'd do well to think about.
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:rolleyes: go get 'em tiger
 
phltz said:
A physician should absolutely not stop seeing a patient because of their views, be they alternative or mainstream, whether the physician agree with them or not.

A physician may stop seeing a patient if said patient's presence in the clinic is a hazard to the other patients.

This is a very important distinction, which you'd do well to think about.
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It is a hazard to other patients. I thought that was implied. We don't do it out of spite.
 
jcu said:
It is a hazard to other patients. I thought that was implied. We don't do it out of spite.
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in addition, while it would be wrong to fire a patient simply due to their views, it is not wrong to deny the patient what their views believe is best for them. As we stated earlier (or maybe that was another thread....) I don't have to recommend snake oil just because the patient wants me to. If I want to treat X condition with Y treatment plan, and the patient wants Z treatment plan, I can tell the patient no, that I will only be writing scripts for Y and s/he can go elsewhere if another treatment is preferred.
 
phltz said:
A physician should absolutely not stop seeing a patient because of their views, be they alternative or mainstream, whether the physician agree with them or not.

A physician may stop seeing a patient if said patient's presence in the clinic is a hazard to the other patients.

This is a very important distinction, which you'd do well to think about.
Click to expand...

Ummm...NO!!!
A physician can stop seeing a patient for ANY or NO reason. As long as they do a proper hand-off & take care of any issues for 30 days after firing them, they are covered.
 
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