March 2010
Women Get Back Get Their VBAC
After years of recommending against vaginal birth after cesarean (VBAC), a NIH consensus panel has called for women to have greater access to the procedure and for women to be able to exercise greater choice over which birthing method (whether repeat cesarean or VBAC) is right for them, says AAFP News Now.
What prompted this change in policy, you might ask? A trumping of women's rights and autonomous choice in reproduction? Not so much. In fact, the recommendation of TOL (trial of labor) before opting for cesarean is based on new evidence that often the outcome for baby and mother is just as good with VBAC as with repeat cesareans.
The recommendation's language is encouraging though: "a shared decision-making process should be adopted and, whenever possible, the women's preference should be honored."
With the data that VBAC and cesarean are equivalent in terms of clinical outcome, it would appear that shared decision-making and autonomy can trump for women in some situations. It's about time.
Summer Johnson, PhD
Bioethics on TV: Watch What Dr. House Does and Do The Exact Opposite.
As previously published in the December 2008 issue of The American Journal of Bioethics, Johns Hopkins researchers Czarny et al told us that medical and nursing students watch television medical dramas in droves (almost 80% of them) and are exposed to moral dilemmas in those dramas that way.
But to our shock, how the characters in those dramas handle those moral problems is more than a little disappointing. Not only are the docs (and nurses) in shows like Grey's Anatomy and House M.D. faced with moral problems, they often create them. And when they are in the midst of these problems, they often do the wrong thing.
At least the wrongdoing, in most cases, is directed toward other doctors, says the latest Czarny study published in the Journal of Medical Ethics. Most of the time, TV doctor respect people's wishes and get their informed consent for procedures, says L.A. Times' Booster Shots.
So the take home lesson here for the 80% of medical and nursing students watching these medical dramas? Enjoy them for their entertainment value, not for the lessons they teach about medical professionalism or ethics. That is unless you take pretty much everything you see Dr. House do with his colleagues and most of his patients and then understand that you should almost always do the opposite.
Summer Johnson, PhD
Second Seed
Yes, apparently it's true, according to the Kansas City Star, that March Madness and vasectomies are linked.
Men willingly choose to schedule this somewhat uncomfortable procedure during the Big Tournament, specifically. Why? What better time to be laid up on the couch with frozen peas between your legs, right? (Just don't get TOO excited as Northern Iowa beats Kansas!)
Not only is there a link between men scheduling vasectomies during the men's NCAA basketball tournament, some doctors are even using it as a marketing ploy. The Oregon Urology Clinic in Eugene's "Snip City 2010" featured Dick Vitale (I wonder if he said the usual "It's Awesome, Baby!") telling potential patients to "take care of the equipment and lower your seed for the tourney."
Oddly, I find this disturbing--the use of sporting events as the deciding factors for major reproductive decisions. While I'm sure most men find this funny (or maybe even a good idea), I'm sure most would be appalled if women were known to be making permanent reproductive choices based on the airing date of the Oscars or the advice of Oprah.
But alas, these are the differences between the reproductive lives of men and women. Men get Dick Vitale and the NCAA tournament and women get....well, well, you tell me.
Summer Johnson, PhD
Three Points of View on Health Care Reform: A Podcast and a Blog
The Bioethics Channel at the Center for Practical Bioethics presents an ethical analysis of the historical passage of health care reform.
John Carney, MHA, Rosemary Flanigan, PhD, and Tarris Rosell, PhD, D.Min, each offer commentary about what health care reform means for the nation now and in the future--from an ethical perspective.
To listen to the podcast, click here.
You can also read Dr. Flanigan's blog post on the subject Health Reform: Not Perfect, But A Start at the Center's website as well.
Summer Johnson, PhD
Doc, Will You "Friend" Me?
It comes as no surprise, to me anyway, that doctors would be catching on to the value of social networking on Facebook for marketing of their practices. But what are the ethical bounds of using social networks for the existing patients under a doctor's care?
According to a recent study by Harvard researcher David Brendel, the "friending" process between doctors and patients was explored to find an ethical way for the physician-patient relationship to remain intact via social networking. Here is what he came up with, according to his own press release:
- Address a patient's online invitation immediately and in person to avoid any damage to the therapeutic relationship.
- Do not enter information obtained on social networking sites into a patient's medical record without his/her consent.
- Use discretion when posting personal information. "I would discourage doctors from participating in any form of social networking, but if they do, I would encourage them to privatize their information," said Brendel.
- Understand a site's privacy settings to assess the risk of privileged information becoming public.
Quite frankly, I have not read a less well thought out set of recommendations in a very long time. The potential for privacy violations on both sides (for doctor AND patient) are so serious here that I can hardly believe that this study was published. If anyone knows anything about how Facebook works, one can only imagine how this would be a complete and total disaster.
Let's imagine just one scenario: a patient goes online and says he/she wants to connect with Doctor Doe on Facebook. How long is too long for Doctor Doe to wait before "damage to the therapeutic relationship" begins? A day? Two days? A week? Of course, this is totally dependent upon how frequently the "requester" uses Facebook. The patient might be on Facebook every hour, while Doctor Doe might be a weekly user. Already there is the potential for the inadvertent snub.
Moreover, most patients are likely to friend doctors right before office visits because they are on their minds or for rapport-building or for hopes of longer than the average 7 minute encounter. So what happens when Doctor Doe wasn't online last night and Patient Paul comes into the exam room and says, "Hey Doc, why didn't you accept my friend invitation on Facebook?" Isn't the patient relationship inherently already damaged?
As for Brendel's second recommendation, it might seem obvious, but it would be all too easy if one were monitoring a patients Facebook page to say, "I noticed last Tuesday you said you were really tired and running a fever and didn't go to work. What was going on?" Those kinds of invasions of privacy that we now think of as being routine on Facebook would be almost unavoidable for doctors and would be inevitably in one's subconsious, whether or not they ever made it to the chart.
Brendel's third recommendation would require making patients a separate group of people in their Facebook lives and making only certain information available to them. But that begs the question, what kind of information is okay to share with patients? That Doc Doe went sailing last Saturday or that he likes Dr. Pepper but not who his other friends are? Drawing those boundaries are incredibly complex and I'm not sure anyone, least of all the medical profession has thought through where the boundaries of information sharing with patients should be drawn, especially when it can reach through to friends of friends of friends.
The same holds true for Brendel's last point. Which leads me to conclude that the friending of Doctors on Facebook and the connecting of patients on all kinds of social networking sites is simply not a good idea, or is at least premature. While social networking is great for marketing and outreach, it in this case creates so many privacy concerns that have been so poorly thought out that it should not be done until someone comes up with concrete and clear guidance for patients and physicians for how networking can proceed so both sides of the interaction can be respected.
But it is a problem that cannot wait and must be resolved quickly, as Brendel's press release notes, 2/3rds of medical students are on Facebook. This means nearly all doctors in the future will be on Facebook. Moreover, we know patients want to have access to doctors and to be able to communicate with them. I'm confident though that Facebook is not the medium through which to do it.
Summer Johnson
Tucked Inside National Health Care Reform is National Menu Reform
And just when you were beginning to worry that national health care reform might not effect you have no fear. Nicely tucked away inside the health reform bill in Section 2572 is the mandate that chain restaurants with more than 20 locations display nutritional and caloric information for all of their consumers, says WSJ Health Blog.
Will this slow or prevent the fattening of America, the obesity epidemic we are facing? Only time will tell. But it is a step in the right direction, a relatively low-cost measure on the part of government and business to give consumers the power to make informed eating choices.
Of course, it doesn't change the fact that for many in low-income neighborhoods the only affordable choice will be the high-calorie, high fat fast food meal. That is another challenge to be tackled entirely. But perhaps with additional information will come some additional exercising of power.
One can only hope.
Summer Johnson, PhD
March Issue of AJOB is Now Online!
Trans fat bans, peer recruitment for human subjects research, and the clash of culture versus the rights of physicians are the featured issues in this month's issue of The American Journal of Bioethics.
First, David Resnik's article questions the limits of government intervention on banning a particular food, or specifically food chemical, and how effective it might be, and the ethical justification for it.
Second, the ethics of a new method for recruiting human subjects in research involving peer-to-peer recruitment is questioned. Is it okay to have the community members involved in research recruit more study subjects? Are they biased or are they they most informed recruiters?
Lastly, the well-documented case of Samuel Golubchuk forces us to confront deeply held values about patient autonomy, the role of the physician, and the influence of culture upon patient decision-making. As this case is revisited, the authors and commentators alike weigh in on what did and what should have happened in the case.
To read more, go to bioethics.net for this exciting issue!
Summer Johnson, PhD
Trans Fats Today. Hot Dogs Tomorrow?
Will banning artificial trans fats today effect your ability to have a hot dog tomorrow?
On the The Bioethics Channel, Lorell LaBoube seeks an answer from David Resnik, a bioethicist and IRB chair for the National Institute of Environmental Health Sciences at the National Institutes of Health.
Dr. Resnik writes about this in the March 2010 issue of the American Journal of Bioethics.
Summer Johnson, PhD
Looking for Dr. Right? Get Yours via Speed Date!
Want to find your "Dr. Right"? Now, you can! You can meet your next doctor on a "speed date."
Dne Texas hospital is trying its hand at a method once left to the dating world and to ads in in-flight magazines like "It's Just Lunch".
Texas Health Harris Methodist Hospital outside Fort Worth has created Doc Shop as a way for prospective patients to meet with docs before committing to being a patient, says CNN. It's a way, they say, to see whether patients and doctors click before signing on to that first appointment. How efficient!
According to AMA and AHA, says CNN, Doc Shop is one of a kind. Could it catch on? Maybe.
But should it? Not a chance. From a patient perspective, one could argue that it saves them from wasting all those hours on initial visits only to find out that doctors don't know the current literature or aren't "their type". Of course, Doc Shop won't tell prospective patients how long the wait in the waiting room is at their office, how good or bad the office staff is, or anything else about the practice. And it certainly tells patients nothing about the quality of the physicians charming them across the table.
Even more so, anyone can put on a good face for a minute or two and hide their uglier side. Doc Shop is a totally contrived situation where doctors are selling themselves just a few minutes at a time. They are not under the pressures of daily medical practice--their pager isn't going off, they don't have a call from an angry patient on line one and an even angrier insurance company on line two.
While Doc Shop may seem like a good idea to frustrated patients who can't find a good doctor, I don't think that they are any more likely to find their dream physician any more than someone is likely to find the love of their life from speed-dating around a room of men or women eager to sell themselves off to any one who would have them.
I say if you need a good doctor, ask a friend.
Summer Johnson, PhD
End of Life-ology
William King is dying from MS. His two twenty-something sons, Ennis and Malcolm, already lost their mother to cancer 15 years earlier and now must deal with his slow deterioration. To make matters worse, the King family is poor, or as they put it "broke" and faced with the difficult choices of a generation that is passing, a generation that is looking to take flight and the tension that comes when illness comes between them.
This is the nexus of the play, "Broke-ology", which I had the privilege of watching last night at the Kansas City Reparatory Theater. The story, set in just across the state line Kansas City, Kansas, has come home to roost after first being produced at the Lincoln Center Theater.
I, of course, am no theater critic, but what drew me to this work of art was essentially the story of two young men and their father struggling with the notions of care giving, the end of life, and ultimately letting go.
You cannot understand the King family unless you understand where they live, which is to understand that they are a poor African-American family living in a rundown, dying (what appears to be) exclusively African-American neighborhood in Kansas City, Kansas. The elder son, Ennis', theory about making it in this community "broke-ology" boils down to a simple formula of living on government dole, thriftiness, hard work, and pride in his own family.
But ultimately, "broke-ology" doesn't get you very far when your father is dying of MS. William greets us in the very first scene before Ennis is even born, young and full of vigor, but by scene two, he comes lumbering down the stairs in bathrobe, slippers, and an eye patch (emblematic of his failing vision from MS). In a paradigmatic representation of health disparities in the African-American community, William and his sons understand very little about his condition. They refer to "his doctor" without name, "expensive medicines" without name, and talk openly about their ignorance about William's prognosis, disease progression, and what will come next.
It is the eldest son, however, who has remained in the community (while the younger brother moved off to UConn to earn multiple college degrees), who has become the caregiver for William, giving him his multiple shots per day, reminding him about medications as his memory as failed. Ennis does this even as his own family obligations (a new wife and child on the way) have created his own burdens and struggles. Malcolm represents the paradigmatic son who returns home with much fanfare and glory and who interjects himself with much tumult into medical decision-making. In a gut-wrenching scene, Malcolm and Ennis scream at each other after a visit to an assisted living facility
"Broke-ology" is not a story about being broke, it is a story about dying. The children becoming the parent for their parent is a time old tale, but the nuance added with this African-American family gives the story some richness it might not have had otherwise. Where the play is weakest is in the development of the mother, Sonia, who appears sporadically throughout the play, but who does give William much of his soul. Her death and her life go largely unexamined, however, and this is a real shame.
But ultimately, the end of life-ology is a tale of a family making tough choices and William's the toughest and most definitive of all. He cannot save his family from their broke-ness, but at least they have one last summer together. For most families with parents suffering from terminal illness, that is pretty much all they could ask for.
**SPOILER ALERT***: Broke-ology ends with William making a choice: the choice to end his life with a fatal overdose. The burden upon his caregivers is too much--so ultimately William gives Ennis and Malcolm the freedom to live their lives in the way that he could never could have or give his own wife. He would not condemn his sons to the same fate.
Sadly, what is left unexamined is whether William's suicide and so many of his simultaneously sad and hilarious moments are the result of dementia, depression, or some other side effect of his MS. So many chronically ill patients, as we know, choose to end their own lives, not out of autonomous choice, but as a result of depression. The clinical facts are lacking in this play because the inter-personal drama seems to make them not matter.
Summer Johnson, PhD
If You Are STILL Wondering Why Health Care Reform Is Important...
Check out this statistic from the Chicago Tribune today: "Illinois consumers to pay up to 60% more [for health insurance premiums], data show." When do they pay more? AFTER they have lost their employer-sponsored health care coverage. In other words, just when they can afford to, right?
Oh and this 60% figure is the base rate for insurance premiums (up from 8.5% last year). It doesn't factor in additional increases in the cost of premiums for age, gender or most importantly, health status.
Whether you believe that access to basic health care services is a right (as I do) or whether you believe there is a right to be healthy (I'm less sanguine on that point), it just seems criminal that while so many industries in health care continue to make money hand over fist, some of the most vulnerable among us (children, the recently unemployed) are finding it increasingly difficult to insure themselves.
I don't think there is just a single culprit here. It would be all to easy to just point a figure at the "evil health insurance industry" or "Washington politicians" who have to date have been unable to pass reform. But it isn't that simple.
Unfortunately, the facts are. Those in the individual insurance market, not just in Illinois, but all over the country, are finding themselves priced right out of a market that was supposed to be designed for them. Something can and must be done, whether it will be--in terms of reforming our health care system--remains to be seen.
Summer Johnson, PhD
