There are times when a doctor knows he’s doing the wrong thing and does it anyway. I’ve done it quite often. This happens when I order laboratory tests for no good medical reason. I am ordering them just to help my patient get their operation or procedure.

Read more at the Minimally Disruptive Medicine blog.

The last chapters of my book propose remaking our health care system on the basis of good communication and positive relationships with our doctors (and nurses, and physician assistants). How do we get to a changed system on the basis of individual behavior? Isn't that unrealistic, even naive?

Remaking our system is a noble, grand struggle, one of the most important tasks for this century. Remaking is already going on in different ways. Obviously, there is health care reform, by which is meant legislation and executive action. This is, mostly, top down. I am not a libertarian: there is nothing I find philosophically inimical about top-down change. Health care is huge and someone has to flip the master switches.

At the same time, however, change has to come from the bottom. Patients are their own people with adequate decision-making capacity: can you believe that some doctors are only just coming around to this truth? But how do we get the system to embody this truth? We can not legislate shared decision making and patient-centeredness; nor can we merely, by fiat (as some e-patients are doing), say that patients are now the owners of the store.

Patients should be the owners of the store, together with their doctors, but just proclaiming that in a loud voice won't get you anywhere. Some of us live out in the woods, where Internet calls-to-action don't carry, and some others of us are too disempowered or intimidated to take charge in our doctors' offices even if we are given permission to by those well-spoken advocates.

I like to make the comparison to the struggle for civil rights, which I am no historical expert in (so correct me if I am wrong). That struggle's success was dependent on both legislative action and bottom-up activism, each of which informed the other. The exercise of the right to vote would not have been possible without the Voting Rights Act. The Voting Rights Act would not have worked without protests.

There is a place for health care reform to encourage primary care providers to establish a relationship with patients, and vice versa. But the importance of communication to such an endeavor, I can't help but think, is not something that will come out from Washington. That will have to bubble up out of each exam room individually.

Tomorrow's the big day! Please - if you have read the book already - review it on Amazon or Goodreads. If you haven't read it, you are warmly invited to do so. Even more important than buying the book is letting me and others know what you think about it. 

Tengo de placer de trabajar como un instructor en la clínica de residentes en el Johns Hopkins. Frecuentemente vemos a pacientes que hablan una u otra idioma aparte del ingles. Es necesario, claro, que los médicos en formación se aprendan como comunicarse con un paciente con la ayuda de un interprete. Sin embargo, tenemos también aclararse para estos doctores menores, que ese no es suficiente. Tienen también entender que cada paciente, de una manera o otra, habla "otro idioma": se usa de palabras diferentes para describir sus problemas de salud; o simplemente no se disfruta de la amplitud de oportunidades que están disponibles para la gente con las ventajas económicas y sociales, y por eso tienen que expresarse de manera diferente, con creencias de salud diferentes del medico. Es decir: cada interacción entre el medico y el paciente se depende en la "traducción" entre dos idiomas, del paciente y del medico. Mi libro nuevo, "Como Comunicar Con Su Medico," se ocupa de estos complicados y urgentes asuntos.

I am privileged to work as a preceptor (teacher) in our residents' clinic, where junior doctors learn how to provide care tailored to individual patients, many of whom have multiple significant medical problems. One thing that all of our residents should learn is the care of a patient who speaks a language other than English. For such a patient, if you don't speak their language, you are supposed to provide an interpreter. That's a way to provide minimal care, but not necessarily to provide good care. Interpreters might be only intermittently available, or for some languages, not at all; interpreters might not be well trained for the medical encounter; and practitioners might labor under the illusion that an interpreter guarantees good communication.

But a broader realization needs to be conveyed as well: every patient speaks a different sort of language. The patient from a different group or culture might express themselves using health beliefs, or health vocabulary, that differs from the doctor's. A patient who is not fluent in the language of the health care system, or of privileged America, might be tongue-tied before the doctor.

The resident, or indeed the attending, might make the same mistake with these speakers of "other languages" as they do with speakers of other languages as ordinarily understood: thinking that it's okay to get by, make do with the minimum because that's better than nothing. In these cases, though, the doctor needs to be their own interpreter. That is hard - to speak in English but make the "translation" to the terms appropriate for a different sort of person. But, from a communication perspective, medicine is not a communicative profession without it.

Catch a radio discussion about the book tomorrow, Thursday, July 11th, on the Dr. Melanie Show, 1pm Eastern, 10am Pacific. http://www.voiceamerica.com/show/1929/the-dr-melanie-show

Listen in now. I'll be on at 20 minutes after the hour. http://www.voiceamerica.com/episode/71620/saving-animals-running-for-a-cause-and-partnering-with-your-doctor

Yesterday I spent the day at a panel sponsored by the Institute of Medicine meant to encourage the broad adoption of shared decision making: that is, a culture where doctors and patients help each other work towards a decision that's right for the person seeking care.

Of course, my first question to myself (which I raise only occasionally to others) is this: what are the assumptions here, and how is this going to help people feel better and live longer?

The assumptions are that people - most people? the average person? the person living the most engaged and healthiest life? - want to be involved in making health care decisions. Advocates of shared decision making like to point out that this is self-evidently true.

But, as I point out in my book, it's just not. Not because people are passive and would like doctors to walk all over them, but for any number of other reasons: they assume that doctors are in general skilled and have the patient's best interests at heart (sometimes true, sometimes - unfortunately - not); they are intimidated and made uncomfortable by the determinedly alien nature of our healthcare system; they are too stressed, poor, uneducated, or sick to keep their mind on anything so complicated as a healthcare decision. One solution to this just-not-so (or the "yeah-but" of the real world that gets in the way of many ideologies) is to explicitly encourage patients to take that step in sharing decision-making with their doctors, to become the passionate self-advocates that many assume we all should be.

But when that doesn't work, we should realize it's not patients' fault, or doctors: we need to remake our system. There are plenty of routes to do so. We can encourage doctors to involve patients in decisions by giving them money to do so; we can put more information in the hands of patients and explain it in a way they can understand; we can make it easier for poor patients, or those from disadvantaged groups, to access the care they need. Or - again, as I point out in my book - we can invest in the emotional foundation of care, a working patient-provider relationship that makes shared decision making more sustainable.

Does shared decision making lead to better health, less unequal care, and lower costs? It has that potential, at least for the first of those three. Whether shared decision making is the right star to chase, the direction to go in through the desert that will lead us to the triple aim of better care, lower costs, and greater satisfaction: that, I don't know. My personal preference is for communication and relationships to be our north star. I can believe in SDM, though, too!

[Picture from engagingthepatient.com]

If I may, a blogpost about something other than the book. Last week I went to a happy hour at a Baltimore watering hole* organized by the National Physicians Alliance. The NPA is an organization that I have felt warmly towards ever since they started the ball rolling on the Choosing Wisely movement. It is a group that wears its ideology and advocacy proudly on its white-coate sleeve and hanging from its stethoscope. (I talk more about the Choosing Wisely campaign in the book, which means this post is actually related. Whew!)

The people I met there were wonderful and of that ideology: primary-care centric, against the blandishments of Big Pharma, for evidence and for the patient at the same time. I don't remember their names, but many of them were in preventive residency programs (most at Hopkins) and a number were specialists in family medicine.

It was with a family medicine doctor that I had the conversation that sticks with me most, more even than the beers I had. I told him I thought a single-payer health care system would never be a reality, and he pointed out that it could, on a state-by-state basis. While all such state-level single-payer proposals have failed (except in Vermont), it wasn't too long ago that gay marriage was illegal in all states - and that too has made its way to legal acceptance through piecemeal, state by state progress.

Which is not to say that these issues are entirely comparable, of course. The permissibility of gay marriage is to my mind a moral cause, and not a hard call at all, while incrementalists have made powerful arguments that single-payer health care is not the only way to go. The long-term question, I suppose, is what comes next after the Affordable Care Act (i.e. Obamacare). Will access, quality, and (hopefully) cost continue to be improved under our employee-based model? Or will we make that leap that I more and more think is necessary, to care for all, indepdendent of employment?

The get-together with the NPA folk was inspiring. And, since most of them were a fair bit younger than I am, it bodes well for at least a corner of the future of healthcare.

*The Brewer's Art, where I was excited to see an artisanal beer called Migdal Bavel [the Tower of Babel, in Hebrew]. How often do you see a Hebrew-named beer in the US? So I asked for it from the bartender. Who couldn't understand what I was saying until I pointed it out on the list. I guess my beer-Hebrew pronunciation is off.

This was a guest post at the Minimally Disruptive Medicine blog by the kind invitation of Victor Montori, MD.

How can we get more clinicians to help the patient receive minimally disruptive medicine? The answer might lie in the improvement of patient-clinician communication. For many conditions, the doctor is encouraged to look into the book – or, more likely, UpToDate – and read out the recommendations of the latest guideline.

But there are two limitations to guidelines. The first, of course, is that all guidelines, whether from the United States Preventive Services Task Force or the International Association of Quackery, are only as good as the methodology and evidence that go into them. The second is that even the best guideline is not a magic recipe for appropriate care for the individual person in question.

If you are discussing screening for prostate cancer via the PSA test, whether you are a patient or provider, you will surely realize that the guidelines of the urologists and internists are now in rare agreement: universal screening is not recommended. What is now recommended is shared decision making, a series of tasks that patients and clinicians do together to communicate about the options and to deliberate to identify the one that fits best with the patient preference and context. 

Whether it’s prostate cancer, diabetes, or depression, how can we bridge the gap from guidelines to individually sensitive care? I think there are two steps. The first, as I outline in my book, is to build a relationship between PCP and patient that can handle the intellectual and emotional stresses of decision making with unclear information. This requires mindfulness; emotional readiness; and specificity and clarity of options.

The second step is to contextualize clinical recommendations in a way that only good communication makes possible. Such contextualization is now being addressed by some fascinating new research. We have already known, through the work of communication researchers (chief among them Debra Roter), how to characterize a true dialogue between patient and clinician.

Unfortunately, the evidence is mixed as to the extent to which such dialogue leads to improved outcomes. In their recent work, Saul Weiner and colleagues at the University of Illinois at Chicago, and at Duke University, try to determine how often physicians take the next step after good communication: using an appreciation for the patient’s individual concerns and customizing their recommendation on that basis. It’s not enough to empathize, in other words, about someone’s job loss, poverty, broken family, or inability to navigate our health system: the doctor’s care must respond to those individualities. They find that physicians who manage that customization offer care which is more appropriate to an individual’s given situation (here is a video that demonstrates “red flags” about contextual issues designed to prompt clinician response, which rarely took place). 

We know that maximally invasive care is often a shortcut taken by physicians (and patients) overwhelmed by the complexities of possible options, and daunted by the challenge of modifying medicine to a person’s unique needs. Contextualizing care through good communication can give us permission to be minimally invasive when appropriate, hopefully for the benefit of person and system alike.

Zackary Berger, MD, PhD, is an internist and researcher in doctor-patient communication at Johns Hopkins General Internal Medicine in Baltimore. He is particularly interested in the role of the primary care provider in cancer control. His book, Talking To Your Doctor, is out on July 16th, 2013.

As one of my preceptors in clinic, Danielle Ofri handed out poems to the residents (some of whom were bewildered by the unexpected literary gift). It's something I never forgot. I still love reading what she writes, especially about Bellevue Hospital. I trained there as a resident and I talk about it a lot in Chapter 1 of Talking To Your Doctor. 

In a new essay in the Los Angeles Times, Ofri talks about what people think of when they hear the name "Bellevue," and how urban medicine has changed for the better - becoming a reflection of what American healthcare might be in the future.