Patient-centered care is all the rage, but what does that actually mean in the medical trenches?
It means “flipping” the entire notion of health care around, says Maureen Bisognano, President and CEO of the Institute for Healthcare Improvement (IHI), speaking today at the nonprofit group’s annual national forum in Orlando, Fl.
Instead of traditional medical care, which focuses on a patient’s disease or illness by asking the question “What’s the matter?” Bisognano says providers should focus on the person and his or hers individual needs and lead with the much more intimate: “What Matters To You?”
An example: A standard mode of assessing whether a patient’s diabetes is under control is through traditional numeric measures, like blood pressure, cholesterol levels and blood sugar. But isn’t it more meaningful, Bisognano suggests, to measure in more human terms, like how many leg amputations and heart attacks were avoided by controlling diabetes, or how many fewer trips to the ER were needed? And of course, what was the dollar savings?
It’s worth listening to Bisognano’s far-reaching talk here, which touches on what health means to a 96-year-old (living pain-free and being productive) and highlights “centering pregnancy” — group prenatal and maternity care visits in which women and teams of providers support each other.
Bisognano also features a young Millennial named Trevor, a self-described “diabetes evangelist” who explains why he’s glad he has Type 1 diabetes (it’s so much easier to be healthy when you’re forced to focus on the nutritional content of food); and what true health means to him (answer: it’s all about staying high-energy in the erratic world of college student life).
It’s raw and miserable out, with snow on the way: a perfect day for a long, sit-down lunch, or just hunkering down to work at home with a laptop, a warm cocoa and a soft couch. Right? No, no and absolutely no.
A new study that followed men in South Wales for 35 years puts numbers on what now should be obvious to us all: exercise is one of the most powerful tools you possess to help prevent dementia and cognitive decline in older age. So get up now and go sweat.
To me, the most eye-popping finding here is that by following a fairly simple health regimen, the chances of a “disease-free” life as you age increase dramatically:
Researchers report that people who consistently stuck to four or five “healthy behaviors” (regular exercise, no-smoking, a low bodyweight, a healthy diet and low alcohol intake) “experienced a 60 percent decline in dementia and cognitive decline – with exercise being the strongest mitigating factor – as well as 70 percent fewer instances of diabetes, heart disease and stroke, compared with people who followed none.”
More from the news release:
“The size of reduction in the instance of disease owing to these simple healthy steps has really amazed us and is of enormous importance in an aging population,” said Principle Investigator Professor Peter Elwood from Cardiff University’s School of Medicine. “What the research shows is that following a healthy lifestyle confers surprisingly large benefits to health – healthy behaviours have a far more beneficial effect than any medical treatment or preventative procedure.
“Taking up and following a healthy lifestyle is however the responsibility of the individual him or herself. Sadly, the evidence from this study shows that very few people follow a fully healthy lifestyle. Furthermore, our findings reveal that while the number of people who smoke has gone down since the study started, the number of people leading a fully healthy lifestyle has not changed,” he added.
Recent surveys indicate that less than one per cent of people in Wales follow a completely healthy lifestyle, based on the five recommended behaviours, and that five per cent of the population follow none of the healthy behaviours; roughly equating to a city with a population the size of Swansea (240,000).
Professor Elwood continued: “If the men had been urged to adopt just one additional healthy behaviour at the start of the study 35 years ago, and if only half of them complied, then during the ensuing 35 years there would have been a 13 per cent reduction in dementia, a 12 per cent drop in diabetes, six per cent less vascular disease and a five per cent reduction in deaths.” Continue reading →
When I was expecting my first baby in 2009, I planned a home birth with a wonderful midwife. My pregnancy was healthy and normal, my prenatal care with my midwife was both empowering and attentive to my health needs and my labor began spontaneously at full term.
Everything was going according to plan, until about 20 hours into active labor at home when my midwife alerted me that my baby’s heart rate indicated a serious problem and we needed urgent medical attention.
In the amount of time it took the ambulance to arrive at my Somerville home, my midwife cut an episiotomy (a skill in which home-birth midwives are trained but don’t practice as a matter of routine) and performed an emergency delivery. My baby had aspirated meconium (the sticky tar-like substance in a newborn’s bowels that is occasionally expelled during birth) and was having trouble breathing even with the aid of the oxygen my midwife carried with her. She needed a transfer to the level III NICU at Children’s Hospital, where she made a complete recovery.
I had a home birth because I wanted the kind of low intervention pregnancy and birth that Certified Professional Midwives (CPMs) offer. But I tell my birth story publicly because it demonstrates something important that people don’t often realize about CPMs: they are skilled professionals who are prepared to handle emergencies, including facilitating transfer to medical care when needed.
CPMs are midwives who are specially trained in out-of-hospital care. They differ from Certified Nurse Midwives (CNMs) who are trained as nurses and typically practice in hospital settings. Currently, Massachusetts licenses CNMs but has no licensing system for CPMs, who provide care for approximately 500 women across the state each year.
So when I recently learned of a petition asking me to support licensing of CPMs in Massachusetts, I immediately wanted to get more involved. I found other moms who want this bill to pass and I’ve had the pleasure of lending my support to this work being carried out by a coalition of advocates from the Massachusetts Midwives Alliance, Massachusetts Friends of Midwives and others. More than 500 Massachusetts residents have now signed the petition.
The bills (HB 2008 and SB 1081) would require all midwives practicing out of hospital to become CPMs, create state licensing requirements for CPMs and establish a Committee on Midwifery under the Board of Registration in Medicine. The nine-member committee will include five CPMs, one obstetrician, one CNM and one consumer of midwifery services.
Supporters of the measures that would license and regulate home birth midwives were energized by an amazing turnout at a Committee on Public Health hearing last month, testifying to the professional skill of these midwives and the valuable ways they serve Massachusetts families. Several moms even brought their charming home birth babies along for the day at the State House.
I have heard from some midwifery supporters who oppose licensing, worrying that new regulations will hamper midwives’ ability to truly practice the midwifery model of care. But midwives themselves will be involved in determining details of regulation. Overall, licensing of our midwives would mean more moms will feel able to choose home birth, because they’d have the security of knowing that in order to hang out her shingle, a midwife must meet state licensing standards.
The Massachusetts Medical Society has also opposed the bills, expressing disapproval of any health care that is delivered outside the team context with immediate M.D. supervision. Continue reading →
Blind opera star Andrea Bocelli speaks during a MIT workshop to introduce new technologies to empower blind people to become more independent. (Stephan Savoia/AP)
What’s a young blind Italian student to do when his beautiful blond crush, Mary, approaches?
Well, if a slew of new assistive technologies now being developed at MIT and Northeastern come to fruition, the intimate interaction might unfold like this: the blind student, wearing a cutting-edge device — a smart jacket, for instance — equipped to communicate a complex array of information privately to a blind user, will be able to sense Mary’s presence, facial expressions and body language, chat intelligently with her about literature and move in to squeeze her hand when a rival suitor approaches.
The characters here are fictional, of course. But the overarching ambitions of this research, funded by the blind Italian opera superstar Andrea Bocelli’s foundation, are both intimate and far-reaching. “The idea was a huge bet,” Bocelli said today. He was speaking through a translator at a workshop at MIT to introduce the array of new technologies to empower blind people to live, study and work more independently. “To create a tool, a device, that would basically substitute itself for the eyes.” He characterized the research as going from the “impossible to the possible.”
The genesis of the Bocelli-MIT venture was a post-concert meeting in Boston several years ago, Bocelli said. He brainstormed with several MIT professors to find out what kind of technology for the blind would “be possible.” Since then, a collaborative team of cross-disciplinary researchers have developed prototypes that may someday be able to deliver critical data to the blind: everything from dynamic information about safe walking terrain and hazards, to enhancing social interactions in real-time through wearable devices or a vibrating watch with a high-resolution tactile display that can deliver important information through the skin.
“I have to be honest, the idea of this project was not born of my own needs — I am in a privileged situation,” with an entourage of helpers all around, said Bocelli, who grew up with low vision and then became completely blind in childhood following a sports-related accident. But “there are many people, some of them my friends, that are living alone in a city, and they have the issue of going to work on their own, going grocery shopping, locating the items on the shelves…The issue is really living on one’s own.” Speaking at a news conference, Bocelli conceded that one day, he might use the technology himself: “Of course, when it will come to fruition, it will be helpful to me as well — because the main problem is that humanity has people who are never happy with what they have. This technology will be helpful first for people who are on their own, but then it will come in handy for people like me, who want to be on their own some times.”
Specifically, The Andrea Bocelli Foundation says it’s given about $500,000 to fund researchers at MIT, and Northeastern to develop these technologies.
Intuitive Surgical Inc. (ISRG), the maker of a $1.5 million robot surgery system, told doctors that friction in the arms of some devices may cause the units to stall, the second warning issued about the company’s products in a month.
The company sent an “urgent medical device recall” Nov. 11 alerting customers of the issue, which affects 1,386 of the systems worldwide, the U.S. Food and Drug Administration said in a Dec. 3 notice on its website. The stalling may result in a sudden “catch-up” if the surgeon pushes through the resistance, the agency said.
Intuitive is facing growing questions about its marketing strategies, training procedures and the safety of its devices, Bloomberg News has reported. The FDA said last month that the number of adverse event reports, including deaths, injuries and system malfunctions, has more than doubled this year as of Nov. 3 compared with all of 2012.
“Reports of friction within certain instrument arms can interrupt smooth instrument motion,” the FDA said on its website. Continue reading →
They just don’t stop coming — the far-flung body parts and systems that you can help by exercising. The latest: Your ears.
Brigham and Women’s Hospital researchers report in the American Journal of Medicine that in women, exercise is linked to a lower risk of hearing loss. (And on the flip side, obesity is linked to a higher rate.) From the Brigham press release:
Using data from 68,421 women in the Nurses’ Health Study II who were followed from 1989 to 2009, researchers analyzed information on BMI, waist circumference, physical activity, and self-reported hearing loss…Compared with women who were the least physically active, women who were the most physically active had a 17 percent lower risk of hearing loss. Walking, which was the most common form of physical activity reported among these women, was associated with lower risk; walking 2 hours per week or more was associated with a 15 percent lower risk of hearing loss, compared with walking less than one hour per week.
But wait just a minute, you may say; for me to exercise, I have to pipe loud music into my ears. Surely that negates any positive effect? I asked the study’s lead author, Dr. Sharon Curhan. She emailed:
Regarding your question about listening to music and using earbuds/headphones while working out–absolutely! What is important is that people learn how to listen to music safely. In order to avoid noise-induced hearing damage, both the “level” (volume) and “duration” of the noise exposure need to be considered. This means that the louder the music, the shorter the time of safe exposure. For example, if you want to listen to your music with earbuds for a long time (say 90 minutes/day or more), then set the volume at 60% volume or less. The longer you want to listen, the lower the volume should be. The headphone types may make a difference, too. Noise-canceling headphones or insert earphones may help reduce background noise so that the volume will not need to be turned as high. However, there are some situations when it is essential to be aware of background noise for safety reasons, such as running or biking on a busy road.
And in case you’re wondering how exercise might preserve hearing, I’d sum up the theories as “exercise makes your body healthier, including your ears.” The paper offers some possible mechanisms: Continue reading →
Mine is a world very few see: pathology and laboratory medicine. More than 70 percent of the information in your medical record comes from laboratory testing. Yet chances are you’ve never been inside the lab that so influences your health care.
So I’d like to offer you a little behind-the-scenes tour of some of the sights and sounds of the top health issues facing the United States. They’re fascinating in and of themselves, but they also may give you added incentive to do what it takes for your own health.
￼ Heart Disease
Heart disease kills more Americans than anything else, accounting for 1 in 4 deaths. Heart disease alone costs the U.S. $108.9 billion each year. Prevention is our best defense (hence the recent fuss over new statin recommendations). This begins with knowing your lipids. Seen and heard here are the sounds of automated instruments analyzing specimens to report a lipid panel.
What is a lipid panel? It includes cholesterol, LDL (low density lipoprotein, “bad cholesterol”), HDL (high density lipoprotein, “good cholesterol”) and triglycerides.
Over a thousand specimens a day are typically analyzed in the Newton Wellesley Hospital chemistry lab. Tubes of blood are analyzed by automated instruments, moving from one station to the next, performing dozens of tests on a single sample. (All photos courtesy M. Misialek.)
Under the Affordable Care Act, many health insurance plans cover preventive care services, including lipid screening, at no cost to you.
Ranking number two in leading causes of death is cancer. Screening exams such as pap smears, colonoscopies and mammograms are vital to early detection and prevention. Once again, the pathology lab plays an integral role. Below, hear and see how tissue slides are produced and evaluated by pathologists. All care begins with a diagnosis. See your physician for what screening tests are recommended for you.
Tissue specimens, after having been cut and put on a glass slide, are stained and coverslipped. Pathologists then examine and diagnose these under a microscope.
Comments ranged from heartfelt, personal stories of family bedsharing to adamant opposition to the practice, from questions about terminology to pleas for more information about safe bedsharing.
Riobound wrote: “I like the idea of ‘educate’ but don’t ‘dictate.’ The State should inform not impose.”
And PilgrimOnTheJames posted that “we shared our bed with each of our seven babies…for the first several months of their post-partum lives…because it allowed my wife to breast-feed them without her having to greatly disturb her much needed rest, and also, because the little tikes smelled so good and were so cute to watch sleeping. We moved them into a separate bed in our room once they were able to consistently sleep through the night. The bonds that were begun then have only grown and strengthened over the past 30+ years of family life. I thank God that we ignored the advice of many well-meaning, but totally scandalized family members and friends.”
Amelia Oliver commented, “Thank goodness the scientific community is finally considering moving away from trying to scare people out of bed-sharing and co-sleeping. The comparison with the policy of advocating abstinence instead of sex-ed is strikingly appropriate since almost everyone does it but we are all afraid to talk about it, let’s start teaching the safe way to do it.”
Molly pointed out “This article…conflates the issues of cosleeping in bed sharing, which are not the same thing. Cosleeping is risk free, end of story. Bed sharing does have risks if not done carefully and correctly.”
So in an effort to shed more light on the topic, I’ll try here to clarify the terms, explain why the research linking SIDS to bedsharing is inherently flawed, and provide some tips to make sleep as safe as possible for all babies.
In the scientific community, “co-sleeping” is a general term for a child sleeping in close proximity to a caregiver, within sensory range. “Room-sharing” is when a child sleeps in the same room as her caregiver. Under this definition are two sub-categories: “separate-surface cosleeping,” in which the child has his own bed, and “same-surface cosleeping,” also known as bedsharing. “Bedsharing” is the term that describes what most Americans think of when they hear “co-sleeping:” a child sleeping in an adult bed with his caregivers. This sort of close proximity is natural to the human species.
2. ’Shaky Evidence’ And A Shift In Thinking
The AAP, a highly influential professional group of pediatricians, opposes bedsharing and has led the charge to promote the idea that sleeping in the same bed as your infant is dangerous. “The American Academy of Pediatrics (AAP) does not recommend any speciﬁc bed-sharing situations as safe,” the organization says in its latest statement on the matter, which then goes on to list what it characterizes as particularly unsafe bed sharing practices to be avoided “at all times,” including, “when the infant is younger than 3 months,” or with a smoker. The AAP also says bed sharing should be avoided “with someone who is excessively tired,” which makes us wonder if any of them have ever actually been parents.
But many researchers, medical professionals and worldwide organizations question the AAP’s position on bedsharing, in large part due to ‘shaky evidence’ as the basis of the academy’s position, and also given the benefits of the practice. Dr. Abraham Bergman, a prominent SIDS researcher and pediatrician said in an email that “the evidence linking bed sharing per se to the increased risk for infant death is shaky, and certainly insufficient to condemn a widespread cultural practice that has its own benefits.” The WHO, UNICEF, La Leche League International, the Breast Feeding section of the AAP, and Academy of Breast Feeding Medicine all disagree with a sweeping recommendation to avoid bedsharing.
The plot keeps thickening when it comes to the connection between your gut and your brain.
A new review article links probiotics to changes in mood and mental health, suggesting these “good” bacteria might have potential as a treatment for depression and other psychiatric maladies. In the study, published in the journal Biological Psychiatry, researchers define the term “psychobiotic” as “a live organism that, when ingested in adequate amounts, produces a health benefit in patients suffering from psychiatric illness.”
These organisms act on what researchers call the “brain-gut axis,” a biological network connecting the intestinal and endocrine systems to the spinal cord and regions in the brain that process stress, such as the HPA-axis.
Is all this plausible? Perhaps. Ghrelin, known as the “hunger hormone” and produced in the intestines, was recently found to play a role in the development of chronic stress. And stress in turn has been found to alter our microbiota. There’s growing evidence that there’s a special connection between the gut and the brain, and as one MGH psychiatrist said recently: “There is a neural feedback from the gut to the brain so chronic gastrointestinal distress can exacerbate anxiety or depression.”
Thomas Insel, Director of the National Institute of Mental Health, stated last December that how “differences in our microbial world influence the development of brain and behavior will be one of the great frontiers of clinical neuroscience in the next decade.”
Dr. Timothy Dinan of University College Cork in Ireland and the psychobiotic study’s lead author says that although the research conducted on humans is sparse, “the animal studies indicate that certain psychobiotics can change brain chemistry.”
It’s so very disconcerting when deeply entrenched health wisdom is suddenly flipped on its head. But that’s the way it often goes in this arena.
So, with such widespread confusion over the new guidelines on cholesterol and statins, cholesterol-lowering drugs, I was relieved to see that veteran health reporter (and my former colleague) Ron Winslow at The Wall Street Journal offered a just-the-facts-ma’am Q & A on exactly what you need to know about the new guidelines. It’s got everything from LDLs to the new risk calculator — which was down when I checked this morning. (What’s going on with all the bugs in our critcal health care sites??)
Here’s a snippet from Winslow:
The new tack recommended by the American Heart Association and the American College of Cardiology is to prescribe moderate to high doses of cholesterol-lowering drugs called statins to patients who fall into one of four risk groups regardless of their LDL status. Here is a look at the implications:
Q. Why get rid of the LDL targets?
A. The targets lack strong scientific evidence. The expert panel that developed the guidelines concluded that by focusing on an individual patient’s overall risk rather than a relatively arbitrary set of LDL targets, the strategy to prevent heart attacks and strokes will be more effective and more personally tailored to the needs and preferences of each patient.
Q. What should patients do in response?
A. Patients already on cholesterol-lowering medication should ask their doctors at their next appointment whether they are on the most appropriate therapy to reduce their heart-attack and stroke risk, says Neil Stone, a cardiologist at Northwestern University who headed the panel that wrote the cholesterol guideline.
For people not on cholesterol drugs, a new risk calculator is available online. If you have a 7.5% chance of having a heart attack over the next 10 years, you are a candidate for treatment with a statin no matter your LDL level under the new guidelines.
Q. I have no heart problems and my LDL was 90 in a recent cholesterol test. Is it possible I should be on a statin anyway? Continue reading →