Legion of Angels News Archive

Doctors and psychotherapists generally don’t like it when their patients don’t get better. But the fact is that lots of patients elude our clinical skill and therapeutic cleverness. That’s often when the trouble starts.

I met one such patient not long ago, a man in his early 30s, who had suffered from depression since his teenage years. In six years of psychotherapy, he had been given nearly every antidepressant under the sun, but his mood hadn’t budged.

Weeping in my office one day, he explained that he was depressed because he was a failure and a whiner. “Even my therapist agreed with me,” he said. “She said that maybe I don’t want to get better.”

I could well imagine his therapist’s frustration. She had been working with him for nearly three years without significant progress, and she was now doing what many clinicians do when the chips are down: blame the patient for failing to improve.

“I think he has an unconscious desire to remain sick,” she told me.

About a month later, I saw this patient respond remarkably well to a novel treatment. Free of depression at last, he was joyful and relieved — an odd reaction, you must admit, from someone who secretly wished to be ill.

Not just that, but he no longer felt like a failure and was much more upbeat about his future prospects.

I decided to challenge him. “How come you’re feeling so much better despite the fact that nothing in your life has really changed in the past few weeks?”

“Well, I guess I just think like that when I’m down.”

Exactly. His sense of worthlessness was a result of his depression, not a cause of it. It’s easy to understand why the patient couldn’t see this: depression itself distorts thinking and lowers self-esteem. But why did his therapist collude with the patient’s depressive symptoms and tell him, in effect, that he didn’t want to get better?

For an all too human reason, I think. Chronically ill, treatment-resistant patients can challenge the confidence of therapists themselves, who may be reluctant to question their treatment; it’s easier — and less painful — to view the patient as intentionally or unconsciously resistant.

I recall an elderly woman who was referred by a colleague for intractable depression, in which I have a special interest. I was eager to help her.several months and many treatments later, I began to get frustrated that she was no better and noticed that my thinking about her shifted. I wondered whether there was something about the sick role that she found rewarding.

After all, she had constant visits from friends and family members, not to mention an army of medical experts who were all trying, in vain, to cure her. If she got better, she might lose all that care and attention.

Then one morning, shortly after starting a new combination of antidepressants, she called. I did not recognize the cheerful voice. “I’m feeling really good,” she told me. “Not depressed at all.”

My delight aside, I felt chagrined that I had begun to write her off as a help-rejecting crank.

Of course, it makes good medical sense for therapists to rethink the diagnosis and treatment of any patient who fails to improve. But this is a double-edged sword.

Another patient, a young woman with unstable moods, was recently hospitalized with a diagnosis of bipolar disorder. When she failed to respond to two mood stabilizers, the staff began to entertain a diagnosis of borderline personality disorder, which involves emotionally chaotic relationships and impaired ability to function in the world.

“She’s pretty aggressive and demeaning, and we think she has some serious character pathology,” one of the residents told me.

But partly treated bipolar disorder can mimic borderline personality disorder, and after she received a third mood stabilizer, her “personality disorder” melted away, along with her provocative behavior.

This patient had frustrated her clinicians with her lack of response to treatment. In turn, her doctors reacted by changing her diagnosis to a personality disorder. The change in thinking shifted the blame from the clinicians to the patient herself, who was now viewed more as bad than sick.

To be sure, some patients really do want to be sick. People with Munchausen syndrome, for example, deliberately produce physical or psychological symptoms for the express purpose of assuming the sick role. And they will go to extraordinary means to defeat doctors who try to “treat” them.

But a vast majority of patients want to feel better, and for them the burden of illness is painful enough. Let’s keep the blame on the disease, not the patient.

Source — The New York Times

As with most cancers, the risk of breast cancer increases with age. Yet while doctors tell women to have annual mammograms after age 40, they often advise 85-year-olds to go two or even three years between scans.

The problem, doctors say, is too little data. Large clinical trials, including those that have found that mammography saves lives, tend to focus on younger people and exclude the very old.

A recent study that tried to assess the usefulness of mammography among 80- and 90-year-olds found that very few women in this age group, 22 percent, underwent regular screenings for breast cancer, but that those who did were more likely to find the cancer early enough to avoid a mastectomy and survive at least five years.

The finding is important, because the population of very old people is rising sharply, with a fourfold rise expected by 2050. According to the National Institute on Aging, two-thirds of those over 85 are women.

But the study may raise more questions than it answers. Some experts dispute any suggestion that all elderly women should have annual mammograms — an idea that raises the specter of frail women being dragged from nursing home beds to be screened for cancer when they are far more likely to die of heart disease or complications from a broken hip.

“It gets back to the question: What is the goal of preventive care in the elderly?” said Dr. Diana B. Petitti, vice chairwoman of the United States Preventive Services Task Force. “In my opinion, it’s to maximize quality of life and function.”

Dr. Petitti and other experts on care for the elderly say the focus on mammography could distract attention from more pressing problems, like high blood pressure, low mobility, depression, chronic pain, and impaired vision and hearing.

The task force’s guidelines do not set a cutoff age for mammography, but they do recommend taking a patient’s other illnesses into account when deciding on screening.

The mammography study, published in May in The Journal of Clinical Oncology, looked at the records of more than 12,000 patients aged 80 and older who were given diagnoses of breast cancer from 1996 to 2002. It found that among those who had a mammogram every year or two before their diagnosis, 68 percent found the cancer at an early stage, compared with 33 percent of those who skipped mammograms altogether.

Five years after the breast cancer diagnosis, 75 percent of the frequent screeners were alive, compared with only 48 percent of those who had not been screened for at least five years before their cancer was found.

But those who had frequent mammograms were not only more likely to survive breast cancer, the study’s authors said, they were more likely to survive other illnesses as well, meaning that they may simply have been healthier to begin with.

“They could be surviving because they’re healthier, and not because you did the screening,” said Dr. Gildy V. Babiera, the study’s senior author and an associate professor of surgical oncology at the University of Texas M. D. Anderson Cancer Center in Houston. “Healthy women were getting more mammograms, because they were able to go to a facility and undergo the procedure. And they could also withstand the cancer treatment.”

Dr. Babiera said she became interested in the subject when she realized that a growing number of patients in their 80s were coming to her for breast cancer treatment.

“When I see a patient with advanced cancer who is 80 or older and has a lot of other diseases, I think, ‘What if she had had a mammogram earlier?’ ” she said. “And then she could have had a lumpectomy, instead of a mastectomy and lymph-node dissection, which are very different in terms of surgery and recovery time.”

About 17 percent of breast cancers are diagnosed in women over 80. But because women over 74 have not been included in any randomized clinical trials of mammography, organizations setting guidelines for older women have had to extrapolate from studies of younger women, and the guidelines are inconsistent and even contradictory.

The Preventive Services Task Force recommends a mammogram every year or two, while the American Geriatrics Society recommends mammograms every two to three years for women over 75, if life expectancy is at least four years. The American Cancer Society recommends annual mammography for all women over 40 and in good health.

“A woman who’s 70 still has close to 19 years of life left on average,” said Robert A. Smith, the society’s director of cancer screening. “As long as she’s in good health and would be a candidate for treatment if she were diagnosed, she should continue to get mammograms.”

But some physicians who specialize in the care of elderly women are critical of such recommendations, arguing that screening tests should focus on women with a life expectancy of at least five years, who are most likely to benefit. Few women in their 80s actually die of breast cancer, which is generally believed to progress more slowly in elderly women.

“Less than 2 percent of women 80 and older die of breast cancer,” said Dr. Mara A. Schonberg, an instructor of medicine at Harvard who does research on mammography and preventive care for elderly women. “There is a time to start screening and a time to stop screening — you don’t start screening at birth, and you don’t continue until death.”

Dr. Schonberg added that the study should have had more to say about the drawbacks of screening, like anxiety over the tests, the possibility of false positives leading to unnecessary procedures, and the higher risk of complications for elderly patients from surgery and anesthesia.

A primary care physician’s limited time with older patients would be better spent, Dr. Schonberg said, encouraging them to exercise and get their immunizations, and discussing problems that can interfere with day-to-day life, like incontinence, falls and the need to keep up social ties.

Dr. Louise C. Walter, a staff physician at San Francisco Veterans Affairs Medical Center who does research on cancer screening in the elderly, agreed.

“The biggest potential harm is that a patient with dementia or congestive heart failure could have a mammogram, and then a biopsy or other procedure that has a high risk of complications, and they have all these things done to them,” she said. “And then, either because of all the distractions or because it was the natural course of events, they die of the disease they already had. And they spent the last year of their life getting all kinds of procedures, when we could have improved their quality of life.”

Source — The New York Times

WASHINGTON — Congress has voted to block a cut in Medicare payments to doctors but has done nothing to solve the fundamental problem that caused the cut, and the issue will come back to haunt the next president and the next Congress, lawmakers and health policy experts say.

Democrats and Republicans agree that the formula for paying doctors is broken, but fixing it would be phenomenally expensive, they say. So Congress provides temporary relief from year to year, the same way it takes care of the Alternative Minimum Tax, which snares more middle-income families every year.

Older Americans are directly affected because they pay higher premiums when Medicare spends more on doctors.

Senator Edward M. Kennedy of Massachusetts made a surprise return to the Senate last week and helped Democrats pass a bill to rescind a 10.6 percent cut in Medicare payments to doctors. The White House says President Bush will veto the bill because it would also reduce subsidies paid to insurance companies that care for some Medicare beneficiaries.

Democratic leaders believe they have the two-thirds majority needed to override a veto. The bill was passed 355 to 59 in the House, and the crucial vote in the Senate was 69 to 30.

The bill would give doctors an 18-month reprieve. But it leaves in place the current system of paying doctors, based on a fee schedule that sets payment rates for 7,000 different services.

“The physician payment mechanism is hands down the most broken part of Medicare,” said Gail R. Wilensky, who was administrator of the Medicare agency under the first President Bush. “We desperately need a new way to reimburse doctors. I fear that the need for fundamental change will be kicked down the road once the latest crisis has passed.”

Senator John D. Rockefeller IV, Democrat of West Virginia, agreed. “We must find a long-term solution,” he said.

Mr. Rockefeller and other lawmakers are pleading with physicians’ groups to come forward with a comprehensive proposal. But that could be difficult because any new formula would almost surely produce winners and losers among doctors.

Dr. Thomas R. Russell, executive director of the American College of Surgeons, said, “We absolutely want to work with Congress to get this fixed in the next 18 months.”

“Doctors who are responsible for the rapid growth in certain areas, like testing and imaging procedures, need to bring those expenses under control,” Dr. Russell said.

But radiologists say it is unfair to hold them accountable for all the growth in imaging services because the services are usually ordered by other doctors, like orthopedic surgeons and internists.

Senator Debbie Stabenow, Democrat of Michigan, called the current formula severely flawed. She said it cut payments to doctors about 5 percent in 2002 and would have caused cuts every year since then if Congress had not intervened.

Senator John Cornyn, Republican of Texas, said, “Congress needs to step up with a permanent solution, not the kind of shameful temporary patches and fixes that require physicians to come hat in hand to Congress every 6 or 12 or 18 months.”

The fee schedule places a limit on payment for each service, from a routine office visit to brain surgery, but does not limit the volume or quantity of services. Medicare officials set payment rates each year, using a complex formula that sets overall goals for spending on doctors’ services.

When actual spending exceeds the goals, payments to doctors are supposed to be reduced. If Congress steps in to block a cut in one year, Medicare recoups the money by making deeper cuts in future years. Under the bill passed by Congress last week, doctors would face a cut of more than 20 percent in 2010.

The purpose of the formula is to control the growth of Medicare spending for doctors’ services. But individual doctors are not rewarded or penalized for their own performance.

Medicare provides the same annual update to doctors, regardless of whether they control costs and keep their patients healthy or provide poor care and perform unnecessary tests.

The Medicare formula, established by Congress in 1997, links spending on doctors to growth of the economy, measured by the gross domestic product. This formula works when the economy is booming, doctors say, but people need their services just as much in a recession.

The formula does not distinguish between appropriate and inappropriate increases in services billed to Medicare. Nor does it reflect the fact that many services can be done with new technology in doctors’ offices, rather than at hospitals.

Dr. Wilensky said that instead of paying for “little bitty units of service,” Medicare should provide a bundled payment to a doctor or group of doctors who care for patients with chronic illnesses like diabetes and congestive heart failure.

Many doctors want to eliminate the payment formula. They say their costs — for malpractice insurance, staff salaries and other expenses — are rising faster than Medicare payment rates.

But the Congressional Budget Office says if Congress repealed the formula and allowed payments to doctors to grow by the rate of medical inflation, the costs could be substantial: $65 billion in the first five years and nearly $200 billion in the next five years.

Source — The New York Times

CHICAGO - Doctors and family members say a 7-year-old boy who fractured his skull when he was struck by a foul ball at Wrigley Field was recovering and expected to live.

Dominic DiAngi of suburban Frankfort was sitting behind the Cubs dugout Thursday afternoon during a game between the Chicago Cubs and Cincinnati Reds when a foul ball off the bat of Cubs pitcher Ted Lilly struck him in the head.

On Friday, the boy was in serious condition. Children’s Memorial Hospital spokeswoman Julie Pesch says the boy regained consciousness on Friday and doctors said he was steadily improving throughout the day.

The game was the first major league game the boy had ever attended.

Source — Yahoo!

Overweight people already know they are overweight. So should doctors keep nagging them to lose pounds?

That’s the issue tackled recently by one of my favorite medical blogs, called “Musings of a Distractible Mind.’’ The author, who goes by “Dr. Rob,” is Dr. Robert Lambert, an Augusta, Georgia physician who is board certified in internal medicine and pediatrics. On his blog, Dr. Rob muses about a variety of topics like llamas, twinkies and favorite patients. But I was particularly moved by a recent post, which was written after Dr. Rob’s encounter with an overweight patient who was clearly accustomed to being lectured about obesity. As Dr. Rob was about to discuss whether the man needed surgery for sciatica and back pain, the patient interrupted him, hanging his head in shame and blaming his weight for the problem. Dr. Rob writes:

This whole episode really bothered me. He was so used to being lectured about his obesity that he wanted to get to the guilt trip before I brought it to him. He was living in shame. Everything was due to his obesity, and his obesity was due to his lack of self-control and poor character. After all, losing weight is as simple as exercise and dietary restraint, right?

Perhaps I am too easy on people, but I don’t like to lecture people on things they already know. I don’t like to say the obvious: “You need to lose weight.” Obese people are rarely under the impression that it is perfectly fine that they are overweight. They rarely are surprised to hear a person saying that their weight is at the root of many of their problems. Obese people are the new pariahs in our culture; it used to be smokers, but now it is the overweight.

Dr. Rob says obese patients don’t need lectures.

Instead of patronizing obese patients with a lecture, I try sympathizing with them. Just because something is simple doesn’t make it easy. How do you quit smoking? You just stop smoking. We should just pull out of Iraq. There should be peace in the middle east. People should stop hurting each other and start being nice. All of these are good ideas, but the devil is in the details. Losing weight is a struggle, and it really helps to have people giving you a hand rather than knocking you down.

Dr. Rob writes that he still tries to help patients to lose weight, but he is concerned that a “culture of accusation and shame” is making matters worse for them.

The idea that their personal worth lies on their BMI is extremely damaging. There are a lot of screwed-up skinny people out there; just look at super-models. It is a lot easier to lose weight when you actually like yourself and want to do something about your health. Our culture of accusation and shame simply makes obese people hate themselves. If you hate yourself, why should you want to take care of your body?

Is obesity a problem? Sure it is. But we need to get off of our self-righteous pulpits. Obese people should not be made into a group of outcasts. The “them” mentality and the finger-wagging are no more than insecure people trying to feel better by putting down others.

What do you think? Is a “culture of shame and accusation” contributing to the nation’s obesity problem? Post your thoughts below.

Source — The New York Times