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Why Patient Autonomy Is Critical To Good Health Care

Many of the patients that I treat have brain injuries. Whether caused by a stroke, car accident, fall, or drug overdose, their rehab course has taught me one thing: nobody likes to be forced to do things against their will. Even the most devastated brains seem to remain dimly aware of their loss of independence and buck against it. Sadly, the hospital environment is designed for staff convenience, not patient autonomy.

In the course of one of my recent days, I witnessed a few patient-staff exchanges that sent me a clear message. First was a young man with a severe brain injury who was admitted from an outside hospital. EMS had placed him in a straight jacket to control his behavior on his trip and by the time I met him, he was in a total panic. Sweating, thrashing, at risk for self harm. He didn’t have the ability to understand fully what was happening but one thing he knew – he was being restrained against his will. The staff rushed to give him a large dose of intramuscular Ativan, but I had a feeling that he would calm down naturally if we got him into a quiet room with dim lights and a mattress with wall padding set up on the floor. As it turned out, the environmental intervention was much more successful than the medicine. Within minutes of being freed to move as he liked, he stopped moving much at all.

Later I was speaking with one of my patients in the shared dining room. An aide arrived with a terry cloth bib to tie around his neck so that he didn’t spill anything during lunch. I saw a flash of anger in my patient’s eyes as he pulled the bib away from his neck with his good arm and placed the towel on his lap instead. I could tell that he found the bib infantalizing, though none of us had thought twice about it before. Here again, a patient did not appreciate having everything determined for him, right down to napkin placement.

Towards the end of the day, I was bidding farewell to a patient whose care would be provided by another attending physician going forward. I was summarizing my view of his progress and expectations for the future, and stopped to ask if he had any questions. What he asked completely flummoxed me. Instead of probing for details about his medical condition and treatment options, he asked, “Will the new doctor be a good listener? Will she pay attention to what I’m saying and be easy to talk to?”

It is unfortunate that healthcare providers and patients are often on very different wavelengths. In Atul Gawande’s recent book, Being Mortal, he argues that nursing homes have often failed to provide healthy environments for patients because they have focused exclusively on safety and meeting basic needs (eating, dressing, bathing, etc.) on their terms. The removal of patient independence unwittingly results in devastating loneliness, helplessness, and depression. It seems to me that hospitals end up doing the same thing to patients – if only for a shorter period of time.

I was moved by Gawande’s book (and I consider it required reading for anyone facing a life-limiting illness or caring for someone who is). It renewed my conviction about the importance of rehabilitation – helping people to become as functionally independent as possible after a devastating injury or disease. Even as we age, we all become less able to do the things we hold dear. Preserving dignity by prolonging independence, and respecting patient autonomy, are often overlooked goals of good health care. It’s time to think about what our actions – even as small as placing a bib around someone’s neck – are doing to our patients’ morale. Maybe it starts with asking the right questions… Or better yet, just watching and listening.

Do Childless Couples Have An Increased Risk Of Death And Mental Illness?

I hate scientific studies that don’t investigate the assumptions on which they’re based.  They do harm.  The findings slither around and get into the heads of people who treat people for the issues the research purports to understand.  And the misconceptions become protocol.  Here’s one example:

The Journal of Epidemiology and Community Health published an article declaring a connection between childlessness and increased risk of death and mental illness.

Among the findings:

  • Having a child cut the risk of early death, particularly among women.
  • The early death rate from circulatory disease, cancers, and accidents among childless women was four times as high as that among those who gave birth to their own child, and 50% lower among women who adopted.
  • Similarly, rates of death were around twice as high among men who did not become parents, either biologically or through adoption.
  • The prevalence of mental illness in couples who adopted kids was around half that of other parents.

What the study states but doesn’t investigate is that for their research they used:  ”population-based health and social registers, we conducted a follow-up study of 21 276 childless couples in in vitro fertility treatment.”

Do you hear the sound of “WHAT!??!” beginning to reverberate?

Might it be that couples who have been living in the infertility system for months, maybe years and have had their original life script expectations erased, have had doctors and drugs and timetables invade their intimate time, have spent gobs of money, and have had repeated cycles of devastating disappointment may be in a very different state than couples who have CHOSEN not to have children?

And let me state my assumption up front.  Choosing not to have children is not dysfunctional.  It’s not a psychological condition.  It’s not an ethical/moral lapse.  It’s not a sign of immaturity or selfishness.  It’s a legitimate choice.

It may be that the researchers’ findings do apply to couples who undergo infertility treatment in order to have a child.

But there is harm in assuming that all couples who don’t have children are at higher risk for death and mental illness.


This post originally appeared at Barbara’s blog, In Sickness As In Health.

Research Suggests Certain Professions Are More Associated With Schizophrenia

People with schizophrenia or bipolar disorder and their first-degree relatives more frequently work in creative professions, suggesting some truth to the long-mythologized link between artists and madness. The way the link plays out along family lines suggests a genetic cause, researchers reported.

While smaller studies have looked specifically at small groups of creative populations such as artist’s workshops and their rates of mental illness, researchers in Sweden conducted a population-based study of how often mental illness occurs among people and their relatives, and its association with creative and non-creative professions.

The researchers performed a nested, case- control study using longitudinal Swedish total population registers and compared it with occupational census data. Creative professions included visual artists such as photographers and non-visual artists such as performers and writers, as well as members of the scientific professions among university academics. Accountants and auditors acted as a control group.

Results appeared in The British Journal of Psychiatry. Overall, Read more »

*This blog post was originally published at ACP Internist*

Pay Tribute To The Veterans In Your Life By Learning More About PTSD

My ability to sit peacefully day after day and write about health or enjoy my family owes more than I’ll ever know to the hard work and sacrifice of generations of American men and women who served in the Armed Forces. On behalf of my colleagues at Harvard Health Publications: Thank you for your service.

One of the challenges faced by many servicemen and servicewomen returning from war is post-traumatic stress disorder, or PTSD.

In a nutshell, post-traumatic stress disorder is a lasting and exaggerated reaction to a terrifying or life-threatening event. It makes a person feel like he or she is living through the event over and over again. PTSD shows itself in three main ways:

Re-experiencing. People with PTSD mentally relive the triggering trauma in daytime flashbacks, nightmares, or inescapable thoughts about the event. Sights, sounds, smells, or other stimuli can bring the event to life.

Avoidance. People with PTSD tend to Read more »

*This blog post was originally published at Harvard Health Blog*

Mental Health Support For Pregnant Women May Save Two Lives

In a recent medical study, violent deaths of pregnant women outnumber traditional causes of maternal deaths such as post partum hemorrhage or pre-eclampsia . I am not surprised. In September 2010, I wrote an article entitled 7 Reasons Why Pregnancy Becomes a Deadly Affair after an 18 year old college student almost lost her life at the hands of her football-playing boyfriend because she became pregnant. Pregnancy is not a benign act and 50% of them are unplanned.

Dr. Christie Palladino, an ob-gyn physician at the Georgia Health Sciences University and main researcher of the study, looked at data from 17 states and found 94 pregnancy-related suicides and 139 homicides from 2003-2007. Approximately 45 % of suicides occur during pregnancy, often precipitated by Read more »

*This blog post was originally published at Dr. Linda Burke-Galloway*

Latest Interviews

IDEA Labs: Medical Students Take The Lead In Healthcare Innovation

It’s no secret that doctors are disappointed with the way that the U.S. healthcare system is evolving. Most feel helpless about improving their work conditions or solving technical problems in patient care. Fortunately one young medical student was undeterred by the mountain of disappointment carried by his senior clinician mentors…

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How To Be A Successful Patient: Young Doctors Offer Some Advice

I am proud to be a part of the American Resident Project an initiative that promotes the writing of medical students residents and new physicians as they explore ideas for transforming American health care delivery. I recently had the opportunity to interview three of the writing fellows about how to…

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Latest Book Reviews

Book Review: Is Empathy Learned By Faking It Till It’s Real?

I m often asked to do book reviews on my blog and I rarely agree to them. This is because it takes me a long time to read a book and then if I don t enjoy it I figure the author would rather me remain silent than publish my…

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The Spirit Of The Place: Samuel Shem’s New Book May Depress You

When I was in medical school I read Samuel Shem s House Of God as a right of passage. At the time I found it to be a cynical yet eerily accurate portrayal of the underbelly of academic medicine. I gained comfort from its gallows humor and it made me…

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Eat To Save Your Life: Another Half-True Diet Book

I am hesitant to review diet books because they are so often a tangled mess of fact and fiction. Teasing out their truth from falsehood is about as exhausting as delousing a long-haired elementary school student. However after being approached by the authors’ PR agency with the promise of a…

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