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Over-Reliance On Tests: Why Physicians Must Learn To Trust Themselves And Their Patients

I met my newly admitted patient in the quiet of his private room. He was frail, elderly, and coughing up gobs of green phlegm. His nasal cannula had stepped its way across his cheek during his paroxsysms and was pointed at his right eye. Although the room was uncomfortably warm, he was shivering and asking for more blankets. I could hear his chest rattling across the room.

The young hospitalist dutifully ordered a chest X-Ray (which showed nothing of particular interest) and reported to me that the patient was fine as he was afebrile and his radiology studies were unremarkable. He would stop by and check in on him in the morning.

I shook my head in wonderment. One look at this man and you could tell he was teetering on the verge of sepsis, with a dangerous and rather nasty pneumonia on physical exam, complicated by dehydration. I started antibiotics at once, oxygen via face mask, IV fluids and drew labs to follow his white count and renal function. He perked up nicely as we averted catastrophe overnight. By the time the hospitalist arrived the next day, the patient was looking significantly better. The hospitalist left a note in the EMR about a chest cold and zipped off to see his other new consults.

Similar scenarios have played out in countless cases that I’ve encountered. Take, for example, the man whose MRI was “normal” but who had new onset hemiparesis, ataxia, and sensory loss on physical exam… The team assumed that because the MRI did not show a stroke, the patient must not have had one. He was treated for a series of dubious alternative diagnoses, became delirious on medications, and was reassessed only when a family member put her foot down about his ability to go home without being able to walk. A later MRI showed the stroke.

A woman with gastrointestinal complaints was sent to a psychiatrist for evaluation after a colonoscopy and endoscopy were normal. After further blood tests were unremarkable, she was provided counseling and an anti-depressant. A year later, a rare metastatic cancer was discovered on liver ultrasound.

Physicians have access to an ever-growing array of tests and studies, but they often forget that the results may be less sensitive or specific than their own eyes and ears. And when the two are in conflict (i.e. the patient looks terrible but the test is normal), they often default to trusting the tests.

My plea to physicians is this: Listen to your patients, trust what they are saying, then verify their complaints with your own exam, and use labs and imaging sparingly to confirm or rule out your diagnosis. Understand the limitations of each study, and do not dismiss patient complaints too easily. Keep probing and asking questions. Learn more about their concerns – open your mind to the possibility that they are on to something. Do not blame the patient because your tests aren’t picking up their problem.

And above all else – trust yourself.  If a patient doesn’t look well – obey your instincts and do not walk away because the tests are “reassuring.” Cancer, strokes, and infections will get their dirty tendrils all over your patient before that follow up study catches them red handed. And by then, it could be too late.

Book Review: I Love You But I Don’t Trust You

Author Mira Kirshenbaum

I Love You But I Don’t Trust You is national bestselling author, Mira Kirshenbaum’s, 11th book about healing relationships. I had the privilege of working with Mira when she was part of my medical expert team at Revolution Health, so I welcomed the chance to review her latest work. Although I had to endure some curious looks from my fiancé (who wondered why I was reading a book with that title), Mira’s writing sparked some interesting discussions between us and reinforced our own trust in each other.

When I first read the title of the book, I assumed that it would be focused on what to do when your partner has an affair. I was surprised to discover that I was utterly wrong. In fact, relational trust deficits can be caused by anything from broken promises, to misrepresenting financial situations, to lording one’s power over another. I Love You But I Don’t Trust You opened my eyes to all the subtle ways that trust can be eroded, and at the same time offered “actionable” advice for shoring up relationships.

Mira’s writing is particularly engaging because she illustrates her ideas with poignant, real-life examples. For every breach of trust under discussion, she offers a case study. Sometimes the couples she describes make outrageous gaffs, and the emotional train wreck that ensues is both terrifying and riveting. Example after example of poor judgment, bad behavior, and selfish acts could potentially be depressing, if it weren’t for the good news that follows. Many of these couples were able to resolve their conflicts and restore trust against all odds. Illustrating how that happens is part of the reason why Mira’s book is a page-turner.

Beyond advice for couples, I Love You But I Don’t Trust You is actually quite relevant for anyone who has been deeply wronged. Mira describes how she herself was able to offer true forgiveness to a former Nazi soldier who had participated (indirectly) in putting her own parents in a concentration camp. She describes a life-changing moment when she was traveling in Europe as a young woman, and she became very ill and fainted at the train station. A German couple took her to their home and nursed her back to health. Mira learned to trust the “untrustable” and became convinced through this experience that no relationship was beyond help. She devoted the rest of her life to relationship counseling, and her passion fosters hope in each of her books.

Some things you will learn from I Love You But I Don’t Trust You:

*All the ways that mistrust can enter a relationship

*Is your relationship worth saving?

*The typical response to broken trust, and the way to minimize collateral damage

*Suggested timeline for change and trust repair

*How to restore trust by working through 6 key questions

The only downside to Mira’s book is that it is based upon, as far as I can tell, the informed experience of only one therapist. Mira does not refer to the academic literature to support her theses or suggestions, nor does she appear to rely upon outside sources for additional insight. Mira speaks from her gut – she has a brilliant way of positioning arguments, and helping people to approach each other in ways that are minimally inflammatory in what is otherwise an emotional mine field. Beyond that, I can’t say if Mira’s approach to conflict resolution is optimal. My instinct says it’s as fine a methodology as any I’ve seen, but from an evidence-based perspective, there isn’t necessarily a lot of data behind it (just had to add that caveat for my science-loving friends).

Nonetheless, in my opinion, I Love You But I Don’t Trust You would be an excellent workbook for people in couples’ therapy. In fact, the Appendix lists suggested topics and questions for discussion groups, so I’m sure that Mira was thinking the same thing when she wrote it.

But most importantly, I think that reading the book in advance of any trust violations in your relationship, could be the best course of action. Simply learning about all the damage that one impulsive decision can cause to a lover and/or family could make you less likely to make that decision! I Love You But I Don’t Trust You might best be used as a preventive health measure for your relationship(s). I’m sure it has strengthened me against trust violations in my future.

**You can order the book on here **

Earning Patient Trust Through The Power Of Touch

Abraham Verghese, MD, Standford University

My wife has two world-class oncologists who help her manage her Stage 4 Lung Cancer.  Both are excellent clinicians.  Yet their skills differ in one very important way.  Her radiation oncologist physically touches her a lot (in a good way of course!).  There are the touches on her arm, a hand on the shoulder, hugs, and of course a thorough hands-on physician exam.  Her medical oncologist not so much.

We all recognize the therapeutic value of touch.  Dr. Abraham Verghese, a Stanford Physician and Professor, at the 2011 Med2.0 Conference, described the power of touch associated with the physical exam.  In the following scenario he describes an interaction with a chronic fatigue patient who came to him after being seen by many other physicians: Read more »

*This blog post was originally published at Mind The Gap*

Doctors Should Be Able To Trust Their Patients

Physicians are still debating whether prescribing placebos is ethical. Dissenters argue that this is dishonest and would erode trust between patients and their physicians. If the practice were to gain acceptance, then physicians’ credibility would be diminished. Patients would wonder whether the medicines their doctors are recommending are evidenced-based or fraudulent.

Patients can now push their own snake oil right back onto their physicians. I learned that the ‘secret shopper’ mechanism for quality assessment has been introduced into the medical profession. I first read about this in the March/April 2010 issue of the Journal of Medical Practice Management, a periodical that I suspect is not widely read by physicians.

Folks are hired as pretend patients and are dispatched to doctors’ offices and hospitals to document their findings. Their mission is to assess office staff, appointment issues and the waiting room experience. I wonder if Read more »

*This blog post was originally published at MD Whistleblower*

Trust Is Critical To Strong Doctor-Patient Relationships

Often the simplest solutions to problems are the best.  So it would seem when it comes to the impact that increasing patient trust in physicians could have on many of the intractable challenges that face the health care industry everyday like non-adherence, lack of involvement, poor health status, dissatisfaction and so on.

I explore the link between patient trust and outcomes in the following infographic I curated and designed.  What surprised me is how a patient’s level of  trust in their doctor, like so much of what I talk about in this blog, boils downs to the patient’s perception of the physician’s ability to communicate: Read more »

*This blog post was originally published at Mind The Gap*

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