A Watchful Eye in Hospitals

DESPITE the intensely personal moments that happen in hospitals, patient privacy can be elusive. Hospitals are multimillion-dollar corporations that look like shopping malls and function like factories. Doctors knock on exam room doors to signal they are about to enter — not to ask permission. The curtain that encircles the hospital bed always lets in a crack of light.

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Yet we do expect some degree of privacy in hospitals. We trust doctors with our secrets in part because they take a 2,000-year-old Hippocratic oath to respect our privacy, an oath enforced by laws like the Health Insurance Portability and Accountability Act. But sometimes, doctors have to weigh patients’ privacy against their health and safety, and that’s when things get complicated.

My hospital, where I am chairman of the bioethics committee, recently wrestled with the question of where patient and family privacy ends. Nurses in the neonatal intensive care unit (N.I.C.U.) worried that a premature infant, whom I’ll call Rickie to protect his identity, was being harmed by his parents.

Read my full op ed at The New York Times

Posted on February 16, 2014 .

Changing the Water in Which We Swim

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As the lights in the auditorium go down, just before I flick on my microphone, I remember what media critic Marshall McLuhan once said about culture: We live “in an electric information environment that is quite as imperceptible to us as water is to fish.”

As a leader of my institution’s curriculum redesign effort, I often speak with departments and even the whole faculty about our plans for the new curriculum. These experiences have made me acutely aware of how well McLuhan’s quote applies to what has been called the “hidden curriculum” in medical education. Medical education, and the culture of medicine in which it occurs, influence personal identity and perception so pervasively that it can be a challenge to talk clearly about how to change the hidden curriculum.

Read the rest of my blog at Health Affairs. It is a response to a very nice article by Liao et al in the January issue of that same journal.

Posted on January 31, 2014 .

This just in: how HIV kills

New findings by researchers at the Gladstone Institute of Virology at the University of California at San Francisco (UCSF) have upended how we understand the pathogenesis of the acquired immunodeficiency syndrome (AIDS). 

Enter Warner Greene, a dapper white-haired professor of medicine at UCSF and its Gladstone Institute of Virology. In a feat of scientific hutzpah sure to trigger fits of envy among other scientific heavy-hitters, Greene shattered the existing model of AIDS pathogenesis in two simultaneous groundbreaking articles in the prestigious journals Science and Nature in late December 2013.

Greene’s team made multiple seminal observations. Their key findings were ...

Read my new post at Scientific American guest blogs to learn more

 

Posted on January 17, 2014 .

Protect Thy Neighbor

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We are now deep into flu season. Forty states are reporting widespread influenza, and the number of deaths is greater thane expected.

Hospitalized patients are among the most vulnerable people in flu season. Immune systems already weakened by kidney failure or another major illness, hospitalized patients contract influenza from loved ones and - most ironically - from hospital workers. From doctors to nurses and beyond, a coughing caregivers can be the worst kind of medicine for vulnerable hospitalized patients.

Should hospital employees be obligated to get a flu shot to protect vulnerable hospitalized patients? Some hospitals - including mine - require employees to get flu shots or else suffer consequences such as mandatory masks, furlough and firing. Is this an unjustified infringement on personal liberty, or a thoughtful way to protect the health of our most vulnerable? 

Ethicist Bill Nelson and I explore this controversial issue in a recent issue of Healthcare Executive.

Posted on January 17, 2014 .

Toward fewer demons

My New Year's resolution 2014: fewer demons.

There were a lot of demons in 2013. Some like Typhoon Haiyan were faceless, and not of our making. Most demons, though, were human, and their demonism was a false and human creation. 

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2013 saw many people treated like demons: Ted Cruz, Barack Obama, Justine Sacco, Miley Cyrus, gays, the GOP, Paula Deen, Pope Francis. The list goes on*. I revere some of these demonized people, and others I don't. But inarguably these people and many others like them have fallen prey to our abbreviated, stereotyped, uncharitable understanding of the Other. The Other is, like us, flawed. Capable of great sin, even. But when we sit in judgment of them, dispassionately, unforgivingly, we commit a second sin of our own. 

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My trip to the United States Holocaust Memorial Museum was a powerful reminder of how this kind of polarization and demonization can lead to evil. One large portion of the determination it took to build that institution came from one of my favorite Georgetown professors, Michael Berenbaum. Berenbaum was an inspirational teacher at Georgetown, and in between classes he flew frequently to Europe to collect artifacts for the Holocaust Memorial Museum. A student once asked Berenbaum how he accomplished so much. Berenbaum paused at the front of the class, silent for a moment with his tie torn in honor of his recently deceased father. He had bags under his eyes from a recent transatlantic flight. "You know how you doubt yourself?" he asked, "You spend time asking, 'Can I do this?' or saying to yourself, 'I'm not smart enough?'" He said he used the time most spend on self-doubt to accomplish a little more of his life mission. In his case that mission was to help avert future evil through the remembrance of the Shoah, but whatever your mission, that there is sound advice.

So: in 2014, I will debate the issues, perhaps even loudly, but I will try my best to be civil and respectful and not to make a demon out of anyone. This is especially important precept to follow amid strong disagreement. Along the way, as much as I can, I will keep my focus on achieving my mission and not on how great or poorly I am looking along the way. 

In a related vein, critic Frank Bruni had a timely message recently: Tweet less, read more. Bruni argues that in the Age of Twitter we are too apt to make snap judgments without letting the full complexity of the situation "steep" in the way it may when we take time to ponder. As we do when reading fiction. Amen, I say, amen! Hallelujah! 

Prohibitions like these - don't hate, don't fear - are good, but they don't fill me up. As a result, I will keep this photograph in mind as well. 

Photo by Sergey Ponomarev for The New York Times (Copyright 2013)

Photo by Sergey Ponomarev for The New York Times (Copyright 2013)

Taken from the Year in Pictures at The New York Times, this is an Afghan schoolgirl, reading. Considering how hard-won the freedom to read a few words of text can be in towns like hers, this powerful reminder of the preciousness of learning and education will be one guide for me through the challenges of 2014.

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Gratitude, too, will guide me. I am grateful for the connections I made in 2014: my wonderful patients, an inspiring troupe of medical educators, our vibrant hospital ethics committee, and a motley cast of Twitter characters. I cannot imagine better company in 2014.

Happy New Year!

 

 

* PS Shortly after I posted this article, I was pained to see a crowd of science writers whom I respect sit in rather snarky judgment of another excellent writer (and my former editor), Bora Zivkovic.

Way back in 2013, Zivkovic had apologized (imperfectly) when accused of sexual harassment by more than one female science writer. As New Year's Day unfolded, Zivkovic's story looked like a hunk of red meat amid a pack of wolves. Much as it had in fall 2013.

There were many reasonable-sounding justifications for the public flogging: sexual harassment must be stomped out, Zivkovic appeared to want to make a fresh start without making enough apologies to satisfy everyone, this was a pattern that exemplifies the male power structure in science, etc etc.

What reasonable person would argue these points? What emerging science writer would dare raise his or her voice amid all that certainty, and blood? Such a person risks being lumped with perpetrators, surely.

Yet silence is not always golden. What was lost amid the din was the idea that there are more effective and more humane ways of rectifying such wrongs than a Twitter hanging. Some writers wrote they were done hearing from not only Zivkovic but a friend who supported him. "They're dead to me," that writer and her supporters seemed to say. Others, most of them not at least publicly victims of the behavior of which Zivkovic is accused, critiqued whether his apology felt ... apologetic enough.

For all involved, I hope this private problem can have a private fix. I just don't see how this public excoriation helps anybody. Certainly decrying sexual harassment in public can do good: it may well discourage other perpetrators and help define what is and what is not harassment. This is the core story to which the public dialog should hew. But this public mastication and remastication of one man's sin went beyond PSA - it looked to me like bloodlust and distracted from the main story.

Instead, private apologies and a private plan for prevention seem the way to salvage some good from this story. Most importantly, any victims (identified in public or not) should have the opportunity to hear an apology and some assurances that harassment will not recur. I get the sense from Zivkovic's writing that he is willing to make such amends and hope this indeed occurs at least to some degree of satisfaction of those he harmed.

What should the rest of us do with our typing fingers while such things occur in private? Get a PSA out there, for sure. Learn. Listen. Consider if we could commit that same sin and how we might avoid it. Most of this can occur with mouths shut and fingers still. (See Bruni, above.) And then: we move forward. 

When identifying a sin such as Zivkovic's, it is too easy to think of him as equivalent to and nothing more than the sin itself. Without considering the full scope of his humanity and his personhood, we essentially commit a second sin. It's an easy sin - we make a joke, we pass judgment, we block a Twitter account. No one of these acts is a major problem. But I worry about a society build on such a foundation.

Some would say such protestations enable the original sin itself. That whatever is done in the defense of those wronged women is fair game. This is the game of empowered white men, goes the screed. They should be quiet and take their licks. It is the turn of the downtrodden to rise up and take the stage.

I disagree. Unless we are simply trading bad power for bad power, we who think of ourselves as good should be able to think with nuance, and to hold two ideas in our heads at once. A sinner can be wronged. A victim can do wrong. (Not to imply this has occurred; I'm saying we should be able to think in more than black and white.) It'd be great if the world were divided into good and evil but the truth is most of us fall somewhere in between. Sinners and pundits look quite a lot alike, it turns out. Perhaps it is the similarity that motivates the pundits to make a starker distinction than really exists? Or perhaps we forget our own troubles for a while when we decry someone else's?

I can only hope the virtual community erected on Twitter and on blogs can learn from the mistakes made in the corporeal society that preceded it. Yes, there are invidious power structures here and we should fight them. We too need justice. But, a system of justice build on vengeance and demonization will ultimately be the downfall of all our lofty ideals. We aren't being soft on crime - we are trying not to compound the original crime with a new one.

The way forward? The original victims should expect reparation. Absolutely. But those looking on from their typewriters, from their comfortable seats at the edge of the town square, should behave as gently and as humanely in their responses to this sinner - this man - as they would hope to be treated when they too walk out into the middle of the square with their sin in full view. We all have our day. What kind of people are we? Are we vengeful, or are we just? 

Posted on January 1, 2014 .

The ethics of research in low and middle income countries

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Many developed world academic institutions are forming international partnerships to improve clinical care, education and research in developing countries. This is a great development, and one I hope will last even when it is no longer trendy. But, particularly the conduct of research in developing world countries brings with it ethical complexities: it's cross-cultural, there are power gradients, and sometimes researchers are motivated more by pecuniary gain than true altruism. To help manage these risks, so our outreach can be most effective and least undermined by such factors, I wrote a review of the history and approach to the ethics of research in low and middle income countries

Posted on December 22, 2013 .

HIV doesn't happen here

The rural state of New Hampshire has some of the lowest HIV incidence and prevalence rates in the United States. That's great news, but it comes with a price. 

Many at risk people in New Hampshire think HIV is a third world or city problem and not something they need to worry about personally. That means they are less likely to take precautions against HIV. 

At the same time, people who have been diagnosed with HIV in New Hampshire face stigma from neighbors and friends who may be less familiar with HIV than people living in urban areas where the disease is more prevalent. Geography adds to those challenges: the ~650 people cared for at Dartmouth-Hitchcock HIV Program come from a much wider geographic area than patients in similarly sized clinics in metropolitan areas. That translates to longer travel times and more complicated access to care.

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Not surprisingly, HIV patients living in rural areas have been shown by Sam Bozzette and others to receive substandard care, probably because HIV experts are not sufficiently accessible.

In formal analyses at the Dartmouth-Hitchcock HIV Program, our HIV expert providers  delivered outstanding care equivalently to rural and urban patients  But despite this my colleagues and I showed that our rural patients have higher rates of depression and even higher mortality. New Hampshire might be a lovely place to live, but living with HIV infection anywhere is no walk in the park. 

Todd Bookman of NHPR touches on these and other issues in nice  radio story in which I was quoted. There are still plenty of battles remaining in the war against HIV in New Hampshire.

Posted on December 18, 2013 .

Glad to Add a Modest Contribution to "The Fist Bump Manifesto"

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How should we protect patients from infections in our hospitals? Although hand washing is the most important intervention, James Hamblin of The Atlantic wrote a great article about the use of the fist bump to prevent infections. I was honored to be interviewed and to contribute some thoughts about hygiene and hipness.

Check out the article at The Atlantic

Posted on November 22, 2013 .

Should we police HIV transmission?

At gay bathhouses in the Bay Area, monitors pop in on the “playroom” irregularly—“every 20 minutes, every 40 minutes, every hour,” one manager says, trying to make sure patrons are having sex safely.

“You put the condom on or get the hell out,” a monitor at one such club said, upon discovering a couple violating the rules.

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William Woods and his colleagues talked to these bathhouse monitors, as well as managers and patrons, about their safer sex monitoring programs, detailed in a recent article in the academic journal Sexuality Research and Social Policy. Some bathhouses enacted aggressive monitoring because “they sincerely care about their patrons’ health,” Woods said. These bathhouses in the Bay Area often were “at the table when the guidelines that are in place were developed, so they have a personal stake in them.” In other cities bathhouses were under threat of closure from state health departments, and their monitoring programs, some implemented so the clubs could remain open, were only lackadaisically enforced.

The attempted policing of HIV transmission has been in the news a lot lately.

 To continue reading, see my full article at The Atlantic. It was republished at KevinMD as well. 

Posted on October 9, 2013 .

If you were exposed, would you want to know?

This past week we  learned that 15 patients in New England were exposed to a rare infection called Creutzfeldt-Jakob disease (CJD) when neurosurgical instruments contaminated with the infection were used in their care. Each had undergone a brain or spinal surgery in early 2013, and now their future was uncertain.

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Creutzfeldt-Jakob disease takes years to develop. Patients exposed to the infection feel fine for years but then they become moodier and forgetful and over the course of months subtle cognitive defects progress to severe dementia. Patients with CJD forget the names and faces of loved ones, they lose the ability to walk, speak, or swallow, and they lapse into a coma that has proven fatal one hundred percent of the time.

When Creutzfeldt-Jakob disease contamination of surgical instruments is discovered, doctors at Catholic Medical Center and other hospitals wonder if it is right to tell patients. In most cases the disease will never occur and there is no effective means of prevention. Even for the unlucky patients who do develop the disease – if any of them do – there is no effective therapy so advance warning gives no extra measure of hope. Worse still, there is no diagnostic test to predict who will escape infection or die, so the only thing patients can do once notified is wait. That means the only real world impact of disclosure, regardless of the eventual outcome, is patient distress. So in this case is knowledge power, or is knowledge just knowledge?

Continue reading my full article at TheAtlantic Health.  It was republished at medpageTODAY's KevinMD.com

Posted on September 10, 2013 .

Doctorstories.org

Medicine is going through tough times. The trusted family doctor who makes house calls has been replaced in the public lore by the benign technician but most recognize we need better models. Public narrative seems like a great way forward. Phil Lederer (@philiplederer) runs a nice website called DoctorStories.org in which he showcases life stories from doctors and other healthcare providers. 

The Campfire by Winslow Homer

The Campfire by Winslow Homer

What brought people to medicine in the first place? Why do they stay? What was their greatest contribution? Read my contribution and others at doctorstories.org, and tell your own story too.  

Posted on September 8, 2013 .

The Dignity of a Porn Star: What Was Lacking in Our Response to Cameron Bay

Porn stars all across Fresno were told to put their clothes back on and go home a couple of weeks ago on the news that a 29 year-old adult actress named Cameron Bay tested positive for HIV.

The Internet lit up. News, judgments, and jokes shot left and right in newsrooms as freely as bodily fluids fly on set. 

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Something important is lacking though: concern for Ms. Bay. This young woman just learned that she has an incurable and potentially lethal disease. Our first emotion, I think, should be concern. We should commiserate. We should be grateful for our health and hopeful for hers. 

I learned this from Jose*, a patient in my HIV clinic. Jose was a muscular guy who wore tight black shirts and a jet-black goatee. The list of movies in which Jose engaged in unprotected anal sex was long. Very long. None of the titles can be repeated here so let’s just say somebody is making good money dreaming up new variations on the Bareback Mountain theme. 

Read the full article at Scientific American guest blogs.  It was also republished at The Health Care Blog.

Posted on September 8, 2013 .

NHPR Panel Discussion about Advanced Directives and End-of-Life Planning

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It was a thrill to join Laura Knoy of NHPR's "The Exchange" and other guests Todd Bookman (NHPR science reporter), Shawn LaFrance (executive director of the Foundation for Healthy Communities) and Michael Skibbie (Policy Director for the Disabilities Rights Center) for a panel discussion about advanced directives, death panels, end-of-life planning and New Hampshire's inadequate surrogate decision-maker laws. Our gracious host said we were "flooded" with calls - including from NH state senator Peggy Gilmore.

Listen in on our conversation at NHPR

Posted on September 5, 2013 .

The Design of a Medical School Social Justice Curriculum

Well over 100 years have passed since Virchow wrote that “physicians are the natural attorneys of the poor, and social problems fall to a large extent within their jurisdiction.” Since that time, the world’s population has septupled, and billions of people are “trapped in the health conditions of” his era.

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As a result, many medical students in the 21st century want to work to decrease health disparities, and increasing numbers of medical graduates indicate they intend to work with people who are often underserved. This groundswell of medical student interest in remedying health disparities joins urgent calls for the integration of specific social justice competencies into medical school curricula and aligns with new considerations and the ranking of the quality of institutions’ “social mission.”

Yet, how can medical students learn about global health and social justice without recapitulating the mistakes of their forebears? 

What skills do they need to be effective in social justice outreach abroad and at home? 

What are physician obligations toward "social justice" if any?

We take on these and additional questions in our new article in Academic Medicine, "The Design of a Medical School Social Justice Curriculum." 

Posted on August 30, 2013 .

Who should decide: a patient who has been suicidal or her legal guardian?

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The team recommended a feeding tube. At first Sasha demurred, pointing to Liz’s refusal. But the psychiatrist clarified that Liz did not have decision-making capacity to refuse the procedure, so we relied upon Sasha. Sasha seemed to understand, and said she didn’t want Liz to starve. She asked what the procedure would entail, and what future steps in Liz’s care would involve. We discussed eventual transfer to a nursing home, and said we doubted Liz would ever care for herself again.

Then the conversation took an unexpected turn. 

Read my whole article at Scientific American guest blogs.

Posted on August 22, 2013 .

Are churches telling HIV patients to stop treatment?

I asked Bill what his pastor and fellow parishioners thought about his decision to stop HIV treatment. “They totally support me,” he said. “In fact, it was their idea.” His congregation had encouraged him to stay off his HIV medications despite his doubts, to see this revelation through “to the end, whatever may come.”

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Bill is not alone in his church’s insistence that welcoming a preventable death is somehow an act of faith, that stoic acceptance of sickness and death are the only road to the conditional love of his Pentecostal brethren. The BBC reported recently that many Pentecostal congregations have advised their parishioners to skip HIV therapy and, like Bill, leave their lives in God’s hands.

Read my full article at The Atlantic - Health.

Great video chat about the story on HuffPost Live with Josh Zepps which was then picked up in HuffPost Religion. Look Ma!

Posted on August 20, 2013 .

Our Fight to Protect Hamid from TB

Hamid is a handsome Tanzanian man with a soft voice and impeccably-pressed clothes who works as a driver for our research program in Dar es Salaam. We talked about his family and his aspirations as we drove back and forth in Dar es Salaam, between meetings and social occasions. 

Hamid (not his real name) was more subdued than usual. His voice was raspy, his eyes bloodshot, and he coughed into his hand as we drove back and forth in his air-conditioned car.  

 

 

 

 

 

Posted on August 11, 2013 .

Replace the med school interview with fMRI: a modest proposal

Finding applicants with the potential to have great bedside manners is the real challenge of the admissions process. Many applicants are smart enough to know enough and think clearly enough to become full-fledged physicians. But those academic traits combined with the kind of compassionresilience and moral reasoning patients need is still rare.

Why not just MRI applicants instead? Check out my guest post at the Scientific American which was republished at The Health Care Blog.

 

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Posted on August 8, 2013 .