Nice Legs. Who owns them?

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You may be wondering whose owns these legs, and why they’re clad in little red and white ribbons. I was wondering that myself, as I was leafing through this week’s American Medical News. It turns out that they belong to television host Meredith Vieira, who apparently rented them to the pharmaceutical giant Sanofi Aventis. Sanofi, it turns out, happens to make enoxaparin, also known as Lovenox® – a low-molecular weight heparin. Meredith and Sanofi have been co-promoting a DVT (deep vein thrombosis) awareness campaign on NBC and MSNBC. To be fair, if any multinational conglomerate television network is going to have a reason to publicize DVT, it’s NBC. Remember that they lost one of their reporters – David Bloom – to a DVT. In any case, it turns out that someone has designated March as “DVT Awareness Month”. Well, not just somone. Brian Dorgan (D-ND) and Arlen Specter (R-PA) managed to pass Senate Resolution 56 on March 2, 2005, which I guess makes it official. Sanofi-Aventis funds an organization called Coalition to Prevent DVT which is driving the current advertising campaign and the DVT awareness month.

Fancy that.In a way, this is clearly a worthwhile effort. As part of my training, I’ve done quite a bit of pediatric hematology and have seen my fair share of deep vein thromboses. I’ve also seen enough pulmonary emboli to make me fear them, and enough venous stasis disease to recognize that the damage done by DVTs is more than just a clot or an embolus. That being said, I am a little uncomfortable that the company that makes one of the main medications for the treatment of DVTs and PEs has co-opted a public figure into doing their advertising. There’s been a huge push to have the relationship between pharmaceutical companies and physicians stripped to is most minimal connection, or severed altogether. People worry that a click pen or pad of PostIt notes will unduly influence physician prescribing habits. Fine. I prefer by non-branded pens and sticky notes anyway.

But I can tell you this: Meredith Vieira reaches 10,000 or 100,000 or 1,000,000 times as many people per day as I do, and going by absolute numbers of people influenced, she clearly wins. However, I don’t see anyone questioning her relationship with a pharmaceutical company. If Sanofi wanted to fly her to meetings and put her up in a nice hotel, I doubt we’d hear people criticizing her objectivity. But have a drug rep a group of starving residents a pizza to get them through a 30-hour shift and stop the presses … we have physicians being corrupted by industry. Thoughts?

“You don’t mind if I tape this, do you?”

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A couple of weeks ago, when I had a serious bout of insomnia, I stayed up until past two o’clock in the morning watching All The President’s Men. It’s one of my all-time favorite movies.I noted the absence of tape recorders as the fictionalized Woodward and Bernstein went about their investigations. This was, of course, 1972, and microcassette recorders weren’t available for $19.99 at your local Staples. It gave me a chance to think about how much easier life is given our ability to record experiences as they happen. We have, as a society, gone far beyond just tape recorders. They’re actually considered quaint. What, with everyone putting everything on the Internet as a podcast or YouTube video, or people recording things with their cell phones, the little cassette recorder that I bought back at the beginning of medical school is practically an antique.

I thought about this long-lost tape recorder when I came across an abstract of an article that appeared recently in the British Medical Journal regarding audiotaping of neonatal consultations. The article, entitled “Provision of taped conversations with neonatologists to mothers of babies in intensive care: randomised controlled trial” (BMJ 2007; 334;28-31) tested whether providing mothers of children in NICUs with audiotapes of their conversations with their doctrs helped the parents to recall information and whether or not these tapes helped with their psychological wellbeing. It is clear that parents of children in NICUs, and in fact many parents with children who are critically ill, often do not remember all of the information that they’re bombarded with.

In my experiences, this is also quite true on the pediatric oncology service – at least in the days or weeks immediately following a new diagnosis. One of the things that I tell parents at the time of diagnosis is that they will likely not remember much of what I say after the words “I think your child has (insert cancer diagnosis here)”. We compensate for this on our service by repeating things over and over, as well as by relying upon many other teachers, including nurse educators, primary nurses on the wards, and primary nurses in clinic. By the time a child has reached the end of their first few weeks of chemotherapy, their parents have had a pretty good education in the the nuts and bolts of caring for a child with cancer. By the end of the first few months parents are pretty savvy, and by the end of a year many know as much about their child’s disease as any of the hospital residents.

That being said, the initial few days are usually a blur, and of course that’s when the “big talk” takes place. By “big talk” I mean the initial informed consent discussion to initiate therapy. We call this the “Day One” talk where I work. It usually is a formal sit-down talk between the family (and whoever the family wants present), the patient’s primary nurse on the ward, the pediatric oncology fellow covering the inpatient ward, and the pediatric oncology attending. Learning how to conduct a Day One talk is one of the most important things learned during the first year of fellowship, and it comes from watching and listening to attendings give good (and sometimes watching and listening to not such good talks). One also learns a great deal from seeing how different families react. Some are so antsy to start treatment that they don’t seem to really want to sit through a 90 minute discussion of the different side effects of the different medications, the various risks and benefits, and the minutae of treatment. They want to sign on the dotted line and get the first dose of chemotherapy in. I don’t think that these families are nonchalant about the details of their child’s care – rather, I think that the amount of information floods an already busy switchboard.

Some families, on the other hand, want every detail and then some. Some bring aunts or uncles or other relatives who have backgrounds in medicine. Some are meticulous note-takers.

A couple of years ago, when I was a relatively new 1st year fellow, a family brought a tape recorder into the room and set it down right in front of me. I can’t remember whether or not they asked me if I would mind being taped (I think they did), but I remember being weirded out by it and telling them that I’d prefer not to have my every word recorded. In the few minutes that I had to react to this, I felt a combination of fear and uncertainty. I wasn’t sure that I was going to do a 100% perfect job (being relatively new at the whole oncologist thing) and I didn’t want that to haunt me at some point later. To be honest, I was afraid that something catastrophic would happen to the patient – something that I wouldn’t have covered in my consent discussion – and that the next time I saw that tape recorder it would be in the hand of a stern-looking malpractice lawyer.

Today, a couple of years older, wiser, and more confident in my understanding of my chosen profession, I believe that I would want that family to record the discussion. In fact, looking back, I wish that all of these types of conversations were recorded. I’m almost surprised that they aren’t, especially when one considers the amount of thought that we give to the Day One talk.

Turning back to the BMJ study of mothers in the NICU, the initial conversation (similar to our Day One talk) as well as subsequent conversations deemed important by the attending neonatologists, were taped and the mothers received a copy of the tape. The results of the study showed that 91% of mothers listened to the tape after one week and 95% listed at least once over the first four months. The mothers who received tapes of these conversations were, as you could imagine, more likely to recall the different diagnostic tests, treatments, and outcomes that were explained to them. There were 6 (of 98) mothers in the control group – those who didn’t receive a tape – who were unable to recall any information from their discussion with the neonatologist.

After reading this paper, I immediately wondered whether or not this has been tried in oncology. It turns out that there’s a fairly substantial literature for the use of taped informed consent discussions in adult oncology. It also turns out that many institution’s websites that discuss clinical research trials recommend patients taping the informed consent discussion, including UCSF, MD Anderson, and the website for the National Cancer Institute.

It also turns out that taping “Day One” talks has been looked at, at least once, in pediatric oncology. There was a paper published in the Journal of Pediatric Hematology/Oncology entitled, “Audiotaping Communication of the Diagnosis of Childhood Leukemia: Parents’ Evaluation” (J Ped Hem/Onc 2003; 25:5) that, while not a randomized study, was notable for the fact that the authors collected their data from January 1997-December 1998. The study was based in Italy, and my review of the medical literature (a cursory review of “related articles” in PubMed) didn’t find any US based studies.

I’m curious as to how this would go over here in the US. I would bet (although I don’t have any data) that many parents of children with cancer would have appreciate having a tape to review at later date. I would also bet (again, without any supporting data – just a hunch) that there would be very few instances of these tapes being used to prosecute a physician in the event that the patient suffered a bad outcome. Given the remarkable problems in health literacy (problems that involve both health care systems as well as patients) one would think that a tool as simple as a tape recorder would be more widely used for complex discussions such as informed consent for chemotherapy. I’m curious what Paul Levy over at Running a Hospital would say about this small idea. I’m also curious to hear what any parents of pediatric oncology patients (or oncology patients themselves) would have to say.

I think that now, being a little more experienced, and a lot more comfortable with the words that I use, I see the benefits to this technique to far exceed the risks. Moreover, I believe that offering parents the opportunity to tape one’s important discussions with them telegraphs a message of confidence and trust, and would go a long way to establish rapport at a very important moment in a family’s life.

When you care enough to send the very best …

I was driving back from my overnight moonlighting gig this morning … well, driving may not be the best word choice. I was inching my way down Route 1 in the middle of morning rush hour traffic, with my trusty coffee at my side and WBUR on the radio, and exercising my extraocular muscles by doing every other minute eye rolls during the report on the Senate’s inability to vote on whether or not to have a vote on a non-binding resolution regarding Iraq.

As you can imagine, I almost choked on my blueberry scone when I heard a little blurb reporting that Hallmark, the greeting card behemoth, has just launched a new line of greeting cards for “life’s more difficult moments”. Like (and I’m serious here) struggling with an eating disorder, quitting smoking, caring for an aged parent, miscarriage, and traumatic loss, such as someone dying in an accident or homicide. They have cards for thanking a hospice worker or organ donor’s family. Cards for waiting for test results. Oh, and of course, the new line of cards also includes those for people tackling cancer diagnoses, treatment, and hair loss. A $2.99 greeting card for chemotherapy-induced hair loss. My goodness.

As reported in this news story:

Others are more happy and even humorous, celebrating a year being cancer-free, nearing the end of chemotherapy or general encouragement for teenagers. There are even a few birthday cards encouraging the recipient to celebrate even though they’ve had a rough year.

Some cards feature whimsical or inspiring photographs – a baby making faces, a marathon runner – but the majority feature abstract designs or just words in flowing script. Card designers said they aimed for bright colors that matched the mood of the card, ranging from bright orange for the more hopeful cards to purples and blues for somber notes …

No topics were off-limits, said company spokeswoman Rachel Bolton, noting two cards that could be sent to gay people who have disclosed their sexuality. The cards don’t directly refer to homosexuality, only extolling the person to “Be You” or “This is who I am” or featuring a rainbow, a symbol of gay pride.

I suppose that this was inevitable. My question is why? The news report on the radio said that Hallmark was doing this in response to feedback from people indicating that they were unable to find cards to express these thoughts. Are moments in life like this so difficult to ponder that people would rather pay $2.95 to buy a pre-made sentiment than take pen to paper in order to write out their own thoughts and feelings? Have we become so used to prepackaged goods that we now need to look for something similar for our emotions?

Even the card writers seem to raise this issue:

Writing the cards proved a challenge because the messages were designed to take a more personal approach than the standard sympathy card, said card writer Sarah Mueller.

“You can’t send somebody who is seriously depressed a ‘cheer-up’ card because it’s insulting and it doesn’t help,” Mueller said. “That’s what depression does, is it makes you feel like you’re all alone. So just being able to write something, the attempt was just to say, I’m here.’ ”

Fellow card writer Linda Morris said society has become more open to discussing people’s feelings on difficult topics, such as divorce or drug recovery or serious illness, which is why people are demanding cards that deal with those issues.

“There was a time when we weren’t so detached, when writing a note to someone was very simple, when picking up the phone and calling was just what you did,” Morris said.

Have we really moved that far away from each other that we rely upon a faceless corporation to help us express our compassion for each other during times of illness or other difficulty? Are people really that averse to calling or writing someone with cancer? I’m not sure how I’d react to someone sending me manufactured best wishes instead of calling to ask me “are you OK?”.

A few weeks ago there was a flurry of stories about the difficulties that physicians face in having difficult conversations with their patients. After hearing this story, it is increasingly clear that this is not a problem solely with physicians. This is a problem with people in general in our modern world. These cards are not part of the problem – they’re a symptom.