Posts for November 30th, 2005

Doctors and Patients

Jodi Hilton for The New York Times

Dr. Beth A. Lown, second from right, an assistant professor of medicine at Harvard Medical School, observed as Dr. Vanessa Vidal, a resident, spoke with a patient at Mount Auburn Hospital in Cambridge, Mass. Dr. Vidal’s instructors also included Dr. Charles Hatem, right.

November 30, 2005
Being a Patient

When the Doctor Is in, but You Wish He Weren’t

Joanne Wong’s doctor correctly figured out what was wrong with her. But he would not tell her.

Ms. Wong, a software engineer in Sunnyvale, Calif., was having abdominal pain and nausea. Her doctor told her to have a blood test, then ushered her out of his office, ignoring her when she asked what the test was for.

"The test came back, and he said I have a virus," Ms. Wong said. "He said, ‘Take this medicine for two weeks.’ I asked, ‘What kind of virus do I have? How did I get it?’ But he just said, ‘Take the medicine and come back in two weeks.’ "

Two weeks later, she still felt ill. "He said, ‘You’re fine, you’re fine,’ " Ms. Wong said. "I said, ‘At least tell me the name of the virus.’ " But, she said, "He just patted my shoulder and sent me out," telling her to return in three months for another blood test.

Perhaps, Ms. Wong said, the doctor did not want to spend the time to talk to her, or perhaps he was put off by her Chinese accent and thought she would not understand. In any event, she never returned to that doctor. When she got her medical records, she learned that she had had hepatitis A, a viral liver infection.

Ms. Wong had come across a bane of the medical profession: the difficult doctor. These doctors may be arrogant or rude, highhanded or dismissive. They drive away patients who need help, and some have been magnets for malpractice claims.

And while such doctors have always been part of medicine, medical organizations say they fear that they are increasingly common – doctors, under pressure to see more patients, are spending less and less time with each one and are replacing long discussions with laboratory tests and scans – and that most problem doctors apparently have no idea of their patients’ opinions of them.

Patients usually do not confront doctors. Instead, most rant to friends or family members about their experiences or simply change doctors. But in most areas of the country, there is an abundance of patients. If a few patients leave a medical practice, plenty more can take their place, so doctors may never even know what their patients think.

"The reality is that a lot of these doctors don’t have a source of objective comments," said Dr. John Freedman, the medical director for quality management at the Tufts Health Plan in Massachusetts, which includes 18,000 doctors.

But now some medical groups are taking steps to address the problem, questioning patients and going so far as to dock the pay of doctors whose patients give them poor ratings.

At the Rochester Independent Practice Association in New York, with 3,000 doctors, patients are surveyed, and their satisfaction scores can account for 20 percent of a doctor’s pay. At Tufts Health Plan, 3,000 to 4,000 doctors had all or part of their bonuses withheld last year because their patients did not rate them highly, said Richard Lynch, the plan’s vice president of network contracting.

In California, said Dr. Ronald Bangasser, the past president of the California Medical Association, eight major health insurers have a new program in which they divide $30 million among 35,000 physicians depending on how their patients rate them. "It could be $3,000, $4,000 or $5,000 per physician," Dr. Bangasser said. "That would get their attention."

Dr. Beth A. Lown, an assistant professor of medicine at Harvard Medical School and the immediate past president of the American Academy of Physicians and Patients, said: "This goes to the heart of medicine – the skillful enactment of communication and a truly heartfelt understanding of the patient’s circumstances. And it seems to have gotten lost as doctors get involved in medical systems that prioritize speed and technology. Increasingly, people are relying on tests instead of talking to patients."

Patients say the problems come in many guises. The arrogant or dismissive doctor. The impatient doctor with his hand on the doorknob. The patronizing doctor. Or, as one young woman experienced, the doctor who is callous and judgmental.

The woman, who lives in Washington, asked not to be identified because she did not want her mother to know about her sex life. Her problem doctor was a new gynecologist she saw for a routine checkup. The doctor began the examination, inserting a speculum into the young woman’s vagina.

"She asked if I was sexually active," the woman said. "I said I was. She asked if I was sexually active at this moment. I said yes."

Leaving the speculum in, and the woman with her feet in the stirrups, legs spread, the gynecologist walked to the head of the exam table and proceeded to lecture her on the perils of sexual activity outside of marriage. "I was so humiliated and so scared," the woman said. "And so embarrassed."

Other times the doctor seems indifferent.

That was the experience of Gloria Erlich, a writer who lives in Princeton, N.J., who saw a neurosurgeon for back pain. He told Mrs. Erlich she needed a myelogram, a scan of the spine that requires a spinal tap to inject dye into the spinal cord. She told him that she had had one, at his request, just a few months before and that the films should have been with her medical records. But the doctor said he could not locate them and asked her to have another one.

Months went by, with the doctor telling Mrs. Erlich he could do nothing for her without a myelogram and her saying she had had one and asking why he could not just find it. Finally, she said that perhaps she should contact a lawyer. "Within half an hour, they found it," she said. "It was irretrievable until I said the word ‘lawyer.’ "

"It may have been busyness," she said, "but it seemed to me a matter of indifference: why bother searching for something when the patient can just repeat the test? Indifference to the pain and risk for me, indifference to the very substantial cost of the test for Medicare." She changed doctors.

Mrs. Erlich’s doctor may never learn how irritating he was. Most doctors do not, said Dr. Richard Frankel, a professor of medicine and geriatrics at Indiana University who teaches medical faculty how to communicate with patients. Even doctors who have bad experiences when they see a doctor rarely speak up, Dr. Frankel said.

"You hear their sad story," he said, referring to doctors who have been patients, "and then you ask, ‘Well, did you say anything to the person who was offensive to you or treated you poorly?’ Ninety-nine point nine percent of the time the answer is no."

One reason, of course, is fear of offending the doctor and getting poorer treatment from then on. But doctors who are rated by their medical groups are forced to confront the evidence, and often are asked to get help or are coerced into it.

For example, said Dr. Bangasser, doctors at his group, the Beaver Medical Group in Redlands, Calif., who get low patient satisfaction scores have been asked to shadow successful doctors to learn their ways. For other doctors, there are counseling and training sessions as well as courses, including some taught by Dr. Lown’s group, to help doctors learn to listen to patients and treat them with dignity and respect.

There also are veiled threats at some of the medical groups.

"We have worked with a number of physicians in a confidential way," said Dr. Freedman, of the Tufts Health Plan. "We say, ‘You appear to have dramatically low scores. We would like to understand your justification for why and explain what actions you intend to take.’ "

And, he added, "if they don’t make bona fide efforts to improve, we can go through a disciplinary process that can result in termination."

As for future doctors, they will at least have to show they know the basics of being nice. As of 2011, all new residents will have to exhibit empathy while examining an actor posing as a patient. The residents know they are examining an actor and that the actor will be assessing their performance, Dr. Lown said. "We are putting teeth in the need to change," she added.

A more subtle problem occurs when doctors who are generally pleasant and communicative act differently toward certain patients, affected more than they realize by their personal prejudices against particular patients, like fat people, hypochondriacs or people who complain about pain.

"If you happen to be the person they don’t like, they can respond very differently than they do to most people," said Dr. Howard Beckman, the medical director of the Rochester Independent Practice Association.

Fat people say they know that problem well. It happened last summer to Tina Hedberg of Conover, Wis., who saw a doctor when a diet she was on was no longer eliciting drastic weekly weight loss. The doctor, Ms. Hedberg said, told her that she had a mental problem because she weighed 400 pounds. Ms. Hedberg was trying to commit suicide by getting so fat, the doctor informed her.

Then the doctor said Ms. Hedberg had two choices. She could be admitted to a mental institution, or, the doctor said, "I could wire your jaws shut so tight that you can’t move your jaws to talk, and if you can’t talk you can’t eat."

Other times doctors get so busy that they seem not to understand a patient’s experience, as Rori Murell discovered recently.

Ms. Murell, a retired therapist who lives in Rochester, was having back pain, so she made an appointment with an orthopedic surgeon recommended by her primary care doctor. When she arrived, a physician’s assistant entered the examining room.

"He looked over some of the X-rays and said, ‘I recommend spinal injections.’ I said, ‘I can discuss that when I meet with the doctor.’ He said, ‘You’re not going to see the doctor.’ "

The doctor, the physician’s assistant explained, was busy seeing patients. "I said, ‘Well, I’m a patient,’ " Ms. Murell said, but she got no reply.

"I realize that doctors get really, really busy," Ms. Murell said. "But someone with a back problem is different than someone with a sniffly nose. I don’t want to sound like I need to be pampered or babied or that I need sympathy. But what’s fair is fair, and what’s professional is professional. I’m 68 and I’m old enough to remember a time when you went to the doctor and you saw the doctor."

Doctors say they are chagrined when they hear such stories. But, they say, it can be hard for them to know how a doctor treats a typical patient when they themselves often are treated with kid gloves.

"You’ll occasionally get a patient who comes from another physician and says something bad about that doctor, but it’s hard to know whether they’re a complaining patient or the doctor is really bad," said Dr. Robert Swerlick, a dermatologist at Emory University.

Some patients say they have to rely on each other’s experience to know which doctors to seek out and which to avoid. The Council on Size and Weight Discrimination, a nonprofit organization, publishes lists of fat-friendly doctors on its Web site. And after her experience with the doctor who would not tell her her diagnosis, Joanne Wong helped found a Web site, RateMDs.com, where patients can rate doctors.

But, said Dr. Swerlick, such ratings are not exactly representative samplings.

They also infuriate doctors, who, Dr. Beckman says, "think these things are capricious and stupid."

It is harder to argue with the methods being used by medical groups, like the Tufts Health Plan and the Rochester Independent Practice Association, that are employing scientific methods to survey satisfaction.

Such practices, Dr. Beckman says, are becoming increasingly common in health maintenance and preferred provider groups that are starting to pay doctors according to their performance. Purchasers of insurance plans are demanding it, he added.

And, he says, there is a common thread to difficult doctors: most have problems talking to, or listening to, patients.

"What often happens," Dr. Beckman said, "is that the patient has something they want to tell the doctor but they’re not allowed because of the doctor’s style to say what they want to say." So the doctor does most of the talking, often alienating patients.

Dr. Beckman teaches doctors simple ways to let patients tell their stories and to show empathy by responding to a patient’s emotionally charged comments. For example, he said, "A patient comes in and says to the doctor, ‘I stopped smoking.’ " Instead of saying, "That’s terrific," the doctor will say something like, "How’s your weight?"

Dr. Beckman said a doctor recently called him, stung by his low scores and asking how it could be that his patients did not like him.

"We looked at his survey results and the area where he was low was the question of, Did the doctor spend enough time with you?" Dr. Beckman said. "I told him a bit about how a person feels that enough time is spent. You have to uncover the heart of their problems."

Of course, Dr. Beckman said, "everyone thinks they’re listening" to patients. But one method does work, he told the doctor. "You use continuers. As you’re working with people, you say ‘uh huh’ three times."

He gave an example: "The patient says, ‘I’ve been having chest pains.’ " Instead of jumping in and suggesting tests, the doctor says, "Uh huh." The patient says, "I’ve also been having headaches." The doctor says, "Uh huh." So the patient says: "It all started when my brother died of an aneurysm in the brain. And I wonder if it’s related."

The doctor, Dr. Beckman said, "looked at me like I’m a little nuts," but agreed to try. Later he returned, elated.

Dr. Beckman recalled him saying: "I can’t believe how different it is. I hear things I don’t usually hear."

"That’s terrific," Dr. Beckman said.

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Tuesday, November 29, 2005

Google as Dominant Force

Who’s Afraid of Google? Everyone.
By Kevin Kelleher

It seems no one is safe: Google is doing Wi-Fi; Google is searching inside books; Google has a plan for ecommerce.

Of course, Google has always wanted to be more than a search engine. Even in the early days, its ultimate goal was extravagant: to organize the world’s information. High-minded as that sounds, Google’s ever-expanding agenda has put it on a collision course with nearly every company in the information technology industry: Amazon.com, Comcast, eBay, Yahoo!, even Microsoft.

In less than a decade, Google has gone from guerrilla startup to 800-pound gorilla. In some ways, the company is a gentle giant. Whereas Microsoft infamously smothered new and open standards, Google is famous for supporting them. And the firm is softening its image, launching a philanthropic arm, Google.org, with nearly $1 billion earmarked for social causes. But that doesn’t reduce the fear factor, and Google knows it. Omid Kordestani, the company’s global sales guru, said at a recent conference, "We’re trying to find ways so we are not viewed as a gorilla." Given its outsize ambitions, that’s one search Google might not be able to handle.

Is the sky falling? That’s how it looks to panicked tech companies across the Valley as they contend with Google’s ever-expanding power and ambition.

VIDEO
Today, Google Video is a motley mix: clips of monkeys performing karate and robot dogs attacking iguanas. Tomorrow? No one knows, but everyone is worried.
Who’s threatened: Comcast and other cable providers, Yahoo!, TV networks that still shun the Net
Signs of panic: Comcast wants to be the Google of television. Yahoo! bristles at any mention of Google Video. Networks were stunned to find Google compiling a database of their programs.
Reality check: Google Video is up and running. The question is, How much content can it attract – or pay for – to fill the database. Watch for a strategic acquisition, even something big. TiVo?

CLASSIFIEDS
When secrecy-obsessed Google let news of "Google Base" slip, it looked like an aggressive entrée into online classifieds. The test service can search ads like used-car and personals listings, which would mesh with Google Local and might even kick-start Orkut, Google’s social network.
Who’s threatened: craigslist, eBay, Monster, Tribe.net
Signs of panic: Within hours of the Base bombshell, eBay’s market value dropped by almost $2 billion. And even before that, the classified sites were nervous. CareerBuilder and others fretted about letting Google host their feeds.
Reality check: This may be an extension of Froogle rather than a stand-alone product. But it could expand to everything from travel to eBay-like offerings.

TELECOM
Free Wi-Fi in San Francisco, instant-messaging software, a widely anticipated VoIP foray – Google’s telecom initiatives seem designed to make life radically easier for users.
Who’s threatened: Comcast, SBC, Verizon, Vonage, what’s left of AOL
Signs of panic: Surprisingly few so far, partially because Google says it has no plans to offer Wi-Fi beyond San Francisco. Still, Comcast coined the word Comcastic – is that its answer to Googlicious?
Reality check: Something’s clearly afoot, and it could be big. With great power comes great regulation – so Google recently opened a DC lobbying shop to combat "centralized control by network operators."

OPERATING SYSTEMS
If anyone can fulfill the dream of turning the Internet into the operating system, it’s Google. If the company chooses to develop an OS, the move will cement Google’s other initiatives into a powerful whole.
Who’s threatened: Apple, Microsoft
Signs of panic: When one of Microsoft’s key operating system engineers defected to Google last year, Microsoft CEO Steve Ballmer threw a chair across an office and vowed to kill Google.
Reality check: The migration of applications from PCs to the Net is already happening – and it’s key to Google’s future. But the likelihood of a Google OS depends on what Microsoft accomplishes with its new OS, Vista.

PRINT
What if a search engine trolled not just every page on the Web, but every page in every book? Amazon.com tried it first, then Google said it would "make the full text of all the world’s books searchable by anyone."
Who’s threatened: Amazon, Microsoft, book publishers
Signs of panic: Against the interests of a legion of obscure writers, the Authors Guild sued Google. The Association of American Publishers, with more to fear, did the same. Microsoft and Yahoo! have joined a group that’s creating its own book search service.
Reality check: Making every book searchable sends a clear signal that Google has the brawn to organize the world’s information. But a vicious backlash could drown out that message.

PRODUCTIVITY PROGRAMS
Google joined with Sun Microsystems in October to jointly promote and distribute apps like the Google Toolbar and Sun’s free OpenOffice software. Wider distribution of the toolbar, Google’s most potent Trojan horse, gives the search engine access to a world of desktops.
Who’s threatened: Apple, Corel, Microsoft
Signs of panic: Microsoft launched its own toolbar and protested the decision of the Massachusetts Information Technology Department to dump Office for open source alternatives.
Reality check: It may be a fiendishly clever way to attack one of Microsoft’s highest-margin products, but this tactic can’t be a top priority. Google Toolbar will thrive without Sun.

ECOMMERCE
Froogle threatens no one yet. But what if, as the development of Google Wallet suggests, Google handled your every online transaction? The potential revenue from Google’s cut of each purchase would make AdSense look like AdCents.
Who’s threatened: Amazon, Buy.com, eBay
Signs of panic: After reports speculated that Google might take on PayPal, eBay said it would pay up to $4.1 billion for VoIP rebel Skype. Wall Street’s read: With PayPal under fire, eBay needed a new growth area.
Reality check: Rather than take on PayPal directly, the company may start with something less ambitious, like handling payments for premium video content. But after that? Watch out

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Children and Behavior

Chip Wass

November 27, 2005
The Nation
Kids Gone Wild
By JUDITH WARNER

CHILDREN should be seen and not heard" may be due for a comeback. After decades of indulgence, American society seems to have reached some kind of tipping point, as far as tolerance for wild and woolly kid behavior is concerned.

Last month, an Associated Press-Ipsos poll found that nearly 70 percent of Americans said they believed that people are ruder now than they were 20 or 30 years ago, and that children are among the worst offenders. (As annoyances, they tied with obnoxious cellphone users.)

The conservative child psychologist John Rosemond recently denounced in his syndicated column the increasing presence of "disruptive urchins" who "obviously have yet to have been taught the basic rudiments of public behavior," as he related the wretched experience of dining in a four-star restaurant in the company of one child roller skating around his table and another watching a movie on a portable DVD player.

In 2002, only 9 percent of adults were able to say that the children they saw in public were "respectful toward adults," according to surveys done then by Public Agenda, a nonpartisan and nonprofit public opinion research group. In 2004, more than one in three teachers told Public Agenda pollsters they had seriously considered leaving their profession or knew a colleague who had left because of "intolerable" student behavior.

Even Madonna – her "Papa Don’t Preach" years long past – has joined the throng, proclaiming herself a proud "disciplinarian" in a recent issue of the British magazine Harpers & Queen and bragging that, as a mom, she takes a tough line on homework, tidiness and chores: "If you leave your clothes on the floor, they’re gone when you come home."

Jo Frost, ABC’s superstar "Supernanny," would be proud.

Whether children are actually any worse behaved now than they ever have been before is, of course, debatable. Children have always been considered, basically, savages. The question, from the late 17th century onwards, has been whether they come by it naturally or are shaped by the brutality of society.

But what seems to have changed recently, according to childrearing experts, is parental behavior – particularly among the most status-conscious and ambitious – along with the kinds of behavior parents expect from their kids. The pressure to do well is up. The demand to do good is down, way down, particularly if it’s the kind of do-gooding that doesn’t show up on a college application.

Once upon a time, parenting was largely about training children to take their proper place in their community, which, in large measure, meant learning to play by the rules and cooperate, said Alvin Rosenfeld, a child psychiatrist and co-author, with Nicole Wise, of "The OverScheduled Child: Avoiding the Hyperparenting Trap."

"There was a time when there was a certain code of conduct by which you viewed the character of a person," he said, "and you needed that code of conduct to have your place in the community."

Rude behavior, particularly toward adults, was something for which children had to be chastised, even punished. That has also now changed, said Dan Kindlon, a Harvard University child psychologist and author of "Too Much of a Good Thing: Raising Children of Character in an Indulgent Age."

Most parents, Dr. Kindlon said, would like their children to be polite, considerate and well behaved. But they’re too tired, worn down by work and personally needy to take up the task of teaching them proper behavior at home.

"We use kids like Prozac," he said. "People don’t necessarily feel great about their spouse or their job but the kids are the bright spot in their day. They don’t want to muck up that one moment by getting yelled at. They don’t want to hurt. They don’t want to feel bad. They want to get satisfaction from their kids. They’re so precious to us – maybe more than to any generation previously. What gets thrown out the window is limits. It’s a lot easier to pick their towel up off the floor than to get them away from the PlayStation to do it."

Parenting today is also largely about training children to compete – in school and on the soccer field – and the kinds of attributes they need to be competitive are precisely those that help break down society’s civility.

Parents who want their children to succeed more than anything, Dr. Kindlon said, teach them to value and prioritize achievement above all else – including other people.

"We’re insane about achievement," he said. "Schoolwork is up 50 percent since 1981, and we’re so obsessed with our kids getting into the right school, getting the right grades, we let a lot of things slide. Kids don’t do chores at home anymore because there isn’t time."

And other adults, even those who should have authority, are afraid to get involved. "Nobody feels entitled to discipline other people’s kids anymore," Dr. Kindlon said. "They don’t feel they have the right if they see a kid doing something wrong to step in."

Educators feel helpless, too: Nearly 8 in 10 teachers, according to the 2004 Public Agenda report, said their students were quick to remind them that they had rights or that their parents could sue if they were too harshly disciplined. More than half said they ended up being soft on discipline "because they can’t count on parents or schools to support them."

And that, Dr. Rosenfeld said, strikes at the heart of the problem. "Parents are out of control," he said. "We always want to blame the kids, but if there’s something wrong with their incivility, it’s the way their parents model for them."

There’s also the chance, said Wendy Mogel, a clinical psychologist whose 2001 book, "The Blessing of a Skinned Knee," has earned her a cult following, that when children are rude, obnoxious and outrageously behaved, they’re trying to tell parents something – something they’ve got to shout in order for them to hear.

"These kids are so extremely stressed from the academic load they’re carrying and how cloistered they are and how they have to live under the watchful eye of their parents," Dr. Mogel said. "They have no kid space."

Paradoxically, she said, parental over-involvement in their children’s lives today often hides a very basic kind of indifference to their children’s real need, simply to be kids. "There are all these blurry boundaries," she said. "They need to do fifth-grade-level math in third grade and have every pleasure and indulgence of adulthood in childhood and they act like kids and we get mad."

If stress and strain, self-centeredness and competition are the pathogens underlying the rash of rudeness perceived to be endemic among children in America today, then the cure, some experts said, has to be systemic and not topical. Stop blaming the children, they said. Stop focusing on the surface level of behavior and start curing instead the social, educational and parental ills that feed it.

This may mean less "quality" time with children and more time getting them to do things they don’t want to do, like sitting for meals, making polite conversation and – Madonna was right – picking their clothes up off the floor.

Judith Warner is the author, most recently, of "Perfect Madness: Motherhood in the Age of Anxiety." She is also the host of "The Judith Warner Show" on XM satellite radio.

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