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Bite your tongue–but not literally

June 17, 2013

IMG_1188[1]Ahh, the things we do to ourselves and our health. I had a dental check-up. Cleaning. Routine. Or so I thought. But then the dentist came in and said that there was a growth under my tongue that he was worried about. He showed me in the mirror. I really couldn’t see it very well. The dentist made an appointment for me to see an ear, nose, and throat surgeon right away. The surgeon said that it indeed needed to come out. So surgery was scheduled. And it came out. And it was studied. And it was pronounced a ‘ hemangioma’–explained to me as a ‘nest of entangled blood vessels bound up in tissue.’

‘Have seen a similar thing in patients who were in auto accidents where they bit their tongue really hard. Or other events where the tongue got bitten. Don’t know what caused yours.’

Yikes. I do. I had developed the habit of literally biting my tongue. I placed the tip at the back of one corner or my mouth and kept quiet during times when I knew I should keep quiet. But I didn’t want to keep quiet. Broke that habit in one moment. How many other bad habits affecting our health could we stop in an instant if we only knew what they were doing to us?

What might happen when a pharmacist uses a conscience clause?

January 16, 2012

A conscience clause — when might a pharmacist feel conflicted about filling a prescription? The most commonly discussed event is birth control. Birth control pills, the morning after pill… these medications cause feelings of conflict between values related to pro-life and anti-abortion, and dispensing the medications.

The store, Target, supports a pharmacist’s rights not to fill these prescriptions. However, a pharmacist must direct a consumer to another Target store where the prescription can be filled. I can find no research that has been done to see how such conversations might take place or what happens when — as in the town where I live — there is one Target store. I don’t know if there is more than one pharmacist there. I don’t know if any of them object to filling these prescriptions. But if they do, what happens? How would I know? Who would tell me?

Old science, new science, and conflicting science about coffee and caffeine–and health

January 12, 2012

Shortly before the holidays, I heard Dr. Oz talking about coffee. He played a game with audience members and emphasized that coarsely ground, light roast coffee made with cold water and NEVER microwaved is best when aiming for the benefits of coffee. Benefits? I thought. Isn’t it interesting how different stories emphasize different results?

On the hunt for the science I went. In 2009, a study reported that 3-5 cups of coffee a day related to a reduced risk –65% less — for dementia and Alzheimer’s disease [http://iospress.metapress.com/content/d885346618q57103/].

I was reminded of my discussion in my book, Talking about health, about old science, new science, conflicting science, and no science. I went online in search of some more science to discuss the coffee and caffeine health benefits. I found the Dr. Oz story: http://www.drozfans.com/dr-ozs-advice/dr-oz-american-roast-coffee-prevents-colon-cancer-coffee-trivia/

An article in 1990 reports findings that the participants who reported drinking more coffee had a higher incidence of colon cancer [http://www.jstor.org/pss/20065645]. 

A study reported in 1993 found no relationship between more than 34,000 women’s reports of caffeine consumption and breast cancer [http://aje.oxfordjournals.org/content/138/6/380.short].

In 2007, a study found that 2 cups of black tea or decaf. coffee each day related to reduced risk for ovarian cancer, but regular coffee did not show this relationship. Again, women self-reported their behaviors [ http://onlinelibrary.wiley.com/doi/10.1111/j.1525-1438.2006.00773.x/full].

Also in 2007, a study found that drinking 2 cups a day of regular coffee greatly reduced — 43% — risk for liver cancer [http://www.gastrojournal.org/article/S0016-5085(07)00568-9/abstract].

What does it all mean? Talking about health means thinking about when a study was conducted, who particpated, and how the research was done. Self-reports are different from clinical studies. I don’t know of any clinical trials where participants are given coffee over time and compared to participants who do not consume coffee. So the research depends on individuals reporting how much coffee they drink. And then clinical reports about their health status provide a picture of what might be making a difference in the health of some compared to others. So when talking about health, don’t lose sight of the meaning of shorthand expressions like, ‘drinking 2 cups of coffee a day reduces your risk for cancer’…

What did Dr. Oz say about genes and health, and what did his guest doctor say about viruses causing cancer that left me talking to the TV–and not in a happy voice?

February 4, 2011

Aieeeeeeeee. Dr. Oz had some visiting doctors on his show again today. As they were wrapping up some of the discussion, Dr. Oz said, “Genes load the gun… The environment pulls the trigger… I want you to remember that.” What?! We have discussed the importance of family health history in this forum before. So the role of genetics is one that is an important topic when talking about health.

But I wonder how many viewers really got the idea that it was family health history they should be thinking about with his expression–“Genes load the gun.” This is an old metaphor for the role of genes for health and has not been very effective. Add to that, the conversation that Dr. Oz was having about genetic mutations on the show. It all got mushed together…

“The environment pulls the trigger.. I want you to remember that.” Really? What does it mean? Again, the meaning of environment in this metaphor has many interpretations. Environment for most people is about where they live, the climate, the neighborhood, pollution… those things all matter when it comes to our health and interact with our family health history. But environment includes our personal behavior and our social environment–friends, family, and culture. What we eat, for example, is part of the ‘environment’ that our genes live in… But I am not confident that this meaning is clear when talking about genes and health with this metaphor… 

Then there was the conversation about viruses–that cause cancer. HPV was one of the two examples discussed. I think that this also was not a good way to discuss the issue. If I have cervical cancer, you cannot ‘catch’ it from me. Cervical cancer is not a virus that can be passed from one woman to another. Cervical cancer is often caused by the lesions that form from genital warts caused by HPV–the humanpapilloma virus. So there is a virus that causes a condition that may be the cause of cancer…and not just cervical cancer but also penile cancer and throat cancer and head and neck cancers… So we may pass a virus between us that leads to genital warts that sometimes do not heal and may cause some changes in our cells and become cancer…

So let’s focus on understanding that increases our health literacy and not shorthand expressions that don’t… And let’s look toward spring and the daffodils that will replace the frozen icy tundra in my woods today…

What is the meaning of uncertainty when it comes to illness?

117_1746April 21, 2010

Communication and uncertainty go hand-in-hand. Many of our theories in communication focus on uncertainty as a reason to communicate. In these cases, we usually focus on communicating to reduce uncertainy. We talk about how we use cues from others–such as how they dress, the hair style they wear, the way that they gesture, and even how fast or slow they talk and their accent–to decide how much we are like another person. In these ways, we are using nonverbal information to reduce our uncertainty about talking with someone.

In already established relationships, we also experience uncertainty. Relational uncertainty may happen because we don’t know if our friend or family member is being ‘honest’ about whether they think we should take the job, go back to school, or in a million little day-to-day situations–like what to wear, what to eat, or what to do with our free time. We often try to reduce our uncertainty in these sitautions as well by communicating. ‘What do you want to do?’ ‘What are you doing to wear?’ ‘Do you think I should take this job?’ ‘What about the fact that we can’t sell the house right now?’ ‘They didn’t offer me any moving costs–can we afford it?’ So relational uncertainty emerges in a thousand different ways as part of having relationships. And it is a challenge to imagine how to balance the relationship needs and well, live our lives. So what happens when into the mix we introduce illness?

A diagnosis, whether it is terminal or not–as suggested by one of the participants in my last post–may spark the motivation to communicate. The diagnosis might be for a chronic condition such as heart disease, high blood pressure, high cholesterol, diabetes, or even HIV. It might be a broken leg or a sprained neck. Into each and every one of these and possibly thousands of other diagnoses enters uncertainty. “Illness uncertainty” is a big part of the uncertainy. But “relational uncertainty” is introduced into a diagnosis as well. To improve our communication about health, keeping both kinds of uncertainty in mind may help.

A diagnosis often leads us to want to reduce illness uncertainty about such things as ‘what is it,’ ‘what does it mean for my life,’ ‘how long will it last,’ ‘how will we treat it,’ and a host of other questions that may lead us to seek information to reduce our illness uncertainty. Sometimes, there will be no answers as we seek information, and so we have to “manage” our illness uncertainty by knowing that we have done what we could to answer our questions and perhaps by joining support groups online or in other ways putting ourselves in a position to keep up-to-date with any new information. What we don’t often think about is that in some situations, “increasing” our illness uncertainty may offer the most hope. As an emotion, hope let’s us look forward to a future that is a positive one and where we see ourselves able to achieve important goals. When we do not have certain information about our illness, that may provide a path toward hope if we frame it based on such comments as, “the doctor told me, ‘I don’t see any expiration date on you'”,–meaning that there is no answer to a question framed as, ‘how long do I have to live’.

In some of my past research, I have talked about the acute phase following a spinal cord injuury. During this phase, patients and families often are most reassured by communication that  increases their uncertainty about the course of the diagnosis. Doctors not knowing whether a patient will walk again is a hopeful thing. At the same time that the patient and family experience hope related to increasing their illness uncertainty, they may experience sadness and fear and anger about a sense of increasing relational uncertainty. This is a case where friends and family may be very supportive in the beginning but seem to be less so over time. Communication may need to be more direct to reveal what is happening. If a friend asks, ‘what can I do for you?’ and the ansswer is always the same–‘nothing’–the friend may quit asking and quit coming around. There are many reasons that we don’t ask for help–and we can discuss those in the coming days–but if we remember that it may increase a friend’s uncertinaty about the relationship if we say ‘nothing’ and we obviously need help. And their lack of helping when we obviously need help may in turn increase our uncertainty about them. And both may contribute to illness uncertainty in negative ways–relating to a lack of tangible and emotional support–perhaps we can stop the spiral and communicate about our health and our relationship in more fruitful ways… not always to reduce uncertainty… but at least in ways to manage it.

What do you say to a loved one just diagnosed with terminal cancer?

122_0562April 13, 2010

Maureen Keeley and Julie Yingling are authors of the award-winning book, Final conversations: Helping the living and dying talk to each other. Through interview data collected from some of us who have gone through the experience of knowing that a close relative has received a terminal diagnosis, Maureen and Julie provide a table of contents that introduce the important topics they address in the book.  Among these–telling our loved one, “I love you.” While saying the words is important, giving clear messages that leave no doubt about the love that has been shared is emphasized in the authors’ summary of what interviewees told them. Telling a parent that she is loved, that you will do your best to live the kind of life she would be proud of, and that you are grateful for the time you had to to share together…these are messages that we want to say explicitly while we have time to do so.

Keeley and Yingling remind of us that a terminal diagnosis does not mean that your loved one is dead–yet. He or she probably wants to go on taking care of everyday business as long as possible. So when your loved one says that he wants to hear about your life, he really means it. There may not be a lot of opportunities left for you to tell him about the everyday and ordinary parts of living.  What did you do at work? Who did you talke to? What did you eat when you went out to dinner last night? Where are you planning to go on vacation this year?

Simple joys…baking cookies for a loved one and eating them with a cup of herbal tea or coffee. Sitting near a window that looks onto a view that is a favorite one. One of my aunts that I felt very close to died from ovarian cancer. I remember her wanting to continue to do some work from the office…right up until she died. Her employer brought some of the bookkeeping to the house and she worked on it when she felt like it. We didn’t say to her, “Why are you spending your time that way?” She wanted to do it. That was enough. An uncle who died from lung cancer wanted to go on a camping trip. It meant getting a trailer that he could be comfortable in so that my aunt could take him on that final campout.

It also may be the time to talk through some things that have been avoided in the past. We don’t have just positive feelings, even about the relatives that we feel close to. A conflict long buried might be on our minds. An invitation to a loved one such as, “Do you want to talk about it?” may open the door to clear the air. We shouldn’t force the invitation, but provide a space for a conversation that many times will be a relief to the living and the dying.

The authors also emphasize how important it can be to say that a connection to a loved one lives on…even when they do not.

Should we ask our doctors about antibiotics?

138_07301February 27, 2010

On the ABC evening news this past week, Dr. Besser advised the audience, “Do not ask your doctor for antibiotics.” He provided the evidence to support the claim that asking for antibiotics greatly increases the chances that a doctor will prescribe antibiotics to a patient. He went on to explain that antibiotics are designed to treat bacteria. They do not treat a virus.

I would reframe this conversation. From the doctor’s side, if a patient asks for antibiotics to treat a virus, this seems like a great opportunity for the doctor to explain, “Antibiotics do not work to treat a virus, and your cold is caused by a virus.”

The advantages of this approach include the chance to improve a patient’s health literacy. We can increase our own understanding about health if our doctors take the opportunity to use these teachable moments to ‘teach’ us.

Another advantage is that we feel able to ask a question about our treatment without concern that our doctor might prescribe something unncessary. One likely unintended of Dr. Besser’s advice to not ask for an antibiotic is that it may lead us to wonder, ‘how often would a doctor prescribe something to me just because I asked for it?’

The medical research supports the conclusion that in the U.S., direct-to-consumer advertising leads patients to ask for tests and prescriptions that increases the likelihood that a doctor will order the tests and/or prescribe the medication. So, like in the case of antibiotics, when a patient asks — a doctor is more likely to prescribe.

But is this always a bad thing? We have decades of research to support the conclusion that the time demands on a doctor and the ever growing body of research about available therapies for various conditions = less chance to consider all options in each situation. To participate in our care, we should ask about treatments we may know about. Just asking may prompt the doctor to consider a path that wasn’t the one being considered. Just because it is considered doesn’t mean it should be selected. Sometimes, however, the doctor might judge it to be a ‘good idea.’

If each time a patient asks a doctor for treatment that is not a good match to the health condition, a doctor feels compelled to prescribe the treatment, it will lead to further waste in the health care system. We know that a doctor is not likely to follow the path a patient suggests if the doctor believes it will be harmful…at least, in the short term. But with antiobiotics as a case to illustrate, we want our doctors to think about our well-being in the long term. And if our request doesn’t make sense, take a minute to tell us why it doesn’t.

This approach means that doctors and patients can keep talking, and that their communication might benefit health in the short term and the long term, and the cost of health care as well.

Do we want doctors to tell us if we have advanced cancer?

117_1755February 18, 2010

In 2002, Hisako Kakai published an article in the journal, Health Communication, about preferences for disclosure of a cancer diagnosis. Dr. Kakai indicates that in Japan, a direct communication style is usually preferred when it comes to disclosing one’s personal diagnosis of cancer. In other words, people want to be told they  have cancer. However, an indirect communication style with no disclosure, or an ambiguous disclosure to the patient was preferred for a family member. The article raises many interesting communication and ethical issues.   

A serious diagnosis raises the question, ‘how do we deal with uncertainty?’ Communication plays a big role. It points to the reality that we often are not good with dealing with uncertainty. We frame uncertainty as ‘bad’ and let uncertainty overtake everything good that might be going on in our lives. This relates to how we communicate about a serious health condition. It also relates to how we communicate about the economy, about security, and about an endless number of issues that equal being — human.

The message communicated often to us is, ‘work hard and it will pay off’ — with payoff crossing a spectrum from health, relationships, and wealth. The message, ‘life is uncertain. Work hard at your relationships and school and work, and take satisfaction in the fact that you worked hard’ — is communicated less often, if at all. And it shows up in our inability to deal with uncertainty, our obsession with …reducing the uncertainty.    

Should the goal in communicating be to reduce uncertainty? When it comes to our health, that may not always be the best aim. If we can learn to manage the uncertainty of a diagnosis, we may be better able to live our lifes as someone living with cancer or heart disease or diabetes. If we make the diagnosis a more integral part of our being and identity, we may communicate in ways that define us to others as being disabled rather than living with a disability, diabetic rather than managing life while living with diabetes, and so on.  

Even more surprising, when we focus on managing our uncertainty as a part of life, we may even discover that there are times when we communicate to increase uncertainty. Instead of being certain that our future, our health, our well-being are uncertain and that is a bad thing, we can use uncertainty as a way to promote hope. In our own research, Ben Cairns and I found that this was particularly important for people who have newly experienced spinal cord injuries and their family members. ‘Will she walk again? Will he be able to do things for himself? Can she sit up on her own? Can he feed himself?’ Not knowing offers people living with the injury and their families and friends the hope that they might do these things again. 

Communicating to increase uncertainty about a diagnosis thus gives some time to adapt to a diagnosis. And that may be the best and more ethical way to communicate about an advanced cancer diagnosis as well. Not telling so that a patient does not know a true diagnosis may seem to offer a way to manage a serious diagnosis and thus to reduce uncertainty. Telling and acknowledging that the diagnosis is serious, even very serious, but that predicting exactly when the end-of-life will happen is uncertain may give some time to adapt to the diagnosis and some hope that important things that have not been said can be…

…a lesson in Dr. Maureen Keeley’s award-winning book, Final Conversations that has been shown to be so important for those who know that they are dying and the loved ones they will leave behind.

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