In This Issue: Communication in the Era of ’Personalized‘ Medicine
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《家庭医学史册》
COMMUNICATION
I n this issue, we launch a new feature: the Annals Journal Club.1,2 this new journal club takes a RADICAL approach, stimulated by the need for local forums to address important problems in primary care, and for a venue for interaction between these groups.
We initiate the Annals Journal Club with 2 qualitative studies that relate to patient perceptions of risk and the implication of these perceptions for communication. Frich and colleagues find that patients with familial hypercholesterolemia use a 2-step process to develop a personal sense of vulnerability to coronary heart disease.3 Goldman et al study patients’ reactions to 3 strategies for communicating risk and find that cardiovascular risk-adjusted age may be a useful strategy for communicating about risk and motivating behavior change.4 As expectations grow about the ability to tailor diagnosis and treatment on the basis of genetic risk,5–12 these front-line studies show the need to understand and include patient perceptions in any planning for (genetically) "personalized medicine."13,14
Both Goldman et al and Frich et al find that earlier-than-usual age at disease onset is a commonly understood indicator of risk for adult diseases. "Risk age," compared with chronologic age, can be a powerful, personalized way of communicating the impact of risk factors and of risk-reducing measures. Premature disease in a family (eg, a heart attack in a middle-aged person) can motivate preventive measures but might also let relatives who have outlived that age feel "exempt" from the risk or prevent younger relatives from engaging in risk reduction until they are closer to the age at which family members have been affected. A dialog focused on age may be a productive way for clinicians to discuss prevention with patients at risk.
Several other studies raise issues that relate to communication between patients and clinicians. Williams et al discover that among patients in Veterans Affairs general medicine clinics whose screening tests are positive for alcohol misuse, the majority are ready to change their behavior.15 In addition, greater alcohol misuse severity is associated with greater readiness to change. These findings counter common stereotypes and should motivate clinicians to ask about alcohol use, to expect motivated patients, and to have systems available to follow up on positive patient responses.
In an international study that compares physicians in the United States and the Netherlands,16 different physician perceptions of their role, family wishes, and knowledge of the patient may explain more aggressive treatment of demented nursing home patients with pneumonia. Thus, the personal, social/societal, and relationship context for communication and decision making can have profound effects on the kind of care that is delivered.
Finally, an essay depicts the transforming effect of a physician’s limited ability to communicate.17 The personal experience of the restrictive effect of communication problems leads to lessons about communicating with patients who don’t speak the same language.
CESAREAN DELIVERY AND PATIENT CHOICE
In this issue, Zweifler et al report on the decline in vaginal births after cesarean sections (VBAC) in California.18 They show that this trend was already underway before a change in American College of Obstetricians and Gynecologist guidelines that might have restricted access to VBAC. Leeman and Plante19 write a provocative essay urging that systems of childbirth care preserve women’s options to choose vaginal birth—eg, after a previous cesarean delivery—amid discussions of elective primary cesarean delivery without labor. In March 2006 the National Institutes of Health convened a State-of-the-Science Conference regarding Cesarean Delivery on Maternal Request (CDMR). The report of this conference, confirmed the nationwide trend for decreasing rates of VBAC and the record-high cesarean delivery rate of 29.1% in 2004. The NIH panel concluded that the incidence of CDMR is unknown but probably contributes to the increase in primary cesarean births. They also concluded that there is insufficient evidence to evaluate its risks and benefits compared with planned vaginal delivery. The conference also proposed research questions to gather further evidence on this controversial topic.
ARTICLES OF POLICY, PRACTICE, AND RESEARCH INTEREST
In a case study of an interesting natural experiment, the leaders of 4 practice-based research networks with very different ways of organizing show how different initial conditions and processes for running a network are associated with different outcomes.20
In another natural experiment, Guirguis-Blake and colleagues21 use the National Practitioner Data Bank to examine the effect of caps in total and noneconomic damages on malpractice insurance payments across all 50 states and the District of Columbia. Amidst wide interstate variation, caps on total and noneconomic damages are associated with lower malpractice payments. The findings provide support for the effectiveness of certain forms of malpractice reform on payments.
A systematic review by Gartlehner and colleagues finds benefit from inhaled corticosteroids for patients with moderate or severe chronic obstructive pulmonary disease, but not for mild disease.22
Lack of trust is at the heart of human participant protection and privacy efforts, laws, and regulations. A new measure of patient trust in medical researchers is found to have good psychometric properties.23 The association with racial differences supports a large body of research showing that African American patients and many other minority groups have lower trust in researchers.24–31 This lower trust is based on many historical and current reasons,24,26,32,33 and is a major reason for lower participation of minority groups in medical research,24,26,27 and the resulting limited relevance of much medical research to minority groups.34,35 The development of a measure is a step toward furthering understanding and solution of this problem.
ACKNOWLEDGMENTS
We are grateful to Esa Davis, MD, MPH, and Sonja Haywood, MD, for their help in preparation of this editorial.
FOOTNOTES
Conflicts of interest: none reported
REFERENCES
Stange KC, Miller WL, McLellan LA, et al. Annals Journal Club: it’s time to get RADICAL. Ann Fam Med. 2006;4:196–197.
Annals Journal Club: A RADICAL approach. Ann Fam Med. 2006;4: iii.
Frich JC, Ose L, Malterud K, Fugelli P. Perceived vulnerability to heart disease in patients with familial hypercholesterolemia: a qualitative interview study. Ann Fam Med. 2006;4:198–204.
Goldman RE, Parker D, Eaton C, et al. Patients’ perceptions of cholesterol, cardiovascular disease risk, and risk communication strategies. Ann Fam Med. 2006;4:205–212.
Snyderman R, Langheier J. Prospective health care: the second transformation of medicine. Genome Biol. 2006;7:104.
Lunshof JE, Pirmohamed M, Gurwitz D. Personalized medicine: decades away? Pharmacogenomics. 2006;7:237–241.
Ferrara J. Personalized medicine: challenges in assessing and capturing value in the commercial environment. Expert Rev Mol Diagn. 2006;6:129–131.
Svinte M. The promise of personalized medicine: a conversation with Michael Svinte. Interview by Michael Millenson. Health Aff (Millwood). 2006;25:w54–60.
Kalow W. Pharmacogenetics and pharmacogenomics: origin, status, and the hope for personalized medicine. Pharmacogenomics J. 2006.
Ginsburg GS, McCarthy JJ. Personalized medicine: revolutionizing drug discovery and patient care. Trends Biotechnol. 2001;19:491–496.
Liotta LA, Kohn EC, Petricoin EF. Clinical proteomics: personalized molecular medicine. JAMA. 2001;286:2211–2214.
Langreth R, Waldholz M. New era of personalized medicine: targeting drugs for each unique genetic profile. Oncologist. 1999;4:426–427.
Snyderman R, Langheier J. Prospective health care: the second transformation of medicine. Genome Biol. 2006;7:104. Epub 2006 Feb 27.
Langreth R, Waldholz M. New era of personalized medicine: targeting drugs for each unique genetic profile. Oncologist. 1999;4:426–7.
Williams EC, Kivlahan D, Saitz R, et al. Readiness to change in primary care patients who screened positive for alcohol misuse. Ann Fam Med. 2006;4:213–220.
Helton MR, van der Steen JT, Daaleman TP, Gamble G, Ribbe M. A cross-cultural study of physician treatment decisions for demented nursing home patients who develop pneumonia. Ann Fam Med. 2006;4:221–227.
Gordon PR. Thoughts on communication. Ann Fam Med. 2006; 4:264–265.
Zweifler JA, Garza A, Hughes S, Stanich M, Hierholzer A, Lau M. Vaginal birth after cesarean in California: before and after a change in guidelines. Ann Fam Med. 2006;4:228–234.
Leeman LM, Plante L. Patient choice vaginal delivery? Ann Fam Med. 2006;4:265–268.
Thomas P, Graffy J, Wallace P, Kirby M. How can primary care networks help integrate academic and service initiatives in primary care? Ann Fam Med. 2006;4:235–239.
Guirguis-Blake JM, Fryer GE, Phillips RL, Szabat R, Green LA. The US medical liability system: evidence for legislative reform. Ann Fam Med. 2006;4:240–246.
Gartlehner G, Hansen R, Carson S, Lohr K. The efficacy and safety of inhaled corticosteroids in patients with COPD: a systematic review and meta-analysis of health outcomes. Ann Fam Med. 2006;4:253–262.
Mainous AG III, Smith D, Geesey ME, Tilley B. Development of a measure to assess patient trust in medical researchers. Ann Fam Med. 2006;4:247–252.
Institute of Medicine Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington, DC: National Academy Press; 2000.
Gamble VN. A legacy of distrust: African Americans and medical research. Am J Prev Med. 1993;9:35–38.
Freimuth VS, Quinn SC, Thomas SB, et al. African Americans’ views on research and the Tuskegee Syphilis Study. Soc Sci Med. 2001;52:797–808.
Corbie-Smith G, Thomas SB, Williams MV, Moody-Ayers S. Attitudes and beliefs of African Americans toward participation in medical research. J Gen Intern Med. 1999;14:537–546.
Petersen LA. Racial differences in trust: reaping what we have sown? Med Care. 2002;40:81–84.
Boulware LE, Cooper LA, Ratner LE, LaVeist TA, Powe NR. Race and trust in the health care system. Public Health Rep. 2003;118:358–365.
Shavers VL, Lynch CF, Burmeister LF. Factors that influence African-Americans’ willingness to participate in medical research studies. Cancer. 2001;91:233–236.
Shavers VL, Lynch CF, Burmeister LF. Racial differences in factors that influence the willingness to participate in medical research studies. Ann Epidemiol. 2002;12:248–256.
Byrd WM, Clayton LA. An American health dilemma: a history of blacks in the health system. J Natl Med Assoc. 1992;84:189–200.
Goodson MG. Enslaved Africans and doctors in South Carolina. J Natl Med Assoc. 2003;95:225–233.
Cooper LA, Hill MN, Powe NR. Designing and evaluating interventions to eliminate racial and ethnic disparities in health care. J Gen Intern Med. 2002;17:477–486.
Gamble VN. Under the shadow of Tuskegee: African Americans and health care. Am J Public Health. 1997;87:1773–1778.(Kurt C. Stange, MD, PhD, )
I n this issue, we launch a new feature: the Annals Journal Club.1,2 this new journal club takes a RADICAL approach, stimulated by the need for local forums to address important problems in primary care, and for a venue for interaction between these groups.
We initiate the Annals Journal Club with 2 qualitative studies that relate to patient perceptions of risk and the implication of these perceptions for communication. Frich and colleagues find that patients with familial hypercholesterolemia use a 2-step process to develop a personal sense of vulnerability to coronary heart disease.3 Goldman et al study patients’ reactions to 3 strategies for communicating risk and find that cardiovascular risk-adjusted age may be a useful strategy for communicating about risk and motivating behavior change.4 As expectations grow about the ability to tailor diagnosis and treatment on the basis of genetic risk,5–12 these front-line studies show the need to understand and include patient perceptions in any planning for (genetically) "personalized medicine."13,14
Both Goldman et al and Frich et al find that earlier-than-usual age at disease onset is a commonly understood indicator of risk for adult diseases. "Risk age," compared with chronologic age, can be a powerful, personalized way of communicating the impact of risk factors and of risk-reducing measures. Premature disease in a family (eg, a heart attack in a middle-aged person) can motivate preventive measures but might also let relatives who have outlived that age feel "exempt" from the risk or prevent younger relatives from engaging in risk reduction until they are closer to the age at which family members have been affected. A dialog focused on age may be a productive way for clinicians to discuss prevention with patients at risk.
Several other studies raise issues that relate to communication between patients and clinicians. Williams et al discover that among patients in Veterans Affairs general medicine clinics whose screening tests are positive for alcohol misuse, the majority are ready to change their behavior.15 In addition, greater alcohol misuse severity is associated with greater readiness to change. These findings counter common stereotypes and should motivate clinicians to ask about alcohol use, to expect motivated patients, and to have systems available to follow up on positive patient responses.
In an international study that compares physicians in the United States and the Netherlands,16 different physician perceptions of their role, family wishes, and knowledge of the patient may explain more aggressive treatment of demented nursing home patients with pneumonia. Thus, the personal, social/societal, and relationship context for communication and decision making can have profound effects on the kind of care that is delivered.
Finally, an essay depicts the transforming effect of a physician’s limited ability to communicate.17 The personal experience of the restrictive effect of communication problems leads to lessons about communicating with patients who don’t speak the same language.
CESAREAN DELIVERY AND PATIENT CHOICE
In this issue, Zweifler et al report on the decline in vaginal births after cesarean sections (VBAC) in California.18 They show that this trend was already underway before a change in American College of Obstetricians and Gynecologist guidelines that might have restricted access to VBAC. Leeman and Plante19 write a provocative essay urging that systems of childbirth care preserve women’s options to choose vaginal birth—eg, after a previous cesarean delivery—amid discussions of elective primary cesarean delivery without labor. In March 2006 the National Institutes of Health convened a State-of-the-Science Conference regarding Cesarean Delivery on Maternal Request (CDMR). The report of this conference, confirmed the nationwide trend for decreasing rates of VBAC and the record-high cesarean delivery rate of 29.1% in 2004. The NIH panel concluded that the incidence of CDMR is unknown but probably contributes to the increase in primary cesarean births. They also concluded that there is insufficient evidence to evaluate its risks and benefits compared with planned vaginal delivery. The conference also proposed research questions to gather further evidence on this controversial topic.
ARTICLES OF POLICY, PRACTICE, AND RESEARCH INTEREST
In a case study of an interesting natural experiment, the leaders of 4 practice-based research networks with very different ways of organizing show how different initial conditions and processes for running a network are associated with different outcomes.20
In another natural experiment, Guirguis-Blake and colleagues21 use the National Practitioner Data Bank to examine the effect of caps in total and noneconomic damages on malpractice insurance payments across all 50 states and the District of Columbia. Amidst wide interstate variation, caps on total and noneconomic damages are associated with lower malpractice payments. The findings provide support for the effectiveness of certain forms of malpractice reform on payments.
A systematic review by Gartlehner and colleagues finds benefit from inhaled corticosteroids for patients with moderate or severe chronic obstructive pulmonary disease, but not for mild disease.22
Lack of trust is at the heart of human participant protection and privacy efforts, laws, and regulations. A new measure of patient trust in medical researchers is found to have good psychometric properties.23 The association with racial differences supports a large body of research showing that African American patients and many other minority groups have lower trust in researchers.24–31 This lower trust is based on many historical and current reasons,24,26,32,33 and is a major reason for lower participation of minority groups in medical research,24,26,27 and the resulting limited relevance of much medical research to minority groups.34,35 The development of a measure is a step toward furthering understanding and solution of this problem.
ACKNOWLEDGMENTS
We are grateful to Esa Davis, MD, MPH, and Sonja Haywood, MD, for their help in preparation of this editorial.
FOOTNOTES
Conflicts of interest: none reported
REFERENCES
Stange KC, Miller WL, McLellan LA, et al. Annals Journal Club: it’s time to get RADICAL. Ann Fam Med. 2006;4:196–197.
Annals Journal Club: A RADICAL approach. Ann Fam Med. 2006;4: iii.
Frich JC, Ose L, Malterud K, Fugelli P. Perceived vulnerability to heart disease in patients with familial hypercholesterolemia: a qualitative interview study. Ann Fam Med. 2006;4:198–204.
Goldman RE, Parker D, Eaton C, et al. Patients’ perceptions of cholesterol, cardiovascular disease risk, and risk communication strategies. Ann Fam Med. 2006;4:205–212.
Snyderman R, Langheier J. Prospective health care: the second transformation of medicine. Genome Biol. 2006;7:104.
Lunshof JE, Pirmohamed M, Gurwitz D. Personalized medicine: decades away? Pharmacogenomics. 2006;7:237–241.
Ferrara J. Personalized medicine: challenges in assessing and capturing value in the commercial environment. Expert Rev Mol Diagn. 2006;6:129–131.
Svinte M. The promise of personalized medicine: a conversation with Michael Svinte. Interview by Michael Millenson. Health Aff (Millwood). 2006;25:w54–60.
Kalow W. Pharmacogenetics and pharmacogenomics: origin, status, and the hope for personalized medicine. Pharmacogenomics J. 2006.
Ginsburg GS, McCarthy JJ. Personalized medicine: revolutionizing drug discovery and patient care. Trends Biotechnol. 2001;19:491–496.
Liotta LA, Kohn EC, Petricoin EF. Clinical proteomics: personalized molecular medicine. JAMA. 2001;286:2211–2214.
Langreth R, Waldholz M. New era of personalized medicine: targeting drugs for each unique genetic profile. Oncologist. 1999;4:426–427.
Snyderman R, Langheier J. Prospective health care: the second transformation of medicine. Genome Biol. 2006;7:104. Epub 2006 Feb 27.
Langreth R, Waldholz M. New era of personalized medicine: targeting drugs for each unique genetic profile. Oncologist. 1999;4:426–7.
Williams EC, Kivlahan D, Saitz R, et al. Readiness to change in primary care patients who screened positive for alcohol misuse. Ann Fam Med. 2006;4:213–220.
Helton MR, van der Steen JT, Daaleman TP, Gamble G, Ribbe M. A cross-cultural study of physician treatment decisions for demented nursing home patients who develop pneumonia. Ann Fam Med. 2006;4:221–227.
Gordon PR. Thoughts on communication. Ann Fam Med. 2006; 4:264–265.
Zweifler JA, Garza A, Hughes S, Stanich M, Hierholzer A, Lau M. Vaginal birth after cesarean in California: before and after a change in guidelines. Ann Fam Med. 2006;4:228–234.
Leeman LM, Plante L. Patient choice vaginal delivery? Ann Fam Med. 2006;4:265–268.
Thomas P, Graffy J, Wallace P, Kirby M. How can primary care networks help integrate academic and service initiatives in primary care? Ann Fam Med. 2006;4:235–239.
Guirguis-Blake JM, Fryer GE, Phillips RL, Szabat R, Green LA. The US medical liability system: evidence for legislative reform. Ann Fam Med. 2006;4:240–246.
Gartlehner G, Hansen R, Carson S, Lohr K. The efficacy and safety of inhaled corticosteroids in patients with COPD: a systematic review and meta-analysis of health outcomes. Ann Fam Med. 2006;4:253–262.
Mainous AG III, Smith D, Geesey ME, Tilley B. Development of a measure to assess patient trust in medical researchers. Ann Fam Med. 2006;4:247–252.
Institute of Medicine Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington, DC: National Academy Press; 2000.
Gamble VN. A legacy of distrust: African Americans and medical research. Am J Prev Med. 1993;9:35–38.
Freimuth VS, Quinn SC, Thomas SB, et al. African Americans’ views on research and the Tuskegee Syphilis Study. Soc Sci Med. 2001;52:797–808.
Corbie-Smith G, Thomas SB, Williams MV, Moody-Ayers S. Attitudes and beliefs of African Americans toward participation in medical research. J Gen Intern Med. 1999;14:537–546.
Petersen LA. Racial differences in trust: reaping what we have sown? Med Care. 2002;40:81–84.
Boulware LE, Cooper LA, Ratner LE, LaVeist TA, Powe NR. Race and trust in the health care system. Public Health Rep. 2003;118:358–365.
Shavers VL, Lynch CF, Burmeister LF. Factors that influence African-Americans’ willingness to participate in medical research studies. Cancer. 2001;91:233–236.
Shavers VL, Lynch CF, Burmeister LF. Racial differences in factors that influence the willingness to participate in medical research studies. Ann Epidemiol. 2002;12:248–256.
Byrd WM, Clayton LA. An American health dilemma: a history of blacks in the health system. J Natl Med Assoc. 1992;84:189–200.
Goodson MG. Enslaved Africans and doctors in South Carolina. J Natl Med Assoc. 2003;95:225–233.
Cooper LA, Hill MN, Powe NR. Designing and evaluating interventions to eliminate racial and ethnic disparities in health care. J Gen Intern Med. 2002;17:477–486.
Gamble VN. Under the shadow of Tuskegee: African Americans and health care. Am J Public Health. 1997;87:1773–1778.(Kurt C. Stange, MD, PhD, )