American College of Physicians: Internal Medicine — Doctors for Adults ®

Tuesday, August 16, 2011

Why we need to go beyond the 'sound bite' for health information

Our society has incubated the evolution of the sound bite and the devolution of civility. This is a perilous pairing if ever there was one, a pernicious influence on discourse and a constant threat to sense, which is, alas, now far from common. We don't even try to understand one another, and so, of course, we don't. No understanding means no agreement, which in turns means no progress.

The immediate basis for this commentary is the roiling debate over responses to severe childhood obesity initiated by the Murtagh and Ludwig editorial in JAMA.

Dr. Ludwig, a friend and colleague, has received hate mail in response to what was, in fact, a very temperate and judicious position. We'll return to that shortly.

But first, let's talk about me. I, too, have received hate mail, and been excoriated in various media, for supporting Dr. Ludwig's position. The irony is: I don't support Dr. Ludwig's position, and that is just what my own take on the issue states!

I am one among a very, very few people to have direct personal experience with state intervention for severe childhood obesity, as I noted before. I was sent by Good Morning America to visit and interview a family whose daughter was taken away from them by the state of New Mexico for this very reason. I got to meet and know the then little girl, Annamarie, her parents, her extended family and her physicians.

I found the family to be loving and concerned, and the health professionals involved in Annamarie's care to be stumped by her inability to lose weight. She lost no weight in state hands, and was returned to her family by much-chagrined and embarrassed authorities. The family was both shamed and traumatized by the "intervention." This is a precautionary tale if ever there was one.

For those wanting to know, I collaborated with Annamarie's physicians, and we settled on a treatment regimen for her severe insulin resistance that slowed her weight gain. However, despite state-of-the-art medical care and her family's best efforts, she has since developed Type 2 diabetes. (She is of Pima Indian descent and has extreme genetic vulnerability to both weight gain and diabetes.)

So, I disagree with Dr. Ludwig's recommendation based in part on this personal experience, and my view that we don't yet have the evidence we need that the state necessarily knows how to help severely obese children whose care it might presume to take on. But even more fundamentally, I disagree with the Murtagh and Ludwig's position because I believe laws should follow norms, not get too far ahead of them.

It is normal in our society to view the beating or starving (willful under-feeding) of a child as a form of abuse or neglect. It is not normal, however, to view overfeeding in that same light. Since by any reasonable definition 50 percent of children or more nationwide are overweight, and since repeated studies show that parents tend to be relatively oblivious to the obesity that develops on their watch, we must be prepared to declare half the parents in the country "mild abusers" if this is abuse. Clearly, we're not there yet. Whether or not we ever get there, or should be there, is not immediately germane.

My view is that we must first decide whether over-feeding, and the neglect or propagation of obesity in a child, is viewed by most of us as a form of new-age abuse. Once we agree it is, then the legal remedies already in place for abuse would pertain. But until it is, the suggestion of legal remedies will sound radical.

But the reality is, Dr. Ludwig's position was never radical in the first place! His recommendation was that the state consider intervening when and only when: (a) obesity is an imminent danger to the health and even life of a severely obese child; (b) the family has been offered every manner of assistance; and (c) the family has willfully ignored or rejected the assistance available. In other words, Dr. Ludwig and Ms. Murtagh were talking about, and only talking about, true abuse of a child.

Folks, it is not radical, not even bold and assuredly not new, to say that parents who are willfully killing their child should not be left alone by the authorities until the child is dead.

I invite all of my very-right-of-center-friends and the staunchest defenders of personal liberty to address this: do you feel that "personal liberty" encompasses the right of malicious or mentally unhinged parents to kill their children? I am presuming not. And if not, then, miracle of miracles, across the political spectrum, we have found something on which we can agree!

But from media reactions to Dr. Ludwig, and frankly to me, I got the impression that we could not possibly agree on anything. For the moment, let's leave alone the fact that Dr. Ludwig's position is cautious, specific and far from radical. Let's leave aside the hate mail and assignations levied at Dr. Ludwig.

I stated quite clearly, as I have again here, that while I respect Dr. Ludwig, I disagree with him on this issue. I don't think we are yet ready to go there. But in this dumbed-down, sound bite, blog-first-and-ask-questions-later world of ours, I have not only been accused of advocating for the state intervention I am advising against, I have been accused of everything up to and including fascism.

The reality, of course, is that entire branches of my family tree were brutally cut off by fascists. So the charge would be bad enough if it were in response to what I actually said or believe. Since it is both vile, and entirely wrong, responding to a position I have explicitly renounced, I believe it is, in a word, stupid.

And that's where we find ourselves. Mired in sound bites, too caught up in diatribe to be capable of dialogue. Too steadfast in our defense of the extremes to bother looking for, let alone find, the sense that often resides somewhere in the middle.

I have come here neither to praise, nor bury, Dr. Ludwig's position, nor my own. It is not immediately relevant that Dr. Ludwig is, in fact, a highly trained and caring physician who takes care of severely obese children, whose very lives are at times in imminent danger. It is not immediately relevant that he has seen first-hand instances of both life-threatening obesity in children and parental rejection of offered assistance. It is not immediately relevant that just as I can cite an instance where state intervention failed, he can cite an instance in which it clearly saved a child's life.

What is immediately relevant is only that none of that seems to matter because we never get past headlines. In fact, if you are still reading this then thank you! I believe that you are part of the solution already. Because whether you agree or disagree with me (or Dr. Ludwig)--love us, hate us, or are agnostic--at least you are listening.

I am here to renounce the sound bite. We are better than that. We can at least listen to one another before we decide to disagree. And when we disagree, we can recall that reasonable people, decent people, loving and thoughtful people can disagree. Insults never foster understanding, they just entrench the differences true dialogue might help us overcome.

Let's give civility a try. We might discover that we disagree far less than we thought. And when we do disagree, we might discover the opportunity to benefit from differing perspectives and devise solutions informed by them.

Let's try listening to one another. I suppose you might disagree with the suggestion, but apparently, you're still here. So I thank you very much indeed for listening to me before deciding.

David L. Katz FACP, MPH, FACPM, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care. He is a board certified specialist in both Internal Medicine, and Preventive Medicine/Public Health, and Associate Professor (adjunct) in Public Health Practice at the Yale University School of Medicine. He is the Director and founder (1998) of Yale University's Prevention Research Center; Director and founder of the Integrative Medicine Center at Griffin Hospital (2000) in Derby, Conn.; founder and president of the non-profit Turn the Tide Foundation; and formerly the Director of Medical Studies in Public Health at the Yale School of Medicine for eight years. This post originally appeared on his blog at The Huffington Post.

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Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

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Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

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Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

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Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

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Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

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Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

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Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

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Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

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One of the most popular anonymous blogs written by an emergency room physician.

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