Educating Patients as Medicine Goes Green

Commentary by Louise P. King, MD, JD, and Janet Brown

Ms. Chen had been going to Dr. Patel’s outpatient gynecology practice for several years for her annual well-woman exam. The rural clinic was understaffed, and it was all the few participating physicians could do to manage the patient load.

LEARNING OBJECTIVELearn about steps being taken by clinics to reduce their harmful impact on the environment and how they must gain leadership support for, and educate patients about, their green policies.

A few months before Ms. Chen’s yearly check-up, Dr. Patel’s small group practice instituted a policy to stop using plastic specula for gynecological exams. The clinic-wide policy was an effort to reduce waste and avoid the increased shipping costs of plastic specula. Signs were posted in the clinic waiting area that informed patients of the practice’s decision to “go green,” and thanking them for their understanding and continued support.

Ms. Chen preferred the single-use plastic speculum, however, for hygiene reasons. She did not want to get a sexually transmitted disease from an improperly sterilized instrument and requested a single-use plastic speculum for her exam. Dr. Patel informed her that the clinic no longer stocked them and reassured Ms. Chen that measures had been taken to guarantee the metal specula were properly sterilized.

Commentary 1

by Louise P. King, MD, JD

Dr. Patel and her small group practice should be commended for “going green”—a movement that has become common in both large academic centers and public hospitals. Experts estimate that U.S. hospitals produce an average of 6,600 tons of waste per day. Over the past 10 years, waste production has increased as much as 15 percent with the escalating use of disposable, single-use products such as plastic specula [1]. Much of our medical waste is incinerated, with the resultant release of noxious gases that many argue are detrimental to the environment [2]. Movement toward recyclable materials should be encouraged not only as a cost-saving measure for hospitals and clinics but also as a necessary change to alleviate some of the burden of medical waste.

At the same time, Ms. Chen should not be faulted for expressing a fear, however unwarranted, that a change to a metal speculum would expose her to infectious disease. She is most likely unaware of the inherent safety of sterilization procedures. Perhaps Dr. Patel could educate her about this, which may or may not alleviate her fears. Ultimately, if Ms. Chen refuses an exam with a sterilized speculum, as the case asks, must Dr. Patel provide her choice of speculum? The answer is probably no.

As a question of principle, Dr. Patel should enforce the new green policy uniformly. Making exceptions in individual cases opens the door to an untenable situation. If enough patients demand specific nonreusable materials, this small practice might end up with a large stock room full of alternative materials. Even assuming one could charge the patient the cost of the speculum or other material, maintaining a room of alternative materials would be cost-prohibitive. More importantly, it would violate the group’s new commitment to green practices, not only by including nongreen materials it had decided to exclude, but also by providing a market, albeit small, for them.

An argument might be made that Ms. Chen suffers from mysophobia (i.e., germaphobia) and that this condition could be recognized as a disability. Certainly no physician can refuse necessary medical care to a patient because of a disability, and the case implies that Ms. Chen cannot easily find another source of medical care. It is even possible that this rural clinic receives federal funding, which might oblige staff to consider making a reasonable accommodation for patients with special needs. This does not automatically mean, however, that ordering plastic specula is a reasonable accommodation for Ms. Chen’s impairment.

Assuming a small, federally funded rural center might be required by law to consider accommodating Ms. Chen’s mysophobia, the accommodation would not stop with the regulation for a plastic speculum. If Ms. Chen needs a biopsy of her cervix, for example, a Tischler biopsy forceps will be used. There is no plastic single-use equivalent. Much of the equipment in physicians’ offices and operating rooms has no single-use equivalent. Ms. Chen might be surprised to learn this, since the process for obtaining consent to treat in either office or operating room does not include a specific description of the materials that will be used.

This raises a broader question. As offices and hospitals move forward to “green” their practices, what form of notification and consent is required? This clinic attempted to make patients aware of the change with a posted sign. But this sign did little to educate Ms. Chen about the relative safety of sterilized metal equipment, and there was no formal process to ensure she consented to this change in practice. It is unlikely that a formal consent process is legally necessary, based on the standard test of what a reasonable person in the patient’s position would want to know; there is no inherent change in the risk of using a metal speculum as opposed to a plastic one. Both pieces of equipment are considered standard of care, and a strong argument can be made that a patient need not be informed of each piece of equipment that will be used for treatment. That said, educating patients on the need for multiple-use equipment and addressing their concerns regarding safety is an important part of the process of “going green.” Perhaps in some instances, merely offering patients a handout that details the problem with medical waste and the process and safety of sterilization will suffice.

There may be situations, however, in which physicians should consider a formal consent process. One example is the trend toward sterilization of devices originally marketed for single-use in the operating room. A reprocessing industry has emerged that collects single-use products—such as laparoscopic trocars or skin staplers—sterilizes, and returns them to the hospital for reuse [3]. The process is inherently safe and does not pose any additional risk to the patient on whom the product is reused. These products, however, are being used in a way not originally intended. An argument can be made that patient consent must be sought specifically for reuse of these products and that they be allowed to opt out. This would make recycled products less attractive to hospitals and would severely hamper an important effort to make our hospitals “green.”

In sum, as hospitals move toward environmentally sound practices, the public must be educated about the safety of new “green” products. This education may take various forms, but without it the public is unlikely to accept alternatives that, at first blush, seem to put them at risk. There is no legal or ethical requirement, however, that physicians adhere to a patient’s request to use single-use products. A physician does not violate any duty to a patient by enforcing green policies in a practice.

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References

1. Hoffman JM. Think “RECYCLE” for medical products. Medical Design News. June 5, 2003.
2. Health Care Without Harm. Medical waste. http://www.hcwh.org. Accessed April 27, 2009.
3. United States Government Accountability Office. Reprocessed single-use medical devices. 2008. http://www.gao.gov/new.items/d08147.pdf. Accessed April 27, 2009.

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Louise P. King, MD, JD, is a third-year resident at Parkland Memorial Hospital in Dallas, in obstetrics and gynecology. Prior to becoming a physician, Dr. King specialized in constitutional and criminal law and legal concerns of indigent individuals.

Acknowledgment

I wish to acknowledge the valuable comments and insights of my colleague Blake E. Frieden, MD.

Commentary 2

by Janet Brown

Hospital mission statements emphasize healing environments, community, wellness, respect, and quality care. Yet, in the process of providing that care, hospitals simultaneously have a negative impact on human health and the environment through intensive energy and water consumption, use and disposal of toxic materials, and waste headed to landfills and incinerators. With the increased understanding of man’s impact on global climate and public health, physicians and health care administrators must demonstrate leadership in addressing health care’s role in environmental sustainability [1].

Over the last several decades, numerous reusable medical devices have been replaced with disposable ones in the name of infection control and ease of use. These decisions are coming back to bite us in the form of reduced landfill space and overuse of red bags—disposal of which costs at least five times more than disposal of nonregulated or regular waste. The sheer volume of waste has prompted health care professionals to look closely at inefficient practices and consider the value of going back to reusables in a number of areas—sharps containers, dishware, drapes, isolation gowns, and hard cases for sterilizing instruments, to name a few. Hospitals are working to reduce red-bag waste generation through staff education, standardized receptacles, and signage, and to cut the overall volume of waste through decreased use, reuse, and recycling.

Waste regulations and segregation practices have sometimes been based on perceived risk associated with a certain item, device, or practice, and not on science. This is precisely why, in the early 1990s when medical waste washed up on the eastern shores, IV bags were regulated in certain states and had to be handled as potentially infectious—not because they were infectious—but because they resembled blood bags. It proved to be a huge mistake costing hospitals hundreds of thousands of dollars to treat noninfectious wastes as if they were potentially harmful. Several years later, this perception-based regulation was changed to reflect scientific reality, but these poor habits have persisted in many facilities, where unnecessary red bagging is commonplace.

Health care professionals are in the best position to demonstrate their leadership through evidence-based approaches in sustainability initiatives and by correcting misinformation. In some cases, where scientific evidence is not yet available or difficult to study (for example, acceptable levels of exposure to multiple chemicals or the timing of fetal exposure), facilities are urged to take the precautionary approach [2]. The Precautionary Principle presumes an ethical imperative to prevent rather than merely treat disease, even in the face of scientific uncertainty. This principle can be understood as: “when an activity raises threats of harm to human health or the environment, precautionary measures should be taken even if some cause and effect relationships are not fully established scientifically” [3].

In the case at hand, Ms. Chen is concerned about the possibility of infection from a reusable speculum. Dr. Patel can step in here to educate her on the safety and environmental benefits of reusable medical device use. Dr. Patel could ask the facility sustainability officer, safety director, or infection-control practitioner to demonstrate the sterilization or high-level disinfection of the reusable speculum recommended by the Centers for Disease Control and Prevention’s Guideline for Disinfection and Sterilization in Healthcare Facilities. Cold-sterilant and high-level disinfectant manufacturers back up their disinfection claims through rigorous study and offer quality assurance controls through protocol of staff training, cleaning and disinfection, and other quality control measures [4]. The quality assurance protocol includes infection control with standardized methodology, staff training, posted policies, verification testing, and periodic, unannounced inspections by safety and infection-control staffers. Joint Commission (on Accreditation of Healthcare Organizations) inspections often include a close review of protocol, including staff interviews and documentation review.

Taking a leadership role on sustainability does not mean cutting corners on safety, quality, or infection control. A diverse team with clinician participation considers all criteria for sustainability interventions, and implementation is preceded by pilot testing, evaluation, policy development, research review, and sign-off from leadership.

Some physicians are not fully engaged with the specific environmental sustainability programs in their health care facilities. “Higher-ups,” for example, sometimes don’t enforce basic training requirements and participation in sustainability programming for all staffers, so a physician may not receive specific training on recycling or red-bag segregation. Health care delivery is a complex organism, and the more engaged staffers (on every level) are in sustainability, the faster and stronger it develops and the more embedded it becomes in the culture of the organization. Having a separation between clinicians and other staffers creates a barrier that can lead to regulatory compliance violations, safety concerns, and reduced morale on the part of other staffers. When it comes to participation in sustainability programs, no one should have an opt-out clause.

Support staffers tend to feel greater respect when physicians and other clinical leaders take that extra step to maintain a safe and healthy environment. An individual who drops a needle should bend down and pick it up and properly discard it in a sharps container even if that individual is the division chief. A person who is rushing down a stairwell and tempted to drop disposable gloves on the ground should hold onto the gloves until a waste receptacle is found. Someone in a hurry after treating a patient at the bedside and tempted to leave the disposable kit with blood-stained material on the table for someone else to clean up should resist the urge. The generator of the waste material should be responsible for its proper segregation into the appropriate containers. Following these guidelines will go a long way in setting a tone of environmental excellence and respectful work environments. The next time someone complains, “Well, those doctors won’t participate”—someone will speak up, “Yes they will; they’re on board and want to participate.”

While new medical students may not feel powerful as they venture into the health care environment, they are the future of health care and have a voice and role in clinical leadership on sustainability. Clinical support of green building, energy and water conservation, and toxicity- and volume-reduction programs can help propel the initiatives to a new level. Clinical leadership has led to elimination of toxic cleaning chemicals and support for building with LEED certification as a goal. It can give a program the push it needs to attract the attention of senior leadership and help connect action with public health; purchasing with disease; materials with air quality; and management with illness.

Often staffers accustomed to a pre-ecoconscious work environment are the most difficult to convince, which is why the incoming clinicians are critical to the mission with their commitment to responsible procurement, training, use, and management of equipment and materials. The next generation of clinicians has greater knowledge of environmental sustainability and eco habits well established in their homes and personal belief systems; they will infuse health care with the enthusiasm, commitment, and determination it needs to move the entire sector.

How do these committed clinicians know where their facility falls on the greening spectrum, where to start, and what to do next? One option is the Green Guide for Health Care, a self-certifying toolkit that steers facilities through greener design, construction, and operations [5]. A project of the Center for Maximum Potential Building Systems, Health Care Without Harm, and Practice Greenhealth, the toolkit breaks greening the landscape into manageable chunks. Facilities can use this toolkit to assess where they are and plot their course to improvements over the long term. Version 3, currently in development, strives to identify the restorative visioning of health care. Concepts like restoring ecosystems; zero waste; renewable energy; collecting rain water; toxin-free purchases, building materials, furnishings, and finishings; and hosting farmers’ markets are part of this future. More and more hospitals and health systems are realizing the value of naming a sustainability officer to lead environmental activities. The activities are steered by a diverse committee—where clinical leadership is a must.

Physician leadership, knowledge, education, and ability to leverage authority are critical to environmental sustainability in health care. Increased physician involvement will help as we progress from a policy of “doing less harm” to one of “healing communities.”

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References

1. Intergovernmental Panel on Climate Change. Climate change 2007: synthesis report. Summary for policymakers. http://www.ipcc.ch/pdf/assessment-report/ar4/syr/ar4_syr_spm.pdf. Accessed December 3, 2008.
2. Raffensperger C, Tickner J, Jackson W. Protecting Public Health & the Environment: Implementing the Precautionary Principle. Washington, DC: Island Press; 1999.
3. Rutala WA, Weber DJ; Healthcare Infection Control Practices Advisory Committee. Guideline for disinfection and sterilization in healthcare facilities, 2008. http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/Disinfection_Nov_2008.pdf. Accessed May 5, 2009.
4. Ashford N, Barrett K, Bernstein A, et al. Wingspread statement on the precautionary principle. 1998. www.gdrc.org/u-gov/precaution-3.html. Accessed May 5, 2009.
5. Green Guide for Health Care. About the Green Guide for Health Care.http://www.gghc.org/about.cfm. Accessed May 6, 2009.

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Janet Brown is the director of sustainable operations for Practice Greenhealth, a membership-based nonprofit organization that helps hospitals improve their environmental performance. Ms. Brown is a member of the steering committee of the Green Guide for Health Care and the planning committee of CleanMed.

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Hospitals and “Used Goods, June 2009

Update on Affordable Healthcare Choices Act (20/220)

Dear Medical Students,

Given our continued commitment to find solutions to help our medical students, resident physicians, and young physicians to better manage their high student loan debt burden, on June 23, 2009, the AMA advocated support for Sen. Richard Burr's amendment to the Senate Health, Education, Labor and Pensions (HELP) Committee's health care reform bill, “Affordable Health Choices Act,” which would restore the debt-to-income pathway (20/220 pathway).

The 20/220 pathway is the economic hardship loan deferment program that many medical residents have relied upon during their initial years of residency, which is scheduled to sunset on July 1, 2009. On June 24, Sen. Burr's amendment passed by voice vote with the support of Acting Chairman Chris Dodd (D-CT), a long time supporter of alleviating medical student debt. This is significant because without Senator Dodd's support, this amendment would not have passed. The reinstatement of the 20/220 pathway loan deferment program is now part of the “Affordable Health Choices Act" that is making its way through Congress. While this bill is unlikely to become law in its current form, we will continue to advocate that any final health care reform bill include significant debt relief provisions, including 20/220 pathway.

Read the letter to Sen. Richard Burr.

Sincerely,


Hans Arora, Chair

Vital Signs Running Out of Life's Blood

A dying patient faces a dropping blood count—and a faith that forbids transfusions.

by H. Lee Kagan

From the June 2009 issue, published online May 28, 2009

Jake’s prostate cancer, diagnosed 16 years earlier, was finally catching up with him. Surgery and radiation therapy, then hormonal treatments and a series of investigational drugs, had each worked for a time. But lately nothing seemed able to stop the relentless growth of his tumor.

It hadn’t spread to his bones, as is common with advanced prostate cancer. Instead there was a progressive increase in size. The tumor had filled much of the space inside Jake’s bladder, blocking the flow of urine through the urethra. His urologist had had to rearrange his plumbing, surgically diverting the ureters (the tubes connecting the kidneys to the bladder) away from his bladder and out through his abdominal wall to a bag that collected his urine. A plastic tube had also been placed in his now-nonfunctional bladder, draining any secretions out to another bag. Despite all this, 90-year-old Jake remained robust and fully in command of his business, a successful manufacturing company.

But now there was a new threat: bleeding. It had started as a small, intermittent trickle a couple of weeks earlier and grown into a persistent ooze through the tube from his bladder. The tumor, laced with its own network of blood vessels, was seeping blood. Here in the emergency room Jake looked ghostly pale. The continuous blood loss had pushed his hemoglobin count down to 6 grams per deciliter, a dangerously low level (the normal count for an adult male is 14 to 16). Hemoglobin plays a key role in oxygen transport, and when it gets low enough, the body’s organs and tissues become starved for the oxygen carried by the red blood cells. Whole systems begin to malfunction. Your brain gets foggy, your heart struggles to pump blood, and you feel too weak even to stand up. If your hemoglobin remains low enough for long enough, your heart gives out and you die.

“Can’t the surgeon just remove the tumor?” Jake’s wife wanted to know. We were standing outside his ER cubicle. I reminded her that her husband had already had two operations that left scarring in his pelvis. The radiation treatments had probably injured the adjacent normal tissue, and the growing cancer had no doubt affixed itself to a lot of vital structures. Trying to remove the tumor would be a surgical nightmare fraught with peril, including more bleeding. “With his hemoglobin this low,” I told her, “he’ll never make it off the operating table—not without transfusions.”

We looked at each other and shared the recognition of how grim the situation was. Jake and his wife were committed Jehovah’s Witnesses. Even though he was facing a life-threatening hemorrhage from an inoperable tumor, he would not accept any blood transfusions. The nurse came out to tell us that Jake had passed more blood. I went in to talk with my patient.

Jehovah’s Witnesses adhere to a proscription against the transfusion of any blood products. According to their interpretation of passages from the Old and New Testaments, whole blood as well as blood cells (red, white, and platelets—the latter essential for blood clotting) and plasma (the liquid portion of whole blood) may not be transfused. This admonition is often traced to a passage from Leviticus: “You must not eat the blood of any sort of flesh.” Although this core article of faith is regarded as controversial by outsiders and even by some members of the religion, it has been credited with helping to promote advances in transfusion-free surgery.

When I finished apprising him of the situation, Jake said, “I’ve had a good life, Doc. Hell, I don’t want to die, but if it’s my time, it’s my time. Do what you can.” He smiled. He knew very well that his life hung in limbo, but he remained firm in his beliefs. And I understood that my role as his physician was not to try to steer him away from the tenets of his religion. I smiled back and said, “I always do, my friend. Hang in there.”

As I left the room, I shook my head in admiration of a man ready to bleed to death for his faith.

Our treatment options were limited, but there were options. The first, surprisingly, was formaldehyde. As an embalming agent, the chemical cauterizes tissue by cross-linking proteins; that is what gives embalmed tissue its feeling of firmness. In medical treatment, formaldehyde can occlude the spiderweb of tiny blood vessels crisscrossing the surface of prostate tumors. Instilling a dilute solution of the chemical directly into Jake’s bladder and bathing the tumor surface with it might halt the steady seepage of blood. Since virtually none of the instilled chemical is able to escape into the rest of the body, there is no toxicity.

Another option hinged on the fact that while the bloodstream stands ready to form clots wherever needed to limit bleeding, it is also constantly breaking down existing clots as wounds heal. Within the circulating blood, therefore, there is a dynamic balance between the formation and dissolution of clots. Substances released by some tumors, including prostate cancer, enhance clot-busting and thus promote bleeding. A medication known as aminocaproic acid, or Amicar, inhibits the activation of the clot-dissolving system, tipping the balance back toward clot formation. Giving Jake Amicar might be another way to stop his life-threatening ooze.

By the time Jake arrived in the intensive care unit, the nurses were ready to start administering formaldehyde and an intravenous drip of Amicar, both ordered by the consulting urologist. The following morning I was pleased to note that the bladder tube drainage was only faintly blood-tinged—a good sign. Jake’s hemoglobin count, however, had dropped to 5.6. I knew he was tough, but this was like asking him to climb Everest without oxygen. We were giving him oxygen, of course, but without red blood cells to carry it to where it was needed, the benefits were limited.

Climate Change and Human Health 101

Kristie L. Ebi, PhD, MPH

Climate change poses real health risks for U.S. populations [1]. Through rising temperature, changes in the hydrologic cycle, and sea level rise, climate change is projected to increase the frequency and intensity of heat waves and other extreme weather events (including floods and droughts); alter the geographic range and incidence of climate-sensitive vector-, food-, and waterborne diseases; increase diseases associated with air pollution and aeroallergens; and add to malnutrition in many regions. Often not the sole cause of increases in the burden of climate-sensitive health outcomes, climate change interacts with other public health stresses.

LEARNING OBJECTIVELearn about the major new health risks to humans brought on by climate change.

Understanding the full range of the health risks of climate change is beyond the scope of this article; for more information, the reader is referred to assessments recently conducted in the United States, Canada, and internationally or to a publication from the Ontario College of Family Physicians aimed at educating family physicians on climate change and health issues [1-4]. Many of these health risks—such as cardiorespiratory illnesses associated with or exacerbated by elevated concentrations of ground-level ozone or injuries and deaths from windstorms and floods—are familiar to most health care professionals. Other risks, however, could challenge health care professionals if unfamiliar climate-sensitive health outcomes become more common, change their distribution, or reemerge.

Greenhouse Gases

The uneven warming of the Earth’s surface is the principal driving force for weather and climate, with complex and changing atmospheric and oceanic patterns redistributing solar energy from the equator to the poles. Atmospheric greenhouse gases (including water vapour, carbon dioxide, methane, nitrous oxide, and halocarbons) absorb and reradiate back to the surface some of the solar radiation emitted by the Earth, raising the surface temperature considerably. Increasing the atmospheric concentrations of greenhouse gases will cause further warming.

Carbon dioxide is a central anthropogenic greenhouse gas. It is not destroyed chemically but removed from the atmosphere through multiple processes that transiently store the carbon in land and ocean reservoirs and ultimately in mineral deposits [5]. Natural processes currently remove about half the incremental anthropogenic carbon dioxide added to the atmosphere annually. The balance is removed over 100 to 200 years [6]. This inertia in the climate systems means the Earth will inevitable endure decades of climate change, even with aggressive reduction of greenhouse gas emissions. About 75 percent of the anthropogenic carbon dioxide emissions to the atmosphere during the past 20 years were due to fossil fuel burning, with most of the rest due to land-use change, especially deforestation [5].

Over the past 100 years, the global average surface temperature rose by 0.74 degrees C, with most of the warming attributable to human activities and with the 1990s being the warmest decade [5]. The linear warming trend over the past 50 years (0.13 degrees C per decade) is nearly twice that for the last 100 years. Under a range of scenarios of greenhouse gas emissions, the global mean surface temperature is projected to increase by 1.1 to 6.4 degrees C by 2100. The projected rate of warming is much greater than the observed changes during the 20th century and is very likely to be without precedent during at least the last 10,000 years.

Heat Waves

The risk of heat waves is generally not well appreciated by the health care community or the public. Heat is the major weather-related cause of death in the United States. From 1999 to 2003, 3,442 reported deaths resulted from exposure to extreme heat, 66 percent of them males [7]. Cardiovascular disease was recorded as the underlying cause of death in 57 percent of cases in which hyperthermia was a contributing factor. Approximately 70 percent of these heat-related cardiovascular deaths occurred among people with known chronic ischemic heart disease. Other underlying causes of heat-associated death included unintentional poisonings in 29 percent of deaths; endocrine, nutritional, and metabolic disorders in 3 percent of deaths; and all other underlying causes, including infection and psychiatric disorders, in 11 percent of deaths. The state with the highest average annual hyperthermia-related death rate was Arizona (1.7 deaths per 100,000 population), followed by Nevada (0.8), and Missouri (0.6). During the 2006 heat wave in California, heat-related emergency department visits increased more than sixfold and hospitalizations increased more than tenfold [8].

About 40 percent of heat-related deaths occur in adults over the age of 65 [7]. Members of this population are more vulnerable because of intrinsic changes in their thermoregulatory systems and the use of drugs such as diuretics, stimulants, beta-blockers, anticholinergics, digitalis, barbiturates, and others that interfere with normal homeostasis [9]. In addition, age correlates highly with increasing illness, disability, and reduced fitness, all of which heighten vulnerability to heat.

Simply informing individuals that they are at greater risk during a heat wave is insufficient. As homeostasis is impaired, the elderly may not be aware that they are becoming ill and therefore may not take appropriate actions to reduce their heat exposure. A survey of adults over the age of 65 in four cities (Dayton, Ohio; Philadelphia; Phoenix; and Toronto, Canada) found that 90 percent were aware that a heat wave early warning had been issued within the previous week, and approximately three-quarters could name at least one action they should have taken to reduce their heat-related risk—yet less than 50 percent actually changed their behavior [10]. The health care community should develop more active outreach to those at increased risk during heat waves, in conjunction with local public health and meteorological departments and services.

Infectious Diseases

Increasing temperatures and changes in the hydrologic cycle provide opportunities for many pathogens and vectors to change their geographic range, replication rate, and transmission dynamics. Climate is a primary determinant of whether a particular location has the environmental conditions suitable for the transmission of several vector-borne diseases, including dengue fever, St. Louis encephalitis, and West Nile virus. A change in temperature may hinder or enhance vector and parasite development and survival, thus lengthening or shortening the season during which vectors and parasites survive. Small changes in temperature or precipitation can cause previously inhospitable altitudes or ecosystems to become conducive to disease transmission (or cause currently hospitable conditions to become inhospitable).

For example, a retrospective review of three independent patient databases in Alaska reported a statistically significant trend in the number of patients seeking care for insect reactions over 14 years [11]. Fairbanks had a fourfold increase in patients in 2006 compared to the 1992 to 2005 period, and Anchorage had a threefold increase between the 1999 to 2002 and 2003 to 2007 periods. A review of the Alaska Medicaid database from 1999 to 2006 also showed statistically significant growth in medical claims for insect reactions in five of six regions, with the largest percentage increases occurring in the most northern areas. Since 1950, average annual and winter temperatures in Alaska rose 3.4 degrees F and 6.3 degrees F, respectively. Average winter temperatures increased at least 6 degrees F in regions that reported a significant rise in bite or sting events, leading the authors to conclude that warmer temperatures may have been a contributing factor.

Climate change also may facilitate the emergence of infectious diseases. For example, Vibrio parahaemolyticus, the leading cause of seafood-associated gastroenteritis in the United States, is typically associated with the consumption of raw oysters gathered from warm-water estuaries. In 2004, an outbreak occurred in Alaska where the consumption of raw oysters was the only significant predictor of illness; the attack rate among people who consumed oysters was 29 percent [12]. All oysters associated with the outbreak were harvested when mean daily water temperatures exceeded 15.0 degrees C (the theorized threshold for the risk of V. parahaemolyticus illness from the consumption of raw oysters). Between 1997 and 2004, mean water temperatures in July and August at the implicated oyster farm increased 0.21 degrees C per year; 2004 was the only year during which mean daily temperatures did not drop below 15.0 degrees C. The outbreak extended by 1,000 km the northernmost documented source of oysters that caused illness due to V. parahaemolyticus. Rising temperatures of ocean water may have contributed to one of the largest known outbreaks of V. parahaemolyticusin the United States.

Conclusion

The inherent inertia in the climate system implies that climate will continue to change for decades after significant reductions in greenhouse gas emissions are achieved, committing future generations to increasing climate-related health risks. Basic understanding of climate change and its potential health impacts should be included in training and professional development courses for health care professionals to reduce current and projected injuries, illnesses, and deaths due to climate-sensitive health outcomes.

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References

1. Ebi KL, Balbus J, Kinney PL, et al. Effects of global change on health. In: U.S. Climate Change Science Program and the Subcommittee on Global Change Research. Analyses of the Effects of Global Change on Human Health and Welfare and Human Systems. Washington, DC: US Environmental Protection Agency; 2008: 51-99.
2. Furgal C. Human Health in a Changing Climate: A Canadian Assessment of Vulnerabilities and Adaptive Capacity. Ottawa, ON: Health Canada; 2008.
3. Parry ML, Canziani OF, Palutikof JP, van der Linden PJ, Hanson CE, eds.Climate Change 2007: Impacts, Adaptation and Vulnerability. Contribution of Working Group II to the Fourth Assessment Report of the Intergovernmental Panel on Climate Change. Cambridge, UK: Cambridge University Press; 2007.
4. Ontario College of Family Physicians. Addressing the health effects of climate change: family physicians are key. 2008. http://www.cfpc.ca/ local/files/Addressing%20the%20Health%20Effects%20of%20Climate %20Change%20Family%20Physicians%20are%20Key%20 April%207,%202008.pdf. Accessed April 28, 2009.
5. Intergovernmental Panel on Climate Change. Summary for policymakers. In: IPCC. Climate Change 2007: The Physical Science Basis. Contribution of Working Group I to the Fourth Assessment Report of the Intergovernmental Panel on Climate Change. New York, NY: Cambridge University Press; 2007.
6. National Research Council Division on Earth and Life Studies Board on Atmospheric Sciences and Climate Committee on Climate, Ecosystems, Infectious Disease, and Human Health. Under the Weather: Climate, Ecosystems, and Infectious Disease. Washington, DC: National Academy Press; 2001.
7. Centers for Disease Control and Prevention. Heat-related deaths—United States, 1999-2003. MMWR Morb Mortal Wkly Rep. 2006;55(29);796-798.
8. Knowlton K, Rotkin-Ellman M, King G, et al. The 2006 California heat wave: impacts on hospitalizations and emergency department visits. Environ Health Perspect. 2009;117(1):61-67.
9. World Health Organization. Heat-waves: risks and responses. 2004. http://www.euro.who.int/document/e82629.pdf. Accessed April 28, 2009.
10. Sheridan SC. A survey of public perception and response to heat warnings across four North American cities: an evaluation of municipal effectiveness. Int J Biometeorol. 2007;52(1):3-15.
11. Demain JG, Gessner BD, McLaughlin JB, Sikes DS, Foote JT. Increasing insect reactions in Alaska: is this related to climate change? Allergy Asthma Proc. In press.
12. McLaughlin JB, DePaola A, Bopp CA, et al. Outbreak of Vibrio parahaemolyticus gastroenteritis associated with Alaskan oysters. N Engl J Med. 2005;353(14):1463-1470.

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Kristie L. Ebi, PhD, MPH, is executive director of the Technical Support Unit for Working Group II: Impacts, Adaptation, and Vulnerability, of the Intergovernmental Panel on Climate Change. Dr. Ebi has conducted research on the impacts of and adaptation to climate change for more than a dozen years, specifically extreme events, thermal stress, food-borne safety and security, and vector-borne diseases. She has worked with the World Health Organization, the United Nations Development Programme, USAID, and others to implement adaptation measures in low-income countries. She has edited four books on aspects of climate change and has more than 80 publications. Dr. Ebi’s scientific training includes a master’s degree in toxicology and master’s and doctorate degrees of public health in epidemiology, and two years of postgraduate research at the London School of Hygiene and Tropical Medicine.

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Medicine’s Role in Mitigating the Effects of Climate Change, June 2009

How doctors can spot lies or head them off

If a physician can establish a rapport with a patient and phrase questions well, it's easier to elicit the truth.

By Karen Ravn of the LA Times
June 8, 2009

Doctors don't want to be hoodwinked by their patients, and Paul Ekman, professor emeritus of the UCSF Medical School and author of the 2001 book "Telling Lies" and inspiration for Fox's "Lie to Me" series,has spent more than 20 years teaching them how to avoid that fate. One of the things he tries to teach: Whenever people try to repress or conceal emotions, micro-expressions -- lasting only a fraction of a second -- flash across their face. It's impossible to fake micro-expressions, he says, but it's very possible to recognize them and thus tell when people are lying.

The same methods he's taught to thousands of medical professionals are now available on his website -- paulekman.com -- and anyone can learn them in an hour, he says.

But even better than identifying lies once they've been told is preventing them in the first place, says Dr. Jeff Rabatin, co-director of the communication in healthcare program at the Mayo Clinic in Rochester, Minn.

To do that, "It's important to establish rapport, so the patient really feels comfortable telling the truth," Rabatin says. "Then we can be partners and work together."

Dr. Robert Klitzman, professor of clinical psychiatry at Columbia University, says doctors can encourage honesty just by asking the right questions to draw them out.

A "don't ask, don't tell" policy, Klitzman adds, isn't productive for doctor-patient relationships. If the doctor doesn't ask about sensitive topics, it's unlikely the patient will volunteer information about them.

Just as important as the questions doctors ask is the way they phrase them. For instance, "Don't say, 'What do you mean you're not taking your meds?' " Klitzman recommends. "Instead say, 'It's great that you're taking your meds half the time. How can we increase that?' "

Doctors need to remember that sometimes patients take a long time working up the nerve to say something. "The doctor may think a conversation is over," Rabatin says, "when the patient says, 'Oh, by the way. . . . ' And it's only then that the doctor finds out the main reason the patient even came. . . . It's better to get that information up front, and it can be done with the proper skills."

The Mayo Clinic, USC and other facilities teach these skills using so-called "standardized patients" -- specially trained actors with medical knowledge. (Read more about them at www.mayo.edu/simulationcenter/documents/SimulationVideoClips.html and mededonline.usc.edu/sp.html.

Doctors who've been through the training at the Mayo Clinic simulation center say they really do feel as if there's an actual patient in front of them, Rabatin says. Their practice sessions are videotaped so they can watch themselves and also be critiqued on how they did.

But overall, with the trend toward specialization in medical training these days, communication skills may be getting short shrift, says Dr. Howard Brody, director of the Institute for the Medical Humanities at the University of Texas Medical Branch in Galveston, Texas. Then there's the problem of increasingly rushed doctors' visits. "In the future," Brody says, "you might not have a doctor you can go to who can sit down and really talk to you."

Body of lies: Patients aren't 100% honest with doctors

When patients aren't truthful, misled doctors may give a wrong diagnosis or treatment.

By Karen Ravn of the LA TimesJune 8, 2009

Bill Moore of Pacific Grove was barely in his 20s when he found out he had cholesterol trouble.

This was bad news for Moore because his father had died of a heart attack at 45 and because, as he told his doctor, Moore was eating all the right stuff.

The doctor prescribed cholesterol-lowering medication, and a subsequent test showed the drug was working very well. Too well.

His doctor was very surprised, Moore says. "I told him I must be unique. I must have a unique body composition." But the truth was Moore had fed his doctor a false written record of his eating habits before beginning the drug -- reporting vegetables and salads that had never been on his menu, and not reporting all the hamburgers and pizzas that had.

Only when he started on the cholesterol drug did he finally begin eating the way he'd been claiming to eat all along. It was that change combined with the drug that made his cholesterol levels plunge.

Inaccurate information can do more than confuse a doctor. It can lead to misinterpreted symptoms, overlooked warning signs, flawed diagnoses and treatments -- potentially endangering a patient's health, even life.

Still, doctors know that at least some of the time, at least some of their patients overstate, understate, embellish, omit, or otherwise stray from a straight and thorough reporting.

"Everybody lies at some point," says Dr. Sharon Parish, a professor of clinical medicine at Albert Einstein College of Medicine in New York City who practices at Montefiore Medical Center. They do it out of embarrassment, to please the doctor, to avoid a lecture.

But doctors and patient advocates agree that in most cases, when patients lie, they're pretty much asking for trouble. Even when telling the truth is unappealing, "getting into a lying relationship with your physician is really far more perilous," says Peter Clarke, director of the Center for Health and Medical Communication at USC and co-author of the 1998 book "Surviving Modern Medicine."

An early lesson

That patients lie is one of the basics doctors learn in medical school. Of 1,500 responders to a 2004 online survey by WebMD, 45% admitted they hadn't always told it exactly like it was -- with 13% saying they had "lied," and 32% saying they had "stretched the truth."

Not included in those figures would be patients who "lie" without knowing they do so by withholding information because it slips their mind or they have no idea it could be useful. (Maybe Aunt Agnes would gladly tell about the time she snored so loud she woke the neighbors if she knew that a diagnosis of sleep apnea could depend on it.)

In the WebMD survey, 38% of respondents said they lied about following doctors' orders and 32% about diet or exercise. Doctor reports bear this out.

"Patients are strongly motivated to have their doctors think they're good patients," says Dr. Steven Hahn, professor of clinical medicine at Albert Einstein College and an internist at Jacobi Medical Center in New York City.

It's hard to make a good impression when you're on an examining table in a flimsy, open-backed gown -- a fact that might make lying that much more tempting. But even fully clothed, talking face to face across a desk, a patient cedes authority to the doctor. And people generally like to please those in authority, says Emanuel Maidenberg, clinical professor of psychiatry at UCLA.

Patients also are prone to lying about the fact that they engage in social taboos, things their doctor might not approve of. In the WebMD survey, 22% lied about smoking, 17% about sex, 16% about drinking and 12% about recreational drug use.

"When you're studying psychiatry, you're taught that if a patient says, 'I use cocaine once a month,' you figure it's twice a month," says Dr. Robert Klitzman, professor of clinical psychiatry at Columbia University. "We were taught to double."

Patients lie because they don't want to be judged, embarrassed or misunderstood. They lie about pursuing alternative health remedies because they disagree with their doctor or because they think an item is none of their doctor's business.

Doctors, of course, make the case that even deeply personal matters such as sexual orientation or having an extramarital affair can affect the care doctors give (how to interpret symptoms, what tests to order, exams that might be important). Patients may see only unpleasant invasions of their privacy -- and a risk that somehow their co-workers, parents or spouses will find out too.

"We live in complex social webs," Klitzman says. "Someone will see the forms. . . . People talk."

But co-workers, parents and spouses aren't the only threats hanging over a patient's head. Health insurance is another. And so -- not surprisingly -- sometimes people lie in order to keep something out of their medical records or out of the hands of their insurance companies.

That can be of genuine concern, say doctors and patient advocates. What happens in the doctor's office doesn't always stay in the doctor's office.

Anything and everything health-related that patients tell their doctors is supposed to go into their medical records. That information is confidential, protected under the federal Health Insurance Portability and Accountability Act.

But in fact, it's only confidential until it isn't.

Whenever patients apply to buy individual insurance policies, and whenever they file claims under policies they own, the insurance company can request their medical records.

Patients can refuse to release the records, but if they do, the company can refuse to sell them a policy or refuse to pay claims. This is part of the deal patients agree to by signing on to the insurance contract.

And it doesn't take much in a patient's records to nix the sale of a policy. "A case of acne can do it," says Jerry Flanagan, an advocate with the Foundation for Taxpayer and Consumer Rights.

And there are other insurance complications. If, when processing a claim, the insurance company finds something in a patient's records that contradicts something the patient said when purchasing the policy, the company can retroactively cancel the policy, Flanagan says. Then it can demand reimbursement for any claims it has already paid -- even if those claims had nothing to do with the reason for canceling the policy.

"I would never advocate lying to your doctor," Flanagan says, "but I can definitely understand why someone might."

Dr. Ken Duckworth, medical director of the National Alliance on Mental Illness, suggests one scenario in which it might be tempting to lie. Say someone learns from a gene testing company that she is carrying a gene that puts her at risk for a disease for which there is no treatment or prevention. Then, he says, "it could be in a patient's interest to conceal that information."

Arthur Caplan, director of the Center for Bioethics at the University of Pennsylvania in Philadelphia, cites yet another hypothetical: Say a patient feels deserving of coverage for a certain condition or treatment, but his symptoms don't quite fit the insurance company's requirements. The patient might adapt the description of his symptoms to qualify for coverage, "and that might arguably be defensible or excusable."

Accuracy is vital

Sometimes, a doctor may be willing to help by overstating a patient's case.

In 1997, Dr. Victor Freeman, then a primary care research fellow at Georgetown University Medical Center, asked 167 internists across the country what doctors should do if one of their patients was at first turned down for coverage of a treatment that was medically indicated.

Almost half -- 45% -- said it was ethical to lie in order to get coverage for the patient. The more serious the condition, the more doctors said lying was appropriate: 57% when bypass surgery was at stake for a patient with severe angina or chronic atherosclerosis; 47% when the issue was comfort care for a patient with terminal ovarian cancer causing abdominal pain and extreme nausea; 32% when a patient with severe depression was seeking a psychiatric referral.

At other times, a doctor may be willing to help by leaving things out of a patient's record.

Dr. Howard Brody, director of the Institute for the Medical Humanities at the University of Texas Medical Branch in Galveston, Texas, suggests patients talk to their doctors if they have symptoms or conditions they fear could disqualify them for insurance coverage.

"There may be times when a doctor will agree to not put it on [record]," he says.

"But that's very iffy. It's not good medical practice as a rule."

Clarke suggests patients have two sets of medical records, a private one between patient and doctor and another for sharing with others.

"The solution is not to lie to your physician but to establish private records that won't be released to third parties," he says. "If your physician won't do that, it's reason enough to leave the physician."

Short of changing to a healthcare system where insurance companies can't refuse to sell anyone a policy because of a health condition -- which he favors -- Flanagan says there's no ideal solution for some patients.

Even so, most doctors, ethicists and patient advocates think it's a bad idea to lie to a doctor, although they all see reasons why patients might want to -- and even scenarios where a lie might be justified.

Some ethicists consider it a moral obligation for patients to tell the truth to their doctors, Brody says. In establishing a patient-doctor relationship, the first step is to take a thorough medical history.

"None of the rest makes any sense without an accurate history to guide you," he says.

Lying about what you eat, how much exercise you get or whether you're taking your medication as prescribed may seem benign but can be hazardous. If it seems you've been doing everything right, and your condition still isn't improving, the doctor could change your current treatment plan to something more serious and invasive -- and unnecessary.

As for embarrassment, perhaps patients worry too much about what their doctors think of them.

"Doctors have heard it all," Klitzman says. "They've seen it all."

In other words: Get over yourself.