Daily Archives: November 11, 2015

Do clothes make the MD? What you wear affects patient perceptions

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What should doctors wear? And how does something as simple as their choice of a suit, white coat, scrubs or slacks influence how patients view them? A new analysis takes a comprehensive look – and finds that the answer isn’t as simple as you might think.

The findings were compiled by a University of Michigan Health System team from a comprehensive international review of studies on physician attire, and other sources. In all, the data they reviewed came from 30 studies involving 11,533 adult patients in 14 countries. Their review has been published in British Medical Journal Open.

In total, 21 of the 30 studies found that patients expressed clear preferences about what they felt doctors should wear, or said that physician attire affected their perceptions of a physician. In 18 of those studies, formal attire or a white coat was the preferred attire.

When the researchers drilled down further, they found that four of the seven studies that involved surgery patients reported that attire choice didn’t matter or that scrubs were preferred. The same was true of four of five studies that involved patients receiving emergency care or intensive care.

One size does not fit all

How you feel about your doctor’s attire can depend greatly on your age and culture, the researchers found. In general, Europeans and Asians of any age, and Americans over age 50, trusted a formally dressed doctor more, while Americans in Generation X and Y tended to accept less-dressy physicians more willingly.

Lead author Christopher Petrilli, M.D., an internal medicine resident at the U-M Health System who worked in the sharp-dressed world of investment banking before switching to medicine, says the study grew out of his conversations with senior physicians, including senior author Vineet Chopra, M.D., MSc, and co-author Sanjay Saint, M.D., MPH.

Chopra, a hospitalist and U-M Medical School assistant professor of general medicine, adds that patient satisfaction now influences how doctors, and hospitals are paid – making the impact of patient perceptions of their doctors’ knowledge, caring, professionalism and trustworthiness all the more important.

And, he says, the findings of the new study suggest that a “one size fits all” approach to policies and guidance for doctors won’t work.

“In order to better tailor physician attire to patient preferences and improve available evidence, we would recommend that healthcare systems capture the ‘voice of the customer’ in individual care locations, such as intensive care units and emergency departments,” he says.

What to wear

The subject of what to wear isn’t covered directly in medical school. Even for physicians in practice at hospitals on the U.S. News & World Report Best Hospitals ranking, specific guidelines are few and far between. Only 5 of those surveyed by the U-M team had official guidance for physicians about attire at all, and most just recommended it be “professional.” The others offered no formal guidance.

Currently, the U-M team is preparing to launch their own international study of the impact of physician clothing choices, under the name “Targeting Attire to Improve Likelihood of Rapport” or TAILOR. They’ll work to quantify how patients’ views of physicians change based on what they’re wearing, and where they’re providing care. The team will also evaluate how attire might affect patients’ trust in what that doctor says or recommends.

Hospitals in three countries have signed on to participate, making it the largest such study of its kind. While pediatric patients and their parents will not be included, the researchers note that this is another area ripe for research.

“Everything is supposed to be evidence-based in medicine,” says Petrilli. “With this review and our new study, we can provide compelling evidence to influence the way physicians dress.”

Posi+ive influence Sacral nerve stimulation offers new hope for children with refractory constipation

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From the day Piper Shumar was born, she suffered from constipation. “Her bowel movements were infrequent, and when she did have one it was softball-sized and hurt her terribly, often causing her to bleed,” says Kimberly Shumar, Piper’s mom.

Year after year, Piper’s constipation issues continued.  She also had a hard time gaining weight.  Even with supplemental nutrition, Piper remained chronically constipated as she turned 4 years old.

“Severe, long-term constipation in children needs to be treated aggressively,” says Dan Teitelbaum, MD, pediatric surgeon and director of the Colorectal Pediatric Surgery Program at C.S. Mott Children’s Hospital.  “Because there can be a number of causes for constipation, accurate diagnosis is the first step in either resolving the issue or ruling out more serious causes.”

A search for a cause

In Piper’s case, her original physicians initially believed she may have Hirschsprung’s disease and recommended an ileostomy.  Piper’s parents sought out a second opinion and were referred to Mott Children’s Hospital.

Dan Teitelbaum, M.D.

Dan Teitelbaum, M.D.

The Shumar family met with Dr. Teitelbaum, who performed additional colon biopsies as part of her evaluation.  Rather than an ileostomy, Dr. Teitelbaum and the colorectal team at Mott recommended an appendicostomy, which would allow Piper’s parents to flush her entire colon to evacuate a bowel movement through a tube in her abdomen once a night.

“Appendicostomy has proven to be effective in select children with intransigent constipation that has failed maximum medical treatment,” says Teitelbaum.  “For many children, this has provided significant relief and a better quality of life.”

Once Piper was placed under anesthesia for the appendicostomy, however, her body relaxed and she had a bowel movement.

“That indicated, to me, that Piper’s problem was actually related to a failure to relax her distal rectum and anal sphincters, says Teitelbaum.  “Based on that information, sacral nerve stimulation was a better alternative for Piper.”

Dr. Teitelbaum left the OR and met with the Shumars to discuss his recommendations with the family, who were pleased to hear that about this new, reversible treatment option.

A pacemaker for the sacral nerve

CIC_Color1Sacral nerve stimulation (SNS) therapy uses a small a neurotransmitter, similar to a pacemaker, implanted under the skin in the upper buttock area. The device sends mild electrical impulses through a lead that is positioned close to the sacral nerve to positively influence the rectal sphincters and pelvic floor muscles.

The Colorectal Pediatric Surgery Program at C.S. Mott Children’s Hospital is one of only a few programs in the country with experience implanting sacral nerve stimulators in pediatric patients.

“Nerve stimulation can be particularly effective for select children with refractory constipation or intractable incontinence caused from injury to the sphincteric complex or congenital problems of the anal canal,” says Teitelbaum.

A two-stage procedure

The procedure is performed in two stages, which allows the team to assess improvement in bowel function during an initial procedure before implanting the subcutaneous device.  Both procedures are performed on an outpatient basis, under general anesthesia by a team of surgeons specially trained in SNS placement.

For most patients, the nerve stimulator can remain in place for three to five years before a new battery has to be replaced.  “At that point, we’ll be able to determine if the stimulation has jump started her system to the point where it’s not necessary anymore,” says Teitelbaum.

In Piper’s case, as soon as the nerve stimulator was implanted and turned on, Piper had a bowel movement. Since the surgery, she’s been having regular bowel movements.

“Piper is like a new kid now. She’s eating well, gaining weight and full of energy,” says Mrs. Shumar. “She calls the stimulator her ‘battery’ and says she loves it.”

C.S. Mott Children’s Hospital Colorectal Pediatric Surgery Program

Sacral nerve stimulation is just one of the cutting-edge treatments offered at Mott for patients who have challenging colorectal disorders. The Colorectal Pediatric Surgery Program team specializes in caring for:

  • Imperforate anus/anorectal malformations
  • Cloacal deformities and cloacal exstrophy
  • Hirschsprung disease
  • Rectal prolapse
  • Familial polyposis
  • Inflammatory bowel disease
  • Anal fissure/fistula-in-ano
  • Bowel management for fecal incontinence and constipation

Mott offers advanced colorectal diagnostics, surgical care and post-operative management of children with these challenging problems. The faculty is committed to incorporating new evidence-based surgical and medical techniques and research discoveries. Unlike many pediatric programs that treat just the disease, Mott provides lifelong support and follow-up care for families of children with colorectal disorders.

Learn more about the Colorectal Pediatric Surgery Program at www.mottchildren.org/colorectal.

Breathing life into fragile lungs Ex vivo lung perfusion makes more lungs available for transplant

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Kyle Clark, 25, of Imlay City was a very sick young man when he was admitted to U-M in February. Oxygen therapy was no longer sufficient to keep the effects of cystic fibrosis at bay, so physicians at the U-M Transplant Center moved him along an expedited pathway to join a groundbreaking clinical trial.

The University of Michigan and Gift of Life Michigan, in collaboration with Henry Ford and Spectrum health systems, are the only study

If only 25 percent of the currently unusable lungs were salvaged, it would double the number of available lungs for transplantation

If only 25 percent of the currently unusable lungs were salvaged, it would double the number of available lungs for transplantation

participants in Michigan. The study, which is on the forefront of science and technology, uses ex vivo lung perfusion to optimize lungs for transplantation that might otherwise have been deemed unusable.

Ex vivo perfusion is based on the heart-lung support technology known as extracorporeal membrane oxygenation, or ECMO, which was pioneered at the University of Michigan by Robert Bartlett, M.D., now a professor emeritus of Surgery.

A lung incubator

The study is evaluating the revolutionary XVIVO Perfusion System from Sweden, which has the ability to warm lungs to normal temperature, re-inflate them and allow physicians to recondition and evaluate them for transplant. The environment permits the potential recovery of transiently damaged lungs in a short period of time.

“Think of the XVIVO as an incubator. Right now, our transplant team has a window of about four hours to determine whether lungs are optimized in the XVIVO and are going to be suitable for transplant. But the window of recovery is brief and the transplant must take place soon after. Things moved rapidly for Kyle,” says Rishi Reddy, M.D., one of the U-M transplant surgeons who performed Clark’s transplant. “In the future, I expect improvements will give us more time to assess donated lungs. Perhaps we could have as long as 24 hours for lungs to be reconditioned and implanted.”

In Clark’s case, the donated lungs would not have been suitable but for the recovery process they went through prior to implantation, and he would have remained on the transplant waiting list, losing more of his ability to breathe as each day passed. Instead, he became the first Michigan resident to receive lungs reconditioned in the XVIVO device.

Salvaging lungs to save lives

“Historically, less than 20 percent of organ donors actually have their lungs used to save a life. Often the nature of a donor’s death traumatizes the lungs, even when other organs are usable. For example, lungs may be bruised or punctured from the trauma of an automobile accident,” says Reddy. “But others are unusable because they are transiently injured. Some of these can benefit from the special incubation and reconditioning in the XVIVO device. This means that in the future, there will be more lungs available for transplant, and people on the list could have shorter wait times.”

Reddy anticipates that even if only 25 percent of the currently unusable lungs were salvaged, it would double the number of available lungs for transplantation. And with quicker access to transplantation, fewer people will die while waiting.

Ex vivo perfusion is one of three research approaches to the shortage of donor lungs, and the first to come to market. Organogenesis and stem cell transplants show promise in replacing or repairing damaged lungs but are not yet ready for clinical study.

Collaborating to raise hope

Collaborating to raise hope (sidebar): Transplants using the XVIVO Perfusion System from Sweden currently take place within the framework of an interventional clinical trial studying the safety of recovering marginal donor lungs for implantation. The University of Michigan, Gift of Life Michigan, who purchased the device, and Henry Ford and Spectrum health systems are collaborating in the clinical trial.

The device resides at U-M where its five lung transplant surgeons use the XVIVO device to provide services to the lung transplant programs at Henry Ford and Spectrum, as well as their own. The U-M Transplant Center ™ is the largest and most experienced in Michigan, and one of the largest in the nation. The collaboration among the three transplant centers is unique in Michigan and was done to bring the hope of transplantation to more patients needing this lifesaving surgery.

Get more information about the XVIVO trial at umclinicalstudies.org or visit clinicaltrials.gov and enter identifier: NCT01365429