Category: Doctor-Patient Communication

Research Spotlight: Dr. Noel Brewer

Last week, Upstream Writers were joined by Noel Brewer, PhD, professor of Health Behavior in the UNC Gillings School of Global Public Health and affiliated scholar with UNC’s Interdisciplinary Health Communication program. Dr. Brewer gave an interesting and informative talk about his recent tobacco research involving the effect of cigarette pack messages. His findings showed that pictorial cigarette pack warnings increased smoking quit attempts and 7-day quitting. Additionally, the pictorial warnings were found to work better than text warnings, as they led to more attention, negative affect, social interactions and thinking about the warnings. Finally, because the study’s findings did not fit existing models of health behavior, Dr. Brewer developed the new Tobacco Warnings Model.

Dr. Brewer received his PhD in psychology from Rutgers University and joined the faculty in the Department of Health Behavior at the University of North Carolina at Chapel Hill in 2004. He studies how people make risky health decisions, and he currently directs the UNC Health Cognition & Behavior Lab where he conducts his research. Furthermore, in addition to Dr. Brewer’s tobacco research involving smoking risk communication, his work also focuses on HPV vaccine communication and increasing HPV vaccine uptake, and he currently serves as Chair of the National HPV Vaccination Roundtable. More information about his research can be found here.

In the spirit of Public Health Thank You Day, thank you, Dr. Brewer, for the work that you do to promote and protect public health! 

Electronic Health Records and the Expert Patient

Electronic Health Records (EHR) are becoming more and more common as means for patient engagement. Medical practice has moved from a paternalistic mode of engagement to a mode of engagement that makes the patient active and directly involved. However, this process also demands more of the patients, both in terms of educating themselves and collecting and inputting data into an EHR.

While the goal of the EHR is better patient outcomes, we should think about accessibility. For patients who might not have access to a computer, the internet, or any means of collecting their own health data, it might be impossible to access an EHR or other patient portal. Additionally, patients with low health literacy or health information literacy might struggle to understand the information being provided to or asked of them.

Aside from difficulties directly using the EHR, patients are pushed into an expert patient role through the same attempt at creating active patients. While this might help with patient engagement, the need to gather information about one’s own health, illness(es), and medication(s) increases the burden on the patient. Being an active participant in one’s own medical care, requires labor on the part of the patient.

While this may improve patient outcomes, it might be impossible for many patients to gather additional health information either because they don’t know where to look or don’t have the time to search. The active patient model and the electronic health record are both features of a modern medical practice that require additional labor from patients and focus on an patient with certain means and abilities. Surprisingly, it may well be increasing the health disparities divide.

These are all considerations that practitioners should keep in mind with regard to electronic health records and the demands placed on their patients.

Do you have an Advance Directive?

Everyone deserves the right to make their own decisions about their health. But sometimes we may found ourselves in certain circumstances in which we are unable to do so, such as during a coma, terminal illness, or serious injury. An important way that we can communicate our decisions during these times, however, is by having an “advance directive” in place.

Advance directives are written, legal documents that outline your decisions regarding medical care when you are unable to make them. They assist doctors and caregivers in making medical decisions on your behalf, and they can be written at any age.

There are several types of advance directives:

Health care power of attorney (also called “durable power of attorney for health care” or “health care proxy”). This is a type of advance directive in which you appoint a person you trust to make medical decisions on your behalf when you are unable to do so. This may be a family member, partner, or friend.

Living will. This is a written, legal document that outlines your wishes for certain medical or end-of-life care treatments. These may range from mechanical ventilation to tube feeding, to even organ and tissue donations.

Do-Not-Resuscitate Orders (DNR). This order informs health care providers not to perform CPR if your breathing or heart were to stop.

While advance directives are not required, it may be a good idea to have one in place so that you can have peace of mind knowing that you’re in control of your health care in the event that you are unable to make decisions for yourself.

It should be noted that state requirements regarding advance directives, such as living wills, may vary, so be sure to check your local state laws if you decide to create one for yourself. Also, be sure to keep a copy of your living will for yourself, as well as provide copies to family members, health care providers, and your health care power of attorney. Advance directives can be changed at any time, but just be sure to redistribute copies as necessary.

For more information about advance directives, check out the following resource links:

Advance Care Planning | UNC Health Care: UNC Medical Center

Living Wills and Health Care Powers of Attorney | North Carolina Bar Association

Living Wills and Advance Directives for Medical Decisions | Mayo Clinic


Advance care directives. (2017, September 5). Retrieved from

Advance directives. (2017, July 24). Retrieved from

Creating advance directives. (2014, November 11). Retrieved from

Living wills and advance directives for medical decisions. (2014, November 11). Retrieved from


Patient-Centered Research: The New Direction in Clinical Research?

What first comes to mind when you think of clinical research? My mind directly goes to thoughts of doctors with white lab coats, experimental treatments, expensive drugs and infamous cancer trials. One thing that doesn’t seem to come to mind is patient-centeredness and stakeholder engagement. This is something that one research institute is attempting to change and shatter the current norms of the clinical trial world.

Patient-Centered Research Outcomes Institute (PCORI) is literally one of a kind (the only 501(c) in the country) non-profit organization whose main mission is to change the conduct of clinical research by engaging patients and other stakeholders in the research process. This could include patients’ involvement in the design of research topics, desired outcomes, patient recruitment and even data analysis and dissemination. The thought is that stakeholder involvement will make research more efficient, results will be disseminated more quickly and the quality of clinical research will be improved.

PCORI was mandated under the Affordable Care Act by Congress in 2010 and today has funded over 500 research studies ranging from exploring alternative pain treatment options to using community health workers in the delivery of health care interventions.

This organization is one to keep in eye out for especially since they are up for reauthorization by Congress in 2019.

September is National Prostate Cancer Awareness Month

Did you know that prostate cancer is one of the most common types of cancer in men, and is the second leading cause of death from cancer in men? This year, the National Cancer Institute estimates that 161,360 new cases of prostate cancer will appear, and the lives of 26,730 men will have been claimed by prostate cancer alone.

There are several factors that can increase men’s risk of prostate cancer, such as age, race, and family history. Older men, African-American men, and men with a family history of prostate cancer have an increased risk for having prostate cancer. Prostate cancer is often asymptomatic in its early stages, and typically grows slowly. When it comes to screening for this disease, it’s important to be as informed as possible. There is no standard screening test for prostate cancer, and scientists are still studying certain screening tests used to detect this disease. Men, particularly those at an increased risk, may want to have a conversation with their health care provider about prostate cancer and the potential harms and benefits of prostate cancer screening.

This September, let us observe National Prostate Cancer Awareness Month by raising awareness of and educating our communities about prostate cancer and its risk factors, empowering men to take an active role in their health, supporting prostate cancer research and advocacy, as well as supporting those individuals currently battling prostate cancer. Together, we can end this disease.

Check out ZERO Prostate Cancer Run/Walk, sponsored by ZERO – The End of Prostate Cancer, a prominent national non-profit organization fighting to end prostate cancer, to find a run/walk near you. Additionally, the UNC Pardee Hospital will be hosting a FREE “ABC’s of Screening for Prostate Cancer” event with Dr. Glover Little on Thursday, September 14, 2017, from 6:00-7:00 pm, at the Cancer Center at Pardee in Hendersonville, NC.

Finally, below are some helpful online resources for more information about prostate cancer:


Cancer Stat Facts: Prostate Cancer. (N.d.) Retrieved from

Prostate Cancer. (2016, November 14). Retrieved from

Prostate Cancer—Patient Version. (N.d.) Retrieved from

Prostate Cancer Risk Factors. (2017). Retrieved from

Prostate Cancer Screening (PDQ®)-Patient Version. (2017, February 17). Retrieved from

Prostate Cancer Screening Draft Recommendations. (2017). Retrieved from

Race Locations. (2017). Retrieved from

It’s Not Me, It’s You: Signs that its time to Break Up With Your Doctor

By: Aria Gray MPH: Maternal and Child Health candidate 2017

I recently broke up with one of my doctors, and while it was a difficult decision, I felt much better once I decided not to see that provider anymore. The doctor was recommended to me as a great expert in the field, but I never felt that they were truly listening to me, which is why I ultimately left.

However, finding a new doctor can be difficult. Learn more below to see if it is time to make a change in your health care.

Poor Communication: It is important to understand your condition and diagnosis as well as the recommended course of treatment. Make sure to ask follow-up questions and to communicate to your doctor that you do not understand. However, if communication issues are still not resolved, it may be time to make a change.

Poor Listening Skills: Patient care should be adjusted based on the needs and experiences of each individual patient. If there is a medication or treatment plan you have tried without success or are not willing to pursue, your doctor should listen to your thoughts and feelings and make a treatment plan accordingly. If you feel your doctor isn’t listening to you, find one that will.

Long Wait Times & Limited Access to Care: If it commonly takes you weeks or months to get an appointment with your doctor or if you consistently face long wait times in the office, it may be time to find a new doctor. It is important to receive prompt treatment and also to have your valuable time respected.

As I mentioned, making the decision to change doctors is not easy, and the process of finding a new doctor is often not easy (not to mention all of the paperwork!). Follow these tips for an easy transition to a new provider.

Publication Planning: You have the data, now what?

Research, in any field, tends to be time-consuming and expensive. This is especially true of large-scale medical research trials. Therefore physicians and pharmaceutical companies, just like researchers in other fields, want to make optimal use of their research activities by producing as many publications from the resulting data as possible.

There are limits to how far these boundaries can be pushed, however. For example, duplicate publications are generally not permissible. This “double-dipping” includes publishing or presenting an identical work in multiple journals or at multiple conferences, but it also bars researchers from reworking a published piece in a way that does not contribute any new knowledge or insights to the results that were originally published.

One study usually measures a large number of variables and can therefore still be broken down into countless publications without violating sanctions against duplicate publications. For a clinical trial of a particular drug, for example, publications could focus on different outcome measures, such as the mechanism of action, safety, efficacy, economic considerations, administration, adherence, etc. Different publications could also examine these variable in various subgroups, such as pregnant women, the elderly, patients with certain co-morbidities, etc.   

In order to balance the desire for publication volume with the need to be ethically responsible by only publishing works that have scientific value, it is essential that large organizations and companies engage in publication planning activities. By convening a group of stakeholders at a publication planning meeting, an organization or company can lay out all of their available study data and determine what can and should be published from it.

In addition, gap analyses can be conducted to determine the topics or types of information that are missing in the current body of literature which can then serve as basis for future research studies intended to produce that information.

In this way, the cycle of medical research and publishing is continually pushed forward to produce new and valuable knowledge, both for the research community and for healthcare providers.

Authorship of Medical Publications

Last week I briefly introduced the concept of professional medical writers. These individuals are hired to write or create medical publications (such as abstracts, journal articles, and conference posters or presentations) on behalf of, or in collaboration with the actual researchers. Medical writers are often used because researchers do not have the time, interest, or the writing expertise to create high quality, publishable work in a timely manner. However, the listed authors still need to be involved in the writing process, and have specific obligations to fulfil in order to qualify as an author.

The International Committee of Medical Journal Editors (ICMJE) recommends that authorship be based on the following 4 criteria:

  1. Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; AND
  2. Drafting the work or revising it critically for important intellectual content; AND
  3. Final approval of the version to be published; AND
  4. Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Authorship is one of the major ways in which researchers get credit for the work that they do, which in turn often leads to professional and financial benefits. However, being designated as an author also carries a level of responsibility, as it serves as a public acknowledgement that an individual is willing and able to vouch for a publication and field any questions or critiques that may arise after publication of the work. Therefore, it is important that ethical authorship practices continue to be upheld, and that medical writers are used appropriately.

Ghost Writing

In addition to the history of suppressing study results, another ethically dubious practice that used to occur regularly in the history of medical publishing was a practice known as ghost writing. Ghost writing is when someone other than one of the listed authors writes (and often directs) the content of a publication without their participation being disclosed.

In addition, prominent physicians or researchers in a particular specialty were sometimes added to a publication as a ghost author (a person who was not actually involved with the research or the writing of the publication) in order to increase the credibility, prestige, or attention given to the publication by the medical community. Authorship was also sometimes used as a form of compensation or reward, another practice which now violates accepted ethical guidelines.

While ghost writing and ghost authorship is no longer an acceptable practice, due to many medical researchers’ lack of time or writing expertise, many now employ professional medical writers to help with the creation of a publication. Medical writers are professionals who have professional obligations to uphold the ethical practice of writing and publishing medical research, and who ensure the proper adherence to authorship guidelines is observed. In addition, the use of medical writers should always be disclosed by the authors, usually in the acknowledgment section of the publication, in order to keep the process transparent.

However, if authors still aren’t actually doing the bulk of the writing, how do you determine who qualifies as an author?

I’ll address this question in next week’s post. Until then, feel free to share your thoughts in the comments below.

Breaking Rural Health Barriers

For those of us that are fortunate to live near hospitals and primary care clinics, that question of rural vs. urban care is unlikely to even cross our minds. But for those living in remote locations, lack of access is a common issue. Unfortunately, what many of us take for granted is another person’s struggle, especially if they are plagued with chronic conditions, such as asthma or diabetes. And in many cases, most folks in this situation often go without treatment.

The National Rural Health Association reports that while a quarter of the U.S. population lives in rural areas, only one-tenth of our nation’s physicians choose to practice in these areas. And while only a third of automobile crashes occur in rural locations, two-thirds of deaths attributed to those accidents occur on rural roads, indicating a shortage in acute trauma care.

These figures certainly give rise to the need for increased access to care within rural communities. Another factor that contributes to this issue is that Medicare reimburses rural hospitals at a lower rate than urban hospitals, resulting in fewer physicians choosing to practice in such locations. Over the last 25 years, nearly 500 hospitals have closed, many of which were located in rural communities.

Fortunately, this is the age of digital know-how. Technology is king, and health care is one of the leading industries taking advantage of such innovation and wisdom. General Electric (GE) is doing its part to improve women’s health in remote areas like Wyoming, where the average woman has to commute 70 miles just to receive a mammogram.

In 2014, the company started the GE healthymagination program, to expedite cancer innovation and improve cancer care to 10 million patients, over the next six years (until 2020). One of the program’s most influential aspects is the GE Mammovan, equipped with mammography technology to provide free mammograms to all women living in remote areas.

GE chose to pilot the program in Wyoming, which has the lowest number of citizens and lowest population density (after Alaska). Many of the women using the van cited it was their first time having ever received a mammogram, stating that travel time or insurance requirements had precluded them from being screened for breast cancer. GE’s website reports that because of Wyoming’s uneven population distribution, a third of women living in that state over age 40 never receive a mammogram.

Since nearly two years ago, the mobile unit has traveled throughout the state, setting up in locations where women can receive a mammogram within an hour, allowing them to avoid the hassles of taking off from work and/or driving long distances. In many ways, the van serves a dual purpose—by eliminating the barriers rural residents previously faced and improving access to preventative care. By detecting breast cancer as early as possible saves the health care industry billions and ultimately, saves lives.

While North Carolina isn’t as rural as Wyoming, you might be surprised to learn that 85 percent of our state’s counties are, in fact, considered to be rural. And with nearly 2 million people receiving Medicaid, access to care is certainly an issue of interest among health care workers and lawmakers. And while mobile units are pricey to create and maintain, the progress the GE Mammovan has made in Wyoming is a good example of how health information technology can work to address some of our most pressing issues that impede quality health for everyone.