Michael J. Green, MD, MS; Ray Rieck
Disclosures: Authors have disclosed no conflicts of interest. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=G14-0009.
Author and Illustrator Information: Michael J. Green, MD, MS, is a Professor of Medicine and Humanities at Penn State College of Medicine. Ray Rieck is a freelance illustrator and graphic designer (www.rayrieck.com).
Corresponding Author: Michael J. Green, MD, MS, Penn State College of Medicine, Department of Humanities, H134, Hershey Medical Center, PO Box 850, Hershey, PA 17033; e-mail, firstname.lastname@example.org.
Author Contributions: Conception and design: M.J. Green, R. Rieck.
Drafting of the article: M.J. Green, R. Rieck.
Critical revisions for important intellectual content: M.J. Green.
Final approval of the article: M.J. Green.
Administrative, technical or logistic support: R. Rieck.
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Robert M Arnold, MD, Anthony L. Back, MD, James Tulsky, MD
University of Pittsburgh, University of Washington, Duke University
April 13, 2015
We finished the graphic story of “Betty P” feeling dismayed by the story’s assumption that the absence of a do-not-resuscitate order was the big problem. While all too common, it is unacceptable that no one - not the primary care doctor, the hospitalist or the oncologist spoke to the patient about her medical condition and goals. They might have found out that her first grandson was supposed to be delivered in two weeks and she was willing to try anything, even if low probability, to see his birth. Or they might have learned that her priority was to be at home with her family and that hospice was the treatment that best matched her goals. We also worry about the depiction of the attending physician’s formative experience as an accomplice to an assault. While this will motivate him to talk to patients, it will not necessarily lead to patient-centered conversations. He (and his resident) need evidence-based skills in order to talk to patients about these difficult topics. The conversation should focus on what, given the medical reality, is important to the patient and how the medical system can help him achieve these goals and avoid interventions that will not achieve the goals and cause distress. The real core of high value medicine is not about unilateral physician decisions—it is about matching treatments to patient values.Luckily, things are improving. VitalTalk, the not-for-profit we founded, has trained over 400 educators over the last five years to go back to their home institutions and develop educational programs for their clinicians. We have developed and taught programs for hospitalists, oncologists, intensivists, nephrologists, geriatricians, cardiologists and palliative medicine physicians about how to talk honestly and compassionately to seriously ill patients at institutions ranging from community clinics to the Veterans Health Administration.Our hope is that five years from now, an attending would grab the resident and say, “Lets go talk to Mrs. Hoffman about her condition and what treatments best match her goals. I learned how to do this as a resident and it helped me be a better doctor. I can help you learn these skills."Robert M Arnold MD; University of PittsburghAnthony L. Back MD; University of WashingtonJames Tulsky MD; Duke University
SKMC, Abu-Dhabi, UAE
May 7, 2015
Empathy...every patient should decide his/her right of DNR way ahead, before not being able to talk to anyone.
Florida International University
I had goosebumps reading the young version of the doctor describe his assault. The illustration really hit that home for me. This makes having the talk regarding the end-of-life issues much preferable to the terrifying descriptions in the comic.
Munising Memorial Hospital
Bingo! The pictures tell a much better story than words ever could.
Element Care (PACE)
Excellent! Please redo with language appropriate for the general public to understand and also in Spanish.
Green MJ, Rieck R. Annals Graphic Medicine - Betty P.. Ann Intern Med. ;162:W74–W79. doi: 10.7326/G14-0009
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Published: Ann Intern Med. 2015;162(7):W74-W79.
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