Neurologic Disease in Women - part 2 pdf

NEUROLOGIC DISEASE IN WOMEN 32 acts using the criterion of caring or responsibility versus an orientation of rights or privilege. One important caveat in considering adult development and research on women’s roles and their health is that most work has involved white women who have above-average economic resources. Studies often do not reflect the reality of poor women’s lives, and women of color are disproportionately poor. WOMEN’S EXPERIENCES OF HEALTH CARE Women have well established themselves as expert consumers of health care services in the United States and as a primary resource for their family’s health care decisions (1,42). Recent innovations in the field of information technology are greatly increasing the access to knowledge of health maintenance and health care, including the expanding interactive capacities of the Internet, electronic mail (e-mail), handheld computers, and cellular tele- phones. The Science Panel on Interactive Communication and Health (43) defines these tools of communication technology or interactive health communications (IHC) as “the interaction of individuals—consumer, patient, caregiver, or professionals—with or through an electronic device or communication technology to access or trans- mit health information or to receive guidance and support on a health related issue” (43, p. 1264). The con- vergence of rapidly developing scientific advances and IHC is changing the nature of contemporary health care experiences and health care communications. The accessibility of up-to-date medical information through the Internet adds another dimension to the consumer power held by women, one which potentially fosters more active participation in health, health care decisions, and confi- dence in obtaining appropriate health care for themselves and their families (44). Equally important to an understanding of women’s experiences of health care are the effects that sociocultural influences have. Acknowledging and sensitively addressing the cultural characteristics and needs of diverse groups during the provision of health care will reduce existing socioeconomic, ethnic, and racial disparities, stereotyping, and gender bias. Women as Health Care Consumers Women represent the largest proportion of health services consumers at all ages in the United States (even after adjusting for childbearing) (45). American women make three-fourths of the health care decisions in their house- holds and spend nearly two of every three health care dol- lars. More than 61% of physician visits are made by women, 59% of prescription drugs are purchased by women, and 75% of nursing home residents over 75 years of age are women (46). Increasingly savvy regarding their health and well-being, women want to be taken seriously during visits with their health care clinicians and yet, frequently find themselves frustrated and dissatisfied when they feel they are not being listened to (47–49). Women regularly express a longing to be more com- fortable asking questions and getting clearer answers from their physicians, despite the pressures of today’s managed care environment, in which time efficiency is at a premium during the medical encounter (47). The advent of IHC holds great promise for enhancing women’s focused interactions with their clinicians, and results in better informed decision-making and greater patient satisfaction. The Influence of Telecommunications on Health Care In 2002, the adoption of Internet use in the United States was at a rate of 2 million new Internet users per month. Over half the nation is now online, and overall Internet use is steadily increasing, regardless of income, education, age, race, ethnicity, or gender. Low family incomes, low levels of overall education, and English as a second language are still the strongest predictors of those within the “unconnected” population (50). Yet, the exponential growth rate in the Internet’s user base, with the greatest increase occurring among younger, school-aged user groups, is rapidly narrowing the “digital divide” (44,51). Women and men demonstrate equal rates of computer utilization. Not surprising, women go online to find information on health services or practices more frequently than men (39.8% of female computer users con- trasted with 29.6% of male computer users). Regular e- mail use was reported by 85.1% of female users versus 82.8% of male users. Routine computer use and Inter- net access at work, school, or libraries is substantially narrowing the “unconnected population” in computer appli- cations nationwide, which subsequently influences increased household usage (50). As the Internet becomes a more conventional information tool, expectations have increased about the reli- ability of health or medical information found online. According to the Pew Internet & American Life Project (52), 67% of Americans believe that health care information found online is reliable, which explains why such information plays an increasing role in people’s interactions with their health care providers and in their more active participation in decision-making. Most Internet “health seekers” are women, who say that they are still careful to consult with a medical professional before acting on online medical advice. Fifty- eight percent of Internet health seekers predict that they will first go online when next they need reliable health WOMEN’S LIVES AND THEIR EXPERIENCES WITH HEALTH CARE 33 care information versus 35% who say that their first move will be to contact a health care professional (52). In an exploratory study to determine the motiva- tions of women who use the Internet to obtain health information, health consciousness as well as health needs and cost-effectiveness were each significant (44). In par- ticular, the efficiency of Internet searching was premium for women whose full daily schedules included managing child care, elder care, and/or personal health issues. Advances in telecommunications and interactive media offer both advantages and potential risks in health communication. The Science Panel on Interactive Com- munication and Health (43) found that the benefits of IHC include enhanced opportunities for the provision of information “tailored” to the specific needs or characteristics of those searching the Web; increased access to information and support at the user’s convenience; greater opportunities for interaction with clinical experts as well as obtaining support from others with similar conditions through e-mail or chat rooms; and enhanced abilities for the widespread dissemination and currency of content. Potential problems with direct Internet access also exist, including the lack of regulation on the quality of the health information presented, which potentially com- promises the accuracy and appropriateness of the mate- rial online. This can result in patients obtaining inappropriate treatment or delay in seeking necessary medical care. Further, greater reliance on IHC can erode people’s trust in their health care professionals and prescribed therapies if there are substantial differences of opinion. Pri- vacy and confidentiality may be violated (43). E-mail is also becoming a useful adjunct to patient–clinician communications, replacing the telephone in efficiency and provider accessibility. Typically, important aspects of health care take place via telephone—patients call to ask advice, get prescription refills, and give feedback on previously prescribed therapies, whereas providers call to discuss lab results or follow a patient’s progress. Problems encountered with this technology include missed telephone calls in either direction, lines that are often busy, or interruptions to the recipient’s activity. Misunderstanding or misinterpretation is com- mon over the phone and can lead to poor compliance with medical advice. The documentation of these calls is often incomplete, which makes the subsequent decision- making process challenging and increases the clinician’s legal liability (53). For nonemergent medical issues, e-mail has the potential to improve patient–clinician communications. For the patient, e-mail can reduce the inconvenience of waiting for call-backs; questions can be formulated more purposefully; the clinician’s instructions can be read, saved, and later reread; sensitive questions may be easier to ask electronically; and the ability to ask quick questions between visits gives a sense of greater access to medical care. For the professional, unsuccessful calls are min- imized, messages can be read and responded to at more convenient times, medical advice can be carefully worded before it is provided, communications can be saved in print form for the patient’s record, and easy references to other sources of information can be provided either in hand-outs or web-links (53,54). As with any new technology, potential problems exist with “digital doctoring” through electronic communications, including concerns over privacy issues; uncertainty as to the reception of the message; nonuni- versal access, especially for those more vulnerable and already underserved populations (55,56); the potential for managing staggering e-mail volume; or an inability to respond in an efficient manner, which could create increasing patient dissatisfaction or enhance the imper- sonal nature of medical encounters (56,53). Specific rec- ommendations for clinical e-mail and medicolegal and administrative e-mail guidelines have been developed to enhance the use of this technology in positive and pro- ductive ways (54). These technologies can have a democratizing effect on access to and control of information between health care professionals and laypersons. These types of interactions have the potential for increased availability, a better understanding of various aspects of the diagnosis or management of a health condition, and better prepara- tion for health care visits (44). Despite all its potential, it is equally important to recognize that these newest information technologies continue to emphasize the gaps between the privileged and the less fortunate of our society (55). Whether the issues are access to obtaining health care, health insurance, or health information, the largest barrier for a substantial portion of women remains the acquisition of adequate education and income to afford these essentials. A major challenge of the future will include finding solutions to bridge the “digital divide” to improve health care services for all. Traditional Communication within Health Care A fundamental component of effective health care is the dialog that occurs between patients and their clinicians. The communication that is exchanged between women and their physicians is central to the quality of the therapeutic alliance that they establish. It is through talk that unique interpersonal relationships are shaped, essential medical information is exchanged, health problems or risks are identified, health education and counseling is dis- cussed, and decisions about treatment options or pre- vention measures are negotiated and carried out. Widely studied, the significant benefits of proficient communication between patients and clinicians include reduced patient anxiety, enhanced patient understanding NEUROLOGIC DISEASE IN WOMEN 34 and recall, increased perceptions of personal control over one’s health, satisfaction with medical care, adherence to medical therapeutics, and subsequent improved health status (57–65). Yet, women’s experiences of the health care system often reflect a less than courteous climate. Women patients may encounter a physician’s inappropriate use of familiar forms of address (i.e., using the patient’s first name), disparagement of their abilities to use medical information rationally, a condescending manner, or with- holding technical information, such as the benefits and risks of informed consent. These kinds of exchanges have been described and interpreted as ways in which the physician controls the medical visit and the patient’s behavior (66–68). The consequences of communication problems, based on a review of studies on physician and patient rela- tions by Stewart (69), include inaccurate medical diag- noses, lack of patient participation in medical care dis- cussions, or inadequate provision of information to the patient. Ineffective communication most commonly results in patient dissatisfaction with a physician’s care and con- sequently, the patient’s termination of their professional relationship (57). From the Commonwealth Fund women’s health survey data, women were approximately twice as likely as men to have changed physicians due to dissatisfaction. Women were also more likely to report communication problems with their physicians, and this issue was cited as the most important contributing fac- tor for switching health care providers for both men and women (70). Ineffective communication is also a major source of stress and anxiety for the patient during the medical encounter (71). Social Context The social context of the medical encounter also influences patient–provider interaction. The dialog between women and their physicians occurs in a variety of clinical settings, between individuals of unequal power, involving issues of vital importance that are both cultur- ally and emotionally laden and thus, necessitate joint cooperation. The ideal patient–provider relationship in which mutual trust exists, communication is reciprocal, and therapeutic goals and decisions are agreed upon, is not easily achieved (64). Communication Styles Communication style differences between genders account for the distinct ways in which men and women use questions, volume and pitch, indirectness, interruptions, silence, or polite refusals. From birth, women and men are treated differently, related to differently, and they talk differently as a result. Girls and boys grow up in different worlds, even when they grow up in the same house- holds. These differences continue into adulthood and reinforce communication patterns established in child- hood (72, p. 133). Recognizing these gender differences, which include differing expectations about the role of talk in relationships, is essential to the provision of quality health care to women. In studies of patient–provider communication, women are more likely to recognize and report symptoms as well as be more articulate and knowledgeable when talking with their physicians during annual medical visits (73). Perhaps because they are more familiar and com- fortable with health system utilization, women talk more and offer more complaints during medical visits (74,61,62); ask more questions (756–77); receive more information and a greater number of explanations from both male and female physicians (78–80), and generally have longer medical visits than men (61,77,62) (as reviewed in 70,81). Among patients with chronic disease, women are more likely to prefer an active role in decision- making that males (82). Hooper and colleagues (78) determined that female patients got more information and empathy from their doctors as well as fewer physician-initiated disruptions during their visits. Findings by Stewart (83) revealed that physicians demonstrated more tension release (e.g., laugh- ter) with female patients and were more likely to solicit their feelings and opinions (81). Power Studies of interactions between physicians and patients, however, have also described the constrained structure of typical medical encounters and the use of power or domination to limit and control medical dialog. The use of interruption and the amount of talk or words, question-asking, information-giving, and adversativeness are examples of methods that physicians employ to control the course of the medical interview (84–88). One study (89) revealed that physicians interrupt patients an average of 18 seconds into the patient’s opening remarks. The patient was only able to complete her primary complaint or concern 23% of the time. But, as Allen and colleagues (90) suggest, perhaps it is not the interruption, but the missed opportunity to disclose information about themselves and their situation that leaves patients feeling that they have not been taken seriously. Meaning Patients must be able to tell their stories, but may be con- fronted with their clinicians’ incompatible frame of ref- erence as to what information should be shared during medical visits (91). Physicians may not be aware of or WOMEN’S LIVES AND THEIR EXPERIENCES WITH HEALTH CARE 35 understand women’s “explanatory models” of their health concerns or their attitudes, values, and beliefs as related to illness and health care (92,93). These models are the patient’s underlying assumptions about their medical condition and its related therapies, which often explain the types of questions that the patient asks about their condition’s etiology, symptoms, the degree of sever- ity, the type of sick role (chronic or acute) they assume, and various treatment options (94). These beliefs are directly influenced by one’s cultural groups and social class (93,95). In analyzing medical discourse, Mischler (96) iden- tifies two opposing voices: the voice of medicine (reflect- ing a scientific, detached attitude) and the voice of the “lifeworld” (patient’s meaning of illness and how this dis- rupts the achievement of personal goals). He sees the medical encounter as a situation of conflict between two distinct efforts to construct meaning (97, p. 81). As Kleinman (92) suggests, the effectiveness of professional communication and health care outcomes is a function of the agreement between the patient’s and clinician’s explanatory models. Understanding the patient’s perspective of her condition is a prerequisite for successful clinician–patient dia- logue. It is also important to recognize how frequently this perspective differs (93). Studies that have explored issues of potential patient–provider conflict include the degree to which physicians meet patient expectations (98), how often physicians are aware of patients’ concerns (99,100), the rate of agreement between patients and physicians about those problems that require follow-up visits (101), and levels of agreement between patients and their physicians regarding the patient’s health status (102). Implications of Cultural Diversity Racial, ethnic and social disparities exist in U.S. health care and have become the focus of a recent Institute of Medicine report uncovering “unequal treatment” (103). Even after controlling for age, insurance status, income, comorbid conditions, and symptom expression, racial and ethnic groups are more likely to experience a sub- standard quality of health care. Explanations for this dis- parity in health care, embedded in historic and contemporary socioeconomic inequalities, are complex. Accountabilities exist on many levels: health systems, administrative and bureaucratic policies, utilization man- agers, and clinicians and patients (103). As the growth of ethnic populations currently referred to as minorities continues, they will comprise 40% of the U.S. population by 2035, and 47% by 2050 (104). The health care needs of an increasingly diverse U.S. population are now established as a goal of public health, thus cultural, linguistic, and literacy differences must addressed (105,106). Clinicians are challenged to examine the part they play in creating these disparities: their expressions of bias (or discrimination), greater clinical uncertainty when inter- acting with minority patients, and the beliefs (or stereotypes) held by professionals about the behavior or health of minorities. In response, patients may contribute to these dynamics through mistrust, treatment refusal, or poor compliance with prescribed therapies. Additional barri- ers to health care access for minorities can include language, geography, and cultural familiarity. Health systems may also contribute to these inequities because of heavy time pressures, cognitive complexities within the clinical encounter, and the push for cost containment (103). As one example, a study by Rivadeneyra and colleagues (107) revealed that Spanish-speaking patients experience a double disadvantage when receiving medical care from English-speaking physicians. Primary care patients who spoke through an interpreter made markedly fewer comments than did patients speaking directly with clinicians. Due to time consumed by the interpretation process, these patients had fewer opportunities to explain their symptoms or raise concerns. Further, when they did offer comments, they were more likely to be ignored than the English-speaking patients. These findings illustrate that non-English speaking patients have communication bar- riers beyond just difficulties with translation. Rivadeneyra and associates suggest that both physician and patient may change their behavior in subtle ways that may compromise the development of mutual trust, increase the likelihood of physician misunderstanding of the complexity associated with the patient’s symptoms, and decrease the possibility of patient compliance with medical advice (107). Other studies have also found that clinicians deliver less information, less supportive remarks, and less proficient clinical performance to black and Hispanic patients and patients from lower economic status than they do to more advantaged patients, even in the same setting (78,80,108). The ability to establish effective interpersonal and working relationships that transcend cultural differences defines “cultural competence.” Within health care, cultural competence describes the process by which a clinician continuously attempts to be effective within the cultural context of a patient, who may be an individual, family, or community (109,106). Strategies to bridge the sociocultural inequities in health care include providing interpreters as well as linguistic competency to health education materials, the incorporation of clinical staff who share similar cultural backgrounds in addition to the inclusion of family or community health workers, and clinic accommodations that adjust hours of operation and physical environment, and increasing the ability of professionals to interact effec- tively within the culture of the patient population through regular continuing education (110,106). NEUROLOGIC DISEASE IN WOMEN 36 Gender Bias Research has also investigated gender bias in the deliv- ery of health care—that is, if and how female patients are treated and perceived in a way different from male patients by physicians. Twenty years ago, McCranie, Horowitz, and Martin (111) reported no evidence that physicians attribute psychogenic illness more frequently to women than men or recommend psychological treat- ments more to women. Verbrugge and Steiner (112) also failed to identify any significant gender differences in tests and procedures in their analyses of National Ambulatory Medical Care Survey data. More recent research in coronary artery disease, kid- ney dialysis and transplantation, and the diagnosis of lung cancer (113–115) provides convincing evidence that differences in the quality of the technical care received by women cannot be explained by other factors, such as poorer health status (116). Bernstein and Kane (117) investigated the relative impact of patient gender and expressivity on attitudes of primary care physicians toward patients. Their research determined that physicians believed that women were more likely to make excessive demands as compared to men, women’s health complaints were assessed as more likely to be influenced by emotional factors, and women were identified more frequently with psychosomatic complaints than men. Their results supported their hypothe- ses that physicians have preconceptions about female patients. They also argue, however, that differences in physicians’ responses are not simply due to bias against women, but may be a complex response to the open and expressive behavioral style more frequently identified in women. They suggest that their findings underline the necessity for physicians to rise above stereotypes and treat each patient as an individual, instead of a member of a group (118, p. 607). Collaboration Increasing evidence exists for the value of a collabora- tive model of communication that promotes mutual interaction between patients and providers. Roter and Hall (87) offer a framework for understanding patient– provider communication as a partnership, each having certain responsibilities to contribute to the quality of their exchange. This model suggests associations between the patient’s question-asking (and the information that is subsequently offered by the provider) with the patient’s overall comprehension, agreement with treatment, and con- tinuance with prescribed therapies. The value of patient involvement during the medical encounter is revealed through enhanced patient satisfaction and loyalty to the clinician (70); among patients with chronic diseases, active patient participation is associated with better health outcomes (116). Patients are also most satisfied by interactions with physicians who encourage them to talk about psychosocial issues in an atmosphere that is characterized by the absence of domination by the physician (118). In summary, women’s experiences of health care services and physician interactions are different from those of their male patient counterparts. The role of communication is paramount to ensuring maximal health outcomes. As information technology becomes more acces- sible and more widely utilized, the nature of this communication will change. Yet, interpersonal interactions are essential to health care provision. A mutual appreciation and respect for the expertise that each individual (patient or clinician) brings to the medical encounter will facilitate more substantive dialog. Assim- ilating the principles of cultural competence enhances the interactions and significantly influences the outcomes of care. 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[...]... prolonged or at term N-Min N-Min N-Min N-Min N-Min N-Min N-Min TABLE 4.10 Anticoagulant and Antiplatelet Drugs FETAL RISK FDA TERIS Heparin Low molecular weight heparin Warfarin Pentoxifylline BREAST-FEEDING C C N-M N-M Safe Safe X C S-M U Compatible Not recommended NEUROLOGIC DISEASE IN WOMEN 52 Although the protracted use of heparin may result in osteoporosis and thrombocytopenia in the mother, there... products and pregnant women Virginia, 1994 Silberstein SD Headaches, pregnancy, and lactation In: 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 Yankowitz J, Niebyl JR, (eds.) Drug therapy in pregnancy Philadelphia, Pa: Lippincott, 20 01 :23 1 25 4 Ethical conflicts and practical realities Proceedings from the Food and Drug Administration conference on regulated products and pregnant women 1994 Use... neurotransmitter that increases appetite Leptin, which also mediates appetite, is elevated in persons gaining weight on valproate (23 ,30) Individuals gaining weight on valproate may have some degree of underlying insulin resistance This hypothesis is supported by observations that fasting and postprandial insulin and proinsulin levels are elevated in obese adolescents and in adults taking valproate (19 ,20 ,22 ) Persons... 9, 14, 16, 17, 22 , 41, 78 NEUROLOGIC DISEASE IN WOMEN 60 the newborn Lithium is excreted in breast milk and results in serum levels in nursing infants of approximately one-third to one-half the maternal serum levels Several authors (98) have reported toxic effects of lithium in neonates born to women who received lithium during pregnancy Lithium is contraindicated during breast-feeding Paregoric (11)... Steroid hormone binding globulins may also be increased, resulting in a decrease in free hormone levels The failure rate of OCs is 0.7 per 100 women years This rate is increased to 3.1 per 100 women years in women who use high-dose estrogen-containing OCs (50 µg or more) and enzyme-inducing anticonvulsants (47) Because the failure rate is higher when more commonly used, lower estrogen-dose OCs are used,... Lamotrigine is excreted into breast milk No adverse effects have been seen in nursing 54 NEUROLOGIC DISEASE IN WOMEN infants of mothers taking lamotrigine, but the number of known cases is too small to adequately assess the safety of this drug during lactation Monitoring infant serum levels of lamotrigine may be required (11) PHENOBARBITAL (11, 12, 76) Phenobarbital has been in use since 19 12, and phenytoin... drugs for use in lactating women (Table 4.5) ( 12, 45) The following prescribing guidelines should be followed (45): • Is the drug necessary? If so: • Use the safest drug (e.g., acetaminophen instead of aspirin) • If there is a possibility that a drug may present a risk to the infant (e.g., phenytoin, phenobarbital), consider measuring the blood level in the nursing infant • Minimize the nursing infant’s... allowing their infants to breast-feed Narcotic use is compatible with breast-feeding (11, 12, 62) CODEINE (11, 62) Indiscriminate codeine use may present a risk to the fetus during the first or second trimester Cleft lip, cleft palate, dislocated hips, inguinal hernia, and cardiac and respiratory system defects have been reported Codeine passes into breast milk in very small amounts PROPOXYPHENE (11, 62) ... VanWaes M, Finnell RH Prenatal prediction of risk of the fetal hydantoin syndrome N Engl J Med 1990; 322 :1567–15 72 Practice parameter: a guideline for discontinuing antiepileptic drugs in seizure-free patients (summary statement) 1994 Robert E, Biubaud P Maternal valproic acid and congenital neural tube defects Lancet 19 82; 2:937 NEUROLOGIC DISEASE IN WOMEN 62 80 81 82 83 84 85 86 87 88 89 90 Lindhout D,... postprandial insulin levels (21 ,22 ) Lamotrigine is not associated with changes in weight in adults (21 ) or adolescents (23 ) Approximately 50% of persons taking valproate for epilepsy experience significant weight gain, defined as more than 4 kg (24 26 ) Significant weight gain affects children and adolescents, as well as adults (23 ,27 29 ), and is usually evident early in therapy (within 3 to 6 months) The . studies Category X: Contraindicated in pregnancy TABLE 4.3 TERIS Risk Rating N — None (A) UN — Unlikely N-Min — None, minimal (A) Min — Minimal (B) Min-S — Minimal-small (D) S — Small S-Mod — Small-Moderate Mod. by allowing their infants to breast-feed. Nar- cotic use is compatible with breast-feeding (11, 12, 62) . CODEINE (11, 62) . Indiscriminate codeine use may present a risk to the fetus during the first. BREAST-FEEDING Simple Analgesics Aspirin C* N-Min Caution Acetaminophen B N Compatible Caffeine B N-Min Compatible NSAIDs Fenoprofen B* U Compatible Ibuprofen B* N-Min Compatible Indomethacin B*

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