Tag: Health care provider

New Zealand Postcards: Cultural Safety: A Wee Way To Go

DSC01879 - Version 2DSC01418This week I had the good fortune of meeting with Denise Wilson, RN, PhD, a Maori New Zealand nurse and Director of the Taupua Waiora Centre for Māori Health Research at AUT School of Public Health and Psychosocial Studies here in Auckland. She talked about her work with cultural safety in New Zealand.

Like many indigenous peoples across the world–including our own in North America–Maori cultural conceptions of health and well-being tend to be much more holistic and less individualistic than mainstream Western ones. As Ms. Wilson explained, for most Maori patients she has worked with (clinically and in research), spirituality and connection with their land and extended family are the most important aspects of health. The Maori word for land, Whenua, also means placenta: it is what nourishes you. The history of colonialization, and being displaced from ancestral lands, have had profound negative effects on Maori health and well-being.

The term ‘cultural safety’ came from a Maori nursing student, Iriphapeti Ramsden (1946-2003), who in the early 1980’s stood up in class one day and asked something like, “We talk about patient safety, physical safety, and ethical safety, but what about cultural safety?” She was specifically referring to the difficulties Maori patients and their families (as well as Maori nursing students such as herslef) have within the Eurocentric health care system in New Zealand. These difficulties continue to contribute to New Zealand’s large health inequities and low representation of Maori nurses and other health care providers in the healthcare system. Ramsden went on to receive her PhD, developing the concept and practice of cultural safety. I discovered that Dr. Ramsden was part of the New Zealand feminist Spiral Collective, which ‘self-published’ Maori writer Keri Hulme’s book The Bone People after it was rejected by all major publishers. The Bone People, of course, went on to win the Man Booker Prize. One of my all-time favorite books, I assigned it as our New Zealand study abroad Common Book this quarter.

According to Denise, a culturally unsafe practice is “anything that diminishes, demeans, or disempowers the cultural identity and well-being of an individual.” A culturally safe or unsafe practice is determined by the patient and the patient’s family (another form of what we term in the U.S. ‘patient-centered care.’) Denise told me that a good ‘cultural safety’ question nurses can ask patients (and their family members) is, “What are things that are really important to you that we need to consider in your care?” Cultural safety includes an emphasis on self-reflection (and action) by the nurse in terms of understanding his or her own cultural and social attitudes that affect their care of patients and communities.

Cultural safety has been taught in New Zealand nursing programs for over twenty years. Since 1992 it has been a requirement for nursing and midwifery registration examinations. What started off as a bicultural focus (Maroi and Pakeha/non-Maori), has been expanded to include things like migrant status, gender/sexual orientation, socio-economic ‘class’ status, and disability. The concept of cultural safety has been adopted by regions in Australia, Canada, and the United States. Denise acknowledged the significant advances that have been made in New Zealand in terms of cultural safety, but she concluded with: “We do have a wee way to go.”

Cultural safety seems to have much in common with my favorite U.S. ‘cultural’ concept of cultural humility, which I have written about in a previous post. Cultural humility was developed as a concept by the African-American physician-nurse duo Tervalon and Murray-Garcia in their 1998 article, “Cultural humility versus cultural competence: a critical distinction in defining physician training outcomes in multicultural education.” (Journal of the Poor and Underserved, 9(2) 117-125.) Since then, both the practice and concept of cultural humility have been further refined. Cultural humility emphasizes: 1) a commitment to lifelong learning and critical self-reflection, 2) recognizing and changing power imbalances, and 3) developing institutional accountability. Take a look at the excellent 30-minute video Cultural Humility: People, Principles and Practices by San Fransisco State professor Vivian Chavez.

Even closer to (my) home of Seattle, the historical roots and “remnants of our unresolved past” of racism and classism are powerfully presented in Shaun Scott’s short documentary A Really Nice Place to Live. In the film, Shaun Scott points out that Seattle is a byproduct of White Western Frontierism. He references historian Richard Drinnon’s work on the ‘Metaphysics of Indian-Hating,” where Drinnon asserts that all of American’s domestic and international race and class dynamics can be traced back to our original interactions with our ‘own’ Indigenous peoples.

We all have a wee way to go in terms of addressing and redressing the effects of racism and classism and all the other ‘isms’ of the world.

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The first photograph here is of the friendly and informative staff at the Alliance Health booth at Auckland’s annual Pasifika Festival, which I attended this past weekend. The staff members were promoting community awareness and prevention of rheumatic heart disease. New Zealand has the highest prevalence of rheumatic heart disease of all industrialized countries, and the highest rates are among Maori. It is a result of untreated ‘strep throat’ and is considered a disease of poverty. One of their community-led ‘interventions’ was the creation of Mama’s House as a culturally-appropriate way to engage the Pasifika community.  “Knowing that mothers, sisters and aunties are the first port of call about all matters relating to family health and well-being. After all, ‘Mama knows best’.” It also happened to be International Women’s Day. (And I also had just played ‘Mama-Nurse’ for some of my students who had developed penicillin- resistant strep throat, resulting in some ‘interesting’ interactions with the New Zealand healthcare system, which–like our own–has ‘a wee way to go.’)

The second photo is an interactive game show called “The Survivors,” part of the Maroi section of Wellington’s excellent Te Papa Museum exhibition Slice of Heaven: New Zealand’s Twentieth Century History. As this photo shows, one of the decisions you have to make while playing the game is whether you (as a Maori young woman in the 1970’s) went to the shorter/cheaper nurse aid program or to the longer/more expensive (and heavily Pakeha/’White European’) program to become a Registered Nurse. Guess which choice led to better outcomes, including lifespan for this woman?

New Zealand Postcards: Misogyny In Sheep’s Clothing (with a G-String)

DSC01009I preface this by saying: I know the Biblical quote that it’s easier to see the speck in another person’s eye than to see the plank in your own. In the U.S. we have a lot of work to do in terms of overcoming misogyny in all its ugly forms (including commercial sex trade/exploitation or perhaps even all the books by Philip Roth?) We have a very large plank, especially in places like Nevada.

But I have to say that one of the most surprising things I’ve learned while in New Zealand these past months is the country’s level of violence against women. Before coming here I mainly knew that New Zealand was rightly proud of the fact that it was the first country in the world to give women the right to vote (in 1893). I also knew that there was a healthy cadre of New Zealand feminists at work influencing national policy through research, direct service, and the arts. What I had not realized was how deeply ingrained the sexism is here, perhaps as yet another direct descendant of British colonialism? That is what one of my Maori female informants and experts on this topic asked somewhat rhetorically in answer to my question to her about this topic. I had not realized that prostitution is legal in New Zealand (the photo here is of the Calendar Girls strip club/’gentleman’s club/brothel left standing in the Red Zone of Christchurch.) I had not realized that New Zealand is one of the worst industrialized countries in terms of violence against women. (See: Facts on Violence Against Women, by Janet Fanslow, New Zealand Herald, 11-25-11.)  Of course, those issues are all interrelated.

A society’s level of sexism and misogyny, plus tolerance of violence, plus racism, plus poverty, plus sexualization of girls, plus a high level of commoditization and commercialism, are all documented risk factors for commercial sexual exploitation (CSE) of girls and women. Additional environmental risk factors for CSE include: open presence of the adult sex industry, transient male populations, and proximity to borders/ports.

I have spent many decades as a nurse working with homeless and prostituted teens and young adults on both coasts of the U.S., as well as in Thailand. There was a time during the early part of the HIV/AIDS epidemic when I bought the idea of sex trade as potentially being empowering work for women, along the idea that legalizing and regulating (including health screens) prostitution/sex work were all good things. But that belief was short-lived when I realized how dangerous the work is, no matter how ‘upscale’ or regulated or sanitized. And when I realized (from both credible research reports and stories from young women I worked with) that the women and children in prostitution anywhere in the world come from the most marginalized and oppressed groups in society. And how many (upwards of 90% in many studies) have untreated PTSD and histories of sexual abuse as children. And there is mounting evidence that legalizing prostitution only increases human/sex trafficking.

Efforts like those in my home state of Washington to decriminalize prostitution for the women/men/girls/trans in sex work (and refer them to appropriate services), while simultaneously stepping up the severity of prosecution of the buyers (‘Johns’) and the traders (‘Pimps’), make the most sense to me. Meanwhile, Nevada has counties near places like Las Vegas where prostitution is not only legal. They lock women inside barbed-wire secured brothels called ‘ranches,’ and then busloads of ‘customers’ arrive to be serviced. Like I said, we have planks in our own eyes.

Nurses and other front-line primary care providers need education and training in how to identify and effectively work with children and adults involved in CSE. Similar to gaining skills in working with victims of intimate partner violence, any screening or intervention is based on building rapport, maintaining appropriate professional boundaries (including not ‘rushing in to the rescue’), understanding PTSD and trauma bonding, using the principles of harm reduction to help the client build a safety plan, and knowing good community resources for appropriate referrals. One important health component I’ve found to be essential is having culturally-clued in positive body work (like yoga) to refer people to. It helps them get cued in to what the body can do, instead of what is done to the body (body as object). And for anyone who doesn’t know how to ask a patient about this topic, here’s the standard screening question: “Have you ever traded sex for money or other things needed to survive?”

And remember the words of Gloria Steinem: “Prostitution isn’t the world’s oldest profession. It’s the oldest oppression.”

Resources:

Polaris Project: For a World Without Slavery

The Washington Anti-Trafficking Response Network: 206-245-0782

National Center for Missing and Exploited Children: 1-800-THE-LOST

National Human Trafficking Resource Center Hotline: 1-888-373-7888

An excellent 5-minute training/education video about the process of ‘grooming’ that can draw young women into prostitution: GEMS The Making of Girl.

New Zealand Postcards: Self-care and the Sea

DSC01150…i nga wa o muri. The surge of the sea. Whether you think of time as something you move through, so that your past is necessarily behind you, or whether you conceive of time as an encompassing continuum (so that your past stands before you, while wrapping you round, and your future is never-present but ready, waiting behind—i nga wa o muri), there is always the pulse of the sea. In us and round us, the sea. We have that constancy. ~ Keri Hulme

This quote is from Hulme’s lovely book HomePlaces (Hodder and Stoughton, Auckland, 1989). I found the book yesterday as a ‘rare’ book in a bookstore in the town of Hokitika on the West Coast, South Island, New Zealand. For my community health course this quarter we’re reading Hulme’s The Bone People (one of my favorite books since it was published in 1984 and a good choice for teaching community health in New Zealand). After purchasing the copy of HomePlaces, I tramped up the beach several miles back to the hostel where we’re staying. A rouge wave from the wild Tasman almost took me—and the book—out to sea. Perspective. Being next to (and inadvertently in) the very cold sea, as well as being temporarily unhooked from the chatter of the internet, has reminded me of the importance of mindfulness training and of self-care in our personal and professional lives.

Professional burnout is never a pleasant thing to have (or to be around). I have crashed and burned in clinical settings at least twice in my life, so I know what it feels like and what personal and collateral damage it can do. And I’m beginning to feel a bit crispy in terms of my academic role this quarter. Something about living with my undergraduate students 24/7 for three months in ten different youth hostels all over both islands of New Zealand was just not a good idea. My passion for teaching is in serious need of refueling (along with the minivan I’m driving them around in).

Compassion fatigue, moral distress, and professional burnout—the gooey mess that health care professionals—and especially nurses—are prone to. What’s the antidote—besides getting whacked by a rouge wave from the Tasman and washed out to sea?

Self-care. Not the self-indulgent variety of going off to expensive spas and eating dark chocolate, but real self-care. What Rachel Naomi Remen, MD calls heart care: “ways of keeping your heart alive in health care.” David Bornstein wrote a nice NYT article “Medicine’s Search for Meaning” about Dr. Remen’s work (Sept 18, 2013). It focuses on physician burnout and mentions that half of all medical students burn out by the end of their training. Nurses burn out at even higher rates, especially in their first few years of practice.

I’ve read (and used in some of my courses) Remen’s book Kitchen Table Wisdom.  But after reading the NYT article, I decided to see what all the fuss was about. I signed up for Dr. Remen’s telephone conference/training call in mid-November. I’m often cynical about self-care, but I also know that cynicism is a marker for burn out. Plus, mid-November in Seattle is a dark and gloomy time, so a little brush-up on self-care sounded like a good idea.

Remen points out that the heart is devalued within health care. She states, “science (the head) is a tool of healing but is not the source of healing—that is the heart.” The heart is an organ of vision—that helps us discern the meaning of the work we do. She outlines a way of establishing a practice that supports the ability to ‘find meaning on purpose’ in one’s work (as opposed to having to be whacked over the head by it).

In response to several questions from some of the conference caller participants, Dr. Remen admitted that we’re all having to work within a broken health care system, but, “that doesn’t prevent us from taking time for self care; staying alive within the system isn’t about changing anything outside of yourself.” And she used this analogy: “If I can’t have a wonderful long drink of fruit juice, I won’t take another sip of water.” She deflected more questions along the same line by saying, “I don’t have an answer for changing the system.”  What I thought—and wanted to say—was that self-care keeps us alive (and healthy) and perhaps gives us more energy to work for systems change. And, of course, that is what Dr. Remen has been doing all these years through her work and writing.

She recommends a series of ‘heart practices.’ The following are the two that I like the most. 

  1. Connect to yourself by the mindfulness practice of attention to one’s breathing. “Paying attention at the very end of an out breath as a moment of absolute rest and peace.” Practicing this can build the capacity to come to rest.  
  2. At the end of the day, ask yourself “What surprised me today?” and “What touched my heart today?”

Sometimes in my more cynical moments this all sounds so woo-woo and kum-ba-yahish, but I am convinced that it works. And I will try to pass it on to my students.

Cultural Humility Redux

English: Haystack
English: Haystack (Photo credit: Wikipedia)

It is past time to retire the term ‘cultural competency’ in favor of the more enlightened ‘cultural humility.’  The word ‘humility’ is a problematic one for people, especially for health care providers or academics used to doing everything possible to avoid being humble. We are groomed to be arrogant. (See earlier post “Cultural Competence, Meet Cultural Humility” Aug. 16, 2011.)

But I’m reminded of one of my favorite quotes from a favorite author, William Maxwell, from his book Time Will Darken It:

“People often ask themselves the right questions. Where they fail is in answering the questions they ask themselves, and even there they do not fail by much. (…)There is no haystack so large that the needle cannot be found. But it takes time, it takes humility, and it takes a serious reason for searching.”

I juxtapose this quote with one from Craig Irvine who teaches in the Columbia University Program in Narrative Medicine. Mr. Irvine is a former Benedictine monk whose area of expertise is narrative ethics. He talks about empathy (necessary for cultural humility) as being “my experience of the mystery of my relationship with another person” as opposed to the usual understanding of empathy (in healthcare settings at least) as knowing the other person or “stepping into their shoes.” Craig states, “empathy brings me to myself.” (Quotes are from my notes of a talk he gave at a narrative medicine conference I attended in October, 2010).

We really never can know someone else, and as William Maxwell points out, many times we fail to even know ourselves. But in the words of Lyle Lovett, “Who would you be if you didn’t even try?”

That brings me to my hearty recommendation of a relatively new video I happily stumbled across yesterday (thanks to Community-Campus Partnerships for Health.) The video was written/produced by Vivian Chavez and is titled, “Cultural Humility: People, Principles and Practices.” (Aug. 9, 2012 release date/ 30 minutes in length.) The video features interviews with various people, including physician Melanie Tervalon and nurse/educator Jann Murray-Garcia, co-authors of the journal article “Cultural humility vs. cultural competence.”(Journal of the Poor and Underserved, 9(2) 117-125.)

According to Tervalon and Murray-Garcia, the three principles of cultural humility include:

  1. Lifelong learning and critical self-reflection
  2. Recognizing and mitigating power imbalances
  3. Institutional accountability (they emphasize for the power imbalances, but I would add accountability for the structures/support/leadership necessary for lifelong learning and critical reflection… these are usually woefully lacking.)

While watching this video for the first time I was thinking—wait! Where are the white people in this? But at least I did recognize my own white privilege arrogance in the question. I continue searching in my haystack.

Where to Get Your Words Out

American Journal of Nursing
American Journal of Nursing (Photo credit: random letters)

Here are some specific resources for where to get published. This is primarily intended for writers of personal essays, short stories and poems dealing with health and health care-related issues. I’ve geared the list towards nurses, but all of the journals included here accept writing from any type of health care provider, as well as from patients and family members.

Remember to do your homework before submitting to any of these journals or blogs: follow their current submission guidelines and read their published content to make sure it is a good fit for your work.

Good general all-around resources for writing and publishing:

  • Duotrope. They have recently added a nonfiction category to their excellent searchable database of literary journals and magazines, as well as information on small presses open to book manuscript submissions.

Good resource for almost all things related to medical humanities (intersection of medicine/healthcare and creative work):

Journals:

  • American Journal of Nursing. I’ve linked to their editorial manager page that has information for potential authors. Check out their Art of Nursing, Viewpoint, and Reflections sections as these are the ones accepting more creative types of writing. (They also pay a $150 honorarium for each published piece!).
  • Bellevue Literary Review/NYC Langone Medical Center. Excellent print publication. Highly selective and they can take up to six months to review a submission, so I don’t recommend them for first-time authors. But I highly recommend the journal for reading good narrative medicine type writing. They also have really cool archived historical photos from Bellevue Hospital, the oldest continuously running hospital in the U.S. (although Hurricane Sandy seriously affected their buildings and operation).
  • Creative Nonfiction. This print journal is highly selective, only includes creative/narrative nonfiction, and is not primarily geared towards health-related writing. But the editor, Lee Gutkind, has his heart in medical narratives.
  • Pulse: Voices from the Heart of Medicine. “An online magazine that uses stories and poems from patients and health care professionals to talk honestly about giving and receiving medical care.” You can sign up to get a weekly short essay (800 word limit) or poem (they currently are closed to poetry submissions as they have too many to review).
  • The Examined Life Journal/University of Iowa Carver College of Medicine. A relatively new (now biannual) print journal from the medical school linked with the most prestigious writing school in the country. This is where Abraham Verghese honed his writing skills. They have a new annual writing contest/deadline is January 10, 2013.

Blogs can be a good place to get started as a writer. Consider submitting to an existing group blog to have your work included as a guest blogger. An excellent one is HealthCetera at the Center for Health Media and Policy at Hunter College. Joy Jacobson, MFA (health care journalist and poet) and James Stubenrauch, MFA (writer and editor) are both Senior Fellows at the Center for Health Media and Policy, Hunter College School of Nursing. They both have worked as editors for the American Journal of Nursing. I ‘spoke’ with them via e-mail this past week and they wanted me to encourage my students (and other nurses) to consider submitting a guest blog post.

So no excuses! Get your words out and get them published.

Nurses and Anti-Vaccination

Last week I wrote about the current pertussis epidemic in my home state of Washington, coincidentally the state with the highest percentage of parents opting out of vaccinating their children for all of the usual vaccine-preventable diseases such as polio, tetanus, diptheria, pertussis and hepatitis B. I concluded by hoping that my own pertussis booster would protect me against a planeload of Washington State coughers I recently had the pleasure of sharing a red-eye with on our way to NYC. Since the average incubation time from exposure to pertussis to symptoms is 7-10 days (and can be as long as 21 days), I’m not yet breathing a non-congested sigh of relief. But I’m hopeful.

I am a critical health care consumer and I teach my students to be critical health care providers.  On a personal basis I don’t accept all health care screening and prevention guidelines without first examining the evidence and deciding for myself what is best for my own health. For instance, I tend to agree with the conclusions about mammography screening written about (beautifully) by Veneta Masson, a nurse practitioner and poet living in Washington, D.C. in her essay “Why I Don’t Get Mammograms” (Health Affairs/Narrative Matters October 2010). I have used naturopathic, acupuncture and other ‘alternative’ medicine modalities for illnesses that are beyond the abilities of allopathic mainstream medicine to treat. But for most vaccinations, I am a discerning early adopter. Having been threatened with an attack by rabid dogs in Northern Thailand, I have even gotten my rabies vaccine series. Doing street outreach has extra hazards in a country like Thailand. I did get the rabies vaccine series in Bangkok since they cost significantly less there—Bangkok is one of the main WHO rabies centers in the world. (Thailand, a Buddhist country opposed to euthanasia of animals—even rabid ones—has one of the highest rates of rabies in the world).

As a health care provider I consider it my professional duty to stay current on recommended vaccinations, including the annual flu vaccine. I have the option of receiving it at my work site (limited times/places so not very convenient) or at my doctor’s office, or—as I usually opt for—at my local Safeway pharmacy. My annual flu shot comes between shopping for groceries, is immediately covered in full by my health insurance, and is administered by a very friendly and knowledgeable pharmacist within about five minutes of registering for it. (I fully realize all of these lack of barriers/facilitators do not exist for everyone). I have read the evidence on risks and benefits of the annual flu vaccine and am convinced on the side of getting the shot. I listen respectfully to my nurse colleagues who opt out of the flu vaccine, but I am dismayed by how many opt out for anything other than religious or valid medical reasons. I haven’t tried to convince them to change their minds because I never saw that as my job. But if any of them happen to be reading this, I hope they will at least reconsider their decision.

The evidence is fairly overwhelming in favor of nurses and other health care workers getting an annual flu vaccine, in terms of reducing the risk of transmission to their patients as well as co-workers. The flu vaccine has proven to be safe and effective, and the flu vaccine ‘industry’ is not exactly a huge profit making one. Since 1981 the CDC has recommended that all health care workers get the flu vaccine on an annual basis. (A good review from a nursing perspective is Paula Sullivan’s “Influenza Vaccination in Healthcare Workers: Should It be Mandatory? OJIN/available on ANA’s website). Most hospitals have relied on voluntary participation of health care workers, sometimes accompanied by vigorous (and I would suspect costly) education campaigns. While rates of flu vaccine compliance are high for most physicians’ groups (with the notable and not surprising exception of surgeons), the rates of flu vaccine compliance among nurses remain much lower. Why the difference?

A recent article in the journal Vaccine “What Lies Behind the Low Rates of Vaccinations Among Nurses Who Treat Infants?

English: Avian flu vaccine development by Reve...
English: Avian flu vaccine development by Reverse Genetics technique. Basa Sunda: Ngembangkeun vaksin flu unggas maké téhnik reverse genetics. (Photo credit: Wikipedia)

” (O. Baron-Epel, et al, 30(21), 5-12-12) explored this question (in this case for pertussis vaccination). Researchers in the UK conducted a series of focus groups with 25 public health nurses working at several Mother and Child Healthcare Centers, about their understanding and beliefs on vaccination. Common themes that emerged from the focus groups included the usual barriers to vaccination: fear of side effects, and a lack of perception of personal risk or risk of harming patients. Other barriers included lack of trust in health care authorities (and of health information), strong value of personal autonomy (being able to refuse vaccination), lack of respect of nurses by hospital administrators, and the fact that they did not view themselves as role models for patients. The researchers concluded “There is the need to increase the nurse’s awareness of the unethical aspect of not being immunized and increase the perception of themselves as transmitters of disease.” (p 3154).

Making America Healthier

http___www.michigan
Image by Sacred Heart Rehabilitation Center via Flickr

This week I attended the John R. Hogness Symposium on Health Care at the University of Washington. This year’s speaker was Daniel R. Williams, PhD, Professor of Public Health/African and African-American Studies/Sociology at Harvard University. Dr. Williams is a sociologist who studies the social determinants of health, including racial and socio-economic health disparities. He is prominently featured on the excellent PBS series, Unnatural Causes, being interviewed on a variety of topics related to his research.

The title of Dr. William’s talk was, “Making America Healthier: Surprising Steps for Every Health Professional.” While Dr. Williams is an excellent public speaker and delivered a cohesive lecture, most all of the information he covered was the same/similar to what is in Unnatural Causes—so it wasn’t really surprising. I suppose though that it is surprising that the information is surprising to health professionals in the US. He was mostly preaching to the choir here in Seattle. I was also surprised (and bemused) by the pre-lecture conversational content of a group of young students sitting beside me. While looking around at the increasing crowd, one student exclaimed, “Wow! So this is like a big deal!” OK, so we have work to do in our educational system.

Dr. William’s main talking points were as follows: 1) the US ranks near the bottom of all industrialized countries on most all health measures—and we are losing ground; 2) immigrants to the US become less healthy the longer they live in the US (“life in the US is bad for your health”); 3) the racial gap for blacks/whites in health is larger for higher educational levels; and, 4) racial segregation in large US cities in the 2000 census was close to the level of racial segregation in South Africa in 1991 under Apartheid. He stated that health care reform is crucial but insufficient—that we also need to address the social determinants of health in order to make America healthier. He included health behaviors/individual lifestyle choices as something we all need to work on—we are now supposed to eat at least nine servings/day of fruits and vegetables and not just five—while acknowledging how poverty and lack of access to healthy choices makes it more difficult for some to ‘do what’s right’ health-wise.

What can we as health professionals do to make America healthier? Of note is that Dr. Williams is not a health care professional, and that fact was reflected in some of his recommendations. He gave examples of successful programs that incorporate social determinants of health into mainstream health care. Heading his list (yeah!) was the Nurse Family Partnership. Then he talked about the Boston Medical Center’s Medical Legal Partnership, which links low-income families with lawyers—for instance to pressure landlords to remedy asthma-inducing mold and cockroach problems in apartments. The third program he mentioned was Health Leads, started by a Harvard undergrad. This is a service-learning project training college students to staff waiting rooms of safety net clinics, linking patients and families with needed social services.

Dr. Williams ended his talk by giving reference to four resources for further information: 1) Unnatural Causes videos, 2) Robert Wood Johnson’s “Build a Healthier America” report, 3) county-level health data at Countyhealthrankings.org, and 4) Biology of Disadvantage: Socioeconomic Status and Health (Annals of the NY Academy of Sciences, Feb 2010–free access to report–there is a companion report/also free/less academic, “Reaching for a Healthier Life: Facts on Socioeconomic Status and Health in the United States.“)

I was left thinking, “Yes-but?” This all sounds good, but what can individual health care providers such as nurses really do to change things in the health care system? How can we include any of Dr. William’s suggested programs? For instance, our local Odessa Brown Clinic, a safety net clinic in a traditionally African-American Seattle Community, had a grant to include legal services for patients. But once the grant ended, the program ended. Our Washington State Maternity Support Services are on the chopping block in the upcoming legislative session. I suppose we could try to replicate the Health Leads program locally, but with food banks and other basic services being cut, it is hard to know what the students would be linking patients to.

I try to maintain healthy skepticism as opposed to unhealthy cynicism in terms of health policy in general, and the social determinants of health in particular. But Dr. William’s talk left me with the vivid impression of all of us health care progressives spitting into the wind. Even the authors of the Biology of Disadvantage report have somewhat similar sentiments, “…thus we face with humility the task of identifying appropriate poverty-reducing strategies that improve health.” (p.247)

Limits to the Active Health Care Consumer

Question Everything
Image by dullhunk via Flickr

As health care consumers, we are being asked to become more active participants in our health care. We are admonished to exercise more, not smoke, wear seatbelts, use sunscreen—all of those individual risk and protective factors—as a way of reducing health care costs. We are asked to be more involved in patient safety—to ask our health care providers questions such as “How many times have you done this procedure?” And “Why do I need this treatment” (see AHRQ’s: Questions Are The Answer website.) And to take in a list of questions to ask your provider. AHRQ doesn’t tell you that all of these questions are a sure way to obtain the instant label of Problem Patient

We are asked to become more involved in health care quality, to report errors/concerns about providers, to shop for the highest quality hospital when we have the lead-time to do so. AHRQ tells us, “Do your homework before you chose a hospital.” Online tools for doing this homework include Medicare’s Hospital Compare and the Joint Commission’s Quality Check.

But how are consumers supposed to know if their doctor, nurse practitioner, dentist, or other health care providers are competent? This, of course, assumes that patients still have a choice of providers—a dwindling luxury with managed care and the fact that the really good providers aren’t taking new patients. Most people go by old-fashioned word-of-mouth, or the media equivalents: Doctors Score Card (really just a Yelp consumer rating of doctors) and HealthGrades. (supposedly more objective, risk-adjusted health outcomes data). Patients are generally good at assessing ingredients of quality of care by providers, such as interpersonal skills and hand washing—but not so good at assessing technical competence of providers.

Instead, consumers rely on others within the health care system to ensure ongoing competence of health care providers: peer reviews, professional organizations, and health professions regulatory systems. None of these are exactly transparent or accountable to the general public. Some states have started to provide accessible online searchable databases of doctors/other providers and their practice histories. Most of these are quite rudimentary and not very helpful. For instance, in Washington State, the site only provides the health care provider’s credential type and status, and whether or not they have had any disciplinary actions: yes/no. California has similarly limited consumer information on individual providers—however, their site does provide consumer information on collagen injections. Really. In contrast, Massachusetts on MyHealthCareOptions allows consumers access to information on individual provider’s malpractice claims, hospital and state licensing disciplinary actions, and criminal convictions. Plus it’s a very cool and user-friendly interface.

Then there is the federal/DHHS/HRSA National Practitioner Data Bank—established by Congress in 1986—which has as its mission “to protect the public by restricting the ability of unethical or incompetent practitioners to move from state to state without disclosure or discovery.” The Data Bank collects individual practitioner data on malpractice claims, and disciplinary actions from state licensing agencies, hospitals, health plans, the DEA, and professional organizations—and makes these data available to hospitals, state licensing agencies, and other health care entities—but not to consumers. And now not even to researchers or journalists.

Until this month, researchers and journalists had access to a public use file from the Data Bank, not to individual practitioner data. But this public use file was recently removed due to a complaint by a neurosurgeon in Kansas who was ‘outed’ by a journalist for having a significant malpractice history/never disciplined by the state. (see NYT article “Withdrawal of Database on Doctors Is Protested” Duff Wilson, 15 Sept 2011). The journalist got this information by being a good investigative journalist and not directly from the Data Bank. Journalism organizations, as well as consumer protection groups, have protested the removal of the Data Bank public use file. They point out that resources such as the Data Bank have informed investigative journalism reports on the serious shortcomings of our health regulatory system. These reports have had significant impact on promoting improvements in the system—including attempts to provide relevant practitioner practice information to consumers.

Ir(regulation) of the Health Professions

The state seal of Virginia.
Image via Wikipedia

This is a cautionary tale about what I have experienced in dealing with the Virginia Department of Health’s Board of Nursing over my own nursing license—and the records they have of my case. It highlights what I believe to be second victim issues stemming from the unfair abuse of power of such health regulatory boards. It is my personal story, based on my own experience. In addition, it is based on research I have conducted, including interviews and an extensive review of public records relating to my own case. From what I know of the Washington State Department of Health’s Health Professions Regulatory Boards, there are similar—if not worse—issues, some of which have come into play in the recent high-profile cases of nurses at Seattle Children’s Hospital.  That will be a topic of a follow-up post once I have gathered more information on Washington State.

First, here is some necessary background for people who aren’t familiar with health professions regulation. Each state regulates health professionals licensed to practice in their specific state. The main purpose of health regulatory boards is to ensure safe and competent delivery of health care services. Each health care profession or division is charged with regulating its ‘own kind.’ The health regulatory boards are included in each state’s department of health and are governed by state laws. As in all other states’ rights issues, there is variability in quality and oversight of the health regulatory boards, as well as considerable variation within a state in terms of the different divisions. Thus, the common perception that Boards of Nursing are more likely than Boards of Medicine to be overly strict is backed by independent audits.

In my home state (Commonwealth) of Virginia, a Joint Legislative Audit of the health regulatory boards in 1999 found that “The Board of Medicine does not adequately protect the public from substandard care by physicians. It rarely sanctions physicians for standard of care violations.” The Board of Nursing was twice as likely as the Board of Medicine to suspend licenses or impose other extreme sanctions for the similar practice violations.

This is the highly condensed version of my initial saga with the Virginia Health Regulatory Board. As soon as I graduated/got my nurse practitioner license in the Spring of 1986, I ran the Cross-Over Health Clinic at the Richmond Street Center. This was a multi-service center for Richmond’s burgeoning homeless adult population. I was the sole health care provider, with physician back up by telephone. Several volunteer physicians would also have Saturday morning clinic hours for our more medically complex patients. I had written and co-signed practice protocols in place, which were required for nurse practitioners in Virginia at the time (and still are). By the end of our first year, I had seen over 1,600 patients for 4,000 clinic visits. The clinic’s entire yearly budget–including medications– was $30,000.

In early October 1987, I received a surprise visit by an downtrodden-looking field investigator from the Health Regulatory Board. He said they had received complaints from Richmond physicians about my practice, and specifically about the scope of my practice as a nurse practitioner. At the time there were no other nurse-managed clinics in Virginia, and I soon found out why. Powerful physician groups did not want them. This began an almost nine-month saga of informal hearings with the State Attorney General’s office, times of our clinic being closed by the Regulatory Board, and long stretches of wondering if my license (and livelihood) would be revoked. At the beginning of the investigation I had a six-month old son and my clinic job was my family’s only source of income. To state that this time of being investigated by the Health Regulatory Board was stressful is an understatement. I lost so much weight my doctor advised me to stop breast-feeding my son. My marriage disintegrated. I became disillusioned about nursing in general and took pre-med courses and applied to med school. I became homeless. I seriously contemplated suicide. More than a few times.

But here’s the irony. I’ve gotten past all of that. My son survived early weaning and is in graduate school. I own my home and have a reasonably stable job. I have a happy and rewarding long term relationship. I now like and even love nursing. I have almost completed a book about that time of my life. In researching that specific part of my story I realized I never had any closure on it—as in I never received any documentation about the outcome of their investigation. I knew it had ended, as had my marriage, as had my job. But I had no proof, and I was curious to find the documentation of the investigation into my practice.

So in January of this year I sent an e-mail inquiry to Jay P. Douglas, RN, MSM, CSAC (that means, I believe, that she is a certified substance abuse counselor and a nurse midwife), who is the current Executive Director of the Virginia Board of Nursing. I briefly explained who I was, that I was writing a book and wanted to get copies of the records/documentation of the investigation of my nursing license. I didn’t hear back from her, so after a month I called her office. It was lunchtime, but the woman who answered the phone happened to know about my case, as she had typed up my reports back in 1988 (really—strange things like this have happened to me with this book project.) She said she didn’t see why I couldn’t have copies of my own report, but that she’d have to defer that decision to Jay P. Douglas. She told me that Frank M. Cody was the Assistant Attorney General who had investigated my case, and that they had closed the case in May 1988 without a hearing, for insufficient evidence. She added that they now try to hire more qualified field investigators than what I’d had—that back then they hired former food and/or rat control inspectors.

I got a letter dated 2-4-11 from Jay P. Douglas stating, “Please be aware that according to section 54.1.2400.2 of the Code, any reports, information, or records received and maintained by any health regulatory board in connection with possible disciplinary proceedings, including any material received or developed by a board during an investigation or proceeding, shall be strictly confidential. A board may only disclose such confidential information pursuant to an order of a court or competent jurisdiction for good cause arising from extraordinary circumstances being shown. Therefore, I am unable to comply with your request.”

In a follow-up telephone conversation I had with her (very civil conversation by the way), Ms. Douglas said that she had sought advise on this from the Virginia Attorney General’s Office. I pointed out that I wasn’t asking to know individual identifiers of who said what about my practice, but then she said that since I wasn’t a Virginia State resident now, she couldn’t release any information. So as of this writing I still have no written documentation that my case was ever resolved, much less what the ‘case’ really involved to begin with. It makes me wonder what they have to hide. It makes me wonder who regulates the health regulatory boards in our country.