Red Blanket Patients

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Very Important Patient red blanket. Photo credit: Josephine Ensign/2016

Although one of our country’s founding principles centers on equality, we know that has always been a lofty goal, and one that conflicts with our real guiding principle of rugged individualism combined with economic competition.

Money talks. Money yells. Money gets you red blanket treatment in many of our country’s hospitals. I’m sure the ‘real’ red patient blankets are much prettier than the swatch of one I knitted and embroidered for this photo, but they do exist both literally and metaphorically–and historically. Red blanket treatment’ of patients has historical roots in pre-WWII emergency medicine practice: a red blanket was placed over a patient triaged as needing rapid transfer to a place of higher-level treatment and attention. Presumably, this older type of ‘red blanket treatment’ was done based primarily on medical need and not on patient socio-economic status.

A different version of ‘red blanket’ VIP (Very Important Patient) hospital practices seems to be proliferating. ‘In the NYT Op-ed article “How Hospitals Coddle the Rich” (October 26, 2015), by Shoa Clarke, a physician currently doing his residency at Brigham and Women’s and Boston Children’s hospitals, writes of his experience during medical school (at an unnamed but readily identifiable hospital in California–as in Stanford) of being introduced to the concept of tiered care in hospitals where hospital administrators draped wealthy patients in scarlet blankets to help ensure they got better care. “This is a red blanket patient,” one of his supervising physicians reportedly said. Such red blanket patients are fast-tracked and given preferential treatment based solely on their wealth and status.

In a follow-up post related to this topic on KevinMD, a dermatology resident physician and medical school classmate of Clarke’s, Joyce Park, contends that she has never seen red blanket VIP patients getting better hospital care than other patients. In her very telling statement, “I have not seen this happen, from the level of nursing all the way up to the attending physicians” she manages to sum up the worst of hospital hierarchy-think and to come across as impossibly naive. (“The Problem with VIPs in the Hospital”, November 15, 2015.) Of course VIP patients get better hospital care, at least in terms of an increase in prompt nursing attention (and probably much lower RN to patient staff ratios), as well as more ‘discretionary’ medical and surgical interventions.

What’s ironic with this equation is that while the improved nursing care translates to improved patient outcomes, an increase in medical surgical interventions typically translates to worse patient outcomes. When nurses go on strike, hospital patient mortality increases; when doctors and surgeons go on strike, hospital patient mortality decreases or stays the same. (See the recent multi-country research study results reported in the British Medical Journal, “What are the consequences when doctors strike?” by Metcalfe, Chowdhury, and Salim. November 25, 2015/ and “Evidence on the effects of nurses’ strikes” by Sarah Wright in The National Bureau of Economic Research.)

The reason for this difference most likely lies in the fact that more medical and surgical care does not mean better health care or better objective health outcomes. As reported in a 2012 Archives of Internal Medicine article, “The Cost of Satisfaction,” (by Fenton, Jerant, Bertakis, and Frank) a study using a nationally representative sample found that higher patient satisfaction (with physicians) was associated with increased inpatient utilization and with increased health care expenditures overall and for prescription drugs. Patients with the highest degree of satisfaction had significantly greater mortality risk. The researchers postulate that patients with more clout who can cajole their physicians into giving them more medications and more discretionary medical-surgical interventions may be more satisfied with their care by physicians, but are also more likely to die from iatrogenic causes.

Perhaps–even if you can afford VIP/concierge/red blanket patient care–you should think twice about what you are really buying. And perhaps as a country we should think about where we’re headed with such an increasingly stratified healthcare system.

The Exquisite Corpse Hits the Hospital

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“Imprint of the Intangible” Mixed media, 2000, Heather Hawley. University of Washington Medical Center.

The exquisite corpse is a French surrealist parlor game named after one of their first nonsensical collaborative sentences, “The exquisite corpse will drink new wine.”  There are written and arts-based (including drawing, collage, sculpture, theater, and dance) versions of the exquisite corpse. They all emphasize elements of unpredictability, collaboration, and tapping into unseen/subconscious sources of creativity. And just plain fun.

This summer I adapted the written version of the exquisite corpse for use in the hospital-based narrative medicine/health humanities course I am teaching. I first had students divide themselves into groups of 4-5 people, each person with a clean piece of paper. Then, I asked them to write one sentence across the top of the paper and base the sentence on one concrete observation about their classroom. I gave them 30 seconds to write the sentence and then asked them to pass their papers to their right. They had another 30 seconds to write a second sentence in response to the first. Before passing the paper again, they were asked to fold down the paper in order to hide the first sentence. We repeated this exercise a total of five times. At the end, they could unfold their papers, read, and share with the class what the group had come up with based on their initial sentence. Much laughter ensued. Then, I had each student write a short reflection on what the experience was like for them.

I learned this classroom version of the exquisite corpse at the 2015 Chuckanut Writers Conference from two writers/creative writing teachers, Brenda Miller and Lee Gulyas, who both teach at Western Washington University in Bellingham. Miller and Gulyas have a recent collaborative essay, “Come Closer,” published in Sweet: A Literary Confection (vol. 7, issue 3, 2015) and an intriguing interview by Carmella Guiol with them about this essay and their collaborative process (July 16, 2015). In their workshop, we were all writers of various sorts, and the prose/poetry pieces our groups came up with were quite funny, creative, and profound.

As were the pieces that my students produced, although they mostly were much more matter-of-fact and not as fanciful as I expected them to be. These were nurses after all–nurses tasked daily with life and death decisions. Flights of fancy and parlor games are typically frowned upon among health care providers. But, since teaching is in itself a creative endeavor, I try to take calculated risks in the classroom and try new things. For this one I’d give myself a B+ for effort.

Feedback from the students (from their written reflections) ranged from, “this felt like a drinking game” (note: no alcohol was consumed in the auditorium as far as I know), through “I don’t understand why we did this exercise,” to perhaps more insightful, critical thinking responses including these:

“Even though we are talking about the same topic we said or have different points of view about our classroom. How we described it is different person-to-person. This is common in workplaces, like when we have to write up patient care plans, we hardly agree on them.”

“I enjoyed the spontaneity of doing this exercise. So much of our class work and assignments has been related to following directions exactly and making sure we are doing everything right.”

“I’m thinking this would be a good tool if I was leading a patient support group or leading a class. Patients with chronic illness get told all the time about what it the right thing to do and this could be used to let them tell their stories a different way.”

In thinking over how this went–my first attempt at doing the exquisite corpse exercise with a group of hospital-based nurses–I’ve realized I probably need to fine tune it for this setting and for these ‘parlor game’ players. Next time I would keep everything the same with the exception of the initial sentence writing prompt. Instead of having them write about their classroom, I’d ask them to write a sentence about a recent frustration at work–and that it can be a minor and seemingly frivolous frustration (in oder to keep it from getting too deeply emotional for this collaborative writing exercise). My aim would be to have it more directly pertinent to their work as nurses, while maintaining the fun, spontaneity, and collaborative nature of the exercise. As physician-educator and innovator in the health humanities Alan Bleakley says, “health humanities creates a serious play space.”

The Color of Hospitals

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Detail from “The Truth and Nothing But the Truth” mixed media installation, 1989, Gayle Bard. Main lobby of the University of Washington Medical Center.

What is the color of hospitals? For most people it’s that peculiar, putrid-green of hospitals we now associate with the movie One Flew Over the Cuckoo’s Nest and other nightmarish, disorienting places of illness, distress, disease, and death. The fact that Martha Stewart has revived the shade, renaming it ‘Sea Glass Green,’ and making it oh-so-hip-retro mixed with ‘Jadeite’ green, doesn’t make it much better.

I did a bit of historical research into ‘hospital green’ for an essay I am writing called ‘Medical Maze,’ about the disorientation caused by our modern health care system for patients, families, staff, and students. Over my years working and teaching and researching within health care, I had heard rumors now and then that the hospital green had something to do with blood. Turns out, these rumors were correct.

Much of our modern health care system–especially the growth and technological advances within health care–come from wars. Hospital green, originally called ‘spinach green,’  was invented during WWI by the American surgeon Harry Sherman. At the time, most all surfaces of hospitals and clinics were painted white, the color associated with purity and cleanliness. Dr. Sherman, who was busy doing numerous surgeries in St. Luke’s San Francisco hospital, found the contrast of blood against the white sheets and walls and staff uniforms to be too glaring. He couldn’t discern the fine detail of the anatomy of patients necessary for successful surgeries. So, using color theory, he experimented with different colors and in 1914 he came up with the ‘spinach green’ as a complement to blood red. He convinced the hospital to help him create a totally green operating room–walls, sheets, and the surgeon’s uniforms. I imagine though, that the St. Luke’s nurses kept their white hats and uniforms. The ‘spinach’ hospital green quickly spread to other hospitals across North America.

At around the same time, the East Coast-based hospital architect, William Ludlow, also advocated the use of ‘calming green’ within hospitals, as well as other ‘colors of nature’ including “…the glorious golden yellow of sunshine.” (Note, this is not the sickly jaundiced yellow of the hospital and health sciences complex I currently work in.) Reading some of what Ludlow wrote about hospitals, I’ve discovered a strong liking for the man. In an article he wrote in 1918 in The Modern Hospital, he states, “the word ‘hospital’ brings to mind a huge caravanary of austere aspect without and glaring white sterility within, a pile without cheer and without welcome.” He goes on to point out that hospitals at the time were built around the mass casualty wartime hospital model, and thus were not designed with individual health and well-being in mind. The title of his article (and speech before the Twentieth Annual American Hospital Association meeting) was: “In Time of War Prepare for Peace–War Time Psychology Forced Us to Think of Men In Terms of Groups, But it is Individual Soul That Counts In Every Sphere–Including Hospitals.”

 

Hospital Healing Gardens

Sheltering Arms Hospital labyrinth and park. Richmond, Virginia. Photo credit: Josephine Ensign/2014

Our hospitals are bustling, intimidating, drama-filled, miraculous, expensive, technology-driven, antiseptic, and confusing places. Anything that can make them more ‘grounded’ and healing should be a welcome thing.

The first photo here is of the walking meditation outdoor labyrinth and wheelchair accessible park/paracourse that was associated with the (now closed) Sheltering Arms Hospital in Richmond, Virginia. This is where I would go for stress-reduction and perspective-seeking when I worked as a rehab nurse at the hospital (1980s), and then much later when my father was in home hospice nearby.

Paul Farmer, physician, anthropologist, global health activist, and founder of the Harvard-based Partners in Health, says that he has two main markers of quality of health care in a hospital that he visits anywhere in the world. His are not the usual quality of health care indicators those of us who work in health care and health services research think of. For hospitals, these include such things as: 1) timely and effective health care for conditions such as heart attack, 2) lower complications (and deaths) from surgeries, 3) lower hospital-acquired infections, and 4) patient report of good communication with doctors and nurses (see the very useful and consumer-friendly online tool based on national Medicare data, Hospital Compare). No, for Dr. Paul Farmer a hospital’s restrooms and gardens are what reveal its overall quality of care.

The fascinating topic of restrooms I will leave for another time, but hospital gardens are something I want to focus on here.

Modern hospitals trace their roots to the cloistered buildings of religious monastic orders that took in those too poor or disabled to be taken care of in their own homes by family members. These early hospitals were often built around a courtyard with a medicinal/herb garden, fruit trees, and a kitchen garden.

Garden of the Hospital in Arles 1, by Vincent Van Gogh. Public Domain license Wikimedia Commons.

The hospital healing garden shown here was an inner courtyard garden of the psychiatric hospital in southern France where Vincent Van Gogh was a patient. The view is from his hospital room. He also painted his famous series of blue irises from the hospital’s gardens. In letters he wrote to his family, he relayed how these gardens were an important part of his tenuous hold on mental and physical health.

Florence Nightingale knew the importance of nature in hospital reform and redesign. She emphasized the role of fresh air, sunlight, flowers, and of patients being able to see out of the window instead of looking at a wall. “She wrote, ‘I shall never forget the rapture of fever patients over a bunch of bright-coloured flowers’ she noted, adding ‘people say the effect is only on the mind. It is no such thing. The effect is on the body too'”(quote from the Wellcome Trust blog post ‘Why every hospital should have a garden,‘ 11-8-13). I wonder what Nightingale would say about our ‘modern’ hospitals banning the delivery of fresh flowers or plants to patients for fear of allergies or mold or whatever it is they fear.

Yesterday I went in search of the healing garden at the University of Washington Medical Center (UWMC) where I work (and where I have been a patient–for a bit more on that see my Medical Maze photo description in Pulse: Voices From the Heart of Medicine 1-23-15 ). I remembered it as an almost shockingly calming and contemplative space near the coffee shop adjacent to the main surgery wing. The UWMC healing garden was a rooftop garden designed by local UW landscape architect Daniel Winterbottom who specializes in healing/restorative gardens. I sought the healing garden in vain, as it was torn down several years ago to make room for yet another wing to this already massive hospital and medical center (at over 6 million square feet of mostly concrete, the UWMC/Health Sciences complex is the world’s largest single university building). The very helpful UWMC information desk staff directed me to this spot (see photo below) as the ‘backup’ healing garden. It appears to be a series of mud puddles with a no smoking sign and smokers happily puffing away. Clearly, there’s much work to be done.

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UWMC mud puddle ‘healing garden.’ Photo credit: Josephine Ensign/2015

Resources:

The Therapeutic Landscape Network has a searchable index ‘Gardens in Healthcare and Related Facilities.’

An excellent (and expensive! see if your local library has/can get a copy) book on the topic is Therapeutic Landscapes: An Evidence-based Approach to Designing Healing Gardens and Restorative Outdoor Spaces, by Clare Cooper Marcus and Naomi Sachs (Wiley: 2013). It includes an extensive collection of case studies of different types of healing and therapeutic gardens associated with hospitals, rehabilitative facilities, nursing homes, and hospices.

A Practical Man and Modern Medicine: The Ending

IMG_2700 - Version 2My father died this morning. He died peacefully in his bed at home surrounded by family members, trusted caregivers, and my late mother’s artwork. This photo, which I took a few weeks ago, shows my father ‘getting his daily exercise’ doing laps inside his house using his walker, under the watchful eye of my mother (the painting is her self-portrait about her own heart disease). My father died from the effects of congestive heart failure. When he died, my father wasn’t exactly wearing his boots and gardening gloves, but very close to it. Our family harvested sweet potatoes yesterday from my father’s backyard garden.

Four years ago, when I began this Medical Margins blog, my first post was about my father’s (and our family’s) struggle to negotiate a dignified and peaceful home death for him amidst the Kafkaesque nightmare of our health care system. (See “A Practical Man and Modern Medicine” 9-26-10). I also wrote an essay about my slightly Quixotic efforts to be my father’s cross-country patient advocate and health care proxy through his countless hospitalizations and transfers in and out of nursing homes and home heath care. (See “Home Death” in The Johns Hopkins Public Health Magazine, Special Issue 2013).

During his last hospitalization (a bounce-back hospitalization after only two days at home and before hospice was finally ordered), my father was moved to six different hospital rooms on the same cardiac floor in less than a week. He became more and more distressed and disoriented with each move. He was being treated with three different antibiotics (two IV) for two different hospital-acquired infections. This was despite the fact that my father had clearly documented Advance Directives requesting none of these unnecessary ‘heroic’ measures. It took a direct plea from me to the head of cardiology to have the antibiotics discontinued and my father released to home hospice. That was only three days ago. His (nonprofit, religious-based) home hospice was terrific.

I’ve realized during this final surreal (is ‘Woolfian’ a word? it should be–it has felt very much like her writing in The Waves) month, that we have created a Frankenstein monster: ‘the creature’ or ‘the wretch’ of our health care system (especially the hospital). I’ve realized that my frustration and anger over my father’s end-of-life care is not as simple as displaced grief over losing my father. My anger can not be directed at any one physician or nurse or hospital. Rather, my anger is really dismay (bordering on despair) that I–that all of us– can have been a part of the maintenance of such a sad and broken wretch. Apart from putting all of our hospitals and nursing homes on (the melting) ice flows along with Frankenstein’s monster, what can we do to reform and redeem this creature we have created?

To the Reverend John Edward Ensign, my force-of-nature father: rest in peace.

______________________________

*The Institute of Medicine just released a fascinating study addressing this problem and question: Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life, 9-17, 2014.

** The NYT recently published a Pulitzer-worthy article by Nina Bernstein: “Fighting to Honor a Father’s Last Wish: To Die at Home” (9-25, 2014).

 

Got Medicaid (Expansion) Virginia?

DSC00367_2My hometown of Richmond, Virginia is fond of putting large statues of white men on horses in the middle of its streets. Richmond is also the setting for a political and health care drama of Southern Gothic proportions. Virginia is an ACA non-Medicaid expansion state, but the state’s leaders have been debating Medicaid expansion over the past year. Earlier this month Phillip P. Puckett, a Virginia Democratic state senator, suddenly resigned to take a job on the Virginia tobacco commission. Curious circumstances surrounding his resignation have led to an investigation by the U.S. Department of Justice and the FBI, as reported in this recent Richmond Times Dispatch article. His resignation flipped control of the Virginia State Senate to Republicans intent on blocking Medicaid expansion efforts. Today Virginia Governor Terry McAuliffe announced his plan to bypass the recalcitrant Republican General Assembly and expand Medicaid to 400,000 low-income Virginia residents. (see: Modern Healthcare Va. Governor to Bypass Lawmakers, Expand Medicaid, 6-20-14). Governor McAuliffe also plans to block funding a $300 million facelift of the Capitol complex where many of the lawmakers have their offices. The bright and shiny Virginia State Capitol is shown in this photo I took about a year ago.

Medicaid plays vital roles in people’s lives and in our health care system. Medicaid improves access to basic health care services for millions of our children, low-income adults, the elderly (long-term care services), and people with disabilities. Medicaid saves lives. Medicaid funds large portions of our public hospitals, health centers, and nursing homes. Without Medicaid, most of our children’s hospitals would be forced to close.

Several of my struggling small business owner nieces and nephews who live in Virginia would benefit from Virginia’s Medicaid expansion. My elderly father who lives in Richmond would benefit from Medicaid expansion for long-term care services not covered by Medicare. My own son who lives in our Medicaid expansion state of Washington is about to get Apple Health, our version of Medicaid because the University of Washington has ended their student health insurance plan–or at least what was masquerading as a health insurance plan (see my previous post, “My Young Invincible, His Lost and Found Toe, and University Health Insurance that ‘Technically Isn’t'” 4-23-14).

Virginia and other Southern states have high ratios of physicians to the general population, yet have the worst poverty and shortest life spans of any region in the U.S. Virginia has the second highest number of free clinics in the country. North Carolina has the most and Georgia is close to Virginia’s number. Most of the free clinics are faith-based and pride themselves on not accepting any ‘government handouts.’ This generally includes the clinics not accepting Medicaid or Medicare reimbursements. These Southern states are part of the Black Belt of entrenched poverty and severe health inequities. Are free health clinics part of the solution or part of the problem?

The deeply entrenched American notion of charity care as the way to provide safety net services engenders stigma, shame, dependency, and resentment among recipients. Charity care is especially pronounced in the Bible Belt South. People do not want to have to depend on the kindness of strangers. Charity care further fragments an already fragmented, disorganized health care system. Charity care clinics have to compete for donations, grants, staff, and patients. Charity care further fragments and separates us as members of society—sorts us into the haves and the have nots, into worthy and unworthy citizens. Charity care perpetuates poverty. Despite compassionate staff and health care providers, charity care is always leftover care, afterthought care, second-rate care. Charity care gets discouraging, both to give and to receive. I know this first-hand, having been on both the giving and receiving ends of charity health care.

Medicaid and Medicare are both basic entitlements; they are not charity care. So Virginians, come down off your high horses and get Medicaid expansion.

The Changing Landscape of Health Care Jobs in the United States

IMG_2285Attention all new nursing grads and other health care job-seekers: Today in the NYT there is a fascinating interactive feature “How the Recession Reshaped the Economy, in 255 Charts” by Alicia Parlapiano and Jeremy Ashkenas. It helps illustrate where the health care jobs are in our country, what the average salaries are within different sectors of the health care system, and what the trends are in terms of growth (or decline) of the different sectors.

Using data from the U.S. Bureau of Labor Statistics, the authors illustrate in easy-to-read charts how the number of jobs have changed for a particular industry over the past decade. These data are only available for private industries, so for health care, public health jobs are (unfortunately) not included. The only middle-wage private industries that did not lose jobs during the recession were those within health care.

One of the charts is titled The Medical Economy and here is what stands out to me:

  • Health care industries that were relatively unaffected by the recession and that have shown steady growth include home health care services, outpatient care centers (both general outpatient care and ones specific to mental health), and physician’s offices.
  • Health screening programs (including blood and organ banks) have recovered and grown.
  • Psychiatric and substance abuse hospitals have recovered and grown.
  • General medical-surgical hospitals remained relatively unaffected by the recession but appear to be mostly flat in terms of growth.
  • Specialty hospitals (excluding psychiatric and substance abuse) have recovered and grown, but they have shown a substantial decline in jobs since March 2012 (with a small blip back up over the past few months). I would imagine these changes for specialty care hospitals are correlated with the roll-out of ACA, especially changes to Medicare reimbursement for hospital care.

Take home lesson for people in the job-search mode within health care: Follow the money and look for jobs in the economically healthier parts of the U.S. health care system. Don’t rely on hospitals as the only places for job-searching.

Take home lesson for those of us in the role of nursing (or other health care professions) education: These ‘hard’ economic data provide even more good reasons to recruit and prepare students for work in primary care, community-based, non-acute care settings.