Toe Saga Enters Health Insurance Maze

toes (Photo credit: ribarnica)

The first bill of sorts came today for my young not-so-invincible son for his recent torn off big toe (previous post). The letter is in reference to a $17 radiology charge from the emergency department of the university-affiliated hospital where he was seen. I assume this charge was for flipping the switch to warm up the X-ray machine, but it doesn’t specify what it was for.

The letter came from his student health insurance company. They are requesting documentation that my son’s missing toe was not a preexisting condition. Their specific wording: “Has (dearest son of mine) received any medical care or medicine for diagnosis code 729.5–pain in limb (for the three months preceding the X-ray)?”  Like what, he’s been running around for the past three months with his
toe in the refrigerator just waiting for his health insurance to kick in
so he can have his toe reattached?

Do U.S. health insurance companies purposefully hire stupid people so they can spend even more on administrative overhead and pass those charges on to us, the mostly overwhelmed and confused health care consumers? At least 15% of our country’s total healthcare expenditures is spent on this sort of inept health insurance administration. That’s over $360 billion annually just for paper pushing. Medicare’s administrative costs are less than 2% of total Medicare expenditures. Meaning: that paper pushing can be done a lot more efficiently.

As Jeffrey Pfeffer wrote in his Bloomberg Business Week News article (4-10-13), “Because insurers are paid a fixed percentage of the claims they administer, they have no incentive to hold down costs. Worse than that, they have no incentives to do their jobs with even a modicum of competence.”

A good overview of the obstacles to reducing administrative costs within our healthcare system is included in this brief NEJM article. The authors point out that Obamacare/ACA has some provisions to address these problems. Here’s hoping.

Of Poems, Hearts, and Hands

hand. (Photo credit: bambola_world)

Last week in my narrative medicine course I had two local authors come to class to read some of their writing and lead class discussions. The first guest speaker was Suzanne Edison, a poet and psychotherapist. She also leads Seattle-area workshops
on therapeutic poetry writing with parents of children with chronic illness, as well as with adolescents with chronic illness—at Seattle Children’s Hospital
and at Odessa Brown Children’s Clinic. Suzanne read poems from her two poetry chapbooks Tattooed With Flowers (2009) and What Cannot Be Swallowed (2012).  In our first class session this quarter we had done a close reading of her powerful poem “Teeter Totter.” Students had questions about some of the metaphors and lines in her poem, so last week they were able to ask Suzanne about them directly. (“Teeter Totter” also appeared in Ars Medica, Fall 2009).

Suzanne led the class in a poetry-writing session that she has developed. First, she asked students to write about a time they had an interpersonal conflict of some sort. Then they went through their prose piece and circled four to five words that stood out to them. Suzanne had them do some other tasks in order to come up with an expanded list of words (a dozen or so). Finally, Suzanne asked them to write a poem (in any form) using all of their words. Several students wanted to share part of or the entire poem they had written, and one student commented on how powerful it was to ‘get it out there.’ Students pointed out that reliving the stressful, difficult interpersonal interactions through the poetry exercise brought on stress responses (sweaty palms or changes in heartbeat and breathing), but that writing the actual poem gave them some distance from it and left them feeling more peaceful. Suzanne explained that the poem is a way to create a container for these powerful memories and emotions. One student wrote of this
as “framing the event in the bubble of a poem.”

I prefaced this poetry-writing exercise by letting the students know that what
they wrote was for their eyes only—that I would not ask them to turn in this
writing to me. Suzanne and I had incorporated the same writing exercise last
fall in my undergraduate community health course, when I did ask students to turn in their poems to me. I got feedback from some students that they found this to be intrusive into their personal lives when they didn’t really know me. Duly noted, and very true since it was a class of 150 students (vs. 40 students in the narrative medicine course). So this time around I set the parameters upfront that they wouldn’t have to share their poems with me. Instead, the first writing prompt I gave them for in-class writing was to share a fragment of their poem, or a key word, and to reflect on what surprised them most about what came out of the poetry exercise. This seemed to work out much better. It probably also helped that this class is specifically on narrative medicine, and students expect to do more creative and personal writing in it than they typically do in a more traditional nursing course.

The second guest author was Mary Oak, author of Heart’s Oratorio: One Woman’s Journey Through Love, Death and Modern Medicine (Goldenstone Press, 2013). (see my previous post/book review “Heart’s Oratorio” from 3-24-13). She read passages from her book and answered student questions. As one of the selections she read was about her stay in the ICU and how disorienting it was, students had questions for her about this. They also asked her what motivated her to write the book and about her development as a writer. Since Mary writes about her genetic heart condition and is a mother, students also asked what the ramifications are for her children, and what that feels like now that’s she’s lived through serious cardiac complications. Much of Mary’s book is set in Seattle and she mentions specific hospitals (Northwest Hospital and University
of Washington Medical Center) and some medical personnel by name. This led to an interesting class discussion on the ethics and legalities of nonfiction medical-related writing. Several students mentioned recent ‘compliance trainings’ they’ve had to go through in their jobs as RNs in Seattle-area hospitals, where the message was that ‘they could never ever write about their work in any context whatsoever!’ They were concerned since they were asked to write about their work for class assignments (like for my course). We reviewed the basic parameters on this for academic writing: 1) no patient identifiers such as name, age, super-rare medical condition, etc.; and, 2) no specific names of providers, hospitals, clinics, care facilities—although I acknowledged this can lead to strange permutations, such as “a large Level-I Trauma Center in the Seattle area” (there is only one Level-1 trauma center in Washington State—in fact within a four state radius—and that would be Harborview Medical Center). And then I briefly discussed various legal and ethical parameters as designated by specific journals, differentiating what I was asking them to write about versus writing for publication. I got on my soapbox briefly to rant about how hospital administrators try hard to intimidate nurses (and others even lower in the food-chain) into not writing about their work—but the intimidation is real and nurses can and do lose their jobs over this stuff—and it is easy for me to rant from the relative security of my tenured academic soapbox.

Back off my soapbox, Mary read them a lovely poem by a nurse poet friend of hers, Lise Kunkel, who works in hospice nursing in New York State. The poem had to do with her hands while caring for a hospice patient. So for my last writing prompt I had students think of a significant patient-nurse interaction they had had and to write it from the perspective of their hands: Tell the story your hands could tell. Since I was really stuck back on my soapbox and hadn’t thought through the specific writing prompts I wanted to use for that class session, this one was completely made-up on the spot. I had no idea what students would do with it until I read through their writing this week.

Wow—just wow! That prompt worked, as nurses most definitely identify and
communicate with their hands. Some students wrote from the perspective of their hands: the punishing abuse from the frequent application of hand sanitizer; the uncertainty of where to place their hands during certain patient-nurse or healthcare team interactions; the patient assessment of skin warmth or clamminess or bulges where there shouldn’t be bulges—and, as one student stated, providing “a loving touch, not a medical touch.”

Addendum: I received an e-mail from hospice nurse Lise Kunkel with a link to one of her published poems, “Reading Aloud to Dad (for Jiggs)” in Oncology Times, 3-10-09, vol 31(5),p. 34. She also told me the name of the poem that Mary Oak read to my class last week: “The Hands of a Hospice Nurse.” She uses some of her poems in trainings she does for hospice volunteers through the Care for the Dying Cooperative in NY State. Lucky volunteers and lucky patients….

Heart’s Oratorio

It is Spring Break and instead of heading to warm beaches I’ve been indulging in a massive reading intensive, staying up into the wee hours of the morning IMG_0775finishing book after book as if they were bonbons. Some have been disappointing reads (like biting into a chocolate bonbon only to discover a nasty fake cherry filling): Kathryn Schulz’s Being Wrong, Ryszard Kapuscinski’s Travels With Herodotus, and Michelle Kennedy’s Without a Net). Others have been rewarding, such as Colum Toibin’s The Blackwater Lightship and Ivan Turgenev’s Fathers and Sons. But one book stands out as a keeper and worthy of future re-reads and study: Mary Oak’s Heart’s Oratorio: One Woman’s Journey through Love, Death, and Modern Medicine (Goldenston Press, 2013).

First, a disclaimer. I know Mary from my monthly writing group—the Shipping Group—that meets at my favorite bookstore, Elliott Bay Book Company. Mary is a quietly strong and centered woman. But that is not why I love her book. I love her book because it is beautifully written and tells a powerful and unique medical narrative. I love her book because it helped me to view the medical system from a different perspective.

Mary has died twice in the past decade. The first time she died was in 2007 in the Houston airport while running to catch a connecting flight to Paris. She collapsed in the airport terminal. Otherwise healthy but having asymptomatic ‘athlete’s heart,’ she experienced sudden cardiac death, then was brought back to life through the actions of emergency medical personnel and hospital treatment. Back home in Seattle, Mary underwent two cardiac surgeries at Northwest Hospital. During the second surgery, to implant a cardiac defibrillator, Mary’s heart stopped once again. But that is just the background medical drama of her story. The real story is Mary’s spiritual journey through it all. Mary comes from a long line of homeopath and Christian Science healers and had avoided most all things allopathic. But as she writes, “Nothing like sudden death to invite a different perspective.” Mary’s book is also a love story: her love and care for her children who may have inherited her cardiac condition, as well as her love of David who becomes her husband and cares for her through her illnesses.

Although I neither share Mary’s spiritual beliefs nor her long family history of spiritual healers, I was drawn into a deeper understanding of and respect for them through her story. I can envision using her book in the nursing education that I do. Many parts of Mary’s medical narrative occurred right here in Seattle in hospitals where my students are trained and may eventually work—so it is literally close to home. Mary describes walking past my own university office (in the world’s largest and ugliest university building/photo attached here) on her way to find her medical records:

“Then I walk city blocks’ worth of narrow hallways with low ceilings and polished tan vinyl floors. I pass countless numbered doors. Only one is open: to a room of legless and armless dummies on the floor for a CPR training. No one is there. As I walk past various laboratories and offices, I wonder how much debt I will incur with this latest round of medical consultations. Will I live to pay it off?”

Into the Sunset

dadatbeachIn October 2010 I first wrote about the journey of my elderly father through declining health and the healthcare maze. In my blog post titled A Practical Man and Modern Medicine this is how I started his/our story:

Today on the phone, my 87-year-old father asked me to be his patient advocate. He is facing tough health care decisions over the condition of his heart, and is scheduled for surgery in a week. He is a practical man, bright, charming, and articulate, with no cognitive deficits that I can detect. He told me where his Living Will and Advanced Directives are, where he wants his body donated for medical research, and what to do when his CD matures (he’ll be in surgery) so that he can roll it over to a money market account. He says he needs access to the money for his after-hospital care, in case he survives surgery. I am thinking about the health policy issues within all of this: 1) heart failure accounts for the largest portion of Medicare expenditures, 2) none of his doctors have talked with him about what all is involved with this surgery, or what quality and quantity of life he can hope for afterward, and 3) home care provided by family members is not well supported (financially and otherwise) in our country. As his daughter and as a family member embedded in the health care system, what do I do with this information?

Almost three years later I still don’t know what to do with this information. I have discovered the healthcare system to be even more bewildering and capricious than I had imagined. I last wrote about my father this past fall in the post Transitions (October 22, 2012), when I was back in Virginia helping him survive the rough crossings between four different health care settings in six weeks—the last one being the calmest and sanest of all—home hospice. My father was weak, oxygen-dependent, and had advanced wasting from end-stage congestive heart failure. His cardiologist didn’t expect him to live much past Christmas. The day after hospice started my father used his walker to get from his hospital bed in the living room to the studio in the back of the house. Once there he strapped himself into his recumbent exercise bicycle and started “getting back into shape again.” We all thought he was nuts, but decided if he wanted to die while riding his bike off into the sunset of the studio that was his choice.

Since then he has confounded his cardiologists who say that by all objective measures my father should be so physically disabled as to be bed bound. Instead, he once again ‘graduated’ out of home hospice and as I write this he is riding his ‘real’ bicycle off into the ‘real’ sunset on a beach in Florida to meet up with friends for Happy Hour, sans alcohol for my teetotaler father. The photo to prove it was taken by my niece who is his caregiver for a few weeks.

Clearly my father’s story is not over, even though he has finished writing his memoir in barely decipherable handwriting on ten legal pads, which are in the mail to me. My father wants me to transcribe them and make into a book. “After all, this whole memoir business was your idea,” he said to me. He wants to proofread the final draft to make sure I didn’t change any of his words.

Last fall I wrote an essay titled Home Death about my experiences with the healthcare system, as I tried to uphold my role as health care advocate and proxy for my father. It was published recently in Johns Hopkins Public Health: The Magazine of the Johns Hopkins Bloomberg School of Public Health, Special Issue 2013. You can read it here.

Head, shoulders, (teeth), and toes….

Dentistry logo
Dentistry logo (Photo credit: Wikipedia)

Of all parts of the human body, only feet and teeth have their own separate health care providers. Feet have podiatrists (although they also have orthopedists/medical specialists). Teeth have dentists and only dentists—there are no medical specialty fields that deal with teeth. Oral surgeons may do some crossover work in medicine, but in the U.S. at least they are still considered dentists. As we all know from living in/with our own bodies, feet and teeth have a lot to do with our overall health. I’ll deal with feet in some future posts, but today I want to take a closer look at teeth and oral health.

First of all, why are dentistry and medicine so separate? That seems to stem from a historical artifact, having to do with the history of Western Medicine, the separation of physicians (higher class) from surgeons (lower class, tied to trades). Surgeons—including ones who did crude dentistry—tended to be barbers, blacksmiths, and silversmiths. Supposedly Paul Revere, our Colonial patriot and silversmith also dabbled in dentistry. Revere developed the field of forensic dental science. The father of dentistry is considered to be the 17th Century Frenchman Pierre Fauchard. He encouraged the gargling of human urine as prevention of dental carries. I assume this was before the concept of minty fresh was popularized.

The continued separation of dentistry and medicine is problematic on many levels. It explains why we have separate medical and dental health insurance industries in our country. It explains why dental insurance and dental care are so expensive, and why dental care is viewed as a luxury item available mainly to the rich. It explains why the American Dental Association is engaged in a turf war trying to block the development and expansion of so-called dental mid-level providers (also called “supervised dental extenders” or “dental therapists.”). It explains why nursing and medical students get little to no education or training in oral health.

Dental problems lead not only to pain, infection (including fatal infection), and tooth loss, but they also contribute to the increased risk for serious medical conditions such as diabetes, heart disease, and poor birth outcomes. Poor people, persons of color, immigrants/refugees, and people living in rural areas of our country have a higher burden of dental problems and less access to dental care. In 2009 (latest available stats I could find) there were 830, 590 emergency room visits in our country specifically for dental problems; this was a 16% increase from 2006. The overwhelming majority of dentists in our country are located in affluent suburbs, and most refuse to treat Medicaid patients. The Healthy People 2020 report includes oral health as a leading indicator of U.S. population health, the first time oral health has been included in our national health guidelines.

The ACA has included children’s dental care as an essential health benefit, but worrisome loopholes in the proposed implementation of the law have developed. As currently worded, dental care would be ‘essential’ as long as dental coverage is offered as an ‘add on,’ meaning that parents could opt out of dental care without being assigned penalties. There is also concern that individual and small group markets under ACA don’t have to cover adult dental coverage. (see: “Gaps in health law dental coverage” by Paige Winfield Cunningham, 2/15/13, Politco).

Some of my nursing students have asked me about their potential ability to get more involved in oral health/dental primary care, over and above the usual dental hygiene/ oral health literacy they know they can do. This will vary by state professions licensing/regulatory laws, but in Washington State nurses can and do provide community-based fluoride varnish services for high-risk children and adults:

“Medical personnel working under the delegation of a licensed physician with documentation of completion of a training program on fluoride varnish are also qualified to apply fluoride varnish in health settings.” (source: Washington State Department of Health website, “Fluorides and Fluoridation.”)

Additional resource:

Dental Crisis in America: The Need to Fix Access. U.S. Senate Report. Senator

Bernard Sanders/Committee on Health, Education, Labor and Pensions. Subcommittee on Primary Health and Aging. February 29, 2012.

I Wasn’t Strong Like This When I Started Out: True Stories of Becoming a Nurse


For those of you in the Seattle area who are interested in narrative advocacy from a nursing perspective, save the evening of Thursday April 18th, 2013 . I’m working with Lisa Oberg and Joanne Rich of the University of Washington Health Sciences library to host a nurse writer panel discussion and reading 6-8:30 pm at Suzzallo library, in the Smith Room (photo is of the Smith Room/ free and open to the public). I’ll be there along with some other author/contributors to the anthology True Stories of Becoming a Nurse (see below for information).

The following is the press release for the book.

I Wasn’t Strong Like This When I Started Out:
True Stories of Becoming a Nurse
Edited by Lee Gutkind
Featuring new work by Theresa Brown, Tilda Shalof, and others.

As editor Lee Gutkind points out in the introduction to I Wasn’t
Strong Like This When I Started Out, “there are over 2.7 million
working RNs in the United States (not to mention our many LPNs
and LVNs), compared to about 690,000 physicians and surgeons.
There are more nurses in the United States than engineers … or
accountants and auditors … And, yet, many of us take the work
these men and women do for granted.”

This collection of true narratives captures the dynamism and
diversity of nurses, who provide the vital first line of patient care.
Here, nurses remember their first “sticks,” first births, and first
deaths, and reflect on what gets them through long demanding
shifts, and keeps them in the profession. The stories reveal many
voices from nurses at different stages of their careers: One nurse-in-training
longs to be trusted with more “important” procedures, while another questions her ability to care for nursing home residents. An efficient young emergency room nurse finds his life and career irrevocably changed by a car accident. A nurse practitioner wonders whether she has violated professional boundaries in her care for a homeless man with AIDS, and a home care case manager is the sole attendee at a funeral for one of her patients. What connects these stories is the passion and strength of the writers, who struggle against burnout and bureaucracy to serve their patients with skill, empathy, and strength.
Pub. Date: March 2013, ISBN: 978-0-393-07156-6, 5 ½ x 8 ¼, Trade Paper, 278 pages,
$15.95, Distributed by Publishers Group West

Lee Gutkind has explored the world of medicine, technology and science through writing for more than 25 years. He is the author of 15 books, including Many Sleepless Nights: The World of Organ Transplantation, and the editor of five anthologies about health and medicine, including At the End of Life: True Stories About How We Die.
In Fact Books is a new imprint founded and edited by Lee Gutkind, editor and founder of Creative Nonfiction. In Fact Books titles help create an understanding of our world through thoughtful, engaging narratives on a wide variety of topics and real-life experiences. All titles are distributed by Publishers Group West. For more information, please visit
For interview requests and other media related questions, please contact:
Hattie Fletcher at or (412) 688-0304.
Early Praise:

A startling collection of stories from the bedside.
—Paul Austin, author of Something for the Pain: Compassion and Burnout in the ER

The elephant in the living room of healthcare is that providers care deeply about and are affected by the people they tend. The best ones are, anyway. In I Wasn’t Strong Like this When I Started Out, nurses recall pivotal moments with patients and families that changed them from onlookers to active
participants in the art of healing. This excellent collection chronicles those experiences in funny, eloquent, and often piercing essays. It should be required reading for anyone beginning a career in healthcare—nurses and physicians alike. —Margaret Overton, MD, author of Good in a Crisis

Within these pages, we learn what it is like to protect a dying patient from a futile procedure, to smooth a newborn’s wrinkled brow for a postmortem photo, to work in a foreign country where medical equipment is improvised from household supplies. These stories teach us the essence of nursing—that even when cure is not possible, comfort is. —Catherine Musemeche, MD, surgeon and author

The nurses in this collection bear witness to life, death, suffering, joy—the many aspects of humanity itself. These are no saccharine tales of self-sacrifice, of stereotypical Florence Nightingale-like ladies with lamps. The men and women in this collection tell stories that cut to the bone, exposing their profession’s deep emotional, intellectual, physical, and spiritual trials. Yet, in those struggles emerges great beauty and human connection. This collection exposes not only the strong, beating heart of nursing, but its brain, muscle, sinew and nerve endings—alive, pulsating, raw, real.
—Sayantani DasGupta, MD, MPH, co-editor, Stories of Illness and Healing: Women Write Their Bodies

An honest and compassionate collection of life in nursing. In voices of novices and veterans in the field, it’s an intimate portrayal of how growth is a two way street. Whether listening, touching or just remembering, when you do anything you can to help your patient, your life is also shaped in the process. They are not just lessons, but gifts, that transcend any hierarchy in medicine.
—Gulchin A. Ergun, MD, Clinical Service Chief, Gastroenterology

Like most physicians, I have a long list of nurses who have mentored me, influencing my practice of medicine in the way they live their lives and care for their patients. This book is a testament to those wise nursing colleagues–and to the paths that have brought them their wisdom.
—Marion Bishop, MD, PhD, Emergency Medicine physician and essayist

With tenderness, honesty, humor, and some anger, the authors of these engaging essays draw us into the complex beauty of nursing from an exhilarating variety of perspectives. This welcome, eye-opening collection should be required reading for every medical student and apprentice hospital administrator.
—Margaret Mohrmann, MD, PhD, University of Virginia

In these powerful narratives, twenty-one nurses unfold what it means to practice their profession: what they are thinking and feeling when they care for patients and when they go home, how they came to choose this difficult and rewarding career, their satisfactions and frustrations, their triumphs and traumas. Moreover: they write exceedingly well.
—Charles Bardes, MD, author of Pale Faces: The Masks of Anemia and Essential Skills in Clinical Medicine

Poignant recollections from often ignored voices in medicine. These wonderful stories resound with truth. —Sandeep Jauhar, author of Intern: A Doctor’s Initiation

Note: My essay “Next of Kin” is included in this anthology. I am the “nurse practitioner wonders whether she has violated professional boundaries in her care for a homeless man with AIDS” included in the book blurb above.

In order to complete the sites visits and other research necessary for writing my essay, I received a 2011 Individual Artist Award from 4Culture. Therefore, this project was supported, in part, by an award from 4Culture; thank you 4Culture.4culture_color


Hospital Quality: A Different View

Paul Farmer (of Partners in Health fame) has an easy-to-apply formula for DSC00749quickly assessing the quality of hospitals or clinics anywhere in the world. He says that given the resources of the country, he looks at the quality of the hospital/clinic bathrooms and the gardens surrounding it. Based on just those two items, he claims he can accurately assess overall hospital/clinic quality—and afterwards correlate it with more ‘objective’ measures of quality and safety. Try out his quality assessment at your own hospital/clinic work-site, and maybe as a New Year’s resolution try to influence improvements.

My office at work is in the world’s largest university building: the Warren G. Magnuson Health Sciences Building at the University of Washington. The building has close to 6,000, 000 square feet of space and is composed of over twenty wings whose hallways are connected, but in a haphazard, disorienting way. The building is an Escher-esque sort of place, with faceless people wandering the hallways and strange concrete staircases going everywhere and nowhere. Ten thousand or so people work (or are hospital patients) in this building. At any given time at least half of the people are lost. I am usually one of them. The building includes a hospital and four health science schools—medicine, nursing, public health and dentistry. The fifth health science school—social work—was lucky and is far across campus in its own (very small) building.

The Health Sciences Building is sandwiched between three busy streets and one busy ship canal. Many of its courtyards are completely covered in concrete, with only a few stalwart and scraggly rhododendrons popping up in places. The bathrooms are tiled and painted a sickly yellow-beige that reminds me of public high school gym locker rooms.

My office is in the ugliest wing of the world’s largest university building. My office has a fault line running through it. There is a 6-inch wide grey rubber seam that bisects my office in two—it runs up one wall, across the ceiling, down the other wall, and across the floor. This rubber seam is the building’s earthquake shock absorbers. I often wonder what it would be like to stand on the fault line during an earthquake. Would I be safer there than ducking under my fake-wood desk? My office also has a door that goes nowhere. Supposedly it allows access to various pipes and electrical wires in the concrete-encased outer phalanges of the building. This door is perpetually locked and I have hung a silk scarf over it to make it seem less weird. I tell students it’s where old faculty members go to die. I often want to crawl in there and take a nap.

The particular part of the Health Sciences building I work in, the T-wing, was built in the late 1960’s and is a prime example of Brutalism. It is also a prime example of why Brutalism is not an architectural style suited either for Seattle weather or for being attached to a hospital. Outside and inside it appears to be made of crumbling, damp and moldy concrete. In one staircase I use there are arm-sized stalactites forming on the ceiling and liquid is perpetually dripping from their pointed ends into a black and green puddle in one corner of a stair landing. It has a bizarre beauty. Over Winter Break the stalactites were removed and the ceiling painted over. I find that I miss them.

University of Washington Medical Center does fairly well on most quality measures included in Medicare’s Hospital Compare. Under ‘patient satisfaction survey’ they include an item on cleanliness of bathrooms. (Gardens aren’t included). If you haven’t used this website before, I encourage you to do a search of hospitals in your area. They have recently added a section on hospital readmission rates.

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).

April Fool

April 16th is the fifth annual National Healthcare Decisions Day (NHDD). According to their website, the mission of NHDD is “to inspire, educate & empower the public & providers about the importance of advance care planning. National Healthcare Decisions Day is an initiative to encourage patients to express their wishes regarding healthcare and for providers and facilities to respect those wishes, whatever they may be.” Nathan Kottkamp, a lawyer who specializes in health care law is the founder and chair of NHDD. In an interview on AARP News, Mr. Kottkamp reports that he launched NHDD in Virginia in 2006 and expanded it nationally in 2008. He chose April 16th, the day after “tax day” because of Ben Franklin’s aphorism “Nothing can be said to be certain except death and taxes.”

Advance medical directives including living wills and health care proxy/agent/power of attorney (who a person wants to make health care decisions for them in case they are incapacitated), are important legal documents recognized (in differing degrees) in all 50 states. At least in theory, having an advance medical directive helps patients have more say in how they die—whether, like the emergency department physician Boris Veysman they want “Shock me, tube me, line me” (Health Affairs, Feb 2010, vol 29(2): 324-326), or like other people they do not want medical procedures that artificially prolong the dying process. And designating a health care proxy—again in theory—helps to avoid unnecessary confusion in health care communication, especially in emergency situations.

I applaud the work of Nathan Kottkamp and others like him to bring greater awareness to the general public about end of life decision making. But as I am currently experiencing, the health care system is not cooperating with sane implementation of the Advance Medical Directives.

Five blocks northeast of Nathan Kottkamp’s law office in Richmond, Virginia is the main hospital of the Virginia Commonwealth University (VCU) health System. My elderly father is now a patient there, after experiencing confusion and shortness of breath at home (from congestive heart failure) and calling the ambulance to take him to see his cardiologist at VCU. Less than two years ago I was with my father in the VCU hospital admission’s office when he was being admitted for possible cardiac surgery. My father had the original copy of his Virginia Advance Medical Directive/Living Will/Appointment of Health Care Agent. My father and I had gone over specific medical procedures—such as resuscitation, mechanical ventilation, and ‘tube’ feeding—with his wonderfully patient and competent primary care physician (who praised my father for having this important conversation and for doing his Living Will).  My father came to VCU hospital fully prepared. His Medical Directive five page document was witnessed/signed by two of the VCU Health Systems hospital admission’s office officials. They made photocopies to give to me and promised the legal document was now part of my father’s hospital medical record. My father named me as his health care agent.

Imagine my surprise yesterday when I was notified by my father’s neighbor that my father had been whisked away to VCU emergency department. But I was even more surprised when I called/talked with a clerk at the VCU ED and was told that to protect patient privacy the nurses/medical staff couldn’t tell me anything about my father—that she wasn’t even supposed to tell me if he was there or not. It did no good when I informed her I was his health care proxy—she said they had no proof of that. He was admitted to the cardiac floor and I was finally able to talk with his nurse (using a special secret HIPAA/patient privacy code—really? The lawyers interpreting HIPAA for hospitals are getting quite creative). She informed me that they had no record of my father’s Medical Directive so he was “full code.” When I told her I had a photocopy of the Medical Directive in front of me and that it was signed by their hospital admission’s department personnel she said, “That doesn’t matter. We get rid of all of that in the medical record and start all over again.” She said that my father should have brought a copy of his Medical Directive to the hospital with him—it was his fault he didn’t have it. I kept expecting her to exclaim “April Fools!” but she didn’t.

So, on April Fools’ Day, I’d like to amend Ben Franklin’s aphorism to proclaim: In this world there is nothing certain except death and taxes and the fact that our US health care system is one crazy-making system…..

(If you haven’t seen/read Atul Gawande’s terrific New Yorker Essay 8-2-10 on end of life decision making ,“Letting Go, What Should Medicine Do When It Can’t Save Your Life?” I highly recommend it. Also see the recent NYT Op-ed piece 3-30-12 “Taking Responsibility for Death” by Susan Jacoby).

Hospital and Doctor Compare: Patient Beware

Patient Recognition Month Poster
Patient Recognition Month Poster (Photo credit: Army Medicine)

Nurse and NYT’s Well Blog contributor Theresa Brown has a NYT Op-ed piece today entitled “Hospitals Aren’t Hotels,” in which she states “…the growing focus on measuring ‘patient satisfaction’ as a way to judge the quality of a hospital’s care is worrisomely off the mark.” She points to the patient satisfaction section of The Centers for Medicare and Medicaid’s Hospital Compare website, where consumers can look up individual hospital quality of care information. Based on Medicare patient data and hospital reporting mechanisms, Hospital Compare includes process and outcome of medical care measures, use of medical imaging, patient safety measures, Medicare payment/volume, as well as a 10-item survey of patient’s hospital experiences.

It is instructive to note that patient satisfaction is only one of six categories of quality of care data on Hospital Compare from which consumers can make more informed medical care decisions. Obviously it is only useful for planned procedures and hospitalizations, since patients having a heart attack aren’t likely to stop and look up Hospital Compare data on their iPads. I used Hospital Compare several years ago when my sister asked my advice as to Seattle-area hospital choices for her planned abdominal hernia repair. At the time, Swedish Hospital had the highest volumes and best patient outcomes (including patient safety) for this surgical procedure, so my sister then picked a surgeon from their list. She had a decent hospital experience. Today for grins I pretended I needed to have laparoscopic gallbladder removal (I don’t) and ‘shopped’ for Seattle-area hospitals based on this specific procedure. Of the three geographically closest hospitals—Group Health Central, Northwest, and University of Washington Medical Center (UWMC), Group Health came out the clear winner overall for quality of care measures that are most meaningful to me: patient safety (UWMC is worse than national average for hospital acquired conditions such as infections and things besides vital organs left in after surgery—and for the ominous sounding “accidental cuts and tears from medical treatment”), having medications explained to me before they are given, nurses and doctors who communicate with patients well, and the area around patient rooms being quiet at night.

It can be and is argued that patient satisfaction with care is not a valid measure of outcome of medical care. I know from teaching that I can make my students happy and get high ‘student satisfaction’ with teaching scores, and still not have done my job of actually teaching them anything of importance. In her NYT Op-ed piece today, Ms. Brown uses an example of an elderly cancer patient who was told by the hospital oncologist that he was basically too old to qualify for treatment and was sent home. He may have not scored that hospital very high on his Medicare hospital survey, since he didn’t get what he wanted. Ms. Brown links to a recent study by Joshua Fenton at UC Davis showing that higher patient satisfaction scores with individual doctors was linked with greater use of hospital services (higher medical cost) and increased mortality. To me that’s a no-brainer and points to the danger of overuse of health care—more health care is not better health care, and health care can be dangerous to your health.

US doctors have been fighting consumer ratings of individual doctors. (see Ron Lieber’s “The Web is awash in reviews, but not for doctors. Here’s why.” NYT, 3-9-12) The developer of the online site created now includes ratings of close to 1.4 million physicians in the US and Canada. The founder of gets at least one lawsuit threat a week from physicians who don’t like what’s been posted about them. A physician reputation management service, Medical Justice, set up a system whereby physicians had patients sign a “no web posting opinions of the doctor” agreement in exchange for enhanced patient privacy protections. That’s almost like a restaurant owner asking you to sign an agreement not to post a review on Yelp in exchange for not putting flies in your soup. The Medical Justice system collapsed after a complaint was filed with the Federal Trade Commission.

Insurance companies and health plans collect consumer ratings and medical outcomes data for individual doctors and other providers, but they don’t make these data available to consumers. With the Affordable Care Act/health care reform, starting January 1, 2013, Medicare will be required to provide consumers more information on doctors as well as on hospitals. (As of this writing, they have a “Physician Compare” site, but it only allows searches to find physicians who accept Medicare.) I disagree with Theresa Brown on this issue. I think that patient satisfaction as one aspect of judging the quality of hospital or other medical care is essential for improving our health care system. It is an essential component of patient-centered care.