Narrative Medicine Collection

product_thumbnail.phpHere are a few of my current favorite narrative medicine/medical humanities things:

  • Heart Murmurs: What Patients Teach Their Doctors (UC Medical Humanities Press, 2014). This new collection of personal narratives by physicians, edited by my colleague Sharon Dobie, MD, a family medicine doctor who teaches and practices relationship centered care. In these essays Dr. Dobie and thirty-five other physicians explore lessons they’ve learned from patients.
  • Those whacky and wonderful Brits have a much better health care system than we do, and they have this wonderful new (creative) collection (is it a book? is it a collage?) on medical humanities. Published by the Wellcome Collection, Where Does It Hurt? The New World of the Medical Humanities is both entertaining and thought-provoking. (While you’re at it, spend some time browsing their website for fun quizzes, interactive educational games, videos, and more). Here’s what they say abut the book:
    “What does it mean to be well? Or ill? And who, apart from you, really knows which is which? Contemporary definitions of medicine and clinical practice occupy just one small corner of a vast field of beliefs, superstitions, cultures and practices across which human beings have always roamed in the search to keep themselves, and others, feeling well.The label ‘medical humanities’ is the best effort we’ve made so far to define the fence that encloses that very large field; recognising that it’s a space in which artists, poets, historians, film-makers, comedians and cartoonists – in fact every one of us – has as much right to explore as any humanities-schooled or clinically trained professional. This book is a walk through that field, a celebration of its rich diversity, a dip into some of the conversations that are going on within it, an attempt to get it in perspective – and an invitation to you to join the conversation yourself.”
  • The always friendly folks in the middle of cornfields in Iowa (University of Iowa) put on a terrific annual narrative medicine conference: The Examined Life Conference. They just announced that a keynote speaker for their upcoming conference (April 16-18, 2015) is poet Jimmy Santiago Baca. His memoir A Place To Stand (Grove Press, 2002) was made into a documentary released last month.

No More Free (drug) Lunches or Pens

As part of the Affordable Care Act (ACA) health care reform, drug companies will soon be required to report payments and free lunches/dinners/cruises/vacations/gifts to physicians or payments to teaching hospitals. It includes any free ‘educational’ service for physicians or teaching hospitals. This is section 6002 of the ACA and is known as the Physician Payment Sunshine Act (sunshine, as in shedding light on or transparency). As part of the mandatory reporting, individual physicians and hospitals will be named, along with what items of monetary value they received and by which companies. This information will be publically available and easily searchable. Companies will be assessed hefty fines of up to $1 million for failing to report the information. This Sunshine Act was supposed to have already been implemented, but has been delayed while government officials at the Centers for Medicaid and Medicare sift through public comment and iron out final details.

I read through the proposed Physician Payment Sunshine Act (vol 76,no. 243/12-19-11 Federal Register), and found that they define “physician” as a doctor of medicine or osteopathy, dentists, podiatrists, optometrists and licensed chiropractors. Teaching hospitals are defined as hospitals having graduate medical education. And here is their rationale for the Sunshine Act:

“2. Transparency Overview

Collaboration among physicians, teaching hospitals, and industry manufacturers may contribute to the design and delivery of life-saving drugs and devices. However, while some collaboration is beneficial to the continued innovation and improvement of our health care system, payments from manufacturers to physicians and teaching hospitals can also introduce conflicts of interests that may influence research, education, and clinical decision-making in ways that compromise clinical integrity and patient care, and may lead to increased health care costs.” (p. 7)

(The NYT has a recent article on this, as does Kaiser Health News–older but good.)

Several states including Vermont have already implemented similar reporting requirements. Some physicians are complaining that drug companies are now wooing more nurse practitioners as a way around the reporting requirements. I saw that in action at this past fall’s regional nurse practitioner conference. It was overrun by aggressive pharmaceutical reps waiving tons of swag (including the ubiquitous drug pens), as well as signing NPs up for free lunches/dinners/talks, etc.

In the community health clinics where I’ve worked, most all of the family physicians were rabidly anti-drug company marketing and influence. One physician in particular would go on a tirade if she discovered one of her medical residents writing with a drug company pen. They—and everyone else in the building—would get a lecture in the evils of drug company influence on physician prescribing practices and health care costs. So I thought I had long ago purged myself of all drug company free stuff. While preparing to write this blog post I engaged in some late winter housecleaning searching for hidden drug company subliminal influences. I found six drug company pens, four of which were for drugs that have been pulled from the market as unsafe. I threw them all away. On a popular blog lamenting the Sunshine Act, one physician complained that he has to buy pens for the first time since he graduated from medical school in 1986.

The only drug company swag I found that I am keeping is a funky glass sun catcher given to me by a retired pharmacist who lives on my street. It has elemental alchemy symbols for strange things like lead and vinegar and talc—but is really an advertisement for a nasal decongestant hidden in small type at the bottom. See if you can find it on the attached photo—but don’t buy the stuff!

In (Nurses) We Trust

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Nurses did it again: topped Gallop’s annual Honesty and Ethics of professions survey for the twelfth straight year. In fact, nursing has topped the Gallop survey every year except one since nursing was added to the list in 1999. Nursing was eclipsed by firefighters in the 2001 poll, which was conducted two months after 911. It is interesting to note that Gallop started the Honesty and Ethics survey in 1976, and nursing wasn’t included until 1999. Prior to 1999 pharmacists or clergy were rated #1.

The 2011 Gallop Honesty and Ethics poll was based on a telephone (landline and cell) survey conducted November 28-December 1st from a random sample of 1,012 adults representing all 50 states and Washington, DC. The survey question was, “Please tell me how you would rate the honesty and ethical standards of people in these different fields—very high, high, average, low, or very low?” Rankings of the professions by overall results are done based on the percentage of respondents answering either ‘very high’ or ‘high.’ This year 84% of those surveyed rated nurses as very high/high (and only 1% rated nurses ‘very low/low). Pharmacists were the next highest medical profession in the ranking, 73%, very high/high, followed by medical doctors at 70%. Military officers and high school teachers rank higher than doctors.

The phrase, “nursing is the most trusted profession in the US” is inserted into many public speeches—by nursing leaders ,of course—but also by politicians pandering to the nursing vote. It is almost taken for granted that nurses are trusted. But why are we so trusted?

First, you can’t trust nursing leaders for the full answer to this question. They have a vested interest in positive spin, such as this recent statement by ANA’s President Karen Daley: “The public’s continued trust in nurses is well-placed, and reflects appreciation for the many ways nurses provide expert care and advocacy.” Well, yes, but isn’t there more to it than that?

If you dig into analysis by the Gallop researchers, they point out that the medical professions as a whole are generally highly trusted in our society, and that stability is the norm in American’s rating of professions. However, American’s opinions do shift in response to real-world events (e.g.: 911 and firefighters), and mostly to large scandals that reflect poorly on a profession. For instance, the clergy took a tumble in ratings in the wake of the Catholic priest sex abuse scandals (as well as the Evangelical sex scandals such as Jim Bakker/closets, etc). For whatever reason (relative low-profile/low power and prestige perhaps?) nurses and pharmacists have been able to avoid widespread scandals.

Sandy Summers (a nurse) on her The Truth About Nursing website states, “The reason the ‘most trusted’ poll results don’t do too much for us is that this public view often goes hand in hand with the prevailing vision of nurses as devoted, angelic handmaidens.” And Suzanne Gordon (a journalist/not a nurse, but rather a die-hard nurse advocate) goes even further, writing on her blog last year, “I am getting tired of these polls that try to assuage nurses and stroke them and make them feel better.” Both Sally and Suzanne point out that trust does not equal respect, and that many people may trust nurses but have little idea what they really do. But I’m not convinced that you have to understand what someone does to be able to trust them.

I find it intriguing that the four most highly trusted professions (listed in order) are nurses, military officers, pharmacists, and grade school teachers. All four have strict codes of ethics and standards of practice, and all—for the most part—work within rigid hierarchies for ‘the man’ or ‘the woman.’ They don’t typically work on their own as physicians can and often do. They all, in various ways, take orders. And they aren’t exactly the highest paid professions around—although the average pharmacist salary now tops six figures. So—taking orders within a rigid hierarchy and not profiting in a huge way would seem to be related to high public trust. The lowest ranked professions on the trust survey are members of congress, car salespeople, telemarketers, and lobbyists. The lesson here for our country? Perhaps more nurses should become members of congress?

Doctor, Doctor, Nurse, Doctor

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We just want to be doctors without having to go to medical school. Yes, that’s it.  I want to be called Doctor Nurse Ensign—or maybe Ensign Doctor Nurse if I ever work in the Navy and want to really confuse people.

Disclosure: I have a master’s degree preparation for being a Family Nurse Practitioner, with a practice doctorate in public health, a DrPH. The DNP—Doctor of Nursing Practice—the newish practice doctorate in nursing—did not exist when I went to nursing school. I am quite happy with my combination of alphabet-soup letters/degrees given my focus on health policy for marginalized populations. If the DNP had existed when I went to nursing school—and if it had been the only option for becoming a nurse practitioner—I suppose I would have done that but still obtained my MPH—Master of Public Health. The two disciplines complement each other well. In my experience, the MPH provides more uniform, concrete, and useful skills than does any degree in nursing—even the DNP in its current incarnation.

Earlier this month there was a NYT article entitled, “When the Nurse Wants to Be Called ‘Doctor’” (by Gardiner Harris, 10/2/11).  It is an excellent, well-balanced article. I also recommend the Well Blog version with interesting reader’s comments/ a longer blog post by Barbara Ficara on the Healthcare Blog.) The NYT journalist discusses how nurse practitioners are moving towards having DNP’s as entry to practice and are asking to be called doctor. Harris writes, “Doctorates are popping up all over the health professions, and the result is a quiet battle over not only the title ‘doctor,’ but also the money, power and prestige that often come with it.”  Pharmacists moved to entry-level practice doctorates in 2004, and physical therapists are moving towards it as well. He says that nursing leaders say the push for the DNP has nothing to do with their fight for expanded scope of practice and higher salaries for advanced practice nurses—but rather with the pressures to keep current because “knowledge is exploding.” Not surprisingly, many physicians are fighting back. Physician lobbying groups around the country are pushing for increased state and federal legislation restricting anyone without a MD or DO (doctor of osteopathy) from using the title ‘doctor.’

As Harris points out in his article, there are no data to support the value added of a doctorate over a master’s degree in terms of quality of care provided by nurse practitioners. And it takes one to two years longer to obtain a DNP vs. a master’s degree. Health economists are concerned this can translate into increased costs for patients and longer wait times to access primary care providers. This disturbs me since the nurse practitioner role was developed specifically to help address access to care issues for the poor, the elderly, rural, and other marginalized populations. It is why I chose to become a nurse practitioner.

Re-scripting Code Pink

Marching in 2004.
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I worked at a community health clinic that was housed in an old restored firehouse with old plumbing designed for a few firefighters and not for hundreds of patients each day. We fairly regularly had “Code Brown” called over the clinic loudspeaker when the sewer system backed up into clinic areas. Sometimes they closed the clinic until it was cleared. Sometimes we worked around it. That’s community health.

I have never worked where they called “Code Pink” and I think I am glad of that. It sounds as if it should be a mammogram emergency. According to nursing leadership expert, former Dean of the Kansas School of Nursing, and current hospital mystery writer Eleanor Sullivan, Code Pink is called by a nurse in a hospital who is being bullied by physicians or others. In her letter to the NYT editor in today’s paper (Sunday May 15th), she writes, “The word is passed nurse to nurse, and colleagues gather around the beleaguered nurse. Few physicians can stand the scrutiny of neutral-faced nurses standing silent beside one of their own.” Somehow I don’t picture the nurses as neutral-faced. All four letters today in “When Doctors Humiliate Nurses” were supportive of Theresa Brown’s Op-ed article “Physician Heel Thyself.” All four letters were relatively bland, especially compared with the responses to her article found elsewhere.

Dr. Kevin Pho on his popular blog, has already written two posts on Theresa Brown’s article. In his first blog post entitled “Theresa Brown unfairly blames doctors for hospital bullying” he states, “Brown has a prominent media platform in the New York Times, and, in a way, she wields it here to metaphorically bully the entire physician profession.” Many self-identified physicians who responded to Dr. Pho’s blog post were supportive of his read of Ms. Brown’s articles, although most stated they refused to (literally) read anything she writes… One person identified as “David MD” did the math, dismissed Ms. Brown as a neophyte nurse since she has a pre-existing PhD and pre-existing children, and admonished her for “extracurricular writing” that “must have violated the terms of her employment at Shadyside Hospital.” He concludes, “From the tone of her other blogs, she must be an absolute nightmare to work with.” David MD stated that he had written a letter to the editor of the NYT in protest of her article.

In his follow-up blog post, “Doctor bashing and confronting physicians in the media,” Dr. Pho admitted that Ms. Brown’s article had brought the topic of hospital bullying into the national health care conversation. He applauded her for bringing up such a difficult topic in the NYT. But he still takes issue with her method, calling it an “adversarial approach,” and alluding to it as “doctor bashing.” He even likens it to the case of the Seattle nurse Kim Hiatt being fired by Children’s Hospital for a medication error, stating that neither will solve larger systemic issues within health care. Instead, for physician bullying, he places blame on the medical education system for perpetuating the socialization of arrogance and bad manners in medical students. That line of reasoning makes no sense to me: Medical education is by and for physicians.

What I find fascinating in many of the physician blog posts and comments to Ms. Brown’s article, is the resentment that, 1) she is a nurse and she can write well, and 2) she has a national media platform through the NYT. In his second blog post on Ms. Brown’s article, Dr. Pho writes, “Brown is a former English professor, and it’s no wonder that the framing of the piece is masterful.” Some of the posts by physicians call for her hospital administration to silence her. In Ms. Brown’s recent article entitled “Nurse as Writer, Writer as Nurse” published in the Clinical Journal of Oncology Nursing (April 2011), she acknowledges that dealing with hospital management has been tricky when it comes to her writing. She never identifies the hospital where she works, although as she says it’s easy enough to figure out who her employer is. She states that when she first started writing, the hospital management wanted editorial control over everything she wrote. “Knowing this was a request they could not legally make, I said, ‘No,’ and have had to repeat this refusal more than once. It’s not always easy, and at times I wasn’t sure I was tough enough to stand up to the healthcare corporation I work for.” I do not know what sorts of blowback Ms. Brown is currently getting from her hospital administration over her NYT Op-ed article “Physician, Heel Thyself.” But if she is feeling this heat, perhaps she could call a Code Pink of the Dr. Sullivan type. I contend that she has done vastly more through her ‘popular press’ writing to effect positive change in nursing and health care than any amount of academic journal articles or IOM reports or White Papers.

For those of you in the Seattle-area, Theresa Brown will be speaking at a public event next week at the University of Washington. Sponsored by Poets and Writers and the School of Nursing, Ms. Brown will give a talk entitled “Nurse as Writer, Writer as Nurse,” UW Health Sciences, Room T-625, Thursday May 26th 10:30-12:20pm. The following is the blurb I wrote to describe the event:

Theresa Brown is an oncology nurse, author of Critical Care: A New Nurse Faces Death, Life, and Everything in Between (harperstudio, 2010), and is a regular contributor to the New York Times’ Well blog. In a recent article entitled “Nurse as Writer, Writer as Nurse” in the Clinical Journal of Oncology Nursing, Ms. Brown addresses the most common questions people ask her, such as, “What about patient confidentiality?” “Do you take notes at work?” and “How do your coworkers (and employer) feel about your writing?” A former English professor who found her true calling as a nurse, Ms. Brown will talk about her dual paths as writer and as nurse.

Narrative Nursing

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The health policy journal Health Affairs has a feature entitled “Narrative Matters,” which are personal essays in the voice of patients, their families and caregivers with a health policy aspect. Health Affairs has been running these essays for 10 years and is a popular feature, crossing over to news features on NPR and in the New York Times. In 2006, the editors of Narrative Matters published a book collection of 46 of their best essays. The essays included in the book are all very powerful. They range from a former governor writing about the culture clashes between medicine and public policy, to a physician’s struggle to care for his father with dementia. What struck me as I read these essays, as well as the other more recent ones available online, was the fact that very few were by nurses. In the book version, there are two essays written by nurses. They are both by male nurses and deal with their moral distress, burnout, and decision to leave nursing. This is a common problem in nursing, and rates of burnout and exit from nursing are much higher for male than for female nurses. It’s good to have their perspectives on the issues voiced, but was disappointing that those were the only essays by nurses included. Of the 10 essays published in 2010, seven were by physicians, two were by patients, and one was by a nurse practitioner. The nurse practitioner wrote about her decision not to have mammograms and the negative reactions she gets when she voices her decision and rationale. We need more nurses writing these sorts of essays, and having them published in high profile journals such as Health Affairs. Publishing in nursing-specific journals is all well and good, but I don’t think many nurses ever read them, and the general public most certainly does not.

Next quarter I am teaching a graduate level course in health politics and policy and in lieu of a course paper I am having students write (and submit) policy-level nursing narratives for Narrative Matters. So stay tuned to Narrative Matters for (hopefully) some stronger nursing voices.