Tag: United States

Ebola: Not In My Backyard

ebola-suit1Until very recently in the United States the general feeling among most people (and among most news reports) was that the catastrophic Ebola epidemic was only a problem ‘over there in the poorest countries of Africa–all of those uneducated Africans who can’t even keep their food from getting contaminated by bat droppings.’ This summer, we were happily dousing ourselves with buckets of ice water in the (dare I say ‘silly and oh so contagious social media’ hype) of the ALS Ice Bucket Challenge. (see my previous blog post: ‘Ice Bucket Challenge for Ebola‘ 8-26-14 for additional perspective on this in light of the global health burden of disease.) At the time that I wrote that blog post we had not yet had any patients tested/confirmed with Ebola in our country. Now, of course, we have multiple confirmed cases in the U.S., including two young nurses who had cared for a patient with Ebola in a Dallas, Texas hospital.

This morning in my community health nursing class of 150 students, I asked how many of them had had any training or preparation or discussion of Ebola in their clinical rotations. Only one student raised her hand and she said that was training through her job at a hospital (presumably Harborview Medical Center in Seattle which supposedly has done a good job of Ebola education and preparedness for its employees). The majority of students said they had been asked by friends or family members for information on Ebola. I encouraged them all to read the excellent training materials for the general public and for health care providers on the CDC website–and to ask for preparedness training in their clinical sites. I also encouraged students to be attuned to subtle and not so subtle racism in news coverage and general conversations about Ebola. Even infographics about Ebola on the CDC website depict only impoverished rural African people with Ebola, in one case showing a man defecating on the ground.

The fact that it is two hospital nurses who are the first confirmed Ebola cases to be contracted in the U.S. should come as no surprise to anyone who knows and loves nurses or who has spent any time in a hospital. Nurses are the front-line, down-and-dirty direct patient care providers. These two nurses were following current (at the time–they have been updated today) Ebola infection control procedures. And whereas the latest nurse with confirmed Ebola, Amber Joy Vinson, was first reported as having breached CDC protocol and flown on a commercial plane while she had a fever, CDC officials are now confirming that she first phoned them when she had a fever and was due to fly: “I don’t think we actually said she could fly, but we didn’t tell her she couldn’t fly,” CDC director Dr. Thomas R. Freiden is quoted as saying. “She called us, (…) I really think this one is on us.” (NYT ‘New Ebola Case Confirmed, U.S. Vows Vigilance’ by Manny Fernandez and Jack Healy, 10-15-14.)

It is always ironic that it takes ‘big scary disease’ epidemics like Ebola to remind us all of: 1) how connected we are to everyone else in the world–their problems are literally our problem, 2) the importance of sustaining a robust public health infrastructure, and 3) how vital nurses are to our health care system.

 

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.

Radical Hat-Burning Nurses Unite!

IMG_1082Radical nurses are back, or perhaps they never left and are just becoming more visible, more organized. The photo here is of my nurse’s cap-wearing trained seal mascot given to me by a friend in nursing school–who promptly dropped out of school because she was too radical for them.

There is the Radical Nurse on Facebook (aka Rebekah Dubrosky, RN) who says of herself, “Radical nurse goes to graduate school with hopes of starting a nursing revolution!” Her profile photo is of the formidable radical nurse and mother of public health nursing, Lillian Wald. Ms. Dubrosky is a doctoral student in the College of Nursing at the University of Wisconsin/Milwaukee. She just published a very good article “Iris Young’s Five Faces of Oppression Applied to Nursing” (Nursing Forum vol 48(3):205-210, July/Sept 2013).

There is the newly-formed Rebellious Nursing! group, which had its first national conference this past fall in Philadelphia. They state: “We believe that Nursing is an inherently political profession and that all nurses are rebellious.” I’m not sure I agree with their tag line, but I do love their logo of a white nurse’s cap going up in flames. An extension of the bra-burning second wave feminists and the corset-burning first-wave feminists. The third-wave feminists seem to have nothing left to burn so they’re putting the push-up bras and corsets back on. (Just kidding. Don’t burn me all you wonderful third-wave feminists–including my former nursing student who introduced me to Rebellious Nursing!).

Going back to the second-wave feminists, there was Casandra: Radical Feminist Nurses Network from the 1980’s. Some of their old newsletters are on Peggy Chinn’s blog, NurseManifest. Peggy Chinn, RN, PhD, is Professor Emerita, University of Connecticut, but she will never truly retire.

There were also Radical Nurse Groups (RNGs) active in the 1980’s within the UK. A nurse blogger who goes by the pseudonym Grumbling Appendix (gotta love British humor) and who works in an NHS hospital (hence the need for a pseudonym), is now archiving material for the RNG’s. In the recent post in the New Left forum, Grumbling Appendix makes the observation that some things have not changed much. I love the Radical Nurses Archive: So….Just How Radical Are You? It includes a funny-sad multiple-choice test from 1982 (when I graduated from wretched nursing school wearing a wretched nurse’s cap), although I need a Brit to help interpret the final scoring scheme.

For an amazing blast from the past that is also sobering in terms of how little things have changed, take a look at the 20 minute film The Politics of Caring from 1977 (produced, directed, and edited by Joan Finck and Timothy Sawyer in collaboration with Karen Wolf, RN.) It is posted on Peggy Chinn’s NurseManifest blog. The only difference between then and now that I see is that the nurses then were still wearing white nurse’s caps (non-flaming) and white dress uniforms (and oh my! those disgusting thick white opaque pantyhose that kept the oh my! pubic hairs from dropping off onto the operating room floor!) There’s something about ‘radical’ and the use of exclamation points….

In the film they begin by saying that while nurses are the largest component of the healthcare workforce they have the least say in health policy. Familiar? They discuss the disconnect between what is taught in nursing school about providing quality of care, and the reality of what is possible within the practice environment. (I hear this from my students all the time). They also question whether nursing can even be called a profession when the majority of nurses don’t have control over their work environments. And they discuss the tensions within nursing with the then newly-emerging role of advance practice nurses/nurse practitioners, pointing out (somewhat rightly so) that these ‘new nurses’ were mainly working within the medical model of care.

As a community health nurse I was fascinated to hear the nurses in the film talk about “the mecca of community nursing” as a place where nurses could practice ‘real nursing’ focusing on health prevention and promotion within the nursing model of care. Community health is what attracted me to nursing in the first place and it continues to be what I love most about my work. But we need hospital nurses and there are nurses who love working in hospitals and don’t want to have to ‘trade up’ to community health, or to become a nurse practitioner or a nursing professor in order to have greater control over their working conditions. Besides unions and Radical Nursing! groups, what is there for them?

My New Year’s Resolution: Avoid Wellness Programs

Eat more fruits!
(Photo credit: miqul)

An increasing number of U.S. companies are ratcheting up their employee wellness programs in order to reduce their cost of health care coverage and payout in employee sick days (thus, of course, increasing their profit for shareholders and executive salaries). They call these wellness programs by all sorts of cute names like Healthy Journey, Move It Program, and Health Counts. They entice employees with rewards programs including cash ‘refunds’ and free membership to health clubs, weight-loss, and smoking cessation classes. Their advertising materials are sprinkled with fairy dust photographs of smiling, fit people munching apples and carrots and bowls of granola. What’s not to love? Wellness is a good thing that everyone wants, right?

This week I received a welcome letter from my medical insurance company, thanking me for continuing with them in 2014, and encouraging me to participate in their wellness program. The letter included a two page ‘notice of privacy’ about how they supposedly protect (and can use under all sorts of ‘exceptions’) my medical information. It has a reading level of post-graduate school, but at least it does have a clearly marked section ‘For questions or complaints’ with a (non-toll-free) phone number to call.

On the wellness program informational brochure they sent me there’s a chart ‘how to earn points and rewards’ that resembles those annoying frequent flyer ‘miles’ offers. They list eight of their top point-earning activities, including diabetes prevention and smoking cessation classes. At the top of their list is an online ‘General Health Assessment’ which they say takes 15 minutes, completion of which qualifies me for a $30 gift card. Beside the chart is a photograph of a bearded, smiling, white coat and black stethoscope wearing Marcus Welby, MD look-alike, inviting me to sit down and tell him all about my health problems. Who can resist?

So I logged on and took their General Health Assessment (GHA) questionnaire, which is created and maintained by the mega-company WebMD. First, I read through their drop-down ‘terms of use’ disclosure statement. Besides reminding me how glad I am that I ditched the law school idea, the fine print states this about my medical insurance company’s wellness program (named X here): “X does not warrant that any X content, visitor content or any other content posted on this site is accurate, complete, reliable, current, or error-free.”

OK, yes, those pesky ‘accurate, reliable, error-free’ things are too much to ask of a medical insurance company, right? Their GHA begins with the profound question, “Are you living your life to the fullest?” The correct answer happens to be ‘No, not if you are bothering to take this silly test.”

To begin with, their ‘gender-specific health’ questions are woefully out-of-date, sticking with the annual pap smear no matter what your HPV status or age, as well as the out-of-date annual mammogram ‘requirement.’ But then I got to the nutrition section and my (normally low) blood pressure really went up. Here is their first nutrition question: “How often do you eat at least six servings of bread, cereal, rice, or pasta?” Choices are: “1) Daily, 2) Several times a week, 3) Few times a month, 4) rarely.” Their fitness and well-being (as in anxiety and depression) questions, were equally imbecilic. I made it through the silly questionnaire, scored a 100/100, but was told I needed to stop eating a high fat diet (I don’t–I was munching on kale at the time) and I need to follow current guidelines on preventive health screens like for mammograms.

Shouldn’t employee wellness programs be required to at least follow accurate, up-to-date medical information and guidelines? Otherwise it seems they do more harm than good. The federal government, as a part of ACA/Obamacare, stepped in this year to issue guidelines for “Incentives for Nondisciminatory Wellness Programs.” (Because besides being inaccurate, many wellness programs are also discriminatory, coercive, etc. See my previous blog post Corporate Employee Wellness Wants You from 10-29-13, as well as links to resources below). Their new guidelines go into effect January 1, 2014.

Reading through the Federal Register on these guidelines I see that people did raise the same questions I have about following national guidelines for screening and prevention. But they decided to stick with the vague ‘reasonable design’ clause and only: “…require that health-contingent wellness programs be reasonably designed to promote health or prevent disease…” The successful argument against requiring evidence-based clinical guidelines and national standards is the oh so American excuse that it would “inhibit innovation.” Inhibit innovation of poorly constructed, out-of-date, misleading, inaccurate, thoroughly frustrating ‘wellness’ screenings and interventions? I will be avoiding all wellness programs in the New Year.

Further resources:

 

Back to the Future of Nursing

wierdflightattendantsBack to the Future of Nursing: A Look Ahead Based on a Landmark IOM Report, part of the Rosenthal Lecture Series, was held today at the National Academy of Sciences in Washington, DC. The panel discussion focused on progress made in the past three years since the release of IOM report The Future of Nursing: Leading Change, Advancing Health (FON). The webcast recording of the event will be posted soon. Check out their infographic poster which is quite nicely done.

Some of the highlights that I picked up on during this panel discussion included efforts to increase diversity in nursing as well as career mobility, and national efforts to increase scope-of-practice for nurse practitioners. Currently there are 17 states that allow nurse practitioners to be fully independent and two additional states that allow nurse practitioners to be ‘almost’ fully independent (Maryland and Utah). In the past three years seven states have removed major barriers to practice, and Nevada recently gave nurse practitioners full practice authority. Opposition by state medical organizations blocked passage of similar bills in Connecticut, Kentucky, New York, and most recently in California. But the momentum is growing in favor of independent practice for nurse practitioners across the country. The Federal Trade Commission is challenging limits to nursing scope-of-practice in many of the recalcitrant states (including, I hope, my home state of Virginia).

At the end of today’s lecture there was an excellent televised address by Rissa Lavizzo-Mourey, MD, who is the director of the Robert Wood Johnson Foundation (sponsor the FON report and follow-up efforts). Among other things she spoke of the need to change the “caste system in hospitals” that treats nurses as second-class citizens. That seems to be a daunting task.

I have read the entire IOM FON report several times and think it is an excellent document. (Previous blog post Undoing Nurses as Functional Doers Nov 24, 2010). Of course, being a primary care nurse practitioner myself with previous run-ins with state health regulatory boards over scope-of-practice issues (see To Forgive, Divine blog post), I have been cheering the efforts in this area spurred on by the IOM Future of Nursing report. And being a nurse educator who loves teaching (and who abhors most approaches to nursing education–another nursing care plan anyone?), I applaud the IOM/FON report section on changes needed within nursing education.

So what has changed for me in the past three years since the IOM FON report? Many faculty members invoke the FON report from time-to-time when making various points about needed changes in the curriculum. Not many of our current students have even heard of the report (shame! I need to assign parts of it as required reading). I’ve seen a large uptick in the support for interprofessional educational experiences for students and faculty. And I’ve seen an increased emphasis on adding leadership content as well as political advocacy skill-building activities for students within our various programs (although there’s still a shameful paucity of resources and nursing role models in these areas). The other thing that bugs me in the area of politics and policy education for nurses is the emphasis on self-advocacy for nursing practice. While that’s important, nurses can and should be using their advocacy skills and energies for less self-serving health policy changes.

Corporate Employee Wellness Wants You

Uncle Sam I Want You - Poster Illustration
(Photo credit: DonkeyHotey)

At least it seems to want me. A corporate/university wellness program is stirring to life at the University of Washington: Whole U. An unfortunate title since a simple Google search of the name brings up numerous spa and ‘body aesthetics’ businesses offering laser treatments and ‘body composition improvement’ (aka: “We’ll take fat from your butt and inject it into your face”).

We already have a university employee wellness program (of sorts) called UWellness (a much better name than Whole U). The stated purpose of UWellness is “balancing the emotional, intellectual, occupational, social, and physical components of health.” Makes sense, except for the intellectual part. Did they just throw that in because we’re a university and should be doing scholarly and intellectual pursuits? What the heck is intellectual health? Avoidance of all writing by French philosophers?

UWellness currently offers the following wellness services: 1) free annual flu shots, 2) referrals to Weight Watchers for weight loss, 3) links to a student-run group promoting bicycle and walking safety (including selling low-cost bike helmets), and 4) free annual ‘routine mammography’ for all women ages 40 and above at an on-campus mobile mammography van (a mammobile?). The first three offerings make sense to me and would earn an A or B according to the U.S. Preventive Services Task Force (USPSTF), an independent panel of non-federal experts in prevention and evidence-based medicine. However, the mammography offering surprised me since the USPSTF changed their breast cancer screening guidelines in 2009 to recommend biennial routine mammography for women aged 50-75 only (biennial screening for women ages 40-50 is optional/not routinely recommended). UWellness contracts with Seattle Cancer Care Alliance to provide the mobile mammography services, so I suppose they are stubbornly following the old guidelines (that the equally stubborn American Cancer Society still follows). There are, of course, intriguing political and economic self-interest issues there that I won’t touch on here…

The Whole U program is a “holistic employee engagement initiative which emphasizes community building, appreciation of the diverse lifestyles and interests of our faculty and staff and participation in programs that promote healthy lifestyles. Establishes a point system that encourages participation through prizes and engages a network of program ambassadors within departments to serve as key communicators in helping direct employees to the Whole U.” Sounds more than a bit Orwellian to me.

Penn State faculty recently staged a successful protest over the roll-out of their  university/corporate wellness program Take Care of Your Healththat required faculty and staff to fill out a questionnaire asking about workplace stress, marital problems and women’s pregnancy plans–or pay a $100 a month penalty. (Good NYT article on it here.) A recent RAND Corporation report Workplace Wellness Programs Study found that half of all U.S. employers offer some sort of employee wellness program, many of which include individual health risk assessments and the use of incentives for participation. The most popular employee wellness programs include support programs for weight loss and smoking cessation. Rigorous cost-benefit analyses of these employee wellness programs are lacking, but the RAND researchers estimate the programs should be cost neutral within five years of implementation.

Starting in January 2014 the ACA allows employers to offer incentives of up to 30% of health coverage costs to employees who participate in the wellness programs, including completion of the health risk assessments (and biometric assessments like body-fat percentage measurements, blood pressure readings, and blood glucose measurements). So get ready to be queried at work on your health behaviors, to have your candy vending machines taken away, and to have your waist and hips measured by ‘program ambassadors.’

Meanwhile, my version of corporate/university employee wellness includes avoidance of French philosophers. I’ve also bought a bouncy exercise ball to use as a desk chair–mainly because someone stole my corporate-issued office chair. And it may come in handy to fend off the Whole U program ambassadors when they come knocking on my door.

Toe Saga Enters Health Insurance Maze

toes
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.

Young Invincible Health Insurance Saga

IMG_1227Last night I had to take my ‘young invincible’ son to a local emergency department to have his toe sewn back onto his body. He had heeded my advice to get back to the gym to exercise, and somehow combined ballet with karate and lost a big toe in the process. His ED physician said he’d never seen anything like it in his 33 years of practice. Oh so reassuring. Also unsettling was this physician mug shot on the vending machine in the ED waiting room. He glared at me all night as I tried in vain to figure out what he was doing there, what his message was. Don’t you dare drink these sugary drinks? You’d better have good health insurance if you want to be seen here? I have some bad news: we somehow lost your son’s toe?

Fortuitously (or so I hope), my son listened to me and signed up for student health insurance–the day before his ballet/karate accident. As a mom and a nurse it was taking years off my life to have him ‘going bare’/uninsured. I now know some of what it feels like to live in fear of an accident, injury, or illness that could ruin my son (and by extension, me) financially. Even though he officially has health insurance to cover his expensive ED visit (X-rays, sutures, IV Vancomycin, physician quips) and ortho follow-up, I do not trust it. There are pages upon pages of exclusions to his health insurance plan, including bungee-jumping and intercollegiate sports–neither of which would seem to apply to losing a toe in ballet/karate. But I know how crafty and devious health insurance companies can be in trying to deny medical claims. I would hope that the university where I am employed and teach (and where my son is now a student) would have a decent health insurance plan option for its students. I guess I’m about to find out.

Health Insurance: Good Luck

Insurance
Insurance (Photo credit: Christopher S. Penn)

If anyone ever questioned whether or not US healthcare is political, they should now be convinced that it is. What with the drama of Obamacare, that Texan Tea Partier/Green Eggs and Ham reading/White Castle hamburger loving/Obamacare hating Senator Cruz, and then the looming shutdown of the federal government.  Not to mention Vanderbilt Medical Center’s recent creative administrators’ cost-cutting move to require nursing staff to take over housekeeping duties, for which they invoked the ghost of Nightingale (yes, HER again!) as the rationale behind their decision. Oh Nightingale! Rise up and smite them with a mop!

And then there is the desperate, mostly behind-the-scenes scramble for state health exchanges to be up and working by this coming Tuesday, October 1, when they are all slated to open for business. As described in today’s NYT article, many state exchanges will most likely be delayed. I especially like the article’s photograph of a roomful of intensely-working computer programmers trying to fix things for Oregon’s health exchange. I wonder how many of those workers have health insurance, and if not, how many of them now understand how to shop for and purchase health insurance once the system they’re working on is functional. Many of them do not look healthy.

My son, age 26, recently aged out of my health insurance plan. He was able to stay on my plan thanks to that provision of Obamacare. For the past few months he has been one of the many ‘young invincibles‘ (or ‘young invisibles’ perhaps?) who has no health insurance. Of course, I bug him constantly about this and want him to be insured. He’s now in graduate school at the University of Washington and is now eligible to purchase their student health insurance plan. The annual fee for one student (including 2014 ACA fees/whatever that means) is $2,748. School started this week, the earliest he would qualify for the insurance. I just checked their website and it has a statement marked urgent: “due to a system error some students who registered for Autumn quarter have had their coverage cancelled.”

This is complex stuff. I have a doctorate in health policy, teach, live and breathe health policy, and I can’t figure it out. Our healthcare system, especially the health insurance scene, has always been complicated, but I’m convinced that this specific part of Obamacare is creating more problems than it solves. It adds layers of administrative complexity and a huge burden (time and frustration–heart attacks anyone?) on consumers to ‘shop and pick a plan.’ These add up to a substantial increase of costs and inefficiencies in our already overly costly, inefficient, ineffectual healthcare system.

The best (mostly fully functional that I’ve seen) interactive tool for consumers ‘explaining’ ACA/Obamacare in more or less vernacular (English and Spanish), is Consumer Report’s Healthlaw Helper. Good luck.

Think Outside the Box: Cultivating Creativity

IMG_1105This weekend I learned some important new terms by taking a nose-dive into the rabbit-hole of an “alternative, non-repressive, nontraditional, self-governing cultural creativity community,” aka Smoke Farm’s Lo-Fi Arts Festival in the Misty Mountains (Northern Cascades/Jack Kerouac lookout tower territory) of Washington State. It’s variously described as being a soggy, slug-infested PNW version of Woodstock or Burning Man, or a hangover from Hempfest. I learned “hipster hobo” and what it looks like and that “GP” seems to have replaced “The Man” in these hipster hobo arty circles, as in “Tomorrow the GP will be coming so be prepared!” That’s almost a direct fireside chat quote from one of their leaders (who works at Microsoft curiously enough). I inappropriately laughed when he said that, thinking of the famous Far Side cartoon where the ‘natives’ say something like ‘quick, hide the TV, here come the anthropologists!”

But they were very welcoming, friendly people who fed me an amazing dinner, gave me a message in a tiny bottle, read my fortune with melted crayons, let me stay overnight on their ‘farm’ in my tent, and exposed me to some young ‘alternative artists’ and their work. I am grateful for all of that. Plus they gave me space to try a new type of writing (lyric essay) and a very different venue for reading my writing: in a grove of mature Douglas firs next to a rock statue of Pan, the skeleton of a kayak suspended in the air on stilts with a curtain of white river rocks tied on strings hanging from it, and a man named Nikoli drumming softly on the nearby hillside. My essay, appropriately enough, was entitled “Degree of Latitude.” This was all a decidedly ‘thinking (and being) outside the box’ experience, a “Toto, we’re not in Kansas (or the University) anymore” sort of thing.

It got me thinking about how little to no time we spend cultivating creativity within our healthcare professions education or practice. Where in our educational system or healthcare environments do we reward curiosity, nontraditional thinking patterns, exploration of new territory, and risk-taking? In my experience we work hard to educate people out of creativity, so it either gets completely extinguished or it goes underground, gets re-directed into hobbies or second (secret) careers. Higher-level complex thinking involves creativity, flexible or divergent thinking, and most people acknowledge that this is sorely missing from our healthcare endeavors. Creativity–like empathy–can’t be taught, but it can be cultivated, it can be incubated and rewarded. It seems as if narrative medicine tries to sneak creativity, or at least an appreciation of creativity, in the back door. But we need more ways of doing this. Ideas anyone?