November 9th, 2008 by Dr. Val Jones in Audio, Expert Interviews
5 Comments »
I was following an interesting conversation on Twitter between several nurses. They were expressing concern about how nursing stereotypes were damaging to their profession. I invited them to discuss the subject with me via podcast.I have summarized some key points below.
You can listen to the whole conversation here.
[audio:http://blog.getbetterhealth.com/wp-content/uploads/2008/11/nursing.mp3]
Participants:
Gina from Code Blog (6 year veteran blogger, and has spent 11 years as an ICU nurse)
Strong One from My Strong Medicine (an anonymous blogger, athletic trainer and nurse of 3 years)
Terri Polick from Nurse Ratched’s Place (has held various positions in nursing, including psychiatric nursing for 20 years)
Current Nursing Challenges:
1. Nursing Instructor Shortage – nursing instructors make about 25% of the salary of nurses who do clinical work. Therefore, there are long wait times to enter nursing school due to instructor shortages. Many students can’t afford to wait, and choose other careers.
2. Inequality of Respect – some nurses feel that they have to continually prove themselves despite their training and qualifications. Patients often express disappointment or annoyance when they see a nurse practitioner (rather than a physician) in a group practice. Some doctors still expect nurses to give up their chairs when they enter the room.
3. Nursing Stereotypes – the “naughty nurse” and “nurse Ratched” images are still very much in the forefront of peoples minds when they think of nursing as a specialty. Some people believe that nurses simply pass out pills and make coffee, when in reality they are active in complex technical procedures and saving lives. These stereotypes and misconceptions denigrate the education and technical expertise of nurses.
4. Primary Care Doesn’t Pay: nurse practitioners incur higher debt and have lower salaries than specialist nurses. Just as in the medical profession, there are no incentives for nurses to choose careers in primary care.
Strengths of Nursing:
1. Nurses Are Better And Brighter Than Ever – since getting into nursing school is so competitive, the quality of individuals who are entering nursing school has never been higher.
2. Job Flexibility – nurses can easily transition to part time work for maternity purposes. Nursing careers offer a wide variety of work experiences – from nursing home work, to cardiothoracic surgery. One license offers hundreds of various opportunities.
3. Job Satisfaction – saving lives and serving patients contribute to a sense of job satisfaction.
What can be done to improve and advance the US nursing profession?
1. Establish an Office of the National Nurse. The National Nursing Network organization is promoting this initiative. The National Nurse would act as a government spokesperson for nurses- promoting preventive medicine, increasing awareness of nursing, and securing financial support for nurse education. He or she would be the chief nurse officer of the US public health service.
2. Do not be afraid to speak up. Nurses should feel comfortable defending their professional ideals, and discouraging stereotypes.
3. Blog to raise awareness of nursing challenges and successes.
**Listen to the podcast**
November 9th, 2008 by Dr. Val Jones in Medblogger Shout Outs, Opinion
2 Comments »
As many of you know, I’ve been pretty upset about the “never events” policy put forward by CMS. That’s because they took a theoretically reasonable punitive rule (Medicare will not pay hospitals for patient care related to gross medical errors, aka “never events,” like wrong-side surgery) and made it far too general (never events include delirium, falls, and any infection – even a cold). It is absolutely impossible to prevent these sorts of things 100% of the time. So how should “never events” be defined?
The Happy Hospitalist nails it:
Can the never event happen at home? If the answer is yes, it cannot be a never event. It is a natural event. Even the criminal events that nobody can foresee are considered never events. Tell me how a hospital can prevent a random crazy family member or hospital guest from going berserk and assaulting an employee or patient. It’s impossible to predict or prevent.
November 8th, 2008 by Dr. Val Jones in Celebrity Interviews, Expert Interviews
8 Comments »
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Dr. Gawande
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Kaiser Permanente sponsored a special event in DC today – Charlie Rose interviewed Dr. Atul Gawande about patient safety in front of an audience of physicians. Dr. Gawande is a young surgeon at Harvard’s Dana Farber Cancer Institute, has written two books about performance improvement, and is a regular contributor to the New Yorker magazine. I had heard many positive things about Atul, but had never met him in person. I was pleasantly impressed.
Atul strikes me as a genuinely humble person. He shifted uncomfortably in his chair as Charlie Rose cited a long list of his impressive accomplishments, including writing for the New Yorker. Atul responded:
I’m not sure how my writing became so popular. I took one fiction-writing class in college because I liked a girl who was taking the class. I got a “C” in the class but married the girl.
He went on to explain that because his son was born with a heart defect (absent aortic arch) he knew what it felt like to be on the patient side of the surgical conversation. He told the audience that at times he felt uncomfortable knowing which surgeons would be operating on his son, because he had trained with them as a resident, and remembered their peer antics.
Atul explained that patient safety is becoming a more and more complicated proposition as science continues to uncover additional treatment options.
If you had a heart attack in the 1950’s, you’d be given some morphine and put on bed rest. If you survived 6 weeks it was a miracle. Today not only do we have 10 different ways to prevent heart attacks, but we have many different treatment options, including stents, clot busters, heart surgery, and medical management. The degree of challenge in applying the ultimate best treatment option for any particular patient is becoming difficult. This puts us at risk for “failures” that didn’t exist in the past.
In an environment of increasing healthcare complexity, how do physicians make sure that care is as safe as possible? Atul suggests that we need to go back to basics. Simple checklists have demonstrated incredible value in reducing central line infections and surgical error rates. He cited a checklist initiative started by Dr. Peter Pronovost that resulted in reduction of central line infections of 33%. This did not require investment in advanced antibacterial technology, and it cost almost nothing to implement.
Atul argued that death rates from roadside bombs decreased from 25% (in the Gulf War) to 10% (in the Iraq war) primarily because of the implementation of check lists. Military personnel were not regularly wearing their Kevlar vests until it was mandated and enforced. This one change in process has saved countless lives, with little increase in cost and no new technology.
I asked Atul if he believed that (beyond check lists) pay for performance (P4P) measures would be useful in improving quality of care. He responded that he had not been terribly impressed with the improvements in outcomes from P4P initiatives in the area of congestive heart failure. He said that because there are over 13,000 different diseases and conditions, it would be incredibly difficult to apply P4P to each of those. He said that most providers would find a way to meet the targets – and that overall P4P just lowers the bar for care.
Non-punitive measures such as check lists and applying what we already know will go a lot farther than P4P in improving patient safety and quality of care.
Atul also touted the importance of transparency in improving patient safety and quality (I could imagine my friend Paul Levy cheering in the background). In the most touching moment of the interview, Atul reflected:
As a surgeon I have a 3% error rate. In other words, every year my work harms about 10-12 patients more than it helps. In about half of those cases I know that I could have done something differently. I remember the names of every patient I killed or permanently disabled. It drives me to try harder to reduce errors and strive for perfection.
Atul argued that hospitals’ resistance to transparency is not primarily driven by a fear of lawsuits, but by a fear of the implications of transparency. If errors are found and publicized, then that means you have to change processes to make sure they don’t happen again. Therein lies the real challenge: knowing what to do and how to act on safety violations is not always easy.
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Charlie Rose
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Charlie Rose asked Atul the million dollar question at the end of the interview, “How do we fix healthcare?” His response was well-reasoned:
First we must accept that any attempt to fix healthcare will fail. That’s why I believe that we should try implementing Obama’s plan in a narrow segment of the population, say for children under 18, or for laid off autoworkers, or for veterans returning from Iraq. We must apply universal coverage to this subgroup and then watch how it fails. We can then learn from the mistakes and improve the system before applying it to America as a whole. There is no perfect, 2000 page healthcare solution for America. I learned that when I was working with Hillary Clinton in 1992. Instead of trying to fix our system all at once, we should start small and start now. That’s the best way to learn from our mistakes.
November 4th, 2008 by Dr. Val Jones in Health Tips, True Stories
4 Comments »
I’m grateful to the Happy Hospitalist for pointing out that color matters when it comes to food consumption. As it turns out, blue light can be an appetite suppressant. And I actually know about this first hand.
I helped to design a research study in connection with Architectural Digest and the Parsons School of Design several years ago. I was a volunteer instructor for a hospital design course in NYC, and wanted to show the students that lighting could influence eating patterns. As it happened, there was a big gala event at a local convention center, and so I worked with my friend Shashi Caan to set up three identical rooms bathed in three different colored lights (yellow, blue, and red).
We had all the gala attendees dress up in white bunny suits (you know, the kind you let patients wear in the OR) and shuttled them through the 3 rooms at regular intervals. The rooms could each hold about 40 guests and copious identical hors d’oeurves were offered.
Guess what we found? The most food was consumed in the yellow room, followed by red, and then a distant third was blue. About 33% fewer snacks were consumed in the blue room during the event (and yes we controlled the number of people in each room so they’d be equal). I found this quite fascinating, but unfortunately never published the results. You see, I didn’t receive IRB approval for any of it.
But the experiment did leave an indelible impression on my mind. As I thought about it, I realized that most fast food restaurants have yellowish interiors. From the golden arches to the lighting – companies like McDonald’s probably recognized (long before I did) that color influences purchasing and eating behavior.
Yep, I’m late to this party – and I’m not painting my kitchen yellow.
November 3rd, 2008 by Dr. Val Jones in Expert Interviews, Opinion
1 Comment »
Following on the heels of the annual ACR scientific assembly (and my interview with Dr. Wallace), I reached out to Sandra Raymond, President and Chief Executive Officer of the Lupus Foundation of America, to discuss lupus from the patient perspective. Sandra’s rhinovirus infection (she had a cold) did not stop her from completing an excellent interview with me.
Listen to the podcast here, or read a summary of the interview below.
Dr. Val: Tell me about the Lupus Foundation of America (LFA).
Raymond: The Lupus Foundation of America is the nation’s leading organization dedicated to finding the causes and cure for lupus. We also provide services, support, and hope to all people living with lupus. We have a national research program called “Bringing Down The Barriers” and we fund grants to researchers in academic institutions across the country. We are also very active on Capitol Hill, lobbying for research and educational efforts. In a few months we’ll be launching a public awareness campaign to help Americans understand this disease.
Dr. Val: Of which key accomplishment of the LFA are you most proud?
Raymond: LFA has been able to expand medical research efforts for lupus. This not only gets us closer to finding a cure, but it offers hope to those who are living with the disease.
Dr. Val: In your view, what do patients with lupus need the most?
Raymond: They need safe, effective, and well-tolerated treatments. November the 20th, 2008, marks 50 years without a new, approved treatment for lupus. The treatments that patients are currently taking can be very harsh. They sometimes cause side effects that are worse than lupus itself! We must step up our research efforts to discover safe and effective treatments to bring this disease under control and provide patients with a better quality of life.
The good news is that there are quite a few pioneering biotech companies who are investing money in finding a cure for lupus. So there may be new drugs on the horizon.
Autoimmune diseases affect 23 million Americans. Lupus accounts for at least 1 million of those, but if we can figure out what causes lupus, there are implications for all disorders of the immune system. Read more »
