There is no way healthcare providers can rely on their memories to guarantee evidence-based practices. We are too busy, too fragmented, and too hurried.
This article from The New Yorker explains why checklists work:
The Checklist
The biggest push in patient safety today is crew resource management which is based upon standard practices to achieve safety in the aviation industry. I think we will be seeing huge differences in medical/healthcare practices in the future.
Friday, December 14, 2007
Thursday, December 6, 2007
Attention to Detail...
I recently got my birthday card from the Commanding Officer. It was handed to me by one of the corpsmen on my old unit, F-2. I've been off that unit since July. The CO has seen me many times since then and knows my current assignment since I was called in to his office on a patient satisfaction issue a week ago and the appointment was set up weeks prior to that.
My first birthday card from this CO went to the ICU. I cut him some slack because he was relatively new to the command and I figured I was just another face in the crowd. To make a mistake like this a second time, well...I realized it just doesn't mean anything at all. So it went right into the trash.
As a believer in good stewardship and using limited resources wisely, it pained me. Whether the CO actually signed it or not, someone took the time to type out a message on command letterhead (good quality) and he signed it or someone stamped his name. Someone made sure my letter got out of his office. And then they couldn't follow through.
My first birthday card from this CO went to the ICU. I cut him some slack because he was relatively new to the command and I figured I was just another face in the crowd. To make a mistake like this a second time, well...I realized it just doesn't mean anything at all. So it went right into the trash.
As a believer in good stewardship and using limited resources wisely, it pained me. Whether the CO actually signed it or not, someone took the time to type out a message on command letterhead (good quality) and he signed it or someone stamped his name. Someone made sure my letter got out of his office. And then they couldn't follow through.
Saturday, December 1, 2007
The Business of Being Born
Celebrity actress/host Ricki Lake's new movie, "The Business of Being Born" points out that some of the most traditional practices of contemporary obstetrics have everything to do with the convenience of the physician, but can actually make delivery more difficult for the mother.
The Next Inconvenient Truth?
"Birth is miraculous, a natural process. But birth is also big business and this movie will change your mind about everything you think you know about it," said Sabrina McIntyre, a Fairfax County mom and former flight attendant who delivered one daughter by Cesarean section (c-section) and another at home by midwife.
To most people, the idea of giving birth outside of a hospital seems foolish and even dangerous: why would any parent limit their newborn's access to technology in the event of an emergency? Why would any couple put their child's life in the hands of a midwife instead of an obstetrician? "When my friend Ricki (Lake) approached me about making this film, I admitted to her that I was afraid to even witness a woman giving birth, let alone film one," said Abby Epstein, the Emmy-winning director of "The Business of Being Born." "I discovered that the business of being born is another infuriating way medical traditions and institutions -- hospitals and insurance companies -- actually discourage choice," said Epstein.
"The point here," observed Dr. Marsden Wagner, former Director of Women's and Children's Health, World Health Organization, "is there's not a good history in obstetric practice of careful study of the long term effects of all these interventions. This is why; if you really want a humanized birth, the best thing to do is get the hell out of the hospital."
A Movement Underway?
Arlington-based midwife, Tammi McKinley, said her practice has "boomed" with the number of women questioning high-tech birth. "Women are really starting to understand that all those gadgets don't always mean a safer birth, and women are looking to replace high-tech birth with high-touch birth," said McKinley, who delivered one child by c-section and her second at home by midwife.
Statistically, the use of c-section, a major surgery, is being widely employed, more as a measure of convenience for both doctor and patient instead of a last resort in the event of an emergency. Dr. Michael Brodman, Chief OB/GYN at New York's Mount Sinai Hospital, cites a study that reveals the peak hours for c-section procedures are 4:00pm and 10:00pm. Brodman interprets the data from the perspective of the hospital-based physician:
FAST FACTS:
-- In America, midwives attend less than 8% of all births and less than 1% of those that occur outside a hospital. At the same time, the US has the second worst newborn death rate in the developed world. Lake and Epstein ask, "Why do less than 8% of Americans take advantage of the benefits of midwifery, which is statistically safer and cheaper than physician-attended birth?"
-- The five countries with the lowest infant mortality rates in the March of Dimes report -- Japan, Singapore, Sweden, Finland and Norway -- midwives were used as their main source of care for 70 percent of the birthing mothers.
-- C-section is the most commonly performed surgery in the US, at a cost of $14 billion per year. Cesarean-delivery rates are now at an all time high in the United States, standing at 1.2 million, or 29.1 percent of live births in 2004. The increase represents a 40 percent increase in the past 10 years.
-- In one 1999 survey, 82% of physicians said they performed a C-section to avoid a negligence claim.
Jennifer Block, author of "Pushed: The Painful Truth About Childbirth and Modern Maternity Care," writes, "Too many Caesareans are literally medical overkill. Yet some US hospitals are now delivering half of all babies surgically. Across the nation, one in four low-risk first-time mothers will give birth via Caesarean, and if they have more children, 95 percent will be born by repeat surgery. In many cases, women have no choice in the matter. Though vaginal birth after Caesarean is a low-risk event, hundreds of institutions have banned it, and many doctors will no longer attend it because of malpractice liability."
She adds, "We've become dangerously cavalier...the Caesarean rate should be a major public health concern."
Natural Solutions to a "Medical" Problem
Midwives are definitely a viable solution; however, many find it difficult to assist with birthing because of the impossibility of obtaining malpractice insurance. Peggy Vincent, a midwife in California, writes candidly about her life as a midwife and the barriers she encountered with regulations and insurance in her book, "Baby Catcher: Chronicles of a Modern Midwife."
I am still bitter about my birthing experiences at San Diego Naval Medical Center. As an active duty sailor, I was not permitted to have a midwife assist with my labors nor was I permitted to have a homebirth. Consequently, I got the physician only on-call when I went labor and that resulted in a an emergency room physician (not even someone doing their residency) catching my baby for only the second time in his life. I suffered a fourth degree laceration (extending through the rectal mucosa to expose the lumen of the rectum) with an infant that weighed only 5 pounds, 13 ounces. At least, I didn't have a Caesarean, although they threatened me with that.
Addendum
ABC News published a story on unassisted home births. You can view the story and comments here:
DIY Deliveries: More Women Go It Alone
Here's an additional resource on the history of childbirth. As someone who studied medical sociology, this book should add depth to the rise of the American Medical Association:
http://www.mcfarlandpub.com/book-2.php?id=978-0-7864-3362-9
The Next Inconvenient Truth?
"Birth is miraculous, a natural process. But birth is also big business and this movie will change your mind about everything you think you know about it," said Sabrina McIntyre, a Fairfax County mom and former flight attendant who delivered one daughter by Cesarean section (c-section) and another at home by midwife.
To most people, the idea of giving birth outside of a hospital seems foolish and even dangerous: why would any parent limit their newborn's access to technology in the event of an emergency? Why would any couple put their child's life in the hands of a midwife instead of an obstetrician? "When my friend Ricki (Lake) approached me about making this film, I admitted to her that I was afraid to even witness a woman giving birth, let alone film one," said Abby Epstein, the Emmy-winning director of "The Business of Being Born." "I discovered that the business of being born is another infuriating way medical traditions and institutions -- hospitals and insurance companies -- actually discourage choice," said Epstein.
"The point here," observed Dr. Marsden Wagner, former Director of Women's and Children's Health, World Health Organization, "is there's not a good history in obstetric practice of careful study of the long term effects of all these interventions. This is why; if you really want a humanized birth, the best thing to do is get the hell out of the hospital."
A Movement Underway?
Arlington-based midwife, Tammi McKinley, said her practice has "boomed" with the number of women questioning high-tech birth. "Women are really starting to understand that all those gadgets don't always mean a safer birth, and women are looking to replace high-tech birth with high-touch birth," said McKinley, who delivered one child by c-section and her second at home by midwife.
Statistically, the use of c-section, a major surgery, is being widely employed, more as a measure of convenience for both doctor and patient instead of a last resort in the event of an emergency. Dr. Michael Brodman, Chief OB/GYN at New York's Mount Sinai Hospital, cites a study that reveals the peak hours for c-section procedures are 4:00pm and 10:00pm. Brodman interprets the data from the perspective of the hospital-based physician:
"It's obvious," he says, "that four in the afternoon is 'It's late in the day, I don't know what's going on here, I want to get out of here and the ten o'clock at night is, 'I don't want to be up all night.'"
FAST FACTS:
-- In America, midwives attend less than 8% of all births and less than 1% of those that occur outside a hospital. At the same time, the US has the second worst newborn death rate in the developed world. Lake and Epstein ask, "Why do less than 8% of Americans take advantage of the benefits of midwifery, which is statistically safer and cheaper than physician-attended birth?"
-- The five countries with the lowest infant mortality rates in the March of Dimes report -- Japan, Singapore, Sweden, Finland and Norway -- midwives were used as their main source of care for 70 percent of the birthing mothers.
-- C-section is the most commonly performed surgery in the US, at a cost of $14 billion per year. Cesarean-delivery rates are now at an all time high in the United States, standing at 1.2 million, or 29.1 percent of live births in 2004. The increase represents a 40 percent increase in the past 10 years.
-- In one 1999 survey, 82% of physicians said they performed a C-section to avoid a negligence claim.
Jennifer Block, author of "Pushed: The Painful Truth About Childbirth and Modern Maternity Care," writes, "Too many Caesareans are literally medical overkill. Yet some US hospitals are now delivering half of all babies surgically. Across the nation, one in four low-risk first-time mothers will give birth via Caesarean, and if they have more children, 95 percent will be born by repeat surgery. In many cases, women have no choice in the matter. Though vaginal birth after Caesarean is a low-risk event, hundreds of institutions have banned it, and many doctors will no longer attend it because of malpractice liability."
She adds, "We've become dangerously cavalier...the Caesarean rate should be a major public health concern."
Natural Solutions to a "Medical" Problem
Midwives are definitely a viable solution; however, many find it difficult to assist with birthing because of the impossibility of obtaining malpractice insurance. Peggy Vincent, a midwife in California, writes candidly about her life as a midwife and the barriers she encountered with regulations and insurance in her book, "Baby Catcher: Chronicles of a Modern Midwife."
I am still bitter about my birthing experiences at San Diego Naval Medical Center. As an active duty sailor, I was not permitted to have a midwife assist with my labors nor was I permitted to have a homebirth. Consequently, I got the physician only on-call when I went labor and that resulted in a an emergency room physician (not even someone doing their residency) catching my baby for only the second time in his life. I suffered a fourth degree laceration (extending through the rectal mucosa to expose the lumen of the rectum) with an infant that weighed only 5 pounds, 13 ounces. At least, I didn't have a Caesarean, although they threatened me with that.
Addendum
ABC News published a story on unassisted home births. You can view the story and comments here:
DIY Deliveries: More Women Go It Alone
Here's an additional resource on the history of childbirth. As someone who studied medical sociology, this book should add depth to the rise of the American Medical Association:
http://www.mcfarlandpub.com/book-2.php?id=978-0-7864-3362-9
Friday, October 19, 2007
Relationships Critical in Effective Leading
This month's issue of Center for Creative Leadership says "the ability to build and maintain relationships and work well with others is in big demand - and in short supply."
While I might think a leader is the one on point setting the pace, it's the manager who collaborates amongst departments to share resources, develop programs, and train personnel while simultaneously integrating direct reports' career and family desires with senior management edicts. So who really adds more value to an organization?
CCL says "Organizations are increasingly operating in ways that involve interdependent, boundary-spanning work - creating a greater demand for leaders who are skilled at participative management, building and mending relationships and change management."
Today's Navy Nurse manager [Division Officer] usually cannot offer choice job assignments although senior management does try to match career desires with billet openings. I have found that giving an expected timeframe for this transfer to a coveted position helps as well as exploiting opportunities for cross-training when workload is light. It also helps that nurse develop relationships with nurses already working in that department so this person is not only getting the benefit of me "pushing" this person to that department, but the department is "pulling" that person to come work with them in staffing meetings.
We cannot pay someone more for working the off-shift, weekend or holiday. This past summer, when staff members were working 18-20 twelve-hour shifts and on-call for more, the Nursing Middle Management Council wanted to reward those staff members with----a pizza party. I rolled my eyes. "Why not reward them with something that REALLY matters?" I asked. "Why not submit a nomination for a Navy Achievement Award---something that would appear on a fitness report and be presented in front of peers by the commanding officer?"
The response? "I'm really busy. I don't have time to write up a nomination." So, calling Pizza Hut or Dominoes is the ineffective leader's gift to direct reports. And it gives me a very good insight as to this manager's relationship abilities.
While I might think a leader is the one on point setting the pace, it's the manager who collaborates amongst departments to share resources, develop programs, and train personnel while simultaneously integrating direct reports' career and family desires with senior management edicts. So who really adds more value to an organization?
CCL says "Organizations are increasingly operating in ways that involve interdependent, boundary-spanning work - creating a greater demand for leaders who are skilled at participative management, building and mending relationships and change management."
Today's Navy Nurse manager [Division Officer] usually cannot offer choice job assignments although senior management does try to match career desires with billet openings. I have found that giving an expected timeframe for this transfer to a coveted position helps as well as exploiting opportunities for cross-training when workload is light. It also helps that nurse develop relationships with nurses already working in that department so this person is not only getting the benefit of me "pushing" this person to that department, but the department is "pulling" that person to come work with them in staffing meetings.
We cannot pay someone more for working the off-shift, weekend or holiday. This past summer, when staff members were working 18-20 twelve-hour shifts and on-call for more, the Nursing Middle Management Council wanted to reward those staff members with----a pizza party. I rolled my eyes. "Why not reward them with something that REALLY matters?" I asked. "Why not submit a nomination for a Navy Achievement Award---something that would appear on a fitness report and be presented in front of peers by the commanding officer?"
The response? "I'm really busy. I don't have time to write up a nomination." So, calling Pizza Hut or Dominoes is the ineffective leader's gift to direct reports. And it gives me a very good insight as to this manager's relationship abilities.
Thursday, October 18, 2007
"Health" Magazine Writer, Suz Redfearn, Advocates Deceptive Practices
The teaser arrived in my email box---Nine Secrets Health Insurers Don’t Want You to Know---and I clicked. Suz Redfearn, a freelance writer, says that
First, this is obviously not a colonoscopy but a flexible sigmoidoscopy. It costs a lot more for the more extensive procedure that checks the right side of the large bowel in addition to the transvers and descending colon. And sedation typically is not given for the flexible sigmoidoscopy. Most patients do not require colorectal cancer screenings before the age of 50. These exceptions include those with a history of familial adenomatous polyposis, obvious changes in bowel habits (bleeding, changes in diameter of stools, and unexplained anemia), and first-degree relatives diagnosed with colorectal cancer.
Other blogs about this article include:
California Medicine Man
Kevin MD Medical Blog
To get tested, talk up your symptoms.Your insurer doesn’t want to pay for a colonoscopy if it’s not necessary. But if your best friend is diagnosed with colon cancer and you want the $675 test to put your mind at ease, here’s how to get one covered: Mention to your doctor that you’ve had some blood in your stool and a lot of gas lately—or simply that your bowel habits have changed.
First, this is obviously not a colonoscopy but a flexible sigmoidoscopy. It costs a lot more for the more extensive procedure that checks the right side of the large bowel in addition to the transvers and descending colon. And sedation typically is not given for the flexible sigmoidoscopy. Most patients do not require colorectal cancer screenings before the age of 50. These exceptions include those with a history of familial adenomatous polyposis, obvious changes in bowel habits (bleeding, changes in diameter of stools, and unexplained anemia), and first-degree relatives diagnosed with colorectal cancer.
The National Cancer Institute has a wonderful site that explains the various options available for colorectal cancer screening. I would encourage all patients to discuss their risks with their providers and not resort to subterfuge or lying in order to obtain a test that may not be necessary.
I sent a letter to Health stating my disappointment with their decision to publish an article that advocates lying and deception in the patient-provider relationship. Healthcare providers already manage patients who claim they take all their medications as prescribed, who exercise as recommended, and who avoid dangerous health practices. Let's add another nail of skepticism to the communication coffin.Other blogs about this article include:
California Medicine Man
Kevin MD Medical Blog
Sunday, October 7, 2007
October is National Breast Cancer Awareness Month
In the summer of 1994, our neighbor wore a turban and we learned she had breast cancer. I remember being invited over to their apartment with walls lined with books from floor to ceiling. She and her husband had three children who were crammed into this little apartment.
One day we came home to find her crying in the hallway. "Are you okay?" we asked, concerned. She shook her head no. "It's in my bones," she said.
I've thought about her off and on over the years. The five-year survival rate for breast cancer with metastasis to the bones is 21%. I hope she is still alive; her husband and children deserve that much.
Breast cancer is the leading cause of death in women ages 20-59 while lung cancer is the leading cause of death in women ages 60 and older. Breast cancer diagnosed in the early stage, that is, while it is still localized to the breast has a 96% chance of survival. This is why mammography is so important. There are no early signs or symptoms of breast cancer; even the monthly breast self-exam (BSE) detects cancers at much later stages than radiology.
My annual mammogram is scheduled for this month and I am not looking forward to it. However, the inconvenience and pain of being diagnosed with breast cancer far outweighs the inconvenience and pain of this diagnostic exam.
For more information, please check http://www.nationalbreastcancer.org/
One day we came home to find her crying in the hallway. "Are you okay?" we asked, concerned. She shook her head no. "It's in my bones," she said.
I've thought about her off and on over the years. The five-year survival rate for breast cancer with metastasis to the bones is 21%. I hope she is still alive; her husband and children deserve that much.
Breast cancer is the leading cause of death in women ages 20-59 while lung cancer is the leading cause of death in women ages 60 and older. Breast cancer diagnosed in the early stage, that is, while it is still localized to the breast has a 96% chance of survival. This is why mammography is so important. There are no early signs or symptoms of breast cancer; even the monthly breast self-exam (BSE) detects cancers at much later stages than radiology.
My annual mammogram is scheduled for this month and I am not looking forward to it. However, the inconvenience and pain of being diagnosed with breast cancer far outweighs the inconvenience and pain of this diagnostic exam.
For more information, please check http://www.nationalbreastcancer.org/
Thursday, October 4, 2007
Too Sick to Take Meds
From the Chicago Tribune:
"In a new study published Thursday, a group of University of Chicago doctors found many diabetics believe that the inconvenience and discomfort of their treatments, especially multiple daily insulin injections, were as bad as the complications that can result from not treating their disease.
"Some patients, 10 percent to 18 percent of the total, said their treatments were so arduous that they would be willing to die sooner -- some said up to 10 years earlier -- if they could stop their medications.
""Some of this might be lack of education and people not understanding the disease process," said Dr. Holly Mattix-Kramer, a specialist in preventive medicine and kidney disease at Loyola University Chicago Stritch School of Medicine. "We need to do a better job educating our patients about what preventive care means and how it may affect their life span.""
I wonder if the providers evaluated these patients for depression.
There is a lot of support given to patients who are diagnosed with cancer. We have cancer support groups, we hold fund-raisers, and we generally don't fault these people for getting cancer (well, maybe we think smokers have it coming....).
In any case, there is no support for diabetics. Many diabetics have made lifestyle choices that have predisposed them to diabetes and, for some, lifestyle choices may have delayed but did not prevent the onset of diabetes. So others look at these people and "should" all over them. "You should have watched your diet. You should have lost weight. You should have..."
You cannot be dumb when you have a chronic illness. You have to track all sorts of medications, the timing, the changes in your diet and lifestyle (to include exercise and stress management as well as checking your feet every night) and then tweak your dosages when the next evidence-based practices are published. This means multiple visits to your provider and pharmacy and maybe visits to the emergency department when you take too much or too little of a medication. Think about all the time spent on managing this illness...
A multitude of factors comes into play here---psychological costs as well as very real physical costs. My only hope, as an adult nurse practitioner and clinical nurse specialist in adult health, is that these patients make INFORMED decisions---that is, they understand the full ramifications of the radical steps they are about to make and understand they may not be able to change their minds once they start down that path.
If they are honestly able to make this decision (and not just overwhelmed with the sheer agony of it all), then we as fellow humans have an obligation to support them in their decision and to allow them to die with dignity and grace.
"In a new study published Thursday, a group of University of Chicago doctors found many diabetics believe that the inconvenience and discomfort of their treatments, especially multiple daily insulin injections, were as bad as the complications that can result from not treating their disease.
"Some patients, 10 percent to 18 percent of the total, said their treatments were so arduous that they would be willing to die sooner -- some said up to 10 years earlier -- if they could stop their medications.
""Some of this might be lack of education and people not understanding the disease process," said Dr. Holly Mattix-Kramer, a specialist in preventive medicine and kidney disease at Loyola University Chicago Stritch School of Medicine. "We need to do a better job educating our patients about what preventive care means and how it may affect their life span.""
I wonder if the providers evaluated these patients for depression.
There is a lot of support given to patients who are diagnosed with cancer. We have cancer support groups, we hold fund-raisers, and we generally don't fault these people for getting cancer (well, maybe we think smokers have it coming....).
In any case, there is no support for diabetics. Many diabetics have made lifestyle choices that have predisposed them to diabetes and, for some, lifestyle choices may have delayed but did not prevent the onset of diabetes. So others look at these people and "should" all over them. "You should have watched your diet. You should have lost weight. You should have..."
You cannot be dumb when you have a chronic illness. You have to track all sorts of medications, the timing, the changes in your diet and lifestyle (to include exercise and stress management as well as checking your feet every night) and then tweak your dosages when the next evidence-based practices are published. This means multiple visits to your provider and pharmacy and maybe visits to the emergency department when you take too much or too little of a medication. Think about all the time spent on managing this illness...
A multitude of factors comes into play here---psychological costs as well as very real physical costs. My only hope, as an adult nurse practitioner and clinical nurse specialist in adult health, is that these patients make INFORMED decisions---that is, they understand the full ramifications of the radical steps they are about to make and understand they may not be able to change their minds once they start down that path.
If they are honestly able to make this decision (and not just overwhelmed with the sheer agony of it all), then we as fellow humans have an obligation to support them in their decision and to allow them to die with dignity and grace.
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