CHMP

Source: Florida NP Network

Florida is one of two states in the country that does not permit nurse practitioners to prescribe controlled substances. Imagine being a primary care provider for patients who need an opioid pain medication and having to refer them elsewhere for it. A perfect example of the barriers to access to care that are embedded in laws at the state and federal level. These barriers are costly in time, money, patient suffering and health. Watch this video to its surprising end:

The Examined Life, a journal from the University of Iowa's Carver College of Medicine

Joy Jacobson is the CHMP’s poet-in-residence. 

Last week CHMP senior fellow Jim Stubenrauch and I traveled to Iowa City for a conference called The Examined Life: Writing, Humanities, and the Art of Medicine. We attended panel discussions, writing workshops, literary readings, and other presentations by physicians, writers, nurses, medical students, patients, and others exploring the ways that literature and health care can intersect. It was exciting, sometimes downright thrilling, to be in Iowa City, a UNESCO City of Literature, and to hear what others from around the country and around the world have been doing to nurture these intersections.

The keynote address was delivered by Philip Levine, the current U.S. Poet Laureate. Levine has published 20 books of poems and won nearly every award we have to bestow on a poet. But he’s produced a body of work not overly concerned with illness or health care. So what was he doing at this conference? It’s a good question, one that raises another: can poetry have a vital role in health care?

Levine opened his reading with a poem originally published in 1980, “The Doctor of Starlight.” In it, a man visits his doctor with an odd ailment: “a tiny star above my heart.” The poem proceeds, through rhythmic short lines, to describe a medical exam in which the doctor asks his patient what he does for work. “I make the glare / for lightbulbs,” the patient says. It’s an extraordinary statement made ordinary by the workaday diction of the poem. Finally, the doctor and a strong-handed nurse pluck the star from the patient’s chest. “What does it mean?” the patient asks the doctor, and the doctor replies:

“Mean?” he said, dabbing the place
with something cool and liquid,
and all the lights were blinking on
and off, or perhaps my eyes were
opening and closing. “Mean?” he said,
“It could mean this is who you are.”

Levine is an entertainer, a storyteller, both in his poems and in his reading of his poems. (His between-poem banter itself rose to the level of art.) And in its realistic and surrealistic depiction of a medical encounter, “The Doctor of Starlight” reveals something about illness—and the distress surrounding illness—that health care does not always acknowledge: that our bodies are glorious, even when there’s something “wrong.”

That awareness ran as a subtle undercurrent through many of the presentations I heard last week. Nellie Hermann, author of the novel A Cure for Grief and a faculty member at Columbia University’s narrative medicine program, summed up, for me, why we need conferences like this. “Writing creatively,” she said in her lecture, “gives us access to parts of ourselves we might not access otherwise.”

On this week’s Healthstyles program, Dr. Nancy Rudner, RN, consultant and health coach, talks about her work as a health coach for frontline workers who may have difficulty accessing health care and living healthy lives. She talks with Healthstyles moderator Diana Mason, RN, about what’s in the Afforldable Care Act (the health care reform law) that is beneficial to frontline workers and shares a new online resource that anyone can use to find out how the new law will affect them. You can hear the program on WBAI-FM (www.wbai.org) on April 26th at 11:00 PM, or on WXMR-FM  (www.wxmrfm.com) on April 23 at 11:00 AM. Or click here to listen to the program: Rudner

Can You Imagine Being Forbidden to Go to College?

Education is the foundation of our lives and fundamental to all the work we do. It is the nourishment required to grow healthy communities, fostering the forward progress of humanity. It is hard to imagine that, in this day and age, leading authorities would deny this basic need to an entire population of its citizens. Such is the case of the Iranian government.

Education Under Fire is a campaign developed to address the Iranian government’s denial of the right to education for ideological and religious reasons. It is designed to help mitigate the effects of these discriminatory policies and to raise awareness of the importance of defending Article 26 of the Universal Declaration of Human Rights, which guarantees education as an inalienable right of every human being.

The campaign’s correspondent 30 minute documentary, Education Under Fire, focuses on the Islamic Republic of Iran’s three decade long policy of denying the members of its Bahá’i community, the second largest religious minority, the right to attend any institution of higher education. The Bahá’i community’s response has been one of resilience, as they formed the Bahá’i Institute for Higher Education (BIHE), a decentralized network of accredited professors delivering college classes in private homes across Iran. In May 2011 the BIHE was attacked by Iranian officials that concluded in the detention over a dozen people. Consequently Nobel Peace Laureates Archbishop Desmond Tutu and President Jose Ramos Horta of East Timorpenned an open letter to the International Academic Community calling for action to aid those whose lives are being subjected to these oppressive laws.  Let us respond to that call, engage in the conversation and assure that education remains possible for us all.

Please join us for the screening of Education Under Fire: Documentary and Conversation with guest panelists on Wednesday, April 18, 2012. Reception is at 5:30pm, the program starts at 6:00pm.

This event is free and open to the public at Roosevelt House Public Policy Institute at Hunter College at 47-49 East 65th Street, New York, NY 10065.

Space is limited and RSVPs are essential; please respond at your earliest convenience:

Please email HumanRights@HUNTER.CUNY.EDU or call 212-396-7946

Health Affairs has just published Amy Berman story about being diagnosed with incurable breast cancer and the challenges she faced–and most terminally ill patient face–in being supported by health care providers to make fully informed decisions about treatment options. Amy is using the remaining time she has to raise the visibility of the issue and help health professionals, as well as patients and families, to understand what “patient-centered care” really means. You can listen to her read her story. Spread the word so we can support Amy in ensuring that we all expect to have full information about our treatment options and to be fully supported in our decision by health care providers.

Jeannette Crenshaw with co-author Elizabeth Winslow

This week on Healthstyles, I interview Dr. Jeannette Crenshaw, RN, DNP, about what the evidence suggests is appropriate for pre-operative fasting--what should you not eat or drink and for how long before surgery. Unfortunately, most people are told to fast for much longer periods of time than is necessary, and this can lead to dehydration and other adverse effects. Catch it on wxmrfm.org or wbai.org. Or click here to listen: Crenshaw

Diana J. Mason,PhD, RN, FAAN, Rudin Professor of Nursing

Organ transplantation is a complex and challenging undertaking for both the patient and providers. It can offer the appropriate patient opportunities for greatly improved quality and length of life and it can also offer an opportunity for profiteering and conflicted behaviors. As outlined below, transplantation produces significant revenue dollars, even for a “non-profit” hospital.

Estimated U.S. Average 2011 Billed Charges Per Transplant:

Heart Only - $997,700

Liver – $577,100

Kidney – $262,900

Nurse Amanda Trujillo identified that a patient she cared for at Banner Del E Webb Medical Center of Arizona lacked full information about what a transplant evaluation and post-transplant self-care entailed. She says she referred the patient for a hospice case management consultation. She was then fired for overstepping her scope of practice. Arizona’s scope of practice for nurses clearly dictates a nurse’s role to promote the client’s best interest.

Banner Del E Webb is one of only three liver centers in Arizona, and the only one that appears to be  aggressively expanding their liver transplant program(the link takes you to a site where you have to build your own report).  In 2011 Banner performed 50% more liver transplants than the year before, while the other centers showed no change.

AZGS-TX1 Banner Medical Ctr.    -   70 in 2011; 46 in 2010       

Clinic Hospital    -  59 in 2011;  60 in 2010 

AZUA-TX1 University Medical Ctr.   -  16 in 2011; 20 in 2010

Banner has also heavily invested in their ability to perform surgeries, and “recently completed a 136,000 square foot expansion and renovation designed by HKS, Inc. hosting 20 state-of-the-art operating rooms, 76 preoperative and postoperative bays” as part of four $300 million construction projects that started around 2010.

These multimillion dollar levels of prospective financial gain and loss expose a potential for conflict of interest at a minimum, and offer one possible explanation why a hospital and providers might be so committed to protecting their surgical alternative versus hospice for a patient.

It is not possible to advocate for a patient if one treatment option enriches the provider and the other would not. Why would physicians not disclose financial conflicts of interests? Informed consent as defined by the AMA only covers risks and benefits of the proposed intervention and any alternatives but never addresses conflicts of interest.

Where is the protection for nurses caught between patients and profits? The American Nurses Association recommends that “nurses attend to and are aware of conflicts of dual loyalty to patients, health care institutions, employers, and agencies that provide payment for services.”

Why is there not a policy of protection for patients from organizational or provider conflicts of interest? Fully disclosing the financial conflicts of interest should include the incentives and bonuses for surgeons and staff to perform procedures as well as the “needs” of a hospital to fill its new surgical suites.

It is time for every informed consent for a medical or surgical procedure to include a written, enforced policy on financial conflict of interest.  

Nurse Richard, alias Richard Dorritie, RN

“Aging in place” was a term used repeatedly at last week’s American Society on Aging Conference in Washington, DC. Every expert I spoke with offered a slightly different perspective on exactly what that means. However, all agreed that it is today’s technology that allows many more seniors to do so, and for a longer time.

One source describes it as “a concept where seniors continue to live at home or with a family regardless of their mental and physical decline. This concept requires resources like in-home caregivers”. An AARP Survey found that nearly 90 percent of seniors (65+) want to stay in their own homes for as long as possible; 80 percent don’t think they will ever live elsewhere.

In a previous blog post, I discussed technology ‘s major role in today’s caregiving. Without it, many older people would be forced to move, to access necessary health services. Some of these technology products and services have actually been around for some time as telehealth tools. According to The Health Resources and Services Administration (HRSA) telehealth uses electronic information and telecommunications technologies to support long-distance clinical health care, patient and professional health-related education, public health and health administration. This might encompass technologies from videoconferencing to streaming media to a web portal.

With a nod towards consumers, laptop computers, and families scattered around the country, telehealth still embraces use of electronic information and telecommunications technologies, but it’s now something you and I — just ordinary folks with aging parents — can regularly access and use. Remote home monitoring is just one example of how health technology has evolved into an everyday consumer product.

It’s gone from sending pacemaker data by phone and “virtual” doctor visits to a full-blown, user-friendly motion detector system hooked into a computer and programmed to call or text a loved one in specific situations. Activity can be monitored from afar – software is able to analyze everything from “did mom leave the stove on?” to “did dad take his medication this morning?” It sounds a bit “big brother-ish” but it’s an example of adaptive and innovative technology use to ensure that a senior can remain at home.

Monitoring of chronic conditions and potential for falls– a major source of disability, injury, and death among seniors — also allows aging in place to continue. This is great news for many seniors. Not so great news for many others.

All this technology comes at a price. Set up fees can range from a few hundred to a few thousand dollars, depending on the equipment, needs, scope, and health issues. Then there are monthly subscription fees — one company said their service averaged around $99 per month. Since many seniors are on a fixed income, it probably falls to adult children to shoulder the costs. CMS reimbursement is unlikely for most equipment and services. So what’s a poor family to do?

Low income seniors and families face the same aging in place issues that the middle income and wealthy do. Only the $99 per month is probably not in the budget; nor is the thousand-dollar set up fee. Aging in place technology has been shown to reduce health costs, improve seniors’ mental health, and provide an unquantifiable benefit of peace of mind for adult children. It can also help to spot early warning signs of more serious conditions, like progression of heart disease or Alzheimer’s.

For low-income seniors, many of whom are also homebound, there is no “quick fix” solution. There’s no power button to push, link to click, or data to transmit. This group of seniors age in place without a technology safety net. Yet another schism in digital divide.

Last week, the Hunter-Bellevue School of Nursing’s students and faculty, as well as guests from clinical agencies, heard an outstanding presentation on the Institute of Medicine’s report on The Future of Nursing and the relevance of the Affordable Care Act. Mary Ann Christopher, MSN, FAAN, the new president and CEO of the Visiting Nurse Service of New York, was the featured speaker. The students were clearly engaged in her presentation and had the opportunity to interact during the discussion period with Ms.Christopher. Repeatedly, the students who came to the microphone to pose questions and react to her presentation identified themselves by first name. As moderator, I asked them to give their full name on several occasions. But it was disturbing to see that they had to be prompted to do so.

This is a common occurrence when I’m with staff nurses, including those who are graduate students. I have been puzzled about why, then recently received an email from a colleague who earned a PhD last year:

“What do you think about nursing badges with the nurses’ first name only on the top line, yet physicians have their first and last name on the top line. I was told if I had my first and last name on the top line of my badge patients might confuse me with a physician.”

This is such rubbish and leads to physicians being called “Dr. Lastname” and nurses being referred to by their first names. Nurses can tell you that both nurses and MDs use first names with each other when the physicians are medical students, interns or residents; but once they become attending physicians, they expect to be called “Dr. Lastname” while still referring to the nurses by first name.

I know that some nurses are afraid that a patient might try to track them down at their homes if they include their last name, but why aren’t physicians? What about social workers or nutritionists or other providers? And why are nurses perpetuating this inequality?

What’s in a name? A lot.

Diana J. Mason, PhD, RN, FAAN, Rudin Professor of Nursing

Nancy Short. DrPH, MBA, RN

Dr. Nancy Short is a professor of nursing who knew that the surgeon you’ve talked with may not be the person who does all or any of your surgery. In the spirit of “patient-centered care”, she discussed with her surgeon a request that he do all of her abdominal surgery that had been scheduled. The surgeon’s, hospital’s, and health plan’s response to Dr. Short’s request and her recommendations for others who are undergoing elective or urgent surgery are the subject of this week’s Healthstyles program on WBAI-FM and WXMR-FM. Producer and moderator Diana Mason, PhD, RN, FAAN, discusses with Dr. Short one of healthcare’s surprising secrets, particularly in academic medical centers. Click here to listen to the program: Nancy_Short