Category Archives: health policy

two stem cell and bone marrow registration drive possibilities: please share

Please share these dates:  6/28 and 7/12 when folks 18-44 can register to register to be stem cell or bone marrow donors if a match is found.  The registry needs you!

Those 45-60 can register on line. Please check out information on bethematch.org regarding what this means!  The registry needs you. A cheek swab and a willingness…

Here is the thing: 97% of whites find a partial match.  65% of African Americans do. Other ethnic groups are lower than Whites and barely higher than those of African descent.  For a full match: 75% whites and only 25-35% of those of African descent.  Others are in between. Diversity in the registry is key. The sites for the drive are because they are diverse, inclusive, and social justice minded.  Please come by.

Feel free to share the fliers

Thanks! Sharon

Matt Dobie Immaculate

Matt Dobie St T

skinny crazy small

I have a young friend who is using theater for raising public awareness.

SCSrevisionDecPost

Actress and playwright Sylvie Mae Baldwin announces the world premier of her original one-woman play skinny crazy small.  And I am delighted to promote it.

The play chronicles the 8 year battle of a young girl with anorexia, seeking to give new voice to the discussion of this illness and to advocate for breaking down stereotypes.

She has an Indiegogo campaign for skinny crazy small that is live for just a few more weeks. Funds will allow Baldwin to pay her director and technical director a fair wage, as well as to rent rehearsal and performance venues. The Indiegogo page has a full breakdown of how funds will be allotted. Please contribute to this project at:

https://www.indiegogo.com/projects/skinny-crazy-small
Your donation is tax deductible, thanks to Fractured Atlas, a non-profit arts organization in New York City. And if your employer matches donations, skinny crazy small can accept those as well!

Great resources to learn more about the show include their website and Facebook page: http://sylviemaebaldwin.wix.com/skinnycrazysmall

http://www.facebook.com/skinnycrazysmall

You can also purchase your skinny crazy small tickets today!: http://skinnycrazysmall.brownpapertickets.com

About Sylvie:

Sylvie Mae Baldwin is an actress, modern dancer, and musician. In May 2015 her original one-woman show, skinny crazy small, will premiere in Seattle, Washington. The play tells the story of a quirky and strong-willed girl’s struggle with anorexia and seeks to promote honest discussion about eating disorders (www.facebook.com/skinnycrazysmall). Regionally, Sylvie Mae has appeared on stage with Antaeus Company (CA), Book It Repertory Theatre (WA), Key City Public Theatre (WA), Lexington Children’s Theatre (KY), Seattle Public Theater (WA), Seattle Theatre Group (WA), and South Coast Repertory (CA). Sylvie Mae also was part of a group of young actors at the Northwest School who spent three years working in collaboration with UCSF Benioff Children’s Hospital tp craft short plays from the poems and journal entries of terminally ill children in the hospital’s ICU. These plays were performed at the UCSF medical facilities and the DeYoung Art Museum. Sylvie Mae trained with Anne Bogart and the SITI Company in New York. She is a proud member of the Actors’ Equity Association. http://www.sylviemaebaldwin.com

writing about patients

Sitting in a coffee shop, I anxiously awaited one of my patients. I invited him to meet with me to read the story I wrote about what I learned within our working together over a period of more than 15 years with me as primary care provider AKA PCP and him as patient. But really, who taught whom and what? As editor and author, I am preparing to submit the manuscript for Heart Murmurs ­–What Patients Teach Their Doctors. All of the stories deserve permission from the patients who are described in the book; fewer than half can be reached to ask for this permission.

Some contacts were emotionally easy. There is a chapter on those whose cheery dispositions brighten our days in clinic. When I met with those patients and family members, they enjoyed that I wrote about them in this way. But what about the more challenging lessons? This was the concern as I waited that day in the coffee shop. His was a difficult story, a past experience for him, and a lasting lesson for me. I wondered if he would veto it being in the book. After arriving and some chatting, he read it. I sat there sweating. He said he loved it, and he added some ideas for changing the details that blinded the story. This is how all these meetings have gone: I am anxious and worried and our patients are gracious and grateful for the project, touched that they have taught us. And there is our respect to change what they need changed in the story telling.

Whose story is it?  Of course, whether published or not, it is the perceptions (with all the bias implicit in perception) of the writer. On another level, when told it is the story of the teller and those about whom we storytellers write.  In patient care, some argue that it is always the patient’s story.  I am hoping to respect that view but to have a broader lens.

Reviewing stories with the individuals represented in them is an activity that adds to the relationships we have. One family member of a person who is deceased agreed with my perceptions and contributed details that were important and enriched the story. Several commented on how the story was accurate but that I left out details that were important to them. Often those had to do with what I did for them (much of which I do not remember and all of which was wonderful to hear, but not the focus of the stories). When reading a difficult narrative, several reached out to reassure me or another author. Each of the reviews went well, validating the project and our perceptions of reciprocity in these patient-doctor relationships. For me, what happened in the sharing of the stories supports my belief that this project is worthy for all, not just doctors.

Our physician authors also reviewed their narratives a year or so before publication; for many this review occurred a number of years after they wrote their stories. Older and more experienced, several commented that the revisit was a reminder of how they thought earlier in their career. They could see how they have changed as well as the characteristics that remain.

The ethics of patient protection has muddy waters.  Strict rules do not quite fit. I do believe that when we meet with patients and have conversation about a written narrative, the relationship grows. The co-creation of stories can enhance relationships where patients have the agency and that makes sense to me.  Doctors have written about their patients for centuries. Most of those writings, until very recently however, spoke to a culture where the patient was less of an equal partner in the physician-patient equation than what we currently believe and teach. Certainly, most of those years also preceded current privacy regulations. As recently as fifteen years ago, this subject was not routinely scrutinized. I have no idea where it will be ten years from now.

The emerging ethic about writing about our patients is not well defined. What can we say? What should we not say? Can we even do this writing? On the one hand, memoirs tell only one person’s perceptions. What should determine how a physician addresses this? In prior works, names and circumstances might be changed, but is that enough? Is there a line that is different when we are writing the story about a relationship that is defined by confidentiality?

At the same time that we ask these questions, medical education is clearly recognizing and supporting reflection by physicians. We teach it; we have reflections in our courses. Those of us attentive to this trend have also cautioned our learners, be they students or residents, about blogging and other social media outlets for sharing their reflections.

What are the answers? Others and I hope any answers encourage compassion and reflection in all of our healing professions.  We hope the answers allow the story telling that is so central to our diagnostic and therapeutic work. However these ethics evolve, I hope that we can support stories being told, shared, and valued, while  of course protecting the right of patients to their privacy in this very special relationship.

How do we reconcile these tensions in the best way we can?

In Heart Murmurs, the authors, including me, wrote about what they learned about themselves because of and within a relationship with a patient. We can’t tell that story without the story of the patient. I believe there is tremendous social value in this reflection and in it coming to the public domain. How then do we protect the covenant of confidentiality? Today I sit with a manuscript with over thirty authors and many stories of mine, over 80 total from all of us. Where I am settling, and I hope it is good for the mores of today, is the following:

All stories must meet several criteria:

  1. The value of telling the story is important to our social dialogue. The purpose of this project is one that meets this criteria for all the narratives included in the project.
  2. The story is told in a respectful way for each person represented. All stories, even those that have difficult circumstances, in this book are respectful, though I recognize how subjective perception is.
  3. If a person believes a story is about them, they should not feel embarrassed or shamed, also subjective and hard to predict in many cases.

All stories in Heart Murmurs have names and some circumstances altered, except for two where family explicitly approved using the actual name. I believe all included stories meet the above criteria. Patients of mine have read their piece and agreed to publication, or they are deceased and a family member read it and agreed to publication, or they are deceased and I could not find a family member for review, or it is a composite, or it is many years ago and I could not find the person to review the narrative.

If another physician contributor wanted to attach their name to their story one of the following criteria had to be be met:

  1. The author shared the narrative with their patient and the patient agreed to it being published; or
  2. The patient could not be found for sharing the story and the circumstances are altered for patient protection; or
  3. The patient is deceased and the author shared it with a family member who agreed that it can be published; or
  4. The patient is deceased and no family member is easily found or reachable and the story is generic enough that the identity seems reasonably protected; or
  5. The story is a composite and thus not attributable to one person; or
  6. The story is from a number of years ago and no one could be contacted and it is blinded enough so that identity seems reasonably protected from any but possibly the patient.

If one of these six criteria was not met, a story will say “anonymous” and the author can have a biographical note if they wish. For stories with an anonymous author, with circumstances changed, and with the authors being from all over the country, I believe patients’ identities are reasonably protected. Even if a person or a family member reads the book and identifies with the circumstances in a story and wonders, their identity should be protected from others. No persons should be certain it is really about them. What I also know: the lessons in every narrative in this book have been experienced in one way or another by individuals and their physicians all over our country.

Not a single story

So many layers.

It always amazes me how we bring many lenses to any situation and these are how we see the world. Some, well maybe most of us, have several lenses, or maybe should.  What do you think?  Which lens rises to the top depends on so many things.

In the story of today, shall we look at this through the just get the person to safety lens?  How about the really weird, as in I can hardly believe I felt this and though it cannot be close, here I am, standing in another’s shoes lens?  Or the health-care system, it really can be better lens?

Or all of the above.  They all fit for me. I like the notion of multiple views.

The story:

It was a busy week back at the ranch, er job: several evening events, a night on call, but no matter.  I had made plans to take Friday off and even arranged coverage for Monday; we were going to the snow, heading for Canada.  “We” would be my neighbors and me.  They drive, I have the housing arranged: me in one room, their daughters in the other, the parents in the living room.  A close friend’s daughter with a season pass wanted to come too and she could sleep in my room.  All set.

Then my friend, mom of the kid who would be my room mate, decided to rent a place in the same building and come as well with another friend of ours.  All good….except she was tired and it was a long week and she was ambivalent.  Her daughter and I both talked with her, and in the end she decided to come.

Thursday evening we all (including my friend’s husband) were at a fund raising dinner, and all seemed ready for the next day.  I arose Friday, packed, and my neighbors and I hit the road.  Many hours later my friend, her daughter, and our other friend arrived.  My friend did not feel well, was nauseated and had abdominal pain all day.  She had not eaten since the night before.

Saturday morning it seemed clear that my friend needed to be seen at the clinic.  She, our mutual friend, and I (all family medicine doctors) feared appendicitis. While my neighbors, my friend’s daughter, and I went to ski, the other two went to the clinic.  By lunch, we knew. Her daughter and I headed down the mountain:  appendicitis.

We were in a location with no hospital.  We knew the ones along the way from there to Seattle.  Her husband was not with us because he had been on call, but had gotten sleep and was able to drive to the border and meet us. We knew there were surgeons in Squamish, then Vancouver, then Bellingham, then Everett, hoping to get her to Seattle.

The punch line is that she did get to Seattle, had her surgery around midnight Saturday night, and was home Sunday evening.

But that in not the point of this post.

I mentioned three lenses above.

Get her to safety: Who should go, where to go, who helped us know?  We had many possibilities.  Who should go?  Should her daughter drive her to Seattle?  What if she got sicker along the route and a doctor was not with her?  How luxurious that there were two other doctors along.  And who should go?

Stand in shoes:  The two doctor friends (Diane and me) decided to drive her to the border. Had we crossed the border, the wait to go north was close to two hours. We did not want her husband driving across. And she did not want us crossing to deliver her and face that wait. We opted to park at the Canadian border, talk to the guards, walk to the US border (about an 8 minute walk, in the pouring rain, our friend doubled over, us carrying her bags), talk to a US guard who by cell phone instructed her husband how to get to us without getting in the 90 min line, and delivered our friend to her husband.  Something hit all three of us, only shared after the fact. What we felt walking across, pouring rain, was a sense of vulnerability. It was a trek. 

Although we knew we had what we needed to get our friend across to the USA and us back into Canada, we were nervous and vulnerable.  How is it for others for whom the border cross has even higher stakes ?

We stood in line at the US station for pedestrians.  There were border patrol folks milling around.  It looked like they were not attentive to the lines and were not doing work.  We stood there.  Our friend was getting more and more hunched over.  We were scared. How much time did she have until she ruptured that appendix?  Finally we asked for help. The guard heard us and did help and a few minutes later our friend was on her way south and we two others were trudging back to Canada.

What do others feel in that walk between borders?  Really, we all knew ours was only 8 min between the two borders in that nomad’s land and yet each of us silently felt that anxt: what if it does not go well?  We all have enough life experience to know that what we felt had to be, given the certainty of our getting across, just a tiny fraction of what many millions feel when crossing a border under duress.

And the health care system:  Our friend had lab results and CT scan that showed the appendicitis.  We had seen the monetary charges: they were half what they would be in the good old USA.  Yet people complain about single payor.  Really? 

OK, once we handed her over to her husband, they were in the good ol USA.  One hospital/ surgeon on call would require she go to the ER.  Even if they accepted the CT scan and labs, there is that charge on top. (and by the way, there would be the delay and risk of rupture) A second hospital/surgeon would admit her straight to a room and then the OR.  Guess which was chosen? Surgery that night, home the next day.

Patients or money first?

What do you see in this story

Patient Centered? Really?

Where I work, we have decided some policy changes.  First of all, let me clarify what “we” means.  “We” is the management of our clinical enterprises, either one or both of them.  I scratch my head in wonder.

Lots of people now are talking about how our relationships with our patients are so important.  Well not exactly.  What they say is put our patients first.  What does that mean really to them? (“them” being the management I mention above in “we”)

They talk about team care, the patient centered medical home.  If we (now I mean me and others actually doing the work) meet some criteria, we get more reimbursement. But is that really putting the patient first?  What are those criteria?

Why is it that no one asks us who see patients what do we do to put our patients first?  Why do they not take it from patients who are satisfied?

But I digress.

Our new policies:

1.     We want our medical assistants to do more, facilitating what the doctors need to do.  They have long templates to complete on multiple visits, much more than the “why are you here?” and its ancillary questions, blood pressure, weight, pulse, respiratory rate, and oxygen saturation (and why does a healthy 20 year old need oxygen saturation anyway? Show me the evidence. I would rather that they remember to obtain and chart the respiratory rate and oxygen saturation when there are symptoms and cause.)

2.     They are to review every medication the patient is on and check them off.

3.     They are to see if any immunizations are needed and to order them for me to sign

4.     If it is a kid for a well child check they are to enter data from a long questionnaire the parent(s) filled out on how the child is doing medically, emotionally, nutritionally, and developmentally.

5.     That is to take place before I see the patient.

6.     What that means is:  our patient calls for an appointment.  Say they have a fever and sore throat.  They get a 15 minute appointment.  Say they are 80 with multiple problems.  They get a 30 minute appointment.  If 1-4 are completed by our medical assistants, I get about 5-6 minutes in a 15 minute appointment and maybe 12  in a longer more complicated appointment.  Do the math.

7.     If I take the time I was supposed to have, I get behind, running the risk of irritating the next few patients on my schedule. If I fill only the time left, I am shortchanging the patient I am seeing, who might feel they did not get to handle enough in the brief time with me.  Oh and by the way, it is fraud if I bill for more.

At the same time, we are pretending that we are being a team.  Don’t get me wrong.  I believe in teams.  I love teams.  It used to be true that our front desk staff were on the team.  They knew the patients when they called for appointments.  They knew who they could squeeze in as an extra, who needed more time.  And our patients trusted them. Now we have a call center for the whole medical center, that I will just say is not the same.  It used to be true that I worked 95% of the time with the same medical assistant.  The patients who call me their doctor knew that medical assistant had their back, whether it was a hug or an urgent medication renewal.  We had a pharmacist and social worker who knew most of our patients and our highest need patients knew them.

That was then and this is now.  Team?  Why is the patient left off the team?  How come they don’t know that the work of the medical assistant is part of their visit?  Why don’t we schedule so that the medical assistant work can happen and I can still have the time my patient and I need to work together on whatever brought that particular person to the visit?  Instead our patients are dissatisfied.  The medical assistants are incredibly stressed with more to do and realizing the more time they take the less time we doctors have.  And I cannot do my job.

This is just one area where not involving regular working stiffs (like me and our staffs) in policy and process development just does not work.  Instead we have institutions trying to get certificates for a reductionist view of what is needed in our encounters, er, yea I mean relationships, with real people around their health concerns.  Check boxes, lists of criteria…most well intentioned and could make for good patient care, but reduced to a get it done without any realism about time and skill and the imperative the patient brings to an encounter with me.

Oh well….I will keep doing what I do.  The next piece may be on Intellectual Freedom, the academy (that would be places where teachers and scholars live in universities), and my institution—that is if I believe the new language in our faculty code that gives us some intellectual freedom and whether I trust that it would supersede the policy of the Medical Center.

The insanity of it all.

A team of four residents (maximum of two at a time in 12-15 hours shifts at the hospital) and an Attending/faculty doctor cares for our family medicine patients when they are hospitalized. Other services have other team structures. Our patients come from our clinic and a number of satellite clinics and are adult medicine patients, women in labor, new moms and their newborns, and some women with prenatal problems requiring hospitalization. The residents are first year (interns) and senior (second and third year).  Our residents are generally smart and attentive and work well with our patients, treating them as individuals with lives outside the hospital and with careful management of the reasons they are in the hospital.  They do a good job running between laboring and delivering women and our very ill internal medicine patients.

Recently when a friend was the attending on the service, a patient with complex medical and psychosocial concerns was admitted.  The team created the time and space to really unearth some of the underlying physical and social challenges faced by this patient.  This led to a carefully orchestrated discharge plan, including where and when she would be seen for ongoing care and what elements that care might contain.

Once again our health care system snatched defeat from the jaws of victory.  The patient’s insurance covered our hospital, but it turns out it did not cover being seen in our neighborhood clinic, which is part of the same health system.  The patient did not get the necessary outpatient care and was readmitted to the hospital.

Last night I heard that one of the major insurers in this area dropped a contract with a major hospital that is used by many physician groups.  Instead they are contracting with another hospital that has its own multispecialty group.  Now all the medical groups who have used the other hospital are rushing to see if the approved hospital will give them privileges to hospitalize their patients. If not, their patients will have to be hospitalized at the approved hospital by doctors who do not know them and whose electronic medical records do not communicate with those of the outpatient doctors from the other hospital.

What has always been clear to me:  the insurance companies will keep their profit margins.  (Oh yes—hospitals and doctors’ groups want to do the same.)  None of this is the recipe for improving health and health status or for curbing health care costs.

The task of trying to provide continuous seamless care for our patients just gets harder and more insane.

Every major country with good health outcomes has lower costs.  Take a look at the expenditure tables in this Commonwealth report.   Look also at : 1) the tables on mortality from index cancers, 2) hospitalizations, 3) deaths in hospital.  For all we spend, we do no better than other industrialized nations spending much less.  According to The State of the Worlds Mothers 2013 report, we are 30th in the world for newborn deaths on the first day of life. 30th!  The top ten with the lowest rates are Finland, Sweden, Norway, Iceland, Netherland, Denmark, Spain, Belgium, Germany, and Austrailia. Our spot, 30th, is worse than any industrialized nation.  Life span, you might ask?  We are 48th in the world, despite our spending.  Each of the industrialized nations with better outcomes than us also has significant government involvement in setting prices and policy, which our electorate continues to fight.

I am far less concerned with the troubles of the ACA website; gee, my electronic medical record crashes on me all the time when I am up late at night doing my charting.  I have to live with it, boot it up again, and still get the job done.  Even fewer choices of where to get care is ok with me.  That may be a price to pay to get more people covered, at least the way we have chosen to go about it in this country.  But if fewer choices and inadequate technology are accompanied by insane lack of coordination of care across locations AND by rising profits of insurance companies, well then, I continue to not understand how Americans can fear a single payer plan.

Assumptions and single stories

It was about 1030 in the evening and I was at home, settling in and at the same time wondering if I would get through the night without hearing from our resident on call. Well, we were both on call, but he would get the first call and then get in touch with me.  I was hoping for sleep and not excitement. On our in-patient service we care for women in labor and manage their deliveries, and then care for them and their newborns after birth. We also care for adults admitted with adult medical (and sometimes surgical) problems necessitating a stay in the hospital. It was calm at that moment and there are no guarantees in this job.

When the call came, I took a deep breath and listened to my resident’s report.  This patient was in the ER and needed admission. He told me she was pretty sick, probably a pneumonia but maybe a pulmonary embolism, and  she was in a lot of pain. On top of her acute problem, she had major chronic health challenges.  She was only 31, but she had a form of muscular dystrophy that was diagnosed during her teens, leaving her with  spasms of some muscle groups and weakness of others. Recently she had gotten her first electric wheel chair. She could transfer from it to a couch or bed, but not walk much more.  What we both knew was that pneumonia, because of her weakened chest wall muscles, could become a recurring event.  What we did not know was what she knew about her life expectancy.

He had appropriately started her on antibiotics and some breathing treatments, and he reviewed the scan that showed it was not a pulmonary embolism. I picked up my things and headed in to see her.

It’s a short drive from my house to the hospital and the drive is through a beautiful wooded arboretumArboretum that always calms me as I race to a delivery or whatever pulls me in during the late hours.  On the drive that night I wondered, what is her life like?  What does she do with her time?  She was wheelchair bound, too weak to walk now.  She had to know her life expectancy was limited.  Our resident has told me she lived at home with her parents and that her mom was in the ER with her.

Another thing was the pain.  She was in pain and asking for increasing narcotics.  I wondered, hmmmm, how much is the sack around the lungs, the pleura, that can really hurt when inflamed and how much was psychic pain?  What was she doing to manage that?  She must have some, right?

Before I was even aware, I had painted a picture of this young woman:  chronically ill, disabled, little life quality, now sick and needing antibiotics and wanting pain medications.

During that week we had cared for another young woman, a lung transplant recipient, who at 21 spent her days at home doing nothing but playing computer games.  I was never able to figure out whether she was depressed, insecure in a world she could now enter with more health than she had as a child, or what held her back.  But knowing she was healthy enough to be in school or working, I had to work to not judge her choices. I clearly was projecting her story onto a reality I was creating in my mind for this woman I had not yet met.

Entering the exam room in the ER, this is what I saw:  a young woman curled into a ball. With every breath she moaned.  She wasn’t breathing fast and because she was not using a lot of extra muscles to breathe, I could tell she was not in respiratory distress (that’s our medicalese for an outsider being able to tell you are having trouble breathing). OK, true, she had oxygen on through those prongs in her nose, but it was not turned up very high, so it clearly was working.

Her mom was sitting at the bedside reading.  60ish, eyes drooping, almost asleep over the book.

I opened with an introduction of me to them and then asked why they were there, apologizing for the fact that they had answered this question already, several times.

“Mom, you tell her.  I’m hurting to much to talk. And I’ll start coughing,” she said.

Her mom told the story of fever, cough, trying the inhalers and chest thumping they had been taught.  None of it worked.  I knew this from the history the resident had obtained, his exam, her labs and imaging studies.  And I wanted to hear it fresh to confirm it.

As we moved along, I was needing to answer that question that nagged me during the drive in to the ER.  What was her life?  As in living her life?  Maybe it was my innate curiosity.  Maybe it was I really didn’t want her to be like the other woman who seemed to have abandoned life.  (Oh, right, those are my standards…and who am I to dictate what is a valuable life?  Have you ever caught yourself in that bind?).  Maybe I really wanted to connect with her.  Maybe all of the above?  (I hate those questions on tests that have is it 1,2,3? or 2, 4? or 1,3? or none of the above. Just sayin’)

Getting to the social history part of our script includes things like where were you born?  With whom do you live? What is your school history?  Do you work? Where? How do you spend your days?  Who supports you? What are your stresses?  (and more, depending on the person and their story).

I opened up:  “I know you are in a lot of pain.  Is this typical?”

She answered, “No absolutely not!”

I countered, “OK, we will help with that. Can I ask you about you and your life?  I am really interested in what school was like, what you are doing now, how you spend your days when you are not in the ER with a pneumonia.”

“Well,” she said, “I am pretty busy.  I work in a book store part time.  I’m a writer so I also tutor kids in their language arts course.  And then there is this start up that is trying to make documentaries about how people with chronic illness have a hard time getting ahead in their jobs. I am a volunteer with that.”

Boom.  Assumptions shattered. I had both made assumptions and given her a “single story.” What the resident told me, colored by the experience with a different patient, shaded by my own biases, and outlined in the drive in had given her a story in my mind that was completely inaccurate.

Yesterday’s post, Tina Shang’s  comments, and a wonderful poem by Nancy Woo all speak to how we make assumptions prematurely and as humans have a tendency to relegate each person to a SINGLE story that does not give the respect that is due to the complexity of the human spirit.

Take a look at this TED talk by Chimananda Adichie. If you have not already seen it, it is more eloquent than I can be.

Living and Limits

I am posting a woman’s entire post below because I found it helpful and provocative.  If you want some other sources that suggest we should really hear this story, look at Josh Freeman’s blog today.  He is talking about what it will take to improve health (and that will also lower health care spending) in our country. He links his thoughts to an earlier post of his, Capability; Why people may not adopt healthy behaviors. That earlier article contains some useful references to rattle your brain.  On a personal level, what really drives each of us in the choices we make?  Some of his references take a scholarly look at that question. None are quite as honestly blunt as the post I quote below.  While I might see the choices available to the writer as more numerous than the writer sees, that is not the point.  And of course my job is to offer what I see and seek ways to steer someone to more healthy choices that might improve their health status, regardless of the givens of their daily life, burdens, and realities. The point is that if we want to improve health, we sure cannot do it from a perch of I never really sat on your perch.  I hope you will read Josh’s post today and his 2010 one along with the one below and savor the richness of who we are as people/individuals.  We each are trying to get through a day, live a life, always in the midst of the expectation that we also make healthy choices.

From killermartinis.kinja.com

“There’s no way to structure this coherently. They are random observations that might help explain the mental processes. But often, I think that we look at the academic problems of poverty and have no idea of the why. We know the what and the how, and we can see systemic problems, but it’s rare to have a poor person actually explain it on their own behalf. So this is me doing that, sort of.

Rest is a luxury for the rich. I get up at 6AM, go to school (I have a full course load, but I only have to go to two in-person classes) then work, then I get the kids, then I pick up my husband, then I have half an hour to change and go to Job 2. I get home from that at around 12:30AM, then I have the rest of my classes and work to tend to. I’m in bed by 3. This isn’t every day, I have two days off a week from each of my obligations. I use that time to clean the house and soothe Mr. Martini and see the kids for longer than an hour and catch up on schoolwork. Those nights I’m in bed by midnight, but if I go to bed too early I won’t be able to stay up the other nights because I’ll fuck my pattern up, and I drive an hour home from Job 2 so I can’t afford to be sleepy. I never get a day off from work unless I am fairly sick. It doesn’t leave you much room to think about what you are doing, only to attend to the next thing and the next. Planning isn’t in the mix.

When I got pregnant the first time, I was living in a weekly motel. I had a minifridge with no freezer and a microwave. I was on WIC. I ate peanut butter from the jar and frozen burritos because they were 12/$2. Had I had a stove, I couldn’t have made beef burritos that cheaply. And I needed the meat, I was pregnant. I might not have had any prenatal care, but I am intelligent enough to eat protein and iron whilst knocked up.

I know how to cook. I had to take Home Ec to graduate high school. Most people on my level didn’t. Broccoli is intimidating. You have to have a working stove, and pots, and spices, and you’ll have to do the dishes no matter how tired you are or they’ll attract bugs. It is a huge new skill for a lot of people. That’s not great, but it’s true. And if you fuck it up, you could make your family sick. We have learned not to try too hard to be middle-class. It never works out well and always makes you feel worse for having tried and failed yet again. Better not to try. It makes more sense to get food that you know will be palatable and cheap and that keeps well. Junk food is a pleasure that we are allowed to have; why would we give that up? We have very few of them.

The closest Planned Parenthood to me is three hours. That’s a lot of money in gas. Lots of women can’t afford that, and even if you live near one you probably don’t want to be seen coming in and out in a lot of areas. We’re aware that we are not “having kids,” we’re “breeding.” We have kids for much the same reasons that I imagine rich people do. Urge to propagate and all. Nobody likes poor people procreating, but they judge abortion even harder.

Convenience food is just that. And we are not allowed many conveniences. Especially since the Patriot Act passed, it’s hard to get a bank account. But without one, you spend a lot of time figuring out where to cash a check and get money orders to pay bills. Most motels now have a no-credit-card-no-room policy. I wandered around SF for five hours in the rain once with nearly a thousand dollars on me and could not rent a room even if I gave them a $500 cash deposit and surrendered my cell phone to the desk to hold as surety.

Nobody gives enough thought to depression. You have to understand that we know that we will never not feel tired. We will never feel hopeful. We will never get a vacation. Ever. We know that the very act of being poor guarantees that we will never not be poor. It doesn’t give us much reason to improve ourselves. We don’t apply for jobs because we know we can’t afford to look nice enough to hold them. I would make a super legal secretary, but I’ve been turned down more than once because I “don’t fit the image of the firm,” which is a nice way of saying “gtfo, pov.” I am good enough to cook the food, hidden away in the kitchen, but my boss won’t make me a server because I don’t “fit the corporate image.” I am not beautiful. I have missing teeth and skin that looks like it will when you live on B12 and coffee and nicotine and no sleep. Beauty is a thing you get when you can afford it, and that’s how you get the job that you need in order to be beautiful. There isn’t much point trying.

Cooking attracts roaches. Nobody realizes that. I’ve spent a lot of hours impaling roach bodies and leaving them out on toothpick pikes to discourage others from entering. It doesn’t work, but is amusing.

“Free” only exists for rich people. It’s great that there’s a bowl of condoms at my school, but most poor people will never set foot on a college campus. We don’t belong there. There’s a clinic? Great! There’s still a copay. We’re not going. Besides, all they’ll tell you at the clinic is that you need to see a specialist, which seriously? Might as well be located on Mars for how accessible it is. “Low-cost” and “sliding scale” sounds like “money you have to spend” to me, and they can’t actually help you anyway.

I smoke. It’s expensive. It’s also the best option. You see, I am always, always exhausted. It’s a stimulant. When I am too tired to walk one more step, I can smoke and go for another hour. When I am enraged and beaten down and incapable of accomplishing one more thing, I can smoke and I feel a little better, just for a minute. It is the only relaxation I am allowed. It is not a good decision, but it is the only one that I have access to. It is the only thing I have found that keeps me from collapsing or exploding.

I make a lot of poor financial decisions. None of them matter, in the long term. I will never not be poor, so what does it matter if I don’t pay a thing and a half this week instead of just one thing? It’s not like the sacrifice will result in improved circumstances; the thing holding me back isn’t that I blow five bucks at Wendy’s. It’s that now that I have proven that I am a Poor Person that is all that I am or ever will be. It is not worth it to me to live a bleak life devoid of small pleasures so that one day I can make a single large purchase. I will never have large pleasures to hold on to. There’s a certain pull to live what bits of life you can while there’s money in your pocket, because no matter how responsible you are you will be broke in three days anyway. When you never have enough money it ceases to have meaning. I imagine having a lot of it is the same thing.

Poverty is bleak and cuts off your long-term brain. It’s why you see people with four different babydaddies instead of one. You grab a bit of connection wherever you can to survive. You have no idea how strong the pull to feel worthwhile is. It’s more basic than food. You go to these people who make you feel lovely for an hour that one time, and that’s all you get. You’re probably not compatible with them for anything long-term, but right this minute they can make you feel powerful and valuable. It does not matter what will happen in a month. Whatever happens in a month is probably going to be just about as indifferent as whatever happened today or last week. None of it matters. We don’t plan long-term because if we do we’ll just get our hearts broken. It’s best not to hope. You just take what you can get as you spot it.

I am not asking for sympathy. I am just trying to explain, on a human level, how it is that people make what look from the outside like awful decisions. This is what our lives are like, and here are our defense mechanisms, and here is why we think differently. It’s certainly self-defeating, but it’s safer. That’s all. I hope it helps make sense of it.

Additions have been made to the update below to reflect the responses received.

UPDATE: The response to this piece is overwhelming. I have had a lot of people ask to use my work. Please do. Share it with the world if you found value in it. Please link back if you can. If you are teaching, I am happy to discuss this with or clarify for you, and you can freely use this piece in your classes. Please do let me know where you teach. You can reach me on Twitter, @killermartinis. I set up an email at killermartinisbook@ gmail as well.

This piece has gone fully viral. People have been asking me to write, and how they can help. After enough people tried to send me paypal money, I set up a gofundme. Find it here. It promptly went insane. I have raised my typical yearly income as of this update. I have no idea what to say except thank you. I am going to speak with some money people who will make sure that I can’t fuck this up, and I will use it to do good things with.

I’ve also set up a blog, which I hope you will find here.

Understand that I wrote this as an example of the thought process that we struggle with. Most of us are clinically depressed, and we do not get therapy and medication and support. We get told to get over it. And we find ways to cope. I am not saying that people live without hope entirely; that is not human nature. But these are the thoughts that are never too far away, that creep up on us every chance they get, that prey on our better judgement when we are tired and stressed and weakened. We maintain a constant vigil against these thoughts, because we are afraid that if we speak them aloud or even articulate them in our heads they will become unmanageably real.

Thank you for reading. I am glad people find value in it. Because I am getting tired of people not reading this and then commenting anyway, I am making a few things clear: not all of this piece is about me. That is why I said that they were observations. And this piece is not all of me: that is why I said that they were random observations rather than complete ones. If you really have to urge me to abort or keep my knees closed or wonder whether I can fax you my citizenship documents or if I really in fact have been poor because I know multisyllabic words, I would like to ask that you read the comments and see whether anyone has made your point in the particular fashion you intend to. It is not that I mind trolls so much, it’s that they’re getting repetitive and if you have to say nothing I hope you can at least do it in an entertaining fashion.

If, however, you simply are curious about something and actually want to have a conversation, I do not mind repeating myself because those conversations are valuable and not actually repetitive. They tend to be very specific to the asker, and I am happy to shed any light I can. I do not mind honest questions. They are why I wrote this piece.

Thank you all, so much. I don’t know what life will look like next week, and for once that’s a good thing. And I have you to thank.”

This post first appeared on killermartinis.kinja.com

Food for Action

The 2013 Farm Bill is now in conference committee (a meeting between the US House and the US Senate to reconcile differences between the two bills that emerged, one from each chamber). At stake are food stamps.  The House version of the bill has a 20 billion dollar cut.  The Senate bill has a 4 Billion dollar cut.  What does this mean?https://i1.wp.com/www.caritas-waco.org/logo%202%20SNAP_LOGO_eng_acro.JPG

1 out of 6 Americans have inadequate access to food. 21% of households with children have what is now called food insecurity. Over 50 million Americans have difficulty keeping food on the table. 1 in 5 children are at risk for hunger; for Latinos and African American children it is 1 out of every 3. 

Take a look at Jennifer Ensign’s post on her blog Medical Margins.

Could you live on $4.20 a day?  Want to take the challenge and try?  Then will you let the media in your town and your congress people know your experience?  Below is a sample letter and ideas for implementing.  We suggest you send it to a Senator or Congressperson on the committee, challenging them to live on the food stamp allotment until the bill is out of conference.  Then, if you take the challenge, share your experience with the press, blogs, and your congresswomen and men.  Below the sample letter is a list of all on the conference committee. The time to act is now; they have been in conference since 10/30/13.

To:  Representative (or Senator)…
Fr:  your name
Re;  The Farm Bill Conference
November 23, 2013

Dear Representative (or Senator) fill in name

We are writing to you in your role as (_________) state’s conferee on the House-Senate Farm Bill Conference.  As individuals from (_________________), we are gravely concerned by the cuts already taken – and being considered – in food stamp benefits. We assume you want to do
what is best for your constituents, and thus might welcome a first-hand understanding of your actions.

This letter has two parts.
(1)  We are calling on you and your conferees on the Farm Bill to limit your spending on food to the current Food Stamp allotment for an individual for the duration of the Conference Committee.   We know that you may have taken a one-week “food stamp challenge;”  we believe it is particularly appropriate that all of the Conferees “take the challenge” for the duration while deciding whether to restore, or further cut, food stamp benefits. We know this will be difficult, given an average benefit for one person in Washington State is just  $4.20/day.   It is not only not easy, it can be harmful – e.g., to people in physically-demanding jobs, while pregnant or recovering from surgery or illness, or dealing with many of life’s challenges.

(2)  At the same time, we will be limiting our own food spending to that same amount.   To aid your deliberations, we will be reporting regularly on the results to your office, and to others throughout our communities.

Indeed, some those who write you may already rely on SNAP and thus live with the reality of food insecurity.  I hope you also hear their stories. As you and your colleagues debate whether or not to make cuts to a program which is necessary for many to get by, we seek to remind you there are people behind the numbers.  In that spirit, we wish to share our stories with you and will do so.

Those of us who are not limited to a food stamp allotment believe that food security is a right and no person should be denied access to adequate food and proper nutrition.  We wish to stand in solidarity with those who face food insecurity and who will be deeply affected by the actions of you and your colleagues.

Some people will feel they cannot participate (e.g., if it would endanger their health or the health of their families).  In those cases, we will share their stories with you.

We look forward to working with you on this issue.

Sincerely

(your name)

___________________________
Why do this:  We believe it would help committee members in the understanding of food insecurity if they were to have even a limited experience in what it is like to have no more than $4.20/person/day (the average benefit in WA) to spend for food.

And, since we realize it may be difficult for a sitting member of Congress to do this, we are asking others to also do this – for as long as the Farm Bill Conference meets.  By signing this letter, you will be agreeing to do the following:

1)      Confine your food consumption to what you can purchase on $4.20/person/day.
2)      Send regular reports to your Senator’s or Representative’s office, telling her how it feels, and whether it is easy or hard.  E.g., whether it affects energy levels; whether you can afford healthful food; how your attitudes are affected.
3)      Send regular reports to others:  social media, traditional media, colleagues, neighbors, family, friends.
4)       If you believe it would be harmful to you or your family to limit food spending so drastically (e.g., if you are diabetic or pregnant or recovering from an illness or surgery), we ask that you send that information to the Representative’s office.   (Food stamp recipients are not given higher amounts if they hold physically demanding jobs, or have special health conditions.)

If this sounds like something you are willing to do (or at least try), please copy this letter, sign it, and send it to the appropriate person for your state or to the chair of the committee.  And then, begin the pledge.
______________________________________

Who is on the committee:

The Senate conferees include:

Democrats:

  • Sen. Debbie Stabenow (D-MI), Chairwoman of the Senate Agriculture Committee
  • Sen. Patrick Leahy (D-VT)
  • Sen. Tom Harkin (D-IA)
  • Sen. Max Baucus (D-MT)
  • Sen. Sherrod Brown (D-OH)
  • Sen. Amy Klobuchar (D-MN)
  • Sen. Michael Bennet (D-CO)

Republicans:

  • Sen. Thad Cochran (R-MS), Ranking Member of the Senate Agriculture Committee
  • Sen. Pat Roberts (R-KS)
  • Sen. Saxby Chambliss (R-GA)
  • Sen. John Boozman (R-AR)
  • Sen. John Hoeven (R-ND)

The House conferees include:

Republicans:

House Committee on Agriculture conferees:

  • Rep. Frank D. Lucas (R-OK), Chairman of the House Agriculture Committee
  • Rep. Steve King (R-IA)
  • Rep. Randy Neugebauer (R-TX)
  • Rep. Mike Rogers (R-AL)
  • Rep. K. Michael Conaway (R-TX)
  • Rep. Glenn ‘GT’ Thompson (R-PA)
  • Rep. Austin Scott (R-GA)
  • Rep. Rick Crawford (R-AR)
  • Rep. Martha Roby (R-AL)
  • Rep. Kristi Noem (R-SD)
  • Rep. Jeff Denham (R-CA)
  • Rep. Rodney Davis (R-IL)

Leadership conferee:

  • Rep. Steve Southerland (R-FL)

House Foreign Affairs Committee conferees:

  • Rep. Ed Royce (R-CA), Chairman
  • Rep. Tom Marino (R-PA)

House Ways & Means Committee conferees:

  • Rep. Dave Camp (R-MI), Chairman
  • Rep. Sam Johnson (R-TX)

Democrats:

House Committee on Agriculture conferees:

  • Rep. Collin Peterson (D-MN), Ranking Member of House Agriculture Committee
  • Rep. Mike McIntyre (D-NC)
  • Rep. Jim Costa (D-CA)
  • Rep. Tim Walz (D-MN)
  • Rep. Kurt Schrader (D-OR)
  • Rep. Jim McGovern (D-MA)
  • Rep. Suzan DelBene (D-WA)
  • Rep. Gloria Negrete McLeod (D-CA)
  • Rep. Filemon Vela (D-TX)

The vote

I started three different posts tonight and cannot decide on the order.  Which first?  Which second?  Which third or not at all.

This blog has 150 “followers.”  Now is your chance to weigh in.  Here are the choices for the next few.  What do you want to hear?

1. Parenting as a noun (vs verb), a back slide (car ride Wed night)

2. life on the other side, eg in the bed as patient

3. Counting on the Latino vote

4. Getting quiet with yourself

Tomorrow will be one of those. If you weigh in, that will decide which.

Students’ eye towards the future

What we know from many studies is that most medical students enter medical school with a stated altruism, many wanting to work for social justice, to serve the underserved, and in primary care careers. And then the attrition starts, moment by moment, and it is down hill from there.

By graduation, the students going into rural and underserved careers drop the majority of those initially interested.

Think of it as a pipeline.  It has a diameter to hold all of the students going who, at entry, want these careers.  At graduation there is a much smaller trickle of those going into primary care and of those, a few drops choose rural or urban underserved practices. I won’t bore you with all that we don’t know about how to impact this; suffice it to say that it matters to some of us medical educators and health policy nuts and so we keep trying.  There are of course the extrinsic factors (like “specialty bashing” or remuneration differentials that select procedures over time spent with a patient in life style conversations) and we don’t control those. And we keep trying to impact what we can.

Tonight, maybe seventy-five people were in the room, ranging from deans to first year medical students with faculty, staff, and second, third, and fourth year students in between.  Two thirds were students. The states of Washington, Wyoming, Alaska, Montana, and Idaho (WWAMI) were represented with both deans, students, and staff.  A few “out of states” students were there as well, at least one from California.

Some of us have spent a good portion of our work lives developing and feeding that pipeline I mentioned above and then nurturing the students in it to continue their commitment to careers caring for rural and urban underserved communities.  The WWAMI states have 28% of the US land mass and only 3.5% of the population, of which 35% are rural residents.  And what we might call rural in Washington is considered urban in Montana, Wyoming, Alaska.

The University of Washington Medical School serves those five states, through the WWAMI Program.  Two recent initiatives to nurture that pipeline are the Underserved Pathway  (UP) and the TRUST Program. The UP is a program any student can join, providing structure to students for planning their curriculum, mentorship, and on-line educational modules.  The TRUST program admits a cohort of students to be scholars (now 10 a year in Montana, 5 in Eastern Washington, 5 in Western Washington, 5 in Idaho, and soon some from Alaska and Wyoming) from an applicant pool who have both the credentials for admission to the school of medicine and those that support a stated desire to have a career in rural or underserved health care. TRUST scholars have a longitudinal relationship with one rural community for the entire four years of medical school. They spend two weeks in their community before first year classes even begin, visit during the years one and two, a month in the summer after first year, and 4-7 months in third year, returning for elective work in fourth year.  All complete the UP.

The regional deans from Alaska, Wyoming, Montana, Idaho, Eastern Washington and Western Washington are in town this week for a variety of meetings purposely packed into one week.  As part of this visit, they like to spend time with the students from their state and we (TRUST and UP) want to pull them all together for an educational session.  That was tonight’s gathering.

After a Kaiser Foundation video on the ACA and a clicker response quiz, small groups formed to discuss hopes, fears, impacts, and real stories these students have already witnessed.  Each state dean gave an overview and update of what is happening in their state.  While Washington is the only of the five with medicaid expansion, several are on board with exchanges and several are having ongoing medicaid expansion discussions with strong support from groups like physicians, hospitals, business, labor, and others.

In the wrap up it was clear that these medical students see their lives as having a social context and contract to improve health and  access.

They worry about their capacity and acknowledge we need new models of care.

They know that whether they are activists or not, they are being political, which opens a discussion of how to be active effectively.

Many believe that universal single payer insurance will be the only thing that will work.

They are realistic that change is hard and will be incremental.

I worried that this would feel like a downer.  From the energy in the room and the comments after, I think it was energizing.  Lesson for me:  hard topics with no easy solutions are less so with the support of others.

And me:  I am deeply touched by the realism, passion, energy, and clarity of these students.  They seem up for the task.  And there are more of them than were in my generation. If our programs keep their fire kindled, I will feel success.  If one of each of us elders fosters two or more who take on the mission, I will feel success.  Tonight I am grateful to be part of the effort and to our students who keep me with some modicum of focus and youth.

Code status continued

Sharon M. posted a comment that I had informed Eva’s son and it was ultimately up to him.  True that he was key in this process.  He was the voice for Eva. If he chose, is everyone who cares for Eva bound by his decision?  What if the harm of resuscitation outweighed the benefit? What if it is a different story and the patient was in an accident and is in a coma.  The doctors think aggressive treatment can save her, return her to a functional life with quality (and who gets to decide that anyway)?  The surrogate says, no, do not intubate.  Whose decision should carry the weight?  How would YOU decide?

What could I do?  What should I do with Eva’s case?

We were taught certain key values in ethics classes:

Autonomy: Every person has the right to self determination.  This would include the surrogate decision maker, like Eva’s son, acting on her behalf.

Beneficence: We are to act for the good of the patient

Non-Maleficence: “Primum no nocere”  or First, do no harm

Justice: This calls for the fair distribution of scarce resources and fairness and equity in delivery of care (not a hallmark of the US Healthcare System)

Respect:  Every person should be treated with dignity

Honesty and clarity: Informed consent comes from this concept.

There is a four box methodology for sorting through all this, which is copied from here 

MEDICAL CONSIDERATIONS
The Principles of Beneficence and Nonmaleficence

  1. What is the patient’s medical problem? Is the problem acute? Chronic? Critical? Reversible? Emergent? Terminal?
  2. What are the goals of treatment?
  3. In what circumstances are medical treatments not indicated?
  4. What are the probabilities of success of various treatment options?
  5. In sum, how can this patient be benefited by medical and nursing care, and how can harm be avoided?
PATIENT PREFERENCES
The Principle of Respect for Autonomy

  1. Has the patient been informed of benefits and risks, understood this information, and given consent?
  2. Is the patient mentally capable and legally competent, and is there evidence of incapacity?
  3. If mentally capable, what preferences about treatment is the patient stating?
  4. If incapacitated, has the patient expressed prior preferences?
  5. Who is the appropriate surrogate to make decisions for the incapacitated patient?
  6. Is the patient unwilling or unable to cooperate with medical treatment? If so, why?
QUALITY OF LIFE
The Principles of beneficence and Nonmaleficence and Respect for Autonomy

  1. What are the prospects, with or without treatment, for a return to normal life, and what physical, mental, and social deficits might the patient experience even if treatment succeeds?
  2. On what grounds can anyone judge that some quality of life would be undesirable for a patient who cannot make or express such a judgment?
  3. Are there biases that might prejudice the provider’s evaluation of the patient’s quality of life?
  4. What ethical issues arise concerning improving or enhancing a patient’s quality of life?
  5. Do quality-of-life assessments raise any questions regarding changes in treatment plans, such as forgoing life-sustaining treatment?
  6. What are plans and rationale to forgo life-sustaining treatment?
  7. What is the legal and ethical status of suicide?
CONTEXTUAL FEATURES
The Principles of Justice and Fairness

  1. Are there professional, interprofessional, or business interests that might create conflicts of interest in the clinical treatment of patients?
  2. Are there parties other than clinicians and patients, such as family members, who have an interest in clinical decisions?
  3. What are the limits imposed on patient confidentiality by the legitimate interests of third parties?
  4. Are there financial factors that create conflicts of interest in clinical decisions?
  5. Are there problems of allocation of scarce health resources that might affect clinical decisions?
  6. Are there religious issues that might affect clinical decisions?
  7. What are the legal issues that might affect clinical decisions?
  8. Are there considerations of clinical research and education that might affect clinical decisions?
  9. Are there issues of public health and safety that affect clinical decisions?
  10. Are there conflicts of interest within institutions or organizations (e.g. hospitals) that may affect clinical decisions and patient welfare?

Back when I first was a student and resident, we involved patients and families in discussions of code status.  Usually we agreed.  If we did not, we would continue to talk with patients and families and tell them if we thought the person was a “no code.”  This process became more formalized in the places I practiced, but there still were still times when the patients and their families did not agree with us, the doctors.  We talked and inevitably we agreed, always, in my practice, erring on the side of letting someone stay in the full resuscitation category.

Never before Eva had I reached this block.  Take a look at the four boxes.  What do you need to know in Eva’s case?  How would you approach this?  If it is totally Eva’s son’s right to decide, do I have an obligation to perform CPR and advanced life support measures, even if they go against what I think I took as a physician’s oath?

In all ethical crises, two or more values come into conflict.  In this one it is where autonomy comes into conflict with beneficence/non-maleficence. Can you weigh in?

Code Status

Curled up like a little child taking a nap, she seemed even smaller than her ninety pounds.  She was clean, her hair in a tidy braid, her skin soft and moist, and she had no signs of skin breakdown or bed sores, the absence of which told us that her son clearly took time bathing her, using moisturizers, and frequently turning her to prevent prolonged pressure on any one area.  Sometimes she would open her eyes but they did not register any recognition — even of her son, even when he called her name, Eva.  Mostly now at 88 years of age, she just lay there all curled up, no longer able to uncurl, eyes closed.  https://i2.wp.com/farm5.staticflickr.com/4080/4823054554_b0ebf60d20.jpg

 We could get no response from Eva unless she experienced pain.  Turning her would sometimes bring a cry and trying to stretch her contracted limbs always brought one.  She wore a diaper that was changed regularly by her son at home and by our staff when she was in the hospital.  A few years earlier she would wake up and could be fed.  That ability had slowly vanished and her son elected to having a feeding tube placed as her sole way to receive nutrition.  He wanted to keep his mother alive as long as he could.  Her diagnosis?  Advanced and advancing dementia, a combination of Alzheimer’s and small strokes.

Eva’s caregiver was her son, a man in his fifties who immigrated with her, leaving his position in their home country. His only income was the state support as his mother’s caregiver.  Every few months Eva would develop some malady—a cough, a urine infection, or mysterious fevers. We would hospitalize her, noting that during her stays, her son rarely visited. This limited our ability to form a relationship, a partnership with this important person in Eva’s life, but we believed everyone needs a break. For that reason, his absence did not bother our interns and residents or me and the other faculty doctors. Usually after several days, we would pronounce Eva well enough for discharge and he would come and get her or be at home to receive her when the cabulance brought her home.

When Eva’s condition progressed to the unresponsive curled up, unable to uncurl or respond being, we initiated a conversation with her son who had durable power of attorney for health matters. If her heart stopped, what would he want for her? What would she want?  He was adamant that he wanted full resuscitation.  We talked with him about how she was in the terminal stages of Alzheimer’s and asked him about the quality of her life.  He remained firm:  resuscitate her if she needed it.

There often are family fears around this discussion of what we call the “code status” (the do or do not resuscitate).  Will we give antibiotics if needed?  Are we stopping all treatment?  Will we be less attentive to someone who is a “DNR” (do not resuscitate) than to someone who is “full code” or do resuscitate? Where is the line drawn?  We emphasized that our care would be ongoing and we would aggressively treat the reason she was in the hospital. The question was a what if.  What if her heart stopped?  What if she needed to be intubated?  He did not change his mind. He wanted her to be a “full code.”

Medical futility is a situation when intervening is not likely to have a good outcome or to produce good quality for the person.  There are easy examples: should a person with advanced lung cancer, with spread to other organs, be given an organ transplant?  When we think about the rususcitate or not question, age and other medical conditions influence the predicatbility of success. For Eva, if her heart stopped, indicating she was basically trying to die, the likelihood of surviving a full resuscitation was less than 1%.  And “codes” are brutal:  ribs get broken, livers and spleens lacerated, lungs punctured.  This is certainly not all the time, but the older and more frail a person is, it is more likely that it will result in what feels to us like torture and it is least likely that the person will survive.  Some states allow a physician, with certain protocols to say it is medically futile.

There have been times when it is clear to me that a family knows they do not want to prolong suffering and yet are incapable of making the decision to have an order of “do not resuscitate.”  When I talk about the odds for the patient as being exquisitely low and say I can sign the form saying and documenting why it is medically futile, they are grateful.  This was not the case with Eva’s son.  He wanted the “full code.”

What could I do?  What should I do?

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The image is a sculpture by Ron Mueck called Old Woman in Bed can be found here. 

 

Ethical questions

Why did I write that story yesterday?

Several conversations brought it back to mind.  One was with Steph Cooper, the ER doc I mentioned, who told me about the piece she wrote on “ethical crises in clinical care.”  (I am still waiting for the link Steph to share it here and increase your readership.)  A second was with some faculty and students with whom I am working to address needed development of our “learning environment.”  We have ongoing discussions about how to make it safe for students, staff, faculty, and residents to report what they perceive as unprofessional behavior, abuse, or mistreatment.  Even defining what is abuse and mistreatment or unprofessional behavior is fraught with large gray zones.  Add to that the differential ranks and our students often don’t feel they can directly give feedback to someone who is going to grade them, especially before the grade is submitted.

I understand that vulnerability and that is why we are creating many avenues for conversation and/or reporting.  At the same time, maybe all people have a line in the sand where, if crossed, they would be willing to stand up in the moment and speak.  Many ethical dilemmas are much smaller than the story I told yesterday and some are larger. Each asks us as individuals to make a determination whether to stand, where to stand, how to stand, speak and walk, and about the direction action or inaction will take us as individuals and as communities.

 These challenges happen in everyone’s lives. I will have some more examples from clinical care over the next few days. Please,  share ones you have faced.

Maria did not have tubal ligation surgery that day.  My colleague and I definitely wondered if we were outliers, which is what the chief resident wanted us to believe. I have no way of knowing how other students would have responded, but would have liked to believe, would still like to believe that my classmates and others would have the same response that we had.

In those days, at that hospital, the on-call attending faculty doctor was not always in the operating room with the chief resident. He was however in the hospital.

One of us stayed in the operating room, threatening to lie across Maria and prevent the surgery.  The other went to call and find the attending doctor and report the incident.  He came immediately, stayed for the cesarean section, and told the chief that he could not perform a tubal ligation. He later spoke with us individually and with the chief resident, making it clear that this incident could not be repeated and that the impact on our performance evaluation from this incident would be neutral from the chief’s perspective and positive from his.

Challenged

It was a typical night on call, if you can name any night on call for a third year medical student as typical. And as much fun as our obstetrics rotation was, this night was would turn out to be neither fun nor typical.

There were probably a couple of patients in labor. Though I don’t remember, that would have been the usual scene.  What I do remember is one woman I’ll call Maria.  Maria arrived having painful contractions three minutes apart for the prior several hours.  This was going to be her 7th birth, which had the other student and I almost gleeful that one of us would actually get to help with a vaginal delivery that night.  If we were lucky, it might even be early enough to get a little sleep in the call room. The “call room” would be better named the bunk-house, with its four bunks and central location a few uninsulated feet from and not out of earshot of anyone in labor.

When she arrived, Maria said her pregnancy had been quite normal although she didn’t have all the prenatal care that was recommended back in 1977.  She recently moved from El Salvador to San Francisco with her husband and 4 of their children, leaving two behind living with grandparents.  They spoke no English.

She was indeed in labor and her cervix was starting to dilate and with each contraction she would concentrate, close her eyes, wipe some sweat from her face and breathe slowly.  The thing we students could do best was coach a woman in labor, but Maria was a pro and clearly could have taken over our job if she were not busy right in those moments. After a bit she and her husband went for a walk around the ward, stopping for each contraction, hoping the labor would speed up. She went from bed and some fetal monitoring to walking every hour or so for many hours.  She did not dilate further.  After many hours and into the middle of the night, “we” (that would be the resident on the service) decided to augment her labor with oxytocin, a medicine that strengthens uterine contractions. Her contractions got closer together and the continuous fetal heart monitoring showed the baby to be tolerating the stronger and closer together contractions.

The head would not descend in her pelvis.  That’s not too unusual for a woman who has had several pregnancies and births, but at some point the cervix needs to dilate and the head needs to descend.  She made it to 6 centimeters dilation and we realized the head was not in a great position to descend.  Usually the head is either occiput anterior (the baby facing the floor if the mom is on her back) or occiput posterior (the baby facing the ceiling, or sunny side up, if the mom is on her back).  This baby was facing one side, or occiput transverse. Babies in this position often have difficulty navigating the birth canal.  We were not able to rotate the head and the head remained too high to safely break her bag of waters and see if then we could rotate the head or if it would descend on its own.  There was another aspect to this labor. Her other babies, born in El Salvador were in the 6-7 pound range and we estimated this baby to be about 9 pounds.

The senior resident discussed the lack of progress with Maria and her husband and she signed the consent for a caesarian delivery.  The operating room was set up and she was taken back and given an epidural anesthesia. I was a bit glum that there would not be a vaginal birth, but along with my fellow student, I was glad to be there and assist with the surgery.  While walking to the operating room with the chief resident, he was talking us through the steps of the surgery.  And then he said, “While she is open I am going to tie her tubes.  She has had plenty of children and does not need more.”

Game changer.  Here we were mere mice in a sea of dragons.  We had been trained to accept our position in the pecking order (though the women in my class were a bit rebellious about this and the many comments made about women invading medicine).  But we KNEW where the power was.  He was in his fourth or fifth year of residency, a full 6-7 years ahead of us.

And he was saying he was going to sterilize a woman who had not given consent.

The year our class entered medical school 3% of the classes nationally were women.  My class at my school was 30% women.  And we were an older and proud to be there and cantankerous group who knew the laws about reproductive health.  Maria had Medicaid and the federal law had been passed a few years prior that required a 30 day period between signing a consent for tubal ligation and the surgery happening (unless for instance there was a premature delivery).

This is called an ethical crisis in medicine.

What should we do?  What could we do?

We told the resident he could not do this.  He told us it was not our decision.  We told him he could not do this.  He said he would have us fired, kicked out of school if we tried to stop him.

What should we do?  What could we do?

I was visiting with a friend, Steph Cooper, an ER doc who writes beautifully about this work we do and its challenges (she has a great piece in the manuscript I am trying to publish). I hope she will send me the link to the narrative she published recently about ethical crises.  They can be big or small.  They are real.

This story:  to be continued.

 

Choosing Wisely

Yesterday I mentioned that Doctors estimate our country spends $6.8 billion in unnecessary tests.  Who can fix this?  We all can, doctors, health systems, patients, and insurers.https://i2.wp.com/ih.constantcontact.com/fs011/1101428692505/img/279.jpg

In 2011 The National Physician’s Alliance (NPA) published work on the Good Stewardship Project, a pilot  which was developed with funding from the American Board of Internal Medicine Foundation.  The initial effort worked with physicians in three specialties to “define 5 things “you can do in your practice” to provide excellent patient care while appropriately conserving health care resources in the fields of internal medicine, family medicine, and pediatrics.”

Subsequent to that pilot the NPA continues to work with specialties to take on both looking at the evidence and the education of patients regarding tests that have no evidence and should be considered unnecessary.  The aim is to engage physicians in conversation with their patients to choose “care that is:

  • Supported by evidence
  • Not duplicative of other tests or procedures already received
  • Free from harm
  • Truly necessary”

Consumer Reports is on board helping to develop materials for patients.  By 2014 more than 30 specialty organizations will have created evidence based lists of care that is not supported by evidence and/or may be unnecessary.  This represents over 500,000 physicians who are represented by these groups who commit to work with their patients to make wise choices. The link to all of the specialty organizations, with links to their lists is here.

The Family Medicine list, as an example, is below. The data and evidence is here.

1. Don’t do imaging for low back pain within the first six weeks, unless red flags are present.
2. Don’t routinely prescribe antibiotics for acute mild-to-moderate sinusitis unless symptoms last for seven or more days, or symptoms worsen after initial clinical improvement.
3. Don’t use dual-energy x-ray absorptiometry (DEXA) screening for osteoporosis in women younger than 65 or men younger than 70 with no risk factors.
4. Don’t order annual electrocardiograms (EKGs) or any other cardiac
screening for low-risk patients without symptoms.
5. Don’t perform Pap smears on women younger than 21 or who have had a hysterectomy for non-cancer disease.
6. Don’t schedule elective, non-medically indicated inductions of labor or Cesarean deliveries before 39 weeks, 0 days gestational age.
7. Avoid elective, non-medically indicated inductions of labor between 39 weeks, 0 days and 41 weeks, 0 days unless the cervix is deemed favorable.
8. Don’t screen for carotid artery stenosis (CAS) in asymptomatic adult patients.
9. Don’t screen women older than 65 years of age for cervical cancer who have had adequate prior screening and are not otherwise at high risk for cervical cancer.
10. Don’t screen women younger than 30 years of age for cervical cancer with HPV testing, alone or in combination with cytology.
11. Don’t prescribe antibiotics for otitis media in children aged 2–12
years with non-severe symptoms where the observation option is
reasonable.
12. Don’t perform voiding cystourethrogram (VCUG) routinely in first
febrile urinary tract infection (UTI) in children aged 2–24 months.
13. Don’t routinely screen for prostate cancer using a prostate-specific
antigen (PSA) test or digital rectal exam.
14. Don’t screen adolescents for scoliosis.
15. Don’t require a pelvic exam or other physical exam to prescribe
oral contraceptive medication.