Polar madness

There’s something about icy cold water that seems to bring out the come-on-I-dare-you factor among some people.

Local volunteers are taking a dip into the freezing waters of Green Lake at 2 p.m. Saturday to raise money for the Special Olympics of Minnesota. This is the sixth year the Kandiyohi County Sheriff’s Office and Willmar Police Department have co-sponsored the Polar Bear Plunge as part of Spicer’s annual WinterFest celebration.

Some co-workers here at the West Central Tribune participated in the Polar Bear Plunge a couple of years ago. According to them, jumping feet first into a lake in January isn’t all that bad. “Exhilarating” is how a couple of them described it.

Uh huh. Whatever you say.

The human body is reasonably well equipped to survive a dunking in chilly water – but only up to a point. An article published awhile back by the Wilderness Medicine Society outlines the physiological response to cold-water immersion:

We now appreciate that sudden immersion in cold water (less than 60 degrees) initiates a series of incapacitating reflexes that increase the risk of drowning. Indeed, the most common cause of death from accidental cold-water immersion is drowning, not hypothermia.

The initial response, which affects breathing, heart function, and muscle strength, is called the Cold-Shock Response. This is a series of reflexes that begin immediately upon sudden cooling of the skin following cold-water immersion. The initial phase of the cold-shock response peaks during the first 30 seconds, and lasts just 2 to 3 minutes. During this time, blood pressure, heart rate, and the workload of the heart all increase, making the heart more susceptible to life-threatening rhythms and heart attack. Simultaneously, gasping begins, followed by rapid and deep breathing. These reflexes can quickly lead to accidental inhalation of water and drowning. This rapid and seemingly uncontrollable over-breathing creates a sensation of suffocation and contributes to feelings of panic. It can also create dizziness, confusion, disorientation, and a decreased level of consciousness.

The author, Dr. Michael Jacobs, warns people to “be prepared for violent shivering and intense pain” if they fall into cold water. And once they manage to get out of the water, hypothermia can quickly set in.

Cold water robs the body of heat 32 times faster than cold air and can “quickly numb the extremities to the point of uselessness,” points out the U.S. Search and Rescue Task Force, which has done more than its share of cold-water rescues. The task force’s advice: “If you should fall into the water, all efforts should be given to getting out of the water by the fastest means possible.”

With the Polar Bear Plunge, of course, we’re not talking about accidental immersion. The participants tomorrow are doing this on purpose. The water isn’t deep, and EMTs will be on hand in case anyone gets into trouble. I’m told there’s also usually a hot tub available where the volunteers can warm up afterwards.

But they’re still subjecting themselves to a fair amount of discomfort – and all for a good cause. In case you’re wondering, the weather forecast for Saturday calls for a high of 13 degrees and a wind chill somewhere between 8 below and 2 above. The least the rest of us (who are either smarter or more chicken-hearted, depending on your point of view) can do is support them by donating to the Special Olympics on their behalf.

West Central Tribune file photo by Ron Adams

Radiation treatment gone wrong

It’s the kind of story that can’t help but be compelling:

As Scott Jerome-Parks lay dying, he clung to this wish: that his fatal radiation overdose – which left him deaf, struggling to see, unable to swallow, burned, with his teeth falling out, with ulcers in his mouth and throat, nauseated, in severe pain and finally unable to breathe – be studied and talked about publicly so that others might not have to live his nightmare.

Sensing death was near, Mr. Jerome-Parks summoned his family for a final Christmas. His friends sent two buckets of sand from the beach where they had played as children, so he could touch it, feel it and remember better days.

Mr. Jerome-Parks died several weeks later in 2007. He was 43.

A New York City hospital treating him for tongue cancer had failed to detect a computer error that directed a linear accelerator to blast his brain stem and neck with errant beams of radiation. Not once, but on three consecutive days.

The story, titled “Radiation Offers New Cures, and New Ways to Harm,” appeared Sunday in the New York Times and has generated some intense online discussion and blog commentary.

Therapeutic radiation is commonly used to treat cancer; more than half of all people diagnosed with cancer will at some point receive radiation therapy. The technology has come a long way over the past couple of decades. Treatment is typically more targeted than it used to be, so healthy cells can be spared the collateral damage of radiation exposure. Refinements such as intensity-modulated radiation therapy, or IMRT, also are increasingly being offered to patients.

But it carries its own set of risks – risks that patients are often uninformed of, and that may not be adequately addressed by the industry. Furthermore, the increasing use of complex equipment, software and treatment protocols is raising the danger that errors will occur and patients will be harmed, the New York Times explains:

“Linear accelerators and treatment planning are enormously more complex than 20 years ago,” said Dr. Howard I. Amols, chief of clinical physics at Memorial Sloan-Kettering Cancer Center in New York. But hospitals, he said, are often too trusting of the new computer systems and software, relying on them as if they had been tested over time, when in fact they have not.

Regulators and researchers can only guess how often radiotherapy accidents occur. With no single agency overseeing medical radiation, there is no central clearinghouse of cases. Accidents are chronically underreported, records show, and some states do not require that they be reported at all.

Many readers who commented on the story were appalled. “I could not finish reading this piece. It was an eternity of agony, even to get halfway through the narrative,” one person wrote. “Horrifying,” wrote someone else.

I count at least five separate and significant issues explored in the article and in the accompanying pieces: 1) the inherent risks of medical radiation; 2) the potential for medical devices to fail, especially as they become increasingly complex; 3) staff competence; 4) appropriate safeguards, checks and balances to ensure patient safety; 5) public accountability by the health care industry to investigate and prevent errors such as the one that killed Scott Jerome-Parks.

Although there’s been increasing focus on the risks associated with radiation exposure from routine CT scans and X-rays, I question whether it’s a fair comparison to therapeutic radiation. Radiation therapy has a specific intent, to treat cancer, so a whole different set of issues comes into play when making decisions whether to subject a patient to therapeutic radiation. Obviously, the amount of radiation required to target a tumor is also far greater and exposes the patient to significantly more radiation than any CT scan, albeit for the purpose of treating a serious disease. It can be a difficult tradeoff for cancer patients, who must weigh the potential risks of radiation treatment against the likelihood of the benefit.

If I were a cancer patient, I’m not sure how I would react to the New York Times story. Indeed, a number of commenters accused the reporting team of sensationalizing the issues and possibly scaring patients into making wrong-headed decisions. One person wrote:

While it is important to appreciate errors in medicine and swiftly correct them, particularly in an age of increasingly complex and computerized equipment, this article does a very effective job at frightening readers, particularly those with a personal experience of cancer therapy. The impression the reader takes is that there is gross negligence running rampant throughout radiation oncology departments as a matter of course. The article fails to mention the quite rigid quality assurance regulations in place for hospitals and physicians at the state and federal levels. This is a highly regulated field – not one of no oversight.

The American Society for Radiation Oncology issued its own statement this week, asserting that radiation therapy is still safe and effective and that errors are rare. A science blogger and cancer researcher offers his own take, drawing parallels between radiation therapy safety and surgical safety:

Reducing medical errors that harm patients is about more than just physicians. It’s about the whole system. In surgery we have been discovering this (and struggling with it) over the last decade or so. It’s not enough to just target the physicians. In my specialty and in the operating room, it’s necessary that everyone be involved, from the nurse who sees the patient when he comes in, the physicians who do the surgery, the scrub techs counting instruments, the scrub nurse verifying surgical site – in essence everyone involved with the care of the patient from the moment he shows up for surgery to the moment he either goes home or is admitted to the hospital. Radiation oncology has at least as many people involved in the care of the patient, if not more: nurses, radiation physicists, radiation oncologists, technicians operating the machinery. Moreover, because unlike surgery radiation is often given in small fractions over many visits, there are many more opportunities for error than in surgery.

Ultimately, I think the reporting by the New York Times has done a major favor on behalf of patient safety. At one time, chemotherapy errors were rarely publicized and efforts to make this form of cancer treatment safer were occurring mostly in piecemeal fashion. This all began changing in the mid-1990s, after the death of Boston Globe reporter Betsy Lehmann, who mistakenly received a lethal overdose of a chemotherapy drug. There’s now much greater awareness within the oncology community about medication safety, and a growing body of literature on chemotherapy administration procedures that have been shown to be safe and effective.

I’m not sure if this has been happening in radiation oncology to the same extent. A good start would be to develop a set of quality criteria – and to share them with the public, so patients and families can be better informed and in a better position to ask questions and advocate for themselves if something doesn’t seem right. It’s also essential to report errors and close calls in order to analyze what happened and redesign processes or systems to make them safer. After all, if you aren’t tracking mistakes, it’s nearly impossible to gauge how often they occur and what the contributing factors might be. Finally, there appears to be a need for more oversight – not just of hospital programs but of how the equipment and software are designed and manufactured and how the people who operate it are trained.

Injuries and deaths related to radiation therapy might be rare, but this is small comfort to patients and families who’ve had it happen to them. Surely the industry owes it to these people to do its best to be safe and accountable.

Photo: linear accelerator, Wikimedia Commons

Towards better hospital care

Right on the heels of the Minnesota Department of Health’s annual report earlier this month on adverse events, the Joint Commission released its own annual report on hospital quality and safety in 2009.

The report tracks improvement over seven years, 2002 through 2008, on 31 quality measures that reflect the current best evidence on effective care for pneumonia, heart attacks, strokes, surgery and other issues that are among the most common reasons for hospital admissions.

Among the findings: There was sustained improvement on 12 of the measures and more limited improvement on 13. In two areas, both in the treatment of pneumonia, hospital performance slipped between 2007 and 2008. Data were submitted by 3,000 hospitals accredited by the Joint Commission, the main accrediting body for hospitals in the United States.

It’s interesting to follow the progress from one year to the next. For instance, on one of the measures for heart attack care back in 2002, these patients were advised 66.6 percent of the time to stop smoking. By 2008, this had risen to 98.9 percent.

These days there’s a lot of data being generated on hospital performance. The Minnesota Department of Health report, for instance, tracks “never” events, which by definition are both rare and serious. The Joint Commission’s quality measures, on the other hand, focus on common, manageable issues shown to help reduce the likelihood of complications that can lead to morbidity, longer hospital stays and higher costs. Routinely giving antibiotics before surgery, for instance, demonstrably cuts down on the risk that the patient will develop a surgery-related infection.

Want to find out how a specific hospital fared on the Joint Commission’s most recent quality report? You can search the online database at Quality Check, a tool developed by the Joint Commission and see detailed results.

There has historically been considerable variation in how hospitals have performed on these measures. In some cases, there wasn’t a pathway to help ensure that best practices were consistently reaching every patient. Sometimes the correct steps were taken but they weren’t documented in the medical record. And sometimes there may have been valid clinical reasons why a particular best-practice measure wasn’t followed for an individual patient – a drug allergy, for instance, or other condition or circumstance that may have made a different course of action the wiser choice.

Quality measures aren’t the be-all and end-all of hospital care. Some things, frankly, are hard to measure objectively. Advising patients who’ve been hospitalized with a heart attack to quit smoking might earn the hospital a checkmark in the appropriate box but it doesn’t necessarily mean the patient actually followed through. Some of the measures that track whether the appropriate drugs were prescribed – an ACE inhibitor and beta blocker for heart attack patients, for example – don’t really address questions of dosage or proper follow-up for the patient, which can be equally important in avoiding complications and ensuring a good outcome. There also should be room for some clinical judgment. What’s good for 95 percent of patients may not be best for the other 5 percent.

Overall, though, performance measurement can be an enormously helpful tool for hospitals to track how well they’re doing and benchmarking themselves against other hospitals. After all, you don’t truly know if you’re good, bad or ugly unless you have actual numbers; otherwise you’re just guessing. And you can’t genuinely improve and sustain your forward momentum for the benefit of patients unless you have a reliable way of measuring your progress.

West Central Tribune file photo by Bill Zimmer

The obituary for health care reform?

In just one year, what a difference. A year ago at this time, there was a sense of – well, maybe not exactly optimism, but a sense of hope that we might accomplish meaningful health care reform in the U.S.

Now the reform initiative is on life support, and it’s not clear what Congress might be able to salvage.

How did it all go wrong? Various commentators have been examining that question this past week. One of the most insightful analyses comes from Kaiser Health News, which points to congressional deal-making, the cost and complexity of the health care bills, and a failure to connect with the American public as the key reasons why health care reform legislation has faltered:

“There’s nothing in it the average person could understand about why your costs would be lower,” says Robert Blendon, professor of health policy at Harvard’s School of Public Health. “They don’t even have good illustrations about how it would be cheaper. They did not find a way to save money for people with job-based insurance.”

… Certainly, relentless attacks by the Republicans – as well as the Democrats’ own inability to clearly articulate the benefits of the legislation – are partly responsible for the legislation’s lack of popularity. So are crucial policy decisions made by Democratic leaders as they struggled to push the legislation through Congress, according to experts of different ideological persuasions.

Does this mean the public no longer supports health care reform? Not so fast, cautions Bob Doherty, who blogs about health care policy for the American College of Physicians. Recent opinion polls suggest the real issue is that people are becoming doubtful and skeptical, Doherty blogged last week:

In my mind, the polls show that opponents have been most effective in raising doubts among Americans on two of the core claims for health care reform: that the bills will lower their costs while improving (or at least not hurting) the quality of care they receive. But I don’t think that the polls show that there has been a wholesale rejection of the need for health care reform, or that most Americans buy into the view that it is too liberal and will lead to government-run health care. Instead, they don’t trust that the bills being debated will deliver on the promises of better care at lower cost, and that is why a majority now oppose them. The proponents of health reform have not yet figured out how to make them feel otherwise.

It’s worth noting that the MoveOn political action committee is holding an emergency rally at Rep. Collin Peterson’s office in Willmar tomorrow to continue pushing for a meaningful health care bill, along with measures to support economic recovery. Clearly at least some among the public haven’t given up yet, and don’t want to see Congress scale back or abandon its efforts at health care reform. But is it going to be too late?

What I’ve seen (and heard) is that many people still care deeply about this issue and want to see genuine change. Many of them, however, have a hard time whole-heartedly supporting the bills on the table. Some of the disagreement seems to be ideological, but I also hear thoughtful people who are questioning whether the current version of reform will come at too high a price and create unintended – and damaging – consequences. Mostly, they’re not sure how it’ll affect them personally, and this uncertainty leaves them worried.

I blogged about this back in July but I’ll say it again: Much of the process seems to have been dominated first by policy wonks and then by politicians. I’m not sure whether consumers or clinicians have truly had much say or whether they’re actually being heard – a fact that was communicated loud and clear during the contentious town hall meetings last August. People are feeling disenchanted, and when they get disenchanted, they start to disengage.

Some of the controversy, I think, was to be expected. There’s really no way to accomplish meaningful health care reform without goring a few oxen along the way. The question is whether we’re losing the collective momentum we possessed one year ago. The clock is ticking. If the current reform effort fails, it’ll likely be years before we regain the political will to give health care reform another chance.

Update, Jan. 29: For a collection of commentaries on the future of health care reform, check out Room for Debate at the New York Times.

The new look of local cancer care

One of the rewarding things about being a reporter is the opportunity to follow a long-term story as it unfolds. This has been the case with the Willmar Regional Cancer Center, starting a few years ago when Rice Memorial Hospital and Affiliated Community Medical Centers began seriously talking about combining their cancer services under one roof.

I’ve heard hospital and clinic officials, physicians and staff explain why they think this is a good move. I’ve seen the design phase of the $2 million project and toured the space several times while construction was under way. And having seen the finished product last week, it’s not hard to understand why the folks involved in this project would be so excited about showing it off to the community this weekend. The open house/grand opening for the public is 1 to 3 p.m. Saturday.

Bricks and mortar aren’t the only thing that’s important, of course. It’s the people who make the cancer center what it is. But you can do a whole lot more for patients when you have a physical environment that supports and enhances the services you provide.

The previous arrangement – having the radiation therapy program at Rice and medical/chemotherapy services at ACMC – has always been somewhat fragmented in terms of the patient experience. It also has hindered the establishment of a strong, unified identity for local cancer services, one that says "we’re here and we can treat you if you’re ever diagnosed with cancer."

Now there’s one place patients can go for everything. They no longer have to figure out how to navigate two different buildings and two different parking lots. They can deal with the same staff each time. It gives them some element of familiarity and predictability at a time in their lives when the rug has been pulled out from under their feet.

The picture above shows the new entrance. It’s much more visible than it used to be, and it’s large enough to accommodate wheelchairs, plus family members, caregivers or whoever else might be accompanying the patient.

Here’s the new waiting area:

And another view of the waiting area:

Even though patients and families are not here for a happy reason, the team that planned the design has done their best to reduce the intimidation factor and make it welcoming:

I have to say I’m impressed with the amount of thought that has gone into the details. For instance, there’s now an on-site lab that makes it more convenient to do blood draws and other lab tests. This might not seem like a big deal, but keep in mind that cancer treatment can take a real toll on the patient’s blood counts, especially infection-fighting white cells, hence people undergoing treatment need to visit the lab often to have their counts monitored. In the past, this has meant trekking down to the laboratory department at ACMC or at Rice. It was an extra thing for patients to deal with at a time when they were often struggling with fatigue, plus it risked exposing them to a whole range of other patients while they were immune-compromised. Now they can have their blood drawn right there in the cancer center – a small thing, perhaps, but one that helps make the treatment experience a little easier.

Ditto with the on-site pharmacy. In the past, all the drug solutions were mixed and prepared by chemotherapy nurses. Given that many patients on chemotherapy are each receiving an average of two to three intravenous drugs, plus pre-treatment IV steroids and anti-nausea medication, this can be very time-consuming. The on-site pharmacy is now staffed by Rice Hospital pharmacists, which has freed nurses to spend more time with patients.

One of the biggest physical improvements, in fact, is the chemotherapy environment. With chemotherapy sessions that can take two – and sometimes as many as six – hours, comfort matters. Patients now have their pick of an open treatment bay or a semi-private room. The treatment bay is large enough to accommodate up to six patients and is equipped with a big-screen TV and snack bar. There are eight semi-private rooms, each with TV, and roomy enough to include family members.

Nice chairs, pleasant lighting and art on the walls might not make much difference in a successful outcome, but if you talk to patients most of them will say they appreciate an environment that helps them feel physically and emotionally more comfortable. After all, they spend a lot of time here under stressful, demanding circumstances. If they’re receiving chemotherapy, they more than likely will undergo multiple sessions of treatment. Radiation therapy generally requires coming in five days a week, often for anywhere from four to six weeks. Many patients have both chemotherapy and radiation, necessitating many, many visits over the course of months. On some level, the physical surroundings do matter.

And let’s not forget the support services. By uniting under one roof, the Willmar Regional Cancer Center is now able to increase these. The staff is especially excited about a new nurse navigator program, which makes a full-time nurse available to help connect patients and families with extra resources, whether it’s financial assistance they need or help with home care or nutrition. It’s a service that, frankly, has been lacking in the past - and one that many patients and families sorely need.

One of the goals of the cancer center is to eventually start a survivorship program as well. It’s increasingly being recognized that the transition out of active cancer treatment is, in its own way, as stressful and uncertain as the beginning of treatment. There has long been an unmet need for helping these patients make the transition. There’s also a growing number of people who survive cancer, as well as people living long term with chronic cancer, who would benefit from support services aimed at helping them live as well as possible.

It’s hard to put a dollar value on services such as a nurse navigator or a survivorship program. But just like the physical environment, these intangible things – the attentiveness, the personal approach – often do matter greatly to patients and families.

There’s a tendency for people to shun their own back yard in the belief they’ll get a better product or service by going out of town. And to be sure, there are times when cancer patients are best served by going to Rochester or the Twin Cities or elsewhere for the specialized care they need. But bigger does not necessarily mean better. There’s a lot to be said for having this level of cancer care available close to home and knowing the quality measures and the outcomes stack up every bit as well as those at larger facilities.

West Central Tribune photos by Ron Adams and Anne Polta

No respect for the thyroid

Pssst. Hey, you. Yes, I’m talkin’ to you.

No, dummy, not your vocal cords. I’m your thyroid. I’m that important gland in your neck that produces hormones you need to help regulate your metabolism. More than that, I’m essential to many major functions such as your heart rate, your blood pressure, your body temperature and the basic activity of all the cells in your body.

Most of the time I just hang out quietly, doing my thing. I don’t expect your gratitude – hey, functioning normally is just what I do. But right now I’m sorta having a pity party for myself. I mean, here it’s January, national Thyroid Awareness Month, and I’m not sure anyone has taken the slightest notice. Come on, ask yourself: When’s the last time you thought about your thyroid? You take me for granted, that’s what, and I’m tired of getting no respect.

You’d think different if I went all haywire on you. Then you’d need me. Then you’d start paying attention. So consider this your wake-up call, your Thyroid 101, before it’s too late.

First things first. I’m located in the front of your neck, nestled against your trachea (or “windpipe,” if you prefer) and just under your larynx. I have a rather pleasing symmetrical butterfly/bowtie-like appearance. As organs go, I’m not all that big – maybe around 2 inches high and weighing anywhere from 18 to 60 grams in an adult - but I’m definitely one of the largest endocrine glands in your body. I’m covered with a nice fibrous sheath – an overcoat, if you will. If you cut me open and look inside, you’ll see that I’m made up mostly of round follicles encased in thyroid epithelial cells, with a bunch of parafollicular cells scattered around for good measure.

I operate on a delicate and complex feedback loop involving me, the pituitary gland at the base of your brain and the hypothalamus within your brain. When everything is working the way it should, all the important thyroid hormones are manufactured and released at the proper levels and you feel hunkydory.

But I can be finicky and sometimes stuff just goes wrong. I might start producing too little thyroid hormone, which can cause you to become hypothyroid – or the opposite, too much hormone, which results in hyperthyroidism. Sometimes I get hit with an autoimmune disease such as Hashimoto’s or Graves’ disease and I stop working normally. It’s the same deal with radiation exposure; I’m susceptible that way. I can develop nodules, most of which are benign but can occasionally cause problems. Sometimes I become enlarged (maybe you’ve heard of goiter). Sad to say, I get cancer too, usually curable but sometimes not.

Here’s the thing that upsets me. Despite all the ways I can wind up in trouble, I’m often the last culprit anyone thinks of. Don’t get me wrong; it’s a relief to not always be the scapegoat for people’s health problems. But you’d think I was invisible or something, or that what I do doesn’t matter. Where’s the respect in that?

According to the people at the Thyroid Awareness Month campaign (and you should listen to them because they’re my BFFs), at least 30 million Americans have some form of thyroid disease. Many people with thyroid dysfunction aren’t even diagnosed, however, so the real number might be closer to 59 million.

You know what really annoys me? When I develop some kind of problem, my symptoms can be so, well, non-specific. If I go hyper on you, you might feel anxious or jittery or overheated but it can easily be written off as nervousness. My hypothyroid symptoms – weight gain, sluggishness, depression, mental fog, feeling cold all the time – are constantly mistaken for other things. Like I said earlier, I don’t always want to get all the blame if you’re not feeling well. But I don’t appreciate being ignored either.

And make no mistake, when I’m not functioning well I can make your life miserable. If you don’t believe me, check out all the love letters written to me at Dear Thyroid. (Some of these people are really angry and they use a lot of four-letter words, so don’t say I didn’t warn you.) I’m not sure I deserve to be the target of their anger; after all, I can’t help it when I screw up their lives. I’m just saying: You’re a babe in the woods if you think thyroid dysfunction is no big deal, easy to treat, just take a pill every day and you’ll be fine. For a lot of people it doesn’t work this way at all. Not that I want to rain on everyone’s parade here; for plenty of people, fixing what ails me is a relatively simple and straightforward thing to accomplish, and happy endings always make me happy. I’m just saying: I can be rather complicated sometimes.

So there’s your introduction. Take some time to read all those links I posted. Get to know me a little better. We’re in this together, after all; we need each other. And while you’re at it, how about taking me a little more seriously from now on? I just want some respect. Is that too much to ask?

Mountains beyond mountains

True stories can be far more compelling than any fiction, which explains why I quickly became engrossed a few years ago in reading "Mountains Beyond Mountains: The Quest of Dr. Paul Farmer, a Man Who Would Cure the World."

It’s the story of a public health doctor and infectious disease specialist who has devoted himself to one of the most poverty-stricken corners of the globe – rural Haiti. Here, in the central highlands, Dr. Farmer helped establish a hospital and health center that became the cornerstone of Partners in Health, the nonprofit organization he co-founded to bring needed health care to the poorest of the poor.

Pulitzer Prize-winning author Tracy Kidder was in Haiti in 1994, reporting on American soldiers who were in the country on a peacekeeping mission, when he met Dr. Farmer. Eventually he decided to write a book about this extraordinary doctor, his work in Haiti and the daunting issue of global health, especially among the poor. "Mountains Beyond Mountains" is the result. (The book’s title refers to a Haitian proverb that describes the never-ending hardships and challenges of life: "Beyond mountains there are mountains.")

It’s an illuminating book, not only for the light it sheds on Haiti and its history and culture but also for its examination of global poverty and the impact of poverty on health.

Here’s how Haiti fares in some of the most recent statistics collected by the World Health Organization: three physicians for every 1,000 people; one nurse or midwife per 1,000 people; less than one dentist per 1,000 people; 13 hospital beds for every 10,000 people. (Figures are for 2007, the most recent year for which complete numbers were available.) Given such a fragile health care infrastructure, it’s not hard to see why last week’s earthquake has had such a profound and devastating effect on the Haitian people.

Dr. Farmer’s organization, Partners in Health, is working to raise funds and coordinate donations and volunteers for earthquake relief. Follow the link to read more about the "Stand With Haiti" campaign, including reflections by Dr. Farmer, the personal account of a physician’s first 12 hours on the scene in Port au Prince, and a blog post by author Tracy Kidder. And I’d highly recommend reading "Mountains Beyond Mountains." A copy of the book is available at the Willmar Public Library.

Update: As the focus shifts from trying to rescue people to caring for the survivors, the health crisis in Haiti is deepening. This story, which appears today in USA Today, explains the challenges ahead. Doctors Without Borders also has posted a firsthand account and slideshow on its Web site.

Photo: Daniel Morel, Wozo Productions

Rooting out medical error

When the Minnesota Department of Health released its annual report last week on preventable medical errors that occurred in 2009 at Minnesota hospitals, it was almost a routine news event. After all, the report has been issued every January since 2005.

It’s anything but routine, however, when you look at the state of medical error reporting in the rest of the United States. Although it has been 10 years since patient safety was thrust into the spotlight with the publication of a landmark Institute of Medicine report, “To Err Is Human,” the majority of states still don’t have a system for tracking and reporting preventable harm to patients. Among those who do, many of these systems aren’t particularly strong and have probably led to underreporting of errors. There are few reliable numbers, other than estimates, on how often major errors occur. It’s known that wrong-site surgery, for instance, is rare, but its true incidence in U.S. hospitals and surgery centers has not been accurately established. In the national discussion about health care reform, patient safety has barely even been mentioned.

There’s still considerable reluctance among hospitals to report adverse events such as wrong-site surgery, serious medication errors, or inadvertently leaving sponges or other surgical items inside a patient. In view of the punitive culture that has long existed in health care, it’s not hard to see why. Many individuals and organizations fear being forthright about mistakes because they don’t trust that they won’t be blamed or punished. They’ve also feared that reporting their errors will lead to the singling-out of hospitals on the basis of their error rates – in effect penalizing them for being honest about mistakes. Right or wrong, it has historically been easier to maintain a wall of silence, even if it means a failure to examine and address what went wrong in hopes of preventing a future breakdown.

This is why the Minnesota report remains extraordinary. It represents a structured, formal effort across the state to study the factors contributing to serious patient harm and identify some of the best and most effective ways to prevent it.

Let’s take “retention of a foreign object,” aka mistakenly leaving something inside the patient during surgery. Here in Willmar, Rice Memorial Hospital reported one such incident in 2009. It’s something that hospitals try mightily to avoid; a retained foreign object often requires additional surgery to remove, which exposes the patient to the further risk of complications and infection, not to mention the added cost.

On the surface, at least to the layperson, it appears as if it would be a relatively simple thing to prevent. But it’s not. When the state Health Department did an in-depth analysis last year, several key findings emerged: First, pre- and post-surgery counts of sponges, sharps and the like often weren’t consistent or clear. (Do you count sponges by the package or do you count them individually?) Many of them didn’t account for wound packing materials that were supposed to be removed after a period of time, or didn’t include small items such as surgical pins. There also were issues with failing to visually compare instruments before and after surgery to check for breakage. The incident at Rice Hospital, for instance, involved a piece of a sizing cuff used in major surgery and led to modifications in how the hospital’s OR teams conduct their count for large procedures.

One of the biggest lessons from the Health Department analysis: Just because the pre- and post-surgery counts are accurate, it doesn’t mean that something wasn’t mistakenly left in the patient. As the department explained, “Counts that appear accurate can often be incorrect, and an accurate count may not be a guarantee that an object has not been retained, particularly if the counting process was flawed.”

The analysis led to several recommendations to help reduce the likelihood of retained foreign objects during surgery - and it’s had an impact. At one time, labor and delivery accounted for the highest number of retained foreign objects; this past year, this type of adverse event was almost eliminated among hospital obstetric units.

Progress doesn’t happen, however, when adverse events don’t get reported and, more to the point, when the information isn’t openly shared and discussed so everyone can learn from it. For the most part, the 27 “never” events that Minnesota hospitals are required to report are relatively rare. They may happen at any given hospital only once or twice a year out of perhaps hundreds or thousands of procedures or patient encounters. It’s hard for hospitals to figure out what went wrong and try to improve when they’re only able to look at a tiny slice of their own data. But when the information is pooled across the state, trends begin to emerge and effective solutions can begin to be identified.

Will Minnesota’s hospitals ever get down to a zero rate of adverse events? Probably not. Health care is complicated and relies heavily on human beings who cannot be perfect 100 percent of the time. But as a whole, Minnesota seems to be well on the way to reducing the number of adverse hospital events as low as it realistically can go, while at the same time building up a body of knowledge that can benefit hospitals all over the U.S. None of this would be happening if it weren’t for open, honest reporting and fearless examination by hospitals of their worst mistakes.

West Central Tribune file photo by Ron Adams

Reflections on customer service

Sometimes, the process of getting past the doctor’s telephone answering system and the staff at the front desk can be like negotiating an obstacle course for the Green Berets – challenging, arduous and frustrating.

It made Susan Giurleo annoyed enough that she decided to fire her primary care doctor, as she relates in this guest column that appeared this week at Kevin, MD.

Giurleo developed a sinus infection and needed to see her doctor to get it treated. She recounts what it took to get an appointment:

The woman who answers the phone sounds annoyed from the first syllable out of her mouth. I asked for Dr. Smith’s office and the response I get is: "Immediate appointment or annual physical appointment?"

Me: "Um, I have a sinus infection, so immediate appointment, please."

Woman: No response… immediate "click" to the lovely music that lets me know I’m on hold.

Hold. Hold. Hold. Recording telling me to see Web site for H1N1 vaccine information. Hold. Hold. Hold. Recording on H1N1. Hold. Hold. Hold. Recording. Hold. Hold. Hold.

20 minutes on hold.

I hang up.

Call back later. Same rude woman.

When Giurleo arrives for her appointment, this is what happens:

Receptionist never looks me in the eye, even as he is confirming my birth date, address, insurance, takes my co-pay and gives me a receipt. Someone’s phone rings in the waiting and he says loud enough for all to hear, "Turn off your phone" in an annoyed tone.

Giurleo likes her doctor but she’s going to find someone new because, as she explains, "Her support staff and their administrative systems don’t work for me."

When it comes to frustration with bureaucracy at the doctor’s office, she has plenty of company. Most of us have had the experience of long waits on hold, having to call two or three times to make an appointment, ending up in voice mail limbo, or dealing with staff who are, to put it kindly, frazzled and not necessarily in the mood for being polite.

Does it matter, as long as the patient receives care that’s timely and appropriate? I don’t think I’d dump a physician over dissatisfaction with his/her office procedures and staff, unless it was a chronic, pervasive issue and efforts to speak up about it didn’t result in any change. But for what it’s worth, I’m dismayed at some of the responses to Giurleo’s guest column. If she wants better service, enroll in a concierge practice, someone suggested. All doctors’ offices are busy, so get over it, others advised. She was even chastised for self-diagnosing and for wanting antibiotics.

Alas, most of these commenters seem to have missed the point. To be sure, rudeness is sometimes in the eye of the beholder. Office practices can’t always run as smoothly as we’d like. Sometimes the staff is just having a really bad day, and it behooves patients to try to be reasonable with their expectations. And in many cases there are valid reasons why patients might have to jump through hoops to make an appointment or get a prescription refilled.

But I don’t think it’s out of line for patients to yearn for good customer service, and to be dissatisfied if they don’t receive it. Even though the primary relationship is between the doctor and the patient, the rest of the office staff is part of the package as well. A physician’s good work can be swiftly undone by staff who are brusque and unhelpful, or administrative systems that are full of barriers. (Not to say that patients can’t be annoying and obnoxious too, but that’s a topic for another day.)

Technical skill and knowledge are important, of course, but they ring rather hollow when they’re delivered curtly and impersonally, or when patients have to scale barbed-wire fences in order to get what they need.

Although the concept of customer service isn’t totally foreign to health care, it hasn’t always been a priority. There’s traditionally been a mindset in clinics and hospitals that "this is the way we do things," and if patients and families had other preferences, they were out of luck. Happily this has been changing as patient- and family-centered care becomes more the norm. For one thing, the health care market, even in relatively rural areas, is getting more competitive. For another, patients are no longer quite the captive audience they used to be; people can and do travel elsewhere to receive care, and they can be quite vocal if they feel they’re not being treated with courtesy. And thirdly, more health care organizations are realizing that good customer service is simply the right thing to do. In other words, yes, it does matter.

 I’m always surprised and grateful when I call the clinic or accompany a relative to the hospital and everyone is – gasp! – nice to me. I appreciate being able to hang up the phone or walk out the door feeling I have been helped. Maybe it’s Minnesota niceness; maybe it’s the fact that local providers seem to genuinely value good customer service. Whatever the case, this kind of experience has become the rule rather the exception, and believe me, it has not gone unnoticed.

West Central Tribune file photo by Ron Adams

Mental health: still a stigma

When former Minnesota senator Mark Dayton recently disclosed his treatment for alcoholism and mild depression, I can’t say I was surprised by the reaction. Many people were understanding and felt Dayton’s issues make no difference in his qualifications as a potential future governor of Minnesota. Others, not so much.

“With all these problems, he’s not up for the job,” one person commented after reading the Minneapolis Star Tribune’s exclusive interview last month with Dayton. Someone else, referring to Dayton’s upbringing in one of Minnesota’s wealthiest families, wondered, “What does he have to be depressed about?”

You have to wonder: Would the reaction have been the same if Dayton had revealed a history of, say, asthma? Or cancer?

When it comes to mental health, there’s still a fair amount of stigma. Or, at the very least, a lot of misinformation about mental illness, the people who have it, the causes of mental illness and how to treat it. (For instance, the inaccurate notion that wealthy people should somehow be immune from clinical depression.)

More than a few experts believe it’s the stigma, not the mental health issues themselves, that’s most likely to derail Dayton’s latest political aspirations. The Star Tribune explains:

Mental illness is not the political kiss of death it once was, partly because it’s now more widely recognized as a treatable brain disease. Depression is now regarded as one of the most common medical conditions, affecting as many as one in five people at some point in their lives, by some estimates. But there is still enough stigma that many people commended Dayton for disclosing his history with both depression and alcoholism.

If this is the case, then I really don’t know what to think about the latest chapter in the story: that the Star Tribune is querying other candidates to find out whether any of them have ever received treatment for drug or alcohol use, depression or anxiety. (Politics in Minnesota broke this development late last week.)

Granted, we’re talking about a group of individuals from among whom Minnesota’s next governor likely will be elected. Perhaps some higher standards of disclosure ought to apply here – and candidates who are uncomfortable with this level of public exposure should rethink whether they truly want to be in public office.

Nevertheless, I’m uneasy with the underlying tone of “gotcha!”, the implication being that mental health issues are the damaging equivalent of a skeleton in the closet that should be dragged forth and revealed. And where, I wonder, do we draw the medical privacy line for candidates for public office?

I’ve been following the discussion at David Brauer’s media blog at MinnPost, where the issue has ripened into a contentious brew of politics, mental health, media ethics and privacy rights. Brauer asks: “Why should mental health questions be off limits if we wouldn’t bat an eye when candidates are asked for their traditional health histories?”

A sample of some of the comments:

- “Politicians are human beings with faults and frailties. It would help society in the long run to realize this, and not to demand some superhuman strength as a precondition of public service.”

- “As someone who feels most of the public can’t adequately understand the most primary of issues, it gives me pause to think we are going to let people make their own judgment about phenomena which aren’t even deeply understood by clinicians.”

- “The stigma doesn’t come from not talking about it. It doesn’t come from talking about it. It comes from treating that element of health as different from… you know… the health of ‘normal’ people.”

- “What do you think, every elected official currently serving is the picture of perfect physical and mental health? Medical records are confidential for a reason; keeping them that way doesn’t stigmatize anyone. The invasion of privacy will not promote human dignity. If we’re all gonna start voting based on our ‘medical’ evaluations of candidates, seriously, stick a fork in us… we’re done.”

- “If a candidate ingests potentially mood-altering drugs on a daily basis, does it really matter whether the candidate is self-medicating (alcohol or some illict drug), had been prescribed Vicodin or methadone for chronic pain, or takes a combination of antidepressants to correct a biochemical imbalance? I don’t think so. What does matter, it seems, is the moral judgment which still attaches to mental health conditions in the minds of many.”

While most of us would like to think we in the United States are understanding and caring when it comes to mental illness, the evidence all too often points to the contrary. Heiress Casey Johnson, for instance, who died last week at the age of 30, captured tabloid headlines for her outrageous lifestyle when in fact she may have been suffering from an undiagnosed – and untreated – psychiatric illness, Dr. Harold Koplewicz, a child and adolescent psychiatrist, writes in a commentary for the Huffington Post. “Regardless of the family’s income or celebrity, the stigma associated with mental illness encourages denial and inhibits the actions of those who care desperately and sincerely want to help,” he wrote.

In Britain, you can’t serve on a jury if you have a history of mental illness. Stigma also has been an issue in the U.S. military, where many service members are unwilling to seek help, even when they need it, because they fear being perceived as weak.

For what it’s worth, I think it was courageous of Mark Dayton to go public. It has put the issue squarely on the table for open discussion. Whether we’re ready to have a constructive discussion about it, especially in the highly charged political arena, is another question altogether. It’s true that we’ve made some progress; 25 or 30 years ago, an admission like Dayton’s could easily have spelled the end of his political career. But we clearly have a considerable way to go yet.

For more information on how to reduce the stigma surrounding mental illness and mental health, visit these online resources provided by the Minnesota affiliate of the National Alliance on Mental Illness.