How many nurses are enough?

How many patients can one nurse safely handle? Is there an optimal nurse-to-patient ratio? Does patient care suffer when there aren’t enough nurses per patient?

These aren’t just academic questions. They go to the heart of one of the more contentious issues in the hospital industry these days: the flashpoint where staffing levels, patient care and profitability collide.

If you’ve been following the news of a pending strike by 12,000 nurses at Twin Cities hospitals, you’ll know that staffing levels are one of the key issues at stake. The hospitals want the ability to adjust staffing in response to patient volume, a move the Minnesota Nurses Association contends is unsafe for patients.

As revenue continues to tighten and hospitals look for ways to become leaner and more efficient, the public can expect to hear a lot more in upcoming months about the nurse-to-patient ratio.

Not surprisingly, it’s an emotional issue. It’s also one that happens to be rather well studied, and most of the studies suggest patients fare better when the hospital is staffed with an adequate number of skilled nurses.

One of the most widely cited studies is this one, which appeared in the Journal of the American Medical Association in 2002 and examines the nurse-to-patient ratio, patient mortality and job dissatisfaction and burnout among nurses. The authors conducted a survey and collected data at 168 hospitals in Pennsylvania and, after analyzing the results, concluded there were “detectable differences in risk-adjusted mortality and failure-to-rescue rates across hospitals with different registered nurse staffing ratios.”

Another key finding from this study: Nurses who worked at hospitals with a high patient-to-nurse ratio were much more likely to report job dissatisfaction and burnout.

These findings have important implications for patient safety and the hospital nurse shortage, the study’s authors wrote:

Our results document sizable and significant effects of registered nurse staffing on preventable deaths. The association of nurse staffing levels with the rescue of patients with life-threatening conditions suggests that nurses contribute importantly to surveillance, early detection, and timely interventions that save lives. The benefits of improved registered nurse staffing also extend to the larger numbers of hospitalized patients who are not at high risk for mortality but nevertheless are vulnerable to a wide range of unfavorable outcomes. Improving nurse staffing levels may reduce alarming turnover rates in hospitals by reducing burnout and job dissatisfaction, major precursors of job resignation. When taken together, the impacts of staffing on patient and nurse outcomes suggest that by investing in registered nurse staffing, hospitals may avert both preventable mortality and low nurse retention in hospital practice.

When the U.S. Agency for Healthcare Research and Quality undertook a review of the existing research, several more conclusions came to light. First, many hospitalized patients are very sick and require considerable care. The AHRQ cited research showing a 21 percent increase in the acuity level between 1991 and 1996 – but no net change in the number of registered nurses. In fact, many hospitals have sought to increase staff efficiencies by hiring nursing assistants to take over some of the more basic tasks of patient care, a move that tends to add to the supervisory workload of RNs.

The AHRQ’s report also attempts to quantify the cost of adverse events that might be associated with short-staffing the number of hospital nurses.  The report notes, for instance, that pressure ulcers account for at least $8 billion in health care spending per year.

Yet another study suggests the cost of having more nurses on staff is balanced by shorter hospital stays for patients and fewer complications and adverse events.

Is there a right ratio for how many patients one nurse can safely care for? This isn’t easy to pin down, as this position paper, produced by the New England Public Policy Center and the Massachusetts Health Policy Forum, demonstrates. It can depend on the hospital unit – intensive care patients, for instance, are sicker and require more care than a same-day surgery unit. It might also depend on the particular mix of patients who are hospitalized on any given day, and on the overall resources of the hospital. There may also be a point of diminishing returns beyond which the benefits of ramping up the nursing staff are minimal.

Patients and the public aren’t accustomed to discussing these policy questions. For the most part, the dialogue about nurse-to-patient ratios has taken place between nursing organizations and hospitals. And maybe that’s appropriate, but the public has a stake here too. If we’re ever hospitalized, or have a family member in the hospital, we’re going to notice if there aren’t enough nurses to go around and it affects the care we receive. We’re also going to notice if we end up paying more for hospital care. It seems only right to give the public more opportunity to become informed and to get involved in this important discussion.

Update, June 4: Check out MinnPost for this thoughtful take on the connection between numbers of nurses, hospital costs and quality of care.

In the waiting room

If you want to get patients riled up, make them sit for a long time in the waiting room. (Or have them wait in the exam room, a practice that’s supposed to make it look as if the doctor will see you soon but, let’s face it, has very few of us fooled.)

Depending on their mood, some people will fume at the wait. Others are quietly resigned to sitting there and maybe paging through a magazine that has been gathering dust since the Eisenhower administration.

Why is it often so hard for doctors to stay on schedule? The answers, as it turns out, are myriad and not necessarily obvious. This article, which appeared last week in American Medical News, was illuminating for how it dissects the many points at which the schedule can go off the rails – and for its behind-the-scenes look at time-management dynamics that patients don’t often glimpse and that most laypeople are probably totally unaware of.

Of course there are the usual suspects: the emergencies, the appointments that take longer than planned, the patients who show up late for a scheduled appointment. Often, however, problems with punctuality have more to do with poor work flow, inefficient staffing and other issues directly related to how the clinic is managed.

Is the issue that physicians are taking longer than expected with patients? That clinical assistants are slow? That exam rooms aren’t turned around quickly? That patients run late?

Before considering those questions, experts recommend answering this one: Is the physician on time for the first appointment?

When you have a physician “who comes in a half hour late every single time, you’re backed up from the get-go,” said Cheryl Gregg Fahrenholz, president of Preferred Healthcare Solutions, a Bellbrook, Ohio-based practice management consultant.

There are many reasons a physician might be late, and not all of them will be the doctor’s fault. But experts said everybody – physicians included – need to be in place and ready to go when the day’s first appointment begins.

Even if everyone in the practice is on time, other matters can put you behind before the first patient enters. Are the exam rooms ready? Have the sharps containers been emptied? Are charts ready? Is everyone aware of who is doing what today? Has there been a huddle to discuss the varieties of appointments that are scheduled?

Most of this isn’t obvious to patients. They might figure the staff is busy chatting or drinking coffee instead of taking care of business. It may not even cross their minds that they might be waiting because of inefficiencies in retrieving charts or setting up the exam room for the next appointment.

These are only a few of the reasons for lengthy wait times. There might also be bottlenecks at the check-in desk, or perhaps the clinic uses block-scheduling that doesn’t allow enough time for certain types of appointments. An ineffective system for walk-in or urgent visits also can upset the schedule and leave the practice running late for the rest of the day.

Many of these issues, the article points out, can be addressed and fixed - more efficient turnover of exam rooms between appointments, for instance, or adequate staffing at the check-in desk. In other words, long waits aren’t necessarily something that everyone just needs to learn to tolerate. It’s all in how you manage the schedule and plan for the inevitable surprises.

When you think about it, similar lessons could apply to patients who can’t seem to get to appointments on time. Do they actually leave the house (or workplace) on time? Do they plan for busy traffic? Have they accounted for the amount of time it takes to find a parking place, get into the clinic and go through the check-in process? Even a seemingly minor delay can end up making them late.

In the ideal world, everyone would always be on time. We wouldn’t need waiting rooms and we’d all be happier. In the meantime, maybe we can settle for being somewhat more aware of what it really takes to stay on schedule.

There’s a tendency to assume that when patients aren’t on time, it means they don’t value the physician’s time or don’t care about the clinic’s schedule. There’s a tendency to assume that when physicians fail the punctuality test, it means they don’t respect the patient’s time. And maybe it’s true there’s a little bit of mutual disrespect sometimes – but when doctor and/or patient are behind schedule, they’re not usually doing it on purpose. Like a finely tuned clock, multiple things have to mesh in order for a clinic to run smoothly and on time. Making this happen, and making it happen consistently, takes effort and it’s a lot harder than it looks.

Photo: Wikimedia Commons

The cost of ordinary care

There’s a Russian proverb: It’s not the sea that drowns you; it’s the puddle.

The American concept of health insurance is shaped by the belief that people need the greatest protection from catastrophic, costly illnesses and conditions. Everything else – in other words, most routine care – is affordable and should be borne by the consumer.

At one time this might have been the case. But I’m not sure how well it continues to hold true. This study, which was published a couple of months ago in the Health Affairs journal, explains some of the cost trends that have been taking place. (Access to the article is by subscription only; a summary of the key points can be found here.)

Broadly speaking, almost 20 percent of working-age Americans now spend 10 percent or more of their pre-tax income on health insurance premiums and medical care. From 2001 to 2006, the number of people in this bracket grew by about 1 percentage point each year. If you estimate that the median household income in rural west-central Minnesota is around $40,000, on average that’s $4,000 worth of annual medical expenses and insurance premiums – and that’s before taxes are figured into the equation. Some individual families obviously are paying considerably less than this if they’re healthy (and lucky enough not to get hit with an expensive illness or injury); others are paying way more.

The study points out that the burden of out-of-pocket health care costs has been growing especially rapidly among middle- and upper-middle-class households with private insurance.

Data were collected from a sampling of 28,000 people under age 65 for each of the years included in the study. Since the survey was conducted before the recession, it’s probably safe to assume there was little change in 2007-2009 in the cost burden being shouldered by many of these households.

There seems to be multiple contributing factors to this trend, starting with household income, especially in the bottom half of the median. Have wages kept up with the cost of living and what it takes to feed, clothe and house a family? Probably not. The other issue, though, is that health insurance premiums and the cost of medical care have been rising faster than the rate of inflation. Put them together and what you have is a widening gap. Efforts to plug the gap have consisted mainly of increasing what people are being asked to pay out of pocket. It’s not at all clear whether this strategy can be sustainable over the long term.

There’s also something else going on: the growing prevalence of pre-existing conditions. Families USA, a national consumer advocacy group for affordable health care, is releasing a report tomorrow that attempts to quantify how many Americans have an identifiable health condition that might previously have precluded them from being able to obtain health insurance. Among the preliminary findings: 57.2 million working-age Americans have some kind of pre-existing condition that potentially affects their ability to be insured.

This is not a direct proxy, of course, for health care costs, nor is it a measure of health care affordability. The point is, millions of Americans have some kind of serious and/or ongoing health issue either in their past or that they’re dealing with currently, and it comes with a cost – not just to the overall system but to these people’s individual finances as well.

This isn’t an argument in favor of scrapping the entire structure and philosophy underpinning the U.S. health insurance system. Most of us, unless we’re millionaires, cannot afford the cost of something catastrophic. Coverage for the major medical bills is, after all, why most people need health insurance. Many Americans cling to the belief, however, that all the rest of it, the so-called routine stuff, is somehow more affordable – even though the evidence is mounting that for a sizeable portion of the population, the cost of routine, ordinary care is no longer routine or ordinary.

Should health insurance do better at covering basic services for which people are most likely to require medical care? Perhaps, although this comes with a hefty price tag of its own. Do we need to rethink the concept of deductibles and copayments and how they’re applied? Would some system of capitation help even out expenses so they’re more manageable for a broader swath of consumers? Or should we concentrate instead on curbing health care inflation or paying livable wages so the cost of ordinary care doesn’t get pushed out of reach?

The day-to-day costs of routine care might not seem like a big deal but they have an insidious way of adding up. In the public discussion about health care costs, we can’t afford to continue ignoring this fact.

Photo: Wikimedia Commons

Bald ain’t beautiful

Can freezing the scalp prevent or minimize hair loss associated with chemotherapy? A story in the Minneapolis Star Tribune on Sunday explored the concept of Penguin Cold Caps, which are being tried on an experimental basis. Two Twin Cities women are raising money to make this option more readily available for patients who want it.

Hair loss, or alopecia, has long been known as one of the less desirable side effects of cancer treatment. Most standard chemotherapy drugs work by attacking rapidly dividing cells, but unfortunately they don’t differentiate between cancer cells and normal cells, such as those in hair follicles, fingernails and the lining of the mouth. As a result, the patient’s hair often falls out during treatment. Although it’s almost always temporary and the hair grows back once chemotherapy is completed, this isn’t necessarily much comfort to someone who wants hair now, not six months from now.

The theory behind the Penguin Cold Caps is that by freezing the scalp, the chemotherapy can be prevented from killing cells in the hair follicles and the hair won’t fall out.

Whether this might help large numbers of patients remains to be seen. The article was careful to point out there have been few studies that rigorously examine the benefits:

Doctors aren’t so sure. Hair loss, especially among breast cancer patients, is an extremely painful and emotional issue, they say. They don’t want to give patients false hope for a costly therapy that may or may not work. “It’s difficult, in the sense that there is no good scientific evidence one way or the other,” said Dr. Tom Flynn, an oncologist and president of Minnesota Oncology. ”All we can do is advise them on what is known and not known, and they have to make their own choice.”

According to the article, the technique is being used in Europe. A handful of small studies suggests it helps some – but not all – patients.

Scientific evidence aside, it’s intriguing that there’s a formal effort under way to address one of the more difficult aspects of cancer treatment. I’m not sure chemotherapy-induced hair loss has been taken all that seriously by the oncology community. Since it has few, if any, medical implications, it tends to be regarded mostly as a psychosocial/cosmetic issue – hard for many patients to deal with but temporary and reversible. The upshot has been a dearth of good research, not to mention effective strategies, on how to minimize this particular side effect of cancer treatment.

The other thing that caught my attention with this story is that in spite of efforts to reshape the message into Baldness Is Beautiful, hair loss remains extremely distressing for a significant percentage of patients. Although the Strib article put most of its emphasis on women undergoing treatment for breast cancer, I think it’s pretty safe to say chemotherapy-related hair loss is difficult for people regardless of what type of cancer they have. I’m sure it’s very difficult for many men too. On some of the online cancer forums, reflections about hair loss are often very personal and wrenching.

Certainly there are people who decide to flaunt their baldness. “I’m going through cancer hell. Why should I hide it? Let my bald head be a warning to you!” wrote one woman in an online cancer community for young adults. Wrote someone else: “You are fighting for your life – you should be comfortable, not worry about how you look.”

Many people simply don’t feel this way, though. One woman wrote, “Except for my initial diagnosis, I can’t remember ever feeling more hopeless, more trapped, more defeated, than when I started losing my hair.”

Carrie Greene, who was profiled in the Strib story, has already been through chemotherapy once. The second time around, she wanted to try the Penguin Cold Cap because, as she told the Strib, she hated being bald. “I didn’t want to be stared at again,” she said. I suspect there are some people who would rather refuse chemotherapy or seek dubious alternative treatment than experience the wholesale hair loss that so often accompanies chemotherapy.

The bottom line, it seems, is that the emotions surrounding chemotherapy-related hair loss are highly individual. Well-meaning people might say it shouldn’t matter if patients lose their hair during cancer treatment, and indeed as a society we’ve become much more willing to embrace this fact. But if the response to the aptly named Rapunzel Project is any indication, the prospect of hair loss during chemotherapy is still difficult and emotional for many folks. Losing their hair doesn’t make them feel militant or empowered; it’s a blow to their self-image that often makes them feel bereaved and vulnerable.

I’ll give the last word to a coffee-shop manager who spoke up in an online forum about the need to recognize that everyone has a different comfort level with this most personal of issues.

Each person “has to do what’s right for them,” she wrote. “I’ve had many people tell me to go without the wigs (one even going so far as to accuse they are a ‘crutch’ for me… hey, when YOU have been in that position, THEN you can talk to me about it) but I am the one who would be walking around feeling self conscious and ugly… I am the one who would be dealing with it, not them. So most mean well and I appreciate it… but I need to do what I’m comfortable with, what works for me, what gives me some help in dealing with something I’m still devastated by.”

Photo: Wikimedia Commons

Fudging the record

There’s a saying in health care: If you didn’t document it, it didn’t get done.

The patient’s chart is supposed to be the official medical record for assessing and diagnosing, delivering treatment and providing care. Documentation also is the basis for payment and for monitoring quality of care. If it isn’t written down, it doesn’t matter whether the physician asked the patient about smoking cessation or the nurse provided hospital discharge instructions. For all intents and purposes, it doesn’t count unless it’s documented.

It almost goes without saying that the patient’s medical record should be complete and accurate. If worse comes to worst, good documentation can help practitioners defend themselves if there are ever complaints about the care they provided or if they’re sued. It’s an axiom that health care professionals have had drilled into them: Document, document, document.

There’s another, and darker, side to this corollary, though: If you don’t document it, you can pretend it didn’t happen.

It’s one of health care’s dirtier little secrets that the medical record can and does get fudged. How often does this happen? It’s impossible to know for sure, although it doesn’t seem to be a commonplace occurrence. A good share of the time, it’s probably unintentional. But there also are times when fudging is deliberately used to obfuscate the facts, especially when something hasn’t gone well with the patient.

Consider the story of Dr. Tricia Pil. Five years ago Dr. Pil underwent a difficult, traumatic labor and delivery, an experience she recounted recently for the patient-safety advocacy organization known as Pulse. One of many disturbing aspects of her story (and it’s unmistakably a very disturbing story) is the repeated discrepancy between her own recollection of events, the official version that appeared in her medical chart and the hospital’s version of what allegedly happened. Here’s an excerpt:

Patient: We are moved to the postpartum floor. Seven hours later, I suddenly feel weak, dizzy and nauseated.  I say, “Somebody help me, I don’t feel well.” The next minute, I’m hemorrhaging. There is blood spurting everywhere, clots the size of frying pans. I think I am going to die. Panicky nurses and residents crowd the room. The crash cart is wheeled in, my baby is wheeled out. My husband is shouting, “Somebody get Doctor B!” I am being stuck everywhere for an IV…

Chart: 7:30 a.m.: Called to see patient passing clots. Passed two medium size clots. Blood pressure 110/67… 100/60… 90/58. Pulse 88… 96. Patient uncomfortable, vomited x2…

Hospital: Once again, we refer you back to to your private physician for a detailed discussion about the hemorrhage you outlined.

Dr. Pil’s newborn son loses weight and starts to vomit while in the hospital. Mother and baby are sent home anyway, but return to the emergency room the same day after the baby vomits more severely and becomes jaundiced and dehydrated.

Patient: My son remains hospitalized, lying in an incubator receiving intravenous fluids and phototherapy. He doesn’t come home for good until he is nearly a week old, requiring yet another week of home phototherapy and daily home care visits before regaining his strength and weight.

Chart: Diagnosis: Obstetrical Trauma Not Otherwise Specified. Disposition: Return in approximately one year – Dr. G.

Hospital: We are sorry that you were so unhappy with your stay. After a thorough investigation of your allegations, we have concluded that the care you received was appropriate. Thank you for taking the time to express your concerns.

Granted, we’re seeing only a limited slice of what happened, not the whole story. But if the only version you saw was the one recounted in the medical chart, how much of the story would be missing, and how accurate would it be? Would you have any sense of what truly happened to this patient or how deeply she was damaged by it?

Sadly, judging from the online feedback to Dr. Pil’s story, this gap between the official record and the patient’s actual experience does not appear to be a single isolated incident. Many of the commenters didn’t even seem surprised by it. “If what you experienced was not malpractice, the collusion between doctors, staff and the hospital after the fact certainly was,” one person wrote. “As a nurse I felt ashamed reading the negligent, evasive and uncompassionate details of the staff,” someone else wrote.

Dr. Pil’s story was picked up last week at Kevin, MD, where the online discussion continued. One commenter recounted having “a frightening C-section” during which the epidural didn’t completely take effect. When she asked for a copy of her medical record afterwards, she found this report from the OR: ”patient tolerated the procedure well.”

From another commenter:

When you check your medical records, do you see anything that doesn’t jive? Times, doctor’s orders, procedures, signature page. Every order and comment needs to be validated throughout the chart. I’ve had cases where the nurse has gone in the week after a patient died in the ER and inserted charting to cover everyone’s butt. She messed up and actually put the current date on the notation. I’ve also been fired for refusing to falsify a patient’s chart.

To be sure, the medical record is meant to be objective and dispassionate. To patients and families who are upset or traumatized about something that happened with their care, plain statements of fact can unintentionally come across as callous. What health care providers have been slow to recognize, however, is the extent to which the patient’s and family’s perspectives are excluded from the official record.

It isn’t just patient care that’s at stake when the chart is fudged. The truth, or at least a wider view of events, can be a casualty too. Officially, Dr. Pil was described in her chart as being “uncomfortable” after her post-delivery hemorrhage. According to her own account of events, though, she was clearly far more than uncomfortable. And if the hospital’s investigation of her complaint was so thorough, why didn’t it seek a statement and narrative from Dr. Pil and her husband, who, after all, were key witnesses? Based on the details in her story, it appears she wasn’t even allowed to challenge the accuracy of her medical record, let alone the conclusion that her care was appropriate - and herein lies the snare in which patients are entangled.

When the chart is viewed as the official record of the patient’s care, it becomes very difficult for patients to question or disprove its accuracy – especially since they have almost no say over what goes into their medical record in the first place. In fact, unless patients specifically ask to see their record, they’re unlikely to even know if it’s inaccurate or incomplete. Disagreements can boil down to a case of he said-she said, and patients and families generally are the losers in this scenario. Even when they’re smart, credible witnesses of what happened, it’s all too easy for providers to disbelieve them or to dismiss them as laypersons with no real understanding of what they saw or experienced. Although falsifying a medical record is a felony in most states, offenders are seldom prosecuted except in the most blatant cases.

I’d like to be able to say I don’t often come across stories such as that of Dr. Pil. Unfortunately it’s not unknown by any means for medical records to be at odds with the patient’s and family’s own memory of what happened. Patients and families can be mistaken, of course, but neither is the medical record infallibly correct. Records can be incomplete. Salient facts can be selectively omitted or glossed over. Records can be altered after the fact or sections of the record can vanish. Sometimes insurance fraud is involved, but other times medical records are tampered with for the sake of covering up an error, bad judgment or simply a situation that might be negatively interpreted if the patient, family or an attorney ever saw the chart.

This isn’t just a case of disgruntled patients or trigger-happy lawyers making unfounded accusations. Medical professionals themselves, if they’re being honest, will admit that sometimes medical records are falsified. This case study, which appeared in 2001 in the British Medical Journal, sparked considerable discussion when it first appeared and is now seen as a classic example of the ethics of disclosure.

An elderly patient, both blind and deaf, is suspected of having an acute heart attack but somehow the results of her ECG fall through the cracks. She dies after five days of unrelieved suffering. After her death, a junior doctor is asked to write the case summary:

Fishing in the pack of X-ray films for the reports, I caught the long strip of an electrocardiogram. It bore the date of admission. I had asked a nurse to do it as part of the routine workup but had not remembered to check the results. The textbook signs of an extensive acute myocardial infarction were plain even to my untrained eye.

I took the tracing to the senior consultant’s office. He cast a glance over it, then stared at me for two uncomfortably long seconds. “Making a fuss about this won’t bring her back,” he said. He tore off the old date and then in a firm hand wrote the current date under the patient’s name. “She has died of an acute myocardial infarction. But let this be a lesson to all of us.”

There are multiple moral lessons wrapped up in this story, not the least of which is the duty to be forthcoming – not only for the sake of the patient and family but also for the sake of learning from what goes wrong so that safer and better systems can be designed.

Fudging the medical record strikes at the heart of this imperative. No health care organization would condone tinkering with patient records, but the industry hasn’t exactly been transparent in acknowledging that this sometimes occurs. And to date there’s been little collective effort to be more responsive to patients and families when disputes arise over the veracity of the chart. All of this needs to change, and the sooner the better.

When patients don’t follow orders

Getting patients to adhere to the doctor’s advice has always been one of the struggles in medicine. Sometimes patients don’t truly understand what’s expected of them or why they would benefit from, say, taking a prescription drug or receiving physical therapy. Sometimes there’s just honest disagreement between doctor and patient about the best course of action.

It can be easy to write off these nonadherent patients as stubborn, misguided or self-destructive. A rather intriguing new study suggests, however, that patients’ own beliefs about their ability to manage their health play an important role in adherence – and that health outcomes tend to be better when the doctor and patient have compatible beliefs. The study appeared in the May issue of the Journal of General Internal Medicine.

Eighteen primary care physicians and 246 patients at the VA Iowa City Medical Center and affiliated clinics were involved in the study, which queried both the doctors and the patients about their beliefs in personal control over health outcomes. Doctors and patients then were assessed for how closely their beliefs matched and how well this match corresponded with the likelihood that the patients filled their prescriptions and had well-controlled blood pressure and blood sugar measurements.

According to the findings, health outcomes were best when physicians and patients shared similar beliefs. This seemed to hold true not only for patients and physicians who both had a strong belief in personal control over their health but also for those who shared a weaker belief in this control. Patients fared less well, though, when there was a gap between their beliefs and the physician’s beliefs.

It should be noted that this study only involved VA patients who had both high blood pressure and diabetes, so the findings can’t necessarily be generalized to the rest of the population. It raises some interesting issues, though, about doctor-patient dynamics, especially when it comes to advising the patient what to do.

Does it matter whether the patient’s values are considered? Maybe it does, the study’s lead author, Alan G. Christensen, explained in an article this week in American Medical News. For instance, patients who place a high importance on control might react negatively – perhaps by not filling a prescription – if they perceive the doctor doesn’t take their values into account. On the other hand, patients who don’t have a strong sense of personal control over their health might feel pressured or overwhelmed if they’re dealing with a doctor who believes in greater empowerment. 

“The nonadherence itself can be a way for the patient to restore some sense of control,” said Christensen, chair of the University of Iowa Dept. of Psychology and senior scientist at the Center for Research in the Implementation of Innovative Strategies in Practice.

Patients don’t all have the same views of how they want to manage their health, he said. “One patient’s empowerment is another patient’s burden.”

Indeed, patients’ values and beliefs influence their actions to a greater extent than many health care professionals realize. Stephen Wilkins, a specialist in health care communication, explored this issue awhile back on his blog, Mind the Gap:

One of the basic tenets of the patient-centered care model is getting to know the “person behind the patient label,” i.e. their health motivations, attitudes, beliefs and so on. Why? It is because people that show up in the doctor’s office each have their own pre-existing set of experiences, knowledge and beliefs about their health and the health care system.

A patient’s motivations, attitudes and beliefs are shaped by a variety of experiences. Maybe they had a family member or friend with the same health condition. Maybe they saw or heard a TV or radio commercial. Or maybe they had a previous bad experience with another provider. Regardless of where this thinking comes from, or whether it is “right or wrong,” patient thinking plays an important yet often overlooked role in patient adherence.

A commenter on Wilkins’s blog brought up another point: Perhaps health care professionals unintentionally encourage nonadherence by what they convey, verbally or nonverbally, to the patient. The commenter writes: “Lack of empathy, focus on the numbers of lab results, threats of complications, judgment, etc., during an office visit (or over the phone) often sets a patient up to feel he/she has already failed (so why bother?), and has an enormous impact on how a patient may or may not manage a chronic disease.”

Whether busy physicians are willing or able to take the time to uncover their patients’ beliefs is a separate question. The authors of the Iowa City VA study suggest a good first step would be to develop a quick assessment tool that could be used to help better understand the patient’s values and motivation, and presumably help tailor the doctor’s recommendations more effectively.

Nonadherence is a tough problem to solve. And it’s not just about the physician; at some point patients have to take responsibility too. Knowing what makes a particular patient tick, however, and gaining insight into why the patient might not be adhering to the doctor’s orders can be a critical step toward addressing it constructively.

Update, May 20: Here’s another look at patient nonadherence, specifically nonadherence to prescription drugs, that appeared today in the New York Times.

Photo: Wikimedia Commons

Sick in the workplace

In many ways, it has been a welcome trend for employers to be more actively involved in promoting healthiness among their workforce. If employers are serious about lowering the cost of health insurance, it stands to reason they should try to do something about it.

More than a few businesses are getting tough, according to a story in the Wall Street Journal this past weekend:

In an effort to control the escalating cost of care, especially from chronically ill workers, many companies have been increasingly providing financial incentives to encourage workers to lose weight, stop smoking and manage a chronic illness. But a growing number also are starting to penalize workers who don’t – with higher insurance premiums, deductibles and out-of-pocket expenses.

“The passive nature of the work force has been troubling for employers, says Jim Winkler, U.S. leader of the health-management practice at consulting firm Hewitt Associates. “What they’re trying to do is motivate people to change their behavior.”

Leaving aside the question of whether this veers into coercion, I can’t help noticing there’s one thing missing from the list of ills among the work force. That’s right: stress.

Stress can be just as costly - maybe even more so – than chronic conditions, smoking or lack of physical activity, the triad that usually gets singled out in workplace wellness initiatives. Consider some of the statistics contained in a report by the National Institute for Occupational Safety and Health.

- In a survey conducted by Northwestern National Life, 40 percent of respondents said their job was “very or extremely stressful,” and 25 percent viewed their job as the main source of stress in their lives.

- In another study carried out by St. Paul Fire and Marine Insurance Co., problems at work were more strongly associated with health complaints than any other source of stress, including family or money issues.

When the nonprofit Families and Work Institute carried out a national survey in 2008, it found that 41 percent of workers reported experiencing three or more indicators of stress sometimes, often or very often. In the same survey, one-third of the respondents said their job drained their energy, leaving them with little left over for family or personal time.

Layoffs, increased workloads and the need to do more with less have arguably made the workplace even more stressful in the past couple of years.

A certain amount of workplace stress is unavoidable. It can even be beneficial when it revs up people’s energy and creativity. But chronic or unrelenting stress at work can ultimately be very corrosive, not only to the employee’s mental well-being but also to his or her physical health. From the NIOSH report:

Short-lived or infrequent episodes of stress pose little risk. But when stressful situations go unresolved, the body is kept in a constant state of activation, which increases the rate of wear and tear to biological systems. Ultimately, fatigue or damage results, and the ability of the body to repair or defend itself can become seriously compromised. As a result, the risk of injury or disease escalates.

In the past 20 years, many studies have looked at the relationship between job stress and a variety of ailments. Mood and sleep disturbances, upset stomach and headache, and disturbed relationships with family and friends are examples of stress-related problems that are quick to develop and are commonly seen in these studies. These early signs of job stress are usually easy to recognize. But the effects of job stress on chronic diseases are more difficult to see because chronic diseases take a long time to develop and can be influenced by many factors other than stress. Nonetheless, evidence is rapidly accumulating to suggest that stress plays an important role in several types of chronic health problems – especially cardiovascular disease, musculoskeletal disorders, and psychological disorders.

By now, you’re probably connecting the dots. Who has the time or motivation to exercise and prepare healthful, home-cooked meals when they work all day long and come home wiped out? How is someone supposed to successfully quit smoking/lose weight if cigarettes/comfort food have been their emotional crutch during times of stress? How do you manage heart disease or high blood pressure when one of the contributing factors to these conditions is stress?

Workers are being asked to keep themselves healthy (and risk being financially dinged if they don’t measure up), yet when they’re under constant stress at their place of employment, it’s hard to see how the work-related stress won’t often undermine their best efforts. By all means, let’s encourage employers who want to do something about employee health – but if they fail to acknowledge the role of workplace stress or take it into account as they design their wellness programs, they’re missing the boat.

Health reform and rural business: debunking the myths

Ever since the federal health care reform bill was signed into law, I’ve heard no small amount of fear and dismay from business owners who worry that the cost of new mandates will force them out of business.

But a new report, issued this month by the Center for Rural Affairs in Lyons, Neb., suggests they don’t need to worry quite so much. In fact, Jon Bailey, the author of the report, says health care reform will benefit rural businesses in the long run by knocking down some of the barriers they’ve faced in obtaining affordable health insurance. Bailey writes:

While exempt from mandates requiring insurance coverage for employees, the tax credits provided by the law will make health insurance more affordable for businesses and provide an incentive to help insure employees. Over time as the primary features of the law are implemented and take effect, particularly the Health Insurance Exchanges, rural small employers will reap the benefits of pooling and larger group coverage that provides comprehensive, affordable, and continuous health care coverage for their businesses and their employees.

In the reams of stuff that has been written analyzing the health care reform bill, I’m not sure due attention has always been paid to its impact on rural America. Nor am I sure that people really have all the facts. It’s not surprising that most of us are still trying to figure out what’s in the bill; after all, it contains hundreds of pages filled with densely technical language and details. Just the same, there’s considerable misinformation floating around. Last week, for instance, I was following an online discussion during which someone lamented the fact that the bill failed to eliminate lifetime spending caps for insurance enrollees – a claim that simply isn’t true.

So it was interesting to read the paper issued by the Center for Rural Affairs, which is going to be the first in a series of papers examining the implications of the health care reform bill for rural communities.

One of the first myths Bailey debunks is the one concerning the insurance mandate. Bailey explains:

There is a general employer mandate in The Patient and Affordable Care Act as a part of the "shared responsibility" for providing health insurance. But the law specifically exempts from this employer responsibility any business with 50 or fewer employees (Section 1513). The result is that nearly all businesses in the nation, including those in rural areas, are exempt from any requirements or mandates to provide health insurance to employees and are free from any penalties for not doing so.

What about affordability? The law provides for a small-business tax credit to help small employers purchase affordable insurance. Bailey calculates that as many as 3.6 million small businesses will be eligible for this tax credit. Small businesses also will be allowed to join health insurance exchanges. Groups of small businesses can even form health insurance cooperatives if they choose.

Bailey also addresses one of the most persistent fears: that the health care reform bill will increase business taxes. It’s true that the bill creates some new taxes and increases other existing taxes, he wrote:

But the real question is who is responsible for those taxes. While each individual and business has unique circumstances that will determine tax liability, it is clear that most rural small businesses will not be affected by the tax changes contained in the Patient and Affordable Care Act.

Rural Americans have always been more likely than their urban and suburban counterparts to be uninsured or underinsured. (If you want to see a visual county-by-county breakdown, check out this map compiled by the U.S. Census Bureau.) In a rural economy dominated by farms and small businesses, the availability and affordability of health insurance has frankly been an issue. It’s not totally unreasonable to assume that entrepreneurship and workforce recruitment have been at least partially held back by concerns over health insurance.

Bailey’s analysis suggests that if some of the insurance barriers can be eased or removed, rural economies will eventually see some benefit. How this will play out is, of course, anyone’s guess. It’s worth keeping in mind, however, that health insurance isn’t just about keeping people healthy; it’s also about Main Street business. How do you weigh the cost to the economy of doing something about health insurance vs. the cost of doing nothing?

West Central Tribune photo by Carolyn Lange

Real nurses

It’s almost impossible to get through Rice Memorial Hospital’s annual “My Nurse Made the Difference” awards ceremony without at least half the audience getting sniffly and teary-eyed.

This year’s awards lunch, which I attended earlier today, was no exception. Rice Hospital has been kind enough to invite the media every year, and I’m always amazed at the depth and variety of individual patient stories that inspire the annual awards. No two are alike, and it doesn’t take much for each story to resonate with the audience.

There’s something about nurses. Most of us admire them. We see them as noble and saintly and caring. If we’re of an older generation, we might lament the fact they no longer wear starched white uniforms. If we’ve watched enough movies and/or TV, we might have other views of nurses that are antiquated, stereotyped, hyped-up or outright chauvinistic.

Real nurses are way more diverse and interesting than this. Real nurses work really, really hard. I wouldn’t last one day in the shoes of a real nurse. They put in 12-hour shifts, mostly on their feet. Their work is a tough and complicated blend of cognitive processing – all those meds, all that charting – and bedside caring.

Real nurses are smart. They have to be. Their field is changing all the time, and they have to know more than they ever did before.

Real nurses have both responsibility and authority. They’re the front-line professionals when it comes to patient safety and quality of care. How often does it happen that a nurse’s sharp wits are the only thing standing between a disaster for the patient vs. a good catch? Probably more times than any of us could count.

Real nurses are tough. You don’t mess with a real nurse, not when he or she is on a mission on behalf of the patient (yes, men are real nurses too). Real nurses know how to advocate. They solve problems. They’re flexible and creative.

Real nurses are team players. Real nurses are leaders.

Real nurses work in hospitals, surgery centers, cancer centers, emergency rooms, home health care, nursing homes and outpatient clinics. They specialize in occupational health, infection control and public health.

Real nurses have terrible days sometimes. Sometimes they make a mistake that harms a patient, or sometimes, no matter how good the care they provide, their patient dies. Over the years, real nurses store up an entire mental library populated with joyful, funny, outrageous and heart-wrenchingly sad memories of the patients and families they’ve encountered. I’m pretty sure real nurses cry rather often, but not always in ways the rest of the world would notice.

I’m told that Rice Hospital gets dozens of entries from patients each year for the “My Nurse Made the Difference” awards, which are always announced in conjunction with National Nurses Week. A judges’ panel has the difficult task of sorting through them all and selecting three – only three! – that are the winners.

Many nurses at Rice will probably never be nominated. Perhaps they’re outstanding nurses but they work in the operating room or the post-anesthesia care unit, where patients don’t see or don’t remember them. Or maybe they’re managers or supervisors whose contributions aren’t directly visible to patients and families. All real nurses are winners, though, whether they’re officially recognized or not.

Real nurses do what they do because they care about being a good nurse. But they appreciate being thanked once in awhile, and it’s never too late to let a real nurse know that he or she helped someone in a way that made a difference.

HealthBeat photo by Anne Polta

Turf wars

Are nurse practitioners and physician assistants just as good as doctors? Should they have more latitude to prescribe drugs, issue orders and care for patients?

There’s a turf battle being waged over the role of mid-level health care professionals. On one side are proponents for expanding the scope of practice for mid-levels and using their capabilities as fully as possible. On the other side are those who fear this may be assigning too much responsibility to professionals whose training is not equivalent to that of a physician.

So who’s right?

It all depends, I guess, on your perspective. In underserved areas, nurse practitioners, midwives, advanced-practice nurses and physician assistants have been a boon. They have helped increase access to basic health services. They’re valuable team players, augmenting physicians in overall care of the patient. These clinicians can assess, diagnose, treat, prescribe, manage chronic conditions and even do some procedures.

There’s little to suggest the mid-level professionals are any less proficient than physicians at providing quality care, and they do so typically at a lower cost. Their patient satisfaction scores also are generally high.

Various studies have borne out all of this. For instance, this study, which appeared some years ago in the Journal of the American Medical Association, tracked patients at four community clinics and one primary clinic at an academic medical center, and found patient outcomes and satisfaction were the same whether patients saw a physician or a nurse practitioner. This study found that low-income, medically underserved patients who needed chronic care for cardiovascular disease perceived their care was better when it was directed by nurse practitioners and community health educators.

Few could argue that mid-level clinicians shouldn’t be part of the model of care.

And yet: Their training isn’t as extensive as that of a physician. Their skills and knowledge base don’t necessarily equip them to care for patients with complex needs. While they can and do play a vital role on the team, they are not the equivalent of someone who is trained and licensed as a doctor.

Unfortunately it’s all too easy for the facts to be either overlooked or overblown in the discussion about the best and most appropriate use of mid-level clinicians. Is some of it about turf protection? I’m sure this figures into it to some degree. Not all physicians like the idea of sharing their power or being seen as interchangeable with someone who doesn’t have the initials M.D. or D.O. behind their name. Given that many mid-level providers, especially nurse practitioners and advanced-practice nurses, are women, I wouldn’t be surprised if there’s some element of sexism involved as well.

Mid-level clinicians, for their part, can feel insulted and devalued when they perceive their skills are being dismissed as not good enough for medical school. They’re often touchy about their titles; in fact the American Academy of Nurse Practitioners officially opposes the term "mid-level" as being inappropriate and potentially derogatory.

At its worst, the conversation devolves into snarkitude and name-calling, such as this online discussion awhile back at Kevin, MD, in which one of the commenters, apparently a physician, sniped: "NP degrees exist in part because the NPs were too LAZY to go back and do a post bacc to obtain the necessary prerequisites to get into medical school or even PA school."

Look beyond the arguing and the turf warfare, however, and you’ll see there are legitimate issues at stake.

There has been a considerable national push to train and deploy more mid-level health care professionals. Many policymakers see the mid-levels as an important part of the solution to increasing access to health care services and lowering the cost. At least 28 states – including Minnesota - are considering legislation to expand the scope of practice for nurse practitioners, a move that would allow them, in some states, to have more prescribing privileges and, in other states, to practice without supervision.

Some of this is in response to the very real shortage of primary care doctors. The Associated Press explored some of these issues in a recent story:

One patient, Karen Reid of Balrico, Fla., said she was left in pain over a holiday weekend because her nurse practitioner couldn’t prescribe a powerful enough medication and the doctor couldn’t be found. Dying hospice patients have been denied morphine in their final hours because a doctor couldn’t be reached in the middle of the night, nurses told The Associated Press.

Massachusetts, the model for the federal health care overhaul, passed its law in 2006 expanding health insurance to nearly all residents and creating long waits for primary care. In 2008, the state passed a law requiring health plans to recognize and reimburse nurse practitioners as primary care providers.

That means insurers now list nurse practitioners along with doctors as primary care choices, said Mary Ann Hart, a nurse and public policy expert at Regis College in Weston, Mass. "That greatly opens up the supply of primary care providers," Hart said.

There’s another side to this, however. Are patients invariably better served by mid-level health professionals? Or are there times when it’s best for patients to have their care overseen by a doctor? Proponents for the more widespread use of mid-levels often imply in their arguments that physicians and mid-levels are more or less interchangeable – "the same as" – even though there are very clear differences in the amount and type of training they receive.

It’s not unreasonable to question where this road might be taking us. Dr. Timothy Malia, a family doctor and blogger in upstate New York, worried and reflected recently about a patient of his who went for a cardiac follow-up visit and was seen not by a cardiologist but by a nurse practitioner:

… To see the "NP" after the name of the provider who saw my patient, and not an "MD," really hit my soul as I sat in that quiet office late at night. "Why?" I ask. Why would a patient with multiple heart problems and cardiac disease risk factors not be seen by one of the cardiology office’s physicians?

Understand that I have many patients who are seen by nurse practitioners and physician assistants in specialists’ offices. They most often seem to be used for work with a narrower focus or for particular procedures. And I have been satisfied with that.

But my patient is complex and had a significant change in his general condition over the last year. He was being seen for an annual follow-up. In that case I want the provider seeing the patient to have my level of formal medical education PLUS advanced study in the particular field. Is it too much to ask that I should be confident that the patient got more advanced care and complex thinking at the specialist’s office than I believe I can offer?

… Honestly, I believe that particular nurse practitioner knows a good deal of cardiology. I do not doubt that. And she may have given a reasonable assessment. But, deep down inside, I cannot be sure that some subtlety of symptoms or exam findings was not integrated into the evaluation.

Dr. Malia wonders if he’s being grumpy and persnickety. I don’t think he is. Although the growth of the mid-level professions has been welcome in many ways, I’m not sure there’s a consensus on the best possible use for these clinicians or where they should fit into the system.

What should the goal be? Is it simply to push patient care down to the lowest and cheapest level? Or is it to provide appropriate care at the appropriate level for the individual patient? Should we be responding to the doctor shortage by promoting the use of mid-level professionals, or should we focus instead on how to shore up the entire medical education and health care system, particularly in primary care?

Ideally, mid-level clinicians should be able to use their skills and training to the fullest capacity. They belong on the team and need to be included. But if we’re going to acknowledge that the mid-levels have something unique and vital to contribute, we also have to acknowledge that physicians bring their own special skills and training to the table. We need to recognize that we can’t substitute one for the other. In the long run, I think we’ll all be far better served when each profession’s role is clearly defined, clearly understood and, yes, respected.

Photo: Wikimedia Commons