Monthly Archives: June 2012

Reactions pour in to health care ruling

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Reactions have been pouring in all day to the Supreme Court’s ruling this morning on the health care reform law.

If there was any doubt that Americans feel a strong personal stake in health care, it’s all been washed away in the commentary, tweeting and water-cooler discussions taking place over the last few hours. Stay tuned throughout the day for updates to this blog.

A sampling of how some of the major media outlets have been reporting the story:

- The big headline at the New York Times: “Health law stands.” Here’s the story, plus a collection of live updates, analysis and reaction.

- From the Washington Post, the main story, a graphic that breaks down how each of the individual Supreme Court justices voted, and an interactive feature to help readers figure out what the ruling means for them.

- If you’d like to read the entire text of the Supreme Court’s decision, it’s here.

- President Barack Obama is known for his use of the social media. Here’s what he tweeted this morning:

- Embarrassing? In early versions of the story, two media outlets got it wrong. What happened? The Associated Press breaks it down for you and concludes that in the rush to report the decision. some of the facts were confused. Alas, some politicos got it wrong too.

So who was first with the news? Early reports said it was the Associated Press, but Bloomberg News issued a statement claiming the honors with a story that moved at 10:07:31 a.m. EDT (and got the facts correct). The Associated Press moved its story at 10:07:55 a.m., a whole 24 seconds later. Does anyone really care? Rem Rieder, editor and senior vice president of American Journalism Review, thinks not.

- Stuart Taylor, legal analyst for Kaiser Health News, offers up this assessment of the Supreme Court’s ruling: “It was the most amazing Supreme Court theater I’ve ever seen.” Watch his video interview or read the transcript here.

Kaiser Health News also has compiled a Q and A on “After the Ruling: A Consumer’s Guide.”

- What does the public think of the Supreme Court ruling? MSNBC Health interviewed two of the millions of Americans who have pre-existing conditions and have been unable to obtain insurance coverage. Jerry Fielder of California and her husband, Charles, were turned down by 16 different insurance providers because Charles had a history of heart problems. The Fielders paid $73,000 out of pocket so Charles could receive surgery; then Jerry was diagnosed with lymphoma that went untreated for 10 months until she was able to qualify for coverage through the health care reform law.

Fielder told MSNBC that she “was on pins and needles” waiting for the Supreme Court to announce its decision. “Then I was like, Oh, my God, they upheld it? I can’t believe it.”

- The conversation on Twitter ranged from ecstatic to sarcastic:

(Do people really want to move to Canada? HappyPlace.com has some news for you…)

- Well-known politicians have been busy tweeting:

- Reaction from the medical community: The American Academy of Family Physicians supported the ruling with a statement saying that “as a result of this decision, more Americans will have access to meaningful insurance coverage and to the primary care physicians who are key to high-quality, affordable health services.”

Ditto the American Medical Association, whose statement also noted that the decision upholds funding for research on the effectiveness of drugs and treatments and protects coverage of preventive and wellness care.

Check out the Health Affairs blog for a more in-depth look at how the ruling is likely to affect providers.

Readers, what do you think about the Supreme Court’s decision? Please weigh in here or join the discussion on the West Central Tribune’s Facebook page.

The traumatic side of illness

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When I read last week about a new study that found heart attack survivors can be at risk for post-traumatic stress disorder, I confess to a rather cynical reaction: “You mean it took this long to recognize that heart attacks are traumatizing for some people?”

The research, which was published this month in the PLoS One journal, analyzed two dozen smaller-scale studies and concluded that about one in eight survivors of a heart attack develops signs of PTSD – and that these people can be at higher risk of a second heart attack.

We’ve become better at recognizing PTSD among the military, especially combat veterans, although it’s debatable whether we’re any better at providing help to those who need it. We’re also better at recognizing that PTSD can occur among survivors of a natural disaster, a fire, an assault or other immediately life-threatening event.

But it seems we have much farther to go when it comes to recognizing that trauma also can be part of people’s medical experiences.

There’s no denying that patients sometimes struggle with anxiety, intrusive thoughts and panic attacks in the wake of a major illness or a hospitalization. Consider the mom who wrote last year to an online parenting advice column about her toddler, who had recently been hospitalized, catheterized and poked repeatedly with needles and IVs. Two weeks after coming home from the hospital, he was clingy, fearful, frightened of unfamiliar places and people, and having trouble sleeping.

Did he have PTSD? his mother wondered. And what could she do to help him?

Post-traumatic difficulties have been reported among both heart and cancer patients, as well as among people who have been hospitalized in intensive care units. They also can occur among patients who’ve experienced a medical injury.

The medical community has been slow to take this issue seriously, however. In fact, there doesn’t even seem to be a consensus on how prevalent it is or the most reliable way to diagnose PTSD stemming from the medical setting. One recent study put the incidence of PTSD at anywhere from 4.8 percent to 29.2 percent of cardiology and oncology patients and concluded that more study is needed.

The PLoS study in fact appears to be the first time that researchers have systematically attempted to more closely examine PTSD among cardiac survivors. The authors write:

In recent years, cardiologists and the broader medical community have become increasingly aware that psychological disorders, particularly depression, are common in patients with [acute coronary syndromes] and are associated with adverse clinical outcomes. Even so, abundant evidence suggests that psychological disorders are underrecognized and undertreated in cardiac populations. While awareness of depression has increased in cardiology practice, awareness of the possibility of PTSD due to ACS has lagged, possibly because many still see PTSD as primarily a disorder of combat veterans or sexual assault survivors.

A commenter who responded to a New York Times news story about the study described her own experience with severe heart disease and how she’s “never been the same since.”

“I suffer from extreme anxiety, hypervigilance and a host of other psychological symptoms related to my cardiac history,” she wrote. Her attempts to relate this to her doctors have “fallen on deaf ears.”

“Now that I have read this article I am hopeful that maybe I will get the help I so desperately need to rebuild my life and rid myself of this insidious fear and stress,” she concluded.

Why has this area of the patient experience been poorly addressed for so many years? Perhaps the medical community has had trouble coming to grips with the fact that their actions, carried out with every intention of helping the patient, can be experienced as upsetting, frightening and traumatic. Perhaps we just have a hard time thinking of PTSD in any context other than combat or violence – and indeed, there seem to be some differences between the two, not to mention a dearth of research on acute medical trauma. Does it have the same fundamental effect on the brain as combat- or violence-related trauma? Or is medical PTSD a separate entity, with different forms and different causes?

One of the most troubling aspects of medical PTSD is that it can leave people fearful and avoidant of anything to do with the medical setting – or, conversely, hyper-anxious about the need to be tested and reassured. Realistically, the avoidant ones will not be able to get through the rest of their lives without ever setting foot in a hospital or doctor’s office again, and the anxious ones are all too easy for busy clinicians to dismiss as being high-maintenance. Researchers, clinicians and the mental health community owe it to these individuals to understand what may be going on in their heads and to find ways to help reduce their suffering.

The loneliness factor: social connections and health

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When it comes to health, loneliness seems to matter, suggests a new study that found a connection between feeling lonely and shorter lifespans.

The study appeared this month in the Archives of Internal Medicine and focused on a specific population: adults over the age of 60. As study participants were tracked over six years, those who self-reported feelings of loneliness were more likely to experience “functional decline” – i.e. decreased mobility, difficulty with activities of daily living and so on – and also died sooner.

The study piggybacks on another piece of research, also published this week in the Archives of Internal Medicine, that found increased mortality among adults who had heart disease or were at high risk of heart disease and who lived alone.

So does this mean loneliness is a threat to health? Some of the headlines have been blunt in concluding this – “Being lonely can kill you, studies say”; “The grim impact of loneliness and living alone,” to name a few.

But it’s not that clear-cut. Moreover, the studies don’t really explain why there would be an association between loneliness/being alone and decreased lifespan. Are these people depressed, hence not taking care of themselves? Is there no one looking out for their well-being, reminding them to take medications, advocating on their behalf at doctor visits, and so on? Does loneliness have a direct and as-yet undetermined effect on the immune system or the aging process?

There’s a difference between living alone and being lonely. In the study that looked at loneliness as a predictor of poorer health as people age, the authors draw this distinction: “Loneliness is the subjective feeling of isolation, not belonging, or lacking companionship… It is possible for persons who live alone to not feel lonely, while some who are married or living with others will still experience loneliness.”

In fact, the majority of the study participants who reported feeling lonely did not live alone. And most of those who said they were lonely were not depressed.

Given the growing number of Americans who live alone (27 percent of all U.S. households, according to the latest census), this is an area that seems ripe for study.

A number of previous studies have explored the whole issue of social connectedness and whether it has a positive influence on health. The findings have been rather intriguing: Church-going has been linked to better health, as has social support in the form of friendships and regular contact with other human beings. Matrimony seems to be beneficial too, although the benefit is strongest for men and less so for women.

But is this because relationships and social engagement have a direct effect on how healthy we are? It could easily be argued that the people who are socially active and go to church every Sunday are simply healthier to begin with and hence more able to engage in social activities. Conversely, functional decline associated with social isolation among older adults could be a cause rather than an effect; perhaps as people decline, they’re less able to mingle with the rest of the world and are more likely to become socially isolated.

It would also be interesting to know how much of this is tied up in what seems to be an American bias in favor of extroversion and youth. Do we expect people to want and seek out companionship and look for negatives when they don’t measure up? Do we assume loneliness and aging go hand in hand?

Teasing out exactly what’s going on here will probably take much more study. Feeling lonely vs. living alone might be two separate issues with dynamics that need to be considered in different ways. How we perceive purpose and connectedness may matter too; someone who seems to be alone might not feel lonely and might in fact be leading a rich existence that derives meaning from other sources – for instance, the arts, or pets or the outdoors.

The real message may be that psychosocial health deserves far more attention than it often receives.

Last year I wrote a story about a survey conducted by Home Instead Senior Care to identify mealtime challenges for older adults. So what was at the top of the list? The expected answer might have been the practicalities of preparing a meal, or access to fresh fruits and vegetables, or the affordability of quality food. But nope, it wasn’t any of these – what the folks who participated in this survey wanted most was companionship at mealtimes. And this was borne out when I went out and actually talked to some older adults who’d had experience both with living alone and with living in an assisted living facility where they had meals together. Virtually all of them preferred eating with someone else for company.

In the medical setting, these things tend to be assessed briefly or not at all. And indeed, primary care doctors often are so pressed to manage the medical aspects of the patient’s care that they may not have time to ask patients if they’re lonely.

But as the authors of the Archives of Internal Medicine study point out, loneliness for many older people “may be more distressing than their medical diagnoses.” With referral to the right kind of intervention, it might help slow or delay a decline in health for higher-risk individuals, the authors suggest.

Ask patients if they’re lonely, the authors urge. “Ultimately, by asking about psychosocial concerns important to patients, our treatment focus may shift, and we will likely enhance the physician-patient relationship. By identifying loneliness we will be better able to target interventions intended to prevent functional decline and disability.”

The case for motorcycle helmets

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On a road trip to the Twin Cities last weekend, a couple on a motorcycle passed me on Highway 7 east of Hutchinson. They were wearing T- shirts, shorts and flip-flops. No helmets.

I know how fast I was driving, and given how rapidly they flew by and disappeared into the distance, I’d estimate their speed (conservatively) at 70-75 mph.

I didn’t hear about any fatal motorcycle crashes afterwards that fit their description, so presumably they arrived safely at their destination. But the science and the statistics unfortunately are stacked against this kind of risk-taking.

A new study by the U.S. Centers for Disease Control and Prevention concludes that motorcyclists are less likely to die in a crash if they’re wearing a helmet – and that states with universal helmet laws incur lower costs associated with motorcycle crashes.

A few key points from the study, which analyzed National Highway Traffic Safety Administration data on fatal crashes from 2008 to 2010:

- Although motorcycles accounted for less than 1 percent of all vehicle miles traveled, 14 percent of U.S. traffic deaths in 2010 involved motorcyclists.

- Of the 14,283 fatal motorcycle crashes that occurred during the three years analyzed in the study, 42 percent of these bikers weren’t wearing a helmet. In the 20 states with a universal helmet law, however, just 12 percent of the fatalities were among motorcycle operators and passengers who weren’t wearing a helmet. For the three states that didn’t have a helmet law of any kind, 79 percent of the fatalities occurred among motorcyclists without a helmet.

- Helmet laws were estimated to save $3 billion in medical costs and lost productivity in 2010.

The report was issued at almost the exact same time as Minnesota officials reported an unexplained spike this summer in motorcycle deaths. As of mid-June, 17 motorcyclists have died on Minnesota roads this year; a year ago it was 10. It’s not clear why, although the mild winter of 2011-12 and an early start to the motorcycle-riding season might be part of the reason.

Whatever the case, it has sparked a new round of debate about motorcycle safety and helmet vs. no-helmet laws. Does it impinge on individual freedom to enact universal helmet laws? Or are these laws necessary to help save lives and reduce the societal cost of motorcycle crashes?

The Star Tribune of Minneapolis didn’t mince words with an editorial this past weekend about the inadequacies of the state’s partial-helmet law, which requires helmets only for those with instructional permits or under age 18. The editorial points out that of the 574 Minnesotans who died in motorcycle crashes over the past 10 years, the majority weren’t wearing a helmet. “Minnesota should be a leader, not a laggard, on this critical public health issue,” the editorial concludes.

There was a speedy response today in the form of a letter to the editor from Mark Backlund, safety coordinator for ABATE of Minnesota, which promotes safety awareness and training for motorcycle operators.

Rather than heavy-handed regulation, the focus should be on preventing crashes in the first place, Backlund argues. “These are not ‘accidents,’ and whether or not one is wearing a piece of equipment has no bearing on why or how the crash took place.”

The motorcycle crash rate undoubtedly could be lower than it is. Whether all crashes are 100 percent preventable is debatable, though, and it seems a multi-pronged effort – crash prevention, operator training and protective gear – would be a more effective strategy at saving lives than relying on prevention or training alone.

To be sure, a helmet does not guarantee someone won’t be seriously injured or killed in the event of a crash. Nor do motorcycle crashes reflect negatively in some way on the operator’s driving ability; all drivers need to learn to share the road safely and watch out for the motorcyclists among them.

But who has a better chance of self-preservation in a crash: Someone on a motorcycle clad in shorts and not wearing a helmet, or someone encased inside a metal vehicle fortified with seatbelts and airbags? The freedom of riding a motorcycle is also the factor that puts operators and passengers most at risk if a crash were to happen.

I’d like to know what readers think. Should helmets be mandatory for all motorcycle operators and passengers? What’s the best way to keep motorcycle riding as safe as possible?

Gender bias in the halls of medicine?

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Going to medical school is no guarantee for women doctors that they’ll break through the glass ceiling, it seems. A new study by the University of Michigan Health System uncovered a $12,000-a-year gap between what male and female doctors earn in one of medicine’s most rarefied areas – research and academia.

The researchers compared men and women who were mid-career physician researchers and found they weren’t paid equally, even though they did comparable work. Over the course of a 30-year career, the difference amounted to $350,000.

The report’s publication this month in the Journal of the American Medical Association comes on the heels of a new report by the University of Minnesota on the persistent gap in what women earn compared to men.

What makes the JAMA study especially notable is that it’s among the few to compare apples to apples. The researchers controlled for specialty and for hours worked. They also adjusted for academic rank, leadership positions and research time – and still came up with a disparity. Nor did the pay gap seem to be influenced by whether the female physician-researchers were raising children, because it persisted even among women who weren’t mothers.

A couple of factors may help explain some of the differences in pay: The female physician-researchers in the study held fewer of the top positions that command higher pay. They also were less likely to be in the higher-paying medical specialties.

It’s not clear whether this was the result of institutional bias, and addressing this question was outside the scope of the study. Perhaps it simply indicates this group of women didn’t pursue leadership positions in academic medical research or that they were less likely to choose higher-paying medical specialties.

The findings from the JAMA study are not isolated. A 2010 study by the Mongan Institute for Health Policy at Massachusetts General Hospital came up with almost the same conclusion: Women in academic medicine make less money, even when differences in work hours, research, teaching, patient care and other professional activities are taken into account.

It all raises the issue: Is there gender bias within the medical profession?

Once upon a time, women weren’t admitted to medical school. In a doubling-down of sexist attitudes, it was presumed that if they wanted a career involving patient care, they could become nurses.

Women who were the first to break through this barrier didn’t face an easy time of it. Dr. Susan Love, well known as a surgeon and outspoken advocate for breast cancer prevention, has spoken often about the obstacles she faced in medical school in the 1960s. There were virtually no female surgeons so she had few role models or mentors. And because she’s a surgeon who’s both female and gay, it “meant that I was never going to be accepted into the ‘old boys club,’” she says. “It meant that I had to be better and I had to serve my patients so well that they would come to me for that reason and not because someone had referred them.”

At the time, between 5 and 10 percent of students entering medical school were female, and quotas were imposed to give these women a chance. These days, women are represented in far greater numbers. According to figures from the Association of American Medical Colleges, 47.3 percent of new medical school applicants in the fall of 2011 were female.

They’re not distributed equally across specialties, though. Women tend to cluster in certain areas – pediatrics, internal medicine, family medicine, obstetrics/gynecology – and gravitate less often toward some specialties such as orthopedic surgery or neurosurgery that continue to be dominated by men and often are higher-paying.

Despite the strides made by women in medicine, it may not be enough. More recently, female enrollment in medical school has declined, for reasons that remain unclear. Are women becoming disenchanted with the prospect of the high stress and long hours that accompany a career in medicine? Have women with undergraduate degrees in the sciences found better opportunities in fields other than medicine?

Even the public tends to think of doctors in terms of “he” rather than “she.”

It’s the goal of most industries, including medicine, to have a diverse workforce. Indeed, a culturally and gender-diverse physician workforce is seen as one way of helping reduce the ethnic and economic disparities in health that persist in the United States. To be sure, there are medical schools, research institutes, hospitals and medical practices that back this wholeheartedly in their hiring and pay policies. But if it isn’t modeled – and supported – as widely as possible in the medical teaching and research institutions where students are molded into doctors, it’s hard to see how any meaningful progress can be achieved.

Clinicians and their spidey sense

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The patient was 35, pregnant, diabetic and a methamphetamine user. Almost from the moment she was admitted to the hospital, Dr. Theresa Chan had an uneasy feeling this was a patient headed for serious trouble.

Scrambling to do rounds on her other patients and taking a quick glance at the woman’s X-ray, Dr. Chan’s unease grew. Although the ER physician who admitted the woman to the hospital gave a preliminary diagnosis of pneumonia, Dr. Chan had some doubts and decided to see for herself.

Her blog describes what happened next:

As I walked into her room, I felt a hair on the back of my neck rising up. Not literally, of course. The hair – and it is only one – has become the symbol for the feeling I get when a patient is really sick. It sprouted during the second year of my residency and has been with me ever since.

To make a long story short, the patient turned out to have inflammatory fluid that had collected in one of her lungs and developed an infection. She could hardly breathe. Within the hour she had a chest tube inserted by a surgeon. She ended up being transferred to a tertiary care center and ultimately lost the pregnancy.

“The moral of this case: Whatever anyone tells you, check the facts for yourself,” Dr. Chan concludes.

Do clinicians have a spidey sense, like the comic-book superhero Spider-Man, that tells them when something is really wrong with a patient?

The pitfalls of relying on perception are outlined in an interesting analysis published online last month in the Journal of General Internal Medicine. It examines a specific area of clinical practice: judging whether a patient is truly getting better in response to treatment.

How do you know the patient is improving? Is this an assessment based purely on test results? Is it based on how well the patient looks? Is it a combination of objective measurements and gut instinct? And how do you avoid misjudgments due to overconfidence, memory lapses, unspoken assumptions and other thought processes that can cloud one’s thinking?

There’s a intriguing role played by clinical intuition – the gut sense, often based on a vague combination of sight, sound, touch and past experience, which helps clinicians recognize when a seemingly minor problem might actually be much more, when the diagnostic facts don’t add up – perhaps even when the patient is a faker or a drug-seeker.

Is it the real deal? Clinical intuition is a somewhat controversial concept in medicine. It’s not clearly defined and it’s not something that’s part of any formal training curriculum. It seems to be more well developed in some people than others, although few clinicians are willing to follow their intuition alone, without objective facts to back it up. And as the journal article demonstrates, gut instinct can be prone to all sorts of cognitive errors.

Yet the spidey sense seems to be genuine, even if it’s hard to pin down. ‘I know it absolutely exists and I am happy to have a decent dose of it,” writes the anonymous ER nurse who blogs at Not Nurse Ratched.

So what is spidey sense? “Your patient just looks wrong. Or DOESN’T look wrong, but you have a gut feeling that something is about to go seriously wrong,” she writes. “Generally, and this is really the point of my post, you’ve got nothing to hang your hat on as far as an assessment finding or anything from the patient’s history, and that makes spidey sense problematic.”

Sometimes the spidey sense generates a false alarm but better to be safe than sorry, she concludes. “If the patient doesn’t look quite right and that’s all I’ve got, I use it. I feel a little silly, but I do.”

Various studies have taken a closer look at the role of intuition in medicine. Empathy, for instance, may be partly intuitive, although there’s still a fair amount of debate over the extent to which it’s innate vs. a skill that can be taught. A small study conducted in 2007 found that nurses often use intuition in their decision-making, and that their use of intuition tends to increase with experience. (The study didn’t analyze how often the nurses’ intuition turned out to be correct, however.)

“Do we need evidence for everything?” wonders Dr. David Hunter in a 2010 American Orthoptic Journal article that questions the assumption that objective, measurable evidence should underlie all medical decisions. “The frequent lack of solid clinical evidence requires clinicians to invoke critical thinking, communication, judgment, and even intuition on behalf of their patients. Medical training is as much an apprenticeship as it is an education, and medicine as much as craft as it is an art.”

Evidence does matter; clinicians can’t make good decisions if they lack facts or knowledge. But it seems there’s a place for intuition as well, even though there’ll likely be debate for years to come on how reliable the spidey sense truly is.

For better health, give a child a book

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Years ago, when I was in grade school, a relative mailed us a boxful of books one summer. They were the Dr. Seuss classics – “The Cat in the Hat,” “Horton Hears a Who,” “If I Ran the Circus,” “The 500 Hats of Bartholomew Cubbins.” There must have been more than a dozen of them, all bound in hardcover.

Every week Mom and Dad would select one new book from the box and read it aloud to me and my siblings. We loved those books and eagerly looked forward each week to the next one. Oh, sure, we had plenty of other books but these were different. They were special.

I remember it took most of the summer to work our way through the entire box. But that wasn’t the end. We continued to read the books over and over, until the pages were dog-eared and the binding started to fall apart.

This memory is one of the reasons why I pay attention whenever I hear about programs that instill a love of reading in children at an early age. Here in rural Minnesota, more than 2,000 kids receive books in the mail each month through Dolly Parton’s Imagination Library, an initiative by the United Way of West Central Minnesota with the Dollywood Foundation. Globally, more than half a million children under the age of 5 are registered in the program.

So why are you reading about children’s books on a blog that’s supposed to be about health? Because the two are connected far more closely than their surface appearances might suggest.

Health literacy, defined as the ability to obtain, process and understand health information and make appropriate decisions, is a major – and often underappreciated – factor in how healthy we are (or aren’t). Perhaps even more than income or education level, it’s one of the critical pieces in health status and health outcomes.

It’s not hard to find statistics about health literacy or overall literacy in the U.S.; a simple Google search will do. And much of the information is eye-opening. For instance, two-thirds of American adults over age 60 are thought to be inadequately literate. A study published in the mid-1990s in the Journal of the American Medical Association found that 81 percent of patients 60 and older who were interviewed at a public hospital were unable to read or understand basic information such as prescription labels.

Although the effects of low literacy aren’t always easy to measure in a health setting, the implications are obvious. It’s harder for these individuals to follow directions for taking a medication safely and correctly. They can have difficulty understanding test results or a new diagnosis. They might struggle to manage a chronic condition such as diabetes or asthma. They might make health decisions that don’t adequately weigh the risks and benefits.

It creates a costly and sometimes life-threatening undertow within the U.S. health care system.

Multiple studies have documented a link between low health literacy and higher use of emergency-room care, greater likelihood of hospitalization, higher risk of taking medications incorrectly, lower rates of flu immunization and, among women, underuse of screening mammograms.

Why is literacy difficult for so many people to accomplish? It’s a question that doesn’t seem to have a single, handy answer. Many factors are thought to contribute – poverty, learning disabilities, chaotic family situations, ineffective strategies to help students who aren’t performing at grade level, mental health issues, cognitive declines in older adults, and even rising expectations for what constitutes literacy.

What’s clear is that low literacy is a societal issue that can’t be solved by the health care system alone, and that it often starts in childhood with children who are unprepared for kindergarten and who often fall farther and farther behind as they progress through school.

This doesn’t mean health care organizations should sit back and let the school system take care of it, however. I’m always impressed whenever I hear about providers who have been purposeful in promoting literacy and learning as part of their patient care.

Here’s how they’re doing it in my own backyard, with the Reach Out and Read program at Affiliated Community Medical Centers. According to a recent story posted on its blog, ACMC gave out more than 10,000 new books last year during well-child visits.

Dr. Amber Vick, a family physician, had this to say:

“It’s always a special time for me when I have the opportunity to give a child a book. When I give out the books, I make sure to tell the child that I am giving them a book to take home and read with mom and dad. We want kids to know that reading is important, and we also want them to know it’s an important thing to do with their parents.

Providers also use the books to assess how well children are meeting developmental milestones – if they’re able to hold the book properly, for instance, and correctly identify colors or pictures. In a measure of its belief in the critical importance of early childhood learning, ACMC commits $24,000 a year to sustaining the Reach Out and Read program.

This may be one small effort but when it comes to preparing young children for success in school, every little bit seems to help. It’s to be hoped that when these youngsters become old enough to start making their own health decisions, they’ll be more capable, more informed and better off for being literate. When you give a child a book, it really can lead, however indirectly, to better health.

Patient privacy vs. the urge to snoop

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When nearly a dozen teens and young adults were hospitalized last year after overdosing on a designer drug at a party in the Minneapolis suburb of Blaine, some hospital employees apparently couldn’t resist the urge to peek at their medical records – a clear violation of patient data privacy regulations.

In one of the largest such cases on record in Minnesota, 32 workers were subsequently fired for accessing medical records they weren’t authorized to see.

What does it say about a health care organization – and the people who work there – when patients find out someone has been prying into their medical record out of sheer curiosity?

It’s undoubtedly embarrassing and damaging, and a recent survey by the Ponemon Institute confirms that it often leads to less trust among patients.

The survey involved 700 people whose patient information had been stolen or misused. Six out of 10 said they lost confidence in the organization because of the incident. Fifteen percent said they would end their relationship, or already had ended the relationship, with the health care facility, and another 40 percent said they would consider doing so.

Not surprisingly, eight out of 10 said they felt organizations that fail to protect personal patient information are not trustworthy.

For all the resources that have been poured into HIPAA compliance – passwords, data encryption, secure servers, staff training and the like – many data breaches seem to be less about technology and more about basic human nature: in other words, the urge to snoop and the lapses in judgment that lead health care workers into this less-than-ethical behavior.

Although theft and hacking are usually regarded as the biggest threat to the security of patient information, it’s unauthorized access or disclosure that consistently ranks as one of the leading issues. A single incident might not be as large or noticeable as, say, the theft of a laptop containing private data on 25,000 patients. But what snooping lacks in scope, it more than makes up for in frequency. According to the most recent federal report on HIPAA breaches under investigation, unauthorized access is second only to theft.

A survey last year found that 70 percent of the organizations in the study had experienced a privacy breach in the previous 12 months that involved unauthorized access to patient records. Most of it was insider abuse rather than theft or hacking from outside. In about one-third of these cases, the target was the medical records of coworkers. Just under one in three involved snooping into patient information belonging to relatives and friends.

You might argue that some of these breaches are accidental rather than a case of deliberate snooping. But it’s disconcerting to note how many of them involve high-profile patients or medical cases that may be more likely to tempt someone’s curiosity.

For instance, there was the employee at Catskill Regional Medical Center in Harris, N.Y., who was fired last November after helping herself to the medical records of friends and coworkers. She apparently accessed more than 400 records in all, even though she had no legitimate reason to look at them. Hospital officials characterized her actions this way: “She was nosy.”

Consider the 16 people who were terminated at Ben Taub General Hospital in Houston, Texas, for allegedly snooping into the medical record of a physician who was on the staff and was hospitalized there after being shot during an attempted robbery. Among those fired were doctors, supervisors and nurses.

Then there were the four people who were fired after looking at the medical records of the victims in the high-profile Tucson supermarket shooting last year. Six people died in that shooting and 13 were wounded, including Arizona Rep. Gabrielle Giffords.

Celebrities who’ve had their medical records breached include Britney Spears, Tom Hanks, Tom Cruise, Drew Barrymore and the late Farrah Fawcett. Last year UCLA Health System paid an $865,000 penalty for multiple allegations that employees accessed patient information belonging to celebrity patients. An investigation by the Office of Civil Rights of the U.S. Department of Health and Human Services found that between 2005 and 2008, employees repeatedly looked at protected health information they weren’t authorized to see.

Although no one likes to acknowledge it, snooping has probably taken place in health care for a very long time. These days, though, the temptations seem to be greater and electronic medical records have made it easier to indulge one’s curiosity. Not only is an electronic record easier to peek at than a paper record, but it also takes a matter of seconds to download, print and/or copy.

On the other hand, auditing tools are getting better at tracking who’s supposed to have access to someone’s patient information and who’s been looking at it. Health care workers who engage in this kind of behavior sooner or later risk being caught, and health care organizations that don’t monitor and enforce internal practices risk earning a bad reputation when someone blows the whistle.

Stalking the elusive wait time

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How long do patients really have to wait to get an appointment with the doctor?

It’s not as easy to measure as you’d think, especially since health care organizations use wait-time yardsticks that are often narrowly defined and can vary widely.

The U.S. Department of Veterans Affairs recently came under fire for allegedly misrepresenting how long it took for veterans with mental health issues to see a provider. Using its own internal measures, the VA had reported that 95 percent of new patients requesting mental health services were seen within two weeks for a comprehensive evaluation. But when the Office of the Inspector General investigated the numbers more closely, it found that fewer than half of veterans were seen within that time frame and the average wait for the rest was 50 days.

Why the discrepancy? Some of it seems to lie in how the data was collected and how scheduling was handled, Stars and Stripes explained:

For new patients, scheduling clerks frequently stated they used the next available appointment slot as the desired appointment date for new patients, thereby showing deceptively short wait times. For established patients, medical providers scheduled return appointments based on known availability, rather than the patient’s clinical need.

The VA is working to improve its scheduling processes and come up with better – and more accurate – measures for reporting wait times.

This isn’t an issue confined to the VA system. From the family doctor’s office to the medical imaging center, health care is grappling with getting a handle on access. How many days, or weeks, does it take for someone to see their doctor? How long is the wait to see a specialist?

Some of it seems to depend on where you live and the care you need. A survey last year of eye patients, for instance, found that the vast majority were able to schedule an appointment within two weeks of calling an eye care professional. Seventy percent were able to book their exam within a week or less.

When Merritt Hawkins conducted a survey of 1,160 medical practices in more than a dozen metropolitan markets three years ago, it uncovered a wide range of responses. Someone in Miami might wait anywhere from four days to 200 days to see a cardiologist for a heart checkup, while the wait for someone in Atlanta ranged from one day to nine days. People in Boston and Philadelphia sometimes waited a year to see a dermatologist for a routine skin exam. Among all the cities that were surveyed, the combined average wait time to see a family doctor for a routine physical was just under three weeks.

Wait times seemed to be influenced by many factors: physician supply, patient demographics, patient demand, insurance trends and even the U.S. economy. Indeed, a shortage of mental health professionals is probably at least one of the reasons behind the long waits for veterans needing mental health care from the VA.

It’s clearly hard, however, to pin down exactly how long patients must wait for an appointment, and there seems to be no agreed-upon yardstick for how this should be measured.

Sometimes it can get downright confusing and perhaps a little deceptive. Many emergency rooms, stung by complaints of patients and families spending hours in the waiting room, have taken steps to fast-track the care they provide, even going so far as to issue promises – backed up by billboard advertising – of half-hour waits or less.

You’d better read the fine print, however, because the 30-minute wait time might not apply to you if your situation isn’t considered an emergency. And you’d better check to see how the promised wait times are calculated. When the Miami Herald explored some of the marketing claims, it found that some ERs measured wait times as a four-hour average recalculated every 30 minutes, others measured it in one-hour increments and some urgent care centers measured it in 30-minute increments.

And although ER spokespeople told the Herald that they take their wait time service pledge seriously, they also admitted it’s an approximation that may vary for individual patients.

An even bigger question is how wait times should be benchmarked. How long, exactly, should patients have to wait between the time they make an appointment and when they actually receive care? What’s acceptable and when might a delay become unsafe?

“Is cancer treatment urgent?” wonders Kathy Day, a nurse and patient safety advocate in Maine who last year faced an agonizing wait between being diagnosed with endometrial cancer and seeing a surgeon. It took her nine days to decide on the specialist she wanted to see. It took another four days to get an appointment. Although her personal doctor told her she should have surgery “within a few months,” Day acknowledges the waiting is difficult and worries that it might affect her prognosis.

She writes on her blog:

On November 1, I was given an appointment on November 30. Tomorrow it is 28 days (4 weeks or 1 month) since I learned of my cancer. November 30 will be 41 days. Then I don’t know how long after that my surgery will be scheduled. That “couple of months” recommendation is frittering away. I honestly never dreamed I would have to wait a full month to see an expert GYN/oncologist for surgery.

How do you measure the wait time in this situation? Does the clock start ticking only when the appointment is made? What about the time patients might need to choose the doctor and then make the phone call? What about additional waits between the time the patient sees the doctor and when he or she undergoes a test, has surgery or receives lab results that help confirm a diagnosis or determine a course of care?

The process isn’t swift, and there are reasons why it can’t always be swift. How health care organizations measure their wait times is often far from straightforward, however, and there can be a wide gap between what providers think their wait times are and the amount of waiting that patients actually experience.

Linkworthy 4.0: The overdue edition

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I’m way overdue for another edition of Linkworthy, my semi-occasional collection of links to interesting health-related stuff recently encountered on the web.

Besides, it’s time we all moved on from the Hatfield-McCoy post, which has accumulated several thousand hits since being published three days ago and is perhaps in need of a rest. (I’m just sayin’.)

Regional news first: The latest issue of Prairie Business Magazine includes a cover story about the use of high-tech diagnostic imaging, how the technology has evolved and how it’s being used in daily care. As a bonus, there’s also a story exploring the demand for doctors in rural health.

Did anyone catch the news earlier this week about a proposal by Michael Bloomberg, mayor of New York City, to ban extra-large soft drinks? On the surface, this might sound like a good tactic in the so-called war on obesity. Many people are questioning, however, the likelihood that a ban on large sodas will make much difference. The critics have weighed in here and here. The most colorful quote probably comes from the online commenter who opined that “we are like a bunch of lemmings headed for tyranny.”

Speaking of obesity, few people could have failed to miss the recent news about a study that discovered exercise does not in fact benefit everyone. Researchers analyzed six earlier studies and found that in about 10 percent of the participants, heart-related measures such as blood pressure, insulin level, cholesterol and triglycerides worsened with exercise.

The spinmeisters have been hard at work. Some are pointing out, and rightly so, that this was only one study – and a relatively small one, at that. Others worry that folks will use it as an excuse to avoid exercise. What this study really seems to be saying, however, is that we need to be careful about cookie-cutter assumptions that a particular intervention or lifestyle is always good for everyone, because often there are exceptions to the rule.

After blogging about three years ago on needle phobia, I heard from a couple of people who have this fear and who felt their anxiety often wasn’t taken seriously by health care providers. So I was intrigued to come across the news that MIT has developed a high-powered liquid injection device that squirts a thin stream of medicine directly into the skin.

According to the developers, it’s so fast and precise that it can barely be felt. But it’s a little premature to hope the device could be coming soon to a health facility near you. The injector device is still in the prototype stage and hasn’t yet been tested on humans. There’s also the not-insignificant matter of cost. Nevertheless, it’ll be interesting to see whether this Star-Trekkian concept catches on.

Most of us have probably heard about Munchausen’s disease, or Munchausen by proxy, in which people go to great lengths to fake illness in themselves or someone close to them. Now it seems there may be a new version of this behavior: Munchausen by Internet.

A rather chilling story from the BBC News Magazine details the behavior – and impact – of individuals who go online and convincingly pretend to be sick or to have someone in their family who is sick. Some of these hoaxes can be incredibly elaborate – for example, a woman in the U.S. who faked having cancer, HIV, anorexia and heart problems, and went so far as to post online pictures of herself in a hospital bed with an oxygen mask and feeding tube.

Many fakers seem to crave attention, and the Internet is the ideal medium for their manipulations, the article notes. “It gives the perpetrator a quick hit of attention, a feeling of being valued, but without really having done anything to deserve it. Just as online fraudsters dream of easy money, these people crave easy attention. And it is, perhaps, just another form of fraud – emotional, rather than financial fraud.”

Consider setting aside a chunk of time for the final piece in today’s series of links, an in-depth look at the huge global business of tobacco smuggling. Cigarettes are the most widely smuggled legal substance in the world, generating multibillion-dollar profits, fueling organized crime and corruption, and diverting much-needed tax revenue from governments.

Since 1999, a team of reporters with the International Consortium of Investigative Journalists has been examining this issue. They’ve just published a new series of reports, assembled by journalists from 15 countries, that takes a look at the influence of organized crime and terrorists groups as well as “the continued complicity of distributors, wholesalers, and tobacco companies themselves” in the illicit tobacco trade.

Most people are likely unaware of the impact of tobacco smuggling, its ties to crime and its impact on developing nations where cigarettes increasingly are being introduced and sold on the black market. This ambitious news project explains what’s happening and, more importantly, why it matters.