Good nurses practice in accordance with the Nurse Practice Act of the state in which they are licensed and working, and in so doing carry out all of the components of the "nursing process," and they do this well. That's all there is to it.
Yet among the thousands and thousands of patients who receive nurses' services every day, and the thousands of organizations that employ nurses, precious few folks seem to know what a "good nurse" truly is or how to spot one.
A nurse can be kind, compassionate, considerate, friendly, thoughtful, smart, funny, and able to change a bandage or administer an injection without causing pain, yet still not be a "good nurse." A nurse can be a conscientious employee who is well-liked, responsible, and loyal, yet not be a "good nurse." And most of all, a nurse can be "nice" (Lord help me if one more person tells me how "nice" a nurse is!), while being a professional disaster at the same time.
The problem is that state laws and professional standards of practice just aren't typical recreational reading for most people, and the essence of good nursing practice often is concealed in mundane activities. So it's all too easy for the public, and for business people who own and/or administer healthcare organizations, to assume that handing out pills and applying cool cloths to fevered brows is professional nursing, and that people who hold RN licenses and do those things well are "good nurses." 'Tain't necessarily so.
Some years ago a recruitment ad running in professional journals showed a nurse standing at the bedside of a patient who was sitting up in bed with a meal tray on the table in front of him. They were smiling at each other and obviously enjoying a pleasant exchange. The caption read something like, "He thinks they're talking about green jello. Actually she's halfway through 146 assessments." That would be true, if she were a good nurse, and the point of the ad, directed to good nurses whom the sponsor hoped to recruit, was that this is the sort of nurse sought and valued by that hospital.
A nurse indeed could merely banter about food with a patient and then head off to hang the next IV, having noticed and learned little. But more probably the nurse at that bedside noticed whether, what, and how much nutrition the patient was taking. She knew if he was enjoying his meal or if eating was a struggle or a chore. She recognized if he seemed to be in pain or to be having difficulty eating, from trouble swallowing to challenges manipulating utensils to inability to see clearly the things that were on his tray. She noticed his color, his breathing, and his speech. She could estimate his level of literacy, and had a sense of his willingness to engage with her and other providers. She had a sense of his communication style and whether he tended to be blunt, evasive, or something in between. She noticed his position and if he favored or guarded any body part, or if he just seemed more comfortable being "crooked" in the bed. She could tell if he was likely to engage, ask questions, and want to be an active participant in his care, or if he preferred a passive "wake me when it's over and I'm all better" approach. The nurse noticed any hearing deficit, if the patient seemed light-headed or dizzy, or if he was confused, forgetful, hallucinating, or demonstrated impaired cognition. She recognized effects, intended or otherwise, of the medications the patient had taken, and whether he might need something more, less, or different. She had a sense of how eating was affecting his stomach and entire GI tract. She noted sensory impairments he might have, such as not realizing that coffee was hot or that a glass was placed too close to the edge of the table. She saw if he had trouble grasping objects or tended to drop them, and if this involved one hand or both. She noticed if he did not move normally, and if he was tired, or tired quickly. She saw how he coped with whatever health problems he had, and knew the approaches to which he likely would be most receptive. She knew if his IV was running properly, if his bandages were intact, and the significance of displays on the monitor over his bed. And more.
The nurse also knew what to do with all of this information. She used it to formulate diagnoses, plan treatment, evaluate the effectiveness of treatment, prepare to teach the patient, include supportive others and exclude others, plan his discharge, and give other team members heads-ups about the patient's status, needs, and actual and potential problems. She knew what to disregard for the moment, and what warranted prompt action. She knew what questions she still had, and had a plan for pursuing their answers.
But when the phone rang and she excused herself from the bedside as the patient answered it, chances are she overheard him saying, "Hi, Honey. I'm having lunch and just was talking with Jane about the jello. It's green! Yeah, Jane's very nice; she's a good nurse."
More sobering are the administrators and executives of healthcare organizations who don't know what good nursing is, or even what nurses are required to do to be in compliance with the law. Recently I spoke with a Clinical Manager of a home healthcare agency who lamented the unnecessary and time-consuming documentation that many nurses new to home healthcare wrote. "All they need to write is what regulators and payors require," she said, "The rest is superfluous and unnecessary."
Wrong.
Those new-to-homecare nurses indeed may have been including unnecessary information in their notes, but they are required by law and by the standards of their profession, to which they would be held accountable in any court of law, to perform and document the entire nursing process, not just the parts that satisfy the specific requirements of regulators and payors. One would hope that Clinical Manager would help new employees ferret out irrelevant information while fleshing out a complete clinical picture of each patient and of the nursing process as it is carried out in each case. I fear that was not the case in this instance.
Employers can be so focused on their business needs that they fail to be mindful of the larger responsibility of professional healthcare providers. If executives hold business degrees rather than professional licenses they may not even know the standards and requirements for which a nurse, or other licensed professional, is accountable. They may even, unwittingly, I hope!, encourage employees to flout the law: "Just document the patient's homebound status, the skilled services provided, and compliance with the treatment plan that the physician signed and be done with it." But business needs cannot be allowed to trump professional standards or the law.
Because an employer gives a directive does not absolve a nurse from the duty to practice in accordance with the law and with professional standards. If a manager told a nurse, "It's ok, you don't have to file a tax return this year," you can bet the IRS still would go after that nurse and would have no sympathy for what the boss had said. If a director told a nurse to reach a destination as quickly as possible, without regard for speed limits, it's a sure thing that flashing lights in the rearview mirror and a speeding ticket would be in that nurse's future, boss's directive or not. Similarly, when a manager or executive tells nurses how to practice and what to document, it is incumbent on those nurses to be sure that their practice and their documentation both satisfy the needs of the employer and those of the law and of the profession.
It's a wonder more nurses don't seem a little schizophrenic from time to time, given that so many of our patients don't realize even a small portion of what our practice with them truly entails and that so many of our employers are focused on the bottom line to the exclusion of good practices and of compliance with the law. But the next time you encounter a nurse and a dish of green jello, please don't be quick to confuse personality with professionalism. Because before you can down the jello that nurse will have completed 146 assessments, formulated diagnoses and a treatment plan, evaluated what has been done and how you have responded so far, and determined with whom she or he next needs to confer to help you take the next right step towards better health. . . if he or she is
A Good Nurse.
Tuesday, April 1, 2014
Saturday, March 15, 2014
We'll Take the Watch from Here
Although he uses the moniker only with tongue squarely in cheek, "Internet Sensation" Chief David A. Oliver of the Brimfield Police Department has created an engaging Facebook page that brings an international community of "crazy cousins" into informative, humorous, and thought-provoking dialog with those who serve and protect a small Ohio town (https://www.facebook.com/BrimfieldPolice). Now over 141,000 followers strong, Chief Oliver and the BPD offer fans a look at the inner workings of a department that is redefining what it means to be public servants. My mornings are not complete until I read the Chief's daily message, as well as any updates from the "Brimfield Triangle" and any Chief's "rants" or "babbles" that may have appeared in the preceding twenty-four hours.
A post that always touches my heart is a tribute to a fallen officer anywhere in the country. Chief Oliver notes what happened and links to a local news report, extends sympathy to the family, and bids his brother or sister in blue "Rest in peace," adding, "We'll take the watch from here." Having known and worked with many fine police officers over the years I can imagine a public servant not quite able to rest, even from the Beyond, without knowing that his or her watch is covered. I am grateful, and struck that a police chief in a little Ohio town thinks to offer that reassurance: "Your watch is covered; be at peace."
Why is it that we can't seem to cover our watches in healthcare, even when they span only the relatively small group of patients entrusted to our care in whatever setting we happen to practice?
"Maria" was an elderly patient of mine last year. She had heart disease, high blood pressure, diabetes, kidney issues, and all the degenerative processes that so often accompany advanced age. As she recovered from a complicated post-surgical course and neared the time of home healthcare discharge, her husband "Frank" was scheduled for surgery himself. He had been told to anticipate a five-day inpatient stay and then a period of recuperation at home that would last some weeks. His planning for this surgery included lining up relatives to assist Maria in his absence, however, I was concerned. In the many months I had seen Maria at home, no family ever had appeared. Greeting cards were displayed at holidays, and now and then Maria and Frank mentioned that someone had visited during the previous weekend, but these visits were infrequent, and no one had shown interest in Maria's health needs or offered to help with her care. So I wondered if they would step up to provide the level of support that she would need while Frank was away and later recovering. Fortunately Maria had enough ongoing issues with her various health problems that I was able to extend my visits to the time of Frank's surgery.
Frank was admitted to the hospital on Monday, for surgery that same day. He underwent a five hour procedure, and spent Tuesday in Intensive Care. Wednesday I was able to reach Maria at home and schedule a visit with her for Thursday, as Frank was doing better and she would not be going to the hospital that day.
My wait on their doorstep Thursday morning seemed interminable. Maria and Frank live on the second floor of a two-flat, and I wondered which family member was so slowly making his or her way down the stairs to admit me. Imagine my surprise when Frank opened the door, breathing heavily, a large surgical dressing covering much of his face and neck, and looking like he was about to fall over. He had been discharged home, alone, Wednesday, the day after leaving intensive care. "They didn't tell me it was going to be like this," he said, breathing hard and grasping the handrail for support. "And I'm supposed to take the bandage off today, but I don't know how. And what do I do about what's under there?" I asked if he had been given fresh bandages or other supplies; he said no.
Somehow Frank and I made it back up those stairs, after which he barely managed to walk several steps to all but collapse in a chair. Maria sat on the couch with her walker nearby, able to move about the apartment herself only with difficulty and certainly unable to provide physical assistance to him. No one else was there.
Frank was not my patient. I was not privy to his treatment plan or to information about his surgical procedure or hospital stay. There were no orders for home healthcare; Frank had not signed a consent for me to lay a hand on him or provide any kind of service. In short, his problems and needs were not my business. Or were they?
Certainly Frank's welfare was material to Maria's, and she indeed was my patient. Perhaps on that basis I could justify a bit of emergency assistance. But ethically there was no question what needed to be done, orders, proper referrals, legal consent forms, or not.
"Frank, would you like me to help you with that bandage?" I asked.
I don't know if the tears or the gratitude in his eyes were greater.
The details of his case aren't important now. The incision under the bandage was healing well and could be covered with a much more simple and easily managed dressing. I could tell Frank generally what to expect, how to take care of himself, what pitfalls to avoid, and what might happen that would warrant a call to his surgeon or, God forbid, an emergency trip back to the hospital. Maria was fine, well, as fine as an old woman with multiple chronic problems and a basket-case of a husband could be, and needed little attention just then. Whether family had risen to the occasion earlier in the week was a moot point: Frank and Maria had food and could manage adequately in their little home without any more trips down the stairs. They knew to call 911 in an emergency, and family or me for anything else.
But what had happened at the hospital?
The surgical team did its job on Monday, the critical care team did likewise on Tuesday, and Frank was handed off to a general surgical floor on Wednesday, determined no longer to be in need of inpatient care, and discharged home. Harsh as it may seem, that might not be unreasonable. Hospitals are dangerous places, with potential for infection of new surgical wounds and much bustle allowing for possible confusion of patients, orders, and needs. If a person does not absolutely need to be there, often it's best for him or her to go somewhere else. Insurance companies and hospital bean-counters wound agree, albeit perhaps for other reasons.
I wonder, though, if anyone asked Frank where he was going (home to a second-floor walk-up apartment), who was available to help him (no one), or if he understood, less than forty-eight hours after general anesthesia and with a load of narcotic pain relievers and other medications on board, what had been done, what he would need to do for himself, how to do that, how safely to maneuver about, what measures to take to build strength, and under what circumstances it might be necessary to seek help, or what that help would be. If anyone did ask those things, under those circumstances, I wonder what was wrong with that person's brain. Frank was an old man two days out of surgery and full of brain-altering drugs!
Frank was a Medicare beneficiary who qualified for home healthcare, yet no one referred him. I wasn't looking for more work to do; truth be told, I was looking forward to discharging Maria because their home was out of the way for me and I had tired of the extra driving. But I, or someone like me, would have seen Frank in a heartbeat. Two or three nursing visits and a session or two with Physical Therapy to see that he moved up and down those stairs safely would have done the job nicely. But it seems that when each hospital team finished its own job, it sent Frank to the next setting on his road to recovery and washed its hands of him. I do not believe there was one iota of malicious intent, and I'd bet money the hospital was busy and its workers harried, striving to do the best they could for the charges in their care, with little time even to think about consequences beyond the next "hand-off."
Yet even when a police officer dies, when his or her tour of duty is ended for the last time and there is no more work for him or her to do ever again, colleagues such as Chief Oliver and thousands of others step up to take over, ever mindful of the need to serve and protect twenty-four hours a day, every day, regardless of circumstances.
Healthcare providers could stand to take a page from the Brimfield Police Department and public servants everywhere, and not rest without knowing that when their work with a patient is done someone, an appropriate party receiving the "hand-off," has said,
"We'll take the watch from here."
A post that always touches my heart is a tribute to a fallen officer anywhere in the country. Chief Oliver notes what happened and links to a local news report, extends sympathy to the family, and bids his brother or sister in blue "Rest in peace," adding, "We'll take the watch from here." Having known and worked with many fine police officers over the years I can imagine a public servant not quite able to rest, even from the Beyond, without knowing that his or her watch is covered. I am grateful, and struck that a police chief in a little Ohio town thinks to offer that reassurance: "Your watch is covered; be at peace."
Why is it that we can't seem to cover our watches in healthcare, even when they span only the relatively small group of patients entrusted to our care in whatever setting we happen to practice?
"Maria" was an elderly patient of mine last year. She had heart disease, high blood pressure, diabetes, kidney issues, and all the degenerative processes that so often accompany advanced age. As she recovered from a complicated post-surgical course and neared the time of home healthcare discharge, her husband "Frank" was scheduled for surgery himself. He had been told to anticipate a five-day inpatient stay and then a period of recuperation at home that would last some weeks. His planning for this surgery included lining up relatives to assist Maria in his absence, however, I was concerned. In the many months I had seen Maria at home, no family ever had appeared. Greeting cards were displayed at holidays, and now and then Maria and Frank mentioned that someone had visited during the previous weekend, but these visits were infrequent, and no one had shown interest in Maria's health needs or offered to help with her care. So I wondered if they would step up to provide the level of support that she would need while Frank was away and later recovering. Fortunately Maria had enough ongoing issues with her various health problems that I was able to extend my visits to the time of Frank's surgery.
Frank was admitted to the hospital on Monday, for surgery that same day. He underwent a five hour procedure, and spent Tuesday in Intensive Care. Wednesday I was able to reach Maria at home and schedule a visit with her for Thursday, as Frank was doing better and she would not be going to the hospital that day.
My wait on their doorstep Thursday morning seemed interminable. Maria and Frank live on the second floor of a two-flat, and I wondered which family member was so slowly making his or her way down the stairs to admit me. Imagine my surprise when Frank opened the door, breathing heavily, a large surgical dressing covering much of his face and neck, and looking like he was about to fall over. He had been discharged home, alone, Wednesday, the day after leaving intensive care. "They didn't tell me it was going to be like this," he said, breathing hard and grasping the handrail for support. "And I'm supposed to take the bandage off today, but I don't know how. And what do I do about what's under there?" I asked if he had been given fresh bandages or other supplies; he said no.
Somehow Frank and I made it back up those stairs, after which he barely managed to walk several steps to all but collapse in a chair. Maria sat on the couch with her walker nearby, able to move about the apartment herself only with difficulty and certainly unable to provide physical assistance to him. No one else was there.
Frank was not my patient. I was not privy to his treatment plan or to information about his surgical procedure or hospital stay. There were no orders for home healthcare; Frank had not signed a consent for me to lay a hand on him or provide any kind of service. In short, his problems and needs were not my business. Or were they?
Certainly Frank's welfare was material to Maria's, and she indeed was my patient. Perhaps on that basis I could justify a bit of emergency assistance. But ethically there was no question what needed to be done, orders, proper referrals, legal consent forms, or not.
"Frank, would you like me to help you with that bandage?" I asked.
I don't know if the tears or the gratitude in his eyes were greater.
The details of his case aren't important now. The incision under the bandage was healing well and could be covered with a much more simple and easily managed dressing. I could tell Frank generally what to expect, how to take care of himself, what pitfalls to avoid, and what might happen that would warrant a call to his surgeon or, God forbid, an emergency trip back to the hospital. Maria was fine, well, as fine as an old woman with multiple chronic problems and a basket-case of a husband could be, and needed little attention just then. Whether family had risen to the occasion earlier in the week was a moot point: Frank and Maria had food and could manage adequately in their little home without any more trips down the stairs. They knew to call 911 in an emergency, and family or me for anything else.
But what had happened at the hospital?
The surgical team did its job on Monday, the critical care team did likewise on Tuesday, and Frank was handed off to a general surgical floor on Wednesday, determined no longer to be in need of inpatient care, and discharged home. Harsh as it may seem, that might not be unreasonable. Hospitals are dangerous places, with potential for infection of new surgical wounds and much bustle allowing for possible confusion of patients, orders, and needs. If a person does not absolutely need to be there, often it's best for him or her to go somewhere else. Insurance companies and hospital bean-counters wound agree, albeit perhaps for other reasons.
I wonder, though, if anyone asked Frank where he was going (home to a second-floor walk-up apartment), who was available to help him (no one), or if he understood, less than forty-eight hours after general anesthesia and with a load of narcotic pain relievers and other medications on board, what had been done, what he would need to do for himself, how to do that, how safely to maneuver about, what measures to take to build strength, and under what circumstances it might be necessary to seek help, or what that help would be. If anyone did ask those things, under those circumstances, I wonder what was wrong with that person's brain. Frank was an old man two days out of surgery and full of brain-altering drugs!
Frank was a Medicare beneficiary who qualified for home healthcare, yet no one referred him. I wasn't looking for more work to do; truth be told, I was looking forward to discharging Maria because their home was out of the way for me and I had tired of the extra driving. But I, or someone like me, would have seen Frank in a heartbeat. Two or three nursing visits and a session or two with Physical Therapy to see that he moved up and down those stairs safely would have done the job nicely. But it seems that when each hospital team finished its own job, it sent Frank to the next setting on his road to recovery and washed its hands of him. I do not believe there was one iota of malicious intent, and I'd bet money the hospital was busy and its workers harried, striving to do the best they could for the charges in their care, with little time even to think about consequences beyond the next "hand-off."
Yet even when a police officer dies, when his or her tour of duty is ended for the last time and there is no more work for him or her to do ever again, colleagues such as Chief Oliver and thousands of others step up to take over, ever mindful of the need to serve and protect twenty-four hours a day, every day, regardless of circumstances.
Healthcare providers could stand to take a page from the Brimfield Police Department and public servants everywhere, and not rest without knowing that when their work with a patient is done someone, an appropriate party receiving the "hand-off," has said,
"We'll take the watch from here."
Sunday, December 1, 2013
What's Wrong with Gratitude
I don't know about yours, but with the advent of Thanksgiving my Facebook news feed turned saccharine. Everyone suddenly experienced a burst of gratitude for their families and friends, their comforts in life, their health, their spiritual practices, their work, and their confidence in a bright future. Thank goodness it's but a one-day holiday closely followed, if not eclipsed, by Black Friday, when grateful people can descend en masse on department stores to slug it out with each other over the right to be the even more grateful owners of brand new big screen TVs, because I don't know how much more of the sickeningly sweet gratitude I could have taken!
Gratitude is in vogue these days. We're exhorted to keep gratitude journals, count our blessings, and focus on the positive. Some believe that the objects of their thoughts and energy grow and multiply, and so spew forth affirmations of gratitude like lava from a volcano, thereby putting the universe on notice that with thanks duly rendered even greater good and bigger gimmes now are past due.
There's an elephant in the room with all this gratitude. Its name is Narcissism, and its language, simply put, is nothing more than the wolf of old-fashioned boasting clad in sheep's clothing of appreciative verbiage. Tedious at best, this big old elephant expends its energy trumpeting about its good life, leaving the rest of us bored while the actual I.O.U. due from the elephant to the universe remains outstanding.
True gratitude is awestruck. Overwhelmed by the magnitude and/or timing and/or convergence of forces for good, true gratitude stands still and small in the face of bounty. And when true gratitude begins to feel its power, that feeling emerges as a call to service. The truly grateful respond to that call, and are much too busy, too enthusiastic, and too outwardly focused in their efforts to deal with, much less become, elephants.
"I am so grateful that my days of roadside breakdowns are over, and for the people at MegaMotors who will deliver my new Porsche tomorrow," or "I thank God for guiding me to the perfect house and for helping me negotiate to buy it for only $3 million," or "I'm filled with gratitude to be the owner of a thriving, successful business that dramatically surpasses growth projections every month" all are clarion calls of the elephant. The elephant in the room indeed would have us believe that as long as it's expressed in the language of gratitude, it's ok to say, "I have have arrived in the world, and in a new Porsche!," or "I'm so well off that I just bought a multi-million dollar home!," or "I'm such a huge success that I exceed even my own expectations every month!"
The elephant, I'm afraid, is not well. Even if its proclamations are modest (a gift or compliment received, a nice vacation), when the elephant trumpets, "Look at how good I have it!" one must suspect that such noise masks underlying, unmet need. There is no shame in needs; everyone has them. But it is sad when genuine need is tamped down and hidden instead of guided gently to the light where it can be met and transformed.
Decades of work in human services, and even longer living in a human body, have taught me that growth cannot be forced or hurried. There first must be willingness to consider that there might be another, better way, and then courage to reach out, to tell the truth, and to try something new, whether it is a new oven cleaner or giving up crack cocaine.
An old friend called early one morning not long ago, waking me up. "Hey, how're ya doin'?" I asked, attempting a cheerfulness to mask both my grogginess and my concern that a call at that hour portended something amiss.
"I'm grateful!" he responded. "My business is doing great. I have a nice home, a wonderful dog, great friends, and good health. How could it be any better?"
Doubting that many people awaken a friend to explain how grateful they are for their perfect lives, I suspect there is an answer to his question, rhetorical though it may have been intended to sound.
While true gratitude need not hide its face, it is not boastful or showy. It finds expression in a combination of humility and service, it tends to be quiet, and it unleashes powerful forces for good. It is the antithesis of cheap thanks, which is focused on the self and expressed as thinly veiled bragging. Cheap thanks tends to be manipulative and deceptive of self and others, and it deprives everyone of the fruits of the full creative potential generously bestowed by a benevolent universe. It is cheap thanks that is
What's Wrong with Gratitude
Gratitude is in vogue these days. We're exhorted to keep gratitude journals, count our blessings, and focus on the positive. Some believe that the objects of their thoughts and energy grow and multiply, and so spew forth affirmations of gratitude like lava from a volcano, thereby putting the universe on notice that with thanks duly rendered even greater good and bigger gimmes now are past due.
There's an elephant in the room with all this gratitude. Its name is Narcissism, and its language, simply put, is nothing more than the wolf of old-fashioned boasting clad in sheep's clothing of appreciative verbiage. Tedious at best, this big old elephant expends its energy trumpeting about its good life, leaving the rest of us bored while the actual I.O.U. due from the elephant to the universe remains outstanding.
True gratitude is awestruck. Overwhelmed by the magnitude and/or timing and/or convergence of forces for good, true gratitude stands still and small in the face of bounty. And when true gratitude begins to feel its power, that feeling emerges as a call to service. The truly grateful respond to that call, and are much too busy, too enthusiastic, and too outwardly focused in their efforts to deal with, much less become, elephants.
"I am so grateful that my days of roadside breakdowns are over, and for the people at MegaMotors who will deliver my new Porsche tomorrow," or "I thank God for guiding me to the perfect house and for helping me negotiate to buy it for only $3 million," or "I'm filled with gratitude to be the owner of a thriving, successful business that dramatically surpasses growth projections every month" all are clarion calls of the elephant. The elephant in the room indeed would have us believe that as long as it's expressed in the language of gratitude, it's ok to say, "I have have arrived in the world, and in a new Porsche!," or "I'm so well off that I just bought a multi-million dollar home!," or "I'm such a huge success that I exceed even my own expectations every month!"
The elephant, I'm afraid, is not well. Even if its proclamations are modest (a gift or compliment received, a nice vacation), when the elephant trumpets, "Look at how good I have it!" one must suspect that such noise masks underlying, unmet need. There is no shame in needs; everyone has them. But it is sad when genuine need is tamped down and hidden instead of guided gently to the light where it can be met and transformed.
Decades of work in human services, and even longer living in a human body, have taught me that growth cannot be forced or hurried. There first must be willingness to consider that there might be another, better way, and then courage to reach out, to tell the truth, and to try something new, whether it is a new oven cleaner or giving up crack cocaine.
An old friend called early one morning not long ago, waking me up. "Hey, how're ya doin'?" I asked, attempting a cheerfulness to mask both my grogginess and my concern that a call at that hour portended something amiss.
"I'm grateful!" he responded. "My business is doing great. I have a nice home, a wonderful dog, great friends, and good health. How could it be any better?"
Doubting that many people awaken a friend to explain how grateful they are for their perfect lives, I suspect there is an answer to his question, rhetorical though it may have been intended to sound.
While true gratitude need not hide its face, it is not boastful or showy. It finds expression in a combination of humility and service, it tends to be quiet, and it unleashes powerful forces for good. It is the antithesis of cheap thanks, which is focused on the self and expressed as thinly veiled bragging. Cheap thanks tends to be manipulative and deceptive of self and others, and it deprives everyone of the fruits of the full creative potential generously bestowed by a benevolent universe. It is cheap thanks that is
What's Wrong with Gratitude
Tuesday, June 25, 2013
It's Obvious
It seems obvious that the way to achieve better health outcomes is to solve problems patients actually have, rather than try to make patients have the problems we best know how to solve. Yet so often the obvious is overlooked, and then we wonder why patients don't improve or are "noncompliant."
"Rose" is 89 years old. She has diabetes, heart disease, chronic back pain, and wounds on her feet. One foot has an open ulcer that just won't heal; a toe was amputated from the other foot, and now not only is the surgical site not healing well, but the adjacent toes are showing signs of breakdown. The foot with an ulcer is hooked up to a machine 24 hours a day; this gently sucks drainage from the wound bed and into an attached canister and stimulates growth of new tissue. Rose carries the machine around in a shoulder bag, being careful not to trip over the tubing attaching the machine to her foot. She also requires two canes to walk, one in each hand. So while she isn't getting much worse but certainly isn't getting much better either, every time Rose wants a drink of water or needs to use the bathroom or seeks a sweater to ward off a chill or anything else, day or night, she must hoist the bag-with-machine onto her shoulder, grab one cane with each hand, carefully adjust the tubing so she neither trips nor pulls it loose, and slowly grunt her way through the little apartment she shares with her husband. Many times I have sat in the living room waiting for Rose to make her way to and from the bathroom, listening to her rhythmic grunt. grunt. grunt., one grunt for each step, because her back hurts when she moves, and she is carrying a machine, avoiding long tubing, and leaning on first one cane and then the other as she goes. A trip to and from the bathroom is grueling exercise for her.
Rose needs to see her vascular surgeon, and I need her to see him, because our treatment no longer is working and we need to adjust the plan. More robust but equally elderly, Rose's husband is confident he can get her down the stairs, into the car, and to the big university medical center where her doctors practice, but he's worried about what will happen once there. In the past they have waited up to forty minutes for a transporter to bring Rose a wheelchair, but now Rose barely can stand for four minutes, much less forty. In the past after appointments they have had equally long waits for a transporter to rescue them again and wheel Rose back to the parking garage. Unless they can get a wheelchair, Rose's husband explains, she can't go to the doctor.
The medical center is full of wheelchairs. I know this. I've been there many times; I've seen them. But I also know Rose's husband is sharp and a straight-shooter not given to exaggeration or fabrication. So I called the social worker whose job is "transitional care," that is, helping people span the gap between the hospital and home, seeing that they have the resources they need to manage safely and well when they are discharged from the hospital, and that they are properly "connected" to doctors and other providers for their follow up care.
The social worker didn't know, she told me, what the situation with wheelchairs was, but she would look into it. With Medicare now exacting significant financial penalties when patients are re-admitted to the hospital for problems that could have been prevented, there is particular emphasis on being sure follow up appointments are kept and that post-hospital care goes smoothly.
A short while later the social worker called me back, startled to have learned that there were only five (5!) wheelchairs and transporters assigned to cover that entire area of the medical center. Patients indeed often had to wait some time for a wheelchair to be available. And, yes, this could have a significant impact on follow up "failures," i.e., patients missing appointments because it was too difficult to get to their doctors' offices when they were tired, hurting, sick. . . and most in need of being there. If they waited until they were sick enough to need to be taken by ambulance to the Emergency Department transportation would be assured: EMS will deliver patients directly to the treatment area, and there are plenty of wheelchairs in the ED to take patients to their hospital beds, yes indeed, more follow up failures turned into re-hospitalizations.
The social worker had seen that a concern about wheelchair availability had been duly registered and was making its way upward through the administrative hierarchy. Meanwhile we remember that Rose is 89 years old. The chances of her living long enough to see administrative resolution of this issue are somewhere between the proverbial slim and none.
So there we were, the social worker and I, on the phone together talking about an elderly patient who needed to see her doctor and who could get to the medical center, but once there could not get to the doctor's office. The social worker wanted to help. Under a special program, Rose qualifies for Medi-car transportation from home to the medical center; the social worker could arrange for the Medi-car. I reminded her that Rose and her husband have a car and can drive themselves. The issue was getting her to the doctor's office once there. The social worker could contact the doctor's office and make an appointment for Rose, she said, and even try to make an appointment with the endocrinologist for the same day. Rose and her husband can dial a phone, I noted; they didn't need help making appointments. They needed help getting from one part of the massive medical center to another. The social worker would see what she could do and get back to me.
Later that day she called with her ultimate resolution: An appointment had been made with the vascular surgeon, and a second appointment a month later with both doctors on the same day. I reminded her again that the problem was transportation from the parking garage to the doctor's office, and she told me curtly that there were only five transporters available and people would have to be patient and wait.
Rose's problem was transportation within the medical center; the medical center's solution was transportation outside the medical center and assistance making appointments that Rose was physically unable to keep. Unable to solve the problem Rose actually had, the social worker provided "help" that wasn't needed, or helpful. But although solutions to problems Rose didn't have and not solutions to her actual problem, this "help" was something the social worker knew how to do. And so that's what she did.
And I'm afraid this happens often.
I could retire comfortably tomorrow if I had a dollar for every time I've been asked to see patients because they were "noncompliant" with their medication regimens and needed "teaching." Information and instruction are proper responses to lack of knowledge or misunderstanding. But patients don't take their medications correctly for a host of reasons, most of which have little to do with knowledge.
They may not be able to afford medications, or medications may have unpleasant side effects, real or imagined. Patients may object to the very idea of taking medicine, or may believe they have too many medicines to take. They may simply forget. The prospect of taking medications may leave some patients feeling "old" or "sick" when they prefer to think of themselves as healthy and vibrant. They may hide medications from their families in order to keep their health issues secret and then miss doses because family members are present and would ask questions, or because in effect they have hidden the medicines from themselves, too. Regimens may be too complicated, or interfere with other activities. People may worry about appearing to be "junkies." They may fear needles or not be able to remove protective covers or child-proof bottle caps. Small pills may be too difficult for arthritic fingers to handle, or may be invisible to eyes with fading vision. Patients may believe their medications don't work, or that doctors prescribe them only so patients will have to keep going back for refills, generating more billable office visits for the doctors. They may understand that while taking some medications they need to give up other things they enjoy, ranging from drinking grapefruit juice to driving, and decide that they'd rather "drink and drive" than take pills. Patients may feel too sick to go to the pharmacy to have prescriptions filled. Large pills may be hard to swallow, liquids may have an unpleasant taste, tablets that need to be broken in half may resolutely refuse to break.
And yes, sometimes, people truly don't understand what they should take, when, why, how, and what the consequences should and could be. This latter group is the one needing "teaching." Yet time and time again I see a nurse or other provider explaining medication names, actions, purposes, administration, and possible side effects, and then considering the job done, and calling patients "noncompliant" and the task of teaching them not do-able when patients continue not to take their medications as ordered. The fact is that such teaching is easy; we know the information and can spew it in our sleep, and then we can feel justified that we have done our work and it is the patient who has failed to take proper advantage of our largesse.
In fact, we have taken the easy road, assuming patients all have the problem that we are best prepared to solve, "knowledge deficit," rather than asking, probing, listening, and comprehensively assessing to ascertain what the real issues are in any individual situation, and then figuring out with the patient how best to address them and move forward. I remember a time when patients were expected to follow "doctor's orders" blindly and were not taught; since then it seems we have come to suppose that imparting information is the solution to all problems with health behaviors. But there's not one of us who never fails to act in accord with what we know to be best: We overeat and underexercise,we sleep too much or too little, we smoke or tan or text while driving, . . . and not for want of "teaching." Providing information is what we healthcare providers know how to do; solving the messy problems of complex human lives is a dicier undertaking. So we assume that anyone who doesn't do what we want him or her to do needs to be taught, less because we have identified real learning needs, and more because teaching is something we know we can provide.
I am working to get Rose her own little wheelchair that can be folded and placed in the car; she and her husband aren't yet sure they want one, but it would make her much less a prisoner in that little apartment, and I have a hunch we'll come to an accord. Failing that, perhaps the vascular surgeon will agree to see her in the medical center's parking garage, if only to call attention dramatically to a simple problem that could be resolved expeditiously if the right people were motivated to do so. And if all else fails I can offer Rose the services of a physician who makes house calls and would evaluate her at home.
Yet through all of this, and in so many similar instances, I am struck by the amount of time, energy, money, and frustration expended by so many providers when by assumption and action, deliberately or not, they try to fit patients into the molds of problems they know how to solve (as by teaching, ordering Medi-cars, and making appointments, whether or not patients need those things) rather than identifying and solving the problems patients actually have. And when patients don't respond by changing their behavior and/or getting better the costs are great, the outcomes poor, and everyone dissatisfied and wondering why. But although challenging, it's no mystery. In fact,
It's Obvious.
"Rose" is 89 years old. She has diabetes, heart disease, chronic back pain, and wounds on her feet. One foot has an open ulcer that just won't heal; a toe was amputated from the other foot, and now not only is the surgical site not healing well, but the adjacent toes are showing signs of breakdown. The foot with an ulcer is hooked up to a machine 24 hours a day; this gently sucks drainage from the wound bed and into an attached canister and stimulates growth of new tissue. Rose carries the machine around in a shoulder bag, being careful not to trip over the tubing attaching the machine to her foot. She also requires two canes to walk, one in each hand. So while she isn't getting much worse but certainly isn't getting much better either, every time Rose wants a drink of water or needs to use the bathroom or seeks a sweater to ward off a chill or anything else, day or night, she must hoist the bag-with-machine onto her shoulder, grab one cane with each hand, carefully adjust the tubing so she neither trips nor pulls it loose, and slowly grunt her way through the little apartment she shares with her husband. Many times I have sat in the living room waiting for Rose to make her way to and from the bathroom, listening to her rhythmic grunt. grunt. grunt., one grunt for each step, because her back hurts when she moves, and she is carrying a machine, avoiding long tubing, and leaning on first one cane and then the other as she goes. A trip to and from the bathroom is grueling exercise for her.
Rose needs to see her vascular surgeon, and I need her to see him, because our treatment no longer is working and we need to adjust the plan. More robust but equally elderly, Rose's husband is confident he can get her down the stairs, into the car, and to the big university medical center where her doctors practice, but he's worried about what will happen once there. In the past they have waited up to forty minutes for a transporter to bring Rose a wheelchair, but now Rose barely can stand for four minutes, much less forty. In the past after appointments they have had equally long waits for a transporter to rescue them again and wheel Rose back to the parking garage. Unless they can get a wheelchair, Rose's husband explains, she can't go to the doctor.
The medical center is full of wheelchairs. I know this. I've been there many times; I've seen them. But I also know Rose's husband is sharp and a straight-shooter not given to exaggeration or fabrication. So I called the social worker whose job is "transitional care," that is, helping people span the gap between the hospital and home, seeing that they have the resources they need to manage safely and well when they are discharged from the hospital, and that they are properly "connected" to doctors and other providers for their follow up care.
The social worker didn't know, she told me, what the situation with wheelchairs was, but she would look into it. With Medicare now exacting significant financial penalties when patients are re-admitted to the hospital for problems that could have been prevented, there is particular emphasis on being sure follow up appointments are kept and that post-hospital care goes smoothly.
A short while later the social worker called me back, startled to have learned that there were only five (5!) wheelchairs and transporters assigned to cover that entire area of the medical center. Patients indeed often had to wait some time for a wheelchair to be available. And, yes, this could have a significant impact on follow up "failures," i.e., patients missing appointments because it was too difficult to get to their doctors' offices when they were tired, hurting, sick. . . and most in need of being there. If they waited until they were sick enough to need to be taken by ambulance to the Emergency Department transportation would be assured: EMS will deliver patients directly to the treatment area, and there are plenty of wheelchairs in the ED to take patients to their hospital beds, yes indeed, more follow up failures turned into re-hospitalizations.
The social worker had seen that a concern about wheelchair availability had been duly registered and was making its way upward through the administrative hierarchy. Meanwhile we remember that Rose is 89 years old. The chances of her living long enough to see administrative resolution of this issue are somewhere between the proverbial slim and none.
So there we were, the social worker and I, on the phone together talking about an elderly patient who needed to see her doctor and who could get to the medical center, but once there could not get to the doctor's office. The social worker wanted to help. Under a special program, Rose qualifies for Medi-car transportation from home to the medical center; the social worker could arrange for the Medi-car. I reminded her that Rose and her husband have a car and can drive themselves. The issue was getting her to the doctor's office once there. The social worker could contact the doctor's office and make an appointment for Rose, she said, and even try to make an appointment with the endocrinologist for the same day. Rose and her husband can dial a phone, I noted; they didn't need help making appointments. They needed help getting from one part of the massive medical center to another. The social worker would see what she could do and get back to me.
Later that day she called with her ultimate resolution: An appointment had been made with the vascular surgeon, and a second appointment a month later with both doctors on the same day. I reminded her again that the problem was transportation from the parking garage to the doctor's office, and she told me curtly that there were only five transporters available and people would have to be patient and wait.
Rose's problem was transportation within the medical center; the medical center's solution was transportation outside the medical center and assistance making appointments that Rose was physically unable to keep. Unable to solve the problem Rose actually had, the social worker provided "help" that wasn't needed, or helpful. But although solutions to problems Rose didn't have and not solutions to her actual problem, this "help" was something the social worker knew how to do. And so that's what she did.
And I'm afraid this happens often.
I could retire comfortably tomorrow if I had a dollar for every time I've been asked to see patients because they were "noncompliant" with their medication regimens and needed "teaching." Information and instruction are proper responses to lack of knowledge or misunderstanding. But patients don't take their medications correctly for a host of reasons, most of which have little to do with knowledge.
They may not be able to afford medications, or medications may have unpleasant side effects, real or imagined. Patients may object to the very idea of taking medicine, or may believe they have too many medicines to take. They may simply forget. The prospect of taking medications may leave some patients feeling "old" or "sick" when they prefer to think of themselves as healthy and vibrant. They may hide medications from their families in order to keep their health issues secret and then miss doses because family members are present and would ask questions, or because in effect they have hidden the medicines from themselves, too. Regimens may be too complicated, or interfere with other activities. People may worry about appearing to be "junkies." They may fear needles or not be able to remove protective covers or child-proof bottle caps. Small pills may be too difficult for arthritic fingers to handle, or may be invisible to eyes with fading vision. Patients may believe their medications don't work, or that doctors prescribe them only so patients will have to keep going back for refills, generating more billable office visits for the doctors. They may understand that while taking some medications they need to give up other things they enjoy, ranging from drinking grapefruit juice to driving, and decide that they'd rather "drink and drive" than take pills. Patients may feel too sick to go to the pharmacy to have prescriptions filled. Large pills may be hard to swallow, liquids may have an unpleasant taste, tablets that need to be broken in half may resolutely refuse to break.
And yes, sometimes, people truly don't understand what they should take, when, why, how, and what the consequences should and could be. This latter group is the one needing "teaching." Yet time and time again I see a nurse or other provider explaining medication names, actions, purposes, administration, and possible side effects, and then considering the job done, and calling patients "noncompliant" and the task of teaching them not do-able when patients continue not to take their medications as ordered. The fact is that such teaching is easy; we know the information and can spew it in our sleep, and then we can feel justified that we have done our work and it is the patient who has failed to take proper advantage of our largesse.
In fact, we have taken the easy road, assuming patients all have the problem that we are best prepared to solve, "knowledge deficit," rather than asking, probing, listening, and comprehensively assessing to ascertain what the real issues are in any individual situation, and then figuring out with the patient how best to address them and move forward. I remember a time when patients were expected to follow "doctor's orders" blindly and were not taught; since then it seems we have come to suppose that imparting information is the solution to all problems with health behaviors. But there's not one of us who never fails to act in accord with what we know to be best: We overeat and underexercise,we sleep too much or too little, we smoke or tan or text while driving, . . . and not for want of "teaching." Providing information is what we healthcare providers know how to do; solving the messy problems of complex human lives is a dicier undertaking. So we assume that anyone who doesn't do what we want him or her to do needs to be taught, less because we have identified real learning needs, and more because teaching is something we know we can provide.
I am working to get Rose her own little wheelchair that can be folded and placed in the car; she and her husband aren't yet sure they want one, but it would make her much less a prisoner in that little apartment, and I have a hunch we'll come to an accord. Failing that, perhaps the vascular surgeon will agree to see her in the medical center's parking garage, if only to call attention dramatically to a simple problem that could be resolved expeditiously if the right people were motivated to do so. And if all else fails I can offer Rose the services of a physician who makes house calls and would evaluate her at home.
Yet through all of this, and in so many similar instances, I am struck by the amount of time, energy, money, and frustration expended by so many providers when by assumption and action, deliberately or not, they try to fit patients into the molds of problems they know how to solve (as by teaching, ordering Medi-cars, and making appointments, whether or not patients need those things) rather than identifying and solving the problems patients actually have. And when patients don't respond by changing their behavior and/or getting better the costs are great, the outcomes poor, and everyone dissatisfied and wondering why. But although challenging, it's no mystery. In fact,
It's Obvious.
Sunday, May 12, 2013
It's Nurses Week!
It's Nurses Week, and also the feast days of several minor saints, and perhaps the time to commemorate uncommon species of rodents or obscure varieties of peppers. As holidays, all warrant about the same degree of observance. But my Facebook news feed does show the annual bump in nurse cartoons, nods of appreciation of nurses that for the most part miss the mark, and a few truly humorous tales about Life with Nurses. One of the latter that hit both Facebook and my inbox more than once is said to have been offered up by the spouse of a nurse: Could be, but if so it's questionable that they actually have been married for 25 years, or that she has been a nurse that long. Or perhaps he's just a lovable slow learner, as many of the fine points and much of the true genius of what we do are missing from his piece. Regardless, in honor of this august occasion (Nurses Week. See, you forgot already), this crone from the Land of Nightingale (that would be Florence. She started all of this. At least in the modern era) is offering a p.s. for those married to nurses, friends and family of nurses, and those otherwise personally involved with nurses:
Don't even think about trying to deceive nurses. They routinely get complete strangers to strip naked and reveal intimate details within three minutes of their first hello. They have treated cheating spouses; criminals; people who don't want their closest intimates to know The Truth (whatever that may be in a given situation); ingenious souls who do anything to get more drugs, or fewer; executives and socialites more concerned about their Image than their lives, much less their health; and even teenagers. And they see all of these in their most vulnerable moments. Nurses go into homes, bedrooms, workplaces, schools, and they keep. going. back. (Facades can be sustained only so long.) Nurses see the cracks in the veneer of carefully crafted public personae, and have uncanny ways of inspiring people to let down their guard and get real. Nurses have a spidey sense like none other. If they haven't discerned exactly what your game is it's because in the overall scheme of things your piddly problem just isn't important enough to warrant the effort. But nurses know when something's off, when people are disingenuous. And God help you once you've triggered that alert.
Don't expect endless sympathy and comfort. Nurses want those they serve to be whole and strong, healthy and self-responsible. This means they dispense Tough Love generously and often. They won't do for you what you can do for yourself, although they may spend hours helping you learn. If you have a symptom or a problem they'll ask what you did to contribute to it and what you can do to make it better. You'll emerge empowered, not coddled. Nurses will help. They'll provide resources, encouragement, referrals, and kicks in the backside. They'll be your loudest cheerleaders and harshest critics. But they're not likely to tuck you in and bring you milk and cookies if you're more than ten years old. And those bedpans and shots so common in nurse jokes? Forget it. Nurses will have you walking to the bathroom under your own power and administering your own injections before you know it.
Odd as it may seem, nurses aren't always looking for more ways to help more people, more tales of woe to hear, or more problems to solve. You have your own family and friends; use them. There is someone in your doctor's practice who actually is being paid to take your call at 2 AM; if you truly need attention at that hour, make him or her earn his or her money. The Emergency Room and EMS are for emergencies; you pay for them with your taxes, your insurance premiums, and your hard-earned pocket money. When you need them, use them. If you call your neighbor or friend or fellow church/PTA/club member, or whoever, who happens to be a nurse, and that person chooses to respond and help you, it is because she or he is a true friend, Good Samaritan, and decent human being (and you should reciprocate in kind). It is not because nurses are limitless givers, doormats, or pathetic, bored souls glad for your giving them something to do on Saturday afternoon.
It's Nurses Week. While I can't speak for the saints, rodents, or peppers, if you're inclined to make an appreciative gesture to nurses you're correct in realizing that there is no thank you big enough for lives saved, medical mishaps averted, wisdom dispensed, confidence inspired, small changes caught early enough to prevent big problems, or the sense that someone who understands somehow knew how to get inside your head and body and guide you back to equilibrium and to new levels of self-care such as you never knew were possible. Empty platitudes, jokes about sex, and caricatures straight from the 1950s don't do it. Safe working conditions, opportunities to practice on the cutting edge and to the full extent of our ability and license, and compensation that reflects our value would help. But for one not in a position to effect those? Be a straight shooter, a respectful fellow citizen, and a self-responsible human being. And you'll find nurses will do the same for you.
P.S.: We also accept Starbucks gift cards, spa days, soft robes, spring flowers, and great dinners! After all,
It's Nurses Week!
Don't even think about trying to deceive nurses. They routinely get complete strangers to strip naked and reveal intimate details within three minutes of their first hello. They have treated cheating spouses; criminals; people who don't want their closest intimates to know The Truth (whatever that may be in a given situation); ingenious souls who do anything to get more drugs, or fewer; executives and socialites more concerned about their Image than their lives, much less their health; and even teenagers. And they see all of these in their most vulnerable moments. Nurses go into homes, bedrooms, workplaces, schools, and they keep. going. back. (Facades can be sustained only so long.) Nurses see the cracks in the veneer of carefully crafted public personae, and have uncanny ways of inspiring people to let down their guard and get real. Nurses have a spidey sense like none other. If they haven't discerned exactly what your game is it's because in the overall scheme of things your piddly problem just isn't important enough to warrant the effort. But nurses know when something's off, when people are disingenuous. And God help you once you've triggered that alert.
Don't expect endless sympathy and comfort. Nurses want those they serve to be whole and strong, healthy and self-responsible. This means they dispense Tough Love generously and often. They won't do for you what you can do for yourself, although they may spend hours helping you learn. If you have a symptom or a problem they'll ask what you did to contribute to it and what you can do to make it better. You'll emerge empowered, not coddled. Nurses will help. They'll provide resources, encouragement, referrals, and kicks in the backside. They'll be your loudest cheerleaders and harshest critics. But they're not likely to tuck you in and bring you milk and cookies if you're more than ten years old. And those bedpans and shots so common in nurse jokes? Forget it. Nurses will have you walking to the bathroom under your own power and administering your own injections before you know it.
Odd as it may seem, nurses aren't always looking for more ways to help more people, more tales of woe to hear, or more problems to solve. You have your own family and friends; use them. There is someone in your doctor's practice who actually is being paid to take your call at 2 AM; if you truly need attention at that hour, make him or her earn his or her money. The Emergency Room and EMS are for emergencies; you pay for them with your taxes, your insurance premiums, and your hard-earned pocket money. When you need them, use them. If you call your neighbor or friend or fellow church/PTA/club member, or whoever, who happens to be a nurse, and that person chooses to respond and help you, it is because she or he is a true friend, Good Samaritan, and decent human being (and you should reciprocate in kind). It is not because nurses are limitless givers, doormats, or pathetic, bored souls glad for your giving them something to do on Saturday afternoon.
It's Nurses Week. While I can't speak for the saints, rodents, or peppers, if you're inclined to make an appreciative gesture to nurses you're correct in realizing that there is no thank you big enough for lives saved, medical mishaps averted, wisdom dispensed, confidence inspired, small changes caught early enough to prevent big problems, or the sense that someone who understands somehow knew how to get inside your head and body and guide you back to equilibrium and to new levels of self-care such as you never knew were possible. Empty platitudes, jokes about sex, and caricatures straight from the 1950s don't do it. Safe working conditions, opportunities to practice on the cutting edge and to the full extent of our ability and license, and compensation that reflects our value would help. But for one not in a position to effect those? Be a straight shooter, a respectful fellow citizen, and a self-responsible human being. And you'll find nurses will do the same for you.
P.S.: We also accept Starbucks gift cards, spa days, soft robes, spring flowers, and great dinners! After all,
It's Nurses Week!
Saturday, October 6, 2012
Don't Poison It
I have taught wound care for years, to university students, to practicing clinicians, and to patients and their caregivers. Here's my lesson, adapted with apologies to the one from whom I learned it, presented so succinctly years ago. At the time I never knew how timeless and universal her teaching would be, and I've long since forgotten the proper citation for my inspiration. Somehow I feel sure she wouldn't mind:
* If it's dirty, clean it.
* If it's broken, protect it.
* If it's dry, moisten it.
* If it's wet, absorb it.
* If it has a hole, fill it up.
* If it's dead, remove it.
* If it's infected, treat it.
* Whatever it is, don't poison it.
That's it. Memorize those,and you can care for any wound, whether you nick yourself shaving, impale yourself on a garden tool, come out on the losing end of a bad car accident, or have the unfortunate experience of surgery gone wrong. Oh, I can turn those eight lines into an hour lecture or an entire course or series of courses, but, bottom line, those simple points are the essence of wound care.
Wounds can't heal properly around dirt, dead matter, and/or infection, so when those are present we need to get rid of them. It's common sense that most anything that's broken benefits from protection until it can be repaired, be it a cracked windshield or a broken heart, and broken skin is no exception. This is why God created bandages. And we know that things function best when they're in optimal condition, be they car engines, the bodies of Olympic athletes, or wounds trying to heal themselves. If those wounds are drowning in excess exudate ("leakage") or are cracked, hard and dry, it's mighty hard for the body to do its healing work. And an empty hole is a flashing neon "Vacancy" sign beckoning infecting organisms to a warm, welcoming place to settle in and have a good meal, so we want to shut down that sign by filling the vacancy, i.e., filling the hole.
We who care professionally for wounds and who have an admittedly bizarre fascination with how the healing process works and how we best can support it can spend years studying the fine points, and we do sit for days in conferences considering the latest data about how best to fill a hole, treat an infection, clean dirt, protect something vulnerable, and create the best possible environment for the body to do its work. But be not confused: We heal nothing. The patient's body does the work, and our job is to give the body the best possible working conditions and then get the heck out of the way.
My patients with wounds often think the purpose of my encounters with them is to change their bandages. It is not. A chimpanzee can learn to change most bandages and doesn't need a professional license to do so, and if a chimp can do it, so can a patient and/or family member or other caregiver. I'm happy to show them how. The only reason they need me is to help them know when a change in the way a wound looks portends healing or a complication, whether a wound is becoming too wet or too dry as it heals and so needs a change in therapy, and if they safely can relax confident in the knowledge that they're doing everything right. Truly, with a little help from his/her friends, the patient does all the work.
And here's the dirty little secret big pharma and insurance companies don't want you to know: In all of healing, not just wound management, the patient does the work. We with our licenses, degrees, and certifications just shine light down the path to wholeness and smooth the way for the body's efforts. Truly: Master light-shining and road-smoothing and you can have yourself a medical degree.
But as an industry we've come to the point of keeping our light under a bushel and of creating more roadblocks than we remove. The body's natural tendency is towards wholeness, yet at every turn we invade it, cut it open, place alien substances inside it, and douse it with chemicals, creating ever more new obstacles for an already challenged body to overcome. We're not evil nor mean-spirited; we're just good science run amok the same way cancer is good cells gone haywire and taking over their host until they kill it. Heaven knows antibiotics and other drugs have saved millions and truly turned the tide of human existence. And so have surgery and angioplasties and CT scans and more. In fact, these have proven to be so good that we look to them more and more . . . more than is necessary, more than is helpful, and more, to the point of being harmful. As with so many things, if a little is good, more isn't always better.
Big pharma's ads on TV say, "Ask your doctor" if you're depressed, impotent, sneezing, sleepless, diagnosed with one disease or another, anxious, headachy, lame, or merely human, yes, ask your doctor if the latest pill won't help you. Usually it won't, bottom line, or your doctor or other provider already would have prescribed it. Trust me: Your doctor watches TV, too, and knew all about those latest pills long before those ads ever ran. S/he doesn't need Madison Avenue to consult in your treatment.
What I long for ads to say is, "Listen to your body and give it a chance." Your doctor is doing his/her job when you walk out of the office without a prescription. Another x-ray, another blood text, another cardiac catheterization may not tell us anything more than your own inner knowing and the wise judgment born of your healthcare provider's years of experience examining and listening to people much like you.
What I long for ads to do is quote one of my old pharmacology professors: "There is only one drug that has no side effects: Arsenic. It just kills you." Sometimes, many times, less is more. That grocery bag full of pill bottles that Grandma carries around may be doing her more harm than good, and when she 'asks her doctor' if she doesn't need the latest pill advertised on TV and the doctor, pressed by financial imperatives to see 15 patients an hour (like Bill Clinton, I like arithmetic: That's four minutes each, folks, including the time to write prescriptions and document in the medical record, with no potty breaks or phone calls allowed), yes, the doctor figures it probably won't hurt and will make her happy and so writes another scrip. Then poor Grandma may go away feeling satisfied that her doctor has done something for her . . . and may add one more toxic substance to a body already processing everything else in that grocery bag of pill bottles, pills to treat the side effects of the side effects of pills, until her kidneys, her liver, or her soul simply says, "Enough."
Can't we say, "Enough" now, before Grandma, or any of us acquires the surgical scars, the stents, the tests, the pills, and the bills? Enough. "Enough" ≠ "none." Enough is enough, that is, enough is what one needs to heal and be whole, nothing more, nothing less.
A riveting, compelling, completely engaging portrayal of the issues in healthcare in America just has hit the big screen, and I cannot endorse Escape Fire enthusiastically enough. Do yourself a favor and go to the movies this weekend: http://vimeo.com/27450676
That last point in my wound care lecture bears revisiting: Whatever it is, don't poison it." Not all that many years ago, in an effort to serve point #1 and clean a dirty wound or avoid infection, we doused wounds with various forms of iodine, hydrogen peroxide, alcohol, and good ol' soap. These do clean wounds and kill bugs all right . . . and they also kill the new, healthy tissue trying to grow and heal. They're poison, albeit used with good intent, but far more toxic than is warranted in vast majority of situations (there are rare exceptions, rare). The rule of thumb now generally is not to put something into or on a wound that one also wouldn't put in one's eye. Truly. So we cleanse with normal saline (salt water), plain water, or wound cleansers formulated to mimic the body's own fluids and tissues.
Would that we reach the point of doing the same in all of healthcare. Would that providers have time and discernment to say, "Let's just watch this and see what happens; the body is working well to right itself. Let's support, rather than confound it. And I will be here for you to evaluate the process as it unfolds, and intervene if necessary. Yes, I have time, yes, I will, this is what I do." Would that the day comes when attending physicians, and other providers, are able truly and simply to attend, to be present.
Would that we prescribe nutrition (now absent from most medical schools' curricula) before pills, would that our research dollars be invested in natural healing and comprehensive approaches to wellness as much as in disease management and medicine, would that insurers pay for and promote health care instead of merely illness care, would that we teach proper exercise, stress management, sleep hygiene, the art of self-knowledge, and good, old-fashioned play. Would that we prize healthy relationships, work settings, and communities, and stop poisoning our air, water,and soil. Would that we consume real food instead of processed, nutrient-poor, chemical-rich pseudo-foods.
Would that each of us, before asking our doctors for the latest pill, ask our own body what it needs to be whole and require that our healthcare providers and policy makers supply this,and our insurers pay for it. May we each cherish the body we have been given, be supported in caring for it, and, yes, in every way see that we
Don't Poison It.
* If it's dirty, clean it.
* If it's broken, protect it.
* If it's dry, moisten it.
* If it's wet, absorb it.
* If it has a hole, fill it up.
* If it's dead, remove it.
* If it's infected, treat it.
* Whatever it is, don't poison it.
That's it. Memorize those,and you can care for any wound, whether you nick yourself shaving, impale yourself on a garden tool, come out on the losing end of a bad car accident, or have the unfortunate experience of surgery gone wrong. Oh, I can turn those eight lines into an hour lecture or an entire course or series of courses, but, bottom line, those simple points are the essence of wound care.
Wounds can't heal properly around dirt, dead matter, and/or infection, so when those are present we need to get rid of them. It's common sense that most anything that's broken benefits from protection until it can be repaired, be it a cracked windshield or a broken heart, and broken skin is no exception. This is why God created bandages. And we know that things function best when they're in optimal condition, be they car engines, the bodies of Olympic athletes, or wounds trying to heal themselves. If those wounds are drowning in excess exudate ("leakage") or are cracked, hard and dry, it's mighty hard for the body to do its healing work. And an empty hole is a flashing neon "Vacancy" sign beckoning infecting organisms to a warm, welcoming place to settle in and have a good meal, so we want to shut down that sign by filling the vacancy, i.e., filling the hole.
We who care professionally for wounds and who have an admittedly bizarre fascination with how the healing process works and how we best can support it can spend years studying the fine points, and we do sit for days in conferences considering the latest data about how best to fill a hole, treat an infection, clean dirt, protect something vulnerable, and create the best possible environment for the body to do its work. But be not confused: We heal nothing. The patient's body does the work, and our job is to give the body the best possible working conditions and then get the heck out of the way.
My patients with wounds often think the purpose of my encounters with them is to change their bandages. It is not. A chimpanzee can learn to change most bandages and doesn't need a professional license to do so, and if a chimp can do it, so can a patient and/or family member or other caregiver. I'm happy to show them how. The only reason they need me is to help them know when a change in the way a wound looks portends healing or a complication, whether a wound is becoming too wet or too dry as it heals and so needs a change in therapy, and if they safely can relax confident in the knowledge that they're doing everything right. Truly, with a little help from his/her friends, the patient does all the work.
And here's the dirty little secret big pharma and insurance companies don't want you to know: In all of healing, not just wound management, the patient does the work. We with our licenses, degrees, and certifications just shine light down the path to wholeness and smooth the way for the body's efforts. Truly: Master light-shining and road-smoothing and you can have yourself a medical degree.
But as an industry we've come to the point of keeping our light under a bushel and of creating more roadblocks than we remove. The body's natural tendency is towards wholeness, yet at every turn we invade it, cut it open, place alien substances inside it, and douse it with chemicals, creating ever more new obstacles for an already challenged body to overcome. We're not evil nor mean-spirited; we're just good science run amok the same way cancer is good cells gone haywire and taking over their host until they kill it. Heaven knows antibiotics and other drugs have saved millions and truly turned the tide of human existence. And so have surgery and angioplasties and CT scans and more. In fact, these have proven to be so good that we look to them more and more . . . more than is necessary, more than is helpful, and more, to the point of being harmful. As with so many things, if a little is good, more isn't always better.
Big pharma's ads on TV say, "Ask your doctor" if you're depressed, impotent, sneezing, sleepless, diagnosed with one disease or another, anxious, headachy, lame, or merely human, yes, ask your doctor if the latest pill won't help you. Usually it won't, bottom line, or your doctor or other provider already would have prescribed it. Trust me: Your doctor watches TV, too, and knew all about those latest pills long before those ads ever ran. S/he doesn't need Madison Avenue to consult in your treatment.
What I long for ads to say is, "Listen to your body and give it a chance." Your doctor is doing his/her job when you walk out of the office without a prescription. Another x-ray, another blood text, another cardiac catheterization may not tell us anything more than your own inner knowing and the wise judgment born of your healthcare provider's years of experience examining and listening to people much like you.
What I long for ads to do is quote one of my old pharmacology professors: "There is only one drug that has no side effects: Arsenic. It just kills you." Sometimes, many times, less is more. That grocery bag full of pill bottles that Grandma carries around may be doing her more harm than good, and when she 'asks her doctor' if she doesn't need the latest pill advertised on TV and the doctor, pressed by financial imperatives to see 15 patients an hour (like Bill Clinton, I like arithmetic: That's four minutes each, folks, including the time to write prescriptions and document in the medical record, with no potty breaks or phone calls allowed), yes, the doctor figures it probably won't hurt and will make her happy and so writes another scrip. Then poor Grandma may go away feeling satisfied that her doctor has done something for her . . . and may add one more toxic substance to a body already processing everything else in that grocery bag of pill bottles, pills to treat the side effects of the side effects of pills, until her kidneys, her liver, or her soul simply says, "Enough."
Can't we say, "Enough" now, before Grandma, or any of us acquires the surgical scars, the stents, the tests, the pills, and the bills? Enough. "Enough" ≠ "none." Enough is enough, that is, enough is what one needs to heal and be whole, nothing more, nothing less.
A riveting, compelling, completely engaging portrayal of the issues in healthcare in America just has hit the big screen, and I cannot endorse Escape Fire enthusiastically enough. Do yourself a favor and go to the movies this weekend: http://vimeo.com/27450676
That last point in my wound care lecture bears revisiting: Whatever it is, don't poison it." Not all that many years ago, in an effort to serve point #1 and clean a dirty wound or avoid infection, we doused wounds with various forms of iodine, hydrogen peroxide, alcohol, and good ol' soap. These do clean wounds and kill bugs all right . . . and they also kill the new, healthy tissue trying to grow and heal. They're poison, albeit used with good intent, but far more toxic than is warranted in vast majority of situations (there are rare exceptions, rare). The rule of thumb now generally is not to put something into or on a wound that one also wouldn't put in one's eye. Truly. So we cleanse with normal saline (salt water), plain water, or wound cleansers formulated to mimic the body's own fluids and tissues.
Would that we reach the point of doing the same in all of healthcare. Would that providers have time and discernment to say, "Let's just watch this and see what happens; the body is working well to right itself. Let's support, rather than confound it. And I will be here for you to evaluate the process as it unfolds, and intervene if necessary. Yes, I have time, yes, I will, this is what I do." Would that the day comes when attending physicians, and other providers, are able truly and simply to attend, to be present.
Would that we prescribe nutrition (now absent from most medical schools' curricula) before pills, would that our research dollars be invested in natural healing and comprehensive approaches to wellness as much as in disease management and medicine, would that insurers pay for and promote health care instead of merely illness care, would that we teach proper exercise, stress management, sleep hygiene, the art of self-knowledge, and good, old-fashioned play. Would that we prize healthy relationships, work settings, and communities, and stop poisoning our air, water,and soil. Would that we consume real food instead of processed, nutrient-poor, chemical-rich pseudo-foods.
Would that each of us, before asking our doctors for the latest pill, ask our own body what it needs to be whole and require that our healthcare providers and policy makers supply this,and our insurers pay for it. May we each cherish the body we have been given, be supported in caring for it, and, yes, in every way see that we
Don't Poison It.
Tuesday, July 24, 2012
Small Courtesies
One who ignores another's milestones and major life events is not a friend. Failure to acknowledge serious illness or death, marriage, or achievement of an important life goal is but affirmation of the obvious: An acquaintance is no more than that, and is lacking in the social graces as well. Most likely one doesn't much care, or understands such disregard as a clear indication that the relationship itself merits being disregarded.
But what of the small things? The birthday greeting that is days, weeks, or months late. The small favor forgotten. The overlooked invitation. The gift that isn't: A lukewarm "Let me know where you want to go out to celebrate your promotion," with no offer to treat or of a date or of a plan, or "It's so hard to shop for you that I haven't gotten around to buying your present [although the occasion has passed and I haven't made much effort]."
Few of us need another birthday card, social obligation, material object, or free meal, and it's easy to reason that careless friends mean well but are busy or disorganized. But both parties lose when we accept that sad conclusion.
It's true that timely birthday and holiday greetings, casual favors, little "just because" gifts, acknowledgments of small triumphs and setbacks, and celebrations no matter how modest are small courtesies, not major life needs.
But good friends are worthy of small courtesies.
Anger and fear abound these days, appearing as road rage, sullen silence, passive-aggressive manipulation, endless self-justification, prolonged seething that suddenly erupts into violence, malignant sadness, compulsive fault-finding, adamant self justification, and defensive isolation.
I wonder if more birthday greetings carefully delivered on time, more I-thought-of-you-when-I-saw-this-and-wanted-you-to-have-it small gifts, more flowers and home-grown vegetables handed over the back fence, more come-for-tea-Sunday-afternoon or I'd-like-to-gather-a-few-friends-next-Friday-to-celebrate-your-new-job, more invitations reciprocated, in short, more simple, small courtesies, if these might be a larger-than-expected step towards peace on earth, and if they might make a significant dent in the epidemic of "cardiodiabesity" and other lifestyle diseases characterized by people trying to fill and comfort themselves in a world that may feel colder and more empty than an observer might suspect.
It seems an experiment worth trying: Indifference, convenience, habit, and self-preoccupation, or
Small Courtesies?
But what of the small things? The birthday greeting that is days, weeks, or months late. The small favor forgotten. The overlooked invitation. The gift that isn't: A lukewarm "Let me know where you want to go out to celebrate your promotion," with no offer to treat or of a date or of a plan, or "It's so hard to shop for you that I haven't gotten around to buying your present [although the occasion has passed and I haven't made much effort]."
Few of us need another birthday card, social obligation, material object, or free meal, and it's easy to reason that careless friends mean well but are busy or disorganized. But both parties lose when we accept that sad conclusion.
It's true that timely birthday and holiday greetings, casual favors, little "just because" gifts, acknowledgments of small triumphs and setbacks, and celebrations no matter how modest are small courtesies, not major life needs.
But good friends are worthy of small courtesies.
Anger and fear abound these days, appearing as road rage, sullen silence, passive-aggressive manipulation, endless self-justification, prolonged seething that suddenly erupts into violence, malignant sadness, compulsive fault-finding, adamant self justification, and defensive isolation.
I wonder if more birthday greetings carefully delivered on time, more I-thought-of-you-when-I-saw-this-and-wanted-you-to-have-it small gifts, more flowers and home-grown vegetables handed over the back fence, more come-for-tea-Sunday-afternoon or I'd-like-to-gather-a-few-friends-next-Friday-to-celebrate-your-new-job, more invitations reciprocated, in short, more simple, small courtesies, if these might be a larger-than-expected step towards peace on earth, and if they might make a significant dent in the epidemic of "cardiodiabesity" and other lifestyle diseases characterized by people trying to fill and comfort themselves in a world that may feel colder and more empty than an observer might suspect.
It seems an experiment worth trying: Indifference, convenience, habit, and self-preoccupation, or
Small Courtesies?
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