"You Brung Me Dem Greens, So Dem's What I Et"

Trying to help an elderly, legally blind, illiterate patient manage his diabetes at home alone is a dicey undertaking. Unable to remember medications more than once a day; unable to read instructions, see reminders, or understand the numbers on his blood glucose meter; and dependent for food on whoever happened to shop or share on a given day or given week, "José" was for me a project. A Southern Black man with an unlikely Hispanic name who landed in Chicago during the Great Migration decades before, José had survived his younger years by fixing cars and picking up whatever unskilled jobs were to be had, and as an old man lived with a string of women passing through his bedroom but otherwise not in his life, a few fellows who turned up now and then to play cards and see what cons they could pull off, and once or twice yearly visits from a daughter who lived elsewhere but used her father's apartment as free accommodations when she came to town to visit her friends. José was estranged from his wife, and his son was in jail. And his blood glucose was elevated.

236, 274, 341, 299. I would arrive early to do the testing that José couldn't, and the results always were well above the "ideal" target range, which for a fellow of his age and his circumstances was approximately 90-120. Lowering the numbers by adjusting his medication was risky, because there was a constant possibility that no one would happen to bring food one day and José simply wouldn't eat. In that case his blood sugar could plummet dangerously low. Mentally competent, José was adamant that he would not move and didn't like the home-delivered meals that a well-meaning social worker once had ordered for him.

In those days one of my neighbors offered her garage as the drop-off point for Community Supported Agriculture shares, and always had unclaimed boxes of fresh organic produce left over from deliveries. She began bringing them to me, and I'd load their contents into an assortment of plastic bags and the next morning take them to poorly nourished, high-risk patients who didn't have the resources to procure such things themselves. One day I dropped off a bag for José.

My next nursing visit was the following day, when I pricked José's finger and waited for the meter to register the usual elevation. Instead it read "96."

"José!" I exclaimed, "That's perfect! What did you do differently yesterday; what did you eat?"

He looked at me tolerantly and replied, "You brung me dem greens, so dem's what I et."

With the once-daily medication regimen that his doctor finally had worked out and a single delivery of fresh produce instead of fast or convenience food, José's blood sugar level went from dangerously elevated to normal.

The problem was access to good foods. We had found ways to work around blindness, illiteracy, difficulty remembering medications, and all the rest, but with poor results . . . for want of food, proper food.

I wish José's problem were unique.

"Ronald" was a tall, skin-and-bones cardiac patient who had undergone heart surgery, and lived in a rough, "food desert" neighborhood on Chicago's west side. His wife once explained that going shopping entailed a long walk to an overpass where they could cross a busy expressway followed by a long walk back on the other side until they reached a grocery store. Then whatever they purchased had to be carried back to the overpass and back home, regardless of the weather, gang activity, or other circumstances. The only alternative was an overpriced "mom and pop" corner store that sold alcohol, lottery tickets, and abundant quantities of chips and pop, with a few staples and dairy products tucked in among the rest.

I told another of my neighbors about Ronald, and she immediately offered excess vegetables from her own garden. Ronald was a man of few words, but he thanked me when I delivered her gift, and the appreciation in his eyes was genuine. But the best part was my visit the next week, when Ronald told me how very much he had enjoyed those vegetables. In fact, although he had been spending his days resting in his bedroom, the day his wife was preparing the vegetables she turned around and found him sitting at the kitchen table.

"Whatchoo doin' there?" she had asked him, incredulous.

"I'm gonna say the blessing," he told her calmly, "because this is a blessing." He added for me, "And it is,it truly is."

That day Ronald enjoyed the most nutritious food he'd had since he left the hospital, if then, and also finally had been inspired to make his way out of his bedroom. When I discharged him from home healthcare a short time later he had progressed to the front porch, and was beginning to walk down the street.

All from an occasional bag of produce that was more than the family that grew it could use.

Ironically, among the boarded up buildings in Ronald's neighborhood there is an abundance of open space. And while José's neighborhood is more densely populated, residents determinedly try to grow what they can.

"Willie" was a long term patient of mine who immediately planted a garden where the city had torn down old, dilapidated buildings across the street from his home. Knowing that land was to be developed as the new district police station I gently suggested Willie's efforts might be for naught and better directed elsewhere, but he was determined . . . to the very moment the bulldozers upended his little plot. "Arlene" had nothing but a concrete stoop outside the door of her row house in the projects, but she carefully tended pots of tomatoes and greens. I drive through other neighborhoods where the sides of buildings meet the sidewalks, which in turn meet the streets, yet residents find patches of land to grow vegetables and herbs, or spots in the sun where pots can be placed and tended.

We know that nutrition is key to good health, and we know that our most malnourished and underserved populations have deep historical roots in caring for the land and growing food, yet vacant lots abound with broken bottles, old tires, and gang activity while we promote health with pharmaceuticals and things medical.

This is easy and relatively inexpensive to change, but it requires some effort and more than a little thought "outside the box," because our medical and social thinking is very much boxed in!

I have written about the importance of change being easy and natural for those affected. In this instance that means engaging people where they already go, tapping the authority they already respect, appealing to what they already value, and strengthening social networks that already are the fibers of their lives.

José and Ronald are African American and live in communities that are deeply religious and have strong ties to the church. Suppose early one Saturday morning the pastor of a church like theirs called leaders of his or her congregation to say that there was something special planned for the next day's services and some extra effort spiffing up the church was in order. I can see the faithful cleaning, touch-up painting, polishing, making their house of worship a reason for pride when their pastor's surprise was unveiled the next day. But suppose the next day just as the pastor stepped into the pulpit there came a great crashing noise and a band of hooting, hollering, unruly youth barged in pushing and pulling dumpsters from the alley, and overturned them, leaving piles of garbage in that freshly cleaned sanctuary. Imagine the pastor continuing his or her sermon: "Scripture tells us that our bodies are temples of God. While we are horrified that someone would dump garbage in our sacred space here, how is it that we put garbage in our equally sacred bodies every day, polluting and poisoning our very own holy temples? You come here wearing your best clothes, with your hair and make-up just so and your shoes freshly shined, just as you cleaned and polished the church yesterday, but is what is inside of you as vile and foul as this rotten, smelly garbage now before us in this sanctuary?"

And suppose that church became a hub for promoting good nutrition, in the name of stewardship of body temples. There would be classes about nutrition and meal planning, gardening groups, and a farmer's market, all springing from such existing activities as the Mothers' Room, the deacons' council, the Sunday School, and more. Fried chicken, macaroni and cheese, ham, and caramel cakes at church suppers would be supplemented, if not replaced, by nutritious, home-grown alternatives, prepared and served by member cooks and kitchen volunteers.

In José's and Ronald's neighborhoods, people "hang out" together, on front porches, street corners, or the "ramps" of public housing. Suppose those groups were mobilized to turn vacant lots, parkways, and back yard plots into gardens. The much-valued camaraderie still would be there, but instead of time being frittered away with idle chatter, games, and crime, gardens would rise, with friends and neighbors there to help, encourage, and celebrate one another. Even gang members who today guard their "turf" might be enlisted to tend and protect it in another way. The harvest not only would feed those who grew it, but would go to the church for those healthier church suppers and for the farmer's market.

Suppose the youth in the church learned to be "personal shoppers" and went in the church van every couple weeks to shop for people like Ronald, who can't hike to the overpass and carry purchases home on foot. Suppose neighborhood schools were enlisted, where students could receive community service credits for assisting with the gardens, classes, and shopping. Suppose assignments in science, English, reading, and other classes incorporated this theme. Suppose students designed a web page for the program, and solicited donations of plants, seeds, and tools. Imagine containers at the checkout counters of home improvement stores and gardening centers inviting patrons to donate not canned goods for a food pantry (so people can eat for a day) but compost and mulch and gardening supplies (so people can feed themselves for a lifetime).

Recently I began the study of Taoist T'ai Chi, after hesitating on learning that all of the instructors are volunteers. "Who has the kind of time to put forth such effort on a volunteer basis?" I wondered. "Will I just be wasting my time?" The answer, I've discovered, in a word is "retirees." Classes are taught by energetic, engaged, enthusiastic highly capable world-traveling former executives and all manner of folks who have come together around their love of this practice and who are eager to share it. Imagine the retirees who love to garden, and would be glad to share their expertise and labor, clergy who no longer serve churches but would enjoy creating sermon notes on the topic for busy pastors, and people who simply have a passion for cooking and eating well and would be happy to share it.

The resources to make programs such as this happen are there. The cost is not great. The need is for leadership from within the community, and resources to assist those leaders in growing and developing their programs.

Where we often err is in assuming that solutions for problems in health and healthcare lie with the "experts," that is, with doctors, nurses, and others who practice professions, as well as scientists, professors, politicians and policy makers, and those ubiquitous "consultants" who look sharp, speak well, charge hefty fees, and ultimately produce little of substance and value.

Many of the answers and resources needed to move forward are latent among the very populations who present with the "problems." This is not about blaming the victim; rather it is about empowering those who are best suited for and most highly invested in making positive change happen in their own lives and in their communities. Identifying and mobilizing appropriate communities is critical, and these must be those that already exist: Church groups, neighbors who socialize, school activities, etc. Surely somewhere in the past every one of us has endured mandatory "group projects" in school where membership was assigned by the teacher or professor and results were mediocre at best, after everyone had endured a painful process of questionable educational value. Indeed, many of the health problems we see are born largely of bad habits: Sedentary lifestyles, poor food choices, and general poor self care. But the energy of true community overcomes the inertia of habit, and it is this that needs to be tapped.

It is important, too, that the various components of community programs be integrated so they are supported and reinforced on multiple fronts. Many will say, "We have community gardens" or "There was a health program at our church last year." While those are valuable and good, small, isolated efforts do not have the same impact as comprehensive, "home grown" programs powered from the "inside" (not imposed by outsiders), where the message is repeated in different forums and in different ways, all complementary and collectively engendering and sustaining a greater energy than a single lecture series or garden club can deliver.

Where to start? Perhaps by driving through a neighborhood like Ronald's, or José's, or yours, knocking on a church or community center door, chatting up the neighbors on the porches and street corners, and starting new community gardens by planting seeds of possibility. Then it very well could be that one day more infirm elders and others would begin to break out in health, just as José did the day his blood sugar dropped to 96, and when outsiders looking on asked in wonder how this could be people could say of that community, in more ways than anyone realized,

"You Brung Me Dem Greens, So Dem's What I Et."

Bring a Solution

Bring a solution.

As far back as I can remember I've told anyone working for me that I don't like surprises, so if there's trouble on the horizon tell me, we'll work through it together, and I'll have his or her back. But if my first clue that something might be amiss comes only when the excrement hits the fan, then my underlings are on their own while I join the lynch mob out to get them. And, when they do come to me with a problem, they also are to bring a solution.

These count as among with wisest dictums I've ever issued, serving to keep communication open even if some people have had to be scared into it, and keeping the focus on forward movement towards goals. Needing to bring solutions along with problems keeps people from being stuck at the level of the difficulty, forcing them to think about what would make things better. It decreases whining and blame-fixing, and effectively thwarts any tendency to try to delegate "up." But most importantly, it brings action ideas from those most closely associated with the problem, as well as closest to resources to solve it, along with insight into potential impediments to the process. The proffered solutions don't need to be perfect, or even very good. They just have to be the best jumping-off point the person identifying the problem can offer. And we go together from there. I will tell you that people generally solve their own problems, and often all I need to do is help clarify, provide resources, and/or keep obstacles out of their paths. It's always made my job easier and our results phenomenal, credit primarily to others than myself.

In this space I tell stories about problems, oddities, and ironies in healthcare, giving "outsiders" an "inside" look and bringing to light situations that otherwise might go unnoticed. From time to time when I've told of a challenging clinical scenario or a broken system someone will ask how such circumstances are to be fixed. And once again I find myself saying, "Those closest to the problem must bring a solution." We can help them do this, and then work together for positive change, but they can lead us to the starting line and then help us stay on course.

Over the next few weeks I'll suggest some jumping-off points that together can help to address the headaches and heartaches of health and healthcare in new ways. Here's the first one:

Help People Become Helpers

Fred Rogers used to tell of being frightened by things in the news as a child and his mother counseling him to "Look for the helpers" in those situations, because there always would be people working to help. We would do well to realize that there also are many people who want to help, who are willing to help, but who don't know how or don't realize their assistance would be valuable.

"Luke" was a seriously ill heart failure patient who also had diabetes, vascular disease, and a host of other problems. One of my favorite patients, he lived in an apartment in a Cabrini-Green high-rise during some of the worst times in "the projects." It was an ongoing struggle to keep him hydrated without overloading his body with more fluid than his heart could handle, to find the best cocktail of medications to help him without potentially deadly side effects, and to teach him and his family to manage his daily care with their few resources and dangerous living circumstances. Some days I would find him sitting on the side of his bed bloated with fluid, hooked up to oxygen, and struggling to breathe; other days he would be smiling and telling me that he had been able to walk to the bathroom and sit in the living room to be with visitors for awhile the day before.

But the time came when I couldn't manage his plethora of problems by myself with the physician only on the other end of the phone line, and all involved knew Luke needed to see his doctor, undergo some tests, and have his treatment plan adjusted. I made the appointment, arranged for the hospital van to meet Luke in front of his building, and hoped he would be having a good day when the time came.

But then Luke gave me a dose of reality.

"I can't go," he said.

"Why not? You must!" I replied, detailing all the reasons he already knew.

"Dem boys. I can't go out there with dem boys. I'm too weak. I can't take care o' myself. I can't even walk."

Luke looked at me with sheer terror in his eyes, and managing both his emotions and shortness of breath explained in winded bursts that the gangbangers hanging out in and in front of his building never would let him pass, and that indeed they would prey on a helpless old man, robbing him at the very least and perhaps harming, even killing him. Luke was a prisoner in his apartment.

I always had a police escort when I saw Luke, and more than once my escort pointed out cause for concern as we approached the building and instructed me to be attentive and prepared to leave suddenly and quickly. The "rules" were that once inside a home I was in charge of the clinical encounter, but going to and from the apartment or any time a danger arose inside the officer was in charge and I did as he told me. On the basis of the warnings I had received from my escorts along with my own observations, I had no doubt Luke was right about the danger awaiting him. The day before his appointment the most Luke would do was agree to scope out the situation the next morning and decide then if he dared venture downstairs to meet the hospital van.

There had to be a better option, I thought, so I called the police lieutenant who provided my escorts and explained the problem. Did he know anyone in the 18th District, where Cabrini-Green was located, I wondered, who might arrange to have a squad car nearby and visible around the time the van was to arrive for Luke? I still can hear his voice telling me, "I have a very good friend over there!" and that a call would be made. I think I fell asleep that night with my fingers crossed.

The next day dawned, bringing with it mounds of newly fallen snow. Clearing snow in Cabrini-Green wasn't high on anyone's priority list, so Luke would be facing one more hurdle. The likelihood of his making it to the medical center seemed to shrink with each passing hour.

The following day I headed back to Luke's home, ready to hear that he had missed the appointment, and trying to think of what more we could do at home with no direct physician evaluation or input and no further test results. Climbing the stairs to Luke's apartment was particularly onerous that day, probably because of the added weight of my own very heavy heart.

But once there and inside I found a calm, bright-eyed, smiling Luke! "Did you go to the doctor yesterday?" I asked.

"Yes, I did, and here are my papers from him," Luke responded, adding, And I couldn't believe what happened!" He went on to explain.

The previous day not only were there big drifts of snow between Luke and any place the van could access, but also the elevators in his building were out of service, as often was the case. But at the appointed hour for Luke to be downstairs there was a knock on his door, and "dem boys" were there, looking for him. No doubt initially terrified to see his visitors, Luke soon discovered they were on a mission of mercy. "Dem boys" carried Luke, in his wheelchair, down those flights of stairs, out of the building, through the snow, and into the van. And when the van brought Luke home "dem boys" carried him back to his apartment, through still more snow, up the stairs, wheelchair and all. Luke had no idea how they knew about his appointment or his need for help.

I, too, never learned exactly how this came to pass, but don't believe the police requested that level of service. Most probably an officer stopped by for a chat, explained that an old man needed to go to the doctor, and pointed out that it would be best if he didn't encounter any trouble doing so. I would bet that, once learning of the need, "dem boys" took care of the rest themselves.

Over the years I encountered many locals of the ilk of "dem boys." From time to time my police escort needed to intervene to assure our safe passage, and now and then we had an occasional mild shouting match: "You DCFS? [child protective services, never a welcome visitor]" I'd be asked harshly. "You blind?" I'd reply, brandishing my stethoscope, or perhaps, "You new in da 'hood, you don't know Sue-the-nurse?"

But when I needed to call EMS to transport a seriously ill patient from Cabrini to the hospital I asked "dem boys" for help every time. To be clear, EMS was in and out of those buildings all the time and didn't need "help," but being shown the respect implicit in a request for assistance shifted the tenor of the interactions with "dem boys" 180 degrees, and smoothed the way for the EMS crew to follow. Shouting was a standard mode of communication in Cabrini, and no offense was taken at raised voices. So I'd emerge from a stairwell and shout at "dem boys" hanging outside, "Hey, a little help here!," ignoring any initial menacing posturing on their part. "I have an old lady on the 9th floor who's really sick and needs to get to the hospital. The ambulance is on the way. I need to go to somebody else, so I need you to be sure the ambulance crew gets up to her and gets her out quickly and safely. Can you do that, and get them an elevator?"

"Dem boys" came through every time.

Over time as I grew more comfortable and well known in Cabrini I made more visits without the police, and without having to ask had "local security" looking out for me each time.

For a host of reasons, "dem boys" hadn't had much success in school, weren't highly marketable, tended to be rough around the edges socially, and couldn't have made a living on the wages of any unskilled labor positions they might have managed to secure, so a life of finding belonging among their "homies" while dealing drugs, running whatever cons they could, and looking for "opportunities" on the streets became their best apparent option. But no matter how tough, how hardened, how angry they were, when asked for help and told how to help, they delivered.

So the first part of my answer to the question of how to fix problems of health and healthcare is to stop looking so very much to the leaders and experts and politicians for answers and instead shift the focus to helping those in the communities and populations we serve become helpers themselves. This does not mean withdrawing or lessening services or support, but rather marrying those with the strengths and possibilities inherent among our patients and in their communities. They are closest to the problems, closest to local resources (make no mistake about who controlled the elevators in Cabrini-Green!), and may be the most credible "experts" to those at highest risk. Where they are more marginal, as "dem boys" certainly were, the best rather than the worst is most likely to be released in them when they are respected as people who can make things happen in their communities instead of treated as somehow lesser for want of sophistication, formal credentials, and finesse.

Likewise, if similar respect were shown the nurses, physicians, and others engaged every day in clinical practice when problems in healthcare delivery need to be solved I have no doubt tremendous insight and resources would emerge. As I write this I also am preparing a course in business development for home healthcare geared to executives and other leaders in the field, and have realized along the way that every idea I ever had that grew into a successful business-building, revenue-generating program came from my experience in practice, not from my tenure in executive suites or ivy-covered towers. I also have taken a gander at curricula of MHA (Master of Healthcare Administration) programs across the country and have yet to find a single one with a clinical component. Courses in finance, strategy, policy, leadership, the politics of healthcare, systems and structures, healthcare law, etc. abound, but there are none that deal with clinical problem-solving, how physicians and other clinicians are trained to think, how various professionals are educated and what they can or must do, issues in the development and management of medical practices, patients' experience in healthcare, the development and use of clinical science, or anything else pertaining to the substance of the businesses MHA students aspire to manage. Yet often it is these executives who determine policies and programs for patient care. I am reminded of a time when I was brand new and very green in my first Director position and summoned to tour new surgical suites under construction. Although I never worked in the OR a day in my life, since I was the Director I was asked to determine where equipment should be mounted for the surgical team to use during operations. Lord have mercy!

Just as "dem boys" needed to know their help was needed and how to deliver it, so avenues need to be opened through which the expertise and insight of those closest to healthcare problems, i.e., patients, communities, and practicing clinicians, can flow. Executives and politicians can work the system to make things happen, but those closest to the problems best know what the essence of those things needs to be.

I chose a career in nursing many, many years ago because my youthful self wanted to help people. What I have learned over the decades that followed is how very pervasive that desire is, with different people having different gifts for helping in different ways. Instead of seeing only "patients" or "personnel" or "problems," we would do well to see potential helpers who, with our respectful collaboration, may in the face of challenges prove best suited to

Bring a Solution.

Easy and Natural

Easy and natural. It took many years and a patient like "Beatrice" to drive home to my conscious awareness how very important those two words are.

There's just no nice way to say it: Beatrice was a mess. In her early fifties, morbidly obese, living with multiple chronic and serious health problems, and in and out of the hospital as often as some people are in and out of the grocery store, Beatrice was a challenge from the moment I first walked in her door. Her home was a sizable apartment in a new development not far from the site of Chicago's old Cabrini-Green, and I supposed Beatrice and her family had been "resettled" there when their building in "the projects" was scheduled for demolition. Despite being new, the apartment held decades of clutter; whatever piles and sprawls had been in the old Cabrini home probably had been shoveled more or less intact into moving boxes, transported to the new location, and dumped out again just as they had been before. The insect population would have traveled along, too, explaining the "creepy crawlies" in evidence from time to time, but I never did figure out how seemingly years of filth had managed to accumulate in a residence that was so newly constructed.

Most recently hospitalized for heart failure, Beverly was bloated with retained fluid in addition to her baseline body fat, and she barely could move. Yet she described herself as the caregiver for her sister, who sat on the small sofa adjacent to Beatrice's chair, smiling brightly but staring vacantly or offering odd comments that seemed to come from nowhere and pertain to nothing. With their respective disabilities there was little the two of them could do except sit side by side staring at the television, and that's pretty much how they spent their days.

Beatrice's daughter also lived with them but was employed and rarely home when I was there. Beatrice's twenty-something year-old granddaughter and five or six year-old great-grandson completed the household, at least as far as I could tell. More than once I caught myself doing the math: If Beatrice was in her early fifties but had a five or six year-old great-grandson clearly there was a multigenerational pattern of very young motherhood in this family. Beatrice had little formal schooling, her granddaughter was struggling to earn her GED, and employed doing unskilled labor, her daughter probably also had little education.

But there they were, often only Beatrice and her sister when I visited, perhaps with the child running about. The granddaughter popped in and out, agreeing to pick up medication for Beatrice and help her go to the doctor, sometimes following through and sometimes not. Indeed, there were times the granddaughter was asleep in a back bedroom and could be only minimally roused, a circumstance that, particularly in a setting like that, triggered my suspicions of illicit substance usage.

A bare mattress on a bed frame sat in one corner of the living room; I never learned if it actually served as someone's bed or if it just was another piece of household detritus that somehow had settled in that location. Occasionally there was a single rumpled blanket, but usually it was just a blank expanse in the room, for which I was grateful as it was the only place to sit or set anything down. Assorted pill bottles were sprinkled about the home in no apparent order and seemingly without consideration of for whom they had been prescribed. Eating happened when someone was hungry and found food among the piles of dirty dishes in the small kitchen or when the granddaughter came home with a bag from a local fast food establishment.

Beatrice was friendly and seemed content to have me around, yet I always had the sense that if I never went back she might briefly wonder what happened but would think little more of it, because in Beatrice's life things just happened to her; she was a passive recipient of fate, not an active agent of her own being. We agreed that Beatrice did not want to have to go back to the hospital and that it would be good to focus on things that could make that less likely. Beatrice made affirmative noises when I explained ways she could act to facilitate this goal, when she realized I was addressing her, that is, as she often looked over me and towards the cartoons on TV. I gathered up all the medication bottles I could find, sorted them according to owner, pulled out the ones currently ordered for Beatrice, and set those pills up in seven-day organizers to make management easier. Beatrice agreed that this helped, but the contents of the boxes week after week suggested that her medication usage continued to be sporadic at best.

One day when the granddaughter once again brought high-fat, high-sodium, nutrient-poor offerings from the local fast-food chicken place, and as I sat looking at pill boxes that should have been empty for the week but instead were more than half full, I stopped. Just stopped. Teaching and explaining and setting up systems and reminders clearly weren't working, and I wondered exactly what to do differently. And then I caught myself starting to say, "When you have breakfast . . . " because we healthcare providers tend to associate many actions, desired and undesired, with meals, as in, "Take your medicine with breakfast," or "Don't have any more/less than one full cup of liquid with each meal."

But it hit me suddenly that Beatrice didn't have breakfast, or any meals. She ate when she was hungry or when someone happened to cook or bring food home. Likewise, Beatrice didn't use clocks, and I don't remember seeing a clock in the home. She went to bed when it was dark and she was tired and/or there was nothing else to do, and she rose when it was light and/or she was awake and feeling more or less rested, hungry, or in need of a bathroom. Is it any surprise she didn't remember her medications, or that, as a passive recipient of life events she perceived as beyond her control, she failed to heed or act upon instructions? To her mind my role was to "check on" her and take action if something was amiss; that she also might have a role in her health and healthcare probably was a most alien, if not incomprehensible, notion.

There in the midst of one of the most extreme clinical situations I've seen, the futility of "teaching" Beatrice to eat regular meals, properly spaced and nutritionally appropriate, and to use those time points along with another called "bedtime," as in a regular, more or less consistent time of retiring for the night, to schedule her medications and other self-care practices, struck me forcefully, and I sat mute, considering. And, if Beatrice had little or no experience of a correlation between her actions and the events in her life; if what she knew was powerlessness sprinkled with seemingly random moments of pleasure and pain, the likelihood that she would modify her habits in the direction of better health and sustain that change was small. Can it be done? Probably, at least to some extent. Can a nurse with limited visits and the constraints of public aid financing make it happen? Unlikely.

Sitting on that bare mattress in the corner, gazing absently towards the dirty kitchen as Beatrice and her sister gazed equally absently at the television, I realized that to help any patient make any change for better health it is incumbent on providers to make that change as easy and natural for the patient as possible. If what we're asking is too difficult, too confusing, too overwhelming, too time-consuming, too disruptive to the rest of a patient's life, or just too bizarre, too different from anything a patient usually does or ever has done before, we're likely to meet with frustration and failure . . . and more hospital stays, more healthcare expenses, more complications, more discouraged or resigned patients, more waste, and more disappointment.

Yet all too often "easy and natural" don't figure into our approaches at all. Instead, we offer up standardized protocols and evidence-based recommendations straight from the most current conferences and journals, and we hand out the same tools and prescribe the same systems to everyone. Make no mistake: The protocols and recommendations and tools and systems are good, often very good, but if they're not adapted to fit into the specific lives of individual patients we're setting everyone up for disappointment and problems.

Some years ago I worked for the home health division of a major medical center affiliated with a rehabilitation hospital, and the rehab patients often came to us. The nurses at the rehab hospital made magnificent medication charts for patients who were going home, with everything clearly set out, easy to read, and color coded; truly, those charts were exquisite. Except that each medication dosage was assigned to a specific clock time: Take this pill at 7 AM, these others at 8 AM, another at noon, one at 5:30 PM, and the remaining ones at 9 PM. I can't tell you how many patients I found over the years trying to turn their lives inside out in order to take medications at those specific times, because that's what the chart said to do, and it said so in such a pretty and powerful way that surely it must be right.

"Sonya" was an early-riser and had been all her life. Long accustomed to rising early to do household chores before sending her son off to school and then leaving for her own office job, as a retiree years later Sonya still rose between 3:00 - 4:00 AM, went about her day, watched the 5 PM news while having dinner, read or watched more TV after that, and was in bed by 7:30 at the latest. After Sonya had a mild stroke and returned home from the rehabilitation hospital she dutifully waited until 7 AM to take any of her medications, even though she had been up and about for hours by then and breakfast was long gone, and she set her alarm clock to awaken herself at 9 PM so she could take her final doses for the day. Sonya was miserable and exhausted, but this is what the chart said to do, so that is what she did.

It took some doing to convince Sonya that the clock times on the chart were arbitrary, and that the important thing was that one medicine be taken an hour before the others and that some things be taken with food and prior to retiring at night, none of which had been happening, as the times on the fancy chart did not coincide with Sonya's actual daily routine.

We fixed it, and over the years I "fixed" many of the fancy charts from the rehab hospital, sometimes shaking my head at the thought that someone went to the trouble to create those elaborate tools without troubling to learn anything about what patients' days actually were like. Sonya, a long time executive secretary who kept high-powered executives on track, followed instructions to the letter. But she was the exception. Most threw the chart away or ignored it, and did the best they could with nothing to guide them unless a visiting nurse or other provider intervened.

If we hand out generic medication charts, no matter how pretty, or dispense long, confusing lists of instructions, we can expect "noncompliance." And the fault lies with us, not with our patients.

As for Beatrice, eventually I managed to transfer her prescriptions to a pharmacy on the corner where her granddaughter waited for the bus to go to school. The granddaughter then began picking up refills on her way home, and filling the pill boxes as soon as she arrived. Having assumed that much responsibility she became more aware of Beatrice's missed doses and stepped up her oversight and reminders. The system faltered when the granddaughter wasn't in school or went away for a weekend, but it was progress. I suggested simple changes in the foods the family brought into the home for Beatrice, such as making the most healthful possible choices from fast food menus and no longer leaving the salt shaker sitting in plain view. The likelihood of long-term significant change is small, but we saw some baby steps in a positive direction before I left, and Beatrice stayed out of the hospital for months. A perfect solution? Not even close. But a few little things that were easy and natural enough for that family that there was some likelihood of their being carried out. Baby steps.

Clearly Beatrice did little to take responsibility for herself and her life, whereas Sonya's efforts were extraordinary. In fact, Sonya eventually was diagnosed with Stage Four cancer and survived and thrived for years longer than anyone would have expected, due, I'm sure, to her strong spirit and meticulous self care. But what about you?

The problem with "easy and natural" is that most of the time no one knows quite what all it is in any given life. What are your left foot and the fourth finger of your right hand doing right this minute? Unless they're hurting, or are too cold or too hot, you probably didn't know until you read that question. Whatever they're doing, it most likely is what feet and fingers easily and naturally do, without any conscious direction or awareness whatsoever. Our bodies autocorrect more than our iPhones, and we mindlessly shift positions as we're talking, sitting, working, and even sleeping. Many other habits are almost as automatic, and we may not become aware of them until they're somehow disrupted. That means you may not know to tell your healthcare providers what they can do to help you be successful in effecting the changes they're recommending. While it's incumbent on us to look and ask, it's incumbent on you to think about this and anticipate and communicate likely problems and needs.

One important way to do this is to speak up when you perceive a difficulty, whether at the time you receive a prescription or instruction or later when you try to do what you've been told. If your Physical Therapist tells you to do exercises at home but you know your apartment doesn't have the needed space, say so right away so the exercise program can be modified, instead of trying to make do, benefiting less, and perhaps injuring yourself. If your doctor directs you to soak an injured body part in a warm bath but you have only a walk-in shower, speak up! There are other ways to apply heat. If you are asked to follow a schedule that conflicts with your work or other responsibilities explain what modifications would be make it easier. If you're given so many things to do throughout the day that your time is chopped up in small blocks punctuated by seemingly endless things medical, ask a nurse to help you simplify this regimen. If the way your nurse shows you to do a procedure feels awkward and difficult, give this feedback. It may be a matter simply of needing more practice, but there are many ways to do most things, and your nurse may be able to offer an alternative that doesn't leave you dropping things or making mistakes. And if it all makes perfect sense in the office, clinic, or hospital room but looks like gobbledly-gook at your kitchen table, pick up the phone.

This activity called healthcare, and the work of getting better and being and doing the best that we can, are sometimes complicated, but in any given scenario may not need to be so much so. Sometimes even one simple change is surprisingly difficult to make, but only because it just doesn't fit into the life a person lives. If we stop to consider for just a moment, it's clear that the best outcomes follow the best choices, and to make those we need to work together to be sure that, on all sides and to the greatest possible extent, we're doing the best things in ways that are most

Easy and Natural.

When Your Care Is Not Their Priority

One would think that patient care is the linchpin on which healthcare turns and the most important consideration of providers, yet these days there are instances, too many of them, when your care is not their priority.

I shy away from this topic. It's painful to consider, risky to acknowledge, and might seem self-serving, you know, the whining nurse looking for sympathy and an easier ride. But the day nurses stop educating and advocating for patients is the day we lose our souls, and patients, together with those who care about them and who might one day themselves become patients, have a right to understand how healthcare works and a duty to join with us to make it better when there are deficiencies that threaten both individuals' health and safety and public health and healthcare overall, now even with its astronomical bottom line not assuring good clinical outcomes or even basic safety.

Just a few days ago popular medical blogger KevinMD sounded the clarion call, writing about the need to reduce nurse burnout (http://www.kevinmd.com/blog/2016/01/reduce-nurse-burnout-treating-nurses-well-treat-patients.html), and noting that "the most overwhelming parts of nursing are the constant system failures" and that "health care organizations . . . function in a way that requires nurses focus more of their limited time and attention diagnosing system needs rather than focusing on patients['] care." That's not about making life cushy for nurses; rather it's the reason your pain medication is late, very late; your call light unanswered for an hour; your questions not heard, much less answered; and the significant decline in your condition unrecognized. Your nurse isn't off sitting in a break room somewhere absently thumbing through a tabloid while chatting on the phone with her boyfriend and waiting for her nails to dry. More likely your nurse hasn't sat down anywhere since arriving at work, her boyfriend long since gave up hope of being able to talk with her at all on days she is working (if he hasn't departed to take up with a more available partner), and she can't remember when her work-worn hands, chapped from being washed so often, last had a manicure.

Writing in The New York Times the very next day, Robert M. Wachter noted the problem of "businesslike efforts to measure and improve quality" having the result that "even superb and motivated professionals . . . come to believe that the boatload of measures, the incentives to 'look good,' had led them to turn away from the essence of their work" (http://www.nytimes.com/2016/01/17/opinion/sunday/how-measurement-fails-doctors-and-teachers.html?src=me&_r=0).

Both writers describe the problem of provider burnout and turnover; beyond this there is an abundance of data demonstrating the correlation between such variables as nurse staffing and clinical outcomes. Today I add my voice, telling you that the problem extends beyond hospital walls and into your own living room, which is to say that the beast of burnout is alive and well in home healthcare, too, with its fire-breathing ways threatening the clinical assessment and care you receive from the one who perhaps is the only healthcare professional you currently see. While hospitalized, patients see many doctors, nurses, technicians of various sorts, and perhaps therapists, dietitians, social workers, and others, and behind the scenes pharmacists are reviewing every drug order, a radiologist reads x-rays before the ordering doctor ever sees them, "case managers" are overseeing care, and more, so if something is missed or an error made, there is some likelihood that someone will notice. But it's a different story at home.

There, it's you, and your nurse and/or therapist(s) who visit intermittently (and never together, as Medicare and others frown on that no matter the benefits of joint practice and collaboration. Indeed, "care coordination" is required, but not permissible face-to-face and in the presence of the patient. Go figure.). If your home healthcare clinician misses something or hurries through instructions so that you don't understand exactly what to do the consequences can be grave before anyone else has occasion to notice.

The Centers for Medicare and Medicaid (CMS) determine what Medicare will reimburse and how the amount is determined. Most other insurers follow the CMS lead. This has resulted in a lengthy and cumbersome assessment tool along with a slew of documentation and "quality" requirements that nurses and therapists must complete. CMS further stipulates exactly which services within each professional discipline are reimbursable, and the requirements beneficiaries must meet to be eligible for any services in the first place. Clinicians must document, repeatedly, precisely which qualifying services have been rendered and that patients who received these services were verified, over and over, to be eligible for them. Individual states toss in additional parameters their surveyors will assess, as do accrediting bodies and organizations that purport to evaluate various forms of quality and bestow distinctions accordingly, or not (the "Magnet" designation for excellence in nursing is an example).

So when your nurse arrives on your doorstep for the very first time, no matter what problem or diagnosis you have, no matter what you need, how you feel, what your questions are, or what you already know, she or he will "teach" you how to be safe in your own home, even in the absence of any discernible safety risks, dangerous conditions, or lack of understanding on your part. Your nurse is required to determine whether or not you have received influenza and pneumonia vaccines and if not, why; whether or not you are depressed; how long it takes you to rise from a particular type of chair, walk ten feet, return to the chair, and sit down again; your nutritional risk, probably using a tool that doesn't actually measure risk at all; the likelihood that you will develop bedsores, again often using a tool developed for inpatient use whose indicators as operationalized there have little meaning in the home setting, and more. Your nurse is required to have you demonstrate, not just explain, how you step in and out of the bathtub or shower, how you dress yourself, how you walk, and how you get in and out of bed and up and down from a chair. The nurse must assess your pain and ask you to rate it on a ten-point scale; if you have no pain at all you still must give it a number. The nurse must discuss advance directives, your rights and responsibilities as a home healthcare patient, what constitutes an emergency and what to do if an emergency arises, how to contact the home health agency and what to do if you have a complaint, your treatment plan, and if for some reason you are inclined ever again to let this person into your home, when she or he will return and how often. Your nurse may be required to screen you for ebola risk or any other hot button issues of the day, and will have forms to fill out and forms for you to sign. Then your nurse can begin to examine you and assess your particular needs. He or she must look at and make a record of all the medications you have on hand and must reconcile this with the list provided by the hospital or your doctor. If you need to learn how to care for a wound or give yourself an injection or check your blood sugar or anything else, the nurse must teach you that. The nurse must be sure you have at least a basic understanding of your health problems and know when and how to reach your doctor. And the nurse must be "nice," assure that somehow in spite of all of this you are "satisfied," and discreetly keep repeating that she or he is providing "excellent" care so you will remember that word and rate the agency's services as "excellent" when completing your post-discharge survey.

In addition, after leaving you the nurse will need to spend at least one to two hours documenting this visit and filling out the required forms. Yours will be but one of five or six visits your nurse is expected to make that day, perhaps one or two less if some of the patients are new to home healthcare. Your nurse will travel through all kinds of weather, traffic, and road conditions, will deal with the absence of parking spaces and house numbers, and will respond promptly to all calls and email. If you or any of his or her other patients need lab tests, your nurse will draw the blood and/or collect other specimens, drive to some lab, find parking, walk to the appropriate location, do more paperwork, and then go back to the car to resume the day, without an extra penny or allowance for the time and effort this requires. Your nurse will attend endless meetings, complete online courses and in-person training whether or not she or he already has demonstrated mastery of the topic, and jump through a seemingly infinite number of hoops to obtain supplies for you, whether a gauze pad or an oxygen machine or anything else. Your nurse will chase doctors, track down those lab test results and see that they get where they need to go and that appropriate action is taken, and make many, many phone calls from home at night. Your nurse also will have his or her documentation questioned by people who haven't ever seen you and often haven't seen any patient at all for years, if ever, but who want to maximize the dollar amount to be made from your case. And, generally your nurse will be paid a modest, flat fee for making each visit to a patient, period. This means that time spent going to and from labs, making phone calls, sitting in traffic, documenting, and all the rest is uncompensated, with meetings and required training often compensated at a lower, below-market rate because those are not billable activities.

If you believe nurses actually do all of this every time they admit patients to home healthcare please message me: I have a bridge for sale in Brooklyn that you'd just love, and some land in Florida, too!

For one thing, our patients are sick or we wouldn't be there. Often they are elderly and have many problems at once. CMS requires that they be "homebound," which, while not meaning that they need to be absolute shut-ins, does mean that going out is a hardship and is something they do infrequently, usually for essential medical appointments. Suffice it to say they're often weak and frail. And if people just have returned home from the hospital it's a sure bet they're tired, because these days hospitals aren't places where people can rest. Nurses know no one in these circumstances can tolerate hours of "assessment" and "instruction."

Nurses also need to self-protect, the "Don your own oxygen mask first" principle. If nurses work eighteen hour days in order to meet requirements and see enough patients to make the money needed to pay their bills they'll soon hurt someone or have an accident themselves. So something has to give. Similarly, being compensated on a per-visit basis and having a "productivity" quota to meet for their employers, nurses need to be sure to make enough duly billable visits. If patients cancel appointments, are admitted to the hospital, suddenly decide to go stay with family at another location, or miss scheduled visits for any other reason their nurses suffer financially and may be penalized for failing to meet the productivity quota, unless it is possible to add more and more visits to subsequent and already full days. That breeds haste, less than thorough care, and heightened potential for errors.

Whatever the specifics of your situation, this may mean all the drop-down boxes on your medical record aren't checked on the basis on an actual assessment. Your nurse may have determined that it was more important that you be able to manage your IV line than that you be screened for ebola risk or that you demonstrate stepping into the shower, but those parameters still must be documented. So in the best of circumstances the nurse makes an educated guess, and uses the visit time to meet your most pressing needs rather than marching through all the required items at the expense of your and/or his or her own welfare.

But it takes an experienced nurse with keen clinical acumen to know which corners safely can be cut, as well as a certain amount of savvy to avoid detection in doing so. The less experienced and less well initiated do burn out and move on, if they're not first caught in the snare of an unfortunate error of judgment or practice. And even the veterans can guess wrong, or, being human, be swayed by such self interest as the need to compensate for canceled appointments by packing more visits into a single day than can be managed safely and well.

Not long ago I was called to see a patient who told his Physical Therapist that he had developed a sore on his foot in the hospital and although he thought it had healed it was bothering him. I found a massive pressure ulcer that could not have developed in the short time the patient had been home, meaning that the nurse who admitted him to home healthcare and determined that there were no needs for nursing, and that the patient needed only Physical Therapy, never examined that foot, even though the patient's particular problem put him at high risk for just that sort of wound in just that location. Instead, the nurse documented that the patient's skin was intact with no lesions or irregularities present. The untreated wound that the nurse overlooked and the patient couldn't see subsequently had significant adverse consequences for that patient.

Even more recently I read the clinical note of the home health nurse who saw a patient I had followed in the hospital. The patient had a complex medical history, but was hospitalized for a heart attack and had needed open-heart surgery. The home health nurse documented extensive diabetic teaching, and not a word about the patient's cardiac status or care. The patient had been diabetic for years, and control of that condition was not a current concern. A colleague who read the same note remarked that it looked like it had been "cut and pasted" from a standard template, something that certainly would have made the documentation process easier and faster. Although I imagine the nurse who saw this patient was "nice" and the visit may have been very pleasant, the job that needed to be done wasn't, and the patient was left at risk and uninformed. I wonder if she remembered to respond that she had received "excellent" care when her post-discharge survey arrived.

A Physical Therapist colleague has told of discovering that another therapist had been caught pushing an elderly, blind patient to hurry her through the session, while yet another therapist saved time and made money by having patients sign multiple visit forms when only one visit was made. That's fraudulent, and if caught would have cost the therapist his license, a hefty fine, and perhaps jail time, but it happened.

I don't believe people choose careers in healthcare and complete rigorous collegiate and often post-graduate training because they want opportunities to push elderly blind people, ignore wounds, teach irrelevancies, or commit fraud. That these happen is an alarm all need to hear, warning that something is going terribly wrong among good people who once had high ideals, passion for a profession, and a commitment to service. All too often in 2016 paperwork and profit are being prized over patients, supposed measures of quality are valued above quality itself, and looking good is valued more than doing good. The toll on providers is beyond sobering, and when you are a patient the cost to you may be extreme

When Your Care Is Not Their Priority

Blue Jeans

Blue jeans, soft, worn, and fitting just right do bespeak comfort, relaxation, and absence of pretense, but I never thought my jeans on my body would have that affect on someone else!

It was a cold, gray, late autumn afternoon back in the days when I routinely rose at 4:15 AM in order to be ready to make home visits in "the projects" while the local rabble rousers still were sleeping off the effects of the previous night. Starting that early meant I often was home by early afternoon and never making calls after dark unless I was "on call" and covering an emergency. That day had been rainy, with that penetrating dampness and cold that sets one's bones to shivering, and I was more than glad to go home to a warm house and slip into my favorite jeans and a soft, cozy sweatshirt. But then the phone rang.

"Corazón" needed a visit, that day. I had picked up a second, part-time job not long before, and Corazón, an elderly Mexican woman, was one of my early patients with that new company. I don't remember now what problem had arisen, but it was unlikely that anyone else in that very small and minimally staffed agency was available to see her. Darkness was gathering, meaning that I'd been going non-stop for twelve hours or more, and the prospect of taking the car out of the garage, driving the three or four miles to her home through late afternoon traffic, and then doing whatever it was that Corazón needed only left me feeling all the more tired. But I would go, I said to the caller, even though I cannot bring myself to change into proper work clothes once again, I told myself. Throwing on a coat, grabbing the necessary supplies, and beckoning my German Shepherd into the back seat, I set out.

Corazón lived with her son, "Joe," a big, imposing man with an air about him that suggested he was chronically dubious about everything. Behind eyes that seemed to think and feel much more than he ever said, he always had been receptive and courteous, but reserved, and as I drove I was a bit concerned about appearing too casual and therefore disrespectful in duds more suited for a night on the couch or a trip to the dog park than to a home visit to provide professional healthcare. But on that day at that time that family was lucky not to receive a nurse in a robe and pajamas, as my director said a few days later when I recounted this story to her. I climbed the front stairs and rang the bell.

Joe responded, and I launched into my explanation that I'd just learned Corazón needed me and had opted to respond quickly instead of taking the time to put myself together in a more professional-looking package.

I don't know that the first sentence was out of my mouth before Joe's face softened, all of the tentativeness and skepticism I might have sensed in our earlier encounters evaporated like a drop of water on a hot grill, and with a huge smile he ushered me into the home. Likewise, Corazón's smile when she saw me lit up her cramped little bedroom more than all the lamps in the home ever could have done. It was unsettling, the sensation one has when tempted to turn around to see if people are looking at and talking to someone else.

Understand that my normal dress for home visits is practical and not fancy or pretentious. If I need to climb on a bed or sit on the floor I do it, and any of a number of possible accidents could result in the need for a sudden change of clothes, so nothing requiring a trip to the dry cleaner or other high maintenance fussing is in my work wardrobe. Washable dresses, skirts, and slacks fill the bill and, one would think, hardly are off-putting.

But something about seeing me on the front porch in the cold dusk with jeans poking out below my coat and sweatshirt sleeves edging over its cuffs put Joe at ease more than ever before, and moments later, Corazón, too.

Throughout our remaining days together Joe's polite cautiousness and undertone of skeptical reserve never reappeared. Not once. It was so much easier to work in that home with the barriers dropped and only authentic connection remaining. And then came the moment when everything stood still.

After reviewing her latest test results Corazón's doctor told me her vital organs were failing irreversibly and there was nothing to be done that would save her. It was time for the family to make a decision about hospice care. All these many years later I don't remember for sure, but I hope the doctor had had a similar conversation with Joe. Corazón was bedbound at home, however, so the doctor would not have been able to talk directly with her.

I remember arriving at the home and talking with Joe about his mother's prognosis and the need to consider hospice care, and noting gently that someone needed to tell her and learn her wishes. Without missing a beat Joe responded, "You tell her." I asked him to consider whether this message might best come from a family member, priest, or even the doctor by phone, but Joe was firm: "You tell her." In Spanish, my second language, in which I yet was less than fluent at that time. "Really?" I asked. "Yes," he said firmly.

In over forty years as a nurse I don't believe there's been another time when I was the first and only person to tell someone that his or her body was failing, medicine could not change this, and she or he was going to die. There's the usual "We will keep you comfortable and help you to have as much good time as you possibly can" addendum, and then the "You will have medical and nursing care and the help you need as long as you live; now we need to decide how that is best to be provided" preliminary to the hospice discussion. But the whammy is the "There's nothing more we can do; I'm sorry" message. In Spanish.

As so often is the case, despite not having been told Corazón already knew, and she comforted me. I didn't see her for much longer after that, as she did enroll in hospice care. But before we parted ways, she made me a bracelet, in the colors of the Mexican flag, which to this day is one of my prized possessions.

I have thought off and on over the years since then that what turned the tide from perfectly adequate and polite encounters to something more profound was my happening to turn up in a sweatshirt and jeans on that one cold, dark late afternoon. Since then, although I have my respectable suits, white coats, and "business casual" garb and do wear them, I've turned up on many a doorstep in jeans . . . and even a bicycle helmet. And I've wondered if sometimes our "professionalism," or at least its symbols are ironic barriers to the authentic connections with those we serve and seek to influence intimately. I'm not advocating widespread dressing down; surely there is reassurance to be had when our doctors look like doctors and other professionals do the same, and how we dress affects how we conduct ourselves in the workplace. But that latter? That's the rub. We need to be mindful, I think, of any tendency to act out the role associated with the clothes we wear, because any acting is a way of being that is less than authentic. And it is compromised authenticity that others sense and from which they pull back.

These days I wear a white coat a good bit of the time, but make a point when I don it to be sure I'm not hiding behind it, and that in my speech, my demeanor, my smile, my being I am as fully present and real as I can be. Because no matter what our business and professional costumes may be - white coat, suit, clerical collar judicial robe, whatever - what most matters and assures the best outcomes is the sort of connection that comes with such things as

Blue Jeans.

My Doctor Needs a Nurse

My doctor needs a nurse.

Several weeks ago while trying to find the ATM at an unfamiliar bank branch I found an unexpected patch of ice instead, and down I went, shattering the end of one of the long bones in one arm, rotating it forty degrees out of place, and bending it backwards. It was not one of my better days. After a stint in the ER I landed in the office of an orthopedic surgeon who took one look at my X-rays and explained that surgery was the only way to put me back together, and not long thereafter I had an opportunity to see the OR from a patient's perspective. Fortunately, the doctors were able to realign my broken parts without nearly the cutting and hardware they had anticipated, and I emerged with what looked like a mummified extremity and was dispatched home to recover.

By the next week I was feeling pretty chipper, if clumsy and less than glamorous wearing the sweatshirts and jacket of a large male friend (the only duds that fit over the surgical dressing on my arm), and set out for my first follow up appointment with the surgeon. I hadn't needed pain medication for a few days, and acute orthopedics not being my field it didn't occur to me to take any that morning.

It's standard practice to ask patients to rate their pain on a ten point scale, with zero being no discomfort at all and ten being the worst possible pain a patient can imagine. When that dressing came off my pain was 23/10, no doubt about it. Any movement or touch was excruciating, and I became lightheaded and nauseated just being examined. The surgeon told me my X-rays looked very good and I was healing well, and having ascertained that nothing was wrong medically proceeded to reposition my hand the way it needed to be for the new cast (pain 52/10). The orthopedic technician then went to work constructing that device (pain holding at 52/10, with me lying down on the table at that point so I wouldn't fall to the floor if I fainted). Once the arm was casted I felt better, although I probably took more pain medication that day than I had the entire previous week.

Fast forward another week and I was feeling like a new woman, swinging my cast around and mastering all manner of one-handed tasks. Preparing for my next appointment with the surgeon I considered taking pain medication, but felt so well that I opted against it. After all, I'd had an entire additional week to heal!

But back in the doctor's office there was a repeat of the previous week's experience, complete with me stretched out on a gurney in the cast room to keep from toppling over.

By the following week I was using the hand of the casted arm more, and had mastered carrying laundry baskets, washing dishes, and vacuuming . . . but, even so, before returning to the surgeon I loaded up on pain medication such as I hadn't taken since my first post-operative day. And the exam, x-rays, and casting process were the proverbial piece of cake, even if the patient was a little "loopy" all the while!

My doctor is on staff at multiple hospitals, chairs the department of orthopedic surgery at a major university, and works in the office of a large and busy orthopedic practice where the air of sophistication and competence is unmistakable. I see many distinguished and renowned surgeons bustling about when I'm there, as well as the technicians who make and fit the various devices that orthopedic patients need, assorted office staff, and a warm, funny, efficient medical assistant who keeps my doctor's practice humming. But I have yet to see a nurse.

And if there were a nurse on hand, I never would have experienced 23/10 or 52/10 or any number much above 4-5/10 again, no matter what the doctor and others were doing.

There are six parameters that nurses assess and manage, regardless of practice setting or specialty. I summarize them crudely when I teach so students easily can remember, and to this day call to mind the same six words every time I look at a patient and ask myself, "Is there anything else? What have I missed?" Those words are: Eat, sleep, move; pee, poop, pain.

No matter what sort of problem a patient has, what kind of doctor she or he is seeing, or where the encounter takes place, a nurse wants to know if and what a patient is eating, the extent to which this meets nutritional needs, and if there are problems or concerns surrounding intake of nutrients and fluids. If the "eat" cue triggers a nurse's radar there are a million assessment parameters and questions that may follow, but whether briefly or in depth, "eat" is assessed and evaluated.

Likewise "sleep." Is the patient resting and sleeping well or poorly, too much or too little, with or without aids? Are there nightmares or discomfort, does the patient need to be in a special position, does anything disrupt sleep?

And "move." How much or how little, how well or with what difficulty,is the patient moving? Are there pain, breathlessness, inertia, or simple bad habits? Is movement safe? How is posture, gait, and the process of getting up and down? Are there indications of complications of decreased mobility, such as skin breakdown, fluid in the chest, or extremities that no longer straighten out all the way? Is the patient manic, constantly in motion, anxious and agitated, unable to relax? How about balance, endurance, and the ability to execute movements needed to do daily tasks? Movement is a parameter that speaks volumes to the astute clinical nurse.

For all the jokes about elimination, it matters. Too much or too little, abnormal character of output, too many or too few trips to the bathroom, bleeding or pain or other symptoms, indications that waste is being retained instead of eliminated, it all matters. And more.

And pain. Is the patient comfortable, and if not, why? Location, severity, onset, duration, what makes pain better and worse, what the patient does to manage pain and how effective those actions are, how the patient copes, whether pain is acute or chronic; it's all important. Is pain physical, emotional, spiritual, or other? What's the patient's story about this aspect of his or her experience?

Eat, sleep, move; pee, poop, pain: This is what a nurse does.

I smiled more than once coming out of surgery and preparing to go home. Rolling me out of the OR the nurse asked if I needed to use the restroom. My first thought was, "Why? I haven't had anything to eat or drink since yesterday, and it's now afternoon!" But I realized I no doubt had been pumped full of IV fluids in the OR . . . and that the nurse needed to be sure I could urinate before I left. Once I was settled in post-op recovery the nurse offered me a sandwich and some juice. Processed turkey meat stuffed between two slices of white bread was the most delicious meal I'd had in my life, and I noticed the nurse noticing my wolfing it down. I did walk to the restroom, and dressed with the assistance of the friend who would take me home, and of the nurse. "Would you like a wheelchair when you leave, or do you think you can walk?" the nurse asked. "I think I can walk," I responded. "I think so, too, " she replied, with a tone both warm and deliberate such that I realized I had been assessed and deemed safe. A lay person might say, "Oh, the nurse was nice, and brought me something to eat and helped me get dressed," but I know that "eat, eliminate, and move" had been assessed and evaluated carefully. "Sleep" had been well monitored in the OR, and the nurse had instructed me about pain management before I went to surgery, explaining that afterwards I would not be in any condition to remember what she said.

Eat, sleep, move; pee, poop, pain: This is what nurses do.

And when we find problems, the solutions are not necessarily medical. A patient with nutritional issues may need a dietician or simply someone to go to the grocery store, not a doctor. Another with mobility problems may need a Physical Therapist, not a physician. Patients who are eating poorly, falling, and living in a dirty homes because they are alone and without help may need a social worker to set them up with community resources and support services, not more medicine.

Everyone needs to eat, sleep, move, eliminate, and be comfortable; hence everyone who engages in a healthcare encounter should be assessed by a nurse. Exceptions might be the person who needs only to pop into the local pharmacy for a shingles vaccine or a clinic for a TB test required by an employer, but where there are health problems to be solved, health screening and prevention to be done, and long term coping and planning to be managed, patients, all of them, need nurses.

Had there been a nurse in my surgeon's office, she or he would have insisted that my pain be managed. My doctor had examined me and looked at my x-rays; he knew that there was no medical issue of concern. The business of diagnosis and treatment, which is what doctors do, had been done, and while sympathetic, he was not overly concerned about my discomfort given that he understood there was nothing medically wrong. But a nurse would have said, "We need to manage this," and not let up until that was done. A nurse would have instructed me to pre-medicate in the future, and explained why (although my arm is healing, I still have a fracture. When the cast is removed there is no support for that broken part, and the weight of my hand is supported only by the wrist that is broken. That hurts!). An orthopedic nurse would have understood the movement and positioning that the doctor wanted, and would have guided and taught me to do this properly, as opposed to the doctor's saying, "Do it!" and scowling when I didn't quite do it right. A nurse would have asked how I was managing at home, and would have known if I was eating properly, including the nutrients I need for healing, if I was resting well, if the medications I was taking had caused constipation or diarrhea, and if I was moving about and functioning reasonably well and safely.

And a nurse in the office would have saved the practice time and money. Having me dizzy, nauseated, and unable to move or cooperate took more of the doctor's and technician's time, and that translates into dollars lost. Is this enough to offset the expense of a nurse's salary? Multiplied by the number of patients going to that office and the number of needs and problems they have that a nurse can anticipate, prevent, solve, and/or minimize, the answer is a resounding "Yes!"

Better care, better clinical outcomes, greater efficiency and cost effectiveness, there's no doubt about it:

My Doctor Needs a Nurse.

That Which Sets Nursing Apart

Nurses and nursing have been thrust into a worldwide spotlight this week after panelists on ABC's "The View" made snarky, uninformed comments about Registered Nurse Miss Colorado's "talent" segment of the Miss America competition, which was a creative monologue depicting the life-changing story of her work with a particularly memorable patient. The backlash was swift and severe, with hundreds of thousands of nurses and their supporters blowing up social media and blasting conventional media as well. Many sponsors pulled or paused their advertising on The View, and television hosts from Ellen to Dr. Oz have scrambled for a piece of the action. There have been many well informed and thoughtfully articulated tributes to nurses from those who know us best, that is, our physician colleagues and others who serve side by side with us every day, as well as our patients, some of whom were so inspired by the nursing care they received that they later became nurses themselves. It has been a week of many proud and humbling moments after an initial ugly slap in our professional faces.

But for all that has been said about nurses and nursing, there remains a critical omission, a missing nod to that which sets nursing apart.

The questions that most define nursing practice perhaps are something like, "What are the barriers to this patient's enjoying the very best possible health?" and "What are this patient's strengths and the things that are working well, upon which we can help him/her build so as to be and do even better?"

The reason this approach and these questions are so important is that they transcend the purview of any individual healthcare discipline. Nobody other than a nurse builds his or her practice around assessment questions broader than his or her own scope of practice.

This does not mean nurses practice beyond their legal and proper scope; rather it means they know the resources to tap to meet their patients' needs, and how to coordinate those resources for efficient care with optimal outcomes. Only a nurse does this.

Physicians diagnose and treat pathology, and often it indeed is one or more disease processes that are significant barriers to optimal health. In those instances physicians order diagnostic tests and appropriate treatments, and often rely on nurses both to implement these orders and to assess and evaluate their effectiveness, alerting the appropriate doctor if problems arise. While this aspect of nursing practice requires great skill and keen clinical acumen, it is but a small part of what nurses do. Indeed, sometimes patients' healthcare needs do not require a physician's input at all, as there is no pathology present that requires medical diagnosis and treatment.

Consider "Shirley." Shirley is a determined, high-energy, almost-ninety year old woman who was headed to an appointment this week when she had an unfortunate encounter with a hose that careless workers had left stretched across a sidewalk. Down she went, evidently with unusually great force, and she couldn't get up. Passersby summoned help, and EMS soon arrived to take Shirley to a nearby hospital. There she was scanned and xrayed, poked and prodded, bled and monitored, and ultimately told she was badly bruised but nothing seemed to be broken, that she should wear an immobilizer on the knee that took the biggest hit when she fell, and that she should follow up with an orthopod as a precaution and see her primary care doctor as previously planned. She then was dispatched home. Later that night she fell again trying to walk to the kitchen for something to eat.

The next morning she called me.

The doctors had reassured her that all was well medically, but had not addressed the things that were wrong otherwise.

I had seen Shirley just one time, several months before. Then she had just been discharged after a hospital stay for a gut infection, and I determined that she was doing well overall but would benefit from some Physical Therapy to help her regain strength properly and safely. The Physical Therapist took over the case, and I signed off. But Shirley remembered the one visit I made, and she kept my phone number. And so the morning after that trip to the ER, when the sun barely had topped the horizon, my phone rang. "This is 'Shirley Holloway,'" a feeble voice said. "I don't know if you remember me, but I live at 1234 Anystreet and you helped me get Physical Therapy once before. [exhausted pause] I need services again. Different services. I would appreciate if you would call me." I did, and then called Shirley's doctor, because Medicare still requires a "doctor's order" before I darken a patient's doorway if Medicare is to pay the bill. The doctor agreed that I should evaluate Shirley, and then call with my findings.

When I arrived the doorman sent me right up, and said Shirley's door was unlocked and that I should just walk in. I did, and found Shirley settled into a recliner almost completely unable to move about. The leg that had taken the brunt of her fall was deep purple from the thigh to the ankle, and quite swollen as well. There were bruises on one arm and one hip, scraped and torn skin on both hands, and a lump on her head. Every time she tried to walk she felt so weak and dizzy that she thought she would fall. She wasn't hungry and had eaten minimally in the past 48 hours. Her blood pressure was low, and fluid was starting to accumulate in her lungs (two points I ascertained by using my stethoscope, a device the ladies of "The View" had dubbed a "doctor's" tool). And she was hurting, alone, and worried.

Shirley already had been worked up by doctors in the Emergency Room, and had been determined to have no pathology in need of medical treatment. So the doctoring was done. But clearly this patient had significant unmet health needs.

I explained why her leg was purple and how to manage the swelling and optimize circulation as well as recognize changes that would signify a problem requiring medical attention, such as blood clots or nerve compression. With Shirley's permission I snapped a photo of the leg and sent it to a Physical Therapist colleague; within minutes we had arranged for him to be there that day to work with her on safe mobility and additional management of the pain and swelling. I explained the hazards of being sedentary in that recliner for days, including the fluid in the bases of her lungs, and the mobility and breathing exercises needed to improve this. We discussed other common complications of decreased mobility, including the potential for everything from skin breakdown to constipation, and the need for attention to hygiene and nutrition. Shirley admitted avoiding drinking in order to minimize trips to the bathroom, fearing the she would fall going or coming. I explained the need for adequate hydration and the relationship between this and her blood pressure; Shirley quickly reached for a glass of water. I referred her to an organization that provides caregiver services, as she had realized she needed someone with her. I showed her how to clean and dress the torn tissue on her hands, and instructed her to "graze" on nutritious snacks throughout the day until her appetite for normal meals returned. We talked about what those snacks might be. I removed loose throw rugs from her hallway and explained the fall risk associated with them, and made sure she was wearing safe footwear with good support.

On reaching my office later I called the physician with an update, and received an, "Oh, ok" in response. There was no medical need, no need for doctoring at that point, nothing for the physician to do.

The next day I returned. Shirley asked if I minded if she iced her leg while we were talking, as the Physical Therapist had given her very specific instructions, and she walked (!) steadily (!) with her cane to and from the kitchen to retrieve the ice. Her bruising was better, she had washed at the sink by herself and changed the bandages on her hands, she was eating and drinking adequately, her blood pressure was normal, and her lungs were clearing. She had called for information about caregiver services, had prices, and was going to follow up. She was on the road to recovery.

Once the Emergency Room doctors had determined that there was no fracture or pathology present, no doctoring or hospitals were needed. But nursing was. And it was the nurse who recognized the need for Physical Therapy and for a caregiver and who made those referrals. It is the nurse who continues to coordinate that care and help Shirley move forward.

Physicians request consultations of other physicians, e.g., the internist requests the opinion of the endocrinologist, the surgeon asks the cardiologist to evaluate a patient before an operation, the hospitalist calls in the nephrologist when a patient's kidney function declines in the course of treatment. But it is the nurse who coordinates all the pieces and knows to add any that have been omitted. It is the nurse's perspective that is broader than pathology and treatment, mobility and function, speech and cognition, mental health and coping, nutrition, wound and skin care, community resource needs, and the functioning of any given body system. It is the nurse whose perspective encompasses all of these, and whose expertise includes knowing whom to consult and how to coordinate the players and assure the patient is progressing. And it is the nurse who is most likely to have occasion to know the patient well as a person and so determine the individual strengths and obstacles likely to be significant to his or her progress, or lack of same.

Physicians look for pathology to diagnose and treat. Physical Therapists look for problems with mobility, strength, and endurance. Occupational Therapists look for needs in functional status and cognition. Speech Language Pathologists look for deficits in communication, swallowing, and mentation. Social workers evaluate social systems and resource needs and provide counseling and referrals. Mental health workers evaluate thought processes and intervene accordingly. Dietitians assess nutrition, recommend meal plans, and teach therapeutic diets and healthy eating. Many specialists are experts in one body system, e.g. Respiratory Therapists in the respiratory system.

But it is the nurse, and only the nurse, who does it all. Not so as to supersede any other healthcare professionals' role or judgment, but rather in order to refer to them and to ensure that not only nursing needs, but also the patient's overall healthcare needs are met.

Nobody else has a perspective so broad and yet so narrowly focused on the particular needs of each unique patient. Consequently while there are many patients who don't need a doctor or don't need a therapist or don't need a counselor or don't need a specialist, there are precious few who, at least briefly, don't need a nurse. And while many of the tasks we do and many of the functions and responsibilities we carry out overlap those of our colleagues in other disciplines, that broad perspective and narrow focus is

That Which Sets Nursing Apart.