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Monday, April 25, 2016

Buddy Check 22 Facebook group: Life-saving through crowd-sharing

David Woolery was in the Marine Corps in eastern Afghanistan in 2004 when a bomb exploded under a convoy he was in, injuring some of the men.  He got through that with the help of his fellow Marines, but the return to the U.S. was more unsettling. 

“Out here is every man for himself,” he said.  People back-stabbing.  It’s all me, me, me.”

In 2015, Mr. Woolery started a Buddy Check 22 Facebook group for his unit, which was “a big lifeline” that later expanded to other veterans.  They shared stories of combat, spoke the same language.  Recently, a member dropped a screen shot of a veteran’s suicidal remark into the group’s page and wrote, “Let’s find this guy.”

“The man had said his good-byes and was about to kill himself,” Mr. Woolery said.  But word spread, and eventually people tracked him down and sent help.  It was lifesaving through crowd-sharing.

Why the name “Buddy Check 22?”  To thousands of veterans and active-duty soldiers, the 22nd of every month is a reminder to make a suicide prevention spot-check on former comrades.  A Department of Veterans Affairs study in 2012 said an estimated 22 veterans committed suicide every day in 2010.  While other studies calculated a lower tally, closer to one or two per day, the number 22 has taken on potent symbolism on social media.

Advice to veterans:  Join this group.

Read another suicide prevention story.  Thanks to Christine Hauser of the New York Times for the source article on April 24. 

Friday, April 22, 2016

Interactive Imagery for Irritable Bowel Syndrome: It changed into a bunny rabbit

As the Director of Oncology Intake at Cancer Treatment Centers of America, Dr. Larry Altshuler has been an integrative medicine specialist for 36 years.   Here’s an excerpt from his new book, Doctor, Say What?:  An insider's scoop to getting the best medical care:

Denise is a 32-year-old woman who had severe IBS [Irritable Bowel Syndrome].  Her IBS had been present for 20 years, and she could never go out because she might have a sudden attack of diarrhea at any time.  While exploring her subconscious through the interactive imagery technique, we discovered that some type of fear had started the condition. I had her image her fear, and suddenly she saw a big, black, hairy rat in a cage (this represented that she had “caged” away her fear).  I I told her to imagine opening the cage and letting out the rat (symbolically “releasing her fear”).  When she did, in her mind, she heard the rat say, “Thank you for releasing me.”  I then asked her to see herself hugging the rat (symbolically “embracing the fear”).  When she did, the image of the rat changed into a bunny rabbit and hopped away, and she heard it say, “Thanks.  You don’t need me anymore.”  After that session, Denise never had another episode of IBS, and that was 12 years ago.

Interactive Imagery (also called Active Imagination)…is significantly more powerful than guided imagery…Instead of creating specific images, you allow your mind to spontaneously present images to you.  These images represent your symptoms, illness, or emotions.  By interacting with these images, you can gain understanding of why you are ill and how you can heal yourself.

Certainly, many of you may think this is in the realm of science fiction, but having used this process with hundreds of patients (most of them skeptical), I can tell you it’s real. 

Read another story of a doctor as a caring thought partner.  Thanks to Mallory Campoli of Smith Publicity for connecting us.

Monday, April 4, 2016

A specialist's patient-centered care: He won't do one

Throughout his career John Rossi has improved medical care, as an industrial engineer by training.  He's the best, and I was privileged to learn clinical quality improvement from him. -Ken

John's story:
My work makes me hypersensitive to flaws in any system I encounter.  I'm naturally curious about those things; I can't restrain my curiosity.

A few years ago I had pain of uncertain origin that my regular dentist couldn't find.  He referred me to an endodontist, saying "If you don't need a root canal, he won't do one."  Some people in that business will just do the root canal and that's the end of the story.

I was able to get in quickly as a new patient.  From the beginning, the experience was as good as you can make it in those circumstances.  I arrived in pain.  The initial paperwork was easy and brief.  They knew exactly what to do with my insurance.  They had already received my information from my dentist, so I didn't need to do any paperwork.  They told me exactly what it would cost me.  

When I first talked with him, he said, Here are the options, in simple terms about what was going on with the tooth.  I had had a root canal years before, and that experience was very different.  They just got in there and started doing the procedure.  Instead, he said, I can pull the tooth, but you'll have a gap that your dentist can fill; that's the other option.  Or if you want to keep the tooth, I can do that with a root canal.  

Having options is always good when you're dealing with a specialist.

He prescribed pain medicine because he couldn't do it that day.  The pain was kind of bad so that helped.

The next visit was for the procedure itself.  He was able to do the first one in one visit.  That was important because you're in the chair for a long time, with your mouth open wide.  That's not painful in itself, since you have lots of novocaine to block the nerves, but it's irritating to sit there for that long; your mouth gets tired.  An earlier root canal with another endodontist had taken three visits.

He explains what he's doing in advance, and as he's doing it:  how this works, and what he's doing.  He has technique that's very good, that's not difficult to tolerate.  He has an assistant, a surgical technician who passes instruments so can move things along very rapidly.  

He explains the aftermath, and if there's to be a second procedure, he'll explain that, telling me, This will take about this amount of time.  He predicts accurately.  And he'll say, If you have pain later, this is how we'll deal with it.  If I need an antibiotic, he gives it to me.  

I've never had any complications.  

For subsequent times, he can see me quickly, because our relationship is established.  There's no barrier to going there, even though in practices like this, it's not self-referral.  I get in there pretty quickly.

His assistant has already worked out an arrangement with the insurance company so they know what balance I owe, as my insurance only pays a certain percentage.  So she says, When you come back, come with a check in this amount, and we'll send you a check back if necessary.  I usually get a little rebate check. This is expensive stuff, ranging in the thousands, even after insurance.  It adds up pretty quickly!

They're making everything as painless as they possibly can:  the procedure itself, the lead up to it, the check-in process, and the settling of accounts at the end. 

The bedside manner is right there.  He's obviously an excellent technician, with a modern setup.  That's the stuff that's hard for the consumer to judge, other than the lack of pain during the procedure.  His manner is very gentle and calming even when you're in pain.  He brings down the anxiety level by explaining.  He'll do some small talk around the edges to bring the anxiety down, because they know people in this situation are usually in considerable pain.

It's a nice contrast.  Some surgeons are very abrupt with their patients, just saying, We're all set, all right, let's go.  That's not easy for patients or their families.  It's a very different experience with this man.

Overall, it's a collection of things, not one thing. It's all of what they do that meets those patient-centered ways of doing things.  I don't expect it as much of the office staff about the making of appointments, arrangements with insurance, the paperwork, and so forth, but they also make that painless.  While I don't like writing a big check of $1,000 or more, I'm not surprised.  It's not, We'll submit this to the insurance company and see what comes back, like with other dentists.  If I've made an overpayment, they'll pay me back.  It's all done smoothly for the patient.

I've had four root canals with this doctor, and the office process and the dental care are amazingly consistent at this high level of patient-centered care.

I give them a lot of credit for that.  If I do have to have more work done, that's where I'll go.  They've made the experience that good.  That has gotten back to my dentist; that's why he'd told me he had no reservations about sending me there.

Ken's Advice: In talking with a specialist, be sure to learn your options.  (John adds:  "If you perceive a lack of options, alarms should go off.  Be assertive, patients!")

Read a story of a dentist's patient-centered care.

Thursday, March 31, 2016

A checklist for post-operative care: 25 minutes was too long

A 17-year-old girl, Mariah Edwards, had a routine tonsillectomy, with Fentanyl as a pain killer.  However, right after the outpatient surgical procedure, she stopped breathing, but no one noticed this for 25 minutes.  The only automatic monitors of her vital signs had been muted.  And no one saw her because a curtain had been pulled around the post-op bay.  She died days later from the lack of oxygen.  This tragedy could have been prevented with proper post-op monitoring and care.

Her family’s lawyers at Ross Feller Casey have posted online a free checklist of questions that patients or their advocates can ask beforehand to assure themselves that doctors and nurses will safely care for their family member.  This is particularly important because the first few hours after surgery are often the most risky due to the use of anesthesia, the delivery of pain medication, and other complications that can arise in the recovery room.

Don’t be shy about questioning credentials or asking about post-op care. You are putting your trust, medical health, and quite possibly your life, in the hands of these people, so it is absolutely appropriate that you want to know about their experience and what to expect in the recovery room. You can, and should, ask to talk to whoever will be participating in the operation. It’s not unreasonable to request to talk with the anesthesiologist, surgeon, and other members of the surgical team before any surgery is performed.

Remember, it is just as important to ask about what will happen after the surgery as it is to ask about the procedure itself. You can ask about anything that you find relevant to the operation and time spent in recovery. It’s a good idea to make a list of questions prior to surgery so that you don’t forget any.  Sometimes asking the right questions about post-op care can make the difference between a positive medical outcome and a tragedy.

Read another checklist story.  Thanks to Mario Cattabiani, the Director of Communications at Ross Feller Casey in Philadelphia and David Bernard of OutpatientSurgery.net for this story. 

Friday, March 25, 2016

Consistently taking non-daily medicine: When it’s time to replace it

I have a minor medical condition for which my doctor suggested an over-the-counter nasal spray, Flonase  (fluticasone propionate).  Sometimes, for months at a time I’ll take it daily, sometimes every other day, sometimes less often, which my doctor says is fine.  The bottle says it contains 120 metered sprays.  How to know when it’s time to replace it?

I keep a scrap of paper and a pen next to it in my bathroom, writing down the date as I administer it to myself each time.  I can count the dates I’ve written so I know when to get a new one.  By doing that, I don’t throw away a bottle with usable medicine, nor keep using a sprayer with no medicine.

This could be useful for anyone who wants to consistently take medicine.  It’s most useful for medications you’re taking on something other than a daily basis.  For daily medicine, a seven-day pill box organizer, or something similar, is probably more convenient.

Sunday, February 7, 2016

End of life treatment: Teddy got ice cream

Barbara Moran’s story:
I dreamed about Teddy Kennedy.  He had died a few days earlier, and his memorial services had blanketed the Boston news.  I was jealous of Kennedy.  He spent the last days at home, smelling the salt of the ocean.  He ate bowls of butter crunch ice cream, watched James Bond movies and shared dinner with friends. 

     I’m sure Kennedy’s death had its share of horror, but that didn’t curb my envy.  Teddy got ice cream; my mom got a sterile sponge soaked in warm ginger ale.  Ted got the ocean; Mom got a gritty rooftop with a windsock.  Ted got his own bed and movies; Mom got the blinking lights of the I.C.U. and the stupid C.A.R.E. channel.  Her TV didn’t even have good reception.

     She did not regain consciousness, and died the next morning. I made peace with her death, but not with her dying.  She had four months of endless and pointless and painful procedures, and final days full of fear and despair.  Why is this medicine’s default death for so many people?

Ken's Advice:  Have the difficult conversation with your oldest relatives.  Start like this:  while eating ice cream with them, tell them what flavor you want in your last meal, tell them about Teddy’s butter crunch, and ask theirs. 

Thanks to science writer http://www.writtenbybarbaramoran.com/”>Barbara Moran for her story, reprinted from today’s New York Times article, “Not Just a Death, a System Failure.”

Sunday, August 16, 2015

Dear Young Doctor: Patient-Centered Dentistry


Dear Doctor, 

After 27 years of seeing Dr. Dorris, upon his retirement I had my first visit to you yesterday for a dental cleaning and exam.

During my cleanings and exams, he played my favorite music from his extensive collection of CDs, as he’d asked his patients to tell him their favorites.  He would put a pair of sunglasses on me to shield my eyes from the bright light and from any water sprayed there accidentally.  He’d spread some numbing stuff on my gums, of a flavor of my choice, to prevent any pain. He’d placed a variety of cartoons and beautiful posters on the ceiling. 

Remarkably, he did the cleanings himself.  Beginning by talking about dental hygiene, he would riff about his philosophy of a healthy life.  The visit would end by having me choose from various kinds of dental floss and toothbrushes, and he’d hand me a home-made page or two with some advice on dental self-care and life.

His new dental hygienist commented yesterday that in my 58-year-old body, I have the teeth of a 20-something.  That’s the evidence of his skill and our partnership.

You installed new technology for cleaning my teeth.  Perhaps my teeth are cleaner; I have no way to tell, though I do know the high-pitched sound as the water jet hit my gums was irksome, it felt endless, and my shirt and my face were wetter at the end.  That said, my teeth felt clean, and I don’t begrudge paying for the cleaning.  But what hurt the most was my shock at your $100 bill for the 30-second exam you gave me after the cleaning.

With those fees, you may make more money than Dr. Dorris.  But I doubt you’ll have patients who drive 40 minutes each way for 27 years for that kind of service.

As is true for most healthcare, your prices are simply way too high. 

Read another story about patient-centered dental care. 

Sunday, May 24, 2015

Oliver Sacks’ memoir: That good doctoring requires

In reviewing Oliver Sacks’ memoir, On the Move:  A Life, book reviewer Andrew Solomon captured the spirit of narrative medicine.  I once saw a carpenter at work, tapping a nail once to set it, and then with a decisive second stroke, driving it all the way home.  Solomon hit the nail on the head just like that:

“The emergent field of narrative medicine, in which a patient’s life story is elicited in order that his immediate health crisis may be addressed, in many ways reflects Sacks’ belief that a patient may know more about his condition than those treating him do, and that doctors’ ability to listen can therefore outrank technical erudition.  Common standards of physician neutrality are in Sacks’ view cold and unforgiving – a trespass not merely against a patient’s wish for loving care, but also against efficacy.  Sacks has insisted for decades that symptoms are often not what they seem, and that while specialization allows the refinement of expertise, it should never replace the generalism that connects the dots, nor thwart the tenderness that good doctoring requires.” 

In Awakenings and The Man Who Mistook His Wife for a Hat, among other books, Sacks describes how he acts as an ally with patients.  He doesn’t cure them, but as a caring thought partner with them, he finds ways to free them from the most imprisoning limitations of their plights.

Advice:   Let’s read Oliver Sacks’ memoir.

Read an example of the use of narrative medicine.  Thanks to Andrew Solomon for his book review in The New York Times of May 17.

Tuesday, April 21, 2015

Part 2 of the Milford Patient Family Advisory Council story: Results and Reflections

In Part 1, Beverly Swymer told the story of how the Patient Family Advisory Council of Milford Regional Medical Center improved care in the Emergency Room for behavioral health patients.

As Part 2, here are my thoughts on their results, and their ingredients of success. –Ken Farbstein

This effort reduced E.R. recidivism by 82% among a group of behavioral health patients who had frequently used Milford’s E.R. (from 7.3 visits/patient to 1.3, n=12 patients over the period of four months before, and four months after, these changes took effect).  This was probably particularly helpful in freeing E.R. capacity because the number of behavioral health E.R. visits at Milford had been growing about 7% each year.  

In interviewing Beverly, I had urged her to elaborate on her role, and I was puzzled at the absence of “I” in her answers. We often preach about the importance of collaborative styles, but rarely see them in practice.  I came to realize that I was hearing from a genuinely collaborative, self-effacing leader.  Beverly served on the PFAC after her long career at Milford as a nurse ended in 2009.  Her leadership style, or indeed her nature, along with her acquaintance with many of the staff, and the active participation of staff including the Chair of Emergency Medicine, helped to bring about these solid accomplishments.  

When I asked bluntly about her own role and contribution, she answered wisely, in a way that might sound clichéd in someone else’s mouth:  “It’s very important to make people feel empowered, to impact the journey, to think this will come about if we work on this together, like we did with rounds in the E.R.  The PFAC was a vehicle to come together to see what we could do to make a difference, and we did make a difference.”

Read about other accomplishments of Milford Regional's PFAC.  Thanks to Terri McDonald, Kim Munto, and Beverly Swymer for these stories.

Thursday, April 16, 2015

The value of a scribe: The patient's care was expedited

Fabio Giraldo is a Scribe with ScribeAmerica.  This is his story:

I was working a night shift in a single-coverage Emergency Room and I happened to be floor training as well. It was a busy night and the E.R. was gridlocked, and patients were starting to pile up in the waiting room. It was common for the triage nurse to place orders to get things started under the attending physician's name when the waiting room started filling up, and this night was no different. Being that the E.R. was gridlocked and we were not seeing any new patients, I took this opportunity to show the trainee how to look up X-rays on the PACS system.  I also started to explain to the trainee that it was important to monitor the waiting room results, being that the physician we were working with was the only physician on, and all of these [X-ray] studies were being ordered under his name.

As the apprentice scribe started pulling up images from patients in the waiting room, I heard him say "Wow!  This X-ray looks really weird."  I looked over to the PACS station and noticed this patient had free air under the right hemi-diaphragm, a finding that is consistent with a bowel perforation [a hole all the way through the wall of the intestine, which causes bacterial contamination of the abdominal cavity or peritonitis, a painful dangerous infection of its lining].  I immediately had my physician look at the X-ray.  He agreed and immediately called the surgeon on call, who took the patient to the Operating Room.

Approximately 30 minutes after the patient was taken to the O.R. my physician received a phone call from Radiology to notify him that one of his patients was found to have a bowel perforation on X-ray.  Because the apprentice scribe was vigilant to the orders placed in the waiting room, this patient's care was expedited and they were already in the O.R. by the time the Radiologist called the E.R.  [The prompt treatment of peritonitis can prevent complications, according to Freed's Medical Dictionary.]

Thanks to Fabio, and to Michelle Thompson of CWR & Partners for connecting us.  Read another story of how one very different medical practice has a technician serve as scribe, enabling the prompt preparation of a visit summary.

Tuesday, March 24, 2015

Happy Anniversary!: Affordable Care Act at the five-year mark

March 23 marked five years since Pres. Obama signed the Affordable Care Act into law.  Ten million more people now have insurance coverage.  As the ACA has only been in effect for a little more than a year, though, to ascertain its other likely effects, it is more useful to consider the first five years of the universal health coverage law in Massachusetts, the model for the ACA.

In Massachusetts, universal coverage became law in April 2006 as Chapter 58.  The most widely cited study of its effects over the first five years describes an improvement in the self-assessed health status of non-elderly Massachusetts adults.  That's the gold standard for whether the whole law was worth it:  do people feel healthier?  Before the law, 60% rated their health as very good or excellent; afterward, 65% rated it that way. Far more people were insured, and got medical care, according to the article by Sharon K. Long, Karen Stockley and Heather Dahlen in Health Affairs in January 2012, "Massachusetts Health Reforms: Uninsurance Remains Low, Self-Reported Health Status Improves As State Prepares To Tackle Costs."

Read a story about the likely effects of universal health insurance on women's health.

Wednesday, March 11, 2015

House calls by nurses: With their eye right up to the screen

Retrace Health provides primary care for families through home visits by nurses and video consultations.  Here’s the story of how they’ve been helping one family:

Ms. B’s story:
I was having some back pain.  They’re very flexible, and have lots of availability, so I was able to call the next day, when the kids were napping.  Otherwise, I would’ve had to figure out childcare for my kids.  They’re age 5, 4, and 3.

The nurse was really helpful in giving me other options, and a referral to a clinic that deals with back pain.  She gave me some suggestions, and made sure there wasn’t anything more serious going on, as I was in a serious amount of pain.  She followed up by sending me exercises I could do and some information for the referral.  A couple of weeks later, she followed up again, asking me how things were going, whether I’d found relief for the pain, and whether I’d tried the referral.  I was seeing a physical therapist.

For my kids, we usually start with a video conference.  If it’s about their eye, we’ll have their eye right up to the video screen.  The nurses are fantastic with the kids, and really make them feel at ease, because at first it would be a little strange for them to be on a computer screen.  They ask nice questions to get the kid to warm up.  There’s often a kid in the background, because this is our house, so it’s not always uninterrupted!  It’s so convenient!  If I have a concern, I can set up an appointment.  They’ll be very thorough, and will do all they can to make sure they get what the kid needs. 

They also have nurse practitioners who can come to our home and look at my kid.  Once they did that for a strep throat, and once for an earache, because you can’t really see that on a video screen, so they’ll come out and run the test here, or look in their ears.

That’s great, so I don’t have to take the kids into a clinic with a bunch of other sick kids, so my kid comes back with something.  They’re really thoughtful in how they ask questions of the kid.  They don’t talk over the kid; instead, they’ll ask them, What are your symptoms?  Then I can add something in if I need to.  They pay attention to the kid, and get them comfortable first to get them to say what’s going on.  We usually use ReTrace Health for things that come up between well-child checks, like a cold, earache, or a rash, where you need to decide whether to bring them to a doctor. 

Thanks to Thompson Aderinkomi of Retrace Health for the connection, and to Ms. B. for our interview.  Read a different story about an innovation in primary care.

Friday, January 16, 2015

Success at New Year's Resolutions: They're modern-day rituals

The poster near the Jewish Community Center's locker rooms proclaims in 288-point type:  "Rabbi Loses 35 Pounds!," and then nudges:  "Exercise and eating well are the new rituals."  

"This program transformed the way I think about meals, food and fitness.  I struggled for years to lose weight and keep it off.  But the TIO (Take It Off) program put it all together in a way that helped me shed pounds, get strong and fit, and feel good about what I eat and what I don't.  Checking in each week in a private session, along with personal training, has helped me keep on track.  I'm not going back to the way I used to eat, and I'm not giving up my regular workouts.  This has truly brought positive change to my life," says Rabbi Barbara Penzner. 

She is being the change, leading by example.  Her leadership in several other realms has been inspirational and life-changing, too.  To name just two:  Years ago, she helped form and guide the Greater Boston Interfaith Organization, an important component of the coalition that brought universal health insurance to Massachusetts.  And she led the Hyatt Hotel boycott, which eventually led to fair treatment for hotel workers in Boston and across the country.

Joan Hayes has served as her personal trainer (and mine) at the Jewish Community Center in Newton, Massachusetts.  Thanks, Joan!

Read another story about sustaining healthier habits.

Tuesday, January 13, 2015

Milford Regional’s PFAC Story, as told by Beverly Swymer [Part 1]

In June of 2012, as members of the Milford Regional Medical Center’s Patient/Family Advisory Council (PFAC), we were searching for a direction to go.  Dr. Jeff Hopkins, Chief of the Emergency Department, gave a presentation to us about the care of behavioral health patients in the Emergency Department and how the volume impacted the E. R. The patients who came to the E.R. needed follow-up care but the resources for staff to refer them to were very limited. With the deinstitutionalization (of mentally ill patients), the use of antipsychotic drugs can help to control the behavior of this patient population but this often results in homelessness and the revolving door syndrome. Patients with drug addiction and/or mental health issues and subsequent problems need active intervention and follow-up care.  They are a growing number of E.R. patients, often seen on an emergent basis.  These people are devastated; they do not know where to turn, so they seek out care and support in the E. R. and often arrive in a crisis state. The staff, not being trained in psychiatric care, aim to keep the patients safe, maintain their medicine regime and actively seek out appropriate behavioral health care support…essentially custodial supportive care while in the E.R. The result was long-term stays in the E.R. (sometimes this meant many hours or even days), which was troubling. It was especially difficult to place patients who’d been violent, children and those patients who had complex medical problems in addition to their behavioral issues as well as the difficulty of placement of behavioral health patients on the weekends.

As the PFAC Co-Chair at the time, I met with Dr. Hopkins to discuss how the PFAC could realistically have an impact on this issue.  We discussed ways to educate the community about the Behavioral Health Care crisis, and to identify ways to short-circuit the crisis step by connecting the E.R. patients to community services in a more timely fashion. This was our initial approach to define the role of the PFAC Subcommittee within the hospital: to define “better care”. We on the PFAC had a couple of meetings to discuss how to accomplish this effort. By September 2012, we started meeting on a monthly basis.

I became the head of the Behavioral Health Subcommittee of the PFAC at that time because I believed the PFAC, through collaboration with other healthcare providers, could make a difference in behavioral health care in the E.R.  I felt this issue impacts us all because it impacts health care in general as well as care in the E.R.  If ten of 30 beds are occupied with behavioral health patients, especially if occupied for extended periods of time, this impacts bed availability for all other patients. The goal of the PFAC Subcommittee was to find ways to improve care with better resources in the community and thus ultimately alleviate the impact on the E.R.

Assuming responsibility as Chairperson, my role through all of this was to get this challenging endeavor on track. Monthly meetings were and continue to be held. To develop a more comprehensive approach to this issue, we reached out to others who dealt with this patient care population. For example, we invited representatives from Case Management, Social Service, Nursing and Riverside Counseling Services to join the subcommittee in an effort to improve care of the behavioral health patient. It took a real strong collaborative approach and the PFAC was part of all of those discussions. As the PFAC Subcommittee chair, I worked with the E.R. behavioral health team to incorporate everyone’s input, obtain feedback from others and evaluated how it was all working.  I, along with other members of the PFAC Subcommittee, presented the PFAC and ED Behavioral Health Program at the Health Care for All PFAC State Conference at Holy Cross, the Massachusetts Coalition for the Prevention of Medical Errors, the Juvenile Advocacy Group (JAG) Community Breakfast and at a webinar hosted by Health Care for All.

We formed a diverse group with Dr. Hopkins, Chief of the Emergency Department, community caregivers, a child psychiatrist, Riverside Emergency Services, Nursing, Case Management, Social Service and a family member who dealt first hand with the issues of trying to find care for her son in crisis, etc

We reached out to the E.R. staff for their input and perspective on Behavioral Health Care in the E.R., asking for their suggestions on how to improve care of the behavioral health patient while in the E.R. The nurses developed a list of very helpful suggestions to enhance the care of the behavioral health patient while under their care. Some creative but simple suggested improvements included: a predictable schedule, showers, attention to proper nutrition, an opportunity to take a walk, exercise, music, etc., since some of these patients were in the E.R. for days. This effort showed the staff we were willing to listen and we valued their input.

As a result of this collaborative effort between the PFAC, Emergency Department, Case Management and Community Benefits, we received a grant from the EOHHS (Executive Office of Health and Human Services). This grant enabled us to provide an educational program for the E.R. nurses interested in Behavioral Health and to provide initial funding for Behavioral Health nursing positions. The first group of behavioral health nurses became mentors for their colleagues in the E. R.  This initiative was very well received by the nursing staff.

An integrated team was developed comprising Case Management, ED front line staff, Riverside, and other mental health care workers. Patients are evaluated during daily rounds in the E.R. Therefore they all know where each patient is in their care management and what follow-up resources could be identified. At one time, for those patients on behavioral watch or at risk of suicide, we had security guards watching over them. A program was developed to train people as Patient Safety Advisors. These people are specifically trained to interact with the behavioral health care patient in the E. R. while they waited for individualized plans of care.

Next we looked into the community for resources available to provide timely care and counseling to the behavioral health patient population. Our thinking was if we could provide opportunity for timely care and support we could short circuit the need for crisis intervention in the E.R. at 3 am.  Information was presented to our PFAC Behavioral Health Subcommittee about the Interface Referral Service of the Massachusetts School of Professional Psychology (MSPP). This service provides information about services available in and around the community and guidance in how to navigate the mental health system.  I, as well as others on the team, reached out and spoke with other communities who had successfully utilized this service. This was the first time this organization would be working in a hospital broad based outreach. In February of 2013, we signed a contract with Interface. In addition to making the information about this service available in our E.R, we notified (via letter) the schools, pediatricians’ offices, Counseling Services, Youth Groups in town, Library’s Youth Department, etc., all in an effort to make the public aware of this referral service.  This was one more step in our effort to make Behavioral Health Care better and available to our community when needed.  We’re trying to meet the patients’ needs for medication, personal needs, etc., with active intervention, not just custodial care in a hospital setting with a broad-based community outreach.

Stay tuned for Part 2.  In the meantime, read a story about other innovations by Patient/Family Advisory Councils at Milford and Beth Israel Deaconess Medical Center. 

Sunday, January 4, 2015

Patient-centered TV: 24 hours a day

We love Grey’s Anatomy, E.R., Chicago Hope, St. Elsewhere, Marcus Welby MD, and all the others:  the drama of near-death experiences and rescue by wise, handsome doctors and beautiful nurses:  What’s not to like?

And hospitals love the publicity of real-life TV shows about their doctors and nurses as heroes, for it polishes their public image.  Some patients may like appearing on TV, too.

But not always.  Anita Chanko was horrified to see her husband’s death in an Emergency Room televised, without her consent, on ABC’s program, “NY Med.”  When her husband had been hit by a truck late one night and brought to the E.R., a doctor had blocked her from seeing him.  But they didn’t block the TV videographers who recorded the hospital’s treatment of patients 24 hours a day.  The hospital’s Vice President of Public Affairs explained that “you can’t buy this kind of publicity, an eight-part series on a major broadcast network.” 

If all patients formally consent beforehand to being broadcast, that is their choice.  But for me, if a hospital is concerned with my dignity and privacy, please don’t broadcast me at my most vulnerable and weakest moment for your viewers’ titillation.

Read a story about the Patients' Bill of Rights.  Thanks to Charles Ornstein of the New York Times for the story, “Dying in the E.R., and on TV,” and Dina Litovsky for the photo.

Wednesday, December 31, 2014

The war on cancer: A public health triumph

In the war on cancer, the American Cancer Society announced in a yearly report by Stacy Simon that over the last 20 years, 22% fewer people have died from cancer, representing 1.5 million avoided deaths.  The biggest single reduction occurred in lung cancer, according to the Society’s Vice President for Surveillance and Health Services Research, Ahmedin Jemal.  There are fewer smokers, as millions quit, and millions of others never started smoking.

This was not primarily the result of medical care, though doctors certainly advised many of their patients to quit.  Rather, quitters used a variety of methods over multiple attempts to quit, including advice from doctors and others, smoking cessation products like patches, gums, etc., reading generic or individualized materials, quitting cold turkey, etc.  So this wasn’t “patient engagement” by the medical system per se, as quitters were not primarily benefiting from their doctors’ active medical management of their smoking.  They weren’t patients; for most quitters, cancer had not developed to the point where they required treatment for cancer.  Rather, in most cases the successful quits came from multiple self-initiated efforts by the “worried well,” often with nudging by family members.

There is much credit to share for all the lives saved, e.g., for doctors who advised patients to quit.  Yet this victory seems due more to public health efforts than to the medical system. 

Efforts to meliorate the toxic effects of other lifestyle choices about alcohol, drugs, overeating, inactivity, etc., might also benefit from focusing on public health efforts addressed to the worried well, in similar ways. 

Advice:  Have a happy New Year!   Give a hug to your public health friends, and let’s celebrate!   

Tuesday, December 30, 2014

Skype psychotherapy and pets: It brings us closer

Joseph Burgo’s story:
I’ve been a clinical psychologist for over 30 years. Trained in the psychoanalytic method, I spent most of my career in an office seated behind clients who lay on a couch. Then, three years ago, after several followers of my blog asked if I would be willing to work with them by Skype, I started practicing face-to-face video psychotherapy with clients all over the world. Usually I “meet” them in their homes.
Often, I meet their pets as well.
Noelle, a 42-year-old woman living in the Australian outback, reached out to me for help coping with a midlife crisis. She had recently learned she would never be able to bear children and was in profound grief. She usually spoke with me from her bedroom, where she would sit cross-legged on the bed. Often I heard her dogs, three Shelties, barking in the background. One day when they seemed especially obstreperous, she gathered them onto the bed with her. I will never forget the agonized expression on her face as she told me, “These are my children.”
As she wept, she held one of them close and buried her face in his fur. My chest ached and tears came to my eyes. Rather than the existential loneliness of weeping on a couch, staring up at a blank ceiling, hers was a grief shared with her animals. Although across the world and thousands of miles away from her, I shared it, too. We were together, all five of us, in the pain.
After all my years in practice, I’ve come to understand that the greatest influence on the healing process in psychotherapy, at least the way I practice it, is the love I feel for my clients and the love they come to feel for me. As a professional, I’m uneasy speaking this truth aloud, and my clients often don’t feel entirely comfortable with it either. The love we feel for our pets helps ease the way. I witness the affection they feel for their pets, they see mine for Alice, and it brings us closer.
Although Sigmund Freud’s psychoanalytic method encourages the analyst to present a blank screen, concealing all details of his personal life, thoughts and feelings, Freud himself practiced from his home and included Jo-Fi, his favorite Chow Chow, in many of his sessions. Freud supposedly relied on his pet’s reaction to a client for help in assessing the person’s character. He also felt that a dog’s presence helped to calm his clients.
I’m sure that if my teachers and supervisors from analytic training were to hear about the work I now do and my views on the healing power of love, they would shake their heads in disapproval, concerned that I had gone to the dogs.
Read another post about the therapeutic power of love. 
Thanks to Joseph Burgo, whose New York Times article and Opinionator blog post are excerpted here.  He is the author of the forthcoming book The Narcissist You Know: Defending Yourself Against Extreme Narcissists in an All-About-Me World.

Monday, December 29, 2014

Medical decision-making among treatment options: The signature medical mistake of my life

     Dr. Jerome Groopman and Dr. Pamela Hartzband wrote a clear and insightful book, Your Medical Mind:  How to decide what is right for you.  They illustrate decision-making through stories about themselves and their patients.

     Dr. Groopman’s father died from poor care for a heart attack, back in the days when some doctors thought that removing the heart attack patient’s blood would unburden the failing heart.  As a reaction, Dr. Groopman became a “maximalist,” believing that modern medical interventions were generally good things.  Following that belief, when suffering from persistent excruciating back pain, he opted for aggressive surgery—spinal fusion--when merely waiting might have been preferable.  The surgery gave him lasting pain and debility; he called it “the signature medical mistake of my life,” with disastrous consequences.  It also gave him a long-term belief in making more nuanced decisions about treatments for himself and his patients. 

     Years later, his doctor advised him to take a statin to reduce his high cholesterol.  In light of the heart disease in his family, he knew he had to do something.  However, Dr. Groopman knew of a friend who had incurred lasting muscle pain, a common side effect of statins.  So he negotiated with his doctor to take a smaller dose of statins, and found that the smaller dose was great enough to lower his cholesterol, and yet small enough to avoid any muscle pain.  

Advice to patients:  Learn from the experiences you and your friends have had and your family history.  Consider them and your biases when making decisions about your medical treatment.  

Wednesday, November 19, 2014

A young AIDS patient: What love is

Dr. Betsy MacGregor’s story:

     We admitted a great number of children who were sick with AIDS to my hospital back in those days, and sadly we lost many of them.  I remember one two-year-old boy in particular.  He touched me deeply.  As was typical, he had acquired the virus from his infected mother when he was born, and despite our best efforts to help him, he was slowly slipping away from us.  He lay quietly in his crib, hollow-eyed and emaciated, never smiling or even crying.  He simply did not have the energy.

     The little boy’s mother had brought him to our emergency room one night, burning up with fever.  The chest x-ray we took showed he had pneumonia, and so we promptly admitted him to the pediatric ward.  His mother lingered at his side for a time, but then departed and never returned.  Eventually we learned she had been admitted to another hospital shortly after leaving ours and had died there from complications of her own AIDS.  The one thing she had left her son was his name. She had called him Angel.

     Angel had been on our pediatric ward for three months.  There was no other place that wanted him, and frankly we were happy to keep him with us.  At least we knew he would be fed and kept clean and sheltered and would occasionally be held in another human being’s arms when one of the staff was able to spare a moment or two.  We knew he had little time left.

     One night, when I was on call and kept busy on the ward into the wee hours of the night, I glimpsed a side of Angel’s story I had not been aware of before.  The lights had all been turned down and most of the children put to sleep in their beds, and I was going about my intern’s work – reviewing orders, checking on patients’ vital signs, and peeking in on the sickest ones – when something caught my ear.  A faint lyrical sound was whispering down one of the dimly lit hallways.  Listening closely I detected the thin notes of a melody carried by a human voice. 

     I was tired and still had chores to do, but the wistful sound called to me, and so I followed it, curious to learn what its source was.  It led me to Angel’s room.  Yet what I saw through the doorway as I approached made me pause and remain in the quiet shadows of the hallway rather than enter.  For it was clear that more was taking place in Angel’s room than the sad wasting of an unfulfilled life.  Something more intimate was happening, something that needed not to be disturbed.

     With Angel was his father.  I had never seen the man before, but during discussions on our daily morning rounds, I had heard that he often came in the wee hours of the night to visit his son.  He was a tough-looking person, unshaven and stamped with the harsh signs of inner city life and his own battle with the AIDS he had acquired during years of drug addiction.  I wondered what factors in his life prevented him from visiting in the light of day as other parents did.  Perhaps he was fully occupied with trying to survive, I thought, or maybe he just preferred the lonely hours of the night, when he was less likely to encounter the accusing stares of strangers’ eyes.

     The man was sitting in a chair, holding Angel on his lap and feeding him infant formula with a dropper.  As I watched, he waited carefully for his son’s lips to accept each drop before offering him another, all the while gazing into his child’s eyes and softly crooning a melody – a hauntingly soothing sound, the notes filled with reassurance and encouragement.  Angel’s eyes remained fastened in turn on his father’s face, as if he were drinking in life-giving nourishment from the look that he saw there.

     The two of them were in such a rapt communion that I remained bound in unmoving silence outside their door.  It seemed that I had been summoned not to enter, but to stand as an observer of this exquisite scene, witness to an act of meaning that lay beyond my mind’s measuring.

     What I had been called to witness, my heart said, was the love that was shining brightly in that little room.  Nothing more than that, and nothing less.  In the light of that love, the tragedy of Angel’s pitiful life – of both their lives – was being lifted up and set aside.  I could feel the truth of that as surely as anything my medical books had ever taught me. 

     The shadows in the hallway seemed to whisper, Do you see?  This is what love is.  It is a force more powerful than even life-destroying disease.  It can tenderly embrace whatever the world has abandoned as hopeless and transform it into something to be cherished.

Read a story about the power of love from a group.  Thanks to Dr. Betsy MacGregor for permission to reprint this excerpt from her book, In Awe of Being Human: A doctor’s stories from the edge of life and death

Tuesday, November 4, 2014

Weight Loss in a Group: The team was my family

Stacie’s story:
Two years ago I decided I was tired of how much I weighed and how I felt.  I’m a former athlete, so I’ve worked with coaches and trainers, but I was missing something.

In an Internet search, I found seven nutritionists in my area, and I settled on Kerri Hawkins because of this wellness group.  It was spring, and the group started in the fall, not summer, because people would miss a lot then, and you have to be committed to it.  I started meeting with Kerri individually.  And then I began with the Wellness Group in September 2013.

There’s one caution about the Wellness Group:  you have to be comfortable talking in a group.  Group settings have always been very positive for me.  My team was my family in high school and college.  Having that support around you when you have setbacks, that’s what I got when I came here. 

They set up an e-list for us.  We met 15 times over 20 weeks, once a week for ten weeks, then every other week.  At each meeting we received a new challenge.  Keri and Dr. Altman encouraged us to talk via email about the challenges.  For example, one challenge was, “No added sugar or artificial sweeteners.”  You’re suddenly looking at all the ingredients.  I had to give up diet soda, which, it turns out, is worse for you than sugar.  For women especially, artificial sweeteners are linked to the risk of stroke, and it triggers cravings in the brain for more sweets later.  I still have popcorn with butter and soda with my husband whenever we go to the movies.  We now share a regular soda. 

The “no added sugar” challenge was really hard for everyone in my group.  We received emails that informed us about people’s success.  These really kept me going; otherwise, it would’ve been easy to get lost in thinking, “I wish I had ___,” etc.

The e-list also let me do one of the things I like most:  to cheer for people.  I made a point to respond to every email that came through, which was helpful for me.  I loved celebrating my group’s successes.

And that’s where the team component comes in.  One woman in the group realized it wasn’t the right setting for her, since she did not feel comfortable sharing like the rest of us.  You have to talk about things that are hard, e.g., being a national level swimmer, with a controlled diet.  When I was no longer a competitive swimmer, my unhealthy relationship with food came out and I put on weight in my 20s and 30s.  I had the support of my group, their encouragement and sometimes a hug (when needed).

This program helped me to develop a healthier relationship to food.  It’s not like a 12-step program with alcohol.  You have to have food every day, so I had to establish a healthy relationship with my food.  I’ve even shared this healthy relationship with my dog Jordy.  He loves sharing a bowl of raspberries or splitting a banana.  I lost 48 pounds in 20 weeks.  I made enduring friends and have the lasting support of a team.

Thanks to Stacie for sharing her story, and Kerri Hawkins and Dr. Wayne Altman for connecting us.

Tuesday, October 28, 2014

Weight Loss Groups: Those who post lose the most!

Howard’s story:
     I retired in 2010 at age 69.  Wayne [Altman, MD, my PCP] said, Howard, you should join these groups that Kerri and I have been running.  I was pre-diabetic, on the threshold of being obese.  I had issues with my blood pressure, glycemic index, cholesterol, and all that stuff.  I was skeptical but I was willing to give it a try, because I’ve dealt with weight issues for all my life, and nothing I’d tried before ever worked (or worked for very long). 

     The secret sauce?  You’re in a group, where we all come from different facets of life.  The thing we have in common is the need to deal with health and fitness.  It doesn’t make a difference if you’re a high-powered executive, or retired, or you work like Stacie.  Over 20 weeks, you bond, and you develop a community, and affection.  These e-lists are set up for each group, and remain even after the group is over.

     I was in Group 4, which began in September 2010.  We had buddies; Gerri was mine.  I was sending emails.  But then I thought: Does she really want to hear this?!  She’s much younger.  I’ll send her an email, and I’ll ask her, Is it too much? I won’t be offended.  Her answer was, Oh, absolutely not!  I love it.  It’s a reminder for her of what SHE had made as a commitment to do in her own life.  It’s support and accountability at the same time. The next week, she shared this, and she suggested Wayne should appoint a nudge to remind the group to do emails.  So I did, sharing a daily email about me and responding to others.  The traffic on the e-list just took off!

     So now we say, Those who post lose the most!  You have to be willing to share your difficulties as well as the successes.  This is for life.  Doing it alone wouldn’t work. 

     I found I was having success.  I decided four months wasn’t enough of a baseline.  So I re-upped with another group.  By June 2011 I lost 30 pounds and eight inches in my waist, and even better, I managed to keep it off.  I sleep like a babe!  I’ve become active – I Nordic walk, power walking with poles, and I go to the gym.

     I’ve been in a regular group or an advanced group since I’ve started.  Although I’ve mastered the exercise and the food piece, my sense is I will always want the connection, the group.  The advanced group meets once a month over ten months.  Also, occasionally we can get together between the monthly meetings. 

     So now I’m giving back, paying it forward.  I serve as a resource for the wellness group program and I’m a regular “guest speaker” at one of the initial weekly sessions of each new 4-month program to share my experience and offer support.  I thank Wayne and Kerri [Hawkins, nutritionist] for saving my life.  All my tests are normal or optimal.  I’m off statins and blood pressure meds, and I just take Vitamin B-12.

     I’m still in contact with my group from 2010, since you develop friendships.  I still post to all the groups I’ve been in, and some people respond, even now.  

Read another story about weight loss.  Thanks to Howard Cloth for sharing his story.