Dear Young Doctor: Patient-Centered Dentistry

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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. 

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.

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.

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.

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.

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.

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.

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. 

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.