The shock of the new
Orphaned by civil war in Sudan, John Bul Dau, Daniel Abol Pach and Panther Bior left behind everything that was familiar. The drive to survive led them across the sub-Saharan desert in the company of thousands of other displaced youths collectively known as "the lost boys." They scrounged for food and fended off lions, hyenas and rebel soldiers. Finally they reached a U.N. refugee camp in Kenya, where John, Daniel and Panther were among 3,800 lost boys selected for resettlement in the United States.
A documentary crew filmed their amazement and apprehension as they boarded a plane for the flight across the Atlantic. Over the next four years, the filmmakers chronicled their new lives in the United States and the process of adjustment. The result is an award-winning documentary, "God Grew Tired of Us," a story both of immigration and of the human response to being culturally uprooted.
I saw the film last night at a film festival being hosted this month by the Willmar Area Comprehensive Immigration Reform coalition. One scene particularly stands out in my mind: Daniel and Panther's visit to a shopping mall at Christmastime, where they're speechless at the sight of Santa Claus and a towering Christmas tree.
Talk about a moment of culture shock.
What exactly is culture shock? Anyone who travels is probably familiar with some of the signs: unfamiliarity, stress, disorientation, homesickness. It's a common reaction to being placed in strange surroundings, and it's often experienced by immigrants, expatriates, international students and anyone who lives or works abroad. The Amigos Web site at San Diego State University describes it this way:
The term, culture shock, was introduced for the first time in 1958 to describe the anxiety produced when a person moves to a completely new environment. This term expresses the lack of direction, the feeling of not knowing what to do or how to do things in a new environment, and not knowing what is appropriate or inappropriate. The feeling of culture shock generally sets in after the first few weeks of coming to a new place.
Anthropologist Dr. Kalervo Oberg appears to have been the first person to coin the term "culture shock" and to identify its distinct stages: the honeymoon phase, when newcomers often are eager to absorb their new surroundings, followed by a hostile and unhappy phase which eventually gives way to adjustment and even enjoyment.
Although it's only been within the last 50 years that culture shock has been officially recognized and given a name, it has surely been a common experience in much of human history. One of the most memorable characters in American immigrant literature can be found in "Giants in the Earth," a saga of Norwegian homesteaders on the Dakota prairie. (The author, O.E. Rolvaag, was the father of Karl Rolvaag, Minnesota's 31st governor; the book was first published in 1929.) It's an unflinching look at the difficulties that come with pulling up stakes and settling in a new home. The intrepid Per Hansa takes to homesteading with gusto but his wife, Beret - lonely, homesick and feeling unmoored from all her familiar values and traditions - cannot adapt. Although I doubt Rolvaag, who was himself an immigrant from Norway, would have used the words "culture shock" to describe Beret's emotional turmoil, he clearly recognized this is how some people react to a new and unfamiliar environment.
In many ways, it's hardly surprising that cultural transplantation leads to some level of stress or difficulty with adapting. Unfamiliar customs and language barriers can make even the normal daily routine more challenging. Moving from a tropical to a more temperate climate, or vice versa, also involves physical adjustment. Then there are all the cultural assumptions that we take for granted when we're at home - for instance, our concepts of privacy and social distance.
For many, the adjustment is not easy, especially if they're transplanted to a culture significantly different from their own. As the global gap widens between the haves and the have-nots, and as people are increasingly displaced by armed conflicts, I suspect the trauma and the adjustment challenges may rise to a level we haven't previously seen. Partway through "God Grew Tired of Us," we learn that one of the lost boys who came to the U.S. with John, Daniel and Panther disappeared for a couple of days, broke down and ended up in a psychiatric hospital.
This doesn't mean everyone who experiences culture shock has a mental health disorder. Most people, in fact, eventually do adjust, although for some it can take many months. By some estimates, approximately half of Americans living abroad never fully integrate into their new surroundings.
How do you know when you've arrived, culturally speaking? An online guide for Americans living and working overseas offers some of the mileposts:
- You begin to feel less isolated.
- You reach the level where you feel you can function effectively in the new environment.
- You don't feel the same frustration or helplessness anymore.
- You find a middle ground where you can converse comfortably in the language.
- You have made friends and can share common enjoyment in leisure pursuits with your new friends.
- You have accepted the differences between your home society and the new society.
This seems to be true regardless of who you are or where you've come from. There were some moments of levity in "God Grew Tired of Us" as the lost boys of the Sudan were introduced to an American escalator and the trappings of a city apartment, none of which they'd ever encountered before. You have to wonder, though, what would happen if the situation were reversed. How many of us would have been able to survive in the desert as these young men did?
By the end of the documentary, John, Daniel and Panther have more or less adjusted and have turned their attention to finding and helping their displaced relatives in Sudan. John plans to return and build a clinic. Panther wants to start a school. None of them are bitter. It's a pretty amazing lesson in how resilient we can be, even in the face of earth-shaking changes in our lives.
For those who are interested, the Willmar Area Comprehensive Immigration Reform is hosting two more nights of its film festival this month. The next film, "La Misma Luna," will be shown at 6 p.m. Monday, March 22, in the theater at Vinje Lutheran Church. The final film, to be shown at 6 p.m. March 29, will be chosen by the audience.
Photo: Immigrant children at Ellis Island, New York, 1908. Source: National Archives.
Posted by: Anne Polta on March 16, 2010 at 11:17 AM | Comments (0) | Permalink
Tags: culture shock, mental health
The patient safety edition
If you read this blog on a somewhat regular basis, you've more than likely noticed I'm a bit obsessed about patient safety. I come by it honestly. Personal experiences such as a case of mistaken identity, which I blogged about in this post, and a close call with a wrong-site surgery, described here, tend to make you highly aware of the potential for things to go wrong.
So I couldn't let national Patient Safety Awareness Week go by without posting at least a few links to some patient safety-related reading, starting with this excellent New York Times interview with Dr. Peter J. Pronovost, medical director of the Quality and Safety Research Group at Johns Hopkins Hospital in Baltimore, Md. (If his name sounds familiar, it's because he has done some ground-breaking research on the effectiveness of checklists to prevent errors.) In the interview, Dr. Pronovost delivers some frank talk about hospital safety, especially about preventing hospital-acquired infections.
One of the points Dr. Pronovost makes is that health care professionals are often their own worst enemies when it comes to providing safer care. Why is this? Most doctors are smart, perfectionistic and dedicated to high standards, but their training doesn't seem to have prepared them well in the skills required to understand patient safety issues or to work collaboratively in analyzing errors and designing safer systems. This is the premise of a newly issued report, developed by the Lucian Leape Institute at the National Patient Safety Foundation and titled "Unmet Needs: Teaching Physicians to Provide Safe Patient Care."
Here's an excerpt that lays it on the line:
Medical schools today focus principally on providing students with the knowledge and skills they need for the technical practice of medicine, but often pay inadequate attention to the shaping of student skills, attitudes, and behaviors that will permit them to function safely and as architects of patient safety improvement in the future. Specifically, medical schools are not doing an adequate job of facilitating student understanding of basic knowledge and the development of skills required for the provision of safe patient care, to wit: systems thinking, problem analysis, application of human factors science, communication skills, patient-centered care, teaming concepts and skills, and dealing with feelings of doubt, fear and uncertainty with respect to medical errors.
The full report can be downloaded here.
At the Agency for Healthcare Research and Quality, the Web-based morbidity and mortality rounds feature an ongoing series of "Perspectives on Safety." In-depth articles and interviews with experts explore issues such as health literacy, disruptive physician behavior, surgical errors, medication bar coding and more. It quickly becomes clear that patient safety is complex, involving multiple factors that cannot be changed overnight.
Then there's the human side of patient safety. Paul Levy, president and CEO of Beth Israel Deaconess Medical Center in Boston, is known as an advocate for patient safety and transparency. He also happens to be a prominent blogger at "Running a Hospital," so when it was his turn a year ago to host the medblogosphere's weekly grand rounds, he chose to collect personal stories about medical error. The result is "When things go awry." Take some time to follow the links and read all the stories, which represent the experiences of health care professionals as well as patients.
It's not hard to sympathize with patients and families when something goes wrong. But what about the doctors, nurses, pharmacists and other health care providers involved in an error, especially when it's an error that harms or kills a patient? I think it's safe to say clinicians invariably suffer as intensely as the patient and family - maybe even more so - yet often receive little support to help them heal. Caring for clinicians after an adverse event has long been a missing, but vital, piece in the response to medical error. A symposium last year, sponsored by a coalition that included Medically Induced Trauma Support Services of Massachusetts, explored this missing link and what can be done to support health care professionals more effectively. The full report is posted on the MITSS Web site and can be downloaded here.
I'd be remiss if I didn't also post some basic information for patients and families about what they can do to reduce the likelihood they'll be on the receiving end of a medical error. Here's the National Patient Safety Foundation's patient and family safety page, which contains several links and other resources. The Web site of the Minnesota Alliance for Patient Safety is here. And here's the consumer medication safety page of the Institute for Safe Medication Practices; it contains a lot of valuable information about the safe use of prescription and over-the-counter medications.
I think we need to be careful about overplaying the ability of patients to influence the safety of their own care. Many things can go wrong over which patients have little, if any, control, and the guilt and self-blame they may feel after an adverse event should not be underestimated. But there are many things patients can do that help make a difference. A little knowledge and empowerment often go a long way.
Update, March 15: Here's an insider's perspective from Dr. Pauline Chen, who writes for the New York Times about the doctor-patient relationship. The online discussion can be found here. A couple of thoughts come to mind. First, what Dr. Chen describes seems to be more than a culture of fear; it's also a culture of hierarchy and dysfunction, in which incident reports about patient harm are used as a weapon instead of a tool for learning. Second, judging from the readers' comments, it's incredibly difficult to have a constructive conversation about how to improve patient safety. Doctors get defensive; the public resorts to doctor-bashing. How are we supposed to make any progress in the face of this siege mentality?
Posted by: Anne Polta on March 11, 2010 at 9:57 AM | Comments (0) | Permalink
Tags: patient safety
A medical home
A month or so after the sad events alluded to in this post, I adopted a new cat from the Hawk Creek Animal Shelter here in Willmar. One of the stipulations of the adoption contract was to bring my new kitty for a veterinary checkup within two weeks - not necessarily because there was something wrong with her but to get her into the veterinary system and make sure a medical file was established for her. As an incentive, the Humane Society of Kandiyohi County even provided a coupon for a free veterinary visit at one of half a dozen participating veterinary clinics in the area.
Everyone, it seems, needs a medical home. Even our animal companions.
The term "medical home" or "health care home" has been around for many years. It was first used back in the late 1960s to refer to a central place where a child's medical record was archived. More generally, it means the location, usually a primary care clinic, where patients receive most of their ongoing care. Regardless of how you define it, though, we're going to be hearing it a lot more frequently in upcoming months as Minnesota rolls out its new "health care home" model this year. Last weekend the Minneapolis Star Tribune featured an article describing how the concept is supposed to work:
While the national health care debate has become mired in an acrimonious mix of ideas and insults, Minnesota is moving ahead, putting in place the building blocks of a landmark 2008 state law designed to improve medical care, keep Minnesotans healthier and ultimately trim soaring costs.
The first of the big changes - the "health care home" - will debut July 1 and then spread across the state, with perhaps one-fourth of the state's 700 clinics certified to offer their sickest patients this new model of care by 2012.
Go to Staples, 150 miles northwest of the Twin Cities, and you can glimpse at the medical future now. That's where 11 family-practice doctors at Lakewood Health System are using the approach to see whether they can offer better and sometimes cheaper care for 524 patients with the most complex conditions.
Minnesota isn't the only state doing this. There are currently more than 90 initiatives across the United States to implement a patient-centered health care home model, and at least one version of the federal health care reform bill contained funding for additional pilot projects. (I haven't been able to find out whether this funding remains in any current form of the bill.)
At first glance, it doesn't seem all that radical. Health care providers in Willmar have been using various pieces of the concept for quite some time - for instance, a collaborative project at Family Practice Medical Center to improve the management of congestive heart failure. The Willmar Regional Cancer Center is another local service that has adopted a form of the case-management model for caring for its cancer patients.
In the larger picture, however, it's a very big deal for the promise it holds of transforming the way primary care is provided: more time for patients who need the most attention, more teamwork, better management of chronic conditions, and, ultimately, improved patient outcomes.
How, exactly, does the medical-home concept work? An in-depth article that appeared in the winter edition of Proto, the magazine of Massachusetts General Hospital, describes a medical home pilot project in Vermont, using the example of a man in his 30s newly diagnosed with diabetes:
Pre-medical home, he might have gotten a session with a nurse educator to talk about monitoring insulin levels and giving himself daily shots, and perhaps to go over recommendations for diet and exercise. But it would have been his job to make follow-up appointments to measure his blood sugar, and no one would have had time to check whether he was going to the gym and losing weight.
With the new system, he gets frequent calls and e-mails from staff members alerted by a computerized patient-tracking system. The team's nutritionist has designed a reduced-carbohydrate diet and an exercise plan for the man, who meets with the team nurse monthly. He has lost 45 pounds and is managing his diabetes without insulin.
At Lakewood Health System in Staples, the physicians decide which patients should be assigned to a health care home. From the Star Tribune article:
Every medical home patient gets a doctor visit of at least 30 minutes, double the usual time. All 11 primary care doctors reserve several slots a day for medical home patients who need immediate care.
"We were getting frustrated. We didn't seem to have enough time for the patients who needed us most," said Dr. John Halfen, 60, medical director at the Staples clinic and the driving force behind the new system, now 16 months old. "I'm not working less now, but I feel like I'm accomplishing more."
Depending on the patient, the health team might include a pharmacist, a psychologist, a specialist, a physical therapist, a home health nurse, the patient's spouse, even a hospice coordinator or nursing home worker.
But it's the care coordinator - a registered nurse and the first point of contact - who keeps the system humming.
The real clincher is that, starting July 1, health insurers will begin paying care coordination fees to providers to help support the extra resources they're investing in medical-home patients. Lack of money has long been the stumbling block to providing more comprehensive care for patients when they need it, and it's one of the reasons why most clinics simply haven't been able to coordinate care to a greater extent.
If the medical-home concept works the way it's supposed to, the money invested up front will be reaped in cost savings with fewer hospitalizations, fewer complications and better overall use of the medical system. Here's more from the article in Proto (it's a lengthy article, but if you want to learn more about the medical home model, I'd recommend taking the time to read it from start to finish):
Yet hopes are high that the medical home model could be at least part of the solution to out-of-control health spending, as well as addressing concerns about quality. A 2004 study by the Future of Family Medicine Project, a collaboration among seven national family medicine organizations, estimated that total health care costs would decrease almost 6% if medical homes became the norm, saving some $70 billion annually. And one major proponent of the model - the Patient-Centered Primary Care Collaborative, a coalition formed in 2006 by IBM and other businesses that has grown to include more than 700 members, including large employers, insurers, consumer groups and physicians - suggested in a report that the patient-centered medical home, "if appropriately conceived and properly implemented," could transform the U.S. health care system.
Obviously we're not there yet. But early results indicate the model does indeed help hold down costs - and both patients and clinicians are generally happy with how it has transformed the way primary care is provided and received.
If I have a criticism, it's this: Most of the medical home initiatives, including the one in Minnesota, focus on those who are already sick, have chronic conditions or need a lot of care management. To be sure, this is a patient population that requires attention. By all accounts, the cost of chronic disease in the United States is going to continue rising, so it's critical to manage these patients as well as possible.
But if one of the goals is to shift the focus of the American health care system from an acute care and disease intervention model to one of wellness and disease prevention, it's hard to picture how this can happen when the model doesn't include patients who are farther upstream - in other words, folks who are healthy to begin with and whom we want to keep healthy. Transformation needs to start somewhere, of course, and it makes sense to start with those who have the most complex needs. In the long term, however, I'm not sure how much change we'll be able to accomplish if we continue to invest our resources primarily on sickness.
The medical home, in its broadest sense, refers to where patients receive most of their care, sick or well. Most studies have concluded that when there's continuity, when patients have a health care team who knows them well, they generally fare better overall. But many Americans simply don't have a health care home. Maybe they only see a doctor when they're sick. Maybe they've never really established an ongoing relationship with a physician or clinic and don't have someone whom they consider to be "their" doctor. If they're uninsured, they're probably outside the system altogether. Until we can bring more of these people into the fold, so to speak, I'm not convinced that American health care will truly be able to transform itself the way we envision.
So, back to my cat. I made the appointment at the same veterinary clinic where we've been a client for many years. The shelter gave me a copy of my new cat's health and vaccination record, which I brought to our visit so it could be copied into her new medical file. We put her on the scale, with good news: Her weight is perfect (although the veterinarian informed me that we wouldn't want it to get any higher). The scanty fur below her right ear suggests she may have had ear mites or an ear infection at some point, but both her ears now look entirely normal. There's some tartar on her teeth, so she'll need a dental cleaning some time this year. All in all, she's a healthy and happy 5-year-old cat. She not only has a home, she also has a medical home and it's going to be all to her benefit.
If we can do this for pets, surely people deserve no less.
Photo: Wikimedia Commons
Posted by: Anne Polta on March 08, 2010 at 11:53 AM | Comments (0) | Permalink
Tags: medical home, primary care
The agony of defeat
The Winter Olympic games are over. The athletes have all gone home. Some have medals (way to go!) but most do not. For every athlete who won gold, there was another who finished dead last.
The thrill of victory is wonderful for those who experience it, but what about the agony of defeat? How do you handle the emotional blow of being a loser without, well, being a loser about it?
It's one of life's hard lessons, usually encountered early in childhood, that you can't always be the winner. Most youth athletes perform on a much smaller stage than the Olympics, but that doesn't make defeat any easier to swallow, explains Dr. Claudia Reardon of the School of Medicine and Public Health at the University of Wisconsin. Here's her perspective for parents and other adults who work with young athletes (it's advice that could equally apply to kids in other competitive activities such as spelling bees and math contests):
"Youth sports can be a really physically and emotionally healthy activity, but the reality is that not every bounce, play or game is going to go your child's way," says Dr. Reardon. "The way you choose to handle can really help them grow, both as individuals and as athletes."
Step one is to acknowledge your child's feelings. While they're likely to take things to a catastrophic extreme when they come up short or their last-second shot bounces off the rim (think phrases like "I'm the worst player EVER" and "My life is ruined!"), you can help them take a more measured approach.
"Saying something as simple as, 'I understand you're feeling upset that you didn't win the race' can open up a discussion and let them know you're there to listen," says Dr. Reardon. "And it's OK if the conversation stops there; some children need to work through the disappointment on their own."
Plenty of adults seem to struggle with this themselves. Bad sportsmanship is getting a lot of attention these days. You have to wonder what it says about someone's emotional disposition when his response to winning a silver medal in men's Winter Olympics figure skating is to snark about the gold-medal winner's failure to include a quadruple jump in his routine. Or what it says about the adults who think it's acceptable to swear at coaches and referees and, in some extreme cases, get physically assaultive. Self-control, anyone?
I'm not sure it helps when certain athletes are uber-hyped by the media. It puts them under heavy pressure to succeed, with the implication that anything less than a gold medal constitutes failure. Not only do their fans expect them to win but there might be, as in the case of South Korean figure skater Kim Yu Na, millions of dollars' worth of endorsements at stake. And what about their teammates, who are often equally hard-working but don't get the same amount of attention?
In spite of the pressure-cooker of the world's most elite sports event, though, there were many moments of Olympic grace, among the winners as well as the losers. These athletes displayed what I like to think of as emotional resilience, the ability to hold up under stress and not resort to negative, potentially destructive thought patterns and behaviors. It's what makes a skater go out on the ice, land a great performance and win a bronze medal less than a week after unexpectedly losing her mother. It's what makes a skier come back and compete the day after painfully wiping out in the slalom.
There's been considerable study in recent years of emotional resilience. It has been linked to better health outcomes, increased resistance to stress and an increased capacity to recover from stress. Researchers are looking at how resilience can be fostered, especially in high-stress situations such as combat, trauma, loss or catastrophic illness.
Why are some people more resilient than others? Is it because of nature or because of nurture? We haven't quite unlocked all the secrets of resilience but most of us know this quality when we see it.
In the end, these are the best lessons I'd like to take home from the Winter Olympics - not who won or lost but how well and how resiliently they played the game.
Photo: Associated Press
Posted by: Anne Polta on March 04, 2010 at 9:54 AM | Comments (0) | Permalink
Tags: mental health, resilience, sports
Blogging slowdown
With a couple of major deadlines this month for the West Central Tribune's annual Focus project, blogging here is going to be sparse through mid-March. I'll continue to post something new a couple of times a week, so please check back from time to time or sign up for my RSS feed. Normal blogging will resume the week of March 22. Thanks for your patience.
Photo: Wikimedia Commons
Posted by: Anne Polta on March 02, 2010 at 3:11 PM | Comments (0) | Permalink
Tags: blogging
Room of horrors
I have a feeling the Rice Memorial Hospital committee that created the "room of horrors" for last week's safety fair had a lot of fun with their assignment.
Just for the day, a mock-up was created of a patient room - hospital bed, faux patient and all - filled with examples of what not to do in safe hospital care. Rice employees were invited to study the scene and come up with a list of everything wrong they could find.
Some of the goofs were obvious; others, a little more subtle. (There were 22 in all.) I spotted a few of them right away. Should that patient be trying to get out of bed unassisted? What's with the used Band-Aid lying on the food tray? And cigarettes are supposed to be off limits, on the hospital grounds as well as in the building itself.
The organizers were quick to assure me that the chance of so many things going wrong in one patient's room was extremely unlikely. Off-the-wall or not, however, the fake scenario underscored the unrelenting effort and attention that's required to deliver safe, quality hospital care. There's a lot to keep track of, after all - the clinical care, the medications, lab tests, the safety of the medical equipment, and even the cleanliness of the environment.
There's another piece to this equation, though: the patient.
I'm not sure the health care industry has quite figured out how much to expect from patients when it comes to safety. On the one hand, there's a much greater focus on asking patients to take responsibility, to be informed, and to speak up and ask questions. I see this as a good thing. On the other hand, there's some genuine reluctance to fully inform patients of all the risks and potential complications of a given treatment or procedure. If you tell them too much, the reasoning goes, they might get scared and refuse to undergo something that would be of benefit to them. Nor is it clear how much, realistically, patients can be expected to participate in their own care, especially when they're in an unfamiliar environment, stressed, anxious and sick. At some point, it's simply going to be asking more than the average person can muster.
But this doesn't have to mean there can't be some basic expectations. Our fake patient at the safety fair, for instance, was sprawled halfway out of his hospital bed, apparently trying to get out of bed unassisted. How many times do hospital patients decide to get up by themselves, even though they're weak or dizzy or not feeling well? Do they use the call button? Do they keep the call button close by, where it can easily be reached if they need it?
I'd like to think most people know that cigarettes and oxygen are a dangerous combination, but perhaps some people aren't aware of this, or perhaps they decide to disregard the warning labels on the oxygen tank.
Many of the "don'ts" at the safety fair were inspired by actual things that have happened at Rice Hospital. The used Band-Aid on the food tray, for instance, apparently occurs with some frequency. Would you remove a Band-Aid and leave it on your kitchen countertop at home? Wait, I take that back; maybe some of you do. If this is the case, you ought to break yourself of this seriously icky habit. Sheets that arrive in the hospital laundry entangled with someone's dentures also is a somewhat regular occurrence.
To be fair, patients oftentimes are sick and disoriented and can't be responsible for everything that happens in their hospital room. Families can't be there every single minute, and on top of that they're often stressed and overwhelmed. Surely there are some basic practices, however, that patients and families can follow in the hospital to help ease the workload on the hospital staff. It seems to me that when we know what isn't safe, we might be more likely to understand why it's important to do what is safe.
The room of horrors, alas, was a one-day-only deal and was dismantled at the conclusion of the safety fair last Thursday. But it's not too late for the public to check out some of the other safety and quality projects being carried out at Rice Hospital. The winning entries in last week's contest are on display outside the cafeteria, in the lower level of the hospital. They can be seen through Friday, March 5. Stop over and take a look; it'll be well worth your time.
West Central Tribune photo by Ron Adams
Posted by: Anne Polta on March 01, 2010 at 10:13 AM | Comments (0) | Permalink
Tags: patient safety
The technology boom
Raise your hand if you've never undergone a CT or MRI scan, never taken a statin to lower your cholesterol or never had a joint replacement. If your hand is still in the air after reading this, you're either in a healthy minority or just haven't caught up yet with the odds.
American health care is very good - a world leader, in fact - at developing and using technology. Just how prevalent our technologic interventions have become is demonstrated in a report recently issued by the National Center for Health Statistics, which takes a look at this technology boom by the numbers.
The findings are rather eye-opening. Take, for instance, the report's summary of the growth of medical imaging over the past couple of decades:
Despite the significant costs of acquiring advanced imaging capability, the availability and use of imaging technologies in the United States has substantially increased since their introduction in the early 1980s. In 2006, there were more than 7,000 sites offering MRI, with an estimated 27 million MRI procedures performed. In 2007, more than 10,000 CT units were in operation at more than 7,600 hospital and nonhospital sites, and the availability of PET and other imaging modalities has been steadily increasing. The site of imaging services has diffused from hospital inpatient and outpatient settings to nonhospital settings such as physician offices or radiology centers. During the past decade, the number of freestanding diagnostic imaging centers owned by radiologists, other specialists, private investors, or for-profit companies has more than doubled.
The report found that from 1996 to 2007, the number of advanced imaging scans ordered during outpatient office visits tripled in number. In emergency rooms, the use of advanced imaging grew fivefold between 1996 and 2007 for patients under the age of 65 and quadrupled for patients 65 and older.
The number of joint replacement surgeries has grown substantially. At least one analysis estimates the demand for total hip replacements could grow by 175 percent in the next 20 years, while the demand for knee replacements could increase sixfold.
The rate of kidney transplantation increased 31 percent between 1997 and 2006. Liver transplants increased 42 percent during this same period. The use of assisted reproductive technology has risen, especially among women younger than 35. From 1988-1994 to 2003-2006, the use of statins to treat high cholesterol rose almost 10-fold, while the use of antidiabetic medications as a replacement for insulin rose by 50 percent.
None of this is necessarily bad. As the report points out, it's "almost inconceivable to think about providing health care in today's world without medical devices, machinery, tests, computers, prosthetics or drugs." Joint replacement surgery has enabled countless people to remain mobile, independent and pain-free. Angioplasties and organ transplants save lives. Drug therapies have staved off illnesses that might otherwise have been fatal and allowed patients to return to normal life.
The flip side to this is that it costs money. A lot of money. Even interventions that are less costly can add up as they become more widely used. From the report:
Technologies applied to new populations and conditions generally come at a cost to individuals and to society as a whole. Technologies can be very expensive (e.g. heart transplants, chemotherapy) or very inexpensive (e.g. the Band-Aid). Total expenditures for a given technology, however, are determined by both use and cost; consequently, widely used inexpensive technologies can often have higher aggregate expenditures than rarely used expensive ones. Some new technologies can be cost-saving - for example, annual influenza vaccinations in high-risk children. Many technologies, however, contribute to increases in overall health care expenditures because they increase utilization (e.g. more doctor visits may be needed to monitor new drug therapies); they may be used on a larger number of patients; they may be more expensive than technologies they replace; or they may increase life expectancy in populations and thus their lifetime health care costs.
In one of the most telling sentences in the entire report, the authors point out: "In general, Americans - both providers and consumers - appear to be more willing and eager to adopt and use new technologies than people in other countries."
This whole issue came to mind when I recently read a New York Times article about robotic surgery. It costs more per patient - $1,500 to $2,000 more. It's not clear if the results are any better than more traditional surgery. But, as the article explains, hospitals and surgery centers are marketing it and patients are asking for "the robot," in some cases walking away from surgeons who don't do robotic surgery.
Readers chipped in with comments. Several said they'd had robotic surgery and couldn't be happier with the results. Others were more skeptical. "Follow the money," one person scoffed.
Last weekend my Sunday paper was accompanied by this article in Parade magazine: "Revealing the body's deepest secrets." It described several new forms of gee-whiz medical imaging technologies that are "transforming medicine." One is the use of MRI for diagnosing heart attacks; another is a fiber-optic probe that can help detect oral cancer. To be fair, there could well be an appropriate niche for these technologies - but at what cost, not only in dollar terms but also in the ratcheting-up of people's expectations? On some online message boards, I've seen people criticize their physician's competence for not ordering a specialized test they felt they should have.
Finally, here's yet another look at the issue, this time from Kaiser Health News, in an article titled "High-Tech Medicine Contributes to High-Cost Health Care":
Just before Christmas, 41-year-old Michael Kelley decided he wanted a whole-body imaging exam, the heavily advertised service touted on television by celebrities like Oprah Winfrey. He didn't smoke, wasn't overweight, and didn't have elevated cholesterol. "I'm pretty normal for a guy my age," he said.
No matter. The electrical engineer scheduled a full-body X-ray computed tomography or CT scan at Virtual Physical, a radiology clinic located in a glass-enclosed office building on a busy commercial strip not far from the headquarters of the National Institutes of Health. The clinic's name, plastered in large red letters on the building's exterior, served as a billboard aimed at cars exiting the high-end shopping mall across the street.
About an hour after checking in, Kelley left the clinic clutching a manila envelope with high-resolution 3-dimensional images of most of his major body systems, including the insides of the major coronary arteries pumping blood to and from his heart. "They said I was fine, no plaque," he said. Kelley paid $1,400 for a CT scan to confirm what he and his doctor already knew - he was perfectly healthy.
The rest of the article delves into some of the difficult issues surrounding the use of medical technology. When does the technology genuinely benefit patients and when does it reach the point of diminishing returns? Is "better" always the best thing? How should we weigh the potential benefit to the patient vs. the risk of harm?
The article concludes that in the long run, technology will probably help save money, but we're not there yet:
When robotic doctors are able to perform micro-surgeries; when arm and leg replacements function as well if not better than the original parts; when pharmacology replaces more expensive treatments and therapies, the U.S. may actually be able to use technology to bend the cost curve of health care downward. Until that time comes, we're stuck with ever-increasing costs and left to wonder whether the investment is greater than the payoff.
What's remarkable about this whole discussion is that it's happening on a wider, more public stage. Ten years ago, maybe even five years ago, I'm not sure the average person was ready to contemplate the down side of technology. More and more, however, these questions are being asked and debated - not just within policy circles but among the public. We might not have the answers, but the sheer fact that we're willing to acknowledge it and talk about it is surely a sign of progress.
West Central Tribune photo by Anne Polta
Posted by: Anne Polta on February 26, 2010 at 12:49 PM | Comments (0) | Permalink
Tags: health care costs, medical imaging, medical technology
The cost of chronic disease
A timely new study confirms what many observers have seen all along: Medicare is now spending more on the outpatient management of chronic diseases than on acute hospital care.
The study appeared last week in the Health Affairs journal. The authors tracked Medicare spending trends across two decades, specifically looking at data from 1987, 1997 and 2006. They estimated the prevalence of chronic disease in each of those years and further analyzed how much was spent on the 10 most expensive chronic conditions, a category that included heart disease, diabetes, cancer, arthritis, high blood pressure and elevated cholesterol.
Among their conclusions: The 10 most expensive conditions accounted for about half of the inflation-adjusted increase in Medicare spending from 1987 to 2006. As chronic disease management shifts towards the outpatient setting, hospital inpatient care has fallen as a percentage of total Medicare spending, while spending on physician office visits and prescription drugs has grown.
To anyone who's been paying attention, none of this should come as any surprise. What's especially interesting about this particular study is what it reveals about trends in chronic disease and chronic disease management.
Twenty years ago, hospital care for heart disease was the largest and fastest growing area of Medicare expenditures. But by 2006, heart disease had fallen to the bottom of the list of the 10 most expensive chronic conditions among the Medicare-age population. The study's authors found this wasn't because heart disease is becoming less common; in fact the prevalence remained the same. What apparently changed is the management of heart disease, which has evolved away from hospital inpatient care to outpatient office care, prescription drugs and home health care. And although overall Medicare spending on heart disease is still rising, the increase isn't nearly as steep and most of the growth is concentrated in physician care, prescription drugs and home health.
Where the spending really rose was for the management of other chronic conditions, such as hypertension, diabetes and cancer. Some of this, as in the case of high blood pressure and elevated cholesterol, wasn't necessarily because the U.S. is having an epidemic of these chronic conditions. Instead, the study's authors explain, the prevalence of hypertension and elevated cholesterol has increased because the threshold has been lowered for treating these two conditions, a move that automatically increases the number of patients eligible for treatment.
In the case of diabetes, however, there appears to be a true increase in the incidence of the disease - not just better identification and diagnosis of these patients, the authors wrote.
Why would these trends matter? Policymakers are focusing a great deal of attention right now on how to slow the growth in health care spending, but their efforts might be misguided if they only consider the big picture. From the study:
Many Medicare reform proposals designed to slow the growth in spending would redirect costs from the government to others, such as enrollees and participating providers. The slowdown would be accomplished by reducing provider payments, increasing the age of Medicare eligibility, implementing means testing for Medicare, restricting coverage as with the Part D "doughnut hole," and increasing copays and deductibles. These approaches are unlikely to produce long-term reductions because they fail to address the key factors driving the rise in health care spending overall and in Medicare spending, particularly for chronic diseases. Understanding these facts is essential to reaching the right policy solutions.
Kenneth Thorpe, the lead author of the study published in Health Affairs, has made a rather distinguished name for himself as an advocate for new models of health care delivery that emphasize chronic disease prevention and management. Thorpe, who's a professor and chairman of the Department of Health Policy and Management at Emory University, has frequently spoken on the need to find better, less expensive ways to deal with chronic disease.
It would be hard for anyone to argue that Medicare spending isn't growing at a pace that's becoming unsustainable. The real implications of this latest study, it seems, lie not within the dollars and cents but in where the money is actually going and what it means for cost containment.
Posted by: Anne Polta on February 25, 2010 at 1:19 PM | Comments (0) | Permalink
Tags: chronic disease, medicare
Close encounters of the awkward kind
You're out running errands, shopping for groceries or walking the dog when you run into, of all people, your therapist. What should you do? Hide? Ignore each other? Politely say hello? Launch into a lengthy conversation?
It's one of those etiquette questions that bedevil the doctor-patient relationship - not only for therapists but for physicians as well.
Dr. Elvira G. Aletta recently explored this issue at PsychCentral, asking the question: "What if I run into my therapist in public?" Then it was taken up at the New York Times Well blog with some interesting discussion and personal stories.
Dr. Aletta writes:
In my dad's day, there would have been no question. Psychoanalytic thinking was very clear back then. Both patient and therapist should pretend they don't see one another, even if it is obvious to both that they have.
There are reasons many therapists still feel that way. One is that it could be seen as inappropriate, even harmful, to acknowledge the working relationship outside of the "therapeutic frame," meaning the clear boundaries of the time and day of the session and the four walls of the office.
Plus there are issues of confidentiality. Saying hi to my patient in public might put them in the uncomfortable position of explaining who I am and why they know me.
Depending on where the encounter takes place, the patient's level of discomfort might be even higher. One reader at the Well blog shared this experience: "About a year after I completed outpatient therapy for alcoholism (and still sober, then as now) I ran into one of the counselors at the supermarket while shopping for a dinner party - on my way to the wine aisle." Someone with bulimia recounted hiding after she spotted her psychiatrist while loading up a shopping basket with junk food.
OK, so it's awkward. But although social encounters outside the professional therapist-client or doctor-patient relationship should be handled with some sensitivity, "I don't believe we need to be all rigid about it," Dr. Aletta declares.
Among the guidelines she offers: The first move belongs to the patient. If you do greet each other, it's up to the therapist to put the patient at ease. The conversation should be kept short and pleasant. References to the therapeutic relationship are off limits.
I'm not sure it should matter who makes the first move, especially if the therapist and client or physician and patient already have a solid relationship. The point, after all, is to be respectful, not to snub each other.
The main question seems to be one of boundaries, which aren't always easy to negotiate - and let's not forget the boundaries go both ways. Therapists and physicians need some personal space too. When Dr. Theresa Chan, a hospitalist in rural California, penned an open letter to the patient who accosted her at the supermarket, it struck a nerve with many of her readers. She wrote:
Dear Neighbor/Patient,
It was very kind of you to inquire after the state of my garden when we bumped into each other at Safeway this morning. We haven't seen much of each other lately and I was pleased to hear your early peas are flowering. We waved good-bye to each other and went about our business. Or so I thought.
Moments later, you cornered me as my food items were being scanned and asked me, "What do you think about all this stuff they're saying about Fosamax? Should I stop taking it?" I was unprepared for such a question, because my navel oranges were bumping into the large globe artichokes and threatened to clog the upstream progress of the red seedless grapes onto the rubber rolling mat that conveys the groceries inexorably towards the bagging platform.
In short, she writes, "I do not like to be asked medical questions when I am conducting my everyday errands."
Readers quickly chimed in with stories of their own. "I'm a family doc in the small town I grew up in and there is no quick trip to the store," one person wrote. Another commenter confessed to switching barbers six times in 10 years. "That's the worst predicament; trapped in the chair providing free medical consultation while someone with sharp objects buzzes around your head," he wrote.
When it comes right down to it, much of this is just Civility 101: being courteous and acknowledging the other person while refraining from being overly familiar or demanding. "The common social contract that most people subscribe to is that you say 'hello' to people that you know," one of the commenters wrote in response to Dr. Aletta's essay.
There are even times when out-of-the-office social encounters, when they're handled well, might help reinforce the relationship between professional and client/patient or be therapeutic in and of themselves. "I find that it comforts a lot of clients to know their therapist is 'human' and does the same things or goes to the same places," one person commented. A therapist who attended a wake for the deceased son of a client and visited another client's daughter in the hospital wrote that this "seemed like the human thing to do. In both cases, my patients expressed their appreciation and I believe that the therapeutic process was enhanced, rather than threatened."
Really, can't we all just get along?
Posted by: Anne Polta on February 23, 2010 at 11:38 AM | Comments (0) | Permalink
Tags: doctors, mental health, patients
Best of the medblogs
There's a lot of compelling and interesting content out there in the medblogosphere. Just ask the readers who voted in the annual Medical Weblog Awards this past month to select the outstanding entries from 2009.
There were a ton of nominees for the awards, demonstrating how active the medical blogging community has become. Finalists were selected by the editors of Medgadget; readers were allowed to vote online for their favorites. The polls closed last week.
So who won? The winners for 2009 are announced here. There are seven of them:
- Best Medical Weblog of 2009.
- Best New Medical Weblog.
- Best Literary Medical Weblog.
- Best Clinical Weblog.
- Best Health Policies/Ethics Weblog.
- Best Medical Technologies/Informatics Weblog.
- Best Patient's Blog.
I was already familiar with many of the entrants but I discovered several newer blogs as well that I want to bookmark and continue to follow. Take some time to follow the links and check out all the blogs; perhaps you'll find some that become your favorites.
The editors at Medgadget note, "We feel that during the last year, the medical blogosphere has matured, and it now displays the level of writing, reporting, and commentary that challenges traditional media." I prefer to think of it as widening the perspective of medical writing, reporting and commentary in ways that weren't previously possible. These bloggers bring a unique voice to the discussion, and it's good to see them recognized. Congrats to all the winners.
Posted by: Anne Polta on February 22, 2010 at 10:21 AM | Comments (0) | Permalink
Health and geography
Does where you live make a difference in your health? There's plenty of research to suggest it does, the latest being a new set of county-by-county health rankings issued this week by the Robert Wood Johnson Foundation and the University of Wisconsin Population Health Institute.
It's the first time anyone has attempted to show how each of the 3,000-some counties in the United States stacks up on a variety of health measures. A wealth of data, ranging from the U.S. Census to poverty and unemployment statistics, was used to come up with the rankings.
You can see here how Minnesota counties fared. All but two of the state's 87 counties are included on the list. It's clear from the map that many of the so-called healthiest counties are clustered around the Twin Cities and in southeast-central Minnesota, while those that fare worse are in rural central and northern Minnesota.
Some caution is warranted in interpreting the rankings. They were compiled with information that came from a wide variety of sources and may not have been measured in exactly the same way. Some of the statistics go back to 2000, making them a decade old. Information on premature death rates was collected from the National Center for Health Statistics for only two years, 2004 to 2006. Unemployment information came from the U.S. Bureau of Labor Statistics and only covered 2008, when the recession was just beginning to deepen in Minnesota. The Behavioral Risk Factor Surveillance System, which tracks health-related behavior such as physical activity, tends to rely on self-reported data from the public that might not be 100 percent reliable.
Without seeing the raw scores for each county, it's also hard to know what separated the good from the not-so-good. Was it a difference of 10 or 20 points, or was it a difference of tenths of a point?
That said, this new report provides some interesting insight into the many contributing factors to what we think of as healthiness. Although we often view behavioral factors - for instance, eating fresh fruit and vegetables and avoiding tobacco use - as the most critical determinants in overall health, in reality they're only part of the picture. Environment can make a difference; so can local culture and ready access to quality health care.
Many of the counties that ranked in the bottom tier also had higher rates of poverty and unemployment. This is no accident; two of the most important predictors for overall health status are income and education level. Income and education appear to have a significant influence on health-related behaviors, although it's not totally clear why this is so. Smoking rates, for instance, generally are lower in the higher income brackets and among the college-educated. And across the board, the poor tend to be more vulnerable to being uninsured, having less access to health care services and suffering worse outcomes than those who are better off.
Geography matters in other ways as well. In highly rural counties and in inner cities, for example, it can be more challenging for people to consume fresh fruit and vegetables each day because there might not be a nearby grocery store that sells fresh produce. Access to medical care is more of an issue, especially in isolated rural areas where resources are thinly spread.
Barriers like these can be overcome, however, suggesting that local decision-making and priorities also have an important role. You'd expect Olmsted County, home of Rochester and the Mayo Clinic, to be one of the top performers on measures of clinical care provided by doctors and hospitals. But look who else scored well in this category: Kandiyohi County at No. 8 and Redwood County at No. 11. On measures of morbidity, or quality of life, the list was topped by small, rural Lac qui Parle County at No. 1, Swift County at No. 2 and Kandiyohi County at No. 9.
So now we know how we stack up, what do we do with the information? The authors of the county-by-county rankings view them as a call to action by health care and community leaders. It's hoped that counties will be spurred to improve in the areas where they're not doing well and reinforce their commitment in areas where they've been successful.
These kinds of initiatives are not a quick fix. It may take years to see improvements that are not only measurable but sustained. It's probably going to take the involvement of community and business leaders and local government; after all, these aren't issues that can be handed off to health care folks to solve themselves. Future report cards will tell the tale of who has responded to the call for action and who has not.
Posted by: Anne Polta on February 19, 2010 at 10:42 AM | Comments (0) | Permalink
Tags: public health
A time for fasting
After the revelry of Mardi Gras yesterday comes Ash Wednesday and the start of Lent, a time when Christians have traditionally fasted so they could better concentrate on matters of the spirit.
Among the world's religions there's a long history of combining fasting and prayer. During the month of Ramadan, observant Muslims fast each day, neither eating nor drinking from sunrise to sunset in order to focus more fully on worship, the mastery of desire and service to Allah. Devout Jews fast on Yom Kippur, the Day of Atonement, to signify repentence. Among Hindus, fasting is observed not only on certain days of the week but during numerous festivals and on other occasions as well, such as the anniversary of the death of one's parents.
Fasting can take various forms. People who fast might limit themselves to one or two small meals a day, or consume only liquids. Or they might abstain from all food and drink for 24 full hours.
Fasting can be rigorous, and it's not without health implications. Experts warn it isn't a good way to lose 10 or 15 extra pounds, especially if your goal is to keep the weight off. According to WebMD, people who are generally healthy can fast for a day or two without ill effects, as long as they get enough fluids. Fasting for long periods of time, however, "can be harmful," says WebMD.
Your body needs a variety of vitamins, minerals, and other nutrients from food to stay healthy. Not getting enough of these nutrients during fasting diets can lead to symptoms such as fatigue, dizziness, constipation, dehydration, gallstones, and cold intolerance. It is possible to die if you fast too long.
Even short-term fasting is not recommended for people with diabetes, because it can lead to dangerous dips and spikes in blood sugar. Women who are pregnant or breastfeeding, or anyone with a chronic disease, should not fast.
If you're healthy enough and you decide to fast during Lent or other religious observances, don't expect it to be easy, advise the folks at HowToFast.net. They explain:
Feeling hungry and not eating does a lot to your mind, body and spirit. It may be physically uncomfortable. Headaches, dizziness and other ailments may arise as a result of detoxification. Hunger pangs can also manifest themselves in a physical way (if you develop any strong physical symptoms or problems you may need to break your fast and possibly go see a doctor).
There has been considerable study on the health effects of fasting. Fasting-related headaches, for instance, are so well documented that they're often referred to as "Yom Kippur headache" or "First-of-Ramadan headache." There's also a fair amount of research on how the body adapts to semi-starvation. It's generally agreed that a Biblical fast for the Lenten period of 40 days and 40 nights is, according to this article that appeared a couple of years ago in an obesity journal, "well within the overall physiological capabilities of a healthy adult" (emphasis added). Muslim athletes who fast during Ramadan have been shown to experience little, if any, decline in physical fitness or performance.
A study of a group of members of the Church of Jesus Christ of Latter-day Saints in Utah found a lower incidence of heart disease among those who routinely fasted - although it should be pointed out that it's not clear if fasting made the difference or if abstinence from tobacco and alcohol also played a role. It's also thought that caloric restriction might contribute to longer life spans, although again, it's unclear whether additional factors are involved or whether it's truly a safe practice for certain groups such as children, pregnant women or people with chronic illness.
In the 21st-century United States, with its surfeit of food, fasting for any reason other than weight loss might seem unbelievably quaint. There's no question it takes discipline. A few years ago I gave up all sweets for Lent. The first couple of weeks were easy. Then it got much harder, not because I craved the sugar but because of the constant mindfulness required to stay on track. I recall attending a meeting during which a plateful of cookies was passed around the table, not just once but two or three times. I had to keep repeating, "No, thank you" and pass the cookies to the person next to me.
Does fasting make us better people? Many Americans seem to have difficult relationships with food. Perhaps by denying ourselves food for a short time, we can discover something about our feelings about food and eating, suggests HowToFast.net. From the Web site:
You can use this as an opportunity to think about how and why you eat. This knowledge can teach you how to eat better during times that you are not fasting. From a spiritual perspective many people use fasting to focus on their beliefs, to enter into periods of prayer, and grow their faith.
Whether we benefit from fasting ultimately depends, I guess, on why we're doing it and what we hope to get out of it.
Image: Sinai desert. Photo courtesy of Wikimedia Commons
Posted by: Anne Polta on February 17, 2010 at 11:27 AM | Comments (0) | Permalink
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