Has anybody out there seen the new documentary on Medicins Sans Frontieres called “Living in Emergency: Stories of Doctors Without Borders.?” If you haven’t, do and then write a letter to MSF as well as to the producers. The film is both impressive, depressing and appalling. To spotlight the work of what is an incredible organization, it focuses on four physicians — three men and one woman. All have gone on tours to truly agonizing places to Liberia and the Congo at the height of their wars. All are overwhelmed by the level of suffering, grief, lack of health care services, poverty and violence. And so are we, as viewers. Choices in these countries and outposts have to be made between procuring anti-biotics and surgical gloves. You choose the latter and the patient dies of an infection. You choose the former and the patient gets an infection. The doctors have a terrible time because they were all trained in high tech medical systems — trained to use the latest gizzmos and there are no gizzmos where they are. Not even enough paid meds, or basic supplies. For them, care is a constant triaging and for each patient they rescue hundreds — no thousands — go untended. The film eloquently captures their anguishing daily dilemmas.
That is the good part of the film What is truly astoudning is that the film and film makers, and by extension MSF itself, depicts this organization and the effort to help deliver medicine to war torn countries as a doctors only enterprise. The majority of MSF volunteers are in fact not doctors but nurses and statisticians and others. There is not a single depiction of a nurse or other health care professional in the film. We see people working with the surgeons who probably are nurses, but who knows. What is even worse is that the relationships of the physicians in the film and at least to the local professionals and staff who are stuck in these terrible places is almost entirely disdainful. Do MSF doctors get any training in dealing with local people? You wouldn’t know it by watching this movie. They berate the locals, speak scornfully of their work and there are no local people who play a prominent role in the film — except as objects of derision. I was really shocked watching the movie.
The film has serious implications for health care. We now know that health care must be delivered in a team, with decent team relationships and team commuication, if it is to be safe and effective. But the media consistently depicts health care — medical treatment — as a doctors only affair. This film is a perfect — quintessential –example. Any young person wanted to do good in medicine who watches it will get the impression that its the heroic doctor who counts — now sometimes a female — but always flying solo. Anyone becoming a doctor, who could potentially understand the value of real teamwork, will learn all the wrong things seeing this film. They will never learn to ask the right questions about health care delivery or how to improve their practice and communication as doctors by watching material like this.
When will the media get it. When will doctors get it? When, will MSF get it. Okay — so its called Medicins San Frontieres, not Medicine Sans Frontiere (Doctors Without Borders not Medicine without Borders) that doesn’t mean the organization should legitimize as it does here the total exclusion of other non-physician members of the team. See the film. Write to MSF.
As I sat in that darkened movie theatre, in Berkeley,California, watching the film with all the progressive Berkeleyites in the cinema with me, I wanted to shout out — hey guys, this is not how it is either out there, or back home here. It takes a village to deliver this kind of care –whether high tech, or low tech, in war zones or back here at home. And that village is a complex entity, in which lots of people who are not physicians do a lot of important and mindful work. When are we going to learn about them?
A few weeks ago, I talked with a friend who was about to have a hip replacement operation. She has been in severe pain for quite some time and as we chatted she said, “you know Suzanne, the insidious thing about pain, is that, unlike other conditions, it is impossible to see. For example, here we are, and can you tell that right now, I am in so much pain I could scream?” Indeed, I could not. As we sat chatting, she looked great, almost luminous. And yet, she was in agony. If she had had cancer, God forbid, or some other disease, she would have been rail thin, pale, sweaty, fainting. You could see it and feel for it. But she seemed in perfect form and yet,was in an agony as profound as anyone with a major, life threatening illness.
As I talked to her I was reminded that I have been remiss in not writing about an incredible new book our series on The Culture and Politics of Health Care Works published in the fall. The book is called Inside Chronic Pain: An Intimate and Critical Account. It is written by Lous Heshusius and is Commentary by Scott Fishman, M.D. who is a pain specialist. http://www.cornellpress.cornell.edu/cup_detail.taf?ti_id=5454 The author writes of her experiences — a long and unrelenting journey — into the world of chronic pain that began after she had a car accident that did irreparable damage to her neck. Her life has been dominated by pain ever since. She talks about how friends, relatives, colleagues, and most importantly, health care personnel, have reacted to her endless struggle to deal with her ever-present companion. The book is amazingly well written, which has little to do with the fact that I was its editor and everything to do with the skill of its author.
People may not want to read this compelling account. In a way, I think people fear listening to people who are in pain because unlike other illnesses, pain is something that it may seem impossible to prevent. You can try to eat your way free of diabetes, unsalt your way free of hypertension, anti-oxidant your way out of cancer, and exercise your way out of heart disease. At least, that’s the American fantasy. But pain? Heshusius’ anguished memoire reminds us that you can survive a car crash and medicine can rescue you — but then…what?
One of the most beautiful and important things about this book — aside from its writing– is that it asks us to come to grips with a very human problem — what do you do when confronted with suffering we can’t fix? Doctors and nurses, and physical therapists work on Heshusius with some success, sometimes. But her pain just won’t go away. And the temptation is to suggest that she is getting secondary gain from it. This concept is really insidious because illness does something to your brain chemistry and we do indeed become involved in a search for a cure, or for relief. And that means we become dependent on doctors, healers, chiropractors, PTs, you name it. But is our relentless search for relief really a sign of weakness or pathology? Or is it a sign of our desperation and, finally, of our ability to hope? Heshusius also talks about people who claim her pain is somehow in her head –not her neck. But how could pain not affect your emotions? Which is something Scott Fishman discusses with great eloquence in his commentary.
I have to use the trite phrase that Inside Chronic Pain is a “must read.” It’s not only that, it is an enlightening, and humanizing read. She doesn’t only challenge medical professionals, it challenges us all. As friends and family members, we all have to deal with pain — not just physical pain like her’s, but emotional pain. We are always confronted by people who suffer and who don’t get better. There’s the friend the pathological horder who can’t bear to throw anything out and seems to be limiting many options because of a lifetime’s love affair with needless stuff. There’s the friend or relative who won’t leave an abusive relationship, the one who can’t ask anything for himself. There’s the person who doesn’t — or so it may seem to us — recover quickly enough from the death of a loved one, or take our good advice about what to do with their kids. We stand helpless in the face of our own and other people’s seemingly intractable hold on what we think they should let go. And, of course, we always think we are exempt from this kind of denial and resistance, or would be in the face of the same situation.
Read this book. Put it at the top of your list if you are a doctor, nurse, PT or involved in any way with health care. Read it if you are in pain or have suffered from chronic pain. But mostly read it because you are a human being and because what it asks us to confront are the challenges — and joys of life itself. Along with its commentaries, I think its one of the best books ever written about a subject we reflect on too little and often too late.
For over a decade now, nurses in Massachusetts and other states have been lobbying for legislation that would mandate safe nurse to patient staffing ratios for hospitalized patients. For these nurses the kind of safe staffing ratios enacted in California in 1999 and implemented in 2004 has been the benchmark. Industry groups like the Massachusetts Hospital Association (MHA) have insisted the California law has not helped patients and that the public should not support staffing bills in other states. Their message to patients and the public is “ trust us and we’ll look out for you.” In spite of dozens of studies documenting that contemporary hospital staffing patterns are linked to patient mortality and preventable complications – hospitals continue to insist that there is no need for either government mandated nursing workloads.
Well just in time for this year’s Nurses’ Week, a major research study has documented the direct connection between California’s staffing ratios and reductions in patient deaths and complications.
The study in question is entitled “Implications of the California Nurse Staffing Mandate for Other States” and appeared in Health Services Research – a prestigious scientific journal. www.nursing.upenn.edu/chopr/…/Aiken.2010.CaliforniaStaffingRatios.pdf
Its authors include a rock star like line-up of the most prominent nursing workforce researchers in the world – like Principal Investigator Linda Aiken and co-investigators Sean Clarke, Joanne Spetz, Douglas Sloane and Linda Flynn. These highly respected academics are by no means mindless boosters of either ratios or the unions that have promoted them as a solution to widespread hospital understaffing. Yet these academics conclude that ratios save lives.
This conclusion is the result of a comparison of nursing workloads and patient outcomes in California and New Jersey, and Pennsylvania – states that have no limits on the nursing workload. California legislation mandates a one to five RN to patient load -on medical surgical floors and 1-4 on specialty floors like oncology. In fact, researchers found that many California hospitals actually had better nurse to patient ratios than were mandated by law. With California as the benchmark researchers collected data on the nursing workload and patient mortality in New Jersey and Pennsylvania. While 88% of medical-surgical nurses in California cared for five patients or less on their last shift, that was only true of 19 and 33 percent of medical-surgical nurses in New Jersey and Pennsylvania respectively.
In those states nurses, on average, care for one or two more patients per shift. Turns out that just one extra patient makes a very big difference. With California style ratios in force, the researchers concluded, there would have been 10.6 percent fewer surgical deaths in Pennsylvania and 13.9 percent fewer in New Jersey. Even managers and chief nurses in California agree that staffing ratios positively impact patient outcomes as well as nurse retention. Which is why the authors argue that “outcomes are better for nurses and patients in hospitals that meet a benchmark based on California nurse staffing mandates whether the hospitals are located in California.”
This research comes out at a particularly critical time for nurses and patient care. Because of the lingering recession, more RNs who left thr workforce because of exhausting patient loads have been forced back into active duty and hospitals been able to declare that the “nursing shortage” is over.. In reality, there’s still a problem because many institutions – like Boston Medical Center and Tufts –are using the economy as an excuse to lay off nurses.
Four years from now, just as RN baby boomers begin to retire in greater numbers, the Patient Protection and Affordability Act of 2010 will kick in. When it does, 31 million Americans who’ve gone without primary care and preventive services will suddenly get health insurance and many of them will end up in the hospital. Laying off nurses and increasing their workloads, –which hospitals are free to do in the absence of legally mandated staffing ratios– is no way to pave the way for this huge influx of patients. As hospitals administrators function more like bankers on Wall Street hedge fund managers, can we afford to let them go unregulated. What we also can’t afford is the persistent myth that ratios are not in effect today. In fact, hospitals already operate on the ratio system. It’s the get-away-with-whatever-you-can ratio system. Hospitals staff according to ratios now. These ratios, however, are determined neither by what the patient needs, or scientific evidence on the connection between nurse staffing and patient care and the ignorance of many in the so-called C-suite (CEOs, CFOs and COO’s) of the importance of nursing care.
The people who now determine how many patients a nurse cares for are the kind of people a nurse manager recently told me about. She was fighting for an appropriate budget for her nursing staff and wanted to staff with an appropriate nurse-to-patient ratio. Many of her nurses had been there more than five years. In her budget meeting, the CFO of the hospital, she said, insisted that ” a nurse is a nurse, is a nurse, is a nurse. A nurse who’s been in practice for more than five years brings no more added value than a new nurse, he insisted. With this kind of disinformation passing as fact it’s no wonder we’re in the situation we are in in health care and nursing.
I have been continuing to read Peter Pronovost’s new book. He has some great things to say about changing hospital culture that everybody should read. His book also highlights some serious problems in the medical hierarchy not only between doctors and nurses but between physicians. This is another area where we could easily learn something from the airline industry.
When the aviation industry began to move from an autocratically reckless culture, with hot sticks (i.e. captains and sometimes other pilots) – the ones who had the right stuff – dominating all of those who didn’t (first officers, flight engineers, flight attendants etc.) they quickly and cleverly challenged the dominant mode of what I call toxic hierarchy. We all live in hierarchies. Some people know more about some things than others. Some people have more money. Some people are actors and some super stars. Hierarchy, however, doesn’t mean you don’t have to listen to others or treat them abusively. In a hierarchy you can assert differences while still insisting on the need to be civil and respectful to others. In a hierarchy, you can still recognize that other people may have useful information to share, that you can learn from and that they represent a potential resource.
In a toxic hierarchy, however, what Paolo Friere describes is the prevailing mode of being. “We have a strong tendency to affirm that what is different from us is inferior. We start from the belief that our way of being is not only good but better than that of others who are different from us. This is intolerance. It is the irresistible preference to reject differences.” http://www.newfoundations.com/GALLERY/Freire.html.
This kind of intolerance prevailed in the cockpit where as one aviation expert, Robert T. Francis, explained, the captain, in one way or another, informed the co-pilots, “I’m the captain, I’m king, don’t do anything, don’t say anything, don’t touch anything, shut up.” Once the captain entered the cockpit, it was as though he, not the airline company, owned the plane, as well as all the passengers. To protect not his judgment, but his authority, he could and sometimes did, make any call, no matter whom or what it jeopardized. All that changed with the advent of Crew Resource Management and the aviation safety movement. Now, as Francis explains, there is still a hierarchy in aviation, but it is no longer toxic. So, as he told me, the captain is still king, but when he enters the airplane and cockpit, the new mantra is “I’m the captain. I’m king, please tell me if you see me making a mistake.”
One of the ways hierarchy is maintained while safety enforced is through the empowerment of the crew and first officer to challenge the captain. As team leaders captains are taught that their job is to make decisions based on all available information and resources. Their job is also to make sure team members can do their jobs efficiently and effectively. Team members are taught that their role is IAA –Inquiry, Advocacy and Assertion. In other words, if a captain says “jump, “ they don’t just reactively say “how high.” Instead, if they are not completely clear on the whole jumping thing, they are trained to “inquire” to clarify the order, if necessary. Keeping in mind that the captain is still in charge, crews learn that if subordinates see that jumping, in this case, may not be the best course of action for the circumstances, they are expected to seek clarity through IQA. Crew members are taught about the two challenge rule: If the captain is about to make a critical mistake –flying into a mountain, for example — you urgently warn him about the situation. If he doesn’t listen, you tell him again, and if he still doesn’t listen, you have a serious decision to make, and if the safety of the flight is clearly at risk, you need to consider taking control of the aircraft. Obviously a first officer is in a position to do this and sometimes does. This is a situation that must only happen with a great deal of forethought, consideration and commitment, for obvious reasons. The point is, the captain is no longer allowed to fly the $70 million plus plane “solo” into the mountain – unchallenged – taking with him the passengers and crew members.
Well, doctors are still flying the health care equivalent of the plane into the mountain and those who are crew members seem to have little leeway to do anything about it. Patients, if they’re alive, their families, if they’re not, can always try to sue. But lawsuits are a very poor and cumbersome way to change a culture.
Just how much the culture needs to change and how much health care needs to learn from aviation is evident in several stories Pronovost recounts in his book. I will only talk about one of them. But it’s a doozie.
Pronovost is a superstar doctor, and head of the Intensive Care Unit at Johns Hopkins. Yet the fact that he’s a physician – and a superstar one at that – doesn’t seem to matter much in the toxic hierarchy of his hospital. In the medical hierarchy, the surgeon, not the intensivist – owns the patient. What he wants to do – or not do, in this case – gets done, or not.
So a 29 -year -old woman comes to Hopkins to have a kidney removed. Apart from her kidney problem, she is otherwise in good health. She comes out of the OR after a laparoscopic procedure and the surgeon insists all is well. But she starts to go down hill quickly. At 10 PMPronovost is paged and talks to the resident, who insists the surgeon says all is well. He nonetheless wants the patient to be taken to an Intermediate Care Unit, which involves Pronovost and a CT scan is done. The CT shows no signs of a surgical complication. The surgeon insists there was none, but the patient has rapidly deteriorated and Pronovost thinks the surgeon has made a “classic diagnostic error” and that the patient needs to be taken to the OR. But the surgeon owns the patient. Four hours later, Pronovost gets a second call. The patient is clearly dying. He knows her condition can’t possibly be due to anything other than a surgical complication. He calls the surgeon –it’s now 2 A.M. – and the surgeon refuses to listen. In fact, he screams at Pronovost, who with difficulty, maintains his cool. Finally the surgeon says or rather yells, “I am not going to the OR. I have to leave town. From now on, talk to the surgeon on call.”
Pronovost does. They take the patient to the OR, open her up and guess what, he was right. The surgeon had accidentally “punctured her intestine and pancreas.” The patient lived. Just. She lost her other kidney, spent six months in the hospital instead of three days, and was in rehab for a year. “This healthy woman,” Pronovost writes,” who had come to Hopkins at 110 pounds, now weighed 80 pounds, had had a tracheotomy, could barely speak or walk, and was on dialysis and needed a kidney transplant, all needlessly.”
Reading this, as I did, you might be tempted to say, hope that surgeon got sued for everything, lost his license, is flipping burgers at McDonalds. Pronovost doesn’t tell us what happened to him, but even if he is dishing out fast food to teenagers, how would that help the next patient and the next? Doctors who are sued get defensive and resentful. Their stories become part of the lore of the malpractice legions ready to storm the gates. People don’t learn from lawsuits and while chasing one doctor out of the elite club may hurt his ego, it doesn’t change the behavior or attitudes of those who remain members in good standing.
Now if this were aviation what would have happened? In the CRM culture, Pronovost as first officer, would have challenged that surgeon on the very first page. In a reformed health care culture, where the patient not the doctor, owns her own body, and the hospital, not the surgeon, owns the facility, the two challenge rule would be immediately put into play. At 10 PM at night when he got the first call from the resident, Pronovost would have called the surgeon, as he did at 2P.M. When the surgeon refused to take the patient to the OR, the intensivist would have urgently and firmly repeated the concern (as Pronovost in fact did) and then, when the surgeon refused, he would have taken the patient out of the surgeon’s control and called the on-call surgeon. Would that have saved the patient’s good kidney, and restored her health, from the book I can’t tell. But I can tell you that without a model in which doctors and nurses can act immediately and urgently to prevent those physicians (or nurses or anyone else) more concerned with their status and authority than patient care from jeopardizing patient safety, patients like myself will always be in danger.
In the airline industry that kind of challenge to the captain’s authority is rare. People don’t do it lightly. But they do it and they are protected when they do. In fact, in aviation today, if a first officer allowed a captain to put the plane and passengers in jeopardy without challenging that captain, he or she would be in a lot of trouble. It’s kind of like being a mandated reporter for child abuse. If you suspect abuse and don’t report it and abuse is later discovered, the direct abuser isn’t the only one in trouble. Maybe that’s what we need in health care. Everyone in the hospital needs to become a mandated reporter for patient abuse – a kind of deputy sheriff empowered by government and the company to protect us when there is absolutely no way we can protect ourselves.
In 2005, with great fanfare, New York University’s Langone Medical Center announced that it had been awarded what is known as Magnet Status. I learned about this from reading my morning New York Times, in which the hospital spent thousands of dollars on a full page ad complimenting its nurses on having achieved an award for nursing excellence.
Oh how quickly they forget. Fast forward to 2010 and NYU’s latest ad. Not only are nurses gone from a new ad the hospital has run in — at least as far as I have seen — the New York Times, The New Yorker, and the Wall Street Journal. To add insult to injury, the hospital’s latest act of nurse recognition is to award nurses’ work to physicians. A full page ad features a man in scrubs standing by the bedside of a patient in an intensive care unit. The headline reads “Intensive” and under it, in parentheses, is the word “Support.” I looked at the ad and thought, great, NYU is continuing to deserve Magnet recognition because it’s continuing to recognize the work and accomplishments of nurses. I spoke — or rather thought — too soon.
Here is the ad copy:
“Sometimes it’s what happens in the hours immediately after surgery that makes the difference. The Critical Care Unit at NYU Langone Medical Center Tisch Hospital is staffed 24/7 by physicians board-certified in critical care medicine, ensuring the intensive support you deserve at the moment you need it most.”
As you will note, there is not a single mention of a nurse. This institutional (a symptom of a larger societal) amnesia is truly remarkable. The people who designed and signed off on this ad seem to have forgotten the fact that the intensive care unit was developed to provide intensive care nursing. As historians Julie Fairman and Joan Lynaugh write in their excellent history of the critical care unit, Critical Care Nursing, the critical care unit developed out of the following dilemma. In the 50′s and 60′s, “all over the country, in erratically staffed but expanding hospitals, nurses found themselves responsible for desperately ill and dying patients whose medical and nursing needs exceeded the nurses’ availability, knowledge, and authority. Left on their own to cope with these difficult and frustrating situations, some physicians and nurses were powerfully motivated to find a better way.” Finding that better way led nurses to found intensive care units because, as one early intensive care nurse said, “The units were invented because of the problems that came from a patient being desperately ill and needing one nurse…Finding a way to respond to that situation multiplied by thousands of times forced us to change the hospital.” (Julie Fairman and Joan Lynaugh. Critical Care Nursing: A History. Philadelphia. University of Pennsylvania Press, 1998). This response led nurses who wanted to gain more knowledge and skill to also found the American Association of Critical Care Nurses.
In their definitive account of the development of the critical care unit, Fairman and Lynaugh include the participation of physicians and certainly do not discount them. But they make the historical and contemporary reality crystal clear. What is unique about the critical care or intensive care unit is that it provides intensive care nursing, usually with a mandated ratio of one nurse to one or two, at a maximum, patients. So what happens to make sure that patients are safe immediately following surgery?
Well, first of all they go to the PACU, Post Anesthesia Recovery Unit, where they are monitored one-to-one by a PACU nurse who makes sure they come out of anesthesia and are otherwise safe. Then they go up to an ICU, if needed, where they are handed over for one to one or one to two nursing care. Of course doctors are involved, but nurses in the ICU are the ones who give the 24/7 support.
Let me make this point again, since it seems so easily to be forgotten — patients are simply not admitted to critical are units unless they need yes- the SUPPORT — of intensive care nurses.
But nurses do not even appear in this ad for NYU’s Langone Medical Center. No where.
Oh well, you might say, it’s just an ad. No one takes ads seriously.
Again not so fast. The implications of this kind of hospital promotion are quite serious. Not just because the hospital that a few years ago was happy to use nursing to get a competitive edge on its competitors seems to have forgotten the plot, but because ads that focus exclusively on doctors convey several other unfortunate messages. First they portray medicine and health care as a physician only affair. Thus NYU is now suggesting that the only thing patients have to worry about in hospitals is the presence or absence of an MD. So don’t worry about a nursing shortage, don’t worry about nursing excellence, doctors do it all –24/7.
This message would have been reprehensible a decade ago, but its even more reprehensible today. Since the 1999 Institute of Medicine Report on medical errors and injuries To Err Is Human, http://www.nap.edu/openbook.php?record_id=9728and its follow-up report Crossing the Quality Chasm http://www.nap.edu/openbook.php?isbn=0309072808, we know that keeping patients safe depends on team work. This team consists not just of physicians but nurses and many other players on the health care stage. If hospitals, in their media( even their advertising media) do not emphasize team work, the American public — which includes people who will eventually become physicians and nurses and other health care workers –will continue to think that medicine , or nursing, or physical therapy etc, is a solo activity. Which is an idea that is as dangerous as it is inaccurate.
I think nurses and patients all over the country should write to the CEO and CNO of NYU Medical Center to politely but firmly complain about ads like this. I for one intend to do just that. The CEO is Robert Grossman and the CNO is Kimberly Glassman. You might also think about emailing some of the members of the hospital’s board of trustees. Their names can be found at http://www.med.nyu.edu/about-us/trustees#nyuh.
You might also want to ask why there is nothing on his hospital’s home page about the Hospital’s Magnet status and not a word about nursing. You have to know to click on nursing at NYU Langone Medical Center to find out anything about nursing. So once again, nursing lives in its own ghetto,except occassionally when its let out and called upon to help a hospital compete. I happen to know that NYU is connected to a top notch nursing school and that there is a lot of fascinating research going on at the hospital and school that involves and includes nurses.
Here’s a suggestion for NYU Langone Medical Center. Obviously ads that feature nurses should be part of any campaign. But why not have ads that feature nurses and physicians as well as other members of the health care team. For example, the ad that just appeared could have easily featured two people at the bedside — an RN and MD (at a minimum) and the copy could have read “The Critical Care Unit at NYU Langone Medical Center’s Tisch Hospital is staffed 24/7 by physicians and nurses certified in critical care medicine and nursing.” Problem solved.