Being Mindful at Fort Miley

SF's Historic Fort Miley

Being Mindful at Fort Miley

by Suzanne Gordon on September 6, 2016


It is Tuesday afternoon, at three o’clock and four unlikely students of “mindfulness meditation” are relearning how to breathe. Instruction in being more mindful is everywhere these days, particularly in the Bay Area. So I could have been sitting through a similar training in Berkeley with a group of 60-something women with crinkling faces, flowing gray hair, and a history of New Age enthusiasms. Or I could have been on Valencia Street in San Francisco, epicenter of that city’s techie take-over, where whiz kids in their twenties and thirties are coping with long hours in Silicon Valley at a studio with a website called stressreductionatwork.com.

The 12-week mindfulness training I am attending takes place in a distinctly different setting, however. It’s held in a corner conference room in Building Number 8, the Behavioral Health Building, at The San Francisco VA Health Care System at Fort Miley and led by clinical psychologist Susanna Fryer and psychology intern Ian Ramsey. The group of veterans in their fifties and sixties who’ve come to Fort Miley are not here only for an intellectual or spiritual exercise. For some of these men, becoming better able to control their thoughts and anxieties through mindfulness is literally a matter of life or death.  Read More

Amazing Story About Innovation in a VA ICU

BN-ON037_howely_J_20160616104927This is amazing story about the Veterans Health Administration appeared in the Wall Street Journal. It’s entirely dependent on the fact that the VHA is one of the only healthcare systems in the country which has spent the money to purchase the kind of lift equipment that keeps nursing personnel and patients safe. And clearly, as evoked here, having the right equipment encourages innovations in real caring.

A Swimming Pool in the ICU
By E. Wesley Ely
Updated June 17, 2016 9:59 a.m. ET

“A swimming pool in the ICU? You must be nuts.” The nurse’s voice was almost lost amid the whooshing ventilator and infusion pumps.

Five days earlier, we had admitted Bennie, a Vietnam veteran, to the intensive care unit of our VA hospital in Nashville, Tenn. Frail and wrinkled, he had a look of utter confusion and a furrowed brow that would pluck the heartstrings of even the most calloused physician. Decades spent in Southern tobacco fields left him looking old enough to remember Hoover’s presidency. Double pneumonia and too much sedation made him delirious.

As his attending physician, I was thankful for his family. His daughter and son, Laura and Len implored: “Take good care of Dad. He’s all we have.” Seeing him on a ventilator is terrifying, they said, but we believe in miracles. While loving, such a mind-set could become problematic since their father’s situation had the makings of a fatal illness despite our best technology.
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With antibiotics and fluids, Bennie improved dramatically and was taken off the ventilator several days later. That same night, though, a massive stroke paralyzed his entire left side, and he went back on life support. We quickly administered clot-busting medicine, and he rallied again, remarkably regaining movement of his left arm and leg. The following day, the intern reported, “His delirium has cleared, and he’s mouthing words around the endotracheal tube despite his wicked aspiration pneumonia.”

I sensed an unexpected window of opportunity. We revisited Bennie’s life goals in light of what had happened and spoke directly about the big picture. With his children looking on, I held Bennie’s hand and looked him in the eyes. Choosing my words based on what I knew about his background and the family’s expectation of miracles, I said, “Bennie, just like tobacco plants eventually wither and wilt, so do we. You have improved in some ways, but overall you are very weak. How can we serve you best?”

The next morning, Laura and Len were upbeat, which confused me since Bennie looked weaker than ever. They pointed to words on a whiteboard in the room, explaining they were Bennie’s goals, “Stable vital signs. Baptism.”

I spotted Kelly, our charge nurse, smiling like a cat who’d swallowed a canary. In her arms she clutched a box containing a large vinyl swimming pool. First I made sure this was actually Bennie’s request and not the family’s. My next thought was that we’d have a chaplain anoint him with holy water in his bed, but Laura disagreed. “Jesus wasn’t sprinkled, Doc, he was dunked.”

A senior physician protested that the patient was on a ventilator and said he’d never seen a bedside baptism like this in 50 years of practice. There was no shortage of opinions about whether this was appropriate, safe, or even possible.

A large area next to Bennie’s bed was cleared and an electric pump inflated the pool. When a multiperson bucket brigade proved too difficult, an engineer rigged dialysis tubing to circulate the pool with a stream of warm water. Bennie was then hoisted high into the air via a patient-transfer lift, and the ventilator was unplugged before he was lowered into the pool.
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Len gently took his father, the man who’d shown him how to farm, into his arms. Following the cherished Christian tradition, he slowly submerged Bennie’s head completely under the water saying, “Dad, I baptize you in the name of God the Father, Son and Holy Spirit.” On cue, the palliative-care social worker began belting out “Amazing Grace.” The rest of us stood frozen in time.

First out of the water was blue corrugated ventilator tubing. Then his face appeared around the breathing tube. Bennie’s huge smile seemed to say, “Better late than never.”

When he died a week later, Laura implored me to tell other people about her Dad, hoping his experience would show them that “we can all become strong through our weakness.” In fact, I have seen scores of patients and families use profound “outer wasting” as a catalyst for deep inner renewal. The two most important “frames” of our life are birth and death. We typically associate baptism with the former, yet Jesus spoke of his death as a baptism to indicate the formative next step that dying represents for our journey.

The ICU team’s bold yet careful response to Bennie’s unusual request taught me an enduring lesson regarding sympathy versus empathy. Sympathy is feeling sorry for someone; empathy is feeling “with” someone. In all the surrounding insanity of the hospital that day, diving deeply into Bennie’s life through his baptism on the breathing machine allowed all of us to be reborn, too. Being “with” him in that pool, and rising with him out of it, we walked into others’ lives better prepared to serve.

Dr. Ely is a professor of medicine and critical care at the Nashville VA Medical Center and the Vanderbilt University Medical Center.

 

New Blog Post on McCain VHA Bill — Bad News

mccainindexI just posted this on the American Prospect blog on McCain’s attempt to flimflam veterans by privatizing the VHA.

 

Tapped: The Prospect Group Blog

McCain Pulls a Bait-and-Switch on Vets

Almost as soon as Senator John McCain had finished working with Senator Bernie Sanders to craft the veterans’ health-care bill now known as the Choice Act in 2014, the Arizona Republican set out to renege on his promise that Choice would be temporary, and began floating plans to make it permanent.

Part of the Choice Act was the establishment of the Commission on Care, whose deliberations the Prospect has covered extensively. This week that Commission is meeting to hammer out its final report, which will include recommendations about what the VHA should look like in 20 years. Instead of waiting to see what the Commission mandated by his own bill recommends, McCain has once again jumped the gun. He is lobbying hard for a bill that would not only make the Choice program permanent, but would eliminate any restrictions on veterans’ access to private-sector health care.

McCain’s gift to veterans is a bill misleadingly labeled The Care They Deserve Act. The subject of hearings on Capitol Hill the week of June 23, the bill would make the Choice Act—a three-year experiment enacted following revelations of delays in care at VHA facilities in Phoenix and elsewhere—permanent. Choice allows veterans to seek care from private-sector health-care providers if they face more than a 30-day wait for an appointment, or trips of 40 miles or more to the nearest VHA facility.

Under McCain’s new plan, the nine million veterans eligible for VHA care would be free to use any private health-care facility or provider, for any form of service, with the federal government paying the tab—no questions asked. McCain has gathered seven other Republican sponsors for his bill, all of them pushing the new conservative narrative that the VHA is broken beyond repair. This, of course, ignores reports by a Choice Act-mandated Independent Assessment of the VHA, which documents that its veteran/patients actually receive better care, at lower cost, than millions of Americans who rely on private sector health care.

What’s wrong with The Care They Deserve Act? Just about everything, which is why many veterans service organizations like the Disabled American Veterans (DAV) and Vietnam Veterans of America oppose the plan, and why the VHA’s own undersecretary for health, David Shulkin, has proposed a more sensible alternative.

Economists advising the Commission on Care estimate that McCain-style privatization could triple the cost of veterans’ care to almost  $450 billion a year—money that would not be well spent. The VHA’s clinicians and other staff specialize in the complex health problems related to military service, and deal with patients who are older, sicker, and poorer, with more mental health problems that those cared for in the private sector. The average elderly patient in the private sector shows up presenting between three to five physical problems. The “co-morbidities” of a Vietnam vet, for example, can number from nine to 12. That’s why VHA primary care providers spend at least 30 minutes with their patients per visit, compared to the ten or 15 minutes allotted to patients in the private sector. Will private sector providers want to take the time to care for aging, sometimes homeless, often mentally ill, veterans? Even if they do, will they be able to detect the difference between ordinary type 2 and Agent Orange-related diabetes, or be equipped to parse the myriad symptoms of PTSD?

McCain’s bill promises veterans a choice between VHA and private sector care. In reality, it would ultimately erode choice by weakening the VHA option, putting the entire veterans’ health system at risk. The VHA’s current budget is determined by how many veterans use the system and for what services. If far more eligible veterans start using private sector health care, there will be less funding available for VHA services that are unavailable elsewhere, and for maintaining the agency’s highly specialized research and clinical expertise in military-related health problems. As funding for costly private sector care eats up more of the VHA’s annual budget, there will be hospital and clinic closings, along with VHA staff layoffs. To reduce expenditures on veteran health care, Congress may also be tempted to make eligibility for veterans’ health-care benefits even more restrictive than it is today.

If Congress wants to improve the VHA, it should embrace the reform proposals of Shulkin and those Commission on Care members who want to allow veterans access to private sector providers in networks coordinated by the VHA. With luck, this recommendation will appear in the Commission’s June report. Strengthening the VHA, and giving veterans the choice to see outside providers if necessary, would really give veterans the care they deserve.

 

 

New Blog Post on Disney and VHA

This was just posted on the American Prospect Blog.

The Hidden Irony of GOP Outrage over the VA Secretary’s Disney Comparison

Poor VA Secretary Bob McDonald. Neither he nor the Veterans Health Administration he oversees can ever catch a break.

On May 23, a reporter questioned McDonald about the VHA’s tracking of patient appointment times around the country. McDonald’s predecessor was forced to quit over allegations of appointment delays and a cover-up at a Phoenix VHA hospital, and McDonald has often been on the defensive about the issue as the agency tries to hire the additional caregivers needed for the influx of Iraq and Afghanistan veterans.

In his response to the reporter, McDonald suggested that in the meantime, the VHA’s performance should be judged by a broader set of metrics. “What really counts is how does the veteran feel about their encounter with the VA?” McDonald said. “When you go to Disney, do they measure the number of hours you wait in line? What is important is your satisfaction with the experience.”

Unfortunately for the secretary, his invocation of the Magic Kingdom triggered a pack-journalism social-media response. The Koch-funded Concerned Veterans for America (CVA), a leading advocate of VHA privatization, immediately denounced McDonald on its website. According to CVA, McDonald showed disrespect for all VHA patients: “The sacrifice that accompanies earning that care is not the same as the sacrifice of taking a road trip to Florida,” the CVA declared. “Shame on Bob McDonald for trivializing veteran wait times this way.”

American Legion National Commander Dale Barnett was similarly offended. House Speaker Paul Ryan called the remark “disgusting” and “beyond the pale,” a sentiment shared by House Veterans Affairs Committee Chair Jeff Miller, a frequent critic of McDonald and ally of CVA in seeking to dismantle and privatize the VHA. There was even talk of calling for McDonald’s resignation.

After two days of negative news coverage, McDonald, a veteran himself, issued a clarification and apology to any veteran who felt his comments trivialized the VHA’s “noble mission.”

But lost in the Republican baying for more blood was a great political irony: Throughout private-sector health care, Disney’s corporate model for gauging customer satisfaction is now widely used to determine patient satisfaction and to regulate the patient “experience.”

Quality patient care requires an application of skills, experience, and teamwork quite different from the prerequisites for good “customer service” in the hospitality or entertainment industries. Yet treating sick people as “customers” has become part of mainstream management thinking.

The Disneyfication trend took off ten years ago after consultant Fred Lee published the bestselling If Disney Ran Your Hospital: 9 1/2 Things You Would Do Differently. Patient surveys using methods and metrics from resort hotels and amusement parks are now the norm in U.S. health care. A hospital’s results on the Hospital Consumer Assessment of Healthcare Providers and Systems standardized survey even determine, in part, its reimbursement rate for federally subsidized patients.

Disneyfication has spawned a huge crowd of high-priced consultants, like Lee, or Quint Studer of the Studer Group, who teach hospitals how to improve their patient-qua-customer experience to score well on questionnaires. As Studer puts it in his HCAHPS Handbook, hospital administrators need to “manage the patient’s expectations” to succeed, by convincing patients they are receiving good personal care—even if the hospital has poor nurse-patient ratios or lousy patient safety records.

In some hospitals, nursing staff trained and managed under this model have been forced to use scripts when interacting with patients and families. They are coached to smile and repeat words and phrases (such as “excellent care”) that administrators want to see echoed in patient surveys.

Some hospitals now designate an employee to be “chief patient experience officer” (CXO), a position enjoying executive status. As CEO of the Cleveland Clinic, Delos “Toby” Cosgrove, now vice-chairman of the VA Commission on Care, has overseen annual patient-experience conferences for the past seven years. Despite having both a CXO and a patient experience office, the Cleveland Clinic has been investigated for patient-safety lapses that almost resulted in the hospital’s suspension from the Medicare program. Some suspect Cosgrove withdrew his name for consideration as VA secretary because confirmation hearings would have led to negative publicity for the clinic.

Inappropriately treating—and, in fact, trivializing—sick patients as customers is a central feature of health-care corporatization, and represents everything the VHA has never been and should not become. If it’s not good for veterans, it shouldn’t be good for any of us. But that would mean Republican critics would apply the same standard to the VHA as they do to private-sector health care. Dream on.

Great New Article on the VHA by Paul Glastris

Please read and share this great new article that appeared on the Boston Globe blog by Paul Glastris.

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Special interest groups want to privatize the VA and nobody is paying attention

 

Should America’s veterans receive health care at hospitals and clinics run by the federal government, as they have for more than a century? Or should they be treated by private doctors and hospitals, with the US Department of Veterans Affairs (VA) picking up the tab?

This enormously important question will be discussed, and perhaps decided, at meetings on Monday and Tuesday of the Commission on Care. That’s a federally chartered group that is writing binding recommendations on the future of the VA.

If you’ve never heard of the Commission on Care, you’re not alone. Virtually none of the mainstream news outlets have covered its public hearings, which have been going on since the fall. This despite the fact that the VA health care system, with 300,000 employees and a $65 billion budget serving more than 9 million patients, is the federal government’s second largest enterprise after the Department of Defense.

The reason Washington is even considering such a radical restructuring of the VA has to do with widely publicized reports in 2014 that 40 veterans in Phoenix died waiting for first-time appointments with VA doctors. These reports led to bipartisan legislation mandating the creation of the commission. But as investigative journalist Alicia Mundy reveals in the Washington Monthly, the reports turn out to have been baseless allegations cooked up by a Koch brothers-funded group, Concerned Veterans for America (CVA), and key Republicans lawmakers who ideologically favor the outsourcing of VA health care.

Soon after the law was passed, the VA’s inspector general’s office published a report based on an exhaustive review of VA patient records. The report concluded that six, not 40, veterans had died experiencing “clinically significant delays” while on waiting lists to see a VA doctor. Of those six, the IG could not confirm that any vets died as a result of waiting for care. (Think of it this way: People die every year waiting in grocery lines, but that doesn’t mean they died because of waiting in grocery lines.) There were certainly problems at some VA facilities. The waiting list numbers were definitely being gamed by VA personnel struggling to keep up with unmeetable performance metrics. The “death wait” allegations, however, were bogus.

But wouldn’t vets receive swifter and better quality care from private hospitals and doctors than from a big bureaucracy like the VA? Actually, no. The law that set up the commission also mandated that $68 million be spent on independent research into the VA’s functioning. The researchers concluded that despite many problems, including plunging morale and a wave of retirements, the VA performed “the same or significantly better” than private sector providers on a wide range of quality measures. They also found that average waits for VA doctors were shorter than wait times for doctors in the private sector.

Given all this, you’d think the commission would easily conclude that outsourcing VA health care to the private sector makes no sense. But that’s not how Washington works. It just so happens that four of the 15 members of the commission are executives with major medical centers that stand to gain from the outsourcing of veterans’ care. Another works for CVA, the Koch brothers-backed group, and yet another for an organization allied with CVA.

Last month these six commissioners plus a seventh were outed for writing a secret draft of the commission’s recommendations — in which they call for full privatization of the VA by 2035 — in possible violation of the Sunshine and Federal Advisory Committee Acts. This revelation infuriated the other commission members. It also led prominent veterans groups, including the American Legion and Veterans of Foreign Wars, to send a letter to the commission chair slamming the secret draft and expressing their united opposition to privatizing the VA.

Amazingly, none of these traditional veterans groups have seats on the commission. Indeed, a big reason the outsourcing push has gotten as far as it has is that the veterans groups allowed themselves to be sidelined politically. Now, finally, they are fighting back.

While they don’t have votes on the commission, the groups do have 5 million members. Several of their leaders will also testify at this week’s commission meetings. So the meeting will likely be an epic showdown between pro- and antiprivatization forces that could profoundly influence the commission’s final recommendations, due out in June. Hopefully, someone from the media will be there to tell us what happened.

Paul Glastris is editor in chief of Washington Monthly.