David vs Goliath: The Patient Loses

I had a conversation last weekend that left me stewing all night.

I spoke with a nurse (whose identity and other particulars I can’t divulge) who told me about a standoff she had had with her employer, a large urban medical center with a reputation to protect.

In a nutshell, she wanted to protect consumers/patients by revealing information that she believed put patients in this hospital at risk. The hospital called out the lawyers and invoked patient privacy. It also reminded this nurse of a contractual agreement that said that all information she gleaned must remain confidential.

This nurse didn’t think that, if the hospital knew patients might be harmed, it would withhold that information or fail to make changes that would ensure patient safety.

The nurse was hired by the medical center to review surgical cases with the idea of improving quality of care. Newspaper accounts of this story also said that the hospital was preparing for a JCAHO review. The nurse came with more than two decades of clinical experience and also had been called upon to consult for malpractice cases, so she was well qualified for such the job.

This nurse did exactly what she was supposed to do.

In reviewing the records, she found several surgical cases that called into question the work of a surgeon, and she also found fault with the review process. After raising concerns about the findings, the hospital fired her. It justified her dismissal using an unrelated excuse.

After she was fired, the nurse described in a document the problems as “serious shortcomings” and made known that she would inform state and federal agencies. That caused the hospital to go to court for an injunction that effectively shut her up.

To this day, there has been no resolution, and no one can say whether the hospital corrected the problems.

This story really made my blood boil. If nurses are supposed to be patient advocates and if consumer safety was at stake, I don’t understand why this nurse was not allowed to bring her concerns to light. I guess it’s a case of David versus Goliath, only this time the giant won—and ethics be damned.

Have you ever had a concern for patient safety, but been told to keep quiet or ignore the problem?

What did you do and how did you feel?

Were there consequences for you and/or the patients?

Tell us about it.

Just Call Microsoft and Google Our New Big Brothers

I’m not sure, but I think Microsoft and Google are taking over the world and here’s why.

In mid-June, Blue Cross Blue Shield (BCBS) of Massachusetts announced that it will be the first insurer to participate in Google Health, an online personal health record service. It is offering this service to its three million members for nothing. Nada. Zip.

And for that price, here’s what Google says the BCBS members can do, according to an Associated Press story in the Boston Herald. They can:
• Decide whether to open accounts or not; it is optional.
• Decide who can access their health records.
• Review their claims and some medical records, which the insurer says helps patients manage their care and have more productive discussions with physicians.
• Link their medical records to pharmacies. When members get new prescriptions, they automatically will be added to the members’ records.
• Delete their records at any time.

The insurer will provide some information, but the total amount of information in the online medical records depends upon the use of them by physicians, according to the story.

On first impulse, this seems pretty cool.

Each person has one medical record—although it might not be complete. The record is available at any time and any place via the Internet, and this system would certainly result in using less paper. And those in favor of using Google Health say subscribers can check lab results as soon as they are posted. Wow—no calling the doctor’s office and waiting for someone to unearth the results and return the call.

But, as they say, there is no free lunch.

The idea of medical records floating around out there in cyberspace is a little scary.

I visited the site and it seems that there are additional “services” available—some of which I didn’t understand, but somehow I think they have to do with using the information.

As for security, BCBS says the program is impenetrable. Sure, we’ve heard that one before. We all know that there are super-geeks out there who can crash any security wall. And think about how gleeful pharmaceutical companies would be to get these records and build their mailing lists and construct their target maps.

What do you think about the idea of creating medical records on the Internet?

Good, bad or you don’t care?

What do you think?

Will Nursing Education Meet the Demands of the Future

Nursing education has a problem, according to a recent white paper written by the California Institute for Nursing & Health Care. The authors say that the current system of educating nurses is not meeting the needs of the state’s population, and I imagine a few other states are having similar problems.

Here’s the situation as the white paper authors see it and why we need to change how we teach prospective nurses:

• The way we care for patients is constantly changing. There is increasing emphasis on patient safety, evidence-based medicine and new technology.
• The use of clinical simulation needs to increase. Proponents say it enhances critical thinking, problem-solving, clinical judgment and rapid-response skills. It also provides opportunities to learn in a safe environment, but it is expensive.
• There is renewed interest in collaboration between associate degree and baccalaureate degree programs. Seventy percent of California’s nursing grads are from associate degree programs. In 2007, only 26 percent of these nurses reported continuing their education to obtain a BSN. (Nationally, that number is 20 percent.)
• There is and will continue to be a nursing shortage unless something changes. California is looking at a deficit of 16,000 full-time nurses by 2020. California is 50th in the country in the number of nurses per population – 580 per 100,000. Nationally, that average number is 825 per 100,000.

I also was pretty shocked to learn that a nurse with 20 years of clinical experience must settle for half her salary if she becomes a teacher, so we should not be surprised that nurses aren’t signing up for classroom duty.

Now, back to that third point—the one regarding articulation from an associate degree program to a bachelor’s degree program. That issue long has been a personal pet peeve. Why is the process going from one program to the other so cumbersome and frustrating? It would seem that at the least community colleges and four-year institutions in the same state could figure out a way to work together to produce a program that takes a two-year nurse seamlessly into a BSN program.

Perhaps the motive for not providing such an opportunity has something to do with protecting turf and job security in both the two-year and four-year arena. But if California and all the other states want to boost the numbers of nurses—all kinds—their institutions of higher learning need to get it together and work together.

To read the entire white paper, visit http://www.cinhc.org/programs/documents/NERCWP_FINAL.pdf.

Are you the product of a two-year program? If so, do you want to eventually earn your BSN?

Have you encountered academic roadblocks? If so, what are they?

What improvements do you think should be made in either the two- or four-year programs?

Tell us what you think.

Don't Forget: Nurses Are Consumer Advocates

It is in the nurse’s creed somewhere that we must be patient advocates, and in today’s world of slick and clever advertising, I think it’s a bit more of a challenge – for both nurses and consumers – to figure out who is selling the snake oil and why.

There are so many gimmicks nowadays to rope in the unsuspecting, and the scams are getting more sophisticated because the boomer generation is a bit more wise and skeptical than generations before. But some hucksters know how to appeal to the aging boomers without insulting their intelligence or making them feel like an easy mark. An example:

For several months now, I’ve noticed the ads for high-tech (and very expensive) hearing aids are increasing – both in my mailbox and in newspapers and magazines. Just recently, I received an ad from a hearing aid company that was cleverly disguised as an invitation to join a focus group with the offer of $25 for participants. The qualification is that you had to either be wearing hearings aids (presumably the ones being sold were better) or suspect that you have a hearing loss.

The focus group will “evaluate the latest scientific breakthrough in digital hearing technology.” The mid-morning sessions is to be held at a room in a nearby library (certainly a library would not be party to fraud!) and the event includes refreshments.

With the “invitation” came a summary of a 13-year-old study that concluded that wearing only one hearing aid, when you have hearing loss in both ears, may result in “decreased speech understanding in the un-aided ear.” This part seems like a no-brainer, but I imagine the warning was included to alarm and motivate -- and to assure that prospective customers think two hearing aids instead of one.

This pitch is not exactly a scam, but it is a clever way to hook people into hearing a sales pitch for something that costs thousands. I suspect participants will get the hard sell once they are in that library meeting room.

The second ad I recently received is one that I get repeatedly. It urges older adults to get ultrasound scans of their carotid arteries and bone density scans, both as prophylactic measures.
These scans are done with portable machines that come to senior centers, nutrition centers, congregate housing and any place where seniors gather.

Some years ago, the machines produced poor-quality images, but today’s models have improved. Still, there remains hefty debate about whether these tests are useful, as they sometimes result in invasive procedures that patients don’t really need.

There are a lot of other examples out there of potentially fraudulent services and products – diet plans are another favorite, directed especially at women . But this is my point: Friends, family and patients will ask nurses what they think about such offers, and hopefully we nurses can give an honest, accurate answers. If we don’t know about a particular topic, we should know how to access correct, unbiased information, or tell those who need to know how to do it.

We should be able to read between the lines of ads that look legitimate, but whose veracity is murky at best.

Have you seen examples of questionable health-related products and services?

Do friends/family/patients ask your opinion and advice about such things?

Do you feel confident in giving advice?

Tell us what you think.

Alabama's Fat Tax

The 37,537 state workers in Alabama are among the lucky. They pay nothing for their health insurance but that could change come January 2010. Employees who are overweight—that is, have a BMI of 30 or higher—will have to pay $25 a month toward their insurance premium.

The reasoning: Being overweight or obese causes other health problems and those problems cost money.

Some people are incensed. They say their employer is acting like Big Brother—that such an action is way too intrusive.

Others hail Alabama for going where few dare to go. Besides, they say, something has to be done in a state that is second only to Mississippi when it comes to overweight citizens, according to the Centers for Disease Control and Prevention. Slightly more than 30 percent of Alabama residents are obese.

It is generally accepted that obesity is a factor in many health problems, among them diabetes, stroke, heart and vessel disease, arthritis, joint injuries, pulmonary problems and more.
“Our goal (is) to make our members aware of those risk factors," Deborah Unger, RN, clinical director for the Alabama State Employees Insurance Board in Montgomery, told WebMD. "As long as you are aware and are doing something to correct it, there won't be a fee. We either do something to control claims costs or you pay the premium anyway."
So here’s what the state is proposing their employees do:

At some point (the several articles I read were not clear when this would be), each employee gets a free medical screening to evaluate BMI, blood pressure and cholesterol and glucose levels. If the employee has “serious problems,” he or she will have a year to make changes. Employees can see a doctor for free and enroll in formal wellness programs or initiate programs on their own.

If after a year there are signs of progress, there won’t be extra charges for their health insurance. If there has been no improvement, employees pay $25 a month starting January 2011.

To help employees shed those pounds, the state is working with the YMCA and Weight Watchers to provide discounted programs, and is directing employees to a Web site that helps with information and encouragement.

Employees who smoke are already paying $25 a month.

So what do you think?

Is charging obese people and/or smokers extra money for health insurance intruding into people’s private lives?

Should everyone have to shoulder the cost of the bad lifestyles of some?

What should companies do to motivate people to get healthy?