An inscrutable brand of optimism and another poem.

This year: some victories and some defeats, human race. But we are brave and we adapt. We recycle our garbage. We try again.

And if that doesn’t do it for you then know inevitably just like every dominant species before, eventually we’ll be gone. This beautiful blue marble will subsume us and our refuse and something new will get a few spins around the sun. (Then the sun will turn into a red giant and then a white dwarf I think and things kinda fall apart? Don’t worry we’ll all be dead.)

YES I AM an optimist. Don’t give me a hard time.

Between the time that I knew I had melanoma with not great survival statistics and my first surgery (a few weeks nearly a year ago) I would do some yoga every night and lay in corpse pose and think about dying. The uncoupling of my molecules and rearranging of my atoms and how that would be a good way to stay on in this world. I’m not gone I’m just different.

Weird mantra, right? Weird times. And I do believe it, the conservation of matter. I’m a gardener (though looking upon my gardens would make Martha Stewart throw up). Composting is a feature of life here and using it as a metaphor for purification and renewal scratches an itch. This is more a spring poem, but here it is in the spirit of the renewing the year.

Excerpt from Walt Whitman’s Leaves of Grass, “This Compost

3.
Now I am terrified at the Earth, it is that calm and patient,
It grows such sweet things out of such corruptions,
It turns harmless and stainless on its axis, with such endless successions of diseas’d corpses,
It distills such exquisite winds out of such infused fetor,
It renews with such unwitting looks its prodigal, annual, sumptuous crops,
It gives such divine materials to men, and accepts such leavings from them at last.

BBC Radio 4 The Future of Medicine – Dr Atul Gawande – 2014 Reith Lectures

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BBC Radio 4 – The Reith Lectures, Dr Atul Gawande: The Future of Medicine – Dr Atul Gawande – 2014 Reith Lectures.

Gleaned from these lectures, questions IMO we should ask all patients. At least once a day for those in the hospital:

“What is your understanding of where you are with your condition or your illness at this time?” “What are your fears and worries…”…“What outcomes would be unacceptable to you?”And with that, they’ve told you their priorities and what they care about and then that tells you both where the bright lines are that you do not cross and what you might actually be aiming for.

I enjoyed so much being stuck in traffic listening to these lectures this week. Gawande, my mentor who doesn’t know he is my mentor, pulls from previous works and his most recent book “Being Mortal,” which covers the medicalization of dying and offers suggestions to bend the system to favor better communication between providers and patients, supporting meaningful living through old age and, hopefully later rather than sooner, an end to life that is most agreeable to the dying person.

I recommend this book people who have parents and loved ones moving into their later 60s, as it kindles the kind of conversations that are much better had over a beer or some tea and biscuits (my dad and mom respectively) than in a hospital room. I promise you it is worth the work now to know what your loved ones want. When they are incapacitated the weight of decision making will fall to you.

I had a loving adult son, flown in from Florida, standing with me in the doorway of his critically ill father’s ICU room the other week. He told me his dad had never been sick a day in his life. He said they knew something would happen some day, but they just didn’t want to think about it.

In truth though enjoy the lectures. Gawande is uplifting and so so logical, a great story teller to boot. One day I will grab the podium and sound like that. Right now it would come out LISTEN TO ME AND FIX IT FIX IT FIX IT. Lacks maturity.

Big Hero 6, starring a nurse, tears of sad and tears of happy.

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I don’t advise anyone to have children (period, cause that’s none of my business) but if I did my first pro argument would be the super children’s movies out there. This week we took my son to see Big Hero 6. It was the greatest. Baymax the robot, main character, IS A NURSE and the best thing to happen to nursing since Flo hit the Crimea. That might be an exaggeration. Baymax assesses his patient, provides excellent pain control, recommends evidence based treatment, does education, and is unable to deactivate until his patient states that they are satisfied with their care. He also wields the defibrillator with his own two stubs (no hands), a tip off that it’s your RN and not your MD who is most likely to analyze your cardiac arrest and defibrillate.

The writers make Baymax a nurse and not a doctor. Not what we’re used to seeing, right? The movie takes place in futuristic San Fransokyo where there is a melding of American and Pan-Asian culture (similar to Joss Whedon’s Firefly and Gary Shteyngart’s Super Sad True Love Story). Over the years I’ve heard of the looming caregiver shortage in Japan. I dug up this 2009 NPR piece about robot caregivers for the elderly. So, naturally, I’m thinking this movie with it Manga-ish style about robot caregivers has got to have roots in Japan. This is the best I could come up with on my internet search: the movie is “loosely based” on a Japanese comic strip of the same name. By way of Marvel, by way of Disney. I looked into Japanese nursing to see what they might be doing differently to achieve a public image that is more congruent with the work we do than anything we see in American media. From my cursory glance it appears the title of nurse requires more education (for RN min two years in America, min 3-4 in Japan). Also, public health nurses and midwives have much more defined roles and are a feature of the daily lives of citizens. Nurses are decoupled from the elbows of doctors–true in American practice as well, but not as visible.

If we want to be Eeyores about it, we can see this movie as another in a long line where jobs of less value are relegated to robots (WALL-E, Star Wars, help me out nerds…). Okay, maybe. BUT in his last act which I will not spoil because if you have a heart in your chest it will make you cry, I would argue that Baymax is sentient, nulling that sad hypothesis. He is a nurse super hero movie star. AND THE PEOPLE (well, just me) IN THE MOVIE THEATER REJOICED!

This was a great movie to see with my kid for 10,000 reasons. So have kids or not but see this movie. Then you better recognize that this nurse right here is an autonomous and patient-centered ass-kicking machine.

FDA Proposes Easing Lifetime Ban On Blood Donations By Gay Men | Kaiser Health News

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FDA Proposes Easing Lifetime Ban On Blood Donations By Gay Men | Kaiser Health News.

Let’s look at some facts and data, shall we? Then I’ve got questions.

Statement from the FDA.
From Red Cross:

redcross blood safety

redcross blood safety 2

What it means: Blood is tested for antibodies to HIV 1&2 as part of the battery of tests performed to ensure donated blood is safe for use. However it may take several weeks to months after infection for HIV antibodies to present in the serum (if you contracted it last night, it may not be apparent until 3 months from now).

From CDC:
cdc hiv transmission rts

What it means: The population of concern are people who have been exposed to HIV but have not yet developed screen-able antibodies–new infections. So we look at the most recent transmission data from the CDC and note that men having sex with men are 2.5 times as likely to have a new infection as the second largest category, heterosexual contact.

My questions: How is the one year waiting period scientifically justified? One year would allow time for antibodies to appear, of course. But there is risk of undetectable infection in blood of people engaging in heterosexual contact, too. Even it it’s 2.5 times less than MSM is that risk not deserving of the one year abstinence period? And then where would be be in terms of blood supply? What is the risk benefit analysis here? I don’t yet get how this is a decision based in evidence on the part of the FDA. To me, it’s a little don’t-ask-don’t-tell-y. And by that I mean homophobic and embarrassing.

Also, I would like to know that data on the risk of transmission of HIV and the Heps when anitgen/antibody complexes are undetectable in the serum. And the number of people per year who contract HIV or Hep B or C from blood transfusions. Add that lit search to the pile.

From the E.R. to the Courtroom: How Nonprofit Hospitals Are Seizing Patients’ Wages – ProPublica

Under federal law, nonprofit hospitals must offer care at a reduced cost to lower income patients, a service often called charity care. But crucial details—how poor patients need to be, how much bills are reduced, and how policies are publicized—are left to the hospital. The Affordable Care Act empowered the IRS to set new requirements for publicizing this information, but those have yet to be finalized.

If a patient can’t pay and Northwest obtains a judgment, it’s too late. Hospital policy says once the collection agency has “incurred legal fees” on a case, the patient is ineligible for charity care, regardless of earnings.

via From the E.R. to the Courtroom: How Nonprofit Hospitals Are Seizing Patients’ Wages – ProPublica.

I’m breaking my break because this spectacular piece of investigative journalism is really all I wanted for Christmas. This is an issue that makes the individual mandate, as Salt-N-Pepa might say, very necessary.

Charity care/financial assistance is available at my academic health system. Patients qualify for financial assistance based on income and payments are calculated with a sliding scale. They may owe nothing, a percentage of the total, or be put on a payment plan. This article uncovers that the criteria for how a patient finds out about or applies for or qualifies for financial assistance is largely left up to the hospital. As a recent cancer patient with massive bills but good insurance and 2/3 of a graduate degree from the academic health system where I received treatment, I still messed up paying the hospital. Medical billing is incomprehensible and damn tricky. Adding the difficulty of applying for financial assistance on top of your stack of bills from many non-communicating entities is the real cherry on top of the garbage sundae. No, it’s an additional garbage sundae on top of the garbage sundae. No, it’s just a pile of garbage.

Bottom line: Access to aid is limited. Barriers to aid are significant. And, most shockingly to me, once you have been sued successfully by the hospital, you no longer qualify for aid. *MIND EXPLODES*

Where is my mind?

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I have really enjoyed dropping off the face of the earth for a few days. The academic schedule suits my glutton-for-punishment alternating with complete and total slacker personality. Of course I can be as maniacal at slacking as I am at work. Over the past week I read a 700 page novel in time to have a meeting of the introverts’ book club. You know–two people at a bar who read the same book. Reading a beautiful novel that has nothing to do with health care then going to a bar, an entirely selfish act for a wife and mother, is my best shot at spiritual renewal.

Early in graduate school our class was introduced to a mindfulness curriculum. It intends to create embodied, resilient, and compassionate providers. Man, I thought, this nonsense is going to burn off like so much morning fog. Then came the infamous mindfulness retreat. There was gentle yoga and meditation to the sounds of jungle rain. No wait that was just me crying uncontrollably. Mindfulness:1, Melissa: 0.

fetal-position-550x550

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I was not ready for mindfulness. It is powerful medicine. What was wrong with my foremothers’ ways of coping with life’s ups and downs? Beating carpets, aggressive scrubbing, tea.

Complementary and alternative medicine (CAM) is a booming area of research. What interests me is finding the best way to provide access to the modalities, germane to many folks aren’t hanging out on Maslow’s lowest 2 or 3 spots, to people who are unfamiliar with CAM and have a list as long as my arm of more immediate food-shelter-safety concerns. The people at Common Ground Healing Arts are making some impressive forays, working in public housing projects and a prison, and showing good results in terms of better controlled diabetes and lowered BPs. I came to them last winter with a note from the cancer center and they took care of my penniless self, too. I want to talk to them about their work. I kind of love them.

So to review, meditation/yoga/acupuncture, the whole package, is a significant thing. I buy it okay, I’m on board. I’m just not all the way ready. So practitioners please be aware that efforts to induce mindfulness may create a paradoxical reaction. Also, it’s okay if your way of clinging to mental health like hang in there kitty is reading a big book, drinking three fingers of whiskey, and talking to your friend about this beautiful line of prose, did you catch that leitmotif, and oh the point is that half of love is yearning.

Happy holidays all, do your thing to get restored.

My free birth control!

Today I marched into my OB’s office and got myself a shiny new long acting reversible contraception/LARC installed. I keep calling it a LARP but that’s another thing entirely. IUDs/LARCs are 99% effective at preventing pregnancy and perfect use is pretty much guaranteed. No missed pills or whoopsies with the condom. The hormonal IUD delivers the smallest dose of progesterone available reducing little discussed but potentially catastrophic side effect of thrombosis attributed to the higher dose hormones in the pill. LARCs are now recommended as first line contraception to sexually active adolescents as well. They are the second coming of female birth control (if you want to get all sacrilegious about it).

My first LARC back in 2010 cost about $250 with insurance. How much was today’s? Zero dollars. Not even a co-pay. ACA preventative care, my dove.

Contraception: Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling, as prescribed by a health care provider for women with reproductive capacity (not including abortifacient drugs). This does not apply to health plans sponsored by certain exempt “religious employers.”

(AHEM HOBBY LOBBY). So no access for employees on their health plans.

But back to my day: whimmy wham wham wazzle no unintended pregnancy for me, no paying for unintended pregnancy for my insurance company. As my bestie CB has been known to say, THANKS OBAMA!

Seriously though let’s lean in on male BC ’cause I love not getting pregnant but I feel like I got punched in the uterus right now (that lasts about 48 hrs).

***Remember kids, only barrier methods can protect you from STDs***

Poetry Monday.

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Enlightenment

BY NATASHA TRETHEWEY

In the portrait of Jefferson that hangs
        at Monticello, he is rendered two-toned:
his forehead white with illumination —
a lit bulb — the rest of his face in shadow,
        darkened as if the artist meant to contrast
his bright knowledge, its dark subtext.
By 1805, when Jefferson sat for the portrait,
        he was already linked to an affair
with his slave. Against a backdrop, blue
and ethereal, a wash of paint that seems
        to hold him in relief, Jefferson gazes out
across the centuries, his lips fixed as if
he’s just uttered some final word.
        The first time I saw the painting, I listened
as my father explained the contradictions:
how Jefferson hated slavery, though — out
        of necessity, my father said — had to own
slaves; that his moral philosophy meant
he could not have fathered those children:
        would have been impossible, my father said.
For years we debated the distance between
word and deed. I’d follow my father from book
        to book, gathering citations, listening
as he named — like a field guide to Virginia —
each flower and tree and bird as if to prove
        a man’s pursuit of knowledge is greater
than his shortcomings, the limits of his vision.
I did not know then the subtext
        of our story, that my father could imagine
Jefferson’s words made flesh in my flesh —
the improvement of the blacks in body
        and mind, in the first instance of their mixture
with the whites — or that my father could believe
he’d made me better. When I think of this now,
        I see how the past holds us captive,
its beautiful ruin etched on the mind’s eye:
my young father, a rough outline of the old man
        he’s become, needing to show me
the better measure of his heart, an equation
writ large at Monticello. That was years ago.
        Now, we take in how much has changed:
talk of Sally Hemings, someone asking,
How white was she? — parsing the fractions
        as if to name what made her worthy
of Jefferson’s attentions: a near-white,
quadroon mistress, not a plain black slave.
        Imagine stepping back into the past, 
our guide tells us then — and I can’t resist
whispering to my father: This is where
        we split up. I’ll head around to the back. 
When he laughs, I know he’s grateful
I’ve made a joke of it, this history
        that links us — white father, black daughter —
even as it renders us other to each other.

Natasha Trethewey, “Enlightenment” from Thrall. Copyright © 2012 by Natasha Trethewey.

A complete novice refutes the statements of a qualified professional

Why I oppose payment reform- Alan Weil, Health Affairs Blog

Interesting article but I’ve got counterpoints ’cause I’m a student with more opinions than I have a right to and am cocksure enough to comment on statements made by the editor-in-chief of Health Affairs.

Summaries of his points are in bold. Please read his article regarding opposing payment reform in health care to get his full and well considered arguments.

The current workforce is unprepared for a model that doesn’t reward for filling beds, doing tests:

  • There are tremendous rewards for innovation in the field of health care right now! These folks have seen the model they came up in become more and more of a frustration to them and their patients. Everywhere I look, from floor staff to executives, the feeling is very get on the train folks, we’re heading to the future. Alternately: retire, find a different gig, or learn to cope with the new requirements. People are learning to become successful and you better believe that new leaders are prepared for these challenges.

Any money saved will move its way to the top (health systems, hospitals) and workers on the front lines won’t see any benefit:

  • Maybe. Based on the ones I’ve spoken to I don’t think dietitians, social workers, and community health workers are expecting a huge raise. But many hospitals are dramatically understaffed in these positions to the point that they are unable to perform the core competencies of their roles. As these workers bring forward evidence showing the financial benefit to hospitals of having, say, a full time dietitian to improve nutrition and reduce pressure ulcer rates, hospitals will have a financial reason to staff these professionals.

There is no current evidence to suggest that payment reform will achieve the goals we need it to achieve, and there is some evidence to the contrary.

  • Okay, your evidence is good here, but early days! There is evidence showing smaller programs put into place are already saving money such as reduced re-admissions with heart failure transitional care (article unfortunately not open access, DOI: 10.1097/JCN.0b013e31827db560).

The original rationale offered for payment reform doesn’t match the current objectives.

  • I think it does match that original rationale (to pay for quality rather than quantity of care). Health systems do not have an incentive to stop a practice for which they are getting reimbursed. We know patient falls are bad thing for a patient, but more days in the hospital to recover from your now necessary hip surgery is money in the hospital’s pocket. Why would you spend money reducing falls to stop yourself from making money? When hospitals are told they won’t be getting paid for the consequences of that fall innovations in care happen and adverse event rates go down. Of course we need metrics to quantify success and failure, and because these rule changes are rolled out in a way that intends to give health systems time to introduce new measures without sinking the rusty old tub. And certainly hospitals with higher acuity patients are getting the shaft, hence even more complex models to try to even the playing field.
Payment reform poses a risk for the growing understanding of the importance of patient-centered care (What is an appropriate value formula when patients differ in their goals for recovery).
  • The value formula is simple: “Patient, are you satisfied that you have reached your stated goal of x?” If your 95 year old patient states his goal is successfully completing the Marine Corps Marathon pain-free then you’ve got to use your negotiating skills to get him back on this planet. The point is to set patient centered appropriate goals before undertaking invasive or potentially harmful interventions.

Interlude

Y’all,

I’ve lived nearly all my adult life in rural Virginia. I’ve tried to leave it and do something shinier with my life, to no avail. It calls me back. As I hone in on where I want my practice to go I’m more and more certain that health care access and preventative care issues among rural people, especial rural black people, is my dissertation in waiting.

And as much as I complain about the year round life-size outdoor nativity set down the road and the absurd number of sheds people have and the omnipresent target rounds being fired, I can’t imaging a life without my incomprehensible neighbors (who btw think I’m a space alien. Running at night down my unlit road with a headlamp confirms that suspicion). I’ve got a great post brewing about how my tiny county has managed, by being so indisputably red and according to a poll of bumper stickers having only two political issues (out of my cold dead hands and NOBAMA), to create progressive local educational and health care initiatives. When no one has to prove their redness, a space opens up for common sense arguments.

I am a physical wreck by the end of my semester and trying to get a tree up and make the Christmas magic happen for my lovely kid, so this make take a day or two. In the meantime enjoy this picture of my doc’s patient room. DISCLAIMER: This is the best PCP I’ve ever had. Hands down.

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