Fee-for-service quick and dirty

In my holiday fervor, I forgot some key points. Doing a quick lit search brought up this lovely paper from 2008 “Health care reimbursement: Clemens to Clinton” by John T. Preskitt, MD. (John you and I should just settle down and raise a family we are perfect for each other). The answer to my stutter about when fee-for-service originated? It evolved along with Medicare, and was recognizable by the late 1950s. Managed care brought it into full flower.

One more point to be made. A crucial drawback of fee-for-service: profiting from mistakes. If you are thoughtlessly administered a drug you are allergic to–and now you’re needing all the care someone in anaphylaxis gets–you and your insurance will be billed for the privilege. Mistakes happen. Medicine is human. But failure should not be rewarded with money.

Pull quote from Preskitt’s article, which I am nicknaming “Ghosts of insurance past”

Managed care was supposed to create a system that would contain costs while simultaneously increasing the quality of care. Our traditional fee-for-service medicine had led to health care inflation because it encouraged caregivers to maximize the number of procedures they perform, ignoring preventive care. Doctors and hospitals were not paid to keep patients well; they were paid to treat them when they were sick.

St. Elizabeths Asylum, Washington, DC.

Lo, I did write thee a splendid piece on my visit to the National Building Museum exhibit on Washington, DC’s great Asylum hospital, St. Elizabeths (no apostrophe). But ay I did it waiting for a surgery to close, needing something to do something with my nervous energy. The patient, when asked the standard pre-surgical question “Why are you here with us today?” (assesses orientation, assures that the patient is informed, confirms procedure), answered “I am dying.” Always believe the patient who says they are dying.

Crash cart at my side, fellow nurse and I finished planning our I-hope-this-doesn’t-turn-into-a-code, I typed out a gem. And upon finishing, ran off to do a thing and lost it.

Instead, here is an excerpt of a letter written by Dr. Charles Nichols, superintendent, to Dorthea Dix (nurse, hero) the greatest advocate for mental health that ever lived whose actions led to the establishment of the hospital, on the selection of a site.

The moral treatment of the insane, with reference to their cure, consists mainly in eliciting an exercise of the attention with things rational, agreeable, and foreign to the subject of delusion; and the more constant and absorbing is such exercise, the more rapid and effectual will be the recovery; but many unbroken hours must elapse each day, during which it is on every account impracticable to make any direct active effort to engage and occupy the patients’ minds. Now, nothing gratifies the taste, and spontaneously enlists the attention, of so large a class of persons, as combinations of beautiful natural scenery, varied and enriched by the hand of man; and it may be asserted with much confidence, that the expenditure of a thousand dollars each year, directed to the single object of promoting the healthy mental occupation of one hundred insane persons, with either amusements or labor, would not be so effectual in recalling reason to its throne, as will the grand panorama of nature and of art, which the peculiar position of the site chosen happily commands. The shifting incidents of the navigation of the Potomac, the flight of railroad cars to and from the city, the operations at the Navy Yard, &c., will continually renew and vary the interest of the scene.

It lifts my iron anchor of a heart to read about this period in time, the asylum movement. Started by Quakers and somehow collecting political support for the mission to create a place, tranquil and serene, to house and heal vulnerable, imprisoned, and cast away persons suffering from mental illness. Public funding! Our government and the people it represents setting aside money to better provide for its poorliest members. Acknowledgement that all people have dignity and value.

**I know you’re thinking asylum? You mean those places where people are locked up and tortured and experimented on? Yes, terrible. But I’ll refer you to the many, many atrocities committed against those walking free: people of colorindigent people seeking care at public hospitals. Medical ethics has an awful lot to answer for. It’s my speculation that we pin it all so easily on asylums, place all our unquiet ghosts there, because of the fear and stigma bound to mental illness. Chew on that. I digress.

Asylums were conceived in goodness. Every pure-hearted reformer may know exactly where the road paved with their good intentions will end up, but I’m glad that they’re trying. We keep trying. We should always be trying.

PS- As Dr. Nichols states, I’m in favor of doing anything that “recalls reason to it’s throne.” Especially in this nuthouse town.

Good Lord “Mercy Street”

I’m obsessed with our image. On a scale of 1 to Gray’s Anatomy (1 being no pain, Grey’s Anatomy being the worst pain you’ve ever felt in your life), most portrayals of nurses on TV and in the movies land in the 7 region. The faces pain scale really works for this:
Pain scale

A few years ago PBS began airing the BBC period nursing drama Call the Midwife, a darling and coherent if sentimental portrayal of post-war era midwives working from a convent in East End London. I like this one even if later episodes did risk giving me cavities. Maybe it reads as authentic because it it drawn directly from the not fictional nursing memoirs of Jennifer Worth, who lends her stories and her name to the main character. Nursing is a real thing in this series.

I guess it was inevitable that in the wake of its success America would give nurses a stab with the new PBS series Mercy Street, about a Union Civil War Hospital set in (my hometown) Alexandria, Virginia. Oh my hopes were high! This show is, so far, unforgivable. It hurts worst. I could feign indifference when it came to the laughable accents, the absurd and awkwardly drama-less rape scene in the first half of the second episode (give me time to love the characters if you’d like to break my heart!), but the characterization of the only actual nurse as the mean and heartless foil for our two sweet and well meaning hero nurses is so disgusting that it can not stand, man.

The uptight bitch nurse is to be hated because she trained with Florence Nightingale in the Crimean War and is suuuuch an expert at things like sanitation and wound care. She is so bossy about telling new nurses how to do things in a safe and evidence based way! The lady knows what she is doing professionally and seeks to better her field and improve the health outcomes and safety of the soldiers in the hospital’s care. What a B. I bet she hasn’t had sex in forever, she’s such an ice queen. Nope. In the second episode we see her sleeping with her boss, the corrupt doctor! So that’s how she got the gig.

Our two heroes are nurses who have no training or experience, but never you mind. They have the calling to serve their fellow man. To provide comfort in times of need. They have tender feminine hearts and strong womanly wills and as god as their witness they shall never let a boy die without a soft hand to hold! They will try to get some food for these soldiers too!

I said I could overlook the accents, they have nothing to do with nursing, but let me just tell you that the southern hero nurse is a native Alexandrian (a city two miles from DC) but makes sounds like her cotton plantation just caught on fire. Robert E. Lee did not sound like Blanche DuBois. Or Blanche Devereaux. But this woman does.

So. I’m sure our hero rookie nurses will use their female intuition and woman-in-a-man’s-world grit to become invaluable assistants to the doctors they work with. But I won’t be around to watch.

I’m going to watch Nurse Jackie.

PS- I tried to find the script writers on IMDB to no avail–but there were about 1200 costume consultants. The costumes are fantastic. The script? What script.

Universal health care through the lens of national history, identity.

The Lancet-The Trap of History

Every country has its own story, its own fears and dark shadows. One of the biggest unacknowledged challenges facing global health is adapting evidence to these national stories, resolving a persistent and troubling discrepancy between knowledge, history, and identity.

A MUST READ. Also though not directly related, an argument for liberal arts education as a grounding force in our science-and-tech obsessed world.

Short but oh-so relevant as we in the US scratch heads and gnash teeth and poor poor policy makers can’t seem to get a handle on HOW DO WE MAKE THESE PEOPLE HAPPY! My dream team that will save US health care: The Social Anthropologist, The Historian, The Sociologist, The Behavioral Economist, The Nurse!, and we’ll have a doc too if Atul Gawande has the time. He we be called The Atul Gawande.

Why the cops don’t get called for campus sexual assaults.

How does it make sense that universities are responsible for adjudicating sexual assaults on campus? Well, Title IX and US Supreme Court rulings dating back to the 1970s. Read the article, it explains the why and makes clear just how short UVA and others are coming up in complying with the mandate. Ugh.

via No, We Can’t Just Leave College Sexual Assault to the Police – Alexandra Brodsky and Elizabeth Deutsch – POLITICO Magazine.

What Alexander helped to establish, then, is that campus rape is not just a crime but also an impediment to a continued education—and to subsequent success in the workplace and public life. That means that Title IX’s protections are necessary for an individual student’s learning opportunities and for gender equality throughout American life. If sexual violence goes unaddressed at universities, women will face unconscionable obstacles to education, professional success and full citizenship.


A seat at the table. Psst this is a feminist issue.

I spent all day yesterday and half of today at the hospital, then the other half of today writing a paper about my profession, then came home and watched this 26 min documentary about the future of nursing. I am so thoroughly in brainwashed/in love (that’s the same thing, right?).

I’m on board with all of this nurses are the answer messaging. But the very last line hits a sour note:

“Wake up public, you vote us most trusted profession but we need your support to be all that we need to be.”

THUMBS DOWN. Don’t spend twenty minutes talking about how we are natural fixers of problems then lob the biggest one we have, our fractured image, into the lap of the public.

Wake up faculty. Teach young nurses that it is absolutely their professional obligation to speak up for their patients. Not just in the hospital. Take that noise to the press, the internet, the state house.

Wake up nurses. That trust we get from the public is sacred. Earn it by being conscientious, whip-smart, and brave. And be public about it.

Cholera Gave a British Doctor the Idea for IVs – The Atlantic

via Cholera Gave a British Doctor the Idea for IVs – The Atlantic.

WOO IV therapy! That’s my bread and butter! Hydration, volume expansion, insulin drips, antibiotics, everything you could want while unconscious. Plus just like in early days, it’s always there for a last ditch attempt. Coding? FLUIDS!

Also, science was much drunker before IRBs and we owe dogs so much apology and gratitude.

In 1656, Sir Christopher Wren wanted to see what would happen if he took a quill and a pig’s bladder and used it to send intoxicants—beer and wine and opium—directly into a dog’s blood. (The dog was intoxicated.)

Panic, Paranoia, and Public Health — The AIDS Epidemic’s Lessons for Ebola — NEJM

Panic, Paranoia, and Public Health — The AIDS Epidemic’s Lessons for Ebola — NEJM.

Please read this because we have to remember our history to learn from our history.

Various politicians called for quarantining of anyone who tested positive for HIV, and commentator William F. Buckley infamously penned an op-ed in the New York Times saying that “everyone detected with AIDS should be tattooed.”

Let us pump our collective brakes.

I mentioned in an earlier post that as an infectious disease, Ebola is a slam dunk for a country with a robust public health system. It poses far fewer challenges then, say, a really bad respiratory virus. This technically-but-really-not-an-epidemic has shown that there are some weakness in public health. Particularly in leadership. I’ll leave you with a parting tweet:

A father’s scars: For Va.’s Creigh Deeds, tragedy brings unending questions – The Washington Post

A father’s scars: For Va.’s Creigh Deeds, tragedy brings unending questions – The Washington Post.

I’ve been sitting on this for several days trying to think of what to say. Ultimately, what comes across in the beautifully written article is how completely, tragically unresolved it all is. Personally for Deeds. By extension for everyone else that has felt the isolation and suffering of loving someone with mental illness.

A few months before I began nursing school I was working for a non-profit doing case management for young adults. My co-worker and I split up the less desirable community functions, so that week he took the career fair at the local high school and I took the meeting with the director of the locality’s CSB (community service board) at the social services office.

Virgnia’s CSBs are tasked with providing a locality (usually a few counties) all legally mandated mental health, intellectual disability, and drug and alcohol recovery resources. They evolved in response to the deinstitutionalization movement that took place between the late 1950s and the 1980s (that is a doctoral thesis in itself, but check pg 1 of this report for a quick overview). Among many other functions, CSBs are the people that you must go through to have an person evaluated for commitment to a pysch facility against their will. They are legally responsible for providing a wide array of services to a vast and growing population, and they are so so desperately underfunded. At Rockbridge Area Community Services psych staff includes an RN, LPN, case manager, 2 psychiatrists, and 2 “telepsychiatrists.” Although not listed on their site, in my experience the professional staff are often part-time and more or less donating their services in addition to maintaining practices of their own. This skeleton crew is required to cover heartbreakingly vulnerable people 24/7. What about private providers? I’m a rural county, and so is Bath. Here at home we have zero mental health providers. In our neighboring country there are 2. There is no financial incentive to practice here.

Back to my story. On time for once, I sat in a small conference room with 10 or so social workers, free clinic volunteers, non-profit people, a few teachers. The standard frumpy, knitted brow people that give their lives to others for peanuts and are a little peeved about it. The CSB directer started his PowerPoint. People. Kept. Coming. More chairs were pulled in and the corners filled up with awkward standers. The PowerPoint went off the rails. It was 150 degrees in there. Voices were raised. “The wait list is 6 months long! I can’t let my erratic off-her-meds client be the caregiver to small children. What am I supposed to do!” His advice: go to the ER with a credible suicide threat and we can bump her to the top of the list. She’ll get seen in a week. The sheriff added, “Several times a week all my deputies are stuck in the ER for hours with a person who has threatened themselves or someone else. You come to the hospital and give us the order to detain them (Emergency Custody Order) and we spend hours driving the person to the closest in-patient psych unit if a bed can be found at all. I can’t afford that!” The “ECO” is time limited. For Gus Deeds time ran out before a facility could be located.

The meeting was an hour over time. The CSB director was pulling out his few remaining hairs. When all was said and done every single person in that room had a story about themselves or a loved one failing to get access to mental health services. I went home and ate a refrigerator of feelings.

How can we all have such intimate experience with the burden of mental illness and feel so ashamed to bring it up publicly? Schizoaffective disorder affects 1 in 100 people in the US. Bipolar is more than twice that. Let’s run some 5ks for goodness sake.

More sexy nurses than you can handle

and by sexy I mean dogged, intelligent, intuitive, creative, and progressive. When I started my nursing education I was looking for the technical skills to care for those in need. Learning more about the field I’ve come to realize that being a nurse is a call to be a strong advocate, influential progressive, and great humanitarian. I can’t describe how thrilling (and daunting) it is to be a part of this heritage.


1.) Florence Nightengale (uh duh): Left life in the lap of luxury to minister to soldiers on the front of the Crimean war, way ahead of the times advocate for sanitation and hygiene, foundations of nursing education, kickass poison pen letters.

2.) Walt Whitman: Volunteer Civil War nurse, recorded dying soldiers’ narratives and wrote letters to their loved ones, fell in love with everything and wrote best poetry of all time forever.

3.) Clara Barton: Fought the man to get supplies to the front in the Civil War, founded Red Cross, sustained bullet holes in petticoat. The only nurse I’ve ever been for Halloween (I was like 10).

4.) Lillian Wald: Visiting Nurse Service of NY providing home visiting nurses to immigrant tenements, Henry Street Settlement House (comprehensive health and social services), foundations of public health nursing and social work.

5.) Margaret Sanger: Women’s health advocate of the century, THE PILL (offering it, doing research on its safety and efficacy), Planned Parenthood, ballsy civil disobedient. Her flier is even multi-lingual! <3 <3 <3