Thursday, October 30, 2008

Reflections on Doctors Reviewed in the NY Times

Reflections on Doctors, the recently-published book of non-fiction by nurses for which I was one of many contributors, has been reviewed for the New York Times by Dr. Abigail Zuger, M.D.

While Dr. Zuger is admittedly underwhelmed by the lack of "literary style" demonstrated by the book's contributors, she states that "each story represents a step in understanding the inherent differences that separate the professions".

Even as the reviewer points out that the relationships described would not elicit "a minute of good television" (an assertion which I reject out of hand), and that the authors "write in shades of gray, describing interactions and relationships that are colorless, courteous, [and] businesslike", the Dr. Zuger seems to conclude that good, thoughtful medical care is, on balance, the end result of nurses' thoughtful reflections on the care that they and their medical colleagues provide.

In the course of her review, Dr. Zuger does indeed bemoan the fact that "no doctor out there is planning to publish a manuscript entitled 'Reflections on Nurses' any time soon", stating that "I am assuming my colleagues concur that such a project would be best left for retirement incommunicado somewhere on a distant Pacific atoll, where the mailman never calls." Sadly, this statement belies the fact that many doctors simply do not take the time to consider the crucial role that nurses play in the delivery of medical care, or, as the reviewer asserts, are potentially concerned that angry letters would ensue whether praise or criticism were duly proffered.

As a nurse blogger, I can attest that some of the best interdisciplinary writing does indeed occur in the medical/nursing blogosphere, and perhaps it is in that venue where the one-way conversation begun in "Reflections on Doctors" can be openly and honestly continued.

However, I can attest that "Reflections on Doctors" is one more step in further elucidating the multifaceted relationships between nurses, doctors and surgeons. Such literary excursions can only serve to inform the public, empower nurses and doctors to communicate, and to open additional avenues for future discussion.

Tuesday, October 28, 2008

New Nurses, Primary Care, and the Calculus of a Multifaceted Shortage

(Note: This is my twelfth---and final---post under the auspices of the nurse blogger scholarship which I recently received from Value Care, Value Nurses.)

It seems that everywhere I turn, someone is telling me that, a) they just applied to nursing school, b) someone they know just applied, or c) they or someone they know was just accepted/rejected from nursing school.

New nurses---and those who wish to be nurses---are entering a profession in transition, a profession that is losing its older members more quickly than its educational institutions can churn out novices ready to enter the fray.

Today I was interviewed on a radio program in Gainseville, Florida about a recently published book of non-fiction writing by nurses in which I was a featured contributor. The show's hosts seemed sincerely perplexed when I explained that older nurses are retiring faster than they can be replaced, and that nursing schools simply cannot offer faculty salaries that can compete with what nurses are paid in clinical positions. Thus, thousands of qualified applicants for nursing school programs are turned away each year since there are not enough professors to educate them.

As a consequence, far too many eager and highly qualified applicants are rejected from nursing schools around the country---and in fact, around the world, as well---and where do they turn? Do they re-apply the following year? Do they look for another school to which they might have a chance of acceptance? Or do they give up their quest to join the nursing profession and simply move in another career direction entirely?

At a time when aging Baby Boomers are living longer with chronic illnesses and are increasingly in need of quality nursing and medical care, it's time for our government and other influential entities to step up to the plate. The government itself must realize that the calculus of the nursing shortage must change, and this continuous hemorrhage of nurses from the profession without a consistent transfusion of new nurses must be short-circuited.

I will grant that we are in difficult economic times. I will also admit that the U.S. healthcare system is dysfunctional at best, and broken at worst. It is also plainly apparent to me that a growing lack of sufficient nurses to provide care in numerous facilities across the country is a recipe for a public health disaster of enormous proportions.

Meanwhile, if an Obama administration gains control of the White House, a push for near-universal healthcare coverage for all Americans will most likely be an important agenda item in the first year of such as administration. This is a laudable goal that may or may not be achieved. However, it must be acknowledged that the process of bringing more citizens into the healthcare system must be met by a similar process of encouraging more healthcare providers to take part in delivering that care.

The nursing shortage is real, and it is effecting how healthcare is provided around the country. Similarly, there is a very real shortage of primary care physicians, with more physicians opting for specialties in which the demands and low pay of primary care are eschewed.

Now, it is easy to see that if more citizens are insured (a goal that should absolutely be pursued despite the current economic climate), then we must simultaneously ensure that a sufficient number of physicians and nurses are available to provide the quality care that would consequently be delivered.

We must create incentives to lure physicians back into primary care, perhaps by reaching out to medical students and residents with a campaign to describe the value and rewards of primary care. Financial incentives such as loan repayment programs could also be enacted for new doctors who enter the field of primary care or family medicine, whether they work with vulnerable populations or not.

In terms of the provision of primary care, an expansion of Masters-level Nurse Practitioner programs and Doctoral nursing programs (especially for the new Doctor of Nursing Practice designation), could go a long way toward assuaging the nationwide shortage of primary care physicians, especially if interest-free loan programs and other incentives are created and fully funded.

We also must urgently expand the capacity of nursing schools by subsidizing nursing professors' salaries, expanding programs, and enacting a massive campaign of grants, scholarships and interest-free loans to make nursing school more readily affordable for a broad spectrum of prospective students.

Yes, these programs would indeed be expensive, and a great deal of money would need to be designated for such a sizable undertaking. Yet we must examine the relative costs of our inaction, and the crisis of untreated chronic illness and substandard medical care that will be the result of such a failure to act.

As the population ages and people live longer with more complicated constellations of chronic illness and multiple comorbidities, the provision of medical care will necessitate an enormous number of nurses as well as a solid base of primary care providers for patients across the lifespan. Nursing education must be funded and supported, nursing faculty must be recruited and well-compensated, and primary care providers must be given viable reasons for remaining in an area of medicine that has fallen from favor.

We cannot afford to ignore the multifaceted issues which are throwing the American healthcare system into crisis, and rest assured that any money invested now in improving the delivery of care will pay astronomical dividends in terms of prevention, improved healthcare maintenance, and increased cost-effectiveness. It is in our best interest to act, and we can only hope that political will and popular support will be enough to set these wheels in motion.

Sunday, October 26, 2008

Nurse, Heal Thyself

The stresses and challenges of practicing as a nurse often seem to preclude something which appears to be ubiquitously foreign to most nurses: self-care. Nurses are notorious for being bad patients, are they not? They work long shifts, spend countless hours perfecting the care of others, give great attention to the details of their patients' care, yet often miss a very important patient---quite well-known to them, in fact---who's just screaming for attention. What's a busy nurse to do?

We all enter nursing for various reasons, but one would hope that the majority are there due to a love of people, a willingness to provide quality care, and a sincere desire to be a participant in the healing of others. Nursing has been espoused to be a "calling" (some of us do indeed hear voices!), an "art", a science, a career, a vocation, and a profession. Bravo to each descriptor listed above, yet nursing can also be defined as a purgatory of stress, a miasma of unmet need, and a mania of martyrdom. To where does the overworked nurse turn?

Self-care is an essential tool in the arsenal wielded by the prudent and self-aware nurse. One must recognize that one's effectiveness in the world---both as a nurse and an individual---is directly affected by one's level of inner satisfaction, healing, and ability to weather the vicissitudes of life. We have all heard stories about nurses suffering from addiction. Whether said nurse has a genetic predisposition to addiction or simply a conscious desire to self-medicate due to stress, that nurse's active healing is paramount to his or her ability to provide optimal care and move effectively in the world.

Whether it be exercise, meditation, gardening, baking, psychotherapy, or blogging, each of us must find ways to nurture ourselves amidst the frequently tumultuous maelstrom of nursing. No matter what aspect of nursing where we find ourselves---university, clinic, homecare, hospital, or research---self-awareness, self-care, and an active role in pursuing optimal mental and physical health is paramount. Sadly, many employers do little to support or encourage self-care, focusing instead on productivity, attendance, and other quantifiable measurements of one's performance. When was the last time your supervisor evaluated you to make sure that you're taking enough vacation time or eating well at lunch? Does your supervisor make sure that you're satisfied and feel cared for at work? Does your annual "performance evaluation" include your employer's sincere desire to ascertain whether your workplace is healthy for you? I would think not. If so, where do you work and are they hiring?

I personally use many forms of healing---both Eastern and Western, orthodox and unorthodox---to continue my own trajectory towards self-actualization and health. With a number of chronic illnesses and personal struggles, my work certainly does impact my life at home, and vice-versa. My many responsibilities seem to bleed into one another, with the "workplace immune system" occasionally invading that of the home, both systems stressed beyond their perceived limits. Exhaustion at work leads to exhaustion at home. Relationships suffer. Personal goals are relinquished. Volunteer activities atrophy. Joy appears to vanish.

So, Nurse Martyr, it's time to focus on yourself. Your employer will not do it for you, and most healthcare institutions will suck you dry and spit you out without a second thought. Protect yourself from the ravages of this most rewarding and exhausting of careers. You deserve it. Your family deserves it. Your patients deserve it. The world deserves it.

Nurse, heal thyself.

Saturday, October 25, 2008

The Nursing Shortage, PBS-Style

(Note: This is my eleventh post under the auspices of the nurse blogger scholarship which I recently received from Value Care, Value Nurses.)

Well, it finally happened. The nursing shortage received some well-deserved coverage that, in many ways, actually did the subject justice. Now with David Brancaccio, a weekly half-hour television show of investigative journalism on PBS (previously hosted and made famous by Bill Moyers), focused its attention on the nursing shortage in America, and I can only hope that the message delivered is heard by the people who most need to hear it.

With a shortage of as many as one million nurses projected by the year 2020, calls to address this crisis within the troubled American healthcare system are becoming louder and louder.

As described in the course of the program which aired this evening on PBS, nurses are the engine that keep the healthcare system humming. While doctors may sometimes receive the lions' share of the praise for life-saving surgical techniques and heroic medical measures, it is round-the-clock nursing care that can often mean the difference between life and death. And as outlined during Mr. Brancaccio's investigative story, a number of studies have demonstrated quite clearly that when the number of patients cared for by nurses increases, mortality also increases. And by most measures, successful outcomes most often directly correspond to the quality of nursing care received.

As the population ages and lives longer with more chronic illness, the need for nurses in hospitals, health centers, nursing homes, and in home care will continue to increase exponentially. (It was pointed out during the broadcast that approximately 75 cents of every healthcare dollar is spent on chronic illness.) And with nurses working harder as salaries remain essentially stagnant in the face of increasing workloads and a sagging economy, attrition from the profession should be of paramount concern.

Speaking of attrition, approximately 25% of new nurses reportedly leave the profession each year, and one can only imagine that falling from the frying pan of nursing school into the fire of full-time nursing may be one of the many factors that push new graduates right out of the profession before they have even had the chance to settle in.

As 25% of new nurses leave the profession, the average age of the American nurse continues to increase, with retirements from active duty occurring on a daily basis. Meanwhile, 70% of nursing schools turn away thousands of qualified applicants due to a shortage of nursing faculty which, if left unchecked, will continue to cripple any efforts to assuage a shortage that only seems to expand with each year that passes.

When it comes to retaining new nurses who have recently entered the field, some facilities (as shown during the broadcast), utilize a year-long residency or internship structure so that new graduates actually receive the guidance and mentorship needed to make it in the real world, post-nursing school. Similar to the medical residency that newly-minted doctors receive, a nursing residency or internship allows a new nurse sufficient time to receive the focused training that he or she will need in order to deliver high quality and safe care. Thus prepared for full-time nursing, the new graduate is thus less likely to burn out, and more likely to succeed in his or her work and be satisfied with a newly chosen profession that desperately needs to retain its newest recruits.

If you would like to watch the Now broadcast in streaming video on your computer, you can click here. To watch a four-minute interview with a University of Pennsylvania School of Nursing professor regarding continuity of care from the hospital to the home, click here. To find what hospitals in your state have received the American Nurses Association "stamp of approval", click here. And to follow a week in the life of a new graduate working on a New York City burn unit, follow this link.

My one criticism of the program is that, like all media covering nursing and the shortage, only hospital-based nursing was addressed. There was no mention of home care, community health, public health, or school nursing, areas which are also struggling mightily with the effects of the shortage. This focus on hospital nursing---however important hospital care certainly is---only serves to underscore the public's (and the media's) misconceptions about nursing. Our society seems to ubiquitously see nurses solely as workers in the hospital, overlooking the fact that nurses provide crucial care to myriad populations of citizens well beyond the walls of the nation's hospitals.

Such media attention on the crisis of the national---and global---nursing shortage is truly needed, and it is only by educating the public (and our elected officials) about the crucial need for nurses that change and growth might occur. While Barack Obama and John McCain both have, to some extent, made gestures vis-a-vis the shortage of nurses in America today, a new administration in Washington will have many pressing issues to address as power is assumed in January of 2009, and fixes to the healthcare system will certainly take time.

No matter how the enonomic climate evolves, people will still get sick and need nursing care and medical care. No matter how many banks fail, hospital doors will still be open, visiting nurse agencies will visit patients at home, and surgeries and emergencies will continue to occur. Even as the global economy reels from the latest financial implosion, qualified applicants will be turned away from nursing schools and shortages of nursing faculty (due to relatively low salaries and other factors) will plague the halls of academia.

A new administration will need to have the political will to take some bold strides vis-a-vis the American healthcare system. The delivery of care as it pertains to chronic illness will need to be addressed. Nursing faculty---the key to educating new nurses in preparation for the workforce---will need to receive improved compensation for their important work as educators of future nurses. Nursing students from a broad socioeconomic spectrum will need scholarships and grants to offset the costs of a community college or university education. And healthcare facilities will need funds to give new graduates the time and attention they need for mentorship and preparation for autonmous practice.

The list above is by no means exhaustive, and the program aired on PBS is also by no means the final word on a shortage that currently is without a forseeable end. Creativity, forethought, vision, and a savvy understanding of both the economy and the vicissitudes of the healthcare industry are all necessary in order for current healthcare problems to be sufficiently addressed and remedied. Many of us are cynical that any meaningful change is close at hand, but we can only hope that our pleading, explanations and supplications do not, in the end, fall on the deaf ears of bureaucrats who just cannot see the healthcare forest for the trees.

Thursday, October 23, 2008

Fiction, Prose and Ephemera

Dear Readers,

I am writing to inform you that, as my creative writing practice grows, I've decided to create a separate blog where I will post poetry, prose, fiction, and other ephemera several times each week. Since Digital Doorway seems to focus mostly on health, healthcare, human rights, and nursing (with some spirituality and politics, for good measure!), I felt it was time for the birth of a new venue that falls outside of my own perceived scope for Digital Doorway.

This new blog is called Fiction, Prose and Ephemera, and will be bookmarked on the right side of Digital Doorway's homepage, where you can also find links to Latter Day Sparks (the story of my dog Sparkey and his final days of life) and A Nurse and His Treo (a photography experiment), two of my other adventures in blogging.

Thank you for your readership, and please know that Digital Doorway is alive and well as it approaches its fourth birthday. Please visit often, and do say hello from time to time.

All the best,


Wednesday, October 22, 2008

Blog Action Day Wrap Up

On October 15th, I took part in Blog Action Day, an annual event wherein bloggers from around the world come together to write posts about the same subject, generally something of import to humanity as a whole. This year, the subject was poverty, and a wrap-up of the event can be found by clicking here.

Apparently, 12,800 bloggers took part this year in writing over 14,000 posts for a total audience of of over 13,000,000 readers.

To read my post, please click here. And if you're moved to take a moment to do something in the fight against poverty, then the movement has been effective. Here are just a few ideas for actions you can take:
  • make a donation to a local soup kitchen, food bank, or food pantry
  • volunteer to tutor a child
  • become a Big Brother or Big Sister
  • start your own non-profit organization
  • volunteer, volunteer, volunteer
  • make a donation to a national or local anti-poverty agency
  • type "poverty" into Google and do some reading and become more informed
  • talk to your friends and family about the reality of global poverty
  • donate time and money in lieu of buying holiday gifts this year
  • sponsor a child in need of education
  • vote

Monday, October 20, 2008

Change of Shift Goes to Nursing School

The latest edition of Change of Shift (that nursing blog carnival that we love) is up and ready for your perusal over at Nurse Ratched's Place. Please pay the good nurse a visit if you can.

The home page of Change of Shift can be found here.

Sunday, October 19, 2008

Healthcare, Politics, Cynicism and Hope

If you are aware of the following current statistics vis-a-vis healthcare in the United States, then you are aware that the system is broken and apparently breaking more every day.
  • Nursing shortage: 587,000 new needed by 2016
  • Physician shortage: expected, indeterminate
  • Uninsured Americans: 47 million
  • National healthcare costs: $2.1 trillion/yr
  • Employment-based healthcare: 9% drop since 1996
  • Healthcare premiums, annual growth: outpacing wage increases x 3
  • Long-term care: growing need
  • U.S. life expectancy: 77-80 years of age
  • U.S. population: 305.4 Million
  • Median Income: $46,000
And if you're of voting age, then you probably have considered both major candidates' healthcare plans (or perhaps healthcare has simply been overshadowed by the current economic crisis that is sweeping the globe).

At any rate, I have plenty of misgivings about both candidates' healthcare plans (see my previous post entitled Obama, Healthcare, and a Trio of Mythic Figures). While I hope that somehow, as a country, we will some day figure out how to actually provide quality healthcare for the majority of Americans, my inner cynic is strong these days when it comes to the machinations of government, and even the idea of a President Obama and a largely Democratic Congress does not assuage my deeply held feeling that America is simply not up to the task.

On that note, freelance writer Jen Rotman has posted an informative piece about the state of healthcare vis-a-vis the current election on the website Online Nursing Degrees, and I highly recommend giving her article a thorough read.

As a provider of healthcare, I certainly hope for the best when it comes to what will happen when a new Democratic administration gains control of the White House, but in light of the current economic turmoil, I feel little hope for the kind of healthcare reform that this country truly needs.

Perhaps in a year or two, I'll happily eat these words and smile as reports surface, detailing how a miraculous bipartisan show of intellect and economic astuteness actually created a conduit through which affordable healthcare for all was enacted.

Just imagine: every child in America fully insured; elders able to afford their medications; the employed and unemployed fully covered. It's a nice vision, and one to which I will cling by the slenderest thread of hope. But will it happen in my lifetime? Just in case, I won't hold my breath waiting to find out.

Saturday, October 18, 2008

Dementia and Devotion

In the home they have owned for more than 40 years, they live their lives as they always have. The same trees are visible through the kitchen window. The grass is still green. The grandfather clock given to them by her parents for their tenth wedding anniversary still chimes in the foyer. The curtains and the sofas haven't changed in years, and the silver flatware in the breakfront drawer still evokes memories of Thanksgiving dinners, birthdays, and family gatherings galore. From the kitchen linoleum to the wood paneling in the family room, little has changed in this cozy suburban home.

While the outward appearances are relatively static, it is her dementia that has permanently changed the calculus of their relationship. It began with mild, transitory forgetfulness, only to slowly escalate into full-blown dementia as the months went by without a formal diagnosis. She would walk into a room and stand there, utterly stumped as to why she was there. He would leave her in the frozen food aisle to look for light bulbs in another part of the grocery store, and when he would return to find her, she would still be there, staring blankly at the ice cream display, apparently lost in thought but actually lost in the absence of cohesive thought.

At a certain point, it was apparent that she could not be alone. She could no longer bathe herself, toilet herself, dress herself, or make even the most rudimentary decisions. Luckily, if a plate of food is placed before her, she will still reflexively use her fork or spoon to scoop up food and bring it to her mouth. Sometimes, the fork spears nothing but air and she must be redirected to bring it down to the plate again. At other times, the food will fall back to the plate or into her lap, but she won't notice. She will bring an empty spoon to her mouth with the same motion and intention as a spoon laden with mashed potatoes. She doesn't recognize the difference, and he monitors her intake with the eyes of a loving, doting husband of 55 years.

He has refused all assistance other than skilled nursing and physical therapy. A home health aide? Never. Meals on wheels? Not a chance. Day care? Unthinkable. She is his project, his object of devotion, the love of his life and the mother of their children. His days revolve around her, and he revolves around her like a moon around a planet with a strong gravitational pull.

Her eyes seem aware, yet it is not clear what they register. She responds to some questions but not others, and it is uncertain how much of her response is reflexive rather than real. Her shuffling gait, her blank gaze, her apparent lack of interest in anything happening around her---these are hallmarks of her state of mind, and he must long for the days of lively conversation and verbal interplay. How lonely he must be, prematurely bereft of his friend, his lover, his bride.

"You see how her hair is set?" he asks. "Friday is Hair Day," he explains. "I wash it, set it, dry it, and then brush it out and spray it. Just like she used to do. We make her beautiful for the weekend when the kids and grandkids come to visit." He smiles proudly.

Sitting in the chair, her hands passively resting in her lap, she stares at me, smiles, and almost looks through me. I hold her hand, tell her I would like to take her blood pressure, and she raises her arm and places it on the table. I thank her for her assistance. She smiles again.

Placing the tools of my trade in my bag after making some final notes, I shake her hand and get up to leave. Her husband walks me to the door and we shake hands warmly.

"You're the model husband, and I can see that she's receiving the best possible care here at home," I say as we shake hands.

"Thank you," he replies. "I try my best. She's all I have, and I want her here with me."

"Let us know if you need more help," I say as I enter the breezeway between the kitchen and the garage. "You're doing a wonderful job and she looks so well-cared for. Take care, and her primary nurse will be back on Tuesday to check that elbow."

"Bye bye, and thanks for coming over." He waves and closes the door.

What other slow and silent human dramas are occurring in the other well-kept homes on this quiet street? How many other spouses are devoting their every minute to the care of a beloved who is no longer quite as healthy and vibrant as they used to be?

Devotion and love are the engines that drive relationships and lead us to selflessly focus our energies on the human objects of that love. Here was a stellar example of how that type of deep, lifelong connection manifests in real life. Despite the sadness and loss that underlie such a situation, the human manifestation of that devotion and love is truly an inspiring sight to behold and an honor to witness.

Wednesday, October 15, 2008

Blog Action Day---Poverty Around the World

Today is Blog Action Day 2008, and this year's goal is to raise awareness about global poverty by having thousands upon thousands of bloggers use their blogs as virtual soap boxes. With the global economy in turmoil and governments planning massive bailouts of banks the world over, we must not lose sight of those for whom the news of a stock market plunge or a failed bank means nothing. Yes, we must do something to keep the economy afloat, but a bailout of the world's poor is more than paramount, and it doesn't even seem to be part of the conversation.

Almost half the world's population---more than 3 billion people---live on less than $2.50 per day. The Gross Domestic Product (GDP) of 41 of the most indebted countries in the world is less than the combined wealth of the seven richest countries.

Meanwhile, a billion people around the world cannot read or write, and an estimated one billion children live in poverty. Speaking of children, 640 million children live without adequate shelter, 400 million lack access to clean water, 270 million have no access to healthcare, and 29,000 children die every day due to the ravages of poverty. (Please click here for source material.)

29,000 children. Every day. Dying, perhaps in their parents' arms. Perhaps alone. Perhaps in the arms of a sibling or a stranger in a refugee camp. 29,000 children dying every day while we go about our business, fret about our 401(k)'s, and fill our gas tanks on the way to the movies.

29,000 dead children every day. Or, 1 child every 3 seconds, or 20 every minute. That's like a tsunami similar to the one that occured in 2004 happening every day.

What's wrong with this picture?

Many countries have apparently been irreversibly impoverished by the actions of the International Monetary Fund (IMF) and The World Bank as loan programs and economic restructuring policies destroy indigenous food production, flood markets with cheap subsidized grain from the United States, and otherwise cripple developing nations, cutting off their economic legs at the knees.

I'm no economist, but it's plain to see that the global economic and banking organizations that lend money to struggling nations do so by imposing conditions that create a level of servitude and financial share-cropping that is inhumane at best, and criminally nefarious at worst. The gap between rich and poor in the United States is ever widening, and the gap between rich nations and poor nations is so vast as to be unfathomable.

And what kills children around the world in the face of crumbling economies, market bailouts, subsidized American grain, decaying infrastructure, and crippled healthcare systems?

Hunger kills children. Diarrhea and dysentery kill children. AIDS kills children. Measles, mumps, rubella, malaria and tuberculosis kill children. War kills children, as does living in refugee camps without adequate shelter, food, clothing and medical care.

If even a fraction of the world's annual military spending was redirected towards ending poverty, we would be well on our way. In 2006, approximately $1200 billion was spent globally for military purposes. Many experts agree that the eradication of poverty and the forgiveness of the developing world's debt on a massive scale would do more to decrease global terrorism and promote peace than any possible amount of increased spending on military might.

So, as a race of beings living on this troubled planet, we weigh our options. Even as 29,000 children die each and every day, we make choices which do nothing to alleviate the suffering that poverty brings to so many. Even as the American economic system implodes upon itself and drags the rest of the world with it, we choose to rescue those who do not deserve to be rescued, and we turn a blind eye to those who've been waiting in vain for a fabled rescue that may never arrive.

In the hour or so that it's taken me to write this blog post, 1200 children have died somewhere on this planet. 1200 children have given up their lives and joined the scores of others who have also died wholly unnecessary and preventable deaths. Tuberculosis, hunger, measles, diarrhea, dehydration---the reasons are many, as are the causes.

Humanity holds the answer to such problems in the palms of its collective hands. But will we ever act? Will we ever wake up and realize that the fate of all is inextricably bound, that our actions have repercussions far beyond our borders?

Today's 29,000 children all lived lives as valuable as any others. We are too late to prevent today's unnecessary deaths, but perhaps we can still prevent tomorrow's.

Monday, October 13, 2008

Blog Action Day: October 15th---Poverty!

October 15th is Blog Action Day, an annual event wherein bloggers from around the world join together and post about a single subject having to do with improving lives, calling attention to important issues of the day, and sparking a global conversation.

In 2007, Blog Action Day focused on the environment, and in 2008, poverty is the focus of thousands of bloggers who will all post about some aspect of poverty on the same day.

If you're a blogger, please consider joining and adding your voice to the conversation. If you're not a blogger, please consider starting a blog today and making your first post about this crucial global issue. If you are neither a blogger nor a person who cares to become one, please tune in to the Blog Action Day website on October 15th, follow links to some of the many posts submitted, and leave comments for the participating bloggers so that we know you're out there and listening.

Thanks, and please check out this video from the Blog Action Day staff.

Blog Action Day 2008 Poverty from Blog Action Day on Vimeo.

Sunday, October 12, 2008

The Irony of Mental Health Parity

(Note: This is my ninth post under the auspices of the nurse blogger scholarship which I recently received from Value Care, Value Nurses.)

In June of this year, I reported on Nurse LinkUp that Congress was poised to once again begin a concerted push to pass legislation bringing parity for insurance coverage for mental health, including addiction, eating disorders, and any illness classified in the DSM-IV. That effort basically failed, and it is only now, just prior to the end of this Congress, that mental health parity legislation has actually become law.

We are all by now (nauseatingly) familiar with the $700 billion financial bailout recently passed by Congress and signed into law by President Bush in the waning days of his presidency (more on that in future). As a part of that package, most health plans are now required to cover mental illness and addiction with the same level of access and cost as any physical illness. After years of struggle, editorials abound, almost ubiquitously praising the legislation which was added to the latest---and ultimately successful---version of the bailout plan.

Beginning, I believe, in 2009, all group insurance plans and companies with more than 50 employees must offer health insurance coverage that provides equal benefits for mental health treatment, potentially benefiting 113 million insured Americans, as well as approximately 82 million self-insured Americans who are not protected by state-mandated mental health parity legislation. Interestingly, 38 states currently have some form of parity laws on the books, a fact of which I was previously ignorant.

Paul Wellstone (D-MN), the late Senator from Minnesota, was one of the great champions of the mental health parity cause, along with his colleague Pete Domenici (R-NM). The bill, the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008, was named for the two senators and honors the posthumous legacy of Wellstone's tireless fight for the rights of Americans living with mental illness and addiction. And it was Senator Edward Kennedy (D-MA) and his son Representative Patrick Kennedy (D-RI), who used their political muscle and clout to ease the bill through the Senate and the House.

As someone who has struggled with depression since childhood, I can attest that obtaining coverage for mental health can be a challenge, especially if one needs ongoing treatment rather than the "episodic care" often covered by many health plans. I can also confirm that many health insurance plans charge much higher co-payments for mental health visits, and impose nonsensical and arbitrary limits on the number of outpatient visits per year.

In terms of inpatient care, insurance regulations regarding mental health are notorious for prematurely cutting short crucial inpatient treatment for mental illness, addiction, and eating disorders. It is plainly obvious that inpatient treatment teams know best vis-a-vis the length of stay which would be most efficacious for a particular patient. Naturally, some oversight should be involved so that billing abuses do not occur, but bureaucrats and statisticians should not be making decisions that only clinically trained professionals should make. The imposition of arbitrary limits on the length of stay for the treatment of such chronic conditions belies the fact that insurance companies are generally more concerned with profitability than the effectiveness and quality of care. In fact, I would hazard a guess that forcing a patient out of detox or an inpatient psychiatric unit before they are clinically ready for discharge more than likely leads to worse outcomes, more frequent relapse, and higher costs over the long term.

Global Ironies: Mind the Gap

Ironically, on October 10th, World Mental Health Day (one week after mental health parity became a legal reality in the United States), the World Health Organization announced that as many as 75% of people living with mental disorders in developing countries receive no care or treatment of any kind. The irony is that while we in the United States pine for lower co-payments and equal access to care, those living in war-torn nations, developing nations, and non-industrialized countries suffer immeasurable harm without even the merest hope of treatment.

The WHO study points out that nine out of ten people in Africa who live with epilepsy are entirely untreated. It also starkly points out that while most countries spend approximately 2% of their health dollars on mental health, one-third of people with schizophrenia, half of those living with depression, and seventy-five percent of those struggling with addiction go untreated worldwide. And tragically, one person dies from a completed suicide every forty seconds of every day, somewhere in the world, mostly due to untreated mental illness.

These numbers tell a story, and even as the United States prepares to tackle the issues of mental illness and substance abuse more fairly, the WHO is calling for governments, foundations, donors and mental health activists to increase funding for treatment worldwide. The program, entitled Mental Health Gap Action Program (mhGAP): Scaling Up Care for Mental Health and Substance Use Disorders, asserts, according to the WHO press release, that "with proper care, psychosocial assistance and medication, tens of millions could be treated for diseases such as depression, schizophrenia, and epilepsy and begin to lead healthy lives, even where resources are scarce."

To bolster their case, the WHO's recent studies demonstrate that "in low-income countries, scaling up a package of essential interventions for three mental disorders – schizophrenia, bipolar disorder and depression – and for one risk factor – hazardous alcohol use – requires an additional investment as low as $US 0.20 per person per year." Claiming that treatment of mental illness, addiction and neurological disorders such as epilepsy should not only be "evidence-based" but "value-based", the WHO plan includes "assessing countries' needs and resources; developing sound mental health policy and legislation; and increasing human and financial resources" in order that "people with these disorders are not denied opportunities to contribute to social and economic life and that their human rights are protected."

Global Parity: A Laudable Goal

So, as mental health parity becomes law in the United States and we continue to wrestle with the needs of the uninsured and the under-insured, the rest of the world---especially the developing world---needs our assistance to offer even the most basic of mental health care to millions and millions of deserving citizens. Mental health is not a luxury, and many in the fields of mind-body medicine (and also mainstream medicine, for that matter) strongly believe that good physical health is simply not possible without solid mental health. In fact, recent research demonstrates quite clearly that untreated depression can absolutely lead to physical symptoms including chronic pain.

I would assert that those who have so valiantly and tirelessly fought for the rights of the mentally ill here in the United States should now challenge themselves to broaden their visual field, take in the big picture of global mental health, and direct some of their energies in supporting the timely efforts of the World Health Organization.

As the global financial system continues its apparent implosion, we can naturally expect the incidence of anxiety, depression and substance abuse to rise as people attempt to manage lives thrown into chaos by economic hardship. We in the United States recently won a long twelve-year battle, happily enough. But now is not the time to rest on our laurels. Now is the time for action on a global scale. It is in humanity's best interest to see that all people have access to treatment for improved mental health, and it is our moral and ethical duty to further that cause.

Friday, October 10, 2008

China Off the Hook

Based on yesterday's post, most readers must have surmised that I have strong feelings about the Chinese government. Those same readers can also correctly surmise that I am disappointed this morning that none of the Chinese dissidents on the short list for the Nobel Prize were nominated. I'm sure that the Chinese government is breathing a sigh of relief, a reprieve that they simply do not warrant.

As I wrote yesterday, the awarding of the Peace Prize to a Chinese dissident struggling for basic human rights would have offered a counter-weight to China's moment in the sun as the undeserving host of the 2008 Summer Olympics. But that was not meant to be.

This morning, the Nobel Committee announced from Oslo that it was awarding the Nobel Peace Prize to former Finnish President Martti Ahtisaari for his role as an effective and accomplished global mediator who influenced the resolutions to conflicts in Kosovo, Namibia, and other troubled countries. While I am sure he is a very deserving and esteemed individual, I cannot help but regret the great opportunity squandered by the Nobel committee to make a globally impactful statement about China's continuing repression of free speech and political and religious freedom.

Perhaps next year will be the time when China's dissidents receive the attention, recognition and notoriety that they deserve. Many of us already know that China's ability to unrealistically polish its image only gets easier as its global economic power and influence grows, even as its penchant for environmental degradation and rampant repression of freedoms goes unchecked.

Thursday, October 09, 2008

The Nobel Peace Prize: Dissidents On the Short List

Tomorrow, Friday the 10th of October, the winner of the Nobel Peace Prize will be announced. Following on the heels of the prizes in medicine, physics, economics and literature, the awarding of the Peace Prize is the crowning moment of the Nobel process.

Rumor has it that Gao Zhisheng, a Chinese dissident, will be awarded the prize. Zhisheng, who has been arrested, detained, and almost assassinated due to his role as the winning lawyer in a case against the Chinese government for the religious freedom of practitioners of Falun Gong, was kidnapped in 2007 and has never been seen again. It is believed that Gao is in the custody of Chinese authorities, that he has suffered torture at the hands of Chinese authorities, and that he was removed from Beijing during the Olympic games following a suicide.

Many of us around the world felt strongly that the International Olympic Committee's decision to give the Chinese the opportunity to host the Olympics sent the wrong message to a country where religious persecution and the revocation of basic freedoms is still widespread. The irony of China's sugar-coating of its horrendous environmental policies and deep-seated political myopia is not lost on those of us who opposed Beijing's hosting of the Olympics on moral and ethical grounds.

Thus, the awarding of the Nobel Peace Prize to a well-known missing Chinese dissident would be a well-deserved slap in the face of a country that still has not learned to value the diversity, individuality, and basic human worth of its citizens.

Tuesday, October 07, 2008

Reflections on Doctors Has Been Published

I am very happy to announce that a chapter which I submitted to Kaplan Publishing for inclusion in a new book of non-fiction by nurses has been included in the recently published volume, Reflections on Doctors: Nurses' Stories About Physicians and Surgeons.

The book is the first in Kaplan's newest series, and I am honored and thrilled to have been included. I cannot reproduce my chapter here on Digital Doorway, so the only way for interested readers to actually read my submission is to buy the book or to some day check it out of a library.

A review of the book has been published on Blissful Entropy, a wonderful nursing blog.

Here is Kaplan's press release about the book:

REFLECTIONS ON DOCTORS Nurses’ Stories about Physicians and Surgeons
Editor: Terry Ratner, RN, MFA

Anyone who has been a patient or visitor to a hospital knows that the long-time image of nurses as helpful ladies in white who administer IV’s and wake patients every four hours to take their temperature, is not the role of modern-day nurses. Coming from varied educational paths and scopes of practice that place them side-by-side with doctors, nurses are no longer the “obedient handmaidens” to doctors that they once were perceived to be. If they disagree with doctors’ orders, nurses today can and do refuse them. The relationship and power dynamic between nurses and doctors has evolved with nurses now trained to ask questions and seek answers.

Through nearly two dozen provocative essays REFLECTIONS ON DOCTORS: Nurses’ Stories about Physicians and Surgeons (Kaplan Publishing; September 2008; $14.95 Paperback/$16.95 Canada), readers are taken behind the closed doors of the OR, the rapid pace of the ER and to many other venues where medical situations are exceedingly intense, and the integrity of the intertwined relationship between nurses and doctors is consistently challenged.

As REFLECTIONS ON DOCTORS’ editor Terry Ratner, RN, MFA says, “The nurses of this anthology represent a spectrum of voices and perspectives, reflecting upon their work alongside physicians. The majority of these nurses have witnessed revolutionary changes in the nurse-physician relationship over time. They are our messengers, our heroes and our scribes.”

The intimate and at times shocking stories in REFLECTIONS ON DOCTORS abound with the honesty of each writer’s respect of and concern for the nursing profession, and the care that patients receive from doctors and fellow nurses alike. For example, in her fascinating essay A Truth about Cats and Dogs, Adrienne Zurub, RN, MA, CNOR says of the competitive environment within the cardiothoracic operating rooms where she has worked, “Arrogance, entitlement, outstanding talents(nurses and surgeons), and palpable confidence dominate the entire operating room suites. A nurse pushes herself or himself through this encompassing fog of testosterone. I say testosterone because the surgeons, the ones who are in charge, are all male. To work in this environment, one has to have the personality and the chutzpah—the balls—to think quickly and react perfectly. Weakness or hesitation is normally not considered an option.”

Readers are further privileged to the gentle musings of nurses such as Keith Carlson, RN who in his essay Where the Heart Rules states, “What I have learned in partnership with these outstanding doctors is that nurses, although often undervalued in outpatient settings, can serve in proactive, clinically meaningful roles if doctors willingly and consciously choose to utilize their specific skills and knowledge base.”

Many of the essays in REFLECTIONS ON DOCTORS provide readers with clear-cut explanations of various medical terminologies, interesting history of the nursing profession and glimpses into its future. The diversity of all the essays is appealing to both new and seasoned nurses, as well as to someone simply interested in understanding the importance and ever-changing relationship between nurses and physicians. Further topping off this collection of engaging essays is a reader’s guide designed to, says Ratner, “stimulate meetings of the minds and begin crucial conversations in hopes of understanding the nurse-physician relationship.”

# # #
Nurses’ Stories about Physicians and Surgeons
Terry Ratner, RN, MFA, Editor
Kaplan Publishing
September 2008
$14.95 Paperback/ $16.95 Canada
ISBN 978-I-4277-9825-I/ Nursing

Terry Ratner is a registered nurse, freelance writer and creative writing instructor. Her nursing career has spanned more than 17 years at Banner Good Samaritan Medical Center, a level-one trauma hospital in Phoenix. She has written for many publications including NurseWeek, Nursing Spectrum and John Hopkins Nursing.

Sunday, October 05, 2008

Public Health and Me

Tomorrow, I begin my position as interim Public Health Nurse right here in my own New England hometown. Having never worked in my town (after almost fifteen years of residence in the area), it will be an interesting experience to actually be a "public figure" for the first time.

While my position is indeed interim, I'm coming on board just at the beginning of flu season, and since I'm the individual who literally holds the key to the town's flu vaccine supply, I have an idea I am about to become very popular.

Understandably, everyone is anxious to get their flu shot. The elderly residents of the town see the annual flu clinic and make-up flu clinic as an inalienable right, and the government's push for the majority of Americans to be vaccinated this year has driven this point home quite widely. Town employees, police, EMTs and firefighters also need to be vaccinated quickly and efficiently in order to decrease the likelihood of such essential personnel being sickened over the winter.

With the CDC and other government agencies expecting this year's vaccine to be more effective than last year's, I'm expecting a great deal of interest in and around town vis-a-vis the influenza vaccine. Our clinics will most likely be very busy events, and I'll need to champion that cause and do it well.

Meanwhile, I'll be taking care of daily infectious disease surveillance, TB case management, as well as other sundry responsibilities that I guess I'll figure out tomorrow.

I start this new job knowing that I'm standing on the shoulders of Lillian Wald and other famous nurses who had the vision of actually creating the institution of public health nursing in the first place. It's an honor to enter this new arena of my profession/vocation, and I look forward to growing personally and professionally throughout the process.

Wednesday, October 01, 2008

Economics and Confusion

Thinking further about the economic issues that I touched on in my last post, it's so hard to get one's brain around what's happening here in the U.S. this week. With such dire news and warnings of financial Armageddon, how does one tease out the truth from all of the hyperbole?

Articles abound about what will happen if the bailout doesn't pass. Blame is passed from hand to hand. But where do we ordinary citizens fit in? What do we stand to lose or gain in the process?

Economics is one area where this nurse is most weak when it comes to understanding the bigger picture. Understanding my own personal economy is difficult enough. But I just can't stop thinking that many of the people in need of a bailout themselves are going to be left in the dust no matter what happens.

Whether we look at the notion of fighting poverty, rejecting what seems like a rescue of Wall Street, or using that $700 billion to help Americans keep the homes they are about to lose, there is enough confusion and different versions of "the Truth" to keep us all reeling from a dose of 21st century financial vertigo.

At this time in history, there are intelligent arguments in favor of nationalized healthcare, while Americans are going into bankruptcy just to pay for healthcare they can't afford but literally can't live without. Meanwhile, many people are losing their homes in record numbers and Wall Street speculators and investment banks look to the federal government to rescue them from their own excesses.

So, where is the bailout for the thousands of poor Gulf Coast residents who lost their homes and have still not been able to return home?

Where is the bailout for first responders disabled in the aftermath of 9/11 and unable to return to work and normal life?

Where is the bailout for the homeless, the uninsured children, the wrongly incarcerated, the disenfranchised, the disabled?

Where are the reparations for slavery? For Native Americans?

These are just some of the questions that come to mind as the sum of $7 billion is bandied about so blithely.