Waiting for NCLEX.

Good news: I graduated! Along with the smartest, finest looking group of nurses this side of anywhere. We are all pretty sure we’re going to fix health care. Be on the lookout.

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Bad news: I hurt my back moving boxes and carrying around my 45 pound child.

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Good news: It’s you and me laptop stuck in a supine position!

I’ve been meaning to blog you this: my short piece of writing was published as an editorial in the Washington Post and then recorded for airing on local NPR affiliate WVTF. I AM LIKE FAMOUS. In all seriousness I am very humbled at how a wee handful of words caused a number of wonderful people to go out on a limb for me and support what I’ve done. My school values writing and reflection as a part of creating resiliency in nurses. My clinical faculty encouraged me to submit my writing. And a very awesome former journalist current writer went out of her way to help get my piece published. You people get a round of applause.

Now that I’m 95% RN I’m waiting for the boards to make it official. I’ve been transcripted, fingerprinted, background checked, notarized, certified by mail, and written many checks. So now I anxiously thumb through NCLEX licensing exam study guides as I wait for the Board of Nursing to approve me for an opportunity to sit for the big test. I secretly love it.

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Poetry Monday

Saturday I had the pleasure of listening to Margaret Mohrmann give the keynote at the UVA’s End-of-Life conference. Blow. Me. Back. The weight of the subject matter and her nimble language. The stories steeped in years of experience ecclesiastical and medical. Is frank compassion a thing? I think it may be her thing. One of the two times she made me well up (for my patients, for my loved ones, for me, for my fellow RNs & MDs, for humanity):

A Blessing for a Friend on the Arrival of Illness
by John O’Donohue

Now is the time of dark invitation
beyond a frontier that you did not expect.
Abruptly your old life seems distant.
You barely noticed how each day opened
a path through fields never questioned
yet expected deep down to hold treasure.

Now your time on earth becomes full of threat.
Before your eyes your future shrinks.
You lived absorbed in the day to day so continuous
with everything around you that you could forget
you were separate.

Now this dark companion has come between you.
Distances have opened in your eyes.
You feel that against your will
A stranger has married your heart.
Nothing before has made you feel so isolated
and lost.

When the reverberations of shock subside in you,
may grace come to restore you to balance.
May it shape a new space in your heart
to embrace this illness as a teacher
who has come to open your life to new worlds.
May you find in yourself a courageous hospitality
towards what is difficult, painful and unknown.

May you use this illness as a lantern
to illuminate the new qualities that will emerge in you.
May your fragile harvesting of this slow light help you
release whatever has become false in you.
May you trust this light to clear a path
through all the fog of old unease and anxiety
until you feel a rising within you,
a tranquility profound enough to call the storm to stillness.

May you find the wisdom to listen to your illness,
ask it why it came,
why it chose your friendship,
where it wants to take you,
what it wants you to know,
what quality of space it wants to create in you,
what you need to learn to become more fully yourself,
that your presence may shine in the world.

May you keep faith with your body,
learning to see it as a holy sanctuary
which can bring this night wound
gradually towards the healing and freedom of dawn.

Cancer: The Emperor of All Maladies and My Cancer: The Wrecker of All Normalcy

Cancer: The Emperor of All Maladies and My Cancer: The Wrecker of All Normalcy

Video: Cancer: The Emperor of All Maladies Trailer | Watch Cancer: The Emperor of All Maladies Online | PBS Video.

You’re all watching this, right? You’ve already watched it?

Good. I need to re-watch a time or two more before I give you my bullet points, but wow.

Hot off the press for my policy class about being a patient and looking at treatment options and statistics. No good choices yet.

The Fear & The Data

I’m the kind of patient who wants to, no insists, on knowing the numbers. When I was diagnosed with melanoma a little bit more than a year ago the sentence after “the tumor is malignant” was me asking “how deep.” I already had the tumor staging chart in front of me. That’s not true. It was dark, I was outside, and I had that thing memorized. My tumor was staged 2B, my stats are 60% survival at 5 years. I absolutely consent to a wide tumor excision and sentinel node excision. I am unable to undergo the recommended course of immunotherapy (12 month course) for adjuvant treatment that would have got me an additional 7% survival, due to my comorbid Lupus. I look for second and third and fourth opinions, and find a reputable oncologist with specific experience in my sub-type of melanoma who recommends adjuvant cutaneous radiation. The doc, my radiation oncologist, and I pull the best studies we can and make a good argument for radiation therapy in reducing recurrence of melanoma at the site (and more than 80% of melanomas of my subtype reoccur at the site) by 12-15%. SOLD! For $6,000 out-of-pocket, 6 weeks of my life, and 2 months of healing third degree burns and radiation toxicity. Steep. But fear is a powerful motivator. And fear of abandoning your young child? I mean I don’t have to tell you.

Would I have done the radiation for 5% reduced recurrence? I am aware that radiation can cause late malignancies. But REGRET. I could never forgive myself a lost chance to raise my child. Despite my lack of faith in integrity of studies in general, my non-surprise at aberrant results, and my belief that as a young person I may have more bounce back in me, I cling to the numbers with fear and with hope. Some people see themselves as the exception. I can’t help but see myself as the rule.

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

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.

Where is my mind?

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.

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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.

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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