We need to make sure kids have access to good food @ChildHealthUSA @bittman @AmerAcadPeds

May 18, 2015

CHW LogoCamping – I just returned from five glorious days of it in rural eastern Virginia – makes you see the world in a different way.  There is a greater intentionality to everything you do.  You have to consider and plan every sip of water, every trip to the “bathroom,” every bite of food.  As a break from contemporary urban living, that focused, mindful, pre-modern approach to everyday activities provides the kind of contemplation and relaxation that we all need to restore ourselves.

But when it’s your day-to-day reality, as it is for the poor in 21st century America, it has the opposite effect.   Constant decisions about trade-offs under conditions of scarcity lead to chronic stress with adverse effects on health.  Poor diet only makes that worse.  In the 1930s, George Orwell wrote about the nutritional challenges for English coal mining families in The Road to Wigan Pier.  Much of what he described still holds true.  First, fresh food is relatively more expensive than processed “food” of dubious nutritional quality.  When confronted with a choice between an apple (assuming you can find it) and an apple pie, you’ll get way more calories per dollar with the latter.  Without adequate package information and guidelines, it can be difficult to understand the drawbacks of that decision.  Thus, for a parent trying to feed her children on an outrageously limited budget, the apple pie may seem like the rational choice.  Moreover, even with the right intentions, decision fatigue can degrade the quality of those choices.  It’s just easier to give in to temptation when you are stressed.  (And as an aside, let’s stop making it sound like this is some moral failing of poor people. It’s the same phenomenon that leads me to eat way too much ice cream after coming home from a shift in the emergency department.  Just because I can afford it doesn’t make me a better person.)  Junk food is also a way for someone without many other pleasures to treat himself.  You might not have the time and money for a movie or a massage, so how about a cupcake.

The societal and economic costs of the obesity epidemic are well known, as is the fact that obesity is a worse problem for the poor, especially poor children.  But given all the above, the food deck is stacked against them.  Two proven interventions make it easier for kids to get the right foods they need: the school nutrition program, and the Supplemental Nutritional Assistance Program (SNAP – aka food stamps).   SNAP for children in particular has been demonstrated to have long-lasting (as in decades!) benefits on health.  Yet recent efforts threaten to undermine both of these.  The School Nutrition Association, now a partially-owned subsidiary of the food manufacturing industry, has opposed the guidelines issued under the 2010 Healthy, Hunger-Free Kids Act.  And legislative efforts in several states, including Wisconsin, would restrict what could be purchased with food stamps.  Missouri, for example, would ban the purchase of fresh seafood (though canned tuna and frozen fish stick would still be allowed), while the bill in Wisconsin would limit purchases of such luxury items as nuts, potatoes, natural peanut butter, and bulk dried beans.  (Canned beans and sugar-added peanut butter are fine, though.)  Aside from being frankly punitive, these measures make it less likely rather than more that poor children will receive the most nutritious food possible.

Camping for a week is fun; living with those kinds of restrictions all the time is not.  Let’s not make it harder for those who have to.  If we truly believe that all kids deserve an equal chance at a healthy life, the place to start is by supporting programs of proven effectiveness that can give them access to one of the most important building blocks of health: real food.

Happy Nurses Week!

May 8, 2015

CHW LogoBy his own admission, it took Arnold Relman, former editor of the New England Journal of Medicine, until age 90 to realize the importance of nurses in providing quality medical care.  It took me until a week after starting my internship.  My first rotation was on 3 Orange, the unit for medically complex children (including many ex-preemies).  In many ways, medical school had not prepared me well for residency.  I had never ordered feeds for a healthy baby, much less one with a 27-item problem list.  My first night on call, covering the entire team, I was asked to order a refill on a medication for someone else’s patient.  I checked my sign out list and wrote (with a pen, on paper) the order; 10 minutes later, the nurse paged me to double check whether that was really what I wanted to order.  It wasn’t: I had mistakenly ordered a soundalike medication, at a dose that would have been harmful if administered.  Embarrassed, I returned to the unit to correct the order.  I made some comment about making a rookie mistake.  The nurse just smiled and said, “It won’t be the last, but don’t worry because we’re all looking out for each other.”

Relman, after being hospitalized for 10 weeks after a fall, wrote a column for the New York Review of Books about his experience, in which he said, “I had never before understood how much good nursing care contributes to patients’ safety and comfort, especially when they are very sick or disabled.  This is a lesson all physicians and hospital administrators should learn.  When nursing is not optimal, patient care is never good.”

Amen.  Over the years, I (and my colleagues) have been bailed out by nurses on occasions too numerous to count.  Mostly not because they caught errors – though in the era before computerized order management that was certainly important.  It’s the subtle change in a child’s behavior pattern that made the nurse call me to re-evaluate a patient who was developing hepatic encephalopathy.  It’s the funny movement that the consultant dismissed, which turned out to be decorticate posturing in a post-craniotomy patient.  It’s the question about why I selected a particular test that made me think through and decide on a different one that was just as good but less traumatic for the patient.  It’s putting a teenager with perplexing symptoms in a room and commenting, “She’s acting just like the aspirin ingestions we used to see,” arriving at the correct diagnosis hours before the physicians.  It’s the insight about family dynamics that allowed me to address concerns I might never have identified on my own.  The list is long.

It’s impossible to overstate my gratitude for all that the many nurses I have worked with over the years have done for our patients.  Their job is intellectually, physically, and emotionally challenging, with rewards that are hardly commensurate with the demands.  And I also appreciate what they have done for me: for my education, my professional development, and my job satisfaction.  We share food on the night shift, we laugh and cry together, we brag about and complain about our families, we encourage each other; we look out for each other.  Those interactions, those shared experiences, are the up button on the mood elevator.

Kids deserve the best.  With our nurses at Children’s Hospital of Wisconsin, they have it.

On Being Too Connected

May 1, 2015

CHW LogoThe common refrain these days is we are “too connected.”  By that, of course, is meant that by virtue of the Internet and the many ways of accessing it, people are too available.  In a wireless world, there is no refuge.  Even Meg Whitman, CEO at Hewlett-Packard (and, like 27% of the American public, a potential presidential candidate), complained about being stressed by always being “on.”

In the past week I’ve attended three events that made me realize that the issue isn’t being too connected.  It’s being connected to the wrong things, in the wrong way.  The events were: the annual scientific meeting of the Pediatric Academic Societies, the annual employee recognition dinner at Children’s Hospital of Wisconsin, and a meeting of the hospital’s Family Advisory Council.  Each of these had an ostensible purpose – presenting new research findings, acknowledging staff with milestone work anniversaries, or providing the voice of the family to guide hospital decisions and improvement efforts.  But each was also an opportunity for connecting, on an individual level, with other people, including colleagues, old friends, co-workers, and even some strangers.  Talking about shared professional or non-work interests, family, hobbies, crises, and much more, and through that finding those points of commonality.  Call it networking, socializing, schmoozing, whatever.  That act of being with someone, really being with them in a meaningful way, is what differentiates us from the server cloud.

This isn’t a rant against technology.  After all, many people can truly connect with others via phone or Skype or social media at least as easily as face to face.  But it is about making the time to establish and renew those connections.  It requires intentionality and focus.  It requires making time with others a priority.  It requires us to disconnect from one thing to connect with another.

At the scientific meeting, I presented some work showing high rates of burnout among pediatric emergency physicians.  In discussing this afterward, a few of were trying to distinguish stress from burnout.  I frequently feel stressed, but would never say I feel burned out.  After an evening with people with up to 45 years of experience at Children’s, and a lunch with parents who volunteer their time to tell us how we can do better, I realize that it is the connections with others that ground me and keep the stress from turning into burnout.  Jean-Paul Sartre famously wrote in No Exit, “hell is other people.”  But with the right connections, help is other people.



To Sleep, Perchance, To Get Brain Damage?

April 17, 2015

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When I was in training, people would talk about “brutane” being their preferred agent for keep a child still during a procedure: hold them down by brute force. We didn’t have a lot of great options for sedation for relatively short procedures, so the choice might be knocking the child out for hours, or just getting it over with. We often went with the latter.

In hindsight, it sounds primitive and inhumane. (You are probably wondering if I studied with Hippocrates, and carried leeches around in my kit. No, and no.) But in the last 25 years, newer short-acting analgesic and sedative agents have been developed and approved. During that same time, there has been an increased understanding of the long-term effects of inadequately treated neonatal and early childhood pain, including changes in the brain’s structure and responsiveness and the immune response. Among pediatric specialists and subspecialists, use of analgesics and sedation for even minor procedures is now exceptionally common, and is in many cases an important quality differentiator.

OK, the sound you hear is that of the pendulum swinging back and getting ready to hit you in the head. In the past 5 years, there has been a growing body of literature demonstrating that the anesthetic and sedative agents we use to treat and prevent procedural pain in infants and children may themselves cause adverse effects in the developing brain. Most of the evidence comes from effects in baby animals, though there is some (albeit still incomplete) data on effects in humans as well. Some professional organizations and the FDA have begun to raise a red flag and suggest that at least some elective procedures should be deferred until after age 3.

There is evidence that pain is bad, and that preventing pain is bad. Now what? Do we go back to brutane? And more importantly, how can we help parents make sense of the options and make the best possible choice for their child.

First, this is a great illustration of the principle that children are not just small adults. Providers with the extra expertise that comes with subspecialty training are in the best position to understand the data and interpret it for families. The evidence for some agents being harmful is stronger than for others, and some have not been linked to these side effects. Pediatric subspecialists are also more likely to be familiar with and have access to the full range of alternatives. For example, sucrose solution (i.e., sugar water) has been shown to provide adequate analgesia and sedation for many minor procedures in infants, but is unlikely to have the kind of adverse effects seen with other agents. My anecdotal experience is that non-pediatric physicians are not as familiar with this option. Non-pharmacologic measures, including swaddling, or distraction and other techniques provided by child life specialists, may also be effective for babies and young children.

While the experts try to sort out the data, I may think twice before automatically giving a strong sedative. I’ll think carefully about the alternatives. And I’ll certainly try to keep up on the literature and emerging guidelines.   But I don’t want to go back to the brutane era. I still have images of children struggling mightily to break free of the 2 or 3 large adults holding them down while I tried to put stitches in or remove a bead from the ear; I have to imagine those kids have even worse memories of it than I do. They deserve better than that. They deserve the best.



The Essentials

April 9, 2015

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I don’t know exactly what a prayer is.

I do know how to pay attention, how to fall down

into the grass, how to kneel down in the grass,

How to be idle and blessed, how to stroll through the fields,

which is what I have been doing all day.

Tell me, what else should I have done?

Doesn’t everything die at last, and too soon?

Tell me, what is it you plan to do

With your one wild and precious life?

-Mary Oliver, “The Summer Day”

It’s virtually impossible to go a day without asking someone how they are doing, and receiving the reply, “Busy.” It’s often implied that this is both good and bad; while we complain about being overwhelmed, we say it with a certain pride, busy-ness indicating success. This mixed message comes not only at the individual level but as a society. Commentators who lament the frenetic pace of the world also imply that this is unique in human history, an unintended consequence of the immense progress in our era. With the explosion of knowledge and technology, we have more options than ever before – how could we not be overwhelmed. More specifically, it arises from the globalization and connectedness begat by the Web. We are advanced, therefore we are busy.

Except this anxiety over lack of time goes back a long way. Back in 1910, Arnold Bennett wrote a small book called “How To Live On 24 Hours A Day.” He points out that people often try to live within a monetary budget, but that time is actually a more finite and therefore precious resource. “The supply of time, though gloriously regular, is cruelly restricted….We never shall have any more time. We have, and we have always had, all the time there is.” Time mis-management is a long-standing feature of our species.

The problem isn’t that we have too many choices now. It is that we are challenged to prioritize among them. This is true whether there are 12 TV channels or 1200. One way of looking at our choices is to categorize in two dimensions: timeliness (urgent vs. non-urgent), and significance (important vs. unimportant). Urgency too often trumps importance.

Greg McKeown, in his book Essentialism: The Disciplined Pursuit of Less, stresses the need to focus on significance, and to identify those things that are truly the most important. Essential. This, of course, sounds far easier than it is. None of us lives in a vacuum, and we do not have complete control over what we need to do. When a Joint Commission surveyor shows up at our hospital, my opinion about whether they are “important” or not doesn’t really matter. I know what I’m going to be doing the next few days.

But we do have a certain amount of discretion, which we fail to fully utilize. And it isn’t just a matter of doing things more efficiently to get more done. Paradoxically, focusing on the essential requires a certain investment of time into doing, well, nothing. More specifically, thinking rather than doing. McKeown emphasizes that determining what is essential takes some discipline itself. It isn’t necessarily obvious, and may not already be known. Taking time to explore and ponder options, time for discernment, is a critical part of essentialism.

Our leadership team, which has been reading McKeown’s book together, is experimenting with some things to help us move ourselves, and the organization, toward an essentialist mindset. One thing we’ve done is commit to building “thinking time” into our schedules. Time for reflection, time for discerning what are those most important things we should spend the rest of our time on. It may not involve kneeling down in the grass, as Mary Oliver’s poem suggests, but it does involve paying attention. How else are we to know what to do with our one wild and precious life?



Cleaner Air, Deeper Breath

April 2, 2015

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It sounds like a plot for a corporate thriller: an industry that poisons people and then profits from selling the antidote.  In a sense, though, this could describe health care.  As one of the most energy-intense industries – hospitals account for 8% of all US energy use – health care facilities are an important contributor to both air pollutants and greenhouse gas emissions.  Those pollutants are an important cause of respiratory illness, especially in children.  We could, unintentionally, be contributing to adverse health effects for the children in our community.  That undermines our values of purpose and health.

Many hospitals, including Children’s, are taking steps to address this.  Our hospital actually already compares favorably to others in its energy footprint.  This year we will be installing new facility operations software that will further reduce our energy consumption.  And the thermal plant on Watertown Plank Road, which provides Children’s and the other facilities on the Milwaukee Regional Medical Campus with steam and chilled water for heating and cooling, is being converted from coal to natural gas, which will decrease both carbon and particulate matter emissions.

The good news is that efforts like these will lead to improved public health.  A recent study from the New England Journal of Medicine showed that in southern California over a 13 year period, pollution reductions as a result of regulations under the Clean Air Act were associated with improvements in lung function in children.  This affirms findings in other studies showing a link between improvements in air quality and overall life expectancy across the US.  Clean air is good.

Other hospitals are going even further.  Gundersen Lutheran, in La Crosse, WI, became the first hospital to go carbon neutral, getting all of its energy from wind, geothermal, solar, and other renewable sources.  That’s a stretch.  But even the steps we are taking will help.  And as individuals we can help to reduce the energy intensity of the organization by turning off lights and computers, using stairs, and other small things that will add up to less waste and healthier kids in our community.


March 27, 2015

CHW LogoI’m a bit of a Cold War nerd.  I loved the novels of John le Carre, and can still recite the list of leaders of the Soviet Union from the pictures that hung on the walls of my 10th grade social studies classroom.  In some ways, the world seemed simple.  There were two big alliances: NATO and the Warsaw Pact.  The world could be divided into East and West.  While these blocs came to represent competing ideologies and politico-economic systems, the original purpose was to assure mutual defense through shared, coordinated military effort. Over time, it came to seem that not only could the world be divided into two camps, but that it had to be.  You were either East or West.  Yet we forget that the majority of nations in the world, especially in Africa but even in Europe, the epicenter of the Cold War, were part of the non-aligned movement.

Health care in 21st century Wisconsin is coming to resemble mid-20th century Europe.  Two large state-wide alliances of health systems are emerging – Integrated Health Network (IHN) and abouthealth.  The former includes, among others, Froedtert, MCW, Wheaton, Ministry, Dean, and HSHS, while the latter counts Aurora, ProHealth, UW Health, ThedaCare, and Gundersen Lutheran among its members.  Such accountable care organizations (ACOs) are an approach to managing health for populations.  Alliances of providers (including physicians, hospitals, and others) jointly take responsibility for both the costs and outcomes of care.  The specifics can vary widely, but some of the common principles include:

  • The providers take on some or all of the financial risk for providing care. Rather than payment for volume, there is payment for value.  Better quality and lower cost are rewarded; poor quality or high cost put the provider at risk.
  • Value is driven by coordination of care, emphasis on prevention, and use of shared data to drive informed decisions by both clinicians and administrators

While this sounds appealing in theory, it is difficult in practice.  Studies of ACOs to date show that achieving the desired combination of improved outcomes and lower cost is challenging at best, with many performing below expectations.  Scale seems to matter, as does expertise.  And most of the experience to date is with adult populations (especially Medicare).

As we work to figure this out in Wisconsin, Children’s is poised to be one of those non-aligned nations, working with both alliances to advance the health of children in our state.  With our scale and expertise, not only in specialty and primary care, but also with care management and coordination (as in Children’s Community Health Plan, our Medicaid HMO), we are uniquely capable of taking on the task of managing the health of the population of the children in the state.  We like to say kids are not just small adults.  This is as true when it comes to managing their health as when managing their illnesses.

Which is why you didn’t see our name listed in either of the two statewide alliances listed above. We do, and hope to continue to, work with both.  There are only about 1.5 million kids in Wisconsin, spread out among many different health systems.  If we are forced to pick one side or another, it is likely that neither of them will have sufficient scale and expertise to do the best job of managing the population of children, in sickness and in health.  I hope the health care equivalent of the Berlin Wall doesn’t get in the way of our vision of the kids in Wisconsin being the healthiest in the nation.


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