Starting With Curious

Children’s Hospital of Wisconsin has a vision that the children of Wisconsin will be the healthiest in the nation.  By some measures we do pretty well, though we continue to struggle with a higher level of disparities than other states.  For example, according to the National Initiative for Children’s Healthcare Quality (NICHQ), Wisconsin has a lower rate of obesity/overweight among children (31%) than the national average; our ranking is 12^th best, and has improved since 2003.  However, when we look at the disparity in obesity, we fare poorly: 17 of 22 when measured by race, and 32 of 35 when based on income.

But let’s step back a second.  Is it really OK to have almost one-third of our 10-17 olds overweight?  Consider this: Oxfam reports the US ranks 121 out of 125 nations in its rate of diabetes and obesity.  I’m not sure it’s enough to aim to be the best in the nation.  That would still leave our kids in sad shape from a global perspective.  Indeed, despite high ratings for food quantity, quality, and affordability, the US is ranked only 21^st in the overall index, due to abysmal statistics on health impact of the food we (over)eat.

And let’s be clear – this is not solely, or even largely, an issue of poor choices or lack of willpower.  It’s primarily a societal issue.  First, while on a global scale obesity is largely associated with affluence, within the developed countries there is an inverse relationship between income and obesity.  Much has been written about “food deserts” in inner cities – neighborhoods without access to healthy food options.  But even when there is such access (and Milwaukee actually does not have food deserts as defined by the USDA), healthy foods may be out of reach.  A study from University of Washington showed that the most energy-dense foods, high in saturated fats and low in other nutrients (think potato chips, Oreos, and Hot Pockets) are 10 times less expensive than the least energy-dense (salad, fresh fruit) on a per-calorie basis ($18.16/1,000 kcal as compared to only $1.76/1,000 kcal).  Worse, the most nutritious foods rose in price by almost 20% over a 2-year period, while the least nutritious actually got even cheaper.  No wonder people with limited income or food stamps pick “junk food” – it may be the only way to afford enough calories to feed the family.

In part, this reflects basic economics – junk food is simply cheaper to produce than the healthy stuff.  But it’s made worse by national farming policy (as enshrined in the latest farm bill), which continues to subsidize industrial producers of products destined to be converted to, in Michael Pollan’s memorable phrase, “edible foodlike substances.”

What can we do?  We already have made important steps, like providing healthier food choices for patients, families, and staff.  Here are some additional suggestions:

• Let’s increase awareness of nutrition as an issue we ask about at patient encounters throughout the system.  We can be intentional asking patients and families about food insecurity, or concerns about their child’s weight.  And it needs to start early; this week’s New England Journal of Medicine has a study demonstrating that childhood obesity is largely present by age 5.
• We can leverage our considerable organizational expertise in feeding and nutrition by creating a pediatric nutritional program of excellence, which can be a resource for providers, patients, and families.  Then we need to steer them toward educational resources to counter the massive advertising by the “edible foodlike substance” industry, and help them identify nutritious yet affordable alternatives.

We can support local efforts such as Fondy Food Market, Walnut Way, and Growing Power, all of which are working to provide affordable access to healthy foods in our poorest communities, in large part by promoting people to grow their own food.

Favorite things about doctoring:  coming up with a diagnosis; simple but gratifying procedures like pulling random objects out of a kid’s ear; getting a high five from a four year old when she’s leaving the emergency department; working with really smart and dedicated people.

Least favorite things about doctoring: not getting to work outside; paperwork.

Now, I have nothing against paper, or work, or working with paper.  But I do have a problem with things that at best add no value, and at worst diminish it.  Paperwork too often falls into that category.  (I recognize the term “paperwork” is undoubtedly passé, as most of what we call paperwork is done on an electronic device of some sort.  But given the bureaucratic connotations of the term, I’ll stick with it.)

The EHR is rapidly becoming a prime source of dissatisfaction for providers across the spectrum of professions and specialties.  A 2013 RAND report, based on interviews and surveys of a representative sample of hundreds of physicians, found a good deal of support for EHRs in principle, and their potential to improve care and facilitate greater to access to information.  But in actual practice, the current state of EHR technology is often plain unfriendly to the provider.  As the report says, “Poor EHR usability, time-consuming data entry, interference with face-to-face patient care, inefficient and less fulfilling work content, inability to exchange health information between EHR products, and degradation of clinical documentation were prominent sources of professional dissatisfaction.”  Providers often spend more and more time simply entering information, leaving them less time for the things they were trained for.  Less doctoring, more paperwork.

In the face of a shortage of physicians, especially those in primary care, one solution is to reduce the waste of this resource, as suggested in a recent Health Affairs article – hand off the administrative and clerical tasks to allow the provider more time to provide care.  An increasingly common solution to the inefficiency of the EHR is the use of scribes.  Several companies now supply scribes to hospitals and physician practices; primary care and emergency departments are among the heaviest users.  The scribes, who typically undergo 3-4 weeks of training in medical terminology and the use of EHRs, accompany the providers into patient rooms and transcribe the history and exam findings simultaneously with the provider’s assessment.

I’ve heard this concept before, and have to admit to being a bit of a skeptic.  First of all, our ED group has developed sufficient templates that for the overwhelming majority of my patients, the documentation is no more burdensome than it was before we installed our EHR, and perhaps less so.  I was also leery of having another person present when I am evaluating a patient.  Would people be as forthcoming?  Would patients and families worry about their privacy?

But the more I think about it, the more it seems worth trying.  I recognize that my practice is exactly that, my practice.  I’ve heard enough from enough other providers that for at least some providers or specialties, the burdens of the EHR are real.  As for having that extra person, I’ve had experience where there was a scribe for my provider, and I have to be honest, it was hard to even remember there was someone else there.  And I’ve not noticed any reticence on the part of patients when I have students or others shadowing me.

The real question is, is it worth it?  Scribes cost money.  Will any efficiencies and provider satisfaction we gain justify that cost?  What’s the value proposition?   The early evidence, albeit anecdotal, suggests it very well might be worth it.

In last week’s posting, I pointed out that people come to the ER, or for health care in general, for all kinds of reasons, not always obvious at first glance.  In fact, it may be difficult to discern unless one asks very specific questions.  And those needs may appear not to be “medical” at all.

But non-medical factors are a more important determinant of health than the care we provide.  The best estimates are that medical care accounts for no more than 10% of an individual’s health status, while behavior accounts for 40% and social/environmental factors, 20% (the remaining 30% belong to genetic predispositions).  One could argue that we’d get far better results focusing on behavior and environment than on medications.

As is so often the case, the Canadians are far ahead of us on this.  A Toronto family physician is pushing for incorporating poverty screening into routine health care, an approach being promoted by the Ontario Medical Association as well.  Dr. Bloch points out that poverty is the second leading cause of lost life in Canada after cancer.  (I wonder how the US would compare?)  He has developed a screening question – “Do you ever have difficulty making ends meet at the end of the month?” – that has 98% sensitivity and 64% specificity for predicting economic need.  (That performs better than a CBC in predicting infection, something we do all the time at $71.50 a pop.)

Identifying people under economic stress has several benefits.  First, unrecognized poverty may mean that people will be unable to obtain prescribed medications or have recommended follow up.   It may also cause or exacerbate a variety of conditions.  One example: a new study in Health Affairs showed that lack of money for food at the end of the month leads to increases in admissions for hypoglycemia in people with diabetes.  Moreover, in early childhood, chronic stress such as that associated with poverty has a long-lasting, and in many cases heritable, biological impact via changes in the developing brain and epigenome.  Early recognition and intervention may be helpful, and is an area of focus for the American Academy of Pediatrics.

Children’s Hospital of Wisconsin has a vision that the children of Wisconsin will be the healthiest in the nation.  The care we provide will only accomplish 10% of that.  We must therefore pay attention to all of the factors that affect the health of the kids we serve.  Identifying economic needs and working to end poverty will accomplish even more.

The medical student presented the case of an infant with nasal congestion for 2 days.  Based on the history and exam findings, it sounded like a baby with a mild cold.  “So why did they come to the ER?” I asked.  Perhaps assuming that, like so many emergency department veterans, I meant this as an indication of irritation with an abuse of the system, he replied, “I don’t know.  It does seem pretty unnecessary.”

“No,” I answered, “they have a reason.  Everyone on the planet has something better to do than to come to the Children’s Hospital ER.  If it doesn’t make sense to you, then you need to dig harder.  Our job is to find out why they are here and to make sure we address that reason.  Go back and see if you can find out more.”

The student returned a few minutes later, a bit exasperated. “I tried to get some more details, but couldn’t really sort it out.  The mom isn’t a great historian.”

“Actually,” I said, “the mother is the primary source.  We are the historians.  Never blame the patient or family for our inability to interpret the facts.”

I will never forget my experience as a fourth-year medical student.  On medicine rounds, we were discussing a patient who was not responding as expected to the prescribed treatment.  The attending physician asked me how I would explain that.  “I suppose he could be non-compliant with his medications,” I ventured.  The intern and senior resident nodded.  “Congratulations,” the attending said. “You’re clearly ready to be a doctor – your first reaction is to blame the patient.”  We were all embarrassed into a prolonged and uncomfortable silence.

People always have a reason for seeking our services.  Contrary to what some of the most jaded people say, it’s never to get a free popsicle or to watch our TV.  Neither is worth a 2-3 hour wait.  Sometimes it’s simply a matter of knowledge.  Most people who bring their child to an ER believe it’s an emergency.   Those of us with specific expertise and training can’t apply our standards to judge whether someone “needed” to come in.  (I hope my car mechanic doesn’t roll his eyes at me for bringing in my car for what turns out to be a benign noise, when I thought for sure the brakes were about to fail.)  In that case, a little education can go a long way toward helping both the child and the parents.

Other times, the physical complaints are not the real motivation for seeking help.  In the case of the baby with the cold, it turned out that the mother had run out of money and couldn’t afford to buy the bulb syringe that her doctor had recommended over the phone.  In my years of working in the emergency department, I’ve seen parents who were out of food for their child, who were victims of domestic violence, who were suffering from schizophrenia.  No one asks to be in those situations.  What they are asking for is help.  Living our value of purpose means finding out what our patients’ needs are and working to meet them.  Without judging. 

Polishing off the last of the Christmas cookies, and looking forward to the crowds of new members at the athletic club – must be New Year’s.  The well-intended but infrequently-kept resolutions we often make when the calendar turns seem to be disproportionately about health: dieting, exercise, de-stressing.  At the risk of hypocrisy (since I’ve never been big on the resolution-making myself), I’d like to suggest that we at Children’s take this opportunity to reflect on and make an effort to live up to our value of health this year.  A few specific thoughts:

1.  Check out the Healthy Rewards program.  Given the substantial savings you can earn on your health insurance, I’m always surprised that everyone doesn’t participate.  Sponsored by Employee Health and Wellness, this is program designed to encourage healthy habits including eating, exercise, and emotional well-being.  It’s not always rocket science, but sometimes a little reminder or friendly competition is what it takes to make a change.

2.  Wash your hands.  I’ve pontificated about this before, but I remain flabbergasted that we are anything less than 100% compliant.  Next time someone gets sick at work, remind them that a little hand sanitizer could have saved them a week of misery.

3.  Don’t be a martyr.  Speaking of being sick, remember that it is OK to be a patient sometimes.  Physicians in particular are notorious for refusing to succumb, powering through fever, nausea, and fatigue.  I suspect this may be shifting, as the previous machismo culture of Parris Island-style physician training yields to a more humane and realistic regimen, but it is still considered a sign of weakness to stay home when you are sick.  We owe it to ourselves, and to the patients and families we put at risk, to lay low when we are ill.

4.  Get moving.  Sitting has been shown to be a risk factor for all kinds of chronic illness and shorter life expectancy.  Perhaps the Zoo Interchange construction will get a few people to consider biking, walking, or taking the bus (and then walking to and from the bus stop) to work.  When the weather allows, try having some one-on-one meetings in the form of a walk around the block.  Take the stairs.

5.  Be at your best.