Hug a Pharmacist

October 22, 2015

CHW LogoA couple of years ago I visited what is purported to be the oldest pharmacy in Europe, in the tiny town of Llivia on the border between France and Spain.  Filled with Latin-labeled jars of various plant materials and other exotic ingredients reminiscent of a Potions class at Hogwarts, it reminded me how far medicine in general, and pharmacy in particular, has come.  And the pace of change is accelerating.  The large majority of medications in current use – entire classes of them – didn’t exist when I was in medical school 30 years ago.  Keeping up with that kind of transformation is a challenge.  Thank goodness for pharmacists!

I want to offer a shout out to my pharmacy colleagues during National Hospital Pharmacy Week.  The range of skills and the many ways pharmacists allow us to provide safe, effective, and efficient care is quite impressive.  At Children’s Hospital of Wisconsin, we have pharmacists working in the main pharmacy and satellite pharmacies for the intensive care units, operating room, and oncology units.  They do far more than oversee the dispensing of medications by the team of pharmacy technicians.  Pharmacists are an integral part of the care team: participating in rounds; providing advice on medication selection, drug interactions, dosing, and adverse effects; leading efforts around antibiotic stewardship and rational formulary development; assisting in medication reconciliation and patient education; and ensuring compliance with the myriad regulations around medications.  Hardly a shift in the emergency department goes by where I don’t have an interaction with the pharmacists in which I am both helped and enlightened!

As you might expect, the role requires a substantial amount of education and training.  Pharmacists typically receive an undergraduate degree and then pursue a four-year doctor of pharmacy program.  While retail pharmacists often stop their training there, hospital pharmacists most often pursue additional training, especially to practice in a specialized area like pediatrics.  Our hospital offers a highly competitive two-year pharmacy residency that prepares people for the rigors of the role of a hospital pharmacist in the modern era of team medicine.

Pharmacy today bears as little resemblance to the mixing of obscure powders in medieval Llivia as surgery does to the barbershop purveyors of the same era.  For my colleagues who are masters of modern pharmacy, I offer my gratitude and appreciation.

The 3 R’s

October 16, 2015

CHW LogoOnce confined to bastions of political correctness like Boston and Berkeley, recycling bins are a staple of modern life in America.  There is certainly a lot of variation – compare, say, Madison (recycling Nirvana)  to Milwaukee (not so much) – but it is a given that we should be recycling more, and that public policy should require and promote it.

Or is it?  Several articles recently have called into question the economics of recycling.  Much of the print debate follows predictable party lines: the Natural Resources Defense Council tends to support it, while the libertarian Cato Institute finds flaws.  John Tierney, writing in the New York Times, notes that recycling tends to lose money.  He does admit the environmental benefits, especially in curbing carbon emissions, but cites the EPA in stating that these are primarily due to recycling a few materials, specifically paper, cardboard, and metals. He goes on to wonder why both the public and many elected officials continue to promote recycling, suggesting that much of it is from liberal do-gooders who want not only to feel virtuous, but to force others to as well.

As I see it, there are several important issues he ignores.  First, few people have argued that recycling makes sense on primarily economic grounds, especially in the US.  Given the heavy subsidies for extractive industries (mining, oil, etc.) and manufacturing, the playing field is not level.  In the absence of these subsidies, and if externalities (such as the cost of future damages due to climate change) were factored in, the economics would look very different.  Rather, the benefits are in large part environmental.  One that Tierney and others dismiss is the preservation of space that would be devoted to landfills.  He ridicules the contention that we are running out of space to place trash.  True, there is a lot of space in the US where trash could be dumped.  But it is also true that no one wants it in their backyard.  The further the trash must travel, the more it costs to dispose of, and the more greenhouse emissions that are generated.  And the argument that landfills can be converted back into nice natural areas is questionable.  A pristine area that is used for dumping and then “restored” is no longer pristine.  There is more to an ecosystem than planting grass and (usually non-native) trees.  I have seen many reclaimed landfills, and while they are better than an open trash pit, they’re not exactly Yellowstone or Pictured Rocks or even Kettle Moraine.

Tierney also postulates that the greenhouse gas benefit isn’t that great.  He points out that recycling a ton of aluminum saves 20 tons of carbon, whereas you would need to recycle 60 tons of glass to save the same 20 tons of carbon.  This is specious, as this is not the relevant question.  In both cases you save a ton of carbon, which was the goal.  It’s a bit like saying you can buy an ounce of gold with an ounce of 10 dollar bills, but you’d need 50 pounds of quarters to buy the same ounce of gold.  You still get the gold. At the same price.

My biggest beef with his argument is the dismissal of recycling as a quasi-religious (his words, not mine) exercise in feeling good.  First of all, most actual religious activity offers no economic benefit to humanity, but we encourage and subsidize it anyway.  Besides, the fact that recycling may be driven by non-economic considerations isn’t necessarily a bad thing.  Intrinsic motivation, such as a desire to improve the planet, is typically more powerful than extrinsic factors like money.  (Indeed, this fact has been used to argue against financial incentives for quality metrics for physicians.)  Psychologists and neural scientists have also long known that acts of altruism – such as recycling – produce a variety of psychological benefits, sometimes referred to as the “helper’s high.”  Given the dire predictions about climate change, and the seeming inevitability of fundamental disruptions to our environment and lifestyle, giving people a sense of hope and optimism has some merit.  Most importantly, the real goal isn’t recycling, it’s generating less stuff in the first place.  The environmental mantra is “Reduce, Reuse, Recycle.” Recycling is the last resort.  But by making people more aware of the waste they generate, recycling might lead to reduction and reuse.  I wonder if, in that regard, we’ve made recycling too easy, and it would be better to have those systems where people need to do their own sorting.  The more I need to think about the waste I generate, the more likely I am to try to create less of it.  And that’s an additional benefit that a traditional economic analysis ignores.

Fortunately, the majority of Americans agree.  A 2014 Nielsen study showed broad support for recycling, and specifically that people would be willing to spend more (an average of 10-13%) for products that are either made from recycled materials or themselves more able to be recycled.

Perhaps next we can talk about composting….

October is Health Literacy Month

October 9, 2015

CHW Logo“She had a temperature of 101.4,” the child’s mother told me in the ER.  When I asked if that was the highest it had gotten, she replied “Oh no, it got as high as 100.8.”

As I considered how to respond, the father slowly interjected, “Wait a minute, 101.4 is higher than 100.8.”

Mom could scarcely contain her scorn. “No it isn’t,” she sneered.  Turning to me for validation, she said “101.4 is not higher than 100.8,right?”

“Actually, he’s right, 101.4 is higher,” I said gently, prompting a satisfied smile from the father and a look of incredulity from the mother.

At the time I found this amusing.  But lack of health literacy and numeracy is both common and concerning.  According to a 2006 report, only 12% of Americans are sufficiently proficient in health literacy, lagging most of the rest of the industrialized world.  Poor health literacy interferes with the ability of people to manage their own health, and undermines efforts to improve patient-centered decision making.

October is Health Literacy Month, underscoring efforts by individuals and organizations to raise awareness of the issue and spur improvements.  An example I learned about recently: Children’s Hospital of Philadelphia is opening the South Philadelphia Community Health and Literacy Center, which will bring together clinics, a recreation center, and a library to address a variety of community needs.  It will include a Consumer Health Resource Center targeting health literacy needs.

As providers there is much we can do as well:

  • Use “teach back” when educating patients and families to check for understanding and identify additional learning needs
  • Rather than asking “Do you have any questions?” end with “What questions to you have?”, thus normalizing the questioning process
  • Augment numbers with simple graphs to illustrate numeric concepts – these are more intuitive than percentages, for example

Improving health literacy is integral to our work as care providers.  After all, the word doctor comes from the Latin docere, meaning to teach. And nurse comes from nutricia which meant, among other things, a female tutor.  Now if only I could figure out this new math….


First Do No Harm @HHIOrg @ChildHealthUSA

October 2, 2015

CHW LogoThe theory of evolution by natural selection, the telephone, the fortissimo E flat major chord at the beginning of Beethoven’s Piano Concerto #5.  All of these are now seemingly mundane things that at first were the product of true genius.  To that list I would add the concept that health care does, but should not, cause harm.  When I was in school 30 years ago, that concept didn’t really exist, the idea that hospitals and physicians could do anything other than good – perhaps as a result of gross incompetence, but not as a byproduct of normal operations..  One of the people who understood and helped raise awareness that providers must acknowledge and control their inherent potential for harm has now been recognized for the genius of that insight.  Gary Cohen, founder of Healthcare Without Harm, was announced this week as a recipient of a 2015 MacArthur Foundation “genius” award.

Cohen began with a grass-roots campaign to eliminate mercury from use in healthcare over 20 years ago.  Given its ubiquity in thermometers, sphygmomanometers (blood pressure cuffs), and other devices, that might have seemed quixotic.  Yet mercury has now essentially disappeared from hospitals.  More broadly, Cohen and his colleagues saw this as just one example of the ways in which health care organizations were major contributors to environmental degradation, with the potential to undermine, directly (e.g., mercury, toxic cleaning chemicals) or indirectly (e.g., power plant emissions) the health and well-being of their patients, workers, and communities.   Healthcare Without Harm brought together all of those stakeholders to not only advocate but also to create solutions.

As noted in the MacArthur Foundation citation, Cohen “led a paradigm shift in the perceived responsibility of health care providers, from a narrow, patient-centered duty of service regarding individual health to a broader obligation to also ‘do no harm’ to surrounding communities, their residents, and the global environment.”  Like the patient safety movement inspired by Don Berwick among others, Healthcare Without Harm and the Healthier Hospitals Initiative (also co-founded by Gary Cohen) are helping hospitals and providers to see their positive responsibility to minimize the negative effects of their activities, and to make the necessary systemic changes to do so.  Hippocrates urged us not to harm the individuals under our care; Cohen urges us not to harm everyone else.  It’s nice to have that recognized as a stroke of genius.

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