Starting With Curious

There are a number of striking features of the American healthcare system compared with those of other developed countries: the huge percentage of our GDP that goes to health (currently at 17.5%); the enormous gap between our spending and health outcomes (i.e., the apparent lack of value); and the tremendous health disparities in this country compared with others.  We have recognized these disparities as a particular problem in Milwaukee, and one of our strategic priorities is to address those disparities in our community.

One area we are addressing is safe sleep.  In Wisconsin, an average of one baby dies each week in an unsafe sleep environment, and while these tragic deaths are spread across the state, they disproportionately affect the underserved.  Children’s Health Alliance of Wisconsin has a safe sleep program that includes a variety of media, hospital, and community-based educational efforts. The ABCs recommendations for safe sleep from the American Academy of Pediatrics include:

• Sleeping alone
• Sleeping on the back
• Sleeping in a crib
• Non-smoking environment

For disadvantaged families, availability of cribs can be a barrier.  So one intriguing element of the CHAW program is the Newborn Nest.  It is essentially a cardboard box for the baby to sleep in.  For real.

Now, lest you think the idea of a baby in a box is crazy, it’s actually based on an extremely successful program from Finland.  Basically, all new mothers in Finland receive a maternity package.  Unlike in the US, where kits may be given out by hospitals but vary widely, it’s the same for all Finnish moms.  The kit comes in a box and includes breast feeding information, along with bodysuits, a sleeping bag, outdoor gear, diapers, bathing products for the baby, as well as bedding and a small mattress – the mattress is designed to go into the box, which serves as a crib!   And the culture is such that everyone uses it.  Mothers have a choice between the kit and a 140 euro cash grant; 95% choose the kit.

This baby box therefore not only provides a safe sleep environment, it levels the playing field.  Imagine how things might be different if all babies in the Milwaukee area, whether they live in Lindsay Heights or Whitefish Bay, napped in the same type of box.  Of course, that would require a cultural change that could be even harder to achieve than income redistribution.  The Finns note that part of the appeal of the maternity kit is the fact that it symbolizes equality.  But when it comes to children, there is a strain of American culture that supports that: for example, the traditional commitment to universal public education dating back to the first years of the Republic.

Our health disparities are a daunting problem.  Could the answer lie in a box?

I’ve been thinking about you two a lot recently, especially when I saw the election results.  It’s probably always challenging to be an almost 11 year old girl, but especially now.  Living in Florida, you’ve certainly seen a lot that was said during this election campaign, no matter how hard your mom might have tried to shield you from it.  And a lot of what was said was ugly, on all sides.  Now, this isn’t about Mr. Trump per se, and I don’t want to talk about what kind of president he might be (you also certainly know that there are many widely varying opinions about that, including within our own family).  I want to talk about what I think this election means for girls and women.

When your mother and I were growing up, it was the era of “women’s liberation.”  Since the early days of this country, there have been laws oppressing women: keeping them from voting, owning property, and in general participating fully in society.  By the 1960s and 70s, many of those legal barriers were gone.  But it was still generally assumed that women were simply not as qualified as men.  (We were lucky to have a mother – your Nana –  that defied those stereotypes.)   And just because women were no longer legally second-class citizens didn’t mean they were treated the same.  Liberty is not the same as freedom; attitudes can hold people back as effectively as laws.  So many women, and many men, worked to change those attitudes.  They also worked to enact laws to counteract the discrimination that came from those attitudes.  For example, even though many people thought sports were only for boys, Title IX meant that schools couldn’t only invest in boys’ sports – they had to provide equal opportunities for girls.  And gradually, things got better.  Not perfect – women still earned less than men, were less likely to be leaders in government and business, and frequently judged by different and stricter standards – but better.  Or so I thought.

A few things became clear during the past year or so.  First, when a woman (Hillary Clinton) and a man (Donald Trump) try to do the same thing, they are still judged very differently.  In particular, Americans still have a very “masculine” view of leadership and strength.  People can be strong in many, many ways.  (Just look at your grandmother.)  But it seems when we are electing a leader, we focus only on the kinds of strength – being pushy, brash, in-your-face – that are traditionally associated with boys and men.  It’s another one of those attitudes that is holding women back.  And I’m not sure that’s actually the right kind of strength for a leader.  Look at Vladimir Putin versus Angela Merkel – I’d take Merkel any day.

What’s more disturbing is that not only is the attitude that women are not as qualified as men still quite common, but so is the attitude that women aren’t as good as men, not worth as much.  That they are in many ways simply objects for men.  During the recent campaign we heard people say things about women that I didn’t think many people actually thought, much less said out loud, much less did.  And worse, we heard so many stories from women who said yes, they had heard it and seen it and experienced it.  The leers, the comments, the put-downs, the touches.  As a man I have never had to put up with what all the women I know say has happened to them.  And as a man I am ashamed for those other men.

Now, very few people actually said this sexual harassment was a good thing (though shockingly some did), and I know that most people who voted for Mr. Trump don’t believe it’s good.  Some people dismissed it as “just talk.”  Others said that’s just what guys do.  And many said yes, it’s bad, but we’re going to ignore it because nobody is perfect, and there are more important issues like security or the economy that we agree with him on.  It’s true no one is perfect – certainly Ms. Clinton isn’t – and we have to view people as a whole package of traits, some admirable and some not.  But there are some things that you can’t ignore: sexual harassment and assault is one of them.  You can’t minimize it, or trivialize it, or excuse it, or rationalize it because at least the trains are running on time.  By doing that, it sends the message that it’s only a little bad.

Which is why I was thinking of you on election night.  Obviously, if Ms. Clinton had won, that would have been a strong positive message for girls and women.  I worry that the message in Mr. Trump’s election is that mistreating , demeaning, and even abusing women is not so bad.  In fact, it may even be good – after all, it shows the kind of strength you need to lead.  Which means things are worse for women than I thought, and that makes me sorry and scared for you.

So know a few things.  First, degrading women is not OK.  It’s wrong.  Always.  Period.

Second, everyone has inherent worth and dignity.  Everyone deserves to be respected.  Don’t ever let anyone deny you that.  Be strong.

Third, it’s not something that all guys do or talk about.  I don’t, your cousins don’t, and most men don’t.  Sexism and misogyny are not carried on the Y chromosome.  They are learned, and they can be unlearned (or better, prevented).

I’m not going to send you this yet.  I wanted to get it off my chest, but I’m going to save this until I think you’re ready.  My sincere hope is that when I send it to you in 10 years or so, things will be better.  That no one will assume what you can and can’t do because you’re a girl.  That you’ll be treated fairly and with respect.  That you won’t have to deal with a demeaning boyfriend, or a creepy boss or colleague.  That no guy will brush up against you or press up against you or grab you.  That you won’t ever be a victim of “date” rape.  I hope that board rooms and legislatures and other halls of power will look like America, and not like an NHL hockey team.  I hope all those things.  But hope is not a plan.  So also know that you have people – women and men, like your aunt and your cousins and me –  who are going to fight like hell to make it so.

Remember the game of Clue?  “Colonel Mustard, in the Billiard Room, with the Lead Pipe.”  What if the lead pipe is dangerous even if it’s not being wielded by the vicious colonel?  Since the story about severe lead contamination in Flint, Michigan surfaced, there is growing concern about lead in drinking water.  While lead isn’t actually good for anybody, it’s particularly a concern for children and pregnant women because of the effect of lead on brain development.  How much of a problem is it?

First, some context.  Lead was used for centuries as a material for water pipes (indeed, the word plumbing comes from the Latin plumbum, meaning lead.)  After the mid-1940s this was largely phased out in favor of copper, but through the 1980s lead-based solder continued to be used.  Thus, most homes and buildings built before 1990 have at least the potential for a problem with lead in the water, as do most cities where the water distribution infrastructure is that old.  Like Milwaukee.

Now, for the most part lead likes to stay in the pipe, rather than getting into the water.  It mainly becomes a problem if the water is corrosive, leaching the lead out.  In 1991, the EPA issued the Lead and Copper Rule, pursuant to the Safe Drinking Water Act of 1974.  This rule requires water utilities to control the corrosivity of its water, which is the simplest way to mitigate the problem.  In Flint, the water utility changed its water source to one that was much more corrosive, and failed to add the required treatment agents.  That is what created the crisis there.  (There was a similar problem in Washington DC in the early 2000s due to inadequate corrosion control.)  If the proper procedures are being followed, the risk is considerably reduced throughout the water system.  Water systems in Milwaukee and surrounding communities follow the procedures and meet the requirements for lead levels. (If you have a question about the quality of your water, you can get the annual Consumer Confidence Report for your water utility.)

Another vulnerability is when the pipes are physically disrupted, such as when a segment is damaged or replaced. This disruption can release lead into the water, an effect that is usually transient.  In homes with lead pipes or solder, it is recommended that when repairs are needed, all the piping should be replaced at once.  Since this is very expensive, few homeowners or landlords do that.  So for the most part, lead in water is not a widespread problem in this community, but it can be for an individual home.  Or school.  Or day care.

So how much should residents of Milwaukee worry about lead in the water?  Toxicologist Dr. Mark Kostic, of the Wisconsin Poison Center, urged a balanced perspective in an interview on WUWM.  He correctly notes that the much bigger concern remains other environmental sources of lead, including paint and soil.

However, for those in older homes who are concerned about the potential for lead in the water, parents can take a number of steps to protect their children.

• Have their child screened for lead poisoning according to guidelines from the American Academy of Pediatrics. This includes a risk assessment starting at age 6 months, with blood lead testing for children identified as at risk.
• If a child is found to have elevated lead levels, the public health department should investigate to identify the causes, which should be addressed.
• For infants being fed formula reconstituted with tap water (a group particularly at risk), consider having home lead water levels tested through the local health department. Alternatively, run cold water (not hot) for 5 minutes before using it to mix with formula.  Filters are available, but these need to be replaced regularly and the cost can add up.  Bottled water is an alternative, but while the risk of lead is lower, it does not provide fluoride which is important for infant dental development.

Just thinking about my upcoming vacation to Acadia National Park, I can feel my stress-induced canker sores melting away.  It’s partly about the time off, and partly about being with family.  Yet there’s something about being in a beautiful natural environment that is especially relaxing.  And healing.  In fact, the health benefits of nature are now sufficiently well understood that in some countries it is becoming common for physicians to prescribe “forest bathing.”

While extended periods in the woods provide even greater benefits – lower blood pressure, decreased levels of stress hormones, higher natural killer cell activity – even a brief stroll can be good for you.  I am grateful to work on a campus that includes green space, including some beautiful woods that used to be part of the county sanitarium.  (Woods that I hope will continue to be preserved in the face of regional development.)  Some days I simply wander over during lunch for a 20-30 minute walk.  It’s amazing how quickly one can forget you are in an urban area, in the midst of a major medical and research center.  And how quickly you can forget the looming deadlines, or the upcoming budget discussions, or the last person who pissed you off.

OK, off to Maine.  For those of you staying home, try the woods across the street.

Simple.  Declarative.  Forceful.  This isn’t just a fluffy, sentimental, feel-good statement.  This four word sentence is a point of advocacy, a recognition that for too long, and still too often, kids don’t actually get the best. It calls attention to ongoing disparities for kids in health care and other areas of society.  For example, while the overall poverty rate is 14.5%, it’s 22% for children. Only 60% of medications used in both children and adults are approved for and have information on pediatric usage. And payment rates for Medicaid, the primary government insurance for children, are lower than for Medicare, which covers adults.

Few people would disagree with the notion that kids deserve at least as good as adults get.  So why do society’s results fall so short of its ideal?  In many ways, the deck is stacked against children’s issues.  Kids don’t vote.  (And they don’t make campaign contributions.). And because they are basically healthy, while children are 28% of the population, they represent only 13% of all health care spending.  So it makes sense that politicians and policy-makers, and health business leaders, are focused more on adult issues.

Now, saying kids deserve the best doesn’t mean adults don’t, too.  Advocating on behalf of kids to bring them to par doesn’t mean I’m advocating against adults.  I’d love for everyone to have a lower poverty rate, or universal access to medications.  But saying “everyone deserves the best” obscures the message that kids have been missing out.  So with all due respect to my fellow adults, I’ll continue to work to ensure kids get what they deserve.   The Best.

As I often do, I had a wonderful run early this morning on the Hank Aaron State Trail!  Extending 12 miles from Lakeshore State Park, just south of Discovery World, to 124^th St (the portion west of 94^th is unfortunately closed during the Zoo Interchange construction), the HAST provides a vital east-west link in the 117-mile Milwaukee County Oak Leaf Trail system.  While there are many wonderful trails in the Milwaukee area (as described by the Journal Sentinel’s talented outdoor writer Chelsey Lewis), the Hank Aaron is one of my favorites.  Love the combination of seeing the Menominee River, the historic Soldier’s Home, Miller Park, and the now re-industrialized Menominee Valley.  One of the joys of being out on the trail is seeing the vibrant mix of bicycle commuters from Tosa and the east side of Milwaukee (including at least a few Children’s Hospital providers and staff!), along with the predominantly Latino and Hmong families from the near south side neighborhoods through which the trail passes out recreating on the trail, all living out our value of health.

To support that value of health, Children’s Hospital of Wisconsin is a sponsor this year of the annual Friends of Hank Aaron State Trail 5k run, on Saturday, August 6^th.  Proceeds from the run support not only trail maintenance and enhancements, but also programming such as the free Bike Adventure Camps for disadvantaged children from the adjacent communities.  It’s a great way for Children’s to partner with other community organizations to provide opportunities for kids in the area to become the healthiest in the nation.

As part of our sponsorship, we have a limited number of complimentary entries for the run.  If you are interested in joining, please contact Robin Pitts.

Several years ago, we had an exchange student from Norway who needed to see a specialist periodically to have a cyst drained.  The day before a big school dance, she told me she needed to go get it taken care of before the dance.  As in, that afternoon!  I explained to her that in the US you can’t simply see a subspecialist to get a non-emergency procedure done at a moment’s notice.  We have these things called appointments.  And you have to make them.  In advance.

Was this just a cultural difference in expectations based on better medical care access in Scandinavia?  (It turns out you can’t just waltz into the ENT office same day in Norway, either.)  Or was it typical Millennial insistence on instant gratification?  Either way, she asked if maybe she could find someone else to do it.  I then explained that her doctor was one of the best, and no, we weren’t going to find just anyone, who might not do as good a job – quality is worth waiting for.

A lot of us in health care tend to rationalize this way.  Quality is most important; convenience is just a frill.  We feel pretty good if our time to next appointment is “only” a week or two.  Yet I routinely get requests from people inside the system who have to wait that long for a family member to see if there is anything that can be done to get them in sooner.  I heard a colleague at another hospital talk about how nearly every day she helps friends and “important donors” get quicker access.  Not only does this create a two-tiered system of easy access for those with connections while regular folks have to wait, it belies the assertion that convenience isn’t important.  Timeliness is one of the six domains of quality espoused by the Institute of Medicine. And while we tend to associate such impatience with the Millennial generation, it appears to be pretty important to the Boomers whom my colleague keeps listed on her phone.

Data from a Healthgrades survey in 2014 suggest that in choosing a physician or hospital, convenient location and hours were cited as factors far more often (56-62%) than outcomes (22-30%).  While this may be accelerating, this has been true for some time: a 2000 study from University of Nebraska of factors used in choosing a primary care physician found that wait time for an appointment was as important as whether she/he had any malpractice history, and more important than factors such as the doctor’s training or years of experience.

To the extent that the prioritization of convenience is a bigger issue for the Millennial generation, then those of us in pediatric health care need to be especially ready to address this, as the Millennials are the parents of our patients.  And they aren’t willing to wait for what they want.

The first time I saw a TV ad for a prescription medication (direct-to-consumer advertising was made legal in 1985), I was appalled.  Not only because of the long list of potential side effects – which as I recall included both flatulence and death) – but the whole concept that companies would try to market something as complex as a drug the same way they would treat floor wax or breakfast cereal.   Health care is not a consumer good!

Well, it’s become clear that health care is, in fact, a consumer good, and those of us who provide health care need to accept that and understand how consumers make decisions about it.  Even when we grudgingly admit that people may be doing some “shopping” for their medical care, we tend to think that health care is still very different.  In some ways that is certainly true.  For example, measuring and reporting on quality is far more challenging in health care.  And there is considerably less ability for consumers to get information on medical cost than for almost any other product or service.  But as a 2015 McKinsey study showed, the factors used by consumers to rate health care and non-health care companies are nearly identical: the top 4 were (in order) customer service, “delivering on expectations,” convenience, and “offering great value.”

It may be that these other factors are merely proxies for actual quality measures.  As noted in a Deloitte report:

Quality tends to be defined with professionals in mind. In lieu of understanding clinical quality, consumers may substitute cost, convenience, and customer experience for quality. Consumers may well equate quality with cost, assuming a direct relationship between the two.

Certainly, health providers like to think that when it comes to picking a doctor or hospital, quality is most important and trumps everything else.  But maybe not so much.  Another McKinsey study found that although patients stated that clinical outcome was most important to them, experience was actually more highly correlated with willingness to choose that provider again.  And cost is increasingly a factor.  In a 2015 survey by FAIR Health, 48% of all respondents indicated they always or usually considered cost when selecting a doctor.  And despite a widespread belief that cost is no barrier when it comes to health care for children, it actually appears to be more important for the generation with kids.  In this survey, cost was more often cited as a key factor for those age 18-44 (58%), those with children (56%), and women (53%).

We can wish away consumerism (and TV ads).  Or we can deal with it.  That doesn’t mean sacrificing quality.  We need to maintain our commitment to the best and safest care.  At the same time, we also need to address families’ real concerns about cost, convenience, and experience.  It starts with one element of our service promise: “I will strive to understand what matters most to you.”  If we don’t know what consumers value, we can’t provide it, or help them navigate the choices they must make.