Nurse and Lawyer have been on vacation! Well, Ok, not really. . . Laywer was taking the bar exam, and Nurse was on vacation.  In the mean time, though, I’ve caught up on some reading. Have you seen this article in the Stanford Social Innovation Review? 

palm trees

I don’t just suggest it because on of the authors (Paul Farmer) is a great inspiration to me, but because it shows great wisdom and promise. . . the authors suggest that health care is in crisis in this country, and that’s a great time to fix it– in part by expanding our concept of what health care means. Perhaps, they suggest, we can take lessons from successful programs in low-resource situations– by, for instance, addressing basic physical and social needs. It’s not a new idea– but it’s not often applied in this genreally rich country. Take a look. Give it a think. 

We’ll be back to regularly scheduled programming soon!

xo, Nurse

Update: Debt Collectors in the ER?

A few weeks ago, we wrote about medical debt collection going on in hospitals, and whether it was interfering with treatment or intimidating patients out of seeking needed care. Now Kaiser Health News is reporting on new Treasury Department proposed rules curbing this practice. (See also: straight from the horse’s mouth, here is the press release). Is the Obama administration reading N & L? (I kid, I kid). These rules are called for in the Affordable Care Act, and, as expected, are controversial– the American Hospital Association, for instance, thinks hospitals are being held too responsible for the actions of 3rd parties when required to provide this new protection– which is just too much to ask, apparently? Come on now, let’s not forget that health care is supposed to be about patients!

From the department of righteous indignation:

I will depart from our regularly scheduled programming to bring you a brief bout of righteous indignation, which, while not technically about law or nursing, affects nurses and lawyers, so here ya go! –Nurse

Have ya seen this? Did ya hear this? Women can’t have it all. 

Anne-Marie Slaughter gets it wrong. Her article is not really about women– it’s about parenting. 

First, she identifies a very real problem: that women are in fewer leadership positions in business and government  that women are paid less, and that this needs to change. But for Slaughter, it needs to change so that these women leaders will let other women spend more time with their children. So she has brought this very real issue of gender inequality back to the desire to spend time with children– implying that women care about this greatly, and men do not. She points to a “maternal imperative felt so deeply that the ‘choice’ is reflexive.” Her argument rests on the fact that she, and some other women, don’t WANT to work long hours in high-powered jobs when they have young children. This situation is, in a way, exactly what she insists that it is not: being less committed to work. It is not, however, a problem just for women. Choosing between work and other pursuits affects everyone. Perhaps, a generation behind Slaughter,  I have view my own options as a woman differently; when I went to college, more women were enrolled than men, birth control was available without hassle, and “alpha-wives” could be married to house-husbands.

 

Slaughter writes that the choice to take time out of the fast-track life to be with children is ultimately damaging to women’s careers. This is true– and it’s ok, when the women in question are the ones who choose to spend more time with their families. The effect is the same on men who do this. Why shouldn’t people (not just women) who would rather spend more time at work than raise families advance faster at work? This IS a choice, and not only for women. What is really damaging to women is when employers take the same position that Slaughter just did– that women feel a deep “maternal imperative” and will always choose family over work. This position creates prejudices against young women. Am I going to disengage and quit my job at any minute that my ovaries start tingling? Are my male counterparts immune from the allure of choosing other things over work? Absolutely not. So while “family friendly” policies and work-life balance are  good ideas for a host of reasons, it’s not about women. So let’s call it what is is.  When Slaughter write of “having it all,” she means having a high-powered career while also having children and spending time with them at home. If that is “all,” I’ll pass.

HYPE! HYPE, I TELL YOU!

So apparently morning-after pills don’t prevent implantation after all? (Which matters because that’s the reason abortion opponents hate them. Or say they do.)

Nurse: Oi vey! I feel like every time we open up a discussion like this, I
put on my sarcastic hat and say something like, “what, does pregnancy
begin at ovulation now, no sperm required?” and then the religious
right is like, “yes, actually, it does.” and then my head explodes and
something inside me dies.

Lawyer: That’s right. We’re all pregnant right now. In fact, we’re born with eggs,
so maybe we’re born pregnant?

Nurse: So now, if, as this article suggests, EC pills actually stop fertilization rather than stopping implantation, you’d think that would make things better, wouldn’t you? I guess my
point is that. . . well, they probably won’t. Whatever the quibble was this time, there will be something else, seemingly unthinkable, to take its place. Such is the nature of this debate. It’s not reasonable or logical.

Lawyer: True, but it’s often couched in those terms. So I think there’s value in
continuing to expose flawed logic. To protect the integrity of logic, if not to win on the actual issue.

Nurse: OK, Mr. Spock!

Lawyer: Plus, there are plenty of people out there who are swayed by logic. So, the
super-fringe will hold fast no matter what. But I have to believe there are people who will listen to reason, or reasonable-sounding things, such that that battle is worth fighting.

Nurse: In terms of the labelling, we sell all kinds of drugs that work without completely understanding the mechanism, and that is all fine and dandy and perfectly legal, right?  Also, the FDA may not really be a great source for cutting-edge science– they are the sanctioned authority, but not necessarily “right.”.

Lawyer: Agreed. What I think is really fascinating here is the power that one line
of an FDA label had. We’ve seen this fight play out a bit with the question of over-the-counter morning after pills, too — a good deal of the debate ends up being about
what’s on the label. But there seems to be a disconnect between how those things get designed and the immense ripples they can create.

Nurse: Finally, I always think it’s interesting when science may be influenced by religion and politics. Who is funding, or suppressing, research? Who knows?

Lawyer: Tell that to Secretary Sebelius.

Nurse: No, ma’am, I don’t like it!

Puff, puff, fail.

NPR recently looked at the problem some colleges have when students with medical marijuana prescriptions bring their drugs with them onto campus– because it’s illegal under federal law, colleges which allow it are at risk for losing federal funding.

Nurse: So what we have here is an issue where a single substance is both a prescription medication under state law and an illegal substance under federal law. So. . . houston, we have a problem. Lawyer, what happens when state law and federal law conflict? We know that the feds could pull funding, but what else? I feel like I heard noise from the federal government that enforcing marijuana laws in states where it was legal was not a priority.

Lawyer: Well, basically, it’s still illegal. The state and the feds act in tandem, and the state has said this isn’t a crime, but the feds have said it is, so the state cops can’t arrest you but the DEA still could. Though as I recall, the Obama administration had decided it wasn’t going to prosecute medical marijuana. It hasn’t been all that much of a problem in the more general sense, but this federal funding thing is thorny. 

Nurse: I’ve heard an argument about this which amounts to, “come on, you can’t let these college kids have pot prescriptions, it’s a crock of shit and they’ll just sell it to their buddies.” But, well, first of all, no, there are legitimate medical uses and everyone knows that, and second, state law has already said it’s ok, so the “come on” argument just doesn’t work. 

Lawyer: But state law doesn’t trump federal law. So the feds can still say “come on,” even if the state says it’s okay. In any event, the thing that college kids are getting prescriptions for and selling to their friends isn’t marijuana — it’s aderall. 

Nurse: Imagine this scenario with another drug– something that isn’t illegal under federal law– and it becomes ridiculous. Your student in chronic pain from a car accident can’t have percocet? Your student with ADD can’t have adderall? Your student with cramps can’t have motrin? The college gets to make rules about these things? But when we have this conflict with federal law, this is not longer a patient specific, private issue. Hmmmm.

Lawyer: What I want to know — and this article doesn’t say — is why they think they may lose their funding. Certainly the feds could do that, but have they given any indication whatsoever that they intend to? I also wonder what exactly we’re looking at here in terms of policies. If the college is silent on the matter — i.e., they have a policy that says generally that students are entitled to use drugs for which they have a valid prescription, but are not entitled to use recreational drugs — where is the issue? Do they need pot-specific policies that would draw this kind of scrutiny? Certainly the student would be subject to the same risks he’d be taking if he used the drug anywhere — the feds could always come for him. Why is it on the college, unless they somehow specifically go out of their way to allow it? No one is talking about student health physicians writing these prescriptions. 

In the mean time, it’s a shame if indeed there are students who cannot attend classes because they need the medication, and their colleges are too risk-averse to deal with the situation and give them access to education as needed.

Nurses protesting NATO

Or, a nurses’ union protesting at the NATO meetings, to be more exact. Lots of news stories covered this story today, so I thought I’d touch on it.

 Perhaps this is puzzling to people who think of nurses as doctors’ handmaidens, bedpan emptiers, and bosses at psych hospitals. Or perhaps it’s troubling to people who feel that nurses should be apolitical, providing compassionate care to everyone without ruffling any feathers or making anyone uncomfortable.

The union members at this particular protest seem to be advocating a “Robin Hood tax” along with a general anti-war message. 

 Whether or not you agree with the politics, I think it’s crucial that our society think of nurses, and that nurses think of themselves, as promoters and protectors of well-being. So, yes, you may see your friendly neighborhood R.N. waving a protest sign for a political cause that affects the well-being of the community– more power to her/him. 

(Just to be clear: I’m not talking about bedside nurses engaging in political actions, or god forbid, discrimination, while in the role of direct caregiver. I hope we all agree that at this level, everyone, regardless of politics, should be treated equally. I am talking about nurses as community members, advocating for causes that they feel are important to the health and well-being of the community. Ok? Ok.)

Nurse Love from the NYT.

The New York Times is all about nurses today!

In this “Fixes” piece on “The Power of Nursing,” David Bornstein talks about the Nurse Family Partnership (where nurses make home visits to families beginning early in a mother’s pregnancy and continuing until the child is 2) and its great successes in improving health and preventing all kinds of troubles — including criminality later in life for the kiddos. Perhaps the most interesting thing he notes? It doesn’t work if someone who isn’t a nurse makes the same kind of visits.

Lawyer’s favorite part:

What’s special about nurses? For one thing, trust. In public opinion polls, nurses are consistently rated as the most honest and ethical professionals by a large margin.

 

That’s definitely not, er, something people say about lawyers. 

 

DSM-V: What’s at Stake?

The American Psychiatric Association is scheduled to publish its next edition of the massive manual of psychiatric disorders next year. Some changes were made at their Annual Meeting last week. Allen Frances has expressed some concerns in a New York Times op-ed.

A few reasons why we care what the APA says is a mental disorder:

It can influence what types of medications and treatments insurance companies will cover.

It can influence what doctors decide to do with any given patient.

It can influence how the law treats different kinds of problems. (One reason for throwing out a suit that alleged a video game maker was liable for ruining the life of a gamer who got addicted to playing it? Video game addiction is not a recognized diagnosis.)

It can affect how responsible people are considered for their actions. (And while having a diagnosis doesn’t qualify you for the insanity defense, it can act as a mitigating factor in sentencing.)

Not to mention the softer factors of telling people they have a disease or mental illness — when that’s debatable.

There are plenty more consequences — please chime in in the comments if you have thoughts!

Really, Kansas? Really?

We could barely bring ourselves to write about this.

The Kansas House has passed what would probably be the most restrictive abortion bill in the country, described here by the Huffington Post.

Lawyer: I think the two most troubling provisions (obviously?) are the ones mandating that doctors tell women certain things, and those authorizing doctors to withhold certain information. 

Nurse: Yeah. . . this seems like it completely undermines the doctor/patient relationship. You can no longer trust that your doctor is telling you what he really thinks is in your best interest. This seems a little. . . facist? I don’t know. The state doctor is going to tell you the state facts about your body now.  True? What do you mean? The state scientist said so. This is coming from the political party that wants the state to intervene less? Um. Ok. I think we really have 3 parties– democrats, fiscal conservatives, and religious right-wing nut-jobs. 

Lawyer: We can look at it both from the perspective of the rights of the patients and the rights of the doctors.  (Let’s not forget that the First Amendment not only prohibits restraining speech — but also compelling speech.)

Nurse: Good one. Plus, I didn’t even get into the fact that, um, the birth control/breast cancer link which is part of this whole argument is not what any informed person would call solid evidence. So there’s another way the state is telling doctors to lie.

Lawyer: It also raises a really thorny question about the relationship between science and law, reminiscent of the debate about teaching creationism. If a legislature deems something fact, that doesn’t make it true — but they do (and properly, I think) have some control over a curriculum. It’s harder to argue that the government has any role in dictating what can happen in the exam room with the door closed.

Nurse: Yep, that was my reaction as well– it’s similar, but worse. Private physicians behind closed doors should not have to tell patients any particular thing. Public schools. . . . more debatable. But, then, how the h-e-double-hockey-sticks are they going to enforce that law? Big brother? 

Lawyer: It’s also just really gross.

Nurse: AMEN, SISTER.

In Nursing News. . .

In nursing news, Centers for Medicare & Medicaid Services made a lot of changes this week, including expanding the definition of “medical staff,” to allow professionals including advanced-practice nurses to practice to the full extent of their training and scope without arbitrary federal rules about physician oversight– state laws already govern scope of practice.

This is a coup on behalf of patient care, healthcare systems, and nurses! CMS is explicitly recognizing that health care is changing, and moving away from a model which is entirely physician-driven.  We had a pretty long discussion   on the issues surrounding advanced practice nurses a while ago. Is this week’s news indicating that the times, they are a changing’?