Sunday, December 27, 2009
Friday, September 11, 2009
September 2, 2009
This is the first of a two-part report about the search for a more cost-effective health care delivery system.
In the national debate over health care, a key factor driving up costs seldom gets discussed: the payment system for doctors.
At present, the more procedures doctors perform, the more they get paid. The health industry calls this practice "fee for service." Many consider it a perverse system — one that lacks incentives to hold down costs. Yet the legislation pending before Congress may not do enough to change it.
Prioritizing Quality Over Profit
At a recent White House news conference, President Obama gave a succinct diagnosis of the nation's health care ills: "We spend much more on health care than any other nation, but aren't any healthier for it."
The remedy the president prescribed, though, was not health care reform — it was health insurance reform, a term he and fellow Democrats have lately begun using to describe Congress' effort to overhaul health care regulations.
But one Democrat warns that the problem goes well beyond health insurance. U.S. Rep. Jim Cooper of Tennessee says the real issue is a system bent on telling consumers that more is better.
Transforming The Model
Read the second in this two-part report on the search for a more cost-effective health care delivery system:
Minnesota Experiment Puts Patient Health First Sep. 3, 2009
"The message of our medical system has been to 'sell, sell, sell, buy, buy, buy,' " Cooper says. "And the real message should be, 'What's really going to help me live longer and healthier?' "
With the fee-for-service model for health care, Cooper says, doctors have little reason to discourage the demand for more and more health procedures.
"I liken fee-for-service medicine to the situation if we paid lawyers by the word, or by the paragraph," he says. "We would have the longest legal documents in the world, and essentially, that's what we do with our doctors, but most of us don't realize it."
Republican Sen. Olympia Snowe of Maine agrees with Cooper. Snowe is one of three Republicans working with three Democrats on the Senate Finance Committee to forge a bipartisan health care bill. She wants legislation holding doctors and hospitals accountable for both the cost and the quality of their treatment.
"The fact is, right now, we encourage volume over value," Snowe says. "We've got to really analyze what is the net outcome, you know, in the procedures and the testing and the care that is provided [to] individual patients, and by whom."
Other lawmakers say incentives for cutting health care costs should be directed more toward the patients themselves.
Wyoming Republican Sen. John Barrasso, who is also an orthopedic surgeon, says there is nothing in the legislation now before Congress to motivate people to live healthier lifestyles — "nothing that's aimed at helping people individually and gives an incentive to that person to eat less, exercise more and quit smoking."
Changing An Unsustainable System
Even outside experts say that while the health care payment system encourages waste, it's not clear what the fix is.
"I think the truth of the matter is, we don't know exactly what would be the best way to reform payments," says Karen Davis, a health care expert who is president of the nonpartisan Commonwealth Fund.
Health Care Legislation
What The 'Gang Of Six' Wants From Health Care Bill Sep. 9, 2009
Davis says the legislation pending before Congress does offer some incentives for more cost-effective health care: Medicare would crack down on excessive hospital re-admissions, and there would be bonus payments for Medicare providers to improve the quality of their health care. Pilot projects would also be funded.
"There are pilots for medical homes for primary care; there are pilots for accountable-care organizations, which certainly cover the continuum of care. But there are also pilots for bundling hospital payments," Davis says. "I think all of those are very important for laying the groundwork for fundamental payment reform."
Rep. Vic Snyder (D-AR), who is also a physician, says the fee-for-service model is unsustainable. But, he says he has hopes for the health care legislation before Congress, which he calls a work in progress.
"Whatever the final version is," Snyder says, "we'll have this discussion maybe after the president's ink is drying on the document. Then we'll say, 'Well, was it a little nudge? A big nudge?' But it will be a nudge in the direction of more efficient delivery of health care services in a way that rewards quality [and] fairly reimburses providers."
Part II of this series can be found online at http://www.npr.org/templates/story/story.php?storyId=112488466&ps=rs
So....what do you see and hear that is encouraging? How might professional providers support YOU in making life style choices that enhance your body and mind's health?
Tuesday, June 9, 2009
Dear Nurse Deb,
Can you recommend iron rich foods for an anemic teenage boy? Would simply not eating enough greens make him anemic?Thank you,
Let's start with some definitions of terms here. Anemia is a general term that is used to describe a blood condition where there are less healthy red blood cells than is expected, available to carry oxygen around to the body's muscles, organs and tissue. This number varies by age and gender and is impacted by living at high elevations or being dehydrated, being pregnant, or menopausal. Generally, a healthy teen male would be expected to have a Hemaglobin (Hgb) level of 14.5, (a range of 14-18 is considered normal) and for females 14 with a range 12-16. People who are anemic often describe symptoms including: feeling easily fatigued, short of breath when exerting oneself, pale skin, and may have 'pica' which means obsessively eating non-food items (dirt, clay, ice, paint, hair, etc).
Anemia can be caused by loss of blood (injury, heavy menstrual flow, bleeding gastric ulcers, etc) or can be triggered by deficiencies in the building blocks our bodies use to form new blood cells in the bone marrow in our 'long bones' of our legs. What are these building blocks? Iron is an important one and a leading cause of anemia in children who have inadequate dietary intake of iron-rich foods. Folic acid or folate is another, ferritin, and Vitamin B12, and protein are the primary components. It makes sense that if you don't provide building materials, the bone marrow will be unable to form enough red blood cells to work for the body. There are other more obscure types of anemia that are related to blood cancers, hypothyroidism, or organ system problems that destroy healthy red cells (heart valve disease or kidney disease) so that they are ineffective workers to carry oxygen around the body, but these types are far less likely to occur in otherwise healthy kids.
HOW IS ANEMIA DIAGNOSED?
Your doctor will want to take a thorough history talking to both the teen and parents about diet, food preferences, and daily food log. S/he will ask about the teen's activity level, any injuries (rule out bleeding), stress level (is this teen at risk for bleeding gastric ulcerations?), medications (are there any that cause cell destruction or impair the ability of the GI tract to absorb nutrients?), under-lying health problems, and family medical history that might reveal predisposition for anemia or other significant illnesses. Blood tests are run (CBC - a 'complete blood count') that will give your doctor information on the hemoglobin, hematocrit, and other tests (MCV etc) that are clear indicators of the health and function of the red cells. I would guess that testing for iron, ferritin, and folate blood levels will also be done.
PUMPING IRON WITH FOOD & VITAMINS
Teens are growing at astronomical rates and are at higher risk to become anemic if their diet doesn't keep pace supplying all the important vitamins and minerals like calcium and Vitamin D, iron, and Vitamin C. Ever notice how these vitamins and minerals show up paired? It is because Vitamin D increases the absorption and utilization of calcium from food and supplement sources as does Vitamin C impact absorption of iron! But here's a problem - calcium and the foods that are rich in it often inhibit the uptake and absorption of iron whether from food or vitamin/supplement form. Let's look at the foods that are strongest for iron and then we'll talk about strategies for managing this paradox. The goal here is 12mg. of iron daily for male, and 15mg. a day for female teens.
'Heme'-rich Iron Sources (ie those from animal source - wouldn't it be great if there were heme-rich iron in energy drinks?! Fat chance.) Chicken livers top the list at 7mg/serving followed by oysters at 4.5mg and drops from there.
- Meats - beef, pork, lamb and liver, and especially organ meats
- Poultry - chicken, turkey, and duck, especially the dark meats and liver
- Fish - shellfish like clams, oysters and mussels are great; sardines, anchovies, other fish
Non-Heme Iron Sources:
- Leafy green veggies of the cabbage family - broccoli, kale, turnip greens, collards, chard
- Legumes - lima beans, green peas, dry beans like pinto, black-eyed peas, canned baked beans
- Whole wheat bread and rolls
- Iron enriched bread, pasta, rice and cereal
Note: the iron absorbed from Heme-rich food sources is 15-30% more efficient than non-heme iron which is absorbed at only a rate of 5%. Eating some of both is a good idea. In the Non-heme iron list, fortified cereals can carry 18mg/serving, legumes 4-8mg, but remember it is less fully absorbed than its 'heme' cousins.
When you read the list of non-heme iron containing foods, you may notice that many of these plant based foods are also good sources of calcium. Even foods like orange juice are being fortified by calcium supplements which can raise the odds of us meeting the target of 1300mg/day for teens. One source commented that most adults never reach their daily intake target for calcium, so why are we surprised that our kids don't either? Good point. Another source claims only 10% of female teens meet the goal for calcium intake - read "I don't want to get fat" here? In addition to deep green leafy veggies, milk and other dairy foods are the biggest source of calcium in the American diet. Fat free and low fat versions generally work as well as the high fat milk and cheeses. But here is our paradox showing up - milk and dairy products are often a significant contributing factor to iron deficiency anemia!
NON-DAIRY CALCIUM-RICH FOODS
Ok...here's the list.
- Salmon and sardines
- tofu, rhubarb
- deep greens like okra, spinach, collards, kale, broccoli, peas, brussel sprouts
- NUTS! Hurrah - almonds, sesame seeds
- Soy milk
- cereals, oatmeal, instant breakfast, oj
I keep wondering how we expect to get sardines, liver, tofu and kale into these kids? Even I wouldn't eat some of it! I guess creative cooks have added hidden ingredients to sauces, pancake mix, and casseroles forever. A case of what we don't know is there will help us, and we may never even taste it! But back to the paradox of calcium/dairy blocking absorption of iron...my suggestion at this point is to alternate what gets eaten - if you're doing lots of dairy, have your iron food several hours later or an hour before you ingest what will block absorption. If need be, ask your doc if adding a multi-vitamin is a good idea or find at the health food stores the protein powder mixes that can be buzzed into a smoothie with fruit to add more of the building blocks to your young person's diet. Or yours! Most of all, start reading food labels if you haven't already made it a habit. There is a wealth of information to be had there and I am betting it will bring you to being more mindful about what you choose to take home from the store, and what you put into your mouth or the mouths or your family.
If any reader has ideas about how a teen might metamorphize from a junk food junkie or king of energy drinks to a healthy eating nut, I'd love to hear about it. I'm reminded that our kids learn far more about living from seeing what we DO than by what we tell them or force them to do. Good luck, Sacramento Gal, with your teen who is entering the mysteries of feeding his body in appropriate ways during these teen years. Check back and let me know how it's unfolding - my email is email@example.com or leave me a comment on this thread!
Monday, May 25, 2009
When we talk about healthy living, choosing foods or actions that serve us well often means that we are faced with making a life change that to give up a habit for a new choice or behavior. Do we go from smoking two packs a day to being a non-smoker just because we think we should? When faced with diabetes how many people do you know who walked easily away from eating sweets to follow the recommended diet? Granted, fear or iron self-discipline can serve people in making big changes, but most often humans go through a pretty predictable process. Maybe you’re like me in that when you have some understanding of WHY you may react as you do, it can make it easier to be kind to self and make different choices. Try this out.
Notice this is not a one time event or a single decision made, but a PROCESS which means as many times as is needed over time to make a true change in habit. Researchers call this Transtheoretical Model or Stages of Change.
FORMAL NAME //SIMPLE NAME
Precontemplation // Unaware, Unwilling
PRECONTEMPLATION describes any of us prior to awareness that what we’re doing may not be a very good choice for us. Example: “I eat all my food fried –what’s the big deal about that? I like it that way and it’s how Mom fixed meals.”
FORMAL NAME //SIMPLE NAME
Contemplation //Listen, consider, inform self
CONTEMPLATION comes when the fried food lover finds out his older brother has had a heart attack and almost died. He hears that eating fried foods can contribute to heart problems, but hey, it’s not HIM who had the heart trouble – it’s his brother. “ Couldn’t happen to me!” Stage two is when our fellow finds out his own cholesterol levels are sky high - a major risk factor for heart attack. NOW he’s more willing to listen to all this talk about diet…he’ll think about it. Can’t hurt to find out what he could do instead.
FORMAL NAME //SIMPLE NAME
Preparation // Making a plan, letting go, grieving the changes
PREPARATION to change a habit includes things like wondering “CAN I change? Do I have what it takes to do something so challenging?” Or “Who can help me – take a cooking class or date that cute little gal who’s such a health freak! She’ll cook for me and show me how.” Selling the deep fryer, getting olive oil to replace the corn oil…grieving the changes, feeling mad that you ‘have to,’ realizing you’re kind of scared and don’t really want to die in your 40’s.
FORMAL NAME //SIMPLE NAME
Action //Starting again, taking small experimental steps
ACTION – making behavior changes, repeated choices to enact the new behavior, wrestle with the longings for the habitual, “Hey! I like baked fish!”
FORMAL NAME //SIMPLE NAME
MAINTENANCE includes staying with the new program to make better choices and can include “slips” when you backslide, ie eating Fish and Chips but not every meal. Slips always are followed by a choice to begin again or to give up, but hopefully there is internal motivation and outward support to keep going.
QUESTIONS FOR YOU……
1. What is it you know in your heart that you do (or not do), right now, that is not good for you?
2. What do you like most about your unhealthy choice?
3. What do you like less well about it?
4. What stage listed above are you in if you were to consider making a change in behavior?
5. What’s one tiny little step you might be willing to take to turn around this habitual action or lack of action?
If you’re contemplating a change in your life style behaviors, you’ll notice that part of that phase is “making a plan.” Most human beings I know and love are fallible, ie they make mistakes, back-slide, and have slips in their new behaviors. Planning can help you to identify who in your world would be supportive of you in making a plan to change how you live. Consider someone from inside your family, friends who may be more objective, adults or “grandparent” types who will respect and nurture you as you tackle the hard stuff, and maybe even young people who have unfailing confidence in you. Getting a number of those folks alerted to become your “pit crew” can make a huge difference in succeeding with your plan for change. Trust me, none of us needs more failure!
Another suggestion is to connect with a health professional who can be your health coach during change process. Ask Nurse Deb! Leave me a comment here if you’d like to arrange for private conversation via phone or email, and see my web page for details of how this process can work for you. http://www.asknursedeb.com/
Sunday, May 24, 2009
Tibetan Medicine and Indian Ayurveda tell us that "food is our first medicine." It implies that food choices can soothe what ails you, or by eating what is in harmony with your body type, you can maintain your good health and skip altogether the experience of getting sick. Perenial wisdom of the 80's assured us "You are what you eat." Feed lot fattened beef filled with chemicals? Chickens so top heavy they cannot walk even if they had room to try? I would suggest that our culture of fast foods, highly processed foods, and allegedly 'fresh' produce that travels >1,500 miles to reach us is not exactly what makes for healthy strong bodies. Small wonder diabetes and immune dysfunction are skyrocketing - we've forgotten what life giving food looks and tastes like and are losing the tribal knowledge of how to prepare food from scratch! (Definition: 'Scratch' means having meat or other protein source, veggies, carbohydrate, beverage, perhaps fruit or desert that you put together and cook to create a meal - not thawing or heating up a pre-packaged item or warming soup from a can!)
How many young people launching into adulthood know how to cook for themselves? Unfortunately that issue is not new to this generation - how many middle aged to elder men know how to cook for themselves? A family tale tells of a young woman whose mother wouldn't allow her to enter "her" kitchen, and upon her marriage in the 1940's, the young couple survived on BLT's until the husband couldn't bear it any longer and offered to teach his bride a few more meal menus. How many times a week do you or someone in your household cook a meal from scratch?
GARDENING & FARMING?
How many people know about gardening? How many people know how to raise a food animal and care for its needs now that family farms have been consumed by agribusiness? I read a disturbing report last year about a survey of both urban and rural students who were asked to identify where common foods come from, answering questions like "Do beans grow on trees, plants, or are they part of a root?" "Does bacon come from a plant or animal source?" Respondants didn't do so well...I guess our young people believe that beans come in cans or frozen in plastic bags from the grocery store and never think more about it. That is, if they eat green things at all! I cringe remembering how my son would assert that "Vegetables are what FOOD (ie cows, chickens, deer etc) eat!" even though he was raised eating salads and fresh veggies from our garden. I'm not sure I want to know what his dinners look like in his bachelor pad.
In my grandparents' generation, gardening and home canning of food to last through the winter was a way of life. The whole family participated from little kids to elders. Victory gardens sprouted in urban yards in response to World War II's food shortages. We began to lose our knowing as refrigeration, transportation and manufacturing boomed and made available to us food from all over the country and now, from all over the globe. But despair not - organic farmers teaching us about healthy soil and are showing us the delightful outcome of preparing food without the petro-chemicals of fertilizers, herbicides and pesticides. Farmers' Markets are thriving and popping up in many communities to provide life-filled, truly fresh produce. We have universities teaching adult learners to be Master Gardeners as we realize just how wonderful a process it is to produce flavorful food from our healthy soil, sunshine, fresh water, seeds, and sweat.
Author Barbara Kingsolver and her family have gifted the world a wonderful book, Animal, Vegetable, Miracle: A Year of Food Life that chronicles their year of exploration of what it means to "eat local" - food that has been produced within 100 miles of their home, and to eat in harmony with the season, foregoing summer fruit from South America in the dark of winter here in the states. The book includes recipes, political and social commentary, web resources, and helpful informational "how to" for things like making your own cheese, mingled with narrative of the successes, frustrations, challenges and satisfaction that accompanied this family's growth. There is also a web site on which people from all over the globe have contributed stories and ideas for furthering the work begun in Animal, Vegetable, Miracle...a down-loadable index to the book's topics and resources, updates and photos. It is an inspiring site to browse! My hunch is that this book will either scare you into finding the nearest Big Mac super-sized meal to hide from the truths told, or it will inspire you to never look at food in quite the same way again. It may even become part of your personal eating evolution! Enjoy, and let me know what you think about all this new/old information and ways of living. May our food be our medicine and may we be healthy and happy!
Tuesday, May 19, 2009
I had never dreamed I would have this experience - and I am so very grateful. I hold the presence of the current class who left for India on Sunday, in my heart and thoughts, wishing them a life-altering experience on their adventure. Enjoy a photo of the Tibetan flag flying over the institute.
In the quest for personal wellness and health, this dog-run program has identified some basic yet essential components of what ensures healthy happy living - exercise, play, good company, time spent outdoors in nature, regularly scheduled mealtimes and adequate restlful sleep. (I am grateful they leave the cooking to us however as I don't think our interpretation of what is a gastronomic delicacy has much in common. )
Here are some questions for you to ponder:
- Who paces YOUR day if you don't have doggy trainers?
- How often are you skipping meals because you're too busy?
- When's the last time you cooked a meal and ate it with your family or housemates?
- How well are you sleeping and do you wake feeling refreshed and rested?
In the next few blog posts, I will comment about ideas for healthy living choices and invite readers to challenge my assertions, be challenged in turn to 'own' the ways they may fall into not so healthy habits, and offer up hard learned suggestions to readers of this thread. I'll also give you something to chew on that describes how we humans dance around with the notion of change, and changing our behaviors.
My doggy health coaches have just rushed in from tussling outside followed by a quick dip in the pond, wagging their soggy tails and smiling widely! When's the last time I felt that kind of exuberant delight with my life? When's the last time I skinny dipped in the neighbor's pond?!
The two of them have taken up positions on the floor recognizing that "She's doing that computer thing again..." followed by deep contented sighs. As I think about it, dogs are pretty adept at patience and quiet meditative 'being-ness' too. Pretty masterful companionship, isn't it?
Thursday, May 14, 2009
Clear, effective communicating is not done easily when one is a patient in a busy clinic setting or when you feel awful and are an in-patient of the local hospital. The following have been noted to contribute to physician/client communication glitches:
- Being undressed ( a bare foot doesn't compare to the GYN exam outfit!)
- Sitting either above or below the physician
- Competing with the computer for the doctor's eye contact and attention
- 15 minute appointment allocations
- Fear about diagnosis (the patient or the doc's distress or both...)
- Stress (I'm late, you've waited a long time, I have someone in the ER that needs me...)
- Topics I don't want to hear or talk about (sex, impotence, mental illness, addiction, etc)
As a client you are pretty powerless to change how your doc is feeling about his/her day, but asking for the first appointment of the morning or afternoon can be one way to find your doc on time and refreshed from a good night's sleep or lunch break - theoretically. (Keep in mind that emergencies have no respect for either sleep or meals so your doc may have slept little or "lunched" with a bag of peanuts thrown down his throat in the elevator.) However, there are things YOU can do for yourself to increase the odds of holding up your end of the communication skills.
- Don't ever go to an appointment alone. The buddy system works well - two sets of ears and two brains can be a bonus. (Keep in mind this person needs to be trusted with your personal medical information and identified in the doc's records as a trusted insider.)
- Talk with your buddy before the visit to fill them in on your concerns, what you want to accomplish in the visit with the doctor, and get their ideas.
- MAKE A LIST of questions you'd like addressed, or of symptoms or changes in your well-being. Prioritize what is most important as you may not get all the way through your list.
- When possible, put your clothes back on and sit in a chair facing your doc at eye level for the "talking" part of your visit. It evens the power.
- Ask your visit buddy to write notes during the visit, or use a tape recorder to track lab data, instructions for medicine changes, words you need to look up later.
- If you know ahead of time that you have many questions or will need time to talk about treatment choices, ask the scheduling person to make it a 30 minute appointment. If you need time to absorb a diagnosis before making a treatment choice, schedule a return visit in a few days. Go home and process, talk it over, feel, react, breathe deeply.
- Consider expressing what you appreciate about the visit with your doc - gratitude is a powerful shifter of moods and enlists your provider in appreciating YOU!
- When you are an in-patient, find out when your doc will likely make 'rounds' so your buddy can be present and advocate for your needs. Be sure to share with this buddy your concerns, questions, changing physical status so they can speak in an informed way if you are unable to speak for yourself. Consider making a copy of your "today notes" and give it to your nurses - they often can advocate/facilitate order changes far more quickly than waiting for a doc to arrive.
Finally, know that we are all imperfect humans living in an often challenging and scary world. There is plenty of room for forgiving foibles, finding humor to lighten instense times, and recognizing we're all doing our best. It may seem evident that your doc is far from a god and oh, so human......but maybe we're all God and just don't remember. So let's practice, shall we?
Tuesday, April 28, 2009
- When do I need to consult with a doctor or other care provider?
- How to make sense out of what you were told at a recent visit to the doctor?
- What a lab test means and how important the results are?
- This is what my doctor recommends - do I have any choices???
- How do I take care of my child and who is the best person to consult for his care?
- What can I do if I don't want to have chemo or other medicine prescibed by my doctor?
- How can I become a healthier person?
You're not alone. People often seek out someone knowledgeable to find out just how their body works, what their choices might be for treating an illness, or what all the big words mean that medicine throws around so readily.
WHY ASK NURSE DEB?
I know how to listen well. I speak the language of medicine. I can help you make sense of what puzzles you given my 30+ years providing professional nursing in a variety of health care settings and age groups from babies to elders. I've learned a lot about living well, dying, and meeting life's challenges with courage, honesty and humor. I know where to look for medical resource information and to discern what is based in scientific knowledge and what is opinion or "spin." Not much about the human body embarrasses me anymore but sometimes I still am surprised by what I have yet to know about being human. I can serve as your health coach as you explore making changes in how you live, supporting your intentions and holding you accountable for the goals you have set for yourself!
I have successfully raised children as a single mom, have learned about grief and loss through personal experience, and am exploring aging first hand for myself and with an elder parent. I use a variety of integrative health modalities for my own well-being and for those who consult me; I can introduce you to many potentially helpful health-enhancing practices that address your whole self.
HOW DOES ASK NURSE DEB WORK?
You will find a growing library of postings here that raise issues in self-care, health related current events, and responses to reader concerns that may be useful to many in the on-line community.
I'm glad to field your questions here as long as the asker is ok with response that can be shared by anyone reading the blog. Check out my web site at http://www.asknursedeb.com/ (under construction at this posting) for information about arranging for email or phone consultations for those issues that are best discussed with privacy and confidentiality.
My goal is to empower each person who brings me a question to make good choices for themselves, to learn to ask great questions of their care providers, and to learn more about how their body, mind, and spirit interact and 'work.' I want you to go away from our conversation feeling like you have been heard and respected, understanding better what had puzzled you. When I don't know the anwers to your question, we'll enter into learning about it together!
Here's to your health and happiness - let the questions begin!