Tools

The other day, I was at my own physician’s office (I see a Family Medicine doctor too) and talked with the nurse about my own job as she was getting my flu shot ready.  She told me that the doctor had asked her to call a certain patient every day to remind her to take her blood pressure medication.  No, it wasn’t an elderly patient, or someone with mental illness or anything like that.  It was a young woman who was working full time, and busy, and simply not taking her medication for whatever reasons. 

 

I don’t know about that.  It seems much more productive to help people find the tools to solve their own problems.  Tools already exist- things like pill boxes, calendars, post-it notes, toothbrushes (as in, keeping the pill bottle next to it…assuming that you do indeed brush your teeth at least once a day).  The nurse went on to say that she called this woman every day until she herself went on maternity leave, and then hadn’t started up again; if she had encouraged the woman to solve her own problem, the leave would not have disrupted anything (and, well, I don’t imagine that the nurse called her at home on the weekends, either).  This sounds catty.  I don’t mean it to be.  I am figuring this out for myself.  People that I have been calling and talking with have told me how nice it is that I took the time to see how they are doing and several have told me that they hadn’t been taking their meds- and started to take them after I called them.  Interestingly,  a recent study shows that when patients perceive that a caregiver does, indeed, care about them, they get better faster. 

 

So I would have asked that patient, what’s something that you do every day at around the same time, something you never forget or skip in your routine?  How could you use that as a trigger to remember to do this other thing?  Or, could you set an alarm?  What else can you come up with?

 

What else can you come up with?

Groups

I’ve done some benchmarking in the past year.  Several months ago I had set up a tour of another big urban Family Medicine clinic in our city, one whose focus is to serve the underserved (as is ours), but that seems to be more innovative in doing so.  One of the things that amazed me about the place- besides the fact that all providers are bilingual in either Spanish or Hmong- is its commitment to offering facilitated peer groups.  They offer all kinds of groups for people with all kinds of chronic conditions.  Diabetic cooking classes.  Salsa dancing for weight loss.  Asthma management groups.  The only offering that was not well-received, they told me, was a group for women with depression.

 

Another “sister” clinic offers a smoking cessation group, prenatal programs, nutrition classes, weight loss, and a diabetic group.

 

We ourselves have had a group for diabetic patients for a couple years now, and recently piloted a prenatal group- the nurse that works with the prenatal group was happy with how it worked out.  “They call each other!” she told me today.  Certainly, it did look like the pregnant ladies were having a good time- and learning- in their meetings.  I can’t help but think that peer groups are the way to go: mutually supportive people coping with similar situations, able to share their own solutions to problems. 

 

I put together a proposal for a six-week stress-management group that we could offer in January and February, the darkest and coldest and most post-holiday time of year here; we’ll see if it is deemed feasible.  It could be fun.  I certainly hope so!

Enough?

I had initially thought that our clinic was going to submit the PCMH application in December; as it turns out, we are submitting it tomorrow.  Have I done enough?  Have I reviewed enough charts?  Have I made enough care plans?  Have I called enough patients?  (Well, calling them and actually reaching them is an entirely different matter.)  Have I filled out the templates correctly in the electronic medical records?  Are there things I should be doing that I am completely unaware of?

 

I did have two meetings with patients this week that went especially well, which keeps me enthusiastic and feeling like I am somewhere near the right track.  But, sending someone off into the wide world with more information, a tool to accomplish something, or a sense of confidence is totally different than “meeting numbers for the month” or “percentage of our diabetic patients that are well-controlled.” 

 

I’m trying not to feel anxious about it.

Sodium

It’s interesting: the more I talk to patients about making lifestyle changes, the more I’ve thought about the same things in my own life and made some changes.  I’ve started being much more aware of the sodium content of foods, too- something that I don’t need to be as concerned about for myself as our hypertensive patients do, but which is concerning on a meta level, because what is inexpensive and convenient is what people are eating.

 

We have in our community a sort of discount chain of food stores and I shopped there twice recently, reading labels.  I found that the cans of non-condensed soup have considerably more sodium content than the cans at the, I guess you would say mainstream supermarket (not discount, not high-end).  Eating consciously takes more effort on a restricted budget, it would seem.  As always, awareness is key: I did find some heat-and-serve organic tomato soup there for a very reasonable price which has lower sodium; but even still, each serving contains 600 mg- 25% of the US RDA- and since the can contains two servings- a person (for example, me) is likely to eat both while on break at work.  Of course, if my other meals are low in sodium, then this is not a problem.  In fact, I know that I will be thirsty after a high-sodium meal, which is something of a disincentive as well.

 

This is something I was never concerned with before; but having heard myself give my own low-sodium instructions so many times, I have internalized it: yet more proof that this kind of thing works.

Urgent acute issues

One of the frustrating things that I encounter when I call a patient, and I am all ready to talk about healthy living and making the most out of life with/despite chronic illness, is that so many people have so many acute issues that come up and disturb this plan that I have.  Or many, many more chronic things that interfere with the day-to-day management of any one of them.  Sometimes it’s an interrelated cloud of problems that makes it hard to deal with any one thing successfully.

 

For example, I might call a patient to see what her blood glucose readings have been, and find that her longstanding back pain is so bad that she’s crying about that.

 

I might call someone about his blood pressure, thinking we are going to talk about exercise, and his asthma is flaring up such that he can’t even think about leaving the house–much less physical activity.

 

Tonight, I called several patients, inviting them to our monthly diabetes support group.  Usually these are quick reminder calls- it’s kind of an easy yes-no-maybe kind of question, with a brief sales pitch if the person seems a bit hesitant or if I have someone new on the list.  Tonight was a bit different for whatever reason.  One patient verbalized intense frustration with her insurance not wanting to cover a medication for a different chronic condition, resulting in an acute flareup.  I offered to contact the insurance company (well, the state, really).  I offered to contact her pharmacy, which I did, and the kind pharmacist did have a very workable-seeming alternate solution.  The patient just got very angry at the situation and nothing that I said or did seemed right to her- she eventually hung up on me.  We never did get around to talking about anything related to diabetes.

 

Health-care providers, what do you do in these situations?  What I have been doing, is dealing with the acute issue, deferring the chronic one to a later, hopefully less-anxious time.  Logical, yes?  Except that the list of deferred things grows ever-longer.  And yes, there are a lot of people out there that have sort of a constant amount of acute urgent things going on.  Any ideas?

Five a day, the color way

One of the handouts that I really enjoy giving out at work is a “Five a Day, the Color Way” list put out by the hospital that our clinic is affiliated with.  I think of it like a shopping list of sorts; one of the scripts that I use (yes, I rely pretty heavily on scripts; it’s not a bad thing) is that I’ve started using it as a kind of shopping list, because I don’t always remember to bring home a variety of fresh produce.  Which I did, yesterday, from the farmer’s market:  muskmelon (orange), eggplant (purple), sweet peppers (green), and apples (red).  Actually, my mom just gave me a bagful of homegrown tomatoes, so I am very well set for red, as you can see.

 

Here is an easy heart-healthy recipe, endlessly adaptable to anything one might come home with from the farmers’ market:

Select any three or more of the following: zucchini, eggplant, tomatoes, mushrooms, onion, yellow squash, potatoes, peppers (any color, any kind- sweet or hot); basically, whatever you have on hand.  Dice into approximately centimeter (half-inch) cubes.  Saute with a little olive oil, just a pinch of salt, and whatever spices you have around- garlic, basil, pepper, rosemary, cilantro, whatever you like.   If I use potatoes, I add a little broth to help them soften.  Don’t overcook it.  You don’t have to hover over it, either.  A couple of gentle stirrings will do while your main dish is cooking.  Serve with whole-wheat pasta or brown rice, or another grain, and your protein entree.

 

Seasonings are key here: freshly-ground pepper is a staple in our house, as are home-grown herbs like basil, rosemary, mint, chives, cilantro, sage, and oregano.  They are easy- I grow them in pots, bringing them inside into a sunny window for our northern winters; many can be grown from seed without much trouble at all.  They keep food tasty and interesting, and flavorful without too much salt. 

 

The “sweet” spices- cardamom, allspice, nutmeg, and the like- keep me from using too much sugar when I bake treats.  In fact, the reason that the store-bought bakery to which most of our taste buds have become accustomed is so sweet, is that it is cheaper to use lots of sugar (or worse, high fructose corn syrup, also known as HFCS) in the process than to use actual flavors other than simply “sweet” (similar to the way processed foods contain a lot of sodium, in order to mask the lack of actual other flavors besides “salty”).  Think about that.  One of the reasons that food you cook yourself has more flavor is because you control the amount of sugar, salt, and real flavors that you can add.  You have control over what you eat!

Walking the walk

I really do believe that living a healthy lifestyle leads to actually feeling better.  More energy, better moods, that kind of thing.  Yet I know how easy it is to fall into bad habits: eating one chocolate chip cookie can lead to an empty box and a queasy stomach, eating too much fast food leads to having to buy all new bigger pants, drinking too much soda leads to a mouthful of cavities.  I have done all of these things, so I know.  (I have been able to develop more of a sense of moderation, however.)

 

I also know that cutting down on sweet things changes a person’s taste buds somehow, making the person desire less; retraining them, so to speak.  And I know that exercising, counterintuitively, will give a person more energy in general: it seems to increase energy.  It doesn’t take, it gives (like love, I guess).

 

My job (my part in getting our clinic ready for the Patient-Centered Medical Home application) involves calling many, many people, seemingly at random, to assess for readiness to make changes like eating a healthier diet, quitting or cutting down on smoking, and the like.  So I did something that was nearly unthinkable to me: I stopped drinking coffee.  Partly to test my theory that if a person really wants to lick a life-permeating addiction, it can be done.

 

Now if you know me in real life, you know that drinking coffee is a part of my identity.  Probably every cell in my body contains coffee compounds.  I have been addicted to caffeine for years, not just the chemical substance, but also the ritual: the making of the first morning coffee, the ritual of the drinking of it, the little break that comes with walking to the coffee machine at work, and meeting people for coffee.  Does this sound familiar?  It does kind of sound like smoking, doesn’t it?  And yes, it is kind of difficult for me to see other people drinking coffee.  I want it.  People continue to drink it in front of me, to offer it to me.  But I recognize also that it feels so much better to not have caffeine in my bloodstream, to not feel anxious and then exhausted, to not smell like coffee- yes, it is a lot like smoking.  And now I feel bad for having said to people, “Go ahead, have just one cup!”

 

Possibly the turning point for me came earlier this summer, when I was camping in the woods with my husband, and we had to stop and get out the stove several times a day to make coffee.  It seemed imperative.  I was exhausted without it and craved caffeine, even in the midst of fresh air and sunshine.  It was impossible to function without it.  I knew then that I had to overcome the dependence. 

 

I did find some teas (delicious ones) that substitute for at least some of the ritual.  That’s important, I think: to find a substitute for what is good about the thing you are giving up.  The idea is not to “deprive” yourself; that has always, always backfired for me.  It is like the old “try not to think about an elephant.”  Um, trying not to think about a butterburger will generally end up with me ordering one…and onion rings.  However, eating something else…something delicious, something fresh and satisfying, will do the trick.  I’ll post more about that next time.

Patient registries

One thing is for certain: health care reform is upon us.  I do certainly hope that there will be less waste in health care, money better spent, and more of a focus on primary and preventative care.

 

One thing that is mentioned in the America’s Affordable Health Choices Act of 2009, as it is called, is patient registries: that is, that each primary care provider will have lists of their patients with chronic illnesses that they are managing.  That is the direction that our clinic is moving in as we apply for the Patient-Centered Medical Home certification.

 

We have registries completed for our patient population for three chronic illnesses.  Hypertension, diabetes, coronary artery disease were selected.  We are a large urban practice, and have many patients with those first two conditions that are not under optimal control.  There are many factors that play into this.

 

We actually started a diabetes registry awhile ago and have been trying a targeted case management approach with that for some time with some success.  I should say, more success than if we had not been using such an approach.  For example, we have one patient at our clinic, a male in his 20′s with DM, who had been having Hgb A1C’s (a measure of blood sugar over time) over 12 in December 2008.  Optimal is 6.  A 12 represents an average blood sugar in the mid-300′s over the previous three months, very poorly controlled diabetes.  His primary care physician talked to him about ways to get into better control, and he agreed to email me his blood sugars starting in April- which he has faithfully done.

 

He has been sending me his fasting blood sugar readings every week and I cut and paste them into his electronic medical record, where I can forward them to his PCP.  At first, in April, they were regularly in the 150′s up to 200.  Every week they came down a little, aided by gradual new orders for increases in insulin which I relayed to him via email, and just the reminder that he was accountable for sending them to me every Monday.  In July I got this email from him also:

 

“I have been feeling better, not really tired and really thirsty since I have been taking my medications and Lantus regularly.”  That is the kind of thing that makes me feel good about my role as a nurse: seeing that kind of change, that increase in motivation, that actually leads to feeling better and living better with a chronic condition.

 

 

How many times?

How many times must a person hear a message before taking it to heart? 

 

The classic example is quitting smoking.  Every smoker knows that he or she “should” quit smoking, and all the reasons why.  I personally would never tell a person to quit smoking.  I suggest cutting down, suggesting ways to cut down.  Quitting smoking is difficult, but smoking less has benefits too and can lead to actual quitting.   I have never been a smoker, but I know that it is one of the harder addictions to lick.

 

I have been thinking about other changes I’ve made in my life, though, and how many times I had to hear “You should…” before making a beneficial change.  In those cases, though, it was an addition of a good behavior, rather than the subtraction of a detrimental behavior- quite a different thing.

 

For instance, my physician had to gently remind me about five times that I needed to take calcium before I started taking it (almost) every day like I should.  But I have a better example.

 

At the church I used to attend, there was an announcement in the bulletin every week about an ESL (English as a Second Language) tutoring program for Spanish-speakers, which in our city are many.  I thought I would probably like to volunteer, but I had a hundred excuses: it was on the other side of town; I had too many other things to do; I was shy, and it was a one-on-one tutoring situation; I didn’t know any Spanish.

 

I probably saw this notice fifty times and went through the same list of excuses every time.

 

Then I had a surgery and ended up being off of work for more than three months.  I watched a lot of TV during that time.  Regular TV got boring and I started watching Spanish-language TV.  I was lonely and needed something to do; I couldn’t work eight hours, but I could tutor for two.  I called the head teacher and got started tutoring.

 

Think about that: I saw the notice fifty times.  The head of the program had spoken about it enthusiastically many times as well.  It took that, plus a life-altering medical issue, to get me to try it.

 

I love it; I’ve been doing it for three and a half  years, during which time I’ve started seriously studying Spanish, in the hopes of being able to better serve the Spanish-speaking patients that come to our clinic.  I’ve become more comfortable talking to people.  It has positively impacted my life in so many ways–and others’ lives as well.  But taking that first step?   That took a lot.

 

So I do understand that it is difficult to make life changes.  But I also understand that positive changes not only benefit the person who makes a good change, but people all around that person.   I keep all of these things in mind every time I interact with a patient.

Learning from every encounter

A couple of weeks ago, I went to see my auto mechanic.  The conversation that we had made me realize that every interaction with another person is a chance to learn, and often the things that I learn are applicable to my work as a nurse.  This particular trip to the mechanic was one such time.

 

I only had to wait a short time for him came out to talk to me, even though I had shown up without calling first.  He listened carefully as I described my car’s problem- I don’t know much about cars, but from what I said he figured out the most likely cause, taking a test drive to verify: sure enough.

 

As we were setting up an appointment for him to actually do the work, I casually mentioned that my husband and I are looking for a new car.  I mentioned that I wanted a hybrid.  He asked me a couple of careful questions and I realized that what I really wanted was the lowest-emission vehicle possible.  He helped me understand my real goal: reducing  the amount of pollution that I create is more important to me than saving gas (our city has enough ozone-awareness days.  The fact that urban populations are already exposed to high pollution has been well-documented; believe me, our clinic gets plenty of asthma exacerbation calls on those muggy, smoggy days). 

 

I hadn’t realized what I really wanted until he teased it out of me- knowing my and my husband’s  habits and opinions, particularly but not exclusively regarding driving,  from having been our mechanic for many years.  He told me a few other things to get me started on my search, distilling his own research on the subject into words I could understand- knowing that I know little about cars besides how to drive.

 

As I was leaving, I asked him if he could fix the malfunctioning “tweet” alarm mechanism that seemed broken: every time I got out of the car, it would tweet at me, seemingly for no reason.  “Oh,” he said simply.  “It’s not broken.  Look.”  He showed me that the transmission was allowing me to remove the key in the “accessory” position, rather than “lock,” causing the alarm to sound.  I wish I could convey here his tone of voice: I had asked him what must have been a stupid-easy question, and he answered simply in a way that did not allow me to feel stupid.  Changing my habit has indeed solved the “problem.”

 

Afterwards, I realized that this is how I would like to be in my work as a nurse: patient, knowledgeable, kind.  Every encounter with another human being can be a learning experience, regardless of whom it is with.