SECOND GUESSING CANCER

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stock-photo-doctor-with-mammography-292061516I’ve written in a previous post about my experience of being diagnosed with breast cancer 18 years ago. I’ve always wondered if I should have forgone a mastectomy and adopted a watch and wait stance. However, when my doctors never gave me that option and my family was aghast at my doing anything less than full warfare on the invading cells in my body, I gave in to surgery.

The type of cancer I had, ductal carcinoma in situ or DCIS, is still under investigation. Is it or isn’t it cancer? If it doesn’t leak out of the lining of the milk glands and metastasize, is it truly deadly? The treatments given to women can sometimes cause more problems than living with cells that, in some instances, resolve. So I was happy to see more attention given to finding answers in a new study about DCIS in the JAMA Oncology (online) August 20, 2015.

I had become an advocate of taking “cancer” out of DCIS label. That way women wouldn’t panic and rush to having mastectomies and in some cases prophylactic double mastectomies. Hopefully “watch and wait” would be an added choice rather than have women succumb to unnecessary treatment.

After I read the original article in JAMA—I am not going to tell you I understood all the statistics—I realized that DCIS is what most cancers are: complicated. Some types of DCIS can predict that a lethal breast cancer can occur in the future. I am more sympathetic of the tightrope that physicians and surgeons walk in counseling their patients.

The accompanying editorial by Laura Esserman in the same JAMA issue gives the following suggestions:

  1. Much of DCIS should be considered a “risk factor” for invasive breast cancer and an opportunity for targeted prevention.

  2. Radiation therapy should not be routinely offered after lumpectomy for DCIS lesions that are not high risk because it does not affect mortality.

  3. Low-and intermediate-grade DCIS does not affect mortality.

  4. We should continue to better understand the biological characteristics of the highest-risk DCIS (large, high grade, hormone receptor negative, HER2 positive, especially in very young and African American women) and test targeted approaches to reduce death from breast cancer.

Hopefully these suggestions will become a common practice in health care settings so women like me won’t be regretting a choice they made based on incomplete knowledge and overdiagnosis by the medical professionals.

OLDER WOMEN: THE NEW TREND IN FASHION

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Joan Didion

Joan Didion

I am always on the lookout for positive trends in aging. Here’s what I found in Creative Review. The Age Issue, (June 2015) on page 40:FullSizeRender

Cooler older women are having a bit of a fashion moment. What started a couple of years ago as a trickle of magazine covers and ads featuring women over 60 has recently turned into a flood: Helen Mirren for L’Oréal, Charlotte Rampling for Nars, Jessica Lange for Marc Jacobs, Joni Mitchell for Saint Laurent . . . the list goes on. When Joan Didion was announced as the new face of Céline SS15, via an ad showing her looking almost unbearably hip in a photo shot by Juergen Teller, Twitter exploded with excitement. For those of us weary with the endless parade of blank-faced young models, the arrival of some older faces—complete with both wrinkles and a story to tell—comes as a relief. (Bold and italics mine). . . Could we finally be seeing a shift away from the obsession with youth and a renewed respect for older womenkind? Could we?

Later, I found an article in the Travel and Style section of the Wall Street Journal: Smith, Erin Geiger. “Websites Predict Your Perfect Dress,” The Wall Street Journal, (6 Aug. 2015), which discussed online shopping. One web site, MM.LaFleur, offers a “ ‘Bento Box’ of clothes and accessories ” based on a series of questions to discover the preferences of the prospective buyer. MM.LaFleur goes on to ask buyers to select their “girl crush.” (I take this to mean which woman you most want to look like). The choices are not supermodels but real people. Okay, famous people and some dead ones, but not with unattainable physical perfection or youth. People like Oprah, Sonia Sotomayor, and Amilia Earhart and wait for this, Joan Didion.

I can only surmise that there is a growing trend, however subtle, toward an expanding female ideal that includes, finally, older women with wrinkles, character and brains.

May this trend continue.

WHEN A NURSE IS AS GOOD AS A DOCTOR

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I couldn’t pass up sharing this article in Consumer Reports about nurse practitioners and physician assistants especially since I just registered with my new provider, a nurse practitioner a week ago. She and a physician assistant cover for each other. Best of both worlds.

Check the comments, which are so positive.

When a nurse is as good as a doctor
Nurse practitioners and physician assistants can offer first-rate care
Published: July 14, 2015 08:00 AM BY ConsumerReports.org

Across the country, nondoctor health care professionals—usually nurse practitioners (NPs) and physician assistants (PAs)—are turning up in a range of medical settings. We see those so-called advanced practice providers most often in primary care and family medicine practices, but they also work as specialists in hospitals and retail clinics, and more. In rural areas, they may be the only health care providers who are regularly available.

Their ranks are growing fast. In the past 10 years, the number of licensed NPs in the U.S. has almost doubled to 205,000. Between 2003 and today, the number of certified PAs grew from about 43,500 to more than 102,000.

One major reason: Demand for doctors, especially family physicians and internists, is outstripping supply. The Association of American Medical Colleges expects a shortage of up to 31,100 primary care doctors and up to 63,700 other physicians by 2025.

Advanced practice practitioners can make up the shortfall. But can they give you the care you need? And how does the care compare with what you’d get from a doctor?
What they do, what they don’t
PAs and NPs are handling many tasks that were once the exclusive domain of doctors: They can write prescriptions in every state. In 21 states and the District of Columbia, NPs can practice autonomously. Some NPs and PAs substitute for residents at academic medical centers.

But there are differences between them and doctors. One distinction: What advanced practice practitioners are permitted by law to do can vary from state to state and even from hospital to hospital. For example, NPs can’t prescribe controlled substances in Florida. In some states, a supervising physician needs to be on site when a PA treats you; in other states, it’s not necessary. Nationwide, an NP’s or PA’s authority to admit you to a hospital is up to the hospital.

Training differs, too. Doctors and PAs train under the so-called medical model (though primary care doctors have about 23,000 hours of education and training, PAs have around 3,000). That teaches physicians to “work through a diagnostic process that directs the questions you ask, the physical you perform, the diagnostic studies and treatments,” says Reid Blackwelder, M.D., chair of the American Academy of Family Physicians’ board of directors. Nurse practitioners are educated under the nursing model, which stresses health promotion and education.

Ultimately, what an NP or PA does in your doctor’s office will depend on his or her experience, the setting, and the speciality, notes Marc J. Moote, PA-C, chief physician assistant at the University of Michigan Health System in Ann Arbor. “Often, each physician/PA/NP team will decide the best use of everyone’s skills on the health care team, and this can vary from practice to practice,” he adds.

6 big benefits
NPs and PAs are indispensable in handling everyday problems such as sore throats or urinary tract infections, freeing primary care doctors to handle more complex conditions, says John Santa, M.D., medical adviser to Consumer Reports. They can also prescreen patients, make hospital rounds, do follow-up care, monitor treatment, manage chronic conditions, and have a place in specialty care as well. “They can be very good at the history taking, reviewing a patient’s records, and coordinating everything the specialist needs,” Santa adds. What’s more, many PAs work as surgical assistants. Though seeing an advanced practice practitioner is unlikely to lower your co-pay, it can help reduce overall health costs. Other benefits may include:

Shorter waits for appointments. Merritt Hawkins, a health care search and consulting firm, found that in 15 metropolitan areas, new patients wait, on average, 18.5 days to see a cardiologist, dermatologist, family physician, obstetrician/gynecologist, or orthopedic surgeon. But with more providers in the office, the PA or NP can see a patient if the doctor can’t.

A team approach. Having an NP or PA on staff makes some aspects of team-based health care more feasible. He or she can check a cough, cut, or sprain, and ensure vaccinations and blood pressure and cholesterol checks are done. A 2013 review in the Journal for Nurse Practitioners reported comparable blood glucose and blood pressure levels in people cared for by NPs as in people seen by doctors.

Convenient care. NPs and PAs staff some walk-in clinics at drugstores. So if you develop a urinary tract infection, for example, you can get the care you need ASAP.

Faster emergency-room treatment. Canadian researchers have found that in ERs with NPs and PAs on duty, people without life-threatening symptoms were twice as likely to be treated within 15 to 60 minutes.

Help with chronic conditions. Once you and your physician decide on a treatment, a PA or NP can make sure it’s going smoothly, for example, that your blood glucose levels are well-controlled.

APPs are especially helpful for seniors with chronic illnesses. A study in the Journal of the American Geriatrics Society noted that older patients managed by both an NP and a physician had higher quality care for dementia, falls, and urinary incontinence than those treated only by a physician. Co-management “is most appropriate for conditions that require a lot of close monitoring, patient engagement, and education,” says study co-author David B. Reuben, M.D., chief of the division of geriatrics at the David Geffen School of Medicine at UCLA.

Lower risk of hospital readmission. Leukemia patients in the hospital for chemotherapy cut their stays by about 6 days and were less likely to be readmitted within 14 days when cared for by PAs instead of doctors in training, according to a small study in the Journal of Oncology Practice. A 2013 study in the Journal of Thoracic and Cardiovascular Surgery found that when PAs make home visits to heart surgery patients as part of a PA home care program, it lowered 30-day readmissions by 25 percent.

See our Guide to Doctor Ratings and get advice on how to choose a doctor.

When to stick with a doctor
More research is needed to definitively assess when seeing a doctor might be preferable to seeing an NP or PA. Advanced practice practitioners have the know-how to play a primary role in diagnosing and treating common ills and an auxiliary role managing complex ailments, says Marvin M. Lipman, M.D., chief medical adviser to Consumer Reports. “Doctors are good for those 5 to 10 percent of patients whose symptoms don’t add up and need more detailed investigation,” he notes.

NPs and PAs say they can handle more than routine tasks. “It’s a misconception to assume they can’t diagnose or manage complex care,” Moote says.

That said, some research suggests physicians may be more skilled in some areas. For example, one 2013 study found that family physicians who referred patients to a medical center better understood what the symptoms might suggest and were more likely to order the right tests than NPs and PAs. The doctors’ referrals showed “a much more logical approach,” says William Mundell, M.D., assistant professor of medicine at the Mayo Clinic in Rochester, Minn. “They were getting closer to the diagnosis.”

Another key question: How many tests are different types of providers ordering? Recent research in JAMA Internal Medicine found that NPs and PAs tend to order slightly (less than 1 percent) more imaging tests than primary care physicians for similar Medicare patients.

The takeaway: All of those providers have an important place in health care. Make sure that you see the right one for you at the right time.

Editor’s Note:
This article also appeared in the August 2015 issue of Consumer Reports on Health.

WAS I DREAMING? PART TWO

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TEAMLast week, I attended the second and last part of the TeamStepps workshop. In another post (“Was I Dreaming?”) I described the first workshop and my surprise at how the doctors willingly and enthusiastically participated in the dialogue and group activities. What would I find this time around?

TeamStepps is a program that promotes teamwork and teaches “team strategies and tools to enhance performance and patient safety.” The audience was a group of professionals who worked in the surgical area of a large teaching hospital. I volunteer at the hospital and attended as an observer, although I did participate in some of the exercises.

The first thing I noticed when I entered the room was the empty chairs at each of the four tables. After we finished with introductions, it was clear most of the absentees were doctors/surgeons. I felt disappointed. Was their eager involvement at the last meeting just a charade?

This seminar was pivotal for implementing TeamStepps. The group in attendance—nurses, OR techs, surgeons, anesthesiologists—were to be the “coaches” who would model effective team work and help “change the culture” of the hospital. The leaders of the workshop, two doctors and four nurses, were poised to teach how to be an effective coach. Furthermore, there had been homework. Each table had been given a “discussion question” at the end of the last meeting with the expectation that the group would present a three to five minute demonstration. The occupants at my table included two nurses, one OR tech and an orthopedic surgeon who was preoccupied with the open laptop in front of him. I had already excused myself from participating in the skit.

When time came for the demonstrations to begin, those at my table seemed to be looking at the question for the first time. The other three groups appeared to be scrambling also. In the meantime, some doctors had slowly been slipping into their seats. Two appeared at our table and joined the activity. The surgeon at the end of the table had closed his laptop. Unbelievably, to me, each group, in turn, stood in front of the room and showed, as instructed, the right and wrong way to address their question.

(Our table was to communicate how the team would handle a situation when a necessary piece of surgical equipment fell to the floor and was contaminated).

In the skits, the surgeons played nurses, the nurses played doctors, OR techs were the anesthesiologists. The shows prompted much laughter and recognition of obnoxious and unprofessional behavior in the “wrong way” skit and applause for “right way” team interaction.

For the remainder of the meeting the leaders introduced peer-to-peer feedback, not easily understood by some of the surgeons who saw themselves as designated leaders and superiors and staff as subordinates. The coordinators, especially the nursing coordinators, gently suggested that the team was made up of peers regardless of occupational titles.

Like the first TeamStepps session, I was impressed with the positive vibes and enthusiasm from the audience. My world of hierarchical structure and deference paid to the medical staff was changing. I believe that this change in culture will bring a safer patient environment.

On the last page of the handout this statement stood out:

Important that staff realize this is not a passing phase—it is our model for patient safety moving forward.

 I think this model will indeed move forward at this hospital even though the ride may be a bit bumpy.

WAS I DREAMING?

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I have been a nurse for eons. Sometimes I feel I go back to Flo’s era. Even though I have been retired for ten years, I try to keep current with nursing/health issues. One evening two weeks ago I attended a TeamStepps workshop sponsored by the large teaching hospital where I volunteer. The purpose of the seminar was to promote teamwork among the hospital staff to ensure patient safety. As a member of an advisory committee, I was encouraged to attend in order to learn about new initiatives at the hospital. I walked out of the workshop four hours later wondering if I had dreamt the whole scenario.

There were about 50 folks in attendance. I approached my assigned table where one woman was seated, a nurse who worked in the operating room. Attendance was mandatory, she told me. She was paid for her time. A few minutes later a skinny guy in scrubs plopped down next to me and said, “What the hell is this all about?” I answered his question by introducing myself. He was an orthopedic surgeon, as were two other men who later joined our table.

Would any of the three last the whole four-hour session? I braced myself for a lot of muttering and antisocial behavior. In my biased mind, orthopedic surgeons stand out as the most paternalistic of all the medical specialists.

A second nurse and a cardiologist rounded out our group.

After we finished introducing ourselves, I realized most worked in surgical areas (The cardiologist inserted stents, a surgical procedure that he performed in the OR).

What followed was not what I expected. The main leaders, one older orthopedic surgeon, who asked to be called by his first name, and two nurses, led the group though team building exercises, videos and discussions. The nurses, OR techs and doctors in the audience, including those at my table, participated. To my surprise, my table built the highest Lego tower demonstrating our superior use of “team work.”iLEGO TOWER

'Relax - we're all in this together.'

‘Relax – we’re all in this together.’

What the workshop demonstrated to me was that the team had replaced the doctor as “Captain of the Ship.” Or at least team members had a say in what happened at the bedside, or in the OR. All professionals were encouraged to speak up if they saw something that would negatively affect a patient outcome. In fact, a bright yellow card to wear hidden behind the staff’s nametag was inserted into our handout folder. It said “I Need Clarity.” It could be flashed at the attending/surgeon, or any team member, so as not to cause a patient anxiety. The team would then go out of earshot of the patient and family to discuss the potential problem. Every team member’s input was important.

As I walked to the parking garage at the end of the class, I wanted to call my old nursing school classmates so they could appreciate along with me how far physicians had come in becoming team players. My classmates and I came from the old school when nurses stood when doctors entered a room. We endured prima donna surgeons that had temper tantrums and threw instruments in the OR when they were angry. The doctors I had just observed took part in an effort to discard old actions and engage in team building behaviors.TEAM BUILDING

Well, things were changing. Okay it’s only one workshop, but it so impressed me.

I am going back for the second half this week. Let you know if I had been dreaming.

Why Caring Lessons Goes to Printers Row Lit Fest

Marianna Crane:

My very good friend, Lois Roelofs, says “Too few nurses write their stories.” Read about her interaction with the visitors that come to her table at the Printers Row Lit Fest in Chicago.

Originally posted on Ramblings by a Retired Nurse (in Chicago):

“Pardon me,” said the well-dressed older man. “But could you tell me when this festival got so big? Last time I was here, there were only a few tents. And today,” he paused, his smile wide, “this is huge, and so many people.”

imageSo began a conversation with a visitor from the East Coast last Saturday at the Printers Row Book Fest, the Midwest’s largest outdoor literary fest. His surprise and enthusiasm is one reason I’ve gone for several years and then displayed my nursing memoir, Caring Lessons: A Nursing Professor’s Journey of Faith and Self, for the past two.

I get excited already when I approach the street where it starts. There are several blocks full of tents with tables lined up on the sides of the streets. You hardly know where to start. Plus there are large outdoor tents and indoor venues for author presentations. When I’m…

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I’M ON VACATION

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painting of house and boatsI am at the beach with my family—our annual get-together. We found a new rental house, one with enough space for the grandkids to enjoy time away from the adults. Need I mention the adults enjoy this situation, too? We are thinking about renting this house next year.

As I type, the sound of the ocean competes with chattering from the birds. This idealistic scene is so unlike what my husband and I left behind in our new community. We are the second wave of about fifteen residents to move into the future eighty-three-townhouse neighborhood. The remaining homes are in various stages of completion. Recently, the most active construction surrounded and bombarded us daily with noise. Cement trucks blocked access to the street and the roads were covered in mud from multiple plantings of trees and shrubs.

Here I feel tranquil. The deck where I am sitting is sheltered from the sun and cooled by a gentle breeze. I can hear my grandkids laughing down by the water. It’s time to put away the computer and slip on my bathing suit and join them. After all, I’m on vacation.

Florence Nightingale: The Crucial Skill We Forget to Mention

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Marianna Crane:

Read this wonderful post about all the compelling reasons nurses need to write.

Originally posted on Off the Charts:

“Suppose Florence hadn’t been a writer? Think about it…”

Karen Roush, PhD, RN, is an assistant professor of nursing at Lehman College in the Bronx, New York, and founder of the Scholar’s Voice, which works to strengthen the voice of nursing through writing mentorship for nurses.

karindalziel/ via Flickr Creative Commons karindalziel/ via Flickr Creative Commons

When we talk about the diversity of what nurses do, there is no better example than Florence Nightingale herself.

She was an expert clinician working in hospitals in Europe and London and caring for soldiers in military hospitals during the Crimean War. She was a quality improvement expert, implementing improvements in military hospitals that had a major impact on patient outcomes. Her work as an educator created the very foundation of nursing as a profession. She was a researcher and epidemiologist, using statistical arguments to support the changes she demanded. She was a public health advocate, campaigning for improvements…

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NEW OLD AGE

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I usually have several topics twirling in my head the days before my bimonthly post is due. I’m never sure which direction I am going until the last minute.

First, I thought I would update you on my cell phone case that Connie Burns had made for me. (See last post: PRIMARY CARE PROVIDER: MD OR NP?) In fact, when I picked

Connie Burn's Custom Creations

Connie Burn’s Custom Creations

up the case, I took her picture at her stand in the Farmers Market and asked permission to use her name and picture, handing her my card with my web site to check this Sunday. Her creation, so beautifully made is also practical. Now I can wear my phone around my neck when my clothes haven’t any pockets rather than leave it somewhere in the house, not able to hear it when a family member desperately needs to reach me. (That would be my husband from the grocery store with a question about which brand of laundry detergent to buy.)

Then I wanted to write about my good friend, who finally decided to lose weight and succeeded. I had been worried about her for a while as she struggled with chronic health issues that now have moderated with dropping extra pounds. She can walk up a flight of stairs without losing her breath. And best of all, her thoughts on future living options have been revised from an assisted living facility to an independent apartment. The gerontological nurse practitioner in me cheers.

imagesI also thought of mentioning something about Nurses Week: May 6 to May 12. But I am having conflicting thoughts about the purpose and relevance of this celebration. So much so that I decided to spare you my rantings.

Last night I watched two episodes of Grace and Frankie on Netflix. If you haven’t been following the hype about this new comedy series it is about “older stars” not “cast as crusty grandparents or needy neighbors.”

I remember all the ballyhoo about the Golden Girls, which premièred in 1985 starring Bea Arthur, Betty White and Rue McClanahan. They were advertised as older, racy free spirits, behaviors inconsistent with their age. So I thought they were ladies in their 80s. I was absolutely shocked that Arthur and White were 63 and McClanahan was only 51. That was NOT old!

This time the cast really is older. The two female leads, Jane Fonda and Lily Tomlin, are 77 and 75, respectively. The men in the series, Martin Sheen and Sam Waterston, are both 74.

Finally, we have a show that aims to reach older viewers. What I do hope is that it catches the attention of a younger audience so that they can watch a program with an older cast, which doesn’t center on disability, dementia and constipation.

I hope you find time to check the show out for yourself.

PRIMARY CARE PROVIDER: MD OR NP?

13080945-farmers-marketMy husband and I moved to Raleigh four months ago. Yesterday, I went to the Farmers Market for the first time. It had opened just the week before. It was more eclectic than I imagined. Besides spring onions, sweet potatoes, a bunch of radishes, strawberries and a baguette from the stand of a local French bakery, I commissioned, for ten dollars, a cloth purse that would hang from my neck and hold my cell phone, and I got the name of a female health provider.

I was happy I didn’t buy more produce than I could reasonably cook. I love nothing more than talking with the farmers about various ways to deal with, to me, an unfamiliar vegetable only to have it sit, forgotten and rotting, in the refrigerator.19826120-fresh-produce-on-sale-at-the-local-farmers-market

At one stall in the market, a woman was selling handmade cell phone cases along with drawstring cloth purses. At the airport on our way to Costa Rica in February, I watched an older woman pull out her cell phone from a small purse that hung about her neck. What a practical way to have a cell phone handy when you haven’t pockets in your slacks but you do have a family that worries when you don’t answer their multiple calls. Only later do they find out you couldn’t hear your cell phone left in the kitchen because you were upstairs in your office. Together, the woman and I designed a Velcro sealed pouch that will hang around my neck or over my shoulder like a handbag. I’ll pick it up next Saturday.

Next, I noted a stall with the sign: “Duke Raleigh Hospital.” Duke sponsors the market. A young woman sat at a table with stacks of brochures. My husband and I hadn’t, as yet, found local health care services.

“We live just a few blocks away from the hospital,“ I said to the woman. “Is there an outpatient clinic there? I need a new provider, preferable a female.”

The young woman smiled. “Yes, there is a clinic. In fact, I go there and see Mary Smith (not her real name). I just love her.” She continued to tell me how wonderful Mary Smith was as she searched for a pen to write down Mary Smith’s name and phone number. She handed me the card, which also had the Duke website for further information.

When I went home, I unpacked the produce, told my husband about the solution to the cell phone issue and that I had the name of a new provider. Upstairs in my office, I checked the Duke web site. I clicked the link “Doctors“ and there was Mary Smith. But she wasn’t a doctor—she was a nurse practitioner. She was listed among other NPs and physicians.

I sat for a moment appreciating the immensity of this: that NPs were listed along with MDs, therefore allowing patients to choose either as their primary provider. Knowing how some physicians still try to limit advanced nursing practice, here was a site, at a major teaching hospital yet, that treated both equally. And the young woman who gave me Mary Smith’s name never thought to clarify that Mary was an NP, not a doctor. How refreshing.

Then the reality set in. Why I didn’t think my primary provider could be an NP? Was it because I had seen a physician for the past fifteen years? However, I was a retired NP. I had my own patients, albeit in collaboration with a physician. I had been in the trenches during my long career fighting against limitation of the NP role and dominance by medical organizations. I promote the contribution that nursing makes to health care. I support the independent role of the NP.

I was appalled at my sudden amnesia.

PICTURE OF NP

While I try to explain this lapse, I’ll call the clinic to find out if Mary Smith is accepting new patients.

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