Through the Eyes of Nurses

On February 25th in the New York Times, two stories appeared about nurses. Both sobering. Both timely. Both essential.

In my last post, I celebrated the fact that although the pandemic is killing scores of people and putting a strain on resources, including health care personnel, nurses have been in the forefront of the media getting the recognition that they have long deserved. And more nurses are speaking out by telling their stories. Long overdue. 

However, the two stories in the NYT need to be read/viewed. One is by Theresa Brown who I have many times spot-lighted here because of her accurate assessment (my view) of nursing issues. A nurse herself, she has been calling attention to the nursing profession in the media and through her books. 

Brown’s piece: Covid-19 Is “Probably Going to End My Career,” is an exposé of what is terribly wrong in the profession and what should be done. She writes bravely and honestly about the precarious state of organized nursing. 

The second article, One I.C.U. Two nurses with cameras, is written, not by a nurse, but by a photojournalist. He filmed a fifteen-minute video that is raw footage of two nurses working with dying Covid patients in the ICU. Unvarnished, compelling and poignant. It’s a must watch that shows exactly what nurses experience during their shifts.    

I’ve attached the links to both essays. The fifteen-minute video is imbedded in both. 

Covid-19 Is “Probably Going to End My Career 

One I.C.U. Two nurses with cameras

An Unethical Question

You May Be Only as Old as You Feel was a thought-provoking read in the New York Times on Tuesday October 22nd by Emily Laber-Warren.

Warren noted that studies show “(W)hen scientists ask, ‘How old do you feel, most of the time?’ the answer tends to reflect the state of people’s physical and mental health.”

Therefore, folks who feel younger are usually healthier than those who feel their age or older. Not surprising. On a lark, I asked Helen, whom I wrote about in my last blog, how old she feels. She just turned 80 and looks much younger, is exercising, and now doesn’t need her blood pressure medication anymore. She said she feels 50! Again, not surprising.

Then I felt guilty asking Helen that question because Tracey Gendron, a gerontologist, questions subjective age research. She thinks that asking the question is perpetuating our cultural bias that aging is fundamentally negative.

The essay stated that in some “cultures where elders are respected for their wisdom and experience, people don’t even understand the concept of subjective age.”

Furthermore, Dr. Gendron suggests that “the study of subjective age may be inherently unethical.”  She goes on to say, “I think we have to ask ourselves the question, are we feeding the larger narrative of aging as decline by asking that question? Older age is a time that we can actually look forward to. People really just enjoy who they are. I would love for everyone to say their age at every year and  celebrate it”

I agree with Dr. Gendron. There are so many subtle “beliefs” in our society that undermine positive aging. I revisited a past post of mine Rethinking How to Handle this Age Issue. I wrote that post not only to promote being proud of our age—at whatever age we are, and as a reminder not to support the premise that old age means decline.

I listed on the Rethinking post a wonderful resource that I will again cite: Old School: An Anti-Aging Clearing House that educates about ageism so we know ageism when we see it.

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A Nurse Tells it Like it Is

A nurse has called attention to our dysfunctional health care system in the OP-ED section of the New York Times. (Our Jury-Rigged Health Care System by Teresa Brown, New York Times, September 6, 2019)

Brown has hit a nerve as evidenced by the 969 comments to date supporting her stance.

Her article discusses how nurses (and physicians) use “workarounds,” that is, they circumvent onerous rules to make sure patients get even basic care.

I found the piece a frightening expose.

May more nurses speak out about our ineffective and unsafe health care system in order to educate consumers and institute functional policy changes.

 

Our Jury-Rigged Health Care

 By Theresa Brown 

  • New York Times, OP-ED Friday, September 5, 2019

 

The nurses were hiding drugs above a ceiling tile in the hospital — not because they were secreting away narcotics, but because the hospital pharmacy was slow, and they didn’t want patients to have to wait. I first heard about it from Karen Feinstein, the president and chief executive of the Jewish Healthcare Foundation, who reported it at a board meeting several years ago. I wasn’t surprised: Hiding common medications is a workaround, an example of circumventing onerous rules to make sure patients get even basic care.

Workarounds are legion in the American health care system, to the extent that ECRI (formerly the Emergency Care Research Institute) listed them fourth among its list of top 10 patient safety concerns for health care organizations in 2018. Workarounds, the group writes, are an adaptive response — or perhaps one should say maladaptive response — to “a real or perceived barrier or system flaw.”

Staff use workarounds because they save valuable time. According to Anita Tucker, a business professor at Boston University, system breakdowns, or what she calls “operational failures,” and the workarounds they stimulate, can “consume up to 10 percent of a nurse’s day.” Most hospital nurses are stretched to their limits during their 12-hour shifts. No nurse has 90 minutes to lose to a slow pharmacy or an inefficient hospital bureaucracy.

I saw the common sense that can underlie workarounds when my hospital floor instituted bar code scanning for medication administration. Using a hand-held scanner to register bar codes on medications and patients’ hospital bracelets sounds smart. But then some medications routinely came without bar codes, or had the wrong bar codes, and we nurses weren’t given an easy way to report those errors. Patients’ wrist bands could be difficult to scan and the process disturbed them, especially if they were asleep. The lists of medications on the computer screen were also surprisingly hard to read, which slowed everything down.

But the biggest problem was that the scanning software did not work with our electronic medical records — so all drugs had to be checked off in both systems. This is a huge problem when dealing with patients like those receiving bone-marrow transplants, who might get 20 drugs every morning — some of which are delivered through IVs and come with nonstandard doses. What was already a lengthy process suddenly took twice as long.

Some nurses responded to the arrival of the bar code system with workarounds, including refusing to use the scanner, or taping copies of patient bar codes to their med carts. I tried to adhere to the rules, but if I was especially busy or couldn’t get a medication to scan, I would chuck the whole process.

However, because bar code scanning has been shown to reduce errors in medication administration, the hospital officials wanted it to be done consistently. They produced a public list of all the nurses on the floor. Each nurse was labeled green, yellow or red, depending on the percentage of medications he or she administered using bar codes. Family members, doctors — anyone could see how a nurse was graded.

Over time the list worked, but the sting of it also endured. We were being punished for taking time for patients, even if it meant bending the rules. No one among the managerial class seemed to understand that nurses care a lot about patient safety. The unheard concern was that a green light for bar code scanning meant a patient could fall into the red zone for something else.

Workarounds in health care always involve trade-offs like this, and often they are trade-offs of values. Increasingly, the entire health care system is built on workarounds — many of which we don’t always recognize as such.

Consider the use of medical scribes, who complete doctors’ electronic paperwork in real time during patient visits. The American College of Medical Scribe Specialists reported that 20,000 scribes were working in 2014, and expects that number to climb to 100,000 in 2020.

I have heard doctors say they need a scribe to keep up with electronic medical records, the mounting demand of which is driving a burnout epidemic among physicians. Scribes allow doctors to talk with and examine patients without having a computer come between them, but at base they are a workaround for the well-known design flaws of electronic medical records.

As a nurse, when I first learned about scribes, I was outraged. On the job, nurses hear repeatedly how health care companies can’t afford to have more nurses or aides to work with patients on hospital floors — and yet, money is available to pay people to manage medical records. Doctors who use scribes tend to see their productivity and work satisfaction increase, but the trade-off is still there: Scribes demonstrate the extent to which paperwork has become more important than patients in American health care.

The Affordable Care Act, which I support because it has made health care available to millions of previously uninsured Americans, is also an enormous workaround. The act expanded Medicaid, protected patients with pre-existing conditions and offered subsidies to make private insurance more affordable. Obamacare, though, was never intended to make sure that all Americans had affordable care; it works around our failure to provide health care to all our citizens. In its own way, the Affordable Care Act is as jury-rigged as using ceiling tiles to stash medications.

The United States spends more per person on health care than any other industrialized country, yet our health outcomes, including overall life expectancy, are worse. And interventions like bar code scanning are a drop in the bucket when it comes to preventable medical mistakes, which are now the third-leading cause of death in the country. Our health care nonsystem is literally killing us.

As the workarounds accumulate, they reveal how fully dysfunctional American health care is. Scribes are workarounds for electronic medical records, and bar code scanning is a workaround for our failure to put patient safety anywhere near the top of the health care priority list. It’s a values trade-off that the nurses on my floor instinctively understood.

Theresa Brown is a clinical faculty member at the University of Pittsburgh School of Nursing and the author of “The Shift: One Nurse, Twelve Hours, Four Patients’ Lives.”

 

 

80 year-old male model

As a retired gerontological nurse practitioner and a woman dealing with my own aging, I am always happy to read about successful aging. This one comes all the way from China. I hope you enjoy 80 year-old Wang Deshun’s story as much as I did.

 

An 80-Year-Old Model Reshapes China’s Views on Aging

 

Sinosphere

By DIDI KIRSTEN TATLOW NOV. 3, 2016

 

Wang Deshun, who turned 80 this fall, at the China Fashion Week in Beijing last year. Credit Quan Yajun
Wang Deshun, who turned 80 this fall, at the China Fashion Week in Beijing last year.
Credit
Quan Yajun

BEIJING — Before cranking up the techno music at his 80th birthday party, the man known as “China’s hottest grandpa” paused from his D.J. duties to poke fun at the country’s staid traditional celebrations for the elderly.

“I should wear a long robe, with the word ‘longevity’ embroidered on the front,” the birthday boy, Wang Deshun, said at his party in September.

Far from looking frail, the silver-haired actor, model and artist wore a crisp white shirt and black jeans, his back straight and his eyes glittering with humor.

“Two young maidens should help me into an old-style wooden chair,” he added, pretending to hobble.

Determined to avoid mental and physical stagnation, Mr. Wang has explored new skills and ideas while devoting ample time to daily exercise. Last year, he walked the runway for the first time, his physique causing a national sensation. He takes obvious joy in subverting China’s image of what it means to be old.

Wang Deshun explains how he became a runway model last year. Video by Redstart Media

And old age in China begins relatively early. The legal retirement age for women is 50 for workers and 55 for civil servants, and 60 for most men.

Being older in China typically means being respected, but also, often, sentimentalized. Someone as young as 50 may be addressed as “yeye” or “nainai” — grandpa or grandma — regardless of whether they have offspring.

Mr. Wang is having none of that.

“One way to tell if you’re old or not is to ask yourself, ‘Do you dare try something you’ve never done before?’ ” he said in a recent interview at a hotel in Beijing.

“Nature determines age, but you determine your state of mind,” he said.

Mr. Wang has not escaped being called grandpa — he has two children and a 2-year-old granddaughter — but the honorific is accompanied by accolades for his vigor and his embrace of the new.

“Grandpa, you’re my idol!” one admirer wrote on Mr. Wang’s Weibo social media account, one of thousands of similar comments.

Sex appeal is part of the mix.

“Grandpa, your stomach is so gorgeous! Incredibly handsome!” another person wrote next to a photo of Mr. Wang, topless in a gym, his skin smooth and pectorals buff.

Mr. Wang said he was always athletic. An avid swimmer as a child, he still swims more than half a mile each day. “Morning is my learning time,” he said. “I read books and news. From 3 to 6 p.m. is my exercise time, in a gym near my home.”

He also drinks less alcohol now, he said, but that is about as far as his dietary restrictions go. “I am not picky at all about what I eat. I eat whatever I want.”

Mr. Wang was born in the northeastern city of Shenyang in 1936, one of nine children of a cook and a stay-at-home mother. At 14, a year after the Communist Party came to power in 1949, he began working as a streetcar conductor.

Mr. Wang blowing out the candles on his 80th birthday cake in Beijing on Sept. 20. Credit Shen Qi

 

“I liked acting, singing, dancing, playing musical instruments so much that I joined my work unit’s band,” he said. At the Workers’ Cultural Palace in Shenyang, he took free lessons in singing, acting and dancing. He later took a job at a military factory and joined its art troupe. Sometimes they entertained soldiers.

“Even if there was just one sentry, say, at the top of a hill, like once in Dalian, we’d surround him and perform,” Mr. Wang said.

Later he worked in radio, film and theater. In the early 1980s, Mr. Wang, who would teach runway modeling at a Beijing fashion school, staged what he believes was the first modeling show in the northeastern city of Changchun.

“In 1982, the clothes Chinese wore were so out of date,” he said. “I went to the city’s biggest department store and told the sales clerks, ‘Give me your nicest clothes, and I’ll organize a show.’ They agreed. The best clothes they had were fur coats, and for men, woolen Sun Yat-sen suits” — also known as Mao suits.

Back then, he said, “Chinese had no sense of color or style. People wore black, white, gray or blue. Some people wore army uniforms. I wanted to start a sense for fashion among ordinary people. We did a swimming-suit show. The girls refused at first, thinking it was indecent. But I insisted.”

By 49, Mr. Wang was eager to move to Beijing, China’s cultural capital. He wanted to be a “living sculpture.” He also needed money.

He began working out, determined to have a lithe body that would allow him to interact, almost naked and covered in metallic paint, with copies of Auguste Rodin’s and Camille Claudel’s sculptures of women. The idea, he said, came from his wife of 48 years, Zhao Aijuan.

After the first show in Beijing, in 1993, the authorities, disturbed by its sensuality, barred Mr. Wang from performing in public. He continued to perform privately.

“I really admire him very much,” said Xiao Lu, 54, a performance artist. “I do body art, and you know, after a certain age. a person’s abilities decline. But he has this amazing sculpted body and spirit. Such power for life really comes from the inside. He makes the feeling that’s in the Rodin sculptures come alive.”

Last year, he appeared bare-chested in a fashion show in Beijing’s 798 arts district, featuring designs by Hu Sheguang.

His appearance on the runway earned him a cultlike following. Some fans call him laoxianrou, or “old fresh meat,” making a play on the word for teen idol: xiaoxianrou, or “young fresh meat.’’

So has old fresh meat replaced young fresh meat?

Perhaps not. But Mr. Wang’s physicality, notable in a society where men rarely highlight their attractiveness, also sets an example in a nation that is growing older fast.

“People can change their life as many times as they wish,” he said. Having a goal is important, he said.

“Being mentally healthy means you know what you’re going to do,” he said. “For example, a vegetable vendor, when he wakes up, he has a goal, he works hard. And when he finishes, he feels fulfilled.”

For Mr. Wang, fulfillment comes in many forms: acting, modeling, exercising and creating art.

And one day soon, he said, parachuting. That is the plan.

 

 

 

 

CANDICE BERGEN, MURPHY BROWN AND ME

On the front of The Arts section of the New York Times this past week was a picture of Candice Bergen. Candice BergenOlder (aren’t we all?) but still lovely even carrying thirty extra pounds. Making no excuses for the weight gain, she says, “I live to eat.” (I can relate to that.) She had written a memoir, her second, which is titled: A Fine Romance.

Candice Bergen played a television reporter in the situation comedy, Murphy Brown, from 1988 to 1998. I loved this show and watched it faithfully. The show resonated with me. Murphy Brown, an independent, smart and tough woman, was in control of her life and took responsibly for her actions. I wanted to live next door to her.

But it was when Murphy Brown was diagnosed with breast cancer the same time as me in October 1997 that I felt a simpatico relationship. As you know, October is Breast Cancer Awareness Month—did the Murphy Brown producers do this intentionally? th-1I wasn’t the only one fixated on Murphy’s cancer—“The show’s handling of the subject was credited with a thirty-percent increase in the number of women getting mammograms.”

One night, I remember sitting in the burgundy recliner with Mittens, our cat, on my lap, in front of the TV watching Murphy deal with her diagnosis. Murphy was shocked and secretive at first, as was I. In that show, she was being carted around in a wheelchair (I think she was being discharged from the hospital) And I don’t know why at that moment she decided not to keep the diagnosis to herself. What I do remember so vividly was that she was stopping people who passed her in the hallway of the hospital, telling them that she had breast cancer. You can imagine the blank look on some faces and on some, fright as if saying, “Let me get away from this lady ASAP.” I nearly fell out of the recliner laughing.

The next day at work I began to share my bad news. I told one of the administrative assistants as she walked out of her office that I was just diagnosed with breast cancer without any preamble. Her face showed a mixture of fright and surprise as I moved on not waiting for her to respond. Later that evening I chuckled at myself.

Thanks Murphy Brown for giving me a reason to laugh many times but especially at a dark moment in my life.

Thank you, Candice Bergen, for ignoring your thirty-pound weight gain in spite of Hollywood’s “beauty standards” and good luck with your new memoir.

FEAR OF GETTING OLDER (FOGO)

 

FOGO

 

It isn’t often that I applaud a drug company. In fact, I can’t remember if I ever have.

Here’s to Pfizer for creating an initiative to stimulate dialogue about getting older, which was described in the New York Times business section this past Wednesday (Elliott, Stuart. Pfizer to Inject Youth Into the Aging Process. The New York Times, 16 July 2014: B9. Print).

Pfizer has set up a website, getold.com, with links to Facebook and Twitter. The main audience is those in their 20s and 30s. Topics revolve around the affirmative aspects of aging, like “Why sex can be better when you’re older” and a story of 90-year-old who runs marathons. Okay, I admit a bit sensational but the emphasis is on the positive.

I only hope Pfizer’s effort to portray the elderly in a flattering light will help diminish ageism which is so prevalent in our society.

Thank you Pfizer.

I challenge you to take the FOGO quiz.

THE HEALTH WAGON

In the last post I wrote about Sandeep Jauhar’s essay in the New York Times, Nurses Are Not Doctors. Dr. Jauhar doesn’t condone independent nurse practitioner practice and he suggests that in order to expand the number of primary care physicians their salaries should be increased.

Somehow that last statement has hounded me. Not so much for the obvious reason that excessive physician salaries drive up health care costs but because I wouldn’t want my primary provider’s impetus to be money versus a genuine concern for his/her patients.

Okay, my reasoning is rather black or white. But I invite you to watch the 60 Minutes episode, The Health Wagon (try to ignore the Viagra ad). You will come away with an appreciation of the work nurse practitioners do to address the unmet health care needs in our country. Clearly they are not motivated by money. (The NPs practice in Virginia and can “diagnose illness, write prescriptions and order tests and x-rays”)

If you wish to bypass the video, visit The Truth About Nursing to read an overview of the program. Plus this is a great blog to follow if you want to keep up with nursing issues.

NURSES DON’T WANT TO BE DOCTORS

For the life of me I don’t know why the New York Times published Sandeep Jauhar’s essay, “Nurses Are Not Doctors,” in the Opinion Pages on April 30, 2014. His essay argued that nurse practitioners shouldn’t practice independently.

As a nurse practitioner it’s obvious that I wouldn’t agree with his opinion but his case was lame. He cited only one study, which was published in 1999. It showed that primary care patients seen by nurse practitioners had 25 percent more specialty visits and 41 percent more hospital admissions than those seen by physicians. Not only was the study dated, it was limited in scope. Come on Sandeep Jauhar. Come on New York Times.

Jauhar further suggested we need more primary care physicians (true) and his solution to encourage graduates to go into primary practice rather than specialize was to increase salaries. Read Shikha Dalmia’s article in Forbes, August 26, 2009: The Evil-Mongering of the American Medical Association, in which she discusses the effects of excessive physician salaries and the historical basis for the physician shortage, which only shows how ludicrous Jauhar’s suggestions were.

Finally, he concluded that nurse practitioners are essential but only “as a part of a physician-led team.”

Angered by the slanted and self-serving article with a title that I had hoped never to view again in my lifetime, and the fact that I thought this essay so beneath the New York Times to print, I wrote a Letter to Editor:

As a retired nurse practitioner, I am disturbed by Sandeep Jauhar’s Op-Ed piece: Nurses Are Not Doctors (April 30). Over the years doctors have criticized nurse practitioners’ practice. “If they want to be doctors, let them go to medical school” has been the American Medical Association’s mantra in spite of the fact nurse practitioners have never claimed that they wanted to be doctors.

What disturbs me is Dr. Jauhar’s focus on limiting NP practice at a time when our health care system has been shown to be inadequate. US life expectancy at birth, 71 years, is ranked 35th. Slovenia ranks 33rd. (WHO, 2013) We need to look at models where physicians, nurses, nurse practitioners, physician assistants and other health care workers can contribute their collective skills to deliver superior health services to all Americans. Rather than propose primary-care doctors get paid more and be designated the leader of the team, I would suggest he, along with the AMA, encourage the expansion of collaborative practice with the end result being accessible, cost effective and appropriate health care for all.

My letter didn’t get published. However, the ones that did and were supportive of nurse practitioners were authored by those more credentialed than I. They made excellent points in debunking Jauhar’s disparaging comments. And the 852 comments on line appearing over the next 17 days, until the comment section was closed, tipped in support of NP’s. (I didn’t check all 852 but did a sampling of the responses.)

Finally, let’s accept the fact that nurses are not doctors and don’t want to be and further agree to allow NP’s to practice “to the full extent of their education and training.”

Now let’s see if the New York Times publishes an essay from a nurse practitioner’s point of view.

A Physician Finally Gets Nursing

I couldn’t write better coverage about Dr. Arnold Relman’s comments about nursing, so I’m reblogging this Post. The comments he made are both “good” and “bad.” Good: Dr. Relman, physician and former editor of the New England Journal of Medicine, stated “When nursing is not optimal, patient care is never good.” Bad: Dr. Relman finally recognized this at age 90!
This just reinforces my belief that nurses need to make themselves more visible (see my post “I was the only one.” )

DOCTORS

A Patient’s-Eye-View of Nurses

By LAWRENCE K. ALTMAN, M.D. date published FEBRUARY 10, 2014 3:37 PM

 

February 10, 2014 3:37 pm

 

Dr. Arnold S. Relman, 90,  fell in June and suffered multiple fractures.

by Tony Cenicola/The New York Times

 

Last June, the month he turned 90, Dr. Arnold S. Relman, the eminent former medical educator and editor, fell down a flight of stairs at his home in Cambridge, Mass. He cracked his skull and broke three vertebrae in his neck and more bones in his face.

By the time he arrived at the emergency room, blood was flowing into his brain and impinging on his windpipe, leading to severe choking and dangerously low oxygen levels. Surgeons cut into his neck to connect a breathing tube from his trachea to a mechanical respirator.

Amid the disciplined medical havoc, his heart stopped three times. Resuscitation efforts saved his life, but at the cost of several broken ribs. His condition remained precarious as he developed complications and endured still more medical procedures.

Astonishingly, he lived to write about all this. After a painful 10-week hospital stay and months of rehabilitation, he can walk — gingerly, with a cane — and is largely recovered, with his mental faculties intact.

His riveting account of the medical adventure, in the Feb. 6 issue of The New York Review of Books, is a testimonial to the best emergency medical care and a tremendous will to live. At the same time, however, it betrays a surprising lack of awareness of some critical aspects of the medical profession and the nation’s fragmented health care system.

Despite decades as a medical educator, researcher, author and editor of The New England Journal of Medicine, Dr. Relman confesses that he “had never before understood how much good nursing care contributes to patients’ safety and comfort, especially when they are very sick or disabled.” Nor did he appreciate the hypnotizing effects of technology, which robs patients of the physician’s bedside manner and affects the training of younger doctors.

How is it that a leading medical professor like Dr. Relman — who has taught hundreds of young doctors at Boston University, the University of Pennsylvania (where he was chairman of the department of medicine) and Harvard — might not have known about the value of modern-day Florence Nightingales?

A number of doctors who have talked to me about Dr. Relman’s article suggest that the culture of medical education may be largely to blame. For example, younger doctors in hospitals spend part of the day on rounds, following professors in their long white coats. Many of these august figures are supremely confident in their observations and opinions; others are more compassionate.

What professors impart on those rounds can have a major effect on the behavior of younger doctors when they go into practice and teach succeeding generations.

Dr. Relman’s initial care was in a major teaching hospital, Massachusetts General in Boston, where the kind of doctors he taught — students, interns and residents — provided the round-the-clock attention that kept him alive. Yet he did not write directly about their role, referring to them only as “a team.”

On their rounds, some medical professors prefer to talk in a hallway just outside the patient’s room as they discuss test results that are crucial in planning further care. Such behavior appears impersonal, perceived perhaps as a way of shielding bad information.

But many doctors see it as efficient, because they can note the information they deem most important — like heart rate, blood pressure and rate of intravenous drip — by standing at a patient’s door and looking in at the monitors. Feeling no need to go to the bedside, they do not. Instead they rely on nurses, failing to recognize that such behavior omits crucial elements in patient care — the physical touch and the personal touch.

Dr. Relman owes the extension of his life to drugs and devices that did not exist in their present form, if at all, when he was younger. Over the years, the surge in the number of such advances, and most importantly in their hazards, has made work vastly more complicated for doctors, nurses and other health workers. Despite the advantages of technology, tender, loving care from family and nurses is priceless, as is the bedside manner of a sympathetic doctor.

But technology’s monitors, images and devices can deflect that doctor’s attention, as Dr. Relman learned when he reviewed his hospital records and the notes he wrote to nurses and his wife, Dr. Marcia Angell (particularly while he was unable to speak because of the breathing tube).

Instead of descriptions of his appearance and feelings, the doctors’ progress notes in his electronic medical records were filled with technical data. “Conversations with my physicians were infrequent, brief and hardly ever reported,” he wrote, adding:

“What personal care hospitalized patients now get is mostly from nurses. When nursing is not optimal, patient care is never good.”

Many hospital administrators have cut nursing staffs. They say it is to make ends meet; many doctors say it is usually to increase the bottom line.

Nurses’ observations and suggestions have saved many doctors from making fatal mistakes in caring for patients. Though most physicians are grateful for such aid, a few dismiss it — out of arrogance and a mistaken belief that a nurse cannot know more than a doctor.

In many ways, Dr. Relman’s insights reflect changes and generational gaps in training doctors, nurses and other health professionals. Because these disciplines have traditionally been taught in separate silos, they often do not work as tightly as they should.

Now, as health care financing changes and doctors spend more time training in outpatient settings, a growing movement demands coordinating the education of health professionals to prepare them to work more smoothly in teams. If these efforts succeed, perhaps the next generation of doctors will no longer be surprised at the importance of nurses and other allied professionals.

GUN CULTURE

It seems fitting to re-post what I wrote last year after 20 children and six teachers were killed at the Sandy Hook Elementary School in Newtown, Connecticut.

Let us not forget.

When we were traveling in Ireland this past October, our Irish tour guide told us that Ireland did not have a “gun culture” as we did in the States. Never having heard that opinion expressed before, the term “gun culture” stayed in my head.

After the recent killings at an elementary school in Connecticut, I looked up the word “culture” in Merriam-Webster’s Collegiate Dictionary, Eleventh Edition, which reads in part: the integrated pattern of human knowledge, belief, and behavior that depends upon the capacity for learning and transmitting knowledge to succeeding generations; the characteristic features of everyday existence shared by people in a place or time.

Charles M. Blow wrote in A Tragedy of Silence, New York Times, that public opinion is shifting away from gun control. In a recent Gallup poll 53 percent to 43 percent opposed the ban on semiautomic guns or assault rifles.

As I watched my nine-year-old grandson’s eyes riveted to the front page of Saturday’s New York Times lying on our coffee table, his look of concern told me I needed to speak out in support of gun control. I hope you will, too.

It’s time for a cultural shift.