Saturday, May 21, 2016

A Lengthy Absence

Well, I'm back after a few very busy weeks. Soon after my last post it was time for final exams, and then afterward I taught a "May-mester" course--25 hours of class time in 2 weeks. Now it's time to catch my breath as I look forward to a summer of writing.

The mini-mester course was composed of RNs who are returning for their bachelor's degrees. This may seem odd to some, but the fact is, nursing has had 3 levels of educational entry for decades. Originally nurses were trained in hospital-based schools of nursing. This provided a labor supply, and guaranteed that student nurses would have practical, clinical training sites, as well as training that would teach them a specific hospital's procedures and inculcate them into that specific hospital's culture.

This passed out of fashion in most parts of the country, in part because nursing students were being treated as a source of labor more than they were being treated to an education that would have applications outside of this or that specific hospital. Also, as health care has matured, many smaller hospitals have closed specialty units such a pediatrics and obstetrics, that form key parts of a nurse's education. Interestingly, Pennsylvania has more remaining hospital-based diploma programs than any other state, although many, like a program in Lancaster PA, have converted into chartered degree granting institutions, providing a more rounded experience that includes things typical in a college education (like history, philosophy, writing, and so on).

Anyway, there are still a lot of community college-based programs throughout the U.S. So there are still lots of 2-year programs out there (although they consist of so many courses, it usually takes 3 years to get through). Many colleges and universities offer so-called "RN to BSN" programs, composed of students who may have practiced little yet, or may have been practicing for many years. Part of my teaching is in such a program.

Why do they go back to school?

In the past it was mostly to secure a promotion track with their employer, or to ready themselves for graduate school to become a nurse anesthetist, nurse practitioner, or educator. By law and custom a master's degree is required for these sorts of advanced practice roles.

Today, many return because their employers require the bachelor's degree. Research that emerged in the early 2000s found some evidence of an improved safety margin when hospitals have a larger number of BSNs working in them. That's good for patients, and it makes hospitals more competitive.

Ah, but what can one teach such nurses? After all, they are already licensed. However if the research found this additional safety margin, then there must be some additional tools we can provide these students. Over the next few posts, I'll discuss what these RNs value in their extra education. Those things speak to several important and interesting features of our health care system.

Wednesday, May 4, 2016

The Same Old Arguments

I'm sitting here watching a recording of Frontline called "Supplements and Safety," which aired on PBS in January of this year. What strikes me early on is the editorial construction of the piece: doctors soberly reporting on their grave concerns about the cases of injury and harm, the lack of quality controls, and the mystery of what's in those dietary supplements. The manufacturers of supplements are shown to be ruthless mercenaries, and the FDA as hapless regulators who may be in the pockets of Big Business. Consumers are rubes, with selected attention paid to those grievously harmed by this relationship.

I don't object to the basis of their journalism. They accurately point out problems with the lack of quality controls in the supplement industry, the complexity and nuance of the data that are said to favor supplement use, and the risks of taking high doses of things you can't fully trust.

What they don't cover is why people do this. There's also a real effort to pump up the emotion, and you accomplish that by keeping arguments pretty simplistic.

In 1994 the Dietary Safety and Health Education Act was passed. The law emerged from the acrimony that resulted from pitting two forces against each other whose differences were irreconcilable. One force was Organized Medicine, led by Dr. David Kessler, then head of the FDA. He saw a problem with supplements--and there was a problem--and he wanted to do something about it.

Unfortunately, he fell prey to the narrow lens of empirical medicine, which tends to view things in a very reductionist manner. Also, it tends to be very chauvinistic. Since the mid-1800s, Medicine as profession has done everything in its power to make people dependent on its methodologies. Medicine condescends to people, branding their ideas, their experiences, and their genuine interests in their own health as wrongheaded and just stupid. Notwithstanding that some individual doctors who view justice and holism as worthy characteristics of medicine in society, as an industry, Medicine has consistently been as greedy and prejudicial as any industry.

On the other side was the supplement industry--not even half of what it is now--still a behemoth, and they started a campaign against the FDA's efforts to regulate supplements. They were very successful, and today the DSHEA's regulations enforce a circumstance that benefits industry at the expense of consumers.

What the Frontline broadcast doesn't get into is the culpability of Medicine and the zeal of the "lifestyle police" in the creation of this circumstance. In the early 1990s, Medicine and The Scientists could have partnered with consumers. They could have tried to think outside the box. During one sequence "Supplements and Safety" talks about Ephedra, known in Chinese medicine as ma-huang (Ephedra sinensis). The use of this herb goes back thousands of years and its use is safe and well-documented. Ephedra is an effective nasal decongestant and energy builder, when indicated.

Who decides when its indicated and how it should be used? How about specialists in Chinese medicine? That's a novel idea that didn't occur to the short-sighted zealots who were crafting a law that would make doctors and the pharmaceutical industry the arbiters of what's "good" for us. In 2004, 10 years after DSHEA, ephedra was pulled from U.S. markets after a number of deaths occurred from overdoses of weight lifting and energy supplements containing ephedra.

Thus, a perfectly useful and effective drug was removed from everyone's use because of the same old argument between the Supplement Industry and Organized Medicine. Had it even occurred to the zealots that giving licensed practitioners of other medical arts a say in the regulation of these products, would encourage partnerships with Medicine that would improve both the health and the safety of consumers?

The problems are threefold. First is money. Anyone with something to gain or lose is going to have a hard time remaining intellectually neutral in any argument when this is the case. If supplements are better regulated, to the point where some supplements are restricted to vetted practitioners of medicine or some other medical art, they lose. Doctors have something to lose when people treat themselves, and when practitioners other than physicians enter the field.

The second is chauvinism. This is a kind of intellectual classism which tends to ignore or denigrate native or folk knowledge. For example rather than viewing supplement use as the province of the ignoramus, doctors could try curiosity. Curiosity teaches us new things, and displays of genuine curiosity open rapport with patients. This is what I teach my students.

The third is rigidity. Medicine and The Scientists are fond of saying, "Where are the controlled clinical trials?"  "This hasn't been proven!" Mark Tonelli, a physician, and Timothy Callahan, a researcher, both from the University of Washington School of Medicine write in Academic Medicine (2001) that the demands that complementary and alternative medicine (CAM) fit into evidence-based practice models is a philosophical demand that doesn't cohere with the various models and understandings of "disease" and "health" in those methods.

It's not that we can't explore the value of CAM methods--or supplements themselves for that matter--using science. We can, we just have to make sure the methods we use are appropriate to the particulars of the thing were exploring! There's nothing scientific about trying to jam a square peg into a round hole. Nor must we simply ignore the square peg and allow it to remain unexplored. (This also argued by Tonelli and Callahan--they aren't giving CAM a pass! They are just suggesting that Science amp up its game, and not rely on models of study that are becoming increasingly limited in their ability to determine value.)

This is about the "same old arguments." Both sides lack verity, both are wrong, because they lack imagination, empathy, and desire to do the best for the most. What would that be? Partnerships that don't start from financial interest or intellectual chauvinism would be a start. The Frontline special shared some initiatives in the supplement industry that would improve quality and safety. These partnerships between researchers and the industry offer us hope that the same old argument is changing.