Grand Opening and other updates

Great news and updates from the Topahkal clinic.

Most importantly, we used up another soap dispenser in the bathroom. This one was used up in less than 6 months, a sure sign we are growing. We could just count the number of visits but as scientists, it's always good to make sure we have corroborating evidence... :> Our patient numbers are vastly outgrowing our capacity. We are consistantly at 10-15 visits per day average with more days per month seeing over 20 patients. We had a new record of 26 patients the other day, which i'll write about in another post.

Almost as importantly, we started a Mercado ("store" in Spanish).

We are selling orgaqnic flax seeds for $2, Auralgan (ear drops for pain) for $4, urine pregnancy tests for $3 and local bee pollen for $2. As you can see, it's an integrated health convenience store. :>

I'd like eventually to be selling organic bulk foods, local organic produce and yogurt, wheelchairs and crutches and canes (organic if possible...), rice socks, tennis and golf balls (for acupressure treatments, although if my patients want to take up the sport, i'd encourage it), and various other sundries, like non-toxic deodorants and soaps.

Other than that, we are still on the hunt for another practitioner, PA, NP or MD. We have a few leads but nothing sure yet. And we are still looking to move our location to another house, larger and easier to find, that has the correct permits to have a business.

Oh yeah, and we are on the verge of signing our first contract with a local non-profit business that will use us for primary and urgent care for their workers coupled with a catastrophic medical plan for hospitalizations and emergencies. I'm a bit nervous, with contracts come the "devil in the details." But realistically, our non-profits are struggling under horrible payment plans right now with managed care companies, high to begin with, raising prices at lesat 15% each year. You can't budget for that in the grant world, it's impossible. So within a few months we'll see what kind of cooperative associations can be formed to help the non-profits and us do our jobs better.

andru

Ambulance Call

after almost two years operational, we made our first ambulance call yesterday. a woman entered the clinic barely able to walk, breathing fast, disorganized in her thought, with a heart rate of 140. i didn't know her previously.

i called 911 and spoke with a very annoying, by the book receptionist who kept scolding me for giving her more information than she wanted, out of sequence with her set of questions. we spent more time with her scolding than anything else, but aside from that, i was really impressed with the emergency response. the ambulance crew arrived within 3 minutes. turns out they were local guys from right around the corner.

the team did a great job assessing her while i finished up seeing a patient with gastritis. they were cool. they felt she was stable and thought she could transport herself to the ER. this would save her over $300. after speaking with the patient, i wound up finishing her care in my clinic so she avoided an ER visit altogether. turns out she was hyperventilating and panicking. she was also on herbal weight loss medicines which probably provoked the attack. she got some IV fluids, reasurance and recovered very nicely from the episode. final cost was $50 for the visit, IV fluids and blood sugar test.

i learned recntly that the paramedic school here in albuquerque is starting to train their paramedics in primary health care because so many of their visits are like this one where the person has a basic problem that could resolve with some simple steps in the field, but the person doesn't have insurance, a doctor or clinic to go to. i'm not sure if this is happening in other states. i support it. if the doctors in the health system don't meet the need, then let another trained group of professionals take over the work.

people need the care.

andru

shake it, shake it like a Polaroid picture

In my next 2 weeks of my family medicine residency program, I'll be working at and learning from various community health projects in LA. These are two weeks that other residents tell me are grounding -- they awaken us sleepy/agitated/tired/hospital-based first year residents to the community health work around us and inspire us again -- THIS is why i went into family medicine, or THIS is community health!

I'll be going to prison clinics, job corps, a clinic at a high school for pregnant teens (started by one of the faculty members when she was a resident!), and a tattoo-removal clinic -- started by one of the former Harbor-UCLA family med residents, in collaboration with Father Greg Boyle and his organization Homeboy Industries, who have been working with former gang-members (with tattoos on their faces and other exposed areas) to help them back into society and into the workforce.

I'm not sure if it's because i'm rested after a vacation, or because i'm ready for something other than the hospital right now, but i'm pumped about this rotation. On one of the afternoons, I'm going to have to talk to high school kids at one of the local schools about a health-related topic, and I've already been thinking about incorporating music into my session, for so many reasons (music is great at breaking the ice, connecting with youth, and helping to convey messages). And really, I just wanna be down with the kids :>

So I was elated when I read about 'musical cues'. Andy Hilbert is a teacher in Los Angeles who runs a blog where he discusses education, the Los Angeles Unified School District, and teaching, from his perspective -- as an 8th grade teacher and chair of the Carson area United Teachers of LA. He's experimenting with musical cues in the classroom:

On my first attempt I opened the class with a question, "What is a musical cue?"
Usually there was little response.

So, I continued. "What if I could play a sound or a tone or a piece of music and everyone in the class would instantly know what to do? Well that would be a musical cue."

The class seemed perplexed yet curious.

"I think musical cues work. I’ll play a note or sound or song and everyone will know what to do and start doing it. It works. You’ll see. Let’s try it."

I walked slowly to the CD player and pushed play on track nine for the song "Hey ya" from which I had lifted the "shake it, shake it, like a Polaroid picture" lyrics. Once my students heard the song, they burst into exclamations of recognition, started singing, smiling, and taking out 8½ by 11 pieces of paper and folding them into word charts. I illuminated the definitions on the screen and everyone started copying the definitions as the song continued to play. When the song finished, the class was in a trance. They could not be bothered. They wanted to complete the word charts quietly by themselves without my instruction. I didn’t have to issue a single instruction, let alone repeat one twenty times. It even took me a little while to bring them back from absolute silence, but I slowly managed to engage the class in discussion about the words.

Now I just have to think of appropriate tunes to cue transitions into group work, silent reading, and clean up time. Hey maybe I can turn my students on to Neil Young, Bob Dylan, Ben Harper, and Victoria Williams. I better not push it; this is supposed to be a job.

Check out the rest of his blog, Horsesense and Nonsense. He's pretty passionate about his classes *and* about Los Angeles politics and education. Rock on.

(cross posted at Los Anjalis)

Insider Igorance

this is a message to all healthcare staff, nurses, doctors, administrators and students.

a patient's mom fell and broke her arm about six weeks ago. after spending nearly 16 hours in the ER, she got good care, was splinted and sent home to heal. after a month, she had a follow-up appointment where it was determined that she was healing poorly, technically called a "mal-union." she was scheduled for a pre-op surgical appointment last week. her adult son accompanied her because she doesn't speak English and has trouble advocating for herself in big systems. he reports that he was told that he was not aloud to accompany her into the visit and had to wait outside. he is a humble man and accepted that at face value without challenging his right to participate. the surgery was discussed, a date was chosen, the patient was sent home and the patient didn't understand a thing.

if possible, i'd like for her to have local instead of general anesthesia to reduce surgical complications and recovery time. she has no idea what kind of anesthesia they are going to use. her son had been prepped by me to ask that question but he wasn't aloud in.

we are getting closer to the message for healthcare workers.

i called this week to try to track down the surgeon. i made it to the right clinic and spoke with a receptionist. i shared my concerns and told her about how the patient's son wasn't aloud to participate in the visit. she became defensive and then flatly denied that the patient's son wasn't aloud to participate, stating that it wasn't policy to exclude family members from visits, and finally, that it didn't really matter because they have interpretation services available so the patient should have been fine on her own.

we will never improve our systems, our quality of care, our ability to care for people who are more vulnerable, if we maintain a defensive, ignorant posture when patients and families share their stories of poor treatment or mis-treatment.

noone is perfect, systems are far from perfect. this isn't a tirade to try to make everything perfect. it's a call to those reading to please stay humble, listen and believe your patients, take what they say with a grain of salt of course, but don't discard the concerns raised because they don't fit nicely into what is supposed to be happening per stated policy.

andru

Disruptive Physician - Are you one?

ever heard of a disruptive physician? i've gotten quite an education on the topic in the last month. there are two surgeons, both in the ENT dept at our publc hospital, who are being forced out of their jobs. Every conflict has two sides so this may sound a bit biased, but after my experience of being forced to resign from UNMH, and having met personally with these two physicians, I am convinced that they are honest, skilled, caring doctors being targeted and pushed out for their advocacy for patients, their concern about certain unethical behaviors within their department and for standing up to the intimidation being thrown at them by their administrators. Our hospital administrators love to play tough with people who express moral or ethical concerns. there is alot to the story of these two physicians that will have to wait for public disclosure but i am proud to say that my community has taken the step of publicly asking the hospital to ensure that these two gentleman have due process and a fair trial. we'll see where it goes from here.

so what is a disruptive phsycian? if you do a google search, you will find plenty of info. in summary, a disruptive physician is a doctor who jeapardizes or compromises patient care by their attitude, behavior, actions, prejudices, etc. a perfect example is a doctor who has caused so much fear in the nursing staff that they are afraid to call that doctor to report a health concern with a patient and the patient has a bad outcome. one could blame the nurse or one could see the deeper toxic dynamic the doctor set up over time by punishing the nurse inappropriately.

it's important for any clinic or institution to be able to identify a disruptive doctor and take corrective or terminative action. when patient care is at the center of the mission, this is a critical necessity. i know plenty of disruptive doctors (we all do). they are all over the place in medical education. they are typically mean, obstructionist, angry, incompetant, and insecure in their abilities. and i wish there were ways to get rid of them because they made my life miserable and they were fundamentally bad docs for the patients. i'm still traumatized to call a surgical or specialist consult years out of my training.

so what's the hubbub about?

well, it's a fine line between a disruptive physician and a doctor who is advocating strongly for his or her patient, especially in a corrupt system where in truth, the administration, not the doctor, is disruptive and obstructionist to patient care. this is what we find in our public hospital system. when you get into the nitty gritty details, adminsitrators play out their little power games by sabotaging the OR schedule, by hiding critical surg ical instruments so that cases for poor people have to be postponed, by cancelling at the last minute a surgey because the person wasn't pre-qualified by the indigent care committee... etc, etc, etc.

in my own time, i witnesses alot of disruptive behavior by administrators but i didn't have a vocabulary word for it, i just got pissed and whined alot. in one of our FP clinics, the docs worked for a year with front desk staff to train them to be nice, to welcome patients before asking for money, to greet people and smile, all the basics. right after things started flowing more smoothly, more patients were getting in (who had no insurance) and patients were happier, the front desk staff were moved to a new location and new staff put in their place. and the cycle started all over again. DISRUPTION.

just as there are being developed mechanisms to identify and remove disruptive physicians, we need a process to identify and remove disruptive administrators, staff, insurance companies, politicians, etc. and we need to be sure that when the charge of disruption is made, that it reflects the truth around patient care. i am proud of the disruption i have caused to the buracracy. buracracy needs disruption, it needs a good kick in the ass.

andru

Blogging others' stories on HIV/AIDS, and "NGO 2.0"

Brian Shartz and Curt Hopkins at Blogswana (creative name) are doing some innovative blogwork. I'm always excited about innovation in web technology, and as this one related to health and storytelling, it piqued my interest. Check out this project:

Our proposed project would involve training about 20 students in Gabarone who would commit to a year of blogging for someone whose life has been effected by HIV/AIDS. They would post blogs for those on the far side of the digital divide, those without access to computers and connectivity. While the scope of this project may be unique, the concept is not. Patrick Makokoro provides a great example of ‘blogging for others’ in AIDS in Zimbabwe: One Orphan’s Story. He allows Chipo Baloyi to tell his own story about the devestating effect AIDS has had on his family:

My day begins very early in the morning when I light the fire and heat the water for my two small brothers and three younger sisters to bathe in before they go to school. If we have access to maize meal, I cook a pot of porridge for them to eat. After seeing them off to school, I start my daily household chores: sweeping the yard, cleaning the dishes and washing the linen soiled by my young siblings. Since it will still be cool, I then go out to the garden and water.

My father was the first one to pass away, in October 2002. He had been sick for quite some time, and we had to sell off some cattle and goats to pay his hospital bills. We also visited traditional healers to get local medicine for his ailments, but all this was in vain. After he succumbed to this strange, unnamed disease, we had to sell two more heads of cattle to pay for the funeral expenses and to pay some people who had done different services for us. This left my family with nothing...

* * * * * * *

As I mentioned in a previous post, I like to talk about the Web 2.0. A few friends and I are putting together a project in the near future (no talking about pipe dreams before they come to fruition, i was advised by a wise sage), and we can't stop talking about the potential of the web 2.0 -- which is why the defined concept of NGO 2.0 grabbed me:

If the transition from Web 1.0 to Web 2.0 can be said to be the transition from static, authorial, unitary, proprietary, non-transferable content to distributed, networked, user-generated, shared and easily transferable content, and if traditional NGOs may be said to function as cash-intensive, centralized, hierarchical, bureaucratic, specialist-driven operations, then Blogswana is, in a sense, NGO 2.0.

Blogswana bypasses the hierarchy of both the traditional charitable organization and of the recipient government. Its organization is largely horizontal. It distributes funds to a network, populated by the actual individual recipients of that aid, to do its work. It aggregates the work product of those individuals. It enlists those recipients to create and distribute the next generation of aid themselves. It’s a user-generated, entrepreneurial, person-to-person network of aid.

It’s NGO 2.0.

Sweet. Thanks for that clarity, Blogswana team. :>