Mass Shootings: How Docs and Nurses Heal

Mass Shootings: How Docs and Nurses Heal

Some healthcare professionals see blood, mangled bodies, and death every day, yet certain days are worse than others. As when, for instance, a dozen police officers are gunned down or 20 kids are killed in their elementary school in a mass shooting. Because public mass shootings happen nearly every 6 weeks in America, these tragedies are having a more frequent impact on the healthcare workforce.

Research data are sparse. One study surveyed 24 surgical residents working at Orlando Regional Medical Center in Florida in 2016. On June 12 that year, a gunman shot 49 people to death and wounded 53 others at the mass shooting at the Pulse nightclub. Three months later, rates of post-traumatic stress disorder (PTSD) and major depression were two and four times greater among the 10 residents on call that night versus the 14 off-duty residents. Though the differences didn’t reach statistical significance, assessments were revealing. A survey of the same residents 7 months after the mass shooting found that PTSD persisted in those affected in the on-call group but completely resolved in the off-call residents.

As part of an ongoing effort by MedPage Today to explore job stress and burnout among healthcare professionals, reporter Shannon Firth talked at length with physicians and nurses who shared personal experiences with mass shootings and how they affected their lives and careers.

Three Encounters With Mass Shootings

“After I Saw What I Saw, I Really Thought to Myself, ‘I Hope I’m Not Broken:'” Richard Kamin, MD (Sandy Hook school shooting, 2012)

“The Worst Night of My Professional Career:” Brian Williams, MD (Dallas police sniper attack, 2016)

“I Still Get That Pit Feeling in My Chest of, I Can’t Believe This is Happening:” Megan Duke, RN, CEN (San Bernardino terrorist attack, 2015)

MedPage Today intern Amanda D’Ambrosio assisted with reporting for these stories.

Originally published by MedPage Today.

Stanford Study Finds no Link Between Immigrant Health Coverage and In-Migration Rates

Stanford Study Finds no Link Between Immigrant Health Coverage and In-Migration Rates

Extending insurance coverage to immigrant children and pregnant women did not appear to influence whether they crossed state borders (known as in-migration) to acquire care, according to survey data.

Among 36,438 lawful permanent residents with children, the average in-migration rate 1 year before public health insurance was expanded to cover immigrants was 3.9% and 1 year after the implementation, the rate remained essentially unchanged at 3.7%, reported Vasil Yasenov, PhD, MA, of the Immigration Policy Lab at Stanford University in California, and colleagues.

Similarly, among 87,418 women of reproductive age, the in-migration rate 1 year before expansion was 2.7% and 1 year after it was 4.6%, the team wrote in JAMA Pediatrics.

“No Discernable Association” Between In-Migration and Insurance Expansion

“If an expansion of health insurance coverage was associated with in-migration to another state, the probability of in-migration would have increased in the treatment group compared with the control group,” the researchers wrote. “There was no discernable association between the in-migration from any state among the treatment group relative to the control group and public health insurance expansion.”

The authors compared the group of immigrants with children with a control group of lawful permanent residents without children. The proportion that migrated among immigrants without children was slightly higher before and after expansion (4.0% and 5.9%, respectively), but not significantly different from immigrants with children, Yasenov and his team reported.

Meanwhile, among a control group of post-reproductive women, the rate of in-migration was 3.5% and 3.9% in the years before and after expansion, respectively, which was also not significantly different than the group of women of reproductive age, the researchers added.

“We hope policy makers concerned with spiraling costs and people flooding in from other states will have the evidence they need to make a decision when thinking about extending public healthcare benefits for legal immigrants in the U.S.,” Yasenov told MedPage Today.

Findings Indicate Immigrants are Fleeing Violence and Corruption, Not Chasing Health Coverage

As of 2016, immigrants with children were covered by public insurance in 31 states and pregnant immigrants were covered in 32 states. Many Democratic candidates for the 2020 election support extending healthcare to undocumented immigrants, a policy that has been suggested will increase the flow of immigration within the U.S.

These null findings make sense in the context in which most U.S. immigration takes place, wrote Jonathan Miller, JD, of the Office of the Massachusetts Attorney General in Boston, and Elora Mukherjee, JD, of the Immigrants’ Rights Clinic of Columbia Law School in New York City, in an accompanying editorial.

Namely, many people coming to the U.S. are fleeing from violence or political corruption in their home countries, and “do not seek refuge in the [U.S.] because of potential access to healthcare,” Miller and Mukherjee said.

“Making it easier for immigrant communities to connect to and seek care from physicians will not radically shift migration patterns. Instead, allowing access to the basic human right of health care shows a common commitment to human decency for all who are in the [U.S.],” the editorialists stated.

Immigrants Sampled Were Below 200% of Fed Poverty Thresholds

For this study, data were collected from individuals residing in the U.S. from 1 to 6 years — but who were not born in the U.S. and were not citizens — from the American Community Survey. Notably, the sample was restricted to individuals who were below 200% of the federal poverty thresholds to identify people who would qualify for public insurance if it were extended, the authors noted. Immigrants on student visas, veterans, or those married to U.S.-born citizens were excluded because they qualify for other healthcare benefits, the team added.

The data were controlled for personal characteristics like age, race/ethnicity, and marital status, as well as things that varied by state and time such as cash assistance and economic conditions.

In total, 208,060 immigrants — mean age of 33 years, 47% of whom were female — were included. About two-thirds were Hispanic (63%), and the in-migration rate among the entire sample was 3%.

“Near-Zero” Likelihood

Overall, the likelihood that lawful permanent residents would migrate to a state where public health insurance has been expanded to cover immigrants was practically zero before and after expansion was implemented (percentage change from -1.21 to 1.78), the authors reported.

The likelihood was also close to zero among lawful permanent-resident women of reproductive age when compared with a control group of lawful permanent-resident post-reproductive women (percentage change from -1.20 to 1.38).

In a model specifically looking at whether public health insurance expansion would bring in migrants from a neighboring state, no association was found between policy implementation and the rates of in-migration of immigrants with children (–0.03 percentage points, 95% CI –0.5 to 0.44) or pregnant women (–0.02 percentage points, 95% CI –0.48 to 0.09), the researchers reported.

The primary limitation of the study, they said, was the inability to account for time-varying factors that could undermine the analysis, and it was also not possible to isolate states among the border and determine whether there was an association between in-migration and health policy specifically in these states. Lastly, the investigators said, the association was not analyzed among county-level or city-level programs.

The study was funded by the Stanford Child Health Research Institute.

The authors and editorialists reported having no conflicts of interest.

Primary Source

JAMA Pediatrics

Source Reference: Yasenov V, et al “Public health insurance expansion for immigrant children and interstate migration of low-income immigrants” JAMA Pediatrics 2019; DOI: 10.1001/jamapediatrics.2019.4241.

  • Secondary Source

JAMA Pediatrics

Source Reference: Miller J, Mukherjee E “Health care for all must include everyone” JAMA Pediatrics 2019; DOI: 10.1001/jamapediatrics.2019.4247.

by Elizabeth Hlavinka, Staff Writer, MedPage Today

This story was originally published by MedPage Today.

Nurses: What is Your Pet Peeve About Doctors?

Nurses: What is Your Pet Peeve About Doctors?

Doctors and nurses work together to provide patients the best care. But you know that everyone has a pet peeve. In this six-minute video, new medical resident Siobhan Deshauer, MD talks with nurses about how physicians get on their nerves. What follows is a transcript…

Siobhan: Hey, guys. I’m Siobhan, a first-year medical resident. I figured today we could talk about how doctors and nurses get along, specifically the things that doctors do that really annoy nurses. It’s really tough as residents because we just kind of parachute into these ICU teams, which are really well formed. They all know each other well. They know how things work and we just need to figure out how it goes on the fly really quickly. The reason that I think this is so important is because this is a team. If we work and communicate better together, it should be better for patient care. Let’s go figure this out. The number one pet peeve that doctors will do.

Pet Peeve: Respect Nurses and Patients

Female Nurse #1: Not introducing yourself when you come into a patient’s room. Like I was telling you before, there was a doctor that walked into my room this morning wearing a winter jacket, boots, and no ID on him whatsoever. He came up and started reaching for my chart instantly. I was like, “Hi! Sorry, why are you touching my chart? Who are you?” Like, any indication? Introduce yourself! Introduce yourself to the patient and the nurse.

Siobhan: We can do that. We can do better at that.

In a Shared Workspace, Respect the Nurse’s Computer

Female Nurse #2: Respecting the nurses’ workspace because you do have your own personal workspace.

Female Nurse #3: I was also going to add that it’s a shared workspace. But sometimes when you’re thinking and you’re thinking for a really long time, that space is just…

Female Nurse #2: There’s a lot of people.

Female Nurse #3: Yeah, there is a lot of people and sometimes you just need… we need that space because it’s the only one we have.

Siobhan: Yeah, you’re actually working on a computer…

Pet Peeve: “RING! RING!” Pick up the Phone…

Female Nurse #3: Yeah. It’s kind of like, “Can you do that stuff and get out?” Because I need to be there. But it’s a shared space obviously and we all respect that for each other. I was just going to say pick up the phone. If it’s ringing, pick it up! It’s not my phone.

Siobhan: You mean even if it’s the phone, even if someone is paging us back?

Female Nurse #2: Yep, wherever you are.

Female Nurse #3: Any phone. Any phone. If you’re walking down the hall and the phone rings…

Siobhan: Just like…

Female Nurse #2: You pick it up.

Female Nurse #3: You’re part of the team. Pick it up. “Hello, ICU. Hang on. Okay, I’ll get you somebody else.” Just pick it up. Usually what happens is you’re sitting in the workspace and you’re taking up this workspace, and we’re probably sitting there like, “Okay. Well, fine, I’ll go do something.” You come back and they’re still there. The phone’s ringing and nobody’s answering, but they are still in the workspace. The phone is still ringing. Pick it up.

Siobhan: That’s amazing. Thank you! I will pick it up. Wow! This is actually very useful to hear all these things just even as a reminder. Let’s go see if there are some more nurses that have a minute to give us their feedback. The number one pet peeve, things that doctors do that you just hate, okay.

Pet Peeve: Again, Respect the Nurse’s Computer, Communicate, and Remember That You Are Not the Nurse’s Boss

Male Nurse #1: Maybe not number one. But when residents or doctors just hop on your computer and look up all these different patients under your name, which compromises my license. Thanks, guys.

Siobhan: Yeah, that’s really bad. That’s really bad. What would be the number one piece of advice that you would give to residents?

Female Nurse #4: Just communication is key. Communication, patient safety, and respect for your colleagues. Don’t think of yourself as we’re in a hierarchy. Again, when I worked on a ward, there was definitely a hierarchy between physicians and nursing staff. Whereas, it’s kind of like you’re not my boss. No. We are meant to work together. We’re a team. We all, I think, some doctors forget that I’m here mainly as a patient advocate and I spend 12 hours a day with them. I spend 12 hours a day with their families. Whereas you guys, yes, you’re all highly intelligent, but you have numerous other patients to see. Just kind of taking into consideration what nursing staff and other members of allied health have to say.

Siobhan: What would be your number one piece of advice for new residents like me?

Pet Peeve: Respect Patients’ Privacy

Female Nurse #5: Carry around an awareness of how immune to privacy, invading people’s privacy, nudity, things that are just commonplace in the hospital. You know what? We’re all guilty of it, walking through that curtain that’s drawn, because we’re trying to address a patient issue. Patients and their families, nurses at the bedside, really appreciate just like a quick hello from the other side of the curtain. “Hey! It’s Dr. so-and-so. Do you mind if I come in?”

Siobhan: I wouldn’t walk up to your room and just like walk in your bedroom door. Right? Like that just seems…

Female Nurse #5: That’s what I am saying.

Siobhan: What if you are changing or anything, right? Just knock. It’s the same thing, right? Pet peeve from doctors.

Pet Peeve: Nurses are Not Your Servants. Clean Up.

Female Nurse #6: One of my pet peeves that I have experienced is that the doctor will come in and do a procedure requiring sterile towels, dressing tray, lots of sharps, and sutures, and they’ll leave it all. They’ll do the procedure and then they’ll leave, leaving the nurse to clean up everything. Really, they should take care of the sharps and ask, “Where can I put these things?” I’d be glad to tell them.

Siobhan: Yeah, that’s so incredibly reasonable and a good reminder.

Female Nurse #7: Just being aware of everyone around that’s participating in rounds.

Siobhan: So not like doing this. [TURNS BACK]

Female Nurse #7: That’s right. Don’t turn your back to the nurse.

Nursing Students are Still Naive. Treasure Them.

Siobhan: As a nursing student, are there things that doctors do that just really bother you?

Female Nurse #7: As a nursing student, I wouldn’t say I’ve had too many negative experiences yet.

Siobhan: Yay!

Female Nurse #7: I would say a lot of them are positive. You guys are very informative and easy to talk to, so overall a positive experience with residents.

Siobhan: That’s awesome! We’ll see. We’ll ask you in like 5 years.

Female Nurse #7: Yes, ask me again in 5 years.

Siobhan: Thank you so much to all of the nurses who helped out with this film. It was fantastic. It was really fun and it gave me a lot to sort of think about and good reminders. Don’t forget to subscribe if you haven’t already and I will be chatting with you guys next week. Bye for now.

Siobhan Deshauer, MD, is an internal medicine resident in Toronto. Before medicine, she was a violinist, which is why her YouTube channel is called Violin MD.

Previously published in MedPage Today.

Unintentional Biases Can Be Overcome

Unintentional Biases Can Be Overcome

NEW ORLEANS — Everyone has unintentional biases, but physician practices can mitigate them with a few simple steps, experts said here.

The speakers defined unintentional biases as “stereotypes or beliefs that affect our actions in a discriminatory manner.” Such bias may affect our actions in a way contrary to our intentions, two speakers said at the Medical Group Management Association annual meeting.

Unintentional biases — also known as unconscious biases — can work against a practice’s commitment to diversity in hiring and workplace inclusion, said Steve Marsh, founder of The Medicus Firm, a physician recruiting firm in Dallas. “Diversity and inclusion go hand in hand,” he said. “you can do a good job of diversity hiring, but if you don’t have an inclusive environment that’s welcoming to all the people you brought in, it’s worthless; in fact, it can backfire on you.”

Achieving these goals “isn’t real complicated, it’s just really hard to do,” he added. “You can’t do a a crash diet on diversity hiring; you can’t do a crash diet on inclusive culture. It’s a lifestyle, not an event.”

188 Types of Bias

Pam Snyder, head of recruiting at Baystate Health, a healthcare system based in Springfield, Massachusetts, cited the launch of the video viewing site YouTube as an example of the perils of a non-diverse workforce. When YouTube’s mobile version launched, “there was a glitch in it — 25% of people were reporting it wasn’t working,” she said.

The reason? The mobile version was designed entirely by people who were right-handed and all turned their phones a certain way to see videos; left-handers turn their phones the opposite way, so the videos all appeared upside down. “Because they had that lack of diversity on their team, the product wasn’t launched accurately.”

A total of 188 types of unconscious bias have been identified, Snyder said. She listed four of the most common types:

  • Affinity bias: We tend to be more receptive to people who resemble our lives in some way. For example, Snyder was hiring a new recruiter on her team, but happened not to be there on the day one candidate came in for an interview. But during a follow-up phone call about the candidate, “I had at least three different staff people say, ‘You’re going to love her; she reminds me of your daughter.’ That was their affinity bias.”
  • Confirmation bias: We look for information that supports our beliefs and ignoring details to the contrary. Snyder, who is from Tennessee, explained that “when you hear someone with an accent like mine … you think they’re not well-educated. Confirmation bias is when you look for things when you’re talking to someone that confirms that.”
  • Halo effect: There’s something good about someone and because of the one good thing, we think everything about them is good. “In Tennessee, when we got a CV and it was from a Harvard grad, we’re like, ‘We’ve hit the jackpot,'” she said. “This halo effect was real; there were things we’d ignore about that candidate because of what was on their CV.”
  • Perception bias: This one is “really scary, worse than confirmation bias,” said Snyder. “You know it — you’ve met one person that had these physical and emotional attributes and you’ve formed your opinion and you can’t get away from that. That’s really the scariest when it comes to recruitment.”

Steps to Overcome Bias

To overcome unintentional bias, “the first thing we have to do is accept the fact that we have it,” said Snyder. “We can’t control the experiences we have had.” She suggested taking an “implicit association” test such as this one offered by Harvard. “You need to take an honest look at your unconscious.”

To mitigate bias and foster a diverse workplace, organizations are moving toward competency and evidence-based recruitment, she continued. Part of the competency-based evaluation for interviewees involves asking behavioral event interviewing (BEI) questions involving something the person experienced in the past. Such questions often begin with “Tell me about a time when…”

“Tell Me About…”

For example, one practice wanted to know whether its candidates for a physician slot would be able to handle the workload, which involved seeing as many as 25 patients per day with only one medical assistant and a shared RN. So they might ask candidates the following about their previous job experience: “Tell me how many patients you saw in a day and what support you had.” If the candidate answers, “I saw 10 patients a day, and had two medical assistants and my own RN,” that might mean that the candidate isn’t a good match for the position, she said.

A question to ask when you want to find out about the candidate’s teamwork abilities is, “Describe a time when you were part of a team that worked well together. What role did you play? How did you show respect for others on the team?” said Snyder. Candidates’ egos can really be revealed with this answer; if they answer the question by just talking about themselves, “it’s a big red flag for us.”

When developing questions for a competency-based evaluation, it’s important to get buy-in from the staffers working in the department being recruited for, and to ask all the candidates the same questions, she said. Having a diverse panel of interviewers is also critical. “If you’re looking at an interview panel of all white males, you failed.” Also, panelists should work in a variety of positions at the company: “if you’re hiring a surgeon, you need someone from the surgery department that’s a non-provider … When you have those different inputs, you get a stronger decision.”

Benefits of Diversity

In addition to unintentional biases, practice managers need to be on the lookout for intentional ones as well, according to Marsh. For instance, “over the last 2 or 3 years, I’ve seen one of the biggest intentional biases ever creep in: politics,” said Marsh. “Five times in the last 2 years — not in group settings, but in individual meetings — I’ve heard, ‘We can’t recruit a Republican’ or ‘We can’t recruit a Democrat.’ I’ve heard it on both sides of the aisle. People have some very strong polarizing biases in the environment we’re in right now, but it has nothing to do with competency. It has nothing to do whether they’re good for this role.”

Hiring a diverse workforce results in more creativity, according to Marsh. “You have all these ideas coming in that you never would have had if everybody looked and acted the same,” he said. “If we’re able to create an environment where everybody has a voice, you’re going to have meetings — and be thankful for them — where somebody says, ‘I don’t think that’s a good idea.’ If you have an inclusive environment and welcome additional ideas, many times you’ll avoid pretty bad circumstances.”

Once a diverse workforce is on board, the next step is to work on inclusion, defined as “a feeling of belonging, a feeling of being appreciated for unique characteristics, and the extent to which employees feel valued, respected, accepted, and encouraged to fully participate,” said Marsh. And you have to have a meaningful process for addressing bias-related concerns. “You can do everything right, with all the good intentions in the world, but if you’re scared to address the issues, it all goes for naught because everybody’s watching.”

Originally published in MedPage Today

HHS: Don’t Withdraw Opioids Suddenly

HHS: Don’t Withdraw Opioids Suddenly

Department issues guideline on tapering and discontinuation

Clinicians seeking to wean patients off opioid painkillers should do so slowly and only with shared decision-making involving the patient, according to a new guideline released Thursday by the Department of Health and Human Services (HHS).

The lone exception is when patients face a life-threatening crisis if opioids are continued, the document stated.

HHS also lists situations in which clinicians should consider tapering dosages or discontinuing opioids altogether, starting with “Pain improves” and ending with “The patient has been treated with opioids for a prolonged period (e.g., years), and current benefit-harm balance is unclear.”

In between are common-sense scenarios including patient request, overdose, evidence of misuse, and use of other medications that shouldn’t be combined with opioids.

Sudden Tapering is Risky

But the guideline’s main thrust is to discourage clinicians from simply stopping prescriptions abruptly.

“Risks of rapid tapering or sudden discontinuation of opioids in physically dependent patients include acute withdrawal symptoms, exacerbation of pain, serious psychological distress, and thoughts of suicide,” the document emphasizes in a colored box. It also notes, perhaps unnecessarily, that “patients may seek other sources of opioids, potentially including illicit opioids, as a way to treat their pain or withdrawal symptoms” if suddenly deprived without their agreement.

Among the steps clinicians should take before changing doses were making a commitment “to working with your patient to improve function and decrease pain.” This could include alternative medications as well as nonpharmacological treatments, the document indicates, adding, “Integrating behavioral and nonopioid pain therapies before and during a taper can help manage pain and strengthen the therapeutic relationship.”

“Obtain Patient Buy-In”

The guideline also advocates a thorough discussion with patients that includes soliciting their perceptions of the risks and benefits of continuing on opioids.

Notably, it also states that “tapering does not need to occur immediately. Take time to obtain patient buy-in.”

Included in the guideline is a multi-step flow chart to walk clinicians through the decision-making process, from the initial assessment of benefits and risks of patients’ current regimens to a recommended quarterly re-evaluation of patients’ progress. And, also in a colored box, is the definition of opioid use disorder as given in the DSM-5 diagnostic manual.

“Care must be a patient-centered experience. We need to treat people with compassion, and emphasize personalized care tailored to the specific circumstances and unique needs of each patient,” said Adm. Brett P. Giroir, MD, assistant HHS secretary for health, in a statement announcing the guideline. “This Guide provides more resources for clinicians to best help patients achieve the dual goals of effective pain management and reduction in the risk for addiction.”

Originally published in MedPage Today

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