Jarret Patton MD
Illiteracy has different faces, its not always easy to identify.
Just as summer is in full swing, the “back to school” advertisements are running. This time of year can be exciting for many; the first day of elementary school, high school or college. For the rest of us, we try to be lifelong learners; learning from our successes and failures, learning from others and if we are lucky learning by reading.
Reading is a skill learned in the early school years. Children spend the first few years of their education learning how to read. After that period ends, in the third or fourth grade, children read to learn. Unfortunately, many of our nation’s school districts have poor reading proficiency by the time children reach and finish high school. This is particularly true of many of our urban and rural school districts. Without good reading skills, life can be challenging.
Literacy is often assumed in most professions, healthcare is not excluded. It is estimated that there are 23 million adults in the U.S. with limited literacy, defined as below basic literacy or non-literate. Often when this population comes to us for help, we ignore the signs of limited literacy. These signs include complaining about forgetting their glasses or being unable to see, having difficulty or taking an extraordinary amount of time filling out forms. This does not include the people made to complete forms in English when they primarily speak another language. When language is considered, the number with below basic literacy or worse is over 30 million.
With so many people having low or limited literacy, one would think healthcare does a good job at providing healthcare instructions in the preferred language. After all, most electronic health records (EHRs) have patient instructions in different languages. However, it may take extra clicks or extra time to load so it doesn’t happen as often as needed. In addition, many pharmacies are able to dispense medication instructions in other languages only if requested by the prescriber. When basic instructions aren’t understood, errors are bound to occur. Low literacy and limited English proficiency have been known to affect hospitalizations, readmissions, morbidity and mortality. If we don’t do this right in healthcare where the stakes are high, why should other industries care?
Fortunately, most adults are literate; however they can also have difficulty navigating our complicated healthcare system. Health literacy is defined as the degree to which individuals have the capacity to obtain, process and understand basic health information and services needed to make appropriate health decisions. Simply stated, the ability of adults to comprehend and use health-related information.
Health literacy has important implications for the ongoing care of many. Studies have attempted to measure health literacy with screening tools or signature time at registration. Various populations have been studied from adolescents to military personnel. However, the elderly seem to have the most trouble with health literacy. This is likely due to the fact they have complex medication regimens and the 18 pages of instructions printed by the EHR is too difficult to follow. This leads to them making mistakes following their discharge instructions thus leading to readmissions and further hospitalizations.
Although many of us work in highly technological and perhaps scientific fields, we need to be wary of those that have limited literacy. We should make our communication simple and understandable, both spoken and written, in the preferred language. Most of all, we need to ensure that we are not overlooking an often under recognized issue- health literacy.
White S. Assessing the Nation's Health Literacy: Key concepts and findings of the National Assessment of Adult Literacy (NAAL). AMA Foundation. 2008.
Jarret Patton MD
Take these steps to get more equitable health outcomes in your organization.
The Institute of Medicine (IOM) states that healthcare should be safe, effective, efficient, patient-centered, timely, and equitable. Our pursuit of better healthcare drives us towards all of these hallmarks of quality health care. As difficult as it is to keep the first five in balance, ensuring equitable care can be very difficult. Areas of health disparities are well published in the medical literature. Asthma, diabetes, cancer, and hospital readmissions are just a few examples from institutions across the country with differences in care. This article will explore some best practices that an organization can undertake in order to practice more equitable medicine.
Collecting, stratifying, and planning strategy based upon REAL(april-06th-2017.html) data are three important steps in which one takes to further equity within an organization. In essence, using REAL data can be the foundation in which all programmatic changes can be made. If you don’t collect REAL data, you must start doing so.
However, collecting the data is not enough; encourage your peers to examine existing quality, customer satisfaction or safety metrics with REAL stratification. There will be different information gained from these reports than the stand alone reports. Once an ongoing analysis is done on the new data, there could be additional programs or interventions implemented to help close the gap on any found disparities. It is important to remember that while looking for disparities, you will likely find them.
Continuing self-directed education is another well studied intervention. Although one can never be culturally competent, many work towards cultural humility. This implies that one is open to develop an understanding about another culture while maintaining one’s own. Respect for difference is a key to cultural humility. Keeping an open mind while making the effort to see a different perspective can go a long way. There are many proprietary and free resources on the web that can provide additional education. This education should be provided at all levels of an institution. It is equally important for the board of trustees to understand these concepts as the front line staff. DoctorJarret can provide educational programming to your institution or small group.
Another basic tenet, communication, must be clear and concise. Primarily, communication must occur in the preferred language to the patient. In a nation founded upon immigrants, we have the fortune of working in an environment with its own vernacular (i.e. code blue, code pink, stat, H&P, I&D, NPO, wRVU, IVF etc.) within a macrocosm that includes many different languages. Every healthcare outlet should have different options for interpreter services. This can include live and cross-trained interpreters, telephonic interpreters, and remote video interpretation, which includes American Sign Language.
Understanding, urges us to seek meaning from cross cultural interactions and be aware of things that can lead to tension during healthcare encounters. In doing so, one learns about another culture and perhaps learns about oneself or tendencies (i.e. bias bias-affects-everything-we-do.html) For instance, timeliness is one that we can all relate to. Does the person base their life on chronological time (like doctor’s appointments) or event based time (i.e. the party gets started whenever I arrive)?
Engagement is a strategy that can be used to negotiate a treatment plan or help when cross cultural conflict arises. A provider can realize what is important to the patient while explaining their own point of view. Using engagement, an acceptable care plan can be developed while achieving mutual goals. The end result is a more satisfied patient encounter which increases the satisfaction of the clinician and the patient.
These strategies can help discover health disparities and begin the elimination of them. What are you waiting for?
1 Institute of Medicine. Unequal Treatment: Understanding Racial and Ethnic Disparities in Health Care. National Academies Press. 2002
2 Health Research & Educational Trust. Rising above the noise: Making the case for equity in Care. HRET. Chicago. 2013. www.hpoe.org
3 Health Research and Educational Trust. Improving Health Equity Through Data Collection AND Use: A Guide for Hospital Leaders. Chicago: Health Research & Educational Trust, 2011. pp 11-12
4 Wilston-Stronks A et al. One size does not fit all: Meeting the health care needs of diverse populations. Oakbrook Terrace, IL. The Joint Commission. 2008
Jarret Patton, MD
Children don't need to exercise their second amendment right, but there is something you can do to protect them.
Over the past several years there have been numerous reports on the rates of death and injury in children with firearms. Although the studies don’t entirely agree, two things are certain; 1 death is one too many and children don’t need to exercise their second amendment rights.
The United States has by far the highest rate of these tragedies of any industrialized nation. Deaths related to firearms in children number at least 100/year. The non-lethal injuries go into the thousands yearly. These injuries and deaths are categorized into three types, accidental, suicide and homicide. Many of the deaths and injuries could be prevented despite the nature of the incident.
Some may disagree, as gun lobbyists oppose restrictions to guns. The NRA and other gun rights advocates believe that it is a right to own as many guns as one wants without restrictions. Opponents such as the American Academy of Pediatrics advocate restriction on guns including a complete ban on assault weapons. Given the divisive nature of these extremes, neither will likely occur soon. Middle ground on the issue must be reached.
Accidental deaths and injuries comprise the most dramatic and preventable type. Often young children, many times less than the age of 6, get their hands on a loaded gun and discharge the weapon erroneously injuring themselves or another child, often a sibling or friend. The natural curiosity of children often draws them to something they may not be completely familiar with, but may have seen used by a parent or on television. This curiosity can cause an unintended catastrophe in both young children and adolescents.
Suicides comprise about a third of the firearm deaths in youth. Like accidents, suicides can happen without warning. Most often this occurs in the adolescent group which can be the most difficult to construe. Open conversation should occur regarding bullying and suicide at home. Additionally, access to social media accounts should also be a parental right. Furthermore, screening for depression should occur in physician offices with a validated tool. Be on the lookout for signs and symptoms of depression including emotional lability, mood swings, appetite changes or a prolonged depressed mood.
Homicides are the most frequent cause of death related to guns in adolescents. Exposures to family violence, historically violent neighborhoods, bullying and having access to handguns are all risk factors. Black males have the highest rate of homicide. Conflict management curricula in schools and involvement in community programs aimed at combating violence can help reduce these events.
The most foolproof method of prevention of these tragedies is to opt out of firearms in the home. However, there are practical uses for guns and they are a way of life in many areas of the country. If guns are stored in the home they should be kept unloaded and locked away in a safe place. Some communities have even implemented trigger lock programs to further secure handguns. Finally, ammunition should be stored and locked in a separate location from guns.
June 2nd represented “wear orange day” for National Gun Violence Awareness Day. This is a day to encourage people to wear orange in support of gun safety and to end gun violence. For those that exercise their 2nd amendment right, keep your guns secure and practice good gun safety protocols. You can join the effort in your local community at wearorange.org.
Dowd, MD and Sege RD et al. Firearm-related injuries affecting the pediatric population. Pediatrics. November 2012 (reaffirmed March 2017)
Innocents Lost: A Year of Unintentional Child Gun Deaths. Everytown for Gun Safety. June 2014
Hemenway D and Solnick SJ. Children and unintentional firearm death. Injury Epidemiology 2 (1). 2015
Jarret Patton MD
We must work together to combat the ill effects of poverty on our children.
Today marks an event that draws attention to child poverty, Red Nose Day. This event was started in the mid 1980’s as a comedic fundraising event to raise awareness and funds to help children. Annually, this event takes place affecting the lives of millions of children globally while raising over $1 billion since inception. With busy personal and professional lives, taking a moment to be grateful for all of our fortunes including independence, health, food and shelter can put everything in perspective. I have this unhappy reminder often as I take care of many children who are in unfortunate circumstances.
The basic necessities of food, shelter and clothing are not a given for all. 19% of children in the United States live at or below the Federal Poverty Guideline. Currently, this means that a family of four makes less than $24,600 annually. This is hardly enough to provide reasonable basic needs to children in the Northeast or any major metropolitan area across the country. 41% of children in the US live in low income families ($49,200 or less for the same family of four annually).
Social needs can be more important than the medical needs of children as the health effects of childhood poverty lasts a lifetime. Insufficiency of resources has an incredible adverse impact on structural brain development further impairing academic functioning (1). Having little school success will lead to lower paying jobs in the future, thus continuing the cycle of poverty. There is also a higher likelihood of dying from cardiovascular disease, asthma or type 2 diabetes. Furthermore, behavioral or mental health issues may persist through adulthood. All of this is compounded by living in a state of toxic stress (2).
Often during the hustle of our busy days, we may forget that someone may have taken over two hours and three busses to get to their appointment when we turn them away for being 15 minutes late. We may not realize that children, or their parents, may act out or seem agitated as a result of food deprivation or inaccessibility to behavioral health services. Taking a moment to understand the circumstances may go a long way to improving both customer relationships and health outcomes.
Across the nation, municipalities have taken advantage of food banks, communal gardens, medical-legal partnerships, community exchanges and other neighborhood based interventions to help temper the effects of poverty. These collaborations have made some headway to create healthier residents by addressing both medical and social needs (3). These civic alliances develop goals and objectives, take a plan of action, and determine funding streams to build a sustainably healthier society (4).
Some hospital systems are taking it upon themselves to help bend the curve towards health while lowering the costs of care. They are deploying teams of employees into the community. These workers can include care managers, social workers, clinical pharmacists and behavioral health specialists that work with clinicians and practices. For instance, asthma navigators can help parents understand the effects of the disease within the context of their own home while enabling the child to take better care of herself.
The need to take care of our patients is greater than simply dispensing clinical care, writing prescriptions and performing interventional procedures. Community interventions in conjunction with episodic clinical care have demonstrated success in cities across the nation. Entire neighborhoods and communities must be involved to combat the ill effects of poverty on our children. Take a stand against child poverty and get involved in your community.
(1) Hair NL et al. Association of Child Poverty, Brain Development, and Academic Achievement. JAMA Pediatrics 2015. 169:9
(2) Raphael D. Poverty in childhood and adverse health outcomes in adulthood. Maturitas 69. 2011
(3) Bachrach et al. Addressing patients’ social needs: An Emerging business case for provider investment. The Commonwealth Fund. May 2014.
(4) Heinze AW et al. A Roadmap to Address the Social Determinants of Health Through Collaboration. Pediatrics. September 2015. 136:e993
Hardly a week goes by without hearing about another case of police brutality. Many times, seemingly unnecessarily lethal force has been used. These incidents have often sparked protests across America. Each case is unique with differentiating circumstances, but the end result is all too often, death. Many people have grouped these incidents together concluding that white officers have unnecessarily killed black men. This has initiated and reinforced mistrust of the entire police force in many communities. Realistically, the majority of the police force is here to protect and to serve. Nonetheless, in many communities, this trust has eroded and left many with the perception that the police force is simply out to violate the rights of racial, ethnic and religious minorities. For others, images of police dogs and fire hoses of the 60’s have been reinforced exclaiming no change. Perceptions move quickly from interpersonal mistrust to institutional mistrust.
For healthcare providers, both types of mistrust can serve as a reminder that we too are subject to the scrutiny of the public. Each of our patients approaches us from a different perspective via various walks of life. Although, the vast majority of our profession has very altruistic values while preventing disease and treating illness, episodes of our collective past may negate those values. Malicious medical experimentation including The Tuskegee Experiment or prisoners in Nazi Germany coupled with physicians who publish fictitious research about vaccines and autism could easily provoke mistrust institutionally.
Trust does not necessarily come automatically with the patient-provider relationship; it may need to be earned. This is often accomplished with taking a little time to know your patient while being friendly, courteous, empathetic and kind. Conversely, we are often pressed for time as our schedules seemingly don’t allow for idle conversation, eye contact, or even a handshake while grappling with a computer.
Scientifically measuring trust has proven to be quite difficult (1). Some even posit that trust increases patient satisfaction, reduces health care disparities, and improves outcomes with better adherence to treatment plans (2). Meanwhile, trust is perceived from both the provider and the patient perspective. A factor playing into our own prescriptive treatment is affected by our trust within our patients. This would be all much simpler with classes in medical school about building trusting relationships (ideally it would be placed between the cardiovascular and neurology section). Even though great interventions to influence trust have not been developed(3), many of us have developed a myriad of trusting relationships with our patients over the years. These relationships are unlikely coincidental. When trust is optimal, the experience of the visit tends to be positive whether patient or provider.
As healthcare providers go about their daily routine, we must be mindful of a patient’s thoughts while being introspective of our own. When an encounter is suboptimal, consider trust as an underlying factor. It may take time to build our individual trust particularly in light of institutional mistrust(4). If a trusting relationship is achieved, it will be stronger with medical literature purporting better outcomes.
After all, we physicians take a privileged part in people’s lives; we must establish trust.
Jarret Patton MD
Twitter, LinkedIn, Facebook, Instagram @doctorjarret
(1) Lee Y, Lin JL; Linking Patients’ Trust in Physicians to Health Outcomes; B J Hosp Med; Jan2008; 69(1) 42-46
(2) Nguyen GC et al. Patient Trust-in-Physician and Race Are Predictors of Adherence to Medical Management in Inflammatory Bowel Disease; IBD; Jan 2009; 15(8) ;1233-1239
(3) Rolfe A; Interventions for Improving Patients’ Trust in Doctors and Groups of Doctors; Cochran Database Syst Rev; 01Jan2014; 3:CD004134
(4) Simonds VW et al; Cultural Identity and Patient Trust Among Older American Indians; J Gen Intern Med; 01MAR2014; 29(3) 500-506
This post is also found on KevinMD.com www.kevinmd.com/blog/2017/04/heroin-public-health-emergency-time-act-now.html
Last week, another local family buried their young adult child due to a drug overdose. Sadly, this same story is playing out daily across the nation.
Upon reading the headline, I paused to think about an encounter leaving work one Friday evening. As I was walking in the dimly lit street to my car, I found a small group of shadows huddled over something lying in the adjacent alley. Once closer, I saw that there were three men and a security officer trying to sit a woman upright on the pavement. As a pediatrician, adults in medical emergencies are a relatively foreign call of duty. However, I put my intimidation of adult patients aside knowing that I needed to act. After a quick assessment of the unresponsive body and a vigorous sternal rub that barely produced a shallow gasp, I knew that she did not need any of the people around her, including me. She needed naloxone, the reversal agent for a heroin overdose. She was quickly carried across the street to the emergency department and administered naloxone. Shortly thereafter, she was conscious and responsive. She survived because she collapsed less than one block away from the hospital.
There is a heroin epidemic in America. It affects families within our inner-cities, suburbs and rural areas. Users come in all types, spanning all demographic categories including socioeconomic status. Particularly, heroin is a drug of choice as the prices have fallen dramatically while its purity has risen remarkably. Compounding the situation, some distributed heroin is laced with other chemicals such as fentanyl, a drug used in anesthesia. This explains why there have been so many deaths and hospitalizations from overdose. Nationally over the past decade, there has been a 63% increase in the usage of heroin. Over the same time period, overdose deaths have quadrupled1. These estimates continue to rise.
Fortunately, some lawmakers have an understanding of the urgency in this issue. Legislation has been changing in order to help save lives. For instance, Pennsylvania Act 139 of 2014 allows many area municipalities to keep naloxone with the local emergency medical services (EMS), police and other first responders. This has saved many lives in Pennsylvania alone as more first responders carry the medication that literally helps breathes life back into the victims. Additionally, there is a movement to make naloxone an over‐the‐counter medication available to families or friends of opioid addicts. It is already available in Pennsylvania and several other states. Many other states are working through their legislature to make naloxone available to all.
Prescription pain medications are also a part of the problem. Teens are known to have pill parties emptying out pill bottles from their home medicine cabinets. Their intent is to meet other teens to take and trade medications. Adults may have been prescribed opioid medications for chronic pain. In both examples, people often start off addicted to prescription pain medicines and move on to heroin for a stronger high. As a result, there is a strong black market for prescription pain medication. Physicians, as prescribers, can also be a part of the problem if we are not judiciously practicing safe prescribing habits2.
We currently have a public health emergency in America that is costing way too many lives. We must all work together to be a part of the solution. Healthcare, law enforcement, schools, rehabilitation services, policy makers and communities all have a role to play. Now is not the time to ignore the problem.
(1) Jones CM et al. Vital Signs: Demographic and Substance Use Trends Among Heroin Users‐ United States 2002‐2013. MMWR. 64:26. July 10, 2015. 719‐725
(2) Pennsylvania Medical Society. Pennsylvania Guidelines on the use of Opioids to Treat Chronic Noncancer Pain.
This post is also found on KevinMD.com www.kevinmd.com/blog/2017/04/heroin-public-health-emergency-time-act-now.html
Do you collect REAL data?
Jarret Patton MD
Collecting REAL data is essential to health equity.
This week many healthcare systems are celebrating national health equity week with education and prominent speakers. These systems are on the road to health equity. Some have gone far down the road while others are just beginning. One of the most important strategies a healthcare system could do is assess their system for evidence of health disparities.
One of the principal steps in this quest is the usage of REAL (race, ethnicity, and language) data. These are basic demographics that can be collected at patient registration across the care continuum. Some systems have expanded REAL data collection to include veteran status, sexual preference or sexual identity as well. The more data you can collect on your patient population, one can determine whether differences in care exist.
Once routine REAL data collection has been collected for a time, you are ready to evaluate the data. This does not have to be separate from evaluations that are done in the quality and safety departments. Simply stratify the data by the REAL categories and evaluate for differences in outcomes.
Finally, don’t be surprised by your results. Commonly administrators feel that the care provided is equal to all. However, most institutions that look for health disparities find them. Remember, you are on a journey towards health equity. First, you must discover if they exist. Once in existence, you can employ strategies to mitigate them. Stays tuned for more information or feel free to contact us. Good luck and continue on the journey.
Jarret Patton MD
This blog explains two types of bias and how it affects our every day decision making.