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The American Psychiatric Association (APA) is nearing completion of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). This will be its first major revision in 17 years. Work on it had already begun 15 years ago when the DSM-4 was only a few years old. The DSM drives research, treatment, health insurance, and public benefits decisions (disability and special needs school services). So you can imagine just how highly charged and politicized the process is of revising the DSM.

The main decision makers behind the DSM are the APA and the mental health branch of the National Institutes of Health (NIMH). The actual revisions are done by workgroups, who collectively are considered an independent third party review. There are 160 members of the DSM-5 workgroups: 97 (MD) psychiatrists, 47 (PhD) psychologists, 2 (MD) pediatric neurologists, 3 (PhD) epidemiologists and then 1 each from (MD) pediatrics, social work, psychiatric nursing, speech/hearing specialist and a consumer group. The one nurse on the workgroups is Barbara E. Wolfe, ARNP, PhD—a psychiatric nurse practitioner on faculty at Boston College and an expert on eating disorders.

There is a DSM-5 website with information on the background/history of the DSM-5, workgroup members names/affiliations, and updated lists of proposed changes to be included in the DSM-5. The developers of the DSM-5 have already held two open public comment sessions on their website, and the third and final public comment session is slated for April. They report that their work is 90% complete, and that they will finalize the DSM-5 by December 2012 (publication date May 2013).

There’s been a fair amount ofnews coverage of several of the proposed DSM-5 changes, most notably a tightening of the definition of Autism, as well as changes in the definition of Bipolar Disorder. In reading through the updated proposed changes to the DSM, I came across the following items of interest. “Stuttering” is being renamed “Childhood Onset Fluency Disorder.” “Hypochondriasis” is being renamed “Illness Anxiety Disorder.” And under the diagnostic category of “Mood Disorders” (includes Depression), they are adding “Premenstrual Dysphoric Disorder. Proposed new mental conditions (listed as ‘under review’) include Apathy Syndrome, Internet Addiction, Seasonal Affective Disorder, Parental Alienation Disorder, and Male-to-Eunuch Gender Identity Disorder (ouch!). They need an “Overdiagnosis of Mental Disorders Disorder Syndrome,” then everyone including the DSM-5 members will be covered.

I read through the proposed Physician Payment Sunshine Act (vol 76,no. 243/12-19-11 Federal Register), and found that they define “physician” as a doctor of medicine or osteopathy, dentists, podiatrists, optometrists and licensed chiropractors. Teaching hospitals are defined as hospitals having graduate medical education. And here is their rationale for the Sunshine Act:

“2. Transparency Overview

Collaboration among physicians, teaching hospitals, and industry manufacturers may contribute to the design and delivery of life-saving drugs and devices. However, while some collaboration is beneficial to the continued innovation and improvement of our health care system, payments from manufacturers to physicians and teaching hospitals can also introduce conflicts of interests that may influence research, education, and clinical decision-making in ways that compromise clinical integrity and patient care, and may lead to increased health care costs.” (p. 7)

(The NYT has a recent article on this, as does Kaiser Health News–older but good.)

Several states including Vermont have already implemented similar reporting requirements. Some physicians are complaining that drug companies are now wooing more nurse practitioners as a way around the reporting requirements. I saw that in action at this past fall’s regional nurse practitioner conference. It was overrun by aggressive pharmaceutical reps waiving tons of swag (including the ubiquitous drug pens), as well as signing NPs up for free lunches/dinners/talks, etc.

In the community health clinics where I’ve worked, most all of the family physicians were rabidly anti-drug company marketing and influence. One physician in particular would go on a tirade if she discovered one of her medical residents writing with a drug company pen. They—and everyone else in the building—would get a lecture in the evils of drug company influence on physician prescribing practices and health care costs. So I thought I had long ago purged myself of all drug company free stuff. While preparing to write this blog post I engaged in some late winter housecleaning searching for hidden drug company subliminal influences. I found six drug company pens, four of which were for drugs that have been pulled from the market as unsafe. I threw them all away. On a popular blog lamenting the Sunshine Act, one physician complained that he has to buy pens for the first time since he graduated from medical school in 1986.

The only drug company swag I found that I am keeping is a funky glass sun catcher given to me by a retired pharmacist who lives on my street. It has elemental alchemy symbols for strange things like lead and vinegar and talc—but is really an advertisement for a nasal decongestant hidden in small type at the bottom. See if you can find it on the attached photo—but don’t buy the stuff!

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The Susan G. Komen for the Cure foundation vs. Planned Parenthood political drama this week was fascinating to follow. This, of course, was the news that Komen was withdrawing all grant funding to Planned Parenthood for breast cancer screenings for low-income women. After a groundswell of public outrage over their decision, Komen’s founder and CEO, Nancy G. Brinker made a public announcement upholding their decision and trying to assure people that it wasn’t politically motivated—the subtext that it had nothing to do with the fact that Planned Parenthood services include abortion. Then when her explanation only made the backlash worse, Brinker announced they would reverse their decision and fund Planned Parenthood at least for this year. This drama all happened over the course of four days.

When listening to people’s conversations about this unfolding drama—especially around my nursing-type friends and colleagues—I was surprised at how many of them were surprised that the Komen foundation would do such a thing. The sacred hot pink halo hovering over the Komen foundation has blinded most nurses—as it has blinded most of the general public. It has never been PC to critique the Komen foundation’s stated “race for the cure” of breast cancer. It was also interesting to discover how many people didn’t realize that Nancy G. Brinker is far right leaning politically. She has long been a major Republican donor, and was named Ambassador to Hungary and then Chief of Protocol (e.g.: official ‘party planner’ for visiting dignitaries to the White House) under Bush.

In 2010 the Komen for the Cure foundation pulled in $311,855,544. The top administrators make over $500,000 per year. And although many Race for the Cure pink t-shirt wearing participants think that most of the money they are raising goes to fund breast cancer research, only ~20% goes to research. At least a million dollars a year seem to be spent on legal fees for the Komen foundation to sue anyone using ‘for the cure’ or anything approximating a pink ribbon in their marketing. Breast cancer has become big business—even for the supposed non-profit Komen foundation. Barbara Ehrenreich (of Nickeled and Dimed fame) uses the term “Cancer Industrial Complex” when discussing everything that profits from cancer—and especially from breast cancer. Writing in November 2001 in Harper’s Magazine (“Welcome to Cancerland: A Mammography Leads to a Cult of Pink Kitsch”) Ehrenreich reports that the breast cancer industry is estimated to be a $12-16 billion dollar a year business in the US, between all the breast cancer centers, radiation centers, mammograms, surgeries and drugs (doesn’t include breast cancer research spending).

And then, of course, there are the dismal statistics pointing to the fact that all the increased breast cancer research, increased focus on mammograms, early detection and treatment, really haven’t changed the death rate from breast cancer.  On the Susan G. Komen website—in amongst the flashing hot pink merchandise to buy—is Nancy G. Brinker’s declaration that the Komen foundation has “changed the world.” The world is pinker perhaps.

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To continue the baby theme and to remind myself–and all of you–about the good stuff of life and of nursing, I want to highlight the Nurse-Family Partnership Program. As they state on their website, the Nurse-Family Partnership Program “is an evidence-based community healthcare program that empowers low-income, first-time mothers to become confident parents and strong women by partnering with nurse home visits.” Based on independent research, for every public health dollar a community invests in the Nurse-Family Partnership Program, the community gets at least five dollars in return from savings in social services, criminal justice and healthcare costs. The program has now been adopted by over 400 countries and 29 states in the US–and is growing due to its wide-spread appeal and proven cost-effectiveness.

I have the good fortune of working with two local nurses involved with the Nurse Family Partnership in Seattle-King County. It should come as no surprise that they are some of the happiest and seemingly healthiest most grounded of all nurses. They always make my day and remind me of the good stuff of nursing.

Here’s a link to my favorite video of the Nurse-Family Partnership–from New York City. Healthy happy babies and moms and nurses! What’s not to like?

OK–the puppies snuck in here and the kittens are close behind….

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And the mother and the midwife.  If you haven’t heard the news on this, the nursing faculty at the University of Washington voted to eliminate their nurse midwifery program. News of the pre-Christmas faculty vote is now making headlines and creating controversy. Several weeks ago there was an impassioned opinion piece about the faculty’s decision, circulated by the listserve for the American Association of University Professors. Today in the Seattle Times, Danny Westneat published a column “UW School of Nursing’s Priorities Can No Longer Bear Midwives.” (1-15-12).

I love nurse midwives and tried to have one deliver my son a quarter century ago. But since I lived in the south—and did I mention it was a quarter century ago?—and had an extremely benign heart arrhythmia and maybe had been exposed to TB by a homeless patient, I was deemed too high risk to rate a midwife. In labor, I went to a birthing center to have my son and was doing just fine with the nurses there and with no real medical intervention—until some uptight female OB/GYN who I’d never met came clicking down the hallway in insanely high heels, yelled at me not to push until she returned—she had to go park her car—and clicked back down the hallway. I wanted to kick her or at least fire her. I’m sure it would have been a better birthing experience if I’d had a nurse midwife.

I’ve worked with nurse midwives in a variety of community-based health settings and they provide wonderful women-centric primary care. It will be interesting to see what emerges in the continuing—hopefully public—debate over the fate of nurse midwives at the University of Washington.

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Donald Berwick, recent Administrator of the Centers for Medicare and Medicaid Services, and past President of the Institute for Healthcare Improvement, has some opinions on patient-centered care. One of his maxims for patient-centered care is: nothing about me without me—addressing transparency and patient participation in care. In one of his speeches, “Escape Fire: Lessons for the Future of Health Care” (Commonwealth Fund, 2002), he rails against the difficulties patients have in having access to their own medical information.

Isn’t it ironic that giving patients access to their own medical charts is considered a radical idea? So radical in fact that the Robert Wood Johnson Foundation—that pioneering, cutting edge organization—is funding research on the feasibility and effectiveness of giving patients access to their own medical records. A one-year pilot project called “OpenNotes” was conducted at three hospitals: Harborview Medical Center in Seattle, Beth Israel Deaconess Medical Center in Boston, and the Geisinger Health system in Pennsylvania. Results from the baseline survey data were reported in the Annals of Internal Medicine (12-20-11). Not surprisingly, patients were overwhelmingly (>90%) supportive of the idea of having access to their doctor’s medical notes, saying it would help them remember important health information. In contrast, the majority of the 173 doctors completing baseline surveys expressed reservations over the OpenNote idea. The doctor’s concerns included: 1) worrying/confusing patients with medical chart information, 2) doctors would be less candid in what they charted about patients, 3) it would take up more of their time in having to answer patient questions raised by access to their charts, 4) it could increase the number of lawsuits, and, 5) personal medical information could end up on Facebook.  The yearlong pilot has ended and OpenNote researchers are now analyzing data to see how patients and doctors who participated in the project felt about it. They are also evaluating how often patients accessed their medical charts, how often they shared them with family/other providers, and how often they corrected errors the doctors had made in the charts.

As Carol Ostrom points out in her recent article on the OpenNote project, doctors may need to change some of their charting habits in terms of labeling patients. (“Patients eager to see doctor’s notes; physicians, not so much” Seattle Times, 12-25-11). She includes calling patients SOBs and charting on their BS (bowel signs). I’m not sure I’ve ever read a medical chart where someone called a patient a SOB, but I last worked in a clinic that had ‘slovenly’ as a standard term in a menu for describing patients. My colleagues and I had a debate, with some saying slovenly was a perfectly acceptable term for patients—similar to unkempt or disheveled. I maintained it was much more insulting because it implied a slur on moral character as well as physical appearance. And then there’s the still used FLK (funny looking kid) in pediatrics, used for describing a baby or toddler ‘just doesn’t look quite right and might have a genetic or other disorder but who hasn’t been diagnosed yet.’ Supposedly some pediatricians have been known to use FLP (funny looking parent) in children’s charts—I suppose by way of saying the FLK is genetic in a FLF (funny looking family) sort of way. I don’t think these terms would go over well in OpenNote.

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Recently, I was in a hospital elevator when three hospital employees walked up to it separately, all deeply concentrating on their smartphones. Their smartphones collided, and they looked up dazedly, sheepishly apologizing as they stepped on to the elevator. Then all three resumed communing with their smartphones. From where I stood I could see that at least two of them were not doing patient or work-related activities on their phones. I considered this research and not elevator eavesdropping.

By now everyone has heard of the dangers of cell phone and texting distraction while driving, although state laws banning or limiting cell phone use while driving seem to be scoff laws. Being a true Seattleite, I bike to work on our lovely Burke-Gilman bike trail. This used to be almost idyllic but now I have to watch for bikers on their phones, weaving as if they’re drunk. I am not a complete curmudgeonly Luddite: I own an iPhone, but I don’t use it while riding my bike, driving, or walking onto a hospital elevator.

A recent NYT article on distracted doctoring and distracted nursing highlights the extent of hospital personnel using smartphones, computers and other electronic devices for things other than work, including when they are doing patient care—even when they are doing surgery. (“As Doctors Use More Devices, Potential for Distraction Grows” by Mike Richtel, 12-14-11). A neurosurgeon reportedly was talking on his cellphone (using a wireless headset) during a surgery that got botched, leaving the patient partially paralyzed. An OR nurse in Portland was reprimanded for surfing an OR computer for airfares while she was covering a spinal surgery. And then for the truly frightening, over half of 439 technicians surveyed admitted to texting while monitoring heart bypass machines.

When my father was in the hospital last year, I noticed that his nurses spent much more time on the mobile computer stations outside of his room than they did in direct patient care. He had some terrific nurses, and they told me that they hated how much time they had to spend in checking and entering patient data in the computers. The legitimate use of technology in health care is all in the name of patient safety. But at what cost does it come in terms of the human interaction necessary as the core of all healing?

The angel statue in the photo is on a cellphone…

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Nurses did it again: topped Gallop’s annual Honesty and Ethics of professions survey for the twelfth straight year. In fact, nursing has topped the Gallop survey every year except one since nursing was added to the list in 1999. Nursing was eclipsed by firefighters in the 2001 poll, which was conducted two months after 911. It is interesting to note that Gallop started the Honesty and Ethics survey in 1976, and nursing wasn’t included until 1999. Prior to 1999 pharmacists or clergy were rated #1.

The 2011 Gallop Honesty and Ethics poll was based on a telephone (landline and cell) survey conducted November 28-December 1^st from a random sample of 1,012 adults representing all 50 states and Washington, DC. The survey question was, “Please tell me how you would rate the honesty and ethical standards of people in these different fields—very high, high, average, low, or very low?” Rankings of the professions by overall results are done based on the percentage of respondents answering either ‘very high’ or ‘high.’ This year 84% of those surveyed rated nurses as very high/high (and only 1% rated nurses ‘very low/low). Pharmacists were the next highest medical profession in the ranking, 73%, very high/high, followed by medical doctors at 70%. Military officers and high school teachers rank higher than doctors.

The phrase, “nursing is the most trusted profession in the US” is inserted into many public speeches—by nursing leaders ,of course—but also by politicians pandering to the nursing vote. It is almost taken for granted that nurses are trusted. But why are we so trusted?

First, you can’t trust nursing leaders for the full answer to this question. They have a vested interest in positive spin, such as this recent statement by ANA’s President Karen Daley: “The public’s continued trust in nurses is well-placed, and reflects appreciation for the many ways nurses provide expert care and advocacy.” Well, yes, but isn’t there more to it than that?

If you dig into analysis by the Gallop researchers, they point out that the medical professions as a whole are generally highly trusted in our society, and that stability is the norm in American’s rating of professions. However, American’s opinions do shift in response to real-world events (e.g.: 911 and firefighters), and mostly to large scandals that reflect poorly on a profession. For instance, the clergy took a tumble in ratings in the wake of the Catholic priest sex abuse scandals (as well as the Evangelical sex scandals such as Jim Bakker/closets, etc). For whatever reason (relative low-profile/low power and prestige perhaps?) nurses and pharmacists have been able to avoid widespread scandals.

Sandy Summers (a nurse) on her The Truth About Nursing website states, “The reason the ‘most trusted’ poll results don’t do too much for us is that this public view often goes hand in hand with the prevailing vision of nurses as devoted, angelic handmaidens.” And Suzanne Gordon (a journalist/not a nurse, but rather a die-hard nurse advocate) goes even further, writing on her blog last year, “I am getting tired of these polls that try to assuage nurses and stroke them and make them feel better.” Both Sally and Suzanne point out that trust does not equal respect, and that many people may trust nurses but have little idea what they really do. But I’m not convinced that you have to understand what someone does to be able to trust them.

I find it intriguing that the four most highly trusted professions (listed in order) are nurses, military officers, pharmacists, and grade school teachers. All four have strict codes of ethics and standards of practice, and all—for the most part—work within rigid hierarchies for ‘the man’ or ‘the woman.’ They don’t typically work on their own as physicians can and often do. They all, in various ways, take orders. And they aren’t exactly the highest paid professions around—although the average pharmacist salary now tops six figures. So—taking orders within a rigid hierarchy and not profiting in a huge way would seem to be related to high public trust. The lowest ranked professions on the trust survey are members of congress, car salespeople, telemarketers, and lobbyists. The lesson here for our country? Perhaps more nurses should become members of congress?

In her work with Somali women, Bria was noticing that many of the women had complaints of pain that doctors were unable to treat through medication or physical therapy. She suspected that massage would be more culturally acceptable and effective for addressing the women’s pain—but it needed to be massage adapted to the women’s religious beliefs and cultural practices. She couldn’t just send the Somali women off to some hippy-dippy massage practice and expect it to work. Bria also knew from her work with the women that they suffered from isolation in this strange new country and big city of Seattle. Many had also experienced multiple traumas in their homeland, and the psychic effects of these traumas could be expressed as body pain. So she started Daryel with the help of female Somali interpreters/cultural brokers.

The Daryel program is offered every Sunday afternoon at a community center/senior center in Rainier Valley/ south Seattle. Today there were about a dozen Somali women who brought traditional food to share. They usually have group yoga sessions as well as individual/private massage, mixed in with wellness/health information.

This past summer I attended one of their yoga group sessions, and found them refreshingly raucous—the women really enjoy talking to each other and laughing as they try out yoga poses. Happy yoga instead of the usual overly serious yoga usually experienced. (For wonderful photo documentation of Daryel—and visual proof of happy yoga–check out Seattle Times photographer Erika Schultz’s photos here). Today, one of the Somali women commented that when Bria had first introduced the idea of yoga, she had been skeptical—but now she looked forward to it and felt refreshed afterwards. Another Somali woman at today’s session told everyone that she was there because her doctor referred her to the program.

Daryel is always on the lookout for additional volunteer female massage therapists. On the Sundays when they can’t get a massage therapist, the women sit in a circle and give each other backrubs. It is an amazingly uplifting program and a fine example of what

Night shift nurses are sometimes referred to as the forgotten nurses. Most patients in hospitals (if they are lucky) sleep through most of the night and never really remember the nurses who check on them in the wee hours of the morning. Nursing leadership and the rest of hospital administration acknowledges their essential function, but rarely actually sees them. Working night shift is often considered a career stall if not an outright career killer, because of the invisibility to daytime administration. It’s also sometimes looked down upon as the ‘easy shift’ since not as much is going on during the night—no tests or surgeries being scheduled for patients. The hard part of night shift nursing is the pesky sleep issue for nurses, so it still comes with a pay differential.

Early in my career when I worked as a hospital nurse on a spinal/brain injury rehab unit, I chose to work evening shift. This was when they still had three 8-hr hospital nursing shifts instead of the more common 12-hour shifts they have now. I liked evening shift because it wasn’t as hectic as daytime shift with its PT/OT/procedures, so I got to spend more time one-on-one with my patients, as well as with their families. When I worked in a nursing home as a nurses’ aid I sometimes was asked to work an evening and a night shift back-to-back when they were understaffed. I remember stumbling home after those double shifts as if I were drunk. Indeed, sleep deprivation can be as bad as alcohol intoxication for basic brain functioning. Not safe for driving home after work and not safe for patient care duties.

Research shows that night shift nurses have higher “sleep debt,” worse circadian rhythm disorders (think chronic jet lag), higher risk of obesity (poor eating options at night plus hormonal/metabolic imbalances from night duty), and higher rates of certain types of cancers (especially colon cancer). Lack of adequate sleep and working too many consecutive hours is linked to higher risk of serious patient adverse events. This is why there have been significant changes by accrediting bodies limiting hours of medical residents (to 80 hours/week). This is similar to aviation rules mandating maximum number of hours that pilots and flight attendants can work. The aviation rules are better enforced since it is a federal mandate through FAA. Limits to medical resident hours are voluntary and rely on self-report.

Ann Rogers, who is Associate Professor at the University of Pennsylvania School of Nursing is an expert on the issue of night shift nursing, health and patient safety. In Patient Safety and Quality: An Evidence-based Handbook for Nurses (AHRQ, 2008) she has a chapter entitled “The Effects of Fatigue and Sleepiness on Nurse Performance and Patient Safety.” There’s a handy algorithm for nurses to use in assessing risk due to sleep deprivation/disruption. It starts with “Have you had at least 7 hours of sleep in the 24 hours prior to starting your shift? It includes “fatigue management” strategies, including naps and caffeine use. Seemingly not endorsed by Starbucks, she writes, “Caffeine should be used therapeutically. Caffeine should not be consumed on a regular basis or when alert.” (p 11)—then “Do not consume caffeine outside of work.” (p. 12) This does not seem to be very practical advice. The short naps strategy can work, but only if supported by colleagues and administration. Many nurses do not even get to take uninterrupted scheduled lunch breaks—which is when sanctioned naptimes could occur.

Hospitals provide 24/7 nursing care, so night shift nursing is an essential—if forgotten, overlooked, or undervalued—part of heath care. I raise a toast (of my double-tall vanilla soy latte) to all you dedicated if sleep-deprived night nurses out there!