Pregnant women – a public service announcement: the facility of choice for your birth experience might be Baby-Hostile. You should probably check.
The World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) has created a “global initiative” entitled The Baby-Friendly Hospital Initiative (BFHI). And thank goodness. What new mother would want to be around people who hate babies? I’m sure they’re promoting things like baby blankets, diapers, stuffed toys. Maybe they have elderly people volunteering to be temporary grandparents. They probably have Twinkle Twinkle Little Star on heavy rotation in the nurseries, which of course are outfitted in top-to-bottom Pottery Barn Kids.
Here’s what the BFHI website says the organizations mission is: (https://www.babyfriendlyusa.org/about-us/baby-friendly-hospital-initiative)
The Baby-Friendly Hospital Initiative (BFHI) is a global program that was launched by the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) in 1991 to encourage and recognize hospitals and birthing centers that offer an optimal level of care for infant feeding and mother/baby bonding. It recognizes and awards birthing facilities who successfully implement the Ten Steps to Successful Breastfeeding.
Oh. It’s a breastfeeding initiative. I see. Now, full disclosure – I did not breastfeed my kids. I tried it with the first one. For a week. It hurt. I dreaded feedings. The baby didn’t like it. She cried. I cried. We stopped trying. Our relationship got much better. So far, my kids are healthy, happy, normally-weighted, and intelligent.
So breastfeeding is Baby-Friendly. Which implies that if you are not breastfeeding, or promoting breastfeeding, you are, what, Baby-Unfriendly? Anti-Baby? Baby-Neutral? Well, regardless of what BFHI is implying, it is most definitely not Mother-Friendly. Here are those Ten Steps:
- Have a written breastfeeding policy that is routinely communicated to all health care staff.
- Train all health care staff in the skills necessary to implement this policy.
- Inform all pregnant women about the benefits and management of breastfeeding.
- Help mothers initiate breastfeeding within one hour of birth.
- Show mothers how to breastfeed and how to maintain lactation, even if they are separated from their infants.
- Give infants no food or drink other than breast-milk, unless medically indicated.
- Practice rooming in – allow mothers and infants to remain together 24 hours a day.
- Encourage breastfeeding on demand.
- Give no pacifiers or artificial nipples to breastfeeding infants.
- Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or birth center.
Those are awesome recommendations! For women who are really motivated to breastfeeding and don’t require sleep, with babies who also take to breastfeeding like proverbial fish. It will be a perfect nightmare for anyone else. Breastfeeding hurts at first. Babies do not always take to it right away. Milk comes in late, or in short supply. Mothers are human beings who need sleep. In a Baby-Friendly hospital, if you can’t or don’t want to breastfeed, if your child has trouble getting the hang of it, if you have other kids at home and really need a rest before you go home with this one, well, your hospital stay will be less than pleasant and probably not a great way to start the journey of motherhood.
Well, what does BFHI say about this?
When a mother specifically states that she has no plans to breastfeed or requests that her breastfeeding infant be given a breast milk substitute, the health care staff should first explore the reasons for this request, address the concerns raised, and educate her about the possible consequences to the health of her infant and the success of breastfeeding. If the mother still requests a breast milk substitute, her request should be granted and the process and the informed decision should be documented. Baby‐Friendly is not about making a mother feel guilty; it is about preventing her regret for decisions made without the proper information. Further, Baby‐Friendly policies protect the mother from the influences of commercial interests so that she may make decisions on the basis of scientific evidence and not marketing material.
We Baby-Friendly hospitals know that grown women can’t protect themselves from Similac and won’t take responsibility for their own decisions. I mean, we have “allowed” mothers and infants to remain together 24/7 after all. Mothers who make bad decisions…well, at least we made them sign something acknowledging their unfitness as mothers. Not to make them feel guilty or anything.
Along comes the Journal of the American Medical Association (JAMA), to save the day. In an article published in August, a meta-analysis found that such institutional implementation of breastfeeding policies don’t actually have the effect of increasing breastfeeding rates. http://jamanetwork.com/journals/jama/article-abstract/2571222#.WBjMUzJ8KfY
In contrast to evidence supporting individual-level interventions [which do work], the evidence review included nine fair- to good-quality studies evaluating the effectiveness of system-level primary care interventions to support breastfeeding and reported that there was no consistent association between system-level interventions and any beneficial outcomes.
Well, when the Baby Friendly folks got wind of this, they struck back with a two-page statement that started with accusing the JAMA article of being “filled with comments not supported by research”. They cited research to support their side (R. Pérez‐Escamilla, J. Martinez and S. Segura‐Pérez, “Impact of the Baby‐friendly Hospital Initiative on Breastfeeding and Child Health Outcomes: A Systematic Review. doi: /mcn.12294.,” Maternal Child Nutrition, 2016) and published an opinion paper in the October issue of JAMA laying out their evidence.
A recent meta-analysis of studies evaluating the BFHI found that the implementation of the BFHI increased exclusive breastfeeding by 49% and any breastfeeding by 66%. (http://jamanetwork.com/journals/jamapediatrics/article-abstract/2546143)
Well, sure, if you bully and guilt women into it. And who is right about such initiatives anyway? The people that think it helps, or the people that don’t? Who the F@#$!% cares? You know who is right? The mother is. Each individual woman, the adult, thinking being attached to the breasts and producer of the milk in question, decides what to do for herself and her baby. And she’s right.
Good news, all you new mothers out there! Now you have something else to feel guilty about, because you needed one more thing to feel guilty about! You already know that you baby must be put to sleep on his back in a crib with a firm mattress and no pillows, blankets, toys, or bumpers. What, that sounds uncomfortable? Your baby can’t sleep like that and screams bloody murder all night? Did you know that you baby now has to share your bedroom? For a year? Fun times!
Yes, folks, the American Academy of Pediatrics, in its infinite wisdom, has created a new recommendation in the list of things parents should do to prevent Sudden Infant Death Syndrome: (https://www.aap.org/en-us/about-the-aap/aap-press-room/pages/American-Academy-of-Pediatrics-Announces-New-Safe-Sleep-Recommendations-to-Protect-Against-SIDS):
- Place the baby on his or her back on a firm sleep surface such as a crib or bassinet with a tight-fitting sheet.
- Avoid use of soft bedding, including crib bumpers, blankets, pillows and soft toys. The crib should be bare.
- Share a bedroom with parents, but not the same sleeping surface, preferably until the baby turns 1 but at least for the first six months. Room-sharing decreases the risk of SIDS by as much as 50 percent.
- Avoid baby’s exposure to smoke, alcohol and illicit drugs.
SIDS is a serious problem, I get it. More than 3,000 babies age 1 and under died of SIDS in 2010. That’s not nothing. If you are a parent to whom this tragedy has struck, you have burden that will last you your whole life. It’s horrible. However, for a little perspective, 4 million babies were born in 2010. Now I suck at math, but 3,000 divided by 4,000,000 is… mumble mumble…divide by 2… scratch head… carry the 1… that’s like, what, 0.0005%? The all-cause infant mortality rate in 2010 was 0.2%. So clearly there are other dangers for infants in the first year of life besides SIDS. Here are two:
Post-partum depression – According to the CDC, an estimated 15% of new mothers will have some degree of post-partum depression, or roughly 600,000 women per year. The American Psychological Association (APA) lists some risk factors for PPD including… wait for it.. Yes! The stress of caring for a newborn! (http://www.apa.org/pi/women/resources/reports/postpartum-depression.asp). The Mayo clinic says that:
When you’re sleep deprived and overwhelmed, you may have trouble handling even minor problems. You may be anxious about your ability to care for a newborn. You may feel less attractive, struggle with your sense of identity or feel that you’ve lost control over your life. Any of these issues can contribute to postpartum depression. (http://www.mayoclinic.org/diseases-conditions/postpartum-depression/basics/causes/con-20029130)
Uh huh. And what are the consequences of PPD on children? The American Academy of Pediatrics itself can tell you: (https://www.aap.org/en-us/about-the-aap/aap-press-room/Pages/Managing-Maternal-Depression-Before-and-After-Birth.aspx)
Maternal postpartum depression can have serious adverse effects on the mother and child relationship, resulting in an environment that can disrupt the infant’s development. Infants who live in a neglectful or depressed setting are likely to show delays in development and impaired social interaction.
I’m not discounting SIDS, nor am I questioning the accuracy of the AAP. I’m sure their data is solid. And in a perfect world, like in Kate Middleton’s for example, where childcare is plentiful and there is a hairdresser on call, I’m sure all mothers could blissfully adhere to this most recent instruction. However, this is not a perfect world, nor is it the world of parenting in the 19th century, and thank goodness for that. Mothers now work, their own extended family is far away, childcare is expensive, breastfeeding is hard when you’re away from home all day, there is no maternity leave. Pressure from voices of authority like the AAP are just not terribly helpful. By the way, this is not the first time that AAP recommendations have defied reality. In 2011 the organization decided that kids should ride in rear-facing car seats until at least age 2 or to the weight limit of the seat, causing millions of parents to watch as their child’s legs grow slowly up toward the ceiling. The breastfeeding recommendations have resulted in a profitable industry for Medela and the now-common sound of whirring and squirting, with the occasional “MOO”, from the bathroom stall next to you in the women’s restroom at work. Breastfeeding, of course, also helps prevent SIDS, but even there you have to be careful. Here is a hilarious quote from the AAP website:
“If you are feeding your baby and think that there’s even the slightest possibility that you may fall asleep, feed your baby on your bed, rather than a sofa or cushioned chair,” said Lori Feldman-Winter, MD, FAAP, member of the Task Force on SIDS and co-author of the report.
“If you do fall asleep, as soon as you wake up be sure to move the baby to his or her own bed.”
Are you F*&^% kidding me?
It is one of the most boring truisms on the planet: “Practice makes perfect.” It is also one of the most misleading. Practice merely ingrains certain patterns after deciding on the best course of action after constant criticism and problem-solving. Performance requires that the body forget the work required to ingrain the pattern and let the pattern happen. Performance requires that we drop all criticism and technical considerations. These two activities are vastly different.
The transition from practice to performance, it turns out, is a matter of belief. I was thinking about this today after reading Seth Godin’s blog. Godin is a fantastic management and leadership expert who also happens to know a lot about performance. Here’s what he said: http://sethgodin.typepad.com/seths_blog/2016/06/taking-notes-vs-taking-belief.html
Is there anything easier than listening to a lecture or reading a book and taking notes? And is there anything more difficult than setting aside our preconceptions and the resistance and acting ‘as if’, being open to belief, at least for a moment?
Practicing is like taking notes. You are trying to ingrain patterns in the brain. At some point you have to decide that the ingraining process is complete and just go take the test. You have to trust your preparation.
Another writer I really like is James Clear, a fitness expert and all-around wise man when it comes to making real change. Here is a bit of one of the central tenents of his philosophy: http://jamesclear.com/identity-based-habits
Changing your beliefs isn’t nearly as hard as you might think. There are two steps. 1. Decide the type of person you want to be. 2. Prove it to yourself with small wins.
Here are some examples of what I’m talking about.
Suppose you are a patient whose doctor has told you that you need to make some lifestyle change for the good of your health. You go and read every book ever written about this change, talk to five different experts, and draw up a fool-proof plan that you have memorized. None of these things is worth anything unless you decide “I am the kind of person who integrates this life-style change into his everyday life.” You have to take the knowledge (practice) and turn it into belief (performance).
Say you are a nurse who is trying to decide whether or not to go to medical school. You read all the books. (Actually there really aren’t any on this subject although I’m working on one. I haven’t quite gotten to the stage of believing I’m the kind of person who can write a book.) You talk to all the experts. You consult with people who have made the transition. You decide medical school is indeed the best choice for you for all of the right reasons (a life-time project in itself). None of this makes any difference unless you decide “I am the kind of person who can successfully complete medical school.” Knowledge, and choice, into belief.
Or perhaps the contrary. You decide that you are happy in nursing. You don’t want to change. You’ve done the research and made your choice. Fine. Same thing. You’ve done the work, now commit to and believe in the choice you’ve made.
Maybe you are a young person from a foreign country and you would like to live and work in the United States. You research your (legal) options, talk to friends who have been to the US, interview people who have done the job you’re interested in. You’re not going anywhere unless you decide “I am the kind of person who can move thousands of miles from my family in pursuit of new experiences.” Choice into belief.
Say you play a musical instrument and you want to get a good orchestra job. You practice for 20 years, put in your focused 10,000 hours. None of those hours count unless you can stop the self-evaluation you have been perfecting for 10,000 hours and trust that those hours have ingrained the necessary patterns and that, at the moment of performance, no more self-evaluation is needed. You just play.
If you’ve done the work, just play.
I was recently honored by a request to write a piece for the journal Outpatient Surgery. Having duly provided a pithy and witty ditty about the Veteran’s Administration MD vs CRNA kerfuffle, the editor dutifully came back at me with an edit. He said: “Can you give a specific example of how the broad knowledge of medicine gives MD anesthesiologists an advantage?” or something to that effect. Hmmm… trying to stir the pot, I thought. Controversial? You want controversial? I thought. So I sent out an email/text/tweet to my colleagues specifically asking for examples of how the broader knowledge of medicine gave them an advantage when it came to the safe practice of anesthesia. Here are some of the responses I got (my friends will likely cease to be my friends after I post this):
“They’re [CRNAs, I assume] often pretty cocky and it’s usually because ignorance is bliss.”
“Just doesn’t demonstrate a solid foundation in the basics of physiology or pharmacology.”
“They often can’t think outside the box.”
“Physiology, pathology, pharmacology, anatomy is just not there. I think it’s a depth of knowledge and problem solving skills. Everything they know is very superficial.”
“Pathophysiology. That’s why we make the plan. They can complete it very competently, but don’t have the extent of knowledge regarding all conditions to make the safest plan for the patient.”
Of all these responses, the last is the only one that comes even close to a specific reason for the existence of the MD anesthesiologist.
Please don’t misunderstand – I truly believe that the presence of an MD in the supervision of the administration of anesthesia is very important. But, friends, we need to be very specific and persuasive. Simply saying “it’s not safe” and “we know better” isn’t going to sway administrators who see cost savings instead of patient savings. We can’t just say we’re worth our price. We have to prove it.
- Ending the Sustainable Growth Rate (SGR) formula for determining Medicare payments for health care providers’ services.
- Making a new framework for rewarding health care providers for giving better care not more just more care.
- Combining our existing quality reporting programs into one new system.
These proposed changes, which we’ve named the Quality Payment Program, replace a patchwork system of Medicare reporting programs with a flexible system that allows you to choose from two paths that link quality to payments: the Merit-Based Incentive Payment System (MIPS) and Advanced Alternative Payment Models.
Consistent with the goals of the law, the proposed rule would improve the relevance and depth of Medicare’s value and quality-based payments and increase clinician flexibility by allowing clinicians to choose measures and activities appropriate to the type of care they provide.
Wait, what? There’s about 100 things wrong with this sentence. MACRA does absolutely nothing to improve the relevance of the government’s “quality” indicators. The indicators are, for the most part, completely irrelevant to actual quality. The metrics are simply percentages of people who received a certain treatment or test deemed appropriate by large organizations like the AMA. Such percentages have little to do with the actual quality of the interaction between doctor and patient. And the flexibility mentioned is merely the flexibility to choose between MIPS and APM. Which isn’t really a flexibility since APM billing pays more.
Clinicians who take a further step towards care transformation – participating to a sufficient extent in Advanced Alternative Payment Models – would be exempt from MIPS payment adjustments and would quality for a 5 percent Medicare Part B incentive payments.
What is and Advanced Alternative Payment Model? Bundled payments, meaning Accountable Care Organizations. Remember those? Lump payments to a group of doctors, money that they keep if they spend less than the lump payment, but that they’re on the hook for if they spend more. CMS wants to funnel everyone into a bundled payment model. Not super flexible, those CMS folks.
OK, one last thing and then I’ll quit bugging you. Here’s the breakdown of the scoring for the incentive payment system:
To prove you’re a good doctor, you better use that EHR to document those quality metrics! Otherwise, CMS might take away your lunch money.
An immigration issue has come to my attention that I thought I would weigh in on. I wrote a piece awhile back in support of Foreign Medical Graduates (FMGs) that bent a bunch of people over at KevinMD out of shape. I guess that makes me an expert in all things foreign and medical-ly, because I was recently contacted by a reporter (Hi Alicia!) who wanted to know what I thought about admitting children of undocumented immigrants (themselves also undocumented if they were children when they came here) to medical school. Apparently there are at least 60 medical schools in the country that are doing this.
I am not a believer in penalizing children for the sins of the parents. Ever. There are tons of good reasons and very few bad ones for granting children of undocumented immigrants the right to health care, education, and the same opportunities other kids have. (I know! Bless my bloody little liberal heart!) The argument is made that denying such privileges further documental (documentary?) misbehavior on the part of people who want to come to this country to help their kids do better than they are. How’s that working out so far? The Department of Homeland Security says the population of undocumented immigrants grows by 275,000 each year (www.dhs.gov). Denying resources to kids who arguably need them most perpetuates the poverty of their families and future generations of their families. They’re coming. They’re here. Might as well help the kids, at least.
But wait, you say! How About Helping Our Own Kids!?!?! I’m not talking about a free ride through school. The same chance for federal loans that everybody else gets would be fine. Oh, did I mention? Undocumented kids admitted to medical school are not eligible for federal financial aid. So…not really an opportunity…really.
That political soapbox having been stood upon, let’s look at one of the discussions circulating around the issue of allowing the children of undocumented immigrants to go to an American medical school: The Doctor Shortage.
Ah, The Doctor Shortage. By this I assume what is meant is the lack of primary care and other services in poor and underserved neighborhoods and counties in the United States. Because if you hold your arms out and spin slowly you’re bound to hit two or three doctors here in Boston. We’re chock-a-block. The Doctor Shortage problem has been farmed out to foreigners for years. Everyone thought FMGs would fill this role. Or People Who Speak The Language Of The Community (translation: black and latino doctors). Now the undocumented.
Here’s a question for you: Why the &^%$ would the children of undocumented immigrants be any more likely to go into primary care in their communities, or remote Appalachia, than any well-documented, voting-eligible medical student? Especially if you deprive them of financial aid? Out of the goodness of their hearts? Out of concern for their paperless neighbors? Maybe some of them. But staring $200,000 in student loans in the face, especially high-interest private loans, makes plastic surgery a really attractive option, I don’t care who you are. Also remember that putting anyone, but especially a smart, ethnically or financially challenged person, into the smart-kid, high achieving environment of medical school and residency, is inevitably going to show them the options available to them. Furthermore, medical school and residency takes up most of people’s 20s. Maybe a smart, talented immigrant falls in love with neurosurgery and the co-ed (non-immigrant) OB-GYN resident down the hall. All the good intentions in the world aren’t going to convince this person that what they really want to do is take their beloved and treat colds and high blood pressure in a community in which only one of the couple feels connected. Life happens while medical school happens.
Medical students, no matter where they come from or what papers they have, don’t go into primary care and/or into underserved communities for two reasons: money and money. Medical school costs too much and primary care doctors get paid too little. (Well, one other reason – paperwork) I know! More people getting their feathers up at KevinMD! A doctor in such a community is making so many multiples more than the people they serve! Doctors are so greedy! Let me refer you here: http://www.kevinmd.com/blog/2011/04/real-life-medical-school-debt.html, or here: http://www.cbsnews.com/news/1-million-mistake-becoming-a-doctor/.
Here’s what I would suggest: children of undocumented immigrants are, arguably, lucky to be here and, if they’re smart, eager to grasp the opportunities their parents have attempted to provide them with. If such a kid wants to go to medical school, great! Provide him or her with the financial aid available to all kids, but put a binding contingency on it. All undocumented students have to commit to a certain number of years of work in their communities or in other underserved areas. And back it up with financial support. The military already does this – medical students get med school paid for if they commit a certain number of post-residency years to military service. Such a program also already exists in the private sector. The National Health Service Corps offers substantial loan repayment for professionals who sign up for a certain number of years of service in an underserved area (https://nhsc.hrsa.gov/loanrepayment/). The NHSC is, in my opinion, underutilized.
The Doctor Shortage will not be solved by making people who are Not Us do the work. It will be solved by effective monetary and regulatory policies that make primary care in remote areas a viable and attractive option.
My thanks to Dr. John Mandrola of theheart.org/Medscape Cardiology for the idea for this post. Dr. Mandrola is an interventional cardiologist but I forgive him for that because he also reads the fine print and dares to question the status quo, particularly when it comes to preventive medicine.
An interesting paper came out this month in the on-line medical journal Open Heart (a branch of the British Medical Journal) about one particular area of prevention – heart attack. The researchers used data from a class of cholesterol drugs called statins, such as Lipitor, which have been shown to have a significant benefit in preventing ischemic heart disease (the study cites evidence that statins can decrease cardiovascular death by 20-30%, a number in some dispute). You can find the whole thing here: http://openheart.bmj.com/content/3/1/e000343.full#aff-1.
The researchers crunched a bunch of numbers and talked to a bunch of people, and these were the results, in part:
- 50 year old smoker with high blood pressure and high cholesterol could have his life extended by up to two years by taking a statin.
- An healthy 50 year old who starts preventive treatment with a statin at 50 can see a lifespan gain of a mean of 7 months.
- BUT, of 100 of those healthy 50 year old men, 93 will see no life extending benefit at all. The other 7 gain a mean of 99 months. 99 months!
- Starting statins later than 50 does not increase the life extending benefit. Quite the opposite.
- Of those healthy 100 50-year-olds, there is no way to tell which ones will be in the group of 7.
But here’s the most interesting part of the study – The researchers went down to the Underground (it’s a UK study) and asked around 400 people a simple question: “Which would you choose – to take a medication that would guarantee you one extra year of life or to take a medication that gives you a 2% chance of living an extra 10 years?” Then they extended the question – “How about if the medication gave you a 10% chance of living an extra 10 years?” and so on up to a 50% chance. As you might expect, as the percent chance of getting the 10 years went up, more people chose the chance option. But, there was always a significant percentage of people who never took the chance option.
So in a certain sense, taking a primary preventive medication, in this case a statin, is a game of chance. Do you choose to take the medication in the hope you are one of the 7 or do you opt out based on the probability that you’re not? How much risk are you willing to assume, all other things being equal? The answers to these questions varies greatly among individuals.
Of course, there are many other factors that go into the decision to start a medication to prevent an illness you might or might not ever get. There are considerations about side effects, cost, life-style, quality of life, etc. However, all or most of those considerations are also subject to probabilities and subjective preferences. Plus, you could die of something besides heart disease that you didn’t take a drug to prevent (or maybe you did but we all have to die of something and sometimes bad stuff just happens.) The take-home is that medicine is not an exact science and every person is different. What is an acceptable risk for one is an unacceptable gamble for another. Here’s what Dr. Mandrola says:
The point of this work is that it brings statistics, probability, and cognitive psychology to the doctor-patient relationship. When it comes to treating people with risk factors, not diseases, embracing uncertainty has always been important. But, now, as technology increasingly measures the human condition and creates more risk factors, comfort with gambling in medical decisions has never been more vital.