Marie-Eileen Onieal, PhD, CPNP, FAANP

Over the past year, we’ve seen ongoing relentless rhetoric, in the medical and lay press, besmirching the competence of PAs and NPs. The motives behind this unsettling trend can be viewed either as a veiled attempt to diminish our standing in patients’ eyes or even constrain our scope of practice. For years, we have tried to stay above the fray and avoid weighing in. However, we now feel compelled to address this rising negative tide.

Recently, Louis J. Goodman, PhD, President of the Physicians Foundation and CEO of the Texas Medical Association, stated, “The idea that nurse practitioners or physician assistants can fill the vacuum [in primary care] is not accurate.” He continued, “They can do some things, but someone needs to make the unequivocal diagnosis, and the person who is best qualified to do that is a physician.”¹

According to a recent white paper from the American Academy of Family Physicians (AAFP),² “Physicians offer an unmatched service to patients and without their skills, patients would receive second-tier care.” This report also recommended the establishment of more patient-centered medical homes in which a physician leads a team of “allied health professionals,” particularly PAs and NPs, as the way to provide optimal care. It is interesting to consider that the AAFP statement flies in the face of evidence to the contrary from credible and powerful organizations, including the Institute of Medicine and the National Institutes of Health.

Even a well-meaning 2011 article in American Medical News, entitled “Bringing PAs and NPs on Board: What to Do if You’re Hiring,”³ had inaccurate assertions about PA and NP practice—for example, that PAs tend to carry out more procedures, while NPs are better suited to provide evaluation and management.

So the question has to be asked: Who is the enemy here? There are plenty of fingers to go around if we are pointing—physicians, administrators, regulators—even ourselves! Truth be told, the enemy is, of course, ignorance. Why, in this world of evidence-based practice, do we so often write, post, and verbalize inaccurate information about each other? Even in light of the fact that in 2009, 49.1% of office-based US physicians worked alongside NPs and PAs, the misconceptions persist.⁴

The concept of patient satisfaction with health care has only recently received the attention it deserves in the medical literature; concurrently, there has been increased interest in patient satisfaction measurements among hospitals and health plans as they compete to attract and retain members. Analysis based on data from an adaptation of the “Art of Medicine” survey (an eight-item, patient-reported measure of clinician style of encounter) supports the finding that patients are indeed satisfied with their care, regardless of the type of practitioner who delivers it. The study found no statistically significant differences between scores for physicians and PAs or NPs, whether provider practice was differentiated by specialty or data were combined for statistical purposes. In addition, it was reported that some patients perceive PAs and NPs as somewhat indistinguishable from physicians.⁵

Regarding the quality-of-care issue, a number of studies—generated by nonbiased authors and entities and available online—have concluded that the quality of care provided by NPs and PAs is comparable to that given by physicians, in terms of functions that all these clinicians usually perform. Case in point: A seminal 1986 policy analysis from the congressional Office of Technology Assessment documented that NPs and PAs provide care of quality equivalent to that provided by physicians.⁶ The researchers found that NPs are more adept than physicians at providing services that depend on communicating with patients and taking preventive action. The evidence also indicated that PAs perform better than many physicians do in supportive care and health promotion activities. 

In addition to communicating more effectively, PAs and NPs have been found to be more proficient than many physicians at managing patients who require long-term and continuous care. Extending early studies, researchers have repeatedly demonstrated the high-quality care delivered by these professionals. 

Since the 1960s, the priority of health policy initiatives has been to make health care accessible to all Americans. As a means to this end, programs were developed to educate future clinicians (maybe even potential patients!) about the NP and PA professions, with the purpose to improve access to care. That, we have done. We have made important contributions to meeting the nation’s health care needs, especially by improving the geographic distribution of care, because we have been willing to practice in underserved rural and inner-city areas. And we will continue to do so, as meeting the health care needs of the nation has always been our priority—more important than disabusing those with misconceptions about our value and competence. 

Bottom line? Health care reform will bring numerous challenges for stakeholders over the next few years. It is imperative that we all focus on what matters most: a collaborative model of care that delivers improved patient outcomes through qualified providers, with access to health care for all Americans. And just as it “takes a village” to raise a child, it will take all of us, working collegially and cooperatively, to meet those challenges.

Our professions have been studied to death. If we continue to focus on the wrong problems, notes health analyst Brian Klepper, PhD, “primary care will continue to flail.”⁷ Let’s get on with the work of providing that care and researching better methods of preventing and treating diseases. Our discussions should be about the patient!

Are we overreacting? Are you tired of the inaccuracies perpetuated about both of our professions? Tell us what you think at PAeditor@qhc.com or NPeditor@qhc.com.                  

REFERENCES
1. Hertz BT. Primary care and the keys to its success: newer revenue and practice models to gain in popularity as primary care skills increase in value. Modern Medicine. Aug 25 2012. www.modernmedicine.com/modernmedicine/Modern+Medicine+Now/Primary-care-and-the-keys-to-its-success/ArticleStandard/Article/detail/785800?contextCategoryId=40158. Accessed October 11, 2012.

2. American Academy of Family Physicians. Primary care for the 21st century: ensuring a quality, physician-led team for every patient (2012). www.aafp.org/online/etc/medialib/aafp_org/documents/membership/nps/primary-care-21st-century/whitepaper.Par.0001.File.dat/AAFP-PCMHWhitePaper.pdf. Accessed October 12, 2012.

3. Elliott VS. Bringing PAs and NPs on board: what to do if you’re hiring. Am Med News. January 10, 2011. www.ama-assn.org/amednews/2011/01/10/bisa0110.htm. Accessed October 12, 2012.

4. Park M, Cherry D, Decker SL. Nurse practitioners, certified nurse midwives, and physician assistants in physician offices. NCHS Data Brief. 2011:69. www.cdc.gov/nchs/data/databriefs/db69.htm. Accessed October 11, 2012.

5. Hooker RS, Potts R, Ray W. Patient satisfaction: comparing physician assistants, nurse practitioners, and physicians. Permanente Journal. 1997;1(1). http://xnet.kp.org/permanentejournal/sum97pj/ptsat.html. Accessed October 11, 2012.

6. US Congress, Office of Technology Assessment. Nurse Practitioners, Physician Assistants, and Certified Nurse-Midwives: A Policy Analysis (1986). www.fas.org/ota/reports/8615.pdf. Accessed October 12, 2012.

7. Klepper B. Care and cost: the wrong battles. http://boards.medscape.com/forums?128@591.ZSwVamdalRA@.2a35001c!comment=1. Accessed October 12, 2012.

Over the past year, we’ve seen ongoing relentless rhetoric, in the medical and lay press, besmirching the competence of PAs and NPs. The motives behind this unsettling trend can be viewed either as a veiled attempt to diminish our standing in patients’ eyes or even constrain our scope of practice. For years, we have tried to stay above the fray and avoid weighing in. However, we now feel compelled to address this rising negative tide.

Recently, Louis J. Goodman, PhD, President of the Physicians Foundation and CEO of the Texas Medical Association, stated, “The idea that nurse practitioners or physician assistants can fill the vacuum [in primary care] is not accurate.” He continued, “They can do some things, but someone needs to make the unequivocal diagnosis, and the person who is best qualified to do that is a physician.”¹

According to a recent white paper from the American Academy of Family Physicians (AAFP),² “Physicians offer an unmatched service to patients and without their skills, patients would receive second-tier care.” This report also recommended the establishment of more patient-centered medical homes in which a physician leads a team of “allied health professionals,” particularly PAs and NPs, as the way to provide optimal care. It is interesting to consider that the AAFP statement flies in the face of evidence to the contrary from credible and powerful organizations, including the Institute of Medicine and the National Institutes of Health.

Even a well-meaning 2011 article in American Medical News, entitled “Bringing PAs and NPs on Board: What to Do if You’re Hiring,”³ had inaccurate assertions about PA and NP practice—for example, that PAs tend to carry out more procedures, while NPs are better suited to provide evaluation and management.

So the question has to be asked: Who is the enemy here? There are plenty of fingers to go around if we are pointing—physicians, administrators, regulators—even ourselves! Truth be told, the enemy is, of course, ignorance. Why, in this world of evidence-based practice, do we so often write, post, and verbalize inaccurate information about each other? Even in light of the fact that in 2009, 49.1% of office-based US physicians worked alongside NPs and PAs, the misconceptions persist.⁴

The concept of patient satisfaction with health care has only recently received the attention it deserves in the medical literature; concurrently, there has been increased interest in patient satisfaction measurements among hospitals and health plans as they compete to attract and retain members. Analysis based on data from an adaptation of the “Art of Medicine” survey (an eight-item, patient-reported measure of clinician style of encounter) supports the finding that patients are indeed satisfied with their care, regardless of the type of practitioner who delivers it. The study found no statistically significant differences between scores for physicians and PAs or NPs, whether provider practice was differentiated by specialty or data were combined for statistical purposes. In addition, it was reported that some patients perceive PAs and NPs as somewhat indistinguishable from physicians.⁵

Regarding the quality-of-care issue, a number of studies—generated by nonbiased authors and entities and available online—have concluded that the quality of care provided by NPs and PAs is comparable to that given by physicians, in terms of functions that all these clinicians usually perform. Case in point: A seminal 1986 policy analysis from the congressional Office of Technology Assessment documented that NPs and PAs provide care of quality equivalent to that provided by physicians.⁶ The researchers found that NPs are more adept than physicians at providing services that depend on communicating with patients and taking preventive action. The evidence also indicated that PAs perform better than many physicians do in supportive care and health promotion activities. 

In addition to communicating more effectively, PAs and NPs have been found to be more proficient than many physicians at managing patients who require long-term and continuous care. Extending early studies, researchers have repeatedly demonstrated the high-quality care delivered by these professionals. 

Since the 1960s, the priority of health policy initiatives has been to make health care accessible to all Americans. As a means to this end, programs were developed to educate future clinicians (maybe even potential patients!) about the NP and PA professions, with the purpose to improve access to care. That, we have done. We have made important contributions to meeting the nation’s health care needs, especially by improving the geographic distribution of care, because we have been willing to practice in underserved rural and inner-city areas. And we will continue to do so, as meeting the health care needs of the nation has always been our priority—more important than disabusing those with misconceptions about our value and competence. 

Bottom line? Health care reform will bring numerous challenges for stakeholders over the next few years. It is imperative that we all focus on what matters most: a collaborative model of care that delivers improved patient outcomes through qualified providers, with access to health care for all Americans. And just as it “takes a village” to raise a child, it will take all of us, working collegially and cooperatively, to meet those challenges.

Our professions have been studied to death. If we continue to focus on the wrong problems, notes health analyst Brian Klepper, PhD, “primary care will continue to flail.”⁷ Let’s get on with the work of providing that care and researching better methods of preventing and treating diseases. Our discussions should be about the patient!

Are we overreacting? Are you tired of the inaccuracies perpetuated about both of our professions? Tell us what you think at PAeditor@qhc.com or NPeditor@qhc.com.                  

REFERENCES
1. Hertz BT. Primary care and the keys to its success: newer revenue and practice models to gain in popularity as primary care skills increase in value. Modern Medicine. Aug 25 2012. www.modernmedicine.com/modernmedicine/Modern+Medicine+Now/Primary-care-and-the-keys-to-its-success/ArticleStandard/Article/detail/785800?contextCategoryId=40158. Accessed October 11, 2012.

2. American Academy of Family Physicians. Primary care for the 21st century: ensuring a quality, physician-led team for every patient (2012). www.aafp.org/online/etc/medialib/aafp_org/documents/membership/nps/primary-care-21st-century/whitepaper.Par.0001.File.dat/AAFP-PCMHWhitePaper.pdf. Accessed October 12, 2012.

3. Elliott VS. Bringing PAs and NPs on board: what to do if you’re hiring. Am Med News. January 10, 2011. www.ama-assn.org/amednews/2011/01/10/bisa0110.htm. Accessed October 12, 2012.

4. Park M, Cherry D, Decker SL. Nurse practitioners, certified nurse midwives, and physician assistants in physician offices. NCHS Data Brief. 2011:69. www.cdc.gov/nchs/data/databriefs/db69.htm. Accessed October 11, 2012.

5. Hooker RS, Potts R, Ray W. Patient satisfaction: comparing physician assistants, nurse practitioners, and physicians. Permanente Journal. 1997;1(1). http://xnet.kp.org/permanentejournal/sum97pj/ptsat.html. Accessed October 11, 2012.

6. US Congress, Office of Technology Assessment. Nurse Practitioners, Physician Assistants, and Certified Nurse-Midwives: A Policy Analysis (1986). www.fas.org/ota/reports/8615.pdf. Accessed October 12, 2012.

7. Klepper B. Care and cost: the wrong battles. http://boards.medscape.com/forums?128@591.ZSwVamdalRA@.2a35001c!comment=1. Accessed October 12, 2012.

Over the past year, we’ve seen ongoing relentless rhetoric, in the medical and lay press, besmirching the competence of PAs and NPs. The motives behind this unsettling trend can be viewed either as a veiled attempt to diminish our standing in patients’ eyes or even constrain our scope of practice. For years, we have tried to stay above the fray and avoid weighing in. However, we now feel compelled to address this rising negative tide.

Recently, Louis J. Goodman, PhD, President of the Physicians Foundation and CEO of the Texas Medical Association, stated, “The idea that nurse practitioners or physician assistants can fill the vacuum [in primary care] is not accurate.” He continued, “They can do some things, but someone needs to make the unequivocal diagnosis, and the person who is best qualified to do that is a physician.”¹

According to a recent white paper from the American Academy of Family Physicians (AAFP),² “Physicians offer an unmatched service to patients and without their skills, patients would receive second-tier care.” This report also recommended the establishment of more patient-centered medical homes in which a physician leads a team of “allied health professionals,” particularly PAs and NPs, as the way to provide optimal care. It is interesting to consider that the AAFP statement flies in the face of evidence to the contrary from credible and powerful organizations, including the Institute of Medicine and the National Institutes of Health.

Even a well-meaning 2011 article in American Medical News, entitled “Bringing PAs and NPs on Board: What to Do if You’re Hiring,”³ had inaccurate assertions about PA and NP practice—for example, that PAs tend to carry out more procedures, while NPs are better suited to provide evaluation and management.

So the question has to be asked: Who is the enemy here? There are plenty of fingers to go around if we are pointing—physicians, administrators, regulators—even ourselves! Truth be told, the enemy is, of course, ignorance. Why, in this world of evidence-based practice, do we so often write, post, and verbalize inaccurate information about each other? Even in light of the fact that in 2009, 49.1% of office-based US physicians worked alongside NPs and PAs, the misconceptions persist.⁴

The concept of patient satisfaction with health care has only recently received the attention it deserves in the medical literature; concurrently, there has been increased interest in patient satisfaction measurements among hospitals and health plans as they compete to attract and retain members. Analysis based on data from an adaptation of the “Art of Medicine” survey (an eight-item, patient-reported measure of clinician style of encounter) supports the finding that patients are indeed satisfied with their care, regardless of the type of practitioner who delivers it. The study found no statistically significant differences between scores for physicians and PAs or NPs, whether provider practice was differentiated by specialty or data were combined for statistical purposes. In addition, it was reported that some patients perceive PAs and NPs as somewhat indistinguishable from physicians.⁵

Regarding the quality-of-care issue, a number of studies—generated by nonbiased authors and entities and available online—have concluded that the quality of care provided by NPs and PAs is comparable to that given by physicians, in terms of functions that all these clinicians usually perform. Case in point: A seminal 1986 policy analysis from the congressional Office of Technology Assessment documented that NPs and PAs provide care of quality equivalent to that provided by physicians.⁶ The researchers found that NPs are more adept than physicians at providing services that depend on communicating with patients and taking preventive action. The evidence also indicated that PAs perform better than many physicians do in supportive care and health promotion activities. 

In addition to communicating more effectively, PAs and NPs have been found to be more proficient than many physicians at managing patients who require long-term and continuous care. Extending early studies, researchers have repeatedly demonstrated the high-quality care delivered by these professionals. 

Since the 1960s, the priority of health policy initiatives has been to make health care accessible to all Americans. As a means to this end, programs were developed to educate future clinicians (maybe even potential patients!) about the NP and PA professions, with the purpose to improve access to care. That, we have done. We have made important contributions to meeting the nation’s health care needs, especially by improving the geographic distribution of care, because we have been willing to practice in underserved rural and inner-city areas. And we will continue to do so, as meeting the health care needs of the nation has always been our priority—more important than disabusing those with misconceptions about our value and competence. 

Bottom line? Health care reform will bring numerous challenges for stakeholders over the next few years. It is imperative that we all focus on what matters most: a collaborative model of care that delivers improved patient outcomes through qualified providers, with access to health care for all Americans. And just as it “takes a village” to raise a child, it will take all of us, working collegially and cooperatively, to meet those challenges.

Our professions have been studied to death. If we continue to focus on the wrong problems, notes health analyst Brian Klepper, PhD, “primary care will continue to flail.”⁷ Let’s get on with the work of providing that care and researching better methods of preventing and treating diseases. Our discussions should be about the patient!

Are we overreacting? Are you tired of the inaccuracies perpetuated about both of our professions? Tell us what you think at PAeditor@qhc.com or NPeditor@qhc.com.                  

REFERENCES
1. Hertz BT. Primary care and the keys to its success: newer revenue and practice models to gain in popularity as primary care skills increase in value. Modern Medicine. Aug 25 2012. www.modernmedicine.com/modernmedicine/Modern+Medicine+Now/Primary-care-and-the-keys-to-its-success/ArticleStandard/Article/detail/785800?contextCategoryId=40158. Accessed October 11, 2012.

2. American Academy of Family Physicians. Primary care for the 21st century: ensuring a quality, physician-led team for every patient (2012). www.aafp.org/online/etc/medialib/aafp_org/documents/membership/nps/primary-care-21st-century/whitepaper.Par.0001.File.dat/AAFP-PCMHWhitePaper.pdf. Accessed October 12, 2012.

3. Elliott VS. Bringing PAs and NPs on board: what to do if you’re hiring. Am Med News. January 10, 2011. www.ama-assn.org/amednews/2011/01/10/bisa0110.htm. Accessed October 12, 2012.

4. Park M, Cherry D, Decker SL. Nurse practitioners, certified nurse midwives, and physician assistants in physician offices. NCHS Data Brief. 2011:69. www.cdc.gov/nchs/data/databriefs/db69.htm. Accessed October 11, 2012.

5. Hooker RS, Potts R, Ray W. Patient satisfaction: comparing physician assistants, nurse practitioners, and physicians. Permanente Journal. 1997;1(1). http://xnet.kp.org/permanentejournal/sum97pj/ptsat.html. Accessed October 11, 2012.

6. US Congress, Office of Technology Assessment. Nurse Practitioners, Physician Assistants, and Certified Nurse-Midwives: A Policy Analysis (1986). www.fas.org/ota/reports/8615.pdf. Accessed October 12, 2012.

7. Klepper B. Care and cost: the wrong battles. http://boards.medscape.com/forums?128@591.ZSwVamdalRA@.2a35001c!comment=1. Accessed October 12, 2012.

As I considered topics for my column this month, I was stymied by the options. Watching the morning news—which was inundated with the devastating events that had occurred in the previous 24 hours—it hit me: October has always been a “prevention” month. Let me therefore address that theme.

A day does not pass without us hearing about the need for some type of preventive action, mostly focused on diseases or injuries—some commonly known and others more obscure or in greater need of “awareness” efforts. But I think all too often we forget about preventing the somewhat obvious dangers that we face on a daily basis.

As the daughter, sister, and aunt of firefighters, I know that one week in October is dedicated to fire prevention. Over the years, as we have concentrated efforts toward other areas in need of recognition, I think perhaps we have overlooked fire safety.

Why focus on fire prevention? Well, think about the impact of being involved in, or affected by, fire. Let me give you some insight.

First, a history tidbit: Fire Prevention Week was established in 1922 to memorialize the infamous Chicago Fire of October 1871, the tragic conflagration that killed more than 250 people, left 100,000 homeless, destroyed more than 17,400 structures, and burned more than 2,000 acres. Fire marshals decided the anniversary of the fire should be observed in a way that would keep the public informed about the importance of fire safety and prevention. According to the National Archives and Records Administration’s Library Information Center, Fire Prevention Week is the longest-running public health and safety observance on record.¹

The financial impact of fire can be devastating. For 2009, the total cost associated with fire was estimated at $331 billion, or approximately 2.3% of the gross domestic product of the United States. Fires caused $14.2 billion in reported or unreported direct property damage, representing 88% of economic losses that year; the remaining 12% was attributed to indirect loss, such as interruption of business.¹ In 2010, home fires alone resulted in $6.9 billion in direct damage, and in 2011, an estimated $11.7 billion in property damage occurred as a result of fire.¹ 

More overwhelming is that deaths from fires and burns are the third-leading cause of fatal injury in the home.² Annually, about 3,000 deaths, or 80% of all fire deaths in the US, are the result of fires in the home.³ Each year, fire is the cause of death for more than 600 children ages 14 and younger; fire-related injuries affect about 3,000 more.⁴ Burn injuries account for nearly 700,000 visits to an emergency department yearly.4 According to the American Burn Association, there are one million burn injuries in the US annually, and an estimated 45,000 hospitalizations.⁵

In 2010, fire departments in the US responded to an estimated 1.3 million fires that caused 3,120 civilian deaths and 17,720 civilian injuries.1 In that same year, 72 firefighters were fatally injured while on duty.¹ The loss of life or limb cannot be fairly assessed in dollars. Only those who have experienced the devastation of fire can truly comprehend the scars—physical and psychological—that remain as a result of being injured by fire. 

There are limited data available about costs for either the initial hospitalization or the long-term care associated with burn injury,⁶ but intuitively we realize the expense can be tremendous because of the lengthy recovery and rehabilitation period required. What is known is that fire and burn injuries represent 1% of the incidence of injuries and 2% of the total costs of injuries each year.⁷ According to 2007 data from the CDC, fire and burn injuries cost approximately $7.5 billion each year: $3.3 billion in fire and burn injuries that do not require hospitalization, $3.1 billion in fatal fire and burn injuries, and $1.1 billion in hospitalization costs. These costs do not include the impact on quality of life that these injuries have on both the burn survivor and the family.  

Everyday objects, if not used properly, can become dangerous and even life threatening. The fact is that people cause fires—and thousands of injuries and deaths could be prevented every year if folks incorporated fire prevention fundamentals into their daily lives. Many, if not all, fire tragedies can be avoided if we educate our patients on the simple strategies to protect themselves—just as we educate them about health promotion strategies.  Here are a few key prevention tips:

•

Install smoke alarms on every level of your home, including the basement. Test your smoke alarms once a month; change the batteries once a year.

•

Use safe cooking practices: Never leave food unattended on the stove, and turn pot handles away from the edge of the stove. 

•

If you use a propane grill, check the gas tank hose for leaks before using it for the first time each year.

•

Clean lint out of the dryer vent pipe and check that the air exhaust vent pipe is not restricted and the outdoor vent flap will open when the dryer is operating.

•

If you burn candles, keep them at least 12 inches away from anything that can burn.

Teach your family and your patients about fire prevention. For more information, log onto the National Fire Protection Association Web site (www.nfpa.org). Let’s include fire and burn injuries on the list of “never events.” And remember: If you do have a fire, get out of the house and call the fire department. 

REFERENCES
1. National Fire Protection Association. www.nfpa .org. Accessed September 18, 2012.

2. Runyan SW, Casteel C (eds). The State of Home Safety in America: Facts About Unintentional Injuries in the Home. 2nd ed. Washington, DC: Home Safety Council; 2004.

3. Fire Sprinkler Initiative. www.firesprinklerinitia tive.org. Accessed September 18, 2012.

4. Shriners Hospitals for Children. www.shrinershospitalsforchildren.org. Accessed September 18, 2012.

5. American Burn Association. Burn Incidence and Treatment in the United States: 2011 Fact Sheet. www.ameriburn.org. Accessed September 18, 2012.

6. Klein MB, Hollingworth W, Rivara FP, et al. Hospital costs associated with pediatric burn injury. J Burn Care Res. 2008;29(4):632-637.

7. CDC. Fire Deaths and Injuries: Fact Sheet. www.cdc.gov/homeandrecreationalsafety/fire-preven tion/fires-factsheet.html. Accessed September 18, 2012.

As I considered topics for my column this month, I was stymied by the options. Watching the morning news—which was inundated with the devastating events that had occurred in the previous 24 hours—it hit me: October has always been a “prevention” month. Let me therefore address that theme.

A day does not pass without us hearing about the need for some type of preventive action, mostly focused on diseases or injuries—some commonly known and others more obscure or in greater need of “awareness” efforts. But I think all too often we forget about preventing the somewhat obvious dangers that we face on a daily basis.

As the daughter, sister, and aunt of firefighters, I know that one week in October is dedicated to fire prevention. Over the years, as we have concentrated efforts toward other areas in need of recognition, I think perhaps we have overlooked fire safety.

Why focus on fire prevention? Well, think about the impact of being involved in, or affected by, fire. Let me give you some insight.

First, a history tidbit: Fire Prevention Week was established in 1922 to memorialize the infamous Chicago Fire of October 1871, the tragic conflagration that killed more than 250 people, left 100,000 homeless, destroyed more than 17,400 structures, and burned more than 2,000 acres. Fire marshals decided the anniversary of the fire should be observed in a way that would keep the public informed about the importance of fire safety and prevention. According to the National Archives and Records Administration’s Library Information Center, Fire Prevention Week is the longest-running public health and safety observance on record.¹

The financial impact of fire can be devastating. For 2009, the total cost associated with fire was estimated at $331 billion, or approximately 2.3% of the gross domestic product of the United States. Fires caused $14.2 billion in reported or unreported direct property damage, representing 88% of economic losses that year; the remaining 12% was attributed to indirect loss, such as interruption of business.¹ In 2010, home fires alone resulted in $6.9 billion in direct damage, and in 2011, an estimated $11.7 billion in property damage occurred as a result of fire.¹ 

More overwhelming is that deaths from fires and burns are the third-leading cause of fatal injury in the home.² Annually, about 3,000 deaths, or 80% of all fire deaths in the US, are the result of fires in the home.³ Each year, fire is the cause of death for more than 600 children ages 14 and younger; fire-related injuries affect about 3,000 more.⁴ Burn injuries account for nearly 700,000 visits to an emergency department yearly.4 According to the American Burn Association, there are one million burn injuries in the US annually, and an estimated 45,000 hospitalizations.⁵

In 2010, fire departments in the US responded to an estimated 1.3 million fires that caused 3,120 civilian deaths and 17,720 civilian injuries.1 In that same year, 72 firefighters were fatally injured while on duty.¹ The loss of life or limb cannot be fairly assessed in dollars. Only those who have experienced the devastation of fire can truly comprehend the scars—physical and psychological—that remain as a result of being injured by fire. 

There are limited data available about costs for either the initial hospitalization or the long-term care associated with burn injury,⁶ but intuitively we realize the expense can be tremendous because of the lengthy recovery and rehabilitation period required. What is known is that fire and burn injuries represent 1% of the incidence of injuries and 2% of the total costs of injuries each year.⁷ According to 2007 data from the CDC, fire and burn injuries cost approximately $7.5 billion each year: $3.3 billion in fire and burn injuries that do not require hospitalization, $3.1 billion in fatal fire and burn injuries, and $1.1 billion in hospitalization costs. These costs do not include the impact on quality of life that these injuries have on both the burn survivor and the family.  

Everyday objects, if not used properly, can become dangerous and even life threatening. The fact is that people cause fires—and thousands of injuries and deaths could be prevented every year if folks incorporated fire prevention fundamentals into their daily lives. Many, if not all, fire tragedies can be avoided if we educate our patients on the simple strategies to protect themselves—just as we educate them about health promotion strategies.  Here are a few key prevention tips:

•

Install smoke alarms on every level of your home, including the basement. Test your smoke alarms once a month; change the batteries once a year.

•

Use safe cooking practices: Never leave food unattended on the stove, and turn pot handles away from the edge of the stove. 

•

If you use a propane grill, check the gas tank hose for leaks before using it for the first time each year.

•

Clean lint out of the dryer vent pipe and check that the air exhaust vent pipe is not restricted and the outdoor vent flap will open when the dryer is operating.

•

If you burn candles, keep them at least 12 inches away from anything that can burn.

Teach your family and your patients about fire prevention. For more information, log onto the National Fire Protection Association Web site (www.nfpa.org). Let’s include fire and burn injuries on the list of “never events.” And remember: If you do have a fire, get out of the house and call the fire department. 

REFERENCES
1. National Fire Protection Association. www.nfpa .org. Accessed September 18, 2012.

2. Runyan SW, Casteel C (eds). The State of Home Safety in America: Facts About Unintentional Injuries in the Home. 2nd ed. Washington, DC: Home Safety Council; 2004.

3. Fire Sprinkler Initiative. www.firesprinklerinitia tive.org. Accessed September 18, 2012.

4. Shriners Hospitals for Children. www.shrinershospitalsforchildren.org. Accessed September 18, 2012.

5. American Burn Association. Burn Incidence and Treatment in the United States: 2011 Fact Sheet. www.ameriburn.org. Accessed September 18, 2012.

6. Klein MB, Hollingworth W, Rivara FP, et al. Hospital costs associated with pediatric burn injury. J Burn Care Res. 2008;29(4):632-637.

7. CDC. Fire Deaths and Injuries: Fact Sheet. www.cdc.gov/homeandrecreationalsafety/fire-preven tion/fires-factsheet.html. Accessed September 18, 2012.

As I considered topics for my column this month, I was stymied by the options. Watching the morning news—which was inundated with the devastating events that had occurred in the previous 24 hours—it hit me: October has always been a “prevention” month. Let me therefore address that theme.

A day does not pass without us hearing about the need for some type of preventive action, mostly focused on diseases or injuries—some commonly known and others more obscure or in greater need of “awareness” efforts. But I think all too often we forget about preventing the somewhat obvious dangers that we face on a daily basis.

As the daughter, sister, and aunt of firefighters, I know that one week in October is dedicated to fire prevention. Over the years, as we have concentrated efforts toward other areas in need of recognition, I think perhaps we have overlooked fire safety.

Why focus on fire prevention? Well, think about the impact of being involved in, or affected by, fire. Let me give you some insight.

First, a history tidbit: Fire Prevention Week was established in 1922 to memorialize the infamous Chicago Fire of October 1871, the tragic conflagration that killed more than 250 people, left 100,000 homeless, destroyed more than 17,400 structures, and burned more than 2,000 acres. Fire marshals decided the anniversary of the fire should be observed in a way that would keep the public informed about the importance of fire safety and prevention. According to the National Archives and Records Administration’s Library Information Center, Fire Prevention Week is the longest-running public health and safety observance on record.¹

The financial impact of fire can be devastating. For 2009, the total cost associated with fire was estimated at $331 billion, or approximately 2.3% of the gross domestic product of the United States. Fires caused $14.2 billion in reported or unreported direct property damage, representing 88% of economic losses that year; the remaining 12% was attributed to indirect loss, such as interruption of business.¹ In 2010, home fires alone resulted in $6.9 billion in direct damage, and in 2011, an estimated $11.7 billion in property damage occurred as a result of fire.¹ 

More overwhelming is that deaths from fires and burns are the third-leading cause of fatal injury in the home.² Annually, about 3,000 deaths, or 80% of all fire deaths in the US, are the result of fires in the home.³ Each year, fire is the cause of death for more than 600 children ages 14 and younger; fire-related injuries affect about 3,000 more.⁴ Burn injuries account for nearly 700,000 visits to an emergency department yearly.4 According to the American Burn Association, there are one million burn injuries in the US annually, and an estimated 45,000 hospitalizations.⁵

In 2010, fire departments in the US responded to an estimated 1.3 million fires that caused 3,120 civilian deaths and 17,720 civilian injuries.1 In that same year, 72 firefighters were fatally injured while on duty.¹ The loss of life or limb cannot be fairly assessed in dollars. Only those who have experienced the devastation of fire can truly comprehend the scars—physical and psychological—that remain as a result of being injured by fire. 

There are limited data available about costs for either the initial hospitalization or the long-term care associated with burn injury,⁶ but intuitively we realize the expense can be tremendous because of the lengthy recovery and rehabilitation period required. What is known is that fire and burn injuries represent 1% of the incidence of injuries and 2% of the total costs of injuries each year.⁷ According to 2007 data from the CDC, fire and burn injuries cost approximately $7.5 billion each year: $3.3 billion in fire and burn injuries that do not require hospitalization, $3.1 billion in fatal fire and burn injuries, and $1.1 billion in hospitalization costs. These costs do not include the impact on quality of life that these injuries have on both the burn survivor and the family.  

Everyday objects, if not used properly, can become dangerous and even life threatening. The fact is that people cause fires—and thousands of injuries and deaths could be prevented every year if folks incorporated fire prevention fundamentals into their daily lives. Many, if not all, fire tragedies can be avoided if we educate our patients on the simple strategies to protect themselves—just as we educate them about health promotion strategies.  Here are a few key prevention tips:

•

Install smoke alarms on every level of your home, including the basement. Test your smoke alarms once a month; change the batteries once a year.

•

Use safe cooking practices: Never leave food unattended on the stove, and turn pot handles away from the edge of the stove. 

•

If you use a propane grill, check the gas tank hose for leaks before using it for the first time each year.

•

Clean lint out of the dryer vent pipe and check that the air exhaust vent pipe is not restricted and the outdoor vent flap will open when the dryer is operating.

•

If you burn candles, keep them at least 12 inches away from anything that can burn.

Teach your family and your patients about fire prevention. For more information, log onto the National Fire Protection Association Web site (www.nfpa.org). Let’s include fire and burn injuries on the list of “never events.” And remember: If you do have a fire, get out of the house and call the fire department. 

REFERENCES
1. National Fire Protection Association. www.nfpa .org. Accessed September 18, 2012.

2. Runyan SW, Casteel C (eds). The State of Home Safety in America: Facts About Unintentional Injuries in the Home. 2nd ed. Washington, DC: Home Safety Council; 2004.

3. Fire Sprinkler Initiative. www.firesprinklerinitia tive.org. Accessed September 18, 2012.

4. Shriners Hospitals for Children. www.shrinershospitalsforchildren.org. Accessed September 18, 2012.

5. American Burn Association. Burn Incidence and Treatment in the United States: 2011 Fact Sheet. www.ameriburn.org. Accessed September 18, 2012.

6. Klein MB, Hollingworth W, Rivara FP, et al. Hospital costs associated with pediatric burn injury. J Burn Care Res. 2008;29(4):632-637.

7. CDC. Fire Deaths and Injuries: Fact Sheet. www.cdc.gov/homeandrecreationalsafety/fire-preven tion/fires-factsheet.html. Accessed September 18, 2012.

At a recent dinner with friends, a discussion arose during the period between sitting down and ordering our meals about how we have changed our diets over the past few years. Several of us no longer drink colas, others have decaffeinated themselves, and one or two are lactose-free. We chuckled at what a challenge it is to invite people for dinner. The query of “What can I bring?” has become “Are there any food restrictions?” 

I find it odd how our bodies have become sensitive or intolerant to food and food additives as we mature. I also find it interesting that in response to those sensitivities, we have reverted to “purer” preparations, to the extent that we can find the unadulterated ingredients. That is definitely easier when you are the “Master Chef,” but when you rely on others—well, that is a very different scenario.

While regulation of food in the United States dates from early colonial times, it took until 1906 to get the Food and Drugs Act, also known as the Wiley Act, established. Harvey Washington Wiley, Chief Chemist of the Bureau of Chemistry in the Department of Agriculture, was the powerhouse behind this law. Wiley believed unsafe foods were a greater public health crisis than adulterated or misbranded drugs. Moreover, he opposed chemical additives to foods, which he viewed as unnecessary adulterants.¹

Interestingly, Upton Sinclair’s The Jungle, an exposé of the revolting state of the meatpacking industry, is credited as the precipitating force behind this meat inspection and comprehensive food and drug law.¹ The Wiley Act banned interstate commerce in adulterated and misbranded food and drugs, and further prohibited the addition of any ingredients that would substitute for the food, conceal damage, pose a health hazard, or constitute a filthy or decomposed substance. Prior to that, basic elements of food protection were absent. 

Despite these inroads, however, concerns about food and drug safety continued, and in 1938, President Franklin D. Roosevelt signed the Food, Drug, and Cosmetic Act into law.² This corrected abuses in food packaging and quality, and it mandated legally enforceable food standards. The first food standards issued under the 1938 act were for canned tomato products; since the 1960s, about half of our food supply is subject to a standard. 

Almost 100 years after the establishment of the Wiley Act, we continued to be plagued with concerns about our food and the contents therein. To address these concerns, in 2004, the passage of the Food Allergy Labeling and Consumer Protection Act required the labeling of any product that contains a protein derived from any of the following foods that, as a group, account for the vast majority of food allergies: peanuts, soybeans, cow’s milk, eggs, fish, crustacean shellfish, tree nuts, and wheat.³ This was an important move, as studies indicate that more than 11 million Americans have one or more food allergies considered a component of chemical intolerance.

The term chemical intolerance (CI) is used to describe the loss of prior, natural tolerance to common foods and drugs that occurs in certain individuals.⁴ In population-based surveys, participants report a 2% to 13% prevalence of CI.⁵ Researchers have also found that patients with CI had an increased incidence of poorer functional states and a tendency toward increased use of the health care system, compared with persons without CI.⁴

Food additives are chemicals used to enhance the flavor, color, or shelf-life of food. While now carefully regulated by federal authorities and various international organizations to ensure that foods are safe to eat and are accurately labeled, in my opinion, they continue to be the most concealed and dangerous sources of CI. The CI recognized as food allergies can be a potentially serious immune response to eating those specific foods. 

The incidence of allergies to food, or food additives, is on the rise. In children younger than 18 alone, there was an 18% increase in the prevalence of reported food allergy between 1997 and 2007.⁶ Often after dining out, those with CI or food allergies suffer for days with gastrointestinal, atopic, cardiovascular, or respiratory symptoms. Anyone who has ever tried to identify exactly what, why, or how they became ill after eating knows how frustrating and sickening it is to go through the process. They also know that as little as one taste of an offending substance can send them to bed for a day—or worse, to the emergency department (ED). 

I never cease to be amazed at the carelessness of some food preparers. As you can imagine, I am outraged that people with food allergies or intolerance seem to be viewed as “picky eaters.” Yes, we are picky: We chose not to be ill after eating in your establishment! I was asked once if I “couldn’t just pick out” the allergen in my dish. My response was “Sure, right after you pick out where the LifeFlight helicopter can land after I eat this!” 

You have the backdrop; now back to our dinner escapades. Our waiter informed us of the daily specials. We listened carefully to his presentation about each dish and the chef’s preparation of it. When he asked if we had any questions, three of us posed queries related to our individual food restrictions. And so began the tribulations. Our meals arrived and contained the items or preparations that each of us had specifically said were taboo. Thankfully, keen eyes and a great sense of smell intervened, preventing us from the guaranteed illness or evening in the ED, had we trusted the kitchen crew.

Food allergies and intolerance are no joke. Those of us with food allergies or intolerance are ever vigilant about reading labels and informing others about our food restrictions. It is imperative that others who prepare food for us be as attentive. Knowing what ingredients are in each dish is important, but also knowing what is in the “base” of how the dish is prepared is critical to preventing dining disasters. That, my friends, is the responsibility of the cook and the servers. 

Hold the mushrooms and coconut, please! If you’d like to share your dining disaster, please send it to NPEditor@qhc.com.

REFERENCES
1. FDA History—Part 1: The 1906 Food and Drugs Act and Its Enforcement. Available at: www.fda.gov/AboutFDA/WhatWeDo/History/Origin/ucm054819.htm.

2. FDA History - Part 2: The 1938 Food, Drug, and Cosmetic Act. Available at: www.fda.gov/AboutFDA/WhatWeDo/History/Origin/ucm054826.htm.

3. About FDA: Significant Dates in U.S. Food and Drug Law History. Available at: www.fda.gov/AboutFDA/WhatWeDo/History/Milestones/ucm128305.htm.

4. Katerndahl DA, Bell IR, Palmer RF, Miller CS. Chemical intolerance in primary care settings: prevalence, comorbidity, and outcomes. Ann Fam Med. 2012;10(4):357-365.

5. Caress SM, Steinemann AC. Prevalence of multiple chemical sensitivities: a population-based study in the southeastern United States. Am J Public Health. 2004;94(5):746-747.

6. Branum AM, Lukacs SL. Food allergy among US children: trends in prevalence and hospitalizations. NCHS data brief, no 10. Hyattsville, MD: National Center for Health Statistics; 2008.

At a recent dinner with friends, a discussion arose during the period between sitting down and ordering our meals about how we have changed our diets over the past few years. Several of us no longer drink colas, others have decaffeinated themselves, and one or two are lactose-free. We chuckled at what a challenge it is to invite people for dinner. The query of “What can I bring?” has become “Are there any food restrictions?” 

I find it odd how our bodies have become sensitive or intolerant to food and food additives as we mature. I also find it interesting that in response to those sensitivities, we have reverted to “purer” preparations, to the extent that we can find the unadulterated ingredients. That is definitely easier when you are the “Master Chef,” but when you rely on others—well, that is a very different scenario.

While regulation of food in the United States dates from early colonial times, it took until 1906 to get the Food and Drugs Act, also known as the Wiley Act, established. Harvey Washington Wiley, Chief Chemist of the Bureau of Chemistry in the Department of Agriculture, was the powerhouse behind this law. Wiley believed unsafe foods were a greater public health crisis than adulterated or misbranded drugs. Moreover, he opposed chemical additives to foods, which he viewed as unnecessary adulterants.¹

Interestingly, Upton Sinclair’s The Jungle, an exposé of the revolting state of the meatpacking industry, is credited as the precipitating force behind this meat inspection and comprehensive food and drug law.¹ The Wiley Act banned interstate commerce in adulterated and misbranded food and drugs, and further prohibited the addition of any ingredients that would substitute for the food, conceal damage, pose a health hazard, or constitute a filthy or decomposed substance. Prior to that, basic elements of food protection were absent. 

Despite these inroads, however, concerns about food and drug safety continued, and in 1938, President Franklin D. Roosevelt signed the Food, Drug, and Cosmetic Act into law.² This corrected abuses in food packaging and quality, and it mandated legally enforceable food standards. The first food standards issued under the 1938 act were for canned tomato products; since the 1960s, about half of our food supply is subject to a standard. 

Almost 100 years after the establishment of the Wiley Act, we continued to be plagued with concerns about our food and the contents therein. To address these concerns, in 2004, the passage of the Food Allergy Labeling and Consumer Protection Act required the labeling of any product that contains a protein derived from any of the following foods that, as a group, account for the vast majority of food allergies: peanuts, soybeans, cow’s milk, eggs, fish, crustacean shellfish, tree nuts, and wheat.³ This was an important move, as studies indicate that more than 11 million Americans have one or more food allergies considered a component of chemical intolerance.

The term chemical intolerance (CI) is used to describe the loss of prior, natural tolerance to common foods and drugs that occurs in certain individuals.⁴ In population-based surveys, participants report a 2% to 13% prevalence of CI.⁵ Researchers have also found that patients with CI had an increased incidence of poorer functional states and a tendency toward increased use of the health care system, compared with persons without CI.⁴

Food additives are chemicals used to enhance the flavor, color, or shelf-life of food. While now carefully regulated by federal authorities and various international organizations to ensure that foods are safe to eat and are accurately labeled, in my opinion, they continue to be the most concealed and dangerous sources of CI. The CI recognized as food allergies can be a potentially serious immune response to eating those specific foods. 

The incidence of allergies to food, or food additives, is on the rise. In children younger than 18 alone, there was an 18% increase in the prevalence of reported food allergy between 1997 and 2007.⁶ Often after dining out, those with CI or food allergies suffer for days with gastrointestinal, atopic, cardiovascular, or respiratory symptoms. Anyone who has ever tried to identify exactly what, why, or how they became ill after eating knows how frustrating and sickening it is to go through the process. They also know that as little as one taste of an offending substance can send them to bed for a day—or worse, to the emergency department (ED). 

I never cease to be amazed at the carelessness of some food preparers. As you can imagine, I am outraged that people with food allergies or intolerance seem to be viewed as “picky eaters.” Yes, we are picky: We chose not to be ill after eating in your establishment! I was asked once if I “couldn’t just pick out” the allergen in my dish. My response was “Sure, right after you pick out where the LifeFlight helicopter can land after I eat this!” 

You have the backdrop; now back to our dinner escapades. Our waiter informed us of the daily specials. We listened carefully to his presentation about each dish and the chef’s preparation of it. When he asked if we had any questions, three of us posed queries related to our individual food restrictions. And so began the tribulations. Our meals arrived and contained the items or preparations that each of us had specifically said were taboo. Thankfully, keen eyes and a great sense of smell intervened, preventing us from the guaranteed illness or evening in the ED, had we trusted the kitchen crew.

Food allergies and intolerance are no joke. Those of us with food allergies or intolerance are ever vigilant about reading labels and informing others about our food restrictions. It is imperative that others who prepare food for us be as attentive. Knowing what ingredients are in each dish is important, but also knowing what is in the “base” of how the dish is prepared is critical to preventing dining disasters. That, my friends, is the responsibility of the cook and the servers. 

Hold the mushrooms and coconut, please! If you’d like to share your dining disaster, please send it to NPEditor@qhc.com.

REFERENCES
1. FDA History—Part 1: The 1906 Food and Drugs Act and Its Enforcement. Available at: www.fda.gov/AboutFDA/WhatWeDo/History/Origin/ucm054819.htm.

2. FDA History - Part 2: The 1938 Food, Drug, and Cosmetic Act. Available at: www.fda.gov/AboutFDA/WhatWeDo/History/Origin/ucm054826.htm.

3. About FDA: Significant Dates in U.S. Food and Drug Law History. Available at: www.fda.gov/AboutFDA/WhatWeDo/History/Milestones/ucm128305.htm.

4. Katerndahl DA, Bell IR, Palmer RF, Miller CS. Chemical intolerance in primary care settings: prevalence, comorbidity, and outcomes. Ann Fam Med. 2012;10(4):357-365.

5. Caress SM, Steinemann AC. Prevalence of multiple chemical sensitivities: a population-based study in the southeastern United States. Am J Public Health. 2004;94(5):746-747.

6. Branum AM, Lukacs SL. Food allergy among US children: trends in prevalence and hospitalizations. NCHS data brief, no 10. Hyattsville, MD: National Center for Health Statistics; 2008.

At a recent dinner with friends, a discussion arose during the period between sitting down and ordering our meals about how we have changed our diets over the past few years. Several of us no longer drink colas, others have decaffeinated themselves, and one or two are lactose-free. We chuckled at what a challenge it is to invite people for dinner. The query of “What can I bring?” has become “Are there any food restrictions?” 

I find it odd how our bodies have become sensitive or intolerant to food and food additives as we mature. I also find it interesting that in response to those sensitivities, we have reverted to “purer” preparations, to the extent that we can find the unadulterated ingredients. That is definitely easier when you are the “Master Chef,” but when you rely on others—well, that is a very different scenario.

While regulation of food in the United States dates from early colonial times, it took until 1906 to get the Food and Drugs Act, also known as the Wiley Act, established. Harvey Washington Wiley, Chief Chemist of the Bureau of Chemistry in the Department of Agriculture, was the powerhouse behind this law. Wiley believed unsafe foods were a greater public health crisis than adulterated or misbranded drugs. Moreover, he opposed chemical additives to foods, which he viewed as unnecessary adulterants.¹

Interestingly, Upton Sinclair’s The Jungle, an exposé of the revolting state of the meatpacking industry, is credited as the precipitating force behind this meat inspection and comprehensive food and drug law.¹ The Wiley Act banned interstate commerce in adulterated and misbranded food and drugs, and further prohibited the addition of any ingredients that would substitute for the food, conceal damage, pose a health hazard, or constitute a filthy or decomposed substance. Prior to that, basic elements of food protection were absent. 

Despite these inroads, however, concerns about food and drug safety continued, and in 1938, President Franklin D. Roosevelt signed the Food, Drug, and Cosmetic Act into law.² This corrected abuses in food packaging and quality, and it mandated legally enforceable food standards. The first food standards issued under the 1938 act were for canned tomato products; since the 1960s, about half of our food supply is subject to a standard. 

Almost 100 years after the establishment of the Wiley Act, we continued to be plagued with concerns about our food and the contents therein. To address these concerns, in 2004, the passage of the Food Allergy Labeling and Consumer Protection Act required the labeling of any product that contains a protein derived from any of the following foods that, as a group, account for the vast majority of food allergies: peanuts, soybeans, cow’s milk, eggs, fish, crustacean shellfish, tree nuts, and wheat.³ This was an important move, as studies indicate that more than 11 million Americans have one or more food allergies considered a component of chemical intolerance.

The term chemical intolerance (CI) is used to describe the loss of prior, natural tolerance to common foods and drugs that occurs in certain individuals.⁴ In population-based surveys, participants report a 2% to 13% prevalence of CI.⁵ Researchers have also found that patients with CI had an increased incidence of poorer functional states and a tendency toward increased use of the health care system, compared with persons without CI.⁴

Food additives are chemicals used to enhance the flavor, color, or shelf-life of food. While now carefully regulated by federal authorities and various international organizations to ensure that foods are safe to eat and are accurately labeled, in my opinion, they continue to be the most concealed and dangerous sources of CI. The CI recognized as food allergies can be a potentially serious immune response to eating those specific foods. 

The incidence of allergies to food, or food additives, is on the rise. In children younger than 18 alone, there was an 18% increase in the prevalence of reported food allergy between 1997 and 2007.⁶ Often after dining out, those with CI or food allergies suffer for days with gastrointestinal, atopic, cardiovascular, or respiratory symptoms. Anyone who has ever tried to identify exactly what, why, or how they became ill after eating knows how frustrating and sickening it is to go through the process. They also know that as little as one taste of an offending substance can send them to bed for a day—or worse, to the emergency department (ED). 

I never cease to be amazed at the carelessness of some food preparers. As you can imagine, I am outraged that people with food allergies or intolerance seem to be viewed as “picky eaters.” Yes, we are picky: We chose not to be ill after eating in your establishment! I was asked once if I “couldn’t just pick out” the allergen in my dish. My response was “Sure, right after you pick out where the LifeFlight helicopter can land after I eat this!” 

You have the backdrop; now back to our dinner escapades. Our waiter informed us of the daily specials. We listened carefully to his presentation about each dish and the chef’s preparation of it. When he asked if we had any questions, three of us posed queries related to our individual food restrictions. And so began the tribulations. Our meals arrived and contained the items or preparations that each of us had specifically said were taboo. Thankfully, keen eyes and a great sense of smell intervened, preventing us from the guaranteed illness or evening in the ED, had we trusted the kitchen crew.

Food allergies and intolerance are no joke. Those of us with food allergies or intolerance are ever vigilant about reading labels and informing others about our food restrictions. It is imperative that others who prepare food for us be as attentive. Knowing what ingredients are in each dish is important, but also knowing what is in the “base” of how the dish is prepared is critical to preventing dining disasters. That, my friends, is the responsibility of the cook and the servers. 

Hold the mushrooms and coconut, please! If you’d like to share your dining disaster, please send it to NPEditor@qhc.com.

REFERENCES
1. FDA History—Part 1: The 1906 Food and Drugs Act and Its Enforcement. Available at: www.fda.gov/AboutFDA/WhatWeDo/History/Origin/ucm054819.htm.

2. FDA History - Part 2: The 1938 Food, Drug, and Cosmetic Act. Available at: www.fda.gov/AboutFDA/WhatWeDo/History/Origin/ucm054826.htm.

3. About FDA: Significant Dates in U.S. Food and Drug Law History. Available at: www.fda.gov/AboutFDA/WhatWeDo/History/Milestones/ucm128305.htm.

4. Katerndahl DA, Bell IR, Palmer RF, Miller CS. Chemical intolerance in primary care settings: prevalence, comorbidity, and outcomes. Ann Fam Med. 2012;10(4):357-365.

5. Caress SM, Steinemann AC. Prevalence of multiple chemical sensitivities: a population-based study in the southeastern United States. Am J Public Health. 2004;94(5):746-747.

6. Branum AM, Lukacs SL. Food allergy among US children: trends in prevalence and hospitalizations. NCHS data brief, no 10. Hyattsville, MD: National Center for Health Statistics; 2008.

The recent outbreak of pertussis in Washington State has generated a flurry of articles and editorials about vaccination and discussion regarding how to address the unvaccinated population. Parents who refuse to have their children vaccinated intrigue me. I cannot understand why they want to gamble with preventable diseases.

However, this is not a tirade about those decisions. It is a response to what has been said in the lay and professional press lately about the Acute Benign Childhood Diseases (ABCDs), and what some health care professionals have done in reaction to those parental decisions.  

I recently read about a primary care provider faced with the challenge of addressing the risk that one family of unvaccinated children was placing his other families in when they presented for well or sick child visits. The provider had mixed feelings: He wanted to respect the beliefs of the one family, but did not feel it proper to impose those beliefs on the other families in the practice. He also noted that the parents’ decision was creating an ethical conflict for him, both personally and professionally. He fully supported vaccination efforts as a component of well-child (and public health) care. As a “win-win” decision, he discharged the family from the practice, allowing both parties to maintain their standards. Standards that, I submit, have drastically changed over the past several decades.  

As a child of the ’50s and the third of eight children, for me exposure to those ABCDs was a rite of passage. You were a hero among your friends if you were the first kid on the block to break out in a rash. Parents sought you out to “share” your illness. We had “Chickenpox Parties” so that the neighborhood suffered the infirmary together. It was the best; once the fever broke, all you were was itchy. You, your siblings, and all your friends could still be out in the yard playing. Woohoo, no school for us—and no “makeup” work, either! 

When we had measles, mumps, and rubella (MMR), the treatment was quite different. In my family, Mom kept us in a dark room and away from everyone else—quite a singular experience. I recall not being allowed to read or watch television (the few shows that were on) for fear I would go blind. Maybe it was my mother’s way of keeping me quiet. Who knows?  

Perhaps because of my experience with the ABCDs, my parents’ belief that vaccines were a good thing, and the fact that “back in the day” you didn’t get into school without them, we received all the available immunizations (that’s what they were called then). There were only a few when I was young; thus, I have natural acquired immunity, which Mosby’s says is “obtained by the development of antibodies resulting from an attack of infectious disease….”¹

I still have my original Certificate of Immunization and Tests. I completed my full series of diphtheria, tetanus, and whooping cough and Salk polio immunizations all before I started kindergarten. I also received the smallpox vaccine (and twice since!). In addition, because one of my childhood friends had contracted polio, when the Sabin vaccine became available, every parent and child lined up at the school where it was administered. 

Based on my experience with the ABCDs, I long felt that children were missing the “fun” when the MMR and later the varicella vaccines became available. None of us had any of the severe sequelae of the ABCDs, but my one experience with a patient who had varicella pneumonia changed my opinion. I had a completely new appreciation for what damage these seemingly “benign” diseases could cause.

We have had our share of ABCD outbreaks in the past, and the push to have everyone vaccinated or revaccinated occurs in response. Yet we still see active disease. In 1989, after years of low incidence of measles cases, there was a sudden reappearance of the disease. During the 1989-1991 period, more than 55,000 cases were reported, and there were 123 deaths.² We continue to see cases of measles, which creates a bit of a concern on my part due to a rise from 43 cases in 2007 to 216 in 2011. 

 Pertussis, one of the first diseases to become vaccine-preventable, reared its ugly head several years ago, moving the infectious disease professionals and immunologists to identify the need to revaccinate adults. Historically, despite the vaccine, cases of pertussis continue to occur, vary from year to year, and tend to peak every three to five years. In 2010, there were 27,550 cases of pertussis reported in the US—and many more cases go unreported.³

Therefore, the recent news about the pertussis outbreak in Washington State was not so surprising to me. Unfortunately, that statewide epidemic is predicted to result in the highest number of reported cases in decades.⁴ Moreover, with that epidemic comes the potential risk for myriad sequelae that could have been avoided.

I think we have become somewhat isolated with regard to the ABCDs. The vaccine programs over the past 50 years have fully or nearly eliminated several vaccine-preventable diseases, but we cannot stop there. We must remain ever vigilant in our vaccination practices and encourage vaccination “across the lifespan.” We must endeavor to educate our patients and their parents about the benefits of vaccination and dispel the myths and misunderstandings about immunizations. We must also exercise every opportunity to update the immunizations of all our patients, so that the risk for contracting these diseases is decreased for all of us. 

What about you—are your immunizations current? Do you review the vaccination status of your patients during their office visits? How do you counsel the parents who refuse to vaccinate their children? Inquiring minds want to know, so please write to NPEditor@qhc.com.

REFERENCES
1. Mosby’s Medical Dictionary. 8th edition. 2009; Elsevier. 

2. Hinman AR, Orenstein WA, Schuchat A. Vaccine-preventable diseases, immunizations, and MMWR—1961–2011 [supplement]. MMWR Morb Mortal Wkly Rep. 2011;60(4):49-57.

3. CDC. Pertussis (Whooping Cough)–What You Need To Know. www.cdc.gov/Features/Pertussis.

4. Washington State Department of Health. Whooping cough cases reach epidemic levels in much of Washington [news release 12-038]. April 3, 2012. www.doh.wa.gov.

The recent outbreak of pertussis in Washington State has generated a flurry of articles and editorials about vaccination and discussion regarding how to address the unvaccinated population. Parents who refuse to have their children vaccinated intrigue me. I cannot understand why they want to gamble with preventable diseases.

However, this is not a tirade about those decisions. It is a response to what has been said in the lay and professional press lately about the Acute Benign Childhood Diseases (ABCDs), and what some health care professionals have done in reaction to those parental decisions.  

I recently read about a primary care provider faced with the challenge of addressing the risk that one family of unvaccinated children was placing his other families in when they presented for well or sick child visits. The provider had mixed feelings: He wanted to respect the beliefs of the one family, but did not feel it proper to impose those beliefs on the other families in the practice. He also noted that the parents’ decision was creating an ethical conflict for him, both personally and professionally. He fully supported vaccination efforts as a component of well-child (and public health) care. As a “win-win” decision, he discharged the family from the practice, allowing both parties to maintain their standards. Standards that, I submit, have drastically changed over the past several decades.  

As a child of the ’50s and the third of eight children, for me exposure to those ABCDs was a rite of passage. You were a hero among your friends if you were the first kid on the block to break out in a rash. Parents sought you out to “share” your illness. We had “Chickenpox Parties” so that the neighborhood suffered the infirmary together. It was the best; once the fever broke, all you were was itchy. You, your siblings, and all your friends could still be out in the yard playing. Woohoo, no school for us—and no “makeup” work, either! 

When we had measles, mumps, and rubella (MMR), the treatment was quite different. In my family, Mom kept us in a dark room and away from everyone else—quite a singular experience. I recall not being allowed to read or watch television (the few shows that were on) for fear I would go blind. Maybe it was my mother’s way of keeping me quiet. Who knows?  

Perhaps because of my experience with the ABCDs, my parents’ belief that vaccines were a good thing, and the fact that “back in the day” you didn’t get into school without them, we received all the available immunizations (that’s what they were called then). There were only a few when I was young; thus, I have natural acquired immunity, which Mosby’s says is “obtained by the development of antibodies resulting from an attack of infectious disease….”¹

I still have my original Certificate of Immunization and Tests. I completed my full series of diphtheria, tetanus, and whooping cough and Salk polio immunizations all before I started kindergarten. I also received the smallpox vaccine (and twice since!). In addition, because one of my childhood friends had contracted polio, when the Sabin vaccine became available, every parent and child lined up at the school where it was administered. 

Based on my experience with the ABCDs, I long felt that children were missing the “fun” when the MMR and later the varicella vaccines became available. None of us had any of the severe sequelae of the ABCDs, but my one experience with a patient who had varicella pneumonia changed my opinion. I had a completely new appreciation for what damage these seemingly “benign” diseases could cause.

We have had our share of ABCD outbreaks in the past, and the push to have everyone vaccinated or revaccinated occurs in response. Yet we still see active disease. In 1989, after years of low incidence of measles cases, there was a sudden reappearance of the disease. During the 1989-1991 period, more than 55,000 cases were reported, and there were 123 deaths.² We continue to see cases of measles, which creates a bit of a concern on my part due to a rise from 43 cases in 2007 to 216 in 2011. 

 Pertussis, one of the first diseases to become vaccine-preventable, reared its ugly head several years ago, moving the infectious disease professionals and immunologists to identify the need to revaccinate adults. Historically, despite the vaccine, cases of pertussis continue to occur, vary from year to year, and tend to peak every three to five years. In 2010, there were 27,550 cases of pertussis reported in the US—and many more cases go unreported.³

Therefore, the recent news about the pertussis outbreak in Washington State was not so surprising to me. Unfortunately, that statewide epidemic is predicted to result in the highest number of reported cases in decades.⁴ Moreover, with that epidemic comes the potential risk for myriad sequelae that could have been avoided.

I think we have become somewhat isolated with regard to the ABCDs. The vaccine programs over the past 50 years have fully or nearly eliminated several vaccine-preventable diseases, but we cannot stop there. We must remain ever vigilant in our vaccination practices and encourage vaccination “across the lifespan.” We must endeavor to educate our patients and their parents about the benefits of vaccination and dispel the myths and misunderstandings about immunizations. We must also exercise every opportunity to update the immunizations of all our patients, so that the risk for contracting these diseases is decreased for all of us. 

What about you—are your immunizations current? Do you review the vaccination status of your patients during their office visits? How do you counsel the parents who refuse to vaccinate their children? Inquiring minds want to know, so please write to NPEditor@qhc.com.

REFERENCES
1. Mosby’s Medical Dictionary. 8th edition. 2009; Elsevier. 

2. Hinman AR, Orenstein WA, Schuchat A. Vaccine-preventable diseases, immunizations, and MMWR—1961–2011 [supplement]. MMWR Morb Mortal Wkly Rep. 2011;60(4):49-57.

3. CDC. Pertussis (Whooping Cough)–What You Need To Know. www.cdc.gov/Features/Pertussis.

4. Washington State Department of Health. Whooping cough cases reach epidemic levels in much of Washington [news release 12-038]. April 3, 2012. www.doh.wa.gov.

The recent outbreak of pertussis in Washington State has generated a flurry of articles and editorials about vaccination and discussion regarding how to address the unvaccinated population. Parents who refuse to have their children vaccinated intrigue me. I cannot understand why they want to gamble with preventable diseases.

However, this is not a tirade about those decisions. It is a response to what has been said in the lay and professional press lately about the Acute Benign Childhood Diseases (ABCDs), and what some health care professionals have done in reaction to those parental decisions.  

I recently read about a primary care provider faced with the challenge of addressing the risk that one family of unvaccinated children was placing his other families in when they presented for well or sick child visits. The provider had mixed feelings: He wanted to respect the beliefs of the one family, but did not feel it proper to impose those beliefs on the other families in the practice. He also noted that the parents’ decision was creating an ethical conflict for him, both personally and professionally. He fully supported vaccination efforts as a component of well-child (and public health) care. As a “win-win” decision, he discharged the family from the practice, allowing both parties to maintain their standards. Standards that, I submit, have drastically changed over the past several decades.  

As a child of the ’50s and the third of eight children, for me exposure to those ABCDs was a rite of passage. You were a hero among your friends if you were the first kid on the block to break out in a rash. Parents sought you out to “share” your illness. We had “Chickenpox Parties” so that the neighborhood suffered the infirmary together. It was the best; once the fever broke, all you were was itchy. You, your siblings, and all your friends could still be out in the yard playing. Woohoo, no school for us—and no “makeup” work, either! 

When we had measles, mumps, and rubella (MMR), the treatment was quite different. In my family, Mom kept us in a dark room and away from everyone else—quite a singular experience. I recall not being allowed to read or watch television (the few shows that were on) for fear I would go blind. Maybe it was my mother’s way of keeping me quiet. Who knows?  

Perhaps because of my experience with the ABCDs, my parents’ belief that vaccines were a good thing, and the fact that “back in the day” you didn’t get into school without them, we received all the available immunizations (that’s what they were called then). There were only a few when I was young; thus, I have natural acquired immunity, which Mosby’s says is “obtained by the development of antibodies resulting from an attack of infectious disease….”¹

I still have my original Certificate of Immunization and Tests. I completed my full series of diphtheria, tetanus, and whooping cough and Salk polio immunizations all before I started kindergarten. I also received the smallpox vaccine (and twice since!). In addition, because one of my childhood friends had contracted polio, when the Sabin vaccine became available, every parent and child lined up at the school where it was administered. 

Based on my experience with the ABCDs, I long felt that children were missing the “fun” when the MMR and later the varicella vaccines became available. None of us had any of the severe sequelae of the ABCDs, but my one experience with a patient who had varicella pneumonia changed my opinion. I had a completely new appreciation for what damage these seemingly “benign” diseases could cause.

We have had our share of ABCD outbreaks in the past, and the push to have everyone vaccinated or revaccinated occurs in response. Yet we still see active disease. In 1989, after years of low incidence of measles cases, there was a sudden reappearance of the disease. During the 1989-1991 period, more than 55,000 cases were reported, and there were 123 deaths.² We continue to see cases of measles, which creates a bit of a concern on my part due to a rise from 43 cases in 2007 to 216 in 2011. 

 Pertussis, one of the first diseases to become vaccine-preventable, reared its ugly head several years ago, moving the infectious disease professionals and immunologists to identify the need to revaccinate adults. Historically, despite the vaccine, cases of pertussis continue to occur, vary from year to year, and tend to peak every three to five years. In 2010, there were 27,550 cases of pertussis reported in the US—and many more cases go unreported.³

Therefore, the recent news about the pertussis outbreak in Washington State was not so surprising to me. Unfortunately, that statewide epidemic is predicted to result in the highest number of reported cases in decades.⁴ Moreover, with that epidemic comes the potential risk for myriad sequelae that could have been avoided.

I think we have become somewhat isolated with regard to the ABCDs. The vaccine programs over the past 50 years have fully or nearly eliminated several vaccine-preventable diseases, but we cannot stop there. We must remain ever vigilant in our vaccination practices and encourage vaccination “across the lifespan.” We must endeavor to educate our patients and their parents about the benefits of vaccination and dispel the myths and misunderstandings about immunizations. We must also exercise every opportunity to update the immunizations of all our patients, so that the risk for contracting these diseases is decreased for all of us. 

What about you—are your immunizations current? Do you review the vaccination status of your patients during their office visits? How do you counsel the parents who refuse to vaccinate their children? Inquiring minds want to know, so please write to NPEditor@qhc.com.

REFERENCES
1. Mosby’s Medical Dictionary. 8th edition. 2009; Elsevier. 

2. Hinman AR, Orenstein WA, Schuchat A. Vaccine-preventable diseases, immunizations, and MMWR—1961–2011 [supplement]. MMWR Morb Mortal Wkly Rep. 2011;60(4):49-57.

3. CDC. Pertussis (Whooping Cough)–What You Need To Know. www.cdc.gov/Features/Pertussis.

4. Washington State Department of Health. Whooping cough cases reach epidemic levels in much of Washington [news release 12-038]. April 3, 2012. www.doh.wa.gov.

After so many changes last year, here we are in 2012. This is the first season of my favorite Sunday evening show, 60 Minutes, without Andy Rooney.

What a loss—I so looked forward to listening to him talk about what irritated him or what should bother us. It prompted a laugh at times, but mostly it was a subtle awakening to what was happening around us, what we often overlooked or let occur.

Speaking of awakening, this year the Today show celebrates its 60th anniversary. Amazing; it seems like only yesterday Today and I were kids! On that show as well, our attention is drawn to what we should be concerned with in our daily lives.

However, “the new 60” is not our age, or the show without Mr. Rooney. No, the new 60 is the initiative to get us moving—off the couch and onto our feet. Many of you who have followed my columns will recall that at least once a year I reflect on getting healthy. Often it is a focus on healthier living, preventive screenings, and better eating. This will be a bit different; it is about including exercise in our daily lives.

Over the past few months, I have become intrigued with the concept of 60 minutes of daily exercise. While the focus of this initiative is on getting our kids moving, the subtle message is to decrease the incidence of obesity in our children. The prevalence, along with the sequelae of lifelong chronic illnesses, has made decreasing childhood obesity a national goal of Healthy People 2020. 

The message is not lost on my generation; however, the delivery is a bit different: “a body in motion tends to stay in motion.” This does not truly address the problem of being overweight in our later years, but it strives to encourage us that if we keep moving the weight will stabilize. At least that is my take on it. 

Unfortunately, our lives have become overrun with electronic conveniences. We shop online and have our packages delivered; we download our music and books to a handheld device. No longer do we spend time window-shopping or browsing library shelves—no, now we “let our fingers do the walking.”

What if we need to return those purchases? Well, we simply call UPS or the postal service and someone comes to pick them up. My goodness, what an inert society we are now!

More importantly, if that is what our children see us doing, what a poor example we set. How can we motivate and direct our youth to get out and get active, if we are not doing it ourselves? We need to join forces with the national momentum and get moving.

The National Football League is enthusiastic about its Play 60 campaign (www.nfl.com/Play60), designed to get all of us to be active for 60 minutes a day (does jumping up and down while watching the game count?), in order to reverse the trends of childhood (and, I would submit, adult) obesity. The campaign site includes links to different activities for young and old alike. Granted, many of the activities appear “football-related,” but as I look deeper, the training to stay in shape for a professional athlete is no different than for the general public. The basics are the same: strength, toning, and endurance. And it isn’t just the NFL. All the professional sports players are pushing us to get moving by doing some type of activity. Walk, run, ride a bike, swim, or play golf. Do anything, but just do it.  

So what does 60 minutes a day entail? Is it an entire hour all at once, or 10 minutes six times a day? If exercise is not a part of your daily routine, any addition is an improvement—so start small and build up. A little bit each day, carve out the time from all your work-related activities. Before you know it, you will be craving that activity!

Remember the suggestions of earlier years: If you must drive to the store, park at the far end of the parking lot. Use the stairs instead of the escalator or elevator, or walk down, ride up. Think of those two suggestions: Get healthy and be green at the same time.

We all know that habits, good or bad, take time to have a foothold on us. Take the time to make being active a habit. It is a good one to get into, especially with activities we can do outdoors. A healthy dose of fresh air makes us feel better, look better, sleep better, and think more clearly.

I am looking differently at 60 now. My goal is 60 minutes a day of some activity. Beginning now: I am off to play golf—walking and carrying my clubs! I hope to live as long as Andy Rooney.

What about you? What does your 60 look like? Share your thoughts by emailing ­NPEditor@qhc.com.

After so many changes last year, here we are in 2012. This is the first season of my favorite Sunday evening show, 60 Minutes, without Andy Rooney.

What a loss—I so looked forward to listening to him talk about what irritated him or what should bother us. It prompted a laugh at times, but mostly it was a subtle awakening to what was happening around us, what we often overlooked or let occur.

Speaking of awakening, this year the Today show celebrates its 60th anniversary. Amazing; it seems like only yesterday Today and I were kids! On that show as well, our attention is drawn to what we should be concerned with in our daily lives.

However, “the new 60” is not our age, or the show without Mr. Rooney. No, the new 60 is the initiative to get us moving—off the couch and onto our feet. Many of you who have followed my columns will recall that at least once a year I reflect on getting healthy. Often it is a focus on healthier living, preventive screenings, and better eating. This will be a bit different; it is about including exercise in our daily lives.

Over the past few months, I have become intrigued with the concept of 60 minutes of daily exercise. While the focus of this initiative is on getting our kids moving, the subtle message is to decrease the incidence of obesity in our children. The prevalence, along with the sequelae of lifelong chronic illnesses, has made decreasing childhood obesity a national goal of Healthy People 2020. 

The message is not lost on my generation; however, the delivery is a bit different: “a body in motion tends to stay in motion.” This does not truly address the problem of being overweight in our later years, but it strives to encourage us that if we keep moving the weight will stabilize. At least that is my take on it. 

Unfortunately, our lives have become overrun with electronic conveniences. We shop online and have our packages delivered; we download our music and books to a handheld device. No longer do we spend time window-shopping or browsing library shelves—no, now we “let our fingers do the walking.”

What if we need to return those purchases? Well, we simply call UPS or the postal service and someone comes to pick them up. My goodness, what an inert society we are now!

More importantly, if that is what our children see us doing, what a poor example we set. How can we motivate and direct our youth to get out and get active, if we are not doing it ourselves? We need to join forces with the national momentum and get moving.

The National Football League is enthusiastic about its Play 60 campaign (www.nfl.com/Play60), designed to get all of us to be active for 60 minutes a day (does jumping up and down while watching the game count?), in order to reverse the trends of childhood (and, I would submit, adult) obesity. The campaign site includes links to different activities for young and old alike. Granted, many of the activities appear “football-related,” but as I look deeper, the training to stay in shape for a professional athlete is no different than for the general public. The basics are the same: strength, toning, and endurance. And it isn’t just the NFL. All the professional sports players are pushing us to get moving by doing some type of activity. Walk, run, ride a bike, swim, or play golf. Do anything, but just do it.  

So what does 60 minutes a day entail? Is it an entire hour all at once, or 10 minutes six times a day? If exercise is not a part of your daily routine, any addition is an improvement—so start small and build up. A little bit each day, carve out the time from all your work-related activities. Before you know it, you will be craving that activity!

Remember the suggestions of earlier years: If you must drive to the store, park at the far end of the parking lot. Use the stairs instead of the escalator or elevator, or walk down, ride up. Think of those two suggestions: Get healthy and be green at the same time.

We all know that habits, good or bad, take time to have a foothold on us. Take the time to make being active a habit. It is a good one to get into, especially with activities we can do outdoors. A healthy dose of fresh air makes us feel better, look better, sleep better, and think more clearly.

I am looking differently at 60 now. My goal is 60 minutes a day of some activity. Beginning now: I am off to play golf—walking and carrying my clubs! I hope to live as long as Andy Rooney.

What about you? What does your 60 look like? Share your thoughts by emailing ­NPEditor@qhc.com.

After so many changes last year, here we are in 2012. This is the first season of my favorite Sunday evening show, 60 Minutes, without Andy Rooney.

What a loss—I so looked forward to listening to him talk about what irritated him or what should bother us. It prompted a laugh at times, but mostly it was a subtle awakening to what was happening around us, what we often overlooked or let occur.

Speaking of awakening, this year the Today show celebrates its 60th anniversary. Amazing; it seems like only yesterday Today and I were kids! On that show as well, our attention is drawn to what we should be concerned with in our daily lives.

However, “the new 60” is not our age, or the show without Mr. Rooney. No, the new 60 is the initiative to get us moving—off the couch and onto our feet. Many of you who have followed my columns will recall that at least once a year I reflect on getting healthy. Often it is a focus on healthier living, preventive screenings, and better eating. This will be a bit different; it is about including exercise in our daily lives.

Over the past few months, I have become intrigued with the concept of 60 minutes of daily exercise. While the focus of this initiative is on getting our kids moving, the subtle message is to decrease the incidence of obesity in our children. The prevalence, along with the sequelae of lifelong chronic illnesses, has made decreasing childhood obesity a national goal of Healthy People 2020. 

The message is not lost on my generation; however, the delivery is a bit different: “a body in motion tends to stay in motion.” This does not truly address the problem of being overweight in our later years, but it strives to encourage us that if we keep moving the weight will stabilize. At least that is my take on it. 

Unfortunately, our lives have become overrun with electronic conveniences. We shop online and have our packages delivered; we download our music and books to a handheld device. No longer do we spend time window-shopping or browsing library shelves—no, now we “let our fingers do the walking.”

What if we need to return those purchases? Well, we simply call UPS or the postal service and someone comes to pick them up. My goodness, what an inert society we are now!

More importantly, if that is what our children see us doing, what a poor example we set. How can we motivate and direct our youth to get out and get active, if we are not doing it ourselves? We need to join forces with the national momentum and get moving.

The National Football League is enthusiastic about its Play 60 campaign (www.nfl.com/Play60), designed to get all of us to be active for 60 minutes a day (does jumping up and down while watching the game count?), in order to reverse the trends of childhood (and, I would submit, adult) obesity. The campaign site includes links to different activities for young and old alike. Granted, many of the activities appear “football-related,” but as I look deeper, the training to stay in shape for a professional athlete is no different than for the general public. The basics are the same: strength, toning, and endurance. And it isn’t just the NFL. All the professional sports players are pushing us to get moving by doing some type of activity. Walk, run, ride a bike, swim, or play golf. Do anything, but just do it.  

So what does 60 minutes a day entail? Is it an entire hour all at once, or 10 minutes six times a day? If exercise is not a part of your daily routine, any addition is an improvement—so start small and build up. A little bit each day, carve out the time from all your work-related activities. Before you know it, you will be craving that activity!

Remember the suggestions of earlier years: If you must drive to the store, park at the far end of the parking lot. Use the stairs instead of the escalator or elevator, or walk down, ride up. Think of those two suggestions: Get healthy and be green at the same time.

We all know that habits, good or bad, take time to have a foothold on us. Take the time to make being active a habit. It is a good one to get into, especially with activities we can do outdoors. A healthy dose of fresh air makes us feel better, look better, sleep better, and think more clearly.

I am looking differently at 60 now. My goal is 60 minutes a day of some activity. Beginning now: I am off to play golf—walking and carrying my clubs! I hope to live as long as Andy Rooney.

What about you? What does your 60 look like? Share your thoughts by emailing ­NPEditor@qhc.com.

One of my responsibilities as the director of a DNP program is reviewing and evaluating the applications to the program. I cheer when I see an applicant who is either a pediatric nurse practitioner (PNP) or a nurse leader whose specialty is pediatrics.

I have noted that my cheers are few and far between, and I began to wonder why. In a recent conversation with Jan Wyatt, PhD, RN, FAANP, Executive Director of the Institute of Pediatric Nursing, I mentioned the paucity of pediatric nurses in our graduate programs. Alas, I discovered that the scarcity is across the board in the pediatric nursing specialty. And thus began my education on how this has become a national concern among pediatric nurses.

The data are staggering: In the US, there are approximately 74 million children. Of that number, 18% are uninsured and 30% have significant health issues such as asthma, depression, and special care needs.¹ While the Children’s Health Insurance Program (CHIP) has facilitated some reduction in the number of uninsured children, the inequity of their access to care persists. Since 2000, one of the Healthy People initiatives has been to reduce health disparities. The 2020 goals have been broadened to “to achieve health equity, eliminate disparities, and improve the health of all groups.”²  

It has been said that the “future of our world lies in the hands, the hearts, and the minds of our children.” If that is so, then it is incumbent upon us to ensure there are a sufficient number of health care providers who are experts in children’s health and to whom children (and their families) have access. Improving the health and well-being of children not only impacts their future health, but also affects, and can identify, future challenges for the entire health care system.

But sadly enough, with regard to caring for the health of our children, it appears that we are no better off than we were 50 years ago. Recall that the first NP program was a model for public health nurses so they could enhance the care available to children and their families. Just as in the 1960s there was a need for access to pediatric care, so too, today, the services for children border on woefully inadequate. With the passage of the 2010 Patient Protection and Affordable Care Act, and the Future of Nursing report, nurses are well positioned to turn that around.

However, the landscape of nursing is changing, and we are witnessing a decline in the number of nurses who choose pediatrics as their specialty. Today, only 7.3% of the RN workforce, and 8.1% of nurses in advanced practice, specialize in pediatrics.³ In our discussion, Dr. Wyatt noted that in the past 10 to 15 years, the percentage of NP students entering PNP programs has significantly diminished.

Also of note is that pediatrics as content in undergraduate education has often been “integrated,” so BSN recipients have very little pediatric experience—and therefore little confidence in their ability to care for sick children—when they graduate. Moreover, the decrease in pediatric content and clinical experience is worsened by the difficulty in recruiting nurse educators who teach in this area.⁴ And as BSN-prepared nurses consider advanced training as an NP, they are being steered toward the family nurse practitioner (FNP), not PNP, track, despite their desire to focus on pediatrics. 

The pediatric, adult, and women’s health NP roles were established long before the FNP role grew into prominence. In the 1970s, the introduction of the birth control pill probably contributed to the need for more health care providers who specialized in the care of women. These roles were viewed as the pioneers of the NP movement, with the PNP being the first. These programs flourished, albeit the PNP programs less so than the others. That said, in 1998 there were 114 primary care PNP programs, which by 2010 had decreased to 98.⁵ Worse, in some states (Idaho and Wyoming, for example), nurses who want to be a PNP need to leave their homes, as there are no PNP programs there.  

As a result of the disappearance of pediatrics in undergraduate education and the decrease in PNP programs (especially primary care), the Pediatric Nursing Certification Board sponsored the establishment of the Institute of Pediatric Nursing (IPN) in 2011. The IPN is a nonprofit educational organization that brings together leaders from nursing organizations and children’s hospitals to provide a collective voice to advocate for strengthening pediatric nursing education and to advocate for improved health and illness care coordination for kids and families, as well as support for access to safe, quality, evidenced-based care for all children and families.⁶

The IPN, partnering with the American Association of Colleges of Nursing, is currently conducting a national survey of undergraduate nursing programs “to explore the challenges, gaps, and successes within undergraduate pediatric nursing education, including an exploration of the perspectives of nursing faculty regarding the future of pediatric nursing residency programs.”⁷ The results of this survey will be presented at the Third Annual Invitational Forum for Pediatric Nursing in October.

When I was deciding on a career, I knew I wanted to work with children. I became a nurse so I could become a PNP, and my decision was supported by my nursing mentor, who directed me to follow my passion. Just as I was encouraged, we need to encourage nursing and NP students to go where their passion lies. Let them follow their heart—if they want another specialty, OK. But if they love pediatrics, support that passion.

We need to honor our roots and not abandon the pediatric nurse practitioner role. Where would we be without it?

References
1. Kaiser Family Foundation. The uninsured: a primer (2009). www.kff.org/uninsured/7451.cfm. Accessed September 16, 2011.

2. US Department of Health and Human Services. Healthy People 2020. www.healthypeople.gov/ 2020/about/disparitiesAbout.aspx. Accessed September 16, 2011.

3. Health Resources and Services Administration. The registered nurse population: findings from the 2008 National Sample Survey of Registered Nurses. bhpr.hrsa.gov/healthworkforce/rnsurvey2008 .html. Accessed September 16, 2011.

4. Society of Pediatric Nurses. Position statement on child health content in the undergraduate curriculum (2007).

5. National Association of Pediatric Nurse Practitioners. PNP programs information: pediatric nurse practitioner school list. www.napnap.org/ForStudents/PNPSchoolListing.aspx. Accessed September 16, 2011.

6. Sperhac A, Wyatt JS. Securing the future of children’s health. Pediatric Nursing. 2010;36(1):8-9.

7. Institute of Pediatric Nursing. www.ipedsnursing.org/ptisite/control/index. Accessed September 16, 2011.

One of my responsibilities as the director of a DNP program is reviewing and evaluating the applications to the program. I cheer when I see an applicant who is either a pediatric nurse practitioner (PNP) or a nurse leader whose specialty is pediatrics.

I have noted that my cheers are few and far between, and I began to wonder why. In a recent conversation with Jan Wyatt, PhD, RN, FAANP, Executive Director of the Institute of Pediatric Nursing, I mentioned the paucity of pediatric nurses in our graduate programs. Alas, I discovered that the scarcity is across the board in the pediatric nursing specialty. And thus began my education on how this has become a national concern among pediatric nurses.

The data are staggering: In the US, there are approximately 74 million children. Of that number, 18% are uninsured and 30% have significant health issues such as asthma, depression, and special care needs.¹ While the Children’s Health Insurance Program (CHIP) has facilitated some reduction in the number of uninsured children, the inequity of their access to care persists. Since 2000, one of the Healthy People initiatives has been to reduce health disparities. The 2020 goals have been broadened to “to achieve health equity, eliminate disparities, and improve the health of all groups.”²  

It has been said that the “future of our world lies in the hands, the hearts, and the minds of our children.” If that is so, then it is incumbent upon us to ensure there are a sufficient number of health care providers who are experts in children’s health and to whom children (and their families) have access. Improving the health and well-being of children not only impacts their future health, but also affects, and can identify, future challenges for the entire health care system.

But sadly enough, with regard to caring for the health of our children, it appears that we are no better off than we were 50 years ago. Recall that the first NP program was a model for public health nurses so they could enhance the care available to children and their families. Just as in the 1960s there was a need for access to pediatric care, so too, today, the services for children border on woefully inadequate. With the passage of the 2010 Patient Protection and Affordable Care Act, and the Future of Nursing report, nurses are well positioned to turn that around.

However, the landscape of nursing is changing, and we are witnessing a decline in the number of nurses who choose pediatrics as their specialty. Today, only 7.3% of the RN workforce, and 8.1% of nurses in advanced practice, specialize in pediatrics.³ In our discussion, Dr. Wyatt noted that in the past 10 to 15 years, the percentage of NP students entering PNP programs has significantly diminished.

Also of note is that pediatrics as content in undergraduate education has often been “integrated,” so BSN recipients have very little pediatric experience—and therefore little confidence in their ability to care for sick children—when they graduate. Moreover, the decrease in pediatric content and clinical experience is worsened by the difficulty in recruiting nurse educators who teach in this area.⁴ And as BSN-prepared nurses consider advanced training as an NP, they are being steered toward the family nurse practitioner (FNP), not PNP, track, despite their desire to focus on pediatrics. 

The pediatric, adult, and women’s health NP roles were established long before the FNP role grew into prominence. In the 1970s, the introduction of the birth control pill probably contributed to the need for more health care providers who specialized in the care of women. These roles were viewed as the pioneers of the NP movement, with the PNP being the first. These programs flourished, albeit the PNP programs less so than the others. That said, in 1998 there were 114 primary care PNP programs, which by 2010 had decreased to 98.⁵ Worse, in some states (Idaho and Wyoming, for example), nurses who want to be a PNP need to leave their homes, as there are no PNP programs there.  

As a result of the disappearance of pediatrics in undergraduate education and the decrease in PNP programs (especially primary care), the Pediatric Nursing Certification Board sponsored the establishment of the Institute of Pediatric Nursing (IPN) in 2011. The IPN is a nonprofit educational organization that brings together leaders from nursing organizations and children’s hospitals to provide a collective voice to advocate for strengthening pediatric nursing education and to advocate for improved health and illness care coordination for kids and families, as well as support for access to safe, quality, evidenced-based care for all children and families.⁶

The IPN, partnering with the American Association of Colleges of Nursing, is currently conducting a national survey of undergraduate nursing programs “to explore the challenges, gaps, and successes within undergraduate pediatric nursing education, including an exploration of the perspectives of nursing faculty regarding the future of pediatric nursing residency programs.”⁷ The results of this survey will be presented at the Third Annual Invitational Forum for Pediatric Nursing in October.

When I was deciding on a career, I knew I wanted to work with children. I became a nurse so I could become a PNP, and my decision was supported by my nursing mentor, who directed me to follow my passion. Just as I was encouraged, we need to encourage nursing and NP students to go where their passion lies. Let them follow their heart—if they want another specialty, OK. But if they love pediatrics, support that passion.

We need to honor our roots and not abandon the pediatric nurse practitioner role. Where would we be without it?

References
1. Kaiser Family Foundation. The uninsured: a primer (2009). www.kff.org/uninsured/7451.cfm. Accessed September 16, 2011.

2. US Department of Health and Human Services. Healthy People 2020. www.healthypeople.gov/ 2020/about/disparitiesAbout.aspx. Accessed September 16, 2011.

3. Health Resources and Services Administration. The registered nurse population: findings from the 2008 National Sample Survey of Registered Nurses. bhpr.hrsa.gov/healthworkforce/rnsurvey2008 .html. Accessed September 16, 2011.

4. Society of Pediatric Nurses. Position statement on child health content in the undergraduate curriculum (2007).

5. National Association of Pediatric Nurse Practitioners. PNP programs information: pediatric nurse practitioner school list. www.napnap.org/ForStudents/PNPSchoolListing.aspx. Accessed September 16, 2011.

6. Sperhac A, Wyatt JS. Securing the future of children’s health. Pediatric Nursing. 2010;36(1):8-9.

7. Institute of Pediatric Nursing. www.ipedsnursing.org/ptisite/control/index. Accessed September 16, 2011.

One of my responsibilities as the director of a DNP program is reviewing and evaluating the applications to the program. I cheer when I see an applicant who is either a pediatric nurse practitioner (PNP) or a nurse leader whose specialty is pediatrics.

I have noted that my cheers are few and far between, and I began to wonder why. In a recent conversation with Jan Wyatt, PhD, RN, FAANP, Executive Director of the Institute of Pediatric Nursing, I mentioned the paucity of pediatric nurses in our graduate programs. Alas, I discovered that the scarcity is across the board in the pediatric nursing specialty. And thus began my education on how this has become a national concern among pediatric nurses.

The data are staggering: In the US, there are approximately 74 million children. Of that number, 18% are uninsured and 30% have significant health issues such as asthma, depression, and special care needs.¹ While the Children’s Health Insurance Program (CHIP) has facilitated some reduction in the number of uninsured children, the inequity of their access to care persists. Since 2000, one of the Healthy People initiatives has been to reduce health disparities. The 2020 goals have been broadened to “to achieve health equity, eliminate disparities, and improve the health of all groups.”²  

It has been said that the “future of our world lies in the hands, the hearts, and the minds of our children.” If that is so, then it is incumbent upon us to ensure there are a sufficient number of health care providers who are experts in children’s health and to whom children (and their families) have access. Improving the health and well-being of children not only impacts their future health, but also affects, and can identify, future challenges for the entire health care system.

But sadly enough, with regard to caring for the health of our children, it appears that we are no better off than we were 50 years ago. Recall that the first NP program was a model for public health nurses so they could enhance the care available to children and their families. Just as in the 1960s there was a need for access to pediatric care, so too, today, the services for children border on woefully inadequate. With the passage of the 2010 Patient Protection and Affordable Care Act, and the Future of Nursing report, nurses are well positioned to turn that around.

However, the landscape of nursing is changing, and we are witnessing a decline in the number of nurses who choose pediatrics as their specialty. Today, only 7.3% of the RN workforce, and 8.1% of nurses in advanced practice, specialize in pediatrics.³ In our discussion, Dr. Wyatt noted that in the past 10 to 15 years, the percentage of NP students entering PNP programs has significantly diminished.

Also of note is that pediatrics as content in undergraduate education has often been “integrated,” so BSN recipients have very little pediatric experience—and therefore little confidence in their ability to care for sick children—when they graduate. Moreover, the decrease in pediatric content and clinical experience is worsened by the difficulty in recruiting nurse educators who teach in this area.⁴ And as BSN-prepared nurses consider advanced training as an NP, they are being steered toward the family nurse practitioner (FNP), not PNP, track, despite their desire to focus on pediatrics. 

The pediatric, adult, and women’s health NP roles were established long before the FNP role grew into prominence. In the 1970s, the introduction of the birth control pill probably contributed to the need for more health care providers who specialized in the care of women. These roles were viewed as the pioneers of the NP movement, with the PNP being the first. These programs flourished, albeit the PNP programs less so than the others. That said, in 1998 there were 114 primary care PNP programs, which by 2010 had decreased to 98.⁵ Worse, in some states (Idaho and Wyoming, for example), nurses who want to be a PNP need to leave their homes, as there are no PNP programs there.  

As a result of the disappearance of pediatrics in undergraduate education and the decrease in PNP programs (especially primary care), the Pediatric Nursing Certification Board sponsored the establishment of the Institute of Pediatric Nursing (IPN) in 2011. The IPN is a nonprofit educational organization that brings together leaders from nursing organizations and children’s hospitals to provide a collective voice to advocate for strengthening pediatric nursing education and to advocate for improved health and illness care coordination for kids and families, as well as support for access to safe, quality, evidenced-based care for all children and families.⁶

The IPN, partnering with the American Association of Colleges of Nursing, is currently conducting a national survey of undergraduate nursing programs “to explore the challenges, gaps, and successes within undergraduate pediatric nursing education, including an exploration of the perspectives of nursing faculty regarding the future of pediatric nursing residency programs.”⁷ The results of this survey will be presented at the Third Annual Invitational Forum for Pediatric Nursing in October.

When I was deciding on a career, I knew I wanted to work with children. I became a nurse so I could become a PNP, and my decision was supported by my nursing mentor, who directed me to follow my passion. Just as I was encouraged, we need to encourage nursing and NP students to go where their passion lies. Let them follow their heart—if they want another specialty, OK. But if they love pediatrics, support that passion.

We need to honor our roots and not abandon the pediatric nurse practitioner role. Where would we be without it?

References
1. Kaiser Family Foundation. The uninsured: a primer (2009). www.kff.org/uninsured/7451.cfm. Accessed September 16, 2011.

2. US Department of Health and Human Services. Healthy People 2020. www.healthypeople.gov/ 2020/about/disparitiesAbout.aspx. Accessed September 16, 2011.

3. Health Resources and Services Administration. The registered nurse population: findings from the 2008 National Sample Survey of Registered Nurses. bhpr.hrsa.gov/healthworkforce/rnsurvey2008 .html. Accessed September 16, 2011.

4. Society of Pediatric Nurses. Position statement on child health content in the undergraduate curriculum (2007).

5. National Association of Pediatric Nurse Practitioners. PNP programs information: pediatric nurse practitioner school list. www.napnap.org/ForStudents/PNPSchoolListing.aspx. Accessed September 16, 2011.

6. Sperhac A, Wyatt JS. Securing the future of children’s health. Pediatric Nursing. 2010;36(1):8-9.

7. Institute of Pediatric Nursing. www.ipedsnursing.org/ptisite/control/index. Accessed September 16, 2011.

There I was, minding my own business, not bothering a soul, when suddenly my inbox was bombarded with e-mails regarding the latest iteration of “let’s fix the system.” A “notice of proposed rulemaking” for the Shared Savings Program appeared in the April 7, 2011, issue of the Federal Register,¹ and it seemed every faction of the health care and business fields had either a workshop or a publication about it on their docket.

Through section 3022 of the Affordable Care Act, a new section (1899) was added to the Social Security Act, establishing the Shared Savings Program (known as “Medicare Shared Savings Regulations”).² Under the new regulations, Medicare is given the authorization to contract with “accountable care organizations” (ACOs).

In my opinion, this is a rerun of the “tried and true” (but didn’t really work so well) performance-based measures. However, with the knowledge that all predictors indicate Medicare will be bankrupt by 2025, something that—at least in some fashion—may result in cost savings has to be tried again.

As I alluded to in my previous column, the US health care system is ripe for improvement, and the opportunities to make the system better for all of us seem boundless. While I wonder whether this “new” approach to improving care and lowering costs might meet the same demise as the previous attempts, I am intrigued by the components of this version of the shared approach to managing the bottom line. But more than that, I was initially pleased to see mention of “other care providers” as integral to this program.

In my desire to get myself back up to speed with the ACO concept, I did some research. I must share with you that, not surprisingly, there seems to be a bit of uncertainty as to the exact definition of an ACO. In simple terms, it is a network of doctors and hospitals who share the responsibility of providing high-quality care to patients.³ It is a modification, if you will, of the old “capitated group” concept that was neither widely received nor successful because of restrictions on provider choice and incentives to deny care.⁴ The difference is the payer focus: namely, Medicare. The sameness is the phrase “network of doctors.”

In the past, despite resistance to “integrated systems,” patients and providers (really physicians, but I choose neutral language) tended to stay within the same network for care. This suggests that organized systems may be preferable and also reduce unnecessary costs and use of resources.⁵ I would submit, anecdotally, that a significant component of the reduction in costs and use of resources is a function of the health care provided by NPs and PAs.

Unfortunately, without the hard facts to support this, we are again in jeopardy of being at the mercy of however individual ACOs are organized. In their report, Devers and Berenson⁵ note a definition of the ACO as “a local entity and a related set of providers, including at least primary care physicians….” To me, this is a warning that we might already be at the stage where which providers must be included—or rather, may be excluded—has been established. 

Over the past few years, the ACO concept has emerged as a means to encourage integration of systems and steer clear of the perceived problems of past efforts. And here is where my activist self re-emerged. I am concerned that the model is still physician driven, even though the statute specifies “other professionals” as eligible to be an ACO.⁶ Without the stipulation (or at least a “such as”) to include NPs and PAs, the opportunity to leave us out of the equation exists—again. We are the very providers who have long been “invisible,” yet we are more likely to spend that extra time with the population who is older than 65. 

I am not suggesting the die is cast, as others maintain that the issue of which providers must be included in the ACOs remains unclear. But it is obvious to me that we must advocate to be included in these organizations. The systems that are identified as possible candidates for ACO status have a history of reducing the number of NP and PA providers, often replacing them with physicians. We must be vigilant in demonstrating that we are the ones with the history of providing cost-effective, resource-sparing, and high-quality care to the populations we serve. 

It is apparent from the discussion regarding health care reform initiatives that collaboration among all health care providers must occur in order for us to move away from the dysfunctional fee-for-service system currently in place. There is also the distinct possibility that some health care organizations will resist a clinical redesign that includes value-based purchasing and incentive-based reimbursement. 

Because the ACO idea is new to the Medicare scene, it is expected to evolve over time. Given that the early language in the model is still somewhat physician specific, it is incumbent upon all health care professionals to stay involved in its progress to ensure there are no barriers to our being part of these systems. My eyes have been opened, and I will be watching as the Medicare Shared Savings Program for ACOs takes effect in 2012.

Send your thoughts on ACOs to NPEditor@qhc.com.

REFERENCES

1. Centers for Medicare and Medicaid Services. Medicare Shared Savings Program: Accountable Care Organizations (76 FR 19528). federalregister.gov/a/2011-7880. Accessed May 16, 2011.

2. US Department of Health and Human Services. Summary of proposed rule provision for accountable care organizations under the Medicare Shared Savings Program (April 2011). www.cms.gov/MLNProducts/downloads/ACO_NPRM_Summary_Factsheet_ICN906224.pdf. Accessed May 16, 2011.

3. Health Affairs/Robert Wood Johnson Foundation. Health Policy Brief: Accountable care organizations (July 27, 2010). www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=20. Accessed May 16, 2011.

4. Shortell SM, Casalino LP, Fisher ES. How the Center for Medicare and Medicare Innovation should test accountable care organizations. Health Affairs. 2010;29(7):1293-1298.

5. Devers K, Berenson R. Can accountable care organizations improve the value of health care by solving the cost and quality quandaries? Robert Wood Johnson Foundation/Urban Institute Policy Brief; October 2009. www.rwjf.org/qualityequality/product.jsp?id=50609. Accessed May 16, 2011.

6. Centers for Medicare & Medicaid Services Office of Legislation. Medicare Accountable Care Organizations Shared Savings Program: New Section 1899 of Title XVIII Preliminary Questions and Answers (May 2010). www.cms.gov/OfficeofLegislation/Downloads/AccountableCareOrganization.pdf. Accessed May 1, 2011.

There I was, minding my own business, not bothering a soul, when suddenly my inbox was bombarded with e-mails regarding the latest iteration of “let’s fix the system.” A “notice of proposed rulemaking” for the Shared Savings Program appeared in the April 7, 2011, issue of the Federal Register,¹ and it seemed every faction of the health care and business fields had either a workshop or a publication about it on their docket.

Through section 3022 of the Affordable Care Act, a new section (1899) was added to the Social Security Act, establishing the Shared Savings Program (known as “Medicare Shared Savings Regulations”).² Under the new regulations, Medicare is given the authorization to contract with “accountable care organizations” (ACOs).

In my opinion, this is a rerun of the “tried and true” (but didn’t really work so well) performance-based measures. However, with the knowledge that all predictors indicate Medicare will be bankrupt by 2025, something that—at least in some fashion—may result in cost savings has to be tried again.

As I alluded to in my previous column, the US health care system is ripe for improvement, and the opportunities to make the system better for all of us seem boundless. While I wonder whether this “new” approach to improving care and lowering costs might meet the same demise as the previous attempts, I am intrigued by the components of this version of the shared approach to managing the bottom line. But more than that, I was initially pleased to see mention of “other care providers” as integral to this program.

In my desire to get myself back up to speed with the ACO concept, I did some research. I must share with you that, not surprisingly, there seems to be a bit of uncertainty as to the exact definition of an ACO. In simple terms, it is a network of doctors and hospitals who share the responsibility of providing high-quality care to patients.³ It is a modification, if you will, of the old “capitated group” concept that was neither widely received nor successful because of restrictions on provider choice and incentives to deny care.⁴ The difference is the payer focus: namely, Medicare. The sameness is the phrase “network of doctors.”

In the past, despite resistance to “integrated systems,” patients and providers (really physicians, but I choose neutral language) tended to stay within the same network for care. This suggests that organized systems may be preferable and also reduce unnecessary costs and use of resources.⁵ I would submit, anecdotally, that a significant component of the reduction in costs and use of resources is a function of the health care provided by NPs and PAs.

Unfortunately, without the hard facts to support this, we are again in jeopardy of being at the mercy of however individual ACOs are organized. In their report, Devers and Berenson⁵ note a definition of the ACO as “a local entity and a related set of providers, including at least primary care physicians….” To me, this is a warning that we might already be at the stage where which providers must be included—or rather, may be excluded—has been established. 

Over the past few years, the ACO concept has emerged as a means to encourage integration of systems and steer clear of the perceived problems of past efforts. And here is where my activist self re-emerged. I am concerned that the model is still physician driven, even though the statute specifies “other professionals” as eligible to be an ACO.⁶ Without the stipulation (or at least a “such as”) to include NPs and PAs, the opportunity to leave us out of the equation exists—again. We are the very providers who have long been “invisible,” yet we are more likely to spend that extra time with the population who is older than 65. 

I am not suggesting the die is cast, as others maintain that the issue of which providers must be included in the ACOs remains unclear. But it is obvious to me that we must advocate to be included in these organizations. The systems that are identified as possible candidates for ACO status have a history of reducing the number of NP and PA providers, often replacing them with physicians. We must be vigilant in demonstrating that we are the ones with the history of providing cost-effective, resource-sparing, and high-quality care to the populations we serve. 

It is apparent from the discussion regarding health care reform initiatives that collaboration among all health care providers must occur in order for us to move away from the dysfunctional fee-for-service system currently in place. There is also the distinct possibility that some health care organizations will resist a clinical redesign that includes value-based purchasing and incentive-based reimbursement. 

Because the ACO idea is new to the Medicare scene, it is expected to evolve over time. Given that the early language in the model is still somewhat physician specific, it is incumbent upon all health care professionals to stay involved in its progress to ensure there are no barriers to our being part of these systems. My eyes have been opened, and I will be watching as the Medicare Shared Savings Program for ACOs takes effect in 2012.

Send your thoughts on ACOs to NPEditor@qhc.com.

REFERENCES

1. Centers for Medicare and Medicaid Services. Medicare Shared Savings Program: Accountable Care Organizations (76 FR 19528). federalregister.gov/a/2011-7880. Accessed May 16, 2011.

2. US Department of Health and Human Services. Summary of proposed rule provision for accountable care organizations under the Medicare Shared Savings Program (April 2011). www.cms.gov/MLNProducts/downloads/ACO_NPRM_Summary_Factsheet_ICN906224.pdf. Accessed May 16, 2011.

3. Health Affairs/Robert Wood Johnson Foundation. Health Policy Brief: Accountable care organizations (July 27, 2010). www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=20. Accessed May 16, 2011.

4. Shortell SM, Casalino LP, Fisher ES. How the Center for Medicare and Medicare Innovation should test accountable care organizations. Health Affairs. 2010;29(7):1293-1298.

5. Devers K, Berenson R. Can accountable care organizations improve the value of health care by solving the cost and quality quandaries? Robert Wood Johnson Foundation/Urban Institute Policy Brief; October 2009. www.rwjf.org/qualityequality/product.jsp?id=50609. Accessed May 16, 2011.

6. Centers for Medicare & Medicaid Services Office of Legislation. Medicare Accountable Care Organizations Shared Savings Program: New Section 1899 of Title XVIII Preliminary Questions and Answers (May 2010). www.cms.gov/OfficeofLegislation/Downloads/AccountableCareOrganization.pdf. Accessed May 1, 2011.

There I was, minding my own business, not bothering a soul, when suddenly my inbox was bombarded with e-mails regarding the latest iteration of “let’s fix the system.” A “notice of proposed rulemaking” for the Shared Savings Program appeared in the April 7, 2011, issue of the Federal Register,¹ and it seemed every faction of the health care and business fields had either a workshop or a publication about it on their docket.

Through section 3022 of the Affordable Care Act, a new section (1899) was added to the Social Security Act, establishing the Shared Savings Program (known as “Medicare Shared Savings Regulations”).² Under the new regulations, Medicare is given the authorization to contract with “accountable care organizations” (ACOs).

In my opinion, this is a rerun of the “tried and true” (but didn’t really work so well) performance-based measures. However, with the knowledge that all predictors indicate Medicare will be bankrupt by 2025, something that—at least in some fashion—may result in cost savings has to be tried again.

As I alluded to in my previous column, the US health care system is ripe for improvement, and the opportunities to make the system better for all of us seem boundless. While I wonder whether this “new” approach to improving care and lowering costs might meet the same demise as the previous attempts, I am intrigued by the components of this version of the shared approach to managing the bottom line. But more than that, I was initially pleased to see mention of “other care providers” as integral to this program.

In my desire to get myself back up to speed with the ACO concept, I did some research. I must share with you that, not surprisingly, there seems to be a bit of uncertainty as to the exact definition of an ACO. In simple terms, it is a network of doctors and hospitals who share the responsibility of providing high-quality care to patients.³ It is a modification, if you will, of the old “capitated group” concept that was neither widely received nor successful because of restrictions on provider choice and incentives to deny care.⁴ The difference is the payer focus: namely, Medicare. The sameness is the phrase “network of doctors.”

In the past, despite resistance to “integrated systems,” patients and providers (really physicians, but I choose neutral language) tended to stay within the same network for care. This suggests that organized systems may be preferable and also reduce unnecessary costs and use of resources.⁵ I would submit, anecdotally, that a significant component of the reduction in costs and use of resources is a function of the health care provided by NPs and PAs.

Unfortunately, without the hard facts to support this, we are again in jeopardy of being at the mercy of however individual ACOs are organized. In their report, Devers and Berenson⁵ note a definition of the ACO as “a local entity and a related set of providers, including at least primary care physicians….” To me, this is a warning that we might already be at the stage where which providers must be included—or rather, may be excluded—has been established. 

Over the past few years, the ACO concept has emerged as a means to encourage integration of systems and steer clear of the perceived problems of past efforts. And here is where my activist self re-emerged. I am concerned that the model is still physician driven, even though the statute specifies “other professionals” as eligible to be an ACO.⁶ Without the stipulation (or at least a “such as”) to include NPs and PAs, the opportunity to leave us out of the equation exists—again. We are the very providers who have long been “invisible,” yet we are more likely to spend that extra time with the population who is older than 65. 

I am not suggesting the die is cast, as others maintain that the issue of which providers must be included in the ACOs remains unclear. But it is obvious to me that we must advocate to be included in these organizations. The systems that are identified as possible candidates for ACO status have a history of reducing the number of NP and PA providers, often replacing them with physicians. We must be vigilant in demonstrating that we are the ones with the history of providing cost-effective, resource-sparing, and high-quality care to the populations we serve. 

It is apparent from the discussion regarding health care reform initiatives that collaboration among all health care providers must occur in order for us to move away from the dysfunctional fee-for-service system currently in place. There is also the distinct possibility that some health care organizations will resist a clinical redesign that includes value-based purchasing and incentive-based reimbursement. 

Because the ACO idea is new to the Medicare scene, it is expected to evolve over time. Given that the early language in the model is still somewhat physician specific, it is incumbent upon all health care professionals to stay involved in its progress to ensure there are no barriers to our being part of these systems. My eyes have been opened, and I will be watching as the Medicare Shared Savings Program for ACOs takes effect in 2012.

Send your thoughts on ACOs to NPEditor@qhc.com.

REFERENCES

1. Centers for Medicare and Medicaid Services. Medicare Shared Savings Program: Accountable Care Organizations (76 FR 19528). federalregister.gov/a/2011-7880. Accessed May 16, 2011.

2. US Department of Health and Human Services. Summary of proposed rule provision for accountable care organizations under the Medicare Shared Savings Program (April 2011). www.cms.gov/MLNProducts/downloads/ACO_NPRM_Summary_Factsheet_ICN906224.pdf. Accessed May 16, 2011.

3. Health Affairs/Robert Wood Johnson Foundation. Health Policy Brief: Accountable care organizations (July 27, 2010). www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=20. Accessed May 16, 2011.

4. Shortell SM, Casalino LP, Fisher ES. How the Center for Medicare and Medicare Innovation should test accountable care organizations. Health Affairs. 2010;29(7):1293-1298.

5. Devers K, Berenson R. Can accountable care organizations improve the value of health care by solving the cost and quality quandaries? Robert Wood Johnson Foundation/Urban Institute Policy Brief; October 2009. www.rwjf.org/qualityequality/product.jsp?id=50609. Accessed May 16, 2011.

6. Centers for Medicare & Medicaid Services Office of Legislation. Medicare Accountable Care Organizations Shared Savings Program: New Section 1899 of Title XVIII Preliminary Questions and Answers (May 2010). www.cms.gov/OfficeofLegislation/Downloads/AccountableCareOrganization.pdf. Accessed May 1, 2011.

It has been one year since the Patient Protection and ­Affordable Care Act, or the Affordable Care Act of 2010 (ACA) was signed into law. It includes provisions that would expand coverage, control costs, and improve health care delivery, while providing insurance coverage for 32 million more Americans.

However, with all the protests about costs, allowable services, and the constitutionality of mandated insurance, I am beginning to doubt whether the ACA will ever be fully implemented. I keep my hopes up because, as many have noted, we are at an important crossroad in health care. 

There is an ongoing discussion about how we will accomplish the change in access to health care. The big question is “Who will provide that care?” We have long faced a shortage of primary care providers (well, MDs, at least). However, we know that historically, PAs and NPs were overlooked when considering the provider-to-consumer ratio.

That oversight is beginning to dissipate, as legislators and other policymakers deliberate about how best to deal with the provider shortage. Finally, as part of these discussions, we are being included for the important role we play in health care—past, present, and future. It is somewhat comforting that NPs, but to a lesser extent (regretfully) PAs, are more often recognized as the solution to the health care conundrum.

Recently, Peter I. Buerhaus,¹ PhD, RN, FAAN, explored the current and the future state of NPs. He identified key elements, such as independence, patient perception, and turf battles, that impact our role. It’s nothing new to many of us, but the expression of those elements reminded me that change is accomplished by maximizing the opportunity in place to make the change.

We “policy wonks” often refer to Kingdon’s window of opportunity—the point at which policy issues move onto the government agenda and toward decision and action—as the prime time to move on change. Kingdon notes that three converging streams are involved in opening that window: the identification of the problem; the development of alternative solutions and proposals; and changes in public opinion, administration, or interest groups that determine the outcome.² The window opens, and the opportunity for action is there for the taking.

The converging streams that opened the health care reform window (taking liberty with Kingdon) were, as I see it, frustration with the current system, rising insurance premiums, and decreased access to health care. We know the problem; the solutions are what have us in limbo. When we discuss what we need to change, it is important to consider the attempts made in the past, and the success or failure of those attempts.

One success in the realm of better access to health care is the increase in nurse-managed clinics nationwide. On college campuses, in occupational health settings, and in retail locations, NPs have demonstrated their value and have produced patient outcomes comparable to those of our physician colleagues. There is evidence that patients of NPs are seen more often, have fewer emergency department visits, shorter hospital stays, and lower prescription costs, and have higher medication compliance.³

Therefore, it is not surprising that one provision in the ACA calls for funding of nurse-managed health centers. There are significant funds for nurse-managed health centers to continue and expand the care provided to vulnerable populations. This is an important milestone, because despite the ACA, millions of Americans will still lack coverage. Those of us who have always provided care to the most vulnerable populations will continue to do so, but we need fair reimbursement.

Payment reform is also necessary. NPs, and our PA colleagues, must be included in Medicare and Medicaid guidelines for reimbursement, in the same way physicians are. It is only right that all providers receive equal reimbursement for equally competent services. It is also necessary that third-party payers include us in primary care provider networks to ensure access to care.

Change does not come easily, and the preparation for reform is paramount. We must be sure that we are able to meet the expectations included in the ACA. We must also be realistic about how long those changes will take to implement. As was quickly realized when Massachusetts mandated universal coverage, it is imperative that there be a sufficient number of primary care providers and health care teams to care for the population.

In a plethora of published articles in the health policy literature, the authors suggest that NPs have the greatest potential to fill the needs in the primary care workforce. However, we must also include our other health care professional colleagues. Because our patients need us to help them navigate the complex health care system, we must build the team that can coordinate care across all disciplines, and ensure that team is well functioning. 

The Affordable Care Act of 2010 places many demands on health professionals, but also offers us many opportunities to create a system that is more patient centered. Now is the time for all of us to pool our resources and face the reality that maximizing the potential of all providers is the solution to access to care for all Americans.

References
1. Buerhaus PI. Have nurse practitioners reached a tipping point? Interview of a panel of NP thought leaders. Nurs Econ. 2010;28(5):346-349.

2. Kingdon J. Agendas, Alternatives, and Public Policies. 2nd ed. New York, NY: Longman; 1995.

3. Hansen-Turton T, Line L, O’Connell M, et al. The Nursing Center Model of Health Care for the Underserved. HCFA Contract No. 18-P91720/3-01. Philadelphia, PA: National Nursing Centers Consortium; 2004.

It has been one year since the Patient Protection and ­Affordable Care Act, or the Affordable Care Act of 2010 (ACA) was signed into law. It includes provisions that would expand coverage, control costs, and improve health care delivery, while providing insurance coverage for 32 million more Americans.

However, with all the protests about costs, allowable services, and the constitutionality of mandated insurance, I am beginning to doubt whether the ACA will ever be fully implemented. I keep my hopes up because, as many have noted, we are at an important crossroad in health care. 

There is an ongoing discussion about how we will accomplish the change in access to health care. The big question is “Who will provide that care?” We have long faced a shortage of primary care providers (well, MDs, at least). However, we know that historically, PAs and NPs were overlooked when considering the provider-to-consumer ratio.

That oversight is beginning to dissipate, as legislators and other policymakers deliberate about how best to deal with the provider shortage. Finally, as part of these discussions, we are being included for the important role we play in health care—past, present, and future. It is somewhat comforting that NPs, but to a lesser extent (regretfully) PAs, are more often recognized as the solution to the health care conundrum.

Recently, Peter I. Buerhaus,¹ PhD, RN, FAAN, explored the current and the future state of NPs. He identified key elements, such as independence, patient perception, and turf battles, that impact our role. It’s nothing new to many of us, but the expression of those elements reminded me that change is accomplished by maximizing the opportunity in place to make the change.

We “policy wonks” often refer to Kingdon’s window of opportunity—the point at which policy issues move onto the government agenda and toward decision and action—as the prime time to move on change. Kingdon notes that three converging streams are involved in opening that window: the identification of the problem; the development of alternative solutions and proposals; and changes in public opinion, administration, or interest groups that determine the outcome.² The window opens, and the opportunity for action is there for the taking.

The converging streams that opened the health care reform window (taking liberty with Kingdon) were, as I see it, frustration with the current system, rising insurance premiums, and decreased access to health care. We know the problem; the solutions are what have us in limbo. When we discuss what we need to change, it is important to consider the attempts made in the past, and the success or failure of those attempts.

One success in the realm of better access to health care is the increase in nurse-managed clinics nationwide. On college campuses, in occupational health settings, and in retail locations, NPs have demonstrated their value and have produced patient outcomes comparable to those of our physician colleagues. There is evidence that patients of NPs are seen more often, have fewer emergency department visits, shorter hospital stays, and lower prescription costs, and have higher medication compliance.³

Therefore, it is not surprising that one provision in the ACA calls for funding of nurse-managed health centers. There are significant funds for nurse-managed health centers to continue and expand the care provided to vulnerable populations. This is an important milestone, because despite the ACA, millions of Americans will still lack coverage. Those of us who have always provided care to the most vulnerable populations will continue to do so, but we need fair reimbursement.

Payment reform is also necessary. NPs, and our PA colleagues, must be included in Medicare and Medicaid guidelines for reimbursement, in the same way physicians are. It is only right that all providers receive equal reimbursement for equally competent services. It is also necessary that third-party payers include us in primary care provider networks to ensure access to care.

Change does not come easily, and the preparation for reform is paramount. We must be sure that we are able to meet the expectations included in the ACA. We must also be realistic about how long those changes will take to implement. As was quickly realized when Massachusetts mandated universal coverage, it is imperative that there be a sufficient number of primary care providers and health care teams to care for the population.

In a plethora of published articles in the health policy literature, the authors suggest that NPs have the greatest potential to fill the needs in the primary care workforce. However, we must also include our other health care professional colleagues. Because our patients need us to help them navigate the complex health care system, we must build the team that can coordinate care across all disciplines, and ensure that team is well functioning. 

The Affordable Care Act of 2010 places many demands on health professionals, but also offers us many opportunities to create a system that is more patient centered. Now is the time for all of us to pool our resources and face the reality that maximizing the potential of all providers is the solution to access to care for all Americans.

References
1. Buerhaus PI. Have nurse practitioners reached a tipping point? Interview of a panel of NP thought leaders. Nurs Econ. 2010;28(5):346-349.

2. Kingdon J. Agendas, Alternatives, and Public Policies. 2nd ed. New York, NY: Longman; 1995.

3. Hansen-Turton T, Line L, O’Connell M, et al. The Nursing Center Model of Health Care for the Underserved. HCFA Contract No. 18-P91720/3-01. Philadelphia, PA: National Nursing Centers Consortium; 2004.

It has been one year since the Patient Protection and ­Affordable Care Act, or the Affordable Care Act of 2010 (ACA) was signed into law. It includes provisions that would expand coverage, control costs, and improve health care delivery, while providing insurance coverage for 32 million more Americans.

However, with all the protests about costs, allowable services, and the constitutionality of mandated insurance, I am beginning to doubt whether the ACA will ever be fully implemented. I keep my hopes up because, as many have noted, we are at an important crossroad in health care. 

There is an ongoing discussion about how we will accomplish the change in access to health care. The big question is “Who will provide that care?” We have long faced a shortage of primary care providers (well, MDs, at least). However, we know that historically, PAs and NPs were overlooked when considering the provider-to-consumer ratio.

That oversight is beginning to dissipate, as legislators and other policymakers deliberate about how best to deal with the provider shortage. Finally, as part of these discussions, we are being included for the important role we play in health care—past, present, and future. It is somewhat comforting that NPs, but to a lesser extent (regretfully) PAs, are more often recognized as the solution to the health care conundrum.

Recently, Peter I. Buerhaus,¹ PhD, RN, FAAN, explored the current and the future state of NPs. He identified key elements, such as independence, patient perception, and turf battles, that impact our role. It’s nothing new to many of us, but the expression of those elements reminded me that change is accomplished by maximizing the opportunity in place to make the change.

We “policy wonks” often refer to Kingdon’s window of opportunity—the point at which policy issues move onto the government agenda and toward decision and action—as the prime time to move on change. Kingdon notes that three converging streams are involved in opening that window: the identification of the problem; the development of alternative solutions and proposals; and changes in public opinion, administration, or interest groups that determine the outcome.² The window opens, and the opportunity for action is there for the taking.

The converging streams that opened the health care reform window (taking liberty with Kingdon) were, as I see it, frustration with the current system, rising insurance premiums, and decreased access to health care. We know the problem; the solutions are what have us in limbo. When we discuss what we need to change, it is important to consider the attempts made in the past, and the success or failure of those attempts.

One success in the realm of better access to health care is the increase in nurse-managed clinics nationwide. On college campuses, in occupational health settings, and in retail locations, NPs have demonstrated their value and have produced patient outcomes comparable to those of our physician colleagues. There is evidence that patients of NPs are seen more often, have fewer emergency department visits, shorter hospital stays, and lower prescription costs, and have higher medication compliance.³

Therefore, it is not surprising that one provision in the ACA calls for funding of nurse-managed health centers. There are significant funds for nurse-managed health centers to continue and expand the care provided to vulnerable populations. This is an important milestone, because despite the ACA, millions of Americans will still lack coverage. Those of us who have always provided care to the most vulnerable populations will continue to do so, but we need fair reimbursement.

Payment reform is also necessary. NPs, and our PA colleagues, must be included in Medicare and Medicaid guidelines for reimbursement, in the same way physicians are. It is only right that all providers receive equal reimbursement for equally competent services. It is also necessary that third-party payers include us in primary care provider networks to ensure access to care.

Change does not come easily, and the preparation for reform is paramount. We must be sure that we are able to meet the expectations included in the ACA. We must also be realistic about how long those changes will take to implement. As was quickly realized when Massachusetts mandated universal coverage, it is imperative that there be a sufficient number of primary care providers and health care teams to care for the population.

In a plethora of published articles in the health policy literature, the authors suggest that NPs have the greatest potential to fill the needs in the primary care workforce. However, we must also include our other health care professional colleagues. Because our patients need us to help them navigate the complex health care system, we must build the team that can coordinate care across all disciplines, and ensure that team is well functioning. 

The Affordable Care Act of 2010 places many demands on health professionals, but also offers us many opportunities to create a system that is more patient centered. Now is the time for all of us to pool our resources and face the reality that maximizing the potential of all providers is the solution to access to care for all Americans.

References
1. Buerhaus PI. Have nurse practitioners reached a tipping point? Interview of a panel of NP thought leaders. Nurs Econ. 2010;28(5):346-349.

2. Kingdon J. Agendas, Alternatives, and Public Policies. 2nd ed. New York, NY: Longman; 1995.

3. Hansen-Turton T, Line L, O’Connell M, et al. The Nursing Center Model of Health Care for the Underserved. HCFA Contract No. 18-P91720/3-01. Philadelphia, PA: National Nursing Centers Consortium; 2004.

As faithful readers know, I often write about the responsibilities of “our generation” with regard to the “next generation.” I have always believed that we must demonstrate the passion and pride we have for our profession, and encourage others to join our ranks.

With that in mind, I couldn’t have been more surprised when this month’s contributor, Melissa Donais, RN, FNP, called me a few years ago to say she wanted to leave chiropractic school because she had decided to become a nurse practitioner. Her excitement about this decision was incredible, and watching her enthusiasm for the profession grow as she progressed through her program has been a joy.   

In September 2008, when I was introduced as the NP Editor-in-Chief, I noted that I didn’t “want to be the only one writing!” and that I hoped “to encourage the nascent author to contribute to Clinician Reviews, … adding to the richness and variety of the content.” This is the first of what I hope will now be many contributions from our “next generation.” —MEO

Last year at this time, I spent the bulk of my days poring over nursing and medical textbooks, answering hundreds of questions from practice board exams online, and shadowing nurse practitioners at a variety of primary care clinics. It was my final year of study in the Family Nurse Practitioner program at Boston College.

Like many of my classmates, I eagerly awaited graduation day. To us, graduation represented the culmination of the years of hard work, the all-nighters, the time spent away from our families to achieve the goal of our master’s in nursing. It was our “finish line,” and we counted the weeks, days, and even hours until we lined up and marched, heads held high, into the Boston College football stadium. While it was certainly a memorable day, reflecting on my experience as an NP student lends an entirely different perspective today.

I was fortunate to begin working as an FNP immediately following graduation. On my first day, I felt that I had accomplished all the prerequisites necessary to be a successful NP. I had thrived in nursing school, I had impressed my preceptors in clinical, and certainly I possessed all the knowledge I needed to excel in practice. I felt like I had “arrived.” However, I quickly learned that in many ways my classmates and I were wrong. Graduation was not our finish line. Instead, graduation was the culmination of our training. We were only beginning our true journey: the marathon that will represent our careers as NPs.

The marathon is a great analogy for the NP entering practice. Like the NP career, the marathon is a challenging mental, physical, and emotional event. One cannot simply show up in Hopkinton at the start of the Boston Marathon and enter the race on a whim. Like nurses, marathoners tend to be individuals who are very dedicated to their event and often spend months or years training for it.

The training in itself is demanding, requiring the runner to forgo social events in favor of tasks that are more suitable to logging miles and resting weary legs. The years I spent in nursing school, mastering the skills I would need for practice, are akin to the marathoner in training, running mileage to prepare her body for the challenge of the event. Graduation day was not my finish line—far from it! Rather, graduation day was my starting line.

This first year of my NP practice brought a swell of contradicting emotions: hope, distress, courage, and fear. With each step that brings triumph, there is another that brings doubt. There is the patient who, now feeling better, is filled with gratitude and thanks me for “curing” her. In these cases, I feel excited and eager, much like the marathoner who loves to run above all else. Then there is the patient whose lab results are so far off that I curse my classes for not going into more detail and I struggle when developing his plan of care. At these times, I feel like my task is daunting, and I wonder how I will ever accomplish what is expected of me, much like the marathoner in her first mile of the race, knowing there are 26 long miles ahead.

Though at times both nursing and running can seem like solitary endeavors, it is important to remember that support is not far away. In the marathon, hundreds if not thousands of spectators line the route, cheering the runners on. Often, runners will encourage each other and may even choose to run alongside a slower friend for part of the journey. Likewise, as an NP, I have a number of colleagues both in my primary care office and through our hospital network who provide support, encouragement, and understanding. The doctor with whom I work directly is an invaluable resource and has mentored me from the beginning. Without this support, neither the runner nor the NP could accomplish her tasks.

When the practice becomes truly bleak, I draw upon the challenges I encountered in my training. I know that the countless hours I dedicated to this journey have given me the strength and knowledge to draw upon in times of uncertainty. The fact that I have completed my training and have made it to this “starting line” demonstrates that I am capable of taking on the challenges that lie ahead of me and that I am ready for success.

My first year of NP practice is just the first mile of my marathon career. I have not chosen an easy task; being a nurse practitioner is often very hard. However, like the marathon, it rewards those who are brave enough to take part in it. It is a challenge that others have tried and failed; it is a distinction to say you are a marathoner or you are an NP. As I discover the victories and obstacles in the miles ahead, I happily realize just how wrong I was when I considered graduation the finish line. No, this is only the beginning ….

Melissa Donais currently practices at North Reading Medical Associates, a primary care clinic affiliated with Winchester Hospital in Massachusetts.

As faithful readers know, I often write about the responsibilities of “our generation” with regard to the “next generation.” I have always believed that we must demonstrate the passion and pride we have for our profession, and encourage others to join our ranks.

With that in mind, I couldn’t have been more surprised when this month’s contributor, Melissa Donais, RN, FNP, called me a few years ago to say she wanted to leave chiropractic school because she had decided to become a nurse practitioner. Her excitement about this decision was incredible, and watching her enthusiasm for the profession grow as she progressed through her program has been a joy.   

In September 2008, when I was introduced as the NP Editor-in-Chief, I noted that I didn’t “want to be the only one writing!” and that I hoped “to encourage the nascent author to contribute to Clinician Reviews, … adding to the richness and variety of the content.” This is the first of what I hope will now be many contributions from our “next generation.” —MEO

Last year at this time, I spent the bulk of my days poring over nursing and medical textbooks, answering hundreds of questions from practice board exams online, and shadowing nurse practitioners at a variety of primary care clinics. It was my final year of study in the Family Nurse Practitioner program at Boston College.

Like many of my classmates, I eagerly awaited graduation day. To us, graduation represented the culmination of the years of hard work, the all-nighters, the time spent away from our families to achieve the goal of our master’s in nursing. It was our “finish line,” and we counted the weeks, days, and even hours until we lined up and marched, heads held high, into the Boston College football stadium. While it was certainly a memorable day, reflecting on my experience as an NP student lends an entirely different perspective today.

I was fortunate to begin working as an FNP immediately following graduation. On my first day, I felt that I had accomplished all the prerequisites necessary to be a successful NP. I had thrived in nursing school, I had impressed my preceptors in clinical, and certainly I possessed all the knowledge I needed to excel in practice. I felt like I had “arrived.” However, I quickly learned that in many ways my classmates and I were wrong. Graduation was not our finish line. Instead, graduation was the culmination of our training. We were only beginning our true journey: the marathon that will represent our careers as NPs.

The marathon is a great analogy for the NP entering practice. Like the NP career, the marathon is a challenging mental, physical, and emotional event. One cannot simply show up in Hopkinton at the start of the Boston Marathon and enter the race on a whim. Like nurses, marathoners tend to be individuals who are very dedicated to their event and often spend months or years training for it.

The training in itself is demanding, requiring the runner to forgo social events in favor of tasks that are more suitable to logging miles and resting weary legs. The years I spent in nursing school, mastering the skills I would need for practice, are akin to the marathoner in training, running mileage to prepare her body for the challenge of the event. Graduation day was not my finish line—far from it! Rather, graduation day was my starting line.

This first year of my NP practice brought a swell of contradicting emotions: hope, distress, courage, and fear. With each step that brings triumph, there is another that brings doubt. There is the patient who, now feeling better, is filled with gratitude and thanks me for “curing” her. In these cases, I feel excited and eager, much like the marathoner who loves to run above all else. Then there is the patient whose lab results are so far off that I curse my classes for not going into more detail and I struggle when developing his plan of care. At these times, I feel like my task is daunting, and I wonder how I will ever accomplish what is expected of me, much like the marathoner in her first mile of the race, knowing there are 26 long miles ahead.

Though at times both nursing and running can seem like solitary endeavors, it is important to remember that support is not far away. In the marathon, hundreds if not thousands of spectators line the route, cheering the runners on. Often, runners will encourage each other and may even choose to run alongside a slower friend for part of the journey. Likewise, as an NP, I have a number of colleagues both in my primary care office and through our hospital network who provide support, encouragement, and understanding. The doctor with whom I work directly is an invaluable resource and has mentored me from the beginning. Without this support, neither the runner nor the NP could accomplish her tasks.

When the practice becomes truly bleak, I draw upon the challenges I encountered in my training. I know that the countless hours I dedicated to this journey have given me the strength and knowledge to draw upon in times of uncertainty. The fact that I have completed my training and have made it to this “starting line” demonstrates that I am capable of taking on the challenges that lie ahead of me and that I am ready for success.

My first year of NP practice is just the first mile of my marathon career. I have not chosen an easy task; being a nurse practitioner is often very hard. However, like the marathon, it rewards those who are brave enough to take part in it. It is a challenge that others have tried and failed; it is a distinction to say you are a marathoner or you are an NP. As I discover the victories and obstacles in the miles ahead, I happily realize just how wrong I was when I considered graduation the finish line. No, this is only the beginning ….

Melissa Donais currently practices at North Reading Medical Associates, a primary care clinic affiliated with Winchester Hospital in Massachusetts.

As faithful readers know, I often write about the responsibilities of “our generation” with regard to the “next generation.” I have always believed that we must demonstrate the passion and pride we have for our profession, and encourage others to join our ranks.

With that in mind, I couldn’t have been more surprised when this month’s contributor, Melissa Donais, RN, FNP, called me a few years ago to say she wanted to leave chiropractic school because she had decided to become a nurse practitioner. Her excitement about this decision was incredible, and watching her enthusiasm for the profession grow as she progressed through her program has been a joy.   

In September 2008, when I was introduced as the NP Editor-in-Chief, I noted that I didn’t “want to be the only one writing!” and that I hoped “to encourage the nascent author to contribute to Clinician Reviews, … adding to the richness and variety of the content.” This is the first of what I hope will now be many contributions from our “next generation.” —MEO

Last year at this time, I spent the bulk of my days poring over nursing and medical textbooks, answering hundreds of questions from practice board exams online, and shadowing nurse practitioners at a variety of primary care clinics. It was my final year of study in the Family Nurse Practitioner program at Boston College.

Like many of my classmates, I eagerly awaited graduation day. To us, graduation represented the culmination of the years of hard work, the all-nighters, the time spent away from our families to achieve the goal of our master’s in nursing. It was our “finish line,” and we counted the weeks, days, and even hours until we lined up and marched, heads held high, into the Boston College football stadium. While it was certainly a memorable day, reflecting on my experience as an NP student lends an entirely different perspective today.

I was fortunate to begin working as an FNP immediately following graduation. On my first day, I felt that I had accomplished all the prerequisites necessary to be a successful NP. I had thrived in nursing school, I had impressed my preceptors in clinical, and certainly I possessed all the knowledge I needed to excel in practice. I felt like I had “arrived.” However, I quickly learned that in many ways my classmates and I were wrong. Graduation was not our finish line. Instead, graduation was the culmination of our training. We were only beginning our true journey: the marathon that will represent our careers as NPs.

The marathon is a great analogy for the NP entering practice. Like the NP career, the marathon is a challenging mental, physical, and emotional event. One cannot simply show up in Hopkinton at the start of the Boston Marathon and enter the race on a whim. Like nurses, marathoners tend to be individuals who are very dedicated to their event and often spend months or years training for it.

The training in itself is demanding, requiring the runner to forgo social events in favor of tasks that are more suitable to logging miles and resting weary legs. The years I spent in nursing school, mastering the skills I would need for practice, are akin to the marathoner in training, running mileage to prepare her body for the challenge of the event. Graduation day was not my finish line—far from it! Rather, graduation day was my starting line.

This first year of my NP practice brought a swell of contradicting emotions: hope, distress, courage, and fear. With each step that brings triumph, there is another that brings doubt. There is the patient who, now feeling better, is filled with gratitude and thanks me for “curing” her. In these cases, I feel excited and eager, much like the marathoner who loves to run above all else. Then there is the patient whose lab results are so far off that I curse my classes for not going into more detail and I struggle when developing his plan of care. At these times, I feel like my task is daunting, and I wonder how I will ever accomplish what is expected of me, much like the marathoner in her first mile of the race, knowing there are 26 long miles ahead.

Though at times both nursing and running can seem like solitary endeavors, it is important to remember that support is not far away. In the marathon, hundreds if not thousands of spectators line the route, cheering the runners on. Often, runners will encourage each other and may even choose to run alongside a slower friend for part of the journey. Likewise, as an NP, I have a number of colleagues both in my primary care office and through our hospital network who provide support, encouragement, and understanding. The doctor with whom I work directly is an invaluable resource and has mentored me from the beginning. Without this support, neither the runner nor the NP could accomplish her tasks.

When the practice becomes truly bleak, I draw upon the challenges I encountered in my training. I know that the countless hours I dedicated to this journey have given me the strength and knowledge to draw upon in times of uncertainty. The fact that I have completed my training and have made it to this “starting line” demonstrates that I am capable of taking on the challenges that lie ahead of me and that I am ready for success.

My first year of NP practice is just the first mile of my marathon career. I have not chosen an easy task; being a nurse practitioner is often very hard. However, like the marathon, it rewards those who are brave enough to take part in it. It is a challenge that others have tried and failed; it is a distinction to say you are a marathoner or you are an NP. As I discover the victories and obstacles in the miles ahead, I happily realize just how wrong I was when I considered graduation the finish line. No, this is only the beginning ….

Melissa Donais currently practices at North Reading Medical Associates, a primary care clinic affiliated with Winchester Hospital in Massachusetts.

The topics for my editorials are often based on current events, either political or professional; some of them reflect the “disease of the month.” Whatever the issue, it is one that strikes me as something about which I think our consciousness must raised, even one that has outraged me. While the political events of this past month could be the topic for this editorial, it is the societal events that have raised my moral outrage.

The multitude of radio and TV news stations bombarding us with “all news, all the time” has turned me into a “headlines-only” consumer of the news. Unless the story is especially interesting, I am usually quick to change the station and search for something a bit more pleasant to my eyes and ears. A sudden awareness of this response caused me to pause and wonder whether I had become inured to what was happening around me. That fear was mitigated when a recent news story so unsettled me that I sat in astonishment, listening to the newscasters repeat story after story about violence in our schools and in the workplace.

I am sure that you have either read or heard stories of nurses being struck by patients or being physically or verbally assaulted by family members. I have no doubt that many of us have experienced similar events throughout our professional careers.

Several years ago, I may have excused these behaviors as reactions to stressful, emotional situations. But there is one instance in which I have never accepted or excused outbursts. That is when professionals intimidate their colleagues by acting out in a violent manner.

In 2008, the concern about workplace violence had become so great that the Joint Commission issued a statement requiring hospitals to adopt a “zero tolerance” policy with regard to disruptive behavior.¹ Historically, it has been physicians who were the perpetrators of the “bad behavior.”

Perhaps the basis for that was an imbalance of power: Physicians stood firmly on the pedestal where society had placed them, and from that vantage point, they saw all other health care providers as beneath them.

One specific incident in my career brought this problem to life for me—and stopped me dead in my tracks as I walked by the people involved. A physician was berating a female colleague, and besmirching her mother’s reputation. Not only were his language and tone of voice offensive to me, but when I saw the anger in the man’s face and the expression of fear and embarrassment on the woman’s face, I was compelled to speak up.

Firmly and through clenched teeth, I told the man, “You may speak to your mother, your sisters, your wife, and your daughters that way, but under no circumstances may you talk to anyone here in that manner.”

I’m not sure which one of us was more surprised by my response—I surely hadn’t planned it—but the physician never raised his voice, or was anything less than professional and gentlemanly from that day forward. I have not had occasion to use that little speech since, but I lend it to anyone who has the need for it, with my permission to modify the genders as necessary.

However, I submit that it isn’t only physicians who have been guilty of this kind of destructive behavior. I have seen such intimidation among all health care professionals. All who are perceived (or who perceive themselves) as being “better” because of their clinical expertise, specialty, or years in practice have been guilty, to one degree or another, of intimidating a colleague. Whether this takes the form of verbal abuse, throwing an instrument, or quietly refusing to cooperate, the behavior can have devastating, far-reaching results. In addition to affecting the people directly involved in these interactions, their sequelae can include a devastating impact on the patient.

Data reflecting the negative effects of disruptive behaviors have been well documented in research by Rosenstein and colleagues.^2-4 The investigators found disruptive behavior to be linked to adverse events, medical errors, compromised patient safety, impaired quality of care, and patient mortality.² In addition to patient care issues, another consequence of inappropriate behavior—nurses leaving the workplace—is increasing shortages in nurse staffing,^3,4 which only compounds the risks to patient safety.

In today’s health care world, quality care and patient safety are held in the highest regard, and the concept of working together as a team is being applied. One effect of these team-building efforts is that the disruptive behaviors of the past are slowly disappearing. Health care providers have come to embrace the realization that there must be respect among all the team members, or the ability to provide safe patient care will be challenged.

The cooperative approach to teaching professionals to identify and manage disruptive behaviors, put forth by the American College of Physician Executives and the American Organization of Nurse Executives, is commendable. As a result of their efforts, bolstered by the implementation of the Joint Commission’s new leadership standard,⁵ which addresses disruptive and inappropriate behaviors and emphasizes respect and professional etiquette, all our health care facilities will soon be healthier environments for everyone who enters their doors.

Have you ever been intimidated or abused by a patient, a patient’s family, or a colleague? Have you ever caught yourself on the verge of being the abuser, reacting in anger or frustration toward a colleague? I’d be very interested to hear about your experiences. You can reach me at NPEditor@qhc.com.

The topics for my editorials are often based on current events, either political or professional; some of them reflect the “disease of the month.” Whatever the issue, it is one that strikes me as something about which I think our consciousness must raised, even one that has outraged me. While the political events of this past month could be the topic for this editorial, it is the societal events that have raised my moral outrage.

The multitude of radio and TV news stations bombarding us with “all news, all the time” has turned me into a “headlines-only” consumer of the news. Unless the story is especially interesting, I am usually quick to change the station and search for something a bit more pleasant to my eyes and ears. A sudden awareness of this response caused me to pause and wonder whether I had become inured to what was happening around me. That fear was mitigated when a recent news story so unsettled me that I sat in astonishment, listening to the newscasters repeat story after story about violence in our schools and in the workplace.

I am sure that you have either read or heard stories of nurses being struck by patients or being physically or verbally assaulted by family members. I have no doubt that many of us have experienced similar events throughout our professional careers.

Several years ago, I may have excused these behaviors as reactions to stressful, emotional situations. But there is one instance in which I have never accepted or excused outbursts. That is when professionals intimidate their colleagues by acting out in a violent manner.

In 2008, the concern about workplace violence had become so great that the Joint Commission issued a statement requiring hospitals to adopt a “zero tolerance” policy with regard to disruptive behavior.¹ Historically, it has been physicians who were the perpetrators of the “bad behavior.”

Perhaps the basis for that was an imbalance of power: Physicians stood firmly on the pedestal where society had placed them, and from that vantage point, they saw all other health care providers as beneath them.

One specific incident in my career brought this problem to life for me—and stopped me dead in my tracks as I walked by the people involved. A physician was berating a female colleague, and besmirching her mother’s reputation. Not only were his language and tone of voice offensive to me, but when I saw the anger in the man’s face and the expression of fear and embarrassment on the woman’s face, I was compelled to speak up.

Firmly and through clenched teeth, I told the man, “You may speak to your mother, your sisters, your wife, and your daughters that way, but under no circumstances may you talk to anyone here in that manner.”

I’m not sure which one of us was more surprised by my response—I surely hadn’t planned it—but the physician never raised his voice, or was anything less than professional and gentlemanly from that day forward. I have not had occasion to use that little speech since, but I lend it to anyone who has the need for it, with my permission to modify the genders as necessary.

However, I submit that it isn’t only physicians who have been guilty of this kind of destructive behavior. I have seen such intimidation among all health care professionals. All who are perceived (or who perceive themselves) as being “better” because of their clinical expertise, specialty, or years in practice have been guilty, to one degree or another, of intimidating a colleague. Whether this takes the form of verbal abuse, throwing an instrument, or quietly refusing to cooperate, the behavior can have devastating, far-reaching results. In addition to affecting the people directly involved in these interactions, their sequelae can include a devastating impact on the patient.

Data reflecting the negative effects of disruptive behaviors have been well documented in research by Rosenstein and colleagues.^2-4 The investigators found disruptive behavior to be linked to adverse events, medical errors, compromised patient safety, impaired quality of care, and patient mortality.² In addition to patient care issues, another consequence of inappropriate behavior—nurses leaving the workplace—is increasing shortages in nurse staffing,^3,4 which only compounds the risks to patient safety.

In today’s health care world, quality care and patient safety are held in the highest regard, and the concept of working together as a team is being applied. One effect of these team-building efforts is that the disruptive behaviors of the past are slowly disappearing. Health care providers have come to embrace the realization that there must be respect among all the team members, or the ability to provide safe patient care will be challenged.

The cooperative approach to teaching professionals to identify and manage disruptive behaviors, put forth by the American College of Physician Executives and the American Organization of Nurse Executives, is commendable. As a result of their efforts, bolstered by the implementation of the Joint Commission’s new leadership standard,⁵ which addresses disruptive and inappropriate behaviors and emphasizes respect and professional etiquette, all our health care facilities will soon be healthier environments for everyone who enters their doors.

Have you ever been intimidated or abused by a patient, a patient’s family, or a colleague? Have you ever caught yourself on the verge of being the abuser, reacting in anger or frustration toward a colleague? I’d be very interested to hear about your experiences. You can reach me at NPEditor@qhc.com.

The topics for my editorials are often based on current events, either political or professional; some of them reflect the “disease of the month.” Whatever the issue, it is one that strikes me as something about which I think our consciousness must raised, even one that has outraged me. While the political events of this past month could be the topic for this editorial, it is the societal events that have raised my moral outrage.

The multitude of radio and TV news stations bombarding us with “all news, all the time” has turned me into a “headlines-only” consumer of the news. Unless the story is especially interesting, I am usually quick to change the station and search for something a bit more pleasant to my eyes and ears. A sudden awareness of this response caused me to pause and wonder whether I had become inured to what was happening around me. That fear was mitigated when a recent news story so unsettled me that I sat in astonishment, listening to the newscasters repeat story after story about violence in our schools and in the workplace.

I am sure that you have either read or heard stories of nurses being struck by patients or being physically or verbally assaulted by family members. I have no doubt that many of us have experienced similar events throughout our professional careers.

Several years ago, I may have excused these behaviors as reactions to stressful, emotional situations. But there is one instance in which I have never accepted or excused outbursts. That is when professionals intimidate their colleagues by acting out in a violent manner.

In 2008, the concern about workplace violence had become so great that the Joint Commission issued a statement requiring hospitals to adopt a “zero tolerance” policy with regard to disruptive behavior.¹ Historically, it has been physicians who were the perpetrators of the “bad behavior.”

Perhaps the basis for that was an imbalance of power: Physicians stood firmly on the pedestal where society had placed them, and from that vantage point, they saw all other health care providers as beneath them.

One specific incident in my career brought this problem to life for me—and stopped me dead in my tracks as I walked by the people involved. A physician was berating a female colleague, and besmirching her mother’s reputation. Not only were his language and tone of voice offensive to me, but when I saw the anger in the man’s face and the expression of fear and embarrassment on the woman’s face, I was compelled to speak up.

Firmly and through clenched teeth, I told the man, “You may speak to your mother, your sisters, your wife, and your daughters that way, but under no circumstances may you talk to anyone here in that manner.”

I’m not sure which one of us was more surprised by my response—I surely hadn’t planned it—but the physician never raised his voice, or was anything less than professional and gentlemanly from that day forward. I have not had occasion to use that little speech since, but I lend it to anyone who has the need for it, with my permission to modify the genders as necessary.

However, I submit that it isn’t only physicians who have been guilty of this kind of destructive behavior. I have seen such intimidation among all health care professionals. All who are perceived (or who perceive themselves) as being “better” because of their clinical expertise, specialty, or years in practice have been guilty, to one degree or another, of intimidating a colleague. Whether this takes the form of verbal abuse, throwing an instrument, or quietly refusing to cooperate, the behavior can have devastating, far-reaching results. In addition to affecting the people directly involved in these interactions, their sequelae can include a devastating impact on the patient.

Data reflecting the negative effects of disruptive behaviors have been well documented in research by Rosenstein and colleagues.^2-4 The investigators found disruptive behavior to be linked to adverse events, medical errors, compromised patient safety, impaired quality of care, and patient mortality.² In addition to patient care issues, another consequence of inappropriate behavior—nurses leaving the workplace—is increasing shortages in nurse staffing,^3,4 which only compounds the risks to patient safety.

In today’s health care world, quality care and patient safety are held in the highest regard, and the concept of working together as a team is being applied. One effect of these team-building efforts is that the disruptive behaviors of the past are slowly disappearing. Health care providers have come to embrace the realization that there must be respect among all the team members, or the ability to provide safe patient care will be challenged.

The cooperative approach to teaching professionals to identify and manage disruptive behaviors, put forth by the American College of Physician Executives and the American Organization of Nurse Executives, is commendable. As a result of their efforts, bolstered by the implementation of the Joint Commission’s new leadership standard,⁵ which addresses disruptive and inappropriate behaviors and emphasizes respect and professional etiquette, all our health care facilities will soon be healthier environments for everyone who enters their doors.

Have you ever been intimidated or abused by a patient, a patient’s family, or a colleague? Have you ever caught yourself on the verge of being the abuser, reacting in anger or frustration toward a colleague? I’d be very interested to hear about your experiences. You can reach me at NPEditor@qhc.com.