Monthly Archives: May 2010

Got Interpreters?

Imagine this:

You are a refugee in a foreign land where they speak a different language.  Your child is sick and you must seek health care.  Without an interpreter your ability to communicate is minimal or non-existent and you are not quite sure what the doctor is saying.  You are sent to the pharmacy with the prescription, but get lost on the way because you can’t read the hospital signage.  Going home takes forever because you misread the bus schedule.  It takes you many days to schedule your child’s needed surgery because of the language barrier with the appointment desk staff, and also because – as a single parent holding two jobs just to make ends meet – you are incredibly short on free time.  The day before surgery you receive a reminder call and even though you don’t quite understand the caller, you say, “yes, yes, OK” because you are trying to be polite.  The day of surgery arrives and by sheer luck a nursing assistant who speaks your language discovers that your child ate a full breakfast that morning.  The surgery is canceled, you receive several “dirty” looks and are sent home to reschedule.

This scenario and many similar ones were unfortunately quite common until recently.  It is only in the last 10-15 years that we in health care started using trained interpreters to communicate with patients and families who have limited proficiency in English.  At Children’s, these days may seem now like a distant past, as we have had a tremendous growth in this area.  Manager of our interpreter services Michelle Chillstrom tells me that we currently have 35 staff interpreters.  Our most frequent languages are Spanish, Somali and Hmong, but the list of languages that are routinely interpreted at Children’s is long – 43 in the past year.

Watch this short video by HRET to get the feel for what a health care encounter might look like at Children’s if we didn’t have interpreters:

Boris Kalanj is the Director of Health Care Equity and Cultural Competence at Children’s Hospitals and Clinics of Minnesota. Read his bio.

How we advocate for children

Scott Leitz After spending the better part of this past weekend watching the legislative sausage being made (and spending a few too many late nights at capitol), I have a few observations to share.

First, as much as its convenient to grouse about politicians, the fact is they have very hard jobs that they do in a very honorable way.  I have the luxury of focusing on health care issues, but the average legislator, in addition to knowing about health care also needs to know agriculture policy, tax policy, economic development issues…and the list goes on.

Second, the challenges facing our state are enormous.  Not only do we have a budget deficit this year, we’ll have a huge one waiting for the new incoming governor next year.  And the range of perspectives among lawmakers (and the public) on how to best proceed moving forward are really quite vast.

On the one hand, Minnesotans are justly proud of the investments we’ve made over the years in education, health care, the environment and other areas.  Many legislators and policymakers feel passionately that we’ve backslid in some of those investments the past few years, and would like to, at a minimum, stop what they consider to be additional slippage.  On the other hand, other policymakers feel just as passionately that our investments have to match up with our means, and that the state spending should be restrained.  In a time of deficit, these two perspectives can be very hard to reconcile, and the process of trying to come to agreement can be messy.  And without good information, sometimes decisions can be made that have unintended impacts.

This is where advocacy can play an important role.  We’ve been working this session to help to educate lawmakers about the importance of Medical Assistance (MA) to pediatric hospitals.  Let’s face it: legislators face tough choices this year in Minnesota—without new revenue, they have to do the best they can within existing resources to make the best policy possible.   That can mean reducing MA and other payments to health care providers like Children’s.

Unfortunately, across the board cuts to MA payment rates to hospitals do not have the same across the board impact.  Certain providers (like Children’s) see much higher numbers of MA enrollees than other providers, and so MA cuts hit them harder and they bear a disproportionate impact.  Helping lawmakers understand this disproportionality can help them think about ways to remedy or mitigate it.

While the cold reality is that sometimes, especially in tight budgetary times, legislators may not be able to fully address the concerns of high Medicaid providers, our goal is to continually help them to understand the impact of the decisions they make on child health so that they can make the best public policy possible for Minnesota.

Scott Leitz is the director of child health policy and advocacy at Children’s. Read more about him here.

More than a medical record

There used to be a way to tell how sick a patient was by the size of their paper chart. Now that records are electronic, it is not that obvious, although I’ve been told that accessing my 14-year-old son’s record takes a while to download. That’s understandable since with a rare, complex chromosome disorder and the sheer volume of medical intervention he has needed in his short life.

But in reality, with his electronic records, you can read how all his organs work, his severe level of intellectual disability, and the various medical equipment he needs every day. You can paint a picture of who he is and what his life is like without ever seeing him in person.

I should mention that with 32 medical conditions and being followed by 13 providers who all seem to have their own medical charting systems (which apparently do not talk to other charting systems), I am pretty confident in saying that a complete medical record doesn’t even exist. (My tip to you: also keep and maintain your own record system process.)

This picture that you can envision by reading a record may lead you to think that this is a child living a miserable life. He is suffering or in pain. The thoughts among the majority of nondisabled persons are that physical or intellectual disability equals suffering. I can tell you for sure that upon meeting my son, the term suffering would be at the bottom of any list of words that came to mind.

He is the opposite of suffering. I have personally diagnosed him with profound happiness. Is that a medical term?  He has emotions of sadness and anger like everyone else, but overall he is happy and when he is around you, it is difficult to not smile.

This, unfortunately, is not in the record. Neither is the fact that he is Barney’s No. 1 fan, he does not like stickers, the best place for an IV is his the left hand, he can tolerate almost every medical procedure if you talk him through it, he is most protective of his eyes so any eye exam takes the most patience, he will not put on his orthotics until his socks are completely smooth, and so on.

I could go on and on with things that make him who he is, and we all have unique traits that define who we are. Being put into a grouping of disability or chronic disease categories doesn’t define who you are. The medical record does not tell you everything, nor is that its purpose, I know.

Don’t misunderstand what I am saying. The medical record is of vital importance. It just doesn’t give you the complete picture.

What have you experienced with your own children’s health records?

Melissa Winger is a member of Children’s Family Advisory Council. Read more about Melissa.

Plastics on My Mind (and Yours Too!)

I don’t want to give away my age, but I remember a classic line from the 1967 movie “The Graduate,” where Dustin Hoffman gets some important career advice in a single word –“plastics.”

The plastics industry has been quite financially successful in the packaging and food container business over the past 30-40 years, but, as it turns out, this has likely come at a cost for us and our kids in terms of brain development and potentially the development of cancer, obesity and diabetes amongst other concerns.

I was thinking about plastics recently as I attended a new “product launch” party in New York City for the first-ever line of environmentally safe baby bottles and related products that are manufactured to be free of harmful chemicals called “endocrine disruptors.”  It is a bit sad to me that this is such a big thing and took so long to get here. I was bottle-fed as an infant, as that was promoted to many moms back then. It made me think: how many kids have been exposed over the years to plastic-related chemicals?

A rather dramatic study from the Environmental Working Group examining the cord blood of 10 newborn babies from minority families showed that the blood samples contained 232 toxic chemicals at the time of birth!  Some feel that the FDA and other government regulatory agencies have been asleep at the wheel for many years as it relates to this issue and that plastics related toxins are only the tip of the iceberg.

Evidence is mounting that many commonly used plastic products that contain our favorite foods and drinks — including baby bottles, canned vegetables and water bottles — tend to leach chemicals called “endocrine disruptors” into our foods and beverages with serious long-term consequences to mind/body health. These chemicals — things like bisphenol A (BPA), Polychlorinated Binphenyls (PCB’s) and phthalates, to name a few — are being linked to breast, prostate and ovarian cancers in adults, and to autism, ADHD and learning disabilities in children (as well as obesity and diabetes). The reality is that, with few exceptions, we have all been exposed to a lot of these chemicals as part of modern life. As a board-certified developmental pediatrician, I am amazed by the rapid increases in mental health and developmental diagnoses in childhood- ADHD, autism, and depression are all occurring in record numbers  and we don’t know really know why. I think we really may have missed something here.

Other adults are now speaking out.  I read about an interesting project called “Mind-disrupted,” which details the toxic exposures of a group of 12 adults who themselves have emotional/learning problems and who also have offspring with learning disabilities. They actually tested themselves for the presence of some 89 toxic chemicals including lead, mercury and plastic residues. The study found that all 12 participants had at least 26 environmental toxins above acceptable levels in their bodies!

The Collaborative on Health and the Environment organization has new report by a working group on learning disabilities and developmental problems in kids (“Scientific Consensus Statement on Environmental Agents Associated with Neurodevelopmental Disorders.”

This report details the various potential links of environmental toxin exposure (the burden of which is higher in low SES kids and families and in developing nations) to a broad spectrum of learning, behavioral and emotional problems in childhood. We know that the developing nervous system in infants and kids is exquisitely sensitive to even very low doses of endocrine system chemicals (hormones) and so during windows of time when the developing fetus, infant and child is exposed-even to low levels of endocrine disruptors (and heavy metals and other pollutants) — profound, detrimental changes can ensue within the developing human.

So where do we go from here? Parents and kids need to let our government know that these regulatory issues need to be better funded and enforced. We all need to heed a time-tested principle in public health – “The Precautionary Principle,” which states that “when an activity raises threats of harm to human health and or the environment, precautionary measures should be taken even if some cause and effect relationships are not fully established scientifically.” Simply stated it means that until we know better, we should err on the side of caution in considering health risks. It is better to ban many of these chemicals that may do harm until we figure it out more definitively.

In the meantime, see the Green Guide for tips when buying plastics. A few tips follow:

  • Don’t microwave food in plastic containers
  • Use fresh or frozen veggies not canned
  • Use metal water bottles
  • Look for not just BPA-free bottles and utensils ,but for products made from materials like “Triton” that are free of “estrogenic activity”

What do you think about this as a parent?

Tim Culbert, MD

Dr. Tim Culbert is the medical director of Children’s Integrative Medicine program. Read more about him in his first post to the Kids’ Health blog.

Moderation is the key

Gigi Chawla, MD, Chief of Staff at Children's of Minnesota Recently, I watched someone eating a bagel with cream cheese drop that bagel, pick it up, brush it off, and start eating it again because it met the criteria of the less-than-5-seconds rule. In clinic that same day, I had a family who used nearly a full container of a hand sanitizer during our visit, and their hands were cracked and irritated from constant alcohol-product exposure.

Shouldn’t there be some middle ground? Abandon anything that drops to the ground. It can’t be worth eating. Don’t use your hand sanitizer constantly, not on open skin, and soap and water still works also. How do you practice moderation to stay healthy?

Gigi Chawla, MD, is the Chief of Staff at Children’s Hospitals and Clinics of Minnesota. Read more about her here.

Why are we calling them “providers”?

Over the last decade the word “provider” has been used more and more when describing physicians and other clinicians. Language is an extremely important catalyst to changing cultures and the utilization of this word “provider” does have significant implications to a not-so-subtle change to our health care culture. Now I understand fully the need to move away from hierarchical thinking and actions in health care, especially in high reliability organizations, but I am also aware that this is having secondary, if not unintended, consequences.

The health care industry over the last decade or so has seen many more non-physicians providing care to patients, whether it’s advanced practice nurses, physician assistants, psychologists, chiropractors, or EMTs. Now some of this is very good because of shortages of doctors, and from pure economics, it also makes sense. Nevertheless, the unintended consequence of this language change is that physicians who take the longest to train and have the strongest background in pathophysiology and treatments are now becoming a commodity.
A commodity that then begin to think of themselves as employees instead of professionals. When they think like an employee, they begin to act like employees: losing the aspect of professionalism that differentiated them from others.

Continue reading