When Patients Share Internet Health Information With Their Physicians

This is an infographic that I created to describe a short “survey” that I conducted for a week in October, 2013 while working for The full description of the survey is found here: How Patients Discuss Internet Health Information With Their Doctors.Infographicpatientmaybe2


Do Nurses Eat Their Young? What’s Wrong With Communication in Health Care?

The Workplace Bullying Institute defines Workplace Bullying as repeated, health-harming mistreatment of one or more persons (the targets) by one or more perpetrators that takes one or more of the following forms:

  • Verbal abuse
  • Offensive conduct/behaviors (including nonverbal) which are threatening, humiliating, or intimidating
  • Work interference — sabotage — which prevents work from getting done

040811_020 retouchedRenee Thompson, MSN, RN, CMSRN, nurse, author, educator and advocate for workplace change, is making it her mission to bring nurse bullying  to light.  In her question “Do nurses eat their young?” she shocks us into awareness of nurse bullying.  “I’ll do whatever it takes,” she asserts. “Enough of us who believe in kindness, support and nurturing each other can do it!  New nurses (and the rest of us) deserve to work in nurturing supportive environments…Bullying has no place in a profession dedicated to caring and compassion.”

So what is wrong with interpersonal and organizational communication in the health care setting? Bullying.  Why is bullying happening?  One theory suggests that since nurses are not valued in the workplace they feel powerlessness.  This results in bullying behavior.  Another points to nursing as a predominantly female profession with a forced hierarchy.  In this model, the cause of bullying lies in female competition for prized males.

Despite these notions, or perhaps because of them, Ms. Thompson speculates that medical and nursing school education may start the process. “Doctors and nurses learn separately, then are forced to work together without training. We wouldn’t do that with an All-Star basketball team,” Thompson says.  “Respectful communication is a skill that can be learned and it is just as important as clinical knowledge.”

Yet it is missing from the beginning.  “Nurse sand doctors don’t learn how to communicate respectfully with each other. Student nurses are not even allowed to speak to doctors when they are learning.”  It makes sense.  “When members of a team learn together, they learn to respect roles and work together.. all working towards the same goal…patient care.”

Research literature describes  nurses “as an occupational group, at considerable risk of violence-related workplace trauma” and recounts experiences of “harassment, bullying, intimidation and assault.”(1)

In her own research for her book, which Ms. Thompson conducted while developing student and new nurse residency programs, she heard horrific stories. In her research she encountered recurring themes. “Students and new nurses are the most vulnerable, but any time you change positions, you are at risk. We are still trying to sabotage, especially when the female is younger, thinner, more beautiful and smarter. While nurses are caring to patients, they can be horrific to each other.”

NursingA study of bullying published in Journal of Professional Nursing in 2009 reveals which departments  in hospitals were most likely to have bullying incidents and who were the perpetrators.  The medical-surgical and critical care units had the highest frequency of incidents at 23 and 18 % respectively.  Bullying incidents occurred within nurses’ first 5 years of employment.  Senior nurses were the highest percentage of perpetrators at 24% followed by charge nurses, nurse managers and physicians (8%).   This research confirms Ms. Thompson’s observations.  “Nurses know we eat our young.  Some nurses think it’s good to “toughen up” the new nurses. In reality it’s not. It decreases confidence and competence. “

In fact it seems to be a vicious cycle.  Those who are bullied lose their confidence and are more likely to be targeted.  Ms. Thompson identifies passive communication styles, like “frequent apologizing, avoiding conflict by keeping quiet, giving others priority” as characteristics of victims.  Other characteristics included being of a different gender, race, or from a different location.

Ms. Thompson has witnessed workplace bullying in the nursing profession.  The behaviors range from“overt-screaming, yelling and openly criticizing in front of others to covert-sabotage, backstabbing and undermining.” Bullying can be as simple as “being nice to your face, but then complaining about you to other nurses all night” or as complicated as “gathering a “posse” against you.”

A 2006 article in Nurse Inquiry suggests that there may be hidden processes at work causing nurse-to-nurse bullying.  The authors propose that health care organizations may actually be maintaining the status quo, recruiting nurses who support a top-down hierarchical structure.  Ms. Thompson uses an Italian saying “the fish rots from the head,” to describe her understanding of what is happening. She believes that many organizations rely too heavily on policy to solve bullying.  Without a robust program, zero tolerance policies don’t work. “Policies don’t solve problems – people do,” she notes.

Bullying can impact patient care.  “Organizations with a high rate of bullying have worse patient outcomes.** Many studies demonstrate bullying prevents nurses from asking for help and calling docs at nursing_02.sized3am,”  Thompson observes.   “I  know some nurses who feel they can’t rely on co-workers if they need help for patient.” Nurses who are bullied suffer physical, emotional and mental distress which is disabling, impacting their ability to effectively care for patients.  “Bullying is pervasive, destructive and nurses are suffering all over the world. I know because they call me!”

Patients are becoming aware of nurse bullying. They are asking questions about it. “They’re on to us! “ she says.  And Ms. Thompson is glad. “Awareness is vital to change. The first step for organizations is awareness. You have to know how bad it is first before you can take action.  We get numb to bad behavior, accepting it as normal. Too often we believe what the bully tells us.”

The most powerful intervention to stop bullying, she notes, is for witnesses of bullying to speak up. “We need to teach people how to establish peer-to-peer accountability.  A simple way is to just starting naming behavior. ‘You are screaming and yelling at me in front of others.’” Thompson proposes “skill development for managers and strong human resources partnerships.”.

StopBullying It sounds a lot like personal courage is key.  “What you ignore – you condone. It doesn’t matter if the aggression is aimed at you or someone else… Set behavioral expectations. You can’t assume everyone knows what respectful behavior looks like. So spell it out….[It’s true] confronting might not work. But not confronting NEVER works. We have to try.”  In speaking up, Renee Thompson has decided to do just that!

For a detailed discussion of this topic, see the transcript of the #hchlitss twitter chat that this summary is based on.

Several chat participants requested seminar information from Renee.  Please visit Renee’s seminar information page at to learn more about her upcoming seminars in:

  • Irvine, CA: February 7th and 8th
  • Orlando, Fl: March 14th and 15th
  • Raleigh, NC: April 24th and 25th
  • Atlantic City, NJ: May 22nd and 23rd

If you are interested in reading Renee’s book, Do No Harm both the hard copy and the Amazon kindle version can be accessed at

1) Vessey, J., DeMarco, R., Gaffney, D., Budin, W. (2009) Bullying of Staff Registered Nurses in the Workplace: A Preliminary Study for Developing Personal and Organizational Strategies for the Transformation of Hostile to Healthy Workplace Environments Journal of Professional Nursing, 25, (5) , 299-306.

2)Hutchinson, M. Vickers, M. Jackson, D. Wilkes, L. (2006).Workplace bullying in nursing: towards a more critical organisational perspective.  Nursing Inquiry 13,( 2),  118–126.

**Aleccia, J. (2008).  Hospital bullies take a toll on patient safety.

What ever happened to old school medicine? It’s still around…

“Nothing connects doctor & patient faster than a simple moment of pure listening. Not just waiting for your turn to talk, but real listening.”

Tweet by Dr. Steven Eisenberg, January 5, 2013

I wrote a post a year ago entitled “What happened to Old School Medicine?”  Perhaps, by putting my mourning  for my father “out there” I have started something in my own life.  My most recent experiences with physicians, specifically with  my child’s pediatrician, has been like walking into the past.  I have found “old school medicine” in Wellesley, Massachusetts.  I don’t live in Wellesley but I took the advice of my child’s school nurse and made an appointment with her children’s pediatrician.

This is an ‘old school’ practice:  two physicians share it.  We have only seen these doctors twice but they both spent a large amount of time talking and listening to us.  When I have had a question, I called the office and later that day, the doctor called me back.  That hasn’t happened in a long time.


And then, there are tweets like the one above.  Faith is a beautiful thing!

Are Patient Communities an Effective Way to Deliver Care?

Are Patient Communities an Effective Way to Deliver Care?

Dr. Andrew Watson
Dr. Jeffrey Benabio

That was the question debated at the 2012 Connected Health Symposium on October 25.  Two physicians, Dr. Andrew Watson, Surgeon and Medical Director for the Center for Connected Health and Dr. Jeffrey Benabio, Physician Director of Innovation with Kaiser Permanente faced off on this topic.  Alexandra Drane, Founder of Eliza Corporation, moderated the event.

Dr Watson presented the argument in favor of patient communities.  Noting the Institute of Medicine’s figures that $750 to $900 billion are wasted by traditional healthcare in the US, Watson feels that the face-to-face system of care needs to evolve.  With so many US patients already online, online communities are a vehicle to reach people over distance and time and the medical community has an obligation to help organize this, he said.

Dr. Benabio began with a quote from another physician “Patients running online communities are like animals running the zoo.”  Although he felt this comment both shocking and insulting, he felt that it expressed the depth of his worry.   He also voiced concern about who sponsors online communities, especially pharmaceutical companies.

After these preliminary comments each debater worked to refute the other’s points.  Dr. Watson asked Dr. Benabio for the research proving that  patient communities cause harm.  He also refuted Benabio’s assertion that all communities are sponsored.  Dr. Watson believes that patients are waiting for physicians to engage.

Dr. Benabio continued providing examples he found on the Internet  to disprove the appropriateness of patient sharing.  For example, he stated that on one site a patient stated that he had a flu vaccine, followed by a seizure.  The patient said he never gets a flu vaccine because of this experience.  Several people “liked” the comment.  Dr. Benabio believed this statement would stop people from getting the flu vaccine.

The debate continued along the same vein.

Perhaps there was a flaw in the question that was asked.  Are patient online communities really about providing care?  Or are they doing something else.  The debate  illustrates the division  among physicians and other healthcare providers concerning patient communities.  However, in the end, patients are moving forward, reaching out to each other to exchange information, support and experience.  Ignoring online communities, standing back and watching, claiming that time spent online is wasted: these are unproductive attitudes. Getting involved with online communities will not only inform patients, it will also inform healthcare providers.  Communications is key and online patient communities are not going away.

What do you think?

After taking the survey please share your thoughts in the comments.  Thank you.

Making a World of Difference: Climate Change and Public Health

“It is an overwhelmingly popular misconception that climate change isn’t occurring or is a natural phenomenon.  While some change is due to a natural progression, we can see that increases in temperatures are far more rapid than occurred historically.”

Mey Akashah, PhD doesn’t flinch or deny global warming but tries to face it, find answers and generate attention to the crisis.

Her journey began studying marine biology.  However she realized that, even though climate change is making a huge difference in the earth’s oceans, people weren’t really interested.  She recognized that, to make meaningful changes in the effects of climate change on the environment, she would need to change. She shifted gears, going to graduate school in global and environmental health and hasn’t looked back.

Now, as a public health professional and award-winning human rights activist, Mey Akashah tries to generate the attention climate change demands.  Her academic publications include compensation for human rights abuses, the impact of climate change and environmental degradation on conflict and sustainable livelihoods, and the health impacts of mercury contamination in the Arabian Gulf.  Towards this end, Dr. Akashah participated in a twitter chat on September 13, 2012.

The chat began with the ozone layer.  Chloroflourocarbons, known agents of ozone layer depletion, are banned.  Yet new evidence published in August describes previously unknown mechanisms of ozone depletion.  Dr. Akashah featured this research by James Anderson and his colleagues on her blog.  Apparently there is a connection between climate change, clouds and cancer.  “Climate change makes storms stronger and more frequent. Strong storms press water into the ozone layer. Water vapor breaks down ozone.  Less ozone equals more UV rays reaching us.  More UV rays equals more skin cancer.”

The cancers of greatest concern are melanomas in areas under the ozone hole.  Countries seeing higher rates of melanoma are Australia and New Zealand.  Since the research was based on observations of storm phenomena over the United States, it can be assumed that this situation is occurring the world over.

Increases in cancer are not the only health concern the world faces.  “Unfortunately, most health effects have begun to be seen already.  The question is one of intensity and frequency.  The World Health Organization (WHO) estimates that anthropogenic climate change already claims over 150,000 lives annually.”  Some of the diseases linked to climate flux include “cardiovascular mortality and respiratory illness due to heat waves, altered transmission of infectious diseases, and malnutrition due to crop failures.”

With a bow to naysayers, Dr. Akashah states “there is uncertainty in attributing the expansion or resurgence of diseases to climate change.  But, this is largely due to the lack of long-term, high-quality data sets, as well as changes in immunity and drug resistance.”  However, Dr. Akashah points out, “we do know enough to know that it is a problem and that we need to act on it now.”

What is being seen is “injuries due to extreme weather, air pollution-related effects : increased infectious diseases (water-, food-born like cholera, vector-born, for example, malaria, and zoonotic, that is, any disease from animals to human and vice versa like rabies.”

Asthma is increasing.  In fact, in Florida it is due to an unusual source, “increased algal blooms (Red tide).” The progression of the health issues will change over time.  “Some of these changes will have a slow onset. Initially, we will see higher acute asthma attacks, heat stroke, etc.  Over time, these occurrences will become more frequent and more severe. This increase in intensity will coincide with more frequent severe weather events and natural disasters.”

Who are the most likely to be affected? “As per usual in situations of increased stress, it is the most vulnerable who will suffer most severely.  We can make the correct assumption that these will be the poor, disenfranchised, older, and younger members of the population.”  Climate change impacts those who are geographically vulnerable.   This includes people who are in extreme climates like desert nations and those in arctic climates. But it also includes areas of low topography, like island nations and nations with high water tables such as Bangladesh.

Yet another locale that is vulnerable are sprawling urban areas.  These areas “where trees and turf have been transformed into asphalt,” (cities include New York, Los Angeles and Dallas) are seeing what is called a “heat island effect.” What this means is that “these changes cause urban regions to become warmer than their rural surroundings, forming an “island” of higher temperatures.”

Why should health care workers be aware of the health effects of climate change?  According to Dr. Akashah, “We need healthcare workers to be aware of these changes… to help track health trends and to identify and spur health communication towards vulnerable populations.  But we also need their help as disasters and acute crises become more frequent.”

There are actions that can be done to help and Dr. Akashah is taking steps.  “Most of the work I do now involves climate change adaptation – facing the inevitability of climate change in poor communities, especially.”   She is attempting to create low cost solutions to flooding, drought and other consequences of climate change.   “Often the best ideas come from the communities, themselves,” she states. “Our job is often to disseminate the knowledge.  I think giving people a voice is the most important hurdle.”

To illustrate, Dr. Akashah told participants, “An example of the dissemination of community-originated ideas is raising ducks instead of chickens in flood-prone areas.”  Dr. Akashah notes the many studies show the importance of listening and supporting communities, “especially when women are empowered with small funds for sustainable harvests…it improves both maternal and child mortality and increases the proliferation of sustainable farming practices.”

Action is important.  Dr. Akashah suggests paying particular attention to sustainable development.  “Sending donor funds to small sustainable entrepreneurships in these areas” can make a world of difference.

For more information on Mey Akashah, PhD  please see her website: Mey Akashah

For a full transcript of the #hchlitss twitter chat please see: Health Communications, Health Literacy and Social Sciences blog.

Does it have to be this way?

My dear dear uncle is at this very minute suffering from bed sores.

Bed sores or pressure sores are horrible.  The skin completely disintegrates…losing layers of skin, exposing tissue under the skin. They are ulcers that are extremely painful and that can be very large.  They occur on skin that has had pressure on it for some time–skin of the buttocks, back and heels are common.  It happens to people who are extremely ill, who cannot turn themselves and must rely on caregivers to turn them, people who cannot take in adequate nutrition. Very vulnerable people.

Even though he has a living will with specific directives that say that extraordinary measures not be used to keep him alive, his wife has had to advocate for those directives to be honored.  There are many factors that are keeping him in the nursing home…one is financial-he has long term care insurance which will cover the cost of his care.  My aunt thinks that hospice care will not be covered by the insurance he has.  Another is that my aunt is elderly, overwhelmed and has poor health literacy.  Her nieces have been doing all they can, long distance, to help her understand all that is happening. But there is no one educating her and helping my uncle where he is.

My mother worked for years at a hospital to reduce the number of bedsores that occurred there.  At the end of her life she got a bedsore in that very hospital.  Hospice was never mentioned by her oncologist.  Also she feared losing the successful pain management that had been achieved at the hospital.  My sisters and I were at the hospital 24/7 to assure that she received the care she needed.  Unfortunately that didn’t help with assuring that she didn’t get a pressure ulcer.  She died in that hospital.

There are ideas for bringing discussions of End of Life and the care that is received out in the open.  One advocate for this is Alexandra Drane with her Engage with Grace website.

There are other advocates in this work: Kathy Kastner is one example.  She blogs at Ability for Life and is beta-testing an End of Life app.

What we need is to get all of healthcare–all patients (physicians and nurses are patients too)–talking about and thinking about how the end of life should be experienced.

What happened to "old school" medicine?

Times they are a-changing.  My dad wouldn’t have liked what’s happening. C. A. Hoffman, Jr.  was an old-school physician.  Often, to the chagrin of his office staff, he spent real time with his patients.  Five o’clock would come and go. His office was busy and filled with his laughter and booming voice.  A ringing office phone made him happy.  There was a blackboard in his office.  It had to be white with chalk, covered with his “To Do” list.

When I visited the office, I would sit on a strange-looking metal safe and watch him as he went from room to room.   That safe was so heavy that no one could move it.  It just sat for years in the middle of the busy office front, taking up space and getting in the way. Dad had an answering service to take calls after hours.  The service would call our house in the middle of the night and on holidays. No matter when, he would return his patient’s calls and order prescriptions for them.  If it was an emergency he would direct them to the Emergency Room of the hospital.  Then he would get up and meet them there.
He worried about his patients.  If he lost a patient, I would know about it because he would be incredibly sad.When he died, there was a line of people that wound around the funeral home, waiting to speak to my family.  I don’t know how many hands I shook that night or how many times I heard, “your father saved my child” or “if it hadn’t been for your father, I wouldn’t be here today.” After he died, my family opened up that safe.  There were thousands of invoices that he had just slipped into the safe and forgotten.  Many, many of his patients received his care for free. My father is not the only physician I have known to do this.  My pediatrician was another.  He did not die a rich man, but he was dearly loved. Now when I go to the doctor’s office, I’m expected to pay at least the copay, before receiving care.  If I couldn’t pay, would I get to speak to the MD?  No; I would have to explain my financial situation to someone at the front desk in front of the other patients.  Probably, I wouldn’t get to see the physician. When I call the doctor’s office after hours, an answering service takes the call.  My call is directed to a nurse on call who is looking at my records on line.  S/he doesn’t know me.  If it is an emergency, I’m sent to the Urgent Care Center.  I don’t see my physician.My father opposed universal health insurance, calling it “socialized medicine.”  But I wonder what he would say if he saw medicine as it is practiced today.Many say the change in medicine is due to the terrible financial burden most medical students incur to become physicians.  I’m afraid I don’t see it that way.  I believe that medicine has become a business and generosity has no substantial place in the business paradigm. Nowadays, I believe we need universal health coverage because there are so few “old school” physicians left.  They are a dying breed.