I first met Susan Adams several weeks ago, at a Thai restaurant tucked into a shopping mall in sunny Marin County, California. An Adams-for-Congress supporter had contacted me, by email, about meeting her candidate.  My interest in nursing and progressive politics would mesh well, she assured me, with Susan’s impressive personal and political profile as a working RN, nursing professor, and Bay Area activist now serving on the Marin County Board of Supervisors. Before the pad thai even arrived, it was clear to me that Adams is a great role model for nurses in the Golden State (and any state), who want to make their voices heard in the public policy arena.

I had brought along a copy of From Silence to Voice: What Nurses Know and Must Communicate to the Public, a book that I co-authored with Bernice Buresh.  I handed Adams the book, over lunch, and the first thing she said (after “thank you”) was “how much do I owe you?”  “Nothing,” I replied, “It’s a gift.”  Without skipping a beat, Adams informed that that she was now “in politics and can’t accept anything.” Not a book, not a lunch.  “You start accepting books and lunches,” she said “and it’s a slippery slope.”  So my present turned into a book sale—not a bad deal for an author, but an unintended expense for a citizen politician who, without great personal wealth, has already had to raise more than $160,000 dollars to remain competitive in the crowded June 5 primary field in California’s 2nd Congressional District .

The constituency Adams seeks to represent runs north from the Golden Gate Bridge all the way to the Oregon border.  Before redistricting, many of these same north coast voters sent Lynn Woolsey, one of the most liberal members of Congress, to Washington, but Woolsey is stepping down next January. Adams is competing against seven other Democrats and two Republicans in a “jungle primary” that will be followed by a general election in November, pitting the two top vote getters against each other.

One of those opponents is State Assemblyman Jared Huffman. He’s also from Marin and the current front-runner (in fund-raising and the polls), who was just endorsed by The San Francisco Chronicle.  Another top tier contestant is Norman Solomon, a well-known progressive activist and writer who shares many of Adams’ views. The second biggest spender in the race so far is Stacey Lawson. She’s a newcomer to politics who is touting her business experience and making a bid for public office backed by her own hi-tech industry fortune in a manner reminiscent of  Meg Whitman’s run for governor last year.

Lawson’s wealthy friends have already endowed her with a campaign treasury five times bigger than Adams, whose bid to replace Woolsey was initially encouraged by the Washington, D.C. feminists at Emily’s List. Before Lawson left the business world and moved to Marin, she didn’t bother to vote much (a record of civic activism similar to Whitman’s in the GOP). But, now, Lawson’s fundraising prowess has led some Inside-the-Beltway queen-makers to shift their attention from Davis to her.

That’s a sad commentary on the affection that money can buy in Democratic politics today. Adams is neither new to elected office nor unfamiliar with the survival struggles of ordinary people, including being laid off and loaded up with night student debt.  A fourth generation Californian with family roots in rural Mendocino County, Adams got her nursing degree from San Francisco State in 1978. She earned both a masters and doctorate in nursing from the University of California at San Francisco (UCSF), where she specialized in women’s health and maternity.

A single mother of two, Adams put herself through school while working as an obstetrical and gynecological Nurse Practitioner at UCSF hospital. She has also served as a clinical professor, mentoring scores of undergraduate and graduate nurses, medical students, interns and residents.  Her nursing practice focused on the problems of chemically-dependent pregnant women, the subject of her doctoral research.
When UCSF hospital merged with Stanford in the1990s, Adams helped organize her facility for the California Nurses Association (CNA) and served on the union committee that negotiated the RNs’ first labor agreement.  Unfortunately, the marriage between Stanford and UCSF ended in divorce, leaving Adams among the casualties of its dissolution. Hundreds of staff positions were eliminated and she was one of those laid off (a management decision that, in her case, may have been motivated by her union activity).

Always politically active, Adams served as a campaign volunteer for now U.S. Senator Barbara Boxer, when Boxer, like Adams now, tried to move up from the Marin County Board of Supervisors to a seat in Congress.  Gradually, Adams gained experience lobbying on nursing issues in Sacramento and Washington.  In the 1999, she decided to run for the state Assembly because “our health care system was broken” and experienced caregivers were under-represented in policy-making circles.  “I threw my hat in the ring,” she explained, “so I could be part of the dialogue. After spending only  $1,000, I did better some of candidates that raised more than $100,000.”

Even though Adams didn’t win an Assembly seat, many of her friends and neighbors in Marin County encouraged her continuing involvement in electoral politics.  Arguing that Marin had a “fractured healthcare system, which wasn’t working for the county’s resident,” she campaigned to become a county supervisor in 2002.  “I wasn’t expected to win that race, because a very popular city council member, Paul Cohen, was also running and he had a lot of support and a whole lot of money,” she told me.

“But nurses have an 85% approval rating and people responded to my message that electing a health care provider could help us create a healthier community and a healthier planet for our families.”  Adams won the race, much to her surprise, and she has been re-elected to the board of supervisors twice since then.   In the decade Adams has served on the board, Marin County has built a health and wellness campus in San Rafael and Novato.  “We have clinics all over the county now.  We used tobacco settlement money for the San Rafael site and it provides comprehensive services in partnership with non-profit providers, including primary care, mental health services, and dental care.”  Patient visits have jumped from 10,000 annually to more than 100,000 a year now.  Says Adams: “This means we are definitely filling a need.”

Adams is particularly proud of a new county program that

“has diverted almost 200 non-violent, mentally ill offenders into treatment rather than jail and reduced recidivism by 85% and psychiatric emergency room visits by 50%.” Most of these former offenders are now gainfully employed and paying taxes again, she observes.  On the county board, Adams also cast the deciding vote that launched the Marin Clean Energy Program, which addresses climate change by encouraging green job creation. Working with other county supervisors, Adams helped obtain $25 million in federal funds for non-motorized transportation projects.

As a result, Marin is now one of only four counties in the country to receive federal demonstration project money for non-motorized pathways (i.e. walk-able and bike-able commuting routes). Another program she helped initiate and facilitate is the nationally recognized Marin Medical Reserve Corps. “In our county today,” she explains, “we have a few hundred healthcare professionals trained in incident command who are ready to jump into action in the event of disaster.  When we were faced with a flu pandemic, we had the whole county vaccinated within a week or two, receiving national recognition for this as well.”

Although several of Adams’ opponents in the 2nd Congressional share her progressive views about single-payer health care, she believes that her hands-on experience in hospitals and leadership role in public health makes her the real expert in the race. After all, how many other 2nd district candidates can boast of “delivering hundreds of babies as a nurse”—a track record that, according to Adams, insures that she’ll “deliver for us in Congress.”

“You’ll be my boss,” she tells the voters of the north coast,” not Wall Street, millionaires, or corporate donors.”  With women holding less than 17% of the seats in Congress, she also hopes “to bring more common sense and collaboration to the table” in Washington. At the very least, at a time when right-wing Republicans are targeting feminist gains on many fronts, it certainly wouldn’t hurt to have an outspoken RN and grandmother of four fighting to protect women’s reproductive rights and access to health care, including contraception.

Win or lose, Susan Adams is the kind of nurse that many patients have been glad to have at their bedside and in the delivery room. She’s a credit to her profession—a living, breathing affirmation of the RN’s duty to be a “patient advocate,” in the broadest and best sense of that term.

(For more information on the Adams campaign, see www.SusanAdamsForCongress.com)

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So here is an excerpt:

SEVERAL DAYS AGO, A FRIEND, WHO IS A MEDICAL EDU-
cator in a residency program at a medical school,
told me a tale. She was accompanying an intern as
they trailed alongside an attending physician who was
seeing patients in an out patient clinic. He
examined three patients in a row and did not clean his
hands before or after examining any of them….

This is about all I can show you, but article makes some suggestions about how to really make patients a part of the hand-hygience process.  And believe me, the solution is not to expect patients to ask their doctors and nurses if they have washed their hands.  We just won’t do it.  It’s too scarry.

In fact, I wonder how many physicians and nurses have ever had patients ask them if they have cleaned their hands?  I would love to know if that ever happens.

I hope people find the JAMA article of interest.

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But that was okay, she was told, because the health care system was updating its computers and introducing all sorts of electronic wizardry (healthcare information technology (HIT) — the kind the Patient Protection and Affordable Care Act (PPACA) has supported and which promises to protect patients from all manner of frightening medical errors and injuries.  Because she was early for her appointment with the doctor, she could take the time to fill out a bunch of forms that would provide critical information that would be entered into the computer and would help physicians and nurses etc make better judgments.  (Obviously, I added the nurses here because no one in health care would ever talk about anyone on the team other than physicians).  Fine, my colleague thought, I’ll be glad to fill out all your forms.

A smart, very literate, upper middle class woman in her sixties, my friend devotedly began reading the forms and trying to enter the correct information, and that’s where the trouble began.  First, she said, they asked her how many sexual partners she had had.  She was incensed.  “Shouldn’t this be a question your doctor asks you? And anyway, who can remember?  I put down many.”

Next they asked her about family history.  Did anyone in her family use alcohol.  “Use?” she asked, “What do they mean by that.  Do they mean abuse?  How do I answer that question.  My father was an alcoholic.  My brother had problems with alcohol but stopped drinking.  My other brother drinks a glass of wine on the weekend.  So what does ‘use alcohol mean exactly in this context?”  My colleague told me there was only a tiny space, an inch by an eighth of inch precisely, in which to make any further notations on the health issue in question.  When it came to her own alcohol use, she was equally stymied.  How, she wondered, does she explain that she used to drink a lot, stopped drinking so much, except at weddings, when she occassionally got bombed, and now has stopped drinking at all because she’s trying to lose weight.

“All of these health issues and our behaviors are dynamic,” she astutely commented.” We read that you shouldn’t microwave with plastic and so you don’t.  You discover that if you weigh 160 pounds, you’re now at the edge of obesity, so you go on a diet.  You aren’t supposed to eat eggs or butter, so you don’t.  Then they tell you it’s actually good for you to eat eggs and some butter, so you do.  How does that fit in an inch by an eighth of an inch?”

As she dutifully proceeded with her family history, she was again stymied by the questions.  Did any family members have headaches.  Well, yes maybe.  Her mother had a really bad headache when she had a brain tumor.  Did they have skin problems?  Her mother had some in her 90′s and her brother had psoriasis.  Is that a yes?  I guess, she said.  Did any of her grandparents have rectal bleeding?  Her paternal ones died thirty years before she was born, so how did she know?  “If I don’t check the box, does that mean they didn’t?  Maybe they did.  I don’t f…..ing know.” She was getting pretty frustrated by now.

Things were no better when it came to questions about her own health.  “They want to know if I have bladder or urine incontinence.  What the hell is the difference?  Did I smoke and  how much?  Well thirty years ago, I smoked a lot.  But sometimes it was two packs a day and sometimes nothing.  There was no room to make those distinctions.  Amazingly, they didn’t ask whether I’d had hormone replacement therapy, which I did.  You’d think someone would want to know about that,wouldn’t you?  As for exercise, they want to know yes or no, and kind and frequency.  Well I bike eight miles, walk for thirty minutes, use weights etc.  There is no room to detail all of this.  The whole thing is ridiculous.”

What was the most unnerving for my colleague was the idea that decisions about her healthcare would be made on the basis of someone — god knows who — interpreting the answers to these questions.  “When you talk to your doctor, you give him all this information and he or she knows what to look for — hopefully — and can make some kind of sense of it all.  They can ask more questions, they can learn something about you.  This….This was a joke.  And I really tried to figure it all out.  Imagine what most people would do with this.”

Maybe somebody in Washington is listening.  Maybe someone will read this and rethink all this magic silver bullet stuff.  In my new book, First Do Less Harm: Confronting the Inconvenient Problems in Patient Safety co-edited with Ross Koppel a world renowned specialist in HIT, Koppel and other raise many of the problems that HIT brings with it.  My colleague’s final word on all this?  “Why don’t they just sit down with us and ask us what they want to know and then let us really tell them?  Oh, and by the way, after sitting and trying to fill out this form, it turned out my doctor couldn’t make the appointment because she was in the hospital delivering a baby.  I asked them if I could get my co-pay back but they couldn’t figure out how to get the computer to do that.”

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1. So Much for the Latest Silver Bullet
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There’s a lot of talk about including patients in their own care but what about action?In my experience as both patient and observer, there’s not enough in this regard.Take the issue of medication errors.In my experience, doctors and nurses don’t take enough time to thoroughly go over details about the medications they are giving and how they should be taken. Here are just two examples – one from my own experience.

Several years ago, when I was hospitalized for appendicitis and received a laporascopic appendectomy, I got a serious complication following the surgery. Because the surgeon chose not to catheterize me during the surgery, I developed a urinary retention problem. When I left the hospital, unable to urinate properly, I had to straight catheterize myself more than 5 times a day. I also had to consult a urogynecologist. This physician decided to do a cystoscopy to see what was up – or rather why what was up wouldn’t go down. I was pretty much a wreck during all of this. I was still recovering from the surgery plus I had to deal with this awful complication.

So there I was in the room where the procedure was to be performed.  The nurse gave me a packet of pills – an antibiotic to prevent a urinary tract infection and another pill whose use I can’t remember.  I was told that I should take 100mg of antibiotics two times a day. Instead of giving me four 100mg tablets, I was instead given eight 50mg pills. The nurse went over what I was supposed to do – not just once but twice. She asked me if I understood. I said yes, I did, thinking to myself “I take one pill in the morning and one at night.” What she never asked me was exactly what I had understood.

So I went home and took one pill in the morning and one pill at night and the next morning I took another pill. And then at night I discovered that there were two pills left over. Woops, it was only then that I realized I had made a mistake and not taken enough tablets. I had misunderstood and because neither nurse nor physician had asked me what I had understood, which would have revealed the misunderstanding, I developed a urinary tract infection.

Case number two is a patient with diabetes who was given instruction in how to give himself insulin shots. Demonstrating on an orange, the nurse showed the patient how to inject himself at home. Or so she thought. The doctor taking care of the patient was surprised that the insulin was having no positive effect on the patient’s blood sugar levels. So he upped the insulin dose.  Again there was no affect. So again he upped the dose.  When this had no affect either, he decided to talk to the patient. What was he doing to take the insulin, the doctor asked?” Well,” said the patient,  ”I’m doing just what the nurse showed me to do?” And what was that the doctor asked. Turns out the patient had understood that he was supposed to go home, inject an orange with insulin and then eat it.

Now you may laugh at this patient, or at me. How could we both be so dumb? Well, guess what: it’s easy. Many of us aren’t operating on all our cylinders when we are at the doctor’s or with the nurse – particularly if we are sick, vulnerable, and anxious. Sometimes, we hear the words, but they don’t register. The save button just doesn’t get pushed on our mental computers. Sometimes we totally misunderstand. Although we may be trying desperately to be good compliant, patients, we comply with what we assume to be correct, which is not. Nurses and doctors, then assume that because we are nodding our heads and saying we understand, that we actually do.

Well assumptions are always – and I mean always – dangerous. Because a lot of the time what we assume is totally false.

There’s a really simple way to deal with this. Talk to the patient. Ask the patient what they have understood. If you are a doctor or a nurse, or a PT, OT or pharmacist get them to repeat back to you what you have just told them. If the nurse who’d been using the orange to demonstrate the process of injection had just asked the patient what he was going to do when he got home, she would have quickly discovered that he’d totally misunderstood her instructions. If the nurse and doctor had asked me to repeat their instructions, I would not have gotten an infection.

It’s so very, very easy. So why does it have to be so very, very hard?

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Check out nursing websites and what you often find are hearts and smiles.  Like for example, Johnson and Johnson’s Campaign for Nursing’s Future. Smiling nurses greet you on every page.

In fact, the Campaign is actually asking nurses to send in pictures — all with a smile — for a mosaic they plan to prepare to inspire and encourage.  As they put it, “Your Smile Will Help Nursing Students Get a Picture Perfect Start”

“In preparation for our 10th Anniversary celebration this year, the Johnson & Johnson Campaign for Nursing’s Future is creating a unique mosaic image that celebrates the nursing profession.
A photo mosaic is a compilation of many individual pictures that are used to create a single image. In recognition of the ten years that the Campaign has been making a difference in the nursing
profession, we are working to collect ten thousand images and have extended the deadline for picture submission until April 30, 2012. The Campaign plans to unveil the final mosaic this fall.”

What’s the probem with smiles?  A lot.  First of all, the focus on all smiles, all the time makes it look like the nurses’ job is simply to cheer people up and on.  Smiles hide the fact that nursing is cognitive work, not sentimental work.  We need nurses because they save our lives, because they prevent catastrophic complications, because they have knowledge, not just kindness.  Of course kindness and caring are critical.  But when it comes to sick patients, kindness and caring involve knowledge work, not virtue work.  Nurses have to know a great deal and maintain enormous self-discipline in order to be kind and caring to people who are sick and in pain, often irritable, sometimes angry, and sometimes even aggressive and at times violent.  This is not work for the faint-hearted.  Or as one wonderful documentary about nursing once put it,“Sentimental Women Need Not Apply.”

From hospital advertising, and media campaigns like J& J’s, it would seem that nursing is only interested in attracting sentimental women and men.  I can understand why J&J harps on the sentimental aspects of nursing.  The company desperately needs to mobilize the “halo effect,” that a connection to nursing provides.  Big Pharma is, after all, not exactly flavor of the month and J&J is a company that has been attracting a lot of bad PR these days.  Just two days ago, an article in The New York Times exposed the fact that J&J has been peddling an artificial hip that was banned in the US in many foreign countries.  The article, entitled, “Hip Implant FDA Rejected Was Sold Overseas,” details the fact that the company has marketed an all metal hip socket cup with a faulty design.  The DePuy orthopedic division of J&J recalled the device in 2010 and has continued to sell it overseas.

This is not the only time that the company seems to have placed profit above patient safety .  In her book Blood Feud, investigative journalist Kathleen Sharp details how a J&J subsidiary marketed an anemia drug, known sometimes as procrit, or epogen (or to cyclists into doping -epo) for dialysis and cancer patients.  J&J encouraged its pharmaceutil reps to market the drug in doses much higher than was safe and to use it for off-label uses for which it was not tested.  Reps used bribes and kickbacks to doctors, hospitals, and pharmacists in order to encourage them to prescribe and stock the drug.  It’s a sorry tale and helps to explain why companies like J&J are so eager to connect themselves with smiling, comforting looking nurses.

Nurses themselves, however, are promoting the image of a professional whose only job is to smile at patients and occasionally hold their hands.  This morning I found an article in The Kansas City Nursing News entitled “Nurses pack sile into meal deliveries.”  The article describes the work of Babette Orlich, a neonatal ICU nurse at North Kansas City Hospital who volunteers to deliver meals her hospital prepares to people in need.  Instead of focusing on the important knowledge she mobilizes to help these sick and vulnerable clients, the article and the nurse herself focus only on the niceness of the nurse and the act of kindness she performs.  Instead of telling us that a nurse with her qualifications is mobilizing knowledge and skill when she enters the home of a sick and vulnerable person, she focuses exclusively on how sweet she is and how good she feels because of her charitable activities.  She greets them with a “sack and a smile,” the article tells us. “I might be the only one they talk to that day,” she explains.  “Hand-holding and smiles are all part of the experience, she said.”

A retired nurse, Evelyn Grill, who also delivers meals, talks about the fact that she has made long-lasting friends over the years.

What’s my problem with this article and the way nurses talk in it?  Am I a grumpy, uncaring lout?  No, I value nurses’ caring.  But this article and so many others like it devalues the knowledge and skill nurses have.  Nowhere in it, do you learn why it’s a plus to have a nurse delivering your lunch or dinner rather than  some other charitably inclined individual.  An ICU nurse will not only hold your hand or smile, they’ll notice if you have a serious problem that deserves more attention.  They can tell if you’re having trouble walking, if your house is a danger zone, if you’re at risk for a fall or some other accident just waiting to happen.  Even the smile and the hand-holding is serious business — not just a nicety or icing on the cake.  Socially isolated human beings do not recover, and if they are in decline, that isolation will only make things worse.

An article like this provides an opening for nurses to explain what they know and why their work and knowledge is so important.  Rather than taking advantage of this opening, nurses have been studiously tutored to slam the door right in our face.  I don’t blame these nurses for that.  Their socialization in what Sioban Nelson and I call the virtue script has made this almost inevitable.  But it’s time for nurses to tell the world what they do and why focusing on smiles is just not enough.

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Emanuel (the doctor, not the mayor) made this blatantly false accusation in a Jan 22  New York Times opinion piece.  In his article, entitled “What We Give Up for Health Care,” he stitches together a complete straw man – in the form of “liberals” (who knew America still had any?) who are so concerned about securing universal health coverage that they fail to grapple with the problem of medical cost inflation and thus end up depriving other government programs of needed funding.

According to the good doctor, the aforementioned “liberals” view any discussion or promotion of health care cost containment as just “ a cover for heartless conservatives who care only about cutting benefits and not about helping people in need.”  “Liberals,” he opines, “are wrong to ignore costs.”

This political smear may have attracted the  attention of  The NYT’s opinion page editors, but Emanuel’s claim is clearly as specious as it is sanctimonious.

Which liberals is Emanuel referring to?  The ones who have been fighting to replace our private insurer and employer dominated healthcare system–that is indeed the most costly in the world–with a single payer plan that would save many billions of dollars? (Sadly, such efforts have never been supported by either Emanuel brother, before, during, or after their influential White House years).

Has Dr. Emanuel forgotten about all those liberals (and other left-of-center health reform advocates) who have correctly targeted Big Pharma, medical equipment manufacturers,  the insurance industry, for-profit hospital chains, and more than a few overpaid medical specialists as major cost escalators in our current system?

In real life, liberals and other progressive healthcare reform advocates are the very people who have been criticizing, for many years, the waste of precious healthcare dollars on unnecessary medical plan marketing and billing costs, not to mention the extravagant salaries and benefit packages bestowed upon hospital administrators and private insurance company executives.

Liberal and radical whistle-blowers have – over and over again — exposed the way huge drug industry profits have been generated from the systematic bilking of the sick, the government, and private insurers, leading to the highest pharmaceutical costs in the industrialized world. These same critics of the status quo have catalogued the cost of under-regulated pill peddling –in the form of direct to consumer advertising, bribing doctors to prescribe off label uses of new drugs,and  producing phony studies to validate and promote FDA approval of these medications (to name only a few costly and unhealthy Big Pharma practices).

Those to the left of Dr. Emmanuel have long noted that American physicians earn much higher salaries than their European or Canadian counterparts, who operate in national health care systems. MD compensation in the U.S.helps  boost our overall health care spending because it is far beyond levels necessary for doctors to pay for their currently very costly medical education and then open,  join, or maintain a medical practice. In any rational system, of the sort most liberals support, medical education and medical practice overhead costs would be socialized.

Finally, we know that Emmanuel’s brother is no fan of unions. But is he himself unaware that one of our largest liberal institutions –  organized labor –spends a huge amount of time trying to help unionized employers save money on health care costs?  These “cost-containment” efforts are, for better or worse (depending on the union involved) a very big part of private and public sector collective bargaining everywhere in the U.S.

In reality, it is not liberals, but conservatives, who have consistently thwarted any effort at real cost-containment – other than various forms of benefit reduction and/or cost-shifting.  It was the well-known non-liberal, President George W. Bush, and his bi-partisan allies in Congress who made sure that the federal government would not be able to negotiate better prices with the pharmaceutical industry when Medicare drug coverage was expanded during his administration.

Conservative legislators, before and since, have always been against any cost-effective regulation of the insurance and hospital industries.  Instead, Republicans in Congress and presidential candidates like Mitt Romney are now focusing their political energies on attacking one of the best publicly-funded healthcare delivery systems in the U.S.–operated by the Veterans Administration.

Can Ezekiel Emanuel point to any single conservative proposal to curb medical cost inflation by addressing the real cost-escalators in the system – insurance company profit and overhead, out of control pharmaceutical costs, and/or costs incurred for unnecessary, futile medical treatment.

It’s an insult to people who have been struggling for real healthcare reform for decades to suggest that American liberals are oblivious to the need for healthcare cost containment. If our health care system was fundamentally reformed, U.S. healthcare costs might finally be brought in line with the rest of the industrialized world and the money saved would indeed be freed up for housing, education, childcare, infrastructure reform, etc.

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“All divisions of labor, whether the labor is physical or cognitive in nature, require distributed cognition in order to coordinate the activities of the participants.Even a simple system of two men driving a spike with hammers requires some cognition on the part of each to coordinate his own activities with those of the other.When the labor that is distributed is cognitive labor, the system involves the distribution of two kinds of cognitive labor:the cognition that is the task and the cognition that governs the coordination of the elements of the task.” [i]

Put in everyday language, what Hutchins is saying is that all the participants in a real Team are thinking not only about their individual work but also about how their individual work meshes with those of the other people with whom they are working.They need to know how to do – and how to think about – their individual task.But they also need to think about how their task, knowledge of their task, and knowledge of the changing context in which their task is performed, affects the activities of those with whom they are working – even if those people are not working right by their side at the moment.

Distributed cognition is much too complex a phenomenon to elaborate on in this short discussion, but one of its fundamental elements is the recognition that the people on your team are, in fact, thinking about their work, and not just doing “mindless work.”On the aircraft carrier that Hutchins describes, those involved in the crucial activity of navigation – the constant effort to figure out where one is and where one is going – combine different “… sources of data that are reasonably independent.” One crew member plots by means of visual bearings, another by means of radar, another by means of ocean depth.Each crew member, however, values the information gathered by the other – a fact that affords the team as a whole “the opportunity for the detection of error through the comparison of independently [calculated] representations.”That is, one crew member does not dismiss the other’s data and concerns because that crew member is lower in status, or acquired their information through direct observation rather than through “objective measures.”

A Danish nurse once told me about a lecture she’d attended given by a military General to a group of health care professionals: The General told the group that when an army is in battle, and a private says, “Stop! there’s a mine,” we don’t say, “no we won’t stop because the person providing this information is just a private.”We all stop.You in health care, he told the audience, are [also] on a battlefield, but when the equivalent of a private – say a nurse – tells a surgeon to stop, you don’t ignore the directive because that person giving it is “just a nurse’.”

The point?In the army everyone implicitly, if not explicitly, recognizes the concept of distributed cognition and acts accordingly.Meanwhile, in health care, concerns about status often lead people to devalue the important information those of lower status actually have.

This is not true in healthcare.Doctors tend think that they are the only people who have minds and actually think critically.They, therefore, devalue what nurses have to say because they don’t understand that nurses bring a different perspective – different that is, not inferior.And they aren’t the only ones who fail to recognize the reality of distributed cognition.RNs mimic physicians in their relationships with people who are lower on the occupational totem pole.Consider the term advanced practice nurse, for example.This term suggests that a nurse practitioner, nurse midwife, or nurse anesthetist – to cite only a few examples – is the only one who has an advanced practice, while a bedside nurse is what… inteferior, retarded?Or consider the RN who looks down on the Licensed Practical Nurse (LPN) or aide because only the RN has critical thin king skills – and thus cognition worthy of the name.We will never be able to keep patients safe unless all those who work in health care recognize that everyone who is near or around the patient has a valuable perspective and valuable information which must be both acknowledged and respected.

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The movie is about a nurse who is stuck with a needle at work and contracts HIV and eventually dies of AIDS.  Evans plays one of the real life lawyers — Mike Weiss, who along with attorney Paul Danziger, was contacted by the nurse as she was sick and dying.  She had a friend who had designed a safe needle that no hospital would purchase.  The needle is a retractable one that makes it almost impossible for a nurse or anyone else to get a needlestick injury.  The two lawyers represented the inventor of this safe,retractable needle and discover that what would seem so obvious as to need no discussion (that hospitals would rush to purchase the safest possible needle available) is absolutely out of bounds.  Hospitals won’t even meet with the inventor, because large Group Purchasing Organizations (GPOs), are middle men between anyone selling anything to a hospital and the people in the hospital who purchase everything from needles to bedsheets.  These GPOs have enormous clout and companies spend millions to influence what they in turn offer to hospitals and other healthcare facilities.

As the story unfolds, Weiss and Danziger (Evans and Mark Kassen) go through the looking glass and enter the bizarre world of kickbacks and corporate influence.  As they pursue their case, they encounter big money lawyers who represent the GPOs and a huge corporation that makes unsafe needles and that is willing to pay anything to destory any competition whatsoever in our so-called free market system.  The movie focuses around this struggle and also on the sad fate of Mike Weiss, who was a brilliant but troubled individual – a drug user who eventually died of an overdose and was unable to complete work on the case.

The movie is a gripping reminder that in spite of some legislative victories many hospitals today still use unsafe needles.  Which is why there are 800,000 needlestick injuries in the US every year.  Yes, every year, nurses, doctors, aides, housekeepers and more are threatened by injuries that could be prevented immediately if hospitals used the kind of safe needles you’ll see on display in this movie.  That means thousands of health care workers are at risk for contracting HIV, hepatitis and other blood borne infections.  These workers then become patients and face immense suffering and even death.  Plus, caring for them adds millions to health care costs.

If you go to the Puncture website, you’ll a great deal about needlestick injuries as well as the scourge of these GPOs, which are purchasing cartels that negotiate over $100 billion in contracts each year and are actually allowed, by law, to give kickbacks to hospitals who purchase from them.  You can also check out a book by Sethi S. Prakash entitled Group Purchasing Organizations: An Undisclosed Scandal in the U.S. Healthcare Industry.   Which is why Congress needs to act to make what is now legal illegal.

Anyone who is a nurse or nursing student — or the parent of a nurse or nursing student — should become involved in this issue.  Be aware, your son or daughter could be at great risk for a needlestick injury because the same kind of corporate greed that has jeopardized our economy continues to jeopardize the health of almost every healthcare worker in America.

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A story entitled “Ban on Cell Use By Drivers Urged,” reported that the National Transportation Safety Board (NTSB), the national agency that is responsible for traffic safety, recommended a ban on all cell phone use because of the danger of distracted drivers.  Turns out 35 states have bans on texting while driving (which means that 15 allow people to text while driving) and only 9 have bans on driving while holding a phone in one’s hands.  Despite the overwhelming evidence, not a single state has bans on cell phone use on the road and 41 allow people to chatter away holding a phone in their hands and driving.  So what has this got to do with cell phone use in hospitals and other health care settings — the subject of the second New York Times article entitled, ” As Doctors Use More Devices, Potential for Distraction Grows?”

This article discusses the fact that more and more doctors and nurses are urged to use  cell phones and other electronic devices to check on the latest developments in medicine, make sure they’re using the right dose of a medication, or search the literature for the right treatment for a malady.  Problem is, they’re also using these electronic devices to check their email, shop on line, text a pal, or phone a friend or loved one.  Not just when they’re on break, but during surgery, or when they’re checking on a patient.  One neurosurgeon, during surgery, reportedly, made ten phone calls to friends and business associates according to an attorney representing a patient who was harmed during the surgery. This is a dangerous distraction, observors note.

Duh!!!

While the Times story depicts this phenomenon as surprising,  the juxtaposition of Wednesday’s story about texting while driving and the Thursday story about texting while doing surgery is very revealing.  In a society that is still debating whether it is safe to text while driving and has not banned texting (not to mention hand held phones) on every road in the nation, why are we surprised that inappropriate use of electronic devices has invaded the professional space of the hospital?

The fact that people are so obsessed with their own need to communicate with a friend, loved one, or business associate while driving that they forget they have a moral and social obligation to focus on the road and not hurting others who share it, parellels our social amnesia in the hospital.  Today, the boundary between the personal and professional, the duties of the latter and the whims of the former have been entirely blurred.  So have the boundaries between one’s obligations and rights as a citizen and one’s rights as an individual– as in the obligation not to kill someone else when you get behind the wheel.  People now feel that their right to self-expression (as in, “honey, don’t forget to get the milk” or to blather away about a boyfriend or the movie one saw last night) supercedes any concern for the safety of other people.  The same people who are texting away on the road now populate the staff of hospitals and other health care institutions.  No one, moreover, is holding them to a higher standard.  The surgeon who called his friends and business associates ten times did this in front of other OR staff – circulating nurses, anesthesiologists, surgical techs etc.  Where were they when this was happening?  Why did no one intervene?  Were they on their cell phones too?  And where is hospital administration and the Joint Commission, and Congress?  All texting too?

I’m all for individual rights and worker’s rights.  But this has got to stop.  Texting is an ever-present temptation.  But as a species we’ve been tempted even before Adam and Eve.  Doctors and nurses aren’t allowed to pick up the phone in a patient’s room and have a chat with their husband or wife.  For years, there have been phones in the OR, but people didn’t take a time out so they could call their broker.  Why do they do this cell phones and other devices?

My suggestion for the OR is one person should be designated as the one who checks things out, just like the circulating nurse is the one to find out needed information now.  Only that person is allowed to use a cell phone, period.  Hospitals need to enforce new rules about electronic use.  By the way, if your doctor needs to check out what procedure you need or how to do it while you’re unconscious in the OR, you are in bigger trouble and at greater risk than you’d ever imagined.

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I had just come out with my book Prisoners of Men’s Dreams and my editor at Little, Brown and Company had this idea — fantasy really — that the book would somehow go far among the women in corporate America.  I can’t really remember all the details but she somehow sent a copy to Estee Lauder, or Evelyn or someone in corporate, who knows but suffice it to say, Evelyn Lauder saw a copy of the book and evinced an interest in having lunch with the author — i.e. me.  I lived near Boston and she was in New York.  Having lunch with Evelyn meant I had to come to New York.  My editor thought it would be worth it.   Her fantasy was that Evelyn would fall in love with me (literarily speaking that is) purchase thousands of copies of the book, distribute it to folks within Estee Lauder and voila — a bestseller is born.  Having had some experience with the one percent, I was a bit more jaded and, dare I say, realistic.   I told my editor that if Evelyn Lauder or Little Brown wanted to pay my way to New York to have lunch, I’d be glad to do it. No way was I spending any of my money on the trip.  Enthrall to her fantasy, my editor said Little, Brown would fork out the money and off I went to New York for lunch.

The lunch was at the Four Seasons.  Back then The Four Seasons, on Park Avenue, was a huge restaurant, with spacious rooms and elegant furnishings.  It was one of THE hot spots for the literati and gliterati.  My editor and I arrived early.    As the Maitre d’ escorted us to “Mrs. Lauder’s Table,” I wondered if she had paid for it in full, so that no one else could ever sit at it, or if it was just borrowed, “Mrs. Lauder’s Table,” when Mrs. Lauder was the lady who lunched?  The table was just like any other four seater, and I began to sit down at one of the chairs.  Big mistake!  As if an untouchable had just been about to sully the throne of a Brahmin, the Maitre d’ practically grabbed my arm to drag me away.  “That is Mrs. Lauder’s chair!” he exlaimed.  God, who knew that Mrs. Lauder not only had her table but her own chair at said table?  Suitably chastened, I began to get the picture.  Do not do anything here at the Four Seasons that Mrs. Lauder has not authorized.

Finally, the great lady arrived and, as I suspected, the  slumming began.  It was pretty clear from the very moment of introduction that my editor’s fantasy was not to be fulfilled.  Evelyn had a free day with nothing of import and why not meet with some writer who might be of interest and to whom one owed absolutely nothing.  We chatted about this and that — all of it imminently forgettable which is why I have forgotten it all.  The waiter arrived with menus and began to tell us about the specials, one of which was lobster salad.  Mrs. Lauder order lobster salad.  My editor ordered lobster salad.  I did not want lobster salad.  As a foodie, I was perusing the menu to see what else The Four Seasons offered.    Like the Maitre d’, the waiter took his status and hierarchy very seriously and had sniffed out who was who in the pecking order at this particular table.  First came Mrs. Lauder, then my editor — a New York would be great lady dressed to play the part — and me, low woman on the totem pole, apparently also dress to play the part (although who knew?).  The waiter grabbed the menu from my hands and whisked it out of sight before I’d finished scanning the appetizers and could move on to the main course.  I guess I was having lobster salad too, like it or not.

As we ate our salads and made small talk, it became clearer and clearer that Mrs. Lauder had never had the slightest intention of doing anything to help promote my book.  Suffering from a case of terminal denial, my editor could not fathom this very evident fact and kept quietly nudging.  I wanted to kick her in the leg, but refrained.  Salads finished, it was time for dessert.  Same drill.  Mrs. Lauder ordered, editor did same, I vainly tried to look at the dessert menu but the waiter knew who was who and what was what and I had what they had.  I’d like to say that I had tea while they had coffee or some such but I honestly don’t remember and can’t imagine I was able to defy the court protocol in any way.

Finally, this entirely wasted lunch was over and I was out of there, glad only that the trip wasn’t on my dime.

The obit about Evelyn Lauder in The New York Times told of Evelyn’s struggles with the domineering grande dame of the Lauder clan, Estee Lauder, who was apparently a major piece of work.  Over her years in the family, Evelyn definitely learned a thing or two about dominance and submission.  That was what I remember from that day in New York.  I was a member of the 99% and the people in the 1%, or who served the 1 % would never let you forget it.  Like dogs marking their territory, it was all about status not about ideas, or good conversation, or, in this case, good works.  Of course, Mrs. Lauder, like so many rich women before her, dabbled in philanthropy, or good causes and interesting people.  Like other trophy wives whose families horde most of their millions (or billions), and give away a pittance, she did her fair share of good works.  I suppose, given the alternative (say Steve Jobs who gave away almost nothing), it’s better that she did that than kept it all.  I have only this one encounter to judge by.  But once again, it highlighted that one immutable fact.  The rich are different and they are determined to never let you forget it.

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