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Improve Health Literacy in Poor Communities: Start a literacy program
The Gift of a Reflective Question
Improve Health Literacy in Poor Communities: Start a literacy program
Quick easy cheap health literacy aid
What should be the core conversation between a doctor and an individual s/he sees for 15 minutes per year?


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What should be the core conversation between a doctor and an individual s/he sees for 15 minutes per year?

This question was raised by Winston Wong, Director of Disparities Improvement and Quality Initiatives at Kaiser Permanente, during the Institute of Medicine's recent workshop, Health Literacy: Past, Present and Future.
The workshop marked 10 years since  IOM released the landmark report Health Literacy: A Prescription to End 
Confusion.  A summary of the workshop proceedings was released this month. Download a summary of the 
workshop free from National Academy of Sciences. Definitely worth the read.

Here's the part that made me stop and applaud

In a discussion about health literacy and its role in achieving equity, Wong  recounted a conversation among
health plan leaders on patients' non-medical needs (social determinants of health), that led to the question: 
What should be the core conversation between a doctor and an individual s/he sees for 15 minutes per year? 
“One interesting proposition is that we should start the discussion with every person we come in contact with 
by asking 'what does a good day mean to you,’" Wong said,  "because that’s really a much more important 
question than ‘what hurts’ or ‘have you been taking your medicine today.’”

Why is this question more important than typical problem-focused inquiries?

It's empowering.
Wong said it reflects the fact that medicine can help with some problems, but what ultimately makes for a 
good day for someone is determined by a constellation of actors that foster good health. The question 
recognizes that on average Americans spend about one hour per year in a clinical setting; the healthcare 
professional is just one actors; s/he marshals resources that account for about 10% of health.  The other 
actors are the people the individual is with the other 8764.81 hours per year. The power to create health, 
and to live well with disease, is with the patient.

What is a good day like for you? addresses the person and his/her "real life",  instead of focusing narrowly
 on the patients' disease and treatment. It suggests the patient's selfcare is achieving some good days, rather 
than reducing the person to a medical problem and assuming that s/he has failed to comply with the medication

What is a good day like for you? is a good reflective question.

> It cannot be answered yes or no. It requires the respondent to think critically about what matters to them,
 to reflect on what they want from medical care and how they will know they got it. It leads to conversation 
about what the person is able and willing to do now to achieve more good days.

> The response serves the patient, rather than simply informing the clinician.

> The response enables the clinician to hear and adopt the patient's words, so the patient is not expected 
to learn medical terminology, and the clinician is not expected to check a glossary of simplified terms.

>  The question allows the patient to figure out and articulate what they want and need, making it easier
 for the provider to achieve patient satisfaction.

> It shifts thinking and conversation from what patient and clinician do not want — disease and suffering— 
and how to get rid of it,  to what they do want —good days— and how to get more of them.

The hard part is waiting for the response

Patients are not accustomed to being asked reflective questions, especially by clinicians. Many, especially 
those who live in poverty and face daily discrimination, are rarely asked questions and may be trained not 
to think.  The reflexive first response is likely to be "I don't know".  They need a way to think about it. Try 
again; Can you remember a good day or a good moment?  Then the hard part: wait.  Let them be the one to
fill the silence.  Ask follow up questions to help the patient clarify what s/he wants, and what will tell her
that she got it; what has worked before and what is needed to achieve more good days. An effective
conversation will end with the patient articulating the action s/he will take and the clinician offering 
supportive information and services.

More on reflective questioning

Reference & further reading:
J. Michael McGinnis, Pamela Williams-Russo and James R. Knickman The Case For More Active Policy Attention
To Health Promotion Health Affairs, 21, no.2 (2002):78-93 doi: 10.1377/hlthaff.21.2.78   Full text online at http://content.healthaffairs.org/content/21/2/78.full.pdf


BLEEP Gag Rules Threaten Public Health, Child Health Protect right not to think

In Florida, if someone scares you to death you can legally shoot them to death with your BLEEP.  But your 
family doctor or pediatrician or health worker cannot legally ask you if a BLEEP is kept in your house or how
it is stored.
Apparently even thinking about the risk of unsecured BLEEPs to their children’s and visitors’ safety threatens  
parents’ and patients’ right to keep BLEEPs anywhere and any way they want.  This BLEEP has been Florida law 
since 2011. (The part that made asking about BLEEPs a felony with jail time and a $5 Million fine did not pass). 
Physicians groups challenged the law. It was upheld as constitutional in Florida since BLEEP ownership and safety 
is a private matter unrelated to medical care.
BLEEPs and tobacco are the only products on the market that when used correctly kill people; BLEEPS kill lots 
of people, often children, in a seconds.  So BLEEPS can’t be a private matter.

Safety Checklist for a Crawler: 
BLEEPS are unrelated to medical care until a child -or some one 
else- or the owner- is injured by the patients’ BLEEPs. Then
taxpayers fund emergency response and medical care for totally 
preventable horrific injury or death, and related court costs, 
increased insurance premiums, and lost contributions to society. 
And we live in fear…. Oh, I see, if you live in fear - get a BLEEP. 
The Texas legislature entertained a similar gag rule this month. 

Death in the United States: A Call to Action From 8 Health Professional Organizations and the American Bar Association.
Ann Intern Med. 2015 Feb 24. doi: 10.7326/M15-0337. [Epub ahead of print]
Ferrris S. Childrens Defense Fund report on ChildsBLEEP deaths, new BLEEP laws Data analysis: More preschool kids dead from BLEEPfire than 
police. May 19, 2014
Walters, E. Bill Would Prohibit Doctors From Asking About BLEEPs. The Texas Tribune March 18, 2015

Pitts, L. Republican  list of things you cannot say. Seattle Times March 19, 2015

New nutrition guidance from the FDA: Eat more fish! But avoid the big, long-lived ones.

In a reversal of its recommendations that have for years cautioned against children and pregnant or breastfeeding women eating fish, the Food and Drug Administration’s new guidelines reflect recognition that fish is a great source of protein and other essential nutrients. For the first time, the FDA has specified a minimum intake of fish and other seafood.
8 to 12 ounces per week— 2 or 3 servings
That’s the new minimum recommendation for a healthy diet. Beginnings Pregnancy Guide (2014) recommends 1 or 2 servings per week, the previous maximum recommendation, now considered overly cautious.
The warning to avoid large, long-lived fish like swordfish, mackerel and tile fish remains. Those big fish live long enough to build up organic mercury in their flesh. According to MedlinePlus, medical evidence suggests that being exposed to large amounts of the organic mercury called methylmercury while pregnant can permanently damage the baby’s developing brain. Small exposures are unlikely to cause any problems.
Choose canned light tuna
Salmon, shrimp. and other seafood that Beginnings lists as safe and healthy, are still safe and healthy.  It is important to caution mothers against canned white albacore tuna since it has three times the mercury of the recommended canned light tuna. The FDA suggests limiting tuna to 6 ounces a week.

Beginnings Pregnancy Guide (2014) pg. 13

Use the Fish Safety Hotline
Call 1-888-SAFEFOOD That’s 1-888-723-3366 to check the safety of fish in your area. This free 24 hour resource is listed on the Pregnancy Guide’s Key Messages Poster and on page 42.

Example from the field: Medication instructions show lots of room for improvement

My dad, age 86,  was hospitalized with arrhythmia. Hospital medical staff said his heart muscle looked strong and undamaged, but later another doctor said he had a minor heart attack. Dad was sent home with several medications with instructions to stop all his usual meds - including the multivitamin, and the stool softener prescribed by his internist. The hospital  nurses could not answer why those should be stopped…  Three days later Dad quit taking the new meds. He said they made him sleep 20 hours a day, and made him stupid when he was awake.  Worried, Mom set an appointment with his personal physician who adjusted the meds, lectured him about the danger of stopping them, and gave him this summary of new instructions.

 New Medications

 Medications to Continue Taking That Have Changed

     Other Medications
     START: amiodarone (amiodarone 200 mg oral tablet) 1 tab(s) Oral, every day. Refills: 0
     STOP:  amiodarone (amiodarone 200 mg oral tablet) 1 tab(s) 2 times a day. Refills: 0
 Medications to Continue with No Changes
     Other Medications

     aspirin (Aspirin Enteric Coated 325 mg oral delayed release tablet) 1 tab(s) Oral, every day, Refills: 0
     dufoxetine (Cynbalta 60 mg oral delayed release tablet) 1 cap(s) Oral, every day. (do not crush or chew). Refills:0

 No Longer Take the Following Medications

     digoxin 125 mcg (0.125mg) oral tablet) 1 tab(s) Oral, every day. Refills: 0

     metoprolol (Metoprolol Tartrate 25 mg oral tablet) 1 tab(s), Oral, 2 times a day. Refills: 0

 Contact your Physician Prior to Taking the Following Medications


 Problem List
 No problem found

 Upcoming Appointments
 No appointment

While the summary shows good intent to inform the patient, it could be much easier to read, understand and act on.

1.     Delete the static 
Too many irrelevant words interfere with efforts to find the important information. The first heading  New Medications is meaningless. It amounts to static interference.  The information about meds to start and stop fits under the third heading:  Medications to Continue Taking That Have Changed; but an indented  subhead - Other Medications- is inserted between - more static. It’s another empty field on the form. These headings should automatically delete when the field is left empty.
2. Use upper and lower case. All the headings are in title case - all the words are capitalized. A capital letter signals the brain to stop and start something new. We recognize words by their shape. The cap changes the shape, and so slows reading and reduces comprehension.  It is odd that the proper names of the medications are not capitalized, but then in parentheses they are.
3. Use active voice and a verb in instructions. Medications to Continue with No Changes is a label.  A call to action is more understandable and actionable:   Keep taking these medications with no changes:
4. Make the changes clear. The information under START and STOP is very similar. It requires careful examination of every word and symbol to discern that the instruction is to take one a day instead of two. Few understand mg. Many do not understand oral, or tab(s), or the difference between cap(s) and tab(s),  or the meaning of delayed release.
5. Explain when to take the medication. What does 2 times a day mean? Before breakfast and after breakfast would comply with the instruction, but that might not be what the prescriber intends.
6.Use the Problem List (it’s a nice table on the form with cells for Onset and Comments). This would be a good place to give the patient and caregiver information about what these drugs are for.  The entry No problems found could leave one wondering why they are taking all this medication, and whether they should have seen the doctor.
7. Use the Upcoming Appointments form (another nice table with cells for date, time, location, appointment type(??) and provider.  The entry is No Appointment; but Mom has written in April 10, 1pm.
This form reflects an effort to be patient centered and improve compliance. But it is designed for ease and speed of entry by the provider, rather than for ease of understanding and right action by the patient and caregiver.  


Government shutdown is all FUD

FUD: Fear Uncertainty & Doubt. That is the foundation of the extreme House
Republican’ position on the Patient Protection and Affordable Care Act of 2010.
That’s why they call it Obamacare- in order not to say “protection” or “affordable”;
and  to hide the fact that the law was enacted 3 years ago, before the President
was soundly re-elected running against an opponent who vowed to repeal it.
FUD, initially an IBM strategy to eliminate market competitors by spreading fear
uncertainty and disinformation about their products, seems to be working for the
House Republicans. At least to some degree, for now. Polls and analyses of social
media suggest that some people favor the Affordable Care Act while opposing Obamacare.
Home visitors: “Obama snoopers” = FUD
I ignored the FUD like a parent ignoring a toddler’s temper tantrum until I saw
the Fox “news report” about the Affordable Care Act’s expansion of home visitation.
That’s  a preventive strategy in which public health nurses, social workers or trained
paraprofessionals connect families to healthcare and community resources and offer
health education and social support.  It’s origins date back to the 1800s. Programs
are run by county health departments, school districts, foundations, and private-public
partnerships. Home visiting programs are open to poor parents who request assistance.
It’s worth noting that in many countries, home visiting has long been standard for all
parents, because they acknowledge that parenting is a challenge and everyone can
use assistance. And because research shows it improves child developmental outcomes
and has immediate and long-term benefits that extend to entire families and to the
healthcare, education and justice systems. My researchshows that parents in home
visitation significantly improve their health literacy, capacity to manage personal and
child health and healthcare.
Pure FUD
A Fox announcer and a “business expert” called home visitors “Obama snoopers". 
They said  in this “brand new federal program”, “government home inspectors”
make random, unannounced  “forced home visits” to snoop on parents.  This is not
news. This is pure FUD - disinformation (lies) that specifically intends to instill fear,
uncertainty and doubt about the Affordable Care Act, to prevent people from learning
they can afford good healthcare coverage.
I have worked for decades with home visitors and know them to be among the most
caring, dedicated, respectful people on the planet, unlike the FUDders on Fox and in
the House.
FUD won’t work for long. Yesterday, the heart of the Affordable Care Act started
(keep saying the real name), opening access to healthcare for millions of poor and
uninsured citizens. Almost 3 million people visited www.heathcare.gov State exchanges
were similarly overwhelmed.  People are about to find out that the Affordable Care Act
makes good healthcare coverage affordable -for them. That will help them see through
the FUD.  Insurance companies are helping too. They are enrolling people they previously
rejected because, with the ACA, it’s good for business. Healthcare executives are calling
for more doctors, nurses and allied health professionals - doesn’t really sound like a
“job-killer” does it?
On the other hand, the House Republicans just put hundreds of thousands of people out of
work in hopes they can FUD us citizens of the richest country in the world into continuing
denying healthcare to poor people and sick people in order to preserve the freedom of
the rich to get richer.

Top Reasons to Promote Maternal Health Literacy #5 (#1 if you are talking to a legislator or business leader)

Skills beget skills. Cognitive and social skills needed to successfully manage
personal and child health and healthcare are those needed for success in
life across cultures. They are skills that empower people to  be what
they want to be, to make choices and transform those choices into desired
actions and outcomes. 
These life skills develop most easily in early childhood given a stable
supportive family environment. Disparity in brain development in children
growing in disadvantaged vs enriched environments becomes apparent in
the first year.  Quality of family life matters more than the number of
parents, their income or education. But poverty and accumulated disadvantage
prevent parents from doing their best to sustain the stimulating home
environments that support optimal development, especially when they
themselves lack skills, resources and role models. Early intervention ---
early childhood education, parenting training, family support and home
visitation programs--- can produce positive and lasting effects on children
in disadvantaged families.  
Nobel Laureate and economics professor James Heckman, makes the business
case for shifting public policy to support programs that offer parents information,
choices and assistance.  Promoting health literacy means providing direct
supplemental assistance that specifically and intentionally enables parents to
develop and hone the range of life skills used to participate in healthcare and
manage personal and family health at home.
Must read: Heckman,  James J. (2013) Giving Kids a Fair Chance (A Strategy
That Works) MIT Press, Cambridge, Mass.  ISBN 978-0-262-01913-2 
In addition to Heckman’s monograph, the book includes illuminating commentary
by 10 experts from multiple disciplines.

Pregnancy Guide Update: Obesity a disease?

The American Medical Association House of Delegates declared obesity a disease
last month. Is this good for maternal and child health?  For public health? 
It’s not new
In 1995 the National Heart Lung and Blood Institute called obesity a “complex
multifactoral chronic disease”. Ten years earlier, almost 30 years ago now,
NIH called prevention and treatment of obesity a national medical priority.
With 90 million Americans now officially obese, it seems few clinicians got the
Obesity prevention not a priority in maternity care
In researching issues of weight gain in pregnancy for  the update of the
Beginnings Pregnancy Guide, I found that weighing is still the only procedure in
early prenatal care that has shown any impact on outcomes. And yet it has
become uncommon for a pregnant woman to be weighed at prenatal visits or
when being admitted to a hospital for birth. Prenatal care providers have reported
they seldom weigh pregnant women or discuss weight for fear the conversation will
interfere with their patient/provider relationship. Others said they do not know how
to calculate BMI. They also must not know about the many BMI calculators that will
do it for them. One can only hope that calling obesity a disease will change these
Healthy mothers, healthy babies. Fat mothers, fat babies
The issue in pregnancy is that a mother with an excess of fat cells produces a baby
with an excess of  fat cells. So we are building obesity and the attendant health issues
into the next generation.
ACEs -Adverse childhood experiences - witnessing or experiencing interpersonal violence
is closely related to obesity. A woman fearing abuse may hide in obesity, intentionally
making herself unattractive to protect herself. Is that a disease? With medical treatment,
many such women have lost weight, and gained it right back. That’s how the lifelong
effects of ACEs were discovered.
Other mothers have said it doesn’t matter if they gain too much in pregnancy since
they are just going to get pregnant again; the weight can come off after that.
Only it rarelydoes.
Turning people into patients
Google “obesity disease”. The first thing that pops up is ad ad for weight loss surgery.
This may be more telling than official statements.
Especially when we consider the Forbes June 28 report that the AMA’s Council on Science
and Public Health, the group appointed to address the question, advised against declaring
obesity a disease. But the delegates chose ignore their own advisors.
We have to ask, what was so compelling?
Perhaps it is the implementation of the Affordable Care Act that will bring healthcare
coverage to millions of Americans previously excluded from the healthcare system.
At least a third of them are obese. Now they can be patients.
According to CDC 35.7% of Americans are obese, 49.5% of African Americans, 40% of
Mexican Americans. Rates vary widely by state. Find your state rate at
http://www.cdc.gov/obesity/data/adult.html.  Now all those people are diseased
and in need of medical treatment.
Calling obesity a disease, again, could draw attention to related health issues, but it
hasn’t in 20 years.  It could result in better maternity care, but the declaration is
unlikely to improve clinicians communication and counseling skills.  It could spark a
Kennedy-style physical fitness craze, but that entails behavior change, and the same
communication issues.  It could increase research on obesity, but NIH already has a
Strategic Plan for Obesity Research and funds nearly a billion dollars worth of studies
annually. Grants.nih.gov lists 49 obesity-related research solicitations currently open
for submission of grant applications. 
Only one thing seems certain, making obesity a disease will increase medical treatments
and costs, and revenue to AMA constituents.

Beginnings Pregnancy Guide Update: “Entertainment Ultrasound” Warning

Choose 2D, 3D or 4D.  In-studio or at your baby shower. Announce your pregnancy
with a “viewing party”. Get a video at the mall. Post it on Facebook. Select the
premium package offered by a Miami OB-GYN’s office and get a weekend discount.
The American Institute of Ultrasound Medicine, American College of Obstetrician
s and Gynecologists, American Academy of Family Physicians, March of Dimes,
US Food and Drug Administration, England’s National Institute for Health and
Clinical Excellence, the UK’s National Collaborating Centre for Women's and
Children's Health, and other national and international experts all have published
strong recommendations against non-medical use of fetal ultrasound.  The Society
of Obstetricians and Gynaecolgists of Canada calls for a complete ban on non-
medical use of fetal ultrasound. The state of Connecticut legislated a ban in 2009. 
The FDA says that creating fetal keepsake ultrasound images is “an unapproved
use of a medical device,” and those who perform ultrasonography scans “without
a physician’s order may be in violation of state or local laws or regulations.”
“You don’t need an excuse to be happy.”
Still internet ads for non-medical ultrasounds abound, complete with slogans like
this, implying you don’t need a medical reason for the “painless, relaxing procedure”.
The growing popularity of “keepsake ultrasounds” is not due to cost or access issues.
Most insurance companies pay for one or two doctor-ordered ultrasounds as part of
routine prenatal care, and commercial ultrasound is not cheap.
Prices start at $175 for the 3D in-studio option. $500 for an “ultrasound party”
at the location of your choice. The cheapest rate I saw was $75 for a basic “gender
determination” scan; it’s discounted to  $55 on Saturdays one OB-GYN’s office. These
commercial services are not regulated or standardized.
Safety Concerns
Commercial sonographers say that ultrasound is safe. I found unclear statements like:
“All research provided has been proven to be safe for expectant mothers and baby,
as long as the procedure is done by a trained professional, and no longer that one
hour intervals.”   First, we have to ask, research provided by whom? and What about
the research that was not provided?  Second, remember that no research ever proves
anything. It can only offer statistical evidence. Then, a more accurate statement is
that repeated ultrasounds have not been proven harmful. Still  the evidence has
convinced all the advisory and regulatory agencies that entertainment ultrasounds
are worrisome.
Ultrasound uses sound waves, not xrays. So radiation is not the issue. But the procedure
targets the fetus with heat and  pressure, especially prolonged, 4-D studies. New York
state legislators proposed a ban on ultrasonography for entertainment purposes, citing
data showing that 4Dl ultrasound equipment can emit eight times more energy than the
machines commonly used in medical settings. The risk of  effects on fetal development
has been demonstrated in both human and animal models, and remains, at least theoretically,
so that  the FDA concludes exposing the fetus to ultrasound with no anticipation of medical
benefit is not justified.
Additional concerns about non-medical ultrasonography include the possibility that non-
medical ultrasonography will fail to identify a problem with the baby, falsely reassuring
the patient and her family; or that a false-positive result could create unnecessary anxiety
and follow-up testing. Machines are unregulated so may not be properly calibrated or
maintained. Technicians may not be well-trained or proficient. “gender determination”
had never been an accepted use of of ultrasound technology and raises thorny ethical issues.
Medical ultrasounds are for doctors         
Here’s the problem:  In medical settings, the sonographer is commonly prohibited from
explaining ultrasound results to the patient, who must then wait for days or weeks to get the
results from the physician who ordered the scan. Family members may be barred from attending
the ultrasound appointment to avoid congestion in the radiology department. Parents may not
receive still pictures or video to take home. If they do, they still cannot send it to a friend or post
it online.  Until these disempowering practices change, parents and  sonographers  will continue
to seek a more informative,  convenient, family friendly experience. 

Check  Technician’s Credentials                      
Qualified sonographers are trained and certified. Find one, or check a technician’s credentials,

Beginnings Pregnancy Guides says, “Ultrasound is safe for you and Baby.”  [p8] That remains true.
The 2014 edition will add this statement: Many healthy pregnancies do not need ultrasound.
Extra  “keepsake" ultrasounds may be harmful.  The Registry of credentialed sonographers
will be posted on the new Mothers’  Resources page at www.BeginningsGuides.com  More on that later.

Don't Order Fetal Ultrasound Videos As Souvenirs: FDA

References:  http://www.aafp.org/afp/2005/1201/p2362.html#afp20051201p2362-b6

With few exception, childbirth is normal % healthy, but...

Of the 10 most frequently performed in-patient procedures,  5 are related to maternity 
and newborn care (2010 figures - latest available).
Bad news: the cesarean section (surgical delivery) rate continues to rise; it is up 41%
since 2004, despite global evidence that rates over 15% do more harm than good. This
is a place to cut the cost of maternity care. A cesarean section costs on average $9956
more than vaginal delivery.
Good news: Fetal monitoring, circumcision and stripping of membranes are performed
less frequently now than in 1997. The reduction in procedures returns to mothers some
control over their most significant life event, and begins to recognize that over-management
is not beneficial.
Procedure Frequency Rank       Number Performed in 2010           Increase in Frequency

Repair of obstetric                   1,292,000                                    No change

Cesarean section                      1,278,000                                    41%

Circumcision                            1,164,000                                    -31%

Artificial rupture of                  917,000                                      -5%

Fetal monitoring                      875,000                                      -23%

Mandy’s Story Part 2 A true teaching story about infant depression

Last time in this space I told Mandy’s Story about the depressed 8-month old
who transformed over the course of one week of simple everyday interactions.
The story illustrates the scientific work of Bowlby and Robertson on the stages
children move through when separated from their mothers due to hospitalization.
Mandy was well beyond the first stage in a child’s response to separation: Protest.
This stage is marked by wailing and sobbing in confusion, fear, grief at being
She was also beyond Stage 2: Despair. The child becomes more hopeless and
apathetic. She withdraws. Like Mandy. This going quiet is not settling in.
It is giving up and shutting down.
Mandy was well into Stage 3: Detachment (or Denial). She had suppressed all
emotion, including - maybe especially, feelings for her mother. She hardly
noticed when her mother left. She was so withdrawn that she sought no
mothering at all.  Now, i would recognize that as a sign of major psychological trauma.
There are many lessons in Mandy’s story. More on that next time. s
For a history of attachment theory and the stages of separation, plus a good
bibliography,  see Van Der Horst, FCP & Van Der Veer, R. (2009). Separation and Divergence:
The untold story of James Robertson’s and John Bowlby’s Theoretical Dispute on Mother-Child
Separation. Journal of the History of the Behavioral Sciences, Vol. 45(3), 236–252. Published
online in Wiley Interscience (www.interscience.wiley.com). DOI 10.1002/jhbs.20380 © 2009
Wiley Periodicals, Inc.
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