Employers’ efforts to reduce stress get low grades in a new poll by NPR, the Robert Wood Johnson Foundation and Harvard’s T.H. Chan School of Public Health.

In particular, among those working adults who say they’ve experienced a great deal of stress at work in the past 12 months, the vast majority (85 percent) rate the efforts of their workplace to reduce stress as fair or poor.

Overall, 43 percent of working adults who told us their job negatively affects their stress levels. Others said their job negatively affects their eating habits (28 percent), sleeping habits (27 percent) and weight (22 percent).

“The takeaway here is that job No. 1 for U.S. employers is to reduce stress in the workplace,” said Robert J. Blendon, professor of health policy and political analysis at the Harvard Chan School, who directed the survey. It included interviews with 1,601 workers, by landline and cellphone. The margin of error is 2.9 percentage points.

The poll also found that only about half of working adults have workplaces that offer wellness or health-improvement programs. About 1 in 4 rate their workplace as fair or poor in providing a healthy work environment, and more than 4 in 10 rate their workplace as fair or poor in providing opportunities for physical exercise or healthful food options at work.

About 1 in 5 working adults (22 percent) say something at their job may be harmful to their health, with chemicals and contaminants topping the list at 30 percent of those who have concerns about their workplace. We found 43 percent of construction or outdoor workers and 34 percent in medical jobs have health concerns in the workplace.

One of the obvious reasons for stress in the workplace may be overwork.

As is detailed in the poll report, working adults in our sample lived up to America’s reputation for being workaholics, with almost two-thirds of them saying they often or sometimes work overtime or on the weekends. About 1 in 5 say they work 50 or more hours each week in their main job.

Of course, taking breaks and vacations may help relieve stress. But our survey found that even among those who get paid vacations days, less than half use all or most of the days they earned in the past year. And when they do take vacation, 43 percent of high-pay workers say they often or sometimes work on vacation, with 28 percent of average pay workers and 18 percent of low-pay workers saying the same.

Why do Americans work so much? A majority (56 percent) of people working 50-plus hours a week in their main job say they do so because “it’s important for their career to work longer hours.” Half (50 percent) say they do so because they “enjoy it,” and 37 percent say they “need the money.”

These responses may be reflected somewhat in the chart below, where higher-paid workers more frequently say they work 50-plus hours, versus lower-pay workers.

It’s a similar story when it comes to sick leave. A majority of workers who get paid sick days and who did not use them all (73 percent) say they weren’t sick enough to use all of their days. More than one-third (37 percent) say a major reason why they didn’t take all their sick days is that they want to save them for another time, while 28 percent say there wouldn’t be enough people to cover their work.

Twenty percent of those who didn’t use all their sick pay say their workload made it too hard to take sick days, while another 20 percent say working more (and not taking sick leave) would help them get ahead at work.

Overall, just 16 percent of workers have used all of their paid sick days in the past year, while 6 percent used most, 45 percent used only some and 32 percent used none.

And then there are those who get no sick leave at all. While two-thirds of full- or part-time employed workers overall say their workplace offers them paid sick days, just 38 percent of workers in low-pay jobs say they get paid sick leave. Those ranking lowest in paid sick leave were those in construction/outdoor jobs (42 percent) and restaurant jobs (22 percent).

Does reluctance to use paid leave lead workers to go to work sick? A majority of working adults in our survey say they do just that. Of interest: Half of restaurant workers and more than half of workers in medical jobs say they still go to work always or most of the time when they have a cold or the flu.

But the connection between paid leave and going to work is fuzzy. Laura Brown, who studies the issue at the Centers for Disease Control and Prevention, tells NPR’s Rae Ellen Bichell that their studies don’t show a strong link between the two.

“Forty percent of workers did say to us that they’d worked while sick in the past because they wouldn’t get paid if they didn’t work,” she says. “But when we look at the data statistically, that doesn’t really seem to be a large driving factor in whether or not people actually work when they’re sick.”

Leaving their coworkers short-staffed was a more likely reason for going to work while sick, she says.

In one of the first stories in our series, “The Workplace and Your Health,” we will look at the issue of juggling medical care with work in more depth, and how the lack of paid leave can lead to more medical problems. In another story, we’ll hear more about the stress that people with disabilities experience at work. Over 6 in 10 (62 percent), say their job has a bad impact on their stress level, compared with 41 percent of workers without disabilities.

Our poll found many working adults have concerns about safety at work. As the chart below shows, those in low paying jobs were more likely than those in high-paying jobs to say they often or sometimes face potentially dangerous situations.

And it’s unclear from the survey why so many restaurant and retail outlet workers say they often or sometimes face potentially dangerous situations on the job. But we did find that, overall, 19 percent of working adults have seen or heard of violence against employees in their workplace.

And while shift workers (54 percent) are more likely than day workers (38 percent) to say they face danger, a significant proportion of shift workers say they do so because it is better for their lifestyle (39 percent) and/or it makes it easier to care for the family (38 percent). Half say better pay associated with shift work is the reason they do it.

But it may be that the workplace is getting safer overall. Among those who ever face potentially dangerous situations at work, almost three-quarters (73 percent) believe their workplace is actively working to reduce these dangerous conditions.

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Recommended article from FiveFilters.org: Most Labour MPs in the UK Are Revolting.

Theranos was poised to revolutionize the blood testing industry by using only a few drops of blood in inexpensive tests. But now, federal regulators say they will bar the company’s dynamic founder and CEO Elizabeth Holmes from owning or operating a lab for at least two years.

“Last year the government began to scrutinize the company after experts found that the results of the blood tests were inaccurate,” as NPR’s Laura Sydell told our Newscast unit.

Centers for Medicare & Medicaid Services, a federal regulator, said in a letter made public Friday that it is also revoking certification for the company’s Newark, California laboratory and cancelling the lab’s approval to receive Medicare payments. The sanctions will not take full effect until September and the company can appeal.

The company will also be fined $10,000 for every day it is out of compliance with the regulator’s recommendations on how to run the labs, starting on July 12.

Theranos repeatedly failed to prove it had corrected issues previously identified by the regulator, according to the CMS letter, including a finding of “immediate jeopardy to patient health and safety.” According to The New York Times, “that apparently referred to erroneous results in a test of blood clotting used for patients who take the blood thinner warfarin.”

Erik Gordon, a business professor at the University of Michigan, told Laura that while the company can appeal, the likelihood for success is miniscule. “If the technology doesn’t work, there’s nothing. There’s just smoke and mirrors. A lot of hype and nothing,” he said. As for Holmes: “She’s radioactive at this point,” Gordon says. “I mean, she can’t stay at the company.”

Theranos said in a statement that it accepts “full responsibility” and vowed to “work non-stop to resolve the issues identified.” It added that Holmes will continue to lead the company and denied that any patients were harmed by their tests.

Holmes dropped out of Stanford at 19 to found the company, which sought to disrupt the tech industry with cheaper, simpler tests. As Laura reported, “Theranos was valued at 9 billion dollars; it had a contract with Walgreens.” Holmes herself was viewed as a wunderkind and drew comparisons to Apple co-founder Steve Jobs, Laura said:

“Holmes had a beautiful vision, backed by hundreds of millions of dollars in investment, and a board of big names like Henry Kissinger and George P. Schulz. The media had a love fest. Time magazine called Holmes one of the 100 most influential people in the world. She was profiled in Fortune andThe New Yorker.”

But as Laura reported, the Theranos story is now viewed as a cautionary tale, “and questions are being raised about whether applying hardware and software business culture to biotechnology is dangerous.”

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Tough love, interventions and 12-step programs are some of the most common methods of treating drug addiction, but journalist Maia Szalavitz says they’re often counterproductive.

“We have this idea that if we are just cruel enough and mean enough and tough enough to people with addiction, that they will suddenly wake up and stop, and that is not the case,” she tells Fresh Air‘s Terry Gross.

Szalavitz is the author of Unbroken Brain, a book that challenges traditional notions of addiction and treatment. Her work is based on research and experience; she was addicted to cocaine and heroin from the age of 17 until she was 23.

Szalavitz is a proponent of “harm reduction” programs that take a nonpunitive approach to helping addicts and “treat people with addiction like human beings.” In her own case, she says that getting “some kind of hope that I could change” enabled her to get the help she needed.

Interview Highlights

On her criticism of 12-step programs

I think that 12-step programs are fabulous self help. I think they can be absolutely wonderful as support groups. My issue with 12-step programs is that 80 percent of addiction treatment in this country consists primarily of indoctrinating people into 12-step programs, and no other medical care in the United States is like that. The data shows that cognitive behavioral therapy and motivational enhancement therapy are equally effective, and they have none of the issues around surrendering to a higher power, or prayer or confession.

I think that one of the problems with the primary 12-step approach that we’ve seen in addiction treatment is that because the 12 steps involve moral issues, it makes people think that addiction is a sin and not a disease. The only treatment in medicine that involves prayer, restitution and confession is for addiction. That fact makes people think that addiction is a sin, rather than a medical problem. I think that if we want to destigmatize addiction, we need to get the 12 steps out of professional treatment and put them where they belong — as self-help.

On the efficacy of maintenance treatment

Buprenorphine and methadone are the two most effective treatments that we have for opioid addiction, and that is when they are taken indefinitely and possibly for a lifetime. So these medications are opioids themselves. They each have slightly different properties … but what they do is they allow you to function completely normally. You can drive. You can love. You can work. You can do everything that anybody else does. …

The way they are able to do that is because if you take an opioid in a regular steady dose every day at the same time and the dose is adjusted right for you, you will not experience any intoxication. The way people with addiction experience intoxication is that they take more and more and more, they take it irregularly, the dosing pattern is completely different. But if you do take it in a steady-state way — which is what happens when you are given it at a clinic every day at the same time — you then have a tolerance to opioids which will protect you if you relapse, and will mean that the death rate from overdose in people who are in maintenance is 50 to 70 percent lower than the death rate for people who are using other methods of treatment, and that includes all of the abstinence treatments.

So maintenance is a really important treatment option for people with opioid addiction. It should be the standard of care. No one should ever be denied access to it. Unfortunately, we have this idea that if you take methadone or buprenorphine, you are just substituting one addiction for another.

On using harm reduction instead of tough love to help addicts

We do know from looking at the data that if you are kind and supportive and empathetic — if you do things like provide clean needles, provide opportunities for people to reverse overdose, provide safe injecting spaces — those things do not prolong addiction. And if tough love was the answer, and the idea was you shouldn’t enable addiction, if that theory was correct, those things should all prolong addiction, and the exact opposite is true. When you go into a needle exchange, one of the most amazing things is people are just treated with dignity and respect. And when you’re an active drug user, when you are injecting, everybody crosses the street to avoid you. And here you’re just seen as a person who deserves to live, and you deserve a chance. And it’s that that gives people hope. And it’s that that shortens the period of addiction.

On not serving any time in prison after being caught with 2.5 kilos of cocaine when she was 20 years old

I have to say that being white and being female and being a person who was at an Ivy League school and being privileged in many other ways had an enormous amount to do with … why I was not incarcerated and why I’m not in prison now. I think our laws are completely and utterly racist. They were founded in racism, and they are enforced in a thoroughly biased manner. I was extraordinarily lucky to have an attorney and a judge that saw that I was getting better, and that allowed me to avoid that.

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Prescription drug prices continue to climb, putting the pinch on consumers. Some older Americans appear to be seeking an alternative to mainstream medicines that has become easier to get legally in many parts of the country. Just ask Cheech and Chong.

Research published Wednesday found that states that legalized medical marijuana — which is sometimes recommended for symptoms like chronic pain, anxiety or depression — saw declines in the number of Medicare prescriptions for drugs used to treat those conditions and a dip in spending by Medicare Part D, which covers the cost on prescription medications.

Because the prescriptions for drugs like opioid painkillers and antidepressants — and associated Medicare spending on those drugs — fell in states where marijuana could feasibly be used as a replacement, the researchers said it appears likely legalization led to a drop in prescriptions. That point, they said, is strengthened because prescriptions didn’t drop for medicines such as blood-thinners, for which marijuana isn’t an alternative.

The study, which appears in Health Affairs, examined data from Medicare Part D from 2010 to 2013. It is the first study to examine whether legalization of marijuana changes doctors’ clinical practice and whether it could curb public health costs.

The findings add context to the debate as more lawmakers express interest in medical marijuana. This year, Ohio and Pennsylvania passed laws allowing the drug for therapeutic purposes, making it legal in 25 states, plus Washington, D.C. The approach could also come to a vote in Florida and Missouri this November. A federal agency is considering reclassifying medical marijuana under national drug policy to make it more readily available.

Medical marijuana saved Medicare about $165 million in 2013, the researchers concluded. They estimated that, if medical marijuana were available nationwide, Medicare Part D spending would have declined in the same year by about $470 million. That’s about half a percent of the program’s total expenditures.

That is an admittedly small proportion of the multibillion dollar program. But the figure is nothing to sneeze at, said W. David Bradford, a professor of public policy at the University of Georgia and one of the study’s authors.

“We wouldn’t say that saving money is the reason to adopt this. But it should be part of the discussion,” he added. “We think it’s pretty good indirect evidence that people are using this as medication.”

The researchers found that in states with medical marijuana laws on the books, the number of prescriptions dropped for drugs to treat anxiety, depression, nausea, pain, psychosis, seizures, sleep disorders and spasticity. Those are all conditions for which marijuana is sometimes recommended.

The study’s authors are separately investigating the effect medical marijuana could have on prescriptions covered by Medicaid, the federal-state health insurance program for low-income people. Though this research is still being finalized, they found a greater drop in prescription drug payments there, Bradford said.

If the trend bears out, it could have other public health ramifications. In states that legalized medical uses of marijuana, painkiller prescriptions dropped — on average, the study found, by about 1,800 daily doses filled each year per doctor. That tracks with other research on the subject.

Marijuana is unlike other drugs, such as opioids, in which overdoses are fatal, said Deepak D’Souza, a professor of psychiatry at Yale School of Medicine, who has researched marijuana. “That doesn’t happen with marijuana,” he added. “But there are whole other side effects and safety issues we need to be aware of.”

Study author Bradford agreed: “Just because it’s not as dangerous as some other dangerous things, it doesn’t mean you want to necessarily promote it. There’s a lot of unanswered questions.”

Because the federal government classifies marijuana as a Schedule I drug, doctors can’t technically prescribe it. In states that have legalized medical marijuana, they can only write patients a note sending them to a dispensary.

Insurance plans don’t cover it, so patients using marijuana pay out of pocket. Prices vary based on location, but a patient’s recommended regimen can be as much as $400 per month. The Drug Enforcement Agency is considering changing that classification — a decision is expected sometime this summer. If the DEA made marijuana a Schedule II drug, the move would put it in the company of drugs such as morphine and oxycodone, making it easier for doctors to prescribe and more likely that insurance would cover it.

To some, the idea that medical marijuana triggers costs savings is hollow. Instead, they say it is cost shifting. “Even if Medicare may be saving money, medical marijuana doesn’t come for free,” D’Souza said. “I have some trouble with the idea that this is a source of savings.”

Still, Bradford maintains that if medical marijuana became a regular part of patient care nationally, the cost curve would bend because marijuana is cheaper than other drugs.

Lester Grinspoon, an associate professor emeritus of psychiatry at Harvard Medical School, who has written two books on the subject, echoed that possibility. Unlike with many drugs, he argued, “There’s a limit to how high a price cannabis can be sold at as a medicine.” He isn’t associated with the study.

And, in the midst of the debate about its economics, medical marijuana still sometimes triggers questions within the practice of medicine.

“As physicians, we are used to prescribing a dose. We don’t have good information about what is a good dose for the treatment for, say pain,” D’Souza said. “Do you say, ‘Take two hits and call me in the morning?’ I have no idea.”

Kaiser Health News is a national health policy news service that is part of the nonpartisan Henry J. Kaiser Family Foundation.

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I was never good at strolling.

If I had a destination, I walked quickly. Not because I wanted exercise, mind you, but because it felt natural.

That all changed with my first pregnancy. The nonpregnant me bolted across a street with five seconds left on the crossing signal. The uber-pregnant me much preferred a full 30-second allotment. Anything less and I waited for the next traffic cycle.

This change of pace was entirely out of my control. As I neared my due date, my once-brisk stride was shorter, my stance wider, my torso tilted farther backward.

I had morphed into a waddler! And I could only waddle so fast.

Now, at 28-weeks pregnant with my second child, I’m beginning to waddle again. I’m thrilled to be expecting, but I’m already missing my normal speed.

Obstetricians tell us that there’s a good explanation for why pregnancy changes our gaits.

“There are a lot of joints in the pelvis. Those are going to loosen as the pregnancy goes on, which is probably how the body adapts to allow a fairly good-sized baby to fit through,” explains Dr. Daniela Carusi, director of both general gynecology and surgical obstetrics at Brigham and Women’s Hospital in Boston. The loosening of the joints and the downward pressure from the growing belly actually cause the pelvis to get wider, she says. A wider pelvis means a wider stance.

That explains part of the waddle. The other part, according to Carusi, is caused by a shift in our center of balance. “As the belly gets bigger, which is the spot in the body which marks the center point, the weight moves forward and that makes the spine curve more inward,” she says.

We pregnant women can’t help but lean back.

I wondered what would happen if I attempted to trade comfort for more graceful motion, if it was even possible to force myself to return to something closer to my former stride.

Carusi warns that it wouldn’t work. “You could reposition your legs, but it’s hard to make your hips narrower,” she says. “What you’d be doing is compensating for the change instead of overriding it.”

“I don’t think it makes sense to narrow the gait,” agrees Stephanie Prendergast, a physical therapist at The Pelvic Health and Rehabilitation Center in Los Angeles. “Keeping the gait wider is safer for balance reasons.”

Prendergast says we could consider making slight adjustments to the way we stand. “When they’re standing still, many pregnant women will push their bellies out and lean backward,” she explains. “But then your ligaments at the front of the hip are holding up your weight.” If we don’t lean back so far, she says, our gluteal muscles could take some of the weight and our hips would hurt less.

I tried to adjust my stride anyway, of course. Unsurprisingly, it felt terrible. When I straightened my back, my shoulders arched forward. When I narrowed my stance, my balance was all off. Other women have had similar experiences.

“I tried to walk with my feet closer together, but after a while that hurt more than changing my gait,” says mother-to-be Keke Gibb, a science professor at Baker University in Baldwin City, Kan., who spoke with me on her due date. “It’s most comfortable if you widen your stance a lot,” she explains. “It feels like my thighs hate each other. I try not to let them touch while I do a really awkward sashay through the neighborhood. I use my whole body to swing one leg forward at a time.”

There is no fighting the pregnant waddle.

I take some comfort in knowing that there’s a small community of scientists investigating how this altered motion affects our lives. These researchers attach reflective stickers to a pregnant woman’s body and then use special cameras to capture the 3-D movement of the stickers as she walks, stands up, or does other simple tasks that can become challenging late in pregnancy.

“When we look in our software, the women look like stick figures moving in 3-D, so we can capture different aspects of how they move, rotate, flex and extend,” says Jean McCrory, a biomechanist at West Virginia University who studies gait and balance in pregnant women.

McCrory documented, for example, how pregnant women walk with pelvises tilted backward and feet spread wider apart. Others have shown how we rise from chairs more slowly, and with a greater attention to balance.

In a recent study, scientists at Hiroshima University studied the mechanics of movement as pregnant and nonpregnant women rose from a chair, picked up two stacked plates, turned to the right, and then walked away. The researchers showed that pregnant women flex their hips less while walking and lean back more while standing.

These findings will come as no surprise to obstetricians or anyone who has ever had a baby bump of her own. But studies like these might one day help scientists figure out how to make everyday tasks safer for pregnant women. McCrory, for example, wants to use her knowledge of pregnant motion to find ways to prevent pregnant women from falling — a worthy goal since over a quarter of pregnant women fall at some point.

I joined that statistic during my last pregnancy when I got overexcited about an old friend visiting. As she got out of her car, I momentarily forgot to waddle and leaped forward to hug her. My toe caught the sidewalk and I fell so slowly and awkwardly that she thought it was intentional — that I was trying to entertain her with some sad attempt at pregnant lady slapstick. The baby and I were fine.

So far I’ve managed to stay on my feet this pregnancy. For the moment, I also still have some of my prepregnancy speed. I know this because, like so many aspects of pregnancy, people comment on it. Last week, as I strode past two men on my way to work, I overheard one say, “Whoa! Look at how fast she walks — for a pregnant lady.”

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Episiotomy, a once-routine surgical incision made in a woman’s vaginal opening during childbirth to speed the baby’s passage, has been officially discouraged for at least a decade by the leading association of obstetrician-gynecologists in the United States.

Nonetheless, despite evidence that the procedure is only rarely necessary, and in some cases leads to serious pain and injuries to the mother, it is still being performed at much higher than recommended rates by certain doctors and in certain hospitals.

In one recent case, Kimberly Turbin, a 29-year-old dental assistant who lives in Stockton, Calif., is suing her former obstetrician for assault and battery after he performed an episiotomy on her in 2013. A video of the birth, with Turbin begging the doctor not to cut her, has been viewed more than 420,000 times.

After the episiotomy, Turbin says, “I had major, major, major, major pain.”

In 2006, the American College of Obstetricians and Gynecologists released a recommendation against the routine use of episiotomy, finding that except in relatively rare cases, the procedure benefited neither mothers nor newborns. In 2008, the National Quality Forum also endorsed limiting the routine use of episiotomies.

Since then, the use of this surgical incision has dropped significantly — from 21 percent of all vaginal births in California in 2005, for example, to fewer than 12 percent in 2014. National trends have been similar.

But that overall drop masks some giant disparities. While the majority of California’s hospitals now have episiotomy rates under 10 percent, according to state data, the technique’s use at individual hospitals can be five or six times as high.

Dr. Alexander Friedman, an assistant clinical professor of obstetrics and gynecology at Columbia University Medical Center in New York City, who has studied the issue, says sky-high rates at some institutions are surely based on factors that go beyond medical need.

“If you perform an episiotomy, you’re more likely than not going to cause more postpartum pain and discomfort,” says Friedman, who was lead author of a 2015 report, published in JAMA, the Journal of the American Medical Association, about the variation in episiotomy rates among hospitals nationally. While the ideal rate of episiotomy is unknown, he says, it should likely be less than 10 percent.

As recently as the late 1970s, episiotomy was used in more than 60 percent of vaginal deliveries across the U.S. because doctors believed a clean incision helped prevent tears between the vagina and rectum, that a clean cut was easier to stitch than a tear, and that the incision prevented overstretching of the muscles surrounding the vagina.

In the past few decades, though, research has shown that the cuts sometimes cause serious pain and injuries, including deep tissue tears, incontinence and sexual dysfunction. The repaired incisions often prove slower to heal than a natural tear.

Armed with this information, many pregnant women started refusing the procedure, and most obstetricians stopped doing it routinely.

But certain doctors are going against that trend.

Dr. Emiliano Chavira, a maternal and fetal medicine specialist at Dignity Health’s California Hospital Medical Center in Los Angeles, says he suspects three main reasons why some providers continue to perform routine episiotomies: They’ve always done them; they lack awareness of best practices; or they want to speed up deliveries.

“Certain segments of the obstetric community are very slow to modernize the practice,” Chavira says. “They’re very slow to abandon procedures that are not a benefit and, in fact, may be harmful. And it’s really disappointing.”

There can also be great variation from hospital to nearby hospital, research shows.

For example, in Los Angeles each of the six hospitals owned by AHMC Healthcare have continued to do episiotomies in more than 29 percent of vaginal births, according to state data. And two of the institutions — Garfield Medical Center in Monterey Park and Whittier Hospital Medical Center in the city of Whittier — have episiotomy rates close to 60 percent. Representatives of the chain and its hospitals didn’t return repeated calls and emails requesting comment.

Meanwhile, Kaiser hospitals in Northern California have seen huge reductions in the use of the procedure since the Oakland-based managed care organization undertook an intentional effort to address overuse.

Dr. Tracy Flanagan, director of women’s health and maternity at Kaiser Permanente in Northern California, says her office began examining episiotomy rates at different hospitals four or five years ago. They first looked at rates at the hospital level, then at the physician level, she says, and found ” a lot of variation.”

They first sent the data to the individual hospitals. Then, doctors at each hospital who rarely performed episiotomies were asked to educate their colleagues about the appropriate use and relative risks of the procedure.

Physicians tend to respond best if other physicians present them with a compelling argument to change their ways, Flanagan says. Reliable data, transparency and peer-to-peer education, she adds, is a good recipe for narrowing variation.

The average episiotomy rate for the Northern California Kaiser hospitals is now about 3 percent, Flanagan says.

Zero percent would be too low, she adds; in some cases — if a baby’s shoulder is stuck, for instance, or the infant’s heart rate drops, or if the mother is exhausted and wants an episiotomy — the procedure’s use is warranted.

Dr. Elliott Main, medical director of the California Maternal Quality Care Collaborative and a clinical OB-GYN professor at Stanford University, says the episiotomy data offer a lesson in how quickly practices can change. This evidence also highlights the hospitals where doctors refuse to alter their ways, he says.

In the case of C-sections, doctors may be motivated to perform the procedures because they allow for faster deliveries or better pay, Main says. But the main reason some doctors still perform too many episiotomies is probably that they always have done so — in some cases for decades.

“It is always hard for people to relearn,” Main says.

His organization is leading an effort to provide doctors and hospitals with data on certain childbirth practices, to show them how they compare with their peers around the state. Beginning in 2010, the group partnered with the March of Dimes to educate providers about the dangers of elective delivery prior to 39 weeks. Within three years, that practice had dropped off rapidly, he says. The organization is currently undertaking similar efforts related to C-sections.

Chavira, the maternal and fetal medicine specialist at California Hospital in Los Angeles, says he would like to see similar transparency with data on episiotomies.

“If you have a hospital where people are doing 5 percent episiotomies and one guy is doing 60 percent episiotomies, all of a sudden he sticks out like a sore thumb,” Chavira says.

A lot of women don’t want the procedure, Chavira notes, and doctors are supposed to honor their patients’ wishes.

In June, a Superior Court judge in Los Angeles County ruled that Turbin’s lawsuit against her former obstetrician can go to trial in the fall. Meanwhile, Turbin says she is terrified of getting pregnant again.

“If I go back to that day, there’s nothing I could have done,” she says. “That doctor was going to cut me, no matter what.”

Kaiser Health News is an editorially independent news service that is part of the nonpartisan Henry J. Kaiser Family Foundation. (Kaiser Permanente has no relationship with Kaiser Health News.)

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At Edgewood Summit retirement community in Charleston, W.Va., 93-year-old Mary Mullens is waxing eloquent about her geriatrician, Dr. Todd Goldberg.

“He’s sure got a lot to do,” she says, “and does it so well.”

West Virginia has the third oldest population in the nation, right behind Maine and Florida. But Goldberg is one of only 36 geriatricians in the state.

“With the growing elderly population across America and West Virginia, obviously we need healthcare providers,” says Goldberg.

That includes geriatricians — physicians who specialize in the treatment of adults age 65 and older — as well as nurses, physical therapists, and psychologists who know how to care for this population.

“The current workforce is inadequately trained and inadequately prepared to deal with what’s been called the silver tsunami — a tidal wave of elderly people — increasing in the population in West Virginia, across America, and across the world really,” Goldberg says.

The deficit of properly trained physicians is expected to get worse. By 2030, one in five Americans will be eligible for Medicare, the government health insurance for those 65 and older.

Goldberg also teaches at the Charleston division of West Virginia University, and runs one of the state’s four geriatric fellowship programs for medical residents. Geriatric fellowships are required for any physician wanting to enter the field.

For the past three years, no physicians have entered the fellowship program at WVU-Charleston. In fact, no students have enrolled in any of the four geriatric fellowship programs in West Virginia in the past three years.

“This is not just our local program, or in West Virginia,” says Goldberg. “This is a national problem.”

The United States has 130 geriatric fellowship programs, with 383 positions. In 2016, only 192 of them were filled. With that kind of competition, Goldberg laments, why would a resident apply to a West Virginia School, when they could get into a program like Yale or Harvard?

Adding to the problem, the average medical student graduates with $183,000 in debt, and every year of added education pushes that debt higher.

Dr. Shirley Neitch, head of the geriatrics department at Marshall University Medical School in Huntington, W.Va., says students express interest in geriatrics almost every year. But, “they fear their debt,” she says, “and they think that they need to get into something without the fellowship year where they can start getting paid for their work.”

This trend troubles many people, including Todd Plumley, whose mother Gladys has dementia, and lives in West Virginia.

“It’s kind of scary that [older patients] don’t have the care that they really need to help them through these times, and help them prolong their life and give them a better life,” Plumley says.

There are no geriatricians in the family’s hometown of Hamlin, so Plumley drives his mother almost 45 minutes to another town, Huntington, to see one. He says seeing this specialist has helped stabilize his mother’s symptoms.

“Right now, if we didn’t have the knowledge and resource,” he says, “I believe my mother would have progressed a lot further along, quicker.”

Plumley is in his 50s. He worries that if he needs the care of a geriatrician as he gets older, driving even 45 minutes may not be an option.

This story is part of NPR’s reporting partnership with West Virginia Public Broadcasting and Kaiser Health News.

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Mental illness has been part of human society throughout recorded history, but how we care for people with mental disorders has changed radically, and not always for the better.

In Colonial days, settlers lived in sparsely populated rural communities where sanctuary and community support enabled the tradition of family care brought from England. “Distracted persons” were acknowledged, but erratic behavior wasn’t associated with disease.

Records indicate unusual tolerance of bizarre behavior. When 18th century Pastor Joseph Moody of York, Maine, unable to face crowds, delivered sermons with a handkerchief covering his face, his behavior was tolerated for three years before he was relieved of his duties.

As urban areas grew in size and number, a transient poor population with no access to family support led to almshouses, the first form of institutionalization, inspired by 18th century reforms in Europe.

A Philadelphia Quaker who had visited an English retreat brought the idea to this country and in 1817 founded the Friends Asylum, a self-sufficient farm that offered a stress-free environment known as “moral treatment.” Other private asylums followed, but they soon became overcrowded. By the late 19th century, this was addressed with larger state hospitals, which soon became overcrowded as well.

People with mental disorders are more likely to be stigmatized owing to fear and misunderstanding when they aren’t part of the community. And stigmatization can discourage those with a mental disorder from seeking or complying with treatment. It also can lead to people being institutionalized against their will, more to protect the public than to provide compassionate care for those with mental illness.

In the mid-1950s, new antipsychotic medications offered relief from some of the most disabling symptoms of schizophrenia and other major disorders, such as psychosis and hallucinations. And in 1963, President John F. Kennedy’s Community Mental Health Act shifted funding from large state hospitals, which had been plagued by scandal, to small-scale community-based mental health centers. With deinstitutionalization, the inpatient population dropped from over half a million in 1955 to about 60,000 by the end of the century.

By 1977, federally funded centers were serving close to 2 million people a year in 60 community mental health facilities. But the law was never adequately funded, and a national standardized system of community care did not emerge. As a result, people began to associate mental illness with homelessness or acts of violence, though the vast majority of people with mental illness pose no threat.

That raises the question of whether it’s possible to reduce stigma so that those with a mental disorder are not feared and shunned. Patrick Corrigan, director of the National Consortium on Stigma and Empowerment, has investigated three approaches to reducing stigma: protest, education and contact.

In one study, subjects received information regarding mental illness in the context of the three approaches. Statements meant to induce a sense of moral outrage protest produced no stigma reduction. Both education and contact with someone known to have a mental illness did produce significant changes in attitude — less blame toward persons with mental illness and greater confidence in their chance of recovery — and encouraged future contact with those known to have mental illness. Previous contact mitigated lingering stereotypes more than education.

To get a sense of how it is possible for community members to have contact with those with mental illness without inciting stigma and fear, it helps to take a look at present-day communities where that happens. For centuries, in Geel, Belgium, community contact has been an everyday event for those with mental illness, with the state paying families to care for “boarders” in their homes. Modern-day Geel combines community care with medical care and psychotherapy, as well as hospitalization if needed. (For more modern-day Geel, see Invisibilia‘s story here.)

In the United States, variations in state funding affect the quality of public mental health care. But dozens of programs offer evidence that it is possible to build sustainable fostering communities.

Gould Farm, a working farm established in Monterey, Mass., in 1913, was the first modern-day residential therapeutic community in the U.S. Here patients are referred to as guests, and all staff — and their families — live on the farm. Daily work, on the farm or at its bakery or cafe, is a key aspect of the therapy.

Today Gould Farm is one of more than 30 members, in 15 states, of the American Residential Treatment Association. These programs are not covered by Medicare or Medicaid, but some ARTA members help families secure financing; health insurance may cover part of the cost. For example, more than 50 percent of Gould Farm “guests” receive financial assistance. But, for the most part, people must assume the expense of a six- to 12-month stay, ranging from $400 to $900 per day.

In Chicago, the Thresholds organization offers services to people with mental illness in more than 100 locations in the city and surrounding counties. It was founded in 1959, by women from Chicago’s National Council of Jewish Women who attended a mental health educational conference and learned that people who had spent years in mental hospitals were often left to fend for themselves upon release. It started as a small volunteer organization that offered social activities, then grew to include residential programs, supported employment, housing-first, and treatment for people with both mental diagnoses and substance disorders. Last year, 75 percent of its services were delivered in the community.

Thresholds is one of 15 programs I’ve visited across the United States in decades of researching models of community care in mental health. Those 15 are a small sample of programs of varying sizes that offer affordable housing or help in finding such housing; occupational training and placement; recreational opportunities and more.

Those with a mental disorder can live a meaningful life, if their community facilitates community contact. It’s been happening in Geel for centuries. It is happening in the U.S. today. The voice of stigma originates in the community, but so does the voice of hope.

Jackie Goldstein is a professor emeritus of psychology at Samford University and author of the 2016 book Voices of Hope for Mental Illness: Not Against, With.

This story is part of Invisibilia‘s episode on solutions, including a report on how residents of the town of Geel, Belgium, have been taking in strangers with mental illness as boarders for centuries. We also talked with Mr. Kitt, who found sobriety and his calling as an artist after he moved off the streets into a Broadway Housing Communities apartment in New York. And NPR reporters Pam Fessler and Nate Rott visit community housing sites on the East and West coasts that aim to provide sanctuary, not just shelter.

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Lisa Lynn Kotnik has been a singer on the New Orleans club circuit for more than 15 years.

“I sang at Fritzel’s for eight years,” she says. “I sang at the Bombay Club for 15 years, I sang at Margaritaville — the list could go on and on and on.”

While Kotnik sings to revelers at night under the stage name Lisa Lynn, in the daytime she’s battled health problems — fibroids, ovarian cysts, a hysterectomy and even a brain aneurysm.

“So, I’ve had a lot of surgeries,” she says. She counts at least five.

And like many of her fellow musicians, Kotnik has never really had health insurance. Her income as a singer is tenuous and fluctuates with the seasons, so insurance has always just been too expensive, she says.

But not anymore.

Kotnik was at the New Orleans Musicians Clinic recently signing up for Medicaid.

Hundreds of thousands of Louisiana’s working poor have health insurance as of July 1 because the state has expanded its Medicaid program, as allowed under the Affordable Care Act. The new insurance benefits Kotnik and many of the other performers and workers who serve the millions of tourists visiting New Orleans every year.

That’s also good news for the New Orleans Musicians Clinic, which has provided health care to the city’s musicians and artists for decades, mostly for free.

The clinic, decorated with vintage Jazz Fest posters and signed photos of musicians like Harry Connick Junior and James Booker, is located on historic St. Charles Street in a building that also hosts doctors and clinics affiliated with Louisiana State University.

But it’s funded mostly by philanthropists, and its services, until now, have been limited.

In the past, Kotnik could see doctors at the clinic; but if she needed a blood test or ultrasound scan, she had to go across town to University Hospital, and potentially wait hours for what in Louisiana is called charity care.

“We have all that in this facility, but it wasn’t covered,” explains Megan McStravick, a social worker at the musicians clinic who helps people like Kotnik get the care they need.

Prescriptions also weren’t covered, so McStravick would spend hours working with drug companies to get her low-income patients the medications they need for free.

Medicaid changes the terms of coverage — and that’s a big deal for the state’s health secretary, Dr. Rebekah Gee.

“These are our heroes,” Gee tells Shots. “These are our local New Orleans heroes — our musicians are the fabric of our community.”

Musicians, restaurant workers and hotel workers are the backbone of much of Louisiana’s tourist economy, she says.

“People love to come to Louisiana, they love to eat our food, hear our music and stay in our hotels,” she says. “Because those jobs are not high income, we have a huge workforce that was uninsured.”

Moving all those people into the Medicaid program has been a huge task.

The poorest and least healthy state in the U.S., Louisiana is now the 31st state to join the Medicaid expansion, and the first in the Deep South to embrace this sliver of Obamacare.

It’s a big turnaround for this Republican state. Bobby Jindal, the former governor, loudly opposed expanding the government program and the state’s Republican-dominated legislature went along with him.

But last fall, a new Democratic governor, John Bel Edwards, was elected after campaigning specifically on expanding Medicaid.

His election, combined with a huge budget crisis, convinced many state officials to embrace the program because Edwards made the case that it would save money by handing over health care costs to the federal government.

“The Medicaid expansion was something that I believed in and I knew it would save money,” Edwards says. “It no longer was optional, because we had to implement every cost saving measure that we could.”

Still, Gee faced a big challenge because the state legislature refused to allocate any money to hire people to sign people up for Medicaid.

“The idea of having more state employees at a time when we were cutting the budget by $3 billion — there just was not an appetite for it,” she says.

It fell to Gee to figure out, without any new help, how to sign up the estimated 375,000 people who were eligible.

“I said to my husband, ‘Gosh, we can maybe get a couple of cards into people’s hands by July, but I have no idea how we’re going to get this done,” she recalls.

So Gee turned to other programs that work with the poor. Anyone who gets food stamps was automatically qualified for Medicaid. And anyone who had been in earlier state health plans for the poor was automatically signed up.

She says she hopes other states in the region will follow Louisiana’s lead.

“We are an island amongst a sea of states that haven’t expanded,” she says. “We are hoping to lead the charge here.”

But insurance is only the start, Gee says.

“Our major challenge is to transform this state from the most unhealthy state in the nation to a state that has a healthy future,” she says.

For people like Lisa Lynn Kotnik, the Medicaid card is at least a start.

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At the center of Geel, a charming Belgian town less than an hour’s drive from of Antwerp, is a church dedicated to Dymphna, a saint believed to have the power to cure mental disorders. It’s a medieval church with stone arches, spires and a half-built bell tower, and it has inspired an unusual centuries-old practice: For over 700 years, residents of Geel have been accepting people with mental disorders, often very severe mental disorders, into their homes and caring for them.

It isn’t meant to be a treatment or therapy. The people are not called patients, but guests or boarders. They go to Geel and join households to share a life with people who can watch over them. Today, there are about 250 boarders in Geel. One of them is a Flemish man named Luc Ennekans. He’s slim and has green eyes, and he’s 51 years old. NPR’s Lulu Miller went to Geel and met him and his host family there and reported this story for Invisibilia.

Like all of the guests in the town today, Ennekans first went to a public psychiatric hospital in Geel that manages the boarder program. Ennekans saw medical professionals and received treatment and an evaluation. Then he was paired with a household. His hosts, Toni Smit and Arthur Shouten, say that living with Ennekans was rough at the start.

Ennekans became deeply attached to Smit. “If it were up to Luc, he would be hugging and kissing me all day,” Smit says. He showered her with such affection, bringing her flowers, little kisses, linking arms with her on walks, that it began to interfere with Smit and Shouten’s marriage. “You couldn’t even give each other a hug or Luc is standing behind us,” Shouten says. Wrinkles like this are common, according to the couple. They’ve had six boarders over the years, each with a unique set of challenges.

One boarder used to lock Smit and Shouten out of the bathroom to furiously wash his hands, and another used to struggle to sleep because he saw lions coming out of the walls. “He was really dementing,” Smit says. But that doesn’t affect the way they see their boarders. Like many hosts in Geel, they accept that this is simply who their boarders are. It’s not abnormal or something they need to change. “It’s just normal life,” Shouten says.

That acceptance of mental differences has become something of a tradition in Geel. It’s at the heart of the boarder program, and some observers think it’s also responsible for the system’s success. Around the world, many different experiments have been attempted over the centuries to provide humane care for people with mental illness and mental disabilities. Geel is one that has endured.

Residents of Geel have not only accepted the eccentric or disruptive behaviors of the boarders but have come up with creative ways to help boarders and residents manage them, says Ellen Baxter, the founder of Broadway Housing Communities, a nonprofit in New York City. It is partially inspired by Geel, which Baxter visited as a young woman.

For example, when Ennekans became too jealous or attached to Smit, Shouten and Smit encouraged him to find a girlfriend or other companionship. When their former boarder hallucinated lions coming through the walls, Smit would pretend to chase the lions away. “And that would work every time,” Smit says.

Shouten and Smit receive a stipend from the Belgian government for taking care of Ennekans, as well as training and support from psychiatric professionals. Hospitalization is available if needed. Several studies have found that the incidence of violence by boarders is low; people who have previously exhibited violent behavior are usually not admitted to the program.

The integration of people with mental disorders into Geel society has fascinated scholars for centuries. In 1862, Dr. Louiseau, a visiting French doctor, described it as “the extraordinary phenomenon presented at Geel of 400 insane persons moving freely about in the midst of a population which tolerates them without fear and without emotion.” Nearly 100 years after that, an American psychiatrist named Charles D. Aring wrote in the journal JAMA, “The remarkable aspect of the Gheel experience, for the uninitiated[,] is the attitude of the citizenry.”

Early psychiatrists who observed Geel noticed that the treatment prescribed for mental patients was, in fact, no treatment at all. “To them, treating the insane, meant to simply live with them, share their work, their distractions,” Jacques-Joseph Moreau wrote in 1845. He and others advocated for that communion. “In a colony, like in Geel, the crazy people … have not completely lost their dignity as reasonable human beings.” In the next half-century, many would uphold Geel’s model as the best standard of practice for mental disorders.

How Geel came to be this way begins with the town’s devotion to St. Dymphna, whose church stands in the center of town. According to legend, Dymphna was a 7th-century Irish princess who fled to Geel from a maddened father and devoted her life to serving the mentally disabled. But she became a martyr when her father discovered her location and traveled to Geel to behead her.

The town built St. Dymphna’s church in the 14th century to honor the saint and enshrine her supposed remains. It became a popular pilgrimage site for people across Europe, who would bring loved ones to the shrine in the hopes of finding relief from their mental distress.

By 1480, the town had built a small hospice on the side of the church to accommodate pilgrims, but the shrine became so popular that the pilgrims overwhelmed the annex’s capacity. “Sometimes the families would return home and leave their uncured relatives in the hospice,” says Mike Jay, a historian of psychiatry and curator for the Wellcome Collection in London, who has studied Geel. “So local people began taking them in as guests or boarders, as they call them.”

The early practice was often mutually beneficial for both the hosts and the boarders, Jay says. Many Geel residents were farmers, and boarders offered a source of labor. In exchange, the boarders got stable housing and a family life. But the integration was not always a happy one. There are stories of abuse, Jay says. “One of the laws was that if a boarder committed a crime, it was the fault of the family. If you had a boarder who was difficult, then some of the families would resort to keeping them chained or restrained.”

As medical treatment for the mentally ill evolved, so did Geel. In the 19th century, a central medical establishment was set up that provided standard medical and psychiatric care to boarders and other residents. But this was at the same time that large insane asylums were considered the most advanced, scientific form of care. Geel became the source of a great debate in psychiatry. “It was a polarizing example,” Jay says. “Some people regarded Geel as a sad remnant of old medieval culture where people were left to toil in the field and never given therapy and no chance of recovery.”

Other early observers noted the same things that Baxter and other more recent visitors have: By and large, people in Geel were happy. “One of the agreeable features is the general contentment manifested by the insane,” wrote John Sibbald, a Scottish psychiatrist, in 1861.

By the turn of the 20th century, the International Congress of Psychiatry had declared Geel an example of best practice to be copied elsewhere. The program continued to be a source of local pride, and it grew. At the program’s peak in 1930, about 4,000 boarders resided in Geel — a quarter of the town’s population.

Over time, Jay says, boarders had become such a part of life and society that distinctions between them and nonboarders blurred. And with that, “a lot of the problems we associate [with mental illness] kind of fade away,” Jay says. “Like trying to navigate a world full of kind of normal people who don’t understand what’s going on and aren’t tolerant towards it.”

There are a few important criteria for acceptance into the Geel program. The program typically selects patients with severe mental illness or cognitive disabilities who have difficulty living independently. In 2003, almost half of the town’s 516 boarders had a cognitive disability, and over 20 percent carry a diagnosis of schizophrenia or other psychotic disorder, according to research by Jackie Goldstein, a professor emeritus of psychology at Samford University. Some boarders have traditionally had other conditions such as learning disabilities or autism.

While scholarship of Geel is rich with observation, there remain few long-term, empirical studies on how these patients do in the system. “The successes and shortcomings of Geel’s system of foster family care had never been thoroughly or systematically examined,” Goldstein noted in a speech presented at the American Psychological Association Annual Convention in 1998. In the 1960s, researchers embarked on a 10-year project studying Geel that Goldstein took part in, but it never reached completion.

Goldstein continued studying Geel throughout her life, and some of her work shows that boarder life is stable. Boarders tend to stay in family care for years. In some cases, when boarders’ caretakers grow too old or die, they continue to live with their caretakers’ children. In 2005, nearly a third of boarders lived in a foster home for more than 50 years.

But the centuries-old custom has been shrinking. The number of boarders has fallen to roughly 250 today, less than 7 percent of its prewar peak. Eugeen Roosens, a Belgian psychiatrist, and Lieve Van De Walle, a former director for rehabilitation in Geel, write, “the time of extended farmer families, who could do with a helping hand, is gone,” in their book, Geel Revisited: After Centuries of Mental Rehabilitation.

There are possible reasons for the program’s decline besides the time and professional pressures of modern life. There may be fewer patients who need supported living thanks to improved psychiatric medication, which might contribute to fewer referrals to the program. Roosens and Van De Walle also note the program lacks enough funding to cover the cost of a boarder. The Belgian government pays 40 euros (less than $45) per boarder per day to support the practice, less than half of which goes to the foster family to cover living expenses.

Still, the tradition persists, in large part because Geelians are proud of it. In a 1962 survey of Geel foster families, American psychiatrist Matthew Dumont found that their main reason for accepting boarders was custom. Roosens and Van De Walle describe the program as part of Geel’s heritage. It’s part of the town’s identity. But, they write, that may not be enough to sustain the program.

With reporting by Lulu Miller.

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