Nurse Practitioners—Valuable but Undervalued
For Nurse Practitioner World News
May/June 2010
By Carla Mills, ARNP
The day healthcare reform was signed into law, the future prospects for nurse practitioners (NPs) changed—whether for better or worse remains to be seen. Thirty million newly insured patients will enter the healthcare system over the next few years, all seeking primary care. Community health centers have already been targeted to receive $11 billion dollars in government funding. But, as valuable as NPs are, the profession continues to be undervalued in terms of reimbursement and practice authority. Reduced Medicare reimbursement rates for NPs compared with physicians and the lack of direct reimbursement to NPs from most private insurers will make it difficult, if not impossible, to make NP run community health centers—or any NP care delivery site—financially viable.
Under present laws, NPs are reimbursed only 85% of the amount Medicare pays physicians for the same services. Private insurers usually tie their reimbursement practices to what Medicare allows. This is an open-and-shut case of unequal pay for equal work. If NPs’ payments were to drop to 85% of the proposed 21% cut to physicians’ pay, it will put NPs out of business altogether. When reimbursement falls below the cost of delivering care, no healthcare provider—whether a physician or an NP—can stay in business.
The assumption that the law of supply and demand will solve the provider shortage is flawed. It takes years of education and clinical experience to grow a skilled clinician, and we already have a shortage of providers, even before 30 million more people seek care. Medical professionals have been increasing their patient volumes for more than a decade in an effort to compensate for pay cuts. Current patient volumes have already dramatically reduced patient visit times, which has done nothing to either reduce costs or improve care.
There are nearly 150,000 NPs already trained and currently practicing, who are hampered at every turn by low reimbursement rates and restrictions against practicing to the full extent of their education and ability. The professional energy that NPs are spending to try to remove these barriers wastes valuable time that would be much better spent creating innovative, patient centered healthcare delivery systems. Community health centers and convenience-care clinics are just two examples of new ways NPs are finding to provide direct care to patients.
Valuing the Right Things
In the last 40 years, chronic diseases have become epidemic. Obesity and smoking are now the leading causes of preventable premature death. These problems and other unhealthy lifestyle behaviors lead directly to a host of other expensive and disabling chronic diseases. While physicians have insisted on having complete and final authority over every aspect of health and medical care in this country, the state of Americans’ health has continued to decline.
Historically, physicians have been the most valued and highly paid health providers in the system. They deserve and have received credit for giant strides made within their scope of practice, which is primarily treating diseases and performing many life-saving treatments and procedures. Although these functions are very important, they come late in the process, while disease prevention, which is the focus of many NPs’ practices, may result in greater overall cost savings for the individual and the healthcare system as a whole.
Purely medical fixes send the wrong message to patients: don’t bother taking care of yourself. Eat yourself into a diabetic state, and when you are 100+ pounds overweight, come to us and we’ll fix it. The focus on treating, not preventing, disease has created a country of uneducated and dependent patients. If there is to be any hope for health and healthcare reform, it will depend on independent, well-educated patients who are skilled in preventive self-care. It’s time to stop over-valuing those providers who treat the sick and under-valuing those providers who promote health. It’s time to empower NPs. It is the only way the healthcare system can be brought into balance.
The Value of NPs
Under the physician-controlled medical system, patient education has suffered more than any other aspect of care over the last 40 years. It is an area in which NPs have proven themselves to be superior providers. I am constantly shocked to see my patients making important health choices based on incomplete knowledge and/or misinformation.
Educating patients takes time and patience—two qualities that physicians freely admit are in short supply in their own practices. Patients need reassurance, support, good information, and acceptance in order to learn to how to effectively prevent or self-manage chronic diseases. Finding effective treatment approaches that fit an individual’s world view can be tedious and frustrating work. There are small victories and frequent setbacks. The work is far from glamorous, and there is absolutely no reimbursement for it under the current payment structure. This explains why physicians are opting out of primary care—no money, no glamour. They have become accustomed to having plenty of both.
Valuing NPs
There is a tsunami of patients on its way. More than thirty million patients will become insured over the next 10 years. It is predicted that 10 million of them will enter the system with chronic diseases that have never been diagnosed or treated. The remaining 20+ million are predicted to be younger and basically healthy.
Never has such an opportunity to put prevention into practice been offered to healthcare professionals. It’s a historic chance to start turning back the scourge of chronic disease. As Florence Nightingale transformed medical care over a century ago, NPs are poised to transform it for the next 100 years. How? By being creative and innovative!
NPs have a responsibility to make their value to the healthcare system clear to everyone involved. But NPs need support too—from their patients, from the physicians with whom they work, from the media, and, most urgently, from lawmakers. It’s time for everyone to stand up for NPs and acknowledge their value. It’s time to remove the practice barriers that prevent them from being as effective as they could be. It’s time for NPs to have full practice and prescriptive authority within their scope so that they can practice without dependence on physicians.
The principle of equal pay for equal work demands that NPs receive the same reimbursement from Medicare and private insurance companies that physicians do for providing the same services. If the value and valuation of NPs are not reconsidered and the crippling financial and practice restrictions persist, there is a very real danger that NPs’ unique brand of healthcare will disappear. And if it does, its innovations and insights will disappear with it.
This information is offered for educational purposes only and is not intended to diagnose, prescribe or treat. For that please seek direct care from a health professional.
2 comments so far. (Post your own)
The American Medical Association Doesn’t Want You to Read This
They say a blog is like a shark – feed it or it dies. I want to explain why the frequency of my posts has declined. Unlike many blogs, the posts I write are not about things that happened 15 minutes ago. While at times I write opinion posts (admittedly more so in recent months), what I really would rather be doing is sharing interesting ideas, research and information that will help you take the best possible care of yourself.
But just because I’m not here as often doesn’t mean there’s not a lot already on the site for you to keep coming back to read. (I know exactly how long visitors spend on the site, gentle readers, and you have not read most of what is already here.) I am confident there is useful information on this site that you have not yet explored. This post explains the issues that are keeping me from writing more blog posts these days.
Health Reform is Passed and Signed into Law
On March 23, 2010 President Obama signed health care reform into law. That stroke of a pen changed everything about health care for everyone – nurse practitioners included. NPs have been functioning in almost every corner of the health care system for more than four decades and many, like me, are primary care providers.
Because of health care reform there is a tsunami of patients headed for a health care system that does not have enough primary care providers to take care of them. Yet in spite of that the AMA (American Medical Association) in this linked document (which they did not release to the public) along with some other physician organizations continue to oppose giving NPs the full practice and prescriptive authority we need. As an NP in primary care, I face crippling practice restrictions everyday that make delivering quality care both inefficient and more costly than it needs to be.
One NP’s Story
Let me tell you my story and you decide whether the AMA’s position is meant to serve you or is serving only the AMA. And please, don’t take my word for it, read the links below for other opinions and studies on the safety of NP practice.
In my case, I share a busy internal medicine practice in Naples, Florida with a single physician. We work in our practice like any two doctors would (though I am an NP). But rather than each having our own separate patients we both see everyone in the practice – patients go back and forth between us depending on our schedules and their preferences. We don’t divide the patients up by “easy” or “hard”. And whenever one of us takes time off the other one covers the whole practice.
We work this way because, as an NP, I have experience and expertise the physician does not – because she’s not a nurse. As a physician, she has experience and expertise I do not – because I’m not a doctor. But 90% of what we both do is exactly the same – whether she does it or I do it we are providing the same care. And because we come from different disciplines, by practicing in this way, we can deliver a broader spectrum of care that either one of us would be able to deliver by ourselves.
This physician does not, nor has she ever, “supervised” me. I have been practicing medicine and nursing in this way for over 15 years. I’m not sure I would have ever landed any job I’ve ever held (except, perhaps, my first one right out of grad school) if I required “the watchful eye” of a physician to oversee the care I provide. Physicians are far too busy themselves to “supervise” other providers. The position the AMA and others have taken with regard to NP autonomy is about control and money only – not your safety. NPs’ quality of care has been proven over and over (and they know it). See the links at the end of this post to see for yourself.
Support NPs
So what does all that have to do with a blog being like a shark? Nothing really, except I don’t want the blog to die because I can’t feed it as often as I would like. I hope the health care wars will end soon so I can come home to the blog for good. In the meantime I am out there speaking and writing. I am working for the legislative reform of draconian laws that are limiting your access to care. Until the impediments that keep NPs from doing what we are trained to do are lifted, the best I can do is send in posts from the front lines. This is one of them.
Please support NPs. Write your elected officials, write the newspapers, post comments on websites (even this one) about your experience with NPs. Stand up for NPs. We have always fought for you and are fighting for you now – but we can not do it alone.
Thanks for being here.
Related Links:
Do physicians deliver better care than Advanced Practice Registered Nurses?
The effect of Evercare on hospital use.
This information is offered for educational purposes only and is not intended to diagnose, prescribe or treat. For that please seek direct care from a health professional.
3 comments so far. (Post your own)
Putting Prevention into Practice
For Nurse Practitioner World News
March/April 2010
By Carla Mills, ARNP
Who is responsible for putting prevention into practice: individuals or society? If it’s an individual’s responsibility, then what business does society (that is, health professionals, employers, insurance companies, and the government) have interfering in people’s personal lives? If it’s society’s responsibility, is it cheaper to practice preventive care, or should we just wait until people get sick and then treat them?
In fact, health is a shared responsibility between a society and its citizens. Society is responsible for maintaining a healthy environment: clean drinking water, safe and healthy food, nontoxic air and soil. Individuals are responsible for their own personal health habits and for paying the price for the choices they make.
Who Pays?
Current “health care reform” (more aptly called “insurance reform”) seeks a way to provide affordable, universal health insurance that will cover medical expenses for accidents and illness without limitations on preexisting conditions. But to expect insurance companies to cover both preventive care and disease management at a low price and to offer the same benefits to everyone is simply unrealistic. The reality is that the care an individual gets is going to depend on the care an individual is able to afford.
Insurance companies can stay in business only when they have a large pool of premium-paying customers who do not file claims. That’s how they get the money to pay for the people who do file claims. The situation today is that an aging population is moving into the years of highest medical utilization, and a younger population is choosing to opt out of health insurance because it’s too expensive and they are not required to buy it. When the uninsured end up in the emergency room, they receive the most expensive care; but lacking insurance, many have no means to pay for the care. This perfect storm has led to personal financial disasters and a failing health care system. The situation is in desperate need of reform.
Historically, health insurance has paid for the largest portion of total health care expenses. The public has shared little responsibility for the rising costs of care. Now the public wants health care reform to provide both medical and preventive services and to do it at a lower cost. This is an unrealistic attitude, and one that threatens to bankrupt our country and topple our economy.
Does Prevention Save Money?
An article titled “Does Preventive Care Save Money” in the February 2008 New England Journal of Medicine reported, “Some evidence does suggest that there are opportunities to save money and improve health through prevention.”
Yet in August 2009, the Congressional Budget Office sent a letter to the US House of Representatives Subcommittee on Health reporting that “Although different types of preventive care have different effects on spending, the evidence suggests that for most preventive services, expanded utilization leads to higher, not lower, medical spending overall.”
As with all complex problems, the devil is in the details. Some interventions save lives and save money; others save lives but cost more; and others save neither lives nor money.
From society’s standpoint, we must continue to identify those interventions that save both lives and money and aim to practice them—providers and patients alike—100% of the time. This is why evidence-based practice is advocated as the gold standard of quality health care.
From an individual’s standpoint, it’s time we recognize that everyone is going to be paying more for health care. We had all best start budgeting for it. Not everyone will be able to afford a new Jaguar; some may be able to afford only a used Volkswagen. We must each tailor our expectations for what we can personally afford.
The cheapest way to save money and reform health care is to decrease utilization, that is, to stay out of the system as much as possible. The best way for each person to do that is to stay healthy, pay for routine screenings (out of pocket, if necessary), and make smart health choices that put prevention into practice in our personal lives.
Does Prevention Save Lives?
Only a few preventive interventions have been analyzed from both a cost and a lives-saved perspective. The same New England Journal of Medicine article reported that the following interventions have been shown to be both life-saving and cost-saving. But they are not practiced nearly enough.
- Daily aspirin for adults—Fewer than 50% of American adults now take a daily aspirin.
- Smoking cessation counseling by a health professional, including an offer for medication and other assistance to quit—Only 28% of smokers receive this counseling now.
- Colon screenings for adults age 50 and older—Only 50% of people in this age group keep up to date with colon screening.
- Annual flu shots for adults age 50 and older—Only 37% get them now.
- Breast cancer screening for women age 40 and older at least every 2 years— Currently, 67% of women have recommended breast cancer screenings.
- Annual chlamydia screening for sexually active young women, which would prevent 30,000 cases of pelvic inflammatory disease—Only 40% of the target population gets screened regularly now.
The New England Journal of Medicine article also listed the following as worthy of further study:
- Screening for diabetes, hypertension, high cholesterol, depression, stress and anxiety, medication compliance, exercise behaviors, weight status, and dietary habits
- The cost-effectiveness and clinical outcomes of health risk assessments and counseling of adults and children
- Effectiveness of smoking cessation programs for youths and adults
- Role of fast food in chronic disease risk development, and whether health warnings should be placed on these foods as they are on tobacco products
Smart Health Choices
A free society cannot and should not dictate personal health behaviors, even if they prevent disease. It is unreasonable to think a health professional, an employer, an insurance company, or the government can keep people healthy.
Ultimately, health is a personal responsibility, personal expense, and personal effort. Every individual must choose his or her own life habits and path. Knowing how to stay healthy and how to reduce the need for expensive sick care services is the most cost effective way to prevent disease and lower health care costs and utilization. Each of us will personally bear the costs of our own health choices and health outcomes, in terms of both money and quality of life.
Nurse practitioners’ preventive interventions beg further study. My book, A Nurse Practitioner’s Guide to Smart Health Choices, outlines the national treatment guidelines for those health risks the New England Journal of Medicine article deemed worthy of further study. The book details simple measurements that NPs, and patients themselves, can use to determine if preventive interventions work.
Nurse practitioners manage chronic illnesses and teach people how to stay well. NPs promote healthy behaviors, see that screenings are up to date, and educate patients how to make smart health choices. NPs put prevention into practice.
This information is offered for educational purposes only and is not intended to diagnose, prescribe or treat. For that please seek direct care from a health professional.
Don’t Give Up on Haiti
These are trying times – wars overseas and terrorist threats at home, a miserable economy, a health care system in crisis and Washington politicians behaving with more pettiness and self-interest than squabbling two year olds – well, it’s just plain disheartening.
Haiti – Whose Problem Is It?
This week a patient of mine lumped Haiti’s problems in along with all those others I just mentioned but I begged to differ. Haiti is neither a governmental nor political problem – it is a humanitarian one. It is not our governments’ problem to solve, it is our own as individuals. We can save Haiti if we don’t give up on her.
I wrote in my last post right after the Haiti earthquake about how important it was to send money immediately. I am writing now to say we must keep sending money as Haiti moves through the years of recovery to come. Since this is a humanitarian effort it is up to humans, not governments, to provide the relief. If we were struck by a disaster we would hope others would do the same for us.
The U.S. government, the United Nations, the World Bank, the World Food Program or other large global organizations – none of them – not even all of them combined have the money to rebuild Haiti. They may have the personnel and equipment and expertise, but they do not have the money. We individual humans must contribute that.
Being Human
I’ve been reflecting on what my patient said about Haiti being just another disaster on the world stage that will tax our resources and strain our economy more, but I can’t think about it that way. To me it’s more personal than that. There but for the grace of God go I.
I have decided I am going to give $10 every month to the Red Cross specifically for Haiti for as long as it takes. It’s a very small sum of money I know. But if humans all over the world each give just a little, it will become a lot. It is humanity’s job to help Haiti rebuild and become a model for other humanitarian projects in the future.
If one million people contribute the same small amount I do – that’s 120 million dollars a year, if two million contribute that is 240 million year – if 100 million people contribute – well, you get the idea. It won’t affect your taxes, your services or the national deficit because it’s coming directly from you – not your government.
Humanitarian aid is humans helping other humans – it’s not a governmental or political issue. In fact, the trick is keeping governments from interfering. It doesn’t have to be a lot of money, but if a lot of humans give a lot can get done.
I’m tired of the bickering and fighting in Washington, I’m frustrated with the economy, I’m weary of wars, I’m angry at terrorists and I’m fed up with the profiteering and turf wars that are keeping health care reform stalled.
Some things should be out of bounds where partisan politics are concerned and humanitarian aid is one of them. I still believe in humanity so I’m not giving up on Haiti anytime soon. I hope you won’t either.
Photo credit: The Big Picture at Boston.com
This information is offered for educational purposes only and is not intended to diagnose, prescribe or treat. For that please seek direct care from a health professional.
Defining Nurse Practitioners
For Nurse Practitioner World News
Jan-Feb 2010
By Carla Mills, ARNP
If NPs are to have a positive impact on health and health care, we must clearly define ourselves for the public and the media. People need to know what makes us distinct and different from doctors and other types of nurses. Ignorance about NPs has stunted our professional development and slowed our evolution as a profession.
Health challenges confront a world with a rapidly aging population and an epidemic of chronic lifestyle diseases. NPs can keep people well and manage the care for those who become sick. But in order to do so, the special talents and skills of NPs need to be clearly defined. If given the necessary authority and the opportunity, NPs are prepared to dramatically and positively change the way health care is delivered.
To define something, one must understand both the meaning of the term (in this case, “nurse practitioner”) and the nature, essential qualities, and boundaries of the words’ meaning (that is, what makes nurse practitioners different from doctors and other types of nurses). Defining our particular uniqueness is challenging because nurse practitioners are both doctors and nurses, yet we are neither.
When Organized Medicine Defines NPs
Our failure to clearly define ourselves created a vacuum that enabled organized medicine, under a pretext of protecting the public, to presume to define us. Long ago, organized medicine appointed itself arbiter of all health care and all health care providers. For years, it has defined NPs using rhetoric that is aimed at shaping public opinion and restricting NP practice.
Terms like “non-physicians,” “physician extenders,” and “mid-level providers” have been widely used to refer to both NPs and physician assistants—as if the two are indistinguishable. These labels diminish NP authority and impede the growth and expansion of NP practice. Constant repetition of these doctor-centric terms in the media has successfully wormed them into the common vernacular and misled everyone about the true nature of NPs. These pejorative terms define NPs not according to what we are, but rather according to what we are not. They obscure the quality of our expertise and deny the potential benefits we can deliver as independent providers. These terms do not protect public trust at all; rather, their use more closely resembles antitrust.
NP Titles Obscure NPs’ Nature
As nursing professionals earn additional degrees, certifications, and honors, they add more and more letters after their names until their titles become unwieldy and indecipherable. These titles are meaningless to the public and media, and they obscure NPs’ common characteristics.
Much has been written about the use of the title “doctor” by DNPs and other doctorate-educated nurses. Nurses who have earned a doctorate degree have every right to use the title “doctor.” But just because one has a right to do something, does that make it the right thing to do? Until a universally understood nomenclature is used by the nursing profession to clearly communicate to the public what distinguishes different types of nursing professionals from doctors and from each other, confusion will prevail. Creating this unnecessary confusion is a disservice we inflict on both the public and ourselves.
The public understands the words “doctor” and “nurse.” It needs to understand “nurse practitioner” better. Sticking with just these 3 titles and not cross-pollinating them would make it easier on everyone. We make more productive use of our valuable time when, instead of explaining and reexplaining what kind of nurse or doctor we are, we spend it on substantive matters that affect our patients.
NP Defined
All NPs are RNs, but all RNs are not NPs. Although both RN and NP practice is rooted in the profession of nursing, the scope of practice is different. NPs and RNs share the same core values and mission. All nurses stand up for and stand by patients suffering mental or physical illness.
As RNs, we are formally educated and clinically trained to care for the sick and the infirm. As NPs, after receiving more formal education and more clinical training, we advance our nursing practice to enable us to prevent, diagnose, and treat diseases. The term “nurse” refers to RNs and the term “nurse practitioner” refers to NPs. We all must see to it that the titles are used correctly on every occasion, and we should request a correction every time and every place they are not.
The medical profession’s expertise is disease; the nursing profession’s expertise is a patient’s experience of disease and the process of healing. NPs diagnose and treat illness within a larger context than doctors do, because NP care encompasses a patient’s whole life. Personal choices, family circumstances, community, and society as a whole all come under NPs’ scrutiny. The most expert medical care in the world cannot produce healthy citizens so long as lifestyles, the community, and society remain sick.
Compared with doctors, NPs tend to spend more time with each patient. NPs do not work more slowly or take more time because they are less intelligent or less efficient than doctors. NPs simply must spend more time, because it is the nature of NP practice. Treatment plans are not dictated to patients by NPs, as they often are by doctors. Rather, NP treatment plans are collaborative agreements reached in partnership with patients after a process that includes evaluating problems, teaching about causes, discussing options, and exploring patients’ own needs and wishes. With this extra time and the knowledge that is gained about the patient and by the patient, NPs are able to deliver care accurately, safely, and according to the patient’s own directives. NPs help patients manage the life changes that come with a chronic disease or a catastrophic event. When it is inevitable, helping patients face death with dignity and grace is intrinsic not just to NP care, but to all nursing care.
When people ask me what an NP is, the one-sentence defInition I give is: “I am a nurse who does the same thing a doctor does, but I do it from the perspective of a nurse.” Personally, I wish we had been named “nurse doctors” instead of “nurse practitioners”—it’s a title that’s less vague and more precise. But then nobody ever asked me.
This information is offered for educational purposes only and is not intended to diagnose, prescribe or treat. For that please seek direct care from a health professional.
9 comments so far. (Post your own)
Help Haiti and Help Yourself – Make a Long Term Commitment
The devastating natural disaster in Haiti has gripped our hearts and minds. Many are suffering without water and food while suffering injuries and the loss of family, loved ones and shelter from the elements. Those people’s circumstances are utterly unimaginable. Please donate money NOW and plan to keep on giving in the future. Recovery will not be quick.
Give Money NOW!
The images coming out of Haiti are horrible. The delay getting food and water and medical care to the millions who need it is gut wrenching. The tens of thousands of dead are rotting in the streets creating a public health emergency of gigantic proportions. Hopefully you’ve already made a donation to the American Red Cross or some other legitimate aid organization that you know will get the money to those who can get supplies on the ground quickly – even $5 or $10 matters!
But don’t plan to stop giving when the news cycle changes. Haiti was on the verge of a major infusion of investment capital that could turn this jewel of the Caribbean from a backward and impoverished third world country into a glittering and prosperous nation. Let’s not give up hope for that future. We can not leave it to governments and movie stars and telathons alone – they don’t have enough money. It’s our $5 and $10 dollars donations – if they keep on coming as Haiti moves through the stages of emergency care, to recovery, to rebuilding – that can bring Haiti and the Haitian people back to life from this terrible disaster. So please don’t go away or forget about Haiti when it’s no longer the top story on the nightly news.
What’s In It for You?
These are dangerous and scary times. All over the world humans face scary threats. The media reports that experts predict there is a 99.7% chance of an earthquake of similar catastrophic proportions in California any day now. Given it’s own current financial crisis, California is at risk just like Haiti – hopefully better building codes will make such a catastrophe, though still devastating, somewhat less deadly. Natural disasters, terrorism and economic ruin seem to be threatening us from every direction. How are we to cope with it all? Here are 3 ideas that will help:
- Help others. Donate money now and donate money, goods or services later to stay connected to the rebuilding of Haiti. It will heal them and heal you.
- Take care of yourself. Those who will survive in Haiti will share two characteristics. One, they were lucky. And two, they are resilient in body, mind and spirit. So let that be a wake-up call for you. Get in shape, maintain a strong mental attitude and stay connected to your spiritual power source – whatever that is for you.
- Stay in it for the long haul. Haiti’s recovery and your own is not going to happen overnight. Time is the great healer for both the rescuer and the rescued. If you are the victim of a disaster you will stand a better chance of survival if you are in good health and decent shape.
Here are some legitimate websites where you can donate money right now. No amount is too small:
American Red Cross
Clinton-Bush Haiti Fund
There are others but double-check they are legitimate before you give them money. And remember, all the experts are saying what’s needed most right now is money.
This information is offered for educational purposes only and is not intended to diagnose, prescribe or treat. For that please seek direct care from a health professional.
Organizing NPs and NP Organizations
For Nurse Practitioner World News
Nov-Dec 2009
By Carla Mills, ARNP
Synergy is the dynamic and energetic atmosphere created when individuals and groups work together to produce results they could not obtain independently. It comes from two Greek words – syn meaning “together” and erg meaning “to work”, i.e. “work together”. My “NPs on the Edge” columns this past year outline a vision for the future that NPs can achieve if we can only learn to work together synergistically.
In my first column in NPWN this year, I evoked two historic nursing visionaries and social reformers. Florence Nightingale brought nurses into positions of respect and advanced the evolution of medicine by sanitizing operative procedures and hospitals. Lillian Wald founded the Henry Street Settlement and the Visiting Nurse Service in New York City in 1893, creating public health institutions still at work today. Both of these women established nurses as social reform leaders. Their actions and achievements prove that disrupting the status quo is essential if the goal of social change is to be achieved. If NPs today are to live up to these visionary leaders’ legacy, we must match their bravery and tenacity with our own. We must come together with their same determination to solve the major public health problem of our time – chronic lifestyle diseases.
In my second column I wrote that in order to fulfill our social responsibility and put right a broken health care system, full practice and prescriptive authority for NPs is essential. This is a non-negotiable mandate that must be demanded by every individual NP and every NP organization. It should be the unifying political cause that directs our legislative agenda. We can not equivocate and we need not doubt ourselves. The essence of NP care suits the health needs of our time just as perfectly as Nightingale’s and Wald’s care suited the health needs of their time. We must defend and take ownership of our methods of practice. We must describe our unique expertise to everyone who does not understand us. At every opportunity we must challenge demeaning labels such as “non-physician”, “mid-levels” and “physician extenders”. We must constantly explain the distinctions between the titles “nurse” and “nurse practitioner” until NPs are well understood.
In my third column I laid out the core measurements for optimum health that will prevent and treat chronic diseases. Reaching these goals requires a combination of healthy lifestyle behaviors and, sometimes, medications. NPs are the only health care professionals who are trained in both medicine and nursing. NPs are trained to treat both the health problem itself and the patient’s response to the problem. Helping patients get to goal on all of these measurements is the only way chronic diseases will ever be effectively controlled and prevented.
Then in my last column I discussed the need for NPs to reach out to the media. Overcoming our social invisibility is the key to having a voice and having influence. Neither legislators, government leaders nor the general public will pay any attention to us until we are seen and heard from in the media.
Challenges for NPs and Our Organizations
So far NPs have not been effective organizers. NP organizations suffer from fragmentation, divisiveness between different groups, and low membership numbers relative to the total number of NPs. It is hard to say they truly represent NPs given the fact that the majority of NPs do not support them by joining and paying dues. Their small sizes and small membership numbers prevent them from garnering the resources and clout they need to accomplish any meaningful political reform or effective media outreach on behalf of NPs. [See the list below of the current membership numbers of the national NP organizations.]
Lack of coordination and resource sharing between national, state and local NP organizations dilute what money and energy members do contribute. Individual and organizational NP initiatives repeatedly hit dead ends because their efforts aren’t supported or carried forward by a unified community of organized NPs working synergistically with the nursing profession as a whole. NP organizations and educational institutions continue focus only on NP issues and ignore issues of public health leaving us lacking in social relevance.
It’s time we take a giant, bold collective leap over the edge and into the future. NPs need to get organized. The NP profession is made up of 147,000 disconnected individuals and a whole host of disorganized organizations, foundations, networks and councils – all have some growing and changing to do and it needs to be done fast.
NP Organizations Need to Organize
NP organizations need to coalesce, merge and share resources. If they want to attract more members (and more dollars) they must prove themselves competent and relevant to a larger percentage of 147,000 practicing NPs.
Reaching out and inviting all NPs (clinicians, educators, researchers, and administrators) to the table and incorporating all the divergent views will find innovative solutions to old problems. Abandoning the status quo will allow NPs to evolve into something more socially relevant.
Specifically, all NP organizations should coordinate their efforts to pursue the following three unified agendas:
- Obtain funding and grass roots support from a majority of NPs in order to lobby effectively to obtain full practice and prescriptive authority for NPs across all 50 states.
- Advocate boldly for a national health initiative led by NPs to get every American to goal on every single health risk.
- Launch a robust and coordinated media outreach campaign that explains and promotes NPs’ vision, authority, and expertise and outlines a clear health care plan for the public.
Individual NPs Need to Become Activists
NPs have an unprecedented opportunity at this moment in history. It is up to each one of us to take full advantage of it. Whatever your passion, whatever cause you support, whatever you believe – act on it and invest money in it. As I see it, every NP should be making 3 types of donations: time, money and self. Every NP should
- Reach out to local, state and national politicians and legislators at every opportunity. Explaining NPs’ urgent need for full practice and prescriptive authority and how we will use that authority to provide exactly the type of health care that’s most needed and in shortest supply. This is easy to do these days via email. It’s a donation of time.
- Join and pay dues to local, state and national NP organizations. Don’t skip organizations because you’ve given to a group on another geographic level. Make additional donations if you feel the organizations’ performance is adequately representing your interests. Do it today! It’s a donation of money.
- Reach out to the media. Write a letter to the editor. Call in a story to your local newspaper. Get interviewed on a local radio show. Meet the press whenever and wherever the opportunity arises. It’s a donation of self.
Synergy = Energy Squared
United and cohesive NP organizations, when aligned with 147,000 NP activists, all working toward the same solutions – that would be a powerful force for health reform!
Finding solutions to the difficult social and behavioral problems that lead to disease is both a humanitarian issue and a political one. Eliminating the causes of chronic disease will require changing the very nature of our social values and disrupting many of our social structures. NPs can help guide those changes if we will work together energetically and synergistically.
National NP Organization Membership #s
TOTAL # of NPs in the U.S. = 147,295 as of 02/2009 (Pearson Report, 2009)
AANP (American Academy of Nurse Practitioners) = 26,600 members as of 09/2009
ACNP (American College of Nurse Practitioners) = 4,500 members as of 10/2009
NPWH (National Association of Nurse Practitioners in Women’s Health) = 2,500 members as of 11/2008
NAPNAP (National Association of Pediatric Nurse Practitioners) = 7,000 members as of 04/2008
GAPNA (Gerontological Advanced Practice Nurses Association) = 1,805 members as of 06/2008
NONPF (The National Organization of Nurse Practitioner Faculties) = 1,100 members as of 10/2009
This information is offered for educational purposes only and is not intended to diagnose, prescribe or treat. For that please seek direct care from a health professional.
2 comments so far. (Post your own)
Top Ten Holiday Gifts for Good Health
Here are Maverick Health’s top ten holiday gifts for good health. Too often the holidays end up in a tailspin of bad health choices. We overeat and gain 5 lbs that we never seem to lose, we feel stressed and we spend more than we planned on gifts that aren’t always appreciated or good for those to whom we give them. But this year things can be different. Here are some healthy gift ideas for your friends and loved ones that say “I care about you and your health”.
- A Nurse Practitioner’s Guide to Smart Health Choices by Carla Mills, ARNP. (A shameless plug for my own book, but it’s the best darn guide I’ve been able to find for people who want to take control of their own health and health care.) Send it as a gift – we’ll gift wrap it for you! Or buy it for yourself! If you don’t agree that it’s one of the most useful health books you’ve ever read, just tell us so and we’ll refund your money – guaranteed.)
- Here are two very important books that I recommend to 95% of my patients. They are best given together and read in this order: First read In Defense of Food by Michael Pollan then read The End of Overeating by David Kessler. Kessler’s book picks up where Pollan’s book leaves off. They are well written and easy reads – not “how to” books. I read them last summer and they have literally transformed my relationship and attitude toward food and restaurants in a good way.
- Jumpsnap Cordless Jump Rope. I own one of these and this is my favorite exercise “gadget”. Aerobic exercise strengthens the heart. The heart is a muscle and the more you work it the stronger it gets. Jumping rope is a fabulous aerobic exercise. The problem comes if you want to jump rope inside (say if you are traveling or the weather is bad). Ceilings are often to low to use a standard jump rope. The Jump Snap is electronic and has no rope so it can be used in hotel rooms or wherever there’s not enough ceiling height for a standard jump rope. Tip: Jumping rope is a secret weapon in the quest for aerobic fitness and weight loss. Jumpsnap makes a great gift. Be sure to check with a health professional before beginning any new exercise program if you have not been physically active.
- Pedometer. Walking is healthy and safe for almost everyone. If you don’t see your gift recipient wanting to jump rope there are other ways to increase physical activity and burn up more calories. One of the most gentle and effective ways is walking. The daily goal is 10,000 steps everyday but studies have shown inactive people only walk about 3,000 steps a day. Clip a pedometer on every day and add 500 steps each day until the goal of 10,000 steps is reached. How? Park further away from stores, take the stairs, walk the mall, take a nature walk – be creative! This device incorporates “exercise” into one’s daily life.
- Sun Mountain Speed Cart V1. This gift was recommended to me by Bob Carney, the creative director for Golf Digest, as a healthy idea for all the golfers out there (you know who you are). Bob writes, “I’ve got three or four fitness machines that never get used. The one healthy thing I, and a lot of my middle-aged friends do, is walk the golf course. Remember, it’s a six-mile walk on average for 18 holes and I play about 50 rounds a year. This product by Sun Mountain is cool because it allows you easily to walk when you play and not have to carry your bag. Unlike a lot of clunky pull carts, or expensive motorized ones, it’s light, easily-storable, and sturdy.” He denies working for Sun Mountain but says this product did get listed in the 2009 Golf Digest “Hot List” Gold Selection this year. Add a pedometer and you’ve got a fun fitness plan!
- Yoga Force Mat. This environmentally friendly, well cushioned, non-slip mat would make a great gift for the yoga practitioner on your gift list. Whether they practice at home or at a yoga studio, the lines on the mat help keep postures properly aligned – plus it is just plain cool looking. I wish I had one.
- Rx Tote Medicine Bags. I really wish all my patients had one of these. Anyone who takes medications should have a place to keep them organized (and should carry them to all appointments with health providers). These kits keep meds travel ready, too. Having all medications in one place vastly improves your chances of taking them correctly. I can’t tell you how much time/energy we waste/spend in my practice just to make sure that our records of what patients are supposed to be taking match what patients actually are taking. I only wish the pill boxes included in these kits were the larger 4 time a day/week rather than the once a day/week kind. Most people on multiple medications take them more than once a day. Make that one change to this product and it will be perfect.
- A Recipe for Life. Good nutrition is so fundamental to good health that without it good health is improbable if not impossible. There are so many diet and cookbooks out there, but not so many nutrition books. Susan Dopart is a registered dietitian who has written an attractive and nutritionally sound book with lots of good recipes to teach you the basics of good nutrition. My book (another shameless plug) teaches the basics of good health, Susan’s book teaches the basics of good nutrition. Put the two together and you have a powerful recipe for better health.
- Save a Child. There is nothing that will enrich your holiday more than giving generously to someone less fortunate than you. Save the Children offers many opportunities for any budget to help children in need. Unlike many gifts which are opened and forgotten, these gifts literally transform and even save lives. Plus you can add a cuddly goat or sheep plush-toy to your order to give the child you help something to unwrap and enjoy this holiday season!
- A Slow Christmas is a FREE GIFT FOR YOU OR A LOVED ONE. This refreshing and calming blog by Porter McConnell deserves a visit. Porter writes “According to the American Psychological Association in this survey and this one, too), holiday stress can contribute to stress-related illnesses. Perhaps the most important way to help people improve their health is for them give themselves permission to take it easy at Christmas this year. The holidays are supposed to be a time to relax and have fun, not to get stuck running endless eleventh-hour errands in a crowded mall. We need to slow down Christmas, and start enjoying it. If we don’t, our health and well-being suffer.” I agree with Porter. Her blog has inspired me to slow down my own holiday this year and it’s feeling good!
Best Wishes for Happy and Healthy Holidays!
This information is offered for educational purposes only and is not intended to diagnose, prescribe or treat. For that please seek direct care from a health professional.
Mammogram Recommendation – What to Do Now?
Last week the U.S. Preventive Task Force Services (USPTF) recommended that screening mammograms were no longer routinely required for women in their 40s and that self-breast exam is no longer advised. What!? Is this just cost-cutting or is this good medicine?
Mammogram Recommendation for Whom?
Before deciding how to react to these guidelines and whether to follow them or not, the first order of business is to put them in perspective in terms of your own personal and comprehensive health care plan. It is our position here at Maverick Health that neither doctors, task forces, organized medicine nor insurance companies should be in charge of your health and health care – you should.
Government agencies (like the USPTF), doctors and insurance companies exist to serve you – not to dictate to you. To get the most out of these services, you must be the one in charge. This means taking on more responsibility for knowing your own circumstances. That’s how you will be able to determine where you fit into these new guidelines. These government agencies come up with these recommendations for whole populations – but treatment decisions must be made by and for individuals.
Health Risk Screening in General
Cancer and, in fact, all health screenings are designed to discover and treat diseases that may not yet be causing symptoms. The goal of screening is early detection to (hopefully) cure but at least treat problems before they develop into chronic diseases or cause death.
Different people have different levels of risk for a long list of chronic diseases and cancers. Risks are the result of family history, personal lifestyle behaviors and, to some extent, luck. I wrote my book, A Nurse Practitioner’s Guide to Smart Health Choices, specifically to help non-medical readers determine their particular risk profile so they are able to direct their health and health care intelligently.
Different individuals have different risk tolerances and your choice about what to do about these recommendations depends a lot on your own personal risk tolerance. You may love taking risks. Does jumping out of airplanes sound fun to you? Or you may hate risk. Do you find stepping outside your own home so risky you dread doing it? Most of us fall somewhere in between these two extremes, but our attitudes about risk determine how we choose to handle our health and health care. One size does not fit all.
The USPTF Mammogram Recommendation
The USPTF recommendation statement was directed at “women 40 years or older who are not at increased risk for breast cancer by virtue of a known underlying genetic mutation (i.e. a strong family history of breast cancer or known BRCA 1 or BRCA 2 genes from prior genetic testing) or a history of chest radiation.” The six USPTF conclusions were:
- For biennial screening mammography in women aged 40 to 49 years, there is moderate certainty that the net benefit is small. Although the USPSTF recognizes that the benefit of screening seems equivalent for women aged 40 to 49 years and 50 to 59 years, the incidence of breast cancer and the consequences differ. The USPSTF emphasizes the adverse consequences for most women—who will not develop breast cancer—and therefore use the number needed to screen to save 1 life as its metric. By this metric, the USPSTF concludes that there is moderate evidence that the net benefit is small for women aged 40 to 49 years.
- For biennial screening mammography in women aged 50 to 74 years, there is moderate certainty that the net benefit is moderate.
- For screening mammography in women 75 years or older, evidence is lacking and the balance of benefits and harms cannot be determined.
- For the teaching of BSE (breast self exam), there is moderate certainty that the harms outweigh the benefits.
- For CBE (clinical breast exam) as a supplement to mammography, evidence is lacking and the balance of benefits and harms cannot be determined.
- For digital mammography and MRI as a replacement for mammography, the evidence is lacking and the balance of benefits and harms cannot be determined.
What I Tell My Patients
- My clinical concern and responsibility is taking care of individuals, not populations. A single case missed is one too many as far as I am concerned. Even though mammography is not the most perfect test in the world, particularly in women under age 50, the practice of combination screening with mammography, an annual clinical breast exam and monthly or bimonthly self breast exam is the best we’ve got at present in my opinion. I plan to continue to recommend a baseline mammogram between age 35 and 40 and will determine frequency after that based on each woman’s particular risks and her financial ability to pay for the mammogram. As for the issue of “adverse consequences” raised by the task force (i.e. anxiety surrounding testing or additional testing such as ultrasounds or biopsies if the mammogram is questionable), that is a non-issue in my opinion. A little anxiety surrounding screening or diagnostic testing pales in comparison to the anxiety associated with a diagnosis of breast cancer. If the mammogram is questionable additional testing clarifies an individual’s breast status at any age.
- For women 50 to 74 years I’ll continue to recommend annual breast surveillance consisting of screening mammography, annual clinical breast exam and monthly or bimonthly self breast exam.
- Breast cancer risk increases with age. For women 75 and older in good health I will continue to recommend annual breast surveillance consisting of screening mammography, annual clinical breast exam and monthly or bimonthly self breast exam. Exceptions are when women are in poor health and would not be good candidates for breast cancer treatment or women who tell me that if they learned they had breast cancer they would not want any treatment.
- This recommendation I really do not understand. What possible “harms” can come from examining one’s own breasts for lumps and who exactly would be harmed? Why anyone would recommend women stop self breast exams is beyond me. My sister picked up her own breast cancer with self breast exam only a few months after her mammogram missed it. Because she caught it early her treatment was less invasive and more likely to have resulted in a cure. I will continue to encourage and teach self breast exams to my patients.
- For clinical breast exam (done by your health professional at your physical exam) they are saying they don’t know if it does any good or not. I haven’t picked up many breast cancers that way over the years, but I’ve picked up a few. In my practice we recommend annual physical exams, though the “benefit” of those too is under question. It’s an opportunity to do a very detailed exam of the whole body (not just a gynecological exam), check on whether health screenings are all up to date, and teach things like self breast exams and self skin exams among other things.
- Digital mammography and breast MRI are also question marks as far as the task force is concerned. At present radiology centers are upgrading to digital and that will be the new standard. Skilled radiologists reading the films – whether plain or digital – are still an essential component. In in the last study I read radiologists are still beating the computers in reading digital mammograms. Breast MRIs are expensive and currently used only for high risk patients or as a follow up to abnormal mammograms.
Postscript on PAPs
Just a couple of days after the USPTF announced their new recommendations the American College of Obstetricians and Gynecologists (ACOG) in a press release announced their own new recommendations that PAP smears can now be delayed until age 21 and only need to be done every couple of years.
FYI: These two new recommendations released during the same week were completely coincidental. They were issued by two different and unrelated organizations and are in no way a “conspiracy” to deprive women of health care. For now mammograms are still being covered in the same way by insurance companies they have always been.
As for the PAPs, women younger than 21 who are sexually active should definitely see a health professional about their gynecological care every year. Topics for discussion are: birth control options, HPV vaccination, timing of PAP smears, sexually transmitted disease risks and safe sex practices.
Bottom line: The best person to take care of you is you. If you’re lucky you have a competent and understanding health professional in the form of a nurse practitioner, physician or physician assistant to help you and advocate for you. If you don’t – see if you can find one.
Your comments are welcomed.
This information is offered for educational purposes only and is not intended to diagnose, prescribe or treat. For that please seek direct care from a health professional.
How to Lower Prescription Drug Costs
I have an idea about how to lower prescription drug costs and save millions (if not billions) of wasted dollars.
I know how to decrease confusion and eliminate much of the unnecessary anxiety related to prescription drugs. And I know how to decrease the cost of prescription drugs for individuals. How?
Pass a law to make it illegal for drug companies to advertise directly to consumers.
The Paradox of the American Health Care Consumer
I find many of my patients resistant to any drug therapy whatsoever – even if it will prolong their life and reduce their risk of chronic diseases or catastrophic events like a heart attacks or strokes. Yet direct-to-consumer advertising sells these very same patients medications they do not need for conditions they do not have and they come to the office actually asking for them by name. And what do the drug companies get out of it? Billions and billions of dollars from blockbuster drugs is what.
Drug companies didn’t begin marketing to consumers until the 1980s. Before that they marketed only the health care professionals – mostly doctors. Today, however, drug companies’ goal is to get patients to ask for a drug – whether they need it or not – because it’s more profitable for the drug companies that way. In the old days they had to convince and then wait for prescribers to decide to use a drug. The only way to create a blockbuster drug is to get people asking for it who don’t even need it. This is a corner of the health care system that really needs reformed but I haven’t heard of any plans to do it.
The Cost of Blockbuster Drugs and Direct-to-Consumer Drug Advertising
The October 2009 AARP Bulletin printed a list of the 50 Most Prescribed Drugs in 2008 and their cost at the pharmacy. They pointed out that prescription drugs account for 10% of the nation’s total health care costs. And though brand name drugs (versus cheaper generics) make up only 22% of the top 50 drugs they account for 62% of the total expense. The total cost of prescriptions drugs in 2008 was 53.2 billion according to AARP.
A recent story on NPR’s Morning Edition reported that drug companies are spending $4 billion a year on direct-to-consumer advertising. NPR reported that Neilson (the company that does TV ratings) estimates there is an average of 80 drug ads every hour on TV. Can you imagine the money that’s costing? But given the money the drug companies are raking in, to them it’s worth it. It’s we consumers who can’t afford it!
The problem as I see it is that the more they spend on direct-to-consumer advertising the more they have to rake in to cover their advertising costs. And how do they do that? Higher drug prices, of course.
Compare Brand Name Drug Costs with Generic Equivalents
Here are just a few comparisons from the AARP Top 50 List with the total cost of brand name drugs (listed first) versus their equivalent generics (listed second). Notice how many extra billions are flowing back to the drug companies just in these few examples.
Cholesterol Lowering Medication:
Lipitor: $5.88 billion (for 49 million prescriptions)
Simvastatin: $1.45 billion (for 60 million prescriptions)
Reflux/Heartburn Medication:
Nexium: $4.79 billion (for 27 million prescriptions)
Omeprazole: $1.15 billion (for 29 million prescriptions)
Depression Medication:
Lexapro: $2.41 billion (for 26 million prescriptions)
Sertraline: $648 million (for 30 million prescritions)
High Blood Pressure Medication:
Diovan: $1.28 billion (for 16 million prescriptions)
No generic equivalent in this drug class
Blood Thinner Medication:
Plavix: $3.80 billion (for 25 million prescriptions)
Warfarin; $317 million (for 23 million prescriptions)
Are Drug Companies Serving the Public or Serving Themselves?
Finding the right medication for a patient involves correctly diagnosing their condition, knowing their medical history, knowing their drug tolerances and intolerances and then choosing a medication that accomplishes three things:
- Does not cause side effects.
- Acheives the desired therapeutic effect.
- Is affordable.
The drug companies argue, “We need these profits for research and development or else we won’t be able to find new cures.” Here’s what I think. I think if they put a complete halt to direct-to-consumer advertising they could use part of the $4 billion they are now spending on advertising to make brand named drugs more affordable. Then they could use the rest to get back to what should be their core business – finding new drugs and new cures. I think they should get out of the advertising business and back into the pharmaceutical business.
Anybody out there agree with me?
This information is offered for educational purposes only and is not intended to diagnose, prescribe or treat. For that please seek direct care from a health professional.
Why NPs Should Reach out to the Media
For Nurse Practitioner World News, Sept-Oct 2009
By Carla Mills, ARNP
Nurse practitioners lack influence in the health care system because we have accepted invisibility. Our work is hidden behind exam room doors. Now that health care reform is under way, NPs have the opportunity to cast off the cloak of invisibility through media outreach. Media exposure is vital if we are to be effective health leaders.
Health care in the future aspires to do exactly what NPs have always done: educate patients about their health status so they can actively participate in their own treatments. For NPs to steer health and health care in healthier directions, we must reach out to the media and share our stories.
My Uncle Walt had a favorite expression: “When you’re up to your a** in alligators, it’s hard to remember you came to drain the swamp.” Demands of clinical practice, restrictions on NP practice, and lack of public understanding about what distinguishes NPs from other nurses are alligators that distract us. A dysfunctional so-called “health” care system that doesn’t do a thing until people get sick is the swamp that needs draining.
Making Media Outreach Part of Your Professional Life
After over 40 years, the NP message is still not well understood. It is up to each of us to do our part to bring our NP methods into the public consciousness. The best way to do that is through the media.
Incorporating media outreach into your professional life doesn’t have to be hard—it can actually be fun! Think for a minute about your own personal core message or solution as an NP. Maybe it’s a project you are developing, an experience you’ve had, or a passion that drives you. Write about it in the most compelling 500 to 600 words you can muster. You might have one story or 10, and they will change over time. When big news happens (or when you feel like reacting to something you see in the media), adapt what you’ve already written. Then send it out to the media.
If you follow Twitter, take a single thought or idea from your core piece and tweet it. If you read news stories, blogs, or editorials online, post comments to them. If you give a talk that is videotaped, post it on YouTube. Take every opportunity to get to know your local newspaper, TV, and radio reporters, and make yourself available to help them when they face tight deadlines.
The goal is to promote your constructive opinions and ideas in a way that will get our message out of the exam room and into the public discussion. Start with media channels you already follow; you already have a good idea of the stories they do and how they do them. As you get more proficient, you may want to branch out. Before sending your piece to more than one media outlet, be aware of “exclusivity” requirements that the larger media organizations often require.
Tips for Compelling Writing
- Have a clearly stated point of view. Stick to it; don’t equivocate.
- Be brief. Keep your writing tight, 600 words max.
- Make your point in the first paragraph.
- Support your opinions with facts.
- Don’t be afraid of controversy.
- Offer insights that educate, but don’t preach.
- Be passionate but controlled.
- Hook your piece to breaking news. Submit it within 12 hours of the news; the sooner the better.
- Close with a short, strong, powerful last paragraph.
- Indicate your expertise in a short “bioline” at the end. Be sure to include your NP credentials, but keep it simple so your audience understands them – Nurse Practitioner is probably enough.
For a great example of compelling writing, read the 274 word Gettysburg Address by Abraham Lincoln.
Media Outreach Ideas
Media channels are always looking for compelling stories and interesting viewpoints. Many pieces can be submitted online. Be sure you follow any submission instructions to the letter.
The more targeted your submissions, the more successful they will be. The trick is to reach the right contact at the right outlet at the right time with the right story. It makes sense to start locally, expand regionally and, as your message or reputation grows, go national. Here are some starting points:
- Op-ed articles are a great way to educate and inform the public and increase NP exposure. Try to tie your topic to breaking news.
- Submit articles or stories to consumer organizations like AARP or business publications like Forbes or Business Week. These channels want to know NPs’ views.
- Share story ideas or op-ed pieces with local newspapers and TV and radio stations. Maybe you can become the local health expert and have a column or featured spot on a show.
- Start a blog. Follow and comment on other blogs.
- Use Twitter, LinkedIn, and Facebook. Always make sure your profile and posts reflect well on you professionally.
- Check out Help a Reporter Out™ (http://www.helpareporter.com). It’s free, and reporters post their story needs 3 times a day. Warning: Never pitch off-topic; it will get you banned from the list.
- Join non-NP business organizations, like the Chamber of Commerce, to meet professional leaders outside your field.
- Consider media training to learn how to do interviews and get comfortable on camera and on the radio.
Media Exposure for One Is Media Exposure for All
Retail clinics have succeeded in putting NPs in the headlines as never before. Most major newspapers throughout the country have had stories about retail clinics, largely because of the controversy surrounding them. Despite the opposition of physician groups, the clinics are thriving. Their services are high quality; they deliver on their promise of convenience; they boast state-of-the-art electronic medical records; and their patient satisfaction numbers are stunning—90% and higher. This high quality, affordable, NP-led care has given millions of uninsured Americans access to care they could not have afforded otherwise. And it has made for marketing and media success. All NPs owe thanks to the Convenient Care Association for its tremendous job coordinating the retail clinics’ media outreach. Now we need to bring similar publicity to NPs everywhere in the health care system.
This fall National Public Radio’s Morning Edition profiled a nonprofit company, Fairview Health Services in Fairview, Minnesota. The company has developed an innovative care delivery system that, if successful, could be a model for the entire nation. The story intrigued me because the care model described didn’t sound like a physician-type approach. An NPR personality interviewed the company’s CEO and a physician on staff, then introduced Valerie Overton, NP, in this way: “Nurse practitioner Val Overton helped oversee the redesign of care at the clinic.” Val then commented: “It’s kind of interesting that Washington is reforming health care, when they’re not the ones in the room with the patient, and that’s really what this project is about: letting the people in the room with the patient reform health care.” It was gratifying to hear an NP’s leadership and vision credited on National Public Radio—with the correct title and everything.
We are living in an enabling time in history for NPs. We have a rare opportunity to advance our core values and to improve health care in this country and around the world. We should seize this moment. Media outreach will be part of our job description from now on, so we would all do well to develop our skills at it. I can’t think of any better way to tame the alligators and drain the swamp.
Carla would like to thank the following people for offering their input and perspectives in the writing of this column: George and Louise Young (publishers of NP World News), Loretta Ford, Eileen O’Grady, and Carolyn Buppert. As always, readers are invited to leave comments.
This information is offered for educational purposes only and is not intended to diagnose, prescribe or treat. For that please seek direct care from a health professional.
Texting While Driving is a Serious Health Risk - Duh!
I know, it’s not you – it’s the other guy. I want to talk about a serous health risk that more than 80 % of us admit to engaging in – texting while driving or talking on a cell phone while driving.
How much faith to you have in yourself as a driver? And how much faith do you have in other drivers? I’m betting you believe you are more competent than most of the drivers with whom you share the road. Be honest, am I right? I think its human nature to find ourselves more competent than everyone else on the road, but when I scrutinize that belief it’s just doesn’t hold up. So let’s get real for a minute about the danger of multi-tasking while driving an automobile.
A View from the Emergency Room
I have spent many years of my career in emergency rooms, so I have seen first hand the damage a human body can suffer in an automobile collision. Back before there were laws requiring seat belts, there were many more (and much worse) injuries than after the law was enacted. I have seen so many people either permanently disfigured or killed, and often young and beautiful people, just because they weren’t wearing seat belts. But cell phones scare me even more.
The thing about accidents is this, AFTER they’ve happened you can’t take them back. And most accidents are preventable. But that’s ONLY IF you will respect the risks and avoid taking them BEFORE something bad happens.
Facts about Texting While Driving and Using a Cell Phone While Behind the Wheel
Consider this:
- More than 50 scientific studies have identified risks in driving and using a cell phone.
- You are 4 times more likely to get in a car crash if you use a cell phone while you are driving.
- Driver inattention is responsible for 80% of all crashes. Cell phones, because they are used so much, are the leading cause of driver distraction.
- Hands free devices do NOT make cell phones any safer.
- Talking to a passenger in your car is not the same as talking on a cell phone. Because the passenger is with you and aware of your surroundings, they see the circumstances you are in. Not only are they are less distracting, they may even alert you to potential dangers.
Texting while driving is even riskier than talking on a cell phone because it requires that you take your eyes off the road. (Really, who thinks they can do this safely?)
The View from My Driver’s Seat
On my way to the office most mornings it seems like everyone I pass has a cell phone plastered to their ear. Others are applying make up, shaving, eating, even reading the paper. It seems everyone is preoccupied with something other than attending to the business at hand – negotiating a deadly vehicle, often moving at a high rate of speed, through congested roads filled with other potentially deadly vehicles driven by equally distracted drivers.
When driving I try to keep away from drivers on phones because I know they aren’t paying attention to what’s going on around them. I see them moving down the road and their driving pattern makes it clear that they are oblivious to what is going on around them. It’s terrifying.
The Laws of the States
Only 5 states prohibit cell phone use by all drivers (and that’s only hand held cell phones): California, Connecticut, New Jersey, New York and Washington. Some other states prohibit young drivers and school bus drivers.
Only seven states prohibit texting while driving: Alaska, California, Connecticut, Louisiana, Minnesota, New Jersey and Washington and the District of Columbia.
What We Say about Ourselves
In a survey of about 2500 people done by the AAA Foundation for Traffic Safety in 2008, four out of five drivers rated drivers using cell phones as either a serious or extremely serious traffic safety problem. Of those surveyed, 46% admitted they used a cell phone while driving at least occasionally.
So, we don’t trust others to use cell phones while driving, but see ourselves as more capable. Since we perceive ourselves as superior creatures with talents and capabilities above those of other mere mortals, we do not feel at risk nor do we believe we put others at risk the way all those “less capable” drivers do. This makes no sense. We all need to start using our common sense to keep us safe.
Ask yourself very honestly, do you really believe the laws of human nature do not apply to you? Acquiring a driver’s license is a right of passage into adulthood, but where cell phones and driving is concerned we are acting like children playing with matches. Sooner or later we are going to get burned.
A Proposed Solution
I propose we all, regardless of our age, start acting like responsible adults, police our own behavior and stop using cell phones when we are behind the wheel of a moving vehicle.
I further propose that we ask our legislators to pass strict laws that ban cell phone use when driving. This would protect the rest of us from those unwilling to police themselves.
Let’s make it the law in all 50 states – just like we did with seat belts – and then let’s enforce it!
A Request
If you receive a call on your cell phone or if you need to make one, please pull off the road and get out of traffic first. And those of you doing your make-up and shaving – please finish dressing before you leave home so you can keep your eyes on the road. Thanks.
What are your comments? Does anyone share my fears and frustrations? For those of you who disagree, does what I say not make sense?
Links to more info:
Cell Phone Use While Driving Fact Sheet
Cell Phones and Driving: Research Update, December, 2008
This information is offered for educational purposes only and is not intended to diagnose, prescribe or treat. For that please seek direct care from a health professional.
6 comments so far. (Post your own)
Swine Flu Symptoms and When You Need Tamiflu
The swine flu (AKA H1N1) has gotten our attention. At my practice we are getting getting calls from patients asking about the symptoms and for prescriptions for Tamiflu to have at home “just in case”.
In this post I want to explain the symptoms of swine flu and when you do and do not need Tamiflu (oseltamivir) – or the other anti-viral medication, Relenza (zanamivir). Also, I want to give you a link to good information sources about swine flu. There is a lot of hype out there and as this is a story that is still being written, so I want you to have reliable sources for the best information.
Symptoms of Swine Flu
- Fever
- Chills
- Cough
- Sore throat
- Runny or stuffy nose
- Body aches
- Headache
And sometimes:
- Vomiting and diarrhea
- Respiratory symptoms without a fever.
In short, the same symptoms as the regular flu!
Do You Need an Antiviral Med like Tamiflu?
Antiviral drugs are not like antibiotics that kill bacteria. Antivirals do not kill the virus or cure you of the illness. All they do is interrupt the virus’s ability to spread. They may shorten and decrease the severity of your symptoms, but that is all. Different antivirals work in different ways.
Which Antiviral Drugs Work and Which Don’t?
Tamiflu (oseltamivir) and Relenza (zanamivir) work by blocking the release of newly created viruses from an infected cell. This will slow the growth of the virus and that is why they lessen the severity of symptoms. Most important, it reduces transmission of the virus to others. That is why the government has stockpiled these drugs and why they are used in places like nursing homes where the spread of the virus needs to be contained.
According to the World Health Organization, “Oseltamivir [Tamiflu] is administered orally and gives higher systemic level. Zanamivir [Relenza] is delivered by oral inhalation and has lower systemic absorption. Oseltamivir [Tamiflu] is the recommended treatment for lower respiratory tract complications (i.e. pneumonia).”
Antiviral drugs DO NOT cure the flu, they merely shorten and lessen its symptoms. They work best if they are started within 48 hours of symptom outbreak.
Who Should Get Tamiflu or Relenza?
According to the Centers for Disease Control and Prevention “most healthy persons who develop an illness consistent with influenza, or persons who appear to be recovering from influenza, do not need antiviral medications for treatment or prophylaxis. However, persons presenting with suspected influenza and more severe symptoms such as evidence of [pneumonia] or clinical deterioration should receive prompt empiric antiviral therapy, regardless of previous health or age.” In other words, ride it out unless you are getting worse. If your symptoms are worsening and you think it’s swine flu, see a health professional promptly.
The following people are in high risk groups and should be treated with Tamiflu (or Relenza):
- Pregnant women
- Patients with worsening lower respiratory infections or pneumonia
- Children younger than 5 years old.
- Adults 65 years of age and older.
- People with chronic pulmonary disease (including asthma), cardiovascular disease (except hypertension), kidney, liver, blood (including sickle cell disease), neurologic, neuromuscular, or metabolic disorders (including diabetes).
- People who are immunosuppressed either from cancer or other chemotherapy or HIV
- People younger than 19 years of age who are on long-term aspirin therapy.
- Residents of nursing homes and other chronic-care facilities.
Why Should Treatment Be Given?
For two primary reasons:
- To decrease the severity of illness in an individual.
- To slow or stop the spread of the virus through a community.
Should You Ask your Health Provider for a Prescription to have at Home “Just in Case”?
NO – for four reasons.
- If you become sick with the swine flu it is important that you are properly diagnosed and identified. At this time the swine flu is a greater threat to the community than it is to you individually.
- You are not a health professional and may take the medication for a virus for which it will not be effective. Or you may start the drug too early or too late for it to be maximally effective. You need to be examined and diagnosed before receiving a prescription unless you are in a community where there is a known swine flu outbreak.
- Used incorrectly drugs that are now effective in slowing the spread of this virus may become ineffective because the virus can mutate and become resistant to them.
- If everyone stockpiles these drugs they will be used in a chaotic rather than an organized way. This will undermine their ability to slow or stop the spread of swine flu among groups (i.e. schools or nursing homes) or the community at large. It also may result in using up the limited supply of these drugs so there will be none available to stop outbreaks as they occur.
How You Can Protect Yourself from Swine Flu?
- Hand washing, hand washing, hand washing.
- Get enough rest.
- See a health professional if you get sick.
- Stay home from work or school if you get sick and don’t go back until you have been without a fever for 24 hours.
- See this post (also on this blog): I’m Down with the Flu – Some Tips for You
Here is a link to information you can trust about swine flu symtoms and and treatments:
Centers for Disease Control and Prevention
This information is offered for educational purposes only and is not intended to diagnose, prescribe or treat. For that please seek direct care from a health professional.
Nurse “Edge Runners” Honored by Maverick Health
The Edge Runner program is a part of the Raise the Voice initiative funded by Robert Wood Johnson Foundation and directed by the American Academy of Nursing. It recognizes nursing professionals who are finding new ways to improve and promote the health of patients.
It hasn’t gotten nearly the media play it should, nor have these Edge Runners had as much recognition as they deserve. To honor of their achievements Maverick Health is inducting them into its Hall of Fame.
On the Edge
With health care reform in full swing we need to hear from nurses on the edge. I write a column for NP World News (it is also posted here on the blog) called “NPs on the Edge”. This “edgy” language is not random. The edge is where you get out from under unquestioned assumptions and try new approaches. The Edge Runners honored by the Raise the Voice initiative (and today by Maverick Health!) are doing just that – and they are succeeding!
Solving the Puzzle of Health (Care) Reform
Nursing wisdom and expertise is still a missing piece in the puzzle of health (care) reform. Health reform will not succeed until nurses’ voices are heard. Nurses have many of the solutions to serious health problems that threaten us today and in the future. Here are just a few of the things NPs and nurses are doing all across the country. There are too many Edge Runners to honor individually but you can read about each one at this Edge Runners list.
NPs Deliver High Quality Primary Care
- NP run health care centers provide high quality primary care (in spite of outdated practice restrictions that continue to limit NP’s effectiveness).
[My Note: These are often called “nurse managed health centers”, but to be accurate they are “nurse practitioner managed health centers”. Only NPs are licensed to provide primary care, RNs are not. Both are nursing professionals but each has a different scope of practice. For more on nurses’ confusing titles and different scopes of practice please read my post “It is a Mistake to Call a Nurse Practitioner a Nurse“.] - NP run retail clinics serve the uninsured and those without medical “homes” with convenient, high quality and affordable care.
- NPs control health care costs by reducing hospitalizations. (A number of the Edge Runner programs have resulted in cost savings in the millions for the communities they serve!)
- NPs coordinate and manage interdisciplinary care among various provider groups to keep care patient-centered rather than provider-centered.
- NPs and nurses are designing databases that measure the quality of patient care and patient outcomes.
- NPs partner with employers to provide wellness coaching and lifestyle counseling to employees that improves employee fitness and reduces health risks.
- NPs have replaced emergency room physicians in some rural areas by partnering with physician specialists who make themselves available for consultations 24/7 via computer connections from distant teaching hospitals.
- An NP created a teaching program for African American women at risk for HIV. It is culturally sensitive, theory driven, gender specific and designed to be easily integrated into other primary care practices.
Nursing Innovations Improve Care for Children and Families
- Independent birthing centers run by nurse midwives offer comprehensive care and reduce pre-term births.
- Nurses teach parenting classes to give parents skills to manage difficult, real-life child behaviors that put parents, children and families at risk.
- Nurses teach middle school children with diabetes coping and communication skills so they can successfully manage both their blood sugars and their lives.
- Nurses created end of life care programs specifically for terminally ill children.
- NPs offer home based interdisciplinary care to support families where grandparents are raising grandchildren.
- NPs designed a program to integrate physical and mental health care for children and adolescents that could change the way primary pediatric care is practiced in the U.S.
- Nurses re-conceptualized the way care is delivered in ICUs (intensive care units) that changes the strictly medical focus to a patient-centered one where family wishes and the patient’s quality of life get included in the plan of care.
Nursing Redefining Elder Care
- NPs are providing home care and case management so seniors can remain in their own homes instead of being forced into nursing homes.
- NPs are managing health care and well-being services for elders and those with complex medical and social needs to overcome fragmentation of care, improve health outcomes, and increase patient satisfaction. (One such program, Evercare, saved the state of Texas $123 million in Harris County alone between February 2000 and January 2002 and has spurred greater use of nurse practitioners in long-term care.)
- NPs are leading programs that improve heart failure patients’ quality of life by teaching them self management skills that reduce their number of hospitalizations.
- Nurses are establishing day programs to serve the needs of elders with cognitive impairments and their families
- Nurses are teaching seniors how to preserve cognitive skills by using attention focusing, memory strategy training, repeated practice, and mind/body integration.
Watch a 6-Minute Video about the Edge Runners
Thank you Edge Runners and thank you Robert Wood Johnson Foundation for recognizing the critical role nursing professionals play in health and health care reform. And welcome all of you to the Maverick Health Hall of Fame – you are an inspiration!
Would anyone like to leave a comment to thank these extraordinary nurses?
This information is offered for educational purposes only and is not intended to diagnose, prescribe or treat. For that please seek direct care from a health professional.
“Smart Choices” Food Labels Dishonored in Maverick Health Hall of Shame
This week I am introducing the first of two new categories to my Areas of Focus on the blog – the Maverick Health Hall of Shame and the Maverick Health Hall of Fame. (Next week I will introduce the first Maverick Health Hall of Famer.)
“Smart Choices” is a shameful food labeling campaign bought and paid for by giant food processers. It is a sham and so deserves its place of dishonor in the Hall of Shame. In these days of contentious debate about health and health care reform I want to do what I can to bring fame to those doing good work and shame to those trying to bamboozle us for a quick (or big) buck.
Dollars to Doughnuts
The “Smart Choices” food labeling campaign is funded (to the tune of $1.47 million dollars so far) by the nation’s largest food manufacturers (Kellogg’s, Kraft Foods, ConAgra Foods, Unilever, General Mills, PepsiCo and Tyson Foods). We’ll get to whether it’s smart to manufacture food at all in a minute. Somehow these manufacturers found a bunch of “experts” willing to endorse putting “Smart Choices” labels on packages of foods that are not “smart choices” at all.
Dr. Eileen T. Kennedy, the dean of the Friedman School of Nutrition Science and Policy at Tufts University is the president of the Smart Choices board. She was quoted in a recent New York Times article as supporting Fruit Loops (of all things) with a green “smart choice” check mark because she says Fruit Loops are a “better” choice than doughnuts. (For the record – Fruit Loops are not food, they are a highly processed food “product” and they contain 41% sugar! There is absolutely nothing “smart’ about them.)
Richard Kahn, PhD, a former chief scientific and medical officer for the American Diabetic Association, participated on the selection panel and now serves on the board of trustees. He was quoted in a recent Forbes article as saying the “guidelines” were designed to help people who are currently making “terrible, terrible choices” with their diets. He thinks it seems “unrealistic” to point consumers toward less-processed foods like fruits and vegetables because the “intended audience” of the Smart Choices program is those who might be choosing between a sugary cereal and a doughnut. “If you get someone who has diabetes and they’re eating doughnuts for breakfast,” he said, “anything down the ladder is a better choice.” Shame, shame – Fruit Loops are 41% sugar! Give me a break. How dumb do these people think we are?
It’s shameful that such well educated health professionals could endorse labeling Fruit Loops as “healthy”. According to them being “better for you than doughnuts” makes them a “Smart Choice”.
As the author of a book titled A Nurse Practitioner’s Guide to Smart Health Choices I am appalled. If this were a good program that actually helped guide consumers to smarter food choices, I’d be thrilled and would put the program in the Hall of Fame – but that is SO not the case here. This whole labeling scheme has nothing to do with helping consumers and everything to do with selling more processed food products. I’ll bet you dollars to doughnuts on that.
What’s a REAL Smart Choice?
In the nutrition chapter of my book and in two recently published books by future Maverick Health Hall of Famers, Michael Pollan and David Kessler, one thing is perfectly clear – most processed/manufactured food is not good for you at all, it is bad for you. Simply stated, a diet of whole foods (mostly fruits and vegetables) prepared simply with healthy fats like olive oil and without excess sodium and sugar is the “smartest choice” you can make.
If you want to know what you should and should not eat I strongly recommend these two entertaining books. Read Pollan’s book first. It leads perfectly into Kessler’s. I’ve been recommending both to all my patients since a registered dietitian friend sent them to me last summer.
- In Defense of Food by Michael Pollan
- The End of Overeating by former FDA chief, David Kessler.
For the Record
Maverick Health receives no outside funding from any individual or organization. Nor will Maverick Health make or accept endorsements in exchange for money or favors. Maverick Health is supported entirely by books sales of A Nurse Practitioner’s Guide to Smart Health Choices, income I earn in my medical practice and, to a small extent, speaking engagements. As Maverick Health’s founder, I have posted extensive information about my professional background and credentials on this website. I encourage you to read these and determine for yourself whether I am a credible health expert.
I always gratefully accept endorsements of my book and of Maverick Health from readers and health professionals who believe that what I am doing can help people get healthier. And I always welcome comments and opinions about the things I write.
So what do YOU think about this “Smart Choices” labeling?
This information is offered for educational purposes only and is not intended to diagnose, prescribe or treat. For that please seek direct care from a health professional.
Add Your Comments
Comment Rules: All comments are monitored before being posted. Please use either your personal name or initials and not your business name. Do not use links to your website in either your name or your comment text as it comes off like spam and so will not be published. Thanks for visiting and adding to the conversation!
Add Your Comments
Comment Rules: All comments are monitored before being posted. Please use either your personal name or initials and not your business name. Do not use links to your website in either your name or your comment text as it comes off like spam and so will not be published. Thanks for visiting and adding to the conversation!
Add Your Comments
Comment Rules: All comments are monitored before being posted. Please use either your personal name or initials and not your business name. Do not use links to your website in either your name or your comment text as it comes off like spam and so will not be published. Thanks for visiting and adding to the conversation!
Add Your Comments
Comment Rules: All comments are monitored before being posted. Please use either your personal name or initials and not your business name. Do not use links to your website in either your name or your comment text as it comes off like spam and so will not be published. Thanks for visiting and adding to the conversation!
Add Your Comments
Comment Rules: All comments are monitored before being posted. Please use either your personal name or initials and not your business name. Do not use links to your website in either your name or your comment text as it comes off like spam and so will not be published. Thanks for visiting and adding to the conversation!
Add Your Comments
Comment Rules: All comments are monitored before being posted. Please use either your personal name or initials and not your business name. Do not use links to your website in either your name or your comment text as it comes off like spam and so will not be published. Thanks for visiting and adding to the conversation!
Add Your Comments
Comment Rules: All comments are monitored before being posted. Please use either your personal name or initials and not your business name. Do not use links to your website in either your name or your comment text as it comes off like spam and so will not be published. Thanks for visiting and adding to the conversation!
Add Your Comments
Comment Rules: All comments are monitored before being posted. Please use either your personal name or initials and not your business name. Do not use links to your website in either your name or your comment text as it comes off like spam and so will not be published. Thanks for visiting and adding to the conversation!
Add Your Comments
Comment Rules: All comments are monitored before being posted. Please use either your personal name or initials and not your business name. Do not use links to your website in either your name or your comment text as it comes off like spam and so will not be published. Thanks for visiting and adding to the conversation!
Add Your Comments
Comment Rules: All comments are monitored before being posted. Please use either your personal name or initials and not your business name. Do not use links to your website in either your name or your comment text as it comes off like spam and so will not be published. Thanks for visiting and adding to the conversation!
Add Your Comments
Comment Rules: All comments are monitored before being posted. Please use either your personal name or initials and not your business name. Do not use links to your website in either your name or your comment text as it comes off like spam and so will not be published. Thanks for visiting and adding to the conversation!
Add Your Comments
Comment Rules: All comments are monitored before being posted. Please use either your personal name or initials and not your business name. Do not use links to your website in either your name or your comment text as it comes off like spam and so will not be published. Thanks for visiting and adding to the conversation!
Add Your Comments
Comment Rules: All comments are monitored before being posted. Please use either your personal name or initials and not your business name. Do not use links to your website in either your name or your comment text as it comes off like spam and so will not be published. Thanks for visiting and adding to the conversation!
Add Your Comments
Comment Rules: All comments are monitored before being posted. Please use either your personal name or initials and not your business name. Do not use links to your website in either your name or your comment text as it comes off like spam and so will not be published. Thanks for visiting and adding to the conversation!
Add Your Comments
Comment Rules: All comments are monitored before being posted. Please use either your personal name or initials and not your business name. Do not use links to your website in either your name or your comment text as it comes off like spam and so will not be published. Thanks for visiting and adding to the conversation!
Add Your Comments
Comment Rules: All comments are monitored before being posted. Please use either your personal name or initials and not your business name. Do not use links to your website in either your name or your comment text as it comes off like spam and so will not be published. Thanks for visiting and adding to the conversation!
Add Your Comments
Comment Rules: All comments are monitored before being posted. Please use either your personal name or initials and not your business name. Do not use links to your website in either your name or your comment text as it comes off like spam and so will not be published. Thanks for visiting and adding to the conversation!
Add Your Comments
Comment Rules: All comments are monitored before being posted. Please use either your personal name or initials and not your business name. Do not use links to your website in either your name or your comment text as it comes off like spam and so will not be published. Thanks for visiting and adding to the conversation!
Add Your Comments
Comment Rules: All comments are monitored before being posted. Please use either your personal name or initials and not your business name. Do not use links to your website in either your name or your comment text as it comes off like spam and so will not be published. Thanks for visiting and adding to the conversation!
Add Your Comments
Comment Rules: All comments are monitored before being posted. Please use either your personal name or initials and not your business name. Do not use links to your website in either your name or your comment text as it comes off like spam and so will not be published. Thanks for visiting and adding to the conversation!
Add Your Comments
Comment Rules: All comments are monitored before being posted. Please use either your personal name or initials and not your business name. Do not use links to your website in either your name or your comment text as it comes off like spam and so will not be published. Thanks for visiting and adding to the conversation!
Add Your Comments
Comment Rules: All comments are monitored before being posted. Please use either your personal name or initials and not your business name. Do not use links to your website in either your name or your comment text as it comes off like spam and so will not be published. Thanks for visiting and adding to the conversation!
Add Your Comments
Comment Rules: All comments are monitored before being posted. Please use either your personal name or initials and not your business name. Do not use links to your website in either your name or your comment text as it comes off like spam and so will not be published. Thanks for visiting and adding to the conversation!
Add Your Comments
Comment Rules: All comments are monitored before being posted. Please use either your personal name or initials and not your business name. Do not use links to your website in either your name or your comment text as it comes off like spam and so will not be published. Thanks for visiting and adding to the conversation!
Add Your Comments
Comment Rules: All comments are monitored before being posted. Please use either your personal name or initials and not your business name. Do not use links to your website in either your name or your comment text as it comes off like spam and so will not be published. Thanks for visiting and adding to the conversation!
Add Your Comments
Comment Rules: All comments are monitored before being posted. Please use either your personal name or initials and not your business name. Do not use links to your website in either your name or your comment text as it comes off like spam and so will not be published. Thanks for visiting and adding to the conversation!
Add Your Comments
Comment Rules: All comments are monitored before being posted. Please use either your personal name or initials and not your business name. Do not use links to your website in either your name or your comment text as it comes off like spam and so will not be published. Thanks for visiting and adding to the conversation!
Add Your Comments
Comment Rules: All comments are monitored before being posted. Please use either your personal name or initials and not your business name. Do not use links to your website in either your name or your comment text as it comes off like spam and so will not be published. Thanks for visiting and adding to the conversation!
Add Your Comments
Comment Rules: All comments are monitored before being posted. Please use either your personal name or initials and not your business name. Do not use links to your website in either your name or your comment text as it comes off like spam and so will not be published. Thanks for visiting and adding to the conversation!
Add Your Comments
Comment Rules: All comments are monitored before being posted. Please use either your personal name or initials and not your business name. Do not use links to your website in either your name or your comment text as it comes off like spam and so will not be published. Thanks for visiting and adding to the conversation!
Add Your Comments
Comment Rules: All comments are monitored before being posted. Please use either your personal name or initials and not your business name. Do not use links to your website in either your name or your comment text as it comes off like spam and so will not be published. Thanks for visiting and adding to the conversation!
Add Your Comments
Comment Rules: All comments are monitored before being posted. Please use either your personal name or initials and not your business name. Do not use links to your website in either your name or your comment text as it comes off like spam and so will not be published. Thanks for visiting and adding to the conversation!
Add Your Comments
Comment Rules: All comments are monitored before being posted. Please use either your personal name or initials and not your business name. Do not use links to your website in either your name or your comment text as it comes off like spam and so will not be published. Thanks for visiting and adding to the conversation!
Add Your Comments
Comment Rules: All comments are monitored before being posted. Please use either your personal name or initials and not your business name. Do not use links to your website in either your name or your comment text as it comes off like spam and so will not be published. Thanks for visiting and adding to the conversation!
Add Your Comments
Comment Rules: All comments are monitored before being posted. Please use either your personal name or initials and not your business name. Do not use links to your website in either your name or your comment text as it comes off like spam and so will not be published. Thanks for visiting and adding to the conversation!
Add Your Comments
Comment Rules: All comments are monitored before being posted. Please use either your personal name or initials and not your business name. Do not use links to your website in either your name or your comment text as it comes off like spam and so will not be published. Thanks for visiting and adding to the conversation!
Add Your Comments
Comment Rules: All comments are monitored before being posted. Please use either your personal name or initials and not your business name. Do not use links to your website in either your name or your comment text as it comes off like spam and so will not be published. Thanks for visiting and adding to the conversation!
Add Your Comments
Comment Rules: All comments are monitored before being posted. Please use either your personal name or initials and not your business name. Do not use links to your website in either your name or your comment text as it comes off like spam and so will not be published. Thanks for visiting and adding to the conversation!
Add Your Comments
Comment Rules: All comments are monitored before being posted. Please use either your personal name or initials and not your business name. Do not use links to your website in either your name or your comment text as it comes off like spam and so will not be published. Thanks for visiting and adding to the conversation!
Add Your Comments
Comment Rules: All comments are monitored before being posted. Please use either your personal name or initials and not your business name. Do not use links to your website in either your name or your comment text as it comes off like spam and so will not be published. Thanks for visiting and adding to the conversation!
Add Your Comments
Comment Rules: All comments are monitored before being posted. Please use either your personal name or initials and not your business name. Do not use links to your website in either your name or your comment text as it comes off like spam and so will not be published. Thanks for visiting and adding to the conversation!
Add Your Comments
Comment Rules: All comments are monitored before being posted. Please use either your personal name or initials and not your business name. Do not use links to your website in either your name or your comment text as it comes off like spam and so will not be published. Thanks for visiting and adding to the conversation!
Add Your Comments
Comment Rules: All comments are monitored before being posted. Please use either your personal name or initials and not your business name. Do not use links to your website in either your name or your comment text as it comes off like spam and so will not be published. Thanks for visiting and adding to the conversation!
Add Your Comments
Comment Rules: All comments are monitored before being posted. Please use either your personal name or initials and not your business name. Do not use links to your website in either your name or your comment text as it comes off like spam and so will not be published. Thanks for visiting and adding to the conversation!
Add Your Comments
Comment Rules: All comments are monitored before being posted. Please use either your personal name or initials and not your business name. Do not use links to your website in either your name or your comment text as it comes off like spam and so will not be published. Thanks for visiting and adding to the conversation!
Add Your Comments
Comment Rules: All comments are monitored before being posted. Please use either your personal name or initials and not your business name. Do not use links to your website in either your name or your comment text as it comes off like spam and so will not be published. Thanks for visiting and adding to the conversation!
Add Your Comments
Comment Rules: All comments are monitored before being posted. Please use either your personal name or initials and not your business name. Do not use links to your website in either your name or your comment text as it comes off like spam and so will not be published. Thanks for visiting and adding to the conversation!
Add Your Comments
Comment Rules: All comments are monitored before being posted. Please use either your personal name or initials and not your business name. Do not use links to your website in either your name or your comment text as it comes off like spam and so will not be published. Thanks for visiting and adding to the conversation!
Add Your Comments
Comment Rules: All comments are monitored before being posted. Please use either your personal name or initials and not your business name. Do not use links to your website in either your name or your comment text as it comes off like spam and so will not be published. Thanks for visiting and adding to the conversation!
Add Your Comments
Comment Rules: All comments are monitored before being posted. Please use either your personal name or initials and not your business name. Do not use links to your website in either your name or your comment text as it comes off like spam and so will not be published. Thanks for visiting and adding to the conversation!
Add Your Comments
Comment Rules: All comments are monitored before being posted. Please use either your personal name or initials and not your business name. Do not use links to your website in either your name or your comment text as it comes off like spam and so will not be published. Thanks for visiting and adding to the conversation!
Add Your Comments
Comment Rules: All comments are monitored before being posted. Please use either your personal name or initials and not your business name. Do not use links to your website in either your name or your comment text as it comes off like spam and so will not be published. Thanks for visiting and adding to the conversation!
Add Your Comments
Comment Rules: All comments are monitored before being posted. Please use either your personal name or initials and not your business name. Do not use links to your website in either your name or your comment text as it comes off like spam and so will not be published. Thanks for visiting and adding to the conversation!
Add Your Comments
Comment Rules: All comments are monitored before being posted. Please use either your personal name or initials and not your business name. Do not use links to your website in either your name or your comment text as it comes off like spam and so will not be published. Thanks for visiting and adding to the conversation!
Add Your Comments
Comment Rules: All comments are monitored before being posted. Please use either your personal name or initials and not your business name. Do not use links to your website in either your name or your comment text as it comes off like spam and so will not be published. Thanks for visiting and adding to the conversation!
Add Your Comments
Comment Rules: All comments are monitored before being posted. Please use either your personal name or initials and not your business name. Do not use links to your website in either your name or your comment text as it comes off like spam and so will not be published. Thanks for visiting and adding to the conversation!
Add Your Comments
Comment Rules: All comments are monitored before being posted. Please use either your personal name or initials and not your business name. Do not use links to your website in either your name or your comment text as it comes off like spam and so will not be published. Thanks for visiting and adding to the conversation!
Add Your Comments
Comment Rules: All comments are monitored before being posted. Please use either your personal name or initials and not your business name. Do not use links to your website in either your name or your comment text as it comes off like spam and so will not be published. Thanks for visiting and adding to the conversation!
Add Your Comments
Comment Rules: All comments are monitored before being posted. Please use either your personal name or initials and not your business name. Do not use links to your website in either your name or your comment text as it comes off like spam and so will not be published. Thanks for visiting and adding to the conversation!
Add Your Comments
Comment Rules: All comments are monitored before being posted. Please use either your personal name or initials and not your business name. Do not use links to your website in either your name or your comment text as it comes off like spam and so will not be published. Thanks for visiting and adding to the conversation!
Add Your Comments
Comment Rules: All comments are monitored before being posted. Please use either your personal name or initials and not your business name. Do not use links to your website in either your name or your comment text as it comes off like spam and so will not be published. Thanks for visiting and adding to the conversation!
Add Your Comments
Comment Rules: All comments are monitored before being posted. Please use either your personal name or initials and not your business name. Do not use links to your website in either your name or your comment text as it comes off like spam and so will not be published. Thanks for visiting and adding to the conversation!
Add Your Comments
Comment Rules: All comments are monitored before being posted. Please use either your personal name or initials and not your business name. Do not use links to your website in either your name or your comment text as it comes off like spam and so will not be published. Thanks for visiting and adding to the conversation!
Add Your Comments
Comment Rules: All comments are monitored before being posted. Please use either your personal name or initials and not your business name. Do not use links to your website in either your name or your comment text as it comes off like spam and so will not be published. Thanks for visiting and adding to the conversation!
Add Your Comments
Comment Rules: All comments are monitored before being posted. Please use either your personal name or initials and not your business name. Do not use links to your website in either your name or your comment text as it comes off like spam and so will not be published. Thanks for visiting and adding to the conversation!
Add Your Comments
Comment Rules: All comments are monitored before being posted. Please use either your personal name or initials and not your business name. Do not use links to your website in either your name or your comment text as it comes off like spam and so will not be published. Thanks for visiting and adding to the conversation!
Add Your Comments
Comment Rules: All comments are monitored before being posted. Please use either your personal name or initials and not your business name. Do not use links to your website in either your name or your comment text as it comes off like spam and so will not be published. Thanks for visiting and adding to the conversation!
Add Your Comments
Comment Rules: All comments are monitored before being posted. Please use either your personal name or initials and not your business name. Do not use links to your website in either your name or your comment text as it comes off like spam and so will not be published. Thanks for visiting and adding to the conversation!
Add Your Comments
Comment Rules: All comments are monitored before being posted. Please use either your personal name or initials and not your business name. Do not use links to your website in either your name or your comment text as it comes off like spam and so will not be published. Thanks for visiting and adding to the conversation!
Add Your Comments
Comment Rules: All comments are monitored before being posted. Please use either your personal name or initials and not your business name. Do not use links to your website in either your name or your comment text as it comes off like spam and so will not be published. Thanks for visiting and adding to the conversation!
Add Your Comments
Comment Rules: All comments are monitored before being posted. Please use either your personal name or initials and not your business name. Do not use links to your website in either your name or your comment text as it comes off like spam and so will not be published. Thanks for visiting and adding to the conversation!
Add Your Comments
Comment Rules: All comments are monitored before being posted. Please use either your personal name or initials and not your business name. Do not use links to your website in either your name or your comment text as it comes off like spam and so will not be published. Thanks for visiting and adding to the conversation!
Add Your Comments
Comment Rules: All comments are monitored before being posted. Please use either your personal name or initials and not your business name. Do not use links to your website in either your name or your comment text as it comes off like spam and so will not be published. Thanks for visiting and adding to the conversation!
Add Your Comments
Comment Rules: All comments are monitored before being posted. Please use either your personal name or initials and not your business name. Do not use links to your website in either your name or your comment text as it comes off like spam and so will not be published. Thanks for visiting and adding to the conversation!
Add Your Comments
Comment Rules: All comments are monitored before being posted. Please use either your personal name or initials and not your business name. Do not use links to your website in either your name or your comment text as it comes off like spam and so will not be published. Thanks for visiting and adding to the conversation!
Add Your Comments
Comment Rules: All comments are monitored before being posted. Please use either your personal name or initials and not your business name. Do not use links to your website in either your name or your comment text as it comes off like spam and so will not be published. Thanks for visiting and adding to the conversation!
Add Your Comments
Comment Rules: All comments are monitored before being posted. Please use either your personal name or initials and not your business name. Do not use links to your website in either your name or your comment text as it comes off like spam and so will not be published. Thanks for visiting and adding to the conversation!
Add Your Comments
Comment Rules: All comments are monitored before being posted. Please use either your personal name or initials and not your business name. Do not use links to your website in either your name or your comment text as it comes off like spam and so will not be published. Thanks for visiting and adding to the conversation!
Add Your Comments
Comment Rules: All comments are monitored before being posted. Please use either your personal name or initials and not your business name. Do not use links to your website in either your name or your comment text as it comes off like spam and so will not be published. Thanks for visiting and adding to the conversation!
Add Your Comments
Comment Rules: All comments are monitored before being posted. Please use either your personal name or initials and not your business name. Do not use links to your website in either your name or your comment text as it comes off like spam and so will not be published. Thanks for visiting and adding to the conversation!
Add Your Comments
Comment Rules: All comments are monitored before being posted. Please use either your personal name or initials and not your business name. Do not use links to your website in either your name or your comment text as it comes off like spam and so will not be published. Thanks for visiting and adding to the conversation!
Add Your Comments
Comment Rules: All comments are monitored before being posted. Please use either your personal name or initials and not your business name. Do not use links to your website in either your name or your comment text as it comes off like spam and so will not be published. Thanks for visiting and adding to the conversation!
Add Your Comments
Comment Rules: All comments are monitored before being posted. Please use either your personal name or initials and not your business name. Do not use links to your website in either your name or your comment text as it comes off like spam and so will not be published. Thanks for visiting and adding to the conversation!
Back to the blog home page
Back to the blog home page
