Saturday, January 4, 2014

The Gift of Patient Advocates

When you purchased holiday gifts online this season, did you check customer reviews before you bought? Of course you did. How wonderful to have insights from customers with experience!

For those wondering what “patient advocates” do, it’s that. Share insights for the patients that come after them, in hopes of helping them have a good experience, and avoid medical harm. (The sentiment is eloquently expressed in this poem shared by Linda Kenney, who founded MITSS -- Medically Induced Trauma Support Services-- after nearly dying from an anesthesia error during ankle surgery.)

“If patients don’t share their stories, who are you going to learn from?” says Alicia Cole, a successful LA actress who now speaks about her near-fatal battle against  necrotizing fasciitis (flesh-eating disease), acquired following "routine" surgery.

But who ARE we, exactly? What DEFINES a “patient advocate”?

Lindsay Nohr Beck, left, with
Dr.Nancy Snyderman, at IHI
I’ve been thinking about this a lot lately, since a telling audience reaction during a plenary speech at the Institute for Healthcare Improvement Forum in Orlando last month, attended by some 6,000 people, mostly providers. On stage was NBC News Chief Medical Editor Dr. Nancy Snyderman and her long-time patient, Lindsay Nohr Beck, who pretty much single-handedly reformed insurance benefits so that cancer patients don’t have to compromise fertility. (Watch the fascinating and moving interview here). In telling her story, Lindsay laughingly referenced the negative reaction when doctors or insurers were told by their staff “the patient advocates are waiting to meet with you”.

In the audience, this comment was met by a ripple of knowing (sympathetic?) laughter. A snicker drew my attention to the man on my left, who met my eyes with a nod and an eye roll. As a patient advocate myself, it stung.

But then, I realized, it’s understandable.

Because, what is it that defines a “patient advocate”, anyway? Is it the nurse who privately encourages a family to ask for a certain treatment? A mom with a third-grade education who insists to her doctors “my baby’s breathing just isn’t right?” A father who loses his son to multiple medical errors and spends a lifetime making sure the same mistakes don’t befall another family? A person with formal advocacy training who hires herself out to sit at a patient’s bedside, managing care, paperwork and billing? A physician who calls a colleague late at night to discuss a tricky diagnosis? A survivor crippled by multiple botched surgeries and impoverished by legal and medical bills firing off desperate, outraged emails to the news media? Or the elderly man who calmly declines aggressive intervention for his terminally-ill wife?

Yes, all of the above. We are a random, diverse and self-defined group. We are collaborative. We are rebellious. We are seasoned and thoughtful. We are raw and angry. We see good in every person who devotes their life to health care. We see enemies everywhere in the “medical/industrial complex”. We have no medical training at all. We have devoted years to taking courses and achieving certifications to understand the system and how we can help improve it. We are a rich, bubbling stew of passions, visions, hurts, head trash, and hope. In short, both before and after our “medical awakening”, we represent the full spectrum of the human condition.

At the IHI Forum for speaker training (second session), L to R:
Pat Mastors, Joyce Resin (IHI), Alicia Staley,
Jean Rexford, Alicia Cole, Dave deBronkart,
Catherine Rose, Barbara Lewis,
Randi Oster (missing: Patty Skolnik)
I can sympathize with health care organizations, working to meet financial and cultural benchmarks of “patient-centered care”, trying to embrace and collaborate with this motley crew of “patient advocates”.  In 2013 I personally was honored to work with the federal Partnership for Patients (PfP), the Center for Connected Health (CCH),the Institute for Healthcare Improvement (IHI), the Consumer's Union Safe Patient Project, the Institute for Patient- and Family-Centered Care (IPFCC), and the National Patient Safety Foundation (NPSF), among others. Of course my colleagues and I appreciate being invited into the conversation, having our input solicited, and in notable cases, seeing our feedback incorporated into practice. (IHI and the PfP in particular deserve credit for taking steps to support professional development for patient advocates.) 

But if we patient advocates want a beefier role in the dynamic of quality improvement than that of “invited guest”; if we truly want to lend meaningful support to clinical excellence, have impact at health conferences, ensure that policies are patient-centric, carry weight in legislatures and on medical boards, and inspire physician practices, we have to elevate ourselves as a group, to consistently convey the very leadership, professionalism and respect we expect from our providers. Otherwise, how will they avoid the “box of chocolates” dilemma? (“You never know what you’re gonna get”)?

More patient advocates than you might think have achieved that respect. Listen to “e-Patient” Dave deBronkartPatty SkolnikRegina Holliday, Alicia Cole or Trisha Torrey do a keynote speech. Invite Helen Haskell to head a committee, develop a protocol or advise your board. Ask Ilene Corina to conduct a patient advocacy training.  Look to Julia Hallisy for patient empowerment resources. Ask Christian John Lillis how to organize and mobilize a patient/provider coalition. Learn from Kim Witczak how to pull a patient-centered conference together. Get Sue Sheridan to review your hospital's policies on disclosure of harm. (By the way, each of these remarkable people can do any of these things). These patient advocates (respectively, a marketing and IT geek, corporate executive, artist, actor, teacher, archeologist, postal worker, dentist, fundraising specialist, advertising consultant and banker) took a traumatic medical experience and transformed it into something instructive, positive and inspiring. And (with sincere apologies for not mentioning others) they’re just a handful of the patient advocate dynamos out there I’ve had the good fortune to meet and learn from. (And there are many more I look forward to meeting)!

But, like pioneers in any new social movement, most of us work with big passion and little help. Though some are modestly compensated through speaking, honoraria or grants, and some head organizations supporting patient agendas, (and some have had projects successfully funded on Medstartr), there’s no over-arching professional infrastructure that exists to support patient advocates’ professional training and development, underwriting the cost for their time and expenses to attend conferences, secure vendor booths, or host “networking” events. 

Pioneering, by definition, is lonely work.

But we continue, hoping we'll become obsolete-- when the issues of safety, inclusion, access and fairness we raise are honestly, meaningfully and routinely addressed. At the same time, the snickering and shuddering at the prospect of working with “patient advocates” will stop when we become respected as a group for the wisdom we've gained from our experiences, and the consistent professionalism with which we share them. 

To get there, both sides need leaders that focus on what we share, instead of what separates us. Who can, with awareness, re-cast seeming debacles into opportunities.

Richard C. Boothman, JD, MITSS 2013 keynote speaker
(Photo courtesy of MITSS)
On that note, I was inspired by the insightful remarks of one such leader, Rick Boothman, Executive Director of Clinical Safety for the University of Michigan Health System, delivering the keynote speech at the 2013 MITSS annual fundraising dinner. (Boothman developed the "Michigan Model", a proactive system of disclosure and compensation for patients following incidents of medical harm.) Here, he’s speaking about President George W. Bush and the infamous incident, following the announcement of US troop withdrawal from Iraq, where an Iraqi journalist hurled his shoes at the President. (In the Arab culture, apparently showing someone the soles of your shoes is a sign of contempt.) 

I leave you with an excerpt from Boothman's speech-- and an invitation to be inspired yourself.

…The journalist  “…was wrestled to the ground, beaten severely and hauled away,
Photo from Seattle Times
sentenced to three years in prison and reportedly tortured. 

Later the same day at another press conference with characteristic, self-indulgent swagger, President Bush quipped, “If you want the facts, it’s a size ten shoe.” 

I have played that incident in my mind over and over for the past five years. 

I think to myself, what if?  What if, in the chaos that followed the incident, as that man was being wrestled to the floor and beaten, the United States President had stepped down from the dais, parted the crowd . . . and helped him up?  And what if, recognizing the depth of emotion that compelled that journalist to do something so risky, so dangerous, so desperate - the same emotion that was driving thousands of Iraqis to protest in the streets - what if our President had invited him to meet privately to talk about how he, and his fellow Iraqis viewed the United States’ occupation of their country?  To explain how their lives had been so profoundly changed by a mistaken war? 

What a stunning scene that might have been, don’t you think? 

It takes more guts to understand, than it does to make light of a man’s desperation.  It’s a lot easier to label someone than to meet them.  It’s not a sign of weakness; it’s a sign of strength and compassion and moral conviction and respect.  This was an opportunity to demonstrate on a very basic level, that though we shared sacrifices profound and intimate and dear with the people of Iraq, we also acknowledged the greater impact that war and ensuing occupation had on the Iraqi people. What a statement that might have been to the people of Iraq, to the people of the Middle East, to the world. 

What are we afraid of?  What prevents us from making such basic human connections?"


  1. Pat, thank you for your insightful and thought-provoking blog. As patient advocates we have a long way to go, but we are making progress. With payments from the government tied to patient satisfaction scores, hospitals need to listen to patients and now they have a financial stake in including the patient voice.
    Barbara Lewis
    Joan's Family Bill of Rights

  2. Barbara, yes, I think we're making strides! Quality is measured in many ways and these scores are certainly part of it-- but there's quite a spectrum of issues for us to work on.That's what I loved about our video recordings at IHI-- each advocate has a unique story, perspective and focus, but taken collectively our voices create a rich tapestry.

    Can't wait to share the videos with everyone!

  3. Thank you, Pat Mastors for sharing your thoughts on Richard C. Boothman's MITSS 2013 keynote speech. It is remarkable how many patient advocates do follow protocol and do not "throw shoes" at the medical establishment. Yes, it is a sign of strength by institutions/conference organizers when harmed patients and their advocates are treated with dignity and respect (as equals). There is hard-fought progress being made and the benefits will be gained both in patient safety and medical progress/innovation that honest practitioners can be proud of. It is possible to have a healthcare system that heals and does not bankrupt individuals and/or a nation! Patient advocates are not hecklers: they are people of conscience and courage.

  4. So true, Joleen - and few work as hard at this as you do! I also appreciate courageous leaders like Rick Boothman and Tim McDonald (who promulgates the "Seven Pillars"of addressing medical harm in a timely and appropriate way). These approaches model excellence in terms of treating wronged individuals with compassion and humanity, and give lie to the notion "it can't be done".

  5. Pat, Thanks for your excellent overview of the patient advocate movement. We are so diverse and have so many "voices", that sometimes our message may be hard to discern. And we can be legitimately very angry at the treatment of ourselves and loved ones and the lack of redress for that hurt. But what we all share is a passion for making health care better based on the authenticity of our experiences. Over time, I think that will make a difference to an individual doctor or nurse, or maybe a hospital administrator, or maybe a roomful of nursing home administrators, or maybe state legislators or maybe the folks that influence national events. That's how change happens.

    Carol Cronin
    Informed Patient Institute

  6. My experience with Mr. Boothman and the University of Michigan's Risk Management Department is very different from what they advertise. My experience has been Defend and Deny with no transparency. Perhaps if I had been in that Boston audience I would have thrown my shoes at Mr. Boothman.

    I watched the video of Mr. Boothman's keynote address and as a harmed patient I found it highly offensive. He mocks the patients in his stories. The woman with no shirt, the man pulling down his pants, and the couple detailing their sex life. How demeaning!

    IMO, nothing he said was inspirational. What inspires me is listening to stories of survivors of medical harm and the details of their struggles. These victims are the true heroes and should be giving keynote addresses at all patient harm/safety gatherings.

  7. EXACTLY CJ megaro!

    #1. I thought mocking his victims was very insulting,

    #2. Gezz-o-peets, Rick is still pitching "the need for hospitals be honest?" WOW , the public are very well aware hospitals are the number three cause of death, and profit from it, and falsify records, and obstruct justice as a normal course of business.. Everyone knows they have taken extreme pleasure in torturing their victims.. this is not news.. I felt Mr Boothman was stuck ten years behind... The Medical community clearly have yet to realize, the public know, it is not a secret, the cat is out of the bag, the jug is up.. 46% of Americans feel the medical complex is corrupt, another 5% and the public will have control of the truth.

    The snowball of exposing the inhumane corruption is at critical mass.. and the cartel have no where to hide their crimes. There is no crime not perpetrated on a daily basis inside hospitals. over 40% of diagnosis are wrong? and this country has been handing over 17% of the GNP! OMG, this stain on American history will not wash off, and you, the medical complex did it your self.

  8. CJ and Danny, I know you have suffered grievous harm in medical care, and for that I am sorry. In the interest of thoughtful discussion here's the link to full text of Rick's comments

  9. Some of us, even in the "Land of the Free", must use pseudonyms and anonymity because we fear, with justification, retribution and penalties from those in regulatory authority. But we will keep advocating and mine is for the RATIONAL treatment of chronic pain. The current climate has already lead to 51 tabulated deaths and over 760 sickened by fungal inoculation as treatment of chronic pain has morphed into medical practices fueled by high reimbursement for injections but bureaucratic and legal penalties for those who practice alternative treatments for the people who have truly disabling, intractable, incurable chronic pain!