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Tip No. 76: For even quicker attention, drive your Hummer straight into the ER. Then offer the triage nurse a chocolate if he'll let you see the physician before all those little pedestrians!

November 2005 -- This month's Good Housekeeping includes 75 "surprising" health tips from "doctors" nationwide. Though nurses excel at such practical advice, not one tip comes from a nurse. That's not "surprising," but we were a bit puzzled by the contempt for nurses we saw in several tips. Michael Roizen, MD, of the Cleveland Clinic, advises readers to "get better [hospital] care" by "supplying the staff with treats." "Dr. X," whose ED tips are presumably considered so hot that his or her identity must be shielded, tells patients to lie to the triage nurse about when symptoms began in order to be seen faster, but to "tell the doctor exactly when symptoms began." In addition to being offensive, uninformed, and likely to backfire, this advice shows real indifference to public health. The tips were "reported" by Janet Bailey, Janice Graham and Leslie Pepper. Good Housekeeping has a reported circulation of five million and a readership of 22 million.

The full headline of the magazine's 12-page tip section is: "What doctors wish you knew...75 surprising tips--from heading off a headache to avoiding a heart attack." It includes advice mainly from MDs, but also from DOs, DDSs, one DPM, and one PhD (in physiology). Many of the tips are worthwhile, such as the one urging readers to ensure that their house number is visible to ambulance drivers, and it's commendable that the magazine ran those. Of course, the magazine appears to have consulted no nurses, even though nurses focus closely on educating the public about just these kinds of pragmatic issues in health care. A notable example is Pat Carroll, whose recent book What Nurses Know and Doctors Don't Have Time to Tell You has countless similar pieces of advice.

But several tips betray a more direct disrespect for nursing. Perhaps the most striking is the triage tip. Tip Nos. 36-39 come in a box headlined: "From Dr. X: How to Get Good Care in the ER." This tipster's identity was presumably kept confidential in part because he or she is telling readers how to game the hospital system by getting physician contacts to call ahead and make special arrangements, and by asserting the right not to use the physician on call. Perhaps there was also awareness that some might not take kindly to tip No. 38, which tells you how to jump the line by fooling the silly triage nurse:

The first person you'll meet at the ER is the triage nurse, who decides how quickly you need to be seen. No matter when your problem actually started, never say more than four hours ago; it will seem less pressing. (But tell the doctor exactly when symptoms began.)

This advice isn't just an astonishing dismissal of the vital and complex triage function, or just a blatant insult to nurses generally. Sure, it does suggest that skilled nursing judgments should be undermined by lying about symptoms, and assumes that experienced ED nurses will not be able to see through at least some of the lies. But it also sends several messages with broader implications for public health.

The tip is a remarkable example of a health professional telling patients to mislead clinicians about their conditions, though getting candid information from patients can be one of the major challenges of clinical practice. It invites patients to pick and choose which clinicians deserve the truth. We guess the tipster thinks that physicians need it, since their judgments matter, but that nurses are pretty much filling out forms. Would Dr. X appreciate Nurse X telling patients never to report their pain as less than an eight out of ten, because otherwise physicians will never prescribe adequate pain medication?

In any case, back in the real world, inviting patients to decide which symptoms can be lied about and when could easily backfire, in the ED and many other clinical settings. For instance, telling an ED triage nurse that your sore throat started four hours ago could result in your being seen much later than if you told her it started several days ago. Likewise, a nurse evaluating a patient with a fever that was only four hours old might wonder why such a patient would bother to show up at all and put the patient on the slow track to the back of the ED. Such practices would distort the triage process and result in unacceptably poor care, even though there would be some poetic justice in that the immediate suffering would be done by the liar.

But if the lies Dr. X is recommending actually achieve their desired result, and the lying patient is seen more quickly than she needs to be, then public health is harmed because more emergent cases are delayed. Patients have been known to leave the ED when the wait is too long. Then they suffer more--and cost more--down the line. If large numbers of people start lying about their symptoms in order to be seen faster, the entire system could break down. Of course, more generally, Dr. X's advice could also be seen to reflect a "me-first" hostility to the public interest that some feel infects much of the current U.S. health care system. The last thing the public needs is a respected health professional telling it to act with unenlightened self-interest.

Other tips just show disrespect for nursing, and may present no special threat to the public, unless you count exacerbating the deadly global nursing shortage. Michael Roizen, MD, evidently felt no need for anonymity in giving tip No. 54:

Get better care in the hospital by supplying the staff with treats. Offer individually wrapped cookies or chocolates, or little packets of nuts.

We're not sure whether to laugh or cry. Of course, people do appreciate small gifts, and they might get you a slightly better attitude. But suggesting--as part of a series of serious health tips--that you will actually get "better care" by giving hospital professionals "treats" is an insult. And while the tip speaks generally of "staff," there's little doubt that Roizen means nurses and other non-physicians. Nurses do more than smile and hold hands. Would anyone suggest that you would get "better care" from a physician by giving her "individually wrapped cookies?" This "treats for nurses" concept was a theme in a recent episode of NBC's "ER", but we did not imagine that an actual health professional would recommend it as a strategy for "better care." On the other hand, if we titrate that dopamine drip correctly and get your blood pressure off the floor, could we get some of those little Belgian chocolate thingees they have in the gift shop? Like, oh my God, those are so excellent.

And tip No. 35, from Evan Levine, MD, of New York City's Montefiore Medical Center, offers the following information:

When choosing a doctor, remember you're also choosing a hospital. If you ever need to be admitted, radiologists, pathologists, and many others will be treating you too.

This tip ignores nurse practitioners in discussing what we assume are decisions about primary care professionals. But the tip also suggests that patients go to the hospital to get care from physician specialists. In fact, hospitals exist primarily to provide nursing care. Any analysis of hospital quality that focuses only on physician skill is dangerously flawed, as patient safety research shows. If you're choosing a hospital, you're choosing the nurses who may well make the difference between whether you live or die.

The Center and 203 supporters have asked Good Housekeeping to make the following amends to the nursing profession:

  1. apologizing to nurses in a form that will reach its 22 million readers, such as an editor's note, and perhaps printing a letter from a nurse about the piece;
  2. telling readers not to lie to the ED triage nurse about their symptoms if they want good care for themselves and their society, and that life-saving nursing care does not depend on cookies;
  3. telling readers that hospital quality depends to a large extent on nursing care;
  4. hiring nurses to serve on Good Housekeeping's board of directors;
  5. routinely using nurse experts as sources for health stories; and
  6. publishing an article with a positive, accurate portrayal of nursing, such as "75 Surprising Tips Nurses Wish You Knew About Your Health."

UPDATE -- Treats, lies, and Good Housekeeping

December 12, 2005 -- To date over 200 supporters have sent letters to Good Housekeeping as part of a Center campaign about the 75 health tips in the magazine's November issue, not one of which came from a nurse. We were particularly concerned about a tip from the mysterious "Dr. X" advising ED patients to lie to the triage nurse in order to be seen faster, and another from Dr. Michael Roizen of the Cleveland Clinic, who advised patients to get better hospital care by "supplying the staff with treats." In a recent telephone call with the Center, Good Housekeeping health editor Toni Hope indicated that the magazine plans to print a nurse's letter to the editor on these subjects in the February 2006 issue. In addition, Ms. Hope promised to work with the Center to ensure the accuracy of future nursing portrayals, and to include us on her list of consulting health experts. Please register with our nurse expert database today, so that if we need an expert in a specific field, we will be able to call on you. Our current list has gaps; for instance, we do not yet have HIV experts. Please help us to improve media portrayals of nursing and other important health issues. Thank you!

UPDATE #2 -- Click here to see our follow-up analysis after a letter was printed in February 2006 issue of Good Housekeeping



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