What is perfect health to an 85-year-old?: evidence for scale recalibration in subjective health ratings

BACKGROUND: If an 85-year-old man rates his health as 90 on a scale in which 100 represents "perfect health," would his rating mean the same thing as a 90 rating from a 25-year-old? We conducted a randomized trial of 3 different ways of eliciting subjective health ratings from participants in the Health and Retirement Study to test whether the meaning of perfect health changes as people age, causing people to recalibrate their self-reported health ratings to account for their age. METHODS: The Health and Retirement Study (HRS) is a nationally representative, prospective study of 22,000 persons born in 1947 or earlier. The data analyzed in this study come from the self-assessed health utilities module administered in 2002 to 1031 randomly selected HRS respondents. Respondents were randomized to receive one of 3 versions of a subjective health rating task. In the perfect health version, they were asked how they would rate their "current health on a scale from 0 to 100, in which 0 represents death and 100 represents perfect health." In the your-age version, the phrase "for someone your age" was added to the end of the question to encourage people to recalibrate their responses based on age, and in the 20-year-old version, the phrase "for a 20-year-old" was added to minimize recalibration. RESULTS: A total of 1015 subjects responded to the rating task (98% response rate). Health ratings varied significantly across versions, with subjects responding to the 20-year-old version reporting lower health (mean rating 66 of 100) than those responding to the your-age version (mean rating of 73, P<0.001) or the perfect health version (mean rating of 73, P<0.001). This result suggests that subjects interpret perfect health to mean "perfect health for someone your age." However, additional analysis showed that the interpretation of the phrase perfect health lies somewhere between the other 2 versions. For example, responses to the perfect health and 20-year-old versions varied significantly by respondent age (both P's<0.075), whereas responses to the your-age scale did not (P=0.8). CONCLUSION: The phrase "perfect health" is ambiguous, causing some people to recalibrate their responses based on their age. Such ambiguity threatens the validity of common subjective health ratings, thereby reducing the comparability of responses across people of different ages or different circumstances.     

Mentorship as a teaching strategy

Nursing is facing challenges perhaps unparalleled in its history. As we face the opportunities of the future, mentors play a more important role than ever. Mentors have "provided inspiration, support, and encouragement during high and low points of my development." "have forever changed the course of our practice," taught through "her commitment to the advancement of her students and colleagues, her gentle but persistent encouragement to grow, and her generosity in providing pivotal opportunities," "taught me three lessons: caring gets results, family comes first, and passionate commitment is contagious," offers a potential buoy in the sea of change in health care, and possibly enhances clinical outcomes. Mentors can be found in your boss, teacher, spouse, friend, colleague, or peer. Mentorship is a gift between two people and must be given and accepted as such. Not everyone should act as a mentor; the relationship cannot occur and develop when there is no desire to share. Nursing is about learning and teaching. "The spirit of the nursing profession dies when it is reduced to a set of abstract theories, legal requirements, and expert skills. These are the results, not the goals, of scholarship and leadership. Scholarly endeavors always occur amidst communities of learners engaged in being better practitioners of their discipline." Mentors are the leaders amidst the community of nursing.     

Scofield as Socrates

Well, as Socrates exclaimed, "By the dog, Gorgias, there will be a great deal of discussion before we get to the truth of all this." In the course of that discussion, we will find that Mr. Scofield does ask many very pertinent questions about the nature and teaching of ethics. Each question is worth examining in itself. But somewhere along the line, he has wandered into exaggerations, rhetoricities, and illogicisms that make it difficult to "get to the truth of all this." If we were being truly Socratic, I would test each assertion and allow him to respond in turn, and he could question me. In so doing, we might elucidate the ideas behind ethics consultation and evaluate its worth. We might then learn, as Socrates would have us learn, how much we do not know. We might also learn, as Socrates desired, how to pursue the elusive answers. Unfortunately, in this essay, Scofield fails as Socrates.     

Diseases of meaning, manifestations of health, and metaphor

Disease and health are commonly thought of as distinct opposites. We propose a different view in which both may be seen to be facets of healthy functioning, each necessary for the other, each giving rise to the other. Thus, disease may be thought of as a manifestation of health. It is the healthy response of an organism striving to maintain physical, psychologic, and spiritual equilibrium. Disease is not necessarily to be avoided, blocked, or suppressed. Rather, it should be understood to be a process of transformation. The process should therefore be facilitated because it is an integral part of the dynamic equilibrium that we ordinarily think of as health. In many cases, perhaps all, people get ill because there is something going "wrong" in their lives. This could occur in a whole range of ways-relationships, environment, food, or job. Our view, however, is that disease is a meaningful state that can inform health workers how to help patients to heal themselves. In this way, instead of being meaningless, people's problems become diseases of meaning, enabling people to see that things are not necessarily "going wrong" but are, in fact, helping them become stronger, to live more fully and with more understanding. Seen from this perspective, depression; cancer; heart disease; neurodegenerative and autoimmune disease; dementia; and conditions such as community violence, genocide, and the problem of environmental devastation are "diseases of meaning." World Health Organization forecasts make it clear that diseases of meaning will continue well into the next millennium to be the major cause of suffering and death worldwide. To deal with them, the world needs to reformulate the biomolecular paradigm that has been exploited in the last two centuries. It does not address the reasons why these diseases arise, attending mainly to their molecular consequences. A paradigm that includes the importance of meaning must now be given top priority. The concept that diseases are a manifestation of health-a call to a different relationship with ourselves and our environment, both animate and inanimate- is in itself a different approach. Programs for care and education based upon it would have immediate application in medicine, industry, education and ecology. We believe that this model would have far-reaching consequences for the understanding, treatment, and prevention of diseases and behaviors that lead to violence and environmental destruction.     

Death and language: some comments on Haussamen

Brock Haussamen argues inventively that there are features of language that are the source of our belief in an afterlife, that something deep about language prevents us from talking about the dead as if they are really dead. He speaks of "language as forcing." In this response to Haussamen's article, the author attempts to show that Haussamen's arguments and examples are not strong enough to make his point. The major suggestion is that there is more to the "deep structure" of language than Haussamen has assumed. Once this is realized, it is easier to see that it is we who choose to speak of the dead as we do. It is we who choose to believe in an afterlife. Language does no forcing.     

Have "evergreen" provider contracts lost their bloom?

An "evergreen contract" is one that automatically renews itself from year to year, unless one of the contracting parties acts at specified intervals (which may be annually or as long as several years) to give notice in the manner required to terminate the otherwise perpetual agreement. Such contracts are in contrast to fixed-term agreements, where both parties must affirmatively agree to extend the term beyond the initial specified term. Such "evergreen contracts" are legally valid, but for compelling reasons health plans and providers may want to consider terminating their evergreen provider contracts now in favor of a contract with a fixed term.     

Homeopathy and the new fundamentalism: a critique of the critics

Though in use for over 200 years, and still benefiting millions of people worldwide today, homeopathy is currently under continuous attacks for being "unscientific." The reasons for this can be understood in terms of what might be called a "New Fundamentalism," emanating particularly but not exclusively from within biomedicine, and supported in some sections of the media. Possible reasons for this are discussed. New Fundamentalism's hallmarks include the denial of evidence for the efficacy of any therapeutic modality that cannot be consistently "proven" using double-blind, randomized controlled trials. It excludes explanations of homeopathy's efficacy; ignores, excoriates, or considers current research data supporting those explanations incomprehensible, particularly from outside biomedicine: it is also not averse to using experimental bias, hearsay, and innuendo in order to discredit homeopathy. Thus, New Fundamentalism is itself unscientific. This may have consequences in the future for how practitioners, researchers, and patients of homeopathy/complementary and alternative medicine engage and negotiate with primary health care systems.     

Public values and beliefs toward nursing as a career.

The purpose of this study was to compare the perceptions of "ideal career" and "nursing as a career." The goal was to provide information for development of innovative recruitment strategies. The sample of 1,116 included college freshmen, students in grades 6 through 12, parents, school nurses, teachers, and counselors. Data were analyzed by t test and analysis of variance to determine differences in attitudes between "ideal career" and "nursing as a career." Similar perceptions for both were opportunities for employment, application of intellectual abilities, caring for people, and an opportunity for academic and scholastic achievement. An "ideal career" was seen as more financially rewarding, more respected, and more powerful than nursing, and as providing more opportunities for leadership, for making decisions, for obtaining and applying knowledge, and for working in a safe environment. Recommendations include strategies to improve recruitment and retention of nurses.     

2000 and beyond: a perspective

There once was a beautiful city in which the people were prosperous and, for the most part, happy. However, there was a very high road that perched precariously along the rim of a deep canyon. A number of people slipped and fell over the edge and were killed. Others were injured in the fall, some very seriously. The medical establishment of this fine city developed a superb emergency response team, built and staffed several trauma centers, and designed efficient rehabilitation facilities. As the population of the city grew, proportionately more people fell off the cliff. The medical establishment gained more experience and devised ways to save people who previously would have died. However, certain people thought of another possibility: Why not erect a fence at the top of the cliff? When they voiced the idea, many were quite disturbed. The ambulance drivers weren't keen on the idea, neither were the ambulance manufacturers, nor were those who made their living in the hospital industry. The medical authorities explained that the problem was far more complex than people realized, that building a fence was far from practical, and that health was far too important to be left in the hands of people who were not experts. "Leave it to us," they said, "for soon we will genetically engineer people who do not bruise or become injured by such falls." So, no fences were built and, as time passed, this city found itself spending more money on medical care than anyone in the history of the world. As the price of treating people kept rising, many people could not afford medical care....     

Chronic pain and occupation: an exploration of the lived experience.

OBJECTIVE: There is limited research on the relationship between chronic pain and occupation. This phenomenological research study explored the lived occupational experiences of people who have chronic pain. METHOD: Via demographic questionnaires, semistructured interviews, and field notes, data were collected on 13 participants with various types of pain. RESULTS: Thematic analysis yielded one main theme: "Chronic Pain Is Life Changing." The following subthemes also emerged: "Chronic Pain Triggers Emotional Distress"; "Chronic Pain Reveals the Strength of Relationships"; "Chronic Pain and Occupation Are Reciprocally Related Forces"; and "Chronic Pain Elicits Innovative Adaptive Responses." Study participants reported experiencing myriad troubling emotions; however, they resourcefully modified their routines and tasks and found enhanced meaning in favored occupations. CONCLUSIONS: This study illuminates the importance of therapeutic listening, the innovativeness of people who have chronic pain, and the possible therapeutic potential of occupation.     

Selecting an appropriate scan rate: the ".65 rule"

Investigators have discovered that the ratio between a user's reaction time and an appropriate scan rate for that user is approximately .65, which we refer to as "the .65 rule." As part of a larger effort to develop software that automatically adapts the configuration of switch access software, data were collected comparing subject performance with a scan rate chosen using the .65 rule and a scan rate chosen by the user. Analysis of the data indicates that for many people, the .65 rule produces a scan rate that is approximately the same as the average switch press time plus 2 standard deviations. Further analysis demonstrates a relationship between the coefficient of variation (the standard deviation divided by the mean) and error rate. If accurate information is available about the mean, standard deviation, and distribution of a client's switch press time, a scan rate can be chosen that will yield a specific error level. If a rigorous statistical approach is impractical, the .65 rule will generally yield a usable scan rate based on mean press time alone.     

Student nurses' perceptions of alternative and allopathic medicine

This exploratory study of student nurses is based on the results of the responses to one question on an open-ended questionnaire: How would you define the relationship between alternative medicine and allopathic (conventional) medicine? A specific goal of the study was to find out how the surveyed respondents conceptualized the relationship between allopathic and alternative medicine. Three themes were identified: (a) "They are not at all alike," (b) "The two can or should be used together," and (c) "Those who practice alternative medicine and those who practice allopathic do not get along very well." The discussion suggests some reasons for these perceptions and considers some implications for future health care.     

Trance and the trickster: hypnosis as a liminal phenomenon

This paper makes the case that hypnotic phenomena are liminal in nature and that hypnotic practitioners (such as Milton Erickson) share many traits with traditional societies' "tricksters." The ambiguous nature of hypnosis has been apparent since the days of Mesmer's animal magnetism. Hypnotized people often report hallucinations that confound their ordinary distinctions between reality and illusion, external and internal processes, and many other binary oppositions, including time and space as well as mind and body. In addition, hypnosis can obscure the distinction between fact and fiction in one's memory, as is evident in the "recovered memory" controversy. The role played by imagination is central to both indigenous rituals and hypnosis, and hypnosis is a multifaceted phenomenon requiring explanation at multiple levels. Some investigators and practitioners have missed the importance of the social context in which hypnosis occurs, while others have come close to destroying the most interesting and useful hypnotic phenomena under the guise of objectivity.     

Relationship of actual response time to call lights and patient satisfaction at 4 US hospitals

This multihospital study examined patient satisfaction with items of "received help as soon as possible" and "help to the bathroom" and their relationship to the actual response time to call lights. We found that faster actual response time to call lights contributed to higher patient satisfaction with "received help as soon as possible." The relationship between response time and patient satisfaction with "help to the bathroom" was not supported.     

Public perception of the risk of blood transfusion

BACKGROUND: Health policymakers are concerned about the proportion of people who say they are unwilling to receive a blood transfusion. This article examines how social, cultural, and political factors affect the perceived risk of transfusions. STUDY DESIGN AND METHODS: Data were collected as part of a large national telephone survey of 1204 people conducted in the United States in 1997 and 1998. The survey elicited images associated with blood transfusions and contained questions about the perceived risk of the blood supply, sensitivity to stigma, world views, trust, and demographics. RESULTS: The results showed that a substantial proportion of people do not consider the US blood supply to be safe and say they would not accept blood if hospitalized. The images evoked most frequently by the stimulus phrase "blood transfusions" were related to AIDS or HIV. The people who tend to perceive the greatest personal and public risk from blood transfusions are female, nonwhite, and less educated, and they have not previously received a transfusion. Sensitivity to stigma, mistrust, one's perceived inability to control hazardous activities and technologies, and fatalistic and egalitarian world views tend to be associated with heightened concern about the risk of blood transfusions. CONCLUSION: Risk perceptions need to be monitored to anticipate and deal with problems of public acceptance. Risk management strategies should be tailored to the specific characteristics of individuals that are important determinants of the perceived risk of transfusions.     

How can we improve the nursing work environment?

It has been suggested by many recently that the nursing work environment needs to be altered to make it more responsive to both nurse and patient needs. One essential aspect of this change would be to increase patient safety. This article suggests that to improve patient safety as well as satisfaction of nurses, the culture of the nursing organization should be transformed into one of a "learning organization." Using this model of an organization, every member of the nursing organization would be encouraged to reach his or her greatest potential, the welfare of the team would become paramount, and a shared vision of where the organization needs to go would emerge, thus maximizing productivity, safety, and job satisfaction for all healthcare team members. This transformation could mean that the terms "Nursing Organizations" and "Learning Organizations" would not have to be oxymorons.     

Responsiveness to laboratory pain in women as a function of age and childbirth pain experience.

Pain responsiveness was investigated experimentally as a function of age and childbirth pain experience. Sensitivity to cold pressor-induced pain was assessed through threshold, tolerance, and visual analog pain ratings. It was hypothesized that childbirth pain experience would mostly modify experimental pain judgment, in accordance with the adaptation-levels model. That is, childbirth pain would be used as an "anchor" in evaluating other painful events. Fifteen parous women were compared to 12 nulliparous women of the same age (mean age: 35 years) as well as to 15 nulliparous younger women (mean age: 24 years). This comparison was undertaken in order to distinguish the effects of age, which was found to correlate with pain threshold. Analysis of variance comparing the three groups of women was performed on each of the three cold pressor measures. A significant effect was found for pain threshold. Multiple comparisons indicated that parous women had a higher pain threshold than both groups of nulliparous women which did not differ from one another. Thus, painful childbirth experience is sufficient to raise cold pressor pain threshold. This finding has never before been reported in the pain literature. It is consistent with anecdotal reports from parous women who, when providing cold pressor pain judgments, say that "nothing compares to labor pain."     

The Myth of the Well-Known Client

A common idiomatic phrase in mental health care is “well known” client, patient, or service user. This phrase is often followed by “to mental health services” or some such, suggesting that a “service” can really know anything. Notwithstanding mental health services, especially public ones are a repository for a lot of information, such as facts about people, their service use, diagnosis, notes and assessments of various kinds; this conglomeration of information is not knowing, any more than a library may be “knowing”. Knowing is a distinctly human activity. This paper will argue that this phrase is arrogant, a signifier of ignorance and ought to be relegated to history or back room banter with phrases like “frequent flyer”, “bed seeker” and other derogatory and objectifying language.