Monday, September 19, 2016

The Case of Lena, Part II: Barton's response to 'A Common Man'


Continued from Part I - Read here.

This exploration of some of Barton's writing outside of professional journals is offered for additional context to assist readers in understanding his concerns and passions that related to the occupational therapy profession.

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The story of Lena got one reader of the Geneva Daily Times "all choked up."  This reader called himself "A Common Man" and wrote a letter to the editor on January 19, 1920 asking more about Lena's story:

Now what I don't understand is this.  It was too bad that Lena couldn't take that elegant job in the 5&10 and I guess the manager was sorry too because they say it's hard to get good girls like Lena and her father would be glad of her help I'll say so.

Well what I want to know is this.  Why couldn't Lena learn something at Oak Mount so that when she got well again she could get a better job... that would help her father more and the extra pay she's get would sort of make up for the time she spent at Oak Mount when she didn't have the 5&10 job.

Maybe I'm just crazy but do you see what I mean?

That letter to the editor motivated Barton to write his own letter to the editor on January 24, 1920, calling it his 'duty and pleasure' to respond.

First, it is interesting to note Barton's compassion for the little girl - indicating that the subject "is not 'just a story' but a very real and dear little girl."   He went on to state that 'A Common Man' "has expressed the very essence of one of the greatest of the problems which now face the United States in this period of reconstruction, of which so much is being said, and so little actually done.  That children and "grown ups" also can be taught much of value to themselves and to society during the long period of convalescence is an assured fact."

Barton had no shortage of criticism for the health care system or existing power structures, a theme which is repeated in his letters to Dr. Dunton.  Representative criticism is in his letter to Dunton dated May 19, 1917 where he states, "So far I have failed to find any one in Washington who seems to know where anything is or should be, though I hope for inside information shortly."  The criticism of health care and government was repeated throughout his book and was just as evident in his Letter to the Editor:

I shall be glad personally to champion these ideas of "Just a Common Man" anywhere, their only weakness lying in the fact that they are in advance of the times.

When enough like him dare to protest against the present hospital method of treating the sick, then the hospitals will change their method because they need his money for their support.  The teachers will study and qualify: and "chasing the cure" will cease to be the awful, dreary, discouraging process it is made to be at present; and Lena will be sent home with resistance to her disease increased, knowing more than she knew before (able to take a better job), and an active home missionary to fight intelligently against tuberculosis.

Until then all that Lena will learn is the discouraging if not disgusting stories of the lives of the other victims with whom she is confined.

What is notable about this Letter to the Editor is that it demonstrates Barton's ongoing passion and commitment to the occupational therapy cause after he stopped participating as formally in the National Society for the Promotion of Occupational Therapy.  Quiroga's characterization of the 'momentary brilliance' of Barton's career needs to be reconsidered.  Barton's journal submissions and book writing ended mostly by 1918 but his work at Consolation House continued in earnest.  Barton did not 'suddenly burn out' but instead just focused his efforts in different directions.

Barton's passion about occupational therapy extended to children, notably evident in his writing about the 'Case of Lena' - and would very soon play out in his life in ways that he might have only been imagining at the time he was writing letters to his local newspaper editor. 

To be continued...

References:

embedded links, Fulton History (newspaper archives) https://www.nypl.org/collections/articles-databases/fulton-history-old-new-york-state-historical-newspapers, and...

Quiroga, Virginia A.M. (1995). Occupational therapy: The first 30 years 1900-1930.  Bethesda: AOTA Press. 

Friday, September 16, 2016

Occupational Therapy Can Be One of the Great Ideas of Myopic 21st Century Health Policy Experts

(with deep apologies to the memory of Mary Reilly)

Social media has been one long party this week in the occupational therapy world with therapists and membership associations popping champagne corks over the recent article that appeared in Medical Care Research and Review entitled "Higher hospital spending on occupational therapy is associated with lower readmission rates."  Click here for the abstract, but please go read the whole thing.

Once you get beyond the abstract you get straight to the nut of the problem where the authors admit right in the introduction that "the relationship between hospital spending and quality...is poorly understood in the literature..."

For background reading on this precise issue and concerns about how people are defining 'quality' in health care outcomes click here and here .

There is unquestionably some 'value' (however one may choose to define that term) in decreasing hospital readmission rates.  People who are NOT in the hospital are almost certainly better off than those who are in the hospital, even if we reduce our operational definition of 'better off' to some biomedical metric of their health status.  So to be clear it is important to note that some 'value' is achieved in decreasing readmission to hospitals.

That point being stipulated, we must return to the larger concern for the profession of occupational therapy:

Is it the intention of the profession of occupational therapy to serve the myopic perspectives of 21st century health policy experts?

Is this what Mary Reilly intended in her Slagle lecture?

There is no blame directed at the administrators and Boards of Trustees of hospitals - it is their jobs to make sure that the hospital is able to financially function and in fact prosper.  This is not an either/or situation either, because by extension any employee of any hospital also has some responsibility for contributing to that financial health of an institution.

But where does the profession draw the line between meeting employment obligations to their worksites and becoming willing stooges to make sure that the myopic perspectives of cost control are realized?

When we define our profession is it our hope to serve the greater needs of Man and his need for competence and achievement and participation in the world, or do we reduce ourselves to a metric of being a band-aid that serves to cover the immediate problem of hospital readmission rates?

Perhaps avoiding hospital readmission is the first step to achieving a more broad vision and purpose, but I warn you all not to allow the financial interests of an institution to define the type of practice that is delivered by this profession.  Read deeply into the article and you will already see the scheming machination of the authors to determine exactly what kind of intervention will be best for the occupational therapists to provide.

Be careful, occupational therapy.  You might just become exactly what a hospital administrator or health policy expert wants you to be. 

Is that your big purpose?

References:

Rogers, A., Bai, G., Lavin, R.A., and Anderson, G.F. (2016). Higher hospital spending on occupational thearpy is associated with lower readmission rates. Medical Care Research and Review, 1-19.

Thursday, September 01, 2016

The Case of Lena

History provides context for understanding.  We are so far removed from the daily life struggles of 100 years ago and our own experiences are so very different that it is difficult for us to develop a clear understanding of  why events unfolded the way that they did.

Occupational therapy is a health related profession that was born from the crucible of American society and culture at the turn of the 20th century.  As such, events from those times greatly influenced the thinking of our primary founders.

George Edward Barton lived in Clifton Springs in Ontario County on the street behind the Clifton Springs Sanitarium (private) which had a capacity of 400 patients.  The Ontario County Sanitorium for Consumptives (Oak Mount) was the public facility, previously known as the County 'Poor House' in nearby East Bloomfield and had a capacity of around 40 patients.

Barton was motivated by realities of the public health crisis of tuberculosis.  He was motivated because of living in the shadow of the Clifton Springs Sanitarium, and by the stories that he read in his local paper (below), and by the reality that he was also afflicted with this terrible disease.

Understanding Barton's motivations yields important information about his values and beliefs and the 'cure' that he believed could be achieved through occupation.  This reprinted article is an exemplar of daily struggles that people had at the time, and subsequent blog entries will outline his specific response to this newspaper article.


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Reprinted from the Geneva Daily Times, Friday January 16, 1920.

That morning the Teacher had sent Lena home from school.  Coming in from the cold air, the child's cough had been worse than ever, and the Teacher had said: "You better go home.  And don't come back till your cold is better.  It is not safe for the others."

All the rest of the morning and while she ate her hasty boarding house dinner, the Teacher had been haunted by the look in Lena's blue eyes.  There had been something she had wanted to say and couldn't.  So much at least was clear; and the teacher determined to take the long walk down to Lena's street after school and see her mother.  She remembered that the child had had a cold ever since the chilly autumn day when she had come to school with wet feet and had a chill.

Lena herself opened the door.  The same frightened look came to her eyes.  She said her mother was out working but would be back about five.  Yes, the Teacher could come in and wait.  After some hesitation she led the way to a back room.  "Pa's in here.  You can come in.  We've got a boarder in the parlor."

The room was small and clean.  It served, one could see for living room, kitchen, and dining room.  A hot fire burned in the stove and near it is a rocking chair sat the shadow of a man, who coughed, much as Lena coughed.

The Teacher sat down and the father told her how he had to give up work, and how his wife had to go out now.  He asked if the Visiting nurse had sent her there.  She replied that she was Lena's teacher.  At that he seemed relieved.  He said the Nurse had wanted him to go away to Oak Mount, but he loved his family and did not want to leave home.  He like ma's cooking better than any other too.

"But we get's on fine and dandy," chimed in Lena.  "We rent the parlor to Mr. Kominsky and two ladies that works at the factory rooms in the back room.  We could of got fifty cents more a week for the front room but we couldn't get both the beds and the crib in the back one."

Just then the back door opened and Lena's mother came in.  She was as neat as Teutonic as her little daughter, than whom no more loyal American ever saluted the flag.

Awkwardly she returned the Teacher's greeting.  The same frightened look came into her eyes when she was told that Lena must stay away from school until her cough was better.

"I'm sorry" the Teacher began, when Lena's mother rose and went into the front hall.  She beckoned to the Teacher and then shut the door.  "Did you come here from the Board of Health?" she asked.

"No."

"You can see how pa is," she returned.  "But he does want to stay home with me."

"But aren't you all sleeping in the same room?"

"Honest, lady, it's the only way we can get along.  You ain't going to report it, are you?  Oscar's well of his cold now."

"Who is Oscar?"

"He's my baby.  He's two.  Mrs. Schmitt, she take care of him when I'm away.  He's awful cute."

"May I see your room?"

"Sure.  But you won't report him?"

"Not now," and the Teacher followed up the stairs.

It was too terribly true.  One room.  One window.  Two beds under the sloping roof.  Oscar's crib between.  All neat and clean.

"Your husband is so ill.  It is not safe to have Lena here.  Will you let me send her to the hospital?" asked the Teacher.

"Hospital?"  She might as well have said "Prison."  The look of terror, dispelled for a moment by pride in her beautiful white beds, returned.

"I know the people there.  They will take care of Lena if there is room and I think there is.  And they will be so kind to her.  She will have good food and can stay there until a better place for children can be provided."

"Mein Gott.  I don't want Lena go away.  She's just a little keed."  Tears were rolling down the weary face.

"But it isn't right to expose her."

"I don't want her to get sick.  But honest, lady, I keep pa very clean."

"I know you do."

"But you won't tell about my baby?"

"Not now if you will promise Lena can go to the hospital."

"Lena did want to keep on learnin.  She's most fourteen.  She could get an elegant place at the five and ten."

"If you let her go and get well, she can go back to school next year."

So Lena is with the other children at the hospital in the contagious building.

But what about Oscar?

And what about all the other children in Ontario County who should be removed from infection, or who already have the dreadful disease, and who can be cured if you "do it now?"