Sometimes all we need is a quick suggestion from our peers to zero in on a good story. Here we turn to front-line journalists for advice, some simple insight to add to our repository of “shared wisdom."
How did you and your colleague Elizabeth Church find on-the-record sources for your award-winning home care series when many clients were afraid to speak out for fear of retribution? – Kelly Grant
We published a few early stories on troubles with home care in Ontario (including an A1 investigation of how the provincial government's efforts to give in-home personal support workers a raise had gone awry) in which we asked readers who had encountered problems with publicly funded home care to contact us. We put our email addresses at the end of the stories.
Next, we approached a health-care advocacy organization that had conducted consultations across the province to put us in touch with clients they had heard from. Finally, we approached opposition MPPs (members of Parliament) and local councillors to see if they would pass on the names of constituents who had asked for their help dealing with the Community Care Access Centres (CCAC.) CCACs. That's how we found the Oshawa mother and son in our lede.
What are key questions that journalists should ask themselves (and their sources) when reporting on hospital scorecards? – Marshall Allen
Who is releasing the hospital ratings and why?
What data are they using and how is that data gathered?
How did the measures get combined to inform the rating?
What counts for or against the hospital?
What are the limitations of the data?
Does my story make statements that are not supported by the data?
It’s never as black and white as anyone would wish.
Marshall Allen covers patient safety for ProPublica. He is one of the creators of ProPublica’s Surgeon Scorecard, which published the complication rates for about 17,000 surgeons who perform eight common elective procedures.
How can reporters make sure that a limited look into a condition or situation is not just an outlier? – Sheila Hagar
If I had been doing an article based on that one afternoon, I would not have seen the true story. It brought home the danger of relying on small observational studies to form an opinion of a therapy, treatment or concept.
I wish we all had the luxury of seeing a non-emergent situation for more than an hour or two for our daily reporting.
How can U.S. health journalists tap into the expertise of our foreign counterparts? – Trudy Lieberman
The next time The Commonwealth Fund publishes its international comparisons, email a panelist in England or the Netherlands and ask why it’s easier to get after-hours care in those countries than it is in the United States. That’s more interesting than simply repeating the stats in a press release.
When the next “blockbuster” statin shows up, contact NICE to learn about the UK’s treatment guidelines. When you write a piece about those sky-high deductibles and out-of-pocket maximums for Obamacare policies, find out how other countries like Portugal deal with user fees. Portugal does have a national health system with some user fees. People with low incomes don’t have to pay them, and those who do pay no more than about $54 U.S. for most services.
How did you come up with the concept for your winning idea and why are you choosing to investigate end-of-life care? – JoAnn Mar
My interest in end-of-life care started with the sensational controversy surrounding assisted suicide in the mid 1990's—Derek Humphrey and the Hemlock society, Jack Kevorkian and his suicide machine were making headlines at that time. Although there was little public support for Kevorkian or Humphrey, a majority of Americans favored physician aid-in-dying. As I dug deeper into this topic, it became clear to me that driving this sentiment was the desire for a "good" death. Most Americans wanted the option of a quick end to their lives, if their final days would most likely be spent in pain and suffering.
In the course of my research in the late 90's, I found out to my surprise that most terminally ill Americans did not receive good end-of-life care. The 1995 Robert Wood Johnson SUPPORT study surveyed ten thousand patients and concluded that a majority of Americans experienced needless pain and suffering at the end of their lives. I wanted to find out why better end-of-life care was not made available to patients living in the most medically advanced country in the world. What I discovered was that pain management and palliative care were not required courses for doctors and medical students. Even today, there are not enough specialists in the field of palliative care to meet the needs of those at the end of life.
At that time, death and dying did not receive much media coverage. In 1999, I produced a three-part documentary program series for public radio on physician-assisted dying and end-of-life care. My goal was to stimulate public discussion around death and focus on care for the terminally ill.
My own mother passed away recently. Her death was quick and unexpected and fortunately, she did not endure any prolonged suffering. My father is now nearing the end of his life and these events have motivated me to revisit the topic of death and dying. My goal is to find out if end-of-life care has improved in the last twenty years since the SUPPORT study came out. Death and dying is a difficult topic that deserves more media attention and I am grateful for this opportunity the AHCJ has afforded me to explore this topic in-depth.
JoAnn Mar is a longtime reporter and now producer at KALW-San Francisco. She has worked as an attorney and adjunct professor in broadcast journalism. As a 2016 AHCJ Reporting Fellow on Health Care Performance she will detail the state of end-of-life care for the terminally ill and whether it has changed or improved since a 1995 landmark study found the majority of Americans spent the end of their lives in pain and suffering.
At what point should a reporter consider filing an FOIA request or even suing a government agency to obtain information? - Fred Schulte
The Justice Department argued that the Centers for Medicare and Medicaid Services has a backlog of some 3,000 requests and may need a decade or more to dig out from under some large cases. Justice said the FOIA office was under “unusual strain” due to the demands of launching the Affordable Care Act.
So does this mean health care reporters are wasting their time filing a FOIA request? The quick answer: Yes, no and maybe.
Sometimes yes: Reporters should resist when officials invoke FOIA, especially when you’re seeking fairly routine information, or types of records the agency has released in the past. Don’t just agree to file that request so it can languish for years. Talk to supervisors and try to negotiate a way around FOIA. Often, the best FOIA request is the one you never had to file.
Sometimes no: Let’s face it. It doesn’t take long to file a FOIA. Several organizations can help if you’re unsure how to compose a FOIA letter. Having a pending FOIA request can keep a channel open to agency officials. It also means you can write about a lengthy delay if you encounter one. And you can’t go wrong planting seeds for future stories, even if they may take years to harvest.
Sometimes maybe: I filed our Medicare Advantage FOIA request with CMS in May 2013. We got nothing, so in May 2014 we filed suit in federal court in Washington, D.C. It took us almost another year, until March 2015, to get any records to speak of – and much of what CMS handed over at first was almost totally blacked out.
Fortunately, U.S. District Judge John D. Bates ordered the government to step up disclosure. Bates said he understood CMS had many demands on its time, but wrote he was “deeply concerned about a proposed production schedule that may take decades to complete.”
Fred Schulte is a four-time Pulitzer Prize finalist who has reporting on Baltimore’s arcane ground rent system, excessive heart surgery death rates in veterans’ hospitals, substandard care by health insurance plans treating low-income people and the hidden dangers of cosmetic surgery in medical offices. He spent much of his career at The Baltimore Sun and the South Florida Sun-Sentinel. He, with the Center for Public Integrity, filed a FOIA lawsuit to obtain financial audits and other documents detailing government oversight of the Medicare Advantage program.
How can journalists go beyond traditional inverted pyramid reporting to tell a story about an event or issue that resonates with readers? - Jacqui Banaszynski
I believe in doing journalistic stories with strong narrative elements. That means you have to know what the narrative elements are before you begin. Ninety percent of good narrative writing is good reporting; 98 percent of great writing is great reporting. The rest of it is just putting those words together. You can’t do the story if you don’t have the raw material. You have to know how to look for and identify strong material.
You have to ask storyteller questions, which are different than institutional questions that are reporting for information. It doesn’t mean they’re bad, but if you think about storytelling questions, you need to work harder to help that person become the storyteller they might not be. Don’t assume people know what you need for your stories, they don’t. Don’t even assume they know how we work. Don’t assume they know why you ask the questions you ask; or why you might need to just sit and watch them for an hour, or take a ride with them in their car and see a tour of their world; tell them.
If you’re going to interview for story, on the phone or in person, the first thing you have to do is explain yourself. What are you exploring? What is your idea or notion or premise about this story? Why are you talking to them? Let them help you determine if you’ve got a central idea or question. Let them know what you’re searching for, and why.
Jacqui Banaszynski (@JacquiB) is a veteran newspaper journalist who teaches at the Missouri School of Journalism, the Poynter Institute and in workshops around the world. In 1988, her series “AIDS in the Heartland” won the Pulitzer Prize in feature writing. This advice comes from her Health Journalism 2015 workshop about narrative writing.
Do you have some tips on shooting video of older people? - Sue Scheible
In 2007, when GateHouse Media and the Patriot Ledger handed out small digital cameras to reporters so they could shoot videos with their stories, I was excited about learning a new skill and having a different way of presenting the engaging seniors I knew to readers. I expected young people to be at ease with the technology, but I was surprised from the start at how comfortable many older people were with the videos. They had had not grown up with this.
The cameras, at that time Casio Exilim, are very small and unobtrusive. I hold the camera next to my face as we are having a conversation. It can be easy to get up close and personal, and the seniors seem to almost forget the camera is there or that it can actually shoot clear video. I have sometimes shown them clips on the camera when we finish to make sure they understand. In a few cases with several centenarians, I dropped by their homes with the edited videos loaded on my laptop to play for them after they were posted.
My technique is very casual. I ask at the start if I can shoot some video and tell them I use it as a reporter's notebook, so I don't have to take a lot of notes, and that if there are some clips that look good, I might use a brief excerpt on the Patriot Ledger web site. In some cases, the entire interview has been so good that I've posted it. I explain that I can edit the video on the computer and will take out parts that are not good, that they can start and stop or make mistakes and I will remove that part. I find most conversations flow naturally and I have captured some delightful candid moments and expressions. To hear the laughter, or the tone of voice, and see the expressions when wisdom or heartfelt emotions are being expressed is so valuable. And to have witness to how sharp these minds still are at advanced ages is a thrill and I hope a way of combating ageism.
Sue Scheible (@sues_ledger) has been a staff reporter at the Quincy, Mass., Patriot Ledger for 46 years and has a weekly column on aging. In a recent video, an 85-year-old woman explained what she’s learned about talking to doctors.
How can journalists make the most of their time and energy when covering a scientific or professional conference? - Mark Taylor
Before you attend, peruse the online or paper conference agenda. It will list topics, speakers and occasionally the work or university affiliations of speakers. Sometimes the program agenda is organized by category, which could include business, science, clinical, social practices or behavior. Look not only for what interests you, but what you can turn into stories.
Mark Taylor is an independent health care journalist based outside Chicago. Taylor was legal affairs reporter for Modern Healthcare magazine and writes for newspapers including The Philadelphia Inquirer, Chicago Sun Times and Gary (Ind.) Post-Tribune. He is a former Kaiser Media Fellow and a co-founder of the Association of Health Care Journalists.
What advice do you have about finding local angles for research that may not otherwise seem pertinent to your audience? — Kay Lazar
We typically don’t report studies that include a relatively small number of participants and do not involve local researchers. But the findings were so striking from the 138-patient North Carolina study published in the Annals of Emergency Medicine — doctors were apparently missing widespread malnutrition among elders in the ER — that it begged for attention.
To put our own stamp on the story, I tapped the expertise of a Boston-area nonprofit that specializes in Meals on Wheels and other services for seniors. The executive director was well-steeped in the everyday problems encountered by local elders, and that helped me to explain to readers how impaired mobility and lost connections to the outside world for many elders can lead to depression, loss of appetite and ultimately malnutrition. That the nonprofit was launching a program to battle depression among home-bound seniors helped further localize the study story for our readers and distinguish it from a more general story about the study they may have seen elsewhere.
When reporting stories, I typically ask service agencies (or physicians, medical centers, etc.) for help in connecting with the type of patient who is involved in the study we are writing about (in this case a senior who faced mobility and nutrition hurdles — and was willing to be interviewed and photographed!) This especially drives home that local, “real person” voice in a story, and gets beyond the general study findings, particularly when other news outlets may be covering the same study.
Boston Globe health reporter Kay Lazar (@GlobeKayLazar) put a local spin on a study out of North Carolina that highlights the problem of malnutrition in the elderly, an issue often overlooked by emergency department physicians when older patients are brought in.
How can reporters maintain emotional distance in storytelling when dealing with issues of death and dying – especially when interviewing patients or family members? – Todd Bookman
It’s easy to overdo the emotion when crafting a story involving death, and radio, as a medium, can really gin up the tears when it wants to. I tried not to turn this series into a saga. While these pieces include the voice of people facing fatal circumstances, the tape I include in the work captures humans talking like rational, funny, thoughtful humans. At the end, we should all be so lucky to have that state of mind.
Todd Bookman began as a news correspondent with New Hampshire Public Radio in 2009, and took over the health beat in 2012. Before his start in journalism, he spent nearly a decade in the nonprofit world, working with international development agencies and anti-poverty groups. He holds a master’s degree in public administration from Columbia University.
In writing about your grandmother, how did you decide it was worthwhile to go public about her cognitive impairment and address privacy concerns? – Janice Lynch Schuster
In writing about the health issues of various family members (and myself) over the years, I have discussed privacy concerns, both with family members, and editors on the stories. In stories that involve my children (five adults now, one 11), I always talk to them first. With my children, I explain what it is I hope to do – reach and inform others who face similar problems, and help them to avoid the pitfalls or terrors we faced. If there are particular issues they do not want revealed, I always honor that. No question.
In terms of the articles about my grandmother and her cognitive impairment, I discussed privacy concerns with my editor at the Post. They had, at one point, wanted her photo, but I felt that would really invade my grandmother's privacy. We agreed, in the end, that by not naming her or where she lives, we shielded her. It helps that our last names are different, too. And the articles (one in the Post and one on MariaShriver.com) do not detail the many specific issues and health conditions that afflict her, just the general diagnosis, and ways to respect, honor, and communicate with people who have dementia. I actually wound up talking about the issues of my grandmother's privacy most with my mother, and in the end, we agreed that an opportunity to help others communicate better with loved ones outweighed the risks of revealing that my grandmother has a cognitive impairment. In fact, many people responded to the article in the Post, and continue to print it out for family members who are facing the same challenge of communicating.
The article on MariaShriver.com is a tribute to my grandmother, and honors all the ways she strengthened my life and my children's. It also discussed what I learned about communicating with someone who has dementia, and describes my efforts to stay in touch with her, even though she is so very far away. Again, it received many positive responses and, I hope, gave others a way to communicate more with their loved ones.
I also wrote more recently about my brother-in-law's death and our decision to name him as an organ donor. In this case, his brothers (my husband and his brother) as well as his daughter, all agreed that Vince would not have minded sharing his story, with the aim of informing and helping.
Janice Lynch Schuster is a poet, essayist, and nonfiction writer who freelances for many publications and websites. She writes about health issues for the Altarum Institute, a nonprofit health systems research and consulting organization.
How do you give a story more depth and meaning if you only have anecdotal evidence to go on? – Lisa Chedekel
At C-HIT, we've been following the problem of patients who are placed on "observation status" during multi-day hospital stays for the last few months – mainly because that status means that Medicare won't pay for their nursing home care after discharge. A lot of our reporting has been anecdotal.
Fortunately, the OIC [U.S. Department of Health and Human Services’ Office of Inspector General] did a little-noticed report on the topic that caught my eye – as usual, lots of data and Medicare cost information that might not be of interest to our readers, but with a few statistics that leapt off the page: Namely, confirmation that hundreds of thousands of Medicare patients had long hospital stays that were considered outpatient or "observation" stays, which deprived them of follow-up nursing home coverage.
Being able to put some numbers on a largely anecdotal problem is one of the happy moments as a health reporter. We write a lot about flaws or glitches in the health care system that are hard to quantify, leaving the reader with the 'sense' that a problem is widespread, but no data to actually back that up. Ninety-nine percent of the OIG, GAO, CMS reports that come through my inbox get scrapped – but it's worth looking at all of them for that 1 percent that help give context to an issue!
You’re launching a new blog on aging. How are you going to approach that? – Barbara Peters Smith
Barbara Peters Smith writes about aging and health issues for the Sarasota Herald-Tribune in Florida, focusing on the major shifts occurring as the U.S. baby boom generation reaches retirement age. She spent most of her career as an editor at newspapers in Santa Barbara, Calif., and Gainesville, Sarasota and St. Petersburg, Fla. Two years ago, when she turned 55, she decided to challenge herself professionally and return to reporting. She is pursuing a master’s degree in American studies at the University of South Florida in Tampa.
Recently I leaped at the chance to divide my health and aging beat with another reporter and concentrate more intensely on the pressing issues that concern baby boomers and their elders. After attending the American Gerontological Society meeting in Boston last year, I wrote a series of analyses about how retiring boomers might reshape Southwest Florida; but aside from occasional stories on horrific nursing homes or Medicare costs, I had not been able to give the aging beat the attention it deserved. With a new health reporter finally on board, I decided to go public by renaming my blog (it was “Pulse;” now it’s “New Wrinkles”) and beginning a more overt dialogue with the large segment of our readership that I’m writing about. Excerpts from the online blog will be reprinted in our Tuesday Health Fitness tabloid, to reach the many elders who still consume their news in paper form.
Sarasota is a retirement community, with almost a third of our residents 65 and older. Not surprisingly, these are our most devoted and attentive readers of the paper product – and I suspect that’s true in just about any U.S. market. We have always exercised news judgment with these readers in mind, and for a time we had a reporter who wrote exclusively about aging – who is now, fortunately, my editor. When layoffs happened and our beats collapsed, we lost that focus, and I want to make sure our readers know we have it back. So I wrote an introductory blog announcing our intentions, and [this] week will be attending this year’s AGS meeting in San Diego, blogging heavily for a week to re-establish ourselves as an authoritative voice on aging.
With 20 years at this paper, I’ve met lots of community elders – which means I have lots of great sources who have passed away, and there is a constant need to refresh the supply. When older readers call me with a problem – and they do – I try to take some extra time to chat about other things and ask if I can call them back sometime to talk about Social Security or Medicare or whatever. There’s a fine line here between outreach and exploitation, and I try to be very vigilant about not taking advantage of readers’ trust. That can mean very long conversations with people who wind up not letting me use their names, but I see that as part of the gig.
My biggest challenge will be to write about aging in a way that engages boomers as well as elders – while also letting other generations know (in a nonthreatening way) that these issues involve them as well. I’m finding that addressing boomers as their parents’ caregivers is a useful segue to helping them focus on their own retirement planning. And even though much of what I am writing about – from elder fraud to home care – revolves around questions of money, my personal goal is to let the humanity of my sources shine through their stories, so that readers of all ages can relate.
What do compounding pharmacies have to do with aging? – Arlene Weintraub
Arlene Weintraub has covered science and health for more than 15 years and is the author of Selling the Fountain of Youth. She has contributed a tip sheet on covering the anti-aging movement.
Hormone replacement continues to be a hot topic among aging baby boomers. When the Women’s Health Initiative studies raised questions about the safety of popular menopause remedies such as PremPro, millions of women turned to anti-aging doctors, who prescribe “bio-identical hormones,” which are concoctions of estrogen and progesterone that are made by largely unregulated compounding pharmacies.
Even though many of these products contain hormones found in menopause remedies that are made by large, highly-regulated drug companies, they don’t have to include the same warning labels that those products do — a continuing source of annoyance for the U.S. Food & Drug Administration, which has tried unsuccessfully to put a halt to improper marketing claims by compounding pharmacists.
The FDA’s continuing efforts in this area are well worth following.
[Editor's note: In the aftermath of the current meningitis outbreak traced to a compounding pharmacy, at least two legislators have said they will draft legislation to give the FDA more oversight of compounding pharmacies.]
You received 90,000 records housed in seven separate databases after the government responded to your request for data about individual nursing homes’ use of antipsychotic medications. How did you make sense of all that information? – Kay Lazar
Kay Lazar discusses the data analysis for "A rampant prescription, a hidden peril," which tracked antipsychotic use in nursing homes. The Globe is making available to AHCJ members two sets of raw data obtained from CMS so that members can do their own analyses.
“My colleague, Matt Carroll, spoke with statistics experts to ensure that the way he was planning to analyze the data was sound. He merged the material into one database and sorted the nursing homes by the percentage of patients who received antipsychotic drugs contrary to CMS recommendations. The homes were broken into quartiles and a median was calculated for each quartile.
I talked to experts who specialize in nursing home research to pinpoint the characteristics we should focus on in our analysis, ultimately choosing staffing levels, method of payment (Medicaid vs. Medicare), and percentage of residents reported by staff to have behavior issues.
We had some false starts.
After the first round of analysis, we realized CMS inadvertently sent 2005 data twice, but labeled one of the years 2007. They sent corrected data, and Carroll re-did the analysis.
Something still didn’t look right. Turns out the agency sent us raw staffing data, but told us it was already calculated in a pre-set and rather complex formula. (CMS counts the number of hours each staffer works over two weeks, then divides that by 14, then divides that by the total residents of a home to compare facilities’ nursing hours per resident, per day.) They apologized, sent the formula, and Carroll re-did the analysis again.”
Why did you change plans and decide not to rely on cause-of-death mortality data from the U.S. Centers for Disease Control and Prevention in your investigation? – A.C. Thompson
There were a couple of reasons. While we’d made a list of causes of death that we considered suspicious, all of those causes of death could also have been the result of innocuous circumstances.
For example, a nursing home patient who died of malnutrition may have been killed because staffers failed to adequately care for the patient. Or the patient may have suffered from a fatal disease that made it impossible to eat and digest food.
With the CDC’s records, it’s impossible to tell what really occurred.
How did you find the information you used to create 'Your Future Selves,' an interactive element that lets people peer forward into time and get a sense of what aging might mean? – Michael Keller
Michael Keller discusses his work on Brave Old World, produced by students from Columbia University’s Graduate School of Journalism. (Read more about the project.) He’s a staff member at The New York World, a new digital project.
The biggest problem in my workflow was finding rich data for the interactive. We had a pretty tall order, too. We wanted data segmented at least three ways: by age, sex and race.
We found out that many organizations only tabulate data across two dimensions. For instance, the CDC can tell you how many Asian men have a certain disease and they can tell you how many women over 65 have it, but they can’t tell you how many Asian women over 65 have it.
The census keeps better data but finding the full data set required getting to know the high level support staff who were able to direct us to their larger repository.
We spent at least six weeks in data collection mode, which was much longer than we had budgeted for. To get our health data, for instance, we got in touch with a well-respected data journalist who tipped us off to a database at the NIH that was much better than the CDC’s.
To use this data, however, we had to learn how to query it, which took a couple of weeks and we consulted with the Columbia statistics department to make sure our methodology was sound and to help us to calculate standard errors on our findings to verify our results.
How did you find the people you featured in this story? – Deborah L. Shelton
Jan. 6, 2011 Finding the right interview subject to lead a story – someone willing to publicly share his or her deepest feelings and personal problems – can be challenging. It took some digging to come up with the right subjects for a recent story I did on long-term care planning. I found several people whose situations fit the bill, but they didn’t want their stories written up in the newspaper.
What worked for me was reaching out to social service agencies that act as resource centers for seniors in crisis, including two area agencies on aging. The agencies were willing to send out an e-mail blast to their caseworkers asking for recommendations for possible interview subjects. (Sometimes a request posted on a professional or patient listserv does the trick.) I made sure everyone knew my deadline.
I ended up with a mother-son pair who were perfect for the story. They were happy to be interviewed and photographed and were open about their situation. Even though their caseworker had already bailed me out, he cheerfully went the extra mile and made time to do a phone interview with me, the cherry on top of the sundae.
What would you advise reporters interested in finding stories about troubled nursing homes in their communities? – Mary Kate Malone
A lot of the information on nursing homes is accessible online. For example, you can look up any nursing home in your area on the Center for Medicare and Medicaid's website. The site provides access to inspection reports and also rates nursing homes against each other. With my story, I was unable to use this site, because it is only for nursing homes, not assisted-living homes.
For reporters who want to find out more about assisted living, I think the best route to take is getting in touch with the long-term care ombudsman (or equivalent) in your area, and they are often a treasure trove of information, and also can provide good, quotable perspective for a story.
[Editor's note:AHCJ offers the Nursing Home Compare data as a series of spreadsheets, allowing the user to filter, sort and use other analysis tools to compare more nursing homes in a more sophisticated way. Obtained from CMS and updated when the agency updates its data, the spreadsheet files include only more serious nursing home deficiencies and star ratings for nursing homes in a format to easily sort and compare.]