Bullying and Its Long-Term Effects

Published in the Spring 2012 Duke University Social Sciences Research Institute Gist From the Mill

By Whitney L.J. Howell

For one 12-year-old girl, the taunting and teasing were almost unbearable. The false rumors that she was already sexually active with several male classmates were humiliating. She was overwhelmed by the daily harassment, and finally, her teachers intervened. Their investigation pinpointed one girl as the source. The reason: both girls were interested in the same boy.

According to 2010 U.S. Department of Justice data, bullying is not uncommon: as much as 20 percent of children ages 2 to 17 were victims of bullying at least once within the previous 12 months. Nearly 10 percent of children were assaulted chronically. A Duke study seeks to answer why certain children are targeted and to identify the long-term effects of victimization.

“A lot of people say when a child is bullied, they become aggressive, hyperactive, or exhibit acting out behavior in some fashion, but we’ve found that those things aren’t something that can be chalked up to bullying,” said Terrie Moffitt, Ph.D., a Duke psychology and neuroscience professor. “What really happens with children who are victims of bullies is that they become anxious and depressed.”

In a seven-year longitudinal study, Moffitt and her colleagues followed 2,200 identical and fraternal twins in the United Kingdom (U.K.) from ages 5 to 12. The research revealed that physical characteristics –weight, hair color, etc. – don’t necessarily play into how a bully targets victims. Instead, bullies often choose children who seemingly have few close, warm relationships with adults and are less likely to report the abuse.

Through home visits and questionnaires, the team also determined while emotional and mental health difficulties can factor into a child being targeted by a bully, being bullied itself can spark a new set of problems.

A recent study conducted by Arizona State University published in February’s Child Development, however, contradicts this assessment. The paper reported depressed children attracted bullies, but further victimization didn’t worsen their depression. Moffitt’s data demonstrated the opposite. Among twins where one was bullied and the other not, the bullied sibling was more vulnerable to depression and anxiety. Following twins gave her team the advantage, she said, because they could control for genetic – as well as environmental – factors, and the Arizona team couldn’t.

The team is also interested in how repeated victimization affects individuals into adulthood. Beginning in May, they have a £3 million grant to follow this same cohort through to age 18, looking not only at their mental health, but also their psychosocial adjustment skills and any stress-related biomarkers.

To date, existing research examining the incidence of bullying among twins has included mainly middle-class families recruited through newspaper advertising. Instead, Moffitt’s team used the U.K’s twin registry to identify a sample group that more accurately reflects the characteristics of children who are most frequently victimized.

“We under-sampled twins born to older mothers who were well educated, well-to-do, and who used fertility treatments, and we oversampled twins born to unwed teenage mothers living in public housing. We wanted to make sure we monitored plenty of kids growing up in poverty and with adverse circumstances,” Moffitt said. “We exceeded beyond our wildest dreams. Many of the kids are in dire conditions. Some moms are opium addicts, and many kids have already been removed from their moms and are in foster care. A number of mothers have already committed suicide, and in many situations the fathers are either absent or in-and-out of jail.”

To assess how children in the study responded to bullying over time, nurses conducted two-hour, in-home visits when the children were ages 5, 7, 10, and 12. They also collected birth weight, breastfeeding history, and vaccine records through a questionnaire at age 2.

The nurses observed mother-and-child interactions during each visit and used two puppy puppets – Iggy and Ziggy – to ask the child questions designed to discover whether the child has been victimized. For example, one puppet asked, “Sometimes bigger boys make me cry. Do bigger boys sometimes make you cry?” Children either answered verbally or touched the puppet with which they identified. Other games pinpointed whether the child could view situations from another’s point-of-view.

In addition, 100 families participated in a laboratory study that measured the twins’ levels of the stress hormone cortisol during an oral math quiz and discussion of their most recent traumatic event. Results revealed that children who hadn’t been bullied experienced an initial cortisol spike, but levels normalized within 45 minutes. However, bullied children didn’t have as high a cortisol rise, but the stress hormone lingered in their bloodstream beyond 45 minutes.

“This result shows bullied children are primed for bad things to happen to them. They just don’t bounce back,” Moffitt said. “That’s the kind of biological change to the stress hormone system than could have a long-lasting effect.”

The child’s emotional state wasn’t the nurse’s only focus, though. They also monitored and took notes on how the mother talked about her child. They focused on the mother’s tone of voice rather than what she said – for example, did she call the child “a pain” in a warm voice or with disdain? This collected data was coded and helped the team identify children who were less likely to have supportive, close relationships with their mother, putting them at greater risk for victimization.

In the long run, Moffitt said she hopes this research will be used to increase awareness among adults about bullying, as well as increase the availability of emotional and social support services for bullied children and their families.

“We certainly don’t want to overblow this since bullying is a normal part of life. We do want our kids to be resilient and learn to deal with conflict,” said Moffitt, pointing out that being an occasional bullying victim is great practice for coping with adulthood. “But when bullying is chronic and secret from adults and the child feels hopeless and alone, that’s the part that parents and schools need to try and catch.”

To read the story at its original location: http://issuu.com/ssriduke/docs/gistspring12_web?mode=window&pageNumber=15

Grand-Aide Model Offers New Solution to Disease Management

Published in the March 2012 AAMC Reporter

By Whitney L.J. Howell

For months, Paloma Saucedo had a patient whose blood-sugar level hovered in the very high 600s. He resisted any dietary changes and did not correctly take his diabetes medication. Saucedo made weekly home visits, attended diabetes meetings with him, and discussed the importance of taking medication properly. Eventually, she said, his blood sugar dropped to 130.

She knew the light bulb had flickered on for him when, during a home visit, she saw a picture of the U.S. Department of Agriculture’s food plate on his kitchen wall. She had picked one up at an earlier diabetes meeting, mentioning to him it was a good reminder when she cooked of how her plate should look. Clearly, he was following her lead.

“I thought to myself, ‘Finally!’ It was a huge success for me,” said Saucedo, who works with the Harrisonburg Community Health Center in Harrisonburg, Va. “Even though I wasn’t telling him what he could and couldn’t eat, I was teaching by example.”

Saucedo didn’t need a medical or nursing degree to make a positive impact on her patient’s health. Instead, she made a difference as a Grand-Aide (GA)—a layperson who receives training as a certified nursing assistant (CNA) to work with patients in their homes, serving as a connection to the health care system.

GAs are the brainchild of Arthur “Tim” Garson Jr., M.D., M.P.H., director of the Center for Health Policy at the University of Virginia School of Medicine (UVA). The idea sprouted when Garson analyzed his patient population 15 years ago. “I realized 50 percent of my patients could be cared for by a good grandmother, and 80 percent of the rest could be taken care of by a good nurse,” he said. “That insight led to Grand-Aides.”

The hope, he said, was that GAs, who are supervised by nurses, would reduce emergency department visits and hospital readmissions by up to 50 percent each by working closely with patients to manage many primary and chronic care needs.

According to Carol A. Aschenbrener, M.D., the AAMC’s chief medical education officer, some patient concerns can be addressed by other caregivers, with appropriate guidance from physicians and nurses. This would free health professionals to focus on providing care at “the top of their license.” With relatively brief training, GAs can be a trusted link to the health care system and meet many day-to-day, low-level patient needs. Although GA programs are still in the pilot stage, they have shown great promise for bringing health care providers together for new collaborations, she said.

“The Grand-Aides program is testing a new, lower cost approach to follow-up for specific categories of patients,” Aschenbrener said. “What I like about this program is that it uses people in midlife who have something to give. They have a maturity and can improve communication between patients and their health care providers.”

To date, one-year pilot programs at federally qualified health centers in Harrisonburg and Houston have tested the GA model by bringing primary care services to about 15,000 Medicaid beneficiaries. The Texas Legislature even appropriated $1.25 million for the endeavor.

In addition to curbing provider visits and lightening the workload for doctors and nurses, GAs are poised to help manage the impending increase of newly insured patients after 2014, when major provisions of the health reform law are scheduled to go into effect. In fact, Garson said, GAs will soften the blow of the looming physician and nursing shortages. According to the AAMC Center for Workforce Studies, the nationwide physician shortage will be more than 90,000 by 2020. The Health Resources and Services Administration has estimated the nursing shortage will reach 1 million in the same year.

“Given the influx of newly covered patients under Medicaid, there are going to be huge medical needs throughout the country,” Garson said. “Grand-Aides can easily fill this void and provide appropriate access to the care and services most patients will need.”

What GAs do

GAs receive training to work with patients in primary or chronic care settings. They gather and relate health information but do not treat or make clinical decisions. Primary care GAs focus on general family and maternal-fetal care, while chronic care GAs focus on five conditions, including diabetes, heart failure, and pneumonia. Training lasts three or four months, depending on whether the person has previous CNA experience. Throughout classroom training, clinical preceptorship, and field work, they learn anatomy, physiology, and the specifics of certain diseases.

GAs and patients meet in either the clinic or the hospital. Primary care GAs split their time among home visits, follow-up phone calls, and preventive calls. Their training, coupled with a predesigned, 20-question protocol, helps them gather health information, relay the data to a nurse, and then explain the appropriate care plan to the patient, Garson said.

Chronic care GAs can be more hands-on. Not only do they accompany patients home from hospital stays, but they also assess living conditions and daily routines to spot habits that can negatively affect patients’ recovery and future health. These visits are “pantry sweeps,” said Donna M. Green, R.N., executive director of the Grand-Aide Foundation, a program of UVA’s Center for Health Policy.

“The Grand-Aides will find bad foods, reinforce smoking cessation, try to get the patients to do at least minimal exercise, and help them establish a day-to-day routine to manage their disease,” she said. “They’re in the patient’s home every day for the first week, and then they stay in touch through telemedicine. The patient never feels cut off from their health care provider.”

Overall, Green said, GAs are effective because patients see them as peers and mentors rather than as an authority figure.

“They often view nurses and doctors as preaching to them without a clear understanding of their life situations,” she said. “But this peer has the time to really work with them, to become their partner, and help them make the best decisions for their health.”

The challenge facing GAs

While both pilots have been successful, gaining widespread support for the GA program depends on whether the industry maintains a fee-for-service model or navigates to a bundled payment system, Garson said.

“When looking at a capitation model, GAs are perfect, because they reduce the number of visits and expenses, accruing savings for clinics,” he said. “But with fee-for-service it gets more complex. How do you pay the GA? The supervisor? And with a reduced number of visits, money earned drops as well.”

According to Garson, the financial impact from GAs has been significant. Over the past year in Houston, GAs prevented nearly 700 clinic and emergency department visits. The net savings per GA for patients and providers was nearly $101,000. In Virginia, the average savings per GA was almost $82,000.

To read the article in its original location: https://www.aamc.org/newsroom/reporter/march2012/276858/grandaide.html

Teaching the Business Side of Radiology Could Have Long-Term Benefits

Published on the March 9, 2012, DiagnosticImaging.com website

By Whitney L.J. Howell

It’s no longer enough for radiology residents to master reading head CT scans or learn all the specifics of MRI imaging. Changing reimbursement structures and different healthcare setting models have made understanding practice management and healthcare policy a must.

In a recent study published in the March Journal of the American College of Radiology, researchers determined both residents and residency directors felt including these instructional topics would greatly benefit residents on the cusp of practice.

“It’s becoming more and more important to stay current on the business and policies of practice. If you’re not aware of what’s going on, then you can’t anticipate or make plans to navigate any changes,” said Jonathan Medverd, MD, lead study author and University of Washington radiologist. “If you don’t understand your place in the system and you don’t know who’s paying you, then you’re at a disadvantage.”

Medverd and colleagues surveyed members of the Association of Program Directors in Radiology and the American College of Radiology (ACR) Resident and Fellow Section (RFS) via email, and members of ACR RFS who attended the 2010 ACR annual meeting and leadership conference. Response rates were 21 percent, 12 percent, and 25 percent, respectively, and 560 individuals participated.

While residency programs do a good job at teaching residents about ethics, quality, and informatics, the curricula focus less on financial literacy, the basic understanding of practice governance, and performance metrics. It’s these areas, as well as strategic planning and accounting principles, where residents could gain from additional education, Medverd said.

In fact, the Association of American Medical Colleges’ 2011 Graduate Questionnaire revealed medical students were also interested in learning more about practice management. Less than 50 percent said they felt their knowledge in this area was adequate.

“Pushing general things, such as basic financial literacy or how Medicare billing works, into medical school could increase confidence among doctors in training,” Medverd said. “Then residency programs can pick up and focus more specifically on how these issues affect their particular fields.”

However, knowing residents should have more instruction in these areas doesn’t mean including it in the curriculum will be easy. According to Jennifer Kohr, MD, a diagnostic radiologist with New York Presbyterian Hospital who helped design and implement a radiology business course as a chief resident, two main challenges exist to beefing up this part of residency education: time and resident motivation.

The number of skills and modalities resident must master has increased in number and complexity, she said, making it harder to squeeze additional, non-clinical topics into the curricula. And even if a program does manage to fit them in, residents are often overwhelmed and lack the motivation to learn something that won’t help them with direct patient care. The benefits, however, are there.

To read the remainder of the article: http://www.diagnosticimaging.com/practice-management/content/article/113619/2044713

More Medical Schools Offer Instruction in Complementary and Alternative Therapies

Published in the February 2012 AAMC Reporter

By Whitney L.J. Howell

At first glance, Megan Wolf believed the man in front of her had been mortally wounded. She was horrified, until he looked up and laughed.

“I gasped, but he giggled at my reaction,” said the third-year student at the University of Pittsburgh School of Medicine. “He said it didn’t hurt at all and that he never felt better than after one of those treatments.”

What Wolf, who is the chair of the American Medical Student Association’s (AMSA’s) Wellness and Student Life Committee, saw—and what the man experienced—was a high-velocity, low-amplitude spinal adjustment. In essence, the chiropractor cracked his neck.

Witnessing this episode was part of Wolf’s introduction to complementary and alternative medicine, or CAM. Also known as integrative or mind-body medicine, these therapies are becoming more common in U.S. medical education.

The push to bring CAM into medical training began in 1999 when the National Center for Complementary and Alternative Medicine (NCCAM), part of the National Institutes of Health, launched the CAM Education Project.

Initially, the center awarded 14 grants of $1 million to $1.5 million to medical schools, teaching hospitals, and AMSA for research projects, such as training pediatric residents on the benefits of CAM in treating childhood diseases or teaching students to communicate effectively about it with patients. Today, a group of more than 50 U.S. and Canadian medical schools and teaching hospitals, called the Consortium of Academic Health Centers for Integrative Medicine, includes CAM in its curricula.

Although opinions about CAM are heated, there is no question that patients use it. According to 2008 data from the Centers for Disease Control and Prevention, nearly 40 percent of adults and 12 percent of children use at least one therapy, and many are reticent when it comes to telling their doctors. The substantial size of this group makes it vital that medical students understand how nontraditional therapies or supplements interact with standard medical care, said Aviad Haramati, Ph.D., a Georgetown University School of Medicine physiologist, who pioneered CAM education at Georgetown in 2000.

“We aren’t educating CAM practitioners,” he said. “But we are giving medical students knowledge so they can talk with their patients in an open-minded way from informed positions, and educate them on the potential risks of mixing complementary techniques or herbal supplements with prescription medications.”

The growing body of evidence-based research supporting CAM in peer-reviewed journals, such as the Annual Review of Medicine and the Journal of the American Medical Association, means academic medicine cannot ignore these modalities, Haramati added.

Opposition to CAM in Curricula

But not everyone in academic medicine agrees that medical students should learn about CAM. Steven Salzberg, Ph.D., medicine and biostatistics professor at Johns Hopkins University School of Medicine, openly opposes integrating CAM into medical education curricula, asserting that alternative modalities are ineffective.

“Whatever term is used—alternative medicine or integrative medicine—this isn’t medicine. At best, these are hypotheses,” Salzberg said. “Over 20 years, NCCAM has spent more than $1 billion, and [there is] no strong evidence that these activities work.”

He also criticized the propensity in academic medicine to group meditation and yoga with acupuncture, chiropractic, and homeopathic treatments. Clear evidence exists to support the efficacy of meditation and yoga, he said, and equating them to other modalities is erroneous.

Despite his objections to including CAM in curricula, Salzberg agreed it could be useful to train physicians proactively about treatments patients might seek on their own.

Challenges to Teaching CAM

Salzberg’s objections have not slowed the integration of CAM into education, but that does not mean getting buy-in for course additions has been easy. There are three main questions about this fusion, said Victor Sierpina, M.D., a professor in the integrative medicine program at the University of Texas Medical Branch in Galveston.

“The biggest concern is people’s unfamiliarity with the evidence behind CAM,” he said. “Once they become aware of peer-reviewed research, the resistance to including these topics drops. The same is true for administrators, faculty, and students.”

Many institutional leaders want details about how faculty will teach CAM from the evidence-based perspective, he said, and they want to know how this knowledge will augment training and turn students into lifelong learners.

Even with these questions satisfied, CAM remains divisive, said Michelle Bailey, M.D., a Duke University School of Medicine pediatric integrative medicine physician. She is also the director of medical education for Duke Integrative Medicine.

“Increasing CAM in allopathic medical training can still be considered controversial,” she said. “But there are many in the consortium who are looking for best practices, as well as the best ways to translate it to medical students.”

Current Course Curricula

Many medical schools and teaching hospitals have elaborate programs featuring CAM. For example, Haramati said, Georgetown launched a five-year program in 2005 for students to earn a master’s in CAM before pursuing their medical degree. The first degree program of its kind includes, among other topics, nutrition, mind-body skills, and CAM use in oncology.

“We brought acupuncture into anatomy and neuroscience, biofeedback into physiology, and the science of stress reduction into endocrinology,” Haramati said. “We want students to experience the mind-body connection firsthand and understand more about themselves.”

At Texas, students receive an orientation to the library that includes case-based information about herbal supplements as well as other CAM strategies, Sierpina said. Second-year students discuss chiropractic and massage in musculoskeletal classes, and others participate in grand rounds about the interaction between over-the-counter supplements and anesthesia. CAM is quickly becoming a fluid part of the curriculum, he said.

“It’s mostly invisible. It’s seamless,” Sierpina said. “We use problem-based learning to train students, and we want them to evaluate all possibilities. When treating a patient, CAM might not be the solution, but we want them to consider all options.”

But medical education is cramped, and many worry adding CAM-focused courses could overwhelm students.

To overcome this barrier, many institutions follow Texas’ example, infusing CAM theories into existing classes. For example, Duke offers two-week elective courses that give second-year students a solid foundation in CAM, Bailey said.

In addition to attending lectures, students meet CAM providers, such as acupuncturists, massage therapists, or health psychologists, and shadow these providers at the Duke Integrative Medicine building.

“It’s important for students to learn the credible information around integrative medicine so they can point patients to reliable sources,” Bailey said. “If, as patient advocates, we are to first do no harm, then we must be armed with information to educate patients and keep them safe.”

Duke students also learn about CAM during their required fourth-year capstone course. As part of this class, the school holds a four-hour integrative medicine health fair bringing in nearly 40 CAM providers from the community. Students visit booths, asking questions and gathering information. A lecture series several days before the fair also presents basic CAM details.

Student Reaction

Medical students know patients benefit when their providers understand CAM, but students also see value for it in their own lives, said AMSA’s Wolf.

“AMSA participants focus on their wellness,” she said. “Our members look at natural things like yoga to handle the stress and pressures of medicine. These things help us take better care of ourselves so we can be better physicians.”

David Darrow, a fourth-year Texas student, agreed that studying CAM gives him empathy for how patients choose to approach their health.

“It’s ironic. As medical students, we approach our education as scientists who make decisions on evidence and fact,” he said. “But learning about CAM has really led me back to the humanistic part of medicine.”

To read the article at its original location: https://www.aamc.org/newsroom/reporter/feb2012/273812/therapies.html

Fictional Characters Bring Life to the Classroom

Published in the Winter 2012 Duke University School of Nursing Alumni Magazine

By Whitney L.J. Howell

Meet Golda and Antonio. She’s a grandmother, rearing her grandson while trying to manage myriad chronic conditions. He’s a Mexican immigrant who’s juggling the tensions of a high-stress job and a young family.

Nurse practitioner students at the Duke University School of Nursing (DUSON) spent the entire Summer 2011 semester closely following Golda and Antonio. They designed health plans to fit the patients’ lifestyles and worried about how any medical changes would affect their daily activities.

But there’s one catch—Golda and Antonio aren’t real. In fact, they’re figments of imagination of DUSON assistant professors Penny Cooper, MSN’02, C’08, RN, FNP-BC, CCRN, and Michael Scott’s, DNP, FNP-BC. They exist only on paper, and students know them simply by class-provided clinical notes. However, that was enough to launch students into intricate, and often heated, discussions about the best way to meet Golda and Antonio’s health needs.

The format for Managing Common Acute and Chronic Health Problems II, said Scott, who co-taught the class with Cooper, was a significant divergence from lecture-based courses formats. It’s a challenge for faculty to step out from behind the podium, he said, but the result is students who are prepared to be independent, proactive nurses.

“This course is a paradigm shift,” he said. “We’ve tried to demonstrate that there are ways to draw students into a discussion. We want students to see and experience for themselves the interplay between context and clinical decision making.”

By training students to look beyond rote learning and synthesize that knowledge with individual circumstances, Cooper and Scott are meeting a charge published in the Institute of Medicine’s October 2010 report The Future of Nursing: Leading Change, advancing health. The report stressed that nurses are ready to augment their roles as primary care providers who can reduce or eliminate gaps in care.

What Happens In Class
The course goal wasn’t to memorize and spout a certain number of facts about medications or conditions, Scott said. Instead, he and Cooper wanted to train students to be life-long learners —knowledgeable, well-trained healthcare providers who know where to turn for information. They wanted to produce nurses who could think beyond textbook knowledge to craft care plans to accommodate a patient’s daily routine and limitations, such as dependency on public transportation.

According to Cooper, the primary care-focused curriculum spanned roughly 20 years of each patients’ life. Students received clinical notes before each weekly class, detailing each patient’s vital statistics, laboratory test results, or life changes. Each week focused on a different content area, such as cardiology or neurology. Armed with this data, they came to class and discussed how best to address clinical, billing, and coding concerns.

The class relied on student-led conversation, Cooper said. She and Scott served as content experts who would only occasionally posit questions if the discussion began to lag. Unlike their other classes, students didn’t take tests to gauge how well they retained information. Instead, Cooper and Scott presented case studies unrelated to Golda and Antonio to evaluate how well students digested and applied their procedural knowledge. Cooper said they also required students to offer opinions during class discussions as well as reflect in writing upon certain cases. Adjusting to this format, though, was difficult.

“There was some initial resistance and discomfort with the class structure. It can be uncomfortable to change the ‘test,’” she said. “Having them do active reflection was a way to ensure that they thought about the different approaches and opinions brought forth.”

Effective and Memorable
For Mary Johnson, MSN’12, FNP, a discussion-format class was a novelty, but it was one that greatly enhanced her learning.

“This was much more effective than listening to a lecture where a professor spits out facts and you regurgitate them,” she said. “The class was like real life. We learned that we won’t always be able to do what we’d like to do medically for our patients—they will have extenuating circumstances, and we’ll have to meet them where they are.”

Talking with fellow students about specific case studies that spanned more than two decades also fit perfectly with the way Danielle DiGennaro, MSN’12, FNP, prefers to learn.

“I, personally, tend to learn best from case studies. The material clicks and sticks with me when it is related to a case,”she said. “We often had a handful of voices that were very prominent. But it was nice to hear from the class as a whole. Different colleagues brought different experiences to the class, be they RN experiences or NP clinical placements.”

The in-depth discussions about clinical conditions pushed students to think holistically about Golda and Antonio, but these small-group interactions also introduced the challenges of inter-professional communication. Some discussions, such as one about end-of-life care and Do Not Resuscitate orders, morphed into ideological fights, Johnson said, and classmates had to learn to navigate the differing, and entrenched, opinions.

Taking the Curriculum Nationwide
With such an overwhelmingly positive response to the class format, Cooper and Scott wanted to see if they could translate the
in-class experience to DUSON’s distance learning programs. The idea of fusing lively discussion with technology that connects the coasts garnered both attention and financial support.

According to Marilyn M. Lombardi, PhD, director of the new Duke Center of Nursing Collaboration, Entrepreneurship, and Technology (CONCEPT), Cooper and Scott’s desire to share the course format outside the school’s walls was a perfect fit for the first Catalyst Faculty Innovation Award. The CONCEPT Catalyst Award was created to support innovative and entrepreneurial faculty endeavors.

Lombardi stressed that entrepreneurial work doesn’t always focus on making money. In fact, many in nursing view that goal as being antithetical to the profession’s service call. She anticipates other DUSON faculty, like Cooper and Scott, will be entrepreneurial on a mainly social level—they’ll endeavor to introduce new ideas to health care delivery that will help patients.

The award gives Cooper and Scott funding to research and identify the best methods for disseminating the course curriculum to the School’s distance education students. At the time of publication, they were actively working with Duke’s videography and information technology services to bring the project to fruition. The idea is simple, but it will be a challenge to create an environment that brings students from different states and time zones together for active discussions about patient care.

“The catalyst award is the seed money that allows faculty to take risks and think beyond customary pathways for education,” Lombardi said. “What [Cooper and Scott] are using is an exciting strategy to introduce technology in support of an innovative approach to teaching and learning. This won’t be a simple matter of setting up a video conference.”

Instead, Lombardi said, the curriculum for the distance class will likely take a more multimedia, documentary approach with both visual and audio components. Using resources provided by CONCEPT, Cooper and Scott will produce 10 5-minute vignettes that cover each course module and bring Golda and Antonio to life.

Finding the right mix that reproduces the in-class experience for students will require creative collaboration with partners outside the School. The CONCEPT office exists, Lombardi said, to foster these relationships and cultivate the inventive spirit that already exists in nursing.

“We launched CONCEPT because we talk a lot about what nurses refer to as the ‘work-around culture,’” she said. “We’re faced with a care environment that isn’t set up to work optimally for patients, so nurses use the materials that they have close at hand—like cotton balls or construction paper—to create improvised alternatives to meet patients’ daily needs.”

CONCEPT gives Duke’s nursing faculty the freedom to be design thinkers, she said. Through partnerships with other schools, such as the Pratt School of Engineering or the Fuqua School of Business, faculty will have the opportunity to take their ideas further and potentially change how nurses work at the front line of care.

To read the story at it’s originial location: http://nursing.duke.edu/sites/default/files/alumni/magazine/winter_2012_issue_final.pdf

Value-Based Purchasing Presents Challenges to Teaching Hospitals

Published in the January 2012 Association of American Medical Colleges Reporter

By Whitney L.J. Howell

Starting October 2012, hospitals will be paid under a new Centers for Medicare and Medicaid Services (CMS) program that ties a percentage of their Medicare reimbursement to performance on a set of quality metrics, including patient satisfaction. Called a value-based purchasing (VBP) program, it is one of three new performance-based payment programs under the Affordable Care Act. The other two payment programs focus on performance related to readmissions and hospital-acquired conditions.

Performing well under VBP will be both a challenge and a financial necessity for teaching hospitals. “It’s a fundamental responsibility of all physicians in all academic medical centers to deliver high-quality, cutting-edge care,” said David Longworth, M.D., chair of the Cleveland Clinic’s Medicine Institute. “Now, we’re being asked to find a way to increase the value of services while cutting costs. It will be challenging, but it’s imperative for our economic survival.”

The VBP program will combine a hospital’s score on a patient satisfaction survey, known as the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), with the facility’s success on 12 process-of-care measures in areas such as heart failure, pneumonia, and health care-associated infections. Poor performance on these measures can mean a reduction in reimbursement—when providers and facilities are already fighting to retain their payments.

Teaching hospitals continue to have concerns over how the program is structured, specifically the current emphasis on the HCAHPS survey. While patient satisfaction is a critical component to quality of care, recent research has shown that a sicker patient population could lead to lower scores and ultimately affect how teaching hospitals will fare under the new program.

“Value-based purchasing will be a real challenge for academic medical centers because they have the most difficult patient population,” said Robert Berenson, M.D., an internist and health care policy expert with the Urban Institute, a nonpartisan commission that analyzes public policy issues. “There is a concern that these facilities will not look like they are doing as well as community hospitals because they often provide more complex care to patients who are already more likely to have a negative outcome.”

However, many teaching hospitals have been incorporating quality-improvement strategies to prepare for the new payment program.

The Cleveland Clinic is using a number of strategies to improve its HCAHPS scores; however, Longworth emphasized that true differences in quality performance start with medical education.

“We’re embedding value by introducing medical students and residents to quality measures and outcomes,” he said. “This way they understand from the beginning that it is our moral imperative as health care professionals to do what we can to improve care quality.”

In 2010, the Cleveland Clinic held a Patient Experience Summit, dedicated to discussing patient quality of care and best practices.

New York-Presbyterian Hospital has several strategies in place, according to Eliot Lazar, M.D., senior vice president and chief quality and patient safety officer. The goal, he said, is to ensure that hospital employees understand the overall importance of quality and patient safety.

“It’s extremely important that our staff understand how to provide the highest-quality care whether it’s based on value-based purchasing or the Joint Commission,” Lazar said. “We make a point of integrating value-based goals with recommendations from our own experiences and national patient safety standards to create a cohesive quality and cost-controlling curricula.”

Residents from the hospital’s affiliated medical schools—Weill Cornell Medical College and Columbia University College of Physicians and Surgeons—have formed Housestaff Quality Councils (HQCs) to give administrators feedback about issues or problems they see at the front lines of patient care. Representatives from all departments meet monthly to craft solutions to common issues that will be easy to implement. For example, the Weill Cornell HQC improved the hospital’s medication reconciliation program by recommending that the electronic health record (EHR) prompt residents to perform a medication reconciliation within six hours of an admission. The EHR also prohibits further orders if the reconciliation is not completed within 18 hours.

“These councils are an excellent way for us to hear from residents who are out there with the patients,” Lazar said. “There are many times when we seek advice from the councils.”

“With less than a year left to gear up for VBP, the AAMC is fully committed to helping its member institutions identify the best strategies that will help them meet the quality-improvement and cost-reduction requirements,” said Jennifer Faerberg, AAMC director of health care affairs.

“We are working with institutions that have taken steps to make VBP implementation easier,” she said. “We are developing a forum for institutions to share their best practices. We cannot change the institutional structure or the patient dynamics, but we can help members do the best they can with what they have.”

To view the article in its original location: https://www.aamc.org/newsroom/reporter/january2012/271170/value-basedpurchasing.html

Medical Schools Get Creative With Child Care Benefits

Published in the December 2011 AAMC Reporter

By Whitney L.J Howell

As a surgeon, Robert Feezor, M.D., never expected he would eat earthworms at work. But as a father, he was thrilled to have the chance.

“It was Father’s Day, and they gave the dads earthworm ice cream,” said Feezor, assistant professor of vascular surgery at the University of Florida College of Medicine. “Basically, it was gummy worms in brownies, so it looked like earthworms in dirt. My son loved giving it to me.”

The treat came courtesy of Baby Gator, the medical center’s on-site day care facility where Feezor sends his three children—ages 5, 3, and 2—daily for a “stimulating educational child care experience.”

Accessible child care is one of the things that can add to the workplace attractiveness of an academic medical center. Baby Gator opened its on-site facility two years ago, joining other academic medical centers that have offered the same benefit—some for as long as 50 years. Many, including Yale and Stanford universities, have housed child care near hospitals and clinics for decades.

According to Sarah Bunton, Ph.D., AAMC research director of organization and management studies, longer hours of operation, close proximity to the hospital or clinic, and the possibility to see a child during the day make on-site day care a priority for faculty—both male and female.

“A dramatic change in the desire for on-site day care has been the increased number of fathers who want to be more involved with arranging care for their kids,” she said. “Through anecdotal reports from faculty affairs administrators and focus groups with select groups of faculty, more male faculty are also asking about and lobbying for this benefit.”

Baby Gator Director Pamela Pallas, Ph.D., said it was the medical school’s dean who first requested a location closer to the hospital.

“The dean called to tell me that top-notch residents were turning him down because he couldn’t guarantee he could offer appropriate child care,” Pallas said. “He was shocked child care was a deal breaker, but he wanted to know how we could get a Baby Gator close to the health sciences center.”

Within six months of opening, Pallas said, the center was at full capacity with112 children. There is now a waiting list 200 children long.

On-site child care is so popular, and the need for quality services so great, that parents scramble to put their children on waiting lists before birth. Some even make the attempt before conception. Jane Grady, Ph.D., associate vice president for human resources at Rush University Medical Center, once had a faculty member contact her upon getting engaged to ask if it was too early to put a yet-to-be-conceived child on the waiting list.

While the question amused Grady, who served as the first director of Rush’s Laurance Armour Day School, she was not surprised. Day care facilities at academic medical centers are more likely than other child care centers to have an educationally focused curriculum, making them a good choice for parents who already value extensive academic training, she said. Facilities on medical center campuses are also more likely to have highly educated staff.

“All our teachers have master’s degrees in early childhood education,” she said. “They are here to help the kids learn and have fun. We want to make sure they are well prepared for school at the same time we provide the excellent care the parents are looking for.”

During the 2008 presidential election, Feezor’s children learned about the various candidates and flags from different countries. When they learned about gardening, his 3-year-old enjoyed showing off the watermelon every time Feezor picked him up on the playground.

From the faculty perspective, paying for medical center-connected on-site day care can be easier than paying a center in the community, Grady said. Faculty can often choose from payroll deduction, using their health savings accounts, or monthly check.

Although these centers are coveted and provide an appreciated benefit to faculty, starting a day care facility is not always simple, said Phillips Kerr, director of compensations and benefits for the University of Massachusetts Medical Center-Worchester, which opened its facility in August 2010. The biggest stumbling block is finding an adequately sized space, as well as the funds to complete renovations, hire staff, and purchase necessary resources. In fact, he said, the best option could be outsourcing the day care’s administration.

“Fortunately, the university owned the space we used for the school,” Kerr said. “But rather than build everything from the ground up, the university decided to partner with an existing company to run the school. It’s been a positive experience.”

To read the article at its original location: https://www.aamc.org/newsroom/reporter/december2011/268878/childcare.html

 

Academic Medicine Explores ACO Model

Published in the December 2011 AAMC Reporter

By Whitney L.J. Howell

The release of the Centers for Medicaid and Medicare Services (CMS) final rule on accountable care organizations (ACOs) in October is helping some AAMC members take a second look at ACOs. Experts are debating whether the final rule, which excludes indirect medical education payments from the shared-savings mix, will help academic medical centers embrace the ACO model.

In an ACO, a network of doctors and hospitals will share responsibility for providing patient care to a minimum of 5,000 Medicare beneficiaries for at least three years. CMS begins accepting applications for the Medicare Shared Savings program in January.

If the U.S. Supreme Court rules that the health reform law is unconstitutional, ACOs and shared savings could become irrelevant. However, many in academic medicine are proactively aligning resources to provide services in quality-focused, collaborative ways to control costs. For some, that means launching multi-disciplinary, patient-centered care centers. For others, changes include integrating health information technology or adding “total health” courses into curricula.

There is no cookie-cutter approach to adopting the ACO model. Academic medical centers must identify strategies that work best for them, but it will be challenging, said Scott Berkowitz, M.D., M.B.A., Johns Hopkins Medicine’s accountable care medical director.

“There will be cultural and financial obstacles,” he said. “But academic medical centers have a golden opportunity to create value in the post-reform era through providing exceptional patient-centered care, engaging in the science of care delivery to supplement more traditional research, and by educating the next generation of health care leaders.”

Johns Hopkins is still reviewing the Shared Savings program but has improved care quality in recent years through several initiatives. The institution expanded its community physician group to more than 250 doctors, including many to augment patient access to both preventive and follow-up care, Berkowitz said.

There are, however, academic leaders who doubt their centers can achieve the ACO model, said John Kastor, M.D., a professor at the University of Maryland School of Medicine. In a February New England Journal of Medicine perspective, Kastor reported that of 37 senior faculty he surveyed nationwide, most believe the ACO structure will prevent care coordination and cost savings.

“Of the people I interviewed, none has figured out how to make this concept work at their center,” Kastor said. “Medical school deans and hospital CEOs often report to different people. Clinical departments tend to be in silos, and training students takes time. These issues will hamper an institution’s ability to form a successful ACO.”

Changing characteristics of teaching hospitals, including paring down didactic resources, to cut costs requires a significant culture shift, he said. But not all would be beneficial. According to AAMC, siphoning money from educational efforts to achieve savings—such as indirect medical education payments—undermines academic medicine’s tripartite mission.

“In our philosophy, these payments are for education and care of the uninsured,” said AAMC Chief Health Care Officer Joanne M. Conroy, M.D. “Excluding them from savings calculations prevents negative impacts on patients, and it stops any gutting of our care system or educational programs.”

However, the onus now weighs heavily on teaching hospitals and health systems to identify cost-saving strategies and demonstrate that they work.

“It’s still a tough road,” Conroy said. “It’s a complex rubric. Academic medical centers must drill down quickly to see what will be successful.”

For Greenville Hospital System University Medical Center in South Carolina, success is already here. According to chief medical officer Angelo Sinopoli, M.D., Greenville began working toward collaborative care nearly seven years ago and first tested the ACO model on its 17,000 employees. Using a $2.7 million Duke Endowment grant, the institution increased preventive care for employees and provided case managers for the sickest patients. The result was a 26 percent drop in emergency department visits and a 55 percent decrease in hospital stays.

The true key to success, Sinopoli said, was when hospital administrators offered on-site health care services to area businesses.

“It was part of our system change. We took our wellness programs to them,” he said. “Depending on the organization’s size, there is a nurse practitioner or physician there to provide a continuum of care, give high-risk patients health education, and eliminate social barriers to care.”

Having a Greenville-affiliated provider in the workplace gives patients more than the typical 20-minute doctor’s visit. They also have access to social workers, case managers, and practitioners who address their needs between appointments.

Achieving this goal was difficult. According to Sinopoli, Greenville faced two challenges when creating its collaborative-care environment. It took 10 years for physicians to embrace the model. The concept is foreign, he said, because physicians train as individuals and are not accustomed to working in teams.

The medical center also purchased health information technology to track accurate patient data, integrate it between sites, and make it readily available to providers. Along with an electronic health record system, the medical center installed a data warehouse so practitioners can mine existing data.

The institution is a newcomer to academic medicine, having joined South Carolina’s University HealthSystem Consortium in 2006, but it pivoted easily to train students about team-based care.

“Our curriculum and students are oriented to total health,” Sinopoli said. “Instead of teaching just the biochemistry of heart failure and what drugs treat it, our curriculum teaches how to coordinate care for a congestive heart failure patient and what resources and evidence-based practices can keep that patient from being readmitted.”

Greenville is still considering whether to apply for the Medicare Shared Savings program, he said. Regardless of the institution’s eventual route, Sinopoli said one thing is certain: Leaders in academic medicine must continuously promote culture change to create a true shift toward patient-centered care.

To read the article at its original location: https://www.aamc.org/newsroom/reporter/december2011/268852/aco.html

 

Life After Residency: Be Nice, Brush Up on Business, Go High-Tech

Published on the Dec. 6, 2011 DiagnosticImaging.com web site

By Whitney L.J. Howell

Over the past 20 years, not only has clinical instruction during radiology residency changed, but so has the practice life that comes after it. Even as a growing number of medical students select radiology as a specialty, practice-setting preferences have shifted for your younger colleagues. They also have a different set of priorities to consider.

Unlike generations past, most radiology residents don’t transition directly into practice. Almost all continue on to fellowship training, preparing themselves for sub-specialty practice. The extra training prepares young practitioners for clinical care, but it does little to get them ready for the realities and complexities of day-to-day practice.

“As an industry, radiology doesn’t do enough to prepare our residents,” said Keith Smith, MD, former director of the radiology residency program at the University of North Carolina at Chapel Hill School of Medicine. “Largely, residents are very focused on passing their board exams and have very little mental energy left for other things. We do talk about life in private practice and billing and documentation, however.”

And, from those conversations, he said, it’s appears that the majority of radiology residents are forgoing private practice for the security of an employment position with a hospital or larger physician practice.

Be Cordial and Cooperative

After residency, the first priority for new practitioners must be changing how their view relationships with referring physicians, Smith said. Residents often maintain an “us versus them” mentality, fostering contentious interactions.

“Many residents look at requests for service from other departments as additional burdens,” he said. “They react with dread when asked to do things when, once they’re out in practice, they begin to see it as a paycheck. Having a good working relationship with referring physicians and understanding their needs can be very helpful.”

Ben Huang, MD, a UNC radiologist who finished residency in 2005, said he once viewed requests from referring physicians as a waste of his time. As an attending today, however, he appreciates the need for collegiality between radiologists and other specialties.

“When I was a resident, I tended to be more obstructionist,” Huang said. “I let the attendings make the final calls, so it didn’t matter if I were diplomatic with the referring physicians.”

But cultivating relationships with referring physicians has been advantageous for him. Primary care providers and other physicians have gotten a clear sense of who he is as a radiologist over time and are comfortable sending their patients to him for diagnostic imaging services. This is increasingly more important as radiologists are becoming a more involved partner in patient care, advising on image appropriateness, a new role spurred by healthcare reform and patient safety initiatives.

To read the remainder of the article: http://www.diagnosticimaging.com/practice-management/content/article/113619/2001863

 

‘Affective Meaning’ in Arabic

Published in the Fall 2011 Gist From the Mill (Duke University Social Sciences Research Institute)

By Whitney L.J. Howell

Stop for a moment, and think about mothers. What image pops to mind? What emotions does that word evoke?

Now consider whether someone from another country and culture would respond the same way. There’s a chance they won’t – but why?

It’s this question that fuels Lynn Smith-Lovin’s research. Her previous work has decoded the answers for societies in China, Japan, Korea, and Germany. Now, with one to five years of funding from the Office of Naval Research (ONR), she’s turned her focus to providing the same clarity for Arabic-speaking cultures.

Smith-Lovin began applying Charles Osgood’s affective control theory — developed in the 1950s to determine how individuals respond cognitively to outside actors and stimuli — to Arabic-speaking populations in October 2010. With faculty and doctoral student collaborators from the sociology department, as well as researchers from Indiana University and the University of Georgia, she developed a survey to collect data from this group.

“We’re using the affective control theory to look at how ethnic groups perceive various social situations. From prior research, we know cultural knowledge is acquired and imprinted through a lifetime of experiences,” said Smith-Lovin, a sociology professor in Duke’s Women’s Studies Program, describing her basic research that will be unclassified and available to all future investigators. “Cultural meaning is a stable feature, and it tells us a lot about social interactions in a society.”

The study population had varying levels of education, ranging from Iraqi refugees to Egyptian professionals who worked in Research Triangle Park. Overall, 33 native Arabic speakers from the Triangle area participated in the eight-part, 200-scenario pre-test, and they offered initial reactions to various situations, such as a mother comforting or striking a child.

For even greater detail, participants rated the interactions based on three additional dimensions: evaluation (how good or bad a scenario or its actors are), potency (strength or weakness), and activity (liveliness or passivity).  To date, very little research like this exists around the Arabic language.

“If we were to find in the pre-test that Arabic speakers tended to see good actors as powerful and bad actors as weak, that would a cultural feature of real importance,” Smith-Lovin said. “We’re aware much military work involves interacting directly with local populations, and having knowledge like that could help soldiers determine who is and isn’t a friend.”

The results and analysis will enhance the military’s cultural training methods, according to Kim Rogers, a sociology doctoral student working with Smith-Lovin. Soldiers in any Middle East combat theater could use the survey’s details to improve interactions with local populations and augment cultural sensitivity to avoid any potential problems from cultural misunderstandings.

In additional to the impact on military activities, studying social interaction and implications in Arabic-speaking societies is valuable because the language has ranked among the top 10 most widely spoken tongues globally for the past 15 years, according to the Summer Institute for Linguistics Ethnologue Survey. There are four distinct dialects within Arabic, and Smith-Lovin’s team has tried to address them all.

Jen’nan Read, one of Smith-Lovin’s sociology faculty partners, agreed studying the Arabic language and how its native speakers respond to social situations will bolster the safety of U.S. military personnel abroad.

“Anything we can do to ease the tasks of the military will be a benefit. We’re giving them a tool they can use so they won’t feel so vulnerable in what is clearly a hard role,” Read said. “By helping them understand these affective meanings, we’re making their work with another culture less of a leap.”

As an expert on American Muslims, Read leveraged her strong ties with this community in the Triangle to explain both the importance and the legitimacy of the research. Many Muslim and Arab-speaking groups often fear outside requests are facades engineered to extract and abuse private information. So, her involvement was imperative because these groups trust her.

“The Arabic speakers who participated in the pre-test were happy to do it because they often feel overlooked since most people don’t know who or where they are,” she said. “It’s important to understand how perceived meanings and culture can help identify if there are differences between groups.”

Despite all Smith-Lovin and her colleagues have gleaned so far, the survey still isn’t in its final form – plans exist not only to perfect it for Arabic-speakers in the United States, but to also design a survey for international use. The process to create a questionnaire that provides accurate, clear feedback hasn’t been simple, said Mary Hovespian, assistant professor of sociology and native Arabic speaker.

The Arabic language has many dialects, and the survey team wasn’t able to query speakers of each dialect, such as Palestinian territory residents, before designing and writing the survey. This is where Hovespian’s expertise came in.

“We had to make sure what was said in the survey was really what was understood by generic Arabic speakers,” Hovespian said. “We had to back-test how the scenarios were written. I met with [Smith-Lovin], who wrote the scenarios in English, to determine if what they were trying to test was actually what was coming through to the participants. And, in some cases, we did have miscommunication.”

Hovespian spent nearly a week translating and checking the survey. During this time, she identified many unclear or incorrect terms that have since been modified to convey the proper meaning.

As the team looks to expand its research to other Arab-speaking countries, such as Lebanon, Morocco, and Tunisia, they are revamping the survey scenarios to ensure they have a good measurement instrument.

“We are hoping our collaborators in the Arab-speaking countries will help us navigate the dialect issues,” Smith-Lovin said. “We are looking for a better sense of the degree to which shared reactions are the same across the Arabic language and whether they change over time.”

To read the article in the original publication: http://issuu.com/ssriduke/docs/fall2011/15