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

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

 

A healthy start to life

Published in the Fall 2010 UNC-Chapel Hill Gilling School of Global Public Health Alumni Magazine: Carolina Public Health

By Whitney L.J. Howell

For 30 years, the number of overweight children has crept higher and higher. In 2008, the Centers for Disease Control and Prevention reported 10 percent of children ages 2 to 5 had an unhealthy body mass index. Those children have a 70 percent chance of being overweight or obese adults.

Establishing good health habits early can reverse this trend and help children have healthy lives. The UNC Gillings School of Global Public Health leads the fight against the obesity epidemic and promotes healthy behaviors locally, nationally and globally.

“Combating obesity is a key strategic area for the School,” says Peggy Bentley, PhD, nutrition professor and the School’s associate dean for global health. “UNC is playing a major role in obesity research. We have faculty and graduate student expertise from the molecular level through epidemiology, economics, interventions and policy.”

You are what your mother eats

Society’s advice to expectant mothers historically has been to “eat for two.” However, contemporary research shows that eating unhealthy, high-calorie foods during pregnancycan put children at risk for weight struggles and health complications before they are born.

For 15 years, Anna Maria Siega-Riz, PhD, RD, nutrition and epidemiology professor and associate dean for academic affairs at the School, has analyzed prenatal nutrition data to determine which health habits give children the best start in life.

“Pregnancy is a happy moment in life, but it’s also when women are most concerned about the health of their child,” she says. “If they have bad health habits, many women are more likely to modify their behavior, at least in the short term.”

Although most women know to limit weight gain during pregnancy, 60 percent still gain more weight than they should, based on Institute of Medicine recommendations.(Siega-Riz was a member of the prestigious IOM panel that developed those guidelines, available at http://tinyurl.com/iom-guidelines.) Fewer than 25 percent receive guidance from their doctors about physical activity. Making and maintaining behavioral changes is difficult unless women have positive, consistent support.

Siega-Riz’s team uses the Internet, podcasts, chat rooms and cell phones to provide health information and online support for pregnant women. One podcast includes a skit in which four women, all at different parenthood stages, advise an expectant mom about choosing nutritious foods.

Women with healthy habits may avoid having a baby who is too large for gestational age (often leading to C-section births), prevent shoulder dystocia for the baby during birth, and limit the child’s risk for developing diabetes and obesity.

“Women who aren’t eating right or exercising need assistance,” Siega-Riz says. “We must help them find balance and give them all the support they require.”

Choosing healthful foods during pregnancy could reduce the burden of chronic diseases later in life, says Mihai Niculescu, MD, PhD, nutrition assistant professor. Whether the “fat gene” exists is debatable (see page 14), but Niculescu’s epigenetic work – research that determines how outside influences alter our DNA – shows that high-fat diets and maternal obesity in mice alter DNA, shutting down some genes and accelerating others. Developmental brain delays in offspring are the result.

When maternal obesity exists, the neurons in mouse fetal brains at 17 days of pregnancy appear less developed, according to Niculescu’s observations. The implications are worrisome, he says, because the effects are evident after three or four generations.

“This may have profound consequences for an offspring’s life, including his or her mental development and ability to learn,” he says. “A high-fat, less nutritious diet can also create food preferences in unborn offspring that lead them to choose unhealthy foods later in life.”

Open the hangar –here comes the airplane!

Parental influence over children’s nutrition doesn’t end at birth, but little research exists on

Karina Agopian, research assistant at UNC’s Nutrition Research Institute in Kannapolis, works with a toddler to determine what and how much the child has eaten. Research shows that early eating habits influence later food preferences and health outcomes.

what increases obesity risk in children under two. In 2002, Associate Dean Bentley became a pioneer in this area when she launched “Infant Care, Feeding and Risk of Obesity,” a study of strategies used by first-time African-American mothers to feed their 3-month to 18-month-old children.

With National Institutes of Health funding, Bentley recruited 217 mother-child pairs in North Carolina through the Women, Infants and Children program and videotaped them at three-month intervals to identify feeding styles. She and her team identified five styles: controlling, laissez-faire, responsive, pressuring and restrictive. Responsive mothers, she says, are “perfect moms” who pay close attention to and correctly interpret child cues of hunger and satiety. They are very engaged during feeding and may provide verbal and physical encouragement and help, when needed. Other styles pressure or even force children to eat when they reject food or overly restrict the quality and quantity of what children eat, often because the mother is concerned about her child becoming fat.

“Many factors play a role in how we feed infants. However, we believe that it is not just what children are fed, but also how they are fed that makes a difference in the child’s acceptance of food and perhaps in later food preferences and health outcomes,” Bentleysays. “Understanding the role these styles play in growth and development outcome sis a big part of what drives our childhood obesity study.”

Meghan Slining, PhD, nutrition assistant professor, analyzed data from Bentley’s study while she was a UNC doctoral student. Overweight infants – those who measured greater than the 90th percentile for weight versus length – were nearly twice as likely as normal-weight infants to have delayed motor development, Slining found.

“While baby fat may be cute,” Slining says, “it increases the chance that a child could become an overweight adult. We also have seen more immediate consequences to extra pudginess. These children have lower gross motor development.” (See a video about Slining’s research at http://tinyurl.com/slining-baby_fat.)

Add a mother with an eating disorder to the mix, and feeding a child becomes even more complex. Jordan Distinguished Professor of Eating Disorders Cynthia Bulik, PhD, used data from the Norwegian Mother and Child Cohort Study, which followed more than 100,000 Norwegian mothers, some of whom had anorexia or bulimia nervosa or binge-eating disorder, to determine how they fed their children. Bulik followed the mothers from 17 weeks’ gestation through their children’s eighth birthdays.

Although some mothers with eating disorders experienced a reprieve from their conditions during pregnancy, this was not universally the case. In fact, a surprising number of women developed binge-eating disorder during pregnancy. Eating disorders during pregnancy expose babies to erratic eating, Bulik says.

“The impact of roller-coaster caloric intake certainly affects growth and development,” Bulik says. “It could also affect obesity and diabetes risk, as well as the weight trajectory for later in life.”

Mothers with eating disorders also abandoned breastfeeding earlier than did healthy mothers, Bulik says. After giving birth,women with eating disorders often feel they no longer “have a reason to be overweight” and choose not to consume adequate calories to support breastfeeding. Bulik’s study also shows that, as these children grow, they are more likely to develop eating problems, such as having stomachaches, vomiting without cause or not enjoying food.

According to Miriam Labbok, MD, Professor of the Practice of maternal and child health and director of the School’s Carolina Global Breastfeeding Institute, a breastfeeding baby will “stop when full,” but bottlefeeding can overpower a baby’s ability to recognize satiety. When a parent insists that the baby empty the bottle, the child learns the habit of overeating, Labbok says. Additionally, breastfed babies are exposed to the tastes of foods eaten by their mothers. For a formula-fed child, food flavors are new and strange, which could cause the child to be a picky eater.

Employing research to instill good eating habits early is paramount to changing the course of human health, Bentley says.

“It’s harder to intervene and prevent nutrition problems when a child is older. They have preferences and eating patterns that make changes more complicated and difficult,” she says. “But, with the research ongoing at the School, we know we’re leading a positive trajectory of implementing healthy habits early.”

To read the story online: http://www.sph.unc.edu/images/stories/news/cph_2010_fall/documents/a_healthy_start.pdf

Babies tainted by many toxins, report says

Published in the April 12, 2010 Raleigh News & Observer & Charlotte Observer

DURHAM — Surprising as it may seem, the umbilical cord blood of babies born today can have traces of industrial chemicals that were banned 30 years ago, a report says. Their bodies can absorb at least 287 toxic chemicals while they are still in the womb.

Ken Cook is president and co-founder of Environmental Working Group, a nonprofit research and advocacy group. He was in North Carolina last week and discussed results of blood tests his organization conducted in 2004 on 10 American babies.

According to Cook, the EWG test is the first to look at how chemicals used in everyday life affect fetuses, and it shows

Ken Cook, president and co-founder of Environmental Working Group, presented environmental toxins research at Duke University in early April.

that industrial pollution begins in the womb.

Although these substances are present in the blood in minute levels, no research exists, he said, to show even small amounts aren’t dangerous.

“Babies should not be born pre-contaminated,” Cook said. “We must encourage our government to draft policies that require closer looks at the safety of these chemicals. We all need to be held accountable for fixing a broken [environmental health and safety] system.”

Cook presented his findings in a lecture co-sponsored by Duke University’s Nicholas School of the Environment and Earth Sciences and the Comprehensive Cancer Center. The partnership brings together researchers to study links between environmental pollution and public health.

The EWG test identified 212 chemicals and pesticides, including DDT; 28 waste byproducts produced by incinerators; and 47 other substances found in products containing nonstick surfaces such as Teflon or stain shields such as Scotchgard. Many contaminants are known carcinogens, are associated with birth defects, or can negatively affect hormones, Cook said.

Rebecca Fry, an assistant professor in environmental sciences and engineering at UNC Chapel Hill, said the EWG’s study is an important first step, and it calls for larger studies to establish the relationship between environmental contaminants in newborn blood and health outcomes.

“Just because we can measure a chemical in our blood doesn’t necessarily mean there will be a negative health outcome,” Fry said. “It is essential that the government become a partner to foster more extensive research.”

It is known that certain environmental contaminants contribute to problems such as low birth weight.

Christina McConnell, who is 24 weeks pregnant and has an 18-month-old son, said she was shocked by the number of chemicals found in cord blood and was concerned there is no foolproof way to avoid passing harmful chemicals to her unborn child.

“It’s surprising that some of these chemicals could have a big impact even in such small amounts,” she said.

“It’s sad that we can’t protect our families just by changing what we buy or eat and that we have to rely on the government to pass new policies.”

http://www.newsobserver.com/2010/04/12/433034/babies-tainted-by-many-toxins.html#ixzz0kswB4306 or http://www.charlotteobserver.com/2010/04/12/1371154/babies-tainted-by-many-toxins.html

Focus on Palliative Care Education Grows

Published in the July 2004 AAMC Reporter

At the end of a hospital hallway in a dimly lit room, a tired, grief-stricken family huddles close to the bedside of the patient, a husband and father. They listen intently as the doctor tells them the chemotherapy and radiation treatments have failed to eradicate the cancer, and there is nothing more that can be done except to make the patient as comfortable as possible.

Whether the disease is cancer or another fatal condition, hundreds of thousands of people die slowly each year, a nightmare no family wishes to undergo. Even when a patient’s condition is terminal, physicians are still responsible for the patient’s quality of life until he or she succumbs to the illness. In recent years, with the growth of hospice care, more and more families expect doctors to demonstrate good faith efforts in end-of-life care, also known as palliative care.

Across the United States and Canada, several medical schools and researchers have implemented palliative education programs and outlined the characteristics  of effective, compassionate end-of-life care. Students at Mount Sinai School of Medicine in New York learn palliative care methods at the Hertzberg Palliative Care Institute while University of California-San Francisco (UCSF) students study at a new symptom management and palliative care program at the school’s Comprehensive Cancer Center.

“We’ve had a startling and consistent positive response to our program because it’s the first place some students learn how to relieve suffering and are given the knowledge and skills to help these patients,” said Diane Meier, M.D., director of the Hertzberg Institute. “I’ve had one student come up to me and say, ‘Now I feel like a good doctor.’”

Dr. Meier is also a professor in Mount Sinai’s geriatrics and medicine department, as well as the director of its Center to Advance Palliative Care.

Acquiring Compassion

The Hertzberg Institute, which received original funding from the Project on Death in America, integrates palliative care instruction through all four years of medical education in the geriatrics and adult development department. As part of the program, students spend increasing amounts of time with dying patients each year.

During the first and second years, students studying hematology and oncology interact with patients experiencing sever illness, learning how they cope and what they need to be comfortable. Patients who are physically able to speak to classes and tell them about their experiences, both good and bad, with hospital care.

Third-year students complete a mandatory rotation, including six lectures outlining palliative care fundamentals. They form small groups, emphasizing role-playing activities that they discuss later with a faculty member.

J. Andrew Billings, M.D., associate professor of medicine at Harvard University, agreed that providing instruction in proper palliative care is essential throughout medical education. Dr. Billings works in palliative care at Massachusetts General Hospital.

“You have to have the appropriate curriculum in end-of-life care at all levels of education,” he said. “All physicians and clinical areas deal with death and dying, and they need to be familiar with the basics.”

Often  medical students and practicing physicians indicate they are uncomfortable treating dying patients, Dr. Billings said. Some doctors worry ill patients and their families receive substandard care due to the physician’s lack of confidence.

The Hertzberg Institute has taken additional steps to give students more assurance and enhanced palliative education. Fourth-year students can choose to participate in an elective rotation with the Palliative Care Consultation Service. Students see patients first and evaluate them before passing along a review and recommendation to the attending physician.

In addition, beginning this month Dr. Meier said Hertzberg will initiate a new fellowship program for post-graduate hematology-oncology students interested in becoming dually qualified in palliative care. The fellowship provides one-on-one mentoring with national palliative care experts, as well as opportunity to provide care in a variety of settings, including ambulatory center, hospices and nursing homes.

Training students to specialize in palliative care could relieve primary care physicians of palliative care physicians of the palliative care responsibility and improve service for dying patients, Dr. Meier said. Tending to the needs of these few patients sometimes puts a strain on the limited time physicians have.

“Some just don’t have the time as primary physicians to be able to provide palliative care, and their willingness to do it is highly unrealistic,” Dr. Meier said. “But if you have physicians trained in palliative care, they take the pressure off their colleagues. So, we’re rounding out the skill set of the whole team.”

Empowering Patients

A team of researchers at the University of Toronto conducted a three-month experiment in 2002 that focused on improving palliative care methods by concentrating on patient comments and needs. Jeff Powis, a fourth-year Toronto medical student, led the project to help physicians improve palliative care based on patient requests for better pain management or symptom control.

During the experiment, Powis functioned as a liaison between 36 families and their physicians, relaying questions, concerns and desires. He said it was his job to ake sure families felt their voices were being heard and to keep doctors aware of patients’ comfort needs.

“Families told me they saw me doing something that needed to be done,” he said, referring to his hallway briefings with physicians. “It gave [the families] a sense of empowerment while I was helping doctors systemize their palliate care.”

By asking patients to prioritize what three things they needed most, such as help with daily activities or improved access to nurses, Powis said he truncated the time doctors spent trying to discover what the patient needs from 30 minutes down to only a few. The three-month trial determined end-of-life care is better when it focuses o patient requests.

Patients and families want someone to listen to their concerns and take action to relieve pain and stress, so teaching students to listen to patients is the most important aspect of palliative care instruction, Powis said. But effective end-of-life care does not rest solely on physicians. It must be a combined effort of everyone involved in healthcare.

Opening Doors

Peter Singer, M.D., University of Toronto professor of medicine and director of the school’s Joint Centre for Bioethics, agreed. The days of shuffling dying patients to the end of a hospital wing have passed, and the time has arrived for doctors, hospital administration and hospital health workers to join in palliative care.

“Talk about improving end-of-life care is cheap,” Dr. Singer said. “You have to make changes to be really effective. If every medical resident spent two weeks doing what [Powis] did, we’d have a generation of physicians appropriately prepared to care for patients and families.”

Toronto is not alone in its efforts to improve palliative care with hands-on involvement. On July 1, UCSF opened the doors to a collaborative effort between its Cancer Center Program in Symptom Management and Palliative Care and the UCSF Comprehensive Cancer Center. The partnership, involving students, a pharmacist, a nurse and a social worker, will share the responsibilities of controlling symptoms and managing pain. The original cancer center program, known as the comprehensive care team, only functioned as a consultative and advisory group for physicians.

Social workers skilled in psychological assessment, communications and support meet with the patients, helping them secure home care services if they need it. But they also discuss the patients’ emotions about dying and try to open communication channels between the sick and their families.

Not everyone involved with end-of-life care is ready to sing the praises of palliative care teams. Some observers believe such groups are detrimental to the movement that advocates greater palliative care training.

Palliative care teams that focus on end-of-life care are hindering the push for palliative care education across the medical industry, said Kerry Bowman, Ph.D., clinical ethicist at Mount Sinai Hospital in Toronto and professor at the University of Toronto’s Medical Joint Centre for Bioethics. Establishing these groups undermines the need for all physicians to have these skills.

“Everything is complicated by creating palliative care teams,” Dr. Bowman said. “If a referral is made to a palliative care worker, then the physician feels as though he’s off the hook. We’re never off the hook.”

But placing students in a team environment where they are faced with dying patients is the best way to teach them the proper

Michael Rabow, M.D., principal investigator for the UCSF collaborative effort between the Cancer Center Program in Symptom Management and Palliative Care and the UCSF Comprehensive Cancer Center.

palliative care skills, said Michael Rabow, M.D., the UCSF program principal investigator. This exposure will also help them face their discomfort with patients who are beyond the reaches of medicine.

“If you look at palliative care as the elephant in the room, the best thing to do is to talk explicitly about the elephant in the room,” he said. “The best thing is not to pretend that something meaningful doesn’t happen through palliative care.”

Palliative care education should exist on two levels, he said. Every physician should have a basic understanding of how end-of-life care can best serve patients. Because the medical community has put a major emphasis on a “good death,” Dr. Rabow said palliative care should also become a specialty, giving patients the opportunity to choose a palliative care expert as they approach death much as they would select a cardiologist for heart surgery.

Before beginning any palliative services, UCSF program participants assess the patients during any treatment they receive to find out what additional services they might need, such as sessions with a social worker. Palliative care can be much more effective if the groundwork is established early rather than postponed until death becomes inevitable, he said.

Patients also have the opportunity to express their emotions and frustrations through art. Rabow’s palliative care team includes a clinical artist trained to assist dying patients with their emotional needs. The artist, who is also a cancer center staff member encourages patients to articulate their feelings through pictures giving them a unique outlet to channel their fears.

“Often, patients will draw something that they might not actually say directly,” Dr. Rabow said. “But the pictures can be used to begin a conversation that might not have happened otherwise, and patients and families will begin to connect with their emotions.”

The Hertzberg Institute and the University of Toronto’s Joint Centre for Bioethics are part of a small cadre of academic institutions beginning to recognize the importance of improved palliative care in both countries. With too many students receiving far too little  in this type of medical treatment, current practitioners must prepare the next generation of physicians to care for dying patients. While palliative care may not carry a high profile, dying with dignity is an important component of the medical ethos,” Dr. Bowman said.

“End-of-life care is not sexy. You’re not going  rich, you’re not going to become famous,” he said. “If you’re looking for fame and wealth, there are sexier areas, but the public is demanding better palliative care. They’re asking for more humane, comprehensive, inclusive medical care.”

Pediatricians Becoming Scarce in Select Areas

Published in the November 2004 AAMC Reporter

When  Cheryl Pflueger’s contractions started four months before her due date, she traveled from her home in Brookings, S.D., to the Sioux Valley Children’s Hospital in Sioux Falls for preemptive steps that could halt early labor. The measures did not work, and Pflueger’s son Ben was born 16 weeks early, weighing 1 pound, 10 ounces.

Doctors immediately put Ben on a respirator designed specifically for the smallest infants, and Pfleuger and Sioux Falls special equipment for premature babies and pediatric specialists saved her son’s life.

“I have no doubt that if he’d been born in Brookings, he would not be here,” she said. “At the time he was born, we only had one pediatrician in Brookings.”

For the next three years, Pflueger, her 2-year-old daughter and Ben drove the one-hour trek between their hometown of 15,000 people and Sioux Falls many times for Ben’s follow-up appointments with eye doctors, hearing specialists and physical therapists. Pflueger’s husband often could not take time away from work, so the family was frequently separated. Traveling for medical treatment created a financial burden, as well.

“It would be great if we had these pediatricians within a short distance so all babies could get the best follow-up care,” Pflueger said. “It’s tough on some parents with the expense of driving, possibly staying overnight and then paying the bills for the doctors and specialists.”

Thousands of parents face similar problems each year when searching for healthcare for their children simply because they choose to live in less populated areas of the United States. The supply of general pediatricians is adequate and even growing in some parts of the country, according to several reports, but rural locations suffer from a scarcity of pediatric sub-specialists. And the problem is mounting.

Growing Without Spreading

From 1978 to 2000, the pediatrician population ballooned by 140 percent, according to a recent study by Gary Freed, M.D., a professor at the University of Michigan School of Public Health. This increase means the number of pediatricians per 100,000 children more than doubled from 49.8 to 106.2 during the period. These doctors, however, are not spread evenly nationwide.

“There is a significant difference in distribution of pediatricians across the country,” said Dr. Freed, who is also director of Michigan’s division of pediatrics. “This is not too say children don’t received healthcare from primary physicians, but this uneven distribution of pediatricians doesn’t provide parents with the choice of whether their kids can receive care from a pediatric sub-specialist.”

Family practitioners often step in to fill th void left by a less robust pediatrician population in smaller cities.

According to the study which was published in Pediatrics, pediatricians flock to more populated states, leading to high pediatrician-to-child ratios in select areas. For example, Massachusetts and New York have 165 and 154 pediatricians per 100,000 children, respectively. Inversely, South Dakota, Wyoming and Idaho have the fewest number of pediatricians per 100,000 children with 41, 35 and 28, respectively.

Visits to pediatric sub-specialists jumped substantially, as well. Children visit pediatricians for roughly 4.5 percent of their appointments, an increase of 2.9 percent since 1980.

Strategic Locations

The promise of higher income, more professional opportunities and increased social interactions drive pediatricians to settle in highly populated states. Dr. Freed said., leaving other states with a fraction of the physician workforce needed to effectively treat children. However, there is no data showing where pediatricians choose to locate.

The shortage is often a result of uneven geography of pediatric education in medical schools. Between 10 percent and 15 percent of medical school graduates each year pursue pediatric residencies, but not all states offer programs in the field. For example, the University of South Dakota School of Medicine does not have a pediatric residency, prompting, on aver, five to seven of its 50 students to leave the state each year, according to Lawrence Fenton, M.D., chair of South Dakota’s pediatrics department. Most graduates do not return after completing their residencies, but individuals who do are often general pediatricians.

“The challenge isn’t the general pediatrics, it’s the pediatric sub-specialties,” Dr. Fenton said. “Our sub-specialty care needs are huge. We’re the only tertiary care center for 250 miles, and it’s important that we serve the needs of all children in our patient area.”

Although South Dakota currently has 22 faculty members trained in various pediatric sub-specialty areas, between 15 percent and 20 percent will retire within the next decade. It will be difficult for South Dakota to entice younger specialists to come to a rural location when there is a desperate need for their services nationwide, Dr. Fenton said.

Michael Anderson, M.D., chairman of the American Academy of Pediatrics (AAP) workforce committee, agreed. Despite the growing pediatric sub-specialist population, such doctors are likely to remain within or close to academic medical centers because that is where they receive their core support. This concentration is a roadblock to easy healthcare access and only exacerbates the shortage problem in rural areas.

“For families who live in less populated areas, the fact that sub-specialties aren’t around can be devastating,” Dr. Anderson said. “Families in underserved areas are at a significant disadvantage because it is difficult to coordinate the amount of services some children need.”

Because of the shortages, some children go without medical attention, Dr. Fenton said, and this problem because visible when a sub-specialist finally moves into town and is immediately swamped with patients.

Recruiting Difficulties

Attracting new pediatricians, especially sub-specialists, to smaller areas could continue to be a struggle, though, said Richard Pan, M.D., MPH, associate residency director of pediatrics for the University of California, Davis. Pediatric students find residency positions mostly at larger medical schools in urban areas, and approximately 40 percent stay in the area to practice. Salary is also a factor, Dr. Pan said, noting that pediatricians’ already low compensation makes moving to rural, less affluent locations even more unappealing.

Other lifestyle factors contribute to the decision to stay in larger cities. Many residents consider their spouse’s career options, whether their children will receive a quality education in smaller city and the question of how a heavier workload due to fewer colleagues might affect their schedules.

“Residents view this decision as a serious  and significant issue with regard to lifestyle,” Dr. Pan said. “These are personal decisions that guide their career decisions.”

Marianne Felice, M.D., chair of pediatrics at the University of Massachusetts Medical School, echoed Dr. Pan’s thoughts, noting only a select few doctors can sustain the stress of being perpetually on-call because no other pediatricians are in town. Higher salaries and insurance reimbursement rates in large regions help to cover medical school debt, as well.

However, Dr. Felice pointed out that it is likely that not all pediatricians counted in Dr. Freed’s study are currently treating many patients. Although they are all licensed physicians, some could be faculty members or researchers, thereby lowering the actual pediatrician-to-child ratio in Massachusetts and other states with a large supply of pediatricians.

According to Scott Shipman, M.D., assistant professor of pediatrics at Oregon Health & Sciences University School of Medicine, budding pediatricians could have difficulty finding the job hey want in a larger city. The higher concentration means they may find themselves competing for a position they would not normally consider.

“There’s significant evidence in pediatrics to show there are fewer jobs available in populated areas,” Dr. Shipman said. “New graduates make sacrifices to stay where they are. They might be working weird hours or where they may not eventually settle down to practice.”

Offering Incentives

There are, however, measures the medical community can employ to i,prove the supply of general pediatricians and sub-specialists in rural locations. Even though it is unlikely that scores of these physicians will choose to relocate in the next few years, medial treatment can still reach children through telemedicine, said AAP expert Dr. Anderson. Not all services will be available through this method, but it could alleviate part of the problem.

Dr. Anderson said additional incentives are needed to entice new pediatricians to forgo a more affluent socially active lifestyle and practice in smaller locations. To draw more physicians in, hospitals could offer to pay off medical school debt if the pediatrician moves into the area.

Just as medical schools contribute to the uneven geographic distribution of pediatricians by virtue of their location, the schools can also help turn the tide to increase sub-specialist supply in the more rural areas across the country, according to Dr. Pan. Discussing the needs of underserved communities and encouraging students to practice there is not enough to improve rural medical care. Medical schools must consider this issue at the admissions phase.

“Medical schools need to look at who they are admitting overall,” Dr. Pan said. “It would be preferable to admit people from underserved or rural communities initially because they are more likely to go back there because they’ve lived there, know it and like it.”

Movie Review: Elf — Recapturing the Christmas Spirit

Published in the December 2003 AAMC Courier

For the past 10 years, at least, I’ve been going to the theaters during the holiday season, hoping to see a movie that recaptures the Christmas spirit I saw in films when I was a child. Needless to say, I’ve had none such luck. Lately, it seems that Hollywood no longer views Christmas as a time of good-natured cheer and family togetherness.

Although I’ve thoroughly enjoyed both Harry Potter and both Lord of the Rings movies (as have many of you) they just don’t fit into the mold of what I grew up expecting from a holiday-time movie. But, this year is different. This year, I met Buddy.

Buddy, played by former Saturday Night Live cast member Will Ferrell, is the central character of director Jon Favreau’s latest movie Elf. As an orphan who mistakenly climbs into Santa’s toy sack years ago, Buddy grows up in the North Pole, and despite his enormous size for an elf, epitomizes the warmth and good-cheer we expect from Santa’s little helpers.

Perhaps best known for his striking impressions of President George W. Bush or his antics as Craig, the awkward, sweaty Spartan cheerleader, Ferrell manages to portray a beautiful child-lie innocence as his character travels via iceberg to New York City in search of hi birth father, Walter, played by James Caan. Caan is also well cast as a hardened book publicist, neglectful of his other young son Michael and none-too-thrilled with the prospect of bringing the “elf” he never knew existed into his life.

At first glance, you may roll your eyes and groan, thinking this is another sappy, syrupy-sweet flick (though Buddy puts syrup on everything — including spaghetti) that runs the formula for a warn-hearted Christmas movie into the ground. But, it’s just not so. Ferrell’s grown-up spin on childish humor and the fact that we’re not left to languish on any sentimental moments sweeps both you and the movie along.

Overall, though, the main draw of Elf is its child-friendly qualities. Though some mild crude language is interspersed in the dialogue and some toilet humor is included, the “offenses” are so minor that they almost slip right by you without even being noticed. Of course, if you have small children, you might want to think about for how many days they would find a very long, loud belch hysterical.

The humor in this movie is simple. Buddy has never been in human society before, so he’s astounded by everything — cars, the tall buildings, revolving doors and even a coffee shop’s claim that it serves the “World’s Best Cup of Coffee.” Simple of not, Ferrell brings the humor alive on the screen in a way that is fun (and funny) for both kids and adults alike.

Other than cartoon-type trips, falls and scuffles, there is no violence to speak of in this film. There is no gore, and the closest we get to bloodshed is the finger-prick Buddy undergoes to have a DNA test in the doctor’s office. There is also no home for sexual content in this movie. Buddy meets his love interest Jovie, an elf at the department store Gimbel’s where Buddy accidentally lands a job. We see one innocent kiss in the movie — and you can count on hearing no overt sexual innuendo.

Now, don’t get me wrong, no movie is perfect. This one, despite its “feel-good” qualities does ask you to stretch the outer boundaries of your imagination a bit. Truly, what is the likelihood that an elf, who ultimately ends up saving Christmas could safely make his way to the Bi Apple on an iceberg? Is it possible for a human to survive on a diet of confections and still look not-so-bad in green tights? Favreau asks you to take a leap of faith to believe that Walter’s wife (Mary Steenburgen) would so gladly take in her husband’s illegitimate son and treat him as her own. But, for this movie, it seems to work, if for no other reason than you want it to.

Ferrell and Favreau prove that you don’t need curse words or suggestive dialogue to entertain and transport your audience for an hour and a half. It can be done with a kind-hearted storyline and a sincere desire to recapture the wonderment you felt as a child during the Christmas season. Amidst the other epic tales on the big screen this year, those that depict war or struggles between good and evil or even those that strive to thrill rated-R audiences, Elf will assuredly be the bright, shining star. You can take your family to this movie and walk away smiling and feeling good about everything — I did.

Running for the Cure

Published in the June 2004 AAMC Courier

As I stood at the corner of Ninth Street and Constitution Avenue at 7:20 a.m., I found myself surrounded by a sea of white T-shirts with more than a few waves of pink. A light rain drizzled down, occasionally giving way to a harder pelt, and the temperature was an unseasonably cool 65 degrees. But the overcast skies, water and chill hadn’t kept the crowd of nearly 60,000 at home.

Instead, thousands covered in light rain parkas or bedecked in spandex running shorts stood in the middle of the street, stretching their muscles — they were preparing to start the 5K National Race for the Cure. And this year, I was one of them.

During childhood, I stood at the finish line, waiting for my father to cross. In my closet, I have shirts from almost every race he finished — the Peachtree Road Race in Atlanta, the Cooper River Bridge Run in Charleston, S.C. or any March of Dimes Race. But I’d never laced up my own sneakers to run.

This June 5 was different, though. Not only had my father surprised me and traveled nine hours to run with me, but we had a reason to run through the middle of Independence Avenue. My mother is a breast cancer survivor, and we ran in her honor.

So, at 8 a.m., we started our run down the Mall, back up in front of the Air and Space Museum, over and back across the Tidal Basin and partly up 15th Street. In a little over a half hour (though the time doesn’t matter), we crossed the finish line, marking two important moments — our first father/daughter race and our first contribution to the fight against breast cancer.

Since the 1940s, the incidence of breast cancer has risen in the United States by 1 percent each year. The numbers are only now beginning to level off. Still, roughly 216,000 American women will be diagnosed in 2004 alone. However, screenings and education programs have drive the mortality rate down, even though occurrence is still high.

Every year since the early 1980s, the Susan G. Komen Breast Cancer Foundation raises tens of millions of dollars to fund research for a cure. Each year, up to 75 percent of funds raised remain in the local communities, supporting educational and outreach programs, as well as screenings for underserved women. At least 25 percent goes to the Foundation, founded in 1983, to back breast cancer research, meritorious awards and scientific programs around the world.

Last year, in D.C. alone, thanks to more than 61,000 participants, the foundation raised more than $2.6 million, and $1 million of that remained in our area to treat local women. That’s a long way to come from the race’s humble beginnings here in the nation’s capital.

The first Race for the Cure in the District occurred in 1990. Former Carter White House Social Secretary Gretchen Poston, Marilyn Quayle  and Washington Post fashion editor Nine Hyde spearheaded the project and gathered roughly 7,500 people and almost $500,000 for the cause.

The way the Foundation has grown in the past 20 years is proof that one person can start a snowball effect that changes the lives of thousands of other people. Nancy Brinker launched the race in 1983 to honor a promise she made to her sister Susan Komen. Before losing her three-year battle with cancer, Komen asked her sister to do everything she could to further breast cancer research and to educate women about the deadly disease. Brinker started fundraising with the first race in Dallas. It had only 800 participants. Today, Race for the Cure is the largest 5K race/walk in the world.

Judging by this year’s turnout, the event will only continue to grow in size. Each year, more and more survivors don their pink shirts, identifying themselves as the ones who beat the disease, and join the thousands in support of those still suffering. While seeing more pink shirts means doctors are diagnosing and treating breast cancer earlier, there are many, my family included, who look forward to the day when the Komen Foundation has reached its goal of finding a cure.

Aggressive Breast Cancer in African-American Women: Investigating the Genetic Link

Published in the 2009 University of North Carolina at Chapel Hill School of Nursing Research Chronicle

African-American women experience less breast cancer than women of other ethnicities. However, the breast cancers these women develop are often more invasive and aggressive. Assistant professor Theresa Swift-Scanlan is investigating the reasons behind this disparity and believes the answer lies in understanding epigenetic modifications to women’s DNA and how they are affected by lifestyle behaviors and environmental exposures. Epigenetic modifications are molecular level changes that alter gene expression without altering the primary sequence of DNA.

According to Swift-Scanlan, African-American pre-menopausal women are more likely than women of other ethnicities to develop basal-like breast cancer, a tumor subtype that does not have receptors for estrogen or the growth factor Her2. Basal-like tumors are resistant to effective therapies that target these receptors, such as tamoxifen and herceptin. The end result is that these tumors are very difficult to treat and are associated with increased morbidity and mortality.

According to previous data, Swift-Scanlan said, basal-like tumors occur in white women and other ethnic groups at all ages, just at a lower frequency than in African-American pre-menopausal women. Differences in the frequency of this tumor subtype appear to be due to varying distributions of risk factors

Asst. Prof. Theresa Swift-Scanlan conducting research into the epigenetics of breast cancer in her research lab.

across ethnic groups. Risk factors for basal-like tumors include not breastfeeding and larger waist-to-hip ratios. Unlike other breast cancer subtypes, having more children at a younger age appears to increase rather than decrease risk for basal-like breast cancer.

The Susan G. Komen Foundation awarded Swift-Scanlan a three-year, $450,000 Career Catalyst in Cancer Disparities Award to study gene methylation in basal-like breast cancer and four other tumor subtypes. The grant funds her efforts to determine whether DNA methylation – which can silence genes by changing the way the DNA is packaged within the cell – in concert with facts known about breast cancer subtype risk factors, could unearth ways to reduce mortality from the disease among African-American women. She also has funding through a National Institutes of Health Career Development Award.

Swift-Scanlan also hopes to identify genes that, when methylated, could contribute to early disease detection and risk assessment for all women.

“I hope that this research will help women in the decision making process,” she said. “Deciding what to do after a breast cancer diagnosis is a very personal and profound choice. Having this knowledge could help providers assist women in making the best decision for them while avoiding the problem of over- or under-treating the disease.”

Swift-Scanlan will analyze breast tissue samples and clinical data from at least 160 African-American women enrolled in the Carolina Breast Cancer Study, 80 of whom are pre-menopausal and 80 who are post-menopausal. Her main collaborators are genetics associate professor Charles Perou at the Lineberger Comprehensive Cancer Center and epidemiology professor Robert Millikan at the School of Public Health.