Category Archives: Voices from the Field
Richard C. Lindrooth, PhD, is an associate professor at the University of Colorado Anschutz Medical Campus. Olga Yakusheva, PhD, is an associate professor of economics at Marquette University. Both are grantees of the Robert Wood Johnson Foundation’s Interdisciplinary Nursing Quality Research Initiative.
The Institute of Medicine (IOM) released the findings of its Committee on the Learning Health Care System in America in a report entitled “Best Care at Lower Cost: The Path to Continuously Learning Health Care in America”[i] in September, 2012. The report recognized that the complexity of clinical decision-making is rapidly increasing and that clinicians need to continuously update their skills in order to keep up with (1) rapidly expanding diagnostic and treatment options and (2) the increasingly complex and chronic clinical condition of patients. Given the growing external demands placed on nurses, the IOM reports that a critical determinant of the success of an organization in dealing with these demands is how “a learning health care organization harnesses its internal wisdom—staff expertise, patient feedback, financial data, and other knowledge—to improve its operations.”
Nurses in particular are in an excellent position to play a central role in creating a virtuous feedback loop such that it is feasible to continuously adjust and incrementally improve systems in response to rapidly changing external demands. The report, supported by the results of a growing and increasingly robust body of academic research, stresses the important role of leadership and management in fostering and maintaining an environment within which continuous learning could take hold.
Ryan Greysen, MD, MHS, is an alumnus of the Robert Wood Johnson Foundation (RWJF) Clinical Scholars program, and an assistant professor of medicine at the University of California, San Francisco (UCSF), Division of Hospital Medicine. He works closely with the Global Health Hospitalist program at UCSF to help train fellows and conduct research in quality improvement for hospitalized patients in developing settings. Phuoc Le, MD, MPH, is an assistant clinical professor of medicine and pediatrics at UCSF. He co-directs the Global Health-Hospital Medicine Fellowship at UCSF, directs the Global Health Pathway for the Pediatric Residency, and is director of international rotations for the Internal Medicine Residency.
U.S. medical education has entered a golden era of growth in global health interest and involvement, but surprisingly little is known about global health after training is completed. In 1978, only 6 percent of graduating medical students reported experiences in global health (GH), but today more than 25 percent participate in global health activities during medical school, and 66 percent plan to participate in GH work during their career. Since this "surge" has started with trainees, many of the recent studies on global health work have focused on medical students or residents.
Interestingly though, we have much less information on what happens after the trainees become full-fledged physicians. Do they continue to engage globally either as professionals or volunteers? If so, do they focus on clinical work, education, research, or health policy? We recently conducted a pair of surveys to answer these questions in two specific groups of doctors: those who have received research and leadership training through the longest- program of this kind in the U.S. (the RWJF Clinical Scholars program) and those who have joined the ranks of the medical profession's fastest-growing sub-specialty: hospitalists.
Beverly Malone, PhD, RN, FAAN, is chief executive officer of the National League for Nursing (NLN). She was recently elected to the Institute of Medicine. Last month, the NLN announced the launch of Accelerating to Practice, a new program designed to help new nurses move more seamlessly from education to practice. It is the inaugural program of the NLN's Center for Academic and Clinical Transitions.
Human Capital Blog (HCB): Why is Accelerating to Practice needed?
Beverly Malone: We've always known that there is a difference between how nurse educators view graduates of nursing programs and how nursing directors view graduates. But we never knew how deep the divide was. A recent survey showed that 90 percent of educators thought that nurse graduates were doing just fine, but almost 90 percent of directors felt that nurse graduates did not have the skills that were needed to practice. That kind of a divide is not a small one. It has so much to do with how care is delivered, and the League felt compelled to do something about it.
HCB: What explains the divide?
Malone: We don't talk enough to one another. There are some exemplars out there where educators and administrators are on the same wavelength, and they have worked very hard to ensure that graduates are prepared in a way to move quality patient care forward. But overall, that's not the picture throughout the United States.
Gretchen Hammer, MPH, is executive director of the Colorado Coalition for the Medically Underserved. She works with local and state health care leaders and policy-makers to improve Colorado’s health care system.
Healing is both an art and a science. On one hand, clinicians are intensely driven by the quantifiable, the measurable, and the evidence-based algorithms that lead to accurate diagnosis and treatment as well as allow us to develop new innovations in medicine. However, healing is also an art. Patients are not just a collection of systems that can be separated out and managed in isolation of the whole patient. Each patient and their family has a unique set of values, life experiences, and resources that influence their health and ability to heal. Recognizing the wholeness and uniqueness of each patient is where the art of healing begins.
Empathy is defined as “the ability to understand and share the feelings of another.” It takes presence of mind and time to be empathetic. For clinicians, finding the balance between the necessary detachment to allow for good clinical decision making and empathy can challenging. This balance can be particularly difficult for students and new clinicians.
Heather J. Kelley, MA, is deputy director of the Robert Wood Johnson Foundation’s (RWJF) Future of Nursing Scholars program. Prior to this role, she was the program associate for RWJF’s Interdisciplinary Nursing Quality Research Initiative and a former vice president in a political advertising firm.
Three years ago, the Initiative on the Future of Nursing at the Institute of Medicine (IOM) set a revolution in motion with the release of The Future of Nursing: Leading Change, Advancing Health report. Among the bold recommendations offered in the report was the call to double the number of nurses with doctoral degrees by 2020.
RWJF recognizes the valuable contributions that PhD-prepared nurse scientists and researchers make in the lives of patients and families. Their discoveries have the potential to change our health care system. However, as the IOM report suggested, we do not have nearly enough doctorally prepared nurses seeking new solutions to ongoing problems. Currently, less than 1 percent of the nursing workforce has a doctoral degree in nursing or a related field.
SreyRam Kuy, MD, MHS, is an alumna of the Robert Wood Johnson Foundation (RWJF) Clinical Scholars program, and a vascular surgery fellow at the Medical College of Wisconsin.
Gallbladder disease, and specifically gallstones, can present as pain in the upper abdomen, usually after eating fatty foods. More severely, gallstones can progress to an inflammation and infection called cholecystitis or cholangitis, both of which require prompt surgical treatment. Gallbladder disease is an important medical problem as it accounts for $650 billion in health care costs annually in the United States[i], making it the second most costly digestive disease in the country.[ii] With more than 700,000 cholecystectomies (surgeries to remove the gallbladder) performed annually in the United States, gallbladder disease is the number one reason for abdominal surgery in the nation.[i] Cholecystectomies can be done with traditional surgery (open cholecystectomy) or performed minimally invasively (laparoscopic cholecystectomy).
The National Health and Nutrition Examination Survey estimates 6.3 million men and 14.2 million women in the United States have gallbladder disease.[iii] It occurs two times more frequently in women than in men.[i][iv] However, during the reproductive years, women have a four-fold higher prevalence of gallstones than men.[iii] As a result of its disproportionate burden on women, gallbladder disease is a critically important topic in women’s health.
There is currently a lack of consensus on whether a patient’s gender affects how soon they get surgery for cholecystitis, what type of surgery they get (open versus laparoscopic cholecystectomy), and how they do after surgery. My prior work and that of my colleagues has clearly shown that older age negatively impacts how patients do following cholecystectomy.[v] Therefore, to determine whether gender, independent of other factors, affects outcome, we examined a national group of patients hospitalized with cholecystitis over an eight-year period, age-matched to account for the effect of age, and identified gender-based differences in patients hospitalized with cholecystitis. We measured outcomes of women compared with men who underwent cholecystectomy during that admission for cholecystitis, and identified factors associated with outcome.
Sheryl Magzamen, PhD, MPH, is an assistant professor in the College of Veterinary Medicine and Biomedical Sciences at Colorado State University and an alumna of the Robert Wood Johnson Foundation (RWJF) Health & Society Scholars program (2007-2009). She recently published two studies exploring the link between early childhood lead exposure and behavioral and academic outcomes in Environmental Research and the Annals of Epidemiology. She discusses both below.
Human Capital Blog: What are the main findings of your study on childhood lead exposure and discipline?
Sheryl Magzamen: We found that children who had moderate but elevated exposure lead in early childhood were more than two times as likely as unexposed children to be suspended from school, and that’s controlling for race, socioeconomic status, and other covariates. We’re particularly concerned about this because of what it means for barriers to school success and achievement due to behavioral issues.
We are also concerned about the fact that there‘s a strong possibility, based on animal models, that neurological effects of lead exposure predispose children to an array of disruptive or anti-social behavior in schools. The environmental exposures that children have prior to going to school have been largely ignored in debates about quality public education.
Promoting Rigorous Interdisciplinary Research and Building an Evidence Base to Inform Health Care Learning, Practice, and Policy
By Mary D. Naylor, PhD, RN, FAAN, Marian S. Ware Professor in Gerontology, director of the NewCourtland Center for Transitions and Health at the University of Pennsylvania School of Nursing, and co-director of the Robert Wood Johnson Foundation’s Interdisciplinary Nursing Quality Research Initiative. This commentary originally appeared on the Institute of Medicine website.
The Institute of Medicine (IOM) established the Roundtable on Value & Science-Driven Health Care to accelerate the advancement and application of science to achieve the best possible health and health care outcomes and value for Americans. The work of the roundtable is predicated on the notion that our health care system must continuously learn from rigorous evidence in order to innovate and improve. To that end, it acknowledges and promotes the importance of identifying best practices in health and health care, developing and testing innovations, and—most importantly— promoting collaborative efforts.
This vision for improving health and health care is shared by the Robert Wood Johnson Foundation, which funds an innovative and unique initiative to improve patient care by examining the role nurses play in improving care quality: the Interdisciplinary Nursing Quality Research Initiative (INQRI). Mark Pauly of the University of Pennsylvania and I have had the great privilege of serving as co-directors of this program since its inception in 2005.
Michelle L. Odlum, BSN, MPH, EdD, is postdoctoral research scientist at Columbia University School of Nursing in nursing informatics. She has more than ten years of experience as a disparities researcher working on a variety of research, evaluation, and health promotion initiatives affecting vulnerable populations. Odlum is a recent recipient of the Robert Wood Johnson Foundation’s (RWJF) New Connections Junior Investigator award.
At this time when our nation’s health care reform is promoting new approaches to primary care, an exploration of health care models from around the globe is essential. With my interest in the transformative role of nursing care, I decided to attend the scientific session [at the American Public Health Association’s annual meeting] entitled: Think Global, Act Local: Best Practices Around the World. Panelists presented on a variety of interesting care models from Europe to Central America.
As we explore initiatives to improve care coordination, it was interesting to hear Erin Maughan, RN, PhD, APHN-BC, an RWJF Executive Nurse Fellow, talk about Scotland’s care coordination approach to children’s health. Maughan discussed home visitors, who provide care to children from birth to five years of age. An important aspect of the relationship forged with children and families is to allow for early identification of developmental needs, thus allowing for timely utilization of resources and services to address these needs. Interestingly, to support effective care outcomes for children with chronic illnesses over the age of five, each family is assigned a district nurse who is a chronic disease specialist.
Scotland has also coordinated health forms utilized by police, schools, and health care facilities; this is a team-centered approach for identifying and working with at-risk children. Scotland’s pediatric care model demonstrates the effective utilization of public health nurses and the implementation of inter-agency care coordination. We, as a nation, can certainly benefit from further understanding of these approaches.
Peter Ubel, MD, is a physician and behavioral scientist. He is the Madge and Dennis T. McLawhorn University Professor of Business, Public Policy and Medicine at Duke University, an alumnus of the Robert Wood Johnson Foundation (RWJF) Generalist Physician Faculty Scholar program, and recipient of an RWJF Investigator Award in Health Policy Research.
During a break between classes, I offered some MBA students the chance to make a little extra money. Some would have a job of sitting in the classroom for five minutes doing nothing, absolutely nothing – no reading, no listening to music; just staring straight ahead. For this effortless job, they would receive $2.50.
Others would have the job of sitting in the same room for those same five minutes, but rather than staring into space they would be asked to solve word puzzles, forming four-word sentences out of five-word combinations. For example, the words “eagle apple majestic soars” could be turned into the sentence: the majestic eagle soars.