Category Archives: Clinical Scholars
Rachelle Bernacki, MD, MS, is director of quality initiatives in the department of psychosocial oncology and palliative care at the Dana-Farber Cancer Institute, associate director of the Serious Illness Care Program at Ariadne Labs, and an alumna of the Robert Wood Johnson Foundation (RWJF) Clinical Scholars program (2004-2006).
The Institute of Medicine recently released a report entitled Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life. The news headlines read: “Panel Urges Overhauling of Health Care of End of Life.”
Here’s why: Most Americans wish to die at home and want to avoid heroic measures to keep them alive. Yet most die in institutional settings like hospitals and nursing homes, and 20 percent die in intensive care units.
The transition of death from the home to institutional settings over the past 40 years has been promoted by the advent of new medical technologies. While these remarkable technologies can be life-saving for certain patients, for many others aggressive therapies may simply prolong the dying process and extend suffering. In addition, many patients who die in institutional settings die with undertreated pain and difficult or labored breathing. And many report inadequate communication with their physicians about their end-of-life preferences.
Numerous studies show that patients want to have conversations about their end-of-life care and expect their physicians to initiate these discussions. When these conversations occur, there is greater alignment between patients’ wishes and the care they receive; higher patient quality of life; less frequent use of non-beneficial life-sustaining treatments; more use of hospice care; reduced family distress; and reduced resource use and costs. However, many physicians do not feel comfortable having these conversations and, in fact, identify more barriers to having these discussions than do patients.
Justin List, MD, MAR, MSc, is a Robert Wood Johnson Foundation (RWJF)/VA Clinical Scholar at the University of Michigan and primary care general internist at VA Ann Arbor Health System. His research interests include community health worker evaluation, social determinants of health, and improving how health systems address the prevention and management of non-communicable diseases.
The emergency sirens sounded loudly for the rising burden of chronic disease in 2014. Chronic diseases, also called non-communicable diseases (NCDs), broadly include cardiovascular disease, chronic respiratory disease, cancer, and diabetes. In 2014, we learned that, overall, 40 percent of Americans born between 2000 and 2011 are projected to develop diabetes in their lifetimes. This is double the lifetime risk from those born just a decade earlier. Rates of obesity, a condition related to many NCDs, remains stubbornly high in the United States. Mortality and morbidity from NCDs, not to mention the social and economic costs of disease, continue to rise.
The United States is not alone in the struggle with a well-entrenched NCD burden. At the end of 2014, a Council on Foreign Relations task force issued a report with a clarion call for the United States to aid in addressing NCDs in low- and middle-income countries (LMICs) where the epidemic of chronic disease poses risks to communities, economies, and security. The task force, which included RWJF President & CEO Risa Lavizzo-Mourey, MD, MPH, among its members, recommended: (1) U.S. global health funding priorities expand from disease-focused objectives to include more outcome-oriented measures for public health; and (2) the United States convene leading partners and stakeholders to address NCDs in LMICs.
Nicole M. Brown, MD, MPH, MHS, is a general pediatrician at Montefiore Medical Center and an assistant professor of pediatrics in the Division of General Pediatrics at Albert Einstein College of Medicine at Yeshiva University in New York City. She is alumna of the Robert Wood Johnson Foundation (RWJF) Clinical Scholars program.
Many patients have left an impression on my heart since I began my journey as a pediatrician, but one I cared for early in my career sticks with me. He was a wiry 8-year-old boy exhibiting symptoms of an anxiety and conduct disorder: He was very aggressive, had acted inappropriately with his younger sister, smeared feces around the house, and was difficult to manage. He had been severely and physically abused, and although child protective services had gotten involved, he had fallen out of the system after the case was “closed” and stopped showing up for therapy.
By the time his grandmother brought him to see me, I was the first doctor to see him in about two years. In the hour that I spent with him that day, it became clear that his treatment—or lack thereof—was inextricably bound up in his family’s various other challenges. His family lived in poverty, and faced food insecurity issues, in addition to a long, cyclical history of abuse and child protective services involvement. His grandmother was shuttling between various social service agencies, doing her best to complete forms and meet the requirements for public assistance. Yet despite her best efforts, she wasn’t really able to manage it all and, as a result, the boy’s health care was falling through the cracks.
The Robert Wood Johnson Foundation (RWJF) Human Capital Blog published nearly 400 posts this year. As we usher in 2015, we take a look back at our ten most-read 2014 posts.
Why Do Deaths from Drugs Like Oxycodone Occur in Different Neighborhoods than Deaths from Heroin? This in-depth look at the role neighborhoods play in shaping substance abuse patterns was written by RWJF Health & Society Scholars program alumna Magdalena Cerdá, PhD, MPH. She compares neighborhoods that have more fatal overdoses of opiate-based painkillers to neighborhoods in which heroin and cocaine overdoses are more likely to occur, identifying characteristics of each. Her piece generated a larger audience than any other post published on this Blog this year, with more than 22,000 visits.
How Stress Makes Us Sick was written by RWJF Health & Society Scholar Keely Muscatell, PhD. A social neuroscientist and psychoneuroimmunologist, Muscatell shares her research into the physical manifestations of stress, its relationship to inflammation, and ways people may be able to reframe their responses to stress in order to alleviate the physical reactions it can cause. Understanding how stress makes us sick, she blogs, “is of extreme importance to the health and longevity of our nation.”
Misfortune at Birth, which drew the third-largest audience among the posts published on this Blog in 2014, asks whether some premature babies are simply born in the wrong place. It reports on nurse-led research that finds seven in ten black infants with very low birth weights have the misfortune of being born in hospitals with lower nurse staffing ratios and work environments than other hospitals. The blog post was written by Eileen Lake, PhD, RN, FAAN, and Jeannette Rogowski, PhD, based on their study funded by RWJF’s Interdisciplinary Nursing Quality Research Initiative.
Pooja Mehta, MD, is a generalist obstetrician/gynecologist and a second-year Robert Wood Johnson Foundation (RWJF) Clinical Scholar at the University of Pennsylvania, with support from the Department of Veterans Affairs. Rebekah Gee, MD, MHS, is Medicaid Medical Director for the state of Louisiana, an assistant professor of health policy and management, and obstetrics and gynecology at Louisiana State University and an alumna of the RWJF Clinical Scholars program.*
The theory of disruptive innovation seeks to explain how complicated, expensive systems may eventually be replaced by simpler, more affordable solutions, driven by new entrants into a market who “disrupt” an older, less efficient, and less accessible order.
In the new issue of Current Opinion in Obstetrics and Gynecology, we track the history of the RWJF Clinical Scholars program (CSP) in the field of obstetrics and gynecology, and offer a curated selection of pieces that suggest that our discipline—now peppered with experts in health services research and health policy trained through the CSP—could be teetering at the precipice of an era of such disruptive innovation.
Highlighting the work of nine current and past scholars, among more than 40 Clinical Scholars working in the field of obstetrics and gynecology, this journal issue covers a range of cutting-edge concepts currently being developed and employed to transform our field from the inside out.
Nathaniel DeNicola, MD, (‘11) discusses the potential uses of social media to disseminate and advance new findings and recommendations to broader audiences. Laurie Zephyrin, MD, MBA, (’03) illuminates how efforts to integrate systems, create interdisciplinary initiatives, and how research-clinical partnerships have allowed for rapid organizational and cultural change and have advanced reproductive health care in the Veterans Affairs system.
Elizabeth Krans, MD, (‘09) writes about ways in which new public funding is allowing for disruptive innovation in the delivery of prenatal care—for example, through dissemination of the highly decentralized, patient-driven Centering Pregnancy model. Working from within a city health department, Erin Saleeby, MD, (‘10) writes about how participatory approaches to public health governance can engage community and clinician leaders in the process of redesigning reproductive care and transforming outcomes.
Katherine Diaz Vickery, MD, MSc, is an alumna of the Robert Wood Johnson Foundation (RWJF) Clinical Scholars program, an assistant professor of medicine at the University of Minnesota Medical School, and a clinician-investigator in the Division of General Internal Medicine at Hennepin County Medical Center. On December 5, she will be a panelist when RWJF holds its first Scholars Forum: Disparities, Resilience, and Building a Culture of Health. Learn more.
People who know me–even just a little–know of my pride for my home state of Minnesota. While there are beautiful lakes, biking trails, farmer’s markets, and a ridiculous state fair (that takes special pride in its offerings of various types of food-on-a-stick), there’s something more... Minnesota has been making strategic efforts to improve the health of its communities for many years.
If I could bring you to Minnesota today (bundle up!), I’d show you what I mean by taking you to Hennepin County Medical Center (HCMC) and specifically to a meeting of the patient advisory board of the Hennepin Health Accountable Care Organization (ACO).
I would introduce you to Jorge, a Mexican-American whose road to recovery from severe depression was paved by his multi-disciplinary care team from Hennepin Health. Jorge might tell you about Susan, the social worker who helped him find transitional housing. Or Lucky, a community health worker who gave him a voucher to get a haircut, a toiletry bag, and helped him find a primary care medical home. And if he really opened up, he might tell you of his career aspirations to take courses to supplement his graduate degree from Mexico and become a family therapist or community health worker.
New studies conducted by Robert Wood Johnson Foundation (RWJF) Clinical Scholars and published as part of a special November supplement of the Annals of Internal Medicine offer fresh insights on a range of topics, including: How hospitals can improve antibiotic prescribing practices; how a simple change to the format of electronic health records can encourage the use of money-saving generic drugs; how a lottery-based incentive program for patients could increase participation in colon cancer screening; and whether a popular smartphone weight-loss app actually helps patients lose weight.
The supplement was published with the support of RWJF. Studies in the issue include:
Special Training for Physicians in Antibiotics Decreases Inappropriate Use and C. difficile Infections
With growing concerns about increasing antibiotic-resistant bacteria, the Centers for Disease Control and Prevention (CDC) has been urging hospitals to adopt antibiotic “timeouts.” Nearly 50 percent of antibiotic use is unnecessary or inappropriate, according to the CDC, so what can hospitals and physicians do to ensure that antibiotics continue to be effective? The McGill University Health Centre (MUHC) in Montreal tested a simple approach: provide monthly in-person trainings for physicians and residents in appropriate antibiotic use and implement a weekly review of all patients receiving antibiotics. This approach decreased inappropriate antibiotic use and resulted in a mild decline in Clostridium difficile infections. “Our pilot program led to significant savings in the cost of antibiotics paid out of our hospital budget,” said RWJF Clinical Scholars alumna and Louise Pilote, MD, PhD, MPH, Chief of Internal Medicine at the MUHC and McGill University. “This is good news for anyone concerned about antibiotic effectiveness and reducing health care costs.”
Mitesh S. Patel, MD, MBA, MS, is an assistant professor of medicine and health care management at the Perelman School of Medicine and the Wharton School at the University of Pennsylvania. He is a staff physician and core investigator at the Center for Health Equity Research and Promotion at the Philadelphia Veterans Administration (VA) Medical Center. Patel is an alumnus of the VA/Robert Wood Johnson Foundation (RWJF) Clinical Scholars Program at the University of Pennsylvania (2012-2014).
Cardiovascular disease is the number one cause of hospitalizations, morbidity and mortality among the veteran population. Building a Culture of Health could address this issue by focusing on individual health behaviors that contribute to risk factors associated with cardiovascular disease such as physical inactivity, diet, obesity, smoking, hyperlipidemia and hypertension.
The current health system is reactive and visit-based. However, veterans spend most of their lives outside of the doctor’s office. They make everyday choices that affect their health such as how often to exercise, what types of food to eat, and whether or not to take their medications.
Connected health is a model for using technology to coordinate care and monitor outcomes remotely. By leveraging connected health approaches, care providers have the opportunity to improve the health of veterans at broader scale and within the setting in which veterans spend most of their time (outside of the health care system). The Veteran’s Health Administration (VHA) is a leader in launching connected health technologies. VHA efforts began in 2003 and included technologies such as My HealtheVet (serving approximately 2 million veterans) and telemedicine (serving about 600,000 veterans).
Ilse Wiechers, MD, MPP, MHS is associate director at the Northeast Program Evaluation Center in the Office of Mental Health Operations of the U.S. Department of Veterans Affairs and faculty with the Yale Geriatric Psychiatry Fellowship. She is an alumna of the Yale Robert Wood Johnson Foundation (RWJF)/VA Clinical Scholars Program (2012-2014).
Health and disease are on a continuum. We are at a point in time where we are trying to understand the constituents of health, whereas historically our focus has been on understanding disease. It is important to recognize that veterans have unique determinants of health not shared with the rest of the population, such as exposure to combat and prolonged time spent away from social support networks during deployment.
These exposures can put veterans at increased risk for mental health problems, such as posttraumatic stress disorder, depression, and substance use problems. The U.S. Department of Veterans Affairs (VA) has a health care system uniquely positioned to help improve the overall health of veterans because of its expertise in addressing these unique mental health needs.
I have the privilege to serve our nation’s veterans through my work as a geriatric psychiatrist conducting program evaluation for the Office of Mental Health Operations (OMHO) at the VA. My work provides me an opportunity to directly participate in several of the key components of the comprehensive mental health services the VA provides for veterans.
Erin Krebs, MD, MPH, is the women’s health medical director at the Minneapolis VA Health Care System and associate professor of medicine at the University of Minnesota Medical School. She is an alumna of the Robert Wood Johnson Foundation (RWJF) Physician Faculty Scholars program and the RWJF Clinical Scholars program.
How can we create a Culture of Health that effectively serves veterans? We can put veterans in charge of their pain care.
Chronic pain is an enormous public health problem and a leading cause of disability in the United States. Although 2000-2010 was the “decade of pain control and research” in the United States, plenty of evidence suggests that our usual approaches to managing chronic pain aren’t working. Veterans and other people with chronic pain see many health care providers, yet often describe feeling unheard, poorly understood, and disempowered by their interactions with the health care system.
Evidence supports the effectiveness of a variety of “low tech-high touch” non-pharmacological approaches to pain management, but these approaches are not well aligned with the structure of the U.S. health care system and are often too difficult for people with pain to access. Studies demonstrate that patients with chronic pain are subjected to too many unnecessary diagnostic tests, too many ineffective procedures, and too many high-risk medications.