RWJF Scholar examines neighborhood-based death rates from opiate-based painkiller overdoses, compared with heroin overdose deaths.
Three Haitian-American Harold Amos Medical Faculty Development Program scholars traveled to Haiti to provide medical services to the victims of the January 12, 2010 earthquake. Among them was Fritz Francois, M.D., M.S., (’09) a gastroenterologist in the department of internal medicine and the assistant dean for academic affairs and diversity at New York University’s Langone Medical Center. Francois said, “When the quake happened, it seemed immediately that everything that I had done throughout my life had prepared me for that moment. It wasn’t even a question of whether I was going to go. It was simply a question of when.” Other program scholars who offered medical care in Haiti were Vernat Exil, M.D., (’98) a pediatric cardiologist at Vanderbilt Children’s Hospital in Nashville, Tenn. and a professor of pediatrics at Vanderbilt University; and Macarthur Charles, M.D., Ph.D., (’08) an instructor of medicine at Weill Cornell Medical College. Other Human Capital programs whose scholars provided assistance in Haiti included the Clinical Scholars and Physician Faculty Scholars. For more on the scholars’ assistance, see this story.
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Stanley Frencher, M.D., M.P.H. (’08) participated in a roundtable discussion hosted by the Prostate Cancer Foundation in the Rayburn House Office Building in Washington, D.C. on April 20th. The roundtable discussed the controversy surrounding prostate-specific antigen (PSA) testing in men, including confusion over who should be getting the PSA test and what information men and their physicians should have about using and interpreting the results. Media coverage included CNBC.
Lenard Lesser, M.D., (’09) was quoted in an American Academy of Family Physicians article discussing the need for physicians to partner with their patients during treatment to make small but significant changes that eventually will result in large shifts in patient behavior. Lesser states, “Those step-by-step things tend to build your relationship with your patients and tend to work better than telling them to make one huge, big change in their whole life.”
The Journal of the American Medical Association (JAMA) published “Moving Reform to the Bedside,” a commentary by Erica S. Spatz, M.D., (’08) and Cary Gross, M.D., (’97) co-director of the Clinical Scholars program at Yale. Spatz and Gross outline concrete steps that physicians can take to play a meaningful role and exert leadership in health care reform.
A March 29 New York Times article described the efforts of a group of Clinical Scholars and other physicians to influence the health reform debate. In the article, Stacy Tessler Lindau, M.D., (’00) Somnath Saha, M.D., (’96) and Cary Gross, M.D., (’97) discuss how health care reform offers an opportunity for physicians to improve the doctor-patient relationship.
Warren Newton, M.D., M.P.H., (’87) executive associate dean for education at the University of North Carolina School of Medicine, was quoted in an article in the (Raleigh, N.C.) News and Observer about a pilot program at the school that revamps medical school residencies. The program abandons the typical “rotations” model, where students shift from one specialty to another, in favor of a “longitudinal” model, where students follow patients throughout their entire treatment process. Newton states, “If you're on a cardiology rotation, you see patient after patient after patient with chest pain. What you don’t see is what happens to that patient later.”
The Deaf Community Health Worker Initiative, directed by Anita Buel, (’08) was featured on the U.S. Agency for Healthcare Research and Quality’s (AHRQ) Health Care Innovations Exchange. AHRQ cited it as a comprehensive program designed to accelerate the development and adoption of innovations in health care delivery. The Deaf Community Health Worker Initiative employs deaf individuals who complete a 13-hour certificate program to help members of the Minnesota Deaf Community, including deaf immigrants, understand medical information and become active participants in their care. The community health workers accompany patients to medical appointments and make home health visits.
Hugh F. “Trey” Daly III, J.D., (’09) of the Legal Aid Society of Greater Cincinnati, is managing Southwest Ohio’s Covering Kids & Families campaign. The campaign kicked off with a March 15, 2010 press conference. The Covering Kids & Families campaign aims to enroll 1,800 eligible children and teens in nine Southwest Ohio counties, where there are an estimated 18,000 uninsured children and teens. Many uninsured families are unaware that their children are eligible for Medicaid coverage, according to Daly. Covering Kids & Families, an RWJF national program, helps state and local coalitions find, enroll and retain eligible children and adults in federal and state health care coverage programs.
Gina Upchurch, R.Ph., M.P.H., (’01) was quoted in a USA Today article examining the effectiveness of new Medicare rules to help senior citizens manage the use of prescription medications, including identifying and responding to side effects. Upchurch, a pharmacist and the founder of Senior PharmAssist, said the Medicare management rules may be unable to detect certain problems associated with the use of prescription drugs because the rules do not require face-to-face meetings with patients. “I can’t teach you to use an inhaler without seeing you,” Upchurch said.
Two Robert Wood Johnson Foundation Executive Nurse Fellows have been nominated for the 2010 Nursing Spectrum’s Nursing Excellence Awards. Suzanne Boyle, R.N., D.N.Sc., (’04) vice president of patient care services at New York-Presbyterian Hospital/Weill Cornell Medical Center, is among this year’s award nominees. She was nominated for her leadership skills that blend empathy and effectiveness and yield ‘phenomenal dividends’ in the face of increased demands and limited resources. Also nominated was Nelson Tuazon, R.N., M.S.N., M.B.A., M.A.Ed., (’05) senior vice president and chief nursing officer at East Orange General Hospital. Tuazon was nominated for being a “knowledge-based, transformational leader who inspires individuals and organizations to achieve excellence.” For more than a decade, the Nursing Excellence Awards program has recognized the extraordinary contributions New York and New Jersey nurses make to their patients, colleagues and to the nursing profession.
Ann Cary, Ph.D., M.P.H, R.N., (’08) was elected chair of the Association of Jesuit Colleges and Universities’ Jesuit Colleges of Nursing Programs, a 20-member group of deans representing Jesuit Schools of Nursing in the United States.
Lynne Dunphy, Ph.D., R.N., (’09) the Routhier Chair of Practice, professor of nursing, and center coordinator of the Rhode Island Center for Nursing Excellence at the University of Rhode Island, was elected to the board of the National Organization of Nurse Practitioner Faculties (NONPF). NONPF is the only organization specifically devoted to promoting quality nurse practitioner education at the national and international levels.
Shon Dwyer, B.S.N, R.N., M.B.A, (’07) was appointed to associate director for operations and chief administrative officer for surgical services at the University of Michigan Health System. Dwyer previously directed the orders management project, where she led the implementation of UM-CareLink, a part of the clinical information system that includes computerized provider order entry (CPOE), electronic medication administration documentation, nursing worklists and pharmacy order perfection. In her new role, Dwyer will work collaboratively with several clinical departments and their leadership.
Jennie Chin Hansen, M.S., R.N., F.A.A.N., a member of the national advisory committee (NAC), was chosen as the new CEO of the American Geriatrics Society (AGS), an organization devoted to improving the health, independence and quality of life of older adults. Hansen, who began her term in April 2010, served as the AARP president from 2008 to 2010.
Bonnie Brueshoff, R.N., P.H.N., M.S.N., (’06) has been selected as a fellow in the National Association of City and County Health Officials (NACCHO) program, “Survive and Thrive: Roadmap for New Local Health Officials.” An RWJF-supported program, NACCHO is geared for public health directors who have two years or less of experience. Survive and Thrive fellows have the opportunity to engage with seasoned colleagues, learn new skills and apply their hands-on experience to the challenges presented by the role of public health official. Brueshoff began the 12-month program in May.
Bill Cody, Ph.D., R.N., F.A.A.N., (’03) was appointed founding dean of the Andrew Blair College of Health at Queens University of Charlotte. Funded by a $7 million gift, the new college will include the present Presbyterian School of Nursing. Cody previously directed the Presbyterian School of Nursing.
Margaret Flinter, R.N., C.R.N.P., (’02) developed a model for nurse practitioner residency programs that was included as a demonstration program in the Patient Protection and Affordable Care Act (Section 5316). Flinter passionately believes that nurse practitioners will be critical players in helping to ensure that the 32 million individuals who will receive health insurance under the law will be able to get quality primary care. She notes that unlike their primary care physician colleagues, nurse practitioners have had to assume their primary care roles without the benefit of formal post-graduate residency training programs.
Barbara Heller, Ed.D., R.N., F.A.A.N. (’98) has been appointed to the board of directors of the World Trade Center Institute of Maryland (WTCI), an organization serving over 2,500 Maryland companies that aims to drive the growth of Maryland’s global business community. Heller also serves as a board member of MedStar Health and as a member of Senator Benjamin Cardin’s Health Care Advisory Committee.
A number of program alumni have been elected members of the American Association of Colleges of Nursing (AACN)’s executive committee and nominating committee. Jane Kirschling, D.N.S., R.N., F.A.A.N., (’00) dean of the University of Kentucky College of Nursing, assumed the role of AACN president-elect and will serve as president from 2012 to 2014. Juliann G. Sebastian, Ph.D., R.N., F.A.A.N., (’98) dean of the University of Missouri-St. Louis College of Nursing, was elected to the AACN board as secretary. Two new members-at-large were elected to the AACN board this year, including Peggy O. Hewlett, Ph.D., R.N., F.A.A.N., (’00) dean of the University of South Carolina College of Nursing. Newly-elected members to AACN’s nominating committee include Paulette Burns, Ph.D., R.N., (’05) dean of the Harris College of Nursing and Health Sciences at Texas Christian University.
Cheri Rinehart, R.N., B.S.N, N.H.A, (’04) was appointed to the Bloomsburg University Department of Nursing’s advisory committee. She also hosted a Pennsylvania Primary Care Workforce Summit, bringing together providers, key stakeholders from academia, practitioners, area health education centers, state associations and others to collaboratively develop strategies to support the development of a robust Pennsylvania primary care workforce. In addition, she presented on two health care reform panels: the first with a U.S. Congressman, an insurance company CEO, and the CEO of a hospital association; the second with executives from a major health insurer, the state hospital association, and the Pennsylvania Department of Public Welfare. Rinehart is president and CEO of the Pennsylvania Association of Community Health Centers.
Linda Thompson Adams, Ph.D., R.N., (’99) was named provost and vice chancellor of academic affairs at North Carolina Agricultural and Technical State University, effective July 1. Chancellor Harold Martin told the News & Record of Greensboro that Adams was selected for her expertise in higher education and skills in public policy, grants, scholarships and fundraising.
Three Haitian-American Harold Amos Medical Faculty Development Program scholars traveled to Haiti to provide medical services to the victims of the January 12, 2010 earthquake. Among them was Fritz Francois, M.D., M.S., (’09) a gastroenterologist in the department of internal medicine and the assistant dean for academic affairs and diversity at New York University’s Langone Medical Center. Francois said, “When the quake happened, it seemed immediately that everything that I had done throughout my life had prepared me for that moment. It wasn’t even a question of whether I was going to go. It was simply a question of when.” Other program scholars who offered medical care in Haiti were Vernat Exil, M.D., (’98) a pediatric cardiologist at Vanderbilt Children’s Hospital in Nashville, Tenn. and a professor of pediatrics at Vanderbilt University; and Macarthur Charles, M.D., Ph.D., (’08) an instructor of medicine at Weill Cornell Medical College. For more on the assistance that these scholars and several Clinical Scholars provided in Haiti, see this story.
Sarah Burgard, Ph.D., M.S., (’03) an assistant professor of sociology at the University of Michigan, was quoted in Psychology Today for her study comparing the physical and mental health of 3,000 workers. She found that those who felt their jobs were in danger were in significantly poorer health than those who were not worried. In fact, they were in worse shape than people who had actually gone through the short, sharp shock of losing their jobs. “The stress response was designed for acute responses, like running away from lions, not for long-term job insecurity,” Burgard said.
Jason Corburn, Ph.D., M.C.P., (’03) an associate professor of city and regional planning at the University of California, Berkeley, was quoted in a Miller-McCune article that discusses the disjointed link between urban design and public health, and how climate change and green technology are impacting the relationship. The article calls for architects and planners not only to consider design, but also health, the environment, social relations, political processes and the economy during the planning process. Corbun states, “This is not to say that design is not important,” but that it should be just one piece of thinking relationally about multiple factors that influence health.
Enrico Marcelli, Ph.D., (’03) an assistant professor of sociology at San Diego State University, was quoted in a Wall Street Journal blog about the pitfalls of counting illegal immigrants. His 2001 survey of Mexican-born people living in Los Angeles is widely used to assume that approximately 10 percent of illegal immigrants are not counted on census surveys. However, Marcelli states, “I do not advise use of my estimated undercounts for the 2000 census outside of L.A. County, nor for migrants from other nations. However, demographers do not have any other empirical evidence at the moment with which to proceed.” The blog discusses the uncertainty surrounding the number of illegal immigrants currently living in Arizona.
David Van Sickle, Ph.D., (’06) was quoted in the Columbia Daily Tribune on the prevalence of asthma in rural areas. Asthma has historically been considered an urban affliction, with global studies showing increased incidences of asthma associated with industrialization. Van Sickle is studying asthma triggers in rural areas and how asthma patients manage their symptoms. He is looking to enroll 135 adults in 12 Midwestern states in a study that will examine how seasonal activity changes, such as working in fields, affect asthma outbreaks. Van Sickle is a fellow at the University of Wisconsin-Madison School of Medicine and Public Health and study director at Reciprocal Sciences.
A review of The Heart of Power: Health and Politics in the Oval Office, a book authored by David Blumenthal, M.D., M.P.P., (’02) and James Morone, Ph.D., (’02) appeared in the April 2010 issue of the Journal of Health Politics, Policy, and Law. The reviewer, Adam Sheingate, Ph.D., is an alumnus of the RWJF Scholars in Health Policy Research program. He writes, “Blumenthal and Morone succeed brilliantly as they portray how each president since Roosevelt has wrestled with the issue of health care and has been tested by it.” Blumenthal is the national coordinator of health information technology at the U.S. Department of Health and Human Services; Morone is a professor of political science at Brown University.
Sheila Burke, R.N., M.P.A., an NAC member and chair of the Institute of Medicine (IOM) Committee on Future Directions for the National Healthcare and Disparities Reports, and José Escarce, M.D., Ph.D., (’04) a member of the IOM Committee, contributed to the April 14, 2010 IOM Report, “Future Directions for the National Healthcare Quality and Disparities Reports.” The report concludes that while the reports have made important contributions in raising awareness of the state of the nation's health care and in identifying gaps in quality and equity, they can be improved to be more influential in promoting health care system change. Burke is an adjunct lecturer and faculty research fellow at Harvard University’s John F. Kennedy School of Government. Escarce is a professor of medicine at the UCLA David Geffen School of Medicine.
Daniel P. Carpenter, Ph.D., (’03) and a Health Policy Fellows alumnus, was quoted in a May 3, 2010 New York Times article about how safety concerns following the introduction of the birth control pill led the FDA to take on the medical establishment and to expand its role in post-marketing surveillance. Carpenter is the Allie S. Freed Professor of Government and director of the Center for American Political Studies at Harvard University.
Lawrence Casalino, M.D., Ph.D., (’99) and colleagues, including former NAC member Stephen Shortell, Ph.D., M.P.H., published on April 29, 2010 a “Perspective” in the New England Journal of Medicine. In “Specialist Physician Practices as Patient-Centered Medical Homes,” the authors argue that “specialist-based medical homes should be required to meet the same standards as primary care-based medical homes, including the requirements for providing first-contact, continuous, and comprehensive care and for using systematic processes to improve the health of the practice’s patients.”
Sandro Galea, M.D., M.P.H., Dr.P.H., (’06) chair of the department of epidemiology at Columbia University Mailman School of Public Health, received media coverage on his study about the effects of post-traumatic stress disorder (PTSD) on the immune system. The study found that PTSD can cause changes in the immune system and possibly decrease immunity. Galea states, “Our findings suggest a new biological model of PTSD in which alteration of genes, induced by a traumatic event, changes a person’s stress response and leads to the disorder.” Galea was quoted in U.S. News & World Report and the St. Louis Globe-Democrat, among other outlets.
Alan Garber, M.D, Ph.D., (’03) published a “Perspective” entitled “Modernizing Device Regulation” in the April 2010 issue of the New England Journal of Medicine. Garber recommends a “more rigorous device-approval process” in conjunction with “increased investments in post-approval studies and pooling of data from electronic health records.” Garber is the Henry J. Kaiser, Jr. Professor and director of the Center for Health Policy at Stanford University’s School of Medicine.
Mark Hall, J.D., (’04) a professor of law and public health at Wake Forest University, was quoted in the media about efforts at the state level to thwart the new health reform law. Hall explains that “Congress is well within its constitutional powers to impose a health insurance mandate.” He adds, “I am surprised by the mobilization of the states. It does strike me as a kind of civil disobedience, a declaration that we’re not going to follow the law of the land.” Hall was quoted on NPR, ABC News, MSNBC.com and in the Boston Globe, among other outlets.
Naa Oyo A. Kwate, Ph.D., (’08) has been appointed as associate professor of Human Ecology and Africana Studies at Rutgers University, effective September 2010. Kwate is currently an assistant professor of Sociomedical Sciences at the Mailman School of Public Health at Columbia University. Her research focuses on the psychological and sociocultural determinants of African-American health behaviors and outcomes.
Edward W. Maibach, Ph.D., M.P.H., (’08) a professor and director of the Center for Excellence in Climate Change Communication at George Mason University, was mentioned in a Lancaster Online article that discussed the debate between meteorologists and climatologists on the cause of global warming. Maibach is a lead investigator on a research project underway at George Mason University that looks to explain meteorologists’ stance on human responsibility for global warming. Recent poll results show that 55 percent of respondents and 25 percent of meteorologists believe in human-induced global warming.
Investigator Award recipients authored two Commentaries that appear in the May 5, 2010 issue of JAMA. In “Is History Relevant to Implementing Health Reform?” Howard Markel, M.D., Ph.D., F.A.A.P., (’07) and colleague Daniel M. Fox, Ph.D., argue that “the real work of health reform is just beginning.” In “Implementing Qualifications Criteria and Technical Assistance for Accountable Care Organizations,” former NAC member Stephen M. Shortell, Ph.D., M.B.A., M.P.H., and Lawrence P. Casalino, M.D., Ph.D., (’99) discuss the elements, capacities, quality improvement approaches, technology, and leadership characteristics that are key to the successful spread of accountable care organizations.
Michelle Mello, J.D., Ph.D., M.Phil., (’07) and Thomas Gallagher, M.D., (’07) and Clinical Scholars alumnus, published a “Perspective” in the April 15 issue of the New England Journal of Medicine. In “Malpractice Reform—Opportunities for Leadership by Health Care Institutions and Liability Insurers,” Mello and Gallagher discuss emerging models of medical injury disclosures and early resolution of cases, as well as their potential for producing information that health care institutions can use to improve patient safety. Mello is a professor in the department of health care policy and management at the Harvard School of Public Health and director of the Program in Law and Public Health. Gallagher is an associate professor of medicine at the University of Washington School of Medicine.
Eric Patashnik, Ph.D., M.P.P., (’08) and his colleague Julian Zelizer published an opinion piece entitled, “Now the Real Health Care Fight Begins,” in Politico on March 30, 2010. The authors argue that the new health reform law is vulnerable and that supporters need to find ways to “make the law more acceptable to a skeptical public, more workable, and most of all, more fiscally sustainable.”
Dorothy E. Roberts, J.D., (’07) the Kirkland & Ellis Professor at Northwestern University School of Law, has been awarded the Dorothy Ann and Clarence L. Ver Steeg Distinguished Research Fellowship. She is the fifth scholar to receive the Ver Steeg Fellowship, Northwestern’s first endowed award for excellence in research by a faculty member.
When most people think of a nurse, chances are they don’t think of a professor and researcher who explores the complex health care dilemmas faced by multicultural populations. But that’s a perfect description of 2008–2009 New Connections award winner Karen Winters, R.N., Ph.D. An assistant professor at the University of Mississippi Medical Center School of Nursing since 1998, Winters credits the New Connections: Increasing the Diversity of RWJF Programming initiative with helping her further her academic career and receive tenure while participating in the program.
“New Connections gave me tremendous, unique opportunities to converse with scholars in my field,” Winters said. “Through the program, I was able to learn about advanced methods of longitudinal analysis and time series analysis at the University of Michigan, with experienced people I might not otherwise have been fortunate enough to meet.”
Winters started out as a floor nurse at Medical Plaza Hospital in Fort Worth, Texas, in 1979. Her journey from clinical nursing to an academic career took her from Mississippi to Alabama, then back to Mississippi again, as she became an expert on topics such as the impact of health insurance status on health care service utilization among elderly heart disease patients. Her analyses of the many different ways that economic status can affect health care inspired her New Connections project, “Examining Racial Variation in Persistently and Episodically High Out-of-Pocket Health Care Expenses and Financial Burden Associated with Chronic Illness.” Her most recent work, “Race, Stability of Health Insurance Coverage, and Prescription Medication Use,” was published in the winter 2010 issue of The ABNF Journal, a publication of the Association of Black Nursing Faculty.
As much as she appreciates the value of research, Winters says she loves nursing and teaching because, she explains, “I like preparing other people to make a difference.” Early in her career, Winters realized she enjoyed guiding other nurses’ careers, which led her to Birmingham, Ala., in 1981. There she became an education coordinator at Baptist Medical Center-Montclair. By the time she left in 1994, she had earned a graduate degree in adult nursing and was well on her way to pursuing another major interest in the medical field: health information systems. By 1998, she was an assistant professor in the School of Nursing at the University of Mississippi Medical Center. But Winters didn't stop there; she went on to do post-doctoral research as part of the Jackson Heart Study to Promote Diversity in Health-Related Research.
Now, as a tenured professor armed with her New Connections experience, Winters’ innovative research on racial disparities in health and access to care places her at the forefront of one of the most important fields in public health today.
Physician Faculty Scholars
National advisory committee member Mary K. Goldstein, M.D., M.S., is the 2010 recipient of the Department of Veterans Affairs (VA) Under Secretary’s Award for Outstanding Achievement in Health Services Research. The award is given to VA researchers for their study of the factors that affect the health of veterans and improve the quality of their care, for contributing to the future of VA health services research by inspiring and training the next generation of investigators, and for enhancing the visibility of VA research through national recognition within the research community. It is the highest award for a VA health services researcher.
Aaron Caughey, M.D., Ph.D., M.P.P., M.P.H., (’07) has been appointed as chair of the Department of Obstetrics & Gynecology at the Oregon Health & Science University (OHSU) and will serve as the Julie Neupert Stott Director of the OHSU Center for Women’s Health, effective July 12, 2010. Initially, Caughey will work closely with faculty and others to develop a strategic plan for women’s health at OHSU, embarking on a 10-year campaign to expand the clinical reach of the department and to establish OHSU as a national leader in women’s health. Caughey is currently an associate professor in residence, director of the Center for Clinical and Policy Perinatal Research, medical director of the Diabetes and Pregnancy Program, and the fellowship program director of Maternal-Fetal Medicine in the Department of Obstetrics & Gynecology at the University of California-San Francisco (UCSF).
Deverick Anderson, M.D., M.P.H., (’09) was elected as a member of the North Carolina Division of Public Health Healthcare-Associated Infections (HAI) Advisory Group.
Samir Shah, M.D., M.S.C.E., (’08) received the Burtis Burr Breese Award from the Pediatric Infectious Diseases Society for his paper entitled “Risk Factors for Intrathoracic Tuberculosis in Children in the Economic Migrant Populations of Two Dominican Republic Bateyes.“ The paper was published in the Pediatric Infectious Disease Journal in September 2009. The award was presented at the annual meeting of the Pediatric Academic Societies (April 30–May 4) in Vancouver.
National advisory committee member and Clinical Scholar and Harold Amos Medical Faculty Development Program alumnus Neil Powe, M.D., M.P.H., M.B.A., was appointed a Master of the American College of Physicians, an award that recognizes physicians who have exhibited preeminence in practice or medical research, or who make significant contributions to medical science or the art of medicine. Powe also received the Association of Professors of Medicine 2010 Diversity Award for his work to cultivate diversity in academic medicine and his scholarship to address health disparities.
Michael Anderson, Ph.D., (’06) was quoted in the Wall Street Journal blog, “Real Time Economics” on April 5, 2010 about his research showing that when adult children are “aged out” of their parents’ health insurance plans, their probability of having health insurance is reduced by 5 to 8 percentage points The blog post discusses a provision of the health care law that that allows parents to keep their dependent children on their health insurance policies up to age 26.
Bradley Herring, Ph.D., (’00) was featured as a health care reform law expert in a May 4, 2010 Washington Post article about the new law. He details some of the law’s provisions and explains how they will affect the public.
RWJF Scholar examines neighborhood-based death rates from opiate-based painkiller overdoses, compared with heroin overdose deaths.
RWJF Nurse Faculty Scholar Jennifer Bellot writes about losing her grandmother to complications from a medical error.
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Team members, grantees, and guests discuss breakthrough ideas that will allow us to move toward solving challenges in health care.
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