Category Archives: Voices from the Field
James Perrin, MD, FAAP, began a one-year term as president of the American Academy of Pediatrics (AAP) in January. A professor in the department of pediatrics at MassGeneral Hospital for Children and Harvard Medical School, Perrin received a Robert Wood Johnson Foundation (RWJF) Investigator Award in Health Policy Research in 1997.
Human Capital Blog: Congratulations on your new role as president of the American Academy of Pediatrics! What is your vision for the organization?
James Perrin: We are focused on addressing three main areas, which have really driven a lot of our thinking and, more importantly, our activity and change in the last several years.
First, we are working to help pediatric practices take on more community-based interventions to help young families raise their kids more effectively. There is a tremendous growth in the number of chronic diseases among children in four major areas: asthma, obesity, mental health, and neurodevelopmental disorders. We recognize these are not classic health conditions; they arise from and within communities, and both their prevention and their treatment are really community-based endeavors, as opposed to office-based activities.
Our second, and highly related priority, is an increased focus on early childhood development. We have understood the tremendous importance of early childhood for years, but there is now so much more science behind it. We know a lot more about how negative experiences and toxic stress can affect child development and how it can affect brain growth and neuroendocrine function. On the positive side, we also have more knowledge about the importance of reading to children, increasing language in the home, and other early-childhood interventions.
Thirdly, we have a better understanding of the tremendous impact of poverty on child health. Almost a quarter of American children live in households below the federal poverty line, and almost 45 percent live in households with incomes less than twice the federal poverty line. So a large number of American children are poor or near poor, and we know that poverty affects essentially everything related to child health. It makes those four categories of chronic conditions—asthma, obesity, mental health, and neurodevelopmental disorders—more prevalent and more serious, and it affects children’s responses to treatment. Lower-income kids with leukemia or cystic fibrosis, for example, have higher death rates than kids with the same diseases who are middle class. It’s impossible not to see on a daily basis how poverty affects child health.
Keon L. Gilbert, DrPH, MA, MPA, is an assistant professor in the Department of Behavioral Science & Health Education at St. Louis University's College for Public Health and Social Justice and a Robert Wood Johnson Foundation (RWJF) New Connections grantee.
In 1999, 28-year-old Demetrius DuBose, a linebacker for the Tampa Bay Buccaneers, was shot 12 times by two officers in his San Diego neighborhood. DuBose was a former co-captain of Notre Dame’s famed football team. His death came after he was questioned and harassed regarding a burglary in his neighborhood. Officers reported they had no choice but to shoot DuBose while he was handcuffed because they feared for their lives.
Many of these details sound similar to those surrounding the death of Michael (Mike) Brown Jr., who was shot at least six times in Ferguson, Missouri, this month. Brown was unarmed. He was reportedly fleeing from a police officer who also felt his life was in danger.
What is missing from this picture is that black males also feel threatened and distrustful of authority figures and are routinely disengaged from contexts such as schools, medical facilities and neighborhoods. The narrative remains the same: Black males who die from excessive force become involuntary martyrs for the sustained legacy of institutional and interpersonal racism that is associated with the health disparities plaguing black communities.
Carolyn Montoya, PhD, PNP, is associate professor and interim practice chair at the University of New Mexico College of Nursing and a recent graduate of the Robert Wood Johnson Foundation (RWJF) Nursing and Health Policy Collaborative at the University of New Mexico College of Nursing.
Human Capital Blog: Congratulations on your award from the Western Institute of Nursing! The award honors new nurse researchers. What does it mean for you and for your career?
Carolyn Montoya: In addition to being quite an honor, receiving the Carol Lindeman Award for new researchers from the Western Institute of Nursing motivates me to continue to pursue my research. I am sure people can relate to the fact that being in the student mode is so very intense that once you finish you need some recovery time. Then you start wanting to use the research skills you worked so hard to obtain, and this award has helped to re-energize my commitment to research.
HCB: The award recognizes your study on children’s self-perception of weight. Please tell us what you found.
Montoya: I was very interested to see if there was a difference between how Hispanic children viewed their self-perception in regard to weight compared with white children. Seventy percent of my study population was Hispanic, and my overall response rate was 42 percent. I found that Hispanic children, ages 8 to 11, are not better or worse than white children in their ability to accurately perceive their weight status. Most surprising, and a bit concerning, was the fact that one-third of the sample expressed a desire to be underweight.
Briana Mezuk, PhD, is an assistant professor at Virginia Commonwealth University Medical Center and an alumna of the Robert Wood Johnson Foundation (RWJF) Health & Society Scholars program (2007-2009). She recently earned the Best Early Investigator Award for the top research study from the American Association for Geriatric Psychiatry.
Human Capital Blog: Congratulations on your award! What led to your interest in suicide risk in long-term care facilities?
Briana Mezuk: Older adults, particularly non-Hispanic white men, have the highest risk of suicide. This risk increases exponentially after age 75, and recent data suggest that men in the Baby Boomer generation have a higher suicide risk than previous cohorts. There are many risk factors for this group, including social isolation, feelings of disconnection to society, and lack of social supports and close confidantes. Older men are often unwilling to talk about mental health problems with their physicians; they think they are supposed to ‘grin and bear it.’
HCB: What was the goal of your study?
Mezuk: We were trying to understand the epidemiology of suicide in long-term care facilities, and in nursing homes and assisted-living facilities in particular. Suicide risk in these settings may be higher, or lower, than in the general community. For example, suicide risk may be lower in supervised settings because residents would have less access to a means to self-harm. But suicide risk might be higher because residents often have health problems and, frequently, depressive symptoms that are risk factors for suicide. We used data from the Virginia Violent Death Reporting System to identify suicides that occurred among residents of, and among individuals anticipating moving into, these types of facilities.
HCB: What did you find?
Adefemi Betiku was a junior at Rutgers University when he noticed that he wasn’t like the other students.
During a physics class, he raised his hand to answer a question. “Something told me to look around the lab,” he remembers. “When I did, I realized that I was the only black male in the room.”
In fact, he was one of the few black men in his entire junior class of 300.
“There’s a huge problem with black males getting into higher education,” says Betiku, currently a Doctor of Physical Therapy (DPT) student at New York University (NYU). “That has a lot to do not just with being marginalized but with how black men perceive themselves and their role in society.”
U.S. Department of Education statistics show that black men represent 7.9 percent of 18-to-24-year-olds in America but only 2.8 percent of undergraduates at public flagship universities. According to the Pew Research Center, 69 percent of black female high school graduates in 2012 enrolled in college by October of that year. For black male high school graduates, the college participation rate was 57 percent—a gap of 12 percent.
Betiku’s interest in the issues black men face, especially in education, deepened at Project L/EARN, a Robert Wood Johnson Foundation-funded initiative with the goal of increasing the number of students from underrepresented groups in the fields of health, mental health and health policy research.
Elizabeth Sweet, PhD, is a biocultural anthropologist researching economic and racial disparities in health and an alumna of the Robert Wood Johnson Foundation (RWJF) Health & Society Scholars program (2008-2010). She was the lead author of a recent study exploring the impact of financial debt on health.
Human Capital Blog: You have published more than one study that looks at the impact of debt on health. What led to your interest in this topic?
Elizabeth Sweet: My interest is driven by both intellectual and personal reasons. As someone who studies the impact of social inequalities on health, I am interested in personal debt as a dimension of socioeconomic status, a site of racial and economic disparity, and a reflection of broader social, cultural, and political-economic forces. Also, as someone who completed education with a fair amount of debt, I am personally familiar with the profound stress that debt can cause.
HCB: College tuition is rising and more people are defaulting on student loan debt. How does student loan debt affect young people’s mental and physical health?
Sweet: This is such an important question. Our study suggests that financial debt indeed impacts the health and well-being of young people—leading to higher stress and depressive symptoms, worse general health, and higher blood pressure. The specific impact of student loan debt, vs. other kinds of debt, is an open question though; the Add Health data that we used did not have that level of detail regarding the types of debt that respondents had.
Peter Buerhaus, PhD, RN, is the Valere Potter Distinguished Professor of Nursing, director of the Center for Interdisciplinary Health Workforce Studies, and professor of health policy at Vanderbilt University Medical Center. He co-authored a new study in Health Affairs that found more nurses are delaying retirement, which is adding to the supply of nurses at a time when shortages had been projected.
Human Capital Blog: A decade ago, you forecast large shortages of nurses by the middle of this decade. That isn’t panning out yet. Why?
Peter Buerhaus: When we did the original research, which was published in 2000 in the Journal of the American Medical Association, we were using data that was available at that time, which was up to about 1997 or 1998. At the time, we observed that enrollment in nursing schools had dropped nearly 5 percent each year over the previous five years. Based on that and some other factors, our projections suggested that unless something big happened—namely that we would get a lot of new people to enter nursing to replace the aging and large number of retiring Baby Boomer registered nurses (RNs)—we would run into large shortages and the RN workforce would stop growing by around 2014 or 2015.
Now we’re seeing two new phenomena: First, there has been a great surge of interest in nursing since the mid-2000s, and this has been reflected in a dramatic increase in the number of graduates from associate- and baccalaureate-degree nursing programs. And second, RNs are, on average, spending more time in the workforce—about 2.5 more years than did their peers back in the 1980s and 1990s.
Charles D. Scales Jr., MD, MSHS, an alumnus of the Robert Wood Johnson Foundation/VA Clinical Scholars program (UCLA 2011-2013), is a health services researcher at the Duke Clinical Research Institute and assistant professor in the division of urologic surgery at Duke University School of Medicine. He is also assistant program director for quality improvement and patient safety for the urology residency training program at Duke University Hospital.
Young doctors training to become surgeons, also called surgical residents, are increasingly caring for patients in an environment that links quality, safety, and value to patient outcomes. Over a decade ago, the Institute of Medicine highlighted the need for improving care delivery in the landmark report, Crossing the Quality Chasm, suggesting that high-quality care should be safe, effective, patient-centered, timely, efficient (e.g., high value), and equitable. Just this week, the Institute of Medicine followed with a clarion call for training new physicians to participate in and lead efforts to continually improve both care delivery and the health of the population, while simultaneously lowering costs of care.
To support this imperative, the Accreditation Council for Graduate Medical Education, which accredits all residency training programs in the United States, mandates that all doctors-in-training receive education in quality improvement. Despite this directive, a number of substantial barriers challenge delivery of educational programs around quality improvement. Health care is increasing complex, driving residents to focus on learning the medical knowledge and surgical skills for their field. Patient care demands time and attention, which can limit opportunities to learn about quality improvement within the context of 80-hour duty limits. This barrier particularly challenges surgeons-in-training, who often spend 12 or more hours daily learning surgical skills in the operating room, leaving little time for a traditional lecture-format session about quality improvement. Finally, many surgical training programs lack faculty with expertise in the skills required to systematically improve the quality, safety, and value of patient care, since these skills were simply not taught to prior generations of surgeons.
Cindy A. Crusto, PhD, is a Robert Wood Johnson Foundation (RWJF) New Connections grantee, an associate professor of psychology in psychiatry, Yale University School of Medicine, and a Public Voices Fellow with The OpEd Project.
Were the findings really a surprise? The recent release of the report The Burden of Stress in America commissioned by NPR, the Robert Wood Johnson Foundation, and the Harvard School of Public Health, highlights the major role that stress plays in the health and well-being of American adults. As a researcher who studies the impact of emotional or psychological trauma on children’s health, I immediately thought about the findings in the context of trauma and the associated stress in the lives of children. That trauma can include violence in the home, school, and community.
Two decades of research has produced clear findings on this significant public health problem: Psychological trauma can have a powerful influence in the lives of children, and if not detected and addressed early, it can (and often does) have long-lasting physical and mental health effects into adulthood. Despite this strong evidence, I have encountered the sheer resistance of some advocates who work with or on behalf of vulnerable children to fully engage in this topic. Perhaps it’s because of the belief that this talk about trauma is a fad—a hot topic that will fade as soon as something “sexier” comes along.
For children, stress can come from sources inside and outside the family. It was recently documented that nearly two out of every three children in the United States have witnessed or been victims of violence in their homes, schools, or communities. That’s a staggering statistic when we consider the well-established link between children’s exposure to stress and their long-term mental and physical health outcomes.
Indeed, we know that early exposure to adverse experiences can change the way that our brains develop and function. We also know that exposure to adversity increases the likelihood that children will develop psychosocial problems, like depression, aggression, and other antisocial behaviors. There is even evidence that exposure to stressors in childhood increases the likelihood of having heart disease and cancer in adulthood!