Category Archives: Voices from the Field
Ayotunde Dokun, MD, PHD, is an assistant professor of medicine at the University of Virginia Health System in Charlottesville, VA. He is also an alumnus of the Harold Amos Medical Faculty Development program (2009-2013), an initiative funded by the Robert Wood Johnson Foundation (RWJF) that supports faculty in academic medicine and dentistry who are from historically disadvantaged backgrounds.
Human Capital Blog: Congratulations on your recent award from the American Heart Association! What does it mean for your work and for your career?
Ayotunde Dokun: It is a great honor to be recognized by the Peripheral Vascular Council of the American Heart Association with an early stage investigator award. For my work, it means the society recognizes the significance of what I have contributed to the field thus far. For my career, it’s a stepping stone hopefully to a brighter future as physician scientist.
HCB: The award recognizes the research and background of outstanding early-career researchers in the field of peripheral vascular disease. Can you describe your current work in this area?
Dokun: Part of my work in this area has been focused on trying to understand why individuals with peripheral arterial disease (PAD) show different levels of disease severity even when their risk factors and extent of vessel occlusions are similar. Some individuals tend to present with mild symptoms, described as “intermittent claudication,” while others present with a severe form of the disease called “critical limb ischemia.” Individuals with intermittent claudication typically have pain in the affected limb when walking, but this pain is usually relieved when they stop walking. Individuals with critical limb ischemia, on the other hand, tend to have pain even when they are not walking and may have associated ulcer or gangrene in the affected limb.
Such individuals are at a several-fold higher risk of limb amputation and death compared to their counterparts who present with intermittent claudication. Interestingly, similar to what is seen in humans, different strains of mice show different levels of injury when PAD is induced experimentally. We therefore hypothesized that the underlying genetic differences might be contributing to this difference in disease severity.
We explored this possibility using experimentally induced PAD in mice, and our work was the first to identify a region on the mouse chromosome that contained genetic information that, when present, allowed the mice to adapt well to experimentally induced PAD. When absent, it was associated with poor adaption, poor recovery, and a tendency to lose the affected limb. More recently, we have now, for the first time, indentified a specific gene in both mice and humans that modifies the severity of PAD.
Brendan Saloner, PhD, is a Robert Wood Johnson Foundation (RWJF) Health & Society Scholar in residence at the University of Pennsylvania and a senior fellow at the Leonard Davis Institute of Health Economics.
In these early days of the Affordable Care Act, the uninsured rate has begun to sharply decrease. One recent estimate suggests 5.4 million adults gained insurance coverage in the first quarter of 2014. The Congressional Budget Office projects that enrollment in Medicaid and the health insurance Marketplaces will increase even more rapidly over the next two years.
The importance of increased health insurance coverage for improved access to health care justifiably receive much of the public’s attention, but the impact of coverage on the financial health of families may be equally important. Subsidized health insurance can increase the disposable income of families by freeing up money that was previously used to pay out-of-pocket for doctor’s visits and prescription drugs. Newly insured individuals also benefit from the risk-protection of health insurance since even people who use little or no health care are at risk of unexpected accidents or newly diagnosed diseases.
A recent study in Oregon that compared adults who received free health insurance through a lottery to those who applied but did not receive the free care found that the “winners” were much less likely to say that they needed to cut back on necessities to pay for health care. They also had much less medical debt and a lower likelihood of receiving a notice from a collection agency.
The first episode of Years of Living Dangerously, a new documentary series exploring the human impact of climate change, aired last Sunday on Showtime. I worked on the series as associate producer and producer, but I am also a scientist who has been studying the impact of climate change on human health for almost a decade. In all that time, I’d developed a good grasp of what climate change looks like from a scientific point of view. But working on the series made me learn a lot more about what climate change looks like, not just here in the United States but worldwide.
This documentary television series consists of nine episodes featuring star correspondents as they meet experts and visit ordinary people who have lived through extreme weather events triggered by climate change. James Cameron, Jerry Weintraub, and Arnold Schwarzenegger served as executive producers of the series, along with former 60 Minutes producers Joel Bach and David Gelber. I worked with Matt Damon on an upcoming segment about heat waves and with Michael C. Hall on another story focusing on Bangladesh, a nation already vulnerable to extreme weather.
E. Alison Holman, PhD, FNP, is an associate professor in nursing science at the University of California, Irvine and a Robert Wood Johnson Foundation Nurse Faculty Scholar.
A year ago today, on April 15, 2013, in the first major terror attack on U.S. soil since September 11, 2001, Dzhokhar and Tamerlan Tsarnaev planted two pressure cooker bombs near the finish line of the Boston Marathon. Three people died and more than 260 were injured. For a week authorities searched for the perpetrators, shootouts occurred, and Boston was locked down. As reporters and spectators filmed the mayhem, graphic images were shown repeatedly in both traditional and social media around the world. Like the September 11, 2001 (9/11) terrorist attacks, the population of the United States was the terrorists’ intended psychological target. Yet most research on reactions to such events focuses on individuals directly affected, leaving the public health consequences for populations living outside the immediate community largely unexplored.
Tens of thousands of individuals directly witnessed 9/11, but millions more viewed the attacks and their aftermath via the media. In our three-year study following 9/11, my colleagues and I found that people who watched more than one hour of daily 9/11-related TV in the week following the attacks experienced increases in post-traumatic stress (PTS) symptoms (e.g., flashbacks, feeling on edge and hyper vigilant, and avoidance of trauma reminders) and physical ailments over the next three years (Silver, Holman et al., 2013).
Adam L. Sharp, MD, MS is an emergency physician and recent University of Michigan Robert Wood Johnson Foundation Clinical Scholar (2011-2013). He works for Kaiser Permanente Southern California in the Research and Evaluation Department performing acute care health services and implementation research.
Violence is a leading cause of death and injury in adolescents. Recent studies show effective interventions can prevent violent behavior in youth seen in the Emergency Department (ED). Adoption of this type of preventive care has not been broadly implemented in EDs, however, and cost concerns frequently create barriers to utilization of these types of best practices. Understanding the costs associated with preventive services will allow for wise stewardship over limited health care resources. In a recent publication in Pediatrics, "Cost Analysis of Youth Violence Prevention," colleagues and I predict that it costs just $17.06 to prevent an incident of youth violence.
The violence prevention intervention is a computer-assisted program using motivational interviewing techniques delivered by a trained social worker. The intervention takes about 30 minutes to perform and was evaluated within an urban ED for youth who screened positive for past year violence and alcohol abuse. The outcomes assessed were violence consequences (i.e., trouble at school because of fighting, family/friends suggested you stop fighting, arguments with family/friends because of fighting, felt cannot control fighting, trouble getting along with family/friends because of your fighting), peer victimization (i.e., hit or punched by someone, had a knife/gun used against them), and severe peer aggression (i.e., hit or punched someone, used a knife/gun against someone).
Linnea Windel, MSN, RN, president and CEO of VNA Health Care in Aurora, Ill., received the Illinois Primary Health Care Association’s Danny K. Davis Award last fall for her leadership of and service to the community health center movement. She is an alumna of the Robert Wood Johnson Foundation (RWJF) Executive Nurse Fellows program (2008-2011).
Human Capital Blog: Congratulations on your award! What does this mean for you and for your organization’s work?
Linnea Windel: The community health center movement (and the work that we do) reaches thousands of uninsured and underinsured people who, in most cases, wouldn’t have access to primary health care services otherwise. The award highlights the purpose of our work and the work of many.
HCB: The award is named for Danny K. Davis, a member of the U.S. House of Representatives and a champion of the community health center movement. How is VNA Health Care carrying out his mission?
Windel: When we became a federally qualified health center (FQHC) 12 years ago, we were serving 6,000 patients; this year we are on track to serve 60,000 patients. In the space of 12 years, we’ve expanded our service area and now have nine health centers in suburban Chicago. We live out the purpose of the community health center movement and the purpose of the award through the provision of care in communities with significant need.
Vanessa Grubbs, MD, MPH, is an assistant professor at the University of California, San Francisco, School of Medicine, and a scholar with the RWJF Harold Amos Medical Faculty Development Program. She is writing a book about what she calls the “sometimes irrational use of dialysis in America,” which will include a version of this narrative essay.
It is a Monday afternoon like any other and time to make my weekly rounds at the San Francisco General Hospital outpatient dialysis center. I push my cart of medical charts down the long aisle of our L-shaped dialysis unit and see Mr. Rojas, my dialysis patient for over a year now. He is in his mid-40s and slender, sitting in the burgundy-colored vinyl recliner. His blue-jeaned legs and sneakered feet are propped up on the extended leg rest. The top of his head shines through thinning salt and pepper hair. White earbud headphones peek through gray sideburns. He is looking intently at his Kindle, rarely glancing up at the activity around him.
I roll my cart up to his recliner, catching his eye. His right hand removes the earbuds as the left pauses his movie. He looks up at me, smiling. “Hola, Doctora. How are you?” he says with emphasis on the “are.”
“I am good. How are you doing?” I smile back at him as I grab his chart from the rack. I write down his blood pressure and pulse—both normal—and the excellent blood flow displayed on the dialysis machine. My eyes shift to his fistula, the surgically thickened vein robustly coursing halfway up his left forearm like a slithering garden snake. It is beautiful to me. Through it, Mr. Rojas is connected to the dialysis machine.
“I am good, Doctora. No problems. I feel healthy. Strong.” His brown eyes glint.
Robin Knobel, PhD, RN, is an associate professor at the Duke University School of Nursing and a Robert Wood Johnson Foundation (RWJF) Nurse Faculty Scholar (2010-2013). The University of Carolina at Chapel Hill (UNC-CH) School of Nursing recently recognized her with its Distinguished Alumna award.
Human Capital Blog: Congratulations on the award! What does it mean for you and for your research?
Robin Knobel: I was truly honored to receive this award from UNC-CH because it recognizes my achievement thus far in my career in my area of research around improving thermal stability with premature infants. I was given great support as a doctoral student at UNC-CH through mentorship in research from faculty who are leaders as nurse scientists. To be recognized by alumni and faculty of the UNC-CH School of Nursing is a tremendous honor.
HCB: You received the award for your research into physiologic processes related to thermoregulation and perfusion in extremely premature infants. Can you explain what this means in lay terms?
Knobel: Yes. Premature infants are born too early to be able to keep themselves warm through the normal methods of heat production. Normally, infants up to one year of age do this through a metabolic production of heat, instead of shivering. Premature infants lack necessary components to accomplish efficient production of heat and consequently can become very cold if exposed to cold air after birth and through stabilization in the neonatal unit. They often experience hypothermic body temperatures during the early weeks after birth, which can lead to instability and possible lasting insults such as brain hemorrhage, infection, or even death. My research is studying the mechanisms around thermal stability in premature infants and ways to prevent bad outcomes from hypothermia.
An interview with Nicole Lurie, MD, MSPH, the assistant secretary for preparedness and response at the U.S. Department of Health and Human Services, and an alumna of the Robert Wood Johnson Foundation (RWJF) Clinical Scholars program. She is the co-author of “The U.S. Emergency Care System: Meeting Everyday Acute Care Needs While Being Ready for Disasters,” published in the December 2013 issue of Health Affairs, which focused on the future of emergency medicine. The interview is part of a series of posts featuring RWJF Scholars who authored articles in the issue.
Human Capital Blog: You write that the nation’s emergency care system is in trouble. What are the challenges facing emergency departments (EDs)?
Nicole Lurie: We’ve understood for at least a decade that the emergency system is in trouble. We ask a lot of this system, and as a result we have EDs that are really crowded and with long wait times, boarding times and throughput times. It’s become a de facto access point for many people who lack access to primary care or insurance, which wasn’t what it was originally set up for. Now, EDs have evolved to be more than places to treat life and limb threats and serve as default diagnostic and therapeutic entry points. But many people who end up in an emergency department may be willing to be treated in a different kind of environment. It is really up to us to build a system that accommodates their needs and ensure our emergency care system can do its important work.
And remember: We changed the way we deliver care in the U.S. from a hospital-based focus to an outpatient focus over the last few decades, but we never really built the infrastructure for it. Outpatient providers have had their visits shortened and group practice environments have changed the relationship between patients and their primary care providers. We hear about the shortage of primary care providers and the crisis of crowding and boarding in emergency departments, but we don’t always connect the dots to understand how we got here. It is a good time to start to have this conversation as payment models are encouraging us to recognize that generating health for our patients is a team effort.
HCB: How do you see the emergency care system evolving, particularly with respect to disaster preparedness?