What she wanted, the patient told the geriatricians evaluating her, was to be able to return to her condominium in Boston. She had long lived there on her own, lifting weights to keep fit and doing her own grocery shopping, until a heart condition worsened and she could barely manage the stairs.
So at 94, she consented to valve replacement surgery at a Boston medical center. “She never wanted to go to a nursing home,” said Dr. Perla Macip, one of the patient’s geriatricians. “That was her worst fear.”
Dr. Macip presented the case on Saturday to a meeting of the American Academy of Hospice and Palliative Medicine. The presentation’s dispiriting title: “The 30-Day Mortality Rule in Surgery: Does This Number Prolong Unnecessary Suffering in Vulnerable Elderly Patients?”
Like Dr. Macip, a growing number of physicians and researchers have grown critical of 30-day mortality as a measure of surgical success. That seemingly innocuous metric, they argue, may actually undermine appropriate care, especially for older adults.
The experience of Dr. Macip’s patient — whom she calls Ms. S. — shows why.
Ms. S. sustained cardiopulmonary arrest during the operation and needed resuscitation. A series of complications followed: irregular heartbeat, fluid in her lungs, kidney damage, pneumonia. She had a stroke and moved in and out of the intensive care unit, off and on a ventilator.
After two weeks, “she was depressed and stopped eating,” Dr. Macip said. The geriatricians recommended a “goals of care” discussion to clarify whether Ms. S., who remained mentally clear, wanted to continue such aggressive treatment.
But “the surgeons were optimistic that she would recover” and declined, Dr. Macip said.
So a discussion of palliative care options was deferred until Day 30 after her operation, by which time Ms. S. had developed sepsis and multiple-organ failure. She died on Day 31, after life support was discontinued.
The key number here, surgeons and other medical professionals will recognize, is 30.
Thirty-day mortality serves as a traditional yardstick for surgical quality. Several states, including Massachusetts, require public reporting of 30-day mortality after cardiac procedures. Medicare has also begun to use certain risk-adjusted 30-day mortality measures, like deaths after pneumonia and heart attacks, to penalize hospitals with poor performance and reward those with better outcomes.
However laudable the intent, reliance on 30-day mortality as a surgical report card has also generated growing controversy. Some experts believe pressures for superior 30-day statistics can cause unacknowledged harm, discouraging surgery for patients who could benefit and sentencing others to long stays in I.C.U.s and nursing homes.
“Thirty days is a game-able number,” said Dr. Gretchen Schwarze, a vascular surgeon at the University of Wisconsin-Madison and co-author of an editorial on the metric in JAMA Surgery. Last fall, she led a session about the ethics of 30-day mortality reporting at an American College of Surgeons conference.
“Surgeons in the audience stood up and said, ‘I can’t operate on some people because it’s going to hurt our 30-day mortality statistics,’” she recalled. The debate is particularly urgent for older adults, who are more likely to undergo surgery and to have complications.
Those questioning the 30-day metric point to potential dilemmas at both ends of the surgical spectrum. Surgeons may decline to operate on high-risk patients, even those who understand and accept the trade-offs, because of fears (conscious or not) that deaths could hurt their 30-day results.
At a hospital in Pennsylvania, for instance, a cardiothoracic surgeon declined to operate on a man who urgently needed a mitral valve replacement. He wasn’t elderly, at 53, but he was an alcoholic whose liver damage increased his risk of dying.
Dr. Douglas White, the director of ethics and decision-making in critical illness at the University of Pittsburgh School of Medicine, was asked to consult. According to Dr. White, the surgeon explained that “we have been told that our publicly reported numbers are bad, and we have to take fewer high-risk patients.”
Other surgeons at the hospital, under similar pressure, also refused. A helicopter flew the patient to another hospital for surgery.
An outlier case? A study in JAMA in 2012 compared three states that require public reporting of coronary stenting results to seven nearby states that didn’t report. Older-adult patients having acute heart attacks had substantially lower rates of the stenting in the reporting states. Doctors’ concerns about disclosure of poor outcomes might have led them to perform fewer procedures, the authors speculated; they might also have weeded out poorer candidates for surgery.
Perhaps as important for older people, when things go wrong, surgical teams concerned about their 30-day metrics may delay important conversations about palliative care or hospice, or even override advance directives.
“There are no good published studies on this, but it’s something we see,” Dr. White said. “Surgeons are reluctant to withdraw life support before 30 days, and less reluctant after 30 days.”
That may have been what happened to Ms. S. Or perhaps her aggressive treatment resulted from a surgical ethos that has little to do with mortality reports.
“We want to cure patients and help them live, and we consider it a failure if they don’t,” said Dr. Anne Mosenthal, who heads the American College of Surgeons committee on surgical palliative care.
With surgeons already prone to optimism and disinclined to withdraw life support, the effect of reporting failures, if there is one, is subtle. Surgeons tell themselves, “Maybe if we wait a little longer, he’ll improve; there’s always a chance,” Dr. Mosenthal said.
But many older patients, and their families, have different ideas about what makes life worth sustaining and might welcome a frank discussion before a month passes.
“The 30-day mortality statistic creates a conflict of interests,” said Dr. Lisa Lehmann, an associate professor of medical ethics at Harvard Medical School. “It can lead to the violation of a physician’s duty to put patients’ interests first.”
Leaders at the nonprofit National Quality Forum, which just endorsed 30-day mortality as a measure for coronary bypass surgery, find such fears overblown. The forum evaluates quality measures for Medicare and other insurers, and went ahead with its endorsement despite some physicians’ objections.
“There is some concern,” said Dr. Helen Burstin, the chief scientific officer of the forum, but “certainly no evidence” that the metric is unduly influencing patient care.
“Is it better not to measure and compare, just because we can’t get it perfect?” added Dr. Lee Fleisher, a co-chairman of the forum’s surgery standing committee.
But critics think other quality measures might serve better. Perhaps the benchmark should be 60- or 90-day mortality. Perhaps patients having palliative surgery to relieve symptoms should be tracked separately, because comfort is their goal, not survival.
Maybe quality should include days spent in an I.C.U. or on a ventilator, Dr. Schwarze said.
“Medicine isn’t just about keeping people alive,” she said. “Some of it is about relieving suffering. Some of it is about helping people die.”
A University of Missouri nurse researcher is working to ensure people who use hearing aids for the first time are not bombarded by sounds that could be overwhelming and potentially painful.
Individuals who wear hearing aids for the first time can potentially hear sounds they have not heard in months of even years, according to a University of Missouri news release on the research. The study, published online Dec. 17, in the journal Clinical Nursing Research, looked at the feasibility and initial effect of Hearing Aid Reintroduction to assist people 70 to 85 years old to adjust to hearing aids.
Some of the noises hearing aids enable their users to hear are not always easy to embrace, researchers found. These include air conditioners, wind and background conversations which can be annoying, painful and tough to ignore, the release said.
Kari Lane, PhD, RN, MOT, assistant professor of nursing at MU Sinclair School of Nursing, studied a group of elderly adults’ satisfaction with hearing aids after participating in HEAR, according to the release. Study participants recorded the total time they wore hearing aids for 30 days. Participants gradually increased the amount of time they wore the hearing aids and the variety and complexity of sounds they experienced, including household appliances or sounds from crowded areas, the release said.
“Hearing loss is a common health problem facing many aging adults that can have serious effects on their quality of life, including heightened chances of depression and dementia,” Lane said in the release. “Hearing aids are not an easy fix to hearing loss. Unlike glasses, which provide instant results, it takes more time for the brains of hearing-aid users to fully adjust to the aids and new sounds they could not hear before.”
All participants at the start of the research reported being unsatisfied with their hearing aids, Lane said. At the end of the study, more than half of participants reported being able to increase their hearing aid use and 60% of them said they were satisfied with their hearing aids, the release stated.
“It is common practice for audiologists to have their patients wear hearing aids all day when they first buy them, but not all persons are able to do this comfortably,” Lane said in the release. “Prior research shows there is a need for alternative ways to teach people how to use hearing aids like the HEAR intervention, which allows hearing-aid users to gradually adjust to using the aids while receiving support and coaching from health professionals and family members.”
Healthcare providers should give patients guidance on conditions they might experience during the aging process, such as hearing loss, according to the release. Such proaction could help to reduce the stigma surrounding hearing aids, Lane said.
“If healthcare professionals begin discussing hearing loss with their patients sooner, before problems arise, the use of hearing aids could be normalized, and individuals would be better prepared for the transition when it is time for them to begin use,” Lane said in the release.
A nurse who contracted Ebola at the Dallas hospital where she worked plans to sue the hospital's parent company, Texas Health Resources, hoping to be a "voice for other nurses," her lawyer said today.
In the suit, which Nina Pham plans to file Monday, the 26-year-old nurse alleges that Texas Health Presbyterian Hospital didn't train the staff to treat Ebola and didn't give them proper protective gear, which left parts of their skin exposed, her lawyer Charla Aldous said.
"One of the most concerning things about the way [the hospital] handled this entire process is you've got a young lady who has this disease which she should not have. And if they properly trained her and given her the proper personal protective equipment to wear, she would not have gotten the disease," Aldous said.
Aldous said Pham hopes the suit will "help make sure that hospitals and big corporations properly train their nurses and healthcare providers."
"This is not something that Nina chose," Aldous said, but "She's hoping that through this lawsuit she can make it a change for the better for all nurses."
Pham is still coping with Ebola's after-effects, including nightmares and body aches, her lawyer said.
"She has not gone back to work yet and she is working on recovering," Aldous said. "I don't know if she'll ever be a nurse again."
Texas Health Resources spokesperson Wendell Watson said in a statement: "Nina Pham bravely served Texas Health Dallas during a most difficult time. We continue to support and wish the best for her, and we remain optimistic that constructive dialogue can resolve this matter."
Last fall, Pham cared for Liberian native Thomas Eric Duncan, who flew to the U.S. and was diagnosed with Ebola at Texas Health Presbyterian Hospital.
Pham took care of Duncan when he was especially contagious, and on Oct. 8, Duncan died from the virus.
Pham tested positive for Ebola on Oct. 11, marking the first Ebola transmission on U.S. soil.
On Oct. 16, Pham was transferred to the National Institutes of Health's hospital in Bethesda, Maryland. She was discharged on Oct. 24.
At the news conference announcing Pham's discharge, Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases at the NIH, said she tested negative for Ebola five times, and that it wasn't clear which treatment saved her because they were all experimental.
"I want to first tell you what a great pleasure and in many respects, a privilege ... to have the opportunity to treat and care for and get to know such an extremely courageous and lovely person," Fauci said, adding that she represents the health care workers who "put themselves on the line."
Pham's dog, Bentley, was also quarantined for several weeks, over fears that he, too, would develop Ebola.
A blind man is now able to see objects and people again, including his wife and family, for the first time in a decade. How? With the help of a bionic eye implant.
Affected by a degenerative condition known as retinitis pigmentosa, Allen Zderad was effectively blind, unable to see anything but a bright light. As the condition has no cure, Zderad, from Minneapolis-Saint Paul, MN, was forced to quit his professional career.
He made adjustments to his lifestyle and was able to continue woodworking through his sense of touch and spatial awareness. However, with the help of his new retinal prosthesis, Zderad is now able to make out the outlines of objects and people, and could even register his reflection in a window.
"I would like to say I think he's a remarkable man, when you consider what he's overcome in dealing with his visual disability," says Dr. Raymond Iezzi Jr., an ophthalmologist from the Mayo Clinic. "To be able to have offered him the retinal prosthesis to enhance what he can already do was a great honor for me."
Retinitis pigmentosa is an inherited condition that causes the degeneration of specific cells in the retina called photoreceptors. The disease can cause some people to lose their entire vision. Mr. Zderad's grandson has the disease in its early stages and, after seeing him, Dr. Iezzi asked if he could meet his grandfather.
The eye implant that Zderad now has works by bypassing the damaged retina and sending light wave signals directly to the optic nerve. A small chip was attached to the back of the eye with multiple electrodes offering 60 points of stimulation.
'Not like any form of vision that he's had before'
Wires from the device on the retinal surface connect to a pair of glasses worn by Mr. Zderad. The glasses have a camera at the bridge of the nose that relay images to a small computer worn in a belt pack. These images are then processed and transmitted as visual information to the implant which in turn interprets them, passing them on to the retina and eventually the brain.
"Mr. Zderad is experiencing what we call artificial vision," explains Dr. Iezzi. "It's not like any form of vision that he's had before. He's receiving pulses of electrical signal that are going on to his retina and those are producing small flashes of light called electro-phosphenes. These small flashes of light are sort of like the points of light on a scoreboard at a baseball game."
There are only 60 of these flashes of light, but it is enough for Zderad to reconstruct scenes and objects. Although he will not be able to see the details of faces or read, Mr. Zderad will now be able to navigate through crowded environments without the use of a cane, significantly improving his quality of life.
Dr. Iezzi would like to see the technology expanded to patients who have lost the use of their eyes, such as wounded soldiers or people with advanced diabetes or glaucoma.
"In addition, while Mr. Zderad has 60 points of stimulation, if we were able to increase that number to several hundred points of stimulation, I think we could extend the technology so that patients could recognize faces and perhaps even read," he concludes.
"It's crude, but it's significant," said Zderad happily, as he first used the device. "It'll work."
Zderad will now be able to see his family again, including his 10 grandchildren and his wife, Carmen. And how does he distinguish her, having not seen her for a decade? "It's easy," says Zderad, "she's the most beautiful one in the room."
At the end of last year, Medical News Today reported on the story of a woman with quadriplegia who is now able to use her mind to move a robotic arm, demonstrating "10° brain control" of the prosthetic.
I find it strangely interesting that this time last year, as I was enduring the beginning of my life with a TBI, I had no idea that March was National Brain Injury Awareness Month. This year I feel compelled to shout it from the rooftops (or the computer screen)! Over the next few weeks, I intend to share with you stories and journeys of those living with a traumatic brain injury (TBI) or caring for a loved one who is recovering from one. My hope is to educate those who aren't familiar with TBI, and to help other TBI-ers understand that they are not alone, and that their symptoms are not just "in their head" (pun intended).
Let me start by offering you some statistics on TBI from BrainTrauma.org:
- Traumatic brain injury (TBI) is the leading cause of death and disability in children and adults from ages 1 to 44.
- Brain injuries are most often caused by motor vehicle crashes, sports injuries, or simple falls on the playground, at work or in the home.
- Every year, approximately 52,000 deaths occur from traumatic brain injury.
- An estimated 1.5 million head injuries occur every year in the United States emergency rooms.
- An estimated 1.6 million to 3.8 million sports-related TBIs occur each year.
- At least 5.3 million Americans, 2 percent of the U.S. population, currently live with disabilities resulting from TBI.
- Moderate & severe head injury (respectively) is associated with a 2.3 and 4.5 times increased risk of Alzheimer's disease.
- Males are about twice as likely as females to experience a TBI.
- Exposures to blasts are a leading cause of TBI among active duty military personnel in war zones.
- Veterans' advocates believe that between 10 and 20 percent of Iraq veterans, or 150,000 and 300,000 service members have some level of TBI.
- 30 percent of soldiers admitted to Walter Reed Army Medical Center have been diagnosed as having had a TBI.
- The number of people with TBI who are not seen in an emergency department or who receive no care is unknown.
There are three levels of traumatic brain injuries: mild, moderate and severe. Don't let these names fool you. A mild TBI is just as serious as a moderate or severe one. The names refer to loss of consciousness and mental alteration as a result of the trauma. In my case, we think I was unconscious for only about a minute or so, therefore classifying me as "mild". But like I said, don't let the name fool you. The resulting damage can be the same for all three -- a TBI does not discriminate.
A TBI changes you. Literally and figuratively. My personality is different. My energy levels and sleep patterns are foreign to me. The confused woman in the kitchen staring at the oven is someone I am just now starting to understand. The woman who has to write a Post-it note for every single task on her to-do list is no longer the multi-tasker she once was. The woman who used to type at 100 words per minute with zero mistakes now has to take her time and correct many keystroke errors as she goes because her brain gets confused with letters.
I am finally coming to terms with this "new me." It has been just over a year since I fell on the ice, landing full force on my skull. In the beginning I was angry. I was confused. I was in a lot of pain, both physically and emotionally. People didn't understand. Didn't believe me. Couldn't understand my hidden injuries. I didn't have a strong support system, but what I did have was determination!
Life with an "invisible" injury or illness can be a real challenge. Since I posted my last blog, "Life With a Traumatic Brain Injury," on The Huffington Post last month, I have made an entirely new circle of friends. I created a group on Facebook, affectionately named "The TBI Tribe." This is a safe place where we can hang out, talk, vent frustrations, share in each other's successes, and more importantly, have a place where we all feel like we fit in. I was craving an environment where others understood my struggles and didn't pass judgement. I have found exactly that in this tribe!
I want to share with you a little bit about one of my new friends, Jennifer L. White from St. Louis, Missouri:
In July of 2000 Jennifer collapsed in her Atlanta, Georgia apartment. She called 911 and told them she was dying. She did, in fact, die in the ambulance on her way to the hospital. Fortunately medics were able to resuscitate her. Doctors determined that she had had a stroke and performed brain surgery to eradicate the brain bleed. She spent 10 days in the ICU followed by several months in a rehab facility. Overnight she went from the vice president of a large marketing firm, to unemployable and on disability. The massive stroke has left Jennifer with cognitive deficiencies, balance issues, and double vision. She jokes that she can, however, make a killer peanut butter sandwich! It's important to have a good sense of humor when dealing with a TBI. Aside from her impairments, Jennifer looks completely healthy and "normal." A few words from Jennifer:
The brain injury has affected me in a variety of ways. Emotionally, I am fragile but working hard to toughen my spirit. I am much more introspective (I don't know if this is from the actual brain injury or the fact I now have more time to be introspective). Things are just harder for me than most people. I have to actually think seriously about where I am stepping.
I define my life in two ways: before and after the stroke. It has certainly delivered me a tough blow. I have been advised not to have children. I am scared that I am predisposed to have something else happen to me, and I am sorry that I don't find sweetness in the sweet things in life because I am more bitter than I want to be. But call me crazy... I am glad to be alive.
I hope that you will join me this month as I share with you more stories and continue to bring awareness to the world about TBI.
For Tabitha Waugh, it was another typical day of chaos on the sixth-floor cancer ward.
The fire alarm was blaring for the second time that afternoon, prompting patients to stumble out of their rooms. One confused elderly man approached Ms. Waugh, a registered nurse at St. Mary’s Medical Center here, but she had no time to console him. An aide was shouting from another room, where a patient sat dazed on the edge of his bed, blood pooling on the floor from the IV he had yanked from his vein.
“Hey, big guy, can you lay back in bed?” she asked, as she cleaned the patient before inserting a new line. He winced. “Hold my hand, O.K.?” she said.
Ms. Waugh, who is 30 and the main breadwinner in her family of four, still had three hours to go before the end of a 12-hour shift. But despite the stresses and constant demands, all the hard work was paying off.
Her wage of nearly $27 an hour provides for a comfortable life that includes a three-bedroom home, a pickup truck and a new sport utility vehicle, tumbling classes for her 3-year-old, Piper, and dozens of brightly colored Thomas the Tank Engine cars heaped under the double bed of her 6-year-old, Collin.
The daughter of a teacher’s aide and a gas station manager, Ms. Waugh, like many other hard-working and often overlooked Americans, has secured a spot in a profoundly transformed middle class. While the group continues to include large numbers of people sitting at desks, far fewer middle-income workers of the 21st century are donning overalls. Instead, reflecting the biggest change in recent years, millions more are in scrubs.
“We used to think about the men going out with their lunch bucket to their factory, and those were good jobs,” said Jane Waldfogel, a professor at Columbia University who studies work and family issues. “What’s the corresponding job today? It’s in the health care sector.”
In 1980, 1.4 million jobs in health care paid a middle-class wage: $40,000 to $80,000 a year in today’s money. Now, the figure is 4.5 million.
The pay of registered nurses — now the third-largest middle-income occupation and one that continues to be overwhelmingly female — has risen strongly along with the increasing demands of the job. The median salary of $61,000 a year in 2012 was 55 percent greater, adjusted for inflation, than it was three decades earlier.
And it was about $9,000 more than the shriveled wages of, say, a phone company repairman, who would have been more likely to head a middle-class family in the 1980s. Back then, more than a quarter of middle-income jobs were in manufacturing, a sector long dominated by men. Today, it is just 13 percent.
As the job market has shifted, women, in general, have more skillfully negotiated the twists and turns of the new economy, rushing to secure jobs in health care and other industries that demand more education and training. Men, by contrast, have been less successful at keeping up.
In many working- and middle-class households, women now earn the bigger paycheck, work longer hours and have greater opportunities for career advancement. As a result, millions of American families are being reconfigured along with the economy.
“The culture still has traditional attitudes about who does what, who brings home the bacon and who scrambles the eggs,” said Isabel Sawhill, co-director of the Center on Children and Families at the Brookings Institution. “The economy is now out of sync with the culture, and I think that’s creating tensions within marriage.”
A New Springboard
At the Waughs’ house, it is T.J. Waugh, 33, who picks up the couple’s two children from the babysitter when he leaves his afternoon shift at a small plant in Huntington.
By the time Ms. Waugh arrives home in rural Salt Rock from her shift, often far later than her 7 p.m. quitting time, the children have been bathed and fed.
The house is usually messy. The bathroom walls are covered with scribbles from bath crayons; dirty clothes pile up. Ms. Waugh often jams six 12-hour shifts into one week, leaving little time for cleaning and laundry. Mr. Waugh mows the lawn and will run the vacuum cleaner now and then, and if there are no clean towels, Ms. Waugh will do a load of laundry. Otherwise, housework waits until she has a stretch of days off.
“I’m just really tired when I get home,” Ms. Waugh said.
Ms. Waugh is the keeper of the family’s books. That she out-earns her husband — a pipe fitter who hunts deer and plays men’s softball on the weekends — is an unspoken given.
“She doesn’t rub that in,” he said.
Without missing a beat, Ms. Waugh adds, “It doesn’t matter where it comes from.”
Most of the new jobs produced by America’s sprawling economy — especially since the turn of the century — are either in highly paid occupations that often require an advanced degree, or, more predominantly, in lower-paid positions providing direct services that cannot be sent overseas and, at least for now, are difficult to automate.
But even with a hollowing out of the job market and a broad stagnation in wages, an analysis by The New York Times has found, a set of occupations has emerged that holds promise as the base of a more robust middle class.
Many are in health care, which has grown sharply over the last few decades.
Economists at the Labor Department project that by 2022, as baby boomers age, health care and social assistance will absorb nearly 20 percent of consumer spending, double the share of manufactured goods. The sector is expected to support over 21 million jobs, five million more than today. This includes half a million more registered nurses.
A Rare Green Shoot
The reordering of the economic landscape can be seen all over West Virginia’s old coal country, where billboards along the highways that run through the region advertise a new cardiac center and an orthopedic clinic; and where a strip mall houses Scrubs Unlimited, a medical outfitter, its retail floor crammed with nursing uniforms in 38 colors and Peter Pan prints.
Hugging the Ohio River as it bends around the Appalachian foothills, Cabell County, which includes Huntington, has often found itself on the wrong side of economic change. The population — about 97,000 today — has shrunk 10 percent over the last three decades, as the old have died and many of the young have left.
The railroad that helps shuttle coal to Huntington, one of the nation’s busiest inland ports, is still a source of jobs. But manufacturing employment — once clustered at the long-gone glassmaking plants and furniture makers — has dwindled to fewer than 5,000 jobs. Recently, a 1920s-era nickel alloy plant laid off dozens of workers after a bankruptcy, a corporate acquisition and weak sales.
In real terms, wages in Cabell County now are lower than in the 1970s, stumbling along well below the national average. One in five residents lives in poverty.
The health care industry — which added 3,000 jobs here over the last 10 years — is one of the few green shoots in a struggling economy.
West Virginia has been battered by the same forces that have reshaped the nation since the late 1970s, when global competition, an overvalued dollar, declining unions and advanced technology began to undercut the jobs created during America’s industrial heyday, deepening income inequality. And since 2000, the share of middle-income workers has been squeezed and wages have stagnated.
Yet many of the jobs added in medical services here and across the nation have turned out to be surprisingly good ones.
That was what motivated the only male registered nurse colleague of Ms. Waugh’s on the sixth-floor cancer unit, Johnny Dial, a former highway construction worker and heavy equipment mechanic. More men are joining nursing, but they still make up only 10 percent of the ranks, compared with 4 percent in 1980.
As Mr. Dial contemplated supporting a family, it came down to health care or the railroad if he wanted job security and benefits. He chose what he thought would be a more fulfilling career, and the same one as his wife, who is also a nurse.
“You get to help people,” Mr. Dial said.
Women Stepped Up
Similar thinking was behind the career choices of Ms. Waugh’s fellow female R.N.s. They include a former waitress, a former journalist, an ex-administrator in a metals factory and a former store clerk at Bath & Body Works. In addition to the satisfaction of the work, they all said, the wages are generally better in health care than they could find in other fields.
Ms. Waugh has urged her husband to try to move up at his company, where he earns about $40,000 in regular wages, plus pay for occasional extra shifts, or to switch to a more lucrative career, maybe even in health care as a radiology technician.
But for Mr. Waugh, the only way up at the plant is to go into sales, a promotion he already turned down because he said he did not want to “deal with people.” He could earn more in the coal mines, but that work is dirty and dangerous.
Mr. Waugh has talked about trying college again; he dropped out twice in the past. At one point, his wife even filled out application papers for him to jump-start his re-enrollment, but he did not pursue class work.
“My philosophy is he is lazy,” Ms. Waugh said, standing in the hospital’s white hallway. “That’s what makes me so mad.”
For all the troubles associated with traditionally male jobs, women have not had an easy ride through the economic turmoil, either.
“The occupational structure has not somehow become more women-friendly,” said David Autor, an economist at M.I.T. who has studied the changing American job market. In fact, he added, “the hollowing out of middle-skill jobs was larger for women than for men.” The process intensified sharply during the financial crisis and the ensuing economic downturn.
But in general women have reacted much better, climbing the educational ladder to capture more of the better jobs. Today, 38 percent of women in their late 20s and early 30s have a college degree, compared with 15 percent 40 years ago. The completion rate for young men is now 7 percentage points lower than for women — back then it was 7 points higher.
This has given women an edge in the new job market: Today, almost 58 percent of registered nurses have a bachelor’s degree or more, compared with about a third in 1980.
This is true across the range of occupations capable of supporting a middle-class life. In 1980, 55 percent of workers who earned the equivalent of $40,000 to $80,000 in today’s dollars had at most a high school diploma, according to the analysis by The Times, which reviewed census returns for employed people ages 25 to 64. Only a quarter had a college degree. Today, the share of college graduates has risen to about 41 percent, while just under 31 percent have completed no more than high school.
“The days when a very, very substantial share of the work force would be able to make good middle-class incomes from jobs that did not require post-high school training are just not the case anymore,” said Francine D. Blau, an economics professor at Cornell University.
Men still hold most of the top jobs in the economy, including seven out of 10 jobs that pay over $80,000 a year. But women are rapidly moving up the ranks. Women hold 44 percent of middle-income jobs, compared with about a quarter 30 years ago.
These trends may not hold forever. Though educational attainment continues to rise for women, their progress in the workplace — in terms of both wages and jobs — has slowed significantly. Tighter controls on the cost of health care could weaken the job growth and pay raises helping support the new American middle. And while the industry is largely immune to foreign competition, it may be affected by advances in labor-saving technology.
Even as more women get ahead, many men are struggling to grab a handhold into higher-paying jobs. After her husband was laid off from a string of auto mechanic jobs, Donna Colbey, 53, urged him to switch careers and become a radiology technician.
It was a job Ms. Colbey knew would offer a good salary and require only two years of training. She had taken the same route, which eventually led her to a nursing career at a Washington hospital.
He enrolled in the courses but dropped out after a few months.
“He got tripped up over the math and didn’t go back,” said Ms. Colbey, who regularly picks up extra shifts to support her family.
A Relentless Pursuit
Far more is expected of nurses now than even two decades ago. Medical advances have kept patients alive longer, meaning many are sicker with more complex illnesses than in the past. Nurses must master technology that helps both treat and track patients, and they are called on to coordinate not just with doctors but also social workers and physical therapists.
At St. Mary’s Medical Center, Ms. Waugh, in her navy scrubs, fed potassium on a recent day into the vein of one woman with a broken hip who was on the cancer floor because of a lack of beds. She gave anti-nausea medicine to a moaning young man with liver cancer in the midst of chemotherapy and prepared pills for a half-dozen other patients, documenting it all on a computer.
An outpatient arrived for his regular blood-drawing and, squatting alongside him in a waiting room, Ms. Waugh unbuttoned his shirt and collected blood from an access port in his chest.
Ms. Waugh’s pursuit of learning to advance her career has been relentless. By her own count, she has been out of school for no longer than two years since kindergarten.
All that education has come with a cost. The couple has amassed about $50,000 in student debt. Ms. Waugh would like to send her children to a better school, but the $10,000 annual tuition that would require is out of reach. “I can’t save for their college and send them to private school,” she said.
To her husband’s co-workers who are raising families on pipe fitters’ salaries, the Waugh family is rich. Ms. Waugh’s purchase of a new Toyota S.U.V. raised eyebrows around the plant.
“We’re not wealthy,” Mr. Waugh said, “but we’re not poor.”
It hasn’t been easy getting to this point. As she made the rounds at the hospital, Ms. Waugh explained how her family was set back in 2008 after Collin was born. She stayed home for one year with the boy, who had digestive problems and required expensive formula. Living on just Mr. Waugh’s salary, they ran through their savings and they accumulated credit card debt that they are still paying off.
“That was a horrible financial situation,” Ms. Waugh said.
But later this year, when her classes and other course work are finished, Ms. Waugh will qualify as a nurse practitioner, a job that she expects will allow her to earn at least 50 percent more than her current salary. And she will be prepared, she believes, for almost anything to come.
“I knew if I was a nurse I could be self-sufficient,” she said, “and wouldn’t have to rely on anyone to take care of me.”
It’s something each of the nation’s 3.1 million RNs understands intimately: Being a nurse is intense. The hospitals and clinics where they work are often stressful. And patient care and healthcare systems have never been more complex.
Nationally, nurse turnover stands at 20 percent, but nearly 40 percent of nurses are ready to leave their job after a single year. About 14 percent leave the field altogether, and the ‘working wounded’ that remain are at best demoralized and at worst error-prone. And dealing with RN turnover is among the biggest, costliest burdens in healthcare today.
It’s why University of Virginia School of Nursing’s Compassionate Care Initiative has sponsored a new Public Radio documentary series – Resilient Nurses, now available online – which will be heard on many public radio stations starting this month and also on Sunday Feb. 22 on the NPR Channel (#122) of SiriusXM satellite radio at 4pm ET / 1pm PT.
Hosted by award-winning documentary producer David Freudberg of Humankind, the program takes a no-holds-barred look at what ails American RNs: the stress, the exhaustion, and the pressured environments that often lead to their burnout.
But beyond sourcing RNs’ biggest challenges, Freudberg offers a promising glimpse into the growing number of nurses hoping to improve their lot by harnessing well-being through resilience. Freudberg also chronicles the growing movement of resilience at a handful of American clinics and hospitals where administrators realize the very real financial and personal stake they have in helping their nurses effectively handle stress.
And the stories are inspiring. Sharing the voices of these powerful, real nurses may be an important step in healing the profession’s broken hearts, strengthening American RNs’ care and practice through a practitioner-centered approach to well-being.
The Resilient Nurses audio podcast is now available online. Editors and bloggers may download and publish graphics and a brief program description from http://www.humanmedia.org/nurse/resources.php.
We hope the program will inspire nurses, nursing professors, nursing students and others in healthcare to begin their own resilient practices.
Christine Phelan Kueter, writer
Source: U.Va. School of Nursing
Far from offering patients pennies for their thoughts, mental health therapists often end up billing them hundreds of dollars per month.
The cost is a growing burden as depression among US adolescents and adults rises. The US is suffering a mental health crisis, with a San Diego State University study in October finding that one in 10 Americans is depressed – and more report symptoms of depression.
More Americans are seeking help, and that help can come at a financial sacrifice of thousands of dollars a year. Aside from the cost of often-weekly visits to psychologists – which may or may not be defrayed by insurance – there can be additional costs for psychiatrists and any medicine they prescribe.
The cost of therapy is especially acute for young Americans, many of whom are underemployed and burdened with college debt. This year, a record number of college freshmen reported being depressed. And while many campuses provide free mental health care, affordable help is often harder to find after students leave school.
The Guardian interviewed seven young professionals about their experiences to find out how young Americans manage to pay for therapy – and if they think it’s worth it. To protect their identities, we have kept their surnames anonymous.
Click on the titles below to read their stories:
– AK, 27
– Matt, 23
– JE, 29
– Eve, 33
- John, 27
– Alex, 27
By MICHAEL TOMSIC
In Medical Park Hospital in Winston-Salem, N.C., Angela Koons is still a little loopy and uncomfortable after wrist surgery. Nurse Suzanne Cammer gently jokes with her. When Koons says she's itchy under her cast, Cammer warns, "Do not stick anything down there to scratch it!" Koons smiles and says, "I know."
Koons tells me Cammer's kind attention and enthusiasm for nursing has helped make the hospital stay more comfortable.
"They've been really nice, very efficient, gave me plenty of blankets because it's really cold in this place," Koons says. Koons and her stepfather, Raymond Zwack agree they'd give Medical Park a perfect 10 on the satisfaction scale.
My poll of the family is informal, but Medicare's been taking actual surveys of patient satisfaction, and hospitals are paying strict attention. The Affordable Care Act ties a portion of the payments Medicare makes to hospitals to how patients rate the facilities.
Medical Park, for example, recently received a $22,000 bonus from Medicare in part because of its sterling results on patient satisfaction surveys.
Novant Health is Medical Park's parent company, and none of its dozen or so other hospitals even come close to rating that high on patient satisfaction. Figuring out why Medical Park does so well is complicated.
First, says Scott Berger, a staff surgeon, this isn't your typical hospital.
"It kind of feels, almost like a mom-and-pop shop," he says.
Medical Park is really small, only two floors. Doctors just do surgeries, like fixing shoulders and removing prostates, and most of their patients have insurance.
Another key is that no one at Medical Park was rushed to the hospital in an ambulance, or waited a long time in the emergency room. In fact, the hospital doesn't even have an emergency room.
The hospital doesn't tend to do emergency surgeries, says Chief Operating Officer Chad Setliff. These procedures are all elective, scheduled in advance. "So they're choosing to come here," he says. "They're choosing their physician."
These are the built-in advantages that small, specialty hospitals have in terms of patient satisfaction, says Chas Roades, chief research officer with Advisory Board Company, a global health care consulting firm.
"A lot of these metrics that the hospitals are measured on, the game is sort of rigged against [large hospitals]," Roades says.
This is the third year hospitals can get bonuses or pay cuts from Medicare (partly determined by those scores) that can add up to hundreds of thousands of dollars.
More typical hospitals that handle many more patients – often massive, noisy, hectic places – are more likely to get penalized, Roades says.
"In particular, the big teaching hospitals, urban trauma centers — those kind of facilities don't tend to do as well in patient satisfaction," he says. Not only are they busy and crowded, but they have many more caregivers interacting with each patient.
Still, Roades says, although patient surveys aren't perfect, they are fair.
"In any other part of the economy," he points out, "if you and I were getting bad service somewhere – if we weren't happy with our auto mechanic or we weren't happy with where we went to get our haircut – we'd go somewhere else." In health care, though, patients rarely have that choice. So Roades thinks the evaluation of any hospital's quality should include a measurement of what patients think.
Medical Park executives say there are ways big hospitals can seem smaller — and raise their scores. Sometimes it starts with communication – long before the patient shows up for treatment.
On my recent visit, Gennie Tedde, a nurse at Medical Park, is giving Jeremy Silkstone an idea of what to expect after his scheduled surgery – which is still a week or two away. The hospital sees these conversations as a chance to connect with patients, allay fears, and prepare them for what can be a painful process.
"It's very important that you have realistic expectations about pain after surgery," Tedde explains to Silkstone. "It's realistic to expect some versus none."
Medical Park now handles this part of surgery prep for some of the bigger hospitals in its network. Silkstone, for example, will have surgery at the huge hospital right across the street — Forsyth Medical Center.
Carol Smith, the director of Medical Park's nursing staff, says that after she and her colleagues took over these pre-surgical briefings, "Forsyth's outpatient surgical scores increased by 10 percent."
But some doctors and patients who have been to both hospitals agree that the smaller one is destined to have higher scores. It is just warmer and fuzzier, one patient says.
Eve, an artificially-intelligent 'robot scientist' could make drug discovery faster and much cheaper, say researchers writing in the Royal Society journal Interface. The team has demonstrated the success of the approach as Eve discovered that a compound shown to have anti-cancer properties might also be used in the fight against malaria.
Robot scientists are a natural extension of the trend of increased involvement of automation in science. They can automatically develop and test hypotheses to explain observations, run experiments using laboratory robotics, interpret the results to amend their hypotheses, and then repeat the cycle, automating high-throughput hypothesis-led research. Robot scientists are also well suited to recording scientific knowledge: as the experiments are conceived and executed automatically by computer, it is possible to completely capture and digitally curate all aspects of the scientific process.
In 2009, Adam, a robot scientist developed by researchers at the Universities of Aberystwyth and Cambridge, became the first machine to independently discover new scientific knowledge. The same team has now developed Eve, based at the University of Manchester, whose purpose is to speed up the drug discovery process and make it more economical. In the study published today, they describe how the robot can help identify promising new drug candidates for malaria and neglected tropical diseases such as African sleeping sickness and Chagas' disease.
"Neglected tropical diseases are a scourge of humanity, infecting hundreds of millions of people, and killing millions of people every year," says Professor Steve Oliver from the Cambridge Systems Biology Centre and the Department of Biochemistry at the University of Cambridge. "We know what causes these diseases and that we can, in theory, attack the parasites that cause them using small molecule drugs. But the cost and speed of drug discovery and the economic return make them unattractive to the pharmaceutical industry.
"Eve exploits its artificial intelligence to learn from early successes in her screens and select compounds that have a high probability of being active against the chosen drug target. A smart screening system, based on genetically engineered yeast, is used. This allows Eve to exclude compounds that are toxic to cells and select those that block the action of the parasite protein while leaving any equivalent human protein unscathed. This reduces the costs, uncertainty, and time involved in drug screening, and has the potential to improve the lives of millions of people worldwide."
Eve is designed to automate early-stage drug design. First, she systematically tests each member from a large set of compounds in the standard brute-force way of conventional mass screening. The compounds are screened against assays (tests) designed to be automatically engineered, and can be generated much faster and more cheaply than the bespoke assays that are currently standard. This enables more types of assay to be applied, more efficient use of screening facilities to be made, and thereby increases the probability of a discovery within a given budget.
Eve's robotic system is capable of screening over 10,000 compounds per day. However, while simple to automate, mass screening is still relatively slow and wasteful of resources as every compound in the library is tested. It is also unintelligent, as it makes no use of what is learnt during screening.
To improve this process, Eve selects at random a subset of the library to find compounds that pass the first assay; any 'hits' are re-tested multiple times to reduce the probability of false positives. Taking this set of confirmed hits, Eve uses statistics and machine learning to predict new structures that might score better against the assays. Although she currently does not have the ability to synthesise such compounds, future versions of the robot could potentially incorporate this feature.
Professor Ross King, from the Manchester Institute of Biotechnology at the University of Manchester, says: "Every industry now benefits from automation and science is no exception. Bringing in machine learning to make this process intelligent -- rather than just a 'brute force' approach -- could greatly speed up scientific progress and potentially reap huge rewards."
To test the viability of the approach, the researchers developed assays targeting key molecules from parasites responsible for diseases such as malaria, Chagas' disease and schistosomiasis and tested against these a library of approximately 1,500 clinically approved compounds. Through this, Eve showed that a compound that has previously been investigated as an anti-cancer drug inhibits a key molecule known as DHFR in the malaria parasite. Drugs that inhibit this molecule are currently routinely used to protect against malaria, and are given to over a million children; however, the emergence of strains of parasites resistant to existing drugs means that the search for new drugs is becoming increasingly more urgent.
"Despite extensive efforts, no one has been able to find a new antimalarial that targets DHFR and is able to pass clinical trials," adds Professor King. "Eve's discovery could be even more significant than just demonstrating a new approach to drug discovery."
The research was supported by the Biotechnology & Biological Sciences Research Council and the European Commission.