Dr. Edward Soffen
Dr. Edward Soffen is a board-certified radiation oncologist and medical director of the Radiation Oncology Department at CentraState Medical Center's Statesir Cancer Center in Freehold, New Jersey. He contributed this article to Live Science's Expert Voices: Op-Ed & Insights.
As a radiation oncologist, my goal is to use radiation as an extremely powerful and potent tool to eradicate cancer tumors in the body: These techniques save and extend patients' lives every day.
Historically, radiation treatments have been challenged by the damage they cause healthy tissue surrounding a tumor, but new technologies are now slashing those risks.
How radiation therapies work
High-energy radiation kills cancer cells by damaging DNA so severely that the diseased cells die. Radiation treatments may come from a machine (x-ray or proton beam), radioactive material placed in the body near tumor cells, or from a fluid injected into the bloodstream. A patient may receive radiation therapy before or after surgery and/or chemotherapy, depending on the type, location and stage of the cancer.
Today's treatment options target radiation more directly to a tumor — quickly, and less invasively — shortening overall radiation treatment times. And using new Internet-enabled tools, physicians across the country can collaborate by sharing millions of calculations and detailed algorithms for customizing the best treatment protocols for each patient. With just a few computer key strokes, complicated treatment plans can be anonymously shared with other physicians at remote sites who have expertise in a particular oncologic area. Through this collaboration, doctors offer their input and suggestions for optimizing treatment. In turn, the patient benefits from a wide community of physicians who share expertise based upon their research, clinical expertise and first-hand experience.
The result is safer, more effective treatments. Here are five of the most exciting examples:
1. Turning breast cancer upside down
When the breast is treated while the patient is lying face down, with radiation away from the heart and lungs, a recent study found an 86 percent reduction in the amount of lung tissue irradiated in the right breast and a 91 percent reduction in the left breast. Additionally, administering prone-position radiation therapy in this fashion does not inhibit the effectiveness of the treatment in any way.
2. Spacer gel for prostate cancer
Prostate cancer treatment involves delivering a dose of radiation to the prostate that will destroy the tumor cells, but not adversely affect the patient. A new hydrogel, a semi-solid natural substance, will soon be used to decrease toxicity from radiation beams to the nearby rectum. The absorbable gel is injected by a syringe between the prostate and the rectum which pushes the rectum out of the way while treating the prostate. As a result, there is much less radiation inadvertently administered to the rectum through collateral damage. This can significantly improve a patient's daily quality of life — bowel function is much less likely to be affected by scar tissue or ulceration. [Facts About Prostate Cancer (Infographic )]
3. Continual imaging improves precision
Image-Guided Radiation Therapy (IGRT) uses specialized computer software to take continual images of a tumor before and during radiation treatment, which improves the precision and accuracy of the therapy. A tumor can move day by day or shrink during treatment. Tracking a tumor's position in the body each day allows for more accurate targeting and a narrower margin of error when focusing the beam. It is particularly beneficial in the treatment of tumors that are likely to move during treatment, such as those in the lung, and for breast, gastrointestinal, head and neck and prostate cancer.
In fact, the prostate can move a few millimeters each day depending on the amount of fluid in the bladder and stool or gas in the rectum. Head and neck cancers can shrink significantly during treatment, allowing for the possibility of adaptive planning (changing the beams during treatment), again to minimize long term toxicity and side effects.
4. Lung, liver and spine cancers can now require fewer treatments
Stereotactic Body Radiation Therapy (SBRT) offers a newer approach to difficult-to-treat cancers located in the lung, liver and spine. It is a concentrated, high-dose form of radiation that can be delivered very quickly with fewer sessions. Conventional treatment requires 30 radiation treatments daily for about six weeks, compared to SBRT which requires about three to five treatments over the course of only one week. The cancer is treated from a 3D perspective in multiple angles and planes, rather than a few points of contact, so the tumor receives a large dose of radiation, but normal tissue receives much less. By attacking the tumor from many different angles, the dose delivered to the normal tissue (in the path of any one beam) is quite minimal, but when added together from a multitude of beams coming from many different planes, all intersecting inside the tumor, the cancer can be annihilated.
5. Better access to hard-to-reach tumors
Proton-beam therapy is a type of radiation treatment that uses protons rather than x-rays to treat cancer. Protons, however, can target the tumor with lower radiation doses to surrounding normal tissues, depending on the location of the tumor. It has been especially effective for replacing surgery in difficult-to-reach areas, treating tumors that don't respond to chemotherapy, or situations where photon-beam therapy will cause too much collateral damage to surrounding tissue. Simply put, the proton (unlike an x-ray) can stop right in the tumor target and give off all its energy without continuing through the rest of the body. One of the more common uses is to treat prostate cancer. Proton therapy is also a good choice for small tumors in areas which are difficult to pinpoint — like the base of the brain — without affecting critical nerves like those for vision or hearing. Perhaps the most exciting application for this treatment approach is with children. Since children are growing and their tissues are rapidly dividing, proton beam radiation has great potential to limit toxicity for those patients. Children who receive protons will be able to maintain more normal neurocognitive function, preserve lung function, cardiac function and fertility.
While cancer will strike more than 1.6 million Americans in 2015, treatments like these are boosting survival rates. In January 2014, there were nearly 14.5 million American cancer survivors. By January 2024, that number is expected to increase to nearly 19 million.
But make no mistake — radiation therapy, one of the most powerful resources used to defeat cancer, is not done yet. As we speak, treatment developments in molecular biology, imaging technology and newer delivery techniques are in the works, and will continue to provide cancer patients with even less invasive treatment down the road.
It may surprise fans of Johanna Basford’s intricately hand-drawn coloring books that the artist is, by her own admission, “pretty bad” at coloring.
“I can’t stay in the lines,” she said sheepishly.
Not that it matters. Ms. Basford’s coloring book “Secret Garden,” a 96-page collection of elaborate black-and-white ink drawings of flowers, leaves, trees and birds, has become a global best-seller.
Since its release in spring 2013, “Secret Garden” has sold more than 1.4 million copies in 22 languages. It shot to the top of Amazon’s best-seller list this month, overtaking books by authors like Harper Lee, Anthony Doerr and Paula Hawkins. Her follow-up, “Enchanted Forest,” which came out in February, is briskly selling through its first print run of nearly 226,000 copies.
What makes Ms. Basford’s breakout success all the more surprising is her target audience: adults who like coloring books.
There are, it seems, a lot of them. Though it is tempting to describe the market for her books as niche, Ms. Basford, a 31-year-old illustrator in Aberdeenshire, Scotland, has quickly outgrown that label.
Like Play-Doh, jungle gyms and nursery rhymes, coloring books have always seemed best suited for the preschool set. So Ms. Basford and her publisher were surprised to learn that there was a robust — and lucrative — market for coloring books aimed at grown-ups. When they first tested the waters with “Secret Garden” a year ago, they released a cautiously optimistic first printing of 16,000 books.
“I thought my mom was going to have to buy a lot of copies,” Ms. Basford said. “When the sales started to take off, it was a real shock.”
Surging demand caught Ms. Basford and her publisher off guard. Fan mail poured in from busy professionals and parents who confided to Ms. Basford that they found coloring in her books relaxing. More accolades flowed on social media, as people posted images from their coloring books.
Hard-core fans often buy several copies of her books at a time, to experiment with different color combinations. Others have turned it into a social activity. Rebekah Jean Duthie, who lives in Queensland, Australia, and works for the Australian Red Cross, says she regularly gathers with friends for “coloring circles” at cafes and in one another’s homes.
“Each page can transport you back to a gentler time of life,” she said of Ms. Basford’s books in an email.
Ms. Basford has become something of a literary celebrity in South Korea, where “Secret Garden” has sold more than 430,000 copies, she says. The craze was kicked off in part, it seems, by a Korean pop star, Kim Ki-bum, who posted a delicately colored-in floral pattern from Ms. Basford’s book on Instagram, where he has 1.8 million followers.
Part of the apparent appeal is the tactile, interactive nature of the books, which offer respite to the screen-weary. “People are really excited to do something analog and creative, at a time when we’re all so overwhelmed by screens and the Internet,” she said. “And coloring is not as scary as a blank sheet of paper or canvas. It’s a great way to de-stress.”
Ms. Basford started out in fashion, working on silk-screen designs. Then she opened a studio on her parents’ trout and salmon farm in Scotland, and began designing hand-drawn wallpaper for luxury hotels and boutiques. When the financial crisis hit, her business evaporated. She closed the studio and found work as a commercial illustrator for companies like Starbucks, Nike and Sony.
Her publishing break came in 2011, when an editor at Laurence King Publishing discovered her work online. The editor thought her graceful illustrations could work well as a children’s coloring book.
“I came back and said I would like to do a coloring book for grown-ups, and it got a bit quiet for a moment,” Ms. Basford said. “Coloring books for adults weren’t as much of a thing then.”
To convince them that it was a viable market, she drew five sample pages of detailed, mosaic-like illustrations. The publishers were sold.
“When Johanna first approached us with the idea, we knew that people would love her illustrations as much as we did, but could never have predicted just how big the adult coloring trend would be,” said Jo Lightfoot, editorial director of Laurence King Publishing.
Ms. Basford spent the next nine months working on the book at night and freelancing as an illustrator during the day. Occasionally she had doubts. “I was worried that coloring for adults was silly and it was just me that wanted to do it,” she said.
It turns out she was far from alone. Other entries to this small but growing category include Patricia J. Wynne’s lavish, nature-themed Creative Haven coloring books — discreetly described as being “designed for experienced colorists” — and the more explicitly titled “Coloring Books for Grownups,” released by Chiquita Publishing. A subspecies of these books promote the meditative aspects of coloring and doodling, including “Color Me Calm” (subtitle: “A Zen Coloring Book”) and books that promise “Easy Meditation Through Coloring.”
Major publishers are seizing on the trend. This year, Little, Brown will release four illustrated coloring books for adults, all subtitled “Color Your Way to Calm.” The books, “Splendid Cities” by the British artists Rosie Goodwin and Alice Chadwick and three titles by the French illustrator Zoé de Las Cases, feature detailed cityscapes with famous landmarks, cafes and street life. Promotional materials for the books emphasize the health benefits of “mindful coloring,” noting that the activity “has been shown to be a stress reliever for adults.”
Ms. Basford is now working on her third book, after soliciting suggestions for themes from fans. A vocal faction has requested an ocean-themed coloring book. “I’ve been drawing starfish and seahorses this afternoon,” she said.
In the meantime, “Secret Garden” has sold out in many markets, to the consternation of fans. Laurence King is reprinting 75,000 copies for the United States.
This month, Ms. Basford tried to calm her followers with a post on her Facebook page, promising that newly printed books would be shipping in a few weeks: “Don’t panic! New stock of Secret Garden and Enchanted Forest is on its way!”
Some were not placated. “WEEKS?” one frantic follower replied. “I can’t possibly wait WEEKS!”
Latinos are the largest ethnic minority group in the United States, and it's expected that by 2050 they will comprise almost 30 percent of the U.S. population. Yet they are also the most underserved by health care and health insurance providers. Latinos' low rates of insurance coverage and poor access to health care strongly suggest a need for better outreach by health care providers and an improvement in insurance coverage. Although the implementation of the Affordable Care Act of 2010 seems to have helped (approximately 25 percent of those eligible for coverage under the ACA are Latino), public health experts expect that, even with the ACA, Latinos will continue to have problems accessing high-quality health care.
Alex Ortega, a professor of public health at the UCLA Fielding School of Public Health, and colleagues conducted an extensive review of published scientific research on Latino health care. Their analysis, published in the March issue of the Annual Review of Public Health, identifies four problem areas related to health care delivery to Latinos under ACA: The consequences of not covering undocumented residents. The growth of the Latino population in states that are not participating in the ACA's Medicaid expansion program. The heavier demand on public and private health care systems serving newly insured Latinos. The need to increase the number of Latino physicians and non-physician health care providers to address language and cultural barriers.
"As the Latino population continues to grow, it should be a national health policy priority to improve their access to care and determine the best way to deliver high-quality care to this population at the local, state and national levels," Ortega said. "Resolving these four key issues would be an important first step."
Insurance for the undocumented
Whether and how to provide insurance for undocumented residents is, at best, a complicated decision, said Ortega, who is also the director of the UCLA Center for Population Health and Health Disparities.
For one thing, the ACA explicitly excludes the estimated 12 million undocumented people in the U.S. from benefiting from either the state insurance exchanges established by the ACA or the ACA's expansion of Medicaid. That rule could create a number of problems for local health care and public health systems.
For example, federal law dictates that anyone can receive treatment at emergency rooms regardless of their citizenship status, so the ACA's exclusion of undocumented immigrants has discouraged them from using primary care providers and instead driven them to visit emergency departments. This is more costly for users and taxpayers, and it results in higher premiums for those who are insured.
In addition, previous research has shown that undocumented people often delay seeking care for medical problems.
"That likely results in more visits to emergency departments when they are sicker, more complications and more deaths, and more costly care relative to insured patients," Ortega said.
Insuring the undocumented would help to minimize these problems and would also have a significant economic benefit.
"Given the relatively young age and healthy profiles of undocumented individuals, insuring them through the ACA and expanding Medicaid could help offset the anticipated high costs of managing other patients, especially those who have insurance but also have chronic health problems," Ortega said.
The growing Latino population in non-ACA Medicaid expansion states
A number of states opted out of ACA Medicaid expansion after the 2012 Supreme Court ruling that made it voluntary for state governments. That trend has had a negative effect on Latinos in these states who would otherwise be eligible for Medicaid benefits, Ortega said.
As of March, 28 states including Washington, D.C., are expanding eligibility for Medicaid under the ACA, and six more are considering expansions. That leaves 16 states who are not participating, many of which have rapidly increasing Latino populations.
"It's estimated that if every state participated in the Medicaid expansion, nearly all uninsured Latinos would be covered except those barred by current law -- the undocumented and those who have been in the U.S. less than five years," Ortega said. "Without full expansion, existing health disparities among Latinos in these areas may worsen over time, and their health will deteriorate."
New demands on community clinics and health centers
Nationally, Latinos account for more than 35 percent of patients at community clinics and federally approved health centers. Many community clinics provide culturally sensitive care and play an important role in eliminating racial and ethnic health care disparities.
But Ortega said there is concern about their financial viability. As the ACA is implemented and more people become insured for the first time, local community clinics will be critical for delivering primary care to those who remain uninsured.
"These services may become increasingly politically tenuous as undocumented populations account for higher proportions of clinic users over time," he said. "So it remains unclear how these clinics will continue to provide care for them."
Need for diversity in health care workforce
Language barriers also can affect the quality of care for people with limited English proficiency, creating a need for more Latino health care workers -- Ortega said the proportion of physicians who are Latino has not significantly changed since the 1980s.
The gap could make Latinos more vulnerable and potentially more expensive to treat than other racial and ethnic groups with better English language skills.
The UCLA study also found recent analyses of states that were among the first to implement their own insurance marketplaces suggesting that reducing the number of people who were uninsured reduced mortality and improved health status among the previously uninsured.
"That, of course, is the goal -- to see improvements in the overall health for everyone," Ortega said.
Source: University of California - Los Angeles
Exactly a year ago, we decided to publish the gender data on founders at Rock Health. Despite women being the majority of our team and our board, only 30% of our portfolio companies had a female founder (today, we are at almost 34%). Because we’d like to help our portfolio companies access a diverse talent pool, we began the XX in Health initiative nearly four years ago.
The aim of this initiative is to bring women together to network and support one another. The 2,400 members of the group share resources and ideas on LinkedIn and meet regularly across the country. This week we’re hosting a webinar on the topic for both men and women, and next week we’ll host our sixth XX in Health Retreat in NYC.
Today, through this initiative, we are proud to share our third annual report on the state of women in healthcare. Our past reports on this topic have been some of our most popular content, and we encourage you to share this report with your colleagues.
Women are still underrepresented in leadership positions in healthcare.
Despite making up more than half the healthcare workforce, women represent only 21% of executives and 21% of board members at Fortune 500 healthcare companies. Of the 125 women who carry an executive title, only five serve in operating roles as COO or President. And there’s only one woman CEOof a Fortune 500 healthcare company.
Hospital diversity fares slightly better. At Thomson Reuters 100 Top Hospitals, women make up 27% of hospital boards, and 34% of leadership teams. There are 97 women that carry a C-level title at these hospitals and 10 women serve as hospital CEO.
We know from our funding data that women make up only 6% of digital health CEOs funded in the last four years. When we looked at the gender breakdown of the 148 VC firms investing in digital health, we understood why. Women make up only 10% of partners, those responsible for making final investment decisions. In fact, 75 of those firms have ZERO women partners (including Highland Capital, Third Rock, Sequoia, Shasta Ventures). Venture firms with women investment partners are 3X more likely to investin companies with women CEOs. It’s no wonder women CEOs aren’t getting funded.
The problem is real, and the problem matters.
We surveyed over 400 women in the industry to better understand the sentiment around gender discrimination. 96% of the women we surveyed believe gender discrimination still exists. And almost half of them cited gender as one of the biggest hurdles they’ve faced professionally.
Often these are micro-inequities that compound over one’s career. MIT Professor Mary Rowe describes these instances as “apparently small events which are often ephemeral and hard-to-prove, events which are covert, often unintentional, frequently unrecognized by the perpetrator.” But they create work environments which hold women back.
When senior women are scarce in an organization, a vicious cycle of “second-generation” gender bias kicks in. Researchers describe this bias as barriers that “arise from cultural assumptions and organizational structures, practices, and patterns of interaction that [put] women at a disadvantage.” Fewer women leaders means fewer role models for would-be women leaders. On the flip side, when women who are early in their career see more women in senior leadership positions, it sends the message that they too belong in the C-suite.
The good news is that achieving diverse leadership teams is not just a moral imperative, it’s good for business too.
Having a diverse team creates a positive, virtuous cycle. Companies with women CEOs outperform the stock market, and companies with women on their boards outperform male-only boards by 26 percent. Researchers even estimate that transitioning from a single-gender office to an office evenly split between men and women be associated with a revenue gain of 41%.
Not only do companies with more women in leadership yield better economic returns, recent research also suggests it helps mitigate risk. One study shows that each additional female director reduces the number of a company’s attempted takeover bids by 7.6%. Another study indicates that companies with more women on their board had fewer instances of governance-related scandals such as bribery, corruption, fraud, and shareholder battles.
Let’s get together and support one another.
Empower your colleagues to promote gender equality in the workplace. This month we challenge you to reach out to that mentor, manager, peer, or mentee with whom you’ve been meaning to connect with. Ask her to grab coffee and send us a picture by April 30 so we can share it on the XX in Health website!
Historically, both men and women have filled the challenging and rewarding role of a nurse. It wasn’t until the Civil War, when nearly 3 million men filled the ranks of two competing American armed forces, that women began to dominate the field.
Today, over 43 million Americans are aged 65 or older – a number that is expected to double over the next 35 years. A larger elderly population means a greater need for long-term health services, and as a result, the healthcare field is one of the fastest-growing industries.
Why does this matter?
1. The U.S. is already on the verge of a nursing shortage.
The American Association of Colleges of Nursing reports that the U.S. is experiencing a shortage of Registered Nurses (RNs) that is expected to intensify as Baby Boomers age and the need for health care grows.
Did you know only 7 percent of nurses are currently men? According to the latest National Sample Survey of Registered Nurses conducted by the Health Resources and Services Administration, the percentage of male nurses has more than doubled in the past three decades, but still lingers at 7% today. This number is expected to triple within the next few decades as the need for both male and female healthcare professionals continues to grow.
2. A diverse population needs a diverse nursing staff.
According to the American Association of Colleges of Nursing (AACN), men are enrolling in nursing programs at a higher rate compared to the past. The IOM report states that there still need to be an emphasis on gender diversification and inclusion in the workforce.
The IOM Report also states that the nursing profession “needs to continue efforts to recruit men; their unique perspectives and skills are important to the profession and will help contribute additional diversity in the workforce.” The increase in men pursuing a nursing career will help create a more diverse healthcare environment.
3. Discrimination issues must be overcome.
The idea that men cannot be nurses will never be eradicated until men take to the profession in greater numbers. While nursing is seen as a nontraditional career for men today, the stereotype must change -- nursing is simply too important of a job, and too attractive of a career.
“There are just far too many benefits that come along with nursing, such as a flexible schedule, a secure position, and high pay,” notes the website NursingWithoutBorders.org, “and so it’s therefore difficult for anyone to refuse to pursue a field that only continues to grow.”
In a Johns Hopkins Outpatient Center exam room, medical interpreter Julie Barshinger is working with a Spanish patient, a woman in her early 40s with a stocky build and a dark ponytail, who is concerned about complications related to her recent nose surgery.
But first, the woman must complete a medical history form. “¿Qué significa vertigo?” (“What is vertigo?”) she asks, as Barshinger goes through the list of symptoms on the form, verbally interpreting them from English to Spanish. Then later, “No sé qué es un soplo cardiac … ” Barshinger interprets the question — “I don’t know what a heart murmur is” — for the nurse who is preparing a nasal spray for the patient that will allow the doctor to look inside her nose.
“If it doesn’t apply to her, don’t answer it,” the nurse says kindly.
“I just want you to know that I have to interpret everything she says,” explains Barshinger, who is one of 18 full-time interpreters in Johns Hopkins Medicine International’s Language Access Services office. Part of Barshinger’s job is educating providers about her role.
Later, the nurse starts to leave the room to see another patient before the woman has completed her medical history form. “I can’t continue if you’re not in the room with me,” Barshinger says. The patient is consistently giving additional information about her symptoms: She doesn’t see well since her operation; she has some nasal bleeding; she sees the room spinning when she lies down. It’s crucial for Barshinger to communicate these potentially important details to the nurse, who stays in the room, answering questions when needed, until the form is complete.
Throughout the interaction, Barshinger knows little about the full scope of the patient’s health history. But she doesn’t need to know. “I’m not in charge of her care,” she says. “I’m only her voice. I want to make sure her voice is being heard by the right people. I’m also the voice of the provider, so she can communicate the very necessary and important information that she has to the patient.”
While Johns Hopkins, like other hospitals that receive federal funding, has been providing interpretation services for 50 years — since passage of the Civil Rights Act of 1964, which prohibits discrimination based on national origin — requests for interpreters at The Johns Hopkins Hospital have grown dramatically since 2010, jumping from 23,000 to more than 50,000 annually.
This is due in part to the slightly rising limited English proficiency population in Baltimore City, which grew by about 4,000 people between 2000 and 2012, according to the U.S. Census. Today, the hospital also serves more refugees, about 2,500 of whom settled in Baltimore City between 2008 and 2012.
But Susana Velarde, administrator for Language Access Services at Johns Hopkins Medicine International, says the increase in requests is also due to the growing understanding among health care providers that they can do a better job treating their patients with limited English proficiency with the help of interpreters.
Because they prevent communication errors, certified interpreters improve patient safety. A 2012 study in the Journal of General Internal Medicine found that patients with limited English proficiency who did not have access to interpreters during admission and discharge had to stay in the hospital between 0.75 and 1.47 days longer than patients who had an interpreter on both days. Moreover, when the interpreter has 100 hours of medical interpretation training — a qualification that researchers have found is more important than years of experience — they made two-thirds fewer errors than their counterparts with less training, according to a 2012 Annals of Emergency Medicine study.
The Language Access Services office’s full-time interpreters—who speak Spanish, Chinese-Mandarin, Korean, Russian, Arabic and Nepali — participate in an extensive two-year training program, which includes classes, tests and shadowing. Fifty percent of the team is certified; the rest are working toward certification, if available in their language. The office also has 45 medical interpreter floaters, and interpretation services are available 24/7 in person, over the phone or through a video monitor for patients with limited English proficiency who live in the Baltimore area and international residents who come to Johns Hopkins for treatment.
“We are the conduit, but also the clarifier,” says Spanish interpreter Rosa Ryan. “We are not simply repeating words but making sure the message is understood.”
For example, at the end of her visit on the otolaryngology floor, Barshinger walks to the front desk with the ponytailed Spanish woman to help her make a follow-up appointment. With Barshinger interpreting, the woman learns that she must get a Letter of Medical Necessity from her current insurer or change insurance companies before coming back to Johns Hopkins. When the administrator walks away, Barshinger checks in with the woman to make sure she understands the instructions.
“The patient might nod, but the information might not be registering,’” she says. “I try to check for clarification if I sense there is a disconnect.”
Interpreters are also cultural brokers. Yinghong Huang, a Chinese-Mandarin interpreter, remembers when a nurse in labor and delivery tried to give a Chinese patient a cup of ice water. “In China, for a woman who has just delivered a baby, we don’t want her to touch anything cold, let alone ice,” Huang explains. This is one of the many rules that Chinese women abide by for a month to help the body recover from childbirth. With Huang present, providers knew to give the patient hot water with her medicine instead.
Despite the increasing demand for interpreters, their expertise too often goes untapped, says Lisa DeCamp, assistant professor of pediatrics at the school of medicine. She is the lead author of a 2013 Pediatrics study that found that 57 percent of pediatricians who completed national surveys in 2010 still reported using family members as interpreters.
This is a bad practice for many reasons, she says. For one thing, family members often don’t have specialized knowledge of medical terminology. Moreover, both patients and family members may censor information. “If you’re talking about something that is intimate or personal and your son is translating for you, you might not want to disclose something about your sexual activity, your drug use or anything else sensitive that could be contributing to your problem,” says DeCamp, who is also a pediatrician at Johns Hopkins Bayview Medical Center.
Even physicians with basic skills in a particular language should use an interpreter to prevent misunderstandings. “I [know] some high school Spanish, but I’m nowhere near fluent, so I need an interpreter,” says Cynthia Argani, director of labor and delivery at Hopkins Bayview, where about 70 percent of her department’s patient population speaks Spanish. “It’s not fair to the patient not to use one. The message can get skewed.”
DeCamp, who has passed a test certifying her as a bilingual physician, offers a real-life example from the literature that shows how this can happen. A pediatrician with limited Spanish language skills instructed parents to use an antibiotic to treat their child’s ear infection. In Spanish, “if you use the preposition, it really means, ‘put in the ear,’” she says. “So the family was putting the specified amount of amoxicillin that should be taken by mouth in the ear. That child is not going to die from an ear infection, but he’s having pain and a fever, and the family doesn’t have clear instructions on how to provide medication.”
On Barshinger’s rounds, after her otolaryngology visit, she walks at an impressively fast pace to The Charlotte R. Bloomberg Children’s Center, where a mother recognizes her and asks her to be her interpreter. The provider who requested Barshinger’s services is not ready yet, so she has time to help.
A doctor carrying a sheaf of papers joins them in a busy hallway. She points to a long list of care instructions translated into Spanish, then begins to explain them to the mother. Because the doctor is verbally giving the instructions, Barshinger interprets. The mother needs to buy an extra-strength, over-the-counter medication and give her daughter a second medication three times a day, which she will need to “swish and spit,” the doctor says. A third medication will be applied to the daughter’s face two times a day, and a special shampoo is needed to wash her hair. Before an upcoming dentist appointment, she’ll also need to give her daughter three amoxicillin. When the doctor steps away, the mother asks Barshinger a question about her daughter’s dental visit, which Barshinger interprets when the doctor returns.
While interpreting, Barshinger stands to the side of the patient’s mother, allowing the doctor and the mother to face each other and communicate directly with one another. This simple tactic encourages providers to develop a rapport with their patients with limited English proficiency.
The goal? “To make the patient feel like the appointment is with him and not with the interpreter,” says Velarde. “The interpreter is just the voice. We want providers to have a bond with their patients, like they do when everyone is speaking English.”
Tapping the expertise of interpreters doesn’t have to complicate things for physicians, says Lisa DeCamp, a bilingual physician at Johns Hopkins Bayview Medical Center. Her advice for colleagues:
Educate the interpreter about what you’re doing so they’re not going in blind. Say a patient has severe abdominal pain. Providers can quickly explain to the interpreter that the first job is to rule out appendicitis.
Sit across from the patient, with the interpreter standing at the patient’s side, and talk directly to the patient. The goal is for the provider and the patient to feel like they have a relationship with each other despite language barriers. When possible, use short phrases to help the interpreter keep up with the conversation.
Found In Translation
Arabic translator Lina Zibdeh remembers the first time she saw the recommendation in a patient education document that leftover medications should be discarded in used cat litter or coffee grounds.
There isn’t a direct translation for this concept in Arabic, a language that is spoken in different dialects by 22 countries but written in one common form. “It can take hours and extensive research to make sure a concept like this is translated correctly,” says Zibdeh, who translates written materials, such as informed consent forms, welcome packets, care instructions, brochures, video scripts and more. In this case, Zibdeh had to add an additional sentence to explain that medications should be disposed of in this way so they are not enticing to children and pets.
While translation programs like Google Translate are readily available and easy to use, they often produce inaccurate translations, which can confuse patients and lead to poor health outcomes. This is because words in sentences can be organized in different ways from one language to another. Thus, when online programs translate those sentences from, say, English to Chinese, they can change the meaning, says Chinese-Mandarin interpreter and translator Yinghong Huang. Some English words, such as discharge, also have multiple meanings. “It’s very rare for a program to get the right meaning,” Huang says. Even Huang has to use tools, such as her cellphone and an online dictionary, to produce accurate translations.
Along with improving health outcomes, documents that are available in a patient’s own language can make him or her feel more comfortable and secure, says Zibdeh, who organized the American Translators Association’s first webinar for the Arabic Division on Arabic Medical Translation in early 2014. “It helps that patient feel closer to home,” she adds.
A Dutch organization called "Ambulance Wens" (Ambulance Wish) fulfills the last wishes of terminally ill patients free of charge thanks to its 200 medical volunteers.
The company says, "There are still too many patients who die without getting to close everything. One of those reasons is the inability to achieve certain desires because the patient is no longer mobile and other existing facilities are inadequate for this purpose."
Special ambulances and stretchers help transport the patients safely and comfortably. Typical excursions include a visit to the beach, a visit to a neighbor who is also no longer mobile, and various places where the patient has special memories.
This woman's final wish was to visit the Rijksmuseum in Amsterdam.
Another woman enjoys the view from her favorite vacation destination in Tuscany.
This gentleman asked for one last view from the Euromast observation tower.
And this man asked to see the mills in Kinderdijk one last time.
Amsterdam is not the only place doing such wonderful things. A hospice outside Seattle made an old forest ranger's dying wish come true.
"Ed expressed one last hope to the hospice chaplain: He wanted to commune with nature one more time."
As the hospice wrote on its Facebook page, "People sometimes think that working in hospice care is depressing. This story ... demonstrates the depths of the rewards that caring for the dying can bring."
Catharine Paddock PhD
Drug development is a costly and lengthy business, not helped by the fact there is a high failure rate in drug testing due to the reliance on animal models. Animal biology is not an ideal substitute for human biology, but until something better comes along, it is all we have. Now, a new study suggests the organ-on-a-chip method may offer a more ideal model.
Study leader Kevin Healy, a bioengineering professor at the University of California-Berkeley, says:
"It takes about $5 billion on average to develop a drug, and 60% of that figure comes from upfront costs in the research and development phase. Using a well-designed model of a human organ could significantly cut the cost and time of bringing a new drug to market."
As around one third of the candidate drugs that are ditched are those that seem to have a bad effect on the heart, Prof. Healy and colleagues decided to design a model based on the human heart.
They conclude that their work is a major step forward in the development of faster, more accurate ways of testing drug safety. Prof. Healy believes that:
"Ultimately, these chips could replace the use of animals to screen drugs for safety and efficacy."
In their study, they describe how they devised the model and tested it with cardiovascular medications.
'Heart-on-a-chip' contains a network of pulsating cardiac muscle cells
The human heart model that Prof. Healy and colleagues devised is a "heart-on-a-chip" comprising an inch-long silicone device with a thin network of pulsating cardiac muscle cells.
In the journal Scientific Reports, the team says their heart-on-a-chip - which they call a "cardiac microphysiological system (MPS)" - is an ideal tool for testing toxic side effects of new drugs on the human heart because it ticks four important boxes:
- It uses cells that have human genes
- The cells are aligned in a way that reflects the structure of human heart tissue
- It mimics the dynamics of blood flow in heart tissue
- It can be used for biological, electrophysiological and physiological analysis.
The authors note that using animal models to predict human reactions to drugs often fail because of fundamental differences in biology between species. For example, the ion channels that conduct the electrical pulses that heart cells send out can vary in number and type between animals and humans.
"Many cardiovascular drugs target those channels, so these differences often result in inefficient and costly experiments that do not provide accurate answers about the toxicity of a drug in humans," Prof. Healy explains.
Device is populated with heart cells made from human-induced pluripotent stem cells
The heart-on-a-chip is made of heart cells generated from human-induced pluripotent stem cells - the adult stem cells that can be coaxed to differentiate into various types of tissue.
The heart-on-a-chip has a 3D geometry and spacing that is comparable to that of connective tissue fiber in a human heart. The researchers then populated this with layers of differentiated heart cells, which in the confined geometry were forced to align in one direction.
Microfluidic channels on either side of the cell-populated area perform like blood vessels and mimic the same dynamics of nutrients and drugs diffusing from blood vessels into human tissue.
Such a setup could also serve as a model of how the cells get rid of their waste products, note the authors.
Lead author Dr. Anurag Mathur, a postdoctoral scholar in Healy's lab and a fellow of the California Institute for Regenerative Medicine, explains:
"This system is not a simple cell culture where tissue is being bathed in a static bath of liquid. We designed this system so that it is dynamic; it replicates how tissue in our bodies actually gets exposed to nutrients and drugs."
Heart-on-a-chip tested with four drugs and reacted as expected
The authors explain how within 24 hours of populating the device with heart cells, the engineered heart tissue was beating on its own at the normal rate of 55-80 beats per minute.
The team tested four well-known cardiovascular drugs on the device: isoproterenol, E-4031, verapamil and metoprolol. They used changes in the pulse rate of the tissue to measure the response to the drugs.
The changes in pulse rate were as expected for the drugs. For example, after half an hour of being exposed to isoproterenol - a drug used to treat slow heart rate, or bradycardia - the pulse rate of the heart-on-a-chip increased from 55 to 124 beats per minute.
Multi-organ testing devices could have hundreds of microphysiological cell systems
The engineered tissue remained viable and worked for several weeks. Such a timescale is sufficient for testing several different drugs, Prof. Healy says.
He and his colleagues are now investigating whether the method can be used to model multi-organ interactions. Prof. Healy notes:
"Linking heart and liver tissue would allow us to determine whether a drug that initially works fine in the heart might later be metabolized by the liver in a way that would be toxic."
The team anticipates the "widespread adoption" of organ-on-a-chip for drug screening and disease modeling and foresee devices containing hundreds of microphysiological cell systems.
The project is funded through the Tissue Chip for Drug Screening Initiative, which is sponsored by the National Institutes of Health.
In October 2014, Medical News Today learned how the University of Kansas is leading the development of a lab-on-a-chip that promises to detect lung cancer - and possibly other deadly cancers - much earlier. That method, which only uses a small drop of a patient's blood, is also based on microfluid technology. It analyzes the contents of exosomes - tiny bags of molecules that cells release now and again.
By Heather Stringer for Nurse.com
In 2010, the Institute of Medicine issued eight recommendations that dared to transform the nursing profession by 2020. This year marks the midway point for reaching the goals outlined in the report “The Future of Nursing: Leading Change, Advancing Health,” and statistics at halftime offer a glimpse into nursing’s progress so far.
Although the numbers in some areas have altered little in the first few years, infrastructure changes have been set in motion that will lead to more noticeable improvements in the data in the next several years, said Susan Hassmiller, PhD, RN, FAAN, the Robert Wood Johnson Foundation senior adviser for nursing. The RWJF partnered with the IOM to produce the report.
“I am a very impatient person and would like things to move faster, but we have to remember that we are changing social norms with these goals,” Hassmiller said. “We are trying, for example, to convince hospital leaders, nursing students and educational institutions that it is important for nurses to have a baccalaureate degree, and that takes time.”
Hassmiller is referring to Recommendation 4 of the report, which calls academic nurse leaders across all schools of nursing to work together to increase the proportion of nurses with a baccalaureate degree from 50% to 80% by 2020. The most recent data collected from the American Community Survey by the Future of Nursing: Campaign for Action found that the percentage of employed nurses with a bachelor’s degree or higher only climbed 2% between 2010 and 2013. However, Hassmiller suggested the percentage is likely to increase rapidly in coming years because nursing schools have increased capacity to accommodate more students. As a result, the number of nurses enrolled in RN-to-BSN programs skyrocketed between 2010 and 2014, from about 77,000 nurses in 2010 to 130,300 students in 2014, according to the American Association of Colleges of Nursing — a 69% increase.
Campaign for Action leaders also are optimistic about the profession’s ability to approach the 80% goal because nursing schools are beginning to experiment with new models of education, such as bringing BSN programs to community colleges.
Traditionally, students spend at least three years in a community college earning an associate’s degree to become an RN — at least a year for prerequisites and another two to complete the nursing program, Hassmiller said. These RNs may work for a few years before returning to school to earn a BSN — and some may not return at all, said Jenny Landen, MSN, RN, FNP-BC, dean of the School of Health, Math and Sciences at Santa Fe Community College in New Mexico. To avoid losing potential BSN students, leaders from New Mexico’s university and community colleges began meeting to discuss a new paradigm: students who were dually enrolled in a community college and a university BSN program.
The educators started by forming a common statewide baccalaureate curriculum that would be used by all community colleges and universities, Landen said. The educators also discussed how to pool resources, such as offering university courses online at local community colleges. “This opens the opportunity of earning a BSN to people who need to stay in their communities during school,” she said. “They may have family commitments locally, and they can take the baccalaureate degree courses at the community college tuition fee, which is much less expensive.”
Four community colleges in New Mexico have launched dual enrollment programs within the last year. At Santa Fe Community College, there are far more applicants than the program can hold, Landen said. Community colleges and universities in other parts of the country also are working together to create programs in which nursing students can be dually enrolled. In addition to nursing schools buying into the need for more BSN-prepared nurses, there also is evidence that employers are moving toward this new standard as well. According to a study released in February in the Journal of Nursing Administration, the percentage of institutions requiring a BSN when hiring new RNs jumped from 9% to 19% between 2011 and 2013.
So far, the national data related to Recommendation 5 — double the number of nurses with a doctorate by 2020 — suggests there have been minimal changes in the number of employed nurses with a doctorate, yet there has been a significant increase in the number of students pursuing this level of education. According to the JONA article, on average about 3.1% of employed nurses in all institutions had a doctorate in 2011. This rose to 3.6% in 2013. This percentage likely will increase in the coming years because of the proliferation of doctor of nursing practice programs since 2010. These programs are geared for advanced practice RNs who are interested in returning to the clinical setting after earning a doctoral degree. Between 2010 and 2013, the number of students enrolled in DNP programs doubled from just over 7,000 students to more than 14,600. There was a lesser increase in the number of students enrolled in PhD programs, up 12% from 4,600 to 5,100, according to the AACN.
“When the DNP degree became an option, it opened the opportunity of a higher level of education to the working nurse, not the researcher, and that was attractive to many nurses,” said Pat Polansky, MS, RN, director of program development and implementation at the Center to Champion Nursing in America. “Getting a research-based PhD takes longer and not every nurse can do that, so the DNP has become a wonderful option.”
Leaders at the Campaign for Action, however, acknowledge that it is important to find strategies to boost the number of PhD-prepared nurses because the profession needs those nurses in academia and other administrative, research or entrepreneurial roles where they are contributing to the solutions of a transformed healthcare system, Hassmiller said. To encourage more nurses to pursue the path of a PhD, in 2014 the RWJF launched the Future of Nursing Scholars Program, which awards $75,000 per scholar pursuing a PhD. This is matched with $50,000 by the student’s school, and the funds can be used over the course of three years.
In December, the nursing profession will have another opportunity to assess progress on the recommendations when the IOM releases findings from a study that is under way to assess the national impact of the Future of Nursing report. The changes happening in areas such as education are remarkable, Hassmiller said, and she is eagerly anticipating the results from the current IOM study.
“I would never modify the goals because you need something to strive for in order to affect change,” Hassmiller said. “I am extremely encouraged because we have never seen anything like this. For the first time in history, more than half of nurses have a bachelor’s degree, and it is going to keep climbing. The most challenging part has been the number of people that need to be influenced to make the business case as to why it is important, and it is finally happening.”
1) Remove scope-of-practice barriers.
2) Expand opportunities for nurses to lead and diffuse collaborative improvement efforts.
3) Implement nurse residency programs.
4) Increase the proportion of nurses with a baccalaureate degree to 80% by 2020.
5) Double the number of nurses with a doctorate by 2020.
6) Ensure that nurses engage in lifelong learning.
7) Prepare and enable nurses to lead change to advance health.
8) Build an infrastructure for the collection and analysis of interprofessional healthcare workforce data.
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