As part of its campaign against "too much medicine" The BMJ has published reviews that question the value of screening for breast cancer in women and aneurysm in men - asking whether the harm of "over-diagnosis" outweighs the benefit of detecting and treating real cases of disease.
In the case of breast cancer, the analysis of the history of screening for the disease, written by a public health expert, calls for "urgent agreement" in the debate and controversy that exists between scientists.
For abdominal aortic aneurysm, the review about screening men who do not have symptoms suggests that the ratio of harm to benefit of carrying out these programs has worsened over the years.
This, they say, is thanks to a reduction in risk factors such as smoking, which has reduced the chance that screening will succeed in finding actual cases.
And a third paper looks at the results of surveys that gauged the level of over-diagnosis people would accept from screening programs aiming to detect different cancers - finding a wide range of attitudes to the harm or benefit of screening.
In the research on abdominal aortic aneurysm (a swelling in the main artery from the heart, which can lead to death when it ruptures), the authors estimate that 176 of every 10,000 men invited to screening are over-diagnosed.
This means smaller aneurysms being picked up - and perhaps being repaired in preventive surgery - even though they might have swelled little and presented a low risk of rupturing.
The researchers describe the real-life consequences of the programs, which, in the UK, invite all men over the age of 65 for screening, and in the US, only those who have smoked (a risk factor that greatly increases the likelihood of an aneurysm). They explain:
"These men are unnecessarily turned into patients and may experience appreciable anxiety throughout their remaining lives."
"Moreover," the authors continue, "37 of these men [out of every 10,000 screened] unnecessarily have preventive surgery and 1.6 of them die as a consequence."
The authors quote men who have had abdominal aortic aneurysms detected by screening - they "report existential thoughts about frailty and mortality after diagnosis." One man describes his diagnosis as "a ticking bomb inside your stomach."
In addition to such risks of psychological burden, the authors cite the surgical risks for those who undergo a preventive operation, and the public health implications over cost-effectiveness.
"When health authorities invite asymptomatic men to screening, there should be no doubt that benefits clearly outweigh harms," the authors conclude. "We cannot judge whether this is true of abdominal aortic aneurysm screening: the harms have not been adequately investigated, as is true for cancer screening."
Value of breast cancer screening 'can be improved'
On the question of how good the harm-to-benefit ratio is for breast cancer screening, Prof. Alexandra Barratt, from the School of Public Health at the University of Sydney in Australia, gives an overview of the history of screening programs, and offers a list of ways to improve their benefit.
Writing her review for The BMJ's "too much medicine" campaign, Prof. Barratt believes "agreement between experts about over-diagnosis in breast cancer screening is urgently needed so that women can be better informed." She presses for the following measures, too:
- Do better research to quantify the true amount of over-diagnosis - by developing "internationally agreed standards" for studies that monitor the problem created by screening programs
- Investigate less aggressive treatment options for screen-detected breast cancers
- Be more wary of new technology - for example, digital mammography has increased cancer detection without reducing death rates, so three-dimensional mammography (tomosynthesis), which "promises a 30-50% increase in detection of breast cancers" should not be implemented without more research on "whether it alters the balance of benefit and harm"
- Provide quality information to women. "Many women continue to be 'prescribed' or encouraged to undergo screening rather than being supported to make an informed choice," says Prof. Barratt, yet "information is an intervention that may have both positive and detrimental effects"
- Think twice before extending screening programs - "extending screening to women in their 70s has been shown to significantly increase the incidence of early-stage breast cancer, and this could have detrimental effects for older women."
Prof. Barrett says lessons have been learned in breast cancer screening that should inform programs for other cancers. Breast cancer has "led the way in developing awareness" about the potential for screening to over-diagnose and treat people who have no symptoms, and this is also needed for "the early detection of lung and thyroid cancers, as well as breast and prostate cancers."
This neatly leads to the subject of the third paper, on cancer screening more generally, which analyzes people's risk attitudes in relation to the early detection of different cancers and varying levels of benefit.
Over-detection is acceptable to patients
Dr. Ann Van den Bruel - a senior clinical research fellow at the University of Oxford's Nuffield department of primary care health sciences in the UK - conducted a survey with colleagues "to describe the level of over-detection people would find acceptable in screening for breast, prostate and bowel cancer."
Her "striking" findings, from asking people in the UK's general population, were that more people would accept a screening program that created over-detection "in the entire population" being tested than would accept "no over-detection at all."
People aged 50 or older accepted less over-detection, however, and there was a wide overall variation in the risks of over-diagnosis that people would accept from cancer screening.
The average levels of "acceptability" ranged from 113 cases of over-detection in every 1,000 people screened, to 313 cases.
People were significantly less happy to accept the risk of being over-diagnosed with bowel cancer than they were of this happening with breast or prostate cancer - the latter, in other words, being more worthwhile screening for in terms of perceived benefit versus risk.
The following results from the study highlight the two extremes expressed for attitudes to screening:
- 4-7% of respondents indicated they would tolerate no amount of over-detection at all from a screening program
- 7-14% considered it would be acceptable for the entire screened population to be over-detected - that is, doing the screening would be worthwhile even if it resulted in all 1,000 people tested being unnecessarily diagnosed.
The survey asked questions about three different types of cancer screening: breast cancer for women, prostate cancer for men, and bowel cancer for both.
For each type, the researchers presented the absolute number of cases there were each year in the UK, plus a description of the treatment, including adverse effects. They then presented two scenarios of screening effectiveness: a 10% reduction in deaths from the specific cancer, or a 50% cut.
Dr. Van den Bruel says:
"People accepted more over-detection when they perceived a higher benefit from cancer screening, so from a 10% mortality reduction to 50% mortality reduction, median acceptability increased significantly, with a maximum of 313 cases per 1,000 people screened for breast cancer."
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.
Each year more than 15,000 women under the age of 55 die of heart disease in the United States. And younger women are twice as likely to die after being hospitalized for a heart attack as men in the same age group.
It doesn't help that women tend to delay seeking emergency care for symptoms of a heart attack such as pain and dizziness, says Judith Lichtman, an associate professor of epidemiology at the Yale School of Public Health. "We've known that for a while," she says.
In a small study published Tuesday in Circulation: Cardiovascular Quality and Outcomes, Lichtman and her colleagues looked into why women delay getting help. The researchers conducted in-depth interviews with 30 women, ages 30 to 55, who had been hospitalized after a heart attack.
It turned out that many had trouble recognizing that they were having symptoms of a heart attack. "A lot of them talk about not really experiencing the Hollywood heart attack," Lichtman tells Shots.
A heart attack doesn't necessarily feel like a sudden painful episode that ends in collapse, she notes. And women are more likely than men to experience vague symptoms like nausea or pain down their arms.
"Women may experience a combination of things they don't always associate with a heart attack," Lichtman says. "Maybe we need to do a better job of explaining and describing to the public what a heart attack looks and feels like."
But even when women suspected that they were having a heart attack, many said they were hesitant to bring it up because they didn't want to look like hypochondriacs.
"We need to do a better job of empowering women to share their concerns and symptoms," Lichtman says.
And medical professionals may need to do a better job of listening, she adds. Several women reported that their doctors initially misdiagnosed the pain, assuming that the women were suffering from acid reflux or gas.
Doctors should pay special attention to women who have high blood pressure or cholesterol, as well as those with a family history of heart disease, Lichtman says.
This is just a preliminary study. Lichtman has already started working on a much larger study investigating why women have a higher risk of dying from heart disease than men.
But the findings aren't too surprising, says Dr. Nisha Parikh, a cardiologist at the University of California, San Francisco who wasn't involved in the research.
"I take care of young women who have heart disease, and this story is very common," she says.
Part of the issue is that most of the research on heart disease has focused on men, since the condition is more common among men. As a result, the diagnostic tools that doctors use to identify heart disease aren't always well suited for female patients.
Cardiologists are just beginning to rethink how to best recognize and treat heart attacks in women, Parikh notes.
Heart disease is the third leading cause of death for women ages 35 to 44, and it's the second leading cause of death for women 45 to 54, according to the Centers for Disease Control and Prevention. (Cancer is the No. 1 cause.)
"Historically we thought of heart disease as sort of a man's disease," Parikh says. "But that's not the case."
This study also highlights the importance of empowering women to speak up about their worries, says. Dr. Jennifer Tremmel, a cardiologist at Stanford University.
"It's interesting because the whole idea of female hysteria dates back to ancient times," Tremmel says. "This is an ongoing issue in the medical field, and we all have to empower women patients, so they know that they need to not be so worried about going to the hospital if they're afraid there's something wrong."
Days before he's scheduled to leave the hospital, he's already gone viral on social media because he was born 'en caul.'
Silas was completely encased in his amniotic sac, said Los Angeles' Cedars-Sinai Medical Center in a Facebook post. That's so rare, that even doctors delivering babies hardly see it. So Silas' doctor snapped a photo with his cell phone.
It looked like the baby was trapped in a big water bubble.
"Even though it's a cliche -- we caught our breath," neonatologist William Binder told CNN affiliate KCAL. "It really felt like a moment of awe."
Then Binder got to work helping Silas to breathe - and giving him special care, because Silas was born three months before his due date via Caesarean section.
Later, Silas' grandmother showed the cell phone photo to his mother, Chelsea Philips.
"It was definitely like a clear film, where you could definitely make out his head and his hair," Philips told the affiliate. Silas was curled up in fetal position inside.
What is 'en caul'
The amniotic sac is an opaque bubble that covers all babies in the womb from right after conception. As the baby grows, it fills with fluid, including the baby's urine.
The sac cushions the baby from bumps and jostles during mom's daily ups and downs.
Normally, during a birth, it breaks, and the fluid rushes out, which is where the term 'breaking water' comes from.
But sometimes, the sac can get stuck around part of the baby, according to Dr. Amos Grunebaum, an obstetrician and gynecologist, who publishes a website on birth and baby care.
It can, for example, get stuck on the baby's head, which makes it look like its wearing a glass space helmet. That's also where the term caul comes from -- it derives from Latin words that refer to a helmet.
Such amniotic sac helmet births are rare enough, but to have the entire baby inside the sac, or 'en caul,' occurs in less than one in 80,000 births, Cedars-Sinai said.
When Philips heard how rare her Baby's birth was, she was flabbergasted. "I was like, oh my gosh, Silas, you're a little special baby," she told KCAL.
It's particularly surprising in a C-section, because the scalpel usually pierces the amniotic sac.
The doctors must have missed Silas's.
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.”
On her 50th birthday, Sandy Oltz sat on the film set of “Still Alice” and listened to actress Julianne Moore speak a line that Oltz, an early onset Alzheimer’s patient, had struggled to write.
“Please do not think I am suffering. I am not suffering,” Moore said as the character of Alice Howland. “I am struggling, struggling to be a part of things, to stay connected to who I once was.”
Playing a woman with early onset Alzheimer's disease, Moore was giving a speech to a fake meeting of the Alzheimer's Association. It's a position that Oltz has been in many times before.
Oltz, a self-described “type-A” person and former nurse, was diagnosed with early onset Alzheimer’s disease at age 47, when she was raising two teenage sons and juggling a high-pressure job.
“There is some family history, but I never really thought that it would be me,” said Oltz of her early diagnosis. "We tried menopause, we tried brain tumor, we thought stroke, seizure. It took about a year to come to Alzheimer’s.”
Months before the “Still Alice” film shoot in New York, Oltz partnered with the cast and crew of the film through the Alzheimer’s Association. She gave tips from her own life about how to cope with Alzheimer's, such as using a highlight to mark text she's reading. The work seems to have paid off with Moore winning a Golden Globe and an Oscar for her role.
"[Moore] would just ask questions like, ‘What does it feel like to have Alzheimer's,'" said Oltz. "I would say, 'Well, it’s like all these words [are here] and you can’t find the right one.'"
After living with the disease for three years, Oltz said she's mostly learned to accept her limitations, but she still worries that her disease will have an impact on how her sons view her.
"I worry ... they’re never going to know how smart I really was," she said. "They see their mom as kind of funny because I have to be."
Oltz said the film was important so that people can understand that it does not just affect the elderly.
“There’s a stigma that they’re grandmas and grandpas, and their life has been lived and they’re done,” she said of stereotypes about Alzheimer patients. “I pray [the film] breaks the stigma.”
Early onset Alzheimer’s disease affects 200,000 people in the U.S., according to the Alzheimer Association. The film “Still Alice” will be released in limited locations this Friday.
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
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.