DiversityNursing Blog

By KAREN BARROW

www.nytimes.com 

Elisabeth Bing, who helped lead a natural childbirth movement that revolutionized how babies were born in the United States, died on Friday at her home in Manhattan. She was 100.

Her death was confirmed by her son, Peter.

Ms. Bing taught women and their spouses to make informed childbirth choices for more than 50 years. (“We don’t call it natural childbirth, but educated childbirth,” she once said.)

She began her crusade at a time when hospital rooms were often cold and impersonal, women in labor were heavily sedated and men were expected to remain in the waiting room, pacing.

Ms. Bing pushed for change. She worked directly with obstetricians, introducing them to the so-called natural childbirth methods developed by Dr. Fernand Lamaze, which incorporated relaxation techniques in lieu of anesthesia and enabled a mother to see her child coming into the world.

Along with Marjorie Karmel, Ms. Bing helped found Lamaze International, a nonprofit educational organization.

She became known as “the mother of Lamaze,” championing the technique in her book “Six Practical Lessons for an Easier Childbirth” (1967) and on the lecture and television talk-show circuits.

Today, Lamaze and other natural childbirth methods are commonplace in delivery rooms, and Lamaze classes, with their emphasis on breathing techniques, are attended by an estimated quarter of all mothers-to-be in the United States and their spouses each year.

For years Ms. Bing led classes in hospitals and in a studio in her apartment building on the Upper West Side of Manhattan, where she kept a collection of pre-Columbian and later Native American fertility figurines.

Ms. Bing preferred the term “prepared childbirth” to “natural childbirth” because, she said, her goal was not to eschew drugs altogether but to empower women to make informed decisions. Her mantra was “Awake and alert,” and she saw such a birth as a transformative event in a woman’s life.

“It’s an experience that never leaves you,” she told The New York Times in 2000. “It needs absolute concentration; it takes up your whole being. And you learn to use your body correctly in a situation of stress.”

There was one secret she seldom shared, however: Her own experience giving birth to her son, Peter, was decidedly unnatural. As Randi Hutter Epstein reported in her book “Get Me Out: A History of Childbirth From the Garden of Eden to the Sperm Bank” (2010), she continually asked her doctor, “Is my baby all right? Is my baby all right,” until the doctor said he could not concentrate with her chatter and gave her laughing gas and an epidural.

“I got everything I raged against,” Ms. Bing told Ms. Epstein. “I had the works.”

Elisabeth Dorothea Koenigsberger was born in a suburb of Berlin on July 8, 1914. Her parents, of Jewish descent, had converted to Protestantism years before her birth, but the family nevertheless felt the virulent anti-Semitism sweeping Germany before World War II. She was kicked out of a university two days into her freshman year, and two of her brothers — a historian and an architect — could not find work because of their Jewish background, she told The Journal of Perinatal Education in 2000.

After Ms. Bing’s father died in 1932, the family left the country; most members settled in England, while one sister moved to Illinois. In London, Ms. Bing studied to become a physical therapist and began work at a hospital. Mostly she helped patients with paralysis, multiple sclerosis and broken bones, but every morning she also visited the maternity ward, to give massages to new mothers and help them exercise. At the time, women were not allowed out of bed for as many as 10 days after giving birth.

She became interested in natural childbirth in 1942 when a patient handed her Dr. Grantly Dick-Read’s influential book “Revelation of Childbirth,” published that year (and later titled “Childbirth Without Fear”). Dick-Read proposed that pain during childbirth was caused by fear, and that a woman could avoid anesthesia by following a series of relaxation techniques aimed at reducing that fear.

Ms. Bing became intrigued and hoped to train with Dick-Read in the north of England, but with the war on and travel all but impossible, she began her own independent study. She read as much as she could and observed obstetricians and their patients — heavily anesthetized women who, she saw, had little control over the birth of their children.

“What I saw I disliked intensely,” she said in her interview with the perinatal journal. “I thought there must be better ways.”

Ms. Bing, who drove an ambulance during the war, began pursuing her interest in natural childbirth after 1949, when she moved to Jacksonville, Ill., to be with her sister, who had recently married. There, while working with handicapped children, Ms. Bing met an obstetrician who, she discovered, knew very little about natural childbirth. Resolving to champion the techniques, she began approaching obstetricians and having them send patients to her for one-on-one classes.

Ms. Bing had planned to return to England in about a year and was on her way back when she stopped in New York to visit friends. There she met Fred Max Bing, an exporter’s agent, and decided to stay. The two were married in 1951.

Besides her son, Ms. Bing is survived by a granddaughter. Her husband died in 1984.

In New York, Ms. Bing again started giving private childbirth education classes. They caught the attention of Dr. Alan Guttmacher, the chief of obstetrics at Mount Sinai Hospital, which had opened its first maternity ward in 1951. He asked her to teach a formal class there.

In her search for other childbirth alternatives, Ms. Bing began to learn about the psychoprophylactic method developed in the mid-1950s by Lamaze, a French obstetrician. Lamaze refined Dick-Read’s approach by incorporating breathing exercises he had observed in the Soviet Union, where anesthesia was a luxury poor women in labor could scarcely afford.

In 1960, Ms. Bing, by then a clinical assistant professor at New York Medical College, and Ms. Karmel founded the American Society for Psychoprophylaxis in Obstetrics, known today as Lamaze International.

Ms. Karmel, an American, had become a natural-childbirth crusader after seeking out Lamaze in Paris to help her deliver her first child, and her best-selling book, “Thank You, Dr. Lamaze” (1959), largely introduced the method to Americans and drew Ms. Bing’s attention.

(In the late 1950s, Ms. Bing had persuaded Ms. Karmel to smuggle into the United States an explicit French educational film, “Naissance,” depicting a woman giving natural birth. When New York City hospitals and the 92nd Street Y refused to show it in prenatal classes — they considered it obscene — the two women held a private screening at Ms. Karmel’s home on the Upper East Side. Ms. Karmel died of breast cancer in 1964.

At the heart of the methods the women promoted was the idea of family teamwork, with the father helping the mother by coaching her in responding to her contractions with breathing exercises and massaging her back, and being present during the delivery.

But in her book, Ms. Bing cautioned, “You certainly must not feel any guilt or sense of failure if you require some medication, or if you experience discomfort or pain.”

Some obstetricians were skeptical of the methods and thought Ms. Bing, not being a physician, was ill qualified to be instructing patients. But the natural-childbirth movement found a receptive public. Women coming of age in the 1960s embraced the idea of taking a more active role in childbirth and wanted fathers to participate more as well.

“It was a tremendous cultural revolution that changed obstetrics entirely,” Ms. Bing said in an interview in 1988.

Ms. Bing was modest about her role in the movement. “It wasn’t really a movement by Lamaze or Read or me,” she told the Disney-owned website Family.com. “It was a consumer movement. The time was ripe. The public doubted everything their parents had done.”

But she rejoiced in the outcome. “We are not being tied down anymore,” she said in 2000. “We’re not lying flat on our backs with our legs in the air, shaved like a baby. You can give birth in any position you like. The father, or anybody else, can be there. We fought for years on end for that. And now it’s commonplace. We’ve got it all.”

Lamaze, himself, did not acknowledge Ms. Bing, never responding to her requests for an interview even though she had made his name part of the American vernacular. During their only meeting, at a lunch in New York, he directed all his comments to a male obstetrician at the table.

“I’ve never thought of myself as someone with a legacy of any kind,” Ms. Bing said in an interview at an Upper West Side cafe. “I hope I have made women aware that they have choices, they can get to know their body and trust their body.”

“If my ideas supported feminist ideas,” she continued, “well, that’s all right. But I’ve never been politically active.”

Dr. Edward Soffen

Source: www.livescience.com

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.

Source: www.livescience.com

BY JENNIFER WALKER

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.” 

Bonding Moments

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.

Source: www.hopkinsmedicine.org

Markus MacGill

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."

Source: www.medicalnewstoday.com

 

 

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.

Source: www.npr.org

By Jodie Diegel, BSN, MBA, RNC, LNCC

Laura* is severely disabled, but when she spent time with Lunar, her caregivers at Little Angels, a non-profit skilled nursing facility in Elgin, Ill., witnessed something they had never seen. Laura began to move her fingers back and forth. Lunar is not a doctor or a therapist, but a 6-year-old specially trained miniature therapy horse from the Northern Illinois-based non-profit organization Mane in Heaven that I started in 2012. Mane in Heaven specializes in animal-assisted activity and therapy visits. Our horses visit with people with physical, mental and emotional challenges ­— from people with severe disabilities to Alzheimer’s and dementia patients to patients who are undergoing treatment for cancer.

Laura’s reaction was no surprise to me. We witness this type of reaction all the time when Lunar — with her chestnut brown coat and blonde eyelashes and her gentle demeanor — or one of her fellow mini-horses meet our clients. I recall another visit between a young man who was blind and disabled and Turnabout, a 3-year-old mini-horse. Turnabout is the only boy in the bunch and has the biggest personality. When the young man put his hands on Turnabout’s face, they obviously made a connection because the man laughed exuberantly again and again. 

It brings us joy to see the light, laughter and hope our minis provide to people experiencing profound illnesses or disabilities — not to mention that these visits can lead to improved physical, mental and emotional well-being. 

I remember when the idea of working with mini-horses came to me. I was surfing the Internet one evening in December 2011 after volunteering with my two therapy dogs, Buffet and Dudley, when an advertisement caught my eye. “Mini Therapy Horses for Sale,” it said. I thought, “I have two big horses, so I know horse behavior, and I’ve done a lot of obedience training with my two therapy dogs. I can train mini-horses to do the same thing that Buffet and Dudley do.” 

But I knew I couldn’t do it alone. Two months later, I had established a volunteer board of directors, including founding board member and friend Dina Morgan, RN, and had acquired three mini-horses — Lunar, Turnabout and 3-year-old Mystery, our smallest horse. In 2013, 2-year-old Jenella joined the group. 

Mane in Heaven volunteers and mini-horses began site visits in June 2013, and since then our volunteers and horses have visited with thousands of people in need. We have relationships with numerous providers and non-profit organizations in the region, including Marklund, a home for infants, children, teens and adults with serious developmental disabilities; Gigi’s Playhouse, which cares for children and adults with Down Syndrome; Wings, which advocates for survivors of domestic violence, as well as homeless women and children; JourneyCare, which specializes in palliative medicine and hospice care; and Rush University Medical Center, a premier hospital located in Chicago. 

A site visit usually lasts up to two hours and involves an exchange of unconditional love between the horses and our clients. People watch, pet, brush, hug and take pictures with the minis. Rather than thinking and talking about themselves and their problems, our clients focus on the animals. When our horses visit a care facility, the residents laugh and interact more, are mentally stimulated by the entertainment and are able to recall personal memories more readily. 

When Corin Garcia, 19, from Palos Hills, Ill., met Lunar at a Mane in Heaven visit at Rush University Medical Center, it changed her whole perspective on her pending treatment. Corin told me it was a day she dreaded more than anything — admission day for “four tedious, boring days of chemotherapy,” she said. But Corin’s attitude changed when her she met Lunar. “I was in an awful mood, yet when two miniature horses walked through the door my mind cleared all its negative thoughts and my heart instantly melted. Being around these beautiful creatures made the worse day turn into the best I have ever had in the hospital.”

Mane in Heaven does not charge for visits; we rely on donations and fundraising, so fundraising is important work for our volunteers. Interest is growing in our services, thanks, in part, to media coverage by CNN, the Associated Press, and local media outlets. Having the support of volunteers helps us to maximize donations, but we hope to find others who believe in our mission and will also support us financially. While our horses are tiny, there are still significant expenses associated with running our organization. One day we’d love to open our own therapy center and acquire more horses, so we can serve more people. 

Running a nonprofit business is challenging while also working full time, but I really never feel like this is work for me. While I may have had the vision for Mane in Heaven, our volunteers have made it a reality. We have a group of amazing and generous volunteers who help special horses help special people. Everyone has challenges in their lives, but whether we are with the minis at training sessions or on visits, we always feel happier and joyful after some “mini love.” We are the privileged ones to be on the other end of the rope.

Source: http://news.nurse.com

By MICHELLE CASTILLO

Pets are getting some pain relief thanks to a centuries-old method that has helped some of their owners: acupuncture.

A dachshund named Samson benefitted from the treatment. Samson was pawed aggressively by another dog at the park and needed surgery immediately. After his first procedure, it was clear he was still in some pain. Doctors recommended a second surgery, but owner Ellie Sutton wasn't so keen to make Samson go under the knife again.

"I wouldn't want to risk something like paralysis," Sutton told CBS News. She decided "to try every other kind of step first."

To her surprise, the veterinarian suggested acupuncture, the traditional Chinese medicine method of inserting needles into the skin to stimulate parts of the body.

Veterinary acupuncturists can use .2 to .3 mm needles that range in length from .5 inches to 1.5 inches on pooches.

"A lot of people come for acupuncture because they've exhausted a lot of the traditional Western medicine roots, whether it's medication or surgery," Dr. Marc Seibert, Samson's vet, told CBS News. Siebert is the owner and medical director of Heart of Chelsea Animal Hospital and Lower East Side Animal Hospital in New York City.

Seibert explained there are two main theories behind how acupuncture works. Eastern medicine teaches that energy flows through channels in the body called meridians. When the meridians are blocked, the person -- or the animal -- experiences physical pain. The acupuncture needles help direct the energy to the correct path.

Western medicine, on the other hand, suggests that acupuncture may help by bringing oxygen to the area that the doctor is trying to treat. Hormones called endorphins, which promote feelings of well-being, are released, and the anti-inflammatory parts of the immune system kick in.

"Most people think of acupuncture as a pain reliever, but it's more than that," says Dr. Ihor Basko, a holistic veterinarian in private practice in Honolulu, certified by the International Veterinary Acupuncture Society in Ft. Collins, Colo., told Paw Nation. "Acupuncture can boost the immune system and improve organ functions, and it has other benefits. It can complement conventional medicines and procedures without dangerous side effects."

Not everyone is convinced the method works. Veterinarian Craig Smith, the complementary-care expert for the American Veterinary Medical Association, told U.S. and World News Report that it's hard to know for sure if canines and felines are feeling relief from their pain.

"While many people treating pets with acupuncture report success, there isn't any data that proves it works," he said.

Ellie Sutton admitted that a lot of the "energy flow" talk is hard for her to believe. But she says Samson has definitely benefited from the treatment.

"The fact is he walks better afterwards," she said.

Source: www.cbsnews.com

By SYDNEY LUPKIN

Seattle Children's Hospital hallways erupted in cheers and applause this weekend as the Seattle Seahawks played a nail-biter of a game against the Green Bay Packers and officially locked down their spot in Super Bowl XLIX.

And 8-year-old Maria Moore's room was no exception. The recovering leukemia patient watched the game while wearing her Seahawks hat and clutching her signed football. On the table next to her, she propped up a photo of herself with Seahawks quarterback Russell Wilson, who visited her at the hospital in November.

At one point, Maria was so bummed that her team appeared to be losing, she shed a little tear, her dad told ABC News. He told her not to worry, that Wilson and the Seahawks would come back. And they did.

"We were just totally shouting and applauding and hollering and giving high fives to each other," Thomas Moore told ABC News. "It was an amazing gave to watch. She was super excited."

Marie was diagnosed with acute lymphoblastic leukemia in September and initially didn't respond to chemotherapy, but the doctors at Seattle Children's and Fred Hutchinson Cancer Research Center helped get her treatment "recipe" just right, he said. Marie underwent a cord blood transplant on Jan. 2, and is in remission, but should be at the hospital a few more weeks, he said.

"We’ll probably be watching [the Super Bowl] from the hospital, but that's OK," he said. "As long as she's doing well, that’s fine by me."

Nearly every Tuesday, the team's star quarterback, Russell Wilson, visits Seattle Children's Hospital to meet with patients, said hospital spokeswoman Kathryn Bluher. So the team holds an extra special place in the hearts of patients and their families.

Wilson visited Maria the day after flying back from an East Coast game in November, and she was "all smiles," Moore said.

"It makes a bigger fan out of me. I really can't say enough," Moore said. "[Wilson] is a down to earth, really nice guy. He takes time talk to the kids, do pictures, sign some things."

After Sunday's win, patients at Seattle Children's Hospital took photos with "Congratulations" signs from their hospital beds to show their support.

"It takes their mind of things," Moore said. "It gives them something fun to think about."

Source: http://abcnews.go.com

By PATTY WIGHT

Some of us are lucky enough to stumble into a job that we love. That was the case for Gabrielle Nuki. The 16-year-old had never heard of standardized patients until her advisor at school told her she should check it out.

"I was kind of shocked, and I was kind of like, 'Oh, is there actually something like this in the world?' "

Since Nuki wants to be a doctor, the chance to earn $15 to $20 an hour training medical students as a pretend patient was kind of a dream come true. Every six weeks or so, Nuki comes to Maine Medical Center in her home town of Portland, Maine, slips on a johnny, sits in an exam room and takes on a new persona.

Third-year medical student Allie Tetreault knows Nuki by her fictional patient name, Emma. A lot of teens avoid the doctor, so it's important for Tetreault to learn how to make them feel comfortable.

"What kinds of things do you like to do outside of school?" Tetreault asks.

"Um, I play soccer, so preseason is coming up soon."

Nuki preps weeks ahead of time for her patient roles. She memorizes a case history of family details, lifestyle habits and the tone she should present. "I've had one case where I was concerned about being pregnant. That was kind of like the most harsh one, I guess."

As Emma, Nuki's playing just a shy, healthy teen.

"How did school finish up for you this year?" Tetreault asks.

"Um, it was good. Yeah, school's been good. Um, yeah."

Emma's an easy role, Nuki says, but she ups the shyness factor because it poses a classic challenge to the medical student: how to get a teen to open up?

"Each case kind of has what's on paper, but then you can come in and kind of add another level," Nuki says. "Depending on how complex it is, you can add your own twist to it."

After asking Emma about her personal history, Tetreault moves on to the physical exam and listens as Emma takes deep breaths.

Tetreault gives Emma a clean bill of health and the practice appointment is over. But the most important part of Gabrielle Nuki's job is about to begin.

The 16-year old now has to evaluate the adult professional. She's smooth and tactful after lots of training on how to deliver feedback. Nuki tells Tetreault she did a good job making her feel comfortable.

"I also liked how you mentioned confidentiality, because for my age group, that's important to touch on," Nuki says. "And I think that maybe you could have had a couple more times where you asked me if I had any questions, but other than that I think you did a really great job."

It's communication skills versus acting skills that really qualify someone to be a standardized patient, says Dr. Pat Patterson, the director of pediatric training at Maine Medical Center.

"A lot of patients want to please their physician," Patterson says. "It's not easy for a patient to say 'That didn't feel right', or 'The way you asked that made me feel bad.' "

Gabrielle Nuki says working with medical students and being forthright about their performance has given her more confidence. In the future, she hopes to take on more complex roles — maybe someone with depression.

But she knows no matter what kind of patient she portrays, this job will prepare her well for when she reverses roles and one day becomes a doctor.

Source: http://www.npr.org