Going public with disease: How much is too much?

I’m rooting for Robin Roberts. As if breast cancer in her 40s wasn’t enough, the warm, sparkly co-anchor of Good Morning America is now dealing with myelodysplastic syndrome, a rare bone marrow disorder that may have been caused by the chemotherapy she underwent five years ago.

Robin, 51, underwent a bone marrow transplant last week and her colleagues from ABC were there on the spot, cameras and all, capturing the moment. Described in news accounts as “visibly spent”, she nevertheless recorded a message from her hospital bed, telling viewers she could “feel the love” from her legions of fans.

She has been open about her medical situation and exceedingly gracious about sharing this challenging journey with the public. No one could possibly wish her anything but the best.

But there’s a troubling side to this story: When does going public with a disease become too much?

ABC has begun taking heat from critics who think the network has gone overboard. Some have leveled accusations that the story is being exploited to gain better ratings. ”It’s a fine line between educating the audience and bringing them up to date, and crossing over and turning that into a ratings booster or an audience grabber,” Arthur Caplan, director of medical ethics at the New York University Langone Medical Center, told the Associated Press.

(You be the judge; the video is here.)

ABC has denied engaging in hype, saying viewers care about Robin and genuinely want to know how she’s doing. There’s value in the emotional support she’s receiving from her many fans.

Nevertheless it ought to make us feel a little uneasy, and not only because of the ethical issues it raises about newsroom decision-making.

At what point does our collective love of a feel-good story trump what’s best for the subject of that story?

It’s not hard for me to put myself in Robin’s place. Regular readers of this blog know I had non-Hodgkin’s lymphoma when I was in my 30s. I’ve done chemotherapy, I’ve done radiation, I’ve done time in an inpatient oncology unit. I know the physical and emotional toll exacted by cancer treatment. I’m all too aware of the potential for serious long-term and late complications such as the myelodysplastic syndrome Robin is being treated for, and the limited options for reducing the risk of late treatment-related toxicity – an angle of Robin’s story that most people unfortunately don’t seem to have picked up on.

So it was rather disconcerting to see Diane Sawyer, Sam Champion and presumably at least one television camera operator crowd into the hospital room with Robin and her family while new bone marrow cells were infused into her. Sure, Robin is a colleague and has many friends at ABC who wish her well. Sure, everyone was appropriately gloved and masked and (I hope) mindful of the infection risk.

But first and foremost this is a patient. Moreover, this is a patient with virtually no immune system, someone who’s highly vulnerable and undergoing a very challenging medical procedure. Even a seemingly minor infection can be a serious threat. Is it truly in her best interest to expose her to the extra risk for the sake of a heart-warming TV moment?

One can only hope it didn’t inadvertently send a message that the immune suppression that accompanies bone marrow transplants, not to mention many standard chemotherapy regimens, is not a big deal. People whose immune system is compromised depend on the community around them to exercise good judgment and avoid the unnecessary spread of germs.

Finally, there’s the emotional aspect to consider. ABC has said that everything being broadcast is with Robin’s permission, and I believe them. Even when there’s consent, though, media coverage of these kinds of stories can exert subtle pressure on the subjects to go along with it. Sometimes the story takes on a life of its own and it becomes difficult to tell the cameras and reporters, “Not now”, especially when someone is sick and perhaps not able to think clearly or be assertive. Sometimes the story stops being about the patient and becomes more about tugging at heartstrings or manipulating the emotions of the audience.

“At a certain point, Robin needs to heal,” Shelley Ross, former executive producer of Good Morning America, told the Associated Press.

Exactly. Although it’s generous for sick people to share their experience with the public, they don’t owe it to us. Rather, we have a responsibility to protect them at a vulnerable time. What’s in their best interest, physically and emotionally, ought to come first always.

When worlds collide: human, critter and virus

Two of the more intriguing health stories this past summer didn’t involve rogue sharks, swine flu or any of the other usual suspects. The stars of this particular show were the hantavirus and the West Nile virus, with supporting roles played by rodents and mosquitoes.

It’s a reminder that we don’t just share the environment with other people; we also share it with a wide assortment of animals and germs, and the inevitable collisions among species can have consequences for human health.

News late this summer of a deadly outbreak of hantavirus in Yosemite National Park may have caught many people by surprise. Nine visitors to the park have gotten sick since July, and three have died.

The virus is carried by deer mice and transmitted to humans via inhalation of airborne dust particles contaminated with mouse droppings. Symptoms resemble influenza and can progress to hantavirus pulmonary syndrome, which affects the lungs and is sometimes fatal.

The Yosemite outbreak isn’t new. I first heard about hantavirus back in 1993, when a severe and puzzling disease broke out in the Four Corners area of New Mexico, Arizona, Colorado and Utah. A healthy young Navajo man suddenly developed a flu-like illness, was rushed to a hospital and died.

What happened next reads like a fascinating detective novel. I’ll let the U.S. Centers for Disease Control and Prevention tell the story:

While reviewing the results of the case, medical personnel discovered that the young man’s fiancee had died a few days before after showing similar symptoms, a piece of information that proved key to discovering the disease. As Dr. James Cheek of the Indian Health Service (IHS) noted, “I think if it hadn’t been for that initial pair of people that became sick within a week of each other, we never would have discovered the illness at all.”

An investigation combing the entire Four Corners region was launched by the New Mexico Office of Medical Investigations (OMI) to find any other people who had a similar case history. Within a few hours, Dr. Bruce Tempest of IHS, working with OMI, had located five young, healthy people who had all died after acute respiratory failure.

An intensive investigation revealed that the mystery disease was a previously unrecognized type of hantavirus. More investigation and research identified the main carrier as the deer mouse, and concluded that exposure to the virus was occurring in rural and semi-rural areas where mice and people lived in close proximity.

But why would the virus suddenly have emerged in the spring of 1993? In fact this form of the hantavirus wasn’t new; Navajo medical tradition had long recognized the disease and accurately linked it to deer mice. Experts think the cluster of cases in 1993 was the result of rapid growth among the Four Corners deer mouse population, brought on by heavy snow and rainfall early that year that increased the food supply and allowed deer mice to reproduce in greater numbers than usual. More mice created more opportunities for them to have contact with humans, hence greater opportunities to pass along the hantavirus.

We know now that there are several types of hantavirus that cause pulmonary syndrome and that the virus is carried in the U.S. by several different rodents, including the white-footed mouse, the cotton rat and the rice rat. Nearly 600 cases have been confirmed in the U.S. since 1993. Sporadic individual cases and small clusters break out from time to time throughout North and South America.

Nevertheless, it’s concerning to see a new group of cases, the largest in the U.S. since the Four Corners cluster almost 20 years ago. And in a reminder of how complex the causal factors can be, experts are still puzzling over the reasons for the outbreak. A booming deer mouse population in the Yosemite Valley might be part of the explanation, but it’s thought that the park’s tent cabins could play a role as well. The cabins, built in 2009, apparently are insulated well enough for deer mice to crawl indoors and nest, and the indoor environment could then allow the hantavirus to survive and flourish. All but one of the Yosemite Valley visitors who came down with the hantavirus had stayed in one of the cabins this summer.

The chances of being exposed to hantavirus can be significantly reduced by making the habitat less favorable for mice – sealing openings in homes and workplaces and keeping  campsites and outdoor areas clean.

The West Nile virus, which is carried by birds and transmitted by infected mosquitoes, offers a similar illustration of how closely entwined the animal and human worlds and surrounding ecosystem can be.

The story of how West Nile virus arrived in North America is another one worthy of a TV crime detection show. First identified in Africa in 1937, it was unknown in the western hemisphere until 1999, when a cluster of severe encephalitis cases popped up in New York City late that summer. Epidemiologists discovered the victims all had three things in common: All were previously healthy, lived within the same 16 square miles and had recently been active outdoors.

Testing and investigation led to the culprit: West Nile virus. Exactly how the pathogen arrived on American shores remains a mystery. What’s clear is that it has established a permanent presence. By the summer of 2002, the number of confirmed cases in North America had reached an unprecedented level and the disease was entrenched coast to coast.

Although we’ve learned much about West Nile virus over the past decade, it seems there’s still a lot that’s unknown about the complex interplay among bird, mosquito and human populations, immunity and weather patterns, and how these all can fluctuate from one year to the next.

Cases surged this year to the highest level since 2003. Some states, such as Texas, have been hit especially hard. A theory favored by many experts is that the weather may be playing a significant role. An unusually mild winter, followed by an early spring, might have allowed mosquitoes to repopulate more quickly. A hot summer may then have increased the virus’s ability to replicate, since it’s known to grow faster in hot conditions. Meanwhile, drought conditions may have prompted the bird population, which is the reservoir for the West Nile virus, to seek water in areas that are more urban, with mosquitoes following closely behind. The drought also has expanded the amount of stagnant water in sewers, catch basins, ponds and so on where Culex mosquitoes, the main transmitters of West Nile virus in North America, like to breed.

Health experts interviewed last month by CBS News offered yet another suggestion for why Texas has been hit so hard: Perhaps the recession resulted in many homes in urban neighborhoods being abandoned with half-empty swimming pools, decorative ponds or other sources of water, creating an environment for mosquitoes to multiply.

No one knows for sure, however, and the complete picture, as with the hantavirus, is likely complex and multi-faceted.

We don’t always notice the critters among us or pay attention to the social, environmental and climate conditions that favor or discourage their presence. All of these factors have a very real impact on human health, however, in ways that are often complicated, sometimes surprising and not to be underestimated.

School lunch and the vegetable strategy

Offer fruit and vegetables on the school lunch menu and kids will be inspired to try them, like them and maybe even start eating them on a regular basis – or so the theory goes.

But a new study has found this isn’t necessarily the case. Although bringing raspberries, asparagus, sweet potatoes and the like into the school cafeteria did seem to have an impact, the effect wasn’t particularly strong, researchers learned after scrutinizing the food choices of more than 26,000 children.

The study appears in the latest issue of the Journal of Clinical Nutrition. It’s one of the first times researchers have attempted to quantify whether school-based programs actually make a difference in how many fruits and vegetables children consume each day.

A bit of background about the study: It analyzed nearly two dozen previous studies involving a total of 26,400 children ages 5 to 12 in several countries, including the U.S., Britain and Australia. The researchers looked at two different kinds of food programs: those in which kids received free or subsidized produce, and those that included elements such as family and nutrition education and communicating with parents. They then compared them with school lunch programs that didn’t do anything specific to encourage more fruit and vegetable consumption.

The results were interesting or dismal, depending on your point of view.

On average, children in school-based food programs ate about one-fourth of a portion more of produce. The effect was especially low for vegetables – only a tenth of a portion more, or the equivalent of half a spear of asparagus.

Notably, this wasn’t confined to school lunch programs in the U.S.; the researchers found similar results in Europe and Australia.

Counting juice as a fruit raised the average consumption a little higher but not by much.

It’s hard to gauge whether such small increases have an overall benefit on children’s nutrition. Perhaps it did help in some subtle, long-term way. Tracking whether these same kids also ate slightly more fruits and vegetables at home and whether they continued these habits into adulthood was outside the scope of the studies selected for the analysis, but even slight changes could have added up over time.

The researchers dug up some especially interesting conclusions regarding the strategies used by schools to encourage more fruit and vegetable consumption.

It seemed to make a difference when schools included more education about nutrition and when they communicated more with families about nutrition. School garden programs also seemed to help.

There’s been a fair amount of study on what schools can do to get children to eat more fruits and vegetables. Should they restrict access to chips, soda and other less desirable foods in the hope that the slack will be picked up with fruits and vegetables? If kids are given more fruit and vegetable options, will they be more likely to try at least one of them? Does it work to offer rewards when kids choose fruits and vegetables in the school lunch line? What about marketing fruits and vegetables to make them cool and fun?

The evidence suggests that most of these strategies may help in some way, albeit moderately. But school lunch programs are only one component in a food environment that also extends to how children eat at home and what they see and experience in the community around them.

On the basis of the Journal of Clinical Nutrition study, it would be easy to conclude that school-based interventions are, at best, only mildly successful and perhaps not worth the effort. There’s another way of looking at it, though: In order to positively influence children’s eating behavior, there may not be the blockbuster solution that many are looking for. It more than likely will take multiple strategies on many fronts – each of them small but adding up to a whole that’s greater than the sum of the parts.

A (flu) shot in the arm

When I rolled up my sleeve last week for my annual flu shot, I was given a new option: an intradermal injection, using a microneedle to deliver the vaccine into the skin instead of the traditional intramuscular stab in the arm.

Who knew the choices for receiving a flu shot could multiply so quickly in just the past 10 years? First there was the introduction in 2003 of FluMist, an inhaled version of the flu vaccine that does away with shots altogether. Now there’s the microinjection – still a shot, technically speaking, but with considerably less of the ouch factor; it involves an ultrafine needle that’s 90 percent smaller than the usual flu vaccine needle and penetrates no deeper than the top few layers of skin.

Many of us could use a guide to what’s available in the world of flu shots these days, and who’s eligible for what. Here’s a quick rundown, courtesy of the U.S. Centers for Disease Control and Prevention:

Regular flu shot: Suitable for most people; not approved for infants younger than 6 months. The regular vaccine accounts for most of the flu vaccine administered in the United States each year. It is given as an intramuscular injection, usually in the upper arm. The vaccine contains inactivated, or killed, influenza viruses. Side effects can include soreness, redness or swelling where the injection was given, muscle aches and low-grade fever.

Nasal spray flu vaccine: An aerosol form of the vaccine that’s given as a spray into the nose. Because it’s made with a weakened form of the flu virus, it’s recommended only for healthy individuals between the ages of 2 and 49. Anyone older or younger than this or who has a chronic condition or other risk factor should not receive the inhaled version of the influenza vaccine. The most common side effects among children include runny nose, headache, wheezing, vomiting, muscle aches and fever. Typical side effects for adults include runny nose, headache, sore throat and cough.

Intradermal flu shot: Administered with a prefilled microneedle into the top layers of the skin. This version of the influenza vaccine was introduced in the 2011-12 flu season. It was offered on a limited basis last year but has become more widely available this year. Besides being somewhat gentler than the traditional flu shot, it contains 40 percent less antigen, meaning it requires a lower amount of active ingredients to deliver the same flu protection as the traditional vaccine. Otherwise, the intradermal flu shot works in the body the same way as a regular flu shot and protects against the same three strains of flu as other yearly versions of the flu vaccine.

Intradermal flu shots are FDA-approved for adults ages 18 through 64. Side effects include redness, swelling, pain, toughness and itching at the injection site. These side effects seem to be somewhat more common with this form of the flu vaccine than with regular flu shots. Other side effects that have been noted include headache, muscle aches and fatigue.

High-dose flu vaccine: Designed for adults 65 and older. The high-dose vaccine contains four times the amount of antigen as a regular vaccine and is intended to provide greater protection for older adults whose immune systems have waned with age. It’s given as an intramuscular shot, the same as the regular flu vaccine.

High-dose flu vaccine is not recommended for older adults who have had a previous severe reaction to a flu shot. As with the intradermal vaccine, side effects seem to be reported more frequently; they include pain, redness and swelling at the injection site, headache, muscle aches, fever and overall malaise.

Although it’s a welcome development to have more options, it puts more burden on the consumer to make an appropriate choice. Aside from eligibility, one of the key questions is this: Regardless of which form of the flu vaccine you choose, will it be effective?

By now, the nasal spray has accumulated a substantial 10-year track record of safety and reliability, especially among children. Some research suggests it’s less effective in adults, however, and the recommendations for who can receive it remain limited to healthy individuals ages 2 to 49.

Because the intradermal vaccine is newer, there are fewer studies that have examined its effectiveness. But most of the researchers’ conclusions are positive, and one study even found that this form of the flu vaccine worked better in older adults. As intradermal flu shots gain wider use, stay tuned for more information evaluating their safety and effectiveness.

One thing on which there’s a clear consensus among the researchers: Whether it’s a shot in the arm, a spray up the nostrils or an injection into the skin, the flu vaccine only works in those who actually receive it.

Downsizing the mega-soda

If there was any doubt that New York City was serious about downsizing the giant sugary drinks sold at restaurants and concession stands, it was erased Thursday with the enactment of a new rule by the city’s Board of Health.

The rule places a 16-ounce limit on the size of non-diet sodas, sweetened teas and other sugar-laden drinks sold at restaurants, theaters, workplace cafeterias and other venues that offer prepared food.

Many public health experts have wrung their hands over the amount of sugared beverages consumed by the average American. Few entities, though, have gone so far as to impose an outright ban on super-sized drinks.

Those who support the measure see it as an important – and pioneering – step for public health. Here’s the take by the Associated Press:

They say the proposal strikes at a leading cause of obesity simply by giving people a built-in reason to stop at 16 ounces: 200 calories, if it’s a regular Coke, compared to 240 in a 20-ounce size. For someone who drinks a soda a day, the difference amounts to 14,600 calories a year, or the equivalent of 70 Hershey bars, enough to add about four pounds of fat to a person’s body.

Beyond the numbers, some doctors and nutrition experts say the proposal starts a conversation that could change attitudes toward overeating. While there are many factors in obesity, “ultimately it does come down to culture, and it comes down to taking some first steps,” said Dr. Jeffrey Mechanick, a Mount Sinai School of Medicine professor who has studied the effect of government regulation on the obesity epidemic.

The ban goes into effect March 13, assuming it isn’t struck down before then.

Supporters of the measure have a point. Soft drinks are large and getting larger. Consider the 7-Eleven Big Gulp series: The Double Gulp contains 50 (!) ounces – more than the capacity of the average human stomach. We have become culturally accustomed to supersized portions of everything from soft drinks to french fries to bagels, with the result that it’s increasingly difficult to gauge what a normal-sized serving should be.

But here’s the big question: Will New York’s ban on the largest sugary drinks actually make a difference in people’s health? The answer is not at all clear.

For one thing, the rule contains a multitude of exceptions. It doesn’t apply to beverages sold in retail grocery stores, vending machines or most convenience stores, allowing people to continue to buy their favorite large sizes without restriction.

It exempts beverages that are 100 percent fruit or vegetable juices, even though these can be, ounce for ounce, almost as full of sugar as a soft drink. (For a comparison, check out this chart compiled by the federal government; a 12-ounce serving of grape juice contains 12 teaspoons of sugar – more than a same-sized serving of either cola or root beer.)

Nor is there anything in the rules that prohibits consumers from short-circuiting the intent by simply buying more smaller drinks to equal a large one. And New Yorkers can continue to drink as much soda in the privacy of their homes as they please (at least for now).

Although this is, strictly speaking, a New York City story, it matters to the rest of us as well. Indeed, the Board of Health’s action has captured wide interest across the United States. Seattle lies the width of the continent from Manhattan, but when the Seattle Times offered an online poll on what readers thought of a similar ban in their own city, folks were quick to weigh in.

There’s considerable – and valid – debate over whether regulation and government enforcement are an appropriate strategy for influencing health-related behavior.

Ethically speaking, it’s a murky area. Should government be making people’s food choices for them? Do consumers have the right to make their own decisions about what they buy and drink, or is this outweighed by the public health impact? If the target today is sugared drinks, what’s going to be next?

In the months before the New York City Board of Health voted on the mega-soda ban, a handful of studies attempted to quantify what the health results might be. In one study that involved analyzing the receipts of 1,600 fast-food customers on the East Coast, researchers concluded that if everyone who had been buying a large-sized drink cut back to a single 16-ounce beverage, they would consume 63 fewer calories per meal. But at least 40 percent of consumers had to take this step, otherwise the impact would be negligible, concluded the study.

Finally, banning giant-sized drinks at some commercial venues does little to address other areas of health-related behavior that may be just as important – physical activity, stress, alcohol use and timely access to appropriate medical care, to name just a few.

It’s going to be interesting to watch how the soda ban plays out. Perhaps this is what it takes to begin changing a community environment into one that fosters better health – the proverbial snowball that gathers speed and mass as it rolls downhill. On the other hand, this is still an experiment with unknown results. It’s to be hoped that the New York City Board of Health will watch this closely and collect some real evidence to help decide whether it was worthwhile or not.

The million-dollar question: Are you a team?

The new patient had a question and, according to Dr. James Salwitz, it was “a zinger”: “What is the culture of collaboration in your group?”

Very few patients ever think to ask this or perhaps even realize it’s important, Dr. Salwitz reflected recently on his blog, Sunrise Rounds. But maybe they should, because when medical groups function effectively as a team, they’re also better able to provide good care. Or, as Dr. Salwitz puts it, “As with lessons learned in kindergarten, if your doctor does not play well with others, your medical care may be in trouble.”

Why would collaboration matter, when the patient’s primary relationship is with his or her own physician? Dr. Salwitz lists some reasons:

- Doctors can’t be available 24/7 and there may come a time when the patient must be seen by someone else. Colleagues need to know the plan of care for the patient, and this takes skilled and consistent communication.

- Doctors need to be able to review cases with their colleagues and give and receive constructive criticism without becoming defensive or isolated.

- Working closely with colleagues is how doctors are able to evaluate each other’s skills and abilities. Doctors depend on this knowledge when referring patients to other physicians.

I’d take this one step further by including the rest of the doctor’s staff. Patients don’t generally get to choose the nurse, the person who answers the phone or the person at the front desk, but these individuals are part of the team too – and what they do, or don’t do, can either enhance the care of the patient or sow confusion, frustration and the potential for error.

The impact of teamwork on patient outcomes is difficult to measure. But as it turns out, there’s a whole chunk of research reinforcing that patient care tends to be better and safer in organizations that emphasize a culture of collaboration.

One classic study, published in 2009 in the American Journal of Surgery, found that poor teamwork was associated with more complications and more deaths among surgery patients. Among the behaviors that seemed to make a difference were the amount of information shared during the surgery and how well the team was briefed during handoffs.

Other studies have documented the problems created when health care professionals engage in disruptive behavior.

And a study of a group of emergency rooms found that when physicians, nurses and technicians received formal training in emergency team coordination, they performed better as a team and made fewer errors.

How can consumers assess the quality of teamwork at their clinic or hospital? There’s no set of standardized online ratings, at least yet, hence not much guidance for the public. But Dr. Salwitz offers a few thoughtful questions with which to start the conversation:

“Do you discuss cases with your partners?” “How do you cover each other on the weekends?” “How long have you been together?” “What do you, as a doctor, look for in other doctors?” “What is your culture of collaboration?” And finally, “Is there a unifying philosophy that the doctors in your practice share? What is it?”

More patients ought to be asking these questions. And maybe more clinicians ought to be thinking about what their response would be.

The most dangerous health occupation

Occupations in the U.S. with the highest rate of work-related fatalities are primarily physical: commercial fishing, logging, mining, farming.

But if you concentrate on the incidence of nonfatal injuries that happen in the workplace, health care is far more injury-prone than perhaps the public realizes – and the highest rates of all for getting hurt on the job are among certified nursing assistants who work in nursing homes, a category that also happens to be the lowest-paid among the health professions.

A report published earlier this year contained some eye-opening statistics. Using data from the National Nursing Home Survey and the National Nursing Assistant Survey, the researchers found that 60.2 percent of CNAs who participated in the survey had experienced a work-related injury in the past year. Three out of five had been hurt more than once and about one-fourth had to quit working because of their injury.

There’s more: Although scratches and cuts were the most commonly reported injury, back injuries and strained muscles were frequent, accounting for almost two in every 10 work-related injuries. Workers who were younger or older (those under age 30 and those older than 45) also had higher rates of injury.

In one of the more startling facts contained in the report, the incidence of nonfatal injuries among nursing assistants was one of the highest of any occupational category, including trucking and construction.

Here’s another concerning statistic: Nursing care assistants working in skilled care facilities often experience violence from the residents they’re trying to help. A report by the U.S. Centers for Disease Control and Prevention found that 12 percent of the CNAs in a nationally representative sample had sustained a human bite wound within the past year. The incidence of assaults and bites was greater for those who worked in units caring for people with dementia.

I was reminded of this when I visited Johnson Memorial Health Services in Dawson, Minn., this past week for the staff’s celebration of earning MnSHARP status from the Minnesota Department of Labor and Industry. The program recognizes organizations that go above and beyond the standard in creating a workplace that’s safe for their employees.

One of the things I learned was that it’s not easy to qualify for this designation. In fact, very few health organizations have made the cut. Johnson Memorial is the first nursing home and only the second hospital in Minnesota to earn certification.

It took three years and continual hard work to get there. As the staff readily admitted this week, it’s going to take ongoing hard work to stay there. But the payoff is fewer work-related injuries for everyone who’s employed at Johnson Memorial, employees who are happier, more productive and better able to provide good care, and lower costs for workers’ compensation, leaving more money to plow back into other priorities.

There’s a growing sense that occupational injuries among nursing assistants have been underrecognized in the past and that more needs to be done to reduce their likelihood of getting hurt at work.

Research has identified a number of factors that seem to make a difference. Nursing assistants are more likely to get hurt when there’s a shortage of staff or when the workload is highly demanding. The probability of injury also tends to be higher among nursing assistants who are new on the job and/or feel they weren’t adequately prepared for the job.

Why does it matter? The U.S. population is aging and it’s becoming increasingly critical to have a good workforce to provide direct care to older adults, many of whom need intensive daily help. Occupational safety, notes the CDC report, “is an important factor for retaining trained, motivated, and capable nursing assistants in long-term care… It has been shown that nursing personnel who were subjected to work-related violence on at least a monthly basis reported higher intent both to leave the nursing profession and to change institutions.”

It might be impossible to achieve zero work-related injuries for certified nursing assistants, but supportive policies and better training – in short, creating an institutional culture that fosters a good workplace environment – seems to go a long way toward making this riskiest of health care occupations more safe for the workers.

Lessons in Professionalism 101

A couple of years ago there was an online flap over a MedPage Today blog post about a group of medical students and a vending machine that dispensed beer.

Writer Charles Bankhead was attending a cardiology conference and was on his way to a breakfast meeting when he encountered the young doctors-in-training gathered enthusiastically around the beer machine. He writes:

As they drained the cans and vowed to return often to worship at this altar, something told me this wasn’t the first time they had consumed beer before breakfast.

And then a thought occurred to me. One day I might have to entrust my heart to the care of these young men.

I found the thought unsettling.

He goes on to muse about medical students these days and their behavior, both bad and good, and winds up with some uplifting observations about the medical trainees who helped staff street-corner clinics in New Orleans, ministering to the many needs in the days and weeks after Hurricane Katrina.

“I hope I can remind myself of that the next time I see a group of young doctors gathered around a beer machine,” he concludes.

Students have rarely been known for maturity or prim behavior, but when it comes to medical students, should there be a higher standard?

Bankhead’s blog entry was reposted at Kevin, MD, where the reaction was decidedly mixed. What’s the big deal? wondered several commenters. One person’s assessment: “Honestly, if you get heart palpitations from the idea of late 20s male doctors finding the idea of a beer dispenser awesome, I don’t want you as my patient any more than you want me as your doctor.”

Not so fast, cautioned another commenter, who observed that “it has been my experience that this type of ‘childish’ behavior (getting excited about a beer machine and drinking DURING a conference) generally does spill over into practice.” These are the future doctors who make fun of patients, ogle the nurses and talk more about their extracurricular activities than the business at hand, the commenter wrote.

So who’s right?

As medical students head back to school this fall and the new crop of residents that began training in July gains some seasoning, it’s an opportune time to consider one of the more intangible lessons of medical school: teaching students how to be professional.

There doesn’t seem to be any formal curriculum for Professionalism 101. Yet it would be hard to find a U.S. medical school that doesn’t value professionalism or create expectations for how students should conduct themselves around each other, the staff and their future patients.

A paper published in 2010 in the International Journal of Medical Education attempted to pin down the teaching of professionalism. Is it shaped by medical school coursework? By being selective about who gains entrance to medical school? By strong role models on the faculty?

The researchers reviewed about three dozen previously published studies and came up with some interesting findings. One of the things that seemed to matter most was the learning environment – whether it was supportive and whether students had a variety of opportunities to gain experience and insight into what it means to practice professionally. The researchers found it was also important to have faculty and staff who set a positive example.

There’s been some debate over the role of the medical school admissions process in selecting students with the right qualities. But as the authors of the review note, it can be difficult to determine at the outset of a medical student’s career whether he or she is capable of learning professionalism. Furthermore, there don’t seem to be any reliable tools for identifying candidates who might not measure up.

Finally, assessment and feedback mattered. The researchers wrote that it’s especially important to monitor medical students for unprofessional or disruptive behavior and to have policies for dealing with problem behavior.

Judging from the online discussions at some of the student doctor forums, most medical students are keenly aware of the professional expectations placed upon them. A student who was ticketed for illegally netting crabs at the seashore fretted that the infraction might result in a rejected application for a residency training program. Some students had bigger problems: a DWI arrest, an assault charge, poor academic performance.

We expect a lot of doctors; perhaps we expect too much. Should a certain amount of partying or immature behavior be acceptable among medical students? Or should even an indiscreet Facebook post be grounds for disciplinary action? Some years back I had a conversation with a medical school instructor who spoke of the challenge of curing young medical students of casual terminology such as the word “butt.” Professionalism seems to be a many-layered creature that extends to language and demeanor, especially around patients, yet it’s not always easy to know where (and when) the line should be drawn.

Here’s a bit of evidence, though, that students who grasp the concept of professionalism might also be better able to practice it: In a study that appeared a few years ago in the New England Journal of Medicine, researchers found that doctors who were disciplined by the state medical board often showed warning signs of problem behavior back in medical school. Indeed, problem behavior in medical school was among the strongest risk factors for disciplinary action later in the physician’s career. Other studies, though, have found only a weak association between medical school behavior and future professionalism.

It points to a need for defining more clearly what is meant, exactly, by medical professionalism. Most future doctors do in fact measure up; it’s a minority who don’t, and a reason why the public has some stake too in the education that helps shape medical students into good doctors.