Whitney Palmer

Healthcare. Politics. Family.

Preventing Burnout in Doctors Young and Old

Published on the Dec. 17, 2014, North Carolina Health News website

Many health care practitioners find themselves overwhelmed and depressed, yet there are few outlets for them to get help. A program at UNC-Chapel Hill is targeting doctors who are burnt out.

By Whitney L.J. Howell

Kara McGee knew something was wrong when she felt all the excitement over her job and empathy for her patients draining away.

“I wasn’t missing things, but it was definitely a more ‘here we go again’ attitude,” she said. “I didn’t want it to happen, but I was disconnecting from what I was doing. It felt like it was protective, like it was my way of coping with what I was seeing on a daily basis. I felt very out of control.”

At the time, McGee was a physician assistant, working in a pediatric surgery and intensive care unit in Miami. Being surrounded by so many children who were dealing with such intense medical issues made it difficult for her to concentrate on the patients who had good outcomes. Instead, McGee said, she dwelled on those who suffered from long illnesses and died.

So she quit. McGee walked away from patient care for three years. During that time, she went back to school to earn a master’s degree in public health, but eventually returned to working with patients after realizing she missed it. It’s different now though. Today she works in HIV medicine at Duke University Medical Center’s Division of Infectious Diseases.

“Now, I can develop long-term relationships with my patients, and that’s extremely rewarding,” McGee said. “In the ICU or emergency department, there’s either a poor outcome or you don’t know what happens because patients go on their merry ways. It’s the relationship building that’s so gratifying.”

Based on existing research, McGee isn’t alone. Medical professionals are more likely than people in other professions to experience burnout. Studies have looked at burnout prevalence among physician assistants and other health care providers. But until now, there’s one group that’s gone without much examination: medical residents, the physicians-in-training.

According to new work conducted by researchers at the University of North Carolina-Chapel Hill though, as many as 75 percent of medical residents experience at least one time period of burnout, and roughly 50 percent identify themselves as burned out at any given time.

“This is an extremely common problem. The academic medicine centers

Samatha Meltzer-Brody, University of North Carolina at Chapel Hill School of Medicine

Samatha Meltzer-Brody, University of North Carolina at Chapel Hill School of Medicine

responsible for training our doctors are under extreme pressure these days,” said Samantha Meltzer-Brody, the lead study investigator. “The entire business of academic medicine and the structure of it are built upon a system that no longer works, and no one is entirely sure what to do about it.

“Residents are on the front lines of providing the care, and I think they feel it acutely.”

Treating the malaise

Physician burnout is a national problem that, in some cases, contributes to an even greater concern: physician suicide. According to Pamela Wible, a family physician and physician-suicide expert, approximately 400 doctors take their own lives annually, and many leave behind letters or evidence of their daily mental stresses.

Meltzer-Brody’s goal is to identify, treat and diffuse those mental stresses and other mental health concerns before residents reach that level of despair.

Increased patient demands, battles with insurance companies, malpractice concerns and medical school debt are known contributing factors to physician burnout. But, according to Meltzer-Brody, who also directs the Perinatal Psychiatry Program in the UNC Center for Women’s Mood Disorders, residents face additional, more contemporary challenges. To identify the residents’ stress mix, she conducted an online survey with 310 UNC HealthCare residents.

In May and June of 2014, she collected survey results from residents in various specialties, including surgery, internal medicine, pediatrics and psychiatry. The questions queried about interpersonal situations, fatigue, depression and feelings around patients who died. Meltzer-Brody noted residents likely had additional stress during this time because they were training to use the UNC Healthcare system’s new electronic health record system, Epic.

Through this survey and her ongoing mental health program for physicians, “Taking Care of Our Own,” Meltzer-Brody has put North Carolina at the forefront of combating this phenomenon. This UNC-based, first-of-its-kind initiative is specifically designed to treat physician burnout by providing education, confidential support services, advice and mental and physical health referrals.

Within its first year, from 2012 to 2013, the program grew by 200 percent.

What residents are feeling and facing

North Carolina’s medical residents face a challenge that could make resident risk of burnout more severe, Meltzer-Brody said.

“We have a growing population that is very diverse. North Carolina is the fifth largest state taking care of Latinos, many of whom are undocumented and use the emergency room as their first point of care,” she said. “The UNC emergency room is exploding as we try to meet the health needs of this influx of people.”

Rural physicians face this same challenge, often having to provide emergency room and hospital coverage in addition to their clinic duties. A significant cadre of physicians and residents in North Carolina fall into this category. According to the N.C. Department of Health and Human Services, 150 to 160 physicians were recruited annually for the past six years to serve the state’s rural populations.

At the same time that there are more patients in waiting rooms, there are fewer residents on call due to a 2003 federal regulation that limited residents to an 80-hour workweek in an effort to create more well-rested residents and increase patient safety.

“The thought was that if residents were more rested, it would decrease medical errors, as well as improve their mental well-being,” Meltzer-Brody said. “Neither has happened. We’re not seeing reduced medical errors, and burnout is at an all-time high.”

Additionally, academic medical centers haven’t increased their resident numbers or hired other personnel, leaving a smaller group of residents responsible for an ever-growing body of work. All these factors contribute to increased daily stress, she said.

Reports from the Physicians’ Foundation revealed that these issues led to 81 percent of doctors finding themselves overextended and half being unlikely to recommend a medical career.

Together, these factors leave little time for team building or mentoring, eroding the sense of community that once existed between residents, attending physicians and other health care personnel, Meltzer-Brody said. Losing that cooperative spirit can fuel a significant burnout feeling.

“What these residents experience isn’t what brought them into being doctors,” she said. “There’s a big disconnect between what’s being emphasized in medical school and what’s happening in actual practice.”

McGee’s advice

Whatever the symptoms, McGee recommended residents or other health care professionals identify someone with whom they can discuss both their physical and mental reactions to work-related stress.

“I think seeking help from employee-assistance groups is an excellent way to cope with the stress you experience as a medical professional,” she said.

In addition, she suggested individuals experiencing burnout take time for self-reflection. If someone’s ability to provide appropriate, compassionate care is compromised, then it’s time to take a break and try something different professionally.

Ultimately, the biggest force behind burnout among medical professionals is the industry’s culture, McGee said, and practitioners need an outlet.

“It’s just like with professional athletes who get injured and play anyway,” she said. “Part of what you do in having to deal with the stress and the patient care is simply putting one foot in front of the other. It’s the culture of medicine that just comes with the territory.”

To read the story at its original location: http://www.northcarolinahealthnews.org/nc-research-news/

January 1, 2015 Posted by | Healthcare | , , , , , , , , , , , , , | Leave a comment

Women in Radiology: How the Specialty Can Bridge the Gap

Published on the May 22, 2013, DiagnosticImaging.com website

By Whitney L.J. Howell

When it comes to women in medicine, the numbers can be confounding. In 2012, women made up nearly 50 percent of medical school applicants, but they accounted for only 34 percent of practicing physicians. And, the statistics for women in radiology drop even lower — roughly 24 percent of all providers are female.

So why are so few female medical school graduates choosing radiology? And, what can be done to change this reality? How can the specialty be more supportive for its female practitioners?

Radiology finds itself in a frustrating cycle, according to Howard Forman, MD, a diagnostic radiology, economics, and public health professor at Yale University School of Medicine. Unless the specialty finds a way to fix these perceived problems, there could be an ultimate impact on patient care.

“If you don’t have women in the specialty, then you don’t have role models for medical students to look to or to aspire to be like. They don’t have those mentors, and that alone creates a bit of a limitation,” said Forman, who led an expert panel discussion on this topic sponsored by the American Roentgen Ray Society in January 2012. “And, if you don’t have women in radiology, then you’re losing the perspective of women in terms of both research and teaching, as well as the perspective of the patient as a woman.”

It’s time, he said, to open a conversation and ask the tough questions about why more women don’t choose radiology as their specialty.

The Perceived Problems with Radiology

Historically, industry leaders have pointed to women’s roles within the family and their child care responsibilities as significant factors that routinely suppress the number of women in medicine, including radiology. Practicing physicians often work long hours in high-stress roles, and in many cases women have opted instead to seek a greater work/life balance.

But there are specific reasons why female students and practitioners say they shy away from a radiology career.

Surveys of female medical students — predominantly women of child-bearing years — revealed it’s the assumed long-term radiation risk, rather than their own family responsibilities, that pushes them away. In addition, women reported they believe radiology has too little patient contact, that the specialty is too highly competitive, and that it requires too many years of additional training. A recent study from Western University in Canada also concluded the idea of working in dark reading rooms isn’t attractive to women.

While these issues might steer some women away from radiology, they are largely

M. Elizabeth Oates, MD, president of the American Association for Women Radiologists.

M. Elizabeth Oates, MD, president of the American Association for Women Radiologists.

misconceptions about the field, said Elizabeth Oates, MD, president of the American Association for Women Radiologists.

“We don’t know the full reason why people have this erroneous view of radiology, but probably one of the biggest reasons is that women — and men — aren’t introduced to the field early in their medical school years,” she said. “Students simply aren’t aware of radiology as a field, what it encompasses, and what it is that we do. It’s a pervasive issue.”

But the medical students wary of pursuing radiology aren’t alone. The women who do enter the field often face difficulties, as well, said Julia Fielding, MD, abdominal imaging division chief at the University of North Carolina at Chapel Hill School of Medicine. Fielding also chairs the newly-formed American College of Radiology’s Commission for Women, a group charged with researching and identifying ways to attract and retain more women in the profession.

“A lot of women in radiology feel isolated from their male colleagues,” she said. “But, a lot of the errors men make aren’t errors of commission. Instead, they’re errors of omission — maybe everyone goes out Tuesdays after work for beers, but they don’t even think to ask you.”

The intent, she said, isn’t to actively exclude women. However, many female providers might be uncomfortable joining into a group activity without an explicit invitation. This isolation can have consequences beyond the work social scene. Women are more likely to be passed over for leadership roles or promotion if they aren’t seen as truly being part of the office culture, Fielding said. The result to-date has been a dearth of women as radiology chairs or heads of national associations.

What Radiology Can Do For Practitioners

Much of the responsibility for making radiology more attractive to women rests on department and practice leaders, Oates said.  If changes come from the top down, the specialty’s culture is more likely to change.

The most important thing senior radiologists can do is give female medical students accurate information to dispel the many myths that currently surround the specialty. For example, practitioners are exposed to radiation, but not to the levels many women fear. When conducting studies, providers are protected by lead aprons, lead glasses, thyroid shields, and many other coverings.

It’s also imperative to introduce students to radiology much earlier during their medical school career. A growing number of medical schools are now incorporating radiology into the basic science curriculum of the first two years of training rather than introducing it only as an elective during the fourth year, Oates said.

“The key is to get female students exposed and into the radiology environment early as observers,” she said. “But we have to avoid having students just sit next to a radiologist in a darkened reading room. Perhaps engaging women providers in breast imaging would be a good way to provide role models for female first-year students.”

It could also a positive move, she said, if school administrators helped identify students who might benefit from having a female radiologist as an advisor.

Radiology leaders must also work hard to counteract the belief that radiologist have little-to-no patient contact, Fielding said. In fact, many female patients request women practitioners, particularly with breast imaging. Although radiologists, as a whole, have fewer direct patient interactions, they do work with patients and have significant contact with other doctors.

“I always tell students and younger providers that they might not always have patient contact, but they have contract with their fellow doctors every day,” she said. “Radiologists have enormous patient impact. It’s almost impossible to get out of the hospital without some type of test, and in a lot of cases, it makes a big difference for the patient.”

There are more tangible ways to grow the number of female radiology leaders, as well. Approving and subsidizing additional education courses can be an effective way to foster career growth among women providers, Fielding said. For example, practice or department leaders can support a colleague through an accounting course if she is interested in pursuing a finance management position within the group.

According to Etta Pisano, MD, vice president for medical affairs and dean of the College of Medicine at the Medical University of South Carolina, sometimes the best way for radiology leaders to support women is to simply listen to their wants and needs. Administrators must be accommodating.

“Those of us in leadership positions must be attentive to what employees are saying to us about what they need to be successful and happy at work,” said Pisano, who is also a radiology professor. “Often, we set meetings outside of work-time boundaries, and that’s going to be very hard for anyone with a family. We need to focus on doing work during the work day.”

To read the remainder of the article at its original location: http://www.diagnosticimaging.com/women-radiology-how-specialty-can-bridge-gap/page/0/2#sthash.RBOTEdrJ.dpuf

For a video perspective on women in radiology: Julia Fielding, MD, on women in radiology

June 19, 2013 Posted by | Healthcare | , , , , , , , , , , , , , , , , , , , , , , , , | Leave a comment

Healthy turnabout for tobacco

Published in the Jan. 17, 2011, Raleigh News & Observer and the Jan. 17, 2011, Charlotte Observer

BY WHITNEY L.J. HOWELL – CORRESPONDENT

RESEARCH TRIANGLE PARK — For generations, tobacco served as North Carolina’s economic engine, creating wealth while also eroding public health.

Now, thanks to an international vaccine company setting up shop in Research Triangle Park, the cash crop could be turning over a new leaf to become an integral part of preserving good health.

A Montreal-based biotechnology firm, Medicago, uses the Australian tobacco strain Nicotiana benthamiana to manufacture H1N1 flu vaccines.

The process takes days and produces larger amounts of vaccine than the traditional months-long method of cultivating the virus in fertilized chicken eggs.

“With this technique, we’re not using the actual virus to produce the vaccine,” said Frederic Ors,

Medicago plant technicians process the viruslike particles produced in the tobacco leaves through the purification process to create clinical-grade particles for the vaccine.

Medicago’s vice president of business development. “That’s the big difference from the egg-based vaccine method where you actually infect the eggs with the live influenza virus.”

 

Medicago uses the Australian tobacco strain, which is not used in cigarettes, because its delicate leaves are highly susceptible and receptive to pathogen infections, Ors said.

The plant also produces a purer vaccine because it does not inject its own DNA into the virus reproduction process. The vaccine is in the second phase of human clinical trials, and the company is currently enrolling volunteers to test it.

The company received a $21 million grant from the Defense Advanced Research Projects Agency in the U.S. Department of Defense to build a 90,000-square-foot facility in RTP, and it aims to produce 10 million vaccine doses per month.

Medicago selected RTP because of its long-standing expertise in high-tech innovation, Ors said.

Medicago broke ground in August and plans to begin large-scale manufacturing next fall. The $42-million plant will be the company’s North American site.

Breaking tobacco tradition

North Carolina traditionally produces tobaccos for use in cigarettes. As of 2009, according to the N.C. Department of Agriculture and Consumer Services, tobacco was still the state’s No.1 cash crop with more than 4,100 pounds produced and an economic impact of more than $7 billion.

Researchers are seeking more beneficial uses of tobacco’s well-mapped and easily modified genome, said Sandy Stewart, a tobacco specialist and crop science assistant professor at N.C. State University. In recent years, the crop has become popular in small-scale pharmaceutical research, and the textile industry is exploring ways to use the fibers to weave and spin thread.

Flu vaccines would be a novel and helpful use, especially if the tobacco approach speeds the drug’s production.

The emergence of the H1N1 flu strain in 2009 after the flu vaccine supply had already been produced highlighted the need for a faster way to create the inoculations.

Vaccine manufacturers use an 80-year-old technology, cultivating the virus in chicken eggs to produce the majority of flu shots each year. The process takes at least six months and uses millions of eggs.

Tobacco offers benefits

According to Ors, using the tobacco plant is beneficial not only because it reduces the risk of allergic reactions, but it also cuts production time to slightly more than two weeks.

“Our method is a very fast technique – faster than even the new cell culture technology to create vaccines,” he said. “The cell culture process takes roughly three months.”

 

Rows of a strain of tobacco native to Australia incubate in Medicago's greenhouse facility in Research Triangle Park.

To make flu vaccine, Medicago gets the DNA sequence of the latest flu strain from the World Health Organization’s website.

 

Instead of using the active virus, the company synthesizes the genetic sequence and creates viruslike particles. VLPs resemble viruses with a protein shell, and they are covered with protein strands specific to the disease the vaccine targets.

A VLP contains no infectious material, so it cannot cause illness even though the human body recognizes it as a real virus.

When making the vaccine, Medicago scientists dip mature tobacco leaves into a solution made with agrobacterium, an organism that easily transfers DNA between itself and plants. The genetically modified bacterium, widely used in biotechnology for two decades, moves into the plant’s cells without transferring its own DNA material and compromising the VLP’s purity.

The leaves remain in solution for two minutes under a vacuum, suctioning the bacteria particles to the plant cells. When the vacuum releases, the leaves soak up the particles, pulling the virus protein into the plant cells for replication, Ors said.

The plants incubate in a greenhouse for four to six days, producing a large amount of VLP in the leaves only. The leaves are then harvested by hand to ensure that no plant stem goes through the purification process, and they are shredded, said Mike Wanner, general manager of Medicago’s RTP facility.

The leaves go through a low-speed centrifuge several times to spin out and separate parts of the plant not intended for use.

“Roughly 99 percent of the leaf is garbage, so we have to isolate the viruslike particles from everything else,” Wanner said, adding that the refuse is safely discarded. “We remove the junk by using a centrifuge and a sterile filtration step. The result is a viruslike particle that is 98 percent pure. That’s as good as or even better than the current vaccines produced.”

Taking it slow

Although manufacturing flu vaccine with tobacco plants could have many benefits, completed vaccine should be introduced to the public on a small scale, said David Weber, a professor in the infectious diseases division at UNC-Chapel Hill School of Medicine.

“It may well turn out that using tobacco plants allows us to generate large amounts of flu vaccine and that purifying the vaccines is easier this way,” he said. “But we don’t know the risks. We know that tobacco isn’t good for you if you smoke it, so there’s a need to ensure a minimal carryover of tobacco into the vaccine.”

But Weber said the positive effect could be felt outside the public health arena. Not only would tobacco farmers benefit from having another use and market for their product, but tobacco-manufactured vaccines could also help fight hunger.

“Currently, 15 percent of the world’s egg supply is used to make vaccines,” Weber said. “Taking them out of the vaccine production process would free up a lot of eggs that can be used to feed people.”

To read the Raleigh News & Observer story online: http://www.newsobserver.com/2011/01/17/924832/healthy-turnabout-for-tobacco.html

To read the Charlotte Observer story online: http://www.charlotteobserver.com/2011/01/16/1985795/healthy-turnabout-for-tobacco.html

 

January 17, 2011 Posted by | Healthcare, Science | , , , , , , , , , , , , , , , , , , , , , , , , , , , | Leave a comment

Invisible Wounds

Published in the Summer 2010 UNC Medical Bulletin

By Whitney L.J. Howell
For Robert and Holly Mullis, both staff sergeants in the Army, Robert’s return from frontline combat wasn’t the happy homecoming that they envisioned. The anticipated family picnics and laughter never materialized. In their place, Robert and Holly found their lives were full of anxiety and loneliness.
“I have a constant ringing in my ears. I can’t sit in a group unless I know everyone. I can’t sit with my back to the door,” Robert says. “I have to know everything that’s going on all the time.”
It wasn’t until the night he took at least four Ambien sleep aid pills that he realized he needed help for his mental condition. While the pills didn’t help him sleep, he said, they did make him black out. He has no memory of his actions over a 32-hour period during which he dressed for work, filled his truck’s gas tank, and then returned home to crawl in bed with his loaded pistol. Holly discovered him and, fearing he would try to hurt himself, called an ambulance to take him to the hospital. He woke up laying in an intensive care unit and surrounded by police officers.
For Holly, though, the biggest issue was isolation and loneliness. Rather than concentrating on rekindling their married life, she says, Robert wanted to see his “battle buddies” to make sure they were safe. She felt that her experiences paled in comparison to his, so she didn’t want to burden Robert with her emotions.

“I just had to keep all my feelings bottled up,” Holly says. “But having anyone to listen to me would just help so much.”

Similar conversations play out in doctors’ offices across the country on military bases, in veterans’ hospitals, and in private practices every day. Since Operation Iraqi Freedom (OIF) in Iraq and Operation Enduring Freedom (OEF) in Afghanistan began in 2001, more than 1.9 million men and women have served abroad. Many return home unscathed. However, others aren’t so fortunate. According to the New England Journal of Medicine, mental health problems are the second most common ailment behind orthopedic needs for returning military personnel.

Technological advancements in medicine and militaryequipment save lives and limbs with up to 90 percent of wounded service members surviving their injuries. But, it’s the unseen injuries—the invisible wounds of war—that now plague returning service men and women the most.

In 2007, the RAND Center for Military Health Policy Research estimated that 300,000 military personnel currently suffer from post-traumatic stress disorder (PTSD) or major depression, and roughly 320,000 individuals potentially sustained a minor traumatic brain injury (TBI) during deployment. More recent RAND statistics published in the February 2010 Journal of Traumatic Stress indicate that at least 15 percent of returning personnel have symptoms specifically of PTSD or depression.

“The best indicator for PTSD is the amount of combat exposure a service member has,” says Lisa Jaycox, PhD, a RAND senior behavioral scientist and clinical psychologist. “It affects their relationships, their ability to work, their physical health, and can contribute to substance abuse.”

Overall post-deployment psychological problems, not only depression and possible TBIs, but also various psychoses, are more prevalent. A 2007 Department of Defense (DoD) Task Force on Mental Health stated that 38 percent of soldiers, 31 percent of Marines and 49 percent of National Guard reservists revealed they developed a mental health issue associated with their service.

The DoD postulates that National Guard reservists have a greater proclivity to report problems, accounting

 

AHEC/CSSP training sessions are scheduled in military time, and commence with the color guard and the national anthem, in an effort to create a military culture “eye-opener” for providers. Photo courtesy of the Citizen Soldier Support Program.

 

for their seemingly higher incidence level of mental health issues. Unfortunately, admitting to a mental health problem doesn’t mean a service member will actively seek help. Only 30 percent of OIF and OEF service members with an official mental health diagnosis endeavor to do so, according to RAND statistics from the February study. Those who don’t are putting themselves at greater risk for unemployment, lower incomes, chronic health conditions, and homelessness, Jaycox says. The decision to get help isn’t an easy one for a service member, and it also doesn’t mean that he or she can.

Barriers to care

Despite the growing mental health needs in the US, clinical investigations show there simply aren’t enough licensed providers. A 2009 Psychiatric Services study conducted at the UNC Cecil G. Sheps Center for Health Services Research found that 96 percent of counties nationwide have too few mental health practitioners to meet the needs in their respective communities.

According to Richard Weisler, MD, adjunct psychiatry professor at the UNC School of Medicine and a practicing community psychiatrist, the military community in North Carolina mirrors the same provider shortage.

“For the nearly 400,000 service members at Fort Bragg and Camp Lejeune, there are only five psychiatrists,” Weisler says. “When you compare that to the data from RAND or other organizations, you see these men and women simply don’t have enough resources for mental health care.”

Not being able to schedule an appointment is only one obstacle service members face. Military culture itself will often dissuade someone from asking for help, said Harold Kudler, MD, a mental health services coordinator for the Department of Veterans’ Affairs (VA). It’s important that providers learn to “speak military,” he says.

“We don’t often think about the military as a distinct  culture in society that requires a certain cultural competency,” he says. “But individuals in this culture are less likely to ask for help. They don’t want to be stigmatized or ‘admit they’re crazy,’ and they don’t want to be taken out of the field because they would feel like they let their buddies down.”

In fact, Kudler says, many service members refer to mental health providers as “wizards,” not because they miraculously make the problems disappear, but because service members who make appointments suddenly vanish from the field.

Many don’t even think of themselves as veterans because they didn’t experience gunfire or were never in the most dangerous positions. This viewpoint can prevent a service member from seeking the care they need, Kudler says, because they do not feel their experienceswere traumatic enough to warrant medical attention.

Service members also fear their commanding officers will find out if they seek help for a mental health issue and will consider them unfit to serve, Kudler says. This concern is large enough that the DoD allows individuals to deny, on official forms, any previous mental health services they’ve received, and many service members will forego the medical care available on a military base or at a veterans’ clinic simply to keep their needs a secret.

Seeking help from a provider in the community, though, can also be an obstacle due to cost. Care in the community is often more expensive, and many nonmilitary physicians do not accept TriCare, the military-provided insurance program, because it provides lower reimbursements than most coverages. Providers farther away from a military installation, particularly those in rural areas, are less likely to accept TriCare despite the presence of service members in the community.

The women’s issue

OIF and OEF are the first military engagements in which women were allowed to serve on the front lines, although there is still an official restriction against women being in the line of fire. Based on VA statistics, 12 percent of the more than 45,000 OIF and OEF servicewomen have sought some type of mental health care. They experience many of the same symptoms as men, but some problems are unique to women.

According to Kudler, servicewomen are more likely to develop depression rather than PTSD when they return home. They also develop more personality disorders than men and, often, become hyper-protective of their children.

Women also experience different barriers to care when searching for treatment. Although the VA system is the traditional health care setting for returning veterans, the system has been slow to accept women as military personnel, and, thus, doesn’t offer the myriad of primary and specialty care services most women require. But women can also work against themselves by holding the belief that a PTSD diagnosis carries a stigma. They believe PTSD makes them bad mothers, so they refuse to acknowledge it and get help.

Carolina’s contribution

North Carolina has a base for every military branch and is among the most military-friendly states. Approximately 700,000 people, nearly 10 percent of the state’s population, have served or are serving in the military. The state’s contribution to the OIF and OEF efforts is unique, because roughly 30 percent of NC service members belong to the National Guard and do not live close to a large base. The result is that up to 50 percent of veterans live in rural or highly rural areas that are historically underserved and far away from most veterans’ clinics or other health care environments designed to help them. Consequently, many forego the treatment they need.

UNC, its clinicians, and its researchers are working to improve the services available to these men and women,as well as make them more accessible. The Citizen Soldier Support Program (CSSP) at The Odum Institute for Research in Social Science connects the military to the services available in the community and trains providers the most effective ways to treat military personnel suffering with mental health problems.

“We need to train clinical providers so they truly understand the issues of returning reservists and their families,” says Bob Goodale, CSSP director. “It’s never been more important. Providers need to understand military culture — they need to know what military conflict is really like.”

First and foremost, Goodale said, providers must remember to ask the gateway question: “Have you or anyone in your family ever served in the military?” Without the answer to that question, he said, mental health specialists and primary care providers (who are the first to see 70 percent of these problems) cannot appropriately treat a patient’s needs.

One of CSSP’s biggest achievements, Goodale says,

is its provider database. Practitioners who are qualified to address military mental health needs, who accept TriCare, and who want to make their services available, register with this database. Service members looking for a provider can search the database and easily find someone in their area who can give the treatment they need.

To ensure community providers know how to treat service members effectively, CSSP partners with the North Carolina Area Health Education Centers Program (AHEC) to provide educational sessions across the state. Some sessions are offered as in-person seminars, but others are webinars or podcasts devoted to specific mental health problems, including PTSD and TBI. In 2008–2009, these courses were offered 15 times and trained more than 1,000 health care professionals, says Karen Stallings, associate director of AHEC. One of AHEC’s main concerns, she says, is to educate more providers and encourage them to choose to become resources for mental health care in rural settings rather than urban ones.

According to Sheryl Pacelli, director of mental health and disaster preparedness at the South East AHEC, AHEC and CSSP are developing a DVD toolkit that will guide other organizations through creating a PTSD or TBI training course, securing logistics and designing the education aspects.

“We want our programs to be a cultural eye-opener for providers,” Pacelli says. “With the face-to-face trainings, we open the day with the color guard, we play the national anthem, and we do the schedules in military time.”

Rather than teach providers to understand the intricacies  and idiosyncrasies of war, she said, the AHEC/CSSP partnership hopes to train them to listen to military personnel more effectively to really hear their concerns and understand the events behind them.

Many of these providers take this training back to the VA system to treat returning service members. The initial therapies for TBI and other mental health issues predominantly occur at the VA because the system is smoothly connected to military bases. There are, however, times when the VA simply doesn’t have the physical capacity to provide care for a veteran despite the individual’s right to access.

These are the instances when these same service members will arrive at the UNC Health Care System, says Harry Marshall, MD, assistant professor of surgery in the UNC School of Medicine’s Division of Trauma and Critical Care Surgery. UNC had nearly 30,000 visits from service members with TriCare insurance in 2009. In many cases, the individual experienced an accident in the civilian world that exacerbated his or her old mental health issues.

“Sometimes simple things unrelated to war cause difficulties, like the headaches, trouble sleeping, and depression associated with a TBI or PTSD, to flare up. And these individuals are likely already dealing with decreased motility, lost limbs or, maybe, a facial deformity,” says Marshall, who also served two tours of duty as a National Guard reservist. “What Agent Orange was to Vietnam, PTSD and TBI will be to the Iraq and Afghanistan conflicts.”

Just as UNC offers all manner of mental health services, from counseling to cognitive therapy to prescriptions for antidepressants, its researchers are also delving into the causes of mental health issues in returning service members but with a twist.

Eric Elbogen, MD, assistant professor of psychiatry at the UNC School of Medicine and researcher at the VA  Hospital in Durham, NC, investigated what protective factors  could improve a service member’s readjustment into civilian society. His study was published in the May 2010 issue of the American Journal of Psychiatry.

Through a survey of 676 OIF and OEF service members, Elbogen determined that service members do not all experience PTSD the same way. Instead, there are three symptoms: flashbacks, avoidance of anything that reminds the individual of the trauma, and a state of hyperarousal and jumpiness. Within these symptoms, he said, anger also manifests itself differently as either typical anger, aggressive impulses, and, at the extreme end of the spectrum, an inability to control violent behavior. Knowing the difference is important to properly treat the patient.

“If we know what factors are related to each symptom, we will know how to target effective therapies,” Elbogen says. “This research gives clinicians the skill set to tailor their treatment just because one vet who walks into the office has anger, it doesn’t mean it’s an identical situation to the next vet who comes in.”

It will be several years, however, before the medical community understands the details of the mental health issues OIF and OEF veterans face. The higher survival rate among wounded service members vaulted health care providers into unchartered territory because long-term studies on the effects of PTSD and its treatments haven’t been possible to date. Over the next few years, however, the health care field hopes to have more definitive data to create evidence-based care for suffering veterans.

“There is one aspect of therapy that we know is fact now,” Elbogen says. “It’s clear that veterans who have the chance to speak with someone about their feelings and problems have better outcomes than someone who never gets the opportunity.”

To view the article as part of the magazine or view the magazine as a whole: http://issuu.com/robitaille03/docs/uncmb_summer10?viewMode=magazine&mode=embed

This story was re-printed in the Fall 2010 N.C. AHEC Newsletter: http://www.ncahec.net/pubs/newsletters/2010_Fall/invisible_wounds.html

August 5, 2010 Posted by | Healthcare | , , , , , , , , , , , , , , , , , , | Leave a comment

   

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