ATLANTA — J. Michael McGinnis, MD, MA, MMP, a highly-regarded epidemiologist and health policy expert, will receive the 2018 Fries Prize for Improving Health. McGinnis is being honored for fundamentally transforming our nation’s understanding about how to improve health by re-conceptualizing the nation’s perspective on its leading health threats through the publication “The Actual Causes of Death in the United States,” and establishing the Healthy People process of national goals and objectives to target action.
The Fries Prize for Improving Health award will be presented today at the American Public Health Association’s (APHA) annual meeting in San Diego. The award recognizes an individual who has made major accomplishments in health improvement with emphasis on recent contributions to health in the United States. It is intended for an individual who has done the most to improve health for the greatest number of people. The Fries Prize for Improving Health award is $60,000.
A senior scholar and Leonard D. Schaeffer Executive Officer at the National Academy of Medicine (NAM), McGinnis has been a leader in national and international health policy for more than four decades. He is well regarded both for his program and policy leadership and his research and publications on population health and the root causes of morbidity and mortality.
“Michael McGinnis’ contributions to health and health care are incalculable. He has been pivotal in his role of guiding health policy and science. His passion and commitment to improving the health and well-being of people have been unwavering,” said Michelle Larkin, RN, MS, JD, associate chief of staff, Robert Wood Johnson Foundation, who helped champion McGinnis’ nomination for the Fries Prize.
McGinnis established the Healthy People process for creating and tracking national health goals. Healthy People provides science-based, 10-year national objectives for improving the health of all Americans. The program encourages collaborations across communities and sectors; empowers individuals to make informed health decisions; and measures the impact of prevention activities.
Since the Healthy People initiative began in 1979, the United States has made significant progress including reducing major causes of death such as heart disease and cancer; reducing infant and maternal mortality; reducing risk factors like tobacco smoking and hypertension; and increasing childhood vaccinations. During the past four decades, the importance of collaborating across agencies at the national, state, local and tribal levels, and with the private and public health sectors has been demonstrated.
In 1993, McGinnis was the lead author on the seminal article “The Actual Causes of Death in the United States” in the Journal of the American Medical Association (JAMA). This pivotal paper demonstrated the factors that determine how long and how well one lives. It challenged public health perceptions about the root causes of health and redefined health priorities by addressing the determinants of health as a means to improve health. The article highlighted that substantial sustained improvements to health required dealing with the causes rather than treatment alone. He was also the lead author on the 2002 article “The Case for More Active Policy Attention to Health Promotion” in the journal Health Affairs. This article conceptualized and assessed the ways health is a function of the interplay of factors in five domains, showing that on a population basis the influence of behavioral, social, and environmental factors overshadowed medical care and inherited factors.
“Dr. McGinnis has created some of the world’s most influential approaches for highlighting the importance of prevention and positive behavior change for addressing major health challenges,” said Judith Monroe, MD, president and CEO of the CDC Foundation. “His research and leadership have had a profound effect on improving the lives of Americans, and we are delighted to award him the Fries Prize for Improving Health for his transformative impact on society.”
McGinnis is an elected member of the National Academy of Medicine, creator of its Learning Health System Initiative and executive director of the NAM Leadership Consortium for a Value & Science-Driven Health System. He held continuous appointments through the Carter, Reagan, Bush and Clinton Administrations at the Department of Health and Human Services (HHS), which has policy responsibilities for disease prevention and health promotion. In this capacity, he was founder and steward of a number of ongoing programs and policies, including the Healthy People program; the HHS/USDA Dietary Guidelines for Americans; the U.S. Preventive Services Task Force; and the Ten Essential Services of Public Health.
In addition, McGinnis served as founding director and chair of the health program at the Robert Wood Johnson Foundation; the World Bank/European Commission Task Force for Health Reconstruction in Bosnia; the Office of Research Integrity; and the HHS Nutrition Policy Board. Early in his career, he served as director of the World Health Organization’s smallpox eradication program in Uttar Pradesh, India.
His recognitions include the Distinguished Service Medal, the 1996 National Health Leader of the Year award and the University of California, Berkeley School of Public Health 2013 Public Health Hero award.
The James F. and Sarah T. Fries Foundation is a nonprofit corporation incorporated in 1991. The mission of the foundation is to identify and honor individuals, organizations or institutions, which have made great contributions to the health of the public. The foundation seeks to reward accomplishment rather than promise, practicality rather than theory.
The CDC Foundation is honored to partner with the James F. and Sarah T. Fries Foundation, which established and funds the award. As of 2016, the CDC Foundation manages and administers the Fries Foundation’s public health award programs, which include the Fries Prize for Improving Health and the Elizabeth Fries Health Education Award.
About the CDC Foundation
The CDC Foundation helps the Centers for Disease Control and Prevention (CDC) save and improve lives by unleashing the power of collaboration between CDC, philanthropies, corporations, organizations and individuals to protect the health, safety and security of America and the world. The CDC Foundation is the sole entity authorized by Congress to mobilize philanthropic partners and private-sector resources to support CDC’s critical health protection mission. Since 1995, the CDC Foundation has launched approximately 1,000 programs and raised over $750 million. The CDC Foundation manages over 300 CDC-led programs in the United States and in more than 130 countries. For more information, visit https://www.cdcfoundation.org. Follow the Foundation on Twitter, Facebook, LinkedIn and Instagram.
ABSTRACT: As health care professionals strive to address the nation’s physical and mental health care issues, they too are often at risk. The purpose of this paper is to inspire a national dialogue about the well-being and resilience of the people to whom Americans turn for care and how well their professions’ accreditation standards address those concerns.
Health care professions acknowledge the importance of health and well-being for their students, faculty, and preceptors/supervisory staff, and for the health care workforce . What is not clear is how closely accreditors from different health professions align their standards for addressing this critical concern with each other. In 2017, Cox et al. developed a model (see Figure 1) that represents the integration of health professionals’ roles in both education and practice settings with that of accreditors to meet four goals identified as the Quadruple Aim: population health, patient experience, per capita cost, and provider work life. Beginning at the entry (foundational) level, the learning continuum continues through graduate/post-graduate education to continuing professional development and intersects with other professions. This interprofessional continuum of learning includes accreditors who, by identifying areas of alignment and potential gaps, can create a framework addressing the well-being of the workforce.
Figure 1 | Role of Accreditors within and across Health Professions and Health Care Delivery for Fostering the Quadruple Aim
SOURCE: Cox, M., et al. 2017. The role of accreditation in achieving the quadruple aim for health .
Ideally, a comprehensive framework would include all health professions and their accreditors as described by Cox et al. (2017); however, a scaled-down approach was designed to start the conversation. Using this model, representatives from medicine, nursing, and psychology examined their professions’ educational models through an accreditation lens to look at how health and well-being fit within each profession’s learning continuum from education to practice, and across the three health professions. This information is detailed later in this paper as an environmental scan. A summary analysis of the scan appears in the sections below. The paper ends with concluding recommendations that describe potential areas of alignment and opportunities for different health professions—beyond just medicine, nursing, and psychology—to work in concert with the different accrediting bodies to build a culture of health and well-being for all.
Accreditors in medicine, nursing, and psychology promote health and well-being across the education continuum that extends into the practice setting. In the foundational years—when learners are first introduced to their chosen profession—areas of alignment in accreditation standards require that organizations support students in developing a professional identity, cultivating skills associated with stress management and self-care, and learning how to work collaboratively as members of interprofessional teams. Organizations must provide student resources that include but are not limited to counseling, tutoring, financial aid, and career guidance. In terms of addressing health and well-being, nursing accreditation standards appear to emphasize the concept of “care of self in order to effectively care for others” . Accreditation standards in psychology emphasize the use of “appropriate professional role models” to guide students, and that students and trainees should engage in “self-reflection” addressing “personal and professional functioning” and in activities that “maintain and improve performance, well-being, and professional effectiveness” . Medicine, in the foundational years, often looks to support students through well-being programs that are guided by Liaison Committee for Medical Education (LCME) standards .
In the graduate/post-graduate years, accreditors have implemented standards that require support for transitioning new graduates into the practice setting. Areas of alignment across the professions include an expectation that learners will be provided with incrementally greater responsibility for patient care, clear performance expectations with documentation of milestones and competencies, and strategies to support their overall health and well-being. Organizations have adopted medicine and psychology accreditation standards more widely than such standards for nursing during this training phase, because accreditation standards for nurse residency/fellowship programs have more recently been established. Medicine and nursing have also worked together through a national collaborative to improve the clinical learning environment and develop strategies to support learners in transition , whereas psychology has more recently moved toward greater interprofessional engagement.
In continuing professional development, accreditation standards across the three professions support educational interventions focused on improving health and well-being. Nursing and medicine (with pharmacy) have formalized a partnership to accredit organizations that provide interprofessional continuing education (IPCE), because research supports the positive relationship between interprofessional collaboration, decreased stress on practitioners, and improved patient outcomes . This collaboration is being expanded to include accreditors from other professions.
From an accreditation perspective, medicine, nursing, and psychology have a tremendous opportunity to learn from one another’s efforts to improve the health and well-being of their students, trainees, and professionals. For example, accreditors of medical schools make sure programs are supporting student well-being, undergraduate nursing accreditors require that curricula include elements of self-care and stress management, and competencies that include well-being and professionalism are compiled during the foundational education for psychology—i.e., at the doctoral and internship level. By keeping data on each of these efforts, successes can be shared among the different professions at national gatherings such as the Health Professions Accreditors Collaborative that meets in conjunction with the Association of Specialized and Professional Accreditors. These findings can then be shared with faculty and preceptors in care environments or at collaborative meetings such as the Interprofessional Education Collaborative (IPEC) or the annual meetings of the National Center for Interprofessional Practice and Education or the National Academies of Practice.
There is a strong need for today’s health professionals to develop skills in interprofessional communication and conflict resolution, and to collaborate as members of the health care team. Improving collaboration can reduce the demand on one profession, thereby decreasing stress and enhancing job satisfaction . The Interprofessional Learning Continuum model (see Figure 2) lays out a pathway for interactions among health professions from education to practice. Applying this model can help address health and well-being and can include accrediting organizations to ensure compliance.
Figure 2 | The Interprofessional Learning Continuum Model
SOURCE: Institute of Medicine, 2015.
NOTE: For this model, “graduate education” encompasses any advanced formal and supervised health professions training taking place between completion of foundational education and entry into unsupervised practice .
But, more important is the opportunity for accreditors to promote continuous improvement, specifically in how education and training programs effectively attend to well-being among their learners, faculty, and preceptors. Data and other outcome measures detailed in the two red boxes shown in Figure 2 could help guide accreditors in monitoring not only learner outcomes related to health and well-being, but also downstream impacts of provider well-being on patients and population outcomes. Learning outcomes across the continuum, as well as health and system outcomes, are heavily influenced by the confounding factors in the green box shown in Figure 2. These factors involve organizational and professional culture and policies that can harm or benefit a learning and health system environment depending on how the organization approaches the factors. Weaving culture and policy into interprofessional accreditation requirements for the well-being of students, faculty, and professionals may be one way to influence the health and well-being of many professions. For example, in nursing, the American Association of Colleges of Nursing’s (AACN) Baccalaureate Essentials require graduates to promote a culture of safety and caring within the work environment; work collaboratively and interprofessionally with patients, families, and colleagues; and promote a blame-free culture of accountability . The Commission on Collegiate Nursing Education, AACN’s accrediting arm, evaluates an organization’s compliance against those standards during the accreditation review. Residency program accreditation standards require that organizations demonstrate a commitment to a culture of interprofessional collaboration and support to include support of residents and faculty [9,10]. In graduate medical education, common program requirements for residency and fellowship programs stress the critical importance of working in interprofessional teams, especially around issues of quality, patient safety, care coordination, and interprofessional activities within the healthcare system . In contrast, psychology focuses on preparing psychologists competent to work in interdisciplinary settings through knowledge acquisition and demonstrated behaviors representing the roles and perspectives of interdisciplinary care delivery. In addition, psychology education promotes a supportive learning environment that may include actual interprofessional activities for entry-level and advanced level competencies .
Because there are no specific standards for health and well-being and learning environments in continuing education/continuing professional development for medicine, nursing, or psychology, there is an opportunity to create new synergies for addressing stress and burnout across the health professions. Currently, accrediting bodies from medicine, nursing, and pharmacy are collaborating in the field of IPCE. They define CE/CPD as “educational activities, which serve to maintain, develop, or increase the knowledge, skills, and professional performance, and relationships that a healthcare professional uses to provide services for patients, the public, or the profession. The content of CE is that body of knowledge and skills generally recognized and accepted by the profession as within the basic healthcare sciences, the discipline of healthcare, and the provision of health care to the public” .
Accredited continuing education providers developing educational activities that focus on the health and well-being of health care professionals may award profession-specific or IPCE credit, assuming all other accreditation criteria requirements are met. Organizations that are jointly accredited to provide team-based education are particularly well-suited to developing education focusing on the health and well-being of health care professionals. Such activity planning requires:
One of the goals of IPCE is to improve interprofessional collaborative practice. Over time, this may help contribute to a more cohesive and healthy working environment, and positively affect the health and well-being of those involved. Inviting additional professions such as psychology to join IPCE may enhance the focus on mental health issues through continuing interprofessional development.
Finally, the Interprofessional Education Collaborative and the National Center for Interprofessional Practice and Education represent opportunities to bring accreditors into conversations with emerging and seasoned health professionals from across the professions to share experiences and resources for improving the health and well-being of health professionals across the learning continuum.
Medicine, nursing, and psychology have their own systems of accreditation based on the learner’s stage of education or training (see Table 1). For medicine and nursing, the foundational level is where learners are first introduced to the basics of their chosen health profession; graduate and post-graduate training is where learners transition into the practice setting; and continuing professional development is where established practitioners engage in lifelong learning. Although this is also generally true for psychology, the foundational level is more commonly at the doctoral level, and the goal of doctoral training, which includes an internship, is entry into practice. Post-doctoral psychology training offers advanced training in which more specialized, supervised experiences are provided. In some jurisdictions, post-doctoral supervised clinical hours are required for license eligibility.
For nursing, the foundational years are often during a four-year baccalaureate degree program, although two-year associate’s degree programs remain a popular entry point to ultimately obtaining a bachelor of science in nursing degree. For medicine, the foundational years are within a graduate, four-year medical or osteopathic school. Similarly, psychology requires a doctoral degree for entry into practice and license eligibility, although some practitioners holding master’s degrees and related credentials may also engage in independent practice. Both medicine and psychology require a bachelor’s degree to be considered for acceptance by a medical school or a graduate psychology degree program. However, the degree does not have to be in pre-medicine or psychology. Table 1 provides a detailed description of the US accrediting agencies for medicine, nursing, and psychology.
Although foundational educational programs for nursing, medicine, and psychology vary, each profession is committed to the health and well-being of its health professionals across the learning continuum (see Box 1). At the undergraduate nursing level, the emphasis is on creating environments that support and promote the health and well-being of students while maintaining rigorous academic standards. Academic curricula must include content related to self-care and stress management. Nursing students learn how to form a professional identity, maintain a professional image, engage in self-reflection, and deliver patient-centered, ethical care. Students must have resources such as academic counseling, tutoring, financial aid, and career guidance. Nursing schools are held by their accrediting bodies to demonstrate how they create a supportive learning environment beyond just the focus on curricular content. For example, the CCNE criteria require that nursing schools provide clinical practical experiences for interprofessional collaboration , and the Commission for Nursing Education Accreditation (CNEA) standards require nursing schools to demonstrate a culture of excellence and care . Nurse residency program accreditors, likewise, require program administrators to demonstrate a supportive practice-based learning environment . To maintain accreditation, psychology programs for all levels of training, including postdoctoral residencies, are expected to provide a “welcoming, supportive, and encouraging learning environment” for all their residents . Within medicine, the LCME standards require programs to support student well-being and personal counseling (when needed) in foundational medical education, and are part of the student survey administered as part of the LCME review process. The site visit also addresses the following question as part of the accreditation visit report:
Summarize medical school programs or other programs designed to support students’ well-being and facilitate students’ ongoing adjustment to the physical and emotional demands of medical school. Describe how students are informed about the availability of these programs/activities .
In psychology and in medicine, accreditation attention to health and well-being presents more prominently at the graduate and post-graduate levels than at the foundational level. At the post-graduate level, duty-hour regulations for medical residents have been a major component of the common program requirements in graduate medical education (GME) for more than a decade. The ACGME also recently revised its program requirements. Section VI, “The Learning and Working Environment,” now includes a new subsection, “Well-Being” (Section VI.C), which goes beyond just duty-hour regulations and was implemented in 2017. The preamble for this section says the following:
In the current health care environment, residents and faculty members are at increased risk for burnout and depression. Psychological, emotional, and physical well-being are critical in the development of the competent, caring, and resilient physician. Self-care is an important component of professionalism; it is also a skill that must be learned and nurtured in the context of other aspects of residency training. Programs, in partnership with their Sponsoring Institutions, have the same responsibility to address well-being as they do to evaluate other aspects of resident competence. 
Section VI.D, “Fatigue Mitigation,” provides more explicit standards on preparing students and faculty to recognize fatigue and intervene for the sakes of learner and patient. Questions on duty hours and fatigue mitigation are included on the ACGME’s annual resident and fellow surveys, and supplemental questions on wellness are under consideration.
For psychology, the APA CoA uses the Standards of Accreditation for Health Service Psychology , which provides standards for education and training programs that include competencies that all students and trainees must acquire. These profession-wide competencies are specific to the level of training.
“Professional values, attitudes, and behaviors”—how trainees are to respond professionally in increasingly complex situations—is a required competency for trainees at the doctoral and internship levels . Trainees are to develop responses that reflect the “values and attitudes of psychology, including integrity, deportment, professional identity, accountability, lifelong learning, and concern for the welfare of others” . In addition, the use of self-reflection concerning personal and professional functioning, with engagement in activities to sustain and enhance performance, establish well-being, and provide effective professionalism are included. Openness and responsiveness to supervisory feedback are also elements of this competency. Accredited programs must include the development of all competencies within training and establish minimum levels of achievement as a requirement for successful completion of a program.
Although psychology accrediting agencies do not specify how competencies are to be taught or developed, a recent commentary written by Grus et al. (2017) described different methods of promoting well-being . These methods emphasized self-care and recommended program leadership, seminars, and committees for describing, promoting, and monitoring the climate and development of self-care activities. The authors recommended that training programs use specific activities such as those promoting student support and growth, especially given the stress associated with academic training from such challenges as managing multiple demands and maintaining a personal-work life balance.
At the nursing graduate level, less emphasis is placed on strategies that promote health and well-being and more is placed on developing leadership and interprofessional skills. Curricular content includes leadership theory, communication skills, conflict resolution, and building and nurturing effective teams. The graduate nursing student’s role in quality and safety is also embedded throughout the curriculum.
A new health professional is likely to be more successful when he or she addresses issues affecting health and well-being before beginning practice. Since 2012, the GME accreditation system for medical residents and fellows has included a Clinical Learning Environment Review (CLER) program. CLER is a continuous quality improvement (CQI) approach to institutional-level accreditation. The CLER process is designed to help institutional leadership integrate residents and fellows into the care processes of the institution, typically a hospital or clinic. CLER involves on-site review by trained surveyors looking at patient safety, health care quality, care transitions, supervision, professionalism, and well-being . The well-being subset has six embedded pathway domains that are designed to help institutional leadership ensure the well-being of its academic staff and learners.
In addition to CLER, the Milestones initiative , another continuous quality improvement–focused aspect of accreditation, is addressing health and well-being as part of a new “harmonized set” that will be used to guide the revision process in the coming years. One of the newer sub-competencies is self-awareness and help-seeking. Milestones describe a developmental trajectory that extends beyond the residency and fellowship period into clinical practice. In this sub-competency, for example, an advanced stage is described as follows: “Independently develops a plan to optimize personal and professional well-being” and “Independently develops a plan to remediate or improve limits in the knowledge/skills of self or team” . Thus, the GME accreditation model is multi-pronged, with standards (the common program requirements) that target individuals, programs, and institutions, but also CQI-driven processes that target institutional leadership and individual professional development through competencies and milestones.
For nursing, the transition to practice has long been recognized as an intensely stressful period. Marlene Kramer described the challenges in her book Reality Shock . Today, newly graduated nurses enter practice environments that are extremely demanding and require a high degree of clinical proficiency, critical thinking ability, and clinical leadership skill. Nurse residency and fellowship programs help to mitigate the stress of transition by incorporating activities that improve clinical skills, critical thinking and clinical reasoning skills, time management, and delegation skills. These programs also help reduce high levels of turnover and vacancy within organizations, as well as the loss of RNs within the profession [25,26]
Accrediting bodies for nurse residency and fellowship programs have embedded criteria that directly address identified stressors, such as programs to help the trainees manage stress and role transition. Residents and fellows learn to manage time, improve communication skills, and work as members of the interprofessional care team while developing strategies to prevent compassion fatigue, promote resiliency, and address ethical dilemmas.
Within psychology, in addition to promoting self-care in professional development, programs are required to document their actions and procedures that “maximize student success.” One mechanism to enhance student success—and on which programs are evaluated—is the institutional climate. Such evaluations determine the supportiveness of the program and the institution in creating such learning environments, so that health may be maintained.
Numerous studies have demonstrated that faculty within the health professions are experiencing significant levels of stress and burnout [27,28,29,30]. This means risking a further reduction of an already reduced number of educators within the health professions. For example, a 2010 study by Aquino et al. (2018) underscored the negative impact burnout is having on the severe nursing faculty shortage that, according to AACN, totaled over 1,500 faculty vacancies in 2016 [31,32]. The causes of burnout point to work overload and emotional exhaustion, which becomes a vicious cycle as the number of available faculty diminish [30,33].
At the post-graduate level in medicine, the CLER initiative explicitly calls attention to the importance of well-being among faculty members. For example, well-being pathway 2 says that the “clinical learning environment demonstrates continuous effort to support programs and activities that enhance the physical and emotional well-being of residents, fellows and faculty members” . In fact, all of the well-being pathways in CLER explicitly include faculty members along with residents and fellows. Without equal attention to faculty member well-being, it is hard to imagine how a training program can maximize well-being for its students.
System-level drivers of burnout that are negatively impacting health care professionals include but are not limited to perceptions of the inability to provide quality care, increasing administrative burden, verbal abuse from patients, heavy patient loads, staffing shortages, and lack of interprofessional collaboration . While the ability of accreditors to address system-level drivers can be a challenge, a unique collaboration of heath care professional organizations, including accreditors, has recently formed to explore how it can collectively work to improve the educational experience and patient care outcomes within clinical learning environments, thus addressing some of the system-level drivers. This group, the National Collaborative for Improving the Clinical Learning Environment (NCICLE), convened a summit in October 2017 to explore characteristics of a high-functioning, interprofessional clinical learning environment. Published on the NCICLE website, the six key characteristics of a positive clinical learning environment include: patient-centered environment, a continuum of learning for all, reliable communication, team-based, care, shared accountability, and evidence-based patient care based on interprofessional experience . The value proposition as depicted below in Figure 3 highlights the positive impact on patients, faculty, hospitals/health systems, and academic centers through a collaborative approach.
In addition to the opportunities for accreditors across the learning continuum, there are opportunities to advance well-being among health professionals from the perspectives of organizations where health care professionals practice. Nursing accreditors, for instance, have developed standards for organizations that promote the health and well-being of nurses in the practice setting. The ANCC’s Pathway to Excellence and Pathway to Excellence in Long Term Care programs set standards for positive practice environments with criteria that require credentialed organizations to demonstrate a healthy workplace for nurses. The following are pathway standards that reflect this mission:
ANCC’s Magnet Recognition Program similarly promotes the health and well-being of nurses through a variety of strategies. Organizations that meet Magnet’s rigorous standards must demonstrate how they implement workplace advocacy, including addressing caregiver stress, supporting nurses’ continuing professional development and career advancement, taking action to support academic progression to the baccalaureate level or higher, and improving interprofessional teamwork and collaboration.
Within medicine, ACCME has been an active partner in the National Academy of Medicine Action Collaborative on Clinician Well-Being and Resilience , as well as at the ACGME yearly conference. Per Graham McMahon, CEO of the ACCME, “all of our commendation criteria are about creating effective learning experiences—engagement in those activities has the ability to nurture self-awareness, provide intellectual fulfillment, create teams, and empower learners to engage in system change—all factors that can create a culture change and address wellness and burnout” (McMahon, personal communication, February 2, 2018). In addition, the ACGME has served the last several years as a convener, bringing experts in wellness and burnout together to explore how the community can help address the burnout physician suicide problem and improve health professionals’ wellness and well-being. This effort has included a yearly invitational conference in Chicago and the creation of a physician well-being resource page on the ACGME website . The ACGME is also collaborating with the LCME and ACCME in these activities.
Likewise, psychology is attending to the need to consider self-care activities within the profession. Authors [20,38,39,40] have described occupational risks to well-being within the profession of psychology and emphasized the need to develop and integrate effective self-care strategies. For example, Wise et al. have shared a number of more formal intervention techniques such as mindfulness-based training, and Wise and Barnett have presented a number of different activities across the stage of professional development, including graduate training . In addition, the APA convened a task force that published guidelines for supervision competence within multiple domains including supervisory relationships, professionalism, and ethics .
In reviewing the environmental landscape and previously published materials, the authors conclude that there are many opportunities for different health professions to learn from each other through health and well-being activities already underway across the learning continuum. However, unless there is a need or requirement forcing joint action, the likelihood is that the professions will work on initiatives from within their individual silos. One exception to this is interprofessional education. Promoting well-being using an interprofessional foundation is a logical approach. At the pre-licensure, foundational level, IPE exposes students to a wider health system than is typically possible from a single profession, and a systems approach has been promoted by individuals and groups at the National Academies as well as other organizations to decrease stress and promote well-being [1,36,41,42]. In addition, accrediting bodies can require demonstration of collaboration across the professions. The LCME requires programs in medical education to incorporate ACGME competencies, and the NLN CNEA and CCNE require evidence of interprofessional teamwork . Although not mandated through their accreditors, the APA is a member of the Interprofessional Education Collaborative and encourages interprofessional education at the foundational level [44,45].
The authors note great promise for collaborative efforts on well-being at the pre-licensure, graduate, and post-graduate levels; however, collaboration on promoting provider health and well-being across professions should start immediately at the practice level. The existing structure for CPD with nursing, medicine, and pharmacy is an ideal entry point for interprofessional continuing education that emphasizes a collective well-being of the workforce. This effort could be expanded to include other health professions in a similar way that HPAC now includes 24 different accreditors, the global forum has 19 different health professions, IPEC has expanded from its original six to now 20 associations, and the National Academies of Practice and the National Center for Interprofessional Practice and Education remain a powerful source of education and information sharing across professions. With all of these interprofessional opportunities in motion, the time to act is now. Representatives from accreditation, health professions education, and health professions practice must use these convening opportunities to promote the health and well-being of all professionals within the health and education system continuum.
Tweet this! Accreditors of health care professions have an opportunity, through alignment of priorities and identification of gaps, to create a culture of health and well-being for students, trainees, and clinicians: https://doi.org/10.31478/201811a #NAMPerspectives
Tweet this! Weaving culture and policy into accreditation requirements for the well-being of clinicians may be one way to promote a culture of safety and caring within the work environment: https://doi.org/10.31478/201811a #NAMPerspectives
Tweet this! Our newest #NAMPerspectives discussion paper acknowledges that there is great opportunity for promoting health and well-being among all clinicians if health care accreditors collaborate: https://doi.org/10.31478/201811a
During and after treatment, cancer patients and survivors suffer from a range of symptoms and side effects, chief among them fatigue and declines in physical functioning. In addition, cancer and its treatment accelerate the aging process, potentially increasing inflammation, taxing major organ systems, and contributing to comorbidities such as cardiovascular disease, diabetes, and/or osteopenia [1-4]. As we celebrate successes in cancer treatment, we also must address the needs of survivors who experience the deleterious consequences of these treatments.
Fatigue and decline in physical functioning are two of the most commonly experienced long-term effects of cancer. During treatment, patients often become deconditioned, possibly because of increased sedentary time, reduced physical activity, and changes in diet or weight. It is common for survivors to lose skeletal muscle mass during treatment because of these decreases in physical activity and/or insufficient consumption (or absorption) of dietary protein and other nutrients needed to sustain or build muscle and bone, leading to declines in physical functioning and increases in osteopenia/osteoporosis that interfere with their ability to perform and enjoy activities they value.
Loss of lean mass may not be apparent from monitoring weight since even when weight is stable, survivors can be replacing muscle mass with fat mass (sarcopenic obesity). Although loss of muscle mass can happen during and after cancer treatment, its effects are exacerbated when patients gain additional weight. Weight loss is not necessarily the answer for many survivors, since weight loss without exercise and adequate dietary protein can contribute to further loss of muscle mass. Cancer survivors with sarcopenic obesity, those with high body fat and low lean mass, are at the highest risk for mortality [5,6].
Physical activity, high diet quality, and weight management may ameliorate many of the problems experienced by cancer patients and survivors. Substantial evidence from randomized trials supports the potential for physical activity, diet, and weight management interventions to reduce cancer-related symptoms and improve quality of life, including functional health outcomes [7-13]. Exercise interventions have been shown to reduce fatigue both in cancer patients under active treatment and post-treatment survivors . Weight loss interventions that encourage a high-quality diet and physical activity have been shown to improve physical functioning, even in older cancer survivors . Furthermore, observational studies indicate that insufficient physical activity, poor-quality diet, and obesity are associated with disease-related outcomes, including recurrence risk, death from cancer, and overall mortality, as well as the risk of subsequent malignancies [15-29].
Given growing evidence suggesting the benefits of physical activity, high diet quality, and weight management (referred to collectively as lifestyle behaviors) for cancer patients survivors, a number of national organizations, including the American Cancer Society, the National Comprehensive Cancer Network, the American College of Sports Medicine, and the World Cancer Research Fund/American Institute for Cancer Research have published guidelines on nutrition and physical activity for cancer survivors [30-33]. These guidelines highlight the importance of maintaining a healthy weight, engaging in aerobic activity of at least moderate intensity for 150 minutes per week and strength-building exercise twice a week, and eating a high-quality diet high in vegetables, fruits, and whole grains, and low in red and processed meat. Many survivors have limited awareness of these guidelines, and most do not achieve the recommended lifestyle goals [34-40]. Clinicians in both oncology and primary care have limited knowledge of the guidelines and are frequently unprepared to counsel patients in these areas . Further, in the United States, effective programs and services to help survivors adopt recommended behaviors are not widely available in survivorship care settings or the community. Despite irrefutable evidence of their health benefits, these interventions for cancer survivors are rarely covered by health insurance.
How do we translate these guidelines into practice? We propose six action steps to increase the availability and uptake of weight management, physical activity, and nutrition interventions for cancer patients and survivors, summarized below and in Figure 1.
Figure 1 | Summary of Action Steps Needed to Increase the Availability and Uptake of Weight Management, Physical Activity, and Nutrition Interventions for Cancer Patients and Survivors
SOURCE: Basen-Engquist, K. et al. 2017. Agenda for Translating Physical Activity, Nutrition, and Weight Management Interventions for Cancer Survivors into Clinical and Community Practice. Obesity (Silver Spring): November 25, Supplement 2:S9-S22. Reprinted with permission.
1. Expand the availability of a range of evidence-based options for weight management, nutrition counseling, and physical activity programs for cancer patients and survivors.
Cancer survivors approach changes in lifestyle behavior with a range of motivations, experiences, resources, and needs. Programs to support them in making changes need to be equally diverse and appropriately tailored to survivors’ preferences, available resources, and characteristics to increase the chances of successful adoption and effect on health. Programs may be facility or home-based, vary in their level of supervision/guidance, and be cancer-specific or geared toward the general population. At least initially, many cancer survivors will likely be more comfortable with cancer-specific programs with guidance that is geared toward their needs. As cancer survivors feel more confident in performing physical activity, they may not require supervision or guidance and may prefer to use home-based and/or community-based programs. What is important is that programs be safe and evidence-based. The evidence may vary among programs. Some programs may be designed to improve cancer outcomes, others may reduce the risk for or treat comorbid conditions such as diabetes and cardiovascular disease, and still others may be designed to address symptoms such as fatigue.
Lack of availability of evidence-based programming for cancer survivors is a major concern, and hinders the dissemination of interventions to the wider population of survivors. Clinic- or facility-based programs, especially cancer-specific programs, are often unavailable outside of major metropolitan areas, and patient access may be limited by cost and transportation requirements. Community-based programs need program standards to ensure quality and give providers more confidence in making referrals. Finally, research is needed to help evaluate which types of programs are effective for whom, and to evaluate effective and sustainable models of program delivery.
2. Improve screening and referral of patients and survivors to exercise, nutrition, and weight management services.
To connect patients and survivors with the right type of programming, a patient-centered, tailored approach is needed to identify the appropriate lifestyle behavior change/rehabilitative services needed for a particular patient or survivor based on his or her goals, motivations, and health limitations (cancer and non-cancer related). However, extensive medical clearance processes and highly supervised programs are costly in terms of both financial requirements and patient time and effort. Requiring all patients/survivors to undergo medical clearance before increasing physical activity or eating a more healthful diet, or to attend supervised cancer-specific programs, can create barriers to participation . Thus the level of screening, and the structure and supervision level of the program, should be tailored to the survivor to optimize efficiency and maximize uptake. For example, an otherwise healthy cancer survivor with few cancer-related limitations should be able to start a moderate-intensity walking or other aerobic exercise program without needing medical clearance or guidance. Figure 2 provides a schematic of a patient-centered process for integrating patient/survivor preferences with information about functional impairments and comorbidities to screen and refer patients to lifestyle programs. Implementation of screening strategies using this approach can help connect patients and survivors with services tailored to their physical needs and personal goals, without producing additional barriers (e.g., needing to attend a specific program at a designated time and place) that might limit participation.
Figure 2 | A Patient-Centered, Tailored Approach to Identify the Appropriate Lifestyle Behavior Change/Rehabilitative Services Needed for a Particular Patient or Survivor that Integrates Information about Patient Goals and Health and Functioning Limitations
SOURCE: Basen-Engquist, K. et al. 2017. Agenda for Translating Physical Activity, Nutrition, and Weight Management Interventions for Cancer Survivors into Clinical and Community Practice. Obesity (Silver Spring): November 25, Supplement 2:S9-S22. Reprinted with permission.
3. Improve health care providers’ capability of screening/assessing and referring survivors to weight management, nutrition, and exercise information, programs, and services.
Cancer patients and survivors express a strong preference for receiving information about physical activity, diet, and weight management from their oncology providers , and studies indicate that such discussions can be influential [44,45] and are associated with increased physical activity among cancer survivors [46,47]. The American Society of Clinical Oncology (ASCO) has published a statement supporting the practice of oncology providers addressing lifestyle behaviors with patients . However, patients are largely not receiving information about physical activity, nutrition, and weight management from providers. Health care providers often report that they do not have the time or appropriate expertise and training to screen patients for services and refer them appropriately, and that their expertise related to physical activity, diet, and weight management is limited . Resources are available to assist providers, including information on addressing obesity in oncology from the ASCO , and a comprehensive evidence-based guide to obesity treatment for the general population has been published by the Obesity Society, the American Heart Association, and the American College of Cardiology  that can be useful to oncology care providers as well.
4. Increase and support the oncology-specific training and certification of dietitians, exercise professionals, physical therapists, and physiatrists to increase the competency of the workforce needed to optimally deliver services to cancer survivors.
With over 15 million cancer survivors in the United States, and projections that this number will expand to 20 million by 2026 , there is a growing need for exercise and nutrition professionals with appropriate training to provide assistance to the rapidly expanding population of cancer survivors. The Academy of Nutrition and Dietetics maintains a certification specialty in oncology nutrition, and the American College of Sports Medicine has a specialty certification for Cancer Exercise Trainer, but the number of professionals certified by these programs is insufficient to meet the needs of the growing cancer patient/survivor population. The American Physical Therapy Association is creating a specialty board certification in oncology. Although there are more than 10,000 board-certified physiatrists in the United States, few are fellowship trained in or practice cancer rehabilitation. The American Academy of Physical Medicine and Rehabilitation is working with cancer rehabilitation physiatrists to develop cancer-specific training, education, and research programs, but no specialty certification is currently available.
Wellness professions need to expand oncology-specific training to ensure a sufficient workforce to provide lifestyle behavior interventions to meet the needs of cancer patients and survivors. Additionally, other types of health professionals could provide lifestyle behavioral support and information with appropriate training. For example, there is a role for patient navigators, health educators, health coaches, and community health workers to help motivate survivors to access recommended services and reinforce messages about leading a healthful lifestyle.
5. Expand dissemination and implementation research to test models for service delivery of evidence-based interventions.
Effective implementation of programs, as well as screening and referral methods, will require dissemination and implementation (D & I) research to develop effective and efficient delivery models and ensure accessibility to patients and survivors who need these services. A recent portfolio review of National Cancer Institute grants on lifestyle interventions in cancer survivors indicates very little ongoing D & I research . Clearly, increased D & I research on existing evidence-based interventions is needed. Additionally, researchers planning new studies on lifestyle behavior among cancer survivors should consider external validity, dissemination, and the potential for sustainability, working toward developing programs that can be generalized to a broader cancer patient and survivor population, particularly those who receive their care outside of major tertiary care centers. There is value to more deeply exploring the context of community oncology clinics and of survivorship care provided in primary care settings, to better understand how programs can be implemented and sustained in these practice settings. Finally, D & I research needs to take patient and survivor preferences for lifestyle interventions into account to maximize uptake, address barriers to implementation, and aid in sustainability of community-based programs.
6. Advocate for and leverage health care policy changes that support availability, access, affordability, and uptake of services.
Public policy has a large effect on the affordability of, access to, and use of evidence-based nutrition, physical activity, and weight management programs and services for cancer patients and survivors. The most prominent influence of policy is regarding payment for these services. Currently, coverage for such services and programs is limited. For individuals with documented need, coverage for rehabilitative services, which can include exercise to improve physical conditioning and address specific functioning deficits, is required under the Essential Health Benefit regulations of the Affordable Care Act (ACA). However, despite required coverage, access to rehabilitative services can still be limited by cost in the form of co-payments or short-term or grandfathered plans not required to cover this service. There is no coverage requirement for oncology nutrition services in the ACA. These services are available to patients at some institutions that offer them freely and reimburse the provider through the cancer center’s overhead or as part of a bundled payment or contract with a third-party organization that provides funding for oncology nutrition services.
However, most cancer survivors do not have access to nutrition support unless they are able to pay for the service out-of-pocket. Given that many cancer patients already experience financial concerns related to their treatment , they may not be able to pay for nutrition services. Diet and physical activity services outside of the clinical setting are not typically covered by private health insurance or Medicare, although some cancer centers and community organizations provide exercise programs for cancer patients and survivors at low or no cost (e.g., Livestrong at the YMCA). However, the area of diabetes prevention provides a potential exemplar or precedent for supportive cancer care. The independent Office of the Actuary in Centers for Medicare & Medicaid Services (CMS) certified that expansion of the Diabetes Prevention Program, a model funded through the Centers for Medicare and Medicaid Innovation, would reduce net Medicare spending and improve patient care . Thus, in 2018, Medicare began reimbursing for providing the Diabetes Prevention Program to all eligible beneficiaries. Several private insurers also cover the program offered by community-based providers such as the YMCA or other in-person or online providers meeting certain standards for effectiveness established by the Centers for Disease Control and Prevention.
There are several opportunities to increase access to programs for cancer patients and survivors. Payment models are moving from traditional fee-for-service payment systems toward systems that focus on value-driven care, which rewards improved care quality and reduced costs. These models may incentivize the delivery of physical activity, nutrition, and weight management services to patients as a way of improving their fitness, nutritional status, quality of life, health, and other outcomes. Additionally, quality measures used to justify value should be expanded to include measures focused on nutritional status, physical functioning, and weight status outcomes that could help to monitor progress and incentivize providers to offer or refer to evidence-based behavioral interventions to improve lifestyle behaviors. Additional research is needed to increase the evidence base about the effectiveness and cost-effectiveness of various lifestyle-change programs and services for cancer survivors, including discerning which programs and services are most effective for whom, how these services affect the value equation, and how insurance coverage and employer provision of programs and services affects usage and outcomes. Engagement of payers is needed in the formulation of research questions so that research results can better inform their decisions about benefit design and coverage.
Cancer patient and survivors’ access to affordable, evidence-based lifestyle-change programs and services, with sustainable funding provided by third-party payers, should be a long-term goal. In the interim, existing innovative service delivery and payment models implemented by cancer centers, employers, and community-based organizations to provide affordable, effective, and personalized lifestyle-change programs to cancer survivors is needed. Scaling programs for broader reach to a larger number of cancer survivors is an additional programming and research goal. Research gaps must be addressed with added D & I research, with the goal of optimizing care and health outcomes for the full population of cancer survivors. A critical component of assuring access to high-quality lifestyle behavior support is the need to train health care providers and to develop programs and systems to accommodate the routine delivery of this care. Patient and survivor preferences around the components, frequency, method of delivery, and setting of lifestyle-change programs should also be studied and taken into account for optimal uptake of such services. In addition, patient, provider, and system-level barriers to delivery and uptake need to be addressed. All stakeholders must play a role in ensuring that cancer patients and survivors have the support they need to engage in healthful dietary, physically active, and weight management behaviors on a long-term basis to improve their functioning, quality of life, and health.
Tweet this! Treatments for cancer leave patients fatigued, sometimes challenged to eat a healthy diet, and can lead to reductions in muscle mass. A new #NAMPerspectives describes some approaches to combat these negative symptoms: https://doi.org/10.31478/201810g #NAMMtg
Tweet this! Guidelines on optimal nutrition and levels of physical activity for cancer survivors exist, but are rarely practiced. Authors of a new #NAMPerspectives provide a roadmap to move from research to implementation: https://doi.org/10.31478/201810g #NAMMtg
Tweet this! Physical activity, a high-quality diet, and weight management may ameliorate many of the problems experienced by cancer patients and survivors. A new #NAMPerspectives provides a closer look: https://doi.org/10.31478/201810g #NAMMtg
Controlling or reducing the risk for cancer was a principal goal of the National Cancer Act, signed by President Nixon in 1971. Long before the human genome was sequenced, and the etiology of many cancers was understood, Americans were determined to find a way to reduce the burden of cancer in the population. The act was passed only seven years after the first US Surgeon General’s report on the health consequences of cigarettes and smoking. As we approach the 50th year since the War on Cancer began, it is helpful to reflect on past and current cancer prevention and control. This paper focuses on 1) early detection and prevention of cancer and 2) cancer survivorship, areas highlighted in the recent Lancet Oncology Commission report on future
cancer research priorities in the United States .
In the early 1970s, the only established cancer screening test was the cervical cancer Papanicolaou (Pap) smear. During a woman’s annual pelvic examination, cervical material was spread on a glass slide, dropped in fixative, and sent for examination. Clinicians understood that cancers could be detected in this way, but they had little knowledge of cervical cancer’s natural history and its relationship to various risk factors (i.e., sexual behavior, human papillomavirus [HPV] infection, or smoking). Clinicians had only begun to routinely screen younger women who were sexually active. Cervical cancer was the number one cause of female cancer deaths worldwide, prematurely taking the lives of women in their thirties and forties. I recall taking care of young women who received a radical surgical procedure called pelvic exenteration— an attempt to eradicate advanced cervical cancer through removal of the cervix, uterus, ovaries, bladder, lymph nodes, and sometimes bowel. Radiation therapy was ineffective in preventing the return of the disease, and death by renal failure was common, due to obstruction of the drainage system from the kidneys. While radical hysterectomy is still performed today, the exenteration surgical procedure was abandoned due to its extreme morbidity and failure to prevent both local and distant metastatic disease.
Today, we understand that almost all cervical cancer results from infection with oncogenic serotypes of HPV that are sexually transmitted. Pap smears are still performed, but at less frequent intervals. Testing for high-risk HPV DNA can be conducted instead, or co-testing can be performed . There are several highly effective vaccines that protect against HPV infection. Active campaigns are underway to immunize all pre-teenage girls and boys, although uptake has been lower than expected . Immunization as a cancer prevention strategy has already shown benefit for hepatitis B virus and liver cancer . In the United States, HPV immunization has taken on even greater importance because of an epidemic of other HPV-associated malignancies (oropharynx, anal), increasing the cancer prevention value of HPV immunization .
There are about 10,000 new cases of cervical cancer each year in the United States. In spite of highly effective tests for early detection, many women are diagnosed with advanced local or metastatic disease and have a five-year survival rate that is just over 60 percent . Disparities in treatment and survival outcomes are substantial, especially for African American women, and much more needs to be done to improve prevention and early detection of cervical cancer in all women through immunization and screening.
Other evidence-based cancer screening tests have been introduced over the past decades (e.g., mammography for breast cancer, and fecal occult blood tests, sigmoidoscopy, and colonoscopy for colorectal cancer) . Some tests were adopted without sufficient evidence, for example, use of the prostate-specific antigen (PSA) blood test for prostate cancer screening. The PSA test was developed to detect metastatic recurrence in prostate cancer patients, but in the 1980s, the PSA test was rapidly adopted as a screening test without evidence that it reduced mortality from prostate cancer. This led to an explosion in the number of prostate cancers diagnosed each year, peaking in 1992 [8,9]. Ultimately, it was recognized that the PSA test identified a reservoir of indolent prostate cancers whose early detection and treatment did not decrease mortality. Prostate cancer screening guidelines have since been revised, and recommendations for PSA screening are much more limited to populations at increased risk [8,9]. This was one of the earliest examples of an “over diagnosis of cancer”, in which screening detects nonlethal, early cancers. Once an early cancer is detected, the person is likely to receive complex therapy that can have significant and long-term side effects, but the treatments do not alter the person’s lifespan.
Screening mammography can reduce mortality from breast cancer among women. However, implementation of regular mammography screening also led to a rapid expansion of cases of ductal carcinoma in situ—a noninvasive pre-cancer that was virtually nonexistent in the 1970s, but now accounts for about 60,000 new cases of breast cancer each year. As in the case of prostate cancer, many of these early breast abnormalities will not develop into lethal cancers. In order to maximize benefits and reduce the harms of screening, guideline developers are currently struggling to recommend and implement more rational, risk-based approaches to breast cancer screening, matching the woman’s risk for disease, based on age and other factors, with the appropriate screening interval and technology. Example strategies include implementing more frequent screening in those at high risk for breast cancer and less frequent screening in those at low risk, to minimize the likelihood of overdiagnosis and treatment of indolent disease .
Lung cancer is the primary cause of cancer mortality in both men and women. Recently, the National Cancer Institute completed a very large lung cancer screening trial using low-dose computerized tomographic (CT) chest imaging in high-risk individuals . The trial was a success in terms of documenting a statistically significant mortality reduction associated with screening. However, there are significant challenges in implementing effective screening programs, including variable access to the technology and clinical expertise needed for screening [12,29]. Screening should also be coupled with interventions for tobacco cessation, which can greatly reduce the risk of lung cancer and other life-threatening conditions. Many individuals who are eligible for screening are also not receiving this test due to lack of insurance to pay for the screening and the post-screening medical evaluations that may be necessary. In addition, low-dose chest CT screening often identifies other incidental radiographic findings, some of which are serious and others that are benign, leading to further invasive procedures and unnecessary testing. Thus, low-dose chest CT lung cancer screening presents new ethical, social, and financial challenges, and also suffers from “over diagnosis” .
Cancer is now preventable for a segment of the population who have certain inherited cancer susceptibility genes . There have been great advances in knowledge about familial cancer syndromes through initial genetic studies in families with multi-generational early onset cancers (e.g., breast, colon, ovary, uterus) and subsequent identification of the associated genes. More knowledge has also come from advances associated with the Human Genome Project and laboratory and commercial developments leading to the widespread availability of clinical testing. Genetic counseling and testing for cancer predisposition is now widely available, providing an opportunity for carriers of deleterious gene mutations to engage in more intensive screening, chemoprevention, or risk-reducing surgical procedures. Although the opportunity to prevent cancers in these families is at hand, access and uptake (care delivery) barriers still exist and highlight an important missed opportunity .
There are over 15 million cancer survivors today, with 18 million expected by 2022  (Figure 1). When the National Cancer Act was signed, there were about 3 million cancer survivors. Great strides in early detection and more effective treatments due to better understanding of the biology of cancer have improved survival and patient outcomes, but these advances have not come without substantial personal and economic costs to patients and their families [17,18].
Figure 1 |Cancer Survivors in the United States
Estimated and projected number of cancer survivors in the United States from 1977 to 2022, by years since diagnosis.
SOURCE: De Moor, J. S., A. B. Mariotto, C. Parry, C. M. Alfano, L. Padgett, E. E. Kent, L. Forsythe, S. Scoppa, M. Hachey, and J. H. Rowland. 2013. Cancer survivors in the United States: Prevalence across the survivorship trajectory and implications for care. Cancer Epidemiology, Biomarkers & Prevention 22(4):561-570. Reprinted with permission.
Fifty years ago, most cancers were treated with extensive surgical resections. For example, the radical mastectomy for breast cancer was initiated by William Stewart Halsted in the late 19th century for control of tumors that often involved the entire breast and were adherent to the muscles of the chest wall. Removal of the entire breast, the pectoral muscles, and all of the lymph nodes under the arm was deemed essential for curing the cancer and preventing it from spreading elsewhere in the body . However, there was no systematic study of this procedure until a randomized clinical trial in the early 1970s demonstrated that there was no survival benefit from the more extensive surgical procedure . Subsequent clinical trials found that it was not necessary to remove the whole breast and that survival was just as good after removing the lump and radiating the remaining breast tissue . Indeed, patients with small tumors in the breast have life expectancies that are similar to unaffected women their age, making it reasonable to avoid mutilating surgical procedures .
Many studies in a variety of solid tumors found that the propensity for cancers to metastasize and cause death was closely associated with the extent of the tumors at diagnosis (cancer staging). Additional research demonstrated that cancer cells from primary tumors often spread to distant organs (lung, bone, liver, brain) early in the course of tumor growth. These occult metastatic deposits would become apparent months to years after removal of the primary tumor. This spawned the clinical evaluation of adjuvant therapies—treatments given to control occult microscopic
disease—when there was no evidence of cancer but high risk for recurrence. Adjuvant therapy is responsible for the high cure rate for many cancer patients and the growing number of survivors. Today, such therapies (chemotherapy, targeted therapy, endocrine therapy) are often given before the tumor is removed (neoadjuvant therapy). This order of treatment provides an opportunity to monitor treatment response in the primary tumor, whose complete disappearance is linked to the likelihood of control of any distant metastatic disease. Further, clinicians are able to biologically profile many cancers today, so specific genetic mutations or biological features allow oncologists to provide more specific, targeted treatments based on biology, not on how the tumor looks under the microscope. This can also help patients avoid unnecessary treatments for low-risk cancers .
In addition to increasing the number of adult cancer survivors, these advances have led to even more striking achievements in the treatment of children with cancer. As the War on Cancer began, average survival times for children with acute leukemia were only a few months. Serial and coordinated clinical treatment trials have resulted in long-term survival for more than 90 percent of children diagnosed with leukemia today. Other types of childhood cancers (e.g., brain tumors, lymphoma, sarcoma) have also experienced significantly improved outcomes. This is a major triumph resulting from basic and clinical cancer research during the past 50 years. However, this achievement is blemished by the shortened lifespan of many childhood cancer survivors, largely resulting from other chronic treatment–related health conditions that lead to ongoing morbidity and premature death . The challenge for pediatric cancer specialists today is how to deescalate
very intensive curative treatments and to decrease and eliminate the well-described adverse outcomes.
Demographic changes associated with an aging population will lead to an even larger number of adult cancer survivors in the years ahead. The cancer screening advances described earlier will increase early detection of the common age-related cancers (breast, prostate, colorectal, and lung), and that will enable less aggressive treatment. Clinical treatment trials supported by the government, foundations, and industry are applying preclinical discoveries to yield successful therapeutic strategies, with accelerated approval of many new treatments in recent years that now lead to high cure rates in many hematologic malignancies and solid tumors. Many new therapies are targeted to specifi c genetic mutations, such as imatinib (commercially known as Gleevec) to target the BCR-ABL1mutation associated with chronic myelogenous leukemia (CML). Gleevec has transformed CML from a uniformly fatal malignancy into a disease that can be successfully treated with a chronic oral medication and allows patients to avoid high-dose chemotherapy and stem cell rescue . Understanding the molecular and genomic features of tumors has improved the effectiveness of treatments and has decreased use of toxic treatments in subpopulations of patients.
One of our biggest challenges is how to provide high-quality care for the growing number of cancer patients and survivors . Multiple oncology specialists participate in a patient’s initial cancer treatment, leading to fragmentation of care. After completion of primary treatment, there is limited coordination of care between oncology specialists and primary care clinicians. Given the extended survival for most cancer patients, as well as comorbidities acquired from treatment and aging, cancer survivors need better strategies for long-term follow-up. This includes management of post-treatment symptoms, disease prevention, and health promotion . While surveillance for cancer recurrence is a priority, cancer survivors are also at substantially increased risk for new cancers . About 15 to 20 percent of incident cancers each year occur in individuals with a past history of cancer, and this is especially an issue among elderly patients. New models of care are required to optimize the coordination of care for cancer patients during treatment and as they transition back to primary care after the completion of treatment .
We have come a long way in understanding the etiologies, pathogeneses, and natural histories of many cancers. This has led to many effective interventions for cancer prevention, screening, diagnosis, and treatment. However, the widespread public health messages about the value of “early diagnosis,” championed by many cancer advocacy organizations and national guidelines, have also put us at risk of doing more harm than good when it comes to cancer screening. It is very hard to modify the extensive communications to both the public and clinicians regarding early detection. The ability to do less frequent and more targeted screening to optimize the risk/benefit tradeoffs is the challenge we face currently. While implementing more strategic prevention, screening, and early detection efforts, we must not overlook important disparities in the receipt of evidence-based care that can reduce the burden of cancer in high-risk and vulnerable populations.
Continuing growth in the numbers of cancer survivors reflects the tremendous success of the War on Cancer, but for many cancer patients, the effects of treatment are not over when treatment ends. Investments in basic and clinical/translational research, clinical trials, and a surge in new cancer treatments are propelling improvements in survival. Many patients are living cancer free. Others engage in chronic therapy and their disease is controlled. Immunotherapy is the current “hot area” of treatment being employed or tested across many cancer sites; however, we know little about the potential late effects of these new therapies. While systematic survivorship research has advanced our knowledge about the long-term and late effects of past cancer treatments, we still have much to learn about these new therapeutic approaches. In addition, the health care system must be prepared to address the physical, psychosocial, and financial toxicities that face the existing population of cancer survivors and their families. Thus, the future of cancer prevention and control research is full of many opportunities and challenges.
Tweet this! Despite significant progress in detecting and controlling #cancer, disparities persist in high-risk and vulnerable populations and must be addressed: https://doi.org/10.31478/201810f #NAMPerspectives #NAMMtg
Tweet this! .@theNAMedicine member Patricia Ganz looks back at the progress of #cancer prevention and control, 50 years after the War on Cancer began: https://doi.org/10.31478/201810f #NAMPerspectives #NAMMtg
Tweet this! There are over 15 million #cancer survivors today, compared to 3 million in 1971. Providing high-quality care to these individuals is challenging, but critical: https://doi.org/10.31478/201810f #NAMPerspectives #NAMMtg
Tweet this! Targeted, specific, and genetically-based tests to screen for #cancers are becoming more of a reality every day, and will reduce the number of false positives from broader cancer screening: https://doi.org/10.31478/201810f #NAMPerspectives #NAMMtg
The National Academy of Medicine (NAM) at its annual meeting announced its inaugural International Health Policy Fellow, Roger Chung, Ph.D., M.H.S., assistant professor in the School of Public Health and Primary Care at The Chinese University of Hong Kong (CUHK). He was chosen by a NAM-appointed selection committee through a highly competitive nomination process in collaboration with CUHK based on his professional qualifications, scholarship, and the quality of professional accomplishments, as evidenced through publications, research grants, as well as relevance of current field expertise to the work of the NAM.
Chung will participate in a two-year fellowship with 25 percent time residency in Washington, D.C., while maintaining his current faculty position and responsibilities at CUHK. At the beginning of the fellowship, Chung will spend a concentrated three-month period at the National Academies of Sciences, Engineering, and Medicine to learn about the organization’s activities. Chung will actively learn about specific National Academies’ activities during the fellowship and select a National Academies report to examine based on his home country.
“Dr. Chung’s work has focused on issues at the forefront of the challenges NAM is currently working to address, such as health inequality, social determinants of health, and end-of-life care,” said NAM President Victor J. Dzau. “Through our international fellowship, he will actively participate in National Academies’ activities to develop and champion sound, evidence-based medicine and policies that can be contextualized to foster better health in his home setting. I am pleased to welcome Dr. Chung as our International Health Policy Fellow from The Chinese University of Hong Kong and am hopeful that, as the first, he’ll pave the way for others in the next generation of health leaders that will participate in this program in the future.”
In recognizing the need to build a pipeline of health policy scholars who are trained in bridging science with policy to put forth informed solutions to some of the world’s most critical health challenges, the NAM established its International Health Policy Fellowship Program in 2017. An additional fellow will be announced early next year.
This program is designed for early- to mid-career scholars in the fields of bioethics, medical ethics and law, economics and health policy, and health care to experience and participate in health care or public health studies that improve care and access to care for patients in domestic and global health care systems. One of the program’s initial fellowships will focus on bioethics and include a fellow from CUHK.
In addition to the International Health Policy Fellowship Program, the NAM administers four national health policy fellowship and scholar programs. More information on those programs is available here.
The National Academy of Medicine, established in 1970 as the Institute of Medicine, is an independent organization of eminent professionals from diverse fields including health and medicine; the natural, social, and behavioral sciences; and beyond. It serves alongside the National Academy of Sciences and the National Academy of Engineering as an adviser to the nation and the international community. Through its domestic and global initiatives, the NAM works to address critical issues in health, medicine, and related policy and inspire positive action across sectors. The NAM collaborates closely with its peer academies and other divisions within the National Academies of Sciences, Engineering, and Medicine.
The winners of the sixth annual D.C. Public Health Case Challenge were announced at this year’s National Academy of Medicine (NAM) Annual Meeting. The challenge aims to promote interdisciplinary, problem-based learning around a public health issue of importance to the Washington, D.C. community.
The challenge topic was “Reducing Disparities in Cancer and Chronic Disease: Preventing Tobacco Use in African American Adolescents.” The teams from D.C.-area universities- each composed of four to six members from at least three disciplines- were given two weeks to develop a solution to this complex problem with a hypothetical $2.5 million budget to be used during a five-year span. The teams presented their solutions to a panel of expert judges, and teams were evaluated on the interdisciplinary nature of their response, feasibility of implementation, creativity, and practicality.
The 2018 Grand Prize winner was the team from the University of Maryland, Baltimore. Team members Jennifer Breau, McMillan Ching, Dominique Earland, Chigoziem Oguh, Erin Teigen, and Adrienne Thomas proposed a solution titled “D.C. Health Passport Project.” The team described a multilevel intervention with a community-based participatory research approach, along with arts and sports programming for youth in D.C.’s Wards 7 and 8.
Three additional prizes were awarded:
Practicality Prize: The George Washington University team’s Project ART PAC (Adolescents Resisting Tobacco and Partnering Alongside Communities) proposed a multifaceted intervention that would provide a continuum of support for young people from middle school through young adulthood, using arts education and integration with the existing D.C. Youth Prevention Leadership Corps. (Team members: Melissa Aune, Harriet Fox, An Harmanli, Angelica Jones, and Anastasia Kanakaris)
Harrison C. Spencer Interprofessional Prize: The Uniformed Services University team’s Community Empowerment and Advocacy for Smoke-Free Environments (CEASE) described a deep engagement framework spanning a school-based intervention, a community-based component, a media campaign, and policy advocacy. (Team members: Shawna Grover, Breda Jenkins, Guzal Khayrullina, Vidya Lala, Michelle Mandeville, and Tonya Spencer)
Wildcard Prize: The U.S. Naval Academy team’s RiseDC solution included a mentorship program involving middle- and high-school students, an SMS smoking cessation intervention for pregnant and postpartum mothers, and mobile and social media components. (Team members: Eric Cal, Garrett Forrester, George Gilliam, Paige Miles, Alex Murray, and Kayla Olsen)
The 2018 panel of judges was comprised of:
The D.C. Public Health Case Challenge is co-sponsored by the NAM’s Kellogg Health of the Public Fund and the National Academies of Sciences, Engineering, and Medicine’s Roundtable on Population Health Improvement, with support from the Global Forum on Innovation in Health Professional Education.
The National Academy of Medicine (NAM) has selected three outstanding health professionals for NAM Fellowships. The fellows were chosen based on their professional qualifications, reputations as scholars, professional accomplishments, and relevance of current field expertise to the work of the NAM and the Health and Medicine Division of the National Academies of Sciences, Engineering, and Medicine. They will collaborate with eminent researchers, policy experts, and clinicians from across the country during their two-year fellowship. In addition, they will help facilitate initiatives convened by the National Academies to provide nonpartisan, scientific, and evidence-based guidance to national, state, and local policymakers, academic leaders, health care administrators, and the public.
The 2018 class of NAM Fellows is:
Kameron Matthews, M.D., J.D., FAAFP, acting deputy undersecretary for health for community care, Veterans Health Administration, U.S. Department of Veterans Affairs, Washington, D.C.
Michelle Kvalsund, D.O., M.S., assistant professor, department of neurology and ophthalmology, Michigan State University, East Lansing
Dima Qato, Pharm.D., Ph.D., M.P.H., assistant professor, department of pharmacy systems, outcomes, and policy, University of Illinois at Chicago College of Pharmacy, Chicago
“Through the hands-on experience provided by the NAM Fellowship program, fellows will examine health care challenges across a range of disciplines to help develop sound health policy advice, and also be able to build a network of mentors whom they can call upon throughout their careers,” said National Academy of Medicine President Victor J. Dzau. “I am pleased to welcome these exceptional health science scholars into the NAM Fellowship program.”
Each fellow will continue in his or her primary academic post while engaging part time over a two-year period in the National Academies’ health and science policy work. Each fellow will also work with an expert study committee or roundtable related to his or her professional interests, including contributing to its reports or other products. A flexible research stipend will be awarded to every fellow.
The overall purpose of the NAM Fellowship program is to enable talented, early-career health science scholars to participate actively in the work of the National Academies and to further their careers as future leaders in the field.
The National Academy of Medicine (NAM) honored three members today at its annual meeting for their outstanding service. The honorees are Elaine L. Larson, senior associate dean of scholarship and research, Anna C. Maxwell Professor of Nursing Research, and professor of epidemiology at Columbia University; Hedvig Hricak, chair of the department of radiology at Memorial Sloan Kettering Cancer Center; and Nicholas Peppas, professor and director of the Institute for Biomaterials, Drug Delivery, and Regenerative Medicine and Cockrell Family Regents Chair in Engineering #6 at the University of Texas at Austin.
“These distinguished members have shown extraordinary dedication to furthering science and improving the health of our nation,” said National Academy of Medicine President Victor J. Dzau. “The countless hours they have volunteered in various roles year after year have been crucial to helping the National Academy of Medicine address critical issues in health, medicine, and related policy, and inspire collective action across sectors. We are delighted to honor them today.”
Larson received the Walsh McDermott Medal, which is awarded to a member for distinguished service to the National Academies of Sciences, Engineering, and Medicine over an extended period. Since her election in 1986, Larson has served on approximately 50 projects, including 17 committees, councils, and boards, such as the NAM Council and its executive committee in the 1990s, and the Board on Health Sciences Policy from 2000-2003. Not only did she serve on the Report Review Committee from 2001-2007 but she also monitored or coordinated a large proportion of the reports that came out of the Academies in that time period, including one on lethal school violence – a topic that is still politically sensitive today. Larson also served as chair or as a member of several consensus study committees covering diverse topics such as environmental health content in nursing practice, school health programs in grades K-12, the Gulf War and veterans’ health, and protective equipment for health care workers to prevent transmission of viral respiratory infections. Larson carefully and methodically helped move reports along from first draft to final product, while striving to be holistic and mindful of the various needs of reports’ readers, such as care providers, scientists, and consumers. To all activities, Larson brought intense dedication to excellence, intellectual rigor, and unwavering commitment to producing unbiased reports to shape national and international policy and practice.
Hricak was awarded the David Rall Medal, which is given to a member who has demonstrated particularly distinguished leadership as chair of a study committee or other National Academies activities, showing commitment above and beyond the usual responsibilities of the position. Since her election in 2002, Hricak has made numerous valuable contributions to the activities and efforts of the NAM and National Academies through her service as chair or member of several committees and symposia, such as the NAM Membership Committee from 2007-2011, the Nuclear and Radiation Studies Board from 2008-2013, and a 2009 symposium focused on radiation exposure from imaging and image-guided interventions. Her contributions to reports of the National Academies, whether on committees or as a reviewer, are numerous and noteworthy and have examined a variety of topics, such as nuclear medicine, cancer clinical trials, radiation from medical diagnostic procedures, and diagnostic error in medicine. Under Hricak’s leadership as chair, the Committee on State of the Science in Nuclear Medicine produced a frequently cited report in 2007, Advancing Nuclear Medicine Through Innovation, which contained five strong recommendations, most of which have since been carried out. Through her exemplary service over about 15 years, Hricak has treasured the NAM as a valuable stimulus for improving science in medicine, the quality of health care, and the state of public health in the U.S. and around the world.
Peppas received the Adam Yarmolinsky Medal, which is awarded to a member from a discipline outside the health and medical sciences who has contributed to the mission of the NAM over a significant period. Peppas is a true pioneer in the development of principles in biomedical and chemical engineering that paved the way for groundbreaking scientific advances with broad ranging applications, such as the delivery of insulin for diabetes treatment, calcitonin for osteoporosis, and interferon alpha and beta for the treatment of cancer and multiple sclerosis, respectively. The tremendous scope and lasting impact of Peppas’ contributions to the literature and to the fields of biomedical and chemical engineering are reflected in over 1,150 publications, which have collectively garnered more than 96,000 citations. His honors include election to several domestic and international societies and receipt of more than 150 awards. Through his service on NAM Membership Committee from 2013-2017 and the Subcommittee on International Members from 2015-2016, Peppas worked tirelessly to recruit and involve members from outside of health and medical sciences, such as chemical engineering and biophysics. He also served on various National Academies committees, such as the Committee on Key Challenge Areas for Convergence and Health, Panel on Benchmarking the Research Competitiveness of the U.S. in Chemical Engineering, and the NSF Graduate Panel on Engineering. In addition to his excellence in research, Peppas is an engaging and effective educator, having mentored more than 230 graduate students and visiting scientists. His unique ability to bring together researchers from disparate fields and his revolutionary research on biomedical and chemical engineering have had a tremendous and lasting impact on the NAM and the nation’s scientific progress.
The National Academy of Medicine (NAM) today announced the election of 75 regular members and 10 international members during its annual meeting. Election to the Academy is considered one of the highest honors in the fields of health and medicine and recognizes individuals who have demonstrated outstanding professional achievement and commitment to service.
“This distinguished and diverse class of new members is a truly remarkable set of scholars and leaders whose impressive work has advanced science, improved health, and made the world a better place for everyone,” said National Academy of Medicine President Victor J. Dzau. “Their expertise in science, medicine, health, and policy in the U.S. and around the globe will help our organization address today’s most pressing health challenges and inform the future of health and health care. It is my privilege to welcome these esteemed individuals to the National Academy of Medicine.”
New members are elected by current members through a process that recognizes individuals who have made major contributions to the advancement of the medical sciences, health care, and public health. A diversity of talent among NAM’s membership is assured by its Articles of Organization, which stipulate that at least one-quarter of the membership is selected from fields outside the health professions — for example, from such fields as law, engineering, social sciences, and the humanities. The newly elected members bring NAM’s total membership to 2,178 and the number of international members to 159.
Established originally as the Institute of Medicine in 1970 by the National Academy of Sciences, the National Academy of Medicine addresses critical issues in health, science, medicine, and related policy and inspires positive actions across sectors. NAM works alongside the National Academy of Sciences and National Academy of Engineering to provide independent, objective analysis and advice to the nation and conduct other activities to solve complex problems and inform public policy decisions. The National Academies of Sciences, Engineering, and Medicine also encourage education and research, recognize outstanding contributions to knowledge, and increase public understanding. With their election, NAM members make a commitment to volunteer their service in National Academies activities.
Yasmine Belkaid, Ph.D., director, microbiome program, and chief, metaorganism immunology section, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md.
For defining fundamental mechanisms that regulate tissue immunity and uncovered key roles for the commensal microbiota and dietary factors in the maintenance of tissue immunity and protection to pathogens.
James M. Berger, Ph.D., professor of biophysics and biophysical chemistry, Johns Hopkins University School of Medicine, Baltimore.
For groundbreaking discoveries about cell growth and genomic stability that impact human disease and therapeutic drug development.
Richard E. Besser, M.D., president and chief executive officer, Robert Wood Johnson Foundation, Princeton, N.J.
For leadership and achievement in public health preparedness and response, and for service as a gifted proponent of public understanding of complex health issues.
Richard S. Blumberg, M.D., Jerry S. Trier Professor of Medicine, Harvard Medical School; and chief, Division of Gastroenterology, Hepatology, and Endoscopy, Brigham and Women’s Hospital, Boston.
For multiple seminal, paradigm-changing contributions to our understanding of mucosal immunology and immune development having identified mechanistic alterations central to several diseases, including inflammatory bowel disease, autoimmune disorders, and cancer.
Azad Bonni, M.D., Ph.D., Edison Professor of Neuroscience, and head, department of neuroscience, Washington University School of Medicine, St. Louis.
For discovering fundamental signaling networks governing brain development that have shed light on the development of cognitive disorders.
Andrea Califano, Dr., Clyde and Helen Wu Professor of Chemical and Systems Biology, departments of systems biology, biochemistry and molecular biophysics, and biomedical informatics, Institute of Cancer Genetics; chair, department of systems biology; director, JP Sulzberger Columbia Genome Center; and associate director, Herbert Irving Comprehensive Cancer Center, Columbia University, New York City.
For his pioneering work in systems biology and its implementation for the discovery of master regulator proteins and the networks they control in cancer cells.
Michael A. Caligiuri, M.D., president, Deana and Steve Campbell Physician-in-Chief Distinguished Chair, City of Hope National Medical Center, Duarte, Calif.
For the discovery of the stages of human natural killer (NK) cell development, the role of IL-15 in NK survival, and in the pathogenesis of NK leukemia and cutaneous T cell lymphoma.
Clifton Watson Callaway, M.D., Ph.D., Ronald D. Stewart Endowed Chair in Research and professor of emergency medicine, University of Pittsburgh, Pittsburgh.
For achievements in basic and clinical research to reduce brain injury after resuscitation from cardiac arrest and improve patient outcomes.
Yang Chai, D.M.D., Ph.D., D.D.S., professor, George and Mary Lou Boone Chair in Craniofacial Biology, and associate dean of research, Ostrow School of Dentistry, University of Southern California, Los Angeles.
For pioneering studies on the molecular regulation of cell types during craniofacial development, leading to novel bioengineered treatment strategies and new hope to patients suffering from debilitating and emotionally devastating malformations of the head and face.
Giselle Corbie-Smith, M.D., M.Sc., Kenan Distinguished Professor, departments of social medicine and medicine, UNC Center for Health Equity Research, School of Medicine, University of North Carolina, Chapel Hill.
For her scholarly work on the practical and ethical issues of engaging communities in research to achieve health and equity.
Peter Daszak, Ph.D., president and chief executive officer, EcoHealth Alliance, New York City.
For identifying the origin and drivers of emerging diseases and developing the map of disease hotspots using sophisticated ecological, socio-economic, and environmental methods.
Michael S. Diamond, M.D., Ph.D., Herbert S. Gasser Professor, departments of medicine, molecular microbiology, and pathology and immunology, Washington University School of Medicine, St. Louis.
For research on the molecular basis and immune-mediated control of global infectious disease threats, including Zika, dengue, and chikungunya viruses, and defining critical viral determinants of the immune response that have facilitated the development of countermeasures to prevent their spread.
Susan M. Domchek, M.D., Basser Professor in Oncology, Abramson Cancer Center, Division of Hematology and Oncology, University of Pennsylvania, Philadelphia.
For contributions in the evaluation and management of hereditary breast and ovarian cancer including the introduction of two BRCA1/2 specific drug therapies.
Francesca Dominici, Ph.D., Clarence James Gamble Professor of Biostatistics, Population, and Data Science, Harvard T.H. Chan School of Public Health, and co-director, Harvard Data Science Initiative, Boston.
For developing and applying innovative statistical methods to understanding and reducing the impact of air pollution on population health.
Benjamin Levine Ebert, M.D., Ph.D., chair of medical oncology, Dana-Farber Cancer Institute; and George P. Canellos MD and Jean Y. Canellos Professor of Medicine, Harvard Medical School, Boston.
For contributions to understanding the genetics and biology of myeloid malignancies, to the characterization of clonal hematopoiesis, and to elucidating the mechanism of action of thalidomide and its analogs.
Jennifer Hartt Elisseeff, Ph.D., Morton Goldberg Professor, department of biomedical engineering and ophthalmology, Johns Hopkins University, Baltimore.
For significant achievements in regenerative medicine therapies and contributions to regenerative immunology.
Robert L. Ferrer, M.D., M.P.H., Dr. John M. Smith Jr. Professor and vice chair for research, department of family and community medicine, University of Texas Health Science Center, San Antonio.
For his innovative application of a groundbreaking capability framework that provides a practical and positive method for addressing the social and environmental determinants of health in participatory interventions that integrate primary care and community health.
Robert M. Friedlander, M.D., M.A., chair, department of neurological surgery, and Walter E. Dandy Professor, University of Pittsburgh Medical Center, Pittsburgh.
For demonstrating the role of caspases in cell-death pathways in neurologic diseases, and for groundbreaking discoveries that have led to the development of novel therapies to improve outcomes for patients suffering from stroke, brain and spinal cord injury, Huntington’s disease, and ALS.
Ying-Hui Fu, Ph.D., professor, department of neurology, University of California, San Francisco.
For pioneering the identification of genes that have significant contribution to human circadian behaviors and genetic causes of altered sleep onset and duration, including familial advanced sleep phase and familial natural short sleep.
William A. Gahl, M.D., Ph.D., senior investigator, Medical Genetics Branch, and clinical director, National Human Genome Research Institute, National Institutes of Health, Bethesda, Md.
For contributions that include creating the Undiagnosed Diseases Program within intramural NIH to meld individualized patient care with next-generation sequencing and to provide insights into new mechanisms of disease; spearheading expansion to the national Undiagnosed Diseases Network and the Undiagnosed Disease Network International; and championing the sharing of genetic databases and best practices.
Joshua A. Gordon, M.D., Ph.D., director, National Institute of Mental Health, National Institutes of Health, Bethesda, Md.
For research demonstrating how distant brain regions cooperate and coordinate their activity in order to guide behavior, and how this coordination is disrupted in experimental systems relevant to psychiatric disorders.
Scott Gottlieb, M.D., commissioner, U.S. Food and Drug Administration, Silver Spring, Md.
For influencing a wide range of public health issues, including key contributions on biomedical innovation policy, tobacco policy, and consumer protection and education.
David Allen Hafler, M.D., M.Sc., William S. and Lois Stiles Edgerly Professor of Neurology and Professor of Immunobiology, and chair, department of neurology, Yale School of Medicine, New Haven, Conn.
For seminal discoveries defining the pathogenesis of multiple sclerosis (MS), including identification of autoreactive T cells and mechanisms that underlie their dysregulation, and the discovery of susceptibility genes that lead to MS.
Evelynn Maxine Hammonds, Ph.D., Barbara Gutmann Rosenkrantz Professor of the History of Science, professor of African and African-American studies, and chair, department of history of science, Harvard University, Cambridge, Mass.
For being one of the nation’s most influential historians investigating the relationship of race, science, and medicine, and her work in clarifying the use of the concept of race as it relates to important health disparities.
David Newcomb Herndon, M.D., FACS, Jesse H. Jones Distinguished Chair in Burn Surgery, professor, department of pediatrics, and director, Institute for Translational Sciences, University of Texas Medical Branch; and director of research, Shriners Hospitals for Children, Galveston, Texas.
For numerous contributions as a leading surgeon-scientist that have improved our understanding of the metabolic effects of burn injury and changed how burned patients are treated.
Steven M. Holland, M.D., NIH Distinguished Investigator, director, Division of Intramural Research, and chief, immunopathogenesis section, Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md.
For distinguished achievements in primary immunodeficiencies and infectious diseases, including the recognition, treatment, genomic identification, and cure of previously unexplained diseases as well as the identification and characterization of novel pathogens in those diseases.
Amy Houtrow, M.D., Ph.D., M.P.H., associate professor of physical medicine and rehabilitation and pediatrics, department of physical medicine and rehabilitation, University of Pittsburgh, Pittsburgh.
For research evaluating disability trends in childhood and the interactions among families, the health system, and social factors, which has uncovered disparities with enormous policy implications for the pediatric population.
Jeffrey Alan Hubbell, Ph.D., Eugene Bell Professor in Tissue Engineering, Institute for Molecular Engineering, University of Chicago, Chicago.
For pioneering the development of cell responsive (bioactive) materials and inventing biomaterials that are now widely utilized in regenerative medicine.
John P.A. Ioannidis, M.D., D.Sc., C.F. Rehnborg Professor in Disease Prevention, professor of medicine, health research and policy, biomedical data science, and statistics, and co-director, Meta- Research Innovation Center at Stanford, Stanford University, Stanford, Calif.
For his dedication to rigorous, reproducible, and transparent health science, for his seminal work on meta -research, for his calls for quality in evidence, and for the positive impact it has had on the reliability and utility of scientific information throughout the sciences.
Robert E. Kingston, Ph.D., chief, department of molecular biology, Massachusetts General Hospital; and professor of genetics, Harvard Medical School, Boston.
For contributions to understanding the role of nucleosomes in transcriptional regulations.
Ophir David Klein, M.D., Ph.D., Hillblom Distinguished Professor in Craniofacial Anomalies, Epstein Professor of Human Genetics, and professor of orofacial sciences and pediatrics, Schools of Dentistry and Medicine, University of California, San Francisco.
For his international reputation in developmental and stem cell biology, focusing on craniofacial, tooth, and bone development and regeneration, destined to lead to the biologically inspired restoration of teeth and other organs.
Alexander H. Krist, M.D., M.P.H., FAAFP, professor, department of family medicine and population health, Virginia Commonwealth University, Richmond.
For pioneering the discovery of active patient engagement informatics solutions, including the invention of MyPreventiveCare, expertise at translating evidence into practice and policy, and serving as a trusted adviser on several national committees and task forces.
John Kuriyan, Ph.D., professor, departments of molecular and cell biology and chemistry, University of California, Berkeley.
For pioneering contributions to understanding the regulation of eukaryotic cell signaling by proteins such as Src-family kinases, and for determining the structural and molecular origin of the specificity of the first precision medicine, the cancer drug Gleevec.
Ellen Leibenluft, M.D., senior investigator, Intramural Research Program, National Institute of Mental Health, National Institutes of Health, Bethesda, Md.
For highlighting the need to carefully evaluate children who may have bipolar disorder; identifying chronic irritability, a new clinical problem which differs from pediatric bipolar disorder; and pioneering the use of cognitive neuroscience to address fundamental clinical questions on nosology and treatment of pediatric mental disorders.
Linda M. Liau, M.D., Ph.D, M.B.A., W. Eugene Stern Professor and chair, department of neurosurgery, David Geffen School of Medicine, University of California, Los Angeles.
For achievements in understanding the immunology of malignant brain tumors and designing clinical trials of dendritic cell-based vaccines for glioblastoma.
Keith Douglas Lillemoe, M.D., chief of surgery, Massachusetts General Hospital; and W. Gerald Austen Professor, Harvard Medical School, Boston.
For his work as a surgical leader and educator who has enhanced patient care, surgical quality, and safety.
Xihong Lin, Ph.D., chair and Henry Pickering Walcott Professor of Biostatistics, professor of statistics, and coordinating director, Program in Quantitative Genomics, Harvard T.H. Chan School of Public Health, Boston.
For contributions to statistics, genetics, epidemiology, and environmental health through influential and ingenious research in statistical methods and applications in whole-genome sequencing association studies, gene-environment, integrative analysis, and complex observational studies.
Catherine Reinis Lucey, M.D., professor of medicine, School of Medicine, executive vice dean and vice dean for education, and the Faustino and Martha Molina Bernadett Presidential Chair in Medical Education, University of California, San Francisco.
For her leadership in reforming medical education to combine the biological and social sciences, humanism, and professionalism to meet the needs of patients in the 21st century.
Ellen J. MacKenzie, Ph.D., M.Sc., Bloomberg Distinguished Professor and dean, Johns Hopkins Bloomberg School of Public Health, Baltimore.
For defining the field of trauma services and outcomes research and being recognized as one of the foremost experts in the area.
Martin A. Makary, M.D., M.P.H., F.A.C.S., professor of surgery and health policy and management, Johns Hopkins University School of Medicine and Johns Hopkins Bloomberg School of Public Health, Baltimore.
For creating the surgery checklist, leading pioneer studies on frailty, minimally invasive surgery, and procedure-specific opioid guidelines, creating metrics of high-value care, and leading national efforts on health care costs that addressed pricing failures, surprise billing, drug price transparency, and vulnerable populations.
Bradley A. Malin, Ph.D., F.A.C.M.I., professor and vice chair, biomedical informatics, and professor of biostatistics and computer science, Vanderbilt University, Nashville, Tenn.
For contributions in natural language de-identification, guiding both national and international policies around research protection and enabling broad sharing and reuse of health and social data at an unprecedented scale.
George Mashour, M.D., Ph.D., associate dean for clinical and translational research, Bert N. La Du Professor of Anesthesiology, and director, Center for Consciousness Science and Michigan Institute for Clinical and Health Research, University of Michigan, Ann Arbor.
For research informing current clinical practice in monitoring general anesthesia and leading to the identification of a common neural correlate of anesthetic-induced unconsciousness across diverse drug classes.
Ann Carolyn McKee, M.D., professor of neurology and pathology, Boston University School of Medicine; and director of neuropathology, VA Boston Healthcare System, Boston.
For her groundbreaking work on chronic traumatic encephalopathy (CTE), Alzheimer’s disease, aging, and vascular neuropathology that has revolutionized medicine’s understanding of the clinicopathological and molecular features of CTE in athletes and veterans exposed to neurotrauma or blast injury and changed the public dialogue on sports-related risk.
Barbara J. Meyer, Ph.D., investigator, Howard Hughes Medical Institute; and professor of genetics, genomics, and development, department of molecular and cell biology, University of California, Berkeley.
For groundbreaking work on chromosome dynamics that impact gene expression, development, and heredity using the nematode as a model organism.
Matthew Langer Meyerson, M.D., Ph.D., professor of pathology, Harvard Medical School, Dana- Farber Cancer Institute, Boston.
For discovery of EGFR mutations in lung cancer and their ability to predict responsiveness to EGFR inhibitors, thereby helping to establish the current paradigm of precision cancer therapy.
Terrie E. Moffitt, Ph.D., Nannerl O. Keohane University Professor, department of psychology and neuroscience, Duke University, Durham, N.C.
For path-breaking contributions to our understanding of human development, including her seminal theory of the development of antisocial behavior, which has had wide-ranging influence on clinical diagnosis of childhood conduct disorders, the early-years intervention movement, and two Supreme Court decisions.
Sean J. Morrison, Ph.D., professor and Kathryne and Gene Bishop Distinguished Chair in Pediatric Research, Children’s Research Institute, University of Texas Southwestern Medical Center, Dallas.
For his accomplishments in distinguishing self-renewing blood-forming stem cells from multipotent progenitors in bone marrow, discovering in the central and peripheral nervous systems a series of key self-renewal mechanisms that regulate stem cell self-renewal and stem cell aging, identifying the unique metabolic requirements for blood stem cells, identifying the hematopoietic stem cell niche, and also serving as President of the International Society for Stem Cell Research.
Charles Alexander Nelson III, Ph.D., Richard David Scott Professor of Pediatric Developmental Medicine Research, Boston Children’s Hospital; and professor of pediatrics, neuroscience, and education, Harvard Medical School and Graduate School of Education, Boston.
For pioneering research on brain development in majority world settings and revealing the powerfully detrimental effects of adversity exposure on brain development in early life.
Kunle Odunsi, M.D., Ph.D., FRCOG, FACOG, deputy director, M. Steven Piver Professor of Gynecologic Oncology, chair, department of gynecologic oncology, and executive director, Center for Immunotherapy, Roswell Park Comprehensive Cancer Center, Buffalo, N.Y.
For identifying key mechanisms of immune suppression within the ovarian tumor microenvironment, pioneering studies to re-engineer mature T cells and hematopoietic stem cells for adoptive T cell therapy, and implementing multi-institutional immunotherapy trials using novel strategies that he developed, to impact outcome and quality of life of ovarian cancer patients.
Lucila Ohno-Machado, M.D., Ph.D., professor of medicine, associate dean for informatics and technology, and chair, department of biomedical informatics, University of California San Diego School of Medicine, San Diego.
For creating an algorithm that allows sharing access to clinical data while respecting the privacy of individuals and institutions.
Jordan Scott Orange, M.D., Ph.D., chair of pediatrics, Vagelos College of Physicians & Surgeons, Columbia University; and pediatrician-in-chief, New York-Presbyterian/Morgan Stanley Children’s Hospital, New York City.
For his research achievements in defining a new class of immune diseases, natural killer cell deficiencies, as well as other genetic immunodeficiencies.
Lori J. Pierce, M.D., professor, department of radiation oncology, University of Michigan School of Medicine, and vice provost for academic and faculty affairs, University of Michigan, Ann Arbor.
For research in developing radiation treatments for breast cancer that leverage advances in medical physics and laboratory science and for national efforts to draw women and people of color into medicine.
Daniel E. Polsky, Ph.D., executive director, Leonard Davis Institute of Health Economics, Robert D. Eilers Professor of Health Care Management, and professor of medicine, University of Pennsylvania, Philadelphia.
For his contributions to advancing methods of economic evaluation of health care services and his research examining the functioning of physician labor markets.
Josiah “Jody ” Rich, M.D., M.P.H., professor of medicine and epidemiology, Brown University; and director, Center for Prisoner Health and Human Rights, The Miriam Hospital, Providence, R.I.
For dedication in his medical and public health research career to improving the health and well -being of people in detention and incarceration, to substance users, and to health and well -being post release in communities in need.
Gene Ezia Robinson, Ph.D., Maybelle Leland Swanlund Endowed Chair, professor of entomology, and director, Carl R. Woese Institute for Genomic Biology, University of Illinois at Urbana Champaign, Urbana.
For pioneering contributions to understanding the roles of genes in social behavior.
Hector P. Rodriguez, Ph.D., Henry J. Kaiser Endowed Chair and professor of organized health systems, School of Public Health, Health Policy, and Management, University of California, Berkeley.
For integrating organization science theories and methods to assess the impact of health care teams and primary care re-organization on patient engagement, patient experience of care, and outcomes particularly for vulnerable populations.
Charles N. Rotimi, Ph.D., chief and senior investigator, Metabolic, Cardiovascular, and Inflammatory Disease Genomics Branch, and director, Center for Research on Genomics and Global Health, National Human Genome Research Institute, National Institutes of Health, Bethesda, Md.
For groundbreaking research in African and African ancestry populations, providing new insights into the genetic and environmental contributors to a variety of important clinical conditions, as well as health disparities locally and globally.
Ralph Lewis Sacco, M.D., M.S., FAAN, FAHA, Olemberg Family Professor, chairman of neurology, and senior associate dean for clinical and translational science, Miller School of Medicine, University of Miami, Miami.
For his instrumental involvement in policies promoting ideal cardiovascular health, brain health, stroke prevention, and non-communicable disease targets.
Judith A. Salerno, M.D., M.S., president, New York Academy of Medicine, New York City.
For her innovative contributions addressing health needs of the underserved and vulnerable, including improved palliative care for veterans, creative programs to combat childhood obesity, and breakthrough initiatives to reduce racial disparities in breast cancer.
Nanette Frances Santoro, M.D., professor and E. Stewart Taylor Chair of Obstetrics and Gynecology, University of Colorado School of Medicine, Denver.
For research discoveries in health predictors of midlife women, participation in cutting-edge clinical trial design and execution.
Stuart L. Schreiber, Ph.D., Morris Loeb Professor, department of chemistry and chemical biology, Harvard University, Cambridge, Mass.
For advancing chemical biology and medicine through the discovery of small-molecule probes for signal transduction and gene regulation pathways.
Arlene Sharpe, Ph.D., M.D., co-chair and George Fabyan Professor of Comparative Pathology, department of microbiology and immunobiology, Harvard Medical School, Boston.
For leadership in functional analysis of co-stimulatory and inhibitory pathways regulating T cell activation.
Marie Celeste Simon, Ph.D., scientific director and investigator, Abramson Family Cancer Research Institute, associate director-shared resources, Abramson Cancer Center, and Arthur H. Rubenstein MBBCh Professor, department of cell and developmental biology, Perelman School of Medicine, University of Pennsylvania, Philadelphia.
For pioneering research that revealed how oxygen gradients are essential for embryonic development, influencing stem cell behavior, angiogenesis, placentation, and hematopoiesis.
Albert L. Siu, M.D., M.S.P.H., professor, department of geriatrics and palliative medicine, Icahn School of Medicine at Mount Sinai, New York City.
For seminal contributions to evidence-based practice in health-services research and in pioneering programs that intersect geriatrics and palliative care.
Claire Sterk, Ph.D., Charles Howard Candler Professor in Public Health and president, Emory University, Atlanta.
For significant public health achievements, specifically in the area of health disparities, and for leadership contributions to higher education both nationally and globally.
Susan Stone, DNSc, CNM, FACNM, FAAN, president, Frontier Nursing University; and president, American College of Nurse-Midwives, Hyden, Ky.
For achievements that have opened the door to more than 5,000 nurses to achieve graduate education and positively impact the accessibility of quality health care for rural families across the United States.
Sylvia Trent-Adams, Ph.D., R.N., FAAN, rear admiral and deputy surgeon general, Office of the Surgeon General, U.S. Department of Health and Human Services, Washington, D.C.
For leading the U.S. Department of Health and Human Services efforts; working with counterparts at the WHO, the U.S. Army, and other governments to build systems of care and strengthen human resources for underserved populations; and contributing to scientific and policy advances to improve health of persons living with HIV/AIDS.
Kara Odom Walker, M.D., M.P.H, M.S.H.S., cabinet secretary, Delaware Department of Health and Human Services, New Castle.
For her career spanning roles as a family physician and community health leader in academic medicine, the Patient Centered Outcomes Research Institute, and state government who has championed health equity and consumer and community engagement.
Peter Walter, Ph.D., investigator, Howard Hughes Medical Institute; and distinguished professor, department of biochemistry and biophysics, University of California, San Francisco.
For elucidation of the unfolded protein response of the endoplasmic reticulum.
Xiaobin Wang, M.D., M.P.H., Sc.D., Zanvyl Krieger Professor and director, Center on Early Life Origins of Disease, department of population, family, and reproductive health, Johns Hopkins Bloomberg School of Public Health, and professor of pediatrics, Johns Hopkins University School of Medicine and Children’s Center, Baltimore.
For contributions leading to the better understanding of fetal-perinatal genetic and environmental precursors of pediatric and chronic diseases, including preterm birth, obesity, asthma, and hypertension.
Ronald John Weigel, M.D., Ph.D., departmental executive officer and chair, department of surgery, Carver College of Medicine, University of Iowa, Iowa City.
For identifying key drivers of hormone response in breast cancer and pioneering the technique of expression analysis from archival breast cancer specimens, heralding the era of molecular diagnostics.
Rachel M. Werner, M.D., Ph.D., professor of medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia.
For advancing our understanding of how health care provider performance measurement and incentives often bring unintended and undesired equity consequences that compete with efficiency goals.
Janey L. Wiggs, M.D., Ph.D., Paul Austin Chandler Professor of Ophthalmology, vice chair for clinical research in ophthalmology, Harvard Medical School; associate chief, ophthalmology, Massachusetts Eye and Ear; and associate member, Broad Institute of MIT and Harvard, Boston.
For research and achievements in the field of ocular genetics, including the discovery of multiple genetic and environmental risk factors for glaucoma, and for developing and implementing genetic testing for inherited eye disease.
Teresa Woodruff, Ph.D., Thomas J. Watkins Professor, and vice chair for research and chief, Division of Reproductive Science, department of obstetrics and gynecology, Northwestern University, Chicago.
For innovation in reproductive health, having cloned key regulators of ovarian and gonadotroph function; pioneering in vitro maturation of human oocytes; discovering roles for zinc in fertilization; and inventing microfluidic systems modeling human ovarian function, all relevant to her work on preservation of fertility in cancer patients, the field she named “oncofertility.”
King-Wai Yau, Ph.D., professor of neuroscience, Johns Hopkins University School of Medicine, Baltimore.
For pioneering research of the function of the retina that has led to our molecular and cellular understanding of circadian rhythms and several forms of hereditary blindness.
Newly elected international members are:
Hanan Mohamed S. Al-Kuwar i, Ph.D., minister of public health, State of Qatar; and managing director, Hamad Medical Corp., Doha, Qatar.
For leadership of Qatar’s largest care delivery system (Hamad Medical Corporation) at 33 years of age, and serving as Qatar’s Minister of Public Health.
Bruce Aylward, M.D., senior adviser to the director-general, World Health Organization, Geneva, Switzerland.
For his global public health leadership and innovation, and spearheading the global polio eradication initiative for 15 years and WHO humanitarian and epidemiological responses to outbreaks such as Ebola in West Africa.
Francoise Barre-Sinoussi, Ph.D., (retired), honorary president, department of virology and International Network, Institut Pasteur, Paris, France.
For her discovery of the human immunodeficiency virus (HIV) as the cause of AIDS for which she was the co-recipient of the 2008 Nobel Prize in Physiology or Medicine.
Linamara Rizzo Battistella, M.D., Ph.D., São Paulo State Secretary for the Rights of Persons with Disabilities; and faculty of medicine, University of São Paulo, São Paulo, Brazil.
For developing the largest rehabilitation network in Brazil, offering clinical services to 100,000 adults and children with disabilities per month.
Zulfiqar A. Bhutta, M.B., B.S. , Ph.D. FCPS, FRCP, FRCPCH, FAAP, Robert Harding Chair in Global Child Health and Policy, The Hospital for Sick Children, Toronto, Canada; and founding director, Center of Excellence in Women and Child Health, The Aga Khan University, Karachi, Pakistan.
For his synthesis of knowledge on effective child health interventions, implementat ion research in marginalized populations, and strategic advocacy for improving child health and development.
Elias Campo, M.D., Ph.D., research director and professor of anatomic pathology, Hospital Clinic of Barcelona, University of Barcelona; and director, Institute of Biomedical Research August Pi i Sunyer, Barcelona, Spain.
For his groundbreaking discoveries regarding the molecular pathogenesis of many Bcell neoplasms including chronic lymphocytic leukemia, mantle cell lymphoma, diffuse large B-cell lymphoma and plasmablastic lymphoma.
Joy Elizabeth Lawn, M.B.B.S., M.P.H., F.R.C.P. (Paeds), Ph.D., FMedSci, professor and chair of maternal reproductive and child health epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom.
For her international leadership role in newborn health and stillbirths, both for epidemiological burden estimates and for the programmatic and clinical evidence base to address the burdens, notably in Africa.
Gabriel Matthew Leung, M.D., Zimmern Professor of Population Health and dean of medicine, University of Hong Kong, Hong Kong.
For leadership in global health and medical education, and for contributions to infectious disease epidemiology and control.
Beverley Anne Orser, M.D., Ph.D. , F.R.C.P.C., professor of physiology and chair, department of anesthesia, University of Toronto; and staff anesthesiologist, department of anesthesia, Sunnybrook Health Science Centre, Toronto, Canada.
For her discovery of the unique pharmacological properties of extrasynaptic GABA-A receptors and their mechanistic role in anesthetic- and inflammation-induced impairment of memory, and for her leadership in academic anesthesiology.
Carol Propper, Ph.D., professor, Imperial College Business School, London, United Kingdom.
For fundamental contributions to the understanding of health reform, health care markets, health systems, international comparisons, environmental impacts on health, inequality and health, and mental health, and for real-world impacts via policy formation.
The National Academy of Medicine (NAM) is pleased to announce the winners of the 2018 Cecil Awards. The Cecil Awards recognize staff from throughout the National Academies who have manifested superb skill and commitment in furthering the mission of the NAM — to improve health for all by advancing science, accelerating health equity, and providing independent, authoritative, and trusted advice nationally and globally. No NAM award ranks above the Cecil in importance.
The following individuals have been selected for the 2018 Cecil Awards by a committee composed of NAM members and staff representatives from across the National Academies:
Each Cecil Award is accompanied by $4,000, a commemorative medal, and a certificate presented at the NAM Annual Meeting. The awards ceremony will be help on October 15 beginning at approximately 9:00 am in the Fred Kavli Auditorium of the NAS Building.
Inquiries should be directed to: Donna Duncan