Weight Loss Programs and Insurance

Another set of two articles to ponder.

The first comes from the Consumer Reports Health Blog: Commercial Weight-Loss Programs: The Evidence

The second comes from Dr. Judith Wurtman on the Huffington Post: Weight Loss: Should Commercial Programs be Covered by Health Insurance?

It's one of those never-ending battles: do weight-loss programs actually work? Some say they do, some say they don't, others say they only work short-term or never allow the participants to have a "normal" food life without gaining all the weight back. And what is the scientific evidence for them? Strangely, there have been very few studies. The blog post from Consumer Reports looks at two recent studies in the Journal of the American Medical Association (JAMA) that looked at lifestyle interventions and prepared meals to help with weight-loss.

The first study lasted one year and split the participants into two groups. The first group had diet and physical activity interventions for the full year, the second group started with just a diet intervention and started physical activity six months later. The results? The group that did both diet and exercise initially had a greater weight-loss at the six-month mark, but after adding exercise, both groups had similar weight loss at the twelve-month mark.

I'm not sold on the study design. I think delaying the exercise in one group, but still having both groups do it, confounds the results. The initial intention wasn't to determine if delaying exercise had any effect on weight loss; it was looking at the efficacy of diet and exercise interventions. If I were planning this study I would have one group with only a diet intervention, one group with only a physical activity intervention, and one group with both interventions. This would (hopefully) allow the researchers to determine which type of intervention, or combination of interventions, was most effective.

So a structured diet and exercise plan works, and helps the participants keep the weight off for at least a year. What about the other study? This study was looking at the effect of pre-packaged meals as part of a structured weight-loss program (this study was funded by Jenny Craig). It compared two groups: one that received ongoing support in addition to prepackaged meals during the initial weight loss, the other group received standard obesity counseling and monthly "contact." The group that received meals and structured support had greater, sustained weight loss.

I like a couple things about this study. First, I like that the two groups were clearly defined; there wasn't any crossing-over with their interventions. Second, a two year follow-up gives a better picture of whether the intervention worked in the long-term. I'm not necessarily a fan of prepackaged meals. I question whether people would actually follow the program if they had to pay the inflated price for all of these meals (the study participants received them for free). And I don't like the idea that people aren't taught the principles of feeding themselves with real, fresh food. I'll be honest, I'm not familiar with the Jenny Craig plans and their prepackaged meals. Perhaps participants are taught the basics of good nutrition, maybe they do learn what to prepare for themselves after the packaged phase. But I'm hesitant. Will these people become reliant on a company to tell them what to eat to stay "healthy" (read: thin). Will they trust their own instincts on feeding themselves? What lessons are they passing on to their children with this? And there are a few bigger issues: the disparity created by those who can't afford these programs and concerns related  to packaged foods. I worry about added salt, sugar, preservatives, and the loss of the concept of real food. (I would love to go on about my views of nutrition, health, weight, and food, but that is best left for another post...or series of posts)

And what to do with this information? This is where the second article I linked to heads: should insurance companies cover weight-loss programs? Insurers are willing to shell out big bucks for obesity drugs and surgeries. Why? Because obesity costs them. And why won't these same companies pay for commercial programs? I'm at a loss there. It appears that it is a cheaper, effective alternative (probably not as effective as surgery, but one could argue that it is more cost-effective). I wonder if the companies see less weight loss as less healthy. I personally think fitness is preferable to thinness and I would presume that diet/exercise programs would achieve that better than surgery. It's an argument that could go around and around.

Thoughts?

~L

The End of the Beginning

It's hard to believe that my first semester of graduate school is almost over. It's gone quickly; I've enjoyed it more than I thought I would, I've learned a lot, and met a lot people.



In some ways I feel a little different than my fellow students. I only took six credits this semester. I worked full-time (40 hours/week) for the first half of the semester and even now that I've cut back to 60% (24 hrs/week), it's still very different work from the graduate assistantships and research assistantships that many of my classmates have. But then I realize that maybe I'm not really that different: we all come from different backgrounds, from different stages of life, some have come directly from undergrad, some have come from careers, and we all do school and the path to a degree just a little differently.



And I'm not sure I'm entirely used to the fact that graduate school is different from undergrad. I went "across the river" for the first time a couple weeks ago. I had forgotten what the between class migrations were like. It seemed so natural to come out of a huge lecture with one or two friends and merge seamlessly into the mass of bodies moving across campus. I haven't had to deal with that all semester. Being on the health side of campus there isn't the same density of classrooms. We all filter in to the building from different places on campus. All the classes are small so we get to know each other to a certain extent. Class ends and we trickle out, some alone, some in small groups, each headed a different direction. And then there's the frenzied ten minutes at the top of the hour. The classes I have this semester and next semester don't fall into that rigid hourly class schedule. There is no rushing insanity when we get out of class.



I'm sure I have more comments on grad school, but I should probably wrap this up and study for the Healthcare Organization and Policy final I have tomorrow afternoon.



~L

Productive Procrastination

I am usually amazed at how incredibly productive I can be while trying to avoid homework.

Today I have not been productively procrastinating. So I'll leave you with a couple videos from my senior flute recital at Iowa State.










~L

Interview with Dr. Paik

What is your educational background?
I have a BA in Public Policy, and an MA and PHD in Sociology.  All of my
degrees are from the University of Chicago, but I did spend four years
working in Washington, DC after college.


How did you get into sociology?
While working in DC, I became fascinated with cooperative relationships
and conflict in organizations.  Indeed, I was living through my share of
both.


How and when did you get started in network research?
Network analysis was a natural way to understand the organization of
work, so I immediately started taking classes in the area.  I took classes
on networks from Ron Burt, John Padgett, Roger Gould, and my advisor Edward
Laumann.  Ed was the person who introduced me to the concept of "sexual
networks." 


What do you think are the biggest benefits of network research? The biggest drawbacks?
The biggest benefit of network analysis is that it emphasizes how social
relationships take concrete forms (i.e., social structure).  This allows
researchers to specify pathways of influence and diffusion.  The biggest
drawback, however, is that network analysis is incredibly data intensive.
As such, we are often limited by the amount of data that we can collect and
by significant amounts of missing data.


What is the most challenging part of researching networks?
The most challenging part of this field is keeping up with it.  Since it
is interdisciplinary in nature, it is extremely fast moving and technical.


You have done some network research into health issues, do you think network research hold promise for public health?
 I do think that combining network analysis with the study of public
health is an excellent opportunity.  There have been several high profiles
articles and texts (e.g., Tom Valente's new textbook) that have highlighted
the natural fit between public health and network analysis.


What do you think sociology can offer to the field of public health?
I would say that network analysis is not just a sociological venture.
Its origins are in sociology and anthropology, but today's researchers come
from many fields, including business, public health, economics, and computer
science.  Sociology, however, can offer ways to think about network
structures.


Thank you Dr. Paik for answering my questions!


~L

Social Networks and Health (Anthony Paik)

I should probably start this with a disclaimer—this is not intended to be an in-depth description of the use of social networks for research. It is simply my rehashing of a departmental seminar that has been filtered through my statistics-challenged brain (I finished all my college math in high school and did my undergrad studies in music so it has literally been years since I studied math with any intensity)

First of all, why do we even want to study social networks? Networks can give different views of a subject than standard data alone can. Networks allow us to see how structure matters, separate metaphors and concrete differences, attributes vs. relations, study how an individual's choices constrained by the social structure they reside in, and compare micro and macro views of the same data.

Visualizing Network Data

Network data can be viewed as both a graph and matrix. Graphs are made by plotting nodes and denoting connections using lines. In one type of graph, known as spring and bedding, nodes are pulled closer by the presence of ties. A matrix corresponds to a graph and numerically describes connections between nodes. (See my extremely simplified, rather rough examples of a graph and matrix below)

	N1	N2	N3	Etc…
N1	-	1	0
N2	0	-	1
N3	1	1	-
Etc…

            1=connection between nodes

            0=no connection

 

After creating visualizations of the data we can then describe and analyze it. The different ways of describing are by composition and structure. Composition would focus on the alters (or nodes) that make up the bedding of the data. Structure can be looked at different ways. By density (less dense areas vs. more dense areas), modal degree, distance between nodes, similarities or patterns of ties.

 

Analyzing Network Data

There are three basic types of data analysis

    Dyadic analysis involves gathering information from a pair of alters

    Egocentric analysis is the collection of data around a single node

    Complete analysis looks at all the information from everyone

The tools that can be used to assist in these types of analysis are visualizations, cultures and subgroups, the network as a dependent variable (this looks at the probability of tie formation in the network), network as the independent variable (this looks as contagion and influence including the flow of information, power/authority, cohesion/solidarity, and competition/comparison)

Networks, like any research, are not perfect. One common issue is the homophily or selection problem. The question with this problem is "did the friendship form on the basis of the variable being studied?" There is a tendency for people with same characteristics to become friends so this is a very real problem. Another issue is confounds—are the results related to a larger contet (e.g. environment) that is shared by both alters?

 

Health Implications

This is where network research appeals to public health practitioners. And I thought this portion of the lecture helped me understand the previous intro to networks. Following is a brief review of actual research using each of the three basic types of network analysis.

Dr. Paik described his research utilizing a longitudinal study of adolescent health (ADO Health)—Wave 1 occurred in 1994-95, with subsequent waves in 96, 01, 04

Examples of the different types of data collection used:

    Dyadic data—interpersonal violence

    Egocentric—sexual concurrency, chlamydia infections

    Complete—peer effects of nonromantic sex

Dyadic data collection to evaluate interpersonal violence:

The independent variable was the partner's prior violence from Wave I. The dependent variable was the victimization of the alter in Wave II. A positive correlation was seen, which essentially means that a partner with a history of violence is more likely to continue to be violent.

Egocentric data collection to determine the connection between sexual concurrency and chlamydia infections:

The dependent variable here is a chlamydia infection. The independent variable was the presence of concurrent (multiple) sexual partners. A positive correlation was seen between these variables. As many people would assume, more prior partners increased infections, but having concurrent sexual partners had an even larger increase in infections.

Using the network to find patterns regarding nonromantic sex and delinquency:

The dependent variable in this example is having nonromantic sex during Wave I (or "hooking up" in laymen's terms). Two different analyses occurred using the mean of friends' delinquency as the first independent variable and the network centrality of the respondent weighted by the centrality of his/her friends as the second independent variable.

As one might assume: the respondents' delinquency had a positive effect on the occurrence of hook-ups as did the mean of the friends' delinquency. Simply looking at the friends' centrality showed no effect, but weighting centrality with delinquency showed two differences: having delinquent and central friends increased the odds that a respondent would hook-up but having delinquent, non-central friends actually decreased those odds.

Further analysis?

    Are hook-ups contagious as the data seems to suggest?

To look at this they looked at the ties found between those who have never hooked up, ties found between those who had hooked up and those who had not hooked up, and the ties found between people who had had hookups.

    Hook-ups did appear to be "contagious". These findings can then be put to use from a public health perspective.

 

Admittedly, this overview of social networks is extremely simplified and possibly just plain wrong, but if it has piqued your interest in networks Dr. Paik suggests a few books that are helpful for learning more.

    Networks and Health by Tom Valente

    Networks an introduction by Mark Newman

    Networks, Crowds, Markets by Easley/Kleinberg

 

 

Coming up—a brief interview with Dr. Paik

 

~L

Checking In

I've had a hectic week here, I'm pretty sure I haven't stopped moving since sometime Monday morning. While I haven't posted in a few days that isn't to say I haven't been working behind the scenes. I have several a lot of posts drafted or outlined.

Just to give you an idea of what to look forward to:

• A discussion of a pair of articles regarding insurance and weight loss
• A brief interview with Dr. Anthony Paik about his research with social networks and a review of the departmental lecture he gave on Wednesday
• A quick update on the Fall Public Health Colloquium from today
• A couple other posts about time management and attention management (yes, really, attention management...it's something I have an issue with for sure)
• A post about my thoughts on nutrition and "real" food and my latest adventure in food DIY
• An intro to my tumblr site

And those are just the ones I've started on already! I have a whole list of things I plan to cover here. All in good time though. I'm trying to harness my enthusiasm to keep it going longer.

I just got home today and now I'm trying to catch up with everything in life....okay, that's not really feasible, so I'll probably just spend a few hours regrouping and gathering materials so my catchup efforts are effective in the next week.

A Productive Day

I wish I had something nice to say about the weather, but I really don't today. It's been in the 30s all day, with strong winds, spitting rain, and a thick cloud cover. A nice day to curl up on the couch with a book, but that's about it. It's a little unfortunate because it's my weekend off and I really love being outside, but I have done the best with what I have and instead have caught up on work inside.

So far today I have:

• Done homework
• Took the dog on a cold run
• Did some work on my vermicompost bin (indoors)
• Washed dishes
• Did laundry
• Cleaned up the mess I created this week when I painted my spare bedroom
• Partially cleared out my email inboxes
• Watched the Dog Whisperer (online, I don't have cable)

I almost didn't go out for a run because of the weather but there were two things that prompted it: a) Zephyr was driving my nuts and b) it's going to get a lot colder before it gets warmer so I just need to suck it up and get used to it.


And there's still more to do! The other stuff I plan to get done today...

• Put plastic over the windows for winter
• Vacuum
• Organize my paper files
• Organize my computer files
• Finish purging my old emails
• Clean the rest of the house
• Do some more laundry
• Brush the dog
• Some more homework and reading
• And I'll probably watch more Dog Whisperer!

Busy times, busy times...


Oh!! and one more thing!
Two of my  uncles wrote a book called "Hawkeye Greats, By the Numbers" It's now available on Amazon. If you're an Iowa fan, I think you should buy a copy ;)


~L

Isolation

I have come across both of these articles recently. Working in the hospital isolation is a big deal so of course I looked at them.

From the AMA: Preventive Measures Shown to Cut CDiff Rates

And in the NY Times: When Isolation Hampers More Than Bacteria

As a bit of background, in a hospital someone is put into isolation when they are infected with MRSA, VRE, Chlostridium Difficile, or any other hospital-acquired infection. The patient is required to be placed in a private room. Everyone who enters the room is required to wear gloves and an isolation gown (this includes all family members and visitors). When the patient leaves the room he/she must wear gloves and an isolation gown. If you're not entirely familiar with this practice I would suggest reading the AMA article which also outlines some more interventions to reduce transmission of a hospital acquired infection (clostridium difficile).

Overall, both articles are fascinating from an epidemiological standpoint: the first is how drastically hospitals have been able to cut their infection rates by aggressively implementing the CDCs guidelines for isolation practices. There are little things included that one may not initially think of, such as placing the trash can near the door so gloves/gowns are removed as the person is leaving. But it also gives other issues to consider. C Diff in particular affects people who are on antibiotics or proton pump inhibitors (PPIs). In an attempt to reduce post-surgical infections, new guidelines have resulted in an increase in antibiotics (antibiotic prophylaxis). So how do we balance the need to reduce post-surgical infections with the need to decrease rates of C diff? This will require further study and cost-benefit analysis to find a better balance.

The second article not only interests me from an epidemiological standpoint, but also in terms of connections with patients (and, I'll admit it, my own laziness). Basically this article looks at the impact of all the isolation precautions on the patients and the connection between the patients and caregivers. Because following isolation precautions involves added time to gown/glove, it is uncomfortable (the gowns are stifling hot), and it hinders a person's natural movement and makes working with the patient harder. Not to mention, the sticky tabs on the gowns pull hair, the gloves makes a person's hand sweaty, and it's nearly impossible to find a decent vein without at least one finger degloved.

This article states outright what I see every day at work: when patients are in isolation staff members purposely reduce contact with them by lumping work into one single trip, having only one person gown up, asking patients questions from the doorway instead of going in, and the patients themselves (if able to walk) avoid coming out at times. It also points out that patients in isolation have more non-infectious complications such as falls, pressure ulcers, depression, anxiety, and most shockingly "as much as a 100% increase in the overall incidence of adverse events." Wow, the very precautions we put in place to decrease particular adverse events actually increase other events.

I latched on to this quote from the article:

In two separate studies, researchers at the Medical College of Virginia in Richmond found that the rate of infection was identical whether health care workers wore gowns and gloves with only the patients in isolation or whether they wore only gloves with all patients.

 First of all, because I would be super psyched if I only had to wear gloves with isolation patients. Second, because of the interesting results of wearing gloves with all patients. Although it sounds benign enough, physical contact and touch is a big part of medicine and even the thin barrier of gloves greatly reduces what a clinician can actually feel and garner from touch. (for an interesting article from a physician's perspective regarding touch and the inner-conflict arising from gloves with all patients check this out)

It will be interesting to not what comes of this finding: those who work in healthcare would love to get rid of the frustration of isolation precautions, patients would love to get rid of the hassle of isolation, hospitals would probably enjoy the break the budget would get without buying isolation gowns. But I'm guessing that it will not be a quick change: we as humans naturally think that more protection (and more visible protection) is always better regardless of the evidence against it. (For example, did you know that the suds from dishsoap and toothpaste don't affect cleaning ability?)

Dr. Ed Wagner

Last week I attended a lecture that was part of the "Prevention and Chronic Care Management" conference hosted by the College of Public Health. Dr. Ed Wagner was awarded the Richard and Barbara Hanson Leadership Award and Distinguished Lectureship (I think the only thing academics love more than acronyms is really loooong names). I would have loved to attend the full conference, but other duties called my name. His lecture was titled "Primary Care and the Future of American Medicine." The title itself was compelling enough to rouse me from my bed before 9 a.m. (a monumental feat). But wake I did and I am very happy for it.

Dr. Wagner’s speech was titled “Primary Care and the Future of American Medical Care.” He began his speech by looking at the current state of primary care. For the purposes of this speech family medicine, internal medicine, and pediatrics were the specialities considered to be “primary care” (some sources also define psychiatry as a primary care field). From 1999-2009 the percentage of medical students choosing family medicine dropped from 15% to approximately 7%. Internal medicine fared even worse with a drop from 13% to 2%. In addition to fewer students entering these specialities, more current practitioners are leaving.

Why does the decline of primary care even matter? For several reasons: countries with better primary care have better health outcomes and lower costs, U.S. states with higher primary care/population rations have reduced costs and better quality. A survey asked if it was important to have “one practice/clinic where doctors and nurses know you, provide and coordinate the care that you need.” 95% agreed that it was important, 85% of those “strongly agreed” with the statement. The decline of primary care physicians per capita has also led to significant declines in satisfaction with the multiple areas of primary care, such as doctor-patient communication, interpersonal treatment, thoroughness of physical exam, visit-based continuity, and care integration.

What is the reason for this decline? One is that as the population grows older and sicker, PCPs are responsible for more content, increased demand and increased complexity. Other reasons are declining income and working harder to just keep up (“hamster wheel”).

Dr. Wagner's has done extensive work in chronic care and this is where the rest of the talk headed. He noted the increase in chronic conditions and how chronic conditions exponentially increase health care costs. One slide showed chronic conditions of medicare beneficiaries: 65% of beneficiaries had two or more chronic conditions and incurred 95% of expenditures! Chronic conditions have always been complex, but with new medications (which are often used in combination with each other) and ever-changing guidelines, the complexity has become even greater. This has affected the ability of the patient to manage his/her own care as well as resulted in a decreased ability of providers to support and educate patients regarding their care. What is the result of all this? "Patients with major chronic illnesses receive recommended care about 1/2 the time."

So, we need a way to combat declining primary care physicians, declining outcomes, and increased costs. The current buzzword is the medical home. The medical home initially grew from the American Academy of Pediatric's pediatric medical home. When combined with the chronic care model, one comes up with the patient-centered medical home (PCMH). The PCMH is a topic too large to discuss in this post, but the central idea is that each patient has a primary-care provider that is their first point of contact for health care and is the person that each subsequent encounter (PCP visit, specialist referral, hospital admission) refers back to. 

The PCMH has been shown to be effective in improving outcomes, but it still faces roadblocks to widespread implementation. Many providers are lacking the IT and infrastructure that is essential to a medical home and the current payment system doesn't reimburse for coordinating functions.

I highly suggest that everyone reads more about the patient-centered medical home as well as the chronic care model. 

Fall in Iowa

I have determined that fall and spring are my two favorite seasons...though I'm not sure which one ultimately wins. But I appreciated this week how truly beautiful fall in Iowa is.

 The leaves change colors. Lawns are covered in a beautiful carpet of reds and golds and browns and yellows. (Rest assured, when I have my own yard, I will be one of those people who doesn't rake) I love the earthy tones of the whole season.

 And those rich colors blend perfectly with the rich scents that are so inextricably linked with fall. Pumpkin, apples, cinnamon. Speaking of pumpkin, I love all things pumpkin: pumpkin yogurt, pumpkin bread, pumpkin pudding, pumpkin muffins, pumpkin ice cream, pumpkin lattes, pumpkin cookies (oddly enough I'm not a huge fan of pumpkin pie).

 I think part of what makes it so enjoyable is that it juxtaposes the best characteristics of summer and winter to create a delightful season that is so very distinct. Fall is the time I can sit in the sun and be very warm, but a cool breeze plays over my skin and makes it a perfect temperature. The best clothes of winter (scarves, sweatshirts, hats) can be worn without the bulkiness that comes with multiple layers in winter. The mornings are chilly with frost but the afternoons are nice enough to wear a t-shirt.

 People are out. Running, visiting parks, raking leaves, grieving the end of summer, relishing the final warm days, and taking it all in before the bitter cold of winter arrives. The final crop is harvested from the garden, dead plants are pulled up and composted, and the soil is readied for its time of rest.

When I wake up in the morning it's chilly enough that I adore the warm comforter on my bed, but stepping out on the bare floor is not painful.

I often feel like people are so disconnected from the earth (at least compared to my rural upbringing), but it seems that a greater number of people are closer to nature during the fall.

 I do believe we have some of the best weather in Iowa. Spring and fall are amazing (so I might be a little biased...), summer is warm, and winter is cold, but not incredibly long. We have all four seasons, each quite distinct, and none of them dominate.

In February I will be questioning my sanity in not moving south when I had the chance. As much as I dislike the chill of winter, I wouldn't give it up for the world because it is part of what makes fall so enjoyable. And these are the days that remind my why I love Iowa so very much.

And though my dread of the coming cold can sometimes affect my enjoyment of fall, I just remind myself to take each day as it is, to step on all the crunchy pieces, breathe in the earthy smells, roll in the grass with my dog, and fully appreciate it all.

~L

4-day Weekends

What did I find to be the hardest thing about starting grad school? All the free time

As an undergrad I had class 5 days a week. And as a music major, most of my classes were classified as "labs"--meaning that I could have up to 3 hours of class time for 1 credit. I believe my lightest semester of undergrad required me to only be in a classroom for 32 hours a week....just shy of a full-time job. So spending 6 hours in a classroom for 6 credits was a HUGE shift.

I will admit that I have really enjoyed my schedule this semester. I only have class on Tuesdays, Wednesdays, and Thursdays. However, it sometimes brings along a motivational challenge--not taking all 4 days off from school work. With my school and work responsibilities there are some weeks when I am absolutely beat, but I have been learning to push myself to do something everyday. I do give myself some lighter days, but there are always journal articles to read...

What have I found that helps?
Lists: I'm a list maker, so I always have to-do lists floating around. Most of them are so long that it would be impossible to finish all the tasks in one day, so I use a "line method." I draw a think black line on my list. All of the items above the line must be completed that day. Anything below the line is a bonus.
Planning: Google calendar saves my life. Class, Work, Seminar, Meetings, Appointments. As soon as anything is added to my schedule I immediately put it in google calendar. I can sync it to my iPod touch too, so I have gotten rid of all the post-its that used to control my life (and continually disappeared). At the beginning of each week I print out the week's calendar so I can see the non-negotiables on it. Then I plan what else needs a dedicated space--exercise, some extra intensive studying, commuting time and if I plan to bike to class/work. Each morning I plan the day's schedule with more detail. My one downfall is not planning enough time to finish something, or forgetting to plan transitions times, etc...but I'm learning.
Environment: Knowing when to change up my environment. There are some days when I can get work done at home. These days can be dependent on the type of work I need to get done, my mood and energy levels, and the state of my dog.*

(*This is Zephyr, my Australian Shepherd. I love him to death, but he has endless energy. No lie....I can take him out and run 5-6 miles and instead of wearing him out it essentially energizes him for the day. So clearly, this is a large factor in deciding where to do homework)

Some things get done best in the library at a desk, others are fine in my favorite chairs on the 8th floor of the hospital, sometimes I just need to put in some time and I can put on a movie/tv show that I have seen before and the background stimulates me enough without distracting me that I can work for a lot longer. It's really a matter of finding out what works best for me in different situations.

And if none of that works? It probably is time to take a break. I go for a run, read something for fun, throw Zephyr some tennis balls, or just enjoy the outdoors (it's been a stunning fall here).

Hello

A quick first post here.

I'm working on getting this blog on its feet. I wish I could magically make it perfectly finished, but it will be a work in progress for a little while so please bear with me if not all the pages are published and not all the links are posted.

It's not been a terribly busy week here. I have one paper to write this week about benefits and challenges of the patient-centered medical home. I am a big proponent of primary care so this is a very interesting topic for me. I am also getting further into my project in another class on improving the percentage of women who receive adequate prenatal care. The next part of that is evaluating different policies that have been implemented by various states to address the issue.

The class schedule for the spring is available as of this week. (Here's the link for current students) I have been looking at my courses and trying to figure out where work will fit in with that. My appointment is 60% so I am required to work a certain number of hours every 6 weeks and 8 or 12 hour shifts can be difficult to work in places. I work in the hospital so it is typical shift work (7-3:30, 3-11:30, 11-7:30). I refuse to get out of bed before 9 a.m. so 7-3:30 is off my list :). I can do overnights occasionally, and have no problem picking them up when needed, but I discovered at my last hospital that working overnight 4 nights/week and going to class from 8 a.m-6 p.m. every day was just a really bad idea. So I tend to shy away from night shift overloads. Evenings fit well with my body and they look to fit with my spring schedule too. That makes me happy.

Have a lovely Wednesday all!