Modern life messes with the microbiome -– the trillions of bacteria and other microbes that live inside the body. Could reconnecting with nature bring this internal ecosystem back into balance?
A new study suggests it can, at least in lemurs. Led by Duke Ph.D. alumnus Sally Bornbusch and her graduate advisor Christine Drea, the research team collected fecal samples from more than 170 ring-tailed lemurs living in various conditions in Madagascar: some were living in the wild, some were kept as pets, and some were rescued from the pet and tourism industries and then relocated to a rescue center in southwestern Madagascar where they ate a more natural diet and had less exposure to people.
Then the researchers sequenced DNA from the fecal samples to identify their microbial makeup. They found that the longer lemurs lived at the rescue center, the more similar their gut microbes were to those of their wild counterparts. Former pet lemurs with more time at the rescue center also showed fewer signs of antibiotic resistance.
By “rewilding” the guts of captive animals, researchers say we may be able to better prime them for success, whether after rescue or before translocation or reintroduction into the wild.
This research was supported by grants from the National Science Foundation (1945776, 1749465), the Triangle Center for Evolutionary Medicine, Duke’s Kenan Institute for Ethics, the Margot Marsh Biodiversity Fund and Lemur Love.
CITATION: “Microbial Rewilding in the Gut Microbiomes of Captive Ring-Tailed Lemurs (Lemur catta) in Madagascar,” Sally L. Bornbusch, Tara A. Clarke, Sylvia Hobilalaina, Honore Soatata Reseva, Marni LaFleur & Christine M. Drea. Scientific Reports, Dec. 27, 2022. DOI: 10.1038/s41598-022-26861-0.
The healthcare industry and academic medicine are excited about the potential for artificial intelligence — really clever computers — to make our care better and more efficient.
The students from Duke’s Health Data Science (HDS) and AI Health Data Science Fellowship who presented their work at the 2022 Duke AI Health Poster Showcase on Dec. 6 did an excellent job explaining their research findings to someone like me, who knows very little about artificial intelligence and how it works. Here’s what I learned:
Artificial intelligence is a way of training computer systems to complete complex tasks that ordinarily require human thinking, like visual categorization, language translation, and decision-making. Several different forms of artificial intelligence were presented that do healthcare-related things like sorting images of kidney cells, measuring the angles of a joint, or classifying brain injury in CT scans.
Talking to the researchers made it clear that this technology is mainly intended to be supplemental to experts by saving them time or providing clinical decision support.
Meet Researcher Akhil Ambekar
Akhil Ambekar and team developed a pipeline to automate the classification of glomerulosclerosis, or scarring of the filtering part of the kidneys, using microscopic biopsy images. Conventionally, this kind of classification is done by a pathologist. It is time-consuming and limited in terms of accuracy and reproducibility of observations. This AI model was trained by providing it with many questions and corresponding answers so that it could learn how to correctly answer questions. A real pathologist oversaw this work, ensuring that the computer’s training was accurate.
Akil’s findings suggest that this is a feasible approach for machine classification of glomerulosclerosis. I asked him how this research might be used in medicine and learned that a program like this could save expert pathologists a lot of time.
What was Akhil’s favorite part of this project? Engaging in research, experimenting with Python and running different models, trying to find what works best.
Meet Researcher Irene Tanner
The research Irene Tanner and her team have done aims to develop a deep learning-based pipeline to calculate hip-knee-ankle angles from full leg x-rays. This work is currently in progress, but preliminary results suggest the model can precisely identify points needed to calculate the angles of hip to knee to ankle. In the future, this algorithm could be applied to predict outcomes like pain and physical function after a patient has a joint replacement surgery.
What was Irene’s favorite part of this project? Developing a relationship with mentor, Dr. Maggie Horn, who she said provided endless support whenever help was needed.
Meet Researcher Brian Lerner
Brian Lerner and his team investigated the application of deep learning to standardize and sharpen diagnoses of traumatic brain injury (TBI) from Computerized Tomography (CT) scans of the brain. Preliminary findings suggest that the model used (simple slice) is likely not sufficient to capture the patterns in the data. However, future directions for this work might examine how the model could be improved. Through this project, Brian had the opportunity to shadow a neurologist in the ER and speculated upon many possibilities for the use of this research in the field.
What was Brian’s favorite part of this project? Shadowing neurosurgeon Dr. Syed Adil at Duke Hospital and learning what the real-world needs for this science are.
Many congratulations to all who presented at this year’s AI Health Poster Showcase, including the many not featured in this article. A big thanks for helping me to learn about how AI Health research might be transformative in answering difficult problems in medicine and population health.
Some dogs have to eat in a high chair—or, more specifically, a Bailey Chair. The chair keeps them in a vertical position while they eat so that gravity can do the work their bodies can’t: moving food from the mouth to the stomach.
These dogs have megaesophagus, an esophagus disorder that can prevent dogs from properly digesting food and absorbing nutrients. When you swallow a bite of food, it travels down a muscular tube, the esophagus, to the stomach. In humans, the esophagus is vertical, so our esophageal muscles don’t have to fight against gravity. But because dogs are quadrupeds, a dog’s esophagus is more horizontal, so “there is a greater burden on peristaltic contractions to transport the food into the stomach.” In dogs with megaesophagus, the esophagus is dilated, and those contractions are less effective. Instead of moving properly into the stomach, food can remain in the esophagus, exacerbating the problem and preventing proper digestion and nutrient absorption.
Leigh Anne Clark, Ph.D., an associate professor at Clemson University, recently spoke at Duke about megaesophagus in dogs and its genetic underpinnings. She has authored dozens of publications on dog genetics, including five cover features. Her research primarily involves “[mapping] alleles and genes that underlie disease in dogs.” In complex diseases like megaesophagus, that’s easier said than done. “This disease has a spectrum,” Clark says, and “Spoiler: that makes it more complicated to map.”
Clinical signs of megaesophagus, or mega for short, include regurgitation, coughing, loss of appetite, and weight loss. (We might use the word “symptom” to talk about human conditions, but “a symptom is something someone describes—e.g., I feel nauseous. But dogs can’t talk, so we can only see ‘clinical signs.’”) Complications of mega can include aspiration pneumonia and, in severe cases, gastroesophageal intussusception, an emergency situation in which dogs “suck their stomach up into their esophagus.”
Sometimes megaesophagus resolves on its own with age, but when it doesn’t it requires lifelong management. Mega has no cure, but management can involve vertical feeding, smaller and more frequent meals, soft foods, and sometimes medication. Even liquid water can cause problems, so some dogs with mega receive “cubed water,” made by adding a “gelatinous material” to water, instead of a normal water bowl.
In dogs, mega can be either congenital, meaning present at birth, or acquired. In cases of acquired megaesophagus, the condition is “usually secondary to something else,” and the root cause is often never determined. (Humans can get mega, too, but as with acquired mega in dogs, mega in humans is usually caused by a preexisting condition. The best human comparison, according to Clark, might be achalasia, a rare disorder that causes difficulty swallowing.) Clark’s current research focuses on the congenital form of the disease in dogs.
Her laboratory recently published a paper investigating the genetic foundation of mega. Unlike some diseases, mega isn’t caused by just one genetic mutation, so determining what genes might be at play required some genetic detective work. “You see mega across breeds,” Clark says, which suggests an environmental component, but the disease is more prevalent in some breeds than others. For instance, 28 percent of all diagnoses are in German shepherds. That was a “red flag” indicating that genes were at least partly responsible.
Clark and her collaborators chose to limit their research study to German shepherds. Despite including a wide range of dogs in the study, they noticed that males were significantly overrepresented. Clark thinks that estrogen, a hormone more abundant in females, may have a protective effect against mega.
Clark and her team performed a genome-wide association study (GWAS) to look for alleles that are more common in dogs with mega. One allele that turned out to be a major risk factor was a variant of the MCHR2 gene, which plays a role in feeding behaviors. In breeds where mega is overrepresented, like German shepherds, “we have a situation where the predominant allele in the population is also the risk allele,” says Clark.
Using the results of the study, they developed a test that can identify which version of the gene a given dog has. The test, available at veterinary testing companies, is designed “to help breeders reduce the frequency of the risk allele and to plan matings that are less likely to produce affected puppies.”
It’s not enough to just publish a great scientific paper.
Somebody else has to think it’s great too and include the work in the references at the end of their paper, the citations. The more citations a paper gets, presumably the more important and influential it is. That’s how science works — you know, the whole standing-on-the-shoulders-of-giants thing.
So it always comes as a chest swelling affirmation for Dukies when we read all those Duke names on the annual list of Most Cited Scientists, compiled by the folks at Clarivate.
This year is another great haul for our thought-leaders. Duke has 30 scientists among the nearly 7,000 authors on the global list, meaning their work is among the top 1 percent of citations by scientific field and year, according to Clarivate’s Web of Science citation index.
As befits Duke’s culture of mixing and matching the sciences in bold new ways, most of the highly cited are from “cross-field” work.
Duke’s Most Cited Are:
Biology and Biochemistry
Charles A. Gersbach
Robert J. Lefkowitz
Christopher Bull Granger
Pamela S. Douglas
Adrian F. Hernandez
Manesh R. Patel
Eric D. Peterson
Tony Jun Huang
Edward A. Miao
David B. Mitzi
Christopher B. Newgard
John F. Rawls
Drew T. Shindell
Pratiksha I. Thakore
Mark R. Wiesner
Barton F. Haynes
Neuroscience and Behavior
Quinn T. Ostrom
Pharmacology and Toxicology
Evan D. Kharasch
Plant and Animal Science
Sheng Yang He
Psychiatry and Psychology
William E. Copeland
E. Jane Costello
Terrie E. Moffitt
Michael J. Pencina
John W. Williams
Congratulations, one and all! You’ve done us proud again.
How does parenting change when infant and child mortality affects every family in society? Recent history may provide an answer. For the entirety of the 19th Century, child mortality was ubiquitous. In the year 1880, nearly 35% of children born in the United States passed away in their first five years. The medical literature that explores the common diseases and public health inadequacies, though expansive, often fails to address the central humanistic questions surrounding such widespread death. How were these children mourned? How did grieving families move on? And how has this mourning changed in the context of the past hundred years of medical advancement?
Throughout the lecture, Klass guided the audience through famous portraits, poems, and prose produced in the 18th Century that memorialized children who had died at a young age. Perhaps the most famous fictional account of childhood death in the 19th century emerged in Uncle Tom’s Cabin by Harriet Beecher Stowe. The emotionally wrenching death scene of young Eva, who succumbed to tuberculosis, struck a chord with virtually all those who read the novel. Published in 1852, Uncle Tom’s Cabin would go on to be reproduced in theaters across the country for several decades, the death scene becoming a ubiquitous anchor that often brought the audience to tears. Klass further described how Beecher Stowe drew from her personal experience, the death of her son Charlie from cholera only a few years prior to the writing of the book, to create this powerful literary scene.
Beecher Stowe was not the only author whose personal experience impacted their art. Charles Dickens, deeply impacted by the death of his children, had created a slew of sentimental yet mortal child characters in his stories. One of the most prominent examples, young Nell from “The Old Curiosity Shop,” was published in installments and developed a strong following. Dickens ended the series with the death of twelve-year old Nell, much to the outrage of international readers.
Perhaps it’s no surprise that parents chose to memorialize their deceased children through literature and art. Wealthy families would often contract famous portrait artists were often contracted to depict their dead children. Some, including the Rockefellers and the Stanfords, channeled the deaths of their children and grandchildren into resourced academic institutions.
For grief to drive philanthropy and art is not a new phenomenon, but the sources of grief that drive such artistic and financial overtures today have changed considerably. Klass sought to bridge this knowledge gap and pull closer the history to which society has the privilege of being oblivious. Maybe, even, it would even inform how we cope with the mortality of young people today.
“How do we situate ourselves in a world where infant and child mortality is so low?” Klass asked at the beginning of her presentation.
The past does not reveal one clear answer, but it does provide a tapestry of options, many lost in our modern collective memory, for mourning, for celebrating, and for memorializing.
As a senior at Duke University in 2010, Dr. Quinn Wang was simply Quinn, an undergraduate English major on the pre-med track, wondering how to combine her love for medicine with her love for English. This is how her senior thesis was conceived – Through the Lens of Medicine: Landscapes of Violence in Cormac McCarthy’s Blood Meridian (1985), All the Pretty Horses (1992), and No Country for Old Men (2005) – which ended up winning the English department’s award for “Most Original Honors Thesis.”
Fast forward 12 years, and Wang can now call herself a double Dukie, having completed medical school here. She went on to complete ophthalmology residency at UCSF and this past Saturday, November 5, came back to her alma mater as part of the Duke Medical Ethics Journal’s Medicine, Humanities, and Business celebration to talk to an eager audience at Schiciano Auditorium about her path from Duke until now.
She began her story during the infamous year of 2020, when she was forced to stop seeing patients at her private practice in California’s Bay Area due to COVID-19. Restless and anxious about how her patients were doing, she tried to keep up with them as best she could, but of course there were limitations. And then, a few months in, one of her patients went blind.
This tragic moment sparked a frustrating realization by Wang that in the tech capital of the world – San Francisco – there was still no good way to test people’s eyesight from home to prevent what should have been preventable. She decided to put together something herself, guided by the one question she thought was most important to answer until COVID-19 abated and people could come into clinics again – “how do we make sure people don’t go blind?”
Wang took common visual eye-testing tools used in clinics, and with some simple Photoshop editing and a little bit of code, turned them into a series of easy multiple-choice questions that could be answered from home. This simple but powerful transformation turned into Quadrant Eye, a start-up she co-founded with software engineer Kristine Hara.
The Quadrant Eye journey has taken her from running a private practice as an ophthalmologist to taking the plunge into business by applying to and getting selected for Y Combinator, which calls itself a “graduate school for startups”. YC invests $500,000 into a selection of early-stage startups twice a year. Then, for three intense months, they provide support to get startups off the ground and in good shape to present to investors for funding. At YC, Hara worked on turning Quadrant Eye into an app, and Wang renewed hundreds of prescriptions.
Ultimately, though, the most significant place Quadrant Eye has led Wang to is a journey of self-mastery that applies to any human endeavor, from building a startup to doing research to just getting up every morning. As she describes, startup life entails always learning new things and always messing up – which, for someone who professes that “I don’t like to do things I’m not good at” – can be challenging. She candidly admitted that she, like everyone, has bad days, when sometimes all she can do is throw in the towel and end work early. “I have more doubts than I care to admit,” Wang says, but at the end of the day, “we’re all climbing our own mountains”. Pushing through requires “superhuman effort” but it’s worth it.
And as for that English thesis? Wang describes how Quadrant Eye’s very first investor – “let’s call him Charlie” – asked her all the requisite questions investors ask early-stage startups (think Shark Tank). But he also asked her for something non-traditional – all fifty or so pages of her undergraduate honors thesis she had written ten years back. Apparently, he had seen a mention of it on LinkedIn and was intrigued. A few weeks later, Wang received a phone call that he was interested in investing – and he admitted that her thesis had played a part. To him, the uniqueness and quality of her thesis showed that Wang could problem-solve, communicate well, and think creatively, and Wang herself agrees. “My English thesis showed me that I can do hard things,” she said, and if Quadrant Eye is any indication, clearly, she can.
“After COVID-19,” senior Cynthia Dong (T’23) remarks, “so much of what was wrong with the medical system became visible.”
This realization sparked an interest in how health policy could be used to shape health outcomes. Dong, who is pursuing a self-designed Program II major in Health Disparities: Causes and Policy Solutions, is a Margolis Scholar in Health Policy and Management. Her main research focus is telehealth and inequitable access to healthcare. Her team looks at patient experiences with telehealth, and where user experience can be improved. In fact, she’s now doing her thesis as an offshoot of this work, researching how telehealth can be used to increase access to healthcare for postpartum depression.
In addition to her health policy work, however, Dong also works as a research assistant in the neurobiology lab of Dr. Anne West, and her particular focus is on the transcription mechanism of the protein BDNF, or brain-derived neurotrophic factor.
While lab research can be clearly visualized by most people (think pipettes, rows of benches littered with bottles and plastic tubes, blue rubber gloves everywhere), health policy research is perhaps a little more abstract. When asked what the process of research through Margolis is like, Dong says that “it’s not team-based or individual – it’s a lot of both.” This looks like individual research on specific topics, talking to different stakeholder groups and people with certain expertise, and then convening for weekly team meetings.
For Dong, research has been invaluable in teaching her to apply knowledge to something tangible. Doing that, you’re often “forced to understand that not everything is in my control.” But on the flip side, research can also be frustrating for her because so much of it is uncertain. “Will your paper get published? Is what you’re doing relevant to the research community? Will people invest in you?”
In that vein, research has humbled her a lot. “What it means to try to solve a societal problem is that it’s not always easy, you have to break it down into chunks, and even those chunks can be hard to solve.”
After graduation, Dong plans on taking a couple of gap years to be with family and scribe before ultimately pursuing an MD-MPH. Because research can be such a long, arduous process, she says that “It took me a long time to realize that the work we do matters.” In the future, though, she anticipates that her research through Margolis will directly inform her MPH studies, and that “with the skills I’ve learned, I can help create good policy that can address the issues at hand.”
What brings seniors Deney Li and Amber Fu together? Aside from a penchant for photoshoots (keep scrolling) and neurobiology, both of them are student research assistants at the lab of Dr. Andrew West, which is researching the mechanisms underlying Parkinson’s in order to develop therapeutics to block disease progression. Ahead lie insights on their lab work, their lab camaraderie, and even some wisdom on life.
(Interview edited for clarity. Author notes in italics.)
What are you guys studying here at Duke? What brought you to the West lab?
DL: I am a biology and psychology double major, with a pharmacology concentration. I started working at a lab spring semester of freshman year that focused on microbial and environmental science, but that made me realize that microbiology wasn’t really for me. I’ve always known I wanted to try something in pharmaceutics and translational medicine, so I transitioned to a new lab in the middle of COVID, which was the West lab. The focus of the West lab is neurobiology and neuropharmacology, and looking back it feels like fate that my interests lined up so well!
AF: I am majoring in neuroscience with minors in philosophy and chemistry, on the pre-med track. I knew I wanted to get into research at Duke because I had done research in high school and liked it. I started at the same time as Deney – we individually cold-emailed at the same time too, in the fall! I was always interested in neuroscience but wasn’t pre-med at the time. A friend in club basketball said her lab was looking for people, and the lab was focused on neurobiology – which ended up being the West lab!
What projects are you working on in lab?
DL: My work mainly involves immunoassays that test for Parkinson’s biomarkers. My postdoc is Yuan Yuan, and we’re looking at four drugs that are kinase inhibitors (kinases are enzymes that phosphorylate other proteins in the body, which turns them either on or off). We administer these drugs to mice and rats, and look at LRRK2, Rab10 and phosphorylated Rab10 protein levels in serum at different time points after administration.These protein levels are important and indicative because more progressive forms of Parkinson’s are related to higher levels of these proteins.
AF: For the past couple of years, I’ve been working under Zhiyong Liu (a postdoc in the lab). There are multiple factors affecting Parkinson’s, and different labs ones study different factors. The West lab largely studies genetic factors, but what we’re doing is unique for the lab. There’s been a lot of research on how nanoplastics can go past the blood-brain barrier, so we are studying how this relates to mechanisms involved in Parkinson’s disease. Nanoplastics can catalyze alpha-synuclein aggregation, which is a hallmark of the disease. Specifically, my project is trying to make our own polystyrene nanoplastics that are realistic to inject into animal models.
What I’m doing is totally different from Deney – I’m studying the mechanisms surrounding Parkinson’s, Deney is more about drug and treatments – but that’s what’s cool about this lab – there are so many different people, all studying different things but coming together to elucidate Parkinson’s.
How much time do you spend in lab?
DL: I’m in lab Mondays, Wednesdays, and Fridays from 9 to 6. All my classes are on Tuesdays and Thursdays!
AF: I’m usually in lab Tuesdays and Thursdays from 12 to 4, Fridays from 9 to 11:45, and then whenever else I need to be.
Describe lab life in three words:
DL: Unexpected growth (can I just do two)?
AF: Rewarding, stimulating, eye-opening.
What’s one thing you like about lab work and one thing you hate?
DL: What I like about lab work is being able to trouble-shoot because it’s so satisfying. If I’m working on a big project, and a problem comes up, that forces me to be flexible and think on my toes. I have to utilize all the soft skills and thinking capabilities I’ve acquired in my 21 years of life and then apply them to what’s happening to the project. The adrenaline rush is fun! Something I don’t like is that there’s lots of uncertainty when it comes to lab work. It’s frustrating to not be able to solve all problems.
AF: I like how I’ve been able to learn so many technical skills, like cryosectioning. At first you think they’re repetitive, but they’re essential to doing experiments. A process may look easy, but there are technical things like how you hold your hand when you pipette that can make a difference in your results. Something I don’t like is how science can sometimes become people-centric and not focused on the quality of research. A lab is like a business – you have to be making money, getting your grants in – and while that’s life it’s also frustrating.
What do you want to do in the future post-Duke? How has research informed that?
DL: I want to do a Ph.D. in neuropharmacology. I’m really interested in research on neurodegeneration but also have been reading a lot about addiction. So I’ll either apply to graduate school this year or next year. My ultimate goal would be to get into the biotech startup sphere, but that’s more of a 30-years-down-the-road goal! Being in this lab has taught me a lot about the pros and cons of research, which I’m thankful for. Lab contradicts with my personality in some ways– I’m very spontaneous and flexible, but lab requires a schedule and regularity, and I like the fact that I’ve grown because of that.
AF: The future is so uncertain! I am currently pre-med, but want to take gap years, and I’m not quite sure what I want to do with them. Best case scenario is I go to London and study bioethics and the philosophy of medicine, which are two things I’m really interested in. They both influence how I think about science, medicine, and research in general. After medical school, though, I have been thinking a lot about doing palliative care. So if London doesn’t work out, I want to maybe work in hospice, and definitely wouldn’t be opposed to doing more research – but eventually, medical school.
What’s one thing about yourself right now that your younger, first-year self would be surprised to know?
DL: How well I take care of myself. I usually sleep eight hours a day, wake up to meditate in the mornings most days, listen to my podcasts… freshman-year-Deney survived on two hours of sleep and Redbull.
AF: Freshman year I had tons of expectations for myself and met them, and now I’m meeting my expectations less and less. Maybe that’s because I’m pushing myself in my expectations, or maybe because I’ve learned not to push myself that much in achieving them. I don’t necessarily sleep eight hours and meditate, but I am a little nicer to myself than I used to be, although I’m still working on it. Also, I didn’t face big failures before freshman year, but I’ve faced more now, and life is still okay. I’ve learned to believe that things work out.
Last Monday, Oct. 17, Duke University students who had conducted global health research had the opportunity to present their work. From North Carolina to Sub-Saharan Africa, the 2022 Global Health Research Showcase featured works that tackle some of the world’s most pressing health issues. Over 40 undergraduate, Masters, and PhD student projects examined a broad range of issues, determinants, and phenomena in countries from almost every continent. Here’s a few project highlights, in case you missed it:
Maeve Salm, pursuing her Master of Science in Global Health, went to Tanzania to study contraceptive use. Tanzania’s youth are highly impacted by teen pregnancy, and Salm wanted to understand desires for contraceptive use among adolescents affected by HIV. She learned that, much like in the U.S., stigma influences access to sexual healthcare for adolescents. This qualitative study aimed to support young people in achieving their desired health outcomes and reducing HIV transmission by examining barriers and facilitators to family planning. Findings indicate that youth agency in reproductive health is of utmost importance.
Wondering about the Covid-19 response in other countries? Master of Science in Global Health Candidate Stephanie Stan explored the barriers and enablers to the pandemic response in Peru. Per capita, Peru experienced the highest mortality rate form the disease compared to any other country. Due to several challenging factors, they were slow to receive COVID-19 vaccines. However, they implemented highly successful vaccination campaigns once vaccines were obtained. What can be learned from Peru’s pandemic response? Prolonged and proactive collaborations between sectors (healthcare, academics, and government) enable swift public health responses in a crisis. It’s important to have elected officials who are empowered to make decisions promoting science.
“Definitely meeting all the incredible people that I interviewed and learning about their work and involvement in Peru’s pandemic response. Learning about what happens moving forward from their point of view.”
Stephanie Stan, when asked about her global health research experience
Winning the first-place Graduate Student Research Award, Judith Mwobobia’s project examined the stigma of cancer in sub-Saharan Africa. Stigma is a huge barrier to receiving treatment, which is a problem considering that 70% of global cancer deaths originate from Africa. Perceptions of financial stress, misconceptions about cancer, and fear of death were common attitudes driving cancer stigma. Proposed interventions included education and policy recommendations for low-resourced communities. Mwobobia is pursuing her Master of Science in Global Health. Clearly a supportive group, her classmates erupted in cheers when the award was announced.
The list of professions that have been pushed to the brink during the pandemic is ever-expanding. However, the sea change that swept over nursing in the past three years rivals that of almost any occupation, said panelists in a Sept. 28 event hosted by Duke University School of Nursing.
Already one of the most overworked professions, the pandemic only seemed to magnify nursing’s enduring problems, according to panelist and journalist Lauren Hilgers. A few months into the pandemic, nurses around the country began quitting in droves due to both burnout and undervaluation by their employers. As the front lines dwindled, hospitals working at full capacity needed to meet patient demand by any means necessary.
Enter travel nursing agencies, independent staffing organizations that matched nurses from across the country with hospitals dealing with acute labor shortages. Already increasing in popularity in the lead-up to the pandemic, demand for travel nurses in recent times has exploded. As this fundamental change in the make-up of the nursing labor pool occurred, people started to take notice.
In February of 2022, an article was published in the New York Times titled “Nurses Have Finally Learned What They’re Worth”. In the piece, Hilgers chronicles the major trends in the nursing workforce over the past three years. Hilgers describes the unique proposition facing the nurses who chose not to quit: remain as a staff nurse on their current salaries or sign up with a traveling agency and uproot their lives, albeit for higher pay. And the pay bump was substantial. Certain travel nurse jobs paid up to $10,000 a week, many times what staff nurses were earning. These nurses would often stay at a hospital anywhere from a couple of weeks to months, providing much-needed relief to healthcare systems. However, as the practice spread, questions soon began to emerge about the disparities in pay between staff and travel nurses, the sustainability of travel nurse programs, and, moreover, how the American healthcare system enabled travel nursing to rise to such prominence in the first place?
“Nursing is the largest segment of the healthcare workforce…yet what we contribute to the health and wellbeing of our country is invisible,” mentioned Dean Ramos at the discussion’s outset.
Smalheer agreed, adding that nurses today are contributing to patient care in ways that were vastly outside of their scope of practice just twenty years ago. A unique combination of technical proficiency, aptitude during crisis response, and ability to provide feelings of care and comfort, Hilgers describes nursing as one of, if not the only, profession in healthcare that considers the “entirety of a patient.”
A frequently cited statistic during the panel presentation referenced results from a Gallup poll indicating that nursing was rated as the most trusted profession for the 20th year in a row. While nurses were always aware of their influence and worth, getting healthcare systems to agree proved to be a much larger effort, one that only grew in importance as COVID-19 progressed.
“The pandemic has hardened us,” explains Smallheer. No longer were nurses willing to tolerate slights against their treatment as a profession. And they had tolerated plenty. Barraza, one of the protagonists of Hilgers’ piece, described the relentless search for purpose amidst constant burnout, especially during the pandemic’s heaviest waves. From finding efficient triage methods during a surge of cases to celebrating patient discharges, Barraza actively sought out ways to be “consistent when there was no consistency.” A charge nurse located in a region with severe labor shortages, Barraza had seen the influx of travel nurses firsthand every week. What ultimately kept him from traveling across the country in the pursuit of a more lucrative job, however, was the relationships he had forged within the hospital. Nurses, students, patients-they had all left an indelible mark on Barraza and enabled him to push through the long and grueling hours. Tennyson reinforced Barraza’s story by claiming that “you can be burnt out and still find value in a profession.” This seemingly contradictory duality may have proved sufficient to retain nurses during the pandemic, but as for long-term solutions, the panelists agree that significant change must occur at a systemic level.
One of the central tensions of Hilgers’ article is that between the hospital and the worker. The explosion of travel nursing during the pandemic was but a manifestation of decades of undervaluation by hospitals of nurses. In order to undo this narrative and enact concrete change, Tennyson argues that nurses must be represented in more interdisciplinary professional spaces, from healthcare administration to policy to business. Hilgers restates this idea more broadly, saying that nurses “need to have a seat at the table” in reshaping the healthcare system post-COVID-19.
Much of this work begins at the level of the educational institution. Smallheer and Tennyson spoke at length about how nurses can better be prepared to navigate the ever-changing healthcare workforce. They both highlighted a few of the Duke School of Nursing’s novel instructional methods, including early exposure to complicated patient cases, extensive practice with end-of-life scenarios, and recognition of overstimulation points in the field. Also important for nurses-in-training and existing nurses, according to all panelists, was collective action. Through supporting state and national nursing associations, writing to local politicians, and speaking to healthcare administrators, they argued that nurses will be better equipped to voice their demands.
As the panel reached its closing stages, one of the main talking points centered around changing the narrative of nursing as solely a burnout profession. Hilgers in particular remains critical of the portrayal of nurses, and more broadly those involved in care work, in popular media. She strongly advocates for authentic storytelling that including the voices of actual nurses, nurses such as Barraza. Ramos describes Barraza as someone who “represent[s] the best in nursing,” and the panelists maintained a strong desire to see such stories of resilience and passion spotlighted more frequently.
There is no simple formula to reform the nursing profession in the United States. However, through a combination of effective storytelling, more current educational standards, greater interdisciplinary involvement, and collective action, the panelists of the Dean’s Lecture Series firmly believe that lasting change is possible.