E4 EZ EE THE WASHINGTON POST.TUESDAY, AUGUST 6 , 2019
BY ABEL J. KOURYW
hen it comes to
news reports about
the impact that
summer has on
student learning,
the news is often bad.
For instance, the Economist
proclaimed in 2018: “Long sum-
mer holidays are bad for children,
especially the poor.” This headline
is fairly typical of how summer
loss is portrayed. Summer has
come to be seen as a time when
children lose as much as a month
of school learning.
Nearly 50,000 media stories on
summer learning appeared in
- The message influences pol-
icy, as well. Lawmakers intro-
duced 293 state bills related to
summer programming in 2017.
These bills dealt with summer
learning in a number of ways —
from a vetoed Maine bill that tried
to establish a “Summer Success
Program Fund” to a California bill
that enables up to 30 percent of
funds for before- and after-school
programs go to summer learning.
Despite the seeming consensus
that children lose learning in the
summer, a 2017 report from the
Brookings Institution showed
that the recent research on sum-
mer learning loss is quite mixed,
with some studies showing signif-
icant loss and others finding little
evidence. Another 2018 analysis
found evidence of learning loss
every summer between second
and ninth grades, but findings
differ vastly from one study to the
next.
This has led some researchers
— including me — to question
whether summer loss even occurs.
Using current, nationally rep-
resentative data and focusing on
elementary kids, I attempted to
determine how big an issue is
summer learning loss. Here’s
what I found:
who were more likely to experi-
ence a summer slide.Summer homework isn’t vital
You also might think that stu-
dents who do regular math, writ-
ing or reading over the summer
would hold on to more knowledge
over the summer. Overall, this
was not the case. For instance,
78 percent of parents of gainers
and 79 percent of parents of slid-
ers read books to their child regu-
larly; about half do writing activi-
ties regularly.
The only exception is that chil-
dren who read to themselves
more frequently were less likely
to slide in reading between first
and second grade. This is based
on my study that shows 71.44 per-
cent of parents of gainers report-
ed that their child regularly read
to themselves, compared with
67.81 percent of parents of sliders.Let them play
All this is not to say that sum-
mer vacation doesn’t come with
its share of risks to children, be-
cause it does. But if I were going to
worry about a threat that summer
break poses to my child, it
wouldn’t be summer loss. I’d be
more concerned about the re-
search that shows children gain
more weight over the summer than
they do during the school year.
I have no quarrel with parents
or educators who want children to
read books or study math over the
summer to stay sharp academical-
ly. But let’s make sure they get to go
outside and play so that they can
stay in shape physically, as well.
[email protected]Abel J. Koury is a senior research
associate at Ohio State University.
This report was originally published
on theconversation.com.PERSPECTIVE
Do summer breaks hurt learning?
A university researcher says that data on elementary school children shows the issue is overblown
I was surprised to hear the
nurse practitioner say that a new
shingles vaccine was available.
The Food and Drug Administra-
tion had approved Shingrix
(zoster vaccine recombinant) in
2017 as a more effective vaccine
than Zostavax, which had been
approved in 2006. If I had known
about the vaccine earlier, I might
have been spared the overwhelm-
ing pain, fatigue and worry about
how long the suffering would last.
But since it was too late for
prevention, we focused on treat-
ment and managing the pain. The
nurse practitioner prescribed an
oral antiviral medication called
valacyclovir (Valtrex) for seven
days, which I took twice a day, and
gabapentin (Neurontin) for pain
relief, which I took three times a
day initially. Gabapentin is an
anticonvulsant used to treat epi-
lepsy that also works for nerve
disorders by changing the way
that nerves send messages to your
brain.
After a week on Valtrex, most of
the liquid-filled blisters had
scabbed over, which the nurse
practitioner told me indicated
that they were no longer infec-
tious.
Until that point, I avoided hug-
ging people because the infection
is spread through direct physical
contact with blisters.
Pritish Tosh, an infectious dis-
ease physician and researcher at
the Mayo Clinic in Rochester,
Minn, also suggests keeping the
lesions covered in public, wash-
ing hands after changing the ban-
dages or dressings, and not shar-
ing towels. If you have children at
home who have not had chicken-
pox or not been vaccinated, Tosh
recommends talking to your pedi-
atrician for guidance.
Meanwhile, I was taking gaba-
pentin and getting frustrated that
my pain wasn’t lessening.
Desperate for relief, I read on-
line about a topical ointment with
lidocaine that acts as a local anes-
thetic by temporarily blocking
the nerves from signaling pain.
The ointment with 5 percent lido-
caine required a prescription,
which my doctor provided. I start-
ed applying the ointment directly
on my rash and, thankfully, that
worked and the pain lessened
within minutes. I used the lido-
caine ointment daily for about
15 days until the pain significantly
lessened. Later, I discovered an-
other option, an over-the-counter
ointment patch with 4 percent
lidocaine.
Amid the pain, I tried to make
myself more comfortable by
wearing loosefitting cotton
clothes (I wore large T-shirts a
lot), taking cool showers with my
back facing the nozzle and just
letting the water drip over my
front, and meditating daily to stay
calm because the pain was stress-
ful. I was extremely tired for the
first few weeks I had shingles and
took naps. I also went for short
walks, watched movies to distract
myself and talked to friends for
support.
About 1 in 3 people in the
United States will develop shin-
gles during their lifetime, and
nearly 1 million cases of shingles
occur annually, according to the
Centers for Disease Control and
Prevention (CDC). Most cases of
shingles occur in people 50 and
older, and 1 in 2 people 80 and
older will have shingles, accord-
ing to the Mayo Clinic.
Age and illnesses can weaken
your immune system and cause
the chickenpox virus to reemerge
from the nerve tissue into the
cells again, Tosh said. Having HIV,
cancer or cancer treatment may
also weaken people’s immune sys-
tems.
Most experience similar symp-
toms to mine, but they may also
have chills, numbness or a fever.
Not everyone develops a rash,
although they typically have the
pain and other symptoms. IfSHINGLES FROM E1 you’re unfamiliar with the signs
of shingles as I was, it’s easy to
mistake them for other condi-
tions.
One lesson learned: Don’t diag-
nose your own symptoms. See a
trained medical professional. I
wasted three or four days going
down the “insect bite” rabbit hole
only to learn that it was shingles.
Most primary care doctors can
diagnose shingles based on the
symptoms and signs. The excep-
tion may be people without the
rash or who “have widespread
lesions due to compromised im-
mune systems,” Tosh said. “If
there’s any question about the
diagnosis, the lesions can be test-
ed by a lab using polymerase
chain reaction [PCR] which is a
highly sensitive and specific test
for the shingles virus.”
Another reason to seek treat-
ment early is that antiviral medi-
cations, which include acyclovir
(Zovirax) and famciclovir (Fam-
vir), work best within 72 hours of
the symptoms appearing.
“Antivirals prevent the virus
from expanding or replicating
and reduces the degree of nerve
inflammation and intensity of
pain,” said Robert Bolash, assis-
tant professor of anesthesiology
and interventional pain physi-
cian at the Cleveland Clinic in
Ohio.
Without antiviral medications,
shingles takes anywhere from
three to five weeks to resolve,
according to the National Insti-
tute on Aging.
When I later asked the nurse
practitioner why she only offered
gabapentin, she mentioned that
patients with shingles have told
her they can’t tolerate lidocaine
on their rash because the skin is
so hypersensitive.
I would have also liked to have
known when the rash would dis-
appear so I didn’t expect it to clear
up when the antiviral medication
stopped. It took another three
weeks to recede. Even two months
later, I can still see pink traces of
the rash that look like teardrops.
In the past few weeks, I have
noticed an on-and-off again mild
burning sensation in the same
area where the rash was. I worry
about developing a painful com-
plication of shingles called pos-
therpetic neuralgia (PHN). “The
pain may disappear entirely and
return or just persist in the form
of hypersensitivity,” Bolash said.
Bolash recommended seeing
your primary care doctor for
PHN, and if the pain doesn’t less-
en, seeing a pain specialist, which
can include physicians and alter-
native medicine practitioners
(acupuncturists and natur-
opaths).
Physicians who are board-cer-
tified in pain medicine/manage-
ment include neurologists, anes-
thesiologists and physiatrists
(physical medical rehabilitation).
They would treat PHN with gaba-
pentin, analgesic skin patches,
low doses of antidepressants or
steroid injections. If those fail to
provide relief, a device can be
implanted surgically beneath the
abdominal skin to deliver pain
medication to the area around the
spinal cord.
Unfortunately, having shingles
once doesn’t prevent you from
having it again, especially if you
are older, have PHN and/or a
compromised immune system.
The CDC recommends that
healthy adults 50 and older be
vaccinated with Shingrix, the new
vaccine — even if you have had
shingles, have received Zostavax,
the older vaccine, or are unsure
you have had chickenpox. Shin-
grix is more than 90 percent effec-
tive when you receive two sepa-
rate shots given two to six months
apart, according to the CDC.
The demand for Shingrix has
exceeded the supply in some
states. You may have to call
around to find a pharmacy with it
or you can get on a waiting list. I
will get vaccinated this summer.
[email protected]I had shingles, a painful
virus. I really should
have gotten the vaccine.
enough for rehab.”
I’ve been putting off checking
on him: afraid his family will
hijack the visit by changing their
minds again.
Walking into his room, I’m
struck by its sharp contrasts. The
daughter and son-in-law, wear
designer black, with Apple watch-
es lighting up their wrists. They
peck away on their iPhones and
laptop. All week, they have been
working from a cramped room
with its 1980’s decor. About the
only color in the room is the
patient’s maroon VA-issued paja-
mas.
I introduce myself, but don’t
engage in lengthy conversation —
not yet.
As the morphine wears off, the
patient awakens to his own
drowning: Gurgling secretions
fill squishy lungs. Too weak to
cough, he grimaces, large eyes
pleading for help. The nurse and I
reposition him. Another dose of
morphine helps with his air hun-
ger, and he drifts off again.
Throughout the morning, I
check in on him. The son-in-law
paces; his daughter types on her
phone. Both seem absorbed and
distracted. I wonder what it’s like
to lose a parent, then quickly shut
out the thought.
About midday I ask them,
“How’s he doing?” I know the
answer: Comfortable for now, but
what about when he wakes up
and can’t breathe?
I suggest that we step outside
to talk about what’s next — specif-
ically, the father’s impending
death.
“He was doing so well last
week,” his daughter says. “I guess
we thought he’d just walk out of
here.” She’s hopeful.
“We know he’s tired. We can tell
he’s given up,” her husband says.
And then, “Do you think he can
recover?”
Their faces give away their
thoughts: How long does he have?
If we remove the oxygen mask
and let nature take its course,
would he suffer?
I take a breath, quieting my
own feeling of loss over this pa-
tient’s future.
“Your father sounds like an
exceptional man,” I say. “Can you
tell me more about him?”
They go way back, filling me in
on his military service, his love for
music and dancing, how he met
his daughter’s mother. About his
beloved garden; he gave away
everything he grew. Moving into
the present, these two middle-
aged adults agree he wouldn’t
want to live like this.
We discuss what happens next
— the mechanics of managing his
symptoms without prolonging
suffering. Mostly, they ask me
DEATH FROM E1 questions I can’t answer.
“How long will it take for him
to die once the oxygen is turned
off ?” I’m not sure.
“Can he feel anything?” Not
sure.
“Can he hear us?” Don’t know.
This man is her father, and my
patient: I want to get this “right.”
“We want him to be comfort-
able,” his daughter says through
tears.
“So do I,” I say. I try to seem
stoic, but my heart races. Al-
though I’ve attended many
deaths, this is only my second
time removing supplemental oxy-
gen — a “terminal wean,” as it’s
called.
Before going back to the pa-
tient’s room, I approach his
nurse.
My check-in is blunt. “Have you
ever seen someone die?” If she
feels moral distress over weaning
the oxygen, I need to find another
nurse to assist me.
“Once,” she says.
“Me too,” I want to say, but
don’t. I feel exposed, like I’m
playing doctor instead of being
one. My mind races: Will I be
relieving his suffering, or actively
killing him? Does anyone die well,
or are we just kidding ourselves?
Too chicken to share these
thoughts, I ask, “Are you okayassisting me?”
“Yes,” she says. Suffering my
own moral distress, I’m not sure
that I’m okay doing this.
Should I sleep on it? Maybe I
just wait till next week, sign it out
to the next hospitalist? I wonder.
He won’t survive until next
week, my mind reminds me firm-
ly. Be the doctor.
I blink hard. I have to get
moving.
The nurse and I go in together.
Tall and blonde, she projects the
poise and confidence I wish I had.
She’s holding two syringes: one in
her right hand, to sedate; one in
her left, for air hunger.
“This is the right thing to do,”
she says, as if to tell me: You’re not
an impostor. You belong here. You
can do this. “He’s suffering, and
we have to help him.”
She turns off the fentanyl drip
and injects each medication. I
make the first downward adjust-
ment to the high-flow oxygen,
and we watch.
Lungs gurgling, our patient re-
mains in an opioid dream. Across
the bed, his daughter holds his
limp hand.
We’ve each staked out our terri-
tory and purpose: the nurse gives
medications, his daughter has a
hand, I have the oxygen, while the
son-in-law paces. Perhaps need-
ing more, I lean over and push my
patient’s stick-straight hair
toward his right-sided part, won-
dering, Did he consider himself
lucky to have this full head of
hair?
Over the next 30 minutes, I
gradually turn down the oxygen
until the machine no longer hiss-
es. He holds his breath — and so
do we. When he finally exhales,
it’s a sputter, while our collective
in-breath is deep and full.
I feel for a pulse. Nothing.
His daughter looks at me. Is he
dead? her eyes ask.I walk around to her side of the
bed, her face splotched red from
crying, her hands firmly clutch-
ing shredded Kleenex.
We embrace. I feel a lump of
emotion stuck in my throat. My
eyes fill with tears that I don’t let
fall.
It’s an honor to be part of this
veteran’s death, I remind myself.
“He died well,” I hear my voice
say, mechanical and far away.
Next comes a blur of paper-
work: death note, organ dona-
tion, consent for autopsy.
Casually, I ask the nurse how
she’s doing.
“Fine.” Maybe sensing my dis-
tress, she says, “He was suffering.
We did the right thing.” Then she
hands me the death certificate.
“Could you sign on this line? No,
not there, here.”
Time of death. Cause of death.
Did tobacco contribute to death?
It’s comforting to be able to work
again. I’m focused and produc-
tive. Tasks getting checked off.
Why is doing task-oriented
work easier than being a witness
to suffering? I ask myself. Why is
standing silently at the bedside to
comfort a patient or family mem-
ber so exhausting? Shouldn’t it be
the other way around?
It’s been 12 hours since I
walked into the hospital. I head
back to my office and scoop up my
belongings. I hit the lights — and
then it hits me.
In the dark, I slide down the
heavy metal door and land seated
among my car keys, handbag,
water bottle and a mostly uneaten
lunch. Knees tucked under my
chin, I sob.
“I just witnessed a person die,”
I whisper. Questions tumble
through my mind: What about
me? What about my distress?
Does being a physician mean that
I have to be an emotional robot?
Why couldn’t I share my vulnera-
bility with the nurse? Why are we
taught that showing emotion at
the bedside is weak? Would I lose
my respect if I was respectfully
authentic? Would it matter?
I take a few breaths.
Take it easy, I tell myself. It’s
only Monday. You have another
six days on service.
Gently, I remind myself that
when I miss a chance to practice
self-compassion, I get one more
chance — and then a thousand
more.
Tonight, in the dark, is my one
more chance.
[email protected]Amy Cowan, an assistant professor in
internal medicine at the University of
Utah, practices as a hospitalist with
the Veterans Affairs facility in Salt
Lake City. This article was first
published on Pulse, voices from the
heart of medicine, a site devoted to
personal stories about health care.ISTOCK
The Food and Drug Administration approved Shingrix (zoster
vaccine recombinant) in 2017 as a vaccine to fight shingles.ISTOCK
After shutting off life support, the doctor says she grappled with
many moral, ethical and emotional questions about her role.ISTOCKMost kids aren’t affected
My study using national data
suggests that, by and large, the
issue of summer learning loss is
overblown. Specifically, only
7 percent of students lose the
equivalent of one month of
school-year learning in reading
and 9 percent in math over the
summer between kindergarten
and first grade. Over the summer
before second grade, this increas-
es to 15 percent in reading and
18 percent in math. This suggests
that the majority of youngsters
don’t experience summer learn-
ing loss.
My research suggests most
children gain or maintain their
skills over the summer.Losses aren’t long-term
I also wanted to know wheth-
er children who slid over the
summer would stay behind dur-
ing elementary school. Using na-
tional data, my findings suggest
that summer sliders and gainers
are not much different by the
end of fourth grade. For in-
stance, the average score for chil-
dren who gained vs. slid over the
summer before second grade dif-
fered by just 0.04 points for math
and 0.12 points for reading two
years later.Strong students lose the most
I was also curious to see wheth-
er it was possible to figure out
what kinds of student charac-
teristics and background fac-
tors relate to summer learn-
ing loss. You might predict
— as I did — that children
with weaker skills before
summer would be more
likely to lose over the
summer. And you would
be wrong — as I was.
It was actually chil-
dren with higher read-
ing or math scores be-
fore the start of summerHow one physician struggled over a patient’s end
“I just witnessed a
person die,” I whisper.
Questions tumble
through my mind:
What about me? What
about my distress?