Florida medical board moves to block gender affirming treatments for minors

“Florida’s medical board on Friday voted to begin the process of banning gender-affirming medical treatment for youths, a move that comes as Republican Gov. Ron DeSantis has become increasingly vocal in his opposition to such therapies.”

“The board also voted to start that process for requiring adults seeking such care to wait 24 hours before going forward with any medical procedures.”

“The American Academy of Pediatrics and the American Medical Association support gender-affirming care for adults and adolescents. But medical experts said gender-affirming care for children rarely, if ever, includes surgery. Instead, doctors are more likely to recommend counseling, social transitioning and hormone replacement therapy.
The proposed rule is the latest step taken by the DeSantis administration to tighten regulatory controls over gender-affirming care. Florida’s Medicaid regulator is also considering a rule that would block state-subsidized health care from paying for treatments of transgender people.”

Hospitals struggle with staff shortages as federal Covid funds run out

“Hospitals across the country are grappling with widespread staffing shortages, complicating preparations for a potential Covid-19 surge as the BA.5 subvariant drives up cases, hospital admissions and deaths.

Long-standing problems, worker burnout and staff turnover have grown worse as Covid-19 waves have hit health care workers again and again — and as more employees fall sick with Covid-19 themselves.”

A nurse made a fatal error. Why was she charged with a crime?

“The argument here is not about whether nurses should be held accountable for their errors; everyone I spoke with about Vaught’s case agrees she bears responsibility for her actions and should face consequences. The real issue is that criminalizing a nurse’s error lets hospitals off the hook for the systemic changes that would improve patient safety.

“Almost no mistakes happen in a hospital by just one person,” said Gatter. Systems exist to prevent medical errors, he said. If those systems don’t work or exist only on paper, errors will happen.

In this case, the system failures were clear: During an unannounced visit to Vanderbilt University Medical Center in late 2018, federal investigators found multiple deficiencies, some of which placed patients at “serious and immediate threat,” according to the 105-page memo documenting the details. For example, hospital policies didn’t require that a second nurse sign off on the use of a highly dangerous medication like vecuronium, nor did it require that patients receiving sedatives be hooked up to a heart and lung monitor. Focusing the blame on one nurse’s error shifts the attention away from those deficiencies.

“I’m quite concerned that this nurse is getting thrown under the bus, and in the hubbub of giving her a jail sentence, that the system itself will escape close examination,” said Gatter.

Even if a nurse were solely responsible for a medical error resulting in patient harm, the way to prevent that nurse from causing further harm is to revoke their license, said Gatter. It’s much harder to explain how punishing a nurse with jail time further prevents them from endangering others.

However, it’s easy to see how that type of punishment can itself create and compound safety risks, he said.

That’s because severely punishing individuals for systemic problems has a chilling effect on others’ willingness to report mistakes.”

“Less transparency in error reporting also means hospitals have fewer opportunities to correct big problems. That means faulty systems stay in place, which translates into more vulnerability and stress for health care providers and less safety for patients.”

“The consequences for professional malpractice should ideally deter wrongdoing without discouraging people from entering the profession altogether — but finding that balance is challenging.”

“American nursing was under enormous strain well before the pandemic. But with the US population aging, surging retirements among bedside nurses and nurse educators, and nurse staffing levels reduced ever lower to contain costs, the pandemic has tipped parts of the country into a full-on nursing shortage.
The last thing the profession needs is another reason for nurses to leave jobs providing direct patient care, but that’s exactly the effect the Vaught ruling is having”

Smallpox used to kill millions of people every year. Here’s how humans beat it.

“More than a million Americans have died of Covid-19, and the World Health Organization estimated this Thursday that the global death toll is around 15 million — a horrifying, and largely unnecessary, tragedy.

But for all that the world has lost in the last few years, the history of infectious disease has a grim message: It could have been even worse. That appalling death toll resulted even though the coronavirus kills only about 0.7 percent of the people it infects. Imagine instead that it killed 30 percent — and that it would take centuries, instead of months, to develop a vaccine against it. And imagine that instead of being deadliest in the elderly, it was deadliest for young children.

That’s smallpox.”

“Before modern vaccine development, humans had to get creative in slowing the spread of infectious disease. It was known that people who’d survived smallpox didn’t get sick again. In China, as early as the 15th century, healthy people deliberately breathed smallpox scabs through their noses and contracted a milder version of the disease. Between 0.5 percent and 2 percent died from such self-inoculation, but this represented a significant improvement on the 30 percent mortality rate of the disease itself.

In England, in 1796, doctor Edward Jenner demonstrated that contracting cowpox — a related but much milder virus — conferred immunity against smallpox, and shortly after that, immunization efforts began in earnest across Europe. By 1813, the US Congress passed legislation to ensure the availability of a smallpox vaccine that reduced smallpox outbreaks in the country throughout the 1800s.”

“By 1900, smallpox was no longer quite as much of a scourge in the world’s richest countries. In the 1800s, about 1 in 13 deaths in London were caused by smallpox; by 1900, smallpox caused only about 1 percent of deaths. Several countries in Northern Europe had also declared the disease eradicated. Over the next few decades, more of Europe, and then the US and Canada, joined them.

But as long as smallpox ravaged other parts of the globe, continual vaccination was necessary to make sure it wasn’t reintroduced, and millions of people continued to die of it. Data is spotty — this is before there was any international authority on infectious disease statistics worldwide — but it is estimated that 10 to 15 million people caught smallpox annually, with 5 million dying of it, during the first half of the 20th century.

It was not until the 1950s that a truly global eradication effort began to appear within reach, thanks to new postwar international institutions. The World Health Organization (WHO), founded in 1948, led the charge and provided a framework for countries that were not always on friendly terms to collaborate on global health efforts.”

“A 1947 outbreak in New York City, traced back to a traveler from Mexico, resulted in a frantic effort to vaccinate 6 million people in four weeks. Europe, Henderson says, repeatedly saw the virus reintroduced by travelers from Asia, with 23 distinct importations (different occasions of someone bringing smallpox into the country) in five years.

As we face down Covid-19, with effective vaccinations finally in hand, we’re encountering the same challenge that the world faced with smallpox in the 1950s: It doesn’t matter if a vaccine exists unless there also exists the international will and creativity to get it to all the people who need it, many of whom will be reluctant and skeptical.”

“features of smallpox made it easier to eradicate than many other diseases. For one thing, it didn’t have animal reservoirs; that is, unlike diseases like Ebola, smallpox doesn’t live in animal populations that can reintroduce the disease in humans. That meant that once it was destroyed in humans, it would be gone forever. And, once a person has survived it, they are immune for life. Only one vaccine is needed for immunity in almost all cases.

Additionally, it largely doesn’t have asymptomatic transmission and has a fairly long incubation period of about a week. That made it possible for public health officials to stay on top of the disease with a strategy of “ring vaccination” — whenever a case was reported, vaccinating every single person who may have come into contact with the affected person, and ideally everyone in the community could keep the disease at bay.”

“Humanity’s triumph over smallpox should stand out as one of our proudest moments. It called on scientists and researchers from around the world, including collaborations between rival countries in the middle of the Cold War.

Unfortunately, we’ve never replicated that success against another virus that affects humans. With some, such as polio, we’re drawing close. Wild polio has been eradicated in Africa and remains only in conflict-torn regions of Afghanistan and Pakistan. “Ring vaccination,” as practiced in the smallpox battle, has been successfully used in public health efforts against other diseases, most recently with the new Ebola vaccine, used against outbreaks in the Democratic Republic of Congo.

But in other cases, like HIV and Covid-19, we’ve let new diseases grow to pandemic proportions. And while those diseases have had devastating effects, it’s worth keeping in mind that they could have been even worse. Some viruses with the potential to escape laboratories or make the jump from animals to humans are as deadly and transmissible as smallpox, and Covid-19 has made it clear that we’re not prepared to handle them.”

“The devastation of Covid-19 has hopefully made us aware of the work public health experts and epidemiologists do, the crucial role of worldwide coordination and disease surveillance programs (which are still underfunded), and the horrors that diseases can wreak when we can’t control them.

We have to do better. The history of the fight against smallpox proves that we’re capable of it.”

The dire health consequences of denying abortions, explained

“important research published in 2020 that compared the fates of women who were forced to carry pregnancies to term versus those who were provided abortions. The influential Turnaway Study, as it’s commonly referred to, found that, among other things, women who were denied an abortion endured more serious pregnancy complications, more chronic pain, and more short-term anxiety.”

“more unwanted pregnancies would be carried to term if the court were to negate a federal right to abortion.”

“The Turnaway Study began in 2007 and followed more than 1,000 women for five years to assess how their lives had been altered, if at all, by the provision or the denial of an abortion. Some of the women had an abortion shortly before reaching the gestational limit set by their state or provider, while others had just passed that limit and were denied an abortion as a result. The differences in the women’s experiences from that critical moment onward were the purview of the study.
“We find no evidence abortion hurts women,” Foster writes in the 2020 book The Turnaway Study that covered the research’s findings. “For every outcome we analyzed, women who received an abortion were either the same or, more frequently, better off than women who were denied an abortion.”

The mental health of women who received an abortion was better immediately after the procedure than that of women who were denied one. Their physical health fared better over the longer term. Their subsequent children developed better.

Foster presents a nuanced picture, noting, for example, that after the five-year period of the study, almost none of the women who ended up carrying an unwanted pregnancy to term said that they still wished they’d had an abortion. But Foster is nevertheless unequivocal in her conclusions about what being denied an abortion meant for the women involved: “We find many ways in which women were hurt by carrying an unwanted pregnancy to term.””

“The most unexpected and tragic outcome noted in the Turnaway Study was that two of the women died because of childbirth complications. It came as a shock to Foster, who wrote that she “did not expect to find even one maternal death in a study of 1,000 women.” The US maternal mortality rate is 1.7 per 10,000, meaning the odds of two women in 1,000 dying were exceedingly low.

Foster was careful not to be definitive about this finding, writing that a much larger sample size would be necessary to draw any firm conclusions about the relationship between being denied an abortion and maternal mortality. The implications remain grim, however: “This level of maternal mortality is shocking,” she wrote.

Short of death, women who are denied an abortion are more likely to have serious complications than women who received an abortion. The Turnaway Study found that 6.3 percent of the women who had given birth suffered life-threatening complications versus about 1 percent of women who had complications from an abortion.

Women who were denied an abortion also saw a higher risk of gestational hypertension, which increases their risk for cardiovascular disease later in life. The study found that 9.4 percent of women who gave birth experienced hypertension during the pregnancy versus 4.2 percent of women who had second-trimester abortions and 1.9 percent of those who had first-trimester abortions.

The women who gave birth also experienced slightly higher rates of chronic head pain and joint pain afterward. On self-reported health, a metric shown to be a strong indicator of future health and mortality, 27 percent of women who carried their pregnancies to term after being denied an abortion said they were in fair or poor health versus 21 percent of women who had second-trimester abortions and 20 percent of women who had an abortion in the first trimester.

“To the extent that there were differences in health outcomes,” Foster wrote, “they were all to the detriment of women who gave birth.””

““We found no mental health harm from having an abortion.””

Can we stop the next pandemic by seeking out deadly viruses in the wild?

“Critics — including researchers who study biosecurity and biosafety — argue it doesn’t really pass a cost-benefit analysis. In some ways, virus hunting is looking for a needle in a haystack — the handful of viruses that might cross over to humans amid tens of thousands that won’t — when we don’t even know how to tell needles from hay, or what to do with a needle once we identify one.
And some experts are raising another, even sharper question: What if viral discovery is not just an ineffective tactic but a terrible idea, one that might not only fail to prevent the next pandemic but potentially even make it more likely?”

“Monitoring the interface between humans and animals for pandemic prevention has value, particularly when the programs are narrowly targeted at certain objectives: say, a focus on reducing spillover, or surveillance of potential animal infections, or studying viruses that have already spilled over into humans. Research published last month in Nature projects that global warming could drive 4,000 viruses to spread for the first time between mammals, including potentially humans and animals, by 2070, underscoring the changing threat from zoonotic spillovers.

But if the risks of virus hunting are higher than the odds of a virus crossing over into humans and sparking a pandemic naturally, then viral discovery doesn’t just look inefficient. It looks like a bad idea.”

Why well-qualified medical school graduates can’t get jobs — despite doctor shortages

“despite the great need for more doctors, there are still huge gaps between the number of aspiring physicians and the space available to train them, a dynamic that keeps perfectly well-qualified medical school applicants and graduates out of the pipeline.

In 2021, for instance, there were a record-setting 42,508 active applicants for residency programs — 3,741 more than in 2020 — but only 35,194 first-year positions, according to the National Resident Matching Program. Although the number of residency spots has been creeping upward in recent years, the growth has not been fast enough to close the gap.

At the root of the mismatch between physician supply and demand are decades-old limits on medical school enrollment and outdated rules governing the federal funding for most residency programs. While Congress has taken some baby steps toward increasing that funding, it has yet to make the kinds of bold changes necessary to create a sustainable and pandemic-resilient physician workforce.”

“The US medical system falls behind those of our peer countries in so many ways. We have higher administrative costs and worse outcomes than other high-income countries — and we also have fewer physicians available per person.

“If you take a look at EU countries that have sophisticated medical systems,” explained Janis Orlowski, chief health care officer at the AAMC, “they have between 30 and 40 physicians per 10,000 people. In the United States, we have about 26 to 27.”

It’s not an apples-to-apples comparison, in part because physicians use their time differently in different systems. But it’s clear the shortage is a burden, and it’s likely to get worse as the US population grows larger and older.”

“In a December 2021 survey conducted by the American Medical Association, one in five physicians said they would likely leave their current practice within two years, and about a third said they’d likely reduce their work hours in the next year.

The larger workforce trend has been dubbed the “Great Resignation,” and the reasons doctors are quitting echo the factors contributing to shortfalls among other health professionals, including nurses, medical assistants, physical therapists, and pharmacists. Burnout, fear of exposure, pandemic-related mood changes, and workload were all associated with intent to leave the profession.”

“It’s easy to imagine a simple solution for this problem: Incentivizing doctors from other countries to immigrate to the US. But this is not as quick a fix as it seems. Most states require doctors to complete residency training in the US, which takes at least three years. That applies even for doctors who practiced independently at expert levels in other countries; the chief of surgery at the fanciest hospital in India would still have to repeat residency in order to practice in the US.

About 13,000 of the residency match applicants this year were graduates of international medical schools, 8,000 of whom were not US citizens. But no matter how many additional doctors want to jump through the hoops necessary to practice in the US, long waits for visas and restrictive terms limiting where and for how long they can practice in the US make it unlikely many more will be added to the health care workforce in the near term.”

“One major bottleneck in the physician pipeline is medical school admissions, which are only graduating about 27,000 students each year. “That started in the 1980s with the freakout over a physician surplus,” said Robert Orr, a social policy analyst at the Niskanen Center in Washington, DC. At the time, miscalculations about population growth and changes in medical care delivery contributed to a moratorium on medical school enrollment that lasted until 2005.

Although medical schools have since continued to grow, expanding too quickly could result in a surplus of medical graduates with nowhere to do their residencies. That’s because of the other major bottleneck in the pipeline — the low number of residency positions. This year’s 36,000 first-year residency slots are inadequate to meet the US need for physicians and inadequate to provide training positions for all the applicants seeking them — and like the dearth of medical school seats, it is a consequence of restrictions created long ago with arguably good intentions.

Since the Medicare and Medicaid Act was first passed in 1965, medical residents have been paid for mostly by the Medicare and Medicaid programs. The goal was to ensure Medicare beneficiaries had access to the best health care, which was thought to be found in teaching hospitals.

In 1983, Medicare made changes to the way it reimbursed hospitals for residency programs. At that time, it created formulas that calculated the dollar amount of residency training funds it supplied to each hospital as a percentage of that hospital’s care expenditures and its volume of Medicare patients — sort of like a restaurant tip, said Orr.

Those formulas have never been updated — and because they tie funding to the cost of care, they have resulted in better funding for hospitals providing high-cost care in high-cost (usually urban) areas.

Over the years, this inequitable distribution of residency program funding has meant that hospitals prioritizing primary care services in rural areas get less funding and fewer residents than those that perform lots of expensive procedures in cities. That leads to fewer primary care specialists, and because physicians often practice near where they train, fewer rural physicians.

This fee structure also incentivizes hospitals to raise the cost of the care they deliver, and results in lower funding for residency programs at hospitals that treat younger populations less likely to be covered by Medicare.

Worse yet, to reduce Medicare expenditures, the Balanced Budget Act of 1997 capped the number of resident slots that could be funded by Medicare each year. It also capped the number of residents each hospital could have at their 1996 levels, which meant hospitals couldn’t get additional residents even if the population they served ballooned in size. Obamacare undid this restriction in 2010, and since then, the number of residency spots has grown modestly.

In 2020, Congress passed a federal budget bill that provided for 1,000 new Medicare-funded residency slots to be added over the next five years. But that’s nowhere near enough to close the current gaps.

Money donated by private insurers funds some residency positions at “the hospitals with the prestige and market power to extract it,” said Orr, but “it’s not a super-equitable way of trying to get residents out to different hospitals where maybe the population isn’t as well served.””

“There are also some solutions that sidestep the residency bottleneck entirely. One of the more promising fixes to the physician shortage is to allow other highly trained providers, like nurse practitioners, physician assistants, and pharmacists, to practice independently of doctors. The American Medical Association has vigorously fought this change for more than 30 years, and physicians who oppose the move often cite patient safety concerns, although they are not substantiated by safety studies.

Much of the real motivation to prevent these providers from practicing independently may be about money and professional sovereignty; private practice doctors in particular are financially disincentivized from expanding the scope of other practitioners.”

They warned about pandemics before Covid-19. Now they have a $100 billion plan to stop the next one.

“Among other priorities, the plan includes funding for: creating vaccine candidates for each of the 26 families of viruses known to infect humans; developing antiviral medications that can work against a broad spectrum of viruses; building out manufacturing capacity for vaccines, antivirals, tests, and other countermeasures; deploying genomic sequencing as a way to track outbreaks; developing broadly useful diagnostic technologies and better regulatory processes for approving and disseminating plentiful rapid tests; and improving security in laboratories dealing with dangerous viruses.

The White House, to its credit, has already proposed funding around this level. Most recently, in its 2023 budget proposal, the Biden administration asked for $88.2 billion in funding over five years on pandemic preparedness. That includes $40 billion for the Office of the Assistant Secretary for Preparedness and Response (ASPR) at the Department of Health and Human Services to “invest in advanced development and manufacturing of countermeasures for high priority threats and viral families, including vaccines, therapeutics, diagnostics, and personal protective equipment (PPE),” as well as $12.1 billion in research funding for the National Institutes of Health for vaccine, therapeutics, and diagnostics development.

Bumb notes that the Biden proposal actually drew on the original Apollo plan put out by the bipartisan commission. That’s part of why the new commission report is so notable: This is a group that’s capable of driving policymaking at high levels.

That said, Congress has yet to appropriate money at the commission’s desired level to prevent the next pandemic. It’s barely interested in further funding response to the current, ongoing pandemic, which is still killing hundreds of Americans a day. A group of senators recently cut a deal for $10 billion to fund Covid-19 response, after slashing funding the White House wanted to help fight the pandemic abroad — only to have Republicans block the deal on the Senate floor over separate immigration concerns. Even if the funding eventually passes, it’ll have to wait until after the Easter recess ends on April 22.”

The American Medical Association Should Help Patients. Instead, It’s Policing Language.

“the AMA now tells doctors to call poor neighborhoods “systematically divested,” not “poor,” it has long lobbied for things that hurt poor people, like restricting the number of doctors.

The U.S. has fewer doctors than other countries. Per person, Austria has twice as many.

“We have the best paid physicians in the world and the scarcest physicians in the world,” says Yglesias. “That’s not a coincidence.”

Years ago, in most of America, anyone could practice medicine. Licensed doctors didn’t like that. That led to the formation of the AMA.

They’re a trade group, says Yglesias. “They…advance the interests of their members.”

Like the teachers union or dock workers union.

“It’s called a trade association rather than a union,” says Yglesias. “But it’s never been all that different.”

In 1986, the AMA called for smaller enrollment in medical schools, to curb an alleged doctor “surplus.” In 1997, it even got the government to pay hospitals not to train doctors!

Today, the AMA supports rules that make it hard for doctors from other countries to practice here. Foreign doctors must complete a U.S. residency program. They don’t get credit for having practiced abroad.

Such rules preserve America’s doctor shortage. That shortage allows the average doctor to make more than $200,000 a year.

Well-paid doctors can be choosy about where they work. It’s why it’s tough to find a doctor in rural America, says Yglesias.”

“Why does the AMA and its “Liaison Committee on Medical Education” even get to approve new schools? I don’t get to approve new TV reporters.

The AMA’s statement claims it supports “increasing…the number of physicians.” If that’s true, it’s long overdue. A study in Annals of Internal Medicine says if there were more primary care doctors, 7,200 lives would be saved.”

The CDC’s New Pain Treatment Advice Aims To Correct the Damage Done by the 2016 Version

“The revised and expanded pain treatment guidelines that the Centers for Disease Control and Prevention (CDC) published today mention “patient abandonment” eight times. They also include two occurrences of this admonition, in bold and italics: “Clinicians should not abandon patients.”

That gives you a sense of the disastrous impact that the original version of the CDC’s advice, published in 2016, had on medical care. Something clearly has gone terribly wrong when clinicians have to be reminded that they are not supposed to abandon patients. At the same time, the CDC’s acknowledgment of the problem signals its willingness to address the needless suffering caused by the 2016 guidelines, which resulted in undertreatment, reckless “tapering” of pain medication, denial of care, and procrustean policies that prioritize reductions in opioid prescribing over the interests of patients.

The original guidelines, which were aimed at primary care physicians and focused on “prescribing opioids for chronic pain,” included grave warnings about the dangers of exceeding 90 morphine milligram equivalents (MMEs) a day. Many physicians, pharmacists, insurers, regulators, and legislators read that threshold as a hard cap, meaning that it should never be exceeded and that chronic pain patients who were already above it should be forced to comply with this arbitrary limit.

Although the 2016 guidelines focused on chronic pain, they also touched on acute pain, because “long-term opioid use often begins with treatment of acute pain.” For acute pain, the CDC said, a prescription for “three days or less will often be sufficient,” while “more than seven days will rarely be needed.” As a result, the CDC notes in the new guidelines, “more than half of all states have passed legislation that limits initial opioid prescriptions for acute pain to a seven day supply or less,” while “many insurers, pharmacy benefit managers, and pharmacies also have enacted similar policies.”

Ostensibly, the guidelines were purely advisory. But in practice, many patients found to their dismay, they were mandatory.”