The coming crisis in American primary healthcare

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Over the past several years, there has been a growing shortage of physicians in this country, especially in primary care. A new report by the Association of American Medical Colleges suggests that the shortage will only worsen in the coming years, in large part because of physician burnout.

A stronger claim could be made that just the opposite would happen.

“The system is grinding us,” said one of the doctors interviewed for the Kaiser Health News article. “It’s grinding good docs and providers out of existence.”

The article noted that burnout is increasingly identified as a major problem facing medicine. Four in 10 physicians report feelings of burnout, according to a 2019 Medscape report. And the physician suicide rate is more than double that of the general population.

In most cases, those barriers were erected by private insurance companies. Among them are the ever-increasing requirement that doctors must get “prior authorization” from insurers before treating their patients, trouble making patient referrals and “endless clicking on electronic medical records.”

Researchers studying physician burnout recently began to apply that term to health care. They concluded that moral injury was an appropriate term to describe the root cause of physicians’ anguish: Physicians know how best to care for their patients but are blocked from doing so by systemic barriers related to the business side of health care.

Physician burnout has reached such proportions among American doctors that researchers are now using a term that comes from war: “moral injury.” As Kaiser Health News reported in February, moral injury was first used to explain why military veterans were not responding to standard treatment for post-traumatic stress disorder. Moral injury, as defined by researchers from veterans hospitals, refers to the emotional, physical and spiritual harm that people feel after “perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations.”

As the supply of doctors continues to shrink we can only expect we will fall even further behind other developed countries in both doctors per 1,000 population and the number of physician visits per year in the future.

Not only that, but Canadians visit their doctors an average of 6.8 times a year, compared to four times a year in the United States. Germans go to the doctor more than twice as often as we do–9.9 times a year on average.

We even perform worse than Canada, a country that reform opponents often cite as a place where doctors are so unhappy they are packing up and moving to the U.S. The truth is that Canada, with 2.7 doctors per 1,000 residents, actually has slightly more doctors available to treat patients than we do. And in Norway, another country with a single-payer system, there are 4.8 doctors per 1,000 people.

According to a recent analysis by the Commonwealth Fund, which monitors the performance of health care systems around the world, there are 2.6 physicians per 1,000 people in the United States–way below the 3.5 per 1,000 average of the 37 countries that comprise the Organization for Economic Cooperation and Development.

The U.S. has already fallen far behind other rich countries when it comes in the number of physicians per 1,000 residents. While the expected shortfall can be explained in part because of changing demographics, the report says a big problem is the fact that more and more physicians are retiring early–a trend that likely will accelerate–because of burnout.

By 2033, the report found, the shortage of physicians is expected to range from 54,100 to 139,000 with the shortage being most pronounced among primary care doctors.  (Tarbell 7/1/2020).

 

Oxford is tying itself in knots over racism

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Oxford University apparently has plans for “trauma dispensation” and the “decolonisation of science degrees”. ( Excuse  me!  What on earth is trauma dispensation and when was science “ colonized”?  Ed.)

”Stepford students! Snowflakes! Students are mocked but in the wake of Black Lives Matter protests, it is vice-chancellors who spot trauma everywhere and want to turn universities into one big safe space.

“The vice-chancellor of Oxford University, Louise Richardson, has announced that students traumatised by the video of George Floyd’s death at the hands of a police officer can ask for special dispensation if they feel they were unable to perform at their best in final exams or assessments. She has urged her colleagues to “reach out to any black students who may be experiencing difficulty at this time”.

“No one who watched Floyd plead for his life was left unmoved. But grades for trauma takes us down a slippery slope. Exactly how many additional marks is a traumatic experience worth? How do students go about proving their distress? The call to “reach out” to black students suggests skin colour will be evidence of suffering.

“Richardson’s announcement means black students at Oxford may have their exams graded more leniently than their white peers. This is a giant leap backwards for racial equality. At first glance, Richardson’s proposal might seem unfair to white students who will struggle to prove they have been traumatised. But it is black students who should be furious.

“You worked hard to win a place at a top university — 18.3 per cent of Oxford students are British BAME, compared with the Russell Group average of 21.6 per cent. Once there, you spent long hours in the lab or the library, before frantic weeks cramming for finals. Exam results are announced and — fantastic news! — your efforts paid off. But rather than celebrating you are left with nagging doubts. Did you score highly because your lecturers felt sorry for you? Will your degree classification be forever shrouded in doubt?  (Joanna Williams, The Times, June 18 2020).

My comment:  I don’t always find myself in agreement with The Times (London), but  I do think Ms. Joanna Williams is right – all this is patronising.  If I were black I would resent being talked down to in this manner.  It will take less than a year before the word goes round that a degree earned by a colored student isn’t worth as much as the same degree earned by a white one, and all the best intentions will be for naught.  If you are accepted by Oxford, you are resilient enough to do the work involved (a huge load) and take the exams on the same basis as everyone else.

I had the experience of a final exam paper on European History which my tutor subsequently told me was the most difficult he had seen for many years.  Like everyone else I messed it up, and as a result, the Final grading for me and everyone else involved was affected negatively.  Did we go crying “unfair” to the authorities?  No, by that time we were adults, I suppose. A non-coddled generation.

Annexation of the occupied West Bank

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(This post is a bit longer than usual, but the injustice is so troublesome that I wanted to reproduce it;  one won’t find it easily in the American media):

Medical Aid for Palestinians (MAP) decries the Israeli government’s intended annexation of significant parts of the occupied West Bank (to start this coming Wednesday), for the intensified widespread and severe violations of Palestinians’ right to health and well-being that it will cause.

Annexation constitutes a flagrant violation of international law and of the post-World War Two international order, which prohibits absolutely the acquisition of territory by force. As stated in a robust rebuke on 16 June of the Israeli government’s plan, by a group of UN experts: “The international community has prohibited annexation precisely because it incites wars, economic devastation, political instability, systematic human rights abuses and widespread human suffering.”

The UN experts said that the 53-year-old Israeli occupation has already been “the source of profound human rights violations against the Palestinian people” and outlined a number of them:

“These violations include land confiscation, settler violence, discriminatory planning laws, the confiscation of natural resources, home demolitions, forcible population transfer, excessive use of force and torture, labour exploitation, extensive infringements of privacy rights, restrictions on the media and freedom of expression, the targeting of women activists and journalists, the detention of children, poisoning by exposure to toxic wastes, forced evictions and displacement, economic deprivation and extreme poverty, arbitrary detention, lack of freedom of movement, food insecurity, discriminatory law enforcement and the imposition of a two-tier system of disparate political, legal, social, cultural and economic rights based on ethnicity and nationality…These human rights violations would only intensify after annexation.”

All of these violations, stemming directly and indirectly from the occupation, impact Palestinians’ health and well-being. The experts’ statement was led by Michael Lynk, Special Rapporteur on Human Rights in the occupied Palestinian territory, who previously documented that Israel is in “profound breach” of its responsibilities with regards Palestinians’ right to health across the territory.

Medical Aid to Palestinians publicizes the health, development challenges and structural impediments to health for Palestinians arising out of decades of displacement and occupation, There are documented barriers to accessing healthcare and impunity for repeated attacks on what Palestinian healthcare there is available.  This is without a mental health crisis and a feeling of constant humiliation.

The consolidation and expansion of settlements, all illegal under international law, is envisaged through annexation. Settlements fuel widespread violations of Palestinians’ right to health and well-being and consequently annexation will exacerbate the damage and suffering they cause. The building and development of settlements can only occur through the confiscation of Palestinian land and resources, to the detriment of the Palestinian economy, environment, livelihoods and well-being.  Their development goes hand-in-hand with restrictions imposed by the occupying power on the development of Palestinian infrastructure, including medical centres. No permanent clinic or hospital is permitted anywhere in Area C of the West Bank.

Five negative trends can be anticipated with regards to the worsening impact of ongoing occupation and annexation on the health of Palestinians:

1.  Restriction of freedom of movement

While movement is promoted for settlers through preferential road and supporting infrastructure, it is obstructed for Palestinians, including for ambulances, mobile clinics, patients and health-workers. Journeys to homes, schools, workplaces and relatives are lengthened and prevented, affecting health, education, livelihoods and family life.

2.  Loss of property, land and other resources

Further extensive loss of privately-owned Palestinian land and natural resources to undermine Palestine’s agricultural, small industry, extractive and other commercial sectors. Less food to be produced, incomes to continue to fall, aid dependency to increase. Access to water, already controlled by Israel, to worsen for Palestinian communities.

3.  Settler attacks, detention of children and demolitions

Already perpetrating a surge of attacks with impunity, settlers will be emboldened to carry out yet more. The attacks cause loss of life, injuries, damage to crops, orchards, homes and vehicles, with self-evident impact on health and well-being. Abusive and illegal arrests and detentions of Palestinian children already occur primarily adjacent to settlements, causing harm to mental health, schooling and family income. Demolitions of Palestinian homes and structures to increase, fuelling an even more hostile environment and probable expulsion of Palestinians from their homes and lands.

4.  Exacerbated risks to vulnerable groups

Worsening socio-economic circumstances to hit disadvantaged groups hardest. Bedouin communities and others in Area C, people with disabilities (through access to education, employment, essential services etc), breastfeeding mothers and young children to suffer worsening rates of malnutrition. Mental health to deteriorate, risking higher rates of attempted and successful suicides, and more domestic abuse.  MAP and its partners will continue to work alongside these made-vulnerable Palestinian communities and groups, striving to alleviate the worsening impacts of occupation and annexation, while also calling for the political drivers of such suffering to be condemned and addressed.

5, Threats to dignity

Systematic inequality and loss of dignity alongside chronic impunity for historical and ongoing injustices to be ever more tangible, causing daily and accumulative indignity for Palestinians.  As stated by the UN experts above:

“The morning after annexation would be the crystallisation of an already unjust reality: two peoples living in the same space, ruled by the same state, but with profoundly unequal rights. This is a vision of a 21st century apartheid.”

MAP is deeply concerned by the scale of the potential further harm to Palestinians’ health and well-being, which relentless occupation and annexation will cause. The UK government and the entire international community must be resolute in opposing the annexation agenda of the Israeli government and in supporting Palestinians’ right to health and well-being, as well as to the most basic principles of international law.   (A statement from Medical Aid for Palestinians 6/27/2020, slightly edited for length).

My comment: This action by the Israel government goes against everything that Epicurus stood for.

 

Basics of Epicureanism

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From time to time I post a brief description of Epicureanism, not for the benefit of the cognoscenti, but for new readers for whom Epicurus is just the name of a philosopher:

Epicureanism is a system of philosophy based on the teachings of Epicurus, founded around 307 B.C. It teaches that the greatest good is to seek modest pleasures in order to attain a state of tranquillity, freedom from fear (“ataraxia”) and absence from bodily pain (“aponia”). This combination of states is held to constitute happiness in its highest form, and so Epicureanism can be considered a form of hedonism, although it differs in its conception of happiness as the absence of pain, and in its advocacy of a simple life.

Epicurus directed that this state of tranquillity could be obtained through knowledge of the workings of the world and the limiting of desires. Thus, pleasure was to be obtained by knowledge, friendship and living a virtuous and temperate life. He lauded the enjoyment of “simple pleasures”, by which he meant abstaining from bodily desires, such as sex and appetites, verging on asceticism. He counselled that “a cheerful poverty is an honourable state”.

He argued for moderation in all things, so that when eating, for example, one should not eat too richly, for it could lead to dissatisfaction later, such as indigestion or the grim realization that one could not afford such delicacies in the future. Likewise, sex could lead to increased lust and dissatisfaction with the sexual partner, and Epicurus himself remained celibate. Even learning, culture and civilization were discouraged, as they could result in disturbing one’s peace of mind, except insofar as knowledge could help rid oneself of religious fears and superstitions, such as the fear of the gods and of death.

Generally speaking, Epicureans shunned politics as having no part in the quest for ataraxia and aponia, and likewise a potential source of unsatisfiable desires and frustration, which was to be avoided.

Like Democritus and Leucippus before him, Epicurus was an Atomist, believing that all matter, souls and gods are all comprised of atoms, and even thoughts are merely atoms swerving randomly.

Epicurus was one of the first to develop a notion of justice as a kind of social contract, an agreement “neither to harm nor be harmed”. He argued that laws and punishments in society are important so that individuals can be free to pursue happiness, and a just law is one that contributes to promoting human happiness. In some respects, this was an early contribution to the much later development of Liberalism and of Utilitarianism.