Is Health Law the Problem Underlying the Physician Shortage?

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By Christopher Robertson

This week, the New York Times Sunday Review has an editorial arguing that the shortage of primary care physicians could be reduced if we drew more heavily upon other professions, including pharmacists and nurse practitioners, who may be able to provide care more efficiently.  The Affordable Care Act’s efforts to increase insurance coverage and eliminate cost-sharing for preventative care, will only exacerbate the shortage of primary care physicians.  More to the point, the editorial alleges that various state and federal laws create barriers to the sort of integration of healthcare professionals to address the shortage.

Those “scope of practice” laws were enacted to either protect consumers from incompetent healthcare or protect physicians from competition in the healthcare marketplace, or likely some mixture of both.  We know where mainstream physicians stand anyway.  In the words of the American Medical Association’s own newsletter,  “physicians [have] fought a blitz of scope-of-practice expansions by other health professionals on legislative, legal and regulatory fronts.”

The shortage of physicians is also a product of the number of young doctors that our medical schools are producing.  Although several new schools have launched in recent years, others are have actually shrunk due to budget cuts.

The Newtown Shootings, Gun Control, and Cultural Cognition

I. Glenn Cohen 1 Comment

Like most (all?) of the blog readers, I find it difficult to return to my every day life this morning in the wake of the Newtown shootings. This post is not about the tragedy, nor is it a political or public health analysis of where to go next. Instead I want to offer a meta-thought on the debate itself. In the past 3 days my social media has lit up with postings, comments, etc, about the shooting. About 2/3 of my facebook friends are left of center and 1/3 right of center, and I’ve seen the usual back and forth about criminalizing gun ownership, “guns don’t kill people, people kill people,” the history of the Second Amendment, more guns in the hands of administrators would have solved the problem, etc.

What has struck me the most, though, is the way in which my very well-educated friends on both sides of the aisle understand the facts about guns and violence. As Dan Kahan and his co-investigators in the Cultural Cognition Project suggest in their study of gun control debates, individuals perceptions about the facts in the debate are highly dependent on world view. To quote from their webpage describing their gun control studies:

From the outset, the Cultural Cognition Project has been focused on the American gun control debate. That debate is naturally framed as one between competing risk perceptions: that too little gun control will increase deliberate shootings and gun accidents; and that too much will render law-abiding citizens unable to defend themselves from violent predation. Associated most famously with the work of Mary Douglas and Aaron Wildavsky, the cultural theory of risk posits that individuals selectively attend to risk in a way that reflects and reinforces their preferred vision of society. Consistent with this thesis, CCP members have found that which “gun risk” individuals take more seriously is indeed strongly predicted by their cultural worldviews. Persons who hold egalitarian and communitarian worldviews worry more about crime and gun accidents, an  anxiety that coheres with their negative association of guns with patriarchy, racism, and selfish indifference to the well-being of others. Persons of a hierarchical and individualistic worldviews, in contrast, tend to see guns as safe, and worry much more about the danger of being rendered defenseless against attack; this perception of risk coheres with their positive associations of  guns with traditional social roles (father, protector, provider) and individualistic virtues (self-reliance, courage, physical prowess).

I would commend all blog readers to this excellent work. Where it leads me, though, is to question whether it is possible to overcome cultural cognition effects in this area? Does doing so require the kind of cultural education (and in which direction?) that we view in other countries as propaganda? If we cannot overcome our cultural cognition differences, will we as a country remain hopelessly deadlocked?

Special issue in the Journal of Philosophy & Technology on evolution, genetic engineering, and human enhancement

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By Yu-Chi Lyra Kuo

A special issue published this month by the Journal of Philosophy & Technology features a collection of articles discussing evolution, genetic engineering, and human enhancement. Recent years have seen a rapidly expanding variety of approaches to exploring the normativity of human enhancement, by philosophers, bioethicists, physicians, and biologists. The articles in this special issue largely focus on the question: how can evolution and aetiological teleology inform biological ethics and theories of human enhancement?

For a separate collection of articles discussing the ethics of human enhancement from the perspective of the physician-patient relationship, see this special issue by the American Journal of Bioethics, published approximately a year ago.

Happy reading, and happy holidays! ~YK

Gun Violence: A Public Health Concern?

Michele Goodwin 3 Comments

By Michele Goodwin

Posted from Amsterdam

I was in India when the tragic news hit; 26 people dead–20 of them children in a massacre at Sandy Hook Elementary School in Newtown, Connecticut on December 14, 2012.   In India, NGOs struggle with ending violence against women and children. Acid tossed in the faces of women by scorned boyfriends is not uncommon nor the increasing, random acts of slitting women’s throats on trains.  Sensational it may seem to us; but very real for women in Mumbai and Bihar.  In fact, the day before learning of the tragedy in Connecticut, Delhi officials announced the hiring of thousands of guards to deploy at 548 elementary schools in South Delhi amid reports of rapes and molestations of little girls who are followed, harassed, and in too many cases harmed on their way home after leaving school.  The government’s response comes on the heels of parents threatening to remove their daughters from school.

In that country and others, broad scale violence is understood as more than a national problem; it is a social and public health problem. In cases of sexual violence and the externalities that result, including sexually transmitted diseases and pregnancies, the public health component may be more visible to those of us in the West.  However, the public health indicators extend physical health problems; violence causes emotional and psychological trauma.  The mental health component of public health must be better understood.  Americans who live in gang infested communities, where violence seems almost endless and difficult to escape, understand this all too well as their kids experience anxieties closer to post traumatic stress disorder as part of their daily lives.

The Newtown shootings offer a moment for reflection on the lives lost and also our nation’s first principles and commitments.  Perhaps this will be a time to consider gun control beyond a very divided constitutional law debate to also understand its public health dimensions.  Who benefits from current policies?  Who are those harmed?  Physical wounds do heal, but the mental health traumas, grief, and anxieties often take a lifetime to manage and overcome.

Twitter Round-Up (12/9-12/15)

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By Casey Thomson
This week’s round-up looks at the problems of substandard drug prevalence abroad, NIH’s possible push for an anonymous grant-awarding process, and the Liverpool Care Pathway investigation. Check it out below!
  • Dan Vorhaus (@genomicslawyer) included a link to a report on the recent launch of Personal Genome Launch Canada. The post includes links to help navigate the content and learn more about the intricacies of this project. (12/9)
  • Frank Pasquale (@FrankPasquale) shared a post on the benefits and detriments of raising the age of Medicare eligibility from age 65 to 67 – an idea that has recently gained sway in the political arena. The author ultimately concludes that the move would only be a matter of cost shifting rather than cost saving, and thus harm the disenfranchised 65-66 year-olds that would front the cost. (12/10)
  • Frank Pasquale (@FrankPasquale) also included this article on Dr. Oz’s wrongful diagnosis on organics. While concerns about finances must indeed be taken into consideration when families decide what foods to purchase, families must also be concerned about the presence of pesticides in their food. Organic food, while more expensive, avoids this health hazard. (12/10)
  • Frank Pasquale (@FrankPasquale) additionally linked to this report on the preponderance of substandard (and oftentimes, consequentially lethal) drugs particularly in emerging markets. Efforts to crackdown on substandard drugs have thus far focused largely on counterfeit drugs, rather than those that are the result of “shoddy manufacturing and handling…or deliberate corner cutting,” which constitute an arguably much greater public health threat. (12/10)
  • Daniel Goldberg (@prof_goldberg) shared this post on the prevalence of worthless clinical practice guidelines. The article notes the need to distinguish the guidelines that meet much of the Institute of Medicine (IOM) quality criteria from the rest. (12/10)
  • Alex Smith (@AlexSmithMD) linked to a blog post on advance care planning and the gap between the needs of the healthcare system and those of patients. Currently, much of the paperwork required for advance directives is given without providing families and patients concrete skills needed for both identifying their desires and communicating such desires to direct their own medical care. This article calls for refocusing on providing direct patient empowerment in addition to the existing efforts to improve clinician communication in order to facilitate the ability of advance care planning to reflect the patient’s wishes. (12/11)
  • Michelle Meyer (@MichelleNMeyer) retweeted an article about the NIH’s consideration of introducing anonymity into the grant-awarding process in order to alleviate some of the concerns with bias that have long-plagued the agency. (12/12)
  • Dan Vorhaus (@genomicslawyer) also posted a report on BGI, a world-leading DNA sequencing organization based in China, and their commercial expansion efforts into the healthcare, agriculture, and aquaculture sectors. The question of whether BGI is more a research institute or commercial enterprise comes into question in the article. (12/12)
  • Stephen Latham (@StephenLatham) included a link to his own blog post on the recently renewed controversy concerning the Liverpool Care Pathway for the Dying Patient (LCP), particularly as to whether patients put on the LCP had a discussion with their care providers prior to the decision and whether hospitals were wrongly putting patients on the pathway. The talk of scandal sparked an independent investigation into the LCP; Latham’s article expressed his hope for thoroughness in the investigation and for serious consideration on how to renew the LCP effectively. (12/12)
  • Arthur Caplan (@ArthurCaplan) posted a link concerning the implications of 23andMe, a personalized genomics company, and their launch of the $99 genetic test in the hopes of inspiring greater numbers to get tested. The article’s author reflects on how the real benefit will likely not be immediate for individuals, but will rather depend on the chance that greater data will lead to more breakthroughs in understanding the human genome. (12/14)

Note: As mentioned in previous posts, retweeting should not be considered as an endorsement of or agreement with the content of the original tweet.

Dreams Deferred

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By Wendy Parmet

After the November election, President Obama’s executive order implementing parts of the so-called “Dream Act” was widely credited with shoring up his support within the Latino community.  Less often noted was his Administration’s decision to exclude the “Dreamers” from the benefits afforded by the Affordable Care Act.

Last August, the Center for Medicare Services (CMS) issued an interim final regulation stating that individuals who benefitted from the President’s program, more formally known as “Deferred Action for Childhood Arrivals” or DACA, would not be considered “lawfully present” for purposes of eligibility to health benefits established by the Affordable Care Act, including the Pre-Existing Condition Insurance Plan and the subsidies and credits that will be available in 2014 to purchase insurance through the health insurance exchanges. Pre-Existing Condition Insurance Plan Program, 77 Fed. Reg. 52614-01 (Aug. 30, 2012) (to be codified 45 C.F.R. § 152.2), https://www.gpo.gov/fdsys/pkg/FR-2012-08-30/html/2012-21519.htm.

The impact of this little noticed determination is quite significant. Although most of the estimated 1.7 million DACA immigrants are healthy, because of their age (under 30), many lack access to employer-provided health insurance. Moreover, if as expected, employers begin to shift their health insurance programs to the ACA-created exchanges, DACA immigrants may find themselves barred from employer-provided plans, even though under the President’s executive order they have a legal right to work in the United States.

The insurance gap created by CMS’ determination that the DACA immigrants are not “lawfully present” in the U.S., a decision that is inconsistent with the Administration’s conclusion that other deferred action recipients are eligible for benefits established under the ACA, illuminates the critical relationship between immigration policy and health policy.  To a surprising degree, the health insurance access problem in the U.S. results from laws that bar immigrants (including many with Green Cards) from many government-supported health insurance programs, including Medicaid. In 2010, over 45 % of non-citizens were uninsured, as compared to less than 14 % of native-born Americans. Approximately 65 % of undocumented immigrants are believed to lack health insurance. The ACA is unlikely to reduce those rates, especially regarding undocumented immigrants. Neither, it is now seems, is DACA.

Bad to the Bone

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By Christopher Robertson

I just came across this excellent story by Mina Kimes, which gives a detailed chronicle of how the lines between physician discretion, off-label promotion, and human subjects research can be blurred by an aggressive manufacturer, in a context where life or death is on the line (bone cement used in spine surgery).  The article also suggests themes about medical malpractice, products liability, and physicians’ conflicts of interest too.

The Risk of Revictimization and the Ethics of Covering School Shootings: What Journalists Can Learn from IRBs

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By Michelle Meyer

Updated below

Like most parents, after learning about the latest mass school shooting this morning, my thoughts immediately went to my own kindergartener. And of course, like most reading this blog, I thought about how poorly we handle guns and mental illness. Before too long, though, I couldn’t help but make a less direct connection between today’s events and my scholarly interests. I’m thinking of the way journalists cover school shootings as compared to how we regulate human subjects research.

As I write in The Heterogeneity Problem, 65 Admin. L. Rev. __ at 14-16 (forth. June 2013):

Studies on sexual abuse and assault, grief, war, terrorism, natural disasters and various other traumatic experiences are critical to better understanding and addressing these phenomena. But exposure to trauma — whether as a survivor or as a first rescuer or other third party — often causes substantial psychological morbidity. . . . Given their potentially fragile state, IRBs understandably worry that “questioning [or otherwise studying] individuals who have experienced distressing events or who have been victimized in any number of ways . . . . might rekindle disturbing memories, producing a form of re-victimization.”

IRBs — local licensing committees who operate according to federal statute and regulation and must approve most studies involving humans before researchers can even approach anyone about possibly participating — sometimes impose burdensome requirements on the way trauma research is conducted in order to protect adult subjects from the risk of revictimization. And they do so in addition to applying regulations that require that researchers disclose that risk (and others) to subjects.

Contrast this with the way journalists cover trauma. Read More

Man Dies after Cowardly Battle with Cancer

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(By Alex Smith, MD, cross posted from GeriPal)

Full credit to the Onion for the title idea for this post, and thanks to James Mittelberger, MD for the tip.

We’ve ranted before on GeriPal about the terminology used by medical professionals and the media to describe patients’ struggle with serious illness: Senator Kennedy loses the battle with cancer,  war on cancer, fighting the disease, etc.

The reason the Onion story is so funny is that it reduces the war metaphor to the absurd.  If the normative approach is to fight the disease, then what does that say about those who accept the seriousness of their condition?  It’s ridiculous to call someone who has come to terms with a poor prognosis, and chooses to focus on comfort rather than cure, a coward.  But that’s what our societies normative standards for approaching serious illness would imply.

I’ll conclude by quoting from Patrice Villars, NP original post on this topic:

How many times have we all heard that someone is “a fighter”, “a survivor”? The rest of us must be wusses. How often do we hear of use terminology that is (inadvertently) offensive to an individual or others? If we see advance illness as a ‘battle’, then there IS necessarily a loser. The implication is that we have full control over our disease process and even our survival if we just have the right attitude. This is a dangerous concept and one we shouldn’t perpetuate. There is so much out in the world telling us what we are supposed to do so we don’t get sick, let alone die. And when we do get sick, we are subtlely shunned as having self-created our own suffering. (“Well, she had a type A personality, you know.” “She never ate properly. I told her to eat only organic macrobiotic foods.” Or, one of my personal favorites, “I guess he just gave up.”)

‘Nuf said.

Ohio Joins In

Temple University Center for Public Health Law Research 2 Comments

By Hosea H. Harvey, JD, PhD

Last week, Ohio joined the vast majority of states that have enacted laws designed to reduce long-term health consequences for youth athletes who suffer concussions (technically, traumatic brain injuries or TBIs) in organized youth sports activities.  Based on my research for an upcoming article “Reducing Traumatic Brain Injuries in Youth Sports” (forthcoming, American Journal of Public Health), it appears that Ohio has followed the lead of most other states by adhering to a common framework and (at the same time) has substantially innovated with respect to certain key provisions of such laws.

Most youth sports TBI laws are organized around three broad risk-reduction methods: 1) educating parents, youth athletes, and/or coaches, 2) requiring the removal of youth athletes suspected of having concussions, and 3) providing criteria that a youth athlete must meet prior to returning to athletic competition. Each of these methods are, in part, derived from legislation crafted after a tragic football injury to Zachary Lystedt in Washington, leading the state to pass the nation’s first such law in April 2009. (You can read the law on LawAtlas™)  Since then, adherence to the “Lystedt framework” has been a common feature of state-level youth sports TBI laws. In this fast-paced legislative environment, unprecedented in scope, Ohio is relatively late to the game. Yet, by moving later, Ohio’s deliberate speed has resulted in legislation that relies on the Lystedt framework but also contains innovations of uncertain efficacy.

Read More