Leftover victims of the SARS-CoV-2 pandemic

On May 8, 2020, the U.S. Department of Labor issued its monthly employment report, which showed that the national unemployment rate jumped to 14.7% in April, its highest level since the Great Depression of the 1930s; it said that 20.5 million people had suddenly lost their jobs due to the country’s lockdown, erasing a sustained rise of employment of the past ten years. A more detailed analysis of those that are abruptly working part-time instead of full-time and those that are not counted showed that the unemployment rate might even be higher. Moreover, the tightening of the federal, state and county budgets will inevitably furlough many more people.

In the previous recession of 2007-2009, the majority of lost jobs belonged to men, as the construction and manufacturing sectors ground to a halt; but this time the real losers are often women as thousands upon thousands of their positions as clerks, secretaries, hairdressers, health care aides, travel consultants, stewardesses, airplane and ship chandlers, restaurant servers and cashiers, dry cleaning employees, etc., evaporate. Once the lockdown is finally levied, albeit in various progressive stages according to the local public health characteristics, many of the once thriving small businesses that used to predominantly employ women will be gone. And there will be hardly any credit for entrepreneurial initiatives as the banks will be reluctant to lend.

Not only did women hold most of the positions offered in the Education and Health Care realms—the hardest hit sectors—but they were also furloughed in greater numbers than men. In a Washington Post article, Heather Long and Andrew Van Dam said: “Before the pandemic, women held 77%of the jobs in education and health services, but they account for 83% of the jobs lost in those sectors…Women made up less than half of the retail trade workforce, but they experienced 61% of the retail job losses. Many of these women held some of the lowest-paid jobs.” A large proportion of those workers are single women with children and members of the Latino and Black minority groups.

These disadvantaged single women usually lack a strong social or family support, for which they disproportionately rely on their children’s school services for their care, instruction, and meals. If they cannot take their kids to school, they will not be able to resume their previous positions, even if they are asked back to work.

In order to re-start our economies we must first help the women that sustain it.

Stay distant. Stay safe. Stay beautiful.

What do you think? Please tell us.

Don’t leave me alone.

 

Physician and Nurse burnout – Part V Suicide

The  stressed-out E.R. personnel of the New York-Presbyterian Allen Hospital

Got used to the company of the little sparrow flying over their place of penance

She was always the first one present when the doors of the ambulance opened

She was always the first one present when they took a patient to an exam table    

She was always the first one present when they hooked the whirring machines

She was always the first one present when the drilled routine of care kicked in

 But one day her heart could not resist so much suffering and stopped beating

 Plunging into the depths of their sorrowful spirits, she gave them a final cheer.

On April 27, 2020, Dr. Lorna Breen, chair of Emergency Medicine at the Columbia-affiliated hospital, committed suicide in her parent’s home in Virginia. She had been diagnosed with a Coronavirus infection, but she fully recovered; she was given a leave of absence from work and she decided to spend it with her folks. In a communication with The New York Times her father said: “She tried to do her job, and it killed her…Make sure she’s praised as a hero, because she was. She’s a casualty just as much as anyone else who also died.” [i] Her father said that she had told him that many patients were already dead when they opened the doors of the ambulances. She never had a history of Mental Health issues, but she seemed detached to him.

 Once a suicidal patient decides to act, a Buddhist peace of mind sets in.             

Physicians have been trained to face most of the stressful situation of our careers with a stiff upper lip and the steely determination to carry on, nonetheless. If you are taught in Medical School and  professional training about the values of fortitude and resiliency, you will be the last one to ask for any help. As a result medical personnel are hard hit by an unusual incidence of suicidal acts and attempts, which will surely worsen after the Coronavirus pandemic finally ends.

Unfortunately, there are personal and institutional barriers  blocking the remedies.

In a 2008 Health Affairs article [ii], Donald M. Berwick, Thomas W. Nolan and John Whittington coined the term “triple aim” to define the simultaneous pursuit of three objectives—improving the experience of care, improving the health of populations and  reducing per capita costs of health care—to fix the care system. In 2014, considering the increasing burn-out and dissatisfaction of physicians and nurses with medical practice, Drs. Bodenheimer and Sinsky argued that: “the Triple aim be expanded to a Quadruple Aim, adding that the goal of improving the work life of health care providers, including clinicians and staff.” [iii]

Professional burn-out is characterized by a most evident and ignored tragic triad:

  1. High emotional exhaustion
  2. High depersonalization
  3. Low sense of personal accomplishment

A – High emotional exhaustion

The increasing demands of payors, administrators and patients on the time and resources of the health care personnel produces a generalized dissatisfaction with the perceived quality of their delivered care services. The level of resilient frustration is so pervasively high in our system that physicians, nurses, technicians, receptionists, and other ancillary personnel are literally “counting the days” until finally the day of salvation arrives—their retirement date.

B – High depersonalization

The negative feelings and bad vibe will inevitably foster the emergence of cynicism and sarcasm in the ranks of providers, with the resultant degradation of their rapport with the patients and families. It is a self-sustaining vicious circle. Patients complain that they are being ignored and/or mistreated, which triggers more negativity and disdain for the staff. As a result, the latter keep their bad attitudes without the possibility of pausing for a moment and reflect calmly on the impasse.

C – Low sense of personal accomplishment

For the majority of us who have chosen the medical career, profit and social standing are secondary considerations. What we most value is the possibility of helping our fellow human beings and at  the same time enjoy the unique standing conferred by possessing a voice of authority. With the landing of the abominable “bean counters”  in both the public and the private payor system, our maneuvering room is being steadily curtailed. Our decreasing satisfaction not only fosters our  early retirement but also all kinds of drug and alcohol abuse in our ranks plus the potential of one day, out of the blue, start mulling about the unthinkable.

Shanabelt et al. studied the incidence of burnout with work-life balance in the US physician and general workforces in 2011 and 2014 to compare the results and significant trends, using the Maslach Burnout Inventory; they invited more than 35,000 physicians to participate and 19% completed the survey. [iv] They said that:  “54.4 % (n=3680) of the physicians reported at least 1 symptom of burnout in 2014 compared with 45.50 % (n=3310) in 2011.Substantial differences in rates of burnout and satisfaction with work-life balance were observed by specialty.” They found minimal differences in the general workforce between those years.

Early on during our training, a taciturn hitchhiker steps into our cockpit.      

Douglas A. Mata et al. conducted a meta-analysis of 31 cross-sectional  and 23 longitudinal studies of the incidence and prevalence of depression in resident physicians.They found : “the overall pooled prevalence was 28.8 % of participants, ranging from 20.9% to 43.2% depending on the instrument used, and increased with calendar year.” [v] One in four physicians-in training has depression.

To glean more information on this issue, Lisa S. Rotenstein et al. extracted data from 167 cross-sectional studies and 16 longitudinal studies from 43 countries. They found: “the overall pooled crude prevalence of depression or depressive symptoms was 27.2%…Depressive symptom prevalence remained relatively constant over the period studied…In the 9 longitudinal studies that assessed depressive symptoms before and during medical school (n=2432), the median absolute increase in symptoms was 13.5 %.” [vi] They also found that only 15.7% sought medical treatment for their symptoms. There is a tall price to pay.

Amy M. Fahrenkopf et al. studied the incidence of medical errors among resident physicians of three urban children’s hospitals by evaluating the depression with the Harvard National Depression Screening day scale, the burnout using the Maslach Burnout Inventory, and the rate of medication errors per resident per month. They found: “24 (20%) of the participant residents met the criteria for depression and 92 (74%) met the criteria for burnout. Active surveillance yielded 45 errors made by participants. Depressed residents made 6.2 times as many medication errors per resident month as residents who were not depressed. Burn-out residents and not-burnt out residents made similar rates of error per resident month.” [i]

There are several factors that block physicians, and other medical personnel, to seek the needed counselling. The crazy work schedule of physicians and residents, the confidentiality issues that might affect the licensing status of practitioners, the personal issue of loneliness and divorce, all contribute to it.  

We have dawdled about writing a book on Physician/Nurse burn-out                 

Lorna’s valiant sacrifice shook our torpor and took us immediately to task

(This article is based on our upcoming new book Emotional Frustration- the hushed plague)

Stay distant. Stay safe. Stay beautiful.

What do you think? Please tell us.

Don’t leave me alone.

References

[i] Amy M. Fahrenkopf, Theodore C. Sectish, Laura K. Barger, Rates of medication errors among depressed and burn out residents: prospective cohort study. British Medical Journal. 2008 March 1: 336 (7642) ; 488-491. Doi: 10.1136/bmj. 39469.763218 BE. https://ncbi.nlm.nih.gov/pmc/articles/PMC2258399

[i]  Top E.R. Doctor Who Treated Virus Patients Dies by Suicide, The New York Times, April 27, 2020. https://nytimes.com/2020/04/27/nyregion/new-york-doctor-suicide-coronavirus/

[ii] Donald M. Berwick, Thomas W. Nolan and John Whittington, The Triple Aim: Care, Health and Cost, Health Affairs, May/June 2008. https://doi.org/10.1377/hltaff.27.3.759

[iii] Bodenheimer T., Sinsky C., From triple to quadruple aim: care of the patient requires care of the provider, Annals of Family Medicine, 2014, November-December; 12(6)573-6. Doi:10.1370/afm.1713. https://ncbi.nlm.nih.gov/pubmed/25384822

[iv] West CP, Dyrbye LN, Shanafelt TD, Physician burnout: contributors, consequences and solutions, Journal of Internal Medicine 2018 June 283 (6) 516-529 doi 10.1111/joim. 12752. Epub 2018 March 24. https://ncbi.nlm.nih.gov/pubmed/29505159/

[v] Douglas A. Mata, Amarco A. Ramos, Narinder Bansal, Prevalence of depression and Depressive Symptoms among resident physicians. A Systematic review and Meta-analysis, Journal of the American Medical Association, 2015, December 8: 314(22) 2373-2383. Doi: 10.1001/jama 2015.15845. https://ncbi.nlm.nih.gov/pmc/sticles/PMC4866499

[vi] Lisa S. Rotenstein, Marco A. Ramos, Matthew Torre, Prevalence of Depression, Depressive Symptoms, and Suicidal Ideation among Medical Students, Journal of the American Medical Association. 2016 Dec.6:316 (21); 2214-2236. Doi: 10.1001/jama 2016.17324. https://ncbi.nlm.nih.gov/pubmed/27923088

Do not listen to (some of) the French

As millions of other citizens and residents of the United States of America that have complied with the largely state-mandated “staying-at-home” guidelines, we have been glued to the television screens when the official daily news conference from the White House appears between 5 and 6 PM Eastern Standard Time. It usually involves the top administration officials and renowned public health and emergency officials that are dealing with the Coronavirus pandemic and the remedial measures.

One of the most mentioned and debated  issues is whether to use chloroquine, an anti-malarial drug, to treat the acute symptoms of the grave infection, which is based on some incidental reports from French physicians that treated patients with Coronavirus. Event though they do clarify that much more comprehensive clinical research studies, which are underway, are needed to give a seal of approval to this drug, the legend of its usefulness persists; it has been used “off-label” by some physicians with mixed results. However, it has produced serious cardiac arrhythmias in others.

In a recent correspondence to The Lancet, Dr. Joan Paul Moattti, a professor of the University of Aix-Marseille, questioned the responses of the French administration. He said : “Faced with criticisms, French authorities claim that their policy towards the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has been evidence-based—they appointed an advisory board of 11 scientists to help manage the crisis. However, in situations where decision makers face radical uncertainty, sticking to conventional approaches might jeopardize the science-policy interface.”

First of all, he criticized the lack of massive testing of the first responders and possible cases in the beginning of the pandemic in March, unlike the authorities of South Korea that tackled the pandemic following the guidelines of the WHO:

  1. Massive tracing
  2. Contact tracing
  3. Social distancing

France did not implement a national lockdown until March 17, many days after the pandemic had been identified. Moreover, he claimed that the country was not prepared to carry out the critically needed massive testing as it only had 45 public health laboratories that could process the samples for a definitive diagnosis of cases. Rather than designing a rational plan to scale up the testing, the authorities argued that massive testing was not needed once the infection became generalized; they only changed course on March 28, after  a national uproar about their carelessness.

The widespread diffusion of the very preliminary—and inconclusive—results of treatment with Chloroquine fueled big speculation in the world media and an acrid controversy in the biomedical community; he claimed that there are alternative methods to evaluate the safety of some drugs without the need to wait months for the definitive opinion of the clinical researchers that conduct rials of the same. This dereliction of duty in a context of urgency: “has reduced the ability of authorities to mitigate the effects of irrational online rumors and regulate prescription practices of health professionals.”

The author has high hopes in a much smarter commission of 12 experts designated by the French authorities on March 28—they seemed to have done a radical public about-face that very day. It is chaired by Dr. Françoise Barré-Sinoussi, a renowned virologist and Nobel Laureate of Medicine in 2008.who, as a highly educated woman, might be endowed with a bigger dose of common sense in the public forum. He said: “the second commission seems an implicit recognition of the intrinsic difficulties of directly using science in political management of a health crisis.”

Stay distant. Stay safe. Stay beautiful.

What do you think? Please tell us.

Don’t leave me alone.

 

Is the SARS-CoV-2 virus a man-made biological weapon?

One of the most resilient conspiracy theories that has emerged during our forced isolation in the midst of the SARS-CoV-2 pandemic is that it is a man-made virus. Some officials of the Trump administration are squarely laying the blame of this pandemic on a bio-engineering product let loose from the Wuhan Institute of Virology, a few kilometers away from that infamous “wet market” in the city center. They claim that lax security measures at the institute provoked the fatal accident.

The SARS-CoV-2 virus is the seventh coronavirus that infected humans recently; SARS-C0V, MERS-CoV and SARS-CoV-2 can produce grave clinical symptoms while HKU1, NL63, OC43 and 229E produce much milder ones. The viral load of bats has been studied for many years, but it is woefully under-sampled at present. Kristian G. Andersen, Andrew Rambaut, W.Ian Lipkin and Edward C.Holmes studied the genomic material of the virus to determine if it was actually man-made.

Based on structural studies and biochemical experiments, the researchers found that:

  1. The virus seems to be optimized for binding to the human receptor ACE2
  2. The spike protein of the virus has a functional (furin) cleavage site at the S1-S2 boundary, which predicted an acquisition of three O-linked glycans.

Viruses bind to a host cell in order to invade them for replication of their genetic material through their receptor-binding domain (RBD) The researchers found that SARS-CoV-2 has an RBD that binds with optimal affinity to ACE2 from human beings, ferrets and cats. However, analysis made with computer programs showed that the RBD sequence is not the ideal one for optimal receptor binding. Therefore they concluded that it was the result of a natural selection process of trial and error and not the calculated result of some perfidious manipulation by wacky warmongers.

The second characteristic of this virus is that it has a polybasic cleavage site (RRAR) at the junction of two subunits of the spike, S1 and S2; this enables the cleavage of proteases like furin, which has a critical role in the high infectivity and host range. These cleavage sites have not been observed in other coronaviruses, but they appear in other kind of betacoroanviruses infecting humans, which indicates they will be found in other species. Some experiments showed that the insertion of a furin at the cleavage site enhance the anchoring to the host cell without affecting viral entry. The function of the predicted 0-linked glycans has not been determined but it could represent a “mucin-like domain” to mask the virus spikes, thus fooling our defenses. This highly favorable medium had not been previously discovered by scientists.

Moreover, these scientists affirmed that if there had been a willful genetic manipulation, one of the previously existing reverse-genetic systems would have been used as a viral scaffolding to construct a biological weapon worthy of the Devil. The authors propose two alternative scenarios of the origin of the SARS-CoV-2:

  1. Natural selection in an animal host before the zoonotic jump into humans.
  2. Natural selection in a human being after the zoonotic jump had happened.

Considering that the SARS-CoV-2 is very similar to other bat SARS-COV-like coronaviruses, it is possible that an animal source was present in that Wuhan market; the illegally imported Malayan pangolins harbor coronaviruses similar to SARS-CoV-2. But neither the bat nor pangolin coronaviruses have the polybasic cleavage sites, which questions their possible progenitor role for this virus. They said: “For a precursor virus to acquire both the polybasic cleavage site and mutations in the spike protein suitable for binding to human ACE2, an animal host would probably have to have a high population density (to allow a natural selection to proceed efficiently) and an ACE2-encoding gene that is similar of the human ortholog.”

The genetic study of all the different variants of the SARS-CoV-2 indicate that there was a common ancestor that made the jump from an animal to a human being—the definition of a zoonosis or a human disease of animal origin. The RBD found in the virus infecting the pangolins is similar to the human variant; the insertion of the polybasic cleavage might have happened during the human-to-human transmission. Computer analyses point to an emergence of the virus in late November 2019, which implies that there was a silent transmission in humans between the zoonotic jump and the insertion of the second feature, the polybasic cleavage site.

Based on these findings, the researchers concluded that there is no scientific basis to determine that this lethal agent was the product of bioengineering in a military lab.

Imbued with Humanistic values, we cannot fathom that it could be a human product.

Sadly, the amazing capacity of human beings to harm other species, including their own kind, has been an historically tragic box of nasty surprises.

 

Dr._Strangelove

The troubling image of Dr. Strangelove (played by the great Peter Sellers) jumps into our mind…

Stay distant. Stay safe. Stay beautiful.

What do you think? Please tell us.

Don’t leave me alone.

Physician and Nurse burn-out – Part IV Vagina penalty

“Le plus scandaleux du scandale c’est de s’y habituer” Simone de Beauvoir

One of the more irritating and at the same time pressing issues that we have to quickly correct in most of our health care delivery systems – not only to stop the “hemorrhage” of so many disillusioned professionals into early retirement that we just cannot afford to continue unabated, but also to promote the recruitment of younger cadres as well – is the thorny issue of Gender Inequality in pay scales and benefits. And let us make a point very clear from the start. It not only affects our women colleagues but, us men, too. We cannot expect to have a congenial workplace if whomever is daily working shoulder to shoulder with us is being paid less than we are for an otherwise totally similar task.

On what grounds does this scandalous state of affairs stand?

A teeny-weeny detail: she is a woman. She is being fined with the vagina penalty.

In our new book Emotional Frustration – the hushed plague we have extensively discussed the various forms of financial and economic discrimination that our dear women are being subjected to, even in our supposedly much more egalitarian times. We will discuss this issue many more times in this series but today we are showing you what we wrote about the inequality in the British National Health Service (NHS)

“In May 2018 the United Kingdom’s Department of Health and Social Care did a study on gender equality in the NHS [i], led by Professor Dame Jane Acre; it used data from 10 years of electronic records of 16,000 general practitioners and 96,000 trust physicians. They found that the gender gap was 17% based on total pay, which contributes to the overall 23% NHS pay gap. “Male doctors are earning 1.17 pounds for every pound earned by female doctors in the NHS, and new data reveals that women are still not represented in equal proportions in senior medical grades, with nearly 32,000 male consultants to just 18,000 females. The General Practice gender gap is 33%, which is far higher than the average in medicine.” [ii]

Even though half of the physicians in training were female, only a third of the most coveted positions were held by women—18,000 women in a total of 32,000 consultants. They were disproportionately present in lower-paying specialties like Dermatology, compared to the higher number of men in higher-paying ones like Surgery. The same study showed that the demands of motherhood and the burden of irregular working hours seriously harmed their career advancement. [iii]

If this abject pay scale disparity for men and women can occur in a supposedly modern society that had recognized the societal value of equitable access for Health Care, what can we expect of other less enlightened ones?  We, the XY-healers, know that our female peers often work much harder than we do. Noblesse oblige.”

What do you think? Please tell us.

Don’t leave me alone.

[i] https://www.gov.uk/govenment/organisations/department-of-health-and-social-care

[ii] Laura Butler, “Male doctors earn 1,17 pounds for every pound earned by female doctors”, Press release, March 29, 2019. https://www.surrey.ac.uk/news/male-doctors-earn-ps117-every-ps1-earned-female-doctors

[iii] Denis Campbell, “Male NHS doctors earn 17% more than their female peers”, The Guardian, March 28, 2019.

https://www.theguardian.com/society/2019/mar/29/male-nhs-doctoors-earn-17-more-than-their-female-peers

Physician and Nurse burn-out – part III  Obnoxious pinging

Historians claim that we wouldn’t be able to stand the atrocious stench that arose from the open gutters of the Middle Ages cities, except for a few that had sewers. Likewise the inhabitants of those same cities would quickly become demented if they were subjected to the humongous noise pollution that we get in public spaces. Steadily yet alarmingly we have become accustomed to multiple noises that creep from all the portable and fixed electronic devices that crowd all the available space.

In our new book Emotional Frustration-the hushed plague, we discussed the trolling toll of Technology (that’s the title of the chapter) in our daily lives, especially after the invasion of the small screens in 2007—those ubiquitous mind-snatchers. Almost all our human relationships have been drastically changed by the gawking at those devices that continually transmit all kinds of information—as well as dis-information—to our minds; at the same time they function as surreptitious emitting antennas that transmit our preferences, contacts, choices, inquiries, to total strangers.

One of the most frustrating experiences that many medical professionals encounter at present is the inability to concentrate properly to fill the humongous amount of paperwork that public and private payors demand to reimburse their care services. For years physicians and nurses have had to write comprehensive medical notes where the main complaints—and all the accompanying modifiers of diagnoses—had to be carefully and honestly described for all kind of care reviewers, including the administrative personnel of the institution and the utilization  review specialists. We discussed in another blog about data how once the patient leaves our office, a torrent of medical information is instantaneously shared out with multiple digital endpoints.

In order to comply with all those strict requirements—especially with the time-sensitive parameters of Electronic Medical Records (EMR)—those professionals need to put some distance with all the noise pollution from colleagues’ and patients’ devices. Who can reasonably focus on an accurate clinical description of a serious illness or a major procedure when there is a multi-faceted explosion of pinging all around? The least we can expect is to have some quiet to reflect on our very difficult choices. The brutal demand of our time should not be synonymous with its constant sullying out.

Like the “loose lips” of World War II, those “loose noises” can still sink our ships.

What do you think? Please tell us.

Don’t leave me alone.

Physician and Nurse burn-out – part II Jockeying games

One of the more insulting and disgusting maneuvers that most physicians and nurses have to contend with in our tough professional careers is the sickening, absurd re-positioning of our roles in a care team by the hospital and clinic administrators. Feverishly eager to find a “better edge” to supposedly deliver a much more “efficient care”—a not so subtle euphemism to mask their perennial quest to save a buck—they usually sit down in their plush air-conditioned offices to concoct all kind of specious changes to our work schedules and organigrams–effectively treating  us as inter-changeable peons in the big chessboard of their institutional structure. And, being usually totally ignorant of how a particular health care delivery team really works, they almost never fail to pick a humble nurse who, being very professional and committed, seemingly does not make much ado at her critical role in the team. She just soldiers on. Their maladroit tampering will trigger a chain reaction with unforeseen consequences.

The jockeying games.

Abusing an equine metaphor, we could say that they treat us as just a bunch of race horses—highly trained but docile animals all the same—whose standing they must continually re-arrange in the start line to get the best performance in the race track; infused with a self-serving objectification of their subalterns,  they “candidly” believe they can make do without any consideration whatsoever for our thoughts, desires, personal issues—let alone our feelings and aspirations. After all, horses do not feel. Or do they?

We have been far too meek to confront them in order to at least voice our concerns. Unfortunately, this perverse maneuvering affects our nursing colleagues the most. Career nurses have taken a long, long time to acquire the skills and expertise to fill critical positions in a specialized care team, something that cannot be replicated “on demand” by the bureaucrats manipulating their schedules and labor requirements.

Moreover, the same difficult and exhausting learning process involves all the other members of a particular care team, which endows them with their precious value. If a careless bureaucrat decides one day, out of the blue, to take one of these highly skilled nurses from that habitat and force-land her in a completely different team altogether, often great misery ensues for all, including the sacrosanct “bottom line.” Even the humblest of nurses is usually much more important than all the physicians combined in order to secure the smooth functioning of a specialized care team. What would happen to the daily surgical schedule of a major hospital if the nurse that does the final check-up at 6 AM is being replaced by a novice graduate in the OR suites?

Worse of all, these committed and expert women have painstakingly accommodated their family obligations to the draconian demands of their career obligations, which is no easy feat. The daily schedules of these devoted wives, mothers and daughters have been methodically calibrated to the latest minute in order to achieve their utmost efficiency for good outcomes for their loved ones. How can they suddenly switch gears and find the alternate arrangements for their partners, children, elderly parents, pets, etc., in that gratuitously provoked (often manly) mess in their agendas?

The institutional mandarins should stop playing around with our personal lives.

What do you think? Please tell us.

Don’t leave me alone.

Physician and Nurse burn-out – part I

-“If they decide to study Medicine, I won’t pay for it…Should flip burgers for it.”

The unusually radical statement by the successful Miami gastroenterologist—referring to his aversion that his children may eventually follow his career’s path—came as not a real surprise for us. He expressed what most practicing physicians feel. The unrelenting micromanagement of our practices by the payors and the increasing demands of patients on time and attention has literally “burned out” the caregivers. Progressively physicians are becoming strongly disenchanted with their profession.

In a 2008 Health Affairs article, Donald M. Berwick, Thomas W. Nolan and John Whittington coined the term “triple aim” to define the necessary simultaneous pursuit of three objectives—improving the experience of care, improving the health of populations and  reducing per capita costs of health care—to fix the US system. In 2014, Drs. Bodenheimer and Sinsky argued that, considering the increasing burn-out and dissatisfaction of physicians, nurses and other staff with the medical practice, proposed that: “the Triple aim be expanded to a Quadruple Aim, adding that the goal of improving the work life of health care providers, including clinicians and staff.”

Professional burn-out is characterized by this most evident and ignored tragic triad:

  1. High emotional exhaustion
  2. High depersonalization
  3. Low sense of personal accomplishment

High emotional exhaustion – The increasing demands of payors, administrators and patients on the time and resources of the health care personnel produces a generalized dissatisfaction with the perceived quality of their delivered care services. The level of resilient frustration is so pervasively high in our system that physicians, nurses, technicians, receptionists and other ancillary personnel are literally “counting the days” until finally the day of salvation arrives—their retirement date.

High depersonalization – The negative feelings and bad vibe will inevitably foster the emergence of cynicism and sarcasm in the ranks of providers, with the resultant degradation of their rapport with the patients and their families. It’s a vicious circle. Patients complain that they are being ignored and/or mistreated, which triggers more negativity and disdain for the staff. As a result, the latter keeps worsening attitudes.

Low sense of personal accomplishment – For the majority of us who have chosen the medical career, profit and social standing are usually secondary considerations. What we most value is the possibility of helping our fellow human beings and at  the same time enjoy the unique standing conferred by possessing a voice of authority. With the onslaught of “bean counters” and their henchmen in both the public and the private payor system, our maneuvering room is being steadily curtailed in practice. The decreasing satisfaction not only engenders early retirement but also drug and alcohol abuse in the physician workforce plus the very real possibility of Suicide.

Shanabelt et al. studied the prevalence of burnout and satisfaction with work-life balance in the US physician and general workforces in 2011 and 2014 to compare the results and significant trends, using the Maslach Burnout Inventory; they invited more than 35,000 physicians to participate and 19% completed the survey. They said that; “ 54.4 % (n=3680) of the physicians reported at least 1 symptom of burnout in 2014 compared with 45.50 % (n=3310) in 2011.Substantial differences in rates of burnout and satisfaction with work-life balance were observed by specialty.” The researchers found minimal differences in the general workforce between those years. Nurses and residents (physicians in training) show similar or higher levels of emotional frustration with their professions and firm intentions to defect. Almost 2,500 physicians retire yearly in the USA and they are not being replaced fast enough, compromising the delivery of efficient Primary Care services for under-served rural or inner-city communities.

This modern-day drama that is being played out daily in all—we repeat IN ALL— the health care delivery facilities in the USA has major and minor consequences for the well-being of patients, which we will discuss in the second part of our series.

What do you think? Please tell us.

Don’t leave me alone.

 

 

 

 

Conflict of Interest in Medical Research

In September 2018, Dr. José Balsega, chief medical officer of Memorial Sloan-Kettering Cancer Institute, ignominiously resigned from his position after a scandal engulfed the institution. In a searing article of ProPublica, which conducted the investigative reporting together with the New York Times, he was accused of clandestinely receiving millions from pharmaceutical companies and never reporting it in many scientific articles that he produced as first or secondary author.

Co-authors Charles Ornstein and Katie Thomas said: “ he has held board memberships or advisory roles with Roche and Bristol-Myers Squibb, among other corporations; he had a stake in start-ups testing cancer therapies; and played a key role in the development of breakthrough drugs that have revolutionized treatments for breast cancer…Balsega did not follow financial disclosure rules set by the American Association for Cancer Research when he was president of the group. He also left out payments he received from companies connected to cancer research in his articles published in the group’s journal, Cancer Discovery.” There are no rules for those who make them.

Considering that modern medicine, with its over-reliance in the biological model, has the capacity to sanction or condemn any new drug or treatment based on the opinion and data of the peer-reviewed medical journals, this lack of clarity in the disclosure of financial interests is very serious. For two decades there have been many honest professional efforts to police the rank and file. In April 2009 the Institute of Medicine (IOM) released a report where it recommends to “standardize the content format and procedures for disclosing financial relationships” and at the same time that these policies should be publicly available, preferably in the institution’s official website. In the past ten years, institutions and professionals have been grappling with this still searing issue.

In an article in Neurology Today, Dr. Corey Ford, professor of neurology and dean of research at the New Mexico School of Medicine said that: “a researcher may be required to only enroll patients in a study, but not to analyze the data or have any influence in the output portion.” With these institutional firewalls, the risk of a biased opinion of the whole process is greatly diminished. Another troublesome aspect is the channeling of companies’ payments directly to the researchers’ pockets in the form of the consulting fees, stipends for board memberships, speaking fees, etc. Dr. Kenneth Tyler, from the University of Colorado, said that all the outside activities of physicians must be channeled through the physician practice plan of the institution for a better oversight.

At the University of New Mexico there is a special institutional review board for senior officials above a certain level where all the major donations and gifts of private companies are scrutinized; moreover, all the outside collaborators in any program must fill the disclosure forms as well. The relationship of academia and the industry can be mutually beneficial as the latter can provide skills, technologies, scale and capital for bonafide initiatives that will serve the public at large. But it must be outlined in advance of any implementation in a way that is convenient for public access, rather than the often-cryptic institutional electronic disclosure systems. It must be cloud-based. There is still a long way to go before there is a truly honest, accurate and straightforward exposé of all the significant medical data in our society.

What do you think? Please tell us.

Don’t leave me alone.

Age, sex and race discrimination in clinical trials–part I

Clinical research trials are the scientific bellwether to determine the safety and efficacity of the new pharmaceutical products that submit an application for approval to regulatory agencies. However, in the past decade many prominent researchers have questioned the bias against age, gender and race in the selection of individuals that wish to participate in these critical studies. Some good retrospective studies have studied those bias and their consequences in the studies. Most studies use a cohort of middle-aged white men that are progressively less representative of the general population in the USA, which has wide race, cultural and lifestyle differentials now.

Health Equity implies the attainment of fair, equitable access for health care services and the participation in clinical research trials that will determine the future of our modern pharmacopeia. It mandates the reconsideration as a whole of the protracted discrimination against minorities and special age groups in order to develop policy and practice protocols to assure equitable access.

In the USA the elderly population is growing rapidly due to the improved healthcare resources and the Wellness interventions in Baby boomers that consume less alcohol, tobacco, animal fat and other noxious substances that severely limited the lifespan of the previous generations. But the entrance to the third phase of our lives entails the arrival of diseases like high blood pressure, diabetes and arthrosis that do not similarly affect the younger and middle-aged members of society. When an elderly patient is admitted to a hospital , there are usually a few co-morbid conditions. Finally, the expense on elderly care represent the largest share of care budgets in modern societies.

Dr. Jaron Lockett et al. examined the Phase III clinical trials funded by the National Institutes of Health from 1965 to 2015 that studied the major causes of hospitalization or disability in older individuals, which are congestive heart failure, cardiac arrhythmias, coronary atherosclerosis, myocardial infarction, stroke, chronic obstructive pulmonary disease, pneumonia, lung cancer, prostate cancer and osteoarthritis. They found that 33% of these studies had arbitrary age limits that excluded older people and 67% of them had  participants witha median age that skewed younger than the usual age of onset for the clinical condition being studied . The presence of co-morbid conditions like polypharmacy/concomitant medication excluded 37% of the cases and cardiac diseases excluded 30% of the potential participants. This underrepresentation of older individual due to age limits and exclusion of patients with common co-morbid conditions in older age severely limit the usefulness of any novel medication that might target the older population.

Historically women have been largely excluded from the major clinical trials, which has hampered the real usefulness of many medications that do not take into account the biological and cultural differences of women and members of the LGBT communities. The biological differences of women provoke pharmacokinetic and pharmacodynamic variations due to their smaller body size, higher fat and less water content, hormonal variations and varying levels of certain body enzymes. The fluctuating levels of hormones during the menstrual cycle and in pregnancy coupled by the metabolic changes when they use contraceptives must be considered when the effects of study drugs are being assessed by researchers. The particular mental and physical construction of gender and sexuality will influence the feminine lifetime experiences and health outcomes.

Minorities like Blacks and Hispanics have largely been under-represented in clinical trials due to absurd discriminatory guidelines that favored a certain segment of the population. The often-cited excuse that the “minorities do not sign up in good numbers” has been disqualified by the surging participation of them when they are properly, respectfully asked to participate in the clinical trials. Mechanically extrapolating all the scientific results obtained with a largely white middle class population can have disastrous consequences for the future treatment of grave chronic diseases. Three recent studies have highlighted that limitation in critical studies on Alzheimer’s Disease.

Dr. Melissa Murray has been the lead investigator in the seminal “Florida Autopsied Multiethnic” (FLAME) retrospective cohort study that examined the records of 1625 deceased Alzheimer’s Disease patients self-reporting as Hispanic/Latino (n=67) Blacks (n=19) and White Americans (n=1539)  The investigators found that: “Hispanic decedents had  a higher frequency of family history of cognitive impairment (58%), an earlier age of onset ( a median of 70 years).longer duration of the disease 9 a median of 12 years) and lower MMSE proximal to death 9 median of 4 points) Black decedents had a lower Braak Tangle stage ( stage V) and a higher frequency of coexisting hippocampal sclerosis (21%) compared to other groups.” The results seem to suggest that there are clinical differences that might affect the effectiveness of the treating medication.

Dr. Mungas et al. found that Hispanics and Black Americans were more likely than White Americans to have post-mortem neuropathological changes of Vascular Disease; they cautioned that the results must be evaluated with caution as only 67 Hispanics and 19 Blacks were included in this study, compared to 1539 White Americans. However, the suggestion that Vascular Disease may play a bigger co-morbid role in the evolution of AD in Minorities opens the door for the evaluation of opportune care and wellness interventions that would improve the health outcomes for these patients.

The growing use of blood biomarkers for the early detection of Alzheimer’s Disease—before the devastating clinical symptoms appear in a patient—has markedly changed the treatment schedules; the presence of apolipoprotein E4 (APOE4) have been shown to be the strongest genetic risk factor. Sid E. O’Bryant et al. analyzed the serum of 363 Mexican Americans (49 patients with AD and 314 normal controls) and found that AD patients had a lower concentration of APOE4 in blood. How could that be if the presence of that blood biomarker had been singled out as pathognomonic? Perhaps its presence, for still unknown reasons, is not clinically significant for the Mexican Americans. We should determine the biological risks for AD across a larger spectrum of different ethnic groups in order to design efficient therapies to control the disease. We still have much to learn.

What do you think? Please tell us.

Don’t leave me alone.