Category: Health

Our apolitical science-driven physicians

by philg

From the New England Journal of Medicine, i.e., the folks whom we can trust to give us science-informed advice on masks and vaccines, untainted by a political point of view… “Failed Assignments — Rethinking Sex Designations on Birth Certificates” (December 17, 2020):

We believe that it is now time to update the practice of designating sex on birth certificates, given the particularly harmful effects of such designations on intersex and transgender people.

Recognizing that the birth certificate has been an evolving document, with revisions reflecting social change, public interest, and privacy requirements, we believe it is time for another update: sex designations should move below the line of demarcation.

Designating sex as male or female on birth certificates suggests that sex is simple and binary when, biologically, it is not. Sex is a function of multiple biologic processes with many resultant combinations. About 1 in 5000 people have intersex variations.

Assigning sex at birth also doesn’t capture the diversity of people’s experiences. About 6 in 1000 people identify as transgender, meaning that their gender identity doesn’t match the sex they were assigned at birth. Others are nonbinary, meaning they don’t exclusively identify as a man or a woman, or gender nonconforming, meaning their behavior or appearance doesn’t align with social expectations for their assigned sex.

Moving sex designations below the line of demarcation wouldn’t imperil programs that support women or gender minorities, it would simply require that programs define sex in ways that are tailored to their goals.

Moving sex designations below the line of demarcation may not solve many of the problems that transgender and intersex people face. Controversies regarding bathrooms, locker rooms, and sports participation will continue, regardless of legal sex designations.

Today, the medical community has a duty to ensure that policymakers don’t misinterpret the science regarding sex and that medical evaluations aren’t being misused in legal contexts.

Also, “A Test of Diversity — What USMLE Pass/Fail Scoring Means for Medicine” (June 18, 2020):

The stakes are high for all students taking this first Step examination of the three required for medical licensure. But students from racial and ethnic groups that are underrepresented in medicine experience great angst.

Recently, the Federation of State Medical Boards (FSMB) and the National Board of Medical Examiners (NBME) decided to change score reporting from a three-digit numerical score for the Step 1 exam (the mean score for first-time takers was 230 in 2018) to a pass-or-fail outcome. … Although the effect on trainees from underrepresented groups remains uncertain, we believe that the change is a critical step toward diversifying the medical profession — particularly the most competitive, and simultaneously least diverse, medical specialties — opening a world of possibilities for physicians and patients alike.

The odds are stacked against students from underrepresented minority groups starting early in their scholastic journeys. Beginning in grade school, they may be subject to teachers’ racial and ethnic biases that can hinder their achievement. Socioeconomic factors such as neighborhood poverty and parental educational attainment may limit their access to high-quality schools, test-preparation resources, and supportive mentorship, widening the achievement chasm.

The medical examination system poses challenges that are especially burdensome to students of color and those with lower socioeconomic status. Step 1, much like the Medical College Admission Test (MCAT), places a financial burden on students that includes the cost of the exam ($645 in 2020) and the study materials required to prepare for it.

As with the MCAT, scores on Step 1 are lower among black, Hispanic, Asian-American, and female students than among their white male counterparts. Although this disparity has multiple causes, historically disadvantageous early education in minority communities probably plays an important role for members of underrepresented minority groups.

… we believe that holistic review will be a tide that raises all ships equitably.

The last sentence is my favorite. There are a limited number of slots for training the most lucrative and cushiest specialties, but everyone will have a better chance of obtaining a slot after this change.

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Experience with One Medical?

by philg

As Toucan Sam likes to remind us, Barack Obama said “If you like your doctor, you can keep your doctor,” but our new insurance company apparently did not get the Presidential memo.

It is thus time for me to shop for a new physician. The new insurer assigned me to a doctor, but after a couple of hours on hold with the big clinic where he works, I learned that (a) he isn’t accepting new patients, and (b) he is mostly retired.

One Medical has a couple of offices here in Boston and claims to be patient-centric rather than insurance-company-centric. Does anyone have experience with this concierge-lite primary care system? (it is $200/year, which is a lot better than waiting on hold for hours!)

Update… part of the sign-up form:

(I decided to sign up based on positive reviews from people here and also a friend who drives 30 minutes from the Boston suburbs to continue his treatment at One Medical. As readers can no doubt imagine, it was tough for me to resist entering a long essay into the Gender Information box. And, then, of course, I had to de-subscribe from One Medical after it turned out that they accept Tufts insurance, yes, but not the particular flavor of Tufts “Platinum” that we have.)

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Is it possible that a COVID-19 vaccine won’t be lucrative?

by philg

Just as Big Pharma’s worst enemy in D.C. is on his way out, we have “Pfizer says early analysis shows its Covid-19 vaccine is more than 90% effective”. In a world where a lot of people have no goal other than avoiding COVID-19, will Pfizer shareholders now become infinitely rich?

I’m wondering if there will be so much competition in the coronaplague vaccine market that this ends up being only moderately profitable.

First, maybe it isn’t that difficult to create immunity to coronavirus. Here’s a curve of COVID-19-tagged deaths in Sweden.

After a few months of mixing in schools, workplaces, restaurants, gyms, etc., it would appear that a lot of Swedes became immune (otherwise, how to explain the drop in deaths? The Swedes didn’t change their laws or behavior after mid-March. From the IHME prophets:

If it was that easy for Sweden to build immunity, maybe most of the current vaccine candidates from all around the world will work fairly well (WHO report on 47 currently in clinical trials, which also mentions 155 in preclinical evaluation). Except in the U.S., therefore, competition should work to drive down the price.

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American health insurance as understood by a licensed health insurance broker

by philg

From an email exchange with our aviation insurance broker, regarding why he uses an agent for his own small business’s health insurance plan, rather than going direct to an insurer:

I would say exposure to more markets (United Health is probably going to be more cost effective than Blue Cross) as well as someone to turn to when you have questions about the different options. I have my health insurance brokers license and the intricate differences between plan offerings still confuse me sometimes.

What hope is there for the rest of us?

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Amy Coney Barrett will inspire Americans to get fit?

by philg

“To Conservatives, Barrett Has ‘Perfect Combination’ of Attributes for Supreme Court” (NYT):

“Amy Coney Barrett meets Donald Trump’s two main litmus tests: She has made clear she would invalidate the A.C.A. and take health care away from millions of people and undermine a woman’s reproductive freedom,” said Nan Aron, the president of Alliance for Justice, a liberal group.

It is unclear to me why people who live in properly governed “Blue states” worry about health insurance and the availability of abortion (on demand at up to 24 weeks here in Maskachusetts, and, after that, available if a single doctor believes that “continuation of her pregnancy will impose on [the mother] a substantial risk of grave impairment of her physical or mental health.”) A repeal of Roe v. Wade would not prevent a state from offering unlimited free abortions right up to 40 weeks of pregnancy. A repeal of Obamacare would not prevent a state from using state funds to offer unlimited free health insurance to every resident.

What else do we know about this judge?

Judge Barrett and her husband, Jesse Barrett, a former federal prosecutor who is now in private practice, have seven children, all under 20, including two adopted from Haiti and a young son with Down syndrome, whom she would carry downstairs by piggyback in the morning. Judge Barrett is known for volunteering at her children’s grade school, and at age 48, she would be the youngest justice on the bench, poised to shape a generation of American law.

So she’s kind of busy. Does that stop her from working out?

Judge Barrett and other university faculty members have been known to work out together at a CrossFit-type program, sometimes with their former provost.

Seven children and a job as a Federal judge do not stop Amy Coney Barrett from going to the gym. What is stopping the rest of us?

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Time to love smokers again?

by philg

Strolling by the smokers’ ghetto outside one of our local airport’s FBOs made me wonder when it will be time to abandon our fanaticism regarding the occasional whiff of tobacco smoke. We are certain that any of our fellow humans may kill us with a breath of coronavirus. Why do we worry about the unpleasantness of someone smoking a cigarette 5′ from an exterior door versus 20′? Do we still need Mini-Mike Bloomberg’s 2011 ban on smoking in various outdoor places, such as beaches and parks?

Do we have the energy to fight the anti-smoking battle at the same time as the anti-coronaplague battle? When do we admit that we’re not as capable as Adolph Hitler and his loyal Germans and even they had trouble fighting on multiple fronts?

I’m not a smoker, but I’m now ready to welcome my smoking brothers/sisters/binary resisters with a hearty “You could be exhaling a lot worse!”

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What happens when cold season starts?

by philg

I’ve been in a bunch of masked-up environments recently. People have their masks off to take a sip of a beverage or a bite of a sandwich. What would happen if someone took off the mask in order to sneeze and wipe his/her/zer/their nose? Pandemonium, panic, and violence?

Are we going to end up with a society more like Japan, in which it is rude to be out in public while coughing or sneezing? (this does not seem to have helped with virus control there; the death rate from flu in Japan has been 2.5X the death rate in the U.S.)

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Cut down on ED visits with doctor and nurse in motorhome for house calls?

by philg

One of the things that I have learned in meetings with a big health insurance company whose claims data we use in the classroom: emergency room (“ED”) visits are expensive. A long wait followed by a temperature and pulse ox test then advice to take two Tylenols will cost the employer who sponsors a health plan at least $1,000.

One idea that I came up with around a conference table with the insurance folks was to put a doctor and nurse in a motorhome crammed with all of the stuff that one would typically find in a primary care clinic. Tell folks enrolled in the plan “You can go to the hospital and wait two hours to be seen and pay a $125 co-pay. Or you can stay comfortably at home and the doctor will be there in four hours.”

This is plainly a bad idea because it is obvious and yet no insurance company is doing it. Maybe it is bad because the U.S. is so short of physicians that it is intolerably inefficient to have the physician idle when driving from one house to another. France has a lot of doctors per capita and they do still make house calls (see this 2009 article).

Perhaps the idea is a little less bad in the Covid-19 age. Do we want people congregating in hospital waiting areas now that we can be pretty sure that at least one of the waiting patients is plagued? If the patients are seen at home, at least there is no patient-to-patient contact/transmission.

We already have the technology and skills to build the motorhome-based clinics. Matthews Specialty Vehicles seems to have built a bunch, for example. Odulair in Wyoming has everything up to mobile CT and mobile MRI (these are perhaps overengineered for checking on a person who has flu-like symptoms). Laboit says that they can fit a primary care clinic with a single exam room into a 28 ft. Class C RV:

Readers: A year ago we would have said it was stupid to pay Americans more in unemployment than they had been getting paid to work. Has my stupid idea also flipped to brilliant?

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Covid-19 is now primarily a mental illness?

by philg

I spent some time recently with two Harvard undergraduates who are camped out in a Cambridge apartment. I’m the oldest person that they’ll have any contact with for the foreseeable future, yet these 20-year-olds behave as though they either worked or lived in a nursing home for 90-year-olds. Asked why they put so much effort into mask-wearing and deny themselves so many social opportunities that they would previous have jumped at, they say that they are personally afraid of getting coronavirus. They’re not obese or chronically ill, so their statistical risk of being felled by Covid-19 is low (see

from mass.gov, statistics that have now been removed), but they seem to perceive Covid-19 as the main risk to their lives and health. They won’t take off their masks, for example, even when outside in mostly-deserted Cambridge. After talking to and observing them, I concluded that, at least for young Americans, Covid-19 is now primarily a disease of the mind. Support for my theory: “We’ve Hit a Pandemic Wall” (NYT, August 5)?

New data show that Americans are suffering from record levels of mental distress.

Let’s start with the numbers. According to the National Center for Health Statistics, roughly one in 12 American adults reported symptoms of an anxiety disorder at this time last year; now it’s more than one in three. Last week, the Kaiser Family Foundation released a tracking poll showing that for the first time, a majority of American adults — 53 percent — believes that the pandemic is taking a toll on their mental health.

This number climbs to 68 percent if you look solely at African-Americans. The disproportionate toll the pandemic has taken on Black lives and livelihoods — made possible by centuries of structural disparities, compounded by the corrosive psychological effect of everyday racism — is appearing, starkly, in our mental health data.

Turns out the extra ten extra pounds around my middle have moved in and unpacked, though I’d initially hoped they were on a month-to-month lease.

The newspaper that has been cheerleading for Shutdown now is surprised that there are some negative consequences? How did the coastal elites not figure out that not everyone’s shutdown experience would be positive? A friend in the Boston suburbs, who was a work-from-home consultant long before the Age of Shutdown, was telling me that his 8th grader hadn’t minded being at home for three months with minimal instruction being provided by the lavishly funded public school. Therefore, he concluded, shutdown was not a big deal, and if the school shutdown lasted another year that was okay too. His son would do fine practicing on the grand piano, learning from Ph.D. Dad and super smart stay-at-home Mom, etc.

I pointed out that not every American child lived in a 6,000 square foot $2 million house with two biological parents who get along at least reasonably well. Would he acknowledge that an inner-city child crammed into a two-bedroom public housing unit with mom, a step-sibling, and mom’s latest boyfriend might have a less favorable view of school shutdown? (he did!)

(see also “Coronavirus impact: Chasm grows between whites, people of color, California poll finds; Spanish-speaking Latinx voters say COVID-19 has seriously hurt their ability to pay for food and rent” (Mercury News, August 6))

Some top-voted NYT reader comments:

This is like the Twin Towers imploding all over again – except this time, one story collapses each day, and there is no ground floor.

The pandemic in and of itself is stressful but then add the stress of Trump’s daily tweets. The thought that he might get re-elected makes the stress almost unbearable.

What I think has caused the national stress-out, Ms. Senior, is that America now knows that it’s on its own. We don’t have a president who actually understands and cares about us.

I stress over the corrupt Republican leadership, so unconcerned for 99.9% of Americans that they let a a spoiled child throw our health, education, and welfare out the window, …

A coworker yesterday confided that about 15 of her relatives are COVID positive after a big family graduation party 10 days ago. I couldn’t hide my disgust. She is a very highly paid executive. We work for a research university health system!!! My neighbors just had a 40-person party for their 9-year-old. And seemed miffed and befuddled that many of us on the block declined to attend. They were all crammed under a tent shoulder to shoulder. Nary a mask in sight.

Maria from Maryland: The thing is, a lot of us are coming to the conclusion that all our problems are the same problem. Botched coronavirus response? Republicans. Insisting on doing things that spread the disease? Same. Economic deprivation? Republicans again. Two generations of failing to address racial issues? Again. Two generations of banging our heads against the same gender barriers? You guessed it. Failure to deal with climate change? Do you need to ask? Guns? Infrastructure? Science? Arts? They’ve been at it my whole adults life, ruining everything. And at their apex, they produced the very worst man in the world. There will be a vaccine for the virus, but what about the humans who are ruining our lives?

Coronaplague wouldn’t bother them at all, apparently, if Joe Biden were the Great Father in Washington right now!

Coronaplague obviously is a real problem for the elderly/vulnerable. And in societies where it is allowed to run wild, e.g., Sweden, it will kill approximately 0.05 percent of the population within a few painful months. But will readers agree with me that if young people are afraid of getting the disease personally, despite having no actual or planned contact with the old/vulnerable, then coronavirus has mutated into something whose main effect is mental illness?

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$100 million to rebrand our local hospitals

by philg

If you want to know how much profit there is in the non-profit world… a friend who works at Partners told me that the enterprise will be spending more than $100 million to rebrand back to what is essentially their old names: “Mass General Brigham” (combination of Massachusetts General Hospital, a.k.a., “the Massive Genital”, and Brigham and Women’s Hospital). That’s confirmed by this article.

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