U.S. Federal Policy Change: “Toppling the Ethical Balance”

A recent commentary (E Sepper. NEJM 2019; 381: 896-8) explains how the current administration’s “Protecting Statutory Conscience Rights in Health Care” policy will create additional problems for patients.

Background:

  • “For nearly 50 years, U.S. federal law has permitted medical professional and religious institutions to refuse, for religious and moral reasons, to provide abortions and sterilizations.”  In addition, there are similar safeguards with regards to professionals who do not want to comply with advance directives.  And, recipients of federal funding like hospitals and clinics are obligated to “not discriminate against individuals that refuse to provide such care.
  • However, “health care providers bear legal and ethical duties to patients. They must provide information about treatment options.”

What is changing?

  • The “Protecting Statutory Conscience Rights in Health Care” policy from the Department of Health and Human Services (HHS) “creates a wide-ranging right to refuse to provide health care services.”  Any entity receiving HHS funding “is barred from requiring anyone to ‘assist in the performance’ of ‘any health service or research activity’ that is contrary to that person’s religious beliefs or moral convictions.”
  • This could include contraception, gender dysphoria treatment, nondiscriminatory care of lesbian, gay, bisexual and transgender patients.  This could affect care for individuals with HIV.
  • “Providers may refuse to refer patients or counsel them about the contested service.”  This is an HHS mandate that affirms an individual provider’s right to not meet the standard of care.
  • This could result in an ICU nurse who will not follow advance directives or a pediatric provider (MD, PA, RN) who will not administer vaccines.
  • In addition, the rule includes no emergency exception.  An ambulance driver could refuse to transport a woman with a miscarriage or ectopic pregnancy to the hospital.

My take: In an effort to pander to religious communities, the administration is giving the green light to medical providers/staff to discriminate and deny services; this denial extends to even providing adequate information.  The results of this policy could result in increased morbidity and even death in those denied services.

Pittock Mansion Hike, Portland, OR

 

“We Have Ruined Childhood” and Possible Link to Depression, Anxiety and Suicide

A recent NY Times commentary (We Have Ruined Childhood) details the rising rates of depression, anxiety, and suicide and suggests a link between these mental health issues and a lack of childhood free play.

An excerpt:

No longer able to rely on communal structures for child care or allow children time alone, parents who need to work are forced to warehouse their youngsters for long stretches of time. School days are longer and more regimented…

The role of school stress in mental distress is backed up by data on the timing of child suicide. “The suicide rate for children is twice what it is for children during months when school is in session than when it’s not in session,..

For many children, when the school day is over, it hardly matters; the hours outside school are more like school than ever…

The areas where children once congregated for unstructured, unsupervised play are now often off limits. And so those who can afford it drive their children from one structured activity to another. Those who can’t keep them inside. Free play and childhood independence have become relics, insurance risks, at times criminal offenses

Many parents and pediatricians speculate about the role that screen time and social media might play in this social deficit. But it’s important to acknowledge that simply taking away or limiting screens is not enough. Children turn to screens because opportunities for real-life human interaction have vanished.

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What Doctors Could Do Together (Organized)

A recent commentary (recommended by one of my sons) by Eric Topol discusses how doctors could be organized to advance the practice of medicine, address the deterioration in doctor-patient relationships, and focus on the needs of patients, whereas current medical organizations are mainly focused on the business interests of medical practice.

An excerpt from Why Doctors Should Organize:

“It’s possible to imagine a new organization of doctors that has nothing to do with the business of medicine and everything to do with promoting the health of patients and adroitly confronting the transformational challenges that lie ahead for the medical profession. Such an organization wouldn’t be a trade guild protecting the interests of doctors. It would be a doctors’ organization devoted to patients. Its top priority might be restoring the human factor—the essence of medicine—which has slipped away, taking with it the patient-doctor relationship. It might oppose anti-vaxxers; challenge drug pricing and direct-to-consumer advertisements; denounce predatory, unregulated stem-cell clinics; promote awareness of the health hazards of climate change; and call out the false health claims for products advocated by celebrities such as Gwyneth Paltrow and Mehmet Oz. This partial list provides a sense of how many momentous matters have been left unaddressed by the medical profession as a whole…

Because of the unique technological moment at which we live, we may not see an opportunity like this one for generations to come. We have a chance to affect the future of medicine; to advocate for patient interests; to restore the time doctors need to think, to listen, to establish trust, and build bonds, one encounter at a time. For these purposes, and in these times, an organization of all doctors is necessary. Rebuilding our relationships with our patients: that is our lane.

“Pistol Butt” Pine. Tree takes on this shape due to heavy snowfall leaning on tree at early stage. Crater Lake, Oregon.

Declining and Aging Rural Physician Workforce

A recent article (L Skinner et al NEJM 2019; 381: 299-301) provided data regarding the worsening disparity in physician availability in rural areas.

Key points:

  • “While the total number of rural physicians grew only 3% (from about 61,000 in 2000 to 62,700 in 2017), the number of physicians under age 50 years living in rural areas decreased by 25%.”
  • “By 2017, more than half of rural physicians were at least 50 years old, and more than a quarter were at least 60.” In urban areas, the numbers were 39% and 18% respectively.
  • It is projected that instead of the current 12 physicians per 10,000 population in 2017 there will be a drop of 23% (9.4 per 10,000) in 2030 in rural areas; in contrast, nonrural physicians supply will be essentially the same in 2030 (29.6 per 10,000) as current supply (30.7).
  • The fact that there will be one-third fewer physicians is coupled with the fact that rural areas have populations that are older, poorer, worse health, lower life expectancy, and less insurance coverage

My take: This report highlights the current disparity in rural health care and how this is worsening as the rural physician population ages.

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