Category Archives: General Health

Dr. John Barnard: Trends in Pediatric Workforce — A Growing Concern

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John Barnard MD gave a great talk today as part of the yearly Donald Schaffner lecture. This lecture also honored Larry Saripkin (see blog post: Thank You Larry) as a master clinician. My notes below may contain errors in transcription and in omission. Along with my notes, I have included many of his slides.

Key Points:

  • Since 2015, there is less interest in U.S.-trained physicians to pursue a career in pediatrics.
  • The pediatric gastroenterology workforce continues to grow. Other pediatric subspecialties are understaffed and not attracting enough younger pediatric trainees
  • The percentage of women and international medical graduates has been increasing; currently 67% of board-certified pediatricians are women and 22% are non-US international medical graduates
  • Women through all medical fields and even in pediatrics segregate to less well-paying positions. For example, pediatric cardiology has a lower percentage of women and has a higher median income compared to many other pediatric subspecialty areas
  • While relatively lower pay is thought to be a driving force in choosing a career in pediatrics/pediatric subspecialty, several surveys of medical students indicate that this is not the only factor; other factors may be more important
When workforce changes are noted in the mainstream press, there is often a clear worrisome trend
This slide does not include pediatricians who are not board-certified (~10% of workforce)
Pediatric physicians’ race/ethnicity is varied but does not match general population
There are a lot of counties without any board-certified pediatricians
68 counties in Georgia without a board-certified pediatrician
Driving distance to see a pediatric gastroenterologist
There is expected to be a substantial increase in pediatric GIs by 2040 (about 1700 now). Even with some adjusting of the number of trainees, this will not make a big change in the projections
In contrast to pediatric GI, the general pediatric workforce is likely to decline modestly.
There is an expected/projected drop in the pediatric population of 6.6 million by 2040
Since 2015, there has been a lower interest (7.9% of U.S. medical students) in U.S. pediatric match positions. From 1990–2015, it had been stable around 10%.
2024 is the first year with an absolute drop in the number of trainees as the number of residency positions have been increasing and open positions after the match can be filled with DO and non-US international medical graduates.
Medical students cite other non-monetary factors as important in their career choices

Physicians are in the top 5% of compensation, though pediatric physicians receive less
compensation than their peers. According to 2024 Doximity survey
(https://press.doximity.com/reports/doximity-physician-compensation-report-2023.pdf)
average physician salary exceeds $350,000 in most metro areas.

The growth of the medical-industrial complex/management may
be a factor affecting physician job satisfaction
Pediatricians are a small fraction of all U.S. physicians.
We need to make sure that our interests and the interests of children are heard.

My take: Dr. Barnard noted that “medicine has never been more exciting than it is today.” Yet, the decreased interest of medical students for a career in pediatrics/pediatric subspecialties needs to be addressed.

Dr. Barnard modified the material and presented the William Balistreri lecture at this year’s NASPGHAN meeting. Here are some additional slides from this talk which focused more on Pediatric Gastroenterology:

Distribution of Pediatric Gastroenterologists

Related blog post: “Why It’s So Hard to Find a Pediatrician These Days”

Impact of “Healthy Low-Carb Diet” and Time-Restricted Eating on Weight Loss

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Li, Lin et al. Cell Reports Medicine, Volume 0, Issue 0, 101801. Effects of healthy low-carbohydrate diet and time-restricted eating on weight and gut microbiome in adults with overweight or obesity: Feeding RCT

    Methods: The participants (n=96 adults) in the combination of Healthy Low Carbohydrate Diet (HLCD) and Time Restricted Eating (TRE group were provided with HLCD and instructed to follow the 10-h TRE. The HLCD … consisted of approximately 30% of total energy from carbohydrates, 50% from fats, and 20% from proteins. Moreover, compared to a traditional low-carbohydrate diet that only focused on carbohydrate restriction, HLCD also emphasized healthy food sources and high-quality macronutrients such as unsaturated fatty acids, plant proteins, and high-quality carbohydrates, including whole grains, fresh vegetables, and fruits. Additionally, 25–35 g of mixed nuts were provided along with HLCD per day, which mainly included walnuts, peanuts, cashews, pistachios, pecans, almonds, and hazelnuts. 10-h TRE required participants to consume the provided meals within 10 h each day. Outside the eating window, only water, and noncaloric beverages were allowed.64 

    Key findings:

    • Each of the patient groups lost between 2.57 to 4.11 kg
    • HLCD was more effective in reducing fat mass
    • Both dietary interventions resulted in changes in the microbiome

    My take: It is still to work on improving diet quality and improving exercise –only a small percentage of patients will be receiving GLP-1 drugs or bariatric surgery. The Mediterranean diet likely has the most data supporting its use for obesity.

    Related blog posts:

    Rock Creek Park, Washington D.C.

    “The Staggering Success of Vaccines”

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    Tara Haelle, Scientific American 10/15/24: The Staggering Success of Vaccines

    Referenced article: A Shattock et al. Lancet 2024; 403: 2307–16. Open Access! Contribution of vaccination to improved survival and health:modelling 50 years of the Expanded Programme on Immunization

    Some excerpts:

    “Vaccines are the first step toward health equity in many parts of the world…Around the globe the measles vaccine has saved nearly 94 million lives over the past 50 years. This and other vaccinations have revolutionized global health…”

    “A May study in the Lancet estimated that vaccines against 14 common pathogens have saved 154 million lives over the past five decades—at a rate of six lives every minute. They have cut infant mortality by 40 percent globally and by more than 50 percent in Africa. Throughout history vaccines have saved more lives than almost any other intervention. And vaccines’ promotion of health equity goes far beyond preventing death. The Lancet study found that each life saved through immunization resulted in an average 66 years of full health, without the long-term problems that many diseases cause. Vaccines play a role in nearly every measurement of health equity, from improving access to care, to reducing disability and long-term morbidity, to preventing loss of labor and the death of caretakers…”

    “If you have no money, then you want the best bang for the buck, and it’s going to be immunization,” says Seth Berkley, former CEO of Gavi. “For every dollar you invest in immunization, you get $54 of benefit.”

    The reduction in mortality equates to 9·0 billion life-years saved.

    “In late 2019, when a novel coronavirus detected in Wuhan, China, kicked off one of the largest, deadliest pandemics in a century, everyone looked to the same solution: a vaccine. COVID’s devastation hit poorer countries with less developed health-care systems particularly hard, and in wealthier countries people from underserved and low-income communities suffered higher rates of illness, death and economic hardship…”

    “A 2022 study in the Lancet Infectious Diseases estimates that COVID vaccination worldwide prevented 19.8 million excess deaths.”

    My take: This is a terrific article and particularly timely given the growing influence of anti-vax proponents. Not only have vaccines prevented millions of deaths, they have helped prevent chronic complications (eg. disability after meningitis). The reduction in mortality in the charts is likely UNDERESTIMATED. Many other vaccines were not included in this estimation: smallpox, human papillomavirus, (HPV), influenza, SARS-CoV-2, Ebola, mpox and other vaccines.

    Related blog posts:

    Hot Weather Affects Mail-Order Medications

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    NY Times (8/13/24, Emily Baumgaertner): Hot Summer Threatens Efficacy of Mail-Order Medications

    An excerpt:

    Doctors and pharmacists say the scorching temperatures enveloping the country could be endangering people’s health in an unexpected way: by overheating their medications.

    Millions of Americans now receive their prescription medications through mail-order shipments, either for convenience or because their health plans require it. But the temperatures inside the cargo areas of delivery trucks can reach 150 degrees Fahrenheit in the summer, according to drivers — far exceeding the range of 68 to 77 degrees recommended by the national organization that sets standards for drug handling.

    Mail-order pharmacies say that their packaging is weather resistant and that they take special precautions when medication “requires specific temperature control.” But in a study published last year, independent pharmaceutical researchers who embedded data-logging thermometers inside simulated shipments found that the packages had spent more than two-thirds of their transit time outside the appropriate temperature range, “regardless of the shipping method, carrier, or season…

    Liquid medications like insulin or AUVI-Q, the epinephrine injection for allergic reactions, are often at heightened risk of degradation because excessive heat exposure can cause the evaporation of liquid components that were compounded at precise ratios. Aerosolized medications, too, are uniquely vulnerable because of the risk of pressure changes in the canister.

    P.B.M.s [pharmacy benefit managers] often force mail order as the only option, constantly exposing our meds to destructive temperatures way outside the manufacturer’s specifications for days on end

    My take: Worsening climate can even affect medication distribution. This article describes the consequences of medications affected by weather conditions including disease progression and liver transplant rejection. Lobbyists for P.B.M.s have effectively stifled regulations. For our patients with serious underlying diseases, mail-order medication efficacy is yet another concern. This NY Times article was published in August -hot weather is likely less of an issue at this time of year.

    Related blog post: The Health Consequences of Climate Change

    Colorado River near Moab, Utah

    IV Fluid Shortage Due to Hurricane Helene

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    NBC News 10/3/24: Hospitals take steps to conserve IV fluid supply after Helene strikes critical factory

    “Baxter International said it would temporarily close production at its North Cove, North Carolina-based facility, raising concerns about a potential nationwide shortage.”

    “There are four primary manufacturers of IV fluids in the U.S. Baxter is the leader, accounting for about 60% of the market…In a statement published online Thursday, Baxter said it doesn’t yet have a timeline for when operations will be back up and running…A part of the problem, the company said, is that bridges to its site were damaged in the storm, limiting transport in and out.”

    “The company is the main supplier for Mass General Brigham in Boston, which uses more than 100,000 liters of IV fluid from Baxter every month. On a call Thursday with reporters, Dr. Paul Biddinger, Mass General’s chief preparedness and continuity officer, said the health system received a letter from Baxter that said that due to the temporary closure, the system would receive only 40% of its usual supply from the manufacturer. “

    My take: This is a nationwide problem and we need to conserve our supplies. This has happened before with Hurricane Maria hitting Puerto Rico in 2018.

    1. Use oral fluids/rehydration fluids when possible in place of IV fluids
    2. For many patients, IVFs can be used at lower rates or held overnight
    3. Would try to complete IVF bags that were started in ED or OR when patient transitions to a hospital floor bed before changing to a new IV fluid bag
    4. Nasogastric (NG) tube fluids can be administered more frequently

    Related blog posts:

    High Rate of Medication Errors in Pediatric Hospitals

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    T Badgery-Parker et al. J Pediatr 2024 272: 114087. Open Access! Child Age and Risk of Medication Error: A Multisite Children’s Hospital Study

    Methods: This study from Australia included (1) prescribing errors identified from chart reviews from two hospitals as well as (2) medication administration errors assessed by direct prospective observation of 5137 administrations at a single hospital. In total, this study examined almost 70 000 medication orders and more than 5000 medication administrations.

    Key findings:

    • There was a modest increase in prescribing errors with age
    • There was a high rate of errors across all age groups. The crude error rate for prescribing was 18.6/100 orders
    • Hospital A had 14.5 prescribing errors per 100 orders using paper prescribing, and this increased to 17.6 per 100 orders during implementation of electronic prescribing then fell to 11.7 per 100 orders a year later.11 Prescribing error rates at hospital B were higher (28 per 100 orders in 2016, falling to 20 per 100 orders in 2020).

    From the associated commentary (DM Goodman): “The Institute for Healthcare Improvement describe the 5 rights of medication administration –right patient, right drug, right dose, right route, and right time. But to achieve these goals, the right systems must also be in place.”

    My take: This study makes me wonder what the error rate in our hospital is –I would think it would be much lower than the rates described in this study. This study makes me more appreciative of the occasional call I get from the pharmacist to adjust the dosing and the built-in alerts in our EMR.

    Related blog posts:

    How to Save a Life

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    From Caitlin Rivers Newsletter (Force of Infection):

    Each year, I share a series of first aid videos to help remind everyone of these life-saving skills. I specifically chose these videos because they are only 2-5 minutes long, so you can get through the entire set on your coffee break. There are plenty of high-quality, longer tutorials on YouTube if you want a deeper dive. Either way, I hope you’ll find some time to review these important lessons.

    (Also note that CPR and choking procedures are different for infants, so if you have babies in your life, please look up specific instructions for them!)

    These videos are best as a refresher. If first aid skills are new to you, I recommend taking an in-person course. Most community centers offer classes for free or at a low cost. Don’t skimp on these valuable skills—they could make all the difference.

    This post is public so feel free to share it.


    Her newsletter allowed links by clicking image. To access the videos from this post, clink on the link rather than the image.

    Link: Recognizing drowning

    Link: CPR for adults and children + using an AED

    Link: CPR 1-12 yrs of age

    Link: How to Use an AED

    Link: How to Stop Severe Bleeding

    Link: Choking rescue

    Huge Numbers of Long COVID Cases -Vaccination Helps

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    Y Xie, et al. NEJM 2024; DOI: 10.1056/NEJMoa2403211. Postacute Sequelae of SARS-CoV-2 Infection in the Pre-Delta, Delta, and Omicron Eras

    Background: Postacute sequelae of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection (PASC), also called “long Covid,” can affect many organ systems.1,2 The risk of PASC appears to increase with greater severity of infection and with the presence of preexisting medical conditions.

    Methods: The authors used the health records of the Department of Veterans Affairs to build a study population of 441,583 veterans with SARS-CoV-2 infection between March 1, 2020, and January 31, 2022, and 4,748,504 noninfected contemporaneous controls.

    Key findings:

    NY Times, Pam Belluck 7/17/24: Vaccines Significantly Reduce the Risk of Long Covid, Study Finds

    An excerpt:

    The lowest rate of long Covid in the study, 3.5 percent, was among vaccinated people who were infected during the latest period in the study, between mid-December 2021 and January 2022. That compares with a rate of 7.8 percent for unvaccinated patients in the study who were infected during the same period…

    To rule out other possible causes, the researchers factored in comparisons between uninfected people who developed similar symptoms…

    Researchers found that among unvaccinated people infected between June 19 and Dec. 18, 2021, when Delta was the dominant variant, the rate of long Covid a year later decreased slightly to 9.5 percent from 10.4 percent among those infected in the first 15 months of the pandemic…

    Among vaccinated people who had been infected, the rates of long Covid were markedly lower…About 5.3 percent of those infected during the Delta period had long Covid a year later, and 3.5 percent of those infected during the Omicron period did.

    My take: A huge number of people in U.S. (and worldwide) have long COVID. This risk is markedly reduced with vaccination.

    Related blog posts:

    Twenty-Five Years After Columbine –What to Do About Firearms and Public Health

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    D Hemenway. NEJM 2024; 390:1352-1353 Twenty-Five Years after Columbine — Firearms and Public Health in the United States

    This commentary notes that in the aftermath of Columbine, Smith and Weston had agreed “to upgrade its products and practices to help reduce the harms caused by its guns. Since a common cause of unintentional shootings is incorrectly believing that the gun is unloaded, its pistols would have chamber load indicators, and magazine disconnects would be available. The company would provide “ballistic fingerprints” on new firearms to help law-enforcement agencies trace guns. It would sell its guns only to dealers who had a plan for preventing gun theft and — to reduce gun trafficking — would agree to limit multiple-handgun sales to any individual buyer. The dealers would also have to agree not to sell large-capacity magazines.1 But the firearms industry immediately began boycotting the company, and its chief executive officer was forced to retire.”

    This article offers the following advice to reduce firearm mortality, the number one killer of children:

    • “The Surgeon General could provide biannual reports on guns and suicide; the federal government could both conduct and fund research into smart guns and safer means of home protection than owning a handgun”
    • “Police could have social workers embedded in precincts”
    • “The faith community could make it clear that it is a cardinal sin to sell a gun to a stranger without a background check”
    • “Probably the most important thing our country can do is to elect more officials who will help make changes where the effect will be greatest — in the gun industry and the gun culture”
    • “To achieve a huge reduction in gun deaths will probably require mandating what is common for car drivers in the United States and for gun owners in other high-income countries: gun licensing, gun training, and handgun registration, along with universal background checks. These requirements are supported by most Americans”
    • “PLCAA (Protection of Lawful Commerce in Arms Act) protections should be eliminated, and the gun industry treated like other industries”
    • “And just as car manufacturers had to be forced to put seat belts, airbags, collapsible steering columns, and safety glass into their vehicles, the gun industry should be forced to take the types of steps that Smith and Wesson was willing to take 25 years ago”

    Related blog posts:

    ‘Physicians Are Not the Victims’ (Plus One)

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    A recent blog post (Is Medicine a “Calling?”) reviewed a commentary about whether physicians have become ‘cogs of capitalism’ leading to dissatisfaction.

    A recent response letter (RL Albin. N Engl J Med. 2024 Apr 18;390(15):1444. doi: 10.1056/NEJMc2403045) offered some useful insights:

    • Before WWII, physicians were paid directly by patients. Afterwards, “taxpayer-subsidized, employment-based health care and social insurance guaranteed healthy incomes. Generous subsidies for higher education lowered barriers to professional entry…”
    • Due to “clever political lobbying, physicians enjoyed these considerable subsidies without major sacrifices of sovereignty.2 This system was economically unsustainable…”
    • “Physician lobbying played a sizable role in defeating efforts toward rational public control, unwittingly advancing corporatization with its gross inefficiency, multiple inequities, and erosion of physician sovereignty. Physicians are “cogs of capitalism,” but we continue to be well-paid, respected professionals. The real victims are the many Americans who lack access to decent health care”

    A related article: K Schulman, B Richman. NEJM 2024; 390: 1445-1447. Hospital Consolidation and Physician Unionization. This article describes the increase in physician unionization that is taking place and makes the following points:

    • “Since the 1990s, hospitals have been consolidating to form health systems that now exert monopolistic leverage in many health care markets in the United States”
    • “In 2012, only 5.6% of U.S. physicians were directly employed by a hospital,1 and another 23% were in a practice that was at least partially owned by a hospital…By January 2022, the proportion of hospital-employed physicians had risen to 52%, with another 22% of physicians being employed by other corporate entities”
    • [Unionization] “is a natural consequence of hospital consolidation and the corporatization of health care delivery… Executives may also consider physicians to be largely interchangeable…Amid shifts in practice structures, physicians may experience a deterioration in their working conditions, job satisfaction, and — most important — involvement in the governance of health care delivery”
    • [Unionization provides] “the opportunity to negotiate over wages with monopolists…Unions often express workers’ concerns about non–wage-related matters, including issues affecting job satisfaction, professional meaning, and workplace conditions”
    • “Physicians supporting these drives have emphasized concerns about staffing, burnout, and the quality of patient care as motivations for unionization. Collective bargaining has been a direct response to the most negative consequences of hospital consolidation”

    My take: Doctoring can be sacred work. While physicians need to work to improve workplace environments and enhance personal interactions with patients, it is sobering to realize that many patients have been harmed much more than physicians with the changes in healthcare delivery and costs.

    Related blog posts: