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Category: Medical Practice

Mental Health Crisis in Miscarriage–an Unrepresented Patient Population

By TAMARA MANNS

I walked into the emergency department already knowing the outcome. In these same rooms I had told women having the same symptoms as me, “I am so sorry, there is nothing we can do for a miscarriage”. I handed them the same box of single ply tissues I was now sobbing into, as I handed them a pen to sign their discharge paperwork.

Two weeks after my emergency room discharge, I continued to live life as if nothing happened, returning to work without any healthcare follow-up to address my emotional burden. Luckily, I had established obstetrician (OB) care with the physician who previously delivered my second child. At only nine weeks gestation I had not seen my OB physician yet, but I was able to follow up in the office to talk about my next steps.

After that two-week hospital follow up, I heard from no one.

Due to the environment of the emergency department, women often complain of unprepared providers with ineffective and impersonal delivery of miscarriage diagnosis and discharge education; this lack of emotional support can result in feelings of abandonment, guilt, and self-blame. Due to the psychological impact of pregnancy loss, a standard of care for screening and referral must be implemented at all facilities treating women experiencing miscarriage.

If I had not reached out to my healthcare provider after my miscarriage, I would have continued suffering through an aching depression without help.

Depression, anxiety, and grief are most severe in the first four months after miscarriage. The symptoms decrease in severity throughout the following year. These symptoms may influence future pregnancies by increasing maternal stress and fear, possibly leading to pregnancy complications.

In the United States (US), one in five women suffer with mood and anxiety disorders while pregnant, and up to one-year after delivery.

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A Baby Step Backwards

Bringing the Tools of Accountable Care to Maternity Care is a Great Idea – But This Sure Ain’t It

By VICTORIA ADEWALE & J.D. KLEINKE

How desperate are we to find some kind of good news about the sorry state of maternity care in America? To find out, look no further than the current cover of no less venerable a health policy journal than Health Affairs.

With the headline “Medicaid ACO Improves Maternity Care” jumping off the cover of its September issue, we were expecting great things from the article “Massachusetts Medicaid ACO Program May Have Improved Care Quality for Pregnant and Postpartum Enrollees” (Megan B. Cole, et al.). The headline certainly promises some rare good news for all of us working to fix the national embarrassment that is maternity care in the US in general, and the maternal mortality crisis in particular.

But alas, the article itself is one more reminder that process improvements are not outcomes improvements. It is also a classic case of earnest researchers’ tendency to torture retrospective data — because it happens to be available for study — into something that might be useful. While it would be easy to dismiss out of hand the listless findings of this study of data-convenience, the danger here is they may well provide yet more ammunition for skeptical payers not to pay for more care that numerous studies have shown patients desperately need.

The authors make a valiant effort with an elegant study design to glean what they can from the “natural experiment” of analyzing pre- and post-natal care delivered to pregnant patients before and after the implementation of Accountable Care Organizations in Massachusetts. But as another old saw goes: when you have a hammer, everything looks like a nail; and patient enrollment in a primary care ACO, as with this dataset, hardly counts as an independent variable with much power to predict the care utilization and outcomes of maternity care for covered enrollees.

It is well established in the literature – not to mention an accepted truism among providers and patients – that when most women become pregnant, the bulk of their care shifts from the primary care setting to obstetrician/gynecologists (OB/GYNs) and certified nurse-midwives (CNMs). Many researchers and clinicians believe that much of this shift occurs even before a confirmed pregnancy, as a consequence of fertility challenges and pregnancy planning.

The authors did find that pregnant patients newly enrolled in ACOs had a small increase in the number of pre- and post-natal visits.

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Why We Still Kill Patients (And What We Need to Stop Doing It)

By MICHAEL MILLENSON

This article is adapted from a talk given Sept. 7 at the 11th Annual World Patient Safety, Science & Technology Summit in Irvine, California, sponsored by the Patient Safety Movement Foundation. World Patient Safety Day is Sept. 17, with a series of events in Washington, D.C. from Sept. 15-17 sponsored by Patients for Patient Safety (US). An agenda and registration, which is free, can be found here.

Since I started researching and writing about patient safety, one question has continually haunted me: given the grievous toll of death and injury from preventable medical harm that has been documented in the medical literature for at least 50 years, why have so many good and caring people – friends, family, colleagues – done so little to stop it?

To frame that question with brutal candor: Why do we still kill patients? And how do we change that? The answer, I believe, lies in addressing three key factors: Invisibility, inertia and income.”

When it comes to invisibility, we’ve all heard innumerable times the analogy with airline safety; i.e., plane crashes occur in public view, but the toll taken by medical error occurs in private. That’s true and important, but there are other factors that promote invisibility that we in the patient safety movement need to address.

For instance, while I’m not a physician, I can say with certainty that every patient harmed in the hospital had a diagnosis (right or wrong), and often more than one. Yet disease groups such as the American Heart Association and American Cancer Society have been uninvolved in efforts to eliminate the preventable harm that’s afflicting their presumed constituents.

Why have we let these influential groups sit on the sidelines rather than make them integral partners in raising public and policy visibility? For instance, there are a number of Congressional caucuses – bipartisan groups of legislators – focusing on cancer. While much attention is paid to the Biden administration’s cancer moonshot, what about the safety of cancer patients treated today, while we wait for an elusive cure?

In a similar vein about missed opportunities for visibility, the stories told by patient advocates about the harm a loved one has suffered are always powerful. However, the specific hospital where the harm took place is typically not mentioned, perhaps for legal reasons, perhaps because it’s become a habit. The effect, however, is to dilute the visibility of the danger. The public is not confronted with the uncomfortable reality that my reputable hospital and doctor in a nice, middle-class area could cause me the same awful harm.

Finally, one time-tested way to hide a problem is to use obscure language to describe it. Back in 1978, RAND Corporation published a paper provocatively entitled, “Iatrogenesis: Just What the Doctor Ordered.” It concluded: “In terms of volume alone, we are awash in iatrogenesis.”  

That would have been a compelling soundbite decades before the 1999 To Err is Human report if everyone in America studied ancient Greek. “Iatrogenesis” is a Greek term meaning “the production of disease by the manner, diagnosis or treatment of a physician.” In short, patient harm is “what the doctor ordered.” Although there was plain English in the paper, the technical focus allowed the stunning prevalence of patient harm to remain publicly invisible.

Of course, today we don’t need to use a foreign language to hide unpleasantness. We can use jargon and euphemism. We have “healthcare-acquired conditions” and “healthcare-associated infections.” At least the Greek term acknowledged causality and responsibility.

The invisibility of the scope and causes of patient harm leads inevitably to inertia and complacency.

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The Doctors Who’ve Helped Patients Declare Their Independence

By MICHAEL MILLENSON

“A reform,” wrote a 19th-century British parliamentarian, “is a correction of abuses. A revolution is a transfer of power.”

As we celebrate the American Revolution, catalyzed by men who broke ranks with their peers to overthrow a power structure that seemed immutable, let’s also celebrate those physicians who broke with their peers and declared independence for American patients.

The British Empire believed it was exercising “benign colonialism.” Physicians, similarly, traditionally believed “that patients are only in need of caring custody,” observed psychiatrist Jay Katz in his 1984 book, The Silent World of Doctor and Patient. As a result, doctors thought it their moral duty to act as “rational agents” on the patient’s behalf.

The first spark to set that notion on fire came immediately after World War II with the publication of a book, The Common Sense Book of Baby and Child Care, that became a surprise best-seller. Dr. Benjamin McLane Spock, author and pediatrician, told parents that their common sense was often as reliable a guide as any doctor’s advice.

At the time, the American Medical Association’s Code of Medical Ethics advised physicians that “reasonable indulgence should be granted to the caprices of the sick.” Even though new moms were not ill, many pediatricians nonetheless deemed it entirely unreasonable for them to decide when to feed their babies. Instead, the doctors gave them given feeding schedules.

Spock, in contrast, reassured moms that centuries of human history showed they could decide for themselves when to feed their infant, doing so “when he seems hungry, irrespective of the hour.”

As I wrote in a history of participatory medicine, as those babies grew into adulthood, they “would use legal, economic and political pressure to undermine a medical culture that genuinely believed sharing too much information could be harmful.”

Along that journey, however, patients would acquire crucial help from doctors with the imagination and courage to think and to act outside the existing paradigm.

It wasn’t a quick process. As with the American Revolution, the abuses had to accumulate and resistance had to build. In 1970, a group of Boston feminists frustrated by a system that told them to listen to their doctor and not ask questions published a booklet entitled Women and Their Bodies. One year later, a court decision resulting from a malpractice case required physicians for the first time to specifically disclose the full risks of a procedure in language the patient could understand. A year after that, in 1973, what had become the Boston Women’s Health Collective published Our Bodies, Ourselves. The book has sold millions of copies.

Also in 1973, the American Hospital Association, facing the threat of Congressional action, adopted a “patient bill of rights” that contained such guarantees as patients having the right to know the names of all the physicians treating them!

Meanwhile, a handful of doctors started chipping away at the medical pedestal, with research uncovering common abuses of power like unnecessary tonsillectomies and hysterectomies. John Wennberg, working with colleagues who deployed nascent computer capabilities, demonstrated enormous variation in even the everyday practice of doctors in the same area seeing the same kind of patients. The “caprices” of judgment, it seemed, were not just a patient problem.

Peer-reviewed medical journals rejected Wennberg’s first article. The university where he worked pushed him to find a different employer. Physician colleagues shunned him. But as policymakers’ concern over soaring medical costs grew, Wennberg’s work went mainstream.

“Inevitably, once you start down the variation path and ask which rate is right, you come up against who’s making the decision and whose preferences are being reflected,” Wennberg later said. “That’s where the revolutionary aspects of what we’re doing really are.”

Following that logic, Wennberg and a fellow physician, Albert G. Mulley, Jr. – who had experienced the impact of practice variation when trying to treat his severe back pain – in 1989 formed the Foundation for Informed Medical Decision Making. Its mission was to develop and disseminate video programs enabling patients to become partners in their care.

It was Wennberg who recommended Katz’s book to me, with its extraordinary statements about doctor “fantasies” of “authoritarian control” and its blunt accusation that doctor’s reluctance to involve patients in jointly thinking about care choices constitutes psychological “abandonment.”

Like Wennberg, Paul Ellwood, who’d coined the term “health maintenance organization,” also tried to put shared decision-making into practice. In 1988, he called for adoption of “a technology of patient experience.” In 1995, he founded the Foundation for Accountability (FACCT), with tools such as “CompareYourCare” to help patients play a more active role in medical decisions.

Meanwhile, Harvey Picker, a successful businessman who said he wanted the health care system to treat patients as persons, not as “imbeciles or inventory,” joined with the Commonwealth Fund to support a group of researchers who promised to promote what Tom Delbanco, the lead physician, called “patient-centered care.” The group’s 1993 book, Through the Patient’s Eyes, helped popularize the concept, which a 2001 report by Institute of Medicine formally designated as one of six aims for the health care system

It was Delbanco who with colleagues in the first decade of the 21st century founded the “open notes” movement to give patients the right to see the doctor’s notes that were still a hidden part of the electronic health record. That push eventually led to legislation and regulations giving patients full access to all their EHR information.

But, of course, by then there was another doctor the public was increasingly turning to: “Dr. Google,” also known as “the Internet.” In 1996, Dr. Tom Ferguson, who had been medical editor of the Whole Earth Catalog, wrote a book entitled, Health Online: How to Find Health information, Support Groups, and Self-Help Communities in Cyberspace. Three years after his death in 2006, a group of physicians and patients would found the Society for Participatory Medicine, following the principles of an individual CNN would call the “George Washington of the empowered patient movement.”

None of these physician revolutionaries acted in a vacuum. While all faced resistance, they also had support from colleagues, physicians and non-physicians alike. Eventually, they were reinforced by patient activism, public opinion, legal requirements and, at a glacial pace, changes in the culture of medicine. Those changes, in turn, came about because of the work of physicians like Donald Berwick, Paul Batalden, Leana Wen, Victor Montori, Danny Sands and many others.

Still, it is those physicians who over the years repeatedly acted to free patients from “authoritarian control” – even if their language was more diplomatic – that blazed the path.

Michael L. Millenson is president of Health Quality Advisors LLC, and author of the classic Demanding Medical Excellence. He can be reached at michael@healthqualityadvisors.

Is getting people off weight loss medications the right move?

By RICHARD FRANK

Demand for GLP-1 medications soared last year and shows no signs of stopping in 2024. Employers and health plans are understandably anxious about how long they should expect to pay for these pricey drugs. They’re itching for an easy off-ramp.

Some solutions are cropping up to pave the way. Many of them claim they can help patients reap the benefits of GLP-1s within a short time frame, and get them off the drugs within 12 months to save costs. But the data doesn’t support that promise. In fact, studies suggest some patients may need to stay on the drugs indefinitely to sustain outcomes while other patients may be able to discontinue the drugs and at least maintain their cardiometabolic risk reduction even if they cannot maintain all of their weight loss. 

A better strategy to control costs is to more accurately pinpoint those who really need the drugs—and keep those who don’t off of them from the start. Of course, there will be times when deprescribing is appropriate, and we need to clinically support patients through that process. But one-size-fits-all solutions centered on medication as a silver bullet to obesity are only setting up patients and payers for failure. Similarly, those whose sole promise is to deprescribe, don’t follow the evidence.

Prescribing GLP-1s with the goal to deprescribe is foolhardy

GLP-1s treat obesity, but they don’t cure it. GLP-1 agonists increase the body’s own insulin production and slow the movement of food from the stomach to the small intestine. The drugs help people eat less by curbing cravings and boosting satiety. Studies show that once people go off semaglutide, the cravings come back in full force—and so does much of the weight.

While GLP-1 medications produce nearly miraculous outcomes in some people, they’re no quick fix. Obesity is a complex chronic disease. Drugs alone can’t solve for genetic predisposition, behaviors, mental and emotional components, social determinants of health, and other compounding elements that contribute to obesity. In the right circumstances, drugs can give people a solid leg up in better managing those contributing factors—but they’re not for everyone.

Keto is not a sustainable replacement for GLP-1s

Highly restrictive diets like the keto diet aren’t for everyone either. Keto requires a drastic reduction in carbohydrate intake, which can be difficult to maintain long-term. Not to mention, the high-fat content of keto diets can also lead to other health issues and isn’t conducive to tapering off of GLP-1 medications. Side effects from the drugs can make a high-fat diet difficult to tolerate.

It’s good to be wary of solutions that promise an off-ramp by way of highly restrictive diets. While a keto diet may help people lose weight in the short term, studies show that weight loss is rarely sustained over the long run and may be detrimental to overhaul health. The diet is associated with many complications that often lead to hospital admissions for dehydration, electrolyte disturbances, and hypoglycemia.

Triage the right care to the right people at the right time

Obesity’s complex nature requires a personalized approach to treatment that delivers the right care to the right people at the right time. That takes a whole care team of specialized providers—like registered dietitians, health coaches, and prescribing physicians to help people at various stages of the disease. And since obesity often occurs alongside other cardiometabolic conditions like hypertension, diabetes, COPD, and more, patients need the help of specialists who understand how those different conditions interact.

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An Urgent Call to Raise Awareness of Heart Disease in Women

By KELLY CARROLL

There is a dire need to raise awareness about heart disease in women. It is the number one killer of American women, and key data points reveal a lack of cognizance among doctors and women.

An assessment of primary care physicians published in 2019 revealed that only 22% felt extremely well prepared to evaluate cardiovascular disease risks in female patients. A 2019 survey of American women showed that just 44% recognized heart disease as the number one cause of death in women. Ten years earlier, in 2009, the same survey found that 65% of American women recognized heart disease as the leading cause of female death, revealing an alarming decline in awareness. 

Recent evidence suggests that many adults don’t know the important health numbers that can help identify heart disease risk factors, like their blood sugar and cholesterol. A 2024 survey of American adults conducted by The Ohio State University Wexner Medical Center found that only 35% of adults knew their blood pressure and 16% of adults knew their cholesterol levels. In comparison, the study reported that 58% knew their childhood friend’s birthday.

Heart Disease Risk Factors in Women

Women have specific risk factors for heart disease that don’t pertain to men. Nanette Wenger, M.D., a cardiologist and researcher, said in an American Heart Association (AHA) statement, “For most of the last century, heart disease was considered a problem for men, and women were believed to have cardioprotective benefits from female sex hormones such as estrogen. However, emerging evidence shows that there are a substantial number of heart disease risk factors that are specific to women or predominant in women.” Some gender-specific risk factors outlined by the AHA are early onset of menstruation, early menopause, autoimmune disease, anxiety, depression, and pregnancy complications.

Bethany Barone Gibbs, Ph.D., an associate professor at West Virginia University, emphasized in an email that pregnancy is a “critical window” for women’s cardiovascular health. She said, “The cardiovascular and metabolic challenge of pregnancy may unmask risk for conditions like hypertension and diabetes, but it is also possible (though not yet clear) that experiencing an adverse pregnancy outcome may independently contribute to the development of maternal cardiovascular disease.” A history of adverse pregnancy outcomes can be associated with more than two times the risk of cardiovascular disease later in life, she explained. 

Filling in knowledge gaps regarding the connections between pregnancy and long-term cardiovascular health is important to improving outcomes.

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The Long and Tortured History of Alpha-Synuclein and Parkinson’s Disease

By STEVEN ZECOLA

This study tracks the decades-long journey to harness alpha-synuclein as a treatment for Parkinson’s disease. Steven Zecola an activist who tracks Parkinson’s research and was on THCB last month discussing it, offers three key changes needed to overcome the underlying challenges.

A Quick Start for Alpha-Synuclein R&D

In the mid-1990’s, Parkinson’s patient advocacy groups had become impatient by the absence of any major therapeutic advances in the 25 years since L-dopa had been approved for Parkinson’s disease (PD).

The Director of National Institute of Neurological Disorders and Stroke (NINDS) set up a workshop in August 1995 that featured scientists with expertise in human genetics who might open novel avenues for PD research.

One such scientist, Robert Nussbaum, made the following remarks at the workshop:

“…finding genes responsible for familial Parkinson’s should be helpful for understanding all forms of the disease. Techniques now available should allow researchers to find the genes responsible for familial Parkinson’s disease in a relatively short time.”

Two years later in 1997, Spillantini et al. showed that alpha-synuclein (A-syn) was a major contributor of abnormal clusters of proteins in the brain, not only in patients with synuclein mutations but, more importantly, in patients with sporadic Parkinson’s disease as well.

As Nussbaum had predicted, progress had occurred rapidly. President Clinton in his 1998 State of the Union address, said:

“Think about this, the entire store of human knowledge now doubles every 5 years. In the 1980’s, scientists identified the gene causing cystic fibrosis. It took 9 years. Last year scientists located the gene that causes Parkinson’s disease in only 9 days.”

The NIH is Asked to Take a Leadership Role

Shortly after President Clinton’s call to action, a Senate Committee asked the National Institutes of Health (NIH) to develop a coordinated effort to take advantage of promising opportunities in PD research.

In response, the NIH and the National Institute of Neurological Disease and Stroke (NINDS) held a major planning meeting that included all components of the PD community. The group’s recommendations formed the basis of a five-year PD Research Agenda.

The Research Agenda was codified in a comprehensive 42-page report that covered all aspects of research from better understanding the disease, to creating new research capabilities, to developing new treatments, and to enhancing the research process.

Noting the “remarkable paradigm shift in Parkinson’s disease research” from the discovery of the effects of alpha-synuclein, the report stated that:

“New insights into the role of synucleins in the pathobiology of Parkinson’s disease would accelerate discovery of more effective therapies and provide fresh research opportunities to advance our understanding of Parkinson’s disease”.

NIH invested nearly $1 billion from FY 2000 to FY 2004 to implement the PD Research Agenda.  A-syn research would be funded out of the funds allocated to the categories of Genetics and Epidemiology, with both categories targeted to receive about 15% of the overall spending.

Overall, there were 19 broad categories with spending authorizations, including $32.7 million allocated to Program Management and Direction.

When the PD Research Agenda reached the end of its 5-year span, NINDS sponsored a second PD Summit which was held in June 2005.  It brought together an industry-wide consortium to assess the progress over the previous five years and to develop future directions for PD research.

The participants generated more than fifty specific recommendations.  NIH considered these plans and the unmet goals from previous efforts and developed a 3-year Plan.

A major focus of that Plan was to identify and intervene with the causes of PD.

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Patients are Not “Consumers”: My Cancer Story 

By JEFF GOLDSMITH

On Christmas Eve 2014, I received a present of some profoundly unwelcome news: a 64 slice CT scan confirming not only the presence of a malignant tumor in my neck, but also a fluid filled mass the size of a man’s finger in my chest cavity outside the lungs. Two days earlier, my ENT surgeon in Charlottesville, Paige Powers, had performed a fine needle aspiration of a suspicious almond-shaped enlarged lymph node, and the lab returned a verdict of “metastatic squamous cell carcinoma of the head and neck with an occult primary tumor”. 

I had worked in healthcare for nearly forty years when cancer struck, and considered myself an “expert” in how the health system worked. My experience fundamentally changed my view of how health care is delivered, from the patient’s point of view. Many have compared their fight against cancer as a “battle”. Mine didn’t feel like a battle so much as a chess match where the deadly opponent had begun playing many months before I was aware that he was my adversary. The remarkable image from Ingmar Bergman’s Seventh Seal sums up how this felt to me.

The CT scan was the second step in determining how many moves he had made, and in narrowing the uncertainty about my possible counter moves. The scan’s results were the darkest moment: if the mysterious fluid filled mass was the primary tumor, my options had already dangerously narrowed. Owing to holiday imaging schedules, it was not until New Years’ Eve, seven interminable days later, that a PET/CT scan dismissed the chest mass as a benign fluid-filled cyst. I would require an endoscopy to locate the still hidden primary tumor somewhere in my throat.  

I decided to seek a second opinion at my alma mater, the University of Chicago, where I did my doctoral work and subsequently worked in medical center administration.

The University of Chicago had a superb head and neck cancer team headed by Dr. Everett Vokes, Chair of Medicine, whose aggressive chemotherapy saved the life and career of Chicago’s brilliant young chef, Grant Achatz of Alinea, in 2007.

If surgery was not possible, Chicago’s cancer team had a rich and powerful repertoire of non-surgical therapies. I was very impressed both with their young team, and how collaborative their approach was to my problem. Vokes’ initial instinct that mine was a surgical case proved accurate.

The young ENT surgeon I saw there in an initial consultation, Dr. Alex Langerman performed a quick endoscopy and thought he spotted a potential primary tumor nestled up against my larynx. Alex asked me to come back for a full-blown exploration under general anaesthesia, which I did a week later. The possible threat to my voice, which could have ended my career, convinced me to return to Chicago for therapy. Alex’s endoscopy found a tumor the size of a chickpea at the base of my tongue. Surgery was scheduled a week later in the U of Chicago’s beautiful new hospital, the Center for Care and Discovery.

This surgery was performed on Feb 2, 2015, by a team of clinicians none of whom was over the age of forty. It was not minor surgery, requiring nearly six hours:  resections of both sides of my neck, including the dark almond and a host of neighboring lymph nodes. And then, there was robotic surgery that removed a nearly golf ball-sized piece of the base of my tongue and throat. The closure of this wound remodeled my throat.

I arrived in my hospital room late that day with the remarkable ability to converse in my normal voice.

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Stephanie Strong, CEO, Boulder

Stephanie Strong is the CEO of Boulder, which has been blazing a trail in the virtual treatment of substance use disorder. She left venture capital to start the company and has been steadily building its capabilities and reach. We talked in depth about how Boulder helps its patients, who are predominantly on Medicaid and in general tend–as you’d expect–not to have easy circumstances. One remarkable thing Stephanie has done is spearhead resistance to the DEA’s proposal to ban telehealth prescribing of the anti-addiction drug Buprenorphine. And it looks like that campaign has been successful. that alone will save many lives. Watch this interview of a young female CEO who is making a real difference, and totally impressing me in the process—Matthew Holt

About That New Generation of Clinicians

By KIM BELLARD

I saw a report last week – Clinician of the Future 2023 Education Edition, from Elsevier Health – that had some startling findings, and which didn’t seem to garner the kind of coverage I might have expected.  Aside from Elsevier’s press release and an article in The Hill, I didn’t see anything about it.  It’s worth a deeper look.

The key finding is that, although 89% say they are devoted to improving patients’ lives, the majority are planning careers outside patient care.  Most intend to say in healthcare, mind you; they just don’t see themselves staying in direct patient care.

We should be asking ourselves what that tells us.

The report was based on a survey of over 2,000 medical and nursing students, from 91 countries, as well as two roundtable sessions with opinion leaders and faculty in the United States and United Kingdom.  Since I’m in the U.S. and think most about U.S. healthcare, I’ll focus mostly on those respondents, except when they’re not split out or where the U.S. responses are notably different.

Overall, 16% of respondents said they are considering quitting their medical/nursing studies (12% medical, 21% nursing), but the results are much worse in the U.S, especially for medical students – 25% (nursing students are still 21%).  That figure is higher than anywhere else. Globally, a third of those who are considering leaving are planning to leave healthcare overall; it’s closer to 50% in the U.S.

Tate Erlinger, vice president of clinical analytics at Elsevier, noted: “There were several things [that] sort of floated to the top at least that caught my attention. One was sort of the cost, and that’s not limited to the U.S., but the U.S. students are more likely to be worried about the cost of their studies.”  Overall, 68% were worried about the cost of their education, but the figure is 76% among U.S. medical students (and for UK medical students).  

Having debt from their education is a factor, as almost two-thirds of nursing students and just over half of medical students are worried about their future income as clinicians, with U.S. medical students the least worried (47%).

It’s worth noting that 60% are already worried about their mental health, and the future is daunting: 62% see a shortage of doctors within ten years and 64% see a shortage of nurses. Globally, 69% of students (65% medical, 72% nursing) are worried about clinician shortages and the impact it will have on them as clinicians.

Where it gets really interesting is when asked: “I see my current studies as a stepping-stone towards a broader career in healthcare that will not involve directly treating patients.” Fifty-eight percent (58%) agreed (54% medical, 62% nursing). Every region was over 50%. In the U.S., the answer was even higher – 61% overall (63% medical, 60% nursing).

Dr. Sanjay Desai, one of the U.S. roundtable panelists, said: “I know this might evolve as they go through their education, but 6 out of 10 in school, when we hope that they’re most excited about that career, are looking at it with skepticism. That is surprising to me.” 

Me too.

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