Category: Medicine

“What is wrong with physicians?” (from the comments)

My top candidates:

1. Loss of locus of control. People go into medicine to save lives. They believe that they will use their demonstrated intelligence and skills to make a difference. Unfortunately, modern medicine is ever more about turning physicians into box checkers. CPT codes, checklists, facility mandates, perpetual boards … a physician quickly loses control of their working day unless they are weird freaks who do extensively more work to retain control. And beyond that the average physician becomes enculturated to this much earlier. Which medical school you get into is largely a function of where you grew up, went to undergrad, and exactly how well you did on a test that everyone aces with a side of barely legal implicit racial quotas. Your residency is determined by where you went to medical school, where you went to medical school, where/what the top candidates want, and how well you did on a test that everyone aces with a side of barely legal implicit racial quotas. You spend a decade where your locus of control in life is minimal. Then you hit the real world and rather than being set free, you get hit by unending paperwork and yet a thousandth petty demand on your time. If you do research it is not uncommon to spend multiplicatively more time on compliance paperwork. If you head out to make money, you will find that your charge capture is more relevant than the quality of care you provide by an order of magnitude. All of this is a textbook case of loss of locus of control that we know is highly correlated with drug use and depression.

2. There is a wild disconnect between “being a physician” as understood by the public and what you actually live. The public thinks this is still the 1980s when you could pay for medical school working a summer job, residency was three years, and salaries were higher in real terms than they are today. Instead, physicians spend much closer to fifteen years going through training as the needed resume padding has grown at every step along the way. This means that they live longer at resident salaries which are close to US median, but typically are located in high population areas with expensive housing costs. And being a resident physician is not cheap. You have high commuting costs because the regs allow your boss to work you 24 out of 28 days. You can, and will, have weeks with over 100 hours of actual patient care. And again, remember that something like half of residencies are in violation of these rules. And all of this is while nursing a second mortage in undischargable medical school debt. Everyone will think you are rich and that you take fine vacations to Europe and the you will drive a flashy care. And maybe you will, but it will not be until after you are 40 and often 45 that the full physician lifestyle of the movies really comes into play.

3. And then we have the stakes. At every step in a physicians formative adult years you face massive ultra-high stakes events that we know are bad for mental health. College admissions (where you will hit a ceiling for medical schools if you get in too low), MCAT and medical school admissions (which will drastically lower your access to certain specialties if you end up having to go DO), Step and the Match (where you will spend five figures to beg for interviews, the folks on the other side will be unable to differentiate you from the thousands of other applicants, and when you get the interview the only thing of meaning that will come forth is if they like you and if you grew up nearby). Then you have boards and your first job. All of these are massively high stakes and they all require performing quite well relative to your peers. This sort of setup is known in experimental animals and people to lead to depression, anxiety disorders, and drug use.

3. Then we have the punctuated nature of the physician’s life. Going back to medical school, you routinely have long weeks with minimal time to enjoy because studying is rampant. Your entire career can theoretically hang on if you memorized which ultra-rare cancer is caused by which mutation in which gene – even if you want to be a psychiatrist. When you have time “off” this may be the only time you get and there is a very strong tendency toward binges and bacchanals. This will continue to residency where you might have one free weekend in a month (the others being taken up with working and studying), which again lends itself toward binging. And it may continue from there with horrid call schedules and long weeks punctuated by long vacations.

4. The stakes never get lower. You go through with your career riding on high stakes tests and your studying time never being accounted for in your official duties. Boards are now never ending and you face ever more theoretically threatening liability for your decisions.

5. And then there is the obvious stuff. Day in, day out you meet people at their worst. And all your coworkers are doing the same. People cry, threaten, swear, and otherwise abuse you. And nobody wants to get mad at somebody who was just paralyzed from the waist down. Likewise, you can only become so inured to death and dying, we are a social species with extremely large portions of our brains dedicated to feeling empathy for others, physicians see the 5% of humanity who is most obviously suffering as their modal patient.

6. Lastly, whatever you think about physician renumeration, it becomes painfully evident that the golden days were decades ago and there is a small army looking for ways to reduce your renumeration. It will fall disproportionately on you even when the major growth in medical expenses has been nursing, administration, and other warm bodies. Whatever you got paid for a highly taxing job last year, there will be a thousand signs that people think you should do it again for less. People who believe wholeheartedly in the stickiness of wages for reasons of morale and who hold that pay cuts are sufficiently difficult that we need to order international finance around inflation and obviating the need for explicit wage reductions will turn around and concoct wild schemes that explicitly reduce your income in real and nominal terms and question your character should your professional organization (to which you don’t belong) object. All, of course, while the administrators who are generally incompetent at understanding medical practice rake in an ever larger share of the money.

Some of this is US specific, but we have set up medicine to be highly backloaded with its rewards for physicians. We have risen the profession to a vocation and made it a truly arduous task to get through. And at every step along the way physicians have not had access to healthy coping mechanisms and repeated psychic injuries of the sort known to cause or exacerbate these conditions. Major life protective events (e.g. marriage, children, home ownership) are routinely delayed and disrupted by the demands of the training. Why again are we surprised that physicians come out bruised, batter, and willing to take the short term fix for some relief?

That is all from Sure.

One scenario for Omicron

That is the theme of my latest Bloomberg column, here is one excerpt:

How will institutions react to a proliferation of cases?

Imagine that a significant percentage of students in a school test positive, but no one is seriously ill. Will that school feel compelled to shut down and move to remote learning?

One possibility is that administrators will realize that virtually everyone is going to catch omicron anyway, articulate that reality to their constituencies, and plough ahead with face-to-face instruction. An alternate scenario is that the mere mention of Covid will prove so scary that closure will be inevitable. After all, how much will be known a month or two from now about the prospects of getting Long Covid from omicron? I am expecting a lot of school closures.

Another habit that will be hard to break is tracking the severity of the virus by counting cases. Until now, cases have been pretty good predictors of subsequent hospitalizations and then deaths. If cases become more detached from bad outcomes, will institutions and authorities be able to respond rapidly to that new reality? By the time they adjust, if they do, omicron might have come and gone.

To those who are inclined to worry, it will be scary how quickly omicron cases accumulate. It might feel as if the apocalypse has arrived, even if a lot of that short-term case activity is simply an acceleration of illness rather than an increase in the year’s total. (How scared would we get if most of the year’s murders happened in the first six or eight weeks of the year?) In any case, hospitals will have to be ready. But it is likely that a lot of health-care professionals might test positive early next year as well.

There is much more at the link.

Model this what is wrong with physicians?

Compared to differences among their male patient counterparts, female patients randomly assigned a female doctor rather than a male doctor are 5.0% more likely to be evaluated as disabled and receive 8.5% more subsequent cash benefits on average. There is no analogous gender-match effect for male patients.

And is it the male or female physicians who are at fault here?  Or is this diagnostic differential somehow optimal?

Here is the full NBER paper by Marika Cabral and Marcus Dillender.

What is wrong with physicians?

There is evidence that physicians disproportionately suffer from substance use disorder and mental health problems. It is not clear, however, whether these phenomena are causal. We use data on Dutch medical school applicants to examine the effects of becoming a physician on prescription drug use and the receipt of treatment from a mental health facility. Leveraging variation from lottery outcomes that determine admission into medical schools, we find that becoming a physician increases the use of antidepressants, opioids, anxiolytics, and sedatives, especially for female physicians. Among female applicants towards the bottom of the GPA distribution, becoming a physician increases the likelihood of receiving treatment from a mental health facility.

That is from a new NBER working paper by D. Mark Anderson, Ron Diris, Raymond Montizaan, and Daniel I. Rees.  Is it personality type?  Or the ease of opportunity?  The stress of the job?  Or something else?

Claims about placebos

…the placebo effect in the United States has actually become quite a lot stronger over time, meaning that drugs that once would have been approved may not be now – because their performance relative to that of placebo is less convincing. This study makes the point clearly – by 2013, drugs produced 8.9% more pain relief than placebos, compared to 27.3% in 1996. In the charts above, it can be seen that the effect of placebo drugs has increased a lot, whereas the effectiveness of pain relief drugs has barely changed, meaning that the treatment advantage (the effectiveness of active drugs as opposed to placebos) has fallen dramatically. Weirdly, it seems like this is only happening in the United States, whereas other countries haven’t seen particularly large increases in the effect size of placebos.

That is from the Substack of Sam.  Hail Bruno M.!

Jason Abaluck writes me about masks and the Bangladesh RCT study

This is all him, no double indent though:

“As a regular reader of your blog and one of the PIs of the Bangladesh Mask RCT (now in press at Science), I was surprised to see your claim that, “With more data transparency, it does not seem to be holding up very well”:

  1. The article you linked claims, in agreement with our study, that our intervention led to a roughly 10% reduction in symptomatic seropositivity (going from 12% to 41% of the population masked). Taking this estimate at face value, going from no one masked to everyone masked would imply a considerably larger effect. Additionally:
    1. We see a similar – but more precisely estimated – proportionate reduction in Covid symptoms [95% CI: 7-17%] (pre-registered), corresponding to ~1,500 individuals with Covid symptoms prevented
    2. We see larger proportionate drops in symptomatic seropositivity and Covid in villages where mask-use increased by more (not pre-registered), with the effect size roughly matching our main result

The naïve linear IV estimate would be a 33% reduction in Covid from universal masking. People underwhelmed by the absolute number of cases prevented need to ask, what did you expect if masks are as effective as the observational literature suggests? I see our results as on the low end of these estimates, and this is precisely what we powered the study to detect.

  1. Let’s distinguish between:
    1. The absolute reduction in raw consenting symptomatic seropositives (20 cases prevented)
    2. The absolute reduction in the proportion of consenting symptomatic seropositives (0.08 percentage points, or 105 cases prevented)
    3. The relative reduction in the proportion of consenting symptomatic seropositives (9.5% in cases)

Ben Recht advocates analyzing a) – the difference in means not controlling for population. This is not the specification we pre-registered, as it will have less power due to random fluctuations in population (and indeed, the difference in raw symptomatic seropositives overlooks the fact that the treatment population was larger – there are more people possibly ill!). Fixating on this specification in lieu of our pre-registered one (for which we powered the study) is reverse p-hacking.

RE: b) vs. c), we find a result of almost identical significance in a linear model, suggesting the same proportionate reduction if we divide the coefficient by the base rate. We believe the relative reduction in c) is more externally valid, as it is difficult to write down a structural pandemic model where masks lead to an absolute reduction in Covid regardless of the base rate (and the absolute number in b) is a function of the consent rate in our study).

  1. It is certainly true that survey response bias is a potential concern. We have repeatedly acknowledged this shortcoming of any real-world RCT evaluating masks (that respondents cannot be blinded). The direction of the bias is unclear — individuals might be more attuned to symptoms in the treatment group. We conduct many robustness checks in the paper. We have now obtained funding to replicate the entire study and collect blood spots from symptomatic and non-symptomatic individuals to partially mitigate this bias (we will still need to check for balance in blood consent rates with respect to observables, as we do in the current study).
  1. We do not say that surgical masks work better than cloth masks. What we say is that the evidence in favor of surgical masks is more robust. We find an effect on symptomatic seropositivity regardless of whether we drop or impute missing values for non-consenters, while the effect of cloth masks on symptomatic seropositivity depends on how we do this imputation. We find robust effects on symptoms for both types of masks.

I agree with you that our study identifies only the medium-term impact of our intervention, and there are critically important policy questions about the long-term equilibrium impact of masking, as well as how the costs and benefits scale for people of different ages and vaccination statuses.”

An update on the mask debate

I am long since tired of this debate, and I see that a lot of people are not joining it in the best of faith.  I can pass along a few updates, namely this study, with some critical commentary attached.  And here is more on the Bangladeshi mask RCT.  With more data transparency, it does not seem to be holding up very well.

That said, I am not sure that either calculation really matters.  Any good assessment of mask efficacy has to be radically intertemporal in nature, and I mean for the entirety of the pandemic.  “Not getting infected” now may well raise your chance of getting infected later on, and that spans for longer than any feasibly designed RCT.  And have you heard about the new “Nu” variant?  It may turn out not to matter, but it does remind us that the pandemic is not over yet.

As a simple first approximation, think of the real value of masks as “a) how many infections are delayed for how long, plus improvements in treatment in the meantime, plus b) how many infections are avoided altogether.”  Even a well-designed RCT is going to focus on a version of b), but only for a limited period of time.  The extant studies don’t at all consider “plus improvements in treatment in the meantime,” or when some of those protected by masks for say a year or two might nonetheless later catch Covid later yet.  So those RCTs, no matter what their results, are grabbing only one leg of the elephant.

To make matters more complicated yet, a “very small” efficacy for masks might (yes, might) translate into a much larger final effect, due to effective R (sometimes) being greater than 1.  So finding a very small effect for masks doesn’t mean masks are only slightly effective.  As the pandemic is ending, you might (again might) have had one less “pandemic cycle” than if you hadn’t tried masks at all.  You can think of masks as a kind of lottery ticket on “one big gain,” paying off only when the timing is such that the masks have helped you choke off another Covid wave.  Again, the RCT is not capable of estimating that probability or the magnitude of its effect.

Yet another part of my mental model of masks has evolved to be the following.  You have two sets of countries, countries that manage Covid well and countries that don’t, argue all you want who goes into which bin but that isn’t the point right now.

Now consider the countries that don’t manage Covid well.  They might wish to stretch out their epidemics over time, so that better treatments arrive, subject to economic constraints of course.  But the countries that manage Covid well probably want the poorly-managed countries to reach herd immunity sooner rather than later, if only to lower the ongoing risk of transmission from a poorly-managed country to a well-managed country.  And to lower the risk of those countries birthing new variants, just as southern Africa now seems to have birthed the Nu variant.

So we have two major points of view, represented by multiple countries, one wanting quicker resolution for the poorly managed countries but the other wanting slower resolution.  Does any study of masks take those variables into account?  No.  Nor is it easy to see how it could.

To be clear, I am not arguing masks don’t work, nor am I making any claims about how much masks may or may not protect you individually, or the people you interact with.  I am claiming that at the aggregate social level we are quite far from knowing how well masks work.

I say it is third doses we should be doubling down on, not masks.  To be clear, I am fine with wearing masks myself, I am used to it, and I dislike it but I don’t hate it.  On this issue, I am not one of those people translating his or her own snowflake-ism into some kind of biased policy view.

But the emerging science on third doses is much stronger, and most countries have been dropping the ball on that one.

Air Pollution Reduces Health and Wealth

Great piece by David Wallace-Wells on air pollution.

Here is just a partial list of the things, short of death rates, we know are affected by air pollution. GDP, with a 10 per cent increase in pollution reducing output by almost a full percentage point, according to an OECD report last year. Cognitive performance, with a study showing that cutting Chinese pollution to the standards required in the US would improve the average student’s ranking in verbal tests by 26 per cent and in maths by 13 per cent. In Los Angeles, after $700 air purifiers were installed in schools, student performance improved almost as much as it would if class sizes were reduced by a third. Heart disease is more common in polluted air, as are many types of cancer, and acute and chronic respiratory diseases like asthma, and strokes. The incidence of Alzheimer’s can triple: in Choked, Beth Gardiner cites a study which found early markers of Alzheimer’s in 40 per cent of autopsies conducted on those in high-pollution areas and in none of those outside them. Rates of other sorts of dementia increase too, as does Parkinson’s. Air pollution has also been linked to mental illness of all kinds – with a recent paper in the British Journal of Psychiatry showing that even small increases in local pollution raise the need for treatment by a third and for hospitalisation by a fifth – and to worse memory, attention and vocabulary, as well as ADHD and autism spectrum disorders. Pollution has been shown to damage the development of neurons in the brain, and proximity to a coal plant can deform a baby’s DNA in the womb. It even accelerates the degeneration of the eyesight.

A high pollution level in the year a baby is born has been shown to result in reduced earnings and labour force participation at the age of thirty. The relationship of pollution to premature births and low birth weight is so strong that the introduction of the automatic toll system E-ZPass in American cities reduced both problems in areas close to toll plazas (by 10.8 per cent and 11.8 per cent respectively), by cutting down on the exhaust expelled when cars have to queue. Extremely premature births, another study found, were 80 per cent more likely when mothers lived in areas of heavy traffic. Women breathing exhaust fumes during pregnancy gave birth to children with higher rates of paediatric leukaemia, kidney cancer, eye tumours and malignancies in the ovaries and testes. Infant death rates increased in line with pollution levels, as did heart malformations. And those breathing dirtier air in childhood exhibited significantly higher rates of self-harm in adulthood, with an increase of just five micrograms of small particulates a day associated, in 1.4 million people in Denmark, with a 42 per cent rise in violence towards oneself. Depression in teenagers quadruples; suicide becomes more common too.

Stock market returns are lower on days with higher air pollution, a study found this year. Surgical outcomes are worse. Crime goes up with increased particulate concentrations, especially violent crime: a 10 per cent reduction in pollution, researchers at Colorado State University found, could reduce the cost of crime in the US by $1.4 billion a year. When there’s more smog in the air, chess players make more mistakes, and bigger ones. Politicians speak more simplistically, and baseball umpires make more bad calls.

As MR readers will know Tyler and I have been saying air pollution is an underrated problem for some time. Here’s my video on the topic:

The Covid pandemic is not taking the very best of turns

This was emailed to me, but I am not doing a double indent…in any case I fear the person might be right…

“The prevailing sentiment is that the COVID pandemic is close to over. The vaccines are of course miraculous but we are not currently on a good trajectory.

  • It is increasingly clear that two shots plus a booster of our current vaccines are the least one needs to have effective medium-term protection. Almost nowhere (least of all the US) is on track to reach this kind of coverage. The messaging in the US remains mistaken, where the CDC to this day recommends boosters only for those aged 50 and older. More broadly, the institutional confusion around boosters shows that the adults are not yet in charge.
  • Even though Delta arose in the spring, we are still vaccinating (and boosting) people with the original Wuhan strain. This is insane, and probably meaningfully less effective, and yet nobody is up in arms about it.
  • Severe outbreaks are manifestly possible even in exceptionally vaccinated populations, especially when booster uptake is low. See: Singapore, Gibraltar, Ireland. One should assume that almost every part of the US will see significant waves before COVID “ends”, whatever that turns out to mean. Note that just 60% of the US population is vaccinated today with two doses.
  • There is early suggestive evidence from Israel that boosters may wane.
  • Waning aside, it’s clear that breakthrough infections in boosted individuals are not uncommon. While the vast majority of those infections are not severe, this does mean that there will still be plenty of mutagenesis.
  • It’s unclear that longitudinal cross-immunity is strong. Getting COVID is not enough to confer long-term protection. We probably can’t just “get this over with”, even if we are willing to tolerate a large number of one-time deaths.
  • The currently-breaking news about the South African Nu strain shows that arguments about how the spike protein is running out of mutation search space are almost certainly wrong.
  • While the fog of war is thick right now, the early data on Nu suggests that it may be a big deal. Even if it’s not, however, it has been obvious since we got the vaccines that vaccine escape is a concern. You can debate whether the probability of a vaccine escaping variant is 20% or 80%, but in any case we need effective contingency plans in place. If we fail to respond effectively to Nu, that will be a considerably greater institutional failure than anything that happened at the outset of the pandemic. We’ve had almost two years since the first COVID case and one year from the vaccine approvals to prepare. So I ask: what is the plan for the vaccine-escaping variant?

On current trends, it looks like we will probably need one of two things to effectively end the pandemic: (1) very effective COVID therapeutics (paxlovid, molnupiravir, and fluvoxamine all being candidates but my guess is that none is a silver bullet) or (2) pan-coronavirus vaccines (with broader protection than what is currently available).

It isn’t over yet.

P.S. Has any U.S. health body recommended the clinical use of fluvoxamine (an already-approved drug), or has the FDA given any guidance as to when it might approve paxlovid? If not, can they outline their reasoning? 1,600 Americans died of COVID on Nov 24.”

Nu, a variant of real concern

Here is the Eric Topol thread.  Do read it.  Here is the scary graph, based on preliminary data.  Here is Bloom Lab.  Here is a layperson’s take from the Times of London:

When was the variant first discovered?
South African authorities raised the alarm at 2pm on Tuesday of this week, when they found samples with a significant number of worrying mutations.

The samples dated from tests taken on November 14 and 16. On Wednesday, even as scientists were analysing the genome, other samples were found in Botswana and China, originating from travellers from South Africa.

Why were scientists initially concerned by this variant?
The spike protein is the tool a virus uses to enter cells, and the part of it our vaccines are trained to spot. This variant had 32 mutations in the spike — meaning it would look different to our immune system and behave differently when attacking a body. As a virologist at Imperial College put it, it was a “horrific spike profile”.

Why has worry increased over the course of the week?
When geneticists and virologists looked at the mutations they realised there was a high likelihood they could increase its transmissibility or help it evade immunity. But these concerns were still theoretical. However, today South African scientists spotted a quirk in the testing regimen. PCR tests look for three genes in the coronavirus and amplify them. If, however, the virus was this variant they were only able to amplify two.

In the province of Gauteng, where the proportion of tests coming back positive has rocketed to one in three, they found the proportion in which only two genes were amplified has also rocketed.

What does this mean?
There are three options. It is still possible — though unlikely — this is chance, with the variant’s apparently increased spread relating to an unusual cluster. If it does have a genuine advantage, then it is either better able to spread or better able to infect people who have prior immunity — either from vaccination or infection. Or, it is both.

This might come to nothing, but it is definitely a matter of concern.  One more general point is that even if Nu is a non-event, it seems to show that the space for possible significant mutations is largely than we had thought.

By any other name

The Northern Territory’s Covid-19 outbreak is expected to grow beyond locked-down areas after nine new cases were detected in the remote community of Binjari, about 320km south of Darwin.

Binjari and nearby Rockhole have been placed into strict lockdown in response to the outbreak, and the Australian defence force has been called in to help with transferring positive cases and close contacts [sic].

The NT’s chief minister, Michael Gunner, on Sunday said a 78-year-old woman was being treated in Royal Darwin hospital, while the other eight cases had been taken to the Howard Springs quarantine centre.

Here is the full story.  And from another story:

“We’ve shared our supply of vaccine with Aboriginal health organisations so they had enough consistent supply for everyone in their care to have a chance to be vaccinated over the past seven months,” Gunner said in a statement.

I wonder what they think Gibraltar should do.  Didn’t all the Australians tell me on Twitter that things would be back to normal soon, once enough vaccines were distributed?

The weirdness of government variation in Covid-19 responses

That is the new Substack post from Richard Hanania, here is one excerpt:

But imagine at the start of the pandemic, someone had said to you “Everyone will face the existence of the same disease, and have access to the exact same tools to fight it. But in some EU countries or US states, people won’t be allowed to leave their house and have to cover their faces in public. In other places, government will just leave people alone. Vast differences of this sort will exist across jurisdictions that are similar on objective metrics of how bad the pandemic is at any particular moment.”

I would’ve found this to be a very unlikely outcome! You could’ve convinced me EU states would do very little on COVID-19, or that they would do lockdowns everywhere. I would not have believed that you could have two neighboring countries that have similar numbers, but one of them forces everyone to stay home, while the other doesn’t. This is the kind of extreme variation in policy we don’t see in other areas.

It’s similar when you look at American jurisdictions.

And:

As the political reaction to COVID-19 has surprised me, I’m still trying to figure it out. But for now I can say it’s shifted my priors in a few ways.

  1. People are more conformist than I would have thought, being willing to put up with a lot more than I expected, at least in Europe and the blue parts of the US.
  2. Americans in Red States are more instinctively anti-elite than I would have thought and can be outliers on all kinds of policy issues relative to the rest of the developed world (I guess I knew that already).
  3. Partisanship is much stronger than I thought. When I saw polls on anti-vax sentiment early in the pandemic, I actually said it would disappear when people would have to make decisions about their own lives and everyone could see vaccines work. This largely didn’t happen. Liberals in Blue States masking their kids outdoors is the other side of this coin. Most “Red/Blue Team Go” behavior has little influence on people’s lives. For example, deciding to vote D or R, or watch MSNBC or Fox, really doesn’t matter for your personal well-being. Not getting vaccinated or never letting your children leave the house does, and I don’t recall many cases where partisanship has been such a strong predictor of behavior that has such radical effects on people’s lives.
  4. Government measures that once seemed extreme can become normalized very quickly.
  5. The kinds of issues that actually matter electorally are a lot more “sticky” than I would have expected. Issues like masks and lockdowns, though objectively much more important than the things people vote on, are not as politically salient as I would have thought. A mask mandate for children eight hours a day strikes me as a lot more important than inflation, but it seems not to be for electoral purposes. If an asteroid was about to destroy earth and Democrats and Republicans had different views on how to stop it, people would just unthinkingly believe whatever their own side told them and it would not change our politics at all.
  6. Democratically elected governments have a lot more freedom than I thought before, especially if elites claim that they are outsourcing decisions to “the science.” Moreover, “the science” doesn’t even have to be that convincing, and nobody will ask obvious questions like how “the science” can allow for radically different policy responses in neighboring jurisdictions without much of a difference in results. This appears true everywhere in the developed world but in Red State America, where people really hate experts, regardless of whether they’re right or wrong.

You should all be getting Richard’s Substack.  Of all the “new thinkers” on the Right, he is the one who most combines extreme smarts and first-rate work ethic, with non-conformism thrown in to boot.  Read him!

The Great Resignation: Health Care Workers

We are short a million health care workers. Today with extreme stress on the system there are 16 million health care workers, about five hundred thousand fewer than when the pandemic began in January of 2020 and about one million fewer than would be expected based on decades of growth. A loss of this many workers is unprecedented.

Ed Yong in the Atlantic discusses Why Health-Care Workers are Quitting in Droves:

Health-care workers, under any circumstances, live in the thick of death, stress, and trauma. “You go in knowing those are the things you’ll see,” Cassandra Werry, an ICU nurse currently working in Idaho, told me. “Not everyone pulls through, but at the end of the day, the point is to get people better. You strive for those wins.” COVID-19 has upset that balance, confronting even experienced people with the worst conditions they have ever faced and turning difficult jobs into unbearable ones.

In the spring of 2020, “I’d walk past an ice truck of dead bodies, and pictures on the wall of cleaning staff and nurses who’d died, into a room with more dead bodies,” Lindsay Fox, a former emergency-medicine doctor from Newark, New Jersey, told me. At the same time, Artec Durham, an ICU nurse from Flagstaff, Arizona, was watching his hospital fill with patients from the Navajo Nation. “Nearly every one of them died, and there was nothing we could do,” he said. “We ran out of body bags.”

…Many health-care workers imagined that such traumas were behind them once the vaccines arrived. But plateauing vaccination rates, premature lifts on masking, and the ascendant Delta variant undid those hopes. This summer, many hospitals clogged up again. As patients waited to be admitted into ICUs, they filled emergency rooms, and then waiting rooms and hallways. That unrealized promise of “some sort of normalcy has made the feelings of exhaustion and frustration worse,” Bettencourt told me.

Health-care workers want to help their patients, and their inability to do so properly is hollowing them out. “Especially now, with Delta, not many people get better and go home,” Werry told me. People have asked her if she would have gone to nursing school had she known the circumstances she would encounter, and for her, “it’s a resounding no,” she said. (Werry quit her job in an Arizona hospital last December and plans on leaving medicine once she pays off her student debts.)

…Many have told me that they’re bone-weary, depressed, irritable, and (unusually for them) unable to hide any of that. Nurses excel at “feeling their feelings in a supply closet or bathroom, and then putting their game face back on and jumping into the ring,” Werry said. But she and others are now constantly on the verge of tears, or prone to snapping at colleagues and patients. Some call this burnout, but Gerard Brogan, the director of nursing practice at National Nurses United, dislikes the term because “it implies a lack of character,” he told me. He prefers moral distress—the anguish of being unable to take the course of action that you know is right.

Health-care workers aren’t quitting because they can’t handle their jobs. They’re quitting because they can’t handle being unable to do their jobs.

Hat tip: Matt Yglesias.