Is Health Law the Problem Underlying the Physician Shortage?

This week, the New York Times Sunday Review has an editorial arguing that the shortage of primary care physicians could be reduced if we drew more heavily upon other professions, including pharmacists and nurse practitioners, who may be able to provide care more efficiently.  The Affordable Care Act’s efforts to increase insurance coverage and eliminate cost-sharing for preventative care, will only exacerbate the shortage of primary care physicians.  More to the point, the editorial alleges that various state and federal laws create barriers to the sort of integration of healthcare professionals to address the shortage.

Those “scope of practice” laws were enacted to either protect consumers from incompetent healthcare or protect physicians from competition in the healthcare marketplace, or likely some mixture of both.  We know where mainstream physicians stand anyway.  In the words of the American Medical Association’s own newsletter,  “physicians [have] fought a blitz of scope-of-practice expansions by other health professionals on legislative, legal and regulatory fronts.”

The shortage of physicians is also a product of the number of young doctors that our medical schools are producing.  Although several new schools have launched in recent years, others are have actually shrunk due to budget cuts.

The Newtown Shootings, Gun Control, and Cultural Cognition

Like most (all?) of the blog readers, I find it difficult to return to my every day life this morning in the wake of the Newtown shootings. This post is not about the tragedy, nor is it a political or public health analysis of where to go next. Instead I want to offer a meta-thought on the debate itself. In the past 3 days my social media has lit up with postings, comments, etc, about the shooting. About 2/3 of my facebook friends are left of center and 1/3 right of center, and I’ve seen the usual back and forth about criminalizing gun ownership, “guns don’t kill people, people kill people,” the history of the Second Amendment, more guns in the hands of administrators would have solved the problem, etc.

What has struck me the most, though, is the way in which my very well-educated friends on both sides of the aisle understand the facts about guns and violence. As Dan Kahan and his co-investigators in the Cultural Cognition Project suggest in their study of gun control debates, individuals perceptions about the facts in the debate are highly dependent on world view. To quote from their webpage describing their gun control studies:

From the outset, the Cultural Cognition Project has been focused on the American gun control debate. That debate is naturally framed as one between competing risk perceptions: that too little gun control will increase deliberate shootings and gun accidents; and that too much will render law-abiding citizens unable to defend themselves from violent predation. Associated most famously with the work of Mary Douglas and Aaron Wildavsky, the cultural theory of risk posits that individuals selectively attend to risk in a way that reflects and reinforces their preferred vision of society. Consistent with this thesis, CCP members have found that which “gun risk” individuals take more seriously is indeed strongly predicted by their cultural worldviews. Persons who hold egalitarian and communitarian worldviews worry more about crime and gun accidents, an  anxiety that coheres with their negative association of guns with patriarchy, racism, and selfish indifference to the well-being of others. Persons of a hierarchical and individualistic worldviews, in contrast, tend to see guns as safe, and worry much more about the danger of being rendered defenseless against attack; this perception of risk coheres with their positive associations of  guns with traditional social roles (father, protector, provider) and individualistic virtues (self-reliance, courage, physical prowess).

I would commend all blog readers to this excellent work. Where it leads me, though, is to question whether it is possible to overcome cultural cognition effects in this area? Does doing so require the kind of cultural education (and in which direction?) that we view in other countries as propaganda? If we cannot overcome our cultural cognition differences, will we as a country remain hopelessly deadlocked?

Special issue in the Journal of Philosophy & Technology on evolution, genetic engineering, and human enhancement

By Yu-Chi Lyra Kuo

A special issue published this month by the Journal of Philosophy & Technology features a collection of articles discussing evolution, genetic engineering, and human enhancement. Recent years have seen a rapidly expanding variety of approaches to exploring the normativity of human enhancement, by philosophers, bioethicists, physicians, and biologists. The articles in this special issue largely focus on the question: how can evolution and aetiological teleology inform biological ethics and theories of human enhancement?

For a separate collection of articles discussing the ethics of human enhancement from the perspective of the physician-patient relationship, see this special issue by the American Journal of Bioethics, published approximately a year ago.

Happy reading, and happy holidays! ~YK

Gun Violence: A Public Health Concern?

Posted from Amsterdam

I was in India when the tragic news hit; 26 people dead–20 of them children in a massacre at Sandy Hook Elementary School in Newtown, Connecticut on December 14, 2012.   In India, NGOs struggle with ending violence against women and children. Acid tossed in the faces of women by scorned boyfriends is not uncommon nor the increasing, random acts of slitting women’s throats on trains.  Sensational it may seem to us; but very real for women in Mumbai and Bihar.  In fact, the day before learning of the tragedy in Connecticut, Delhi officials announced the hiring of thousands of guards to deploy at 548 elementary schools in South Delhi amid reports of rapes and molestations of little girls who are followed, harassed, and in too many cases harmed on their way home after leaving school.  The government’s response comes on the heels of parents threatening to remove their daughters from school.

In that country and others, broad scale violence is understood as more than a national problem; it is a social and public health problem. In cases of sexual violence and the externalities that result, including sexually transmitted diseases and pregnancies, the public health component may be more visible to those of us in the West.  However, the public health indicators extend physical health problems; violence causes emotional and psychological trauma.  The mental health component of public health must be better understood.  Americans who live in gang infested communities, where violence seems almost endless and difficult to escape, understand this all too well as their kids experience anxieties closer to post traumatic stress disorder as part of their daily lives.

The Newtown shootings offer a moment for reflection on the lives lost and also our nation’s first principles and commitments.  Perhaps this will be a time to consider gun control beyond a very divided constitutional law debate to also understand its public health dimensions.  Who benefits from current policies?  Who are those harmed?  Physical wounds do heal, but the mental health traumas, grief, and anxieties often take a lifetime to manage and overcome.