Hardening Of The Categories: Why We Have A Shortage Of Physicians To Treat COVID-19 Patients

Because science is advancing our understanding of medicine at an exponential rate, physicians and surgeons have been turning to subspecialization as a means to narrow their required domains of expertise.  “Carving out a niche” makes sense in a profession where new research is being published at a rate of two million articles per year. Just filtering the signal from the noise can be a full time job.

However, the consequences of narrowing one’s expertise is that you lose flexibility. For example, an orthopedist who has subspecialized in the surgical management of the shoulder joint doesn’t keep her skills sharp in knee replacement surgery or other general surgical procedures that she once performed. Neurologists who focus on movement disorders become comfortable with a small subset of diseases such as Parkinson’s, but then close their doors to patients with migraines or strokes.

The continued march towards ultra-subspecialization has been a boon in urban and academic centers, but has left spotty expertise in surrounding areas and small towns. And now, the COVID-19 pandemic has unmasked the biggest downside of niche medicine: a hardening of the categories that prevents many physicians from being able to help in times of crisis. Retina specialists, plastic surgeons, rheumatologists, and radiation oncologists (to name just a few) may want to help emergency medicine physicians (EM), internists (IM), and intensivists (CCM) expand their reach as COVID cases surge and hospitals become overwhelmed. But what are they to do? They are not trained to manage airways, place central lines, or monitor renal function, and legitimately fear legal repercussions should they attempt to do so.

Medicine is fundamentally based upon apprentice-style learning – this is why we undergo years of residency training – to stand shoulder-to-shoulder with more senior experts and learn their craft under close supervision. Upon graduation from medical school, physicians are deemed ineligible to treat patients until they have practical experience under their belts. The old adage: “see one, do one, teach one” is the bedrock of how we train. So now, there needs to be a pathway available for those who have completed residency to re-train to meet the demands of this crisis and others.

Perhaps it’s a radical idea to consider pairing subspecialist physicians with current frontline COVID-19 doctors – but turfing patients to “non physician practitioners” or NPPs when access is limited to an emergency medicine specialist,  internist, or intensivist, seems to be the current plan. I believe that medical school and internship are a solid foundation for COVID management (common to all physicians), and that given a designated EM, IM, or CCM mentor, the willing subspecialists will be able to follow protocols and take on new challenges rapidly and with excellence. I hope that the government will issue more detailed “good Samaritan” type laws to protect mentors and their subspecialty partners from frivolous law suits in times of COVID (those in place are for volunteer positions only), and that the house of medicine, led by the AMA and other sub-specialty organizations, will pave the way for rapid cross-disciplinary instruction and certification.

Going forward, there should be opportunities for post-residency, mid-career physicians to complete fellowship programs outside of their sub-specialty’s usual offerings. An ophthalmologist should have the ability to spend a year studying pulmonary medicine, for example, if they want to moonlight with an ICU physician in the future. In our current system, it is very difficult to obtain a fellowship after significant time has elapsed since one’s residency training. While there are a few “re-entry programs” for physicians who haven’t practiced clinical medicine for years, there is no path established for those who simply wish to switch specialties or assist outside of their specialty in a time of crisis.

I am not arguing that a fellowship should be considered equivalent to a residency program. We may need to create a new type of physician certification that allows fellowship-trained physicians from unrelated residency programs to operate under the license of an agreeable mentor/sponsor already established in the field by virtue of medical school and residency training. This would open up employment opportunities for over-specialized physicians, while not threatening those who are residency-trained in the field. In essence, this would allow physicians to operate in the way that NPPs have been for decades, and get subspecialty physicians off the bench and into the fight against COVID and perhaps into underserved areas more effectively as well.

For those subspecialists who have become disillusioned with their field, but still enjoy medicine or surgery – their talent could be retained if there were a path to re-training. An estimated 20% of physicians would change their specialty if they could. Currently, physicians have few clinical options if they no longer wish to practice in the field in which they completed a residency. I suspect that sweeping physician burnout rates (highest among mid-career physicians) could be improved by providing opportunities for “reimagining” themselves – and course-correcting to rekindle the scientific and clinical passion that led them to apply to medical school in the first place.

This would require some mental and regulatory flexibility – which could be a good side effect of the otherwise dreadful COVID pandemic.

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Global health insurance card to replace EHIC under new rules

UK residents can apply for the new card to access emergency medical care when their EHIC card runs out.

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Covid: The truth behind videos of ’empty’ hospitals

Videos have been posted online taken inside hospitals claiming they’re empty. Here’s why they’re wrong.

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Covid: Mass vaccination centres to open in England

Hundreds of GP-led and hospital services also open this week as the vaccination programme ramps up.

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Covid-19: Hancock warns flexing of rules ‘could be fatal’

Health Secretary Matt Hancock says the NHS is under “very serious pressure” and warns people to stay home.

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The Paradoxical Under-employment of Rehab Physicians During the COVID-19 Pandemic

I used to joke that for all the hardships of being a physician, at least we had job security. Little did I know that a viral illness would put some physicians “on the bread line.”

The COVID-19 pandemic has negatively impacted the physician workforce in both anticipated and unanticpated ways. While stay-at-home orders decrease temporary demand for cosmetic and elective surgical procedures by dermatologists and orthopedic surgeons, inpatient rehabilitation facilities are also feeling the squeeze, though the number of patients who need their services are growing exponentially (due to post-COVID syndromes).

In states of emergency, hospitals at (or over) capacity have the right to commandeer beds from other units within their system. So for example, if there is a unit devoted to the rehabilitation of stroke or car accident victims, the hospital might re-allocate those beds to COVID-19 patients. There is also financial incentive to do so because Medicare pays 20% higher rates to hospitals for each COVID patient that requires admission.

So what happens when the rehab unit turns into a COVID unit? A few things. First, the patients who need inpatient rehabilitation with close physician monitoring are turfed to nursing homes. Fragile stroke patients, those with high risk for neurological or cardiac decompensation, and inpatients with complex medical problems (such as internal bleeding, kidney failure, or infectious diseases) are sent to a lower level of care without suficient oversight by physicians. These patients often crash, get readmitted to the hospital, or in the worst case, decline too quickly to be saved.

Second, the physicians who take care of rehab patients (rehabilitation physicians, also known as physiatrists) hand over care of the COVID patients (in the former rehab unit) to hospitalists, reducing their own workloads substantially while the hospitalists are overwhelmed and at risk for burn out.

Third, hospitals are struggling to cut costs due to the suspension of their lucrative elective surgical pipelines during COVID surges – and put a moratorium on hiring additional physicians who would normally be assisting with growth and expansion efforts in neuromuscular, brain and spinal cord injury rehabilitation.

Finally, in some cases rehab units are experiencing low censuses not because their beds were commandeered for COVID patients, but because elective surgeries have diminished and patients are afraid of coming to the hospital. Many of those with symptoms of heart attacks, strokes, brain injuries, etc. are staying home and “gutting it out” while reversible or treatable injuries and disabilities become permanent. The devastating toll will be difficult to quantify until normal medical surveillance and care resumes.

Meanwhile, physiatrists with outpatient practices and pain management clinics are experiencing a dramatic drop in patient throughput, with telemedicine visits largely inaccessible to the poor and disabled populations they serve. Those outpatient physicians seek to augment their income with part-time inpatient work, and unprecidented numbers are seeking employment through locum tenens agencies. Unfortunately, agencies have scant inpatient jobs to offer for the reasons I discussed above, and competition is fierce among agencies and physicians alike. It’s often the case that 7 or more agencies will contact a physician within hours of a new job posting, and that job will be filled before the physician can respond – and at an hourly rate 20-30% lower than pre-COVID days (based on my personal experience).

These are some of the unexpected underemployment consequences of the COVID pandemic for one sub-specialty group: physiatry. I imagine the forces at play may be similar for my peers in oncology, neurology, or preventive medicine, for example.

One thing is for sure: emergency medicine physicians, internists, and critical care specialists are facing a tsunami of patients while others of us are sitting on the bench, wanting to help but not trained to do so, “sheltering in place” as the non-COVID march of disease and disability continues apace.

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Covid-19: Rapid tests for asymptomatic people to be rolled out

People who cannot work from home should be prioritised for rapid tests in England, the government says.

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Scientists discover slimy microbes that may help keep coral reefs healthy

Corals have evolved over millennia to live, and even thrive, in waters with few nutrients. In healthy reefs, the water is often exceptionally clear, mainly because corals have found ways to make optimal use of the few resources around them. Any change to these conditions can throw a coral’s health off balance.

Now, researchers at MIT and the Woods Hole Oceanographic Institution (WHOI), in collaboration with oceanographers and marine biologists in Cuba, have identified microbes living within the slimy biofilms of some coral species that may help protect the coral against certain nutrient imbalances.

The team found these microbes can take up and “scrub out” nitrogen from a coral’s surroundings. At low concentrations, nitrogen can be an essential nutrient for corals, providing energy for them to grow. But an overabundance of nitrogen, for instance from the leaching of nitrogen-rich fertilizers into the ocean, can trigger mats of algae to bloom. The algae can outcompete coral for resources, leaving the reefs stressed and bleached of color.

By taking up excess nitrogen, the newly identified microbes may prevent algal competition, thereby serving as tiny protectors of the coral they inhabit. While corals around the world are experiencing widespread stress and bleaching from global warming, it seems that some species have found ways to protect themselves from other, nitrogen-related sources of stress.

“One of the aspects of finding these organisms in association with corals is, there’s a natural way that corals are able to combat anthropogenic influence, at least in terms of nitrogen availability, and that’s a very good thing,” says Andrew Babbin, the Doherty Assistant Professor in Ocean Utilization in MIT’s Department of Earth, Atmospheric and Planetary Sciences. “This could be a very natural way that reefs can protect themselves, at least to some extent.”

Babbin and his colleagues have reported their findings in the the ISME Journal.

Dead zone analogues

Babbin’s group studies how marine communities in the ocean cycle nitrogen, a key element for life. Nitrogen in the ocean can take various forms, such as ammonia, nitrite, and nitrate. Babbin has been especially interested in studying how nitrogen cycles, or is taken up, in anoxic environments — low-oxygen regions of the ocean, also known as “dead zones,” where fish are rarely found and microbial life can thrive.

“Locations without enough oxygen for fish are where bacteria start doing something different, which is exciting to us,” Babbin says. “For instance, they can start to consume nitrate, which has then an impact on how productive a specific part of the water can be.”

Dead zones are not the only anoxic regions of the ocean where bacteria exhibit nitrogen-feasting behavior. Low-oxygen environments can be found at smaller scales, such as within biofilms, the microbe-rich slime that covers marine surfaces from shipwrecked hulls to coral reefs.

“We have biofilms inside us that allow different anaerobic processes to happen,” Babbin notes. “The same is true of corals, which can generate a ton of mucus, which acts as this retardation barrier for oxygen.”

Despite the fact that corals are close to the surface and within reach of oxygen, Babbin wondered whether coral slime would serve to promote “anoxic pockets,” or concentrated regions of low oxygen, where nitrate-consuming bacteria might thrive.

He broached the idea to WHOI marine microbiologist Amy Apprill, and in 2017, the researchers set off with a science team on a cruise to Cuba, where Apprill had planned a study of corals in the protected national park, Jardines de la Reina, or Gardens of the Queen.

“This protected area is one of the last refuges for healthy Caribbean corals,” Babbin says. “Our hope was to study one of these less impacted areas to get a baseline for what kind of nitrogen cycle dynamics are associated with the corals themselves, which would allow us to understand what an anthropogenic perturbation would do to that system.”

Swabbing for scrubbers

In exploring the reefs, the scientists took small samples from coral species that were abundant in the area. Onboard the ship, they incubated each coral specimen in its own seawater, along with a tracer of nitrogen — a slightly heavier version of the molecules found naturally in seawater.

They brought the samples back to Cambridge and analyzed them with a mass spectrometer to measure how the balance of nitrogen molecules changed over time. Depending on the type of molecule that was consumed or produced in the sample, the researchers could estimate the rate at which nitrogen was reduced and essentially denitrified, or increased through other metabolic processes.

In almost every coral sample, they observed rates of denitrification were higher than most other processes; something on the coral itself was likely taking up the molecule.

The researchers swabbed the surface of each coral and grew the slimy specimens on Petri dishes, which they examined for specific bacteria that are known to metabolize nitrogen. This analysis revealed multiple nitrogen-scrubbing bacteria, which lived in most coral samples.

“Our results would imply that these organisms, living in association with the corals, have a way to clean up the very local environment,” Babbin says. “There are some coral species, like this brain coral Diploria, that exhibit extremely rapid nitrogen cycling and happen to be quite hardy, even through an anthropogenic change, whereas Acropora, which is in rough shape throughout the Caribbean, exhibits very little nitrogen cycling. “

Whether nitrogen-scrubbing microbes directly contribute to a coral’s health is still unclear. The team’s results are the first evidence of such a connection. Going forward, Babbin plans to explore other parts of the ocean, such as the tropical Pacific, to see whether similar microbes exist on other corals, and to what extent the bacteria help to preserve their hosts. His guess is that their role is similar to the microbes in our own systems.

“The more we look at the human microbiome, the more we realize the organisms that are living in association with us do drive our health,” Babbin says. “The exact same thing is true of coral reefs. It’s the coral microbiome that defines the health of the coral system. And what we’re trying to do is reveal just what metabolisms are part of this microbial network within the coral system.”

This research was supported, in part, by MIT Sea Grant, the Simons Foundation, the MIT Montrym, Ferry, and mTerra funds, and by Bruce Heflinger ’69, SM ’71, PhD ’80.

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A beginner’s guide to DNA origami

In a technique known as DNA origami, researchers fold long strands of DNA over and over again to construct a variety of tiny 3D structures, including miniature biosensors and drug-delivery containers. Pioneered at the California Institute of Technology in 2006, DNA origami has attracted hundreds of new researchers over the past decade, eager to build receptacles and sensors that could detect and treat disease in the human body, assess the environmental impact of pollutants, and assist in a host of other biological applications.

Although the principles of DNA origami are straightforward, the technique’s tools and methods for designing new structures are not always easy to grasp and have not been well documented. In addition, scientists new to the method have had no single reference they could turn to for the most efficient way of building DNA structures and how to avoid pitfalls that could waste months or even years of research.

That’s why Jacob Majikes and Alex Liddle, researchers at the National Institute of Standards and Technology (NIST) who have studied DNA origami for years, have compiled the first detailed tutorial on the technique. Their comprehensive report provides a step-by-step guide to designing DNA origami nanostructures, using state-of-the-art tools. Majikes and Liddle described their work in the Jan .8 issue of the Journal of Research of the National Institute of Standards and Technology.

“We wanted to take all the tools that people have developed and put them all in one place, and to explain things that you can’t say in a traditional journal article,” said Majikes. “Review papers might tell you everything that everyone’s done, but they don’t tell you how the people did it. “

DNA origami relies on the ability of complementary base pairs of the DNA molecule to bind to each other. Among DNA’s four bases — adenine (A), cytosine (C), guanine (G) and thymine (T) — A binds with T and G with C. This means that a specific sequence of As, Ts, Cs and Gs will find and bind to its complement.

The binding enables short strands of DNA to act as “staples,” keeping sections of long strands folded or joining separate strands. A typical origami design may require 250 staples. In this way, the DNA can self-assemble into a variety of shapes, forming a nanoscale framework to which an assortment of nanoparticles — many useful in medical treatment, biological research and environmental monitoring — can attach.

The challenges in using DNA origami are twofold, said Majikes. First, researchers are fabricating 3D structures using a foreign language — the base pairs A, G, T and C. In addition, they’re using those base-pair staples to twist and untwist the familiar double helix of DNA molecules so that the strands bend into specific shapes. That can be difficult to design and visualize. Majikes and Liddle urge researchers to strengthen their design intuition by building 3D mock-ups, such as sculptures made with bar magnets, before they start fabrication. These models, which can reveal which aspects of the folding process are critical and which ones are less important, should then be “flattened” into 2D to be compatible with computer-aided design tools for DNA origami, which typically use two-dimensional representations.

DNA folding can be accomplished in a variety of ways, some less efficient than others, noted Majikes. Some strategies, in fact, may be doomed to failure.

“Pointing out things like ‘You could do this, but it’s not a good idea’ — that type of perspective isn’t in a traditional journal article, but because NIST is focused on driving the state of technology in the nation, we’re able to publish this work in the NIST journal,” Majikes said. “I don’t think there’s anywhere else that would have given us the leeway and the time and the person hours to put all this together.”

Liddle and Majikes plan to follow up their work with several additional manuscripts detailing how to successfully fabricate nanoscale devices with DNA.

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Gene therapy strategy found effective in mouse model of hereditary disease TSC

Patients with tuberous sclerosis complex, a genetic disorder characterized by the growth of noncancerous tumors in multiple organs of the body, have limited treatment options. A team led by investigators at Massachusetts General Hospital (MGH) has now shown that gene therapy can effectively treat mice that express one of the mutated genes that cause the disease. The research is published in Science Advances.

The gene, called TSC2, codes for tuberin, a protein that acts to inhibit cell growth and proliferation. When mutations occur in TSC2, resulting in a lack of tuberin in cells, the cells enlarge and multiply, leading to the formation of tumors.

To restore the function of TSC2 and tuberin in a mouse model of tuberous sclerosis complex, researchers developed a form of gene therapy using an adeno-associated virus vector carrying the DNA that codes for a condensed form of tuberin (which fits within the vector’s carrying capacity) and functions like the normal full-length tuberin protein. Mice with tuberous sclerosis complex had a shortened life span of about 58 days on average, and they showed signs of brain abnormalities consistent with those that are often seen in patients with the disease. When the mice were injected intravenously with the gene therapy treatment, however, their average survival was extended to 462 days, and their brains showed reduced signs of damage.

“Current treatments for tuberous sclerosis complex include surgery and/or lifelong treatment with drugs that cause immune suppression and potentially compromise early brain development. Therefore, there is a clear need to identify other therapeutic approaches for this disease,” says co-lead author Shilpa Prabhakar, an investigator in the MGH departments of Neurology and Radiology. “Adeno-associated virus vectors have been used widely in clinical trials for many hereditary diseases with little to no toxicity, long-term action in nondividing cells, and improvement in symptoms,” adds Prabhakar. She notes that benefits can be seen after a single injection, and some forms of the viral vector can efficiently enter the brain and peripheral organs after intravenous injection.

The U.S. Food and Drug Administration has approved a limited number of gene therapy products for use in humans, and the results from this study suggest that clinical trials are warranted to test the strategy’s potential in patients with tuberous sclerosis complex.

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Materials provided by Massachusetts General Hospital. Note: Content may be edited for style and length.

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