I’m sure everyone is tired of my pessimism about politics so I thought I would try something new. Here is a piece on pessimism about health care.
This Brietbart article discusses the looming doctor shortage.
Lieb notes, that the U.S. is only seeing 350 new general surgeons a year. That is not even a replacement rate, she observed.
A few years ago, I was talking to a woman general surgeon in San Francisco who told me that she did not know a general surgeon under 50 years old. The “reformers” who designed Obamacare and the other new developments in medicine are, if they are MDs, not in practice and they are almost all in primary care specialties in academic settings. They know nothing about surgical specialties.
They assume that primary care will be delivered by nurse practitioners and physician assistants. They are probably correct as we see with the new Wal Mart primary care clinics.
The company has opened five primary care locations in South Carolina and Texas, and plans to open a sixth clinic in Palestine, Tex., on Friday and another six by the end of the year. The clinics, it says, can offer a broader range of services, like chronic disease management, than the 100 or so acute care clinics leased by hospital operators at Walmarts across the country. Unlike CVS or Walgreens, which also offer some similar services, or Costco, which offers eye care, Walmart is marketing itself as a primary medical provider.
This is all well and good. What happens when a patient comes in with a serious condition ?
For patients with complex issues, Dr. Severance said, the goal was for Walmart to be a patient’s first stop and part of a continuum of care. “In that circumstance, it’s our desire to get those individuals established with a primary care provider, preferably a physician within the community,” he said.
They are assuming that primary care physicians will be available Will they ?
Maybe it is just not that attractive. The emphasis on trying to get students into primary care was existing when I was a medical student 50 years ago.
I repeatedly ask medical students if they would choose a career in primary care if it would completely erase their student loan debt. A few hands go up, but not many. In fact, for a while now, the federal government has dedicated millions of dollars to repaying loans for students who choose primary care. Yet residency match numbers show that the percentage of students choosing primary care is not increasing. Though loan forgiveness is a step in the right direction, medical students realize that by choosing a more lucrative specialty, they can pay off their loans just fine.
But what if those “lucrative specialties” aren’t there, either ?
“Our young people are not trained as well as we were,” she continued.
“We are now the number one profession for suicide. We lose 400 doctors a year to suicide. That’s like losing an entire medical school,” Hieb stated.
Hieb also cited a shortage of “things” or medical supplies–the first she has seen in her 40 years of involvement in medicine. She recalled ativanoral almost having to close an operating room for shortages of propofols, which are used to put people to sleep; as well as shortages of tetanus vaccine, shoulder catheters and thyroid medication shortages, among other items.
The cause, according to Hieb, is “this huge over-regulatory environment.”
Medicine is not as much fun as it was 50 years ago even though treatment is better.
Hieb referenced work in an Arizona area where 85% of payers were government-paid through Medicare, Medicaid and Tricare. Four orthopedic surgeons would do the work that 10, 11 or 12 in more affluent Flagstaff would take on. She said the average orthopedic surgeon in America takes care of 12,000 people. Conversely, the region where Hieb worked was serving approximately 90,000, which later ballooned to 120,000 as Hieb left and only three surgeons remained. She said her 53-year-old former colleague from the region died thereafter under the long and strenuous work.
“The big black hole is already starting to open up,” Hieb said.
She mentioned traveling two hours to reach an obstetrician, waiting six hours to be seen by an orthopedic surgeon, or three or four months to see a rheumatologist as problems facing those in less affluent regions.
“In a free market, when there’s a shortage, it gets filled,” Hieb said.
Medicine is no longer a free market, if it ever was since 1978 after PSRO began. PSRO stands for “Professional Standards Review Organization” and was all about cost, not “standards.”
There is a developing alternative. Here is a comment from that doctor shortage piece.
I had to get some medical attention while in Tucson for business recently, and I found a great place down there called Southern Arizona ugent care. They offer concierge medical services at reasonable rates. Check them out.
Opting out is an alternative I have mentioned before.
Most family doctors will convert to a retainer-type practice within the next 15 or 20 years, said Dr. Christopher Ewin, president of the nonprofit Society for Innovative Medical Practice Design in Fort Worth, Texas.
‘‘We believe that there is a primary care problem in this country,” said Ewin, a primary care physician. ‘‘We have been working for the wrong employer for way too long — the insurance companies and the government.”
Ewin’s retainer practice, he said, reduces the cost of an MRI from about $1,500 to $500. Laboratory blood analysis that would normally cost $300 through insurance costs $33.
This, of course, applies to doctors who can afford to do so. New medical school graduates can’t. I keep encouraging students to consider military options during medical school. They can get tuition paid and spend a few years as an Army doctor for the ability to practice with no debt. They still don’t choose that option.
We are heading into a crisis period with no good indication of a solution. Obamacare has led to rapid consolidation of health care facilities. The hospital where I practiced for 25 years has now been purchased by a national chain and has already gone through some troubling changes. It will get worse.
22 thoughts on “The Coming Shortage of Doctors.”
Don’t underestimate the effect of medical tourism and Doc in the Box.
Thank you, Dr. Kennedy for post. As medical student, I have idea on what to expect from the rodeo known as American medicine in the coming years, assuming I can get spot to residency programs. On the student side of the spectrum of becoming a doctor, we have rising cost of tuition and testing cost. For example, last year its cost about $1200 to take the STEP 2 CS portion of the medical licensing exam, now its $1500. Add in the increase focus on your scores to determine your future in medicine, you got majority of miserable medical students. I’m not adding in the messes that Caribbean medical student have to go through. Lot of graduates are going to be miserable coming out of school, assume if they survive residency programs. Too many people are going to cookie jar know as American medicine and its going to break it. I just hope there enough students and doctors that have not drink the American Left’s Koolaid to build something new or fix it.
I’m having one of those weeks where the notion of having to talk to one more doctor’s office’s front desk makes me want to scream. We had a minor emergency over the weekend that dropped us into an ER. The emergency aspect resolved itself spontaneously before an attending physician could be persuaded to hump his butt into the ER, but we need a specialist to look into an issue that may give recurring trouble of the same sort without warning. Within 24 hours we went from having to argue gently but firmly against being stuck with a $5K out-of-pocket ambulance transfer to a better-equipped ER 15 minutes away (we arrived by private car and managed easily to transfer ourselves the same way), to being told the situation was so boring the best we could hope for was an office appointment in three weeks, at which time we’d have a chance of obtaining an appointment for the diagnostic procedure itself after several more weeks.
This was after answering the same questions posed by every single one of more than a dozen nurses and doctors: any outstanding medical issues like diabetes or hypertension? Any allergies? Each of them dutifully wrote down the answer somewhere apparently inaccessible to anyone else. Ten minutes later someone else would come in and ask the same question.
One doctor with almost no English asked, “Have you ever had this trouble before?”–listened blankly to the careful, coherent answer (yes, often over a period of decades, but this is the first time it got bad to warrant medical intervention), and responded blankly, “So, have you ever had this trouble before?”
And yet, a bright spot: we both need to see a dermatologist about having this and that looked at and/or removed. Semi-local doctors an hour away aren’t seeing any new patients and were gobsmacked by the mere notion of scheduling us both for the same time, so we could drive an hour to the nearest office only once. In contrast, our old dermatologist in Houston had no problem with agreeing to see us together, and will take care of whatever removals one or both of us needs when we get there without making us drive 3 hours to see him first for a consultation and then another 3 hours on a different day for the removal. His front office can handle all these arrangements in fluent English without any heads coming to a point. I only fear the day when he retires!
PS: Concierge/retainer practice hasn’t caught on nearby yet, but I’m very interested if and when it does. We have individual coverage and lost our grandfathered plan, so we’re experiencing the wonders of an Obamacare policy at triple our old cost. This year we had a choice of three insurers and chose the only one–Assurant–with a decent network. Assurant has now dropped out of the market, so in November we get to find out whether we have 1 or 2 options, neither of which is likely to have a decent network. Going bare, signing up for a concierge practice, and negotiating for cash sounds like the future for us. What’s the use of expensive insurance if you’re just going to pay cash for the first $12K (our joint deductible) in any year when nothing very scary is happening, but the first time you really need elaborate care, your insurance kicks in only for whatever desperate doc-in-the-box practice your carrier allows into your constricted little network? If we’re going to have to pay cash to get a really good doctor in a scary illness anyway, I’d at soon skip the $13.5K/year premium, thanks.
Texas99, that is a harrowing story. Being 77, I have escaped the worst although I did have a coronary bypass in Tucson three years ago. My wife, a nurse practitioner with three degrees, has finally (we hope) learned why she has been getting recurrent lung infections for several years. Her immunity is very low for reasons we don’t yet understand.
I am so glad I am retired from practice. I still go up to LA to examine military recruits two or three times a week. I have now quit teaching as the electronic medical record has won its battle with me.
Thersites, ten years ago I told my students that, at least by the time they had finished training, all this upheaval in medicine would be over. I’ve quit telling the new group that.
At one point I researched the statistics behind the number of doctors. I remember the magnitudes. There are about 800,000 doctors in the US and a population of ~320 million. That is about 2.5 p/1000 pop. OECD average is close to 3.3. Which puts us about 250,000 doctors behind. Germany and Switzerland run 4/1000 which we would need 450,000 docs to reach.
The US medical schools graduate ~20 thousand per year. There are internship slots for about ~25K new doctors per year, which are filled by the graduates of American medical schools and about 5000 graduates of foreign medical schools. Clearly the gate in the system is training of new physicians.
My understanding is that the Federal government holds the keys because it funds the internship programs through Medicare and controls the designation of teaching hospitals.
If the feds wanted to control the price of medical care they would invest in training more doctors. The US should be graduating at least 30,000 a year.
Instead money is spent to support demand by subsidizing insurance coverage.
Sadly, medicine is not the only place where demand side policies are implemented. In housing, the Feds have created a mortgage market designed to allow buyers to bid up the existing housing stock to price levels that bear no rational relation to savings or incomes, by suppressing interest rates and minimizing down payments.
Higher eduction displays a particularly perverse form of demand side policy. where all of the federal aid goes to student loans and grants which bid up tuition with no relation to outcomes or utility.
All of these policies are sold on the excuse that they are helping consumers afford some very highly prized good, but all of them increase demand without increasing supply, and prop up prices. All of the policies transfer wealth to vested interests at the expense of taxpayers. Some of those interests maybe broad, e.g. home owners, and some quite narrow such as hospitals.
This can only lead to the complete nationalization of medicine. If the trend line continues there will soon be huge sections of the public who simply cannot access any medical care at all, either because they cannot afford it, or if they can, it is too far away or already fully booked. When it becomes an electoral issue, you just KNOW the democrats will want to grab the whole industry and place it under their control. You won’t be able to practice medicine in any form unless you work for the government and are paid by medicare.
“If the feds wanted to control the price of medical care they would invest in training more doctors. ”
This was the policy of the Johnson Administration which doubled the enrollment of most medical schools and subsidized the creation of more. My school, USC, went from 66 graduates in 1966 to 220 the past few years.
One problem is that teaching hospitals are excluded from most of Obamacare and most of the big public hospitals are now filled with illegals and have been downsized. When I was a student in 1965, LA County hospital had 3500 beds and most were filled. It now has 660.
Medical training is very expensive,
From a political perspective, people need to know the doctors in their community and how much danger their health care is in due to this coming shortage. So far as I know, nobody has made a general audience, widely distributed report that enables people to quickly see that for their own personal situation. I suspect such a report will be relatively easy to make but nobody has made the effort.
Without the general public becoming aware soon enough to take measures to fix the problem, we literally are in for a world of hurt.
It turns out there are concierge practices (somewhat) nearby after all, and we’re seriously considering one now. It seems like luxurious extravagance, but I suppose the other way to look at it is that it’s a way to circumvent insurance-company pricing without restricting us to doctors who opt out of insurance networks altogether. How long, I wonder, before the regulators find a way to close that loophole? In any case, we’re working through how much it makes sense to pay in order to have some assurance that we’ll have at least a GP who answers his phone and will see patients on the day they call. It doesn’t solve the problem of specialists, but the GP’s office can help somewhat with a personal network. How much future retirement security is it worth to pay this extra annual medical cost?
I hope concierge medicine will evolve into something a bit more flexible. If the average doctor has 12,000 patients and the average concierge doctor voluntarily limits himself to 600 to 1,200 patients but charges $1,400-$1,700 at the gate, there might develop a market for doctors who limit their practices to 5,000 or 2,000 patients while charging a smaller retainer. Right now I’m trying not to let myself get stampeded into taking on a considerable extra expense merely to avoid being stiff-armed by another front desk, but gosh, it’s tempting. And who knows, maybe we won’t live long enough to run out of retirement savings.
I saw this on the web yesterday. What is the equivalent topic on which modern doctors are being entirely wrong-headed?
“The first intervention to promote hand hygiene in hospitals was a short treatise by Alexander Gordon in 1795. Nobody read it and it had no effect. Wonderful, witty Oliver Wendell Holmes repeated the attempt with a privately published treatise in 1855. This merely provoked the response from his professor that “Obstetricians are gentlemen, and gentlemen have clean hands.” Ignaz Semmelweiss introduced caustic chlorinated lime handwashes on his maternity wards in the 1840s and raged at anyone caught entering without them. He called his fellow practitioners murderers. He published his own book in 1862. This also failed to popularise the procedure. ….. The 21st century approach recommended by the World Health Organization comprises system change, training and education, observation and feedback, reminders in the hospital, and a hospital safety climate. This network meta-analysis proves that these work. Now this would have really pleased John Haygarth of Chester, who first came up with something remarkably similar in his Fever Hospital Rules of 1783.”
Serious condition? tough titty, I guess. Rahm’s brother said 75 was plenty (for kulaks, I’d imagine he meant) guys like him, and the “poor” got the hook-up, so they won’t be sweating it. Last doctor I had was this Russian guy who was personable but, I have no idea if he was up to par. Also, he would only refer me to other Russians, most of which had no business working in a Veterinarian’s office, let alone with humans. That was over ten years ago. Now, it’s these walk in clinics. I have no idea. What comes after pessimism?
“people need to know the doctors in their community and how much danger their health care is in due to this coming shortage.”
There is still considerable resentment, especially on the left, about doctors being prosperous. Certain specialties are quite prosperous. Ophthalmology is my unrequited love of a specialty that went largely non-insured with LASIK and has exploded as a life style as well as remunerative field. Catcall surgery began it but it has really blossomed with LASIK, PRK and the other versions. Interestingly enough, radial keratotomy the precursor, began in the Soviet Union.
Orthopedic surgery is quite successful economically and there are many orthopods who have dropped insurance and especially Medicare.
I even know of general surgeons who have dropped insurance and I suspect we will see more of this as the scarcity begins to hit.
There needs to be something done about medical student debt. All I can do is to encourage them to join the military, which will pay for training. I see students from weak medical schools signing up but my own school does not seem interested.
One reason Semmelweisse failed was the failure to see the organisms. Florence Nightingale and John Snow accomplished wonders (which can read about in my first book, without ever knowing what the nature of the cause of disease was.
Snow stopped a cholera epidemic in London before the germ theory existed. Florence did much the same. They used statistics in a primitive fashion but saved hundreds of lives.
I got sick in NJ a few years ago, needed some meds.I had had this same issue before and needed an inhaler to reduce some coughing. Was there for a funeral so it was sort of important. Went to a clinic , in which everyone there was even sicker. . Left ASAP before I contracted TB or some other nasty from sitting in the same room with spewing coughing hackers.. Went to a pharmacy, who would not fill my needs without a prescription. Called my Doc across the country, who picked up the phone and called the pharmacy with my prescription. To say the pharmacist was gobsmacked was an understatement -she said “do you realize how rare that is?” My Doc is gone now, a victim of zerocare along with my insurance.
Being as the new insurance was twice the monthly, and double the deductible, resulting in a $22,000 out of pocket before it reimbursed anything, I reluctantly went on a subsidy. After some searching, I found a Doc. It isn’t easy- most seem to be are maxed out with existing patients. The new Doc had an opening for a routine physical. What a waste- yes, it was “covered”- height, weight, blood pressure. Standard comprehensive panel of blood work, prostate exam (the most painful I have ever had). No blood count, no A1c, (I told him my entire family was diabetic) he did not even look at me-literally. My back could have been covered with skin cancer, he did not even have me take off my shirt. I had all my records from my old Doc, no one had the slightest interest in looking at them. It was a check the prescribed boxes, do the minimum, get the patient out of here asap. I felt like a lab rat- my cats get more attention when I bring them to the vet.
How do I find a concierge practice? My plan is not fully resolved, but the idea of 2K a year for a local Primary care Doc, with a back up of cash payment to someplace like the Oklahoma Surgery Center if needed, or perhaps a flight to some other country for severe care is the best I can think of.
Right now I have a cold, and could use an inhaler, but going back to that guy is about the last resort…
They must be counting on all the old folks, the ones who remember what decent medical care and a free country was like, dying off before the Full Venezuela. Because we do seem to going Full Venezuela.
“The Full Venezuela” has a nice ring to it. You could Goggle (or Bing which I use) local cash practice and concierge practice and see what comes up. I called around here but found only one general practice. I still have an internist and cardiologist who take Medicare and I don’t know how long that will last.
Mayo Clinic Phoenix told their patients they will no longer take Medicare.
The solution, I think, would be high deductible plans that are cheap because they don’t include all the Democrat constituency stuff. California had a workers comp reform about ten years ago when there was still some sanity. Before that I saw carpal tunnel syndrome being treated with “out of body experience.”
The solution for Medicare would be to allow “balance billing” which would turn it into the French system which I like.
Of course, no one cares what I think.
Cash practices are going to grow I think and if they get too popular, you will see an attempt to force docs to participate in O-care as a condition of license. That’s been proposed in Massachusetts but, so far, is not happening.
I found a few concierge practices here by Googling and finding a company called MDVIP. You type in your zip and keep increasing the “within x miles” factor until you include a nearby town big enough to have a a chance. If you sign up with an MDVIP doc you get a certain amount of reciprocity with other members when you travel.
I’ve also had decent luck at urgent-care clinics for those issues that aren’t quite ER-worthy but can’t wait 3 weeks for the GP to bother seeing you, either. Otherwise I found that I was routinely seeing PAs if I needed something from the GP’s office on short notice. If the issue is extremely simple–in fact, I’ve probably already self-diagnosed–that often works well. We’re getting to an age, though, where it’s more important to me to have genuine medical expertise available in a crunch. Rolling the dice on the ER seems like a terrible idea.
“I was routinely seeing Pas ”
This is the future. I’ve told my students who express any interest in primary care to get an MBA because they will be managing Pas and NPs. USC has an MD-MBA program and two of them took it.
My group from last year were all engineers and USC has an MD-PhD program in biomedical engineering. They were in that program.
Primary = PA and NP.
Mike K: Here is a good, although longish and kind of Techie, rant on how Congress and the Federal Bureaucracy have created a mess with mandates on electronic medical records and privacy, among other things:
Why Health Care Reforms Fail by Mark Hammer
Also, Amplifying how Federal Policy creates market chaos by bad policy based on financing demand:
“This Housing Bubble Will End Badly, Too: We’ve inflated another bubble; count on the crash.”
By Kevin D. Williamson — August 4, 2015
“People complain about high prices when they’re buying, not when they’re selling, and that’s why housing bubbles are always politically popular: The sort of people who own homes are the sort of people who vote and volunteer on political campaigns and make donations. And the fact that tax revenue tends to increase as housing prices rise doesn’t go unnoticed by the nation’s mayors and governors. Renters tend to have more sensible views — you’ll never hear a renter say, “Hey, my rent is doubling this year — that’s awesome! The economy must be doing great!” But nobody listens to them.
* * *
“Instead, housing prices are going up for the same reason that college tuitions are: because the government facilitates lending people money at concessionary rates to purchase them. The Fed has, despite the occasional sobering gander in the direction of reality, been keeping the cheap-money sluices pretty much wide open. The federal regulators have loosened their grip over Fannie Mae and Freddie Mac’s lending activities, and, according to a Fed report released Monday, banks are once again loosening up their lending standards. This ended badly the last time. It’ll end badly this time, too.”
“Credit Supply and the Rise in College Tuition: Evidence from the Expansion in Federal Student Aid Programs”
by: David O. Lucca, Taylor Nadauld, and Karen Shen
“When students fund their education through loans, changes in student borrowing and tuition are interlinked. Higher tuition costs raise loan demand, but loan supply also affects equilibrium tuition costs—for example, by relaxing students’ funding constraints. To resolve this simultaneity problem, we exploit detailed student-level financial data and changes in federal student aid programs to identify the impact of increased student loan funding on tuition. We find that institutions more exposed to changes in the subsidized federal loan program increased their tuition disproportionately around these policy changes, with a sizable pass-through effect on tuition of about 65 percent. We also find that Pell Grant aid and the unsubsidized federal loan program have pass-through effects on tuition, although these are economically and statistically not as strong. The subsidized loan effect on tuition is most pronounced for expensive, private institutions that are somewhat, but not among the most, selective.”
A few thoughts…
– the US could solve all doctor shortage and all other nurse / etc… shortages by opening our doors to immigration. No matter how bad it gets here, it is always better than 99% of the world, sadly enough. We would need to perhaps retrain some and administer credentials but they would flood here
– this is just like computer programming – we are always about to run out of programmers – but then somehow we find a way to bring in or leverage offshore talent and then the problem goes from being acute to merely bad
– medicine is going to be like electricity or public education. A hit or miss semi-subsidized mess. If you want to get decent medical care, you need to go where there are intact communities, strong standards and a decent local infrastructure. Move to a suburb, or to a place like Des Moines. Absolutely, over time, all of these advantages will fade away, but like with anything socialist, for a while parts of it still work OK if you know where to look or how to ride the roller coaster, and then it all collapses into rubble
– something will emerge out of this. The government will offer a crappy solution, clinics and care and the like, and then a private solution on a mega scale will grow alongside it. Out of this private solution will come huge innovations in productivity, since it will be on an economic and not socialist basis. Expect the use of distance medicine, texting, actual useful medical records, a dis-investment in overhead and physical buildings, and leveraging the hell out of existing facilities through time of use and other modern practices and not just building because the money exists in a reserve fund somewhere or it is near a political groups’ home base
– look at schools. It was separate but equal, then they attempted integration, for a while integration kind of worked in a few places, and now we are back to full segregation by class. We are back to where we started, but it isn’t by law, it is by class and location. This is where medicine is going, too
– medicine is terribly inefficient when you look at all the money spent on overhead and under utilized facilities and the lack of usage of modern technology for office productivity. Everywhere else you see self checkout and apple pay and self service but this is rare in the medical setting. They need to have far less people and far more specialization. And billing is an utter disaster, this is a monstrosity that must be tackled
“Everywhere else you see self checkout and apple pay and self service but this is rare in the medical setting.”
This is coming as cash practice grows.
The argument about foreign graduates ignores the huge volume that is already coming. The present numbers are greater than most realize.
Nearly a quarter of all active U.S. physicians are international medical graduates (IMGs)—physicians trained outside the United States and Canada. We describe changes in characteristics of IMGs from 1981 to 2001 and compare them with their U.S. medical graduate (USMG) counterparts. Since 1981, the leading source countries for IMGs have included India, the Philippines, and Mexico. IMGs were more likely to be generalists and to practice in designated underserved areas than USMGs but slightly less likely to practice in isolated small rural areas and persistent-poverty counties. IMGs are an important source of primary care physicians in rural and underserved areas.
We got a lot of Canadian doctors in the 80s as Canada adopted their single payer system. Those were mostly specialists.
Primary care here will increasingly be delivered by PAs and NPs.
What we are seeing is a huge consolidation of everything, including medicine.
We’re headed for an economic system in which many industries have a handful of large, cartelized businesses— think 6 big banks, 5 big health insurance companies, 4 big energy companies, and so on.
I’m not sure that is a solution.
My wife and I recently (in late May) moved to Greenville, SC, from Colorado. Needing a new doc, we decided to try a concierge practice here. They don’t like that term and prefer to call there style of practice “direct pay”. You pay at the time of service by cash, check or credit card. One of the two owners will take your phone call 24/7. You can either become a “member” or just be a regular patient. Members pay $69 per month, which entitles you to free office visits, a free complete physical, free routine lab tests including EKG, guaranteed appointments within 24 hours, and nurse visits to your home if needed. Other fees are steeply discounted. If you don’t want to be a member you can just be a patient of the practice, in which case you are subject to higher fees, but they are (in my opinion) very reasonable. Office visits range in price from $49 for a “simple” visit to $89 for a “complex” visit; EKGs are $45; a sutured laceration is $100, etc. My wife decided to become member and I opted for patient. She had her included physical and was very happy with the services. I was also very impressed by the amount of time that was spent with me on my initial appointment. Time will tell, but so far so good.
I’ve been involved in the past in trying to control medical costs and was the President of a health care alliance in Louisiana for awhile. I must admit that despite this involvement, I have little to add to the discussion on the future of medicine. I spent years thinking about the various approaches and have yet to come up with conclusions that make sense.
For Dr. Kennedy…..I just finished your “War Stories” book. Thank you very much for writing it. I’m not a medical person and some of the more technical descriptions were a little over my head, but I learned a substantial amount about many things.
The Full Venezuela (love that!):
The sign seems to translate as “Hunger and the underworld are driving change”
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