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Majority of clinicians in US safety net practices report ‘moral distress’ during COVID-19 pandemic

CHAPEL HILL, NC – The distress of doctors and nurses working in hospitals during the COVID-19 pandemic has received much attention in news media and…

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CHAPEL HILL, NC – The distress of doctors and nurses working in hospitals during the COVID-19 pandemic has received much attention in news media and academic research, including their moral distress witnessing so many deaths at times when they could offer so little. Much less attention has been paid to the moral distress of clinicians working in other settings during the pandemic.

Credit: UNC School of Medicine

CHAPEL HILL, NC – The distress of doctors and nurses working in hospitals during the COVID-19 pandemic has received much attention in news media and academic research, including their moral distress witnessing so many deaths at times when they could offer so little. Much less attention has been paid to the moral distress of clinicians working in other settings during the pandemic.

Using data from a survey of more than 2,000 primary care, dental, and behavioral health clinicians who work with low income patients in safety net clinics, UNC School of Medicine’s Donald Pathman, MD, MPH, found that nearly 72 percent reported experiencing either mild or intense levels of moral distress during the first year of the pandemic due to limits on what they could do for their patients, witnessing their patients’ struggles and the challenges of their own work situations.

This analysis, published in BMJ Open, was conducted from data late in 2020 from practices in 20 states.

“Most people receive their health care in office settings, and many clinicians working there experienced moral distress from how the pandemic limited the care they could provide to patients and from witnessing the pandemic’s effects on patients and coworkers,” said lead author Donald Pathman, MD, MPH, a professor in the UNC Department of Family Medicine.

Moral distress was defined in the survey as when one witnesses or does things that contradict deeply held moral and ethical beliefs and expectations. “Moral distress is a concept developed to understand the consequences of disturbing situations nurses can experience in hospitals, but the concept of moral distress is likely just as useful in understanding a type of distress clinicians in all disciplines and work settings experience,” Pathman said.

Respondents in the survey were 2,073 clinicians who work in community health centers, mental health facilities and other types of safety net clinics that provide care to low income patients who face barriers to receiving care in the mainstream U.S. healthcare system. Many of these patients are also members of racial-ethnic minority groups.

Among respondents, 28.4% reported no moral distress related to work during the pandemic. But 44.8% reported “mild” or “uncomfortable” levels of moral distress, and 26.8 percent described their moral distress as “distressing,” “intense” or “worst possible.” The latter two groups combined are 71.6% of respondents, a substantial majority.

Many of this study’s office-based clinicians reported moral distress from not being able to provide care to all patients — think of the closed practices early in the pandemic that then reopened but limited care to only the sickest patients — and not being able to provide best care to their patients when care protocols changed to minimize infecting patients and staff within the office and virtual visits were required even when in-office, face-to-face visits were better for their patients.

Other respondents felt moral distress witnessing how the pandemic affected the health and lives of their patients, some of whom they had known for years. One study nurse practitioner in North Carolina noted moral distress watching how the pandemic “has impacted families in our clinic and feeling powerless to make meaningful change.”

Other clinicians were morally distressed when their coworkers’ health was jeopardized or they lost their jobs. Respondents sometimes regarded the hardships for coworkers as unavoidable during the pandemic but sometimes as due to their employers’ lack of concern for clinic staff’s wellbeing. One dentist reported: “All our manager and director seem to care about is making money and how many patients we see. I was having to balance being exposed to so many patients then going home to my family and potentially exposing them.”

Some respondents reported moral distress from patients, clinic staff and people in the community not wearing masks or following public health recommendations, as well as the politicization of the pandemic. As healthcare professionals, they knew these precautions worked, and when people did not follow them they knew others would be infected needlessly.

Social inequities and health disparities morally distressed some respondents, such as a respondent distressed from, “Seeing how my patient population has been disproportionately affected by illness and death because of socioeconomic issues.” Pathman noted that, “given the type of individual who chooses to provide healthcare in low income communities, it is not surprising that some would be morally distressed watching the pandemic worsen the health and lives of their patients because of their limited resources.”

The consequences of moral distress are concerning. The article notes that moral distress is known to cause burnout, compassion fatigue, disengagement from patients and job turnover for nurses in hospital settings and is likely to also do so for clinicians in safety net practices.

Co-authors of the article are Jeffrey Sonis, MD, MPH, an associate professor in the UNC Departments of Social Medicine and Family Medicine; Thomas E. Rauner at the Nebraska Division of Public Health; Kristina Alton, MD, at Vanderbilt University Medical Center; Anna S. Headlee at the University of Nebraska-Lincoln, and Jerry N. Harrison at New Mexico Health Resources.


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Spread & Containment

License Plates Could Be Printed On McDonald’s Bags To Stop Littering

License Plates Could Be Printed On McDonald’s Bags To Stop Littering

There’s been talk about McDonald’s in southwest Great Britain could print…

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License Plates Could Be Printed On McDonald's Bags To Stop Littering

There's been talk about McDonald's in southwest Great Britain could print car license plates on drive-thru bags to prevent customers from littering. 

"It's not clear exactly how the number plate would be printed on packaging, but it could be scanned onto the brown bags that contain the food," Daily Mail noted. 

Chris Howell, Swansea Council's head of waste, parks and cleansing, told a climate change corporate delivery committee meeting: 

"The Welsh Government has explored with McDonald's, or their franchises, whether or not they could print number plates of cars collecting takeaways from their drive-throughs with a view that that would discourage people from discarding their materials (litter)."

Howell said one of the biggest hurdles with fast-food companies is that if one chain adopts the climate initiative, customers will go to competitors that don't print license plates on bags. 

"If McDonald's do it, then people will just go to Burger King instead of McDonald's, because nobody wants to have their private details printed on that packaging." He added: "I think it's a really good idea but at the minute it's fraught with some difficulties." 

The nationalist political party in Wales, Plaid Cymru, first proposed the idea more than two years ago during the pandemic lockdown when party leaders noticed a spike in fast-food trash along city streets and highways. 

Welsh Government spokesperson told MailOnline:

"There are no current plans to introduce a requirement for drive-through restaurants to add vehicle registration details to fast food drive-through packaging.

"We are continuing to support Keep Wales Tidy with other initiatives to tackle roadside litter including their No Regrets campaign and their Adopt a Highway initiative."

Now 'the cat is out of the bag'. It's only a matter of time before governments start forcing fast-food companies to print license plate numbers on drive-thru bags. The dangers of this could be more surveillance, and who knows what corporations would do with license plate data if such a system were implemented. 

Tyler Durden Sat, 11/26/2022 - 18:00

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International

COVID Lockdown Protests Erupt In Beijing, Xinjiang After Deadly Fire

COVID Lockdown Protests Erupt In Beijing, Xinjiang After Deadly Fire

Protests have erupted in Beijing and the far western Xinjiang region…

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COVID Lockdown Protests Erupt In Beijing, Xinjiang After Deadly Fire

Protests have erupted in Beijing and the far western Xinjiang region over COVID-19 lockdowns and a deadly fire on Thursday in a high-rise building in Urumqi that killed 10 people (with some reports putting the number as high as 40).

Crowds took to the street in Urumqi, the capitol of Xinjiang, with protesters chanting "End the lockdown!" while pumping their fists in the air, following the circulation of videos of the fire on Chinese social media on Friday night.

Protest videos show people in a plaza singing China's national anthem - particularly the line: "Rise up, those who refuse to be slaves!" Others shouted that they did not want lockdowns. In the northern Beijing district of Tiantongyuan, residents tore down signs and took to the streets.

Reuters verified that the footage was published from Urumqi, where many of its 4 million residents have been under some of the country's longest lockdowns, barred from leaving their homes for as long as 100 days.

In the capital of Beijing 2,700 km (1,678 miles) away, some residents under lockdown staged small-scale protests or confronted their local officials over movement restrictions placed on them, with some successfully pressuring them into lifting them ahead of a schedule. -Reuters

According to an early Saturday news conference by Urumqi officials, COVID measures did not hamper escape and rescue during the fire, but Chinese social media wasn't buying it.

"The Urumqi fire got everyone in the country upset," said Beijing resident Sean Li.

According to Reuters

A planned lockdown for his compound "Berlin Aiyue" was called off on Friday after residents protested to their local leader and convinced him to cancel it, negotiations that were captured by a video posted on social media.

The residents had caught wind of the plan after seeing workers putting barriers on their gates. "That tragedy could have happened to any of us," he said.

By Saturday evening, at least ten other compounds lifted lockdown before the announced end-date after residents complained, according to a Reuters tally of social media posts by residents.

Tyler Durden Sat, 11/26/2022 - 12:00

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Government

The Doctor Who Can Rebuild Trust: Joseph Ladapo

The Doctor Who Can Rebuild Trust: Joseph Ladapo

Authored by Jeffrey Tucker via The Brownstone Institute,

If you are like me, you are exhausted…

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The Doctor Who Can Rebuild Trust: Joseph Ladapo

Authored by Jeffrey Tucker via The Brownstone Institute,

If you are like me, you are exhausted of the lies. Every day seems to bring new revelations about how our lives came to be upended. The connections are becoming clearer between the pandemic response and the growing economic crisis, the ballooning debt, the growth of the surveillance state, the corruption and scams, chilling absence of integrity in public life, and, with the failure of FTX, the way in which an outright financial scam was integral to the calamity. 

While we await new revelations, depositions, coverups, pleas for amnesty, and bad economic news, whom can we trust? Is anyone telling the truth? 

Today was Anthony Fauci’s last White House press conference, and he spoke as if life is all normal and everything is fine. It’s as if the whole disaster never happened. He never locked anyone down, he says. He has happy for any investigations, he says, because he has nothing to hide. And then he ended with a final push for everyone to get booster #5 or whatever number we are on. 

It’s like we live in two universes: our own lives in which we read true things in some places, and official life, in which shills and publicists keep repeating the same nonsense over and over without flinching or providing anything like an honest account of these last three years. 

Perhaps for this reason – and also because by any historical standard this is a tremendous autobiography – reading Dr. Joseph Ladapo’s Transcend Fear is a welcome relief from the nonsense of our times. It is brutally honest. It is emotionally affecting. It is careful and precise but also deeply radical in its observations. If what’s called the “public health world” has lost touch with both the public and health, this book provides a path to restoring it. In short, it is a beautiful and inspiring experience. 

Dr. Ladapo is the Surgeon General of the State of Florida, picked by Governor Ron DeSantis to forge and explain the state’s health decisions and priorities to the public in the midst of a grave crisis. He has faced down the national press time and time again with Zen-like wisdom. He seems emotionally unflappable while also sticking to the science as he understands it. He is the only public health official in the country who has been upfront about the limits of the vaccines and warned healthy young people that they don’t need them. 

What we learn from this book is that he has been a warrior against pseudoscience from the very beginning of this pandemic and the government response. After the lockdowns, most scientists and health professionals fell silent, fearing reputational and financial loss. Dr. Ladapo was different, On March 24, 2020, still within the window of “15 Days to Flatten the Curve,” he wrote in USA Today:

We are fretting and we are fuming. As a country, we have been caught miserably flat-footed after receiving warnings about what lay ahead when cases of Covid-19 began exploding in Wuhan, China. Messages from local and state leaders about how to respond to the pandemic change almost daily—a sure sign they have no idea what they are doing. Shutdowns are happening here in California and in New York, and will probably spread to the rest of the nation….

Here’s the problem: Because of the (understandable) fear and hysteria of the moment, few US leaders are seriously talking about the endgame. The epidemiologic models I’ve seen indicate that the shutdowns and school closures will temporarily slow the virus’ spread, but when they’re lifted, we will essentially emerge right back where we started. And, by the way, no matter what, our hospitals will still be overwhelmed. There has already been too much community spread to prevent this inevitability. 

We don’t have a totalitarian government like China, and we value our civil liberties too much to take the measures (i.e., total lockdown) that would be needed to rapidly decrease the infection rate to zero. This means that, even with shutdowns, the virus will still spread. Unfortunately, this also means that rates of “community immunity,” often referred to as “herd immunity,” will slow. As a result, we will always be vulnerable to the virus spreading rapidly again as soon as shutdown measures are lifted, unless they are immediately reimplemented—over and over and over again.

Was he the first post-lockdown voice from public health profoundly to object in a public forum of this magnitude? Perhaps so. Consider the bravery and presence of mind it required to write those sentences. The entire country was on a wartime footing with unprecedented horribles taking place. The media was screaming “Run for your lives” but most of us weren’t even allowed out of our homes to do that. 

These were utterly crazy times. The whole world was going bonkers. And yet this man kept his cool. 

This book explains where his cool comes from. You see, he is the son of an immigrant from Nigeria, born 1979. A math and science whiz, he attended Wake Forest and then entered Harvard Medical School. While he was involved in his studies, he noted the existence of the Kennedy School of Government and enrolled there too. On graduation day, he was granted a MD plus a PhD in public policy. So essentially: the highest credentials in two fields that this country offers. He became professor of medicine at New York University and then the University of California, Los Angeles. 

The trouble was that none of his training had prepared him to deal with medical issues closer to home, namely his wife’s unrelenting migraines that often landed her in the hospital and his own underlying psychological fears of social interaction. The details are very painful and told in this book with disarming detail. Long story short: his search for answers led him toward alternative medical paths that eventually fixed both issues, and burned a lesson in his mind. Health is individual, and the right path is not the same for everyone and not always found in expertise as codified in the textbooks and institutions. 

It was soon after these difficult times that the pandemic broke and, along with it, the claims that the experts had all the answers in lockdowns and eventual universal mandates for vaccination. 

Dr. Ladapo had meanwhile developed the self-confidence to speak about such matters truthfully and fearlessly. And he never stopped. He wrote for every venue he could, month after month, urging an end to the lockdowns, a focus on therapeutics, attention to the science we had, and genuine concern for the health of actual individuals, who are not lab rats but people with human rights and freedom. 

Even though Dr. Joseph Ladapo is obviously a hero (and one for the ages, so far as I’m concerned), the prose here is remarkably lucid, humble, and precise. That’s why I say that the humane concern in this book is an inspiration. Moreover, reading it is a form of therapy because he connects with a common sense that we all had in 2019 before the world descended into utter madness. 

What’s more, this book shows a path forward not only for public health but for all of us as individuals. He urges personal reflection as the first step in recovery, overcoming whatever hidden fears we had that caused too many among us to go along with the preposterous parade of dangerous nonsense that controlled our lives for so long. 

In my own view, this book is a classic of our times. Its value added is not only the author’s credentials, though he has them galore, or even how it speaks so directly to issues that have profoundly affected all our lives. Its real value is as a model of autobiography that offers lessons for all of us without exception. 

We at Brownstone are deeply honored that Dr. Ladapo will be our dinner speaker at our annual conference and gala in Miami, December 3, 2022. There is still time to attend. You can register here

I write as Dr. Fauci just finished his last press conference without offering so much as a hint of apology for what has happened. Meanwhile, I’m sure Dr. Ladapo is tending to his work in Florida where he has been charged with dealing with public health policy with honesty, truth, and wisdom. I know who gets my vote for hero of the pandemic. 

Tyler Durden Fri, 11/25/2022 - 16:00

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