What STAT readers think about premed requirements, too much health care, harm reduction, and more

STAT now publishes selected Letters to the Editor received in response to First Opinion essays to encourage robust, good-faith discussion about difficult issues. Submit a Letter to the Editor here, or find the submission form at the end of any First Opinion essay.

“The end of affirmative action means it’s time to revise pre-med requirements,” by David Velasquez

The ability to do well in both general and organic chemistry as well as physics that requires calculus are courses that test both reasoning and attention to detail more than the ability to memorize! In order to arrive at the correct diagnosis, one must be able to reason effectively. In 40 years of practice I achieved good outcomes and I did not get sued for malpractice.
— Philip Meadow

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The perspective on med school admission requirements is thoughtful and timely. Reflecting on my experience at Wayne State in Detroit, I would agree that organic chemistry was not a crucial part of clinical decision-making! As a consideration, most Canadian med schools have much less rigorous science requirements, and my observation from 30 years of teaching students on both sides of the border is that perhaps the science requirements are not what our current students need.
— Michael Rieder, University of Western Ontario

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Velasquez’s suggestion has merit if the only aim of medical school was to create clinicians. Note that many clinician places are now being filled (in medicine as well as in my field of dentistry) by so-called “midlevel providers.” If this is the direction medicine is headed, just beware of unintended consequences.
— Steven Bornfeld

“Many Americans receive too much health care. That may finally be changing,” by Elsa Pearson Sites

Well stated but difficult to achieve in our pay for service economy that promotes over treatment. Remember what Arnold Relman referred to as the medical industrial complex. It is only growing since he was editor of the New England Journal of Medicine.
— Fred Schwartz, UMASS School of Medicine

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The logic model in this article would be hard to refute from any perspective. However, it assumes that each patient has a leading physician who manages, or at least knows about, all the other specialists involved in their patient’s care. Excepting for patients in HMOs or similar care settings, this is not the case. Instead, each physician involved in a patient’s care may at times choose to refer them to another specialist, i.e., an allergy specialist may suggest adding a pulmonologist in order to have someone watching for lung structure changes and provide more sophisticated tests than the allergist’s basic spirometry. An immunologist may add another immunologist with the capacity to provide IViG infusions. Gradually, the physician “tree” treating a patient grows. In the best case scenario, the primary care physician receives visit notes/reports from all the other physicians, but they can scarcely be expected to read them all, let alone suggest that another physician’s decisions be second-guessed or eliminated. So, as it stands in our current health system, reducing treatment or treatment providers falls into the category of a wish and a prayer, despite the fact that once in a while we lose a patient because their cancer specialist prescribed a maintenance medication and the referring physician prescribed the same medication under a different brand name.
— Marilyn Hoyt

“There’s a real risk that harm reduction could be a fad,” by Alexandra Plante

As a person who used drugs when introduced to harm reduction in 1986 and has been a member of the harm reduction movement since, this article points out what we have known for decades and some myths. Harm reduction is peer-driven and is not a road to recovery, though recovery is an outcome many times. In harm reduction recovery is NOT the goal. The goal is to keep people who use drugs (PWUD) free from disease (HIV/AIDS, infections and abscesses, and death). We’ve always been on the outside and ignored by the federal agencies that funded mental health and drug use organizations. These organizations labeled us enablers and part of the problem by providing clean syringes and naloxone. We supported ourselves through small private grants and second and sometimes third jobs.

Now that the federal government has taken notice and released funding, it seems these same treatment and prevention have all of a sudden embraced harm reduction, calling their recovery coaches harm reduction specialist who can bill from for services. In reality they are frauds and thieves claiming to provide harm reduction services. If funding goes away for harm reduction today, they will follow. True harm reductionists will remain after the larger organizations fail in the engagement of PWUD. The funders don’t know who to fund, and those they are funding don’t know the questions to ask when hiring employees to do the work. Basically the solution is simple: STAY IN YOUR LANE.
— Gary Langis, Boston Medical Center

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Without the inclusion of individuals who have/are successfully employing harm reduction in their lives and have skin in the game, as the primary contact on the “street” level, married to consistent, readily available, and scalable modalities fitted to the individual, any success will be marginal at best. I have been in recovery since 1985 and have been a treatment professional for over 20 years, working on the front lines, not the front office.

To be clear: Recovery is not and has never been one size fits all. The paths of treatment and recovery available are numerous, yet decades of often bitter experience has clearly demonstrated though that whether it is classic 12-step recovery, medication-assisted treatment (MAT), harm reduction, CBT, DBT, EMDR, Smart Recovery, Celebrate Recovery, etc., lacking engagement with individuals intimately familiar with the curious nature of addiction thinking, having personal experience with life’s inevitable difficulties, challenges and successes, sustainable healthy long-term recovery, as the current overdose death and relapse rates attest, is the norm. You can’t get there from here without guides who have made the trek successfully.

Portugal dramatically changed their laws concerning drug use/addiction in 2000. It was a success, for a time. What changed? Much of the funding to assist sufferers long-term was withdrawn with the inevitable spike in drug related crimes and overdose deaths. Oregon passed a similar law in 2020 which included provisions for treatment, but of the 6,000-plus tickets issued for drug possession under the new law less than a hundred individuals sought help of any kind, instead opting to pay a small fine or just ignore it completely. Having worked with thousands of individuals from all walks and strata of life, both as someone intimately familiar with addiction as well as a treatment professional it is clear we have the tools, MAT and harm reduction part of that tool kit. But without continuing consistent engagement, marrying professional modalities with long term support from those possessing real world experience, failure, as has been demonstrated, is assured.
— Vincent Jones

“Congress must reauthorize the National Advisory Committee for Seniors and Disasters,” by Robert Kadlec, Sue Anne Bell and Michael Wasserman

It should be intuitively obvious to the most casual observer that seniors should be included along with children and the disabled when it comes to their health and welfare. Congress would be negligent in not authorizing this other advisory committee for the elderly.
— Benny Wasserman

“I worked for CMS. Even I struggle to help family navigate dual eligibility,” by Dawn Alley

I’m sympathetic to the author’s experience and wish her aunt a speedy recovery. But I’m struck by her inability to recognize the poor outcomes from well-intentioned bureaucratic regulations, which create perverse incentives. Additionally she doubles down on failed policy. Perhaps it’s time to rethink the notion that CMS/Central planners have all the answers.
— Arvind Cavale

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Thank you for acknowledging the issues that are thrown into our laps.
— Michelle Wentzel