STAT readers on burnt-out infectious disease doctors, 12-month prescriptions, and counting disabled Americans

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 infectious disease doctor shortage threatens future pandemic preparedness,” by Raul Ruiz

It’s imperative to think about the working conditions of infectious disease (“ID”) specialists if we’re serious about sustaining a pipeline. ID doctors are renowned in the medical education world for their meticulous history-taking and comprehensive review of medical records. Given their pivotal role in antibiotic stewardship, infection control, and diverse diagnostic challenges, it is not uncommon to witness ID pvractitioners tirelessly working long hours, even on weekends and holidays. Although this isn’t universally applicable to all ID physicians, the exposure of the field to trainees, including me, significantly shapes our perception of ID specialists — often depicted as overworked, burdened with bureaucratic tasks, and inadequately compensated.

And while there is a pressing need for ID physicians in rural America, these regions also exhibit higher levels of distrust toward public health and ID specialists. Political polarization has, unfortunately, led practitioners to endure hostile acts of vandalism, threats, and harassment during the Covid-19 pandemic. It’s no wonder that ID doctors are some of the most burnt-out in our profession, and these are the considerations that weigh on my mind when contemplating the type of work I aspire to pursue and sustain.

During my fourth year of medical school, I rotated in the ID hospital consultation service, encountering fascinating cases involving monkeypox, rabies, and complications stemming from HIV, syphilis, and tuberculosis. The ID faculty that I learned and worked with were ardently committed to serving marginalized communities including refugees, people experiencing homelessness, and those with a history of incarceration. ID specialists are truly at the frontlines with these communities and confronting the health challenges that are exacerbated by a multitude of systemic factors. Neglecting to tackle the shortage of infectious disease specialists represents a step backward in addressing the deficiencies within our public health and health care systems. And while financial considerations are crucial, focusing solely on monetary aspects may fall short of addressing the deeper systemic issues associated with the scarcity of infectious disease experts.
— Daniel Pham (Note: On Wednesday, Dec. 6, Rep. Ruiz will respond to this letter on the “First Opinion Podcast.”)

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Public health and health care are different. It is very concerning to see Rep. Ruiz apparently misconstrue this basic fact. If we want a stronger public health system, then we need to distinguish public health from health care. Conflating these terms, which was done numerous times through the pandemic, will only further subordinate public health to health care and not address root problems in the system.
— Eric M. Coles, Tule River Indian Health Center

“Filling 12-month prescriptions is one practical way to help the pharmacist crisis,” by Stephen Buck

Twelve months is a good idea, but for those with space problems, and safe storage issues, the management of drugs can be a pain. Sizing the containers never seems to be a concern for pharmacists, but for old people with 10 medications, organization and dosing can be very difficult. Patients sometimes need smaller containers, or extra small containers because drawers are too shallow, or deep and medicine cabinets are nonexistent or overflowing. Every pharmacist should visit a few homes periodically to see how it is done, because it can be a mess. Labels are impossible to read without glasses or a magnifier. Really, go big, but also go smarter.
— Steve Bunting

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I worked retail for over 40 years and it has been a constant battle for more staffing to ensure patient safety. When I first started, there were only cash fills or Medicaid. With consistently lower reimbursements, this was a battle that the retail pharmacist would never win. There actually used to be a profit (remember dispensing fees, etc.) in pharmacy. Now it’s a loss leader. If you implement 12-month prescription fills, management will just reduce staffing accordingly, don’t be fooled otherwise. I also doubt insurers will allow it since there is still the question of adjusting dosage if changing medication completely with the subsequent waste of insurer’s premiums. It’s always been a no-win situation for the retail pharmacist.
— Richard Reginelli

“The next Census could undercount the number of disabled Americans by 20 million,” by Bonnielin Swenor and Scott Landes

This essay misses the point that the Washington Group (WG) questions collect a range of difficulties because of the response categories are not yes/no. If the “some difficulty” cutoff is used, it actually identifies more people with disabilities. We don’t have to use the “lot of difficulty” cutoff. Plus, the WG questions are more useful in terms of policy because they show the range of exclusion. The American Community Survey (ACS) questions, because they are yes/no, combine people with different level of functional difficulties. Using them to disaggregate outcome indicators therefore masks the high degree of exclusion that some people face because you are combining many people with moderate limitations with a fewer number of people with more significant limitations.

So the WG questions can identify more people with disabilities, with greater nuance which is useful for policymakers. For example, people with a lot of difficulty according to the WG questions have a 14% employment rate. Those with some difficulty have a 40% employment rate. The ACS doesn’t allow us to see that, and since there are many more people with some difficulty, the ACS questions don’t allow us to see the high rates of exclusion faced by people with significant difficulties.
— Daniel Mont, Center for Inclusive Policy

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I am curious why the Washington Group questions would be used when they ask the respondent to self-describe the level of disability they have. Especially among Hispanics, it more likely that the degree of difficulty will be understated instead of being correctly reported, whether due to difficulty with language or an unwillingness to appear needful. As noted in the article, the disability community is lacking assistance, and this counting using the Washington Group questions will result in even less help to make them as independent as possible.
— Jose L. Loera