When Allison Ruddick was diagnosed with stage 3 colorectal cancer in October 2014, she turned to the world of hashtags.

After her initial diagnosis it wasn’t clear if the cancer had metastasized, so she was in for a nerve-wracking wait, she says. She wanted outside advice. “But they don’t really give you a handbook, so you search kind of anywhere for answers,” Ruddick says. “Social media was one of the first places I went.”

Under the hashtags #colorectalcancer and #nevertooyoung on Facebook, Twitter and Instagram, other patients were sharing a fuller picture of their experience with cancer treatments.

Later she found even more advice on specialized message boards. Patients posted everything from the details of their surgeries to the ice packs they liked best as they recovered. “These weren’t things that my doctor could tell me, and as much as I appreciate their expertise, it’s also really limited by the fact that they’ve never really experienced any of this themselves,” Ruddick says.

Partly because of that experience gap, doctors and drug companies are keen to learn from online communities, too. They’re analyzing social networks to get a faster, wider look into how patients react to drugs, sometimes picking up information about side effects that clinical trials missed.

The rule of three

Stanford University dermatologist Bernice Kwong specializes in skin conditions that tag along with cancer treatments. In her practice and on patient message boards, she’s constantly on the lookout for symptoms that could be drug reactions.

In January 2017, a patient came to Kwong’s office with an unusual complaint. “I’ve noticed that when I work out, I just get really hot,”he told Kwong. “I don’t sweat anymore, and I used to sweat so much.” He was taking a drug called Tarceva,or erlotinib, that’s used against lung cancer.

At first, Kwong thought the problem might be hormonal. But soon after, two more of her patients at Stanford on the same drug reported that they’d also stopped sweating. “Anytime something hits three, I think, OK, I gotta look into this a little bit more,” she says.

But she hadn’t seen any reports before of a lack of sweating — hypohidrosis — as a side effect for Tarceva. Her sample size of three patients was small. She’d need more data to figure things out.

From talking with patients and perusing online forums, Kwong knew people discussed their treatments and side effects online. In fact, hundreds of thousands of people participate in support groups and communities she’d looked at on the website Inspire. She partnered with the site with the idea that its trove of patient reports could connect more dots between hypohidrosis and Tarceva.

A sharper data set

Inspire’s focused groups are filled with patients’ experiences with diseases and treatment, so analyzing posts requires less filtering than Facebook or Twitter data would, says Nigam Shah, a Stanford University bioinformatics specialist who collaborated with Kwong. It also helped that the skin reactions they were interested in are relatively easy for patients to describe.

Still, the posts on Inspire’s boards are less precise than insurance claims and health records typically used for studies on side effects.

Take loss of sweating. Most doctors would refer to that as hypohidrosis, so a records-based study could focus on that phrase. In online message boards there’s a lot of variety. One person’s “I can’t sweat anymore” might be another’s “I’m overheating.”

Kwong, Shah and their colleagues used a deep learning algorithm to process the phrases surrounding reports of symptoms, basically finding contextual clues to identify the different ways patients referred to side effects.

In 8 million posts on Inspire from a 10-year period, 4,909 users mentioned Tarceva, or erlotinib generically. Although clinical reports don’t link the drug and hypohidrosis, 23 patients wrote about the medicine and loss of sweating in the same post — a statistically significant connection, Kwong says. The research group’s findings were published in JAMA Oncology in March.

Using the same approach to monitor posts about a different class of immunotherapy cancer drugs, the researchers found mentions of autoimmune blistering that also predated the clinical reports of the side effect.

Given the stakes of cancer treatment, Kwong says she’s inclined to help patients manage side effects instead of stopping a given drug. But earlier alerts from systems like this could have made a difference in her practice. “If we had had this program already, I would’ve been looking out for [blistering] sooner and maybe I would’ve noticed it earlier in some patients,” Kwong says.

How clinical trials miss side effects

From numbers alone, it’s no surprise that clinical trials for drugs don’t pick up every side effect. The Food and Drug Administration first approved Tarceva in 2004 on the basis of a trial that enrolled 731 patients, 488 of whom received the drug. Uncommon effects might not show up in a group that size.

On Inspire’s message boards, more than 10 times as many patients reported using Tarceva, so it’s reasonable to imagine that online posts could include reports of rarer side effects.

And while drug trials do collect data on side effects, their overriding goal is to find out whether or not a drug works, says Dr. Aaron Kesselheim, a professor of medicine at Harvard University. “After a drug is approved, it is absolutely essential to continue to observe, follow and study the drug rigorously as it’s used in a larger population to try to really get a handle on the safety of the drug,” he says.

Collecting data about a drug from insurance claims and health records typically happens with quite a time lag. So mining the Internet and social media for casual patient reports is tempting, Kesselheim says, because of its potential scale and speed. But the approach also has drawbacks. “You just get this tidal wave of data, and it’s hard to know how to assess it in a rigorous and thoughtful fashion,” he says.

That hasn’t stopped drug companies from wading in. Roche has sampled mentions of their products from Twitter, Tumblr, Facebook and blogs to learn more about drug safety. GlaxoSmithKline has tried it too, analyzing millions of mentions of drugs from Twitter and Facebook.

Much of the work published so far has focused on drug reactions. But scraping public social media data isn’t just a matter of product safety. The company Synthesio touts its social data services for drugmakers as a way to answer customer questions, conduct market research and influence purchasing.

Surfing responsibly

In terms of extending studies to mine even bigger networks, like Twitter or Facebook, for potential side effects, Kesselheim points to issues of representation and privacy. As with any analysis, a deep learning model like the one Shah used on the Inspire message boards can only make conclusions about the information it sees.

And it’s hard to guarantee that message boards and social media represent all patients. In 2012, researchers gave 231 breast cancer patients in rural Michigan and Wisconsin computers, Internet access and training to use an online cancer support group. The researchers found that white women were much more likely to log on and post in the group than black women. Younger women were also more likely to post information.

While the long-standing approach to post-approval drug studies — using health records and claims data — may be slower, Kesselheim says, they’re more established. “There are methodologies and tools that you can use in claims data to try to make sure that you are making conclusions that can be generalizable across different races and ethnicity and genders and parts of America,” he says.

There’s also the issue of privacy — patients’ health records are protected by the Health Insurance Portability and Accountability Act of 1996, whereas public data online aren’t, Kesselheim says.

For Stanford researcher Shah, this wasn’t an issue. Inspire’s privacy statement tells patients their posts may be used for research if they’re not private, and Shah feels comfortable following common sense rules when using public data. “As in, if somebody did [something] with my data and I would be upset, don’t do that with someone else’s data,” he says.

But the newness of social media makes Kesselheim wary. “There are big questions that remain about how patient privacy is upheld in those social media contexts, and I think that’s a really big issue to think about moving forward as people are trying to use those outlets to provide insight into drug safety and side effects.”

As a patient, Ruddick isn’t bothered by the idea of researchers and pharmaceutical companies studying data from social media and patient message boards, as long as the data are public or there’s mention of data sharing in a privacy statement.

She works as a communications director in New York City, so she’s thought a lot about the nature of information online. “If I’m putting something out there on the Internet, it’s for the Internet. I know the world is going to see it,” Ruddick says.

She knows other patients might feel differently, but she’s optimistic that analyzing patients’ interactions online could improve the treatments available. “It’s one thing, being in a lab and developing these drugs,” she says. “But it’s a completely different thing to see how they’re being used out there in the world, and to see how they’re affecting somebody’s life.”

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The Trump administration named HIV expert Dr. Robert Redfield to lead the Centers for Disease Control and Prevention, ignoring complaints that he botched high-profile vaccine research more than 20 years ago.

The Army in 1994 acknowledged accuracy issues with HIV vaccine clinical trials led by Redfield, but concluded at the time that the data errors did not constitute misconduct.

In an announcement Wednesday afternoon, Health and Human Services Secretary Alex Azar emphasized Redfield’s care of HIV/AIDS patients and his work as a researcher, which included the controversial research.

Yet one of the whistleblowers who first raised the matter to the Army told Kaiser Health News this week that he remains so troubled about Redfield’s handling of the vaccine research that he has decided to speak out publicly.

Redfield was principal investigator over clinical trials of a treatment vaccine at the Walter Reed Army Institute of Research. The research was conducted at a time when there was intense pressure to come up with a treatment for HIV/AIDS, which often killed patients within a matter of months.

“Either he was egregiously sloppy with data or it was fabricated,” said former Air Force Lt. Col. Craig Hendrix, a doctor who is now director of the division of clinical pharmacology at Johns Hopkins University School of Medicine. “It was somewhere on that spectrum, both of which were serious and raised questions about his trustworthiness.”

In a letter to Trump this week, Washington Sen. Patty Murray, the ranking Democrat on the health committee, cited the research controversy as an example of a “pattern of ethically and morally questionable behavior” by Redfield that should prompt the president to reconsider the appointment.

Redfield’s appointment, which does not require Senate confirmation, was leaked to the news media over the weekend. Redfield did not respond to questions.

Redfield, who denied any scientific misconduct at the time, is now an HIV/AIDS specialist at the University of Maryland School of Medicine. He has been praised by his supporters for his care of patients. He oversees a clinical program that treats 6,000 patients in the Baltimore-Washington area, according to an online bio.

But Redfield’s critics said the appointment demonstrates that the Trump administration is not vetting appointees thoroughly. The first CDC head, Brenda Fitzgerald, stepped down in January after a controversy over her purchase of tobacco stocks, and former HHS Secretary Tom Price resigned late last year amid criticism over his use of government and private planes for official travel.

“The White House claimed they would do better background checks,” said Dr. Sidney Wolfe, founder and senior adviser of Public Citizen’s Health Research Group. “But that statement is dangerously laughable. If they had done a proper background check, they wouldn’t have chosen Dr. Redfield.”

Public Citizen, a Washington watchdog group, was a leading critic of the Army’s handling of Redfield’s data at the time and obtained and published documents that detailed the controversy.

Hendrix, who was the director of an Air Force HIV clinical unit when he raised the concerns, said: “Two members of his [Redfield’s] team told me they had tried to replicate the analysis, but they couldn’t. When they tried to go to the Army, they said they were ignored.”

After Hendrix couldn’t replicate the results, he drafted a letter to his superiors reporting the data problems.

Hendrix said Redfield’s superiors initially told him not to send a letter detailing the concerns. Instead, the military scheduled a meeting with Redfield and other researchers so Hendrix could discuss the concerns. In the meeting, Hendrix recalled, Redfield acknowledged he had overstated how promising the results were.

“I thought it was resolved,” said Hendrix, who said he later called Redfield to say he was proud to work in an organization that could openly discuss such concerns.

However, Hendrix soon heard Redfield make the same inaccurate representations of the data at a conference and decided to file an official complaint requesting an investigation into scientific misconduct.

An Air Force institutional review board also recommended that the Army launch an inquiry stating: “The committee agreed the information presented by Dr. Redfield seriously threatens his credibility as a researcher and has the potential to negatively impact AIDS research funding for military institutions as a whole.”

But the Army did not appear to launch a full investigation, said Hendrix, who was interviewed at the time by the military official who conducted the inquiry. The military official declined Hendrix’s attempts to provide documented evidence, telling him the investigation was “informal.”

Hendrix later asked the commander of his hospital about the outcome of the investigation. He recalled that the commander called another officer to ask.

“I just remember him saying “Yes, sir,” he said. “When he hung up, he told me, ‘We will not be discussing this again.’ “

Redfield was transferred from the laboratory he headed and assigned to treat patients, although the Army said he was not being punished. The Army also said the data would be corrected, and the military scrapped the program.

The project had earlier drawn criticism because Congress had set aside $20 million for the vaccine after lobbying by a former senator on behalf of the manufacturer.

Hendrix said he occasionally interacted over the years with Redfield and holds no grudges.

“Before this happened, he made important contributions to HIV-prevention efforts,” he said. “I respected him.”

However, he said, he remains disturbed by the military’s handling of the matter. He teaches a class on medical ethics and uses his own experience without naming Redfield to describe to his students the ethical quandaries faced in research.

Faulty data can lead other scientists to repeat the same mistakes and prompt participants to seek out trials for drugs and vaccines that don’t work.

“It’s a huge waste of funds,” he said. “But just as importantly, it diminishes trust, which is essential in science. If truth is eroded, then the whole enterprise falls apart.”

Kaiser Health Newsis a nonprofit news service covering health issues. It is an editorially independent program of the Kaiser Family Foundationthat is not affiliated with Kaiser Permanente.

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Celina Raddatz quit her job at a nursing home in 2014 when she realized she would have to take care of her mother full-time. Raddatz’s mother, Guadalupe Pena Villegas, 83, suffers from Alzheimer’s and bipolar disorder, a combination that sometimes makes her a danger to herself and others, and thus requires her to be supervised 24 hours a day.

Raddatz and one of her sisters, Rosalia Lizarraga, 61, had been caring for their mother together. But as the Alzheimer’s progressed, the task became too stressful for Lizarraga. The full responsibility fell on Raddatz, who was determined to fulfill a promise she and her siblings had made their mother as children.

“When my mother was sane, she made us promise never to put her in a nursing home. And of course, us young kids said, ‘OK, mom we would never …’ ” Raddatz says. “But we never ever once ever thought that she would get sick like this.”

As the elderly population in the United States grows, an increasing number of people require extra help in their daily lives. Because of this, the Bureau of Labor Statistics predicts employment for home health aides will grow 40% between 2016 and 2026. Hiring private caregivers, however, can be a financial burden for some families who can’t afford to pay an average of $22,170 a year for extra help.

Many families take on the responsibility of caring for their aging relatives. In some cases, like Raddatz’s, it can leave little time for other employment. Luckily, there are federally and state-funded programs across the country that allow elderly individuals like Raddatz’s mother to use Medicaid funds to hire their own personal caregivers – including family members.

“We noticed that she was not right”

Raddatz, 57, was born in Mexico. Her mother, a widow, supported nine children as a food vendor. When Raddatz was 8 years-old, her mother married a U.S. soldier, who immigrated the entire family to the United States, where the couple had two more children.

Raddatz’s mother and stepfather divorced two years after moving to the U.S. in 1971 and the family relocated Los Angeles.

“My mom was a very strong woman,” Raddatz says. Due to gang activity in their east L.A. neighborhood, when Raddatz was growing up, her mother quit her job and began collecting welfare so she could stay home and keep an eye on her children.

“She would take us to school and bring us home. She would not let us walk alone to school.”

Raddatz and her siblings first began to notice their mother changing in 2005 after she had a bad fall while working as a housekeeper.

“She kept telling this story that she fell at work and her head fell in her lap and she picked it up and put it back on her shoulders,” Raddatz says. “We kept telling her, ‘Mom, that’s impossible’ and she would get upset. And that’s when we noticed that she was not right.”

In 2006, Raddatz’s mother was diagnosed with Alzheimer’s disease.

“It’s just constant, constant, work”

At the time, Raddatz was working as an activity director at a nursing home in La Mesa, Calif. Her job was to make sure the residents remained engaged with their community through special outings and social events. “You get close to these people after working there for so many years and we felt like a family. Definitely,” Raddatz says.

It’s a field in which she’d spent more than 30 years working across California, having started out as certified nursing assistant. And she noted, her inspiration to pursue a career caring for the elderly came from tending to her grandmother as a teenager.

So when it became clear that her mother could no longer live by herself, Raddatz’s siblings turned to her as the most qualified to look after the elderly matriarch. Raddatz knew, however, there was a distinction between providing care professionally at a facility and caring for an elderly relative at home.

“It’s a lot easier doing it at work because you get a break,” Raddatz says. “And when you go home and you work taking care of your own parent, you don’t get a break. It’s 24/7, nonstop. It’s just constant, constant, work.”

But nonetheless, she quit her job at the nursing home and moved her mother in with her.

Shortly after leaving her job, Raddatz lost her apartment in El Cahon, Calif. and moved into her sisters’ home in Riverside. She cares for her mother around the clock, preparing her meals, helping her bathe and dress, and keeping her calm and entertained during the day. They also share a bedroom, so Raddatz can assist her mother when she wakes up throughout the night.

“Cash and Counsel” program

For about a year Raddatz cared for her mother without an income until one day in December, 2015, a social worker friend of hers recommended a government program called In-Home Supportive Services (IHSS). IHSS is what is called a “Cash and Counsel” program, which allows disabled and elderly individuals to use federal and state funds to hire their own help as they need it. These caregivers help their employers with anything from getting dressed to cooking meals to making sure they take their medication. Caregivers can be anyone the employer chooses (as long as the person passes a background check), including friends and family.

“I was very excited,” Raddatz says. “I was happy to hear that the government had such a program because we were in so much need.”

Raddatz registered her mother with IHSS and completed her background check. But when a social worker came to their home to evaluate her mother’s level of need, she was only granted 44 hours a month to hire a caregiver for an hourly wage of $10.50.

Programs like IHSS use evaluations to determine how much time a day an individual requires assistance and with what tasks. For the evaluation process, a social worker from San Diego County came to Raddatz’s home and did a physical and mental assessment of her mother. Because her mother is able-bodied and was able to respond to the simple interview questions the social worker asked, it was determined she needed less extensive care.

Raddatz was taken aback by how few hours her mother had been approved for, based on the amount of care she provided her mother every day. She felt the interview portion of her mother’s assessment hadn’t been thorough enough to accurately gauge her mother’s need for care. The social worker only asked two or three simple questions during the interview, to which Raddatz’s mother’s responses didn’t demonstrate the full extent of her dementia.

Caring for her mother “until the very end”

Raddatz had learned about a home care providers’ union, UDW, during her registration with IHSS and reached out to them out to see if they could help. With UDW, Raddatz began the process of appealing the number of hours her mother was given. But even with the lack of paid hours, Raddatz says she is determined to care for her mother until the very end because “it’s more than a job.”

“It’s a family responsibility because of the promises we made her when she was younger,” Raddatz says.

After her mother passes, Raddatz says she intends to return to her old job and when she does, it will be with a greater understanding of the families she serves. It used to pain Raddatz to see families leave their relatives with dementia in a nursing home. Now, she says, she has a personal appreciation for the emotional and physical sacrifices that caring for an elderly loved one involves.

“I can relate more to these families and my heart goes out to them,” says Raddatz says. “Even more so now than before.”

After Raddatz was interviewed for this story, San Diego County conducted another evaluation of her mother’s needs. In November, it was determined her mom was eligible for the maximum number of hours allowed through IHSS, which is 283 hours a month — approximately 70 hours a week. Additionally, Raddatz is paid overtime for every hour she works past 40 a week, is receiving back-pay for hours worked since June, 2017 and was given a small raise at the beginning of the year.

Raddatz says even though her hourly rate is lower than her old job, she is now making more than she did as a nursing home activity director. With the recent improvements to their standard and quality of life, Raddatz and her mother hope to move out of her sister’s house soon and into their own home.

NPR’s Alexi Horowitz Ghazi contributed to this report.

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Abortions in the United States are safe and have few complications, according to a landmark new study by the National Academies of Sciences, Engineering and Medicine.

The report, called “The Safety and Quality of Abortion Care in the United States,” examined the four major methods used for abortions — medication, aspiration, dilation and evacuation, and induction — and examined women’s care from before they had the procedure through their follow-up care.

“I would say the main takeaway is that abortions that are provided in the United States are safe and effective,” says Ned Calonge, the co-chair of the committee that wrote the study. He is an associate professor of family medicine and epidemiology at the University of Colorado and CEO of The Colorado Trust.

Calonge says the researchers found that about 90 percent of all abortions happen in the first 12 weeks of pregnancy. And complications for all abortions are “rare,” the report says.

But the report did find that state laws and regulations can interfere with safe abortions.

“Abortion-specific regulations in many states create barriers to safe and effective care,” the report says.

Calonge says those rules often have no basis in medical research.

“There are some requirements that require clinicians to misinform women of the health risks, that say you have to inform a woman that an abortion will increase her risk of breast cancer,” he says.

There is no evidence that breast cancer follows abortion, for example, but five states require doctors to tell women there is a link, according to the Guttmacher Institute, a research group that focuses on reproductive and sexual health.

“There are policies that mandate clinically unnecessary services like pre-abortion ultrasounds, separate inpatient counseling. There are required waiting periods,” Calonge says.

According to Guttmacher, 27 states make women wait at least 24 hours for an abortion and 11 states require women to have an ultrasound before they can terminate their pregnancy.

And there are state laws that dictate who can perform abortions and where they can do them. Some require all abortions to happen in the equivalent of a hospital or surgery center. Others require a doctor to have admitting privileges at a nearby hospital.

The National Academies report says waiting periods and requirements for unnecessary tests can result in long delays because women may have to travel to get care and have trouble getting appointments.

“Delays put the patient at greater risk of an adverse event,” the report says.

Hal Lawrence, the CEO of the American College of Obstetricians and Gynecologists, says the report settles the debate over abortion-restricting laws and regulations.

“Those sorts of laws have been totally debunked,” he says.

He says the study shows most of those laws do nothing to improve women’s health.

“Abortion is safer when it’s performed earlier in gestation,” Lawrence says. “And so delaying and making people wait and go through hoops of unnecessary, extra procedures does not improve the safety. And actually by having them delay can actually worsen the safety.”

The U.S. Supreme Court in 2016 voided some state abortion laws when it ruled that Texas’ strict rules around abortion facilities impose an undue burden on women. But other laws remain in place even without any backing in medical research.

Still, Donna Harrison says there are good reasons for the requirements.

“The tendency to look at abortion as though it were not a serious medical procedure is irresponsible. I mean, we all know that the fetus is killed during an abortion but women can be harmed by irresponsible medical care,” says Harrison, the executive director of the American Association of Pro-Life Obstetricians and Gynecologists.

She says data on complications from abortion is incomplete because doctors and patients don’t always report it accurately, or at all.

“There is no good data collection — and when you have garbage in, and you have garbage out,” she says.

And she says waiting periods are important so that women can give fully informed consent before they undergo what she says is a sometimes dangerous, surgical procedure.

The new report — which runs more than 200 pages — addresses most aspects of abortion care, including the use of the abortion pill mifepristone.

For example, it concludes that the strict requirements on how doctors can administer mifepristone may need review. The researchers say the rules may be erecting unnecessary barriers.

The report also says nurse practitioners and physician assistants can perform abortions just as safely as physicians.

Also, abortions have no long-term consequences on women’s physical and mental health, the report says.

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Virginia is among 18 states that have not expanded Medicaid under the Affordable Care Act. But this year, the state legislature is going into a special session to continue discussions about whether or not to include it in its budget. By the time the regular session adjourned Saturday, members of Virginia’s GOP-controlled House of Delegates and Senate could not reach agreement on whether or not to expand Medicaid.

Republican Delegate Barry Knight from the Virginia Beach area calls it “the 800-pound gorilla in the room.” He’s one of more than a dozen Republicans who voted to include Medicaid expansion in the House budget — along with a work requirement — this year.

It’s a big shift in the House position on the issue and comes after 15 seats flipped in the so-called “blue wave” of last November’s election, which also saw the election of Democratic Gov. Ralph Northam.

“On the big-picture issues, I think it was a re-awakening and a call to look at things from a different perspective,” says Republican Delegate Chris Peace, from the Richmond area.

At a recent rally outside the state Capitol in Richmond, Northam continued his campaign message. “Are you all ready to get this done?” he called to the crowd’s cheers. “Are you ready to expand coverage?”

A December poll showed over 80 percent of likely Virginia voters support an expansion.

“I think the House heard that message, loud and clear. I think the Senate still needs to listen a little bit,” Northam says.

He’s referring to a strong movement against expansion, led by Senate Majority Leader Tommy Norment from the Tidewater area in southeastern Virginia. Norment has come out against the House Republicans who want to expand. He reminds them that despite a slim margin, Republicans are still in charge and could stop Medicaid expansion.

“I do think that the House of Delegates is waiting for that moment of lucidity and epiphany to realize that their majority is 51 to 49,” Norment says.

But President Trump has managed to mobilize Democratic voters, says Bob Holsworth, a former political science professor at Virginia Commonwealth University. He thinks expansion has a greater chance this year.

It could pass in the Senate, he says, because of a potential wildcard.

That wildcard is Republican Sen. Emmett Hanger, from mostly-rural central Virginia. Hanger has expressed support for some form of Medicaid expansion, and has a track record of voting independently, says Holsworth.

“What Hanger has said that’s very interesting … is that if he decides to support some version of Medicaid expansion, he says, ‘There are a number of other Republicans who are going to go over with me.’ “

However, Hanger isn’t happy about a tax on hospitals that has been incorporated into the House’s budget to help pay for the state’s share of expansion costs. The tax accounts for about three quarters of the over $400 million Medicaid-related gulf between House and Senate budgets.

If legislators don’t come up with a budget that includes Medicaid expansion, Northam has a plan B. He says he’ll introduce an amendment to add it back into the budget. In the amendment process, the lieutenant governor, Justin Fairfax, gets a vote if the Senate ties. Fairfax says he’d be happy to vote to expand coverage to up to 400,000 low-income Virginians.

“There are so many people that we can help and we have the means to do it if we expand Medicaid. We just have to have the political will to do it,” Fairfax says.

Among those expansion would help in Virginia: low-income adults without children.

“An adult who does not have children can have zero income — can be totally impoverished — and they cannot get Medicaid,” says Jill Hanken with the Virginia Poverty Law Center.

And a family of three with a total income of about $10,000 doesn’t qualify for Medicaid, she says.

“It’s hard to explain to them that they don’t have a choice, they’re not eligible for Medicaid,” she says, and they’re not eligible for subsidies for insurance on the exchange, so health insurance is out of reach. “And the reason is because Virginia hasn’t expanded Medicaid,” she says.

The special session begins April 11. The state needs a budget agreement by June 30 to prevent a government shutdown.

This story is part of a reporting partnership with NPR, local NPR stations and Kaiser Health News.

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Being a medical student or resident is hard enough, but what if you have a disability that adds to the challenge?

One medical resident with a physical disability was about a year and a half into training when the medical institution finally installed an automatic door he needed. Another student faced frustrations when arranging accommodations for taking tests, with it seeming like the medical school was “making up rules along the way.” When another resident with a disability first sought support, the disability representative was allegedly unfamiliar with the Americans with Disabilities Act.

These firsthand experiences are documented in a report issued Tuesday by the Association of American of Medical Colleges and the University of California, San Francisco about the accessibility and inclusion of students and doctors with disabilities in the medical field. The culture and the environment surrounding disabilities varies across the board, it found, with some places doing far better than others.

About 1,500 medical students in the U.S. have disclosed a disability and receive formal accommodations. That’s about 2.7 percent of students, according to the report, and represents a lower percentage than other undergraduate programs, which average at about 11 percent for students who have disclosed a disability. The report found that in medicine especially, many students hide their disability out of a real “fear of judgment, bias, and skewed perception of ability.”

Medicine is an incredibly tough and competitive field where, historically, doctors have been viewed as superhumans, operating at the highest physical and mental capacity at all hours of the day and night, performing miracles and saving lives. There’s an expectation of perfection.

But doctors are human, too.

A lack of understanding about disabilities can create big challenges for otherwise qualified and talented future doctors, says Lisa Meeks, co-author of the report and a disabilities expert at the University of Michigan Medical School. Yet some schools may not even be aware of what they could be doing to foster a more inclusive environment.

“I don’t know of a school that doesn’t want to do the best practice,” says Meeks, who is also co-founder of the Coalition for Disability Access in Health Science and Medical Education, adding that schools might just not have the tools.

For Dr. Geoffrey Young, AAMC’s senior director for student affairs and programs, the nearly 100-page report is a much needed blue print for medical institutions to better understand policies and perceptions of those with disabilities, whether that be the easily identifiable physical kind or lesser seen invisible ones.

“I think we have to do a better job of educating those in the field about what the potential is for those with disabilities, verses what is consumed or assumed to be an automatic inability,” Young says, adding that the culture is shifting in medicine. “We are having this conversation in a very open way.”

The report identifies very clear barriers and considerations schools can take in response. That includes everything from the way disabilities are discussed in the admissions process to having a person within the institution who is well versed in both disability access issues and medical school requirements, to help future doctors better navigate their training.

For Dr. Lina Mehta, associate dean for admissions at Case Western Reserve University School of Medicine in Cleveland, improvements start with changing attitudes and approaches at the onset. Case was sited in the report as an example for the disabilities language it has adopted in its materials.

“In admissions, we sort of dictate the face and function of what medicine is going to look like by virtue of who we bring in,” Mehta says. Having a more diverse future physician population, one that includes those with disabilities, improves the field’s ability to understand and care for patients, she says. “It’s critical we bring in a group of learners and future practitioners who will mirror patient populations that they’re taking care of.”

This story is part of a reporting partnership with NPR, WHYY’s health show The Pulse andKaiser Health News.

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