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With few MDs practicing in rural areas, a different type of doctor is filling the gap

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With few MDs practicing in rural areas, a different type of doctor is filling the gap

Osteopathic physician Kevin de Regnier of Winterset, Iowa, checks Chris Bourne, who came in for an adjustment of his anxiety medication on May 9, 2023.

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Osteopathic physician Kevin de Regnier of Winterset, Iowa, checks Chris Bourne, who came in for an adjustment of his anxiety medication on May 9, 2023.

Tony Leys/KFF Health News

WINTERSET, Iowa — For 35 years, this town’s residents have brought all manner of illnesses, aches, and worries to Kevin de Regnier’s storefront clinic on the courthouse square — and he loves them for it.

De Regnier is an osteopathic physician who chose to run a family practice in a small community. Many of his patients have been with him for years. Many have chronic health problems, such as diabetes, high blood pressure, or mental health struggles, which he helps manage before they become critical.

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“I just decided I’d rather prevent fires than put them out,” he said between appointments on a recent afternoon.

Broad swaths of rural America don’t have enough primary care physicians, partly because many medical doctors prefer to work in highly paid specialty positions in cities. In many small towns, osteopathic doctors like de Regnier are helping fill the gap.

Osteopathic physicians, commonly known as DOs, go to separate medical schools from medical doctors, known as MDs. Their courses include lessons on how to physically manipulate the body to ease discomfort. But their training is otherwise comparable, leaders in both wings of the profession say.

Both types of doctors are licensed to practice the full range of medicine, and many patients would find little difference between them aside from the initials listed after their names.

Osteopathic physician Kevin de Regnier has provided primary care for more than 35 years from this office on the courthouse square in Winterset, Iowa.

Tony Leys/KFF Health News

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A growing share of the physician workforce

DOs are still a minority among U.S. physicians, but their ranks are surging. From 1990 to 2022, their numbers more than quadrupled, from fewer than 25,000 to over 110,000, according to the Federation of State Medical Boards. In that same period, the number of MDs rose 91%, from about 490,000 to 934,000.

Over half of DOs work in primary care, which includes family medicine, internal medicine, and pediatrics. By contrast, more than two-thirds of MDs work in other medical specialties.

The number of osteopathic medical schools in the U.S. has more than doubled since 2000, to 40, and many of the new ones are in relatively rural states, including Idaho, Oklahoma, and Arkansas. School leaders say their locations and teaching methods help explain why many graduates wind up filling primary care jobs in smaller towns.

De Regnier noted that many MD schools are housed in large universities and connected to academic medical centers. Their students often are taught by highly specialized physicians, he said. Students at osteopathic schools tend to do their initial training at community hospitals, where they often shadow general practice doctors.

U.S. News & World Report ranks medical schools based on the percentage of graduates working in rural areas. Osteopathic schools hold three of the top four spots on the 2023 edition of that list.

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Osteopathic schools train doctors where the need is

William Carey University’s osteopathic school, in Hattiesburg, Mississippi, is No. 1 in that ranking. The program, which began in 2010, was intentionally sited in a region that needed more medical professionals, said Dean Italo Subbarao.

After finishing classwork, most William Carey medical students train in hospitals in Mississippi or Louisiana, Subbarao said. “Students become part of the fabric of that community,” he said. “They see the power and the value of a what a primary care doc in a smaller setting can have.”

Leaders from both sides of the profession say tension between DOs and MDs has eased. In the past, many osteopathic physicians felt their MD counterparts looked down on them. They were denied privileges in some hospitals, so they often founded their own facilities. But their training is now widely considered comparable, and students from both kinds of medical schools compete for slots in the same residency training programs.

Michael Dill, director of workforce studies at the Association of American Medical Colleges, said it makes sense that osteopathic school graduates are more likely to go into family practice, internal medicine, or pediatrics. “The very nature of osteopathic training emphasizes primary care. That’s kind of their thing,” said Dill, whose group represents MD medical schools.

Dill said he would be confident in the care provided by both types of doctors. “I would be equally willing to see either as my own primary care physician,” he said.

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Alice Collins of Winterset, Iowa, shows osteopathic physician Kevin de Regnier a spot on her hand during an office visit on May 9, 2023. A surgeon recently removed a tumor from her hand.

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Alice Collins of Winterset, Iowa, shows osteopathic physician Kevin de Regnier a spot on her hand during an office visit on May 9, 2023. A surgeon recently removed a tumor from her hand.

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Data from the University of Iowa shows osteopathic physicians have been filling rural roles previously filled by medical doctors. The university’s Office of Statewide Clinical Education Programs tracks the state’s health care workforce, and its staff analyzed the data for KFF Health News.

The analysis found that, from 2008 to 2022, the number of Iowa MDs based outside the state’s 11 most urban counties dropped more than 19%. Over the same period, the number of DOs based outside those urban areas increased by 29%. Because of the shift, DOs now make up more than a third of rural Iowa physicians, and that proportion is expected to grow.

In Madison County, the picturesque rural area where de Regnier practices, the University of Iowa database lists seven physicians practicing family medicine or pediatrics. All are DOs.

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De Regnier, 65, speculated that the local dominance of the osteopathic profession is partly due to the proximity of his alma mater, Des Moines University, which runs an osteopathic training center 35 miles northeast of Winterset.

Des Moines University has one of the country’s oldest osteopathic medical schools. It graduates about 210 DO students a year, compared with about 150 MD students who graduate annually from the University of Iowa, home to the state’s only other medical school.

Many patients probably pay no attention to whether a physician is an MD or a DO, but some seek the osteopathic type, said de Regnier, who is a past president of the American College of Osteopathic Family Physicians. Patients might like the physical manipulation DOs can use to ease aches in their limbs or back. And they might sense the profession’s focus on patients’ overall health, he said.

‘When he sits down on that stool, he’s yours’

On a recent afternoon, de Regnier worked his way through a slate of patients, most of whom had seen him before.

One of them was Ben Turner, a 76-year-old pastor from the nearby town of Lorimor. Turner had come in for a check of his diabetes. He sat on the exam table with his shoes off and his eyes closed.

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Osteopathic physician Kevin de Regnier of Winterset, Iowa, checks the feet of Ben Turner, a local pastor who has diabetes.

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Osteopathic physician Kevin de Regnier of Winterset, Iowa, checks the feet of Ben Turner, a local pastor who has diabetes.

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De Regnier took out a flexible plastic probe and instructed Turner to say when he felt it touch his feet. Then the doctor began to gently place the probe on the patient’s skin.

“Yup,” Turner said as the probe glanced against each toe. “Yup,” he said as de Regnier brushed the probe against his soles and moved to the other foot. “Yeah. Yeah. Yup. Yeah.”

The doctor offered good news: Turner had no signs of nerve damage in his feet, which is a common complication of diabetes. A blood sample showed he had a good A1C level, a measure of the disease. He had no heaviness in his chest, shortness of breath, or wheezing. Medication appeared to be staving off problems.

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Chris Bourne, 55, of Winterset, stopped in to consult de Regnier about his mental health. Bourne has been seeing de Regnier for about five years.

Bourne takes pills for anxiety. With input from the doctor, he had reduced the dose. The anxious feelings crept back in, and he had trouble sleeping, he told de Regnier, sounding disappointed.

De Regnier noted the dose he prescribed to Bourne is relatively low, but he had approved of the attempt to reduce it. “I’m glad you tried,” he said. “Don’t beat yourself up.”

In an interview later, Bourne said that until he moved to Winterset five years ago, he’d never gone to an osteopathic physician — and didn’t know what one was. He’s come to appreciate the patience de Regnier shows in determining what might be causing a patient’s problem.

“When he sits down on that stool, he’s yours,” Bourne said.

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Another patient that day was Lloyd Proctor Jr., 54, who was suffering from previously undiagnosed diabetes. His legs were swollen, and he felt run-down. Tests showed his blood sugar was more than four times the normal level.

“The pancreas isn’t happy right now, because it’s working too hard trying to take care of that blood sugar,” the doctor told him.

De Regnier diagnosed him with diabetes and prescribed medication and insulin, saying he would adjust the order if necessary to minimize Proctor’s costs after insurance. He brought out a syringe and showed Proctor how to give himself insulin injections. Proctor listened to advice on how to measure blood sugar.

“And maybe I should quit grabbing Mountain Dew every time I’m thirsty,” the patient said, ruefully.

De Regnier smiled. “I was just getting to that,” he said.

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The appointment was one of the doctor’s longest of the day. At the end, he reassured Proctor that they could get his diabetes under control together.

“I know that’s a lot of info. If you get home and think, ‘What’d he say?’ — don’t hesitate to pick up the phone and give me a call,” de Regnier said. “I’m happy to visit anytime.”

KFF Health News, formerly known as Kaiser Health News (KHN), is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — the independent source for health policy research, polling, and journalism.

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Microsoft hires DeepMind co-founder Mustafa Suleyman to run new consumer AI unit

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Microsoft hires DeepMind co-founder Mustafa Suleyman to run new consumer AI unit

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Microsoft has hired Mustafa Suleyman, the co-founder of Google’s DeepMind and chief executive of artificial intelligence start-up Inflection, to run a new consumer AI unit.

Suleyman, a British entrepreneur who co-founded DeepMind in London in 2010, will report to Microsoft chief executive Satya Nadella, the company announced on Tuesday. He will launch a division of Microsoft that brings consumer-facing products including Microsoft’s Copilot, Bing, Edge and GenAI under one team called Microsoft AI.

It is the latest move by Microsoft to capitalise on the boom in generative AI. It has invested $13bn in OpenAI, the maker of ChatGPT, and rapidly integrated its technology into Microsoft products.

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Microsoft’s investment in OpenAI has given it an early lead in Silicon Valley’s race to deploy AI, leaving its biggest rival, Google, struggling to catch up. It also has invested in other AI start-ups, including French developer Mistral.

It has been rolling out an AI assistant in its products such as Windows, Office software and cyber security tools. Suleyman’s unit will work on projects including integrating an AI version of Copilot into its Windows operating system and enhancing the use of generative AI in its Bing search engine.

Nadella said in a statement on Tuesday: “I’ve known Mustafa for several years and have greatly admired him as a founder of both DeepMind and Inflection, and as a visionary, product maker and builder of pioneering teams that go after bold missions.”

DeepMind was acquired by Google in 2014 for $500mn, one of the first large bets by a big tech company on a start-up AI lab. The company faced controversy a few years later over some of its projects, including its work for the UK healthcare sector, which was found by a government watchdog to have been granted inappropriate access to patient records.

Suleyman, who was the main public face for the company, was placed on leave in 2019. DeepMind workers had complained that he had an overly aggressive management style. Addressing staff complaints at the time, Suleyman said: “I really screwed up. I was very demanding and pretty relentless.”

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He moved to Google months later, where he led AI product management. In 2022 he joined Silicon Valley venture capital firm Greylock and launched Inflection later that year.

Microsoft will also hire most of Inflection’s staff, including Karén Simonyan, co-founder and chief scientist of Inflection, who will be chief scientist of the AI group. Microsoft did not clarify the number of employees moving over but said it included AI engineers, researchers and large language model builders who have designed and co-authored “many of the most important contributions in advancing AI over the last five years”.

Inflection, a rival to OpenAI, will switch its focus from its consumer chatbot, Pi, and instead move to sell enterprise AI software to businesses, according to a statement on its website. Sean White, who has held various technology roles, has joined as its new chief executive.

Inflection’s third co-founder, Reid Hoffman, the founder and executive chair of LinkedIn, will remain on Inflection’s board. Inflection had raised $1.3bn in June, valuing the group at about $4bn, in one of the largest fundraisings by an AI start-up amid an explosion of interest in the sector.

The new unit marks a big organisational shift at Microsoft. Mikhail Parakhin, its president of web services, will move along with his entire team to report to Suleyman.

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“We have a real shot to build technology that was once thought impossible and that lives up to our mission to ensure the benefits of AI reach every person and organisation on the planet, safely and responsibly,” Nadella said.

Competition regulators in the US and Europe have been scrutinising the relationship between Microsoft and OpenAI amid a broader inquiry into AI investments.

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Threats, debt and Trump's advances: 'Stormy' doc examines the life of Stormy Daniels

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Threats, debt and Trump's advances: 'Stormy' doc examines the life of Stormy Daniels

Stormy Daniels from the Peacock documentary Stormy.

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Stormy Daniels from the Peacock documentary Stormy.

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The new documentary Stormy begins in 2023 — around the time former President Donald Trump was indicted over hush-money payments made during his 2016 presidential campaign.

Stormy Daniels, who was paid by Trump’s lawyer Michael Cohen to keep quiet about their alleged previous affair, watches the news unfold on TV and then says, “Let’s go,” before she walks off screen.

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Stormy chronicles Daniels’ life from her childhood in Baton Rouge, La., to her rise as an adult film actor and then, in the opinion of some, a feminist hero. It also gives viewers a glimpse into how she went from friend to foe of a celebrity businessman who became president of the United States.

“I am here today to tell my story and even if I just change a few people’s minds, it’s fine. If not, at least my daughter can look back on this and know the truth,” she said in the film.

Trump’s criminal trial over the hush-money payments has been delayed until mid-April. He faces 34 felony counts, alleging he falsified New York business records to conceal damaging information before the 2016 presidential election. Trump denies the allegations that he had an affair with Daniels and has pleaded not guilty to all counts.

On Monday, a judge rejected Trump’s bid to block Cohen and Daniels — whose legal name is Stephanie Clifford — from testifying. The trial date will be set at a hearing on March 25.

The film, released Monday on Peacock, mainly captures Daniels’ life between 2018 and 2023. Here are the main takeaways from the documentary:

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1. Daniels explains why she didn’t say no to Trump’s advances back in 2006

Daniels alleged that she was abused by a neighbor in Louisiana when she was 9 years old. She did not go into further detail except to say that the man, whom she did not name, had abused other young girls and has since died.

Later in the film, as Daniels explained why she did not refuse Trump’s advances when the two met in 2006, she said, “I didn’t say no because I just, I was 9 years old again.” At the time, Daniels was in her 20s and Trump was 60.

Though she described the alleged affair as consensual, Daniels said she did not want to have sex with Trump.

“To this day, I blame myself and I have not forgiven myself because I didn’t shut his a** down in that moment, so maybe make him pause before he tried it with someone else,” she said. “The hardest part about all of this is I feel like I am partially responsible for every woman that could have come after me.”

2. Threats against Daniels have become more disturbing

Throughout the film, Daniels is forced to navigate insults and threats hurled at her and her family.

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But she described herself as having thick skin. In one scene from 2018, Daniels joked that she was disappointed she could not find any hate comments on Twitter after she had received a key to West Hollywood from the city’s mayor.

Fast forward to this past year, after Trump’s indictment, Daniels said the hate comments had become more intense and disturbing.

“Back in 2018, there was stuff like ‘liar, s***, gold digger,’ ” she said. “This time around, it is very different. It is direct threats. It is ‘I’m going to come to your house and slit your throat.’ “

Daniels added that she did not feel protected by the justice system, and accused it of ignoring her concerns about her safety.

3. Daniels says her ‘soul is so tired’ but she is willing to testify against Trump

Amid the six-year conflict with Trump, Daniels’ marriage ended, her relationship with her daughter became strained, and she felt her safety was constantly jeopardized.

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But with Trump about to go on trial, Daniels said she’s willing to testify in court against the former president.

“I’m more prepared with my legal knowledge but I’m also tired. Like, my soul is so tired,” she said. “I won’t give up because I’m telling the truth. And I kind of don’t even know if it matters anymore.”

4. Daniels owes Trump over $600,000 in attorney fees

Near the end of the documentary, it’s clear that Daniels also suffered financially as a result of her years-long legal battle against Trump.

In 2018, Daniels sued Trump for defamation. The suit was based on a tweet Trump wrote that year, which suggested Daniels had lied about being threatened in 2011 to not speak out about her alleged previous affair with Trump.

A federal judge later dismissed the suit and ordered Daniels to pay the then-president’s legal fees.

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Daniels appealed but lost. She now owes Trump over $600,000 in attorney fees. The film asserts that Daniels is afraid she may lose her home.

5. Seth Rogen and Jimmy Kimmel speak on Daniels’ behalf

Among the people who appeared in the documentary were actor Seth Rogen and late-night TV host Jimmy Kimmel.

Rogen, who worked with Daniels on the 2007 film Knocked Up, recalled talking with her about Trump. At the time, Daniels said she was communicating with Trump about possibly being on his former reality TV show Celebrity Apprentice.

“She didn’t realize she would one day be at the center of this giant thing as she was messing around with some game show host,” Rogen said. “She’s someone who made an enemy of the most powerful guy on the planet and didn’t, like, cower.”

Kimmel invited Daniels to his show in 2018, when Daniels’ nondisclosure agreement about her previous affair with Trump was still in effect.

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Kimmel described Daniels as having a good sense of humor but also afraid of violating her NDA. He nodded to this during their interview, in which he brought out puppets to reenact her interactions with Trump.

“She told the truth and she paid a price for that,” Kimmel said in the film. “It’s not something that just goes away.”

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Calpers to invest more than $30bn in private markets

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Calpers to invest more than $30bn in private markets

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Calpers, the US’s biggest public pension plan, is to increase its holdings in private markets by more than $30bn and reduce its allocation to stock markets and bonds in an effort to improve returns.

A proposal to increase the $483bn fund’s positions in assets such as private equity and private credit from 33 per cent of the plan to 40 per cent was approved on Monday, according to an announcement by the fund and notes from its board meeting. 

The formal approval comes two years after Calpers admitted that a decision to put its private equity programme on hold for 10 years had cost it up to $18bn in returns.

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However, a review of its investment policy found that, despite the gains it had already missed, private equity was still the asset class with the highest expected long-term total return.

“Strong and ongoing growth in private equity returns is behind this measured and appropriate increase,” said Calpers trustee David Miller, chair of the investment committee. 

“Market conditions are evolving and the investment team needs latitude to deploy capital intelligently to keep the fund on track for sustainable returns.”

According to analysis published by Calpers alongside its board notes, private equity was the top-performing asset class in the decade to June 30 2023, with annualised returns of 11.8 per cent. That compares with 8.9 per cent from public equities and 2.4 per cent from fixed income. The documents did not disclose if the figures took account of fees.

The portfolio shake-up, which was confirmed after a scheduled asset allocation review, will bring the California-based plan into line with other big retirement systems in the US, including Calstrs, which has just over 40 per cent of its portfolio in private markets.

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As part of the move, Calpers will increase its bet on private equity from 13 per cent to 17 per cent of its portfolio, although this could potentially rise as high as 22 per cent.

At the same time, it is pulling back from investing in stock markets, with its allocation to equities set to fall from 42 per cent to 37 per cent of its portfolio. It will also trim its allocation to fixed income from 30 per cent to 28 per cent.

In 2021, Calpers’ board approved an expansion into private assets including private equity, real assets and private debt, from 21 per cent to 33 per cent of the portfolio, and also gave itself the ability to borrow money to invest in assets that would help diversify its holdings.

Last year the Financial Times reported that Calpers was planning a multibillion-dollar move into international venture capital, as the fund moved towards investing in riskier assets to drive returns.

The fund also reported a return of 10.3 per cent last year. It is yet to announce a replacement for chief investment officer Nicole Musicco, who resigned last year after 18 months in the role.

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