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What military doctors can teach us about power in the United States

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What military doctors can teach us about power in the United States

Power is invisible, but its effects can be seen everywhere — especially in the health records of active duty military personnel.

By examining details of 1.5 million emergency room visits at U.S. military hospitals nationwide, researchers found that doctors invested significantly more resources in patients who outranked them than in patients of equal or lesser rank. The additional clinical effort devoted to powerful patients came at the expense of junior patients, who received worse care and were more likely to become seriously ill.

Military rank wasn’t the only form of power that translated into inequitable treatment. The researchers documented that patients fared better when they shared the same race or gender as their doctor, a pattern that tended to favor white men and caused Black patients in particular to be shortchanged by their physicians.

The results were published Thursday in the journal Science.

The findings have implications far beyond the realm of the military, said Manasvini Singh, a health and behavioral economist at Carnegie Mellon University who conducted the research with Stephen D. Schwab, an organizational health economist at the University of Texas at San Antonio.

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For instance, they can help explain why Black students do better in school when they are taught by Black teachers, and why Black defendants get more even-handed treatment from Black judges.

“We think our results speak to many settings,” Singh said.

The disparities wrought by power imbalances are easy to spot but difficult to study in real-world scenarios.

“It’s just hard to measure power,” Singh said. “It’s abstract, it’s complicated.”

That’s where the military health records come in.

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The Military Health System operates 51 hospitals across the country. The doctors who staff them are active-duty personnel, as are many of the patients they treat. Comparing their ranks gave Singh and Schwab a handy way to gauge the power differential between physicians and the people in their care.

The researchers restricted their analysis to patients who sought treatment in emergency departments, where patients are randomly assigned to doctors. That randomness made it easier to measure how power influenced the treatment patients received.

To further isolate the effects of power, the researchers made comparisons between patients of the same rank. If they happened to outrank their doctor, they were considered a “high-power” patient. If not, they were classified as a “low-power” patient.

The medical records showed that doctors put 3.6% more effort into treating high-power patients than low-power ones. They also utilized significantly more resources such as clinical tests, scans and procedures, according to the study.

Those extra resources translated into better care: High-power patients were 15% less likely to become sick enough to be admitted to the hospital over the next 30 days.

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To see if they could replicate their results, Singh and Schwab narrowed their focus to doctors who treated patients within a one-year period before or after the patients were promoted to a higher rank. The researchers found that doctors devoted 1% more effort to patients post-promotion, as well as more medical resources. Those differences may have been small, but they were statistically significant, Schwab said.

Next, the pair considered what happened to low-power patients while high-power patients were getting extra attention. One hypothesis was that ordering additional tests for one patient might prompt doctors to order the same tests for everyone they treated that day. It was also possible that the decisions doctors made for their high-power patients had no bearing on their other patients.

Neither turned out to be the case. Instead, the added effort spent on high-power patients was siphoned away from low-power patients, who got 1.9% less effort from their doctors. On top of that, their risk of needing to return to the ER or be admitted to the hospital over the following 30 days increased by 3.4%, the researchers found.

“The powerful unwittingly ‘steal’ resources from less-powerful individuals,” Schwab and Singh wrote.

Outside the military, doctors and patients can’t use official rank to measure their power relative to each other, but they do contend with the effects of race and gender. That led the researchers to investigate whether the physicians in their study treated patients differently if they shared these attributes.

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White doctors devoted more effort to white patients than to Black patients across the board, the researchers found. The gap was the same regardless of whether the doctor had a higher or lower rank than the patient.

However, white doctors increased their effort for high-power patients by the same amount regardless of race. As a result, white doctors treated high-power Black patients the same, on average, as low-power white patients.

The story was different for Black doctors. When they outranked their patients, they gave essentially the same amount of effort to everyone. But on the rare occasions when they encountered a higher-ranked Black patient, the amount by which they dialed up their efforts was more than 17 times greater than it was when they treated a higher-ranked white patient.

It’s not clear what accounted for this “off-the-charts effort,” the researchers wrote. They speculated that since Black service members were underrepresented among the pool of high-power patients, Black doctors were particularly attuned to their status.

The effects of gender were more difficult to ascertain, since biology dictates that men and women require different kinds of care.

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Both male and female doctors invested the most effort in female patients who outranked them. But male doctors upgraded their care for high-power patients of both genders to a much greater extent than female doctors. And unlike female doctors, male doctors devoted more effort to female patients across the board.

Finally, the researchers wondered whether doctors gave preferential treatment to high-power patients because of their elevated status or because those patients had the authority to make trouble if they were unsatisfied with their care. To make inferences about this, they compared the treatment of retirees (who retained their status but had given up their authority) to the treatment of active-duty patients (who still had both).

Schwab and Singh found that high-power patients continued to elicit extra effort from doctors for up to five years after they retired, suggesting that status was an important factor.

“I think it’s really, really cool that even after retirement, you still have these effects,” said Joe C. Magee, a professor of management and organization at the NYU Stern School of Business who studies the role of hierarchy. He sees that as a strong sign that status was driving doctors’ decisions all along.

“What these folks are able to show is that it has real health consequences,” Magee said.

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Eric Anicich, a professor of management and organization at the USC Marshall School of Business, called the study “impressive” and the findings “important.”

Although a 3.5% increase or a 1.9% decrease in physician effort may seem small, their cumulative impact is meaningful, especially when it comes to something as critically important as healthcare, he said.

The inequities documented in the study aren’t unique to doctors or to the armed forces, Schwab and Singh said. The mathematical model they developed to describe the behavior in military emergency rooms also helps explain why people in all kinds of situations give preferential treatment to people who look like them: It may help minimize the effects of societal disparities.

In a commentary that accompanies the study, Laura Nimmon of the University of British Columbia’s Centre for Health Education Scholarship wrote that “the ephemeral and unobservable nature of power has made it profoundly difficult to study.” But she said it’s worth the effort to make sure doctors wield their power more fairly.

The disparities reported by Schwab and Singh are “of serious concern to society at large,” she wrote.

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Opinion: Most older Americans who need hearing aids don't use them. Here's how to change that

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Opinion: Most older Americans who need hearing aids don't use them. Here's how to change that

Having depended on hearing aids for nearly three decades, I’m astounded by the lack of Medicare coverage for devices that can solve a problem afflicting tens of millions of older Americans.

Nearly two-thirds of Americans over age 70 have some degree of hearing loss, and over half of those 75 and older experience impairment serious enough to be considered disabling. But most don’t wear hearing aids.

Because the legislation that created Medicare nearly 60 years ago specifically excluded hearing aids, those who rely on the program’s traditional coverage must pay for them out of pocket. That expense is among the chief barriers to wider use of the devices.

Age-related hearing loss impedes basic communication and the relationships that depend on it. Expanded access to hearing aids could therefore do no less than enable more older Americans to establish and maintain the social connections that are essential to a meaningful life.

Hearing loss is like an invisible, muffling curtain that falls in front of anyone speaking. Asking people to repeat themselves can yield irritated and hurtful responses. And it’s hopeless to ask a soft-spoken person to speak up. Sometimes it’s easier just to nod and smile.

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Many older people I know choose to avoid social gatherings altogether because they can’t hear well. Without hearing aids, I’d stay home too.

Hearing loss can harm one’s health in other ways. For example, I’ve written about the need for a comprehensive approach to reducing cancer risk at older ages, including preventive services such as colorectal cancer screening. But these services rely on conversations between patients and their healthcare providers. An older patient’s ability to hear and understand such conversations shouldn’t be taken for granted or ignored.

The Food and Drug Administration did improve access to hearing aids by making some of them available without a prescription in 2022, but the over-the-counter devices are inadequate for serious hearing loss like mine. My private health insurance, meanwhile, started covering hearing aids a few years ago, providing up to $2,500 for them every five years. One hearing aid alone can cost that much or more, however.

Despite its limitations, my private coverage for hearing aids is better than nothing, which is what traditional Medicare provides.

Hearing loss is more common among lower-income people and those without advanced education. The toll from noisy workplaces compounds age-related hearing loss for some. One analysis found that most Americans with a serious hearing disability can’t afford the typical price of hearing aids.

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Many of the older adults who can’t come up with these significant out-of-pocket expenses spent their working years in low-wage jobs that our country depends on. Denying them treatment for their hearing loss is a lousy way to treat people who gave years of service to our society.

Although some older adults with hearing loss won’t benefit from hearing aids, Medicare coverage for the devices might encourage more beneficiaries to get their hearing tested so they can get the treatment that’s right for them. And while Medicare coverage alone won’t address the stigma some people associate with hearing aids, the availability of newer, more comfortable and less obvious technology might win over some refuseniks.

Legislation reintroduced with bipartisan support last year would finally correct this glaring gap in Medicare coverage by removing the hearing aid exclusion from the law. There’s no reason to delay action on this any longer. Are our representatives listening?

Mary C. White is an adjunct professor of environmental health at Emory University’s Rollins School of Public Health, a Public Voices fellow at AcademyHealth in partnership with the OpEd Project and a former federal epidemiologist.

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Second human case of bird flu detected in Michigan dairy worker

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Second human case of bird flu detected in Michigan dairy worker

A second human case of bird flu in a diary worker has been confirmed in Michigan, state and federal health officials announced Wednesday.

The symptoms were mild, consisting of conjunctivitis. The Texas dairy worker who contracted the virus in March also came down with pink eye.

At a press call on Wednesday, Nirav Shah, principal deputy director of the U.S. Centers for Disease Control and Prevention, said the finding was “not unexpected” and that it was a scenario “that we had been preparing for.”

He said that since the discovery of H5N1 in dairy cattle, state and federal health officials have been closely monitoring farmworkers and slaughterhouse workers and urging farmers and farmworker organizations to “be alert, not alarmed.”

Federal officials say they still believe the human health risk of bird flu is low; however, it underscores the need for people who are interacting with infected or potentially infected farm animals or birds to take precautions, including avoiding dead animals and wearing personal protective equipment (PPE) if there’s a need to be in close contact.

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Though a nasal swab from the person in Michigan tested negative for influenza, an eye swab from the patient was shipped to the CDC and tested positive for influenza A(H5N1) virus.

This is the third case of H5N1 reported in the United States. A poultry worker in Colorado was identified in 2022.

Although the symptoms in the three farmworkers in the U.S. have been mild, people elsewhere in the world have suffered more severe illness, including death. According to the World Health Organization, between Jan. 1, 2003, and March 28, 2024, there have been 888 cases of human infection from 23 countries; 463 were fatal.

In preparation for a more widespread outbreak, the CDC updated its guidance for PPE in dairies and issued a nationwide order for healthcare providers to be on the lookout for novel influenza.

On Tuesday, the CDC asked clinical laboratories and health departments to increase the number of influenza samples being analyzed “to maximize the likelihood of catching a case of H5N1 in the community,” Shah said.

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The US Department of Agriculture is also expanding its surveillance and support by providing $1500 to non-infected farms to beef up biosecurity, and $100 to producers who want to buy inline samplers to test their milk. The agency will also provide $2000 per farm to cover veterinary fees for testing, as well as shipping costs to send those tests to laboratories for analysis.

There have been no cases of H5N1 detected in California’s dairy herds.

Officials said ongoing analysis of the nation’s dairy supply suggests it is safe to consume, Despite the risk to human health being low, an official with the Administration for Strategic Preparedness and Response said it will make Tamiflu available upon request “to jurisdictions that do not have their own stockpile and are responding to pre-symptomatic persons with exposure to confirmed or suspected infected birds, cattle or other animal exposures.”

Dawn O’Connell, assistant secretary of the preparedness agency, said it started the “fill and finish” process for approximately 4.8 million doses of vaccine “that is well matched to the currently circulating strain of H5N1 through the national pre-pandemic influenza vaccine stockpile program.”

She said the decision to get started on H5N1 vaccines was not a response to any heightened concern, but since it takes several months to fill and finish vaccine doses, the agency “thought it made sense given what we were seeing.”

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Gas stoves may contribute to early deaths and childhood asthma, new Stanford study finds

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Gas stoves may contribute to early deaths and childhood asthma, new Stanford study finds

Lung-irritating pollution created by cooking with gas stoves may be contributing to tens of thousands of premature deaths and cases of childhood asthma in the United States, according to a new study published in the journal Science Advances.

For decades, scientists have known the flames from a gas stovetop produce nitrogen dioxide, a pungent gas that can inflame a person’s lungs when inhaled. But for the first time, a team of researchers from Stanford University and Oakland-based research institute PSE Healthy Energy published a nationwide estimate of the long-term health consequences associated with cooking with natural gas and propane stoves.

Researchers concluded that exposure to nitrogen dioxide emissions alone may contribute to nearly 19,000 premature deaths in the United States each year. It has also resulted in as many as 200,000 current cases of pediatric asthma compared with cooking with electric stoves, which do not produce nitrogen dioxide.

Aggressive and impactful reporting on climate change, the environment, health and science.

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Stanford researcher Yannai Kashtan noted higher levels of pollution were correlated with the amount of gas that was burned. But pollution also accumulated at higher levels inside smaller homes.

“If you live in a smaller house, you’re exposed to more pollution, and that can lead to income and racial disparities in exposure,” Kashtan said. “In general, folks living in neighborhoods with higher levels of outdoor pollution also tend to have higher indoor pollution. So this environmental injustice extends indoors as well.”

The American Gas Assn., a trade organization representing more than 200 local energy companies nationwide, dismissed the findings as “misleading and unsupported.”

“Despite the impressive names on this study, the data presented here clearly does not support any linkages between gas stoves and childhood asthma or adult mortality,” the association’s president and CEO, Karen Harbert said in a statement earlier this month.

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The study is the latest examining the serious health effects associated with breathing fumes from gas stoves, which release planet-warming carbon emissions and a variety of air pollutants. In recent years, the popular household appliance has become a political hot-button issue as policymakers and regulators have weighed environmental impacts against consumer choice.

Many large cities in California, including Los Angeles, have moved toward phasing out gas stoves in newly constructed residences. Earlier this month, the California Assembly advanced a bill to the Senate that would require gas stoves to come with warning labels detailing the pollution and health effects that can arise from cooking with gas.

Gas stoves emit a variety of pollutants, including asphyxiating carbon monoxide, cancer-causing formaldehyde and benzene. The flame also creates nitrogen dioxide, a precursor to smog and a pollutant that can cause difficulty breathing.

Environmental groups say consumers should be notified about these pollutants and the potential harm they can cause.

“Gas stoves create pollution in our homes, increasing the risk of childhood asthma and other respiratory problems for our families,” said Jenn Engstrom, state director for California Public Interest Research Group. “However, this risk has largely been hidden from the public. Consumers deserve the truth when it comes to the danger of cooking with gas. Warning labels will give consumers what they need to make informed decisions when they purchase appliances for their homes.”

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Kashtan and other researchers had previously discovered cooking with gas stoves presented a similar cancer risk as inhaling second-hand cigarette smoke. They also found some gas stoves leaked contaminants even when the burners were off.

The effects are especially devastating to children, whose smaller and still-developing lungs need to take more breaths than adults, Kashtan said. Older adults, especially those with cardiovascular or respiratory illness, are also more vulnerable to pollution from gas stoves.

To alleviate indoor air pollution, experts recommend using ventilation hoods and opening windows while cooking,

Starting in 2008, California required new and redeveloped homes to have ventilation that could prevent pollution from building up indoors. But during their research, measuring emissions in more than 100 households across the country, Yannai said they found many kitchens didn’t have ventilation hoods at all.

Although the health effects of breathing these pollutants are clear, researchers still wonder to what degree these conditions could be reversible. As communities take steps to mitigate their exposure or transition away, he said we could soon see the results.

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“It’s never too late to stop breathing in pollution,” he said.

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