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Chief Medical Resident Dr. Julia Vermylen, right, critiques interns during an "intern boot camp," held at Chicago's Northwestern Memorial Hospital in June. (ASSOCIATED PRESS)

Hospitals Fight Proposed Changes In Medical Training

by Julie Rovner
Jul 31, 2014 (Kaiser Health News)

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An influential report that urges sweeping changes in how the federal government subsidizes the training of doctors has brought out the sharp scalpels of those who would be most immediately affected.

The reaction also raises questions about the sensitive politics involved in redistributing a large pot of money -mostly from Medicare — that now goes disproportionately to teaching hospitals in the U.S. Northeast. All of the changes recommended would have to be made by Congress.

The report for the Institute of Medicine, released Tuesday, called for more accountability in the distribution of the federal funds earmarked for doctor training — $15 billion annually. About two-thirds of that cash comes from Medicare. The report also called for an end to providing the money directly to the teaching hospitals and to dramatically alter the way the funds are paid.

The money in question is for graduate medical education — the training of medical school graduates that's required before these interns and residents can be licensed to practice in any state.

"We recognize we are causing some disruption," said Gail Wilensky, a health economist and co-leader of the panel that produced the report. "But we think we are doing so in a thoughtful and careful way," including recommending phasing in the payment changes over 10 years.

Some of the major players in medical education don't see it that way, however.

"Today's report on graduate medical education is the wrong prescription for training tomorrow's physicians," the American Hospital Association said in a written statement, adding that the group's leaders were "especially disappointed" to see the suggestion that funding from Medicare should be shifted away from hospitals toward some clinics that even don't treat Medicare patients.

In its report, Wilensky's panel explained why it proposed shifting funding toward community clinics, writing, "Most, if not all residencies must train physicians to treat a wide range of patients - many of whom are under age 65 and not eligible for Medicare coverage."

The American Academy of Family Physicians welcomed the proposal to move funding away from a hospital-based system to more community-based training sites. "By giving these organizations more control over how they train residents, the financial investment will better align with the health needs of a community," the group's president, Reid Blackwelder said in a statement.

But the broader-based doctor group, the American Medical Association, reacted negatively, saying: "Despite the fact that workforce experts predict a shortage of more than 45,000 primary care and 46,000 specialty physicians in the U.S. by 2020, the report provides no clear solution."

Wilensky says that's because her panel didn't agree with studies that project there's going to be shortage of doctors. Rapid changes in medical practice, she says —including the greatly increased use of non-physician health professionals, such as physician assistants and nurse practitioners — might be enough to provide care to aging baby boomers and people now getting insurance coverage under the Affordable Care Act.

And even if a shortage does occur, the medical education system needs to better manage training since it now produces more specialists than primary care providers, and leaves major areas of the country with too few doctors, said Malcolm Cox, who recently retired from running the medical education program for the Department of Veterans Affairs. "Will an unregulated expansion produce the right physicians with the right skills in the right areas of the country?" he said at a panel discussion of the report.

Wilensky, who ran Medicare when Congress overhauled the physician payment system in the early 1990s, said the chances for making such changes depend very much on lawmakers from states that currently get less funding - which is most of them.

Given the fact that a disproportionate amount of current funding goes to institutions "in New York, New Jersey, and Massachusetts," Wilensky says she's surprised "that everyone else has tolerated this peculiar distribution of funds" for so long.

Whether change happens will depend on "whether some of the have-not states are willing to say 'wait a minute'," she says.

The New York teaching hospitals, in particular, are well-known for their clout on Capitol Hill.

"They are fantastically great in terms of their protection of their turf," said Bill Hoagland, a longtime Senate Republican staffer and now senior vice president of the Bipartisan Policy Center. "People talk about the third rail of politics as not touching Social Security. I have found that you touch anything dealing with medical education you get bombarded."

By far the most heated criticism of the report's recommendations came from the Association of American Medical Colleges, which represents medical schools and the teaching hospitals they affiliate with.

"While the current system is far from perfect, the IOM's proposed wholesale dismantling of our nation's graduate medical education system will have significant negative impact on the future of health care," said the group's president and CEO Darrell Kirsh. The proposed redistribution in funding, he says, "will slash funding for vital care and services available almost exclusively at teaching hospitals, including Level 1 trauma centers, pediatric intensive care units, burn centers, and access to clinical trials."

Still, those supporting the IOM's recommendations say the way we train doctors is in major need of change. "The current system is unsustainable," said Edward Salsberg, a former top official at the Bureau of Health Workforce at the Department of Health and Human Services. "Health care is moving to the community, but our system of financing graduate medical education is tied to inpatient care."

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Chief Medical Resident Dr. Julia Vermylen, right, critiques interns during an "intern boot camp," held at Chicago's Northwestern Memorial Hospital in June. (ASSOCIATED PRESS)

CIA Chief Apologizes To Sens. Feinstein, Chambliss Over Computer Intrusion

by Eyder Peralta
Jul 31, 2014 (Kaiser Health News)

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Ending a contentious and very public spat between two branches of government, Central Intelligence Agency chief John Brennan apologized to Sen. Diane Feinstein and Sen. Saxby Chambliss, because some CIA officers improperly accessed computers used by the Senate Select Committee on Intelligence.

If you remember, this spat started when Feinstein, a Democrat from California, took to the floor of the Senate to say that the CIA was tampering with the committee's work by searching through computers provided by the agency so the committee could access classified documents on a network called RDINet.

As we reported:

"'In place of asking any questions, the CIA's unauthorized search of the committee computers was followed by an allegation — which we now have seen repeated anonymously in the press — that the committee staff had somehow obtained the document through unauthorized or criminal means,' she said.

"In a separate appearance in Washington today, CIA Director John Brennan said the agency had not hacked into the committee's computers.

"'Nothing could be further from the truth,' Brennan said at a Council on Foreign Relations event. 'We wouldn't do that. I mean, that's just beyond the scope of reason.'"

In a statement, CIA spokesman Dean Boyd said the CIA launched an internal investigation into the matter and the CIA's Office of Inspector General found "that some CIA employees acted in a manner inconsistent with the common understanding reached between SSCI and the CIA in 2009 regarding access to the RDINet."

"The Director subsequently informed the [Senate Select Committee on Intelligence] Chairman and Vice Chairman of the findings and apologized to them for such actions by CIA officers as described in the OIG report," Boyd said.

Boyd added that Brennan is commissioning and "accountability board," which will be chaired by former Sen. Evan Bayh.

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"The 'Asian accent' tells the story of Chinese-American assimilation in a nutshell," Arthur Chu writes. (Getty Images)

Breaking Out The Broken English

by Arthur Chu
Jul 31, 2014 (Kaiser Health News)

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A little part of me cringes every time I do it, but at this point it's second nature.

It's hard to describe in words, but it involves a lot of levelling, a lot of smoothing. The tongue stays closer to the center of the mouth rather than doing the pronounced, defined highs and lows that shape the L and R sounds. The vocal chords vibrate in smooth, singing tones rather than doing the little hop up and down that makes for a normal American English syllable.

And after a few practice sentences, it slips effortlessly from my mouth. "Herro, and wercome to Beijing. Zhis is yoah guide to an ancient culchah..."

Lo and behold, I'm speaking English in a "Chinese accent."

I shouldn't complain — no actor can really get upset about a source of steady work. As I've pointed out, when Asian characters don't have accents it just means that white voice artists end up playing them. In all the kerfuffle about the "whitewashing" of M. Night Shyamalan's live-action version of The Last Airbender, people totally ignored that the voice cast of the cartoon it was based on was also almost all white people playing Asian characters.

Nor is there ever anything blatantly offensive in the content that makes me not want to take the role. I get uncomfortable with a narration having a "Chinese accent" just to give "color," so to speak, to a video set in China, but it's no different in spirit than having a Southern-accented narrator for a video set in Texas.

Most of my discomfort, I have to admit, is personal.

Because here's the thing. Nearly every Chinese immigrant I've met does in fact "talk like that," because it's almost impossible not to have a thick accent when your first language is as fundamentally phonetically different from English as Mandarin or Cantonese is.

But it's equally true that every single Chinese-American kid born here I've met emphatically does not "talk like that." In fact there isn't a Chinese-American accent the way there's a distinct cadence to how black Americans or Latino Americans talk. Most Chinese-Americans have a pitch-perfect "invisible" accent for wherever they live.

If anything, the thing that made me weird as a kid was that my English was too perfect. My grammar was too meticulously correct, my words too carefully enunciated — I was the kid who sounded like "Professor Robot." In order to avoid being a social pariah in high school I had to learn to use a carefully calibrated proportion of slurred syllables and street slang in my speech—just enough to sound "normal," not enough to sound like I was "trying too hard." I would actually sit at home, talking to myself, practicing sounding like a normal teenager.

I don't think I'm alone in this, though of my Chinese-American colleagues I'm one of the few who's taken the quest to develop a perfectly "neutral" voice so far that I now market said voice to produce corporate videos and voicemail greetings.

The "Asian accent" tells the story of Chinese-American assimilation in a nutshell. Our parents have the accent that white Americans perceive as the most foreign out of all the possible alternatives, so our choice is to have no accent at all. The accent of our parents is the accent of the grimy streets of Chinatown with its mah-jong parlors and fried food stalls and counterfeit jewelry, so we work to wipe away all traces of that world from our speech so we can settle comfortably into our roles as respectable middle-class doctors, lawyers, engineers hundreds of miles from Chinatown.

No wonder we react so viscerally to the "ching-chong, ching-chong" schoolyard taunt. To attack our language, our ability to sound "normal," is to attack our ability to be normal. It's to attack everything we've worked for.

And make no mistake about it, to sound like a "normal" American is to wield privilege.

I remember translating for my parents at customer service desks or in restaurants, where despite my youth my ability to carefully round my R's and use perfectly grammatical sentences made my complaints more credible. Taking my mother's scattered notes in "broken English" and crafting perfectly respectable job applications and cover letters out of them, all the while in the back of my mind wondering "What are they going to think when she actually shows up for work and I can't translate for her?"

Most vividly I remember being on vacation at Glacier National Park in Canada, bemusedly translating between my dad and a park ranger, both of whom were speaking English. One of them would say something. The other would blink in confusion. Only when I repeated it did they understand. And suddenly I realized—my dad's Chinese accent and the ranger's Canadian accent were too far apart from each other to be mutually intelligible.

I had the magic power, the royal privilege, of speaking the "correct" kind of English, the kind broadcast on the radio and TV. When I said something, people understood. My dad, who'd spoken English most of his life, and the ranger, who'd spoken English all his life, both depended on me to understand each other.

How strange, to be so important, to wield so much power, just because your version of the English language is the "right" one. How strange to be in a profession where people will pay you money to read words they wrote because their own, real, personal accent and dialect is "wrong".

And how terrifying it is to have that awesome feeling of privilege and safety in speaking the "right" language be attacked. When I was a contestant on Jeopardy! one of my quirks was that, having studied using books and flashcards, a lot of my pronunciations of words were unusual.

An enterprising YouTuber put together a supercut of all my pronunciation flubs—like saying "obstretrics" for "obstetrics" in the heat of the moment — and capped it with a clip from Pulp Fiction, Samuel L. Jackson screaming, "ENGLISH, MOTHER******! DO YOU SPEAK IT?!"

Of all the people making fun of me online for my weight, my appearance, my dour expression or my general unlikeability, the attacks on my ability to speak English cut deepest. More than all the other YouTube videos made of me, that one made me want to jump in the comments yelling, "Yeah, well, my wife until last year said 'rheTORic' instead of 'RHEtoric' but you wouldn't question her fluency in the English language over that because she's white and she was born here and that's racist!"

Luckily I restrained myself. But this weird fear of somehow losing my American-ness still haunts me.

So those embarrassing "Chinese accent" voiceover jobs? I don't think it's just the money; I think I go after them as a weird form of self-therapy, facing what you fear in order to master it.

I spent my entire childhood learning how to pass for "normal" in the way I spoke, to grasp for the privilege that came with assimilation. But as any linguist will tell you, the idea of "perfect" speech is an illusion. No one actually has a "perfect" accent; the definition of "proper" English is arbitrary and fluctuates wildly over time.

Indeed, the single biggest barrier I have to getting voiceover jobs now is that my voice is too perfect, that the most common note you see from producers on spec sheets is "Not too announcer-y, must sound like a real person." The "proper" English that was on TV when I was a kid isn't "proper" anymore; the definition of proper English keeps updating itself, keeps readjusting to match what people think of as "real."

Well, the English I grew up with as "real" isn't the English I painstakingly forced on myself from listening to TV and my peers at school. It's the English of my parents, complete with under-pronounced L's and R's, dropped "and"s and "the"s, sing-songy and "broken" and embarrassing.

That accent is real, but my use of it can never be, not after so many years of renouncing it and avoiding it and exterminating any trace of it from my day-to-day speech. After a lifetime of rehearsals and training, the "announcer voice" is my voice, and the only reliable way to sound "less announcer-y" is to put on an accent that isn't mine, be it Brooklyn, Biloxi or Beijing.

What a paradox. When I sound real, I'm fake, and when I sound fake, I'm real. I can only wonder how many of my fellow hyphenated Americans can say the same.

Arthur Chu is a bi-coastal Chinese-American nerd who's currently settled down in Cleveland, Ohio. An actor, comedian and sometime culture blogger, he somehow captured national attention for becoming an 11-time Jeopardy! champion in March 2014 and is now shamelessly extending his presence in the national spotlight by all available means. He lives with his wife and an indeterminate but alarmingly ever-growing number of cats. Follow him on Twitter at @arthur_affect.

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How will you die? (for NPR)

How Will You Die?

Jul 31, 2014 (Kaiser Health News)

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So let's cut to the chase. Depending on where you live on Earth, cooking dinner, having sex and going to the bathroom are either three of life's many pleasures or they're the riskiest things you you can do.


When you dig into global statistics, two interesting facts pop out. The first is that, from a scientific perspective, we all pretty much die the same way: lack of blood to the brain. But how we get to that last stage varies quite a bit. And in a global sense, it varies depending on where you live and how much money you make.

The World Bank says there are 213 countries (but the specific number depends on how you count). It divides them into three groups based on average income per person: high-, middle- and low-income countries.

Two of these groups probably make less money than you'd think.

Here's the rough breakdown, in average dollars earned per person each year: High income $39,312, middle income $4,721, low income $664.

Most people in the world, about five billion of them, fall somewhere in the middle-income category. Then there are about a billion people in high-income countries and a billion in low-income countries.

So if you live in a high-income country, the top three ways to die are heart disease, stroke and lung diseases, including lung cancer, the WHO says.

But if you live in one of the world's poorest countries, the top killers are lower respiratory infections, HIV/AIDS and diarrhea.

In rich countries, 7 out of 10 people make it past their 70th birthday. In poor countries, that percentage drops to 2 out of 10 people. In fact, in the 34 poorest countries in the world, only 6 out of 10 people make it past their 15th birthday.

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The full moon rises above the castle of Somoskoujfalu, northeast of Budapest, Hungary, earlier this month. (AP)

Scientists Say The Moon Is Hiding A Lumpy Middle

Jul 31, 2014 (Kaiser Health News)

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What shape is the moon? When it's full, we'd all agree that it looks perfectly round. But careful measurements by a team of scientists have shown that's not the case.

Like many an Earth-bound observer, it turns out that our nearest neighbor in space is hiding a slight bulge around the waist. It's less like a ball and more like a squashed sphere, with a lump on one side.

That's according to Ian Garrick-Bethell, a planetary scientist at University of California, Santa Cruz, who is the lead author in the newly published findings in Nature.

"If you can imagine a water balloon flattening out as you spin it," Garrick-Bethell says, describing the slight "lemon-shape" of the moon.

How did it get that way? It all goes back to a time when the moon was formed after a collision between a very young Earth and an ancient body known as Theia. The crust solidified, but the moon's center was still largely molten.

According to The New York Times: "Efforts to pinpoint the moon's exact shape have long been stymied by the presence of large craters on its surface that formed after the crust solidified. There have also been inconsistencies between its measurements and what we know about its past."

The Times says:

"To overcome the crater problem, [Garrick-Bethell] and his colleagues used highly accurate maps of the moon's topography, made with a laser altimeter, then ran calculations to see what the surface could have looked like before the craters formed.

"The measurements that emerged help explain how the moon acquired its shape, the researchers say. Its squashed appearance is probably a result of the gravitational process called tidal heating or acceleration, which stretched the moon's crust as it was being formed. The equatorial bulge probably dates to a later period, when the moon was still spinning but was slowing down and moving away from earth, freezing a tidal surge in place."

The BBC says Garrick-Bethell and his team were inspired by similar research in a 2013 study by researchers from the University of Texas at Austin. They calculated how tidal heating caused by Jupiter's massive tug was causing warmer water under the ice crust on Europa.

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