This is amazing to see. Spina Bifida is tough as it can range anywhere from “wheelchair bound and substantial intellectual disability” to “has a hard time with potty training”, and you won’t really know until your child has been born.
My daughter is seven now and was born with spina bifida and it’s been a long journey full of pain, but also joy. The first nine months she had breath holding any time she’d get upset (which for a baby is all the time) so she was simultaneously the healthiest and least healthy baby in the NICU.
She’s wheelchair bound, but intellectually very sharp. Getting her a spinal shunt a few weeks after birth helped alleviate spinal fluid pressure in her brain, although it elevates scenarios of “kid has an headache” to “maybe we need to go to the ER at 3am in the worst snowstorm of the season”, but she’s extremely sociable and a light to everyone that meets her.
I’m glad work is being done that can mitigate this and improve quality of life for these children. She keeps asking me when she’ll get her robot legs and we tell her they have to test it out on adults first to make sure it’s safe! Exciting times for people with physical disabilities.
Thanks for sharing about your daughter. It's good to hear from other parents dealing with it. My daughter with spina bifida is only 18 months. It's early of course, but so far she's right on track cognitively and socially. I expect she'll be in a wheelchair full time, but don't know for sure yet. She's also just the most joyful, loving, social, happy toddler.
I know what you mean about elevating otherwise normal kid illness. She had her first shunt failure in January. It was pretty stressful going from "hmm, she's fussy" to surgery within less than 24 hours. But she was back to her happy self with hours of the surgery too, which was a pretty stark indicator of how much the shunt is doing for her.
One of the nicest things anyone ever did for me was the day after she was born, when I had just started at a new job, an older dev asked if he could talk to me and pulled me into a meeting room. I didn’t know anyone there and was confused. He’d overheard me talking about my daughter just being born, and said “I’m nearly 60, I have spina bifida, and I want you to know it’s going to be alright.” He stressed how important doing a regular catheter routine is, as the most likely thing to kill him in the next 10 years is kidney failure due to bad catheter habits as a kid and young adult. Also, overnight foley catheters with a bag has been a lifesaver, and gave us our sleep back. The doctors often just won’t mention these things, and the quality of care can vary greatly depending on your care team, as I’m sure you’re well aware. At least the doctors seem to have some respect for us as caregivers to a medically complicated child and they often trust our judgment.
Hopefully it’ll make you feel better, but the shunt revisions became far less common for us as her growth slowed down. She had one around a year old, but they put a good amount of tubing in there, and they haven’t had to go do a revision in the past 6 years.
As the brother of a young, amazing man who we lost due to another genetic ailment (CF), whenever I see stories like this, it makes me so hopeful for families in the future never having to see a loved one deteriorate due to a bad roll of the dice.
Hats off to everyone out there putting in the hours to make the lived experience of these folks much better than they would have otherwise been. If only we had more of you in the world.
Spina Bifida is not primarily a genetic disease. It's caused by a failure of the neural tube in the developing embryo to close fully. No one knows the exact causes, but folic acid deficiency in the mother before and during pregnancy makes it more likely. It also seems to run in families a little, but only weakly, and we haven't identified any specific genetic cause. This treatment is very promising, but it's not a cure, just a (hopefully) even better treatment than the existing in-utero surgery that doesn't include stem cells.
Long ago, my next door neighbor's daughter had severe SB and was confined to a wheelchair, slow mental and emotion development, etc. Nobody thought she'd live, but in fact got to adulthood. It was basically a full-time job for her (single) mom.
Sadly, the divorce rate is over 50% for parents of spina bifida children. My daughter is almost 7 and my wife and I are happy, we have a good life and I’m fortunate to have a career that lets her stay at home to tend to our daughters multiple monthly doctors appointments, and one where I can largely work from home to help when she needs carrying (which is often!)
That said, our daughter is a miracle, she’s intellectually sharp, and we do everything we can to give her all the experiences any other bright and outgoing child would have. I hold her up so she can play the games she can’t reach at Dave and Busters, even if my arms get tired. We go on hikes with an expensive stroller that’s also a bike made for off road biking because we read Little House and she wanted to know what prairie looked like. We plan on getting an RV to take her to national parks.
Her wheelchair tennis coach recently tried an exoskeleton that allows him to walk at a research lab in New York, she was elated. She asks me when her robot legs are coming. I tell her we don’t know but robots in every house would certainly help that sort of technology move forward. I tell her “they’ve got to test it on adults before kids can get one!”
When she was one, they told us to make plans for the future, to get our affairs in order. Three years later the palliative care worker who had told us our child wouldn’t live past her second birthday came to visit us during a hospital visit and talk to us, so happy to see a case where they’d all been wrong. I’m so happy they were.
My high school hosted the county's special day class for kids with severe cognitive and physical disabilities, a majority from spina bifida. If this stem cell method can actually repair the spinal cord before birth, the quality of life improvement is absolutely enormous.
Tangentially related, but it is increasingly obvious that there's an ever-growing chasm between these two aspects of medicine in the U.S.:
- What's possible for medical professionals to do for certain conditions, in large part due to the amazing levels of investment into research and implementation.
- How difficult it is for ordinary people to receive care. Primarily due to private insurance companies intentionally making it more difficult to get care.
Like the fact we're giving stem cell therapy to fetuses successfully is amazing, yet any time I go to a doctor's office or bloodwork company I hear an elderly person explain to the front desk person that they've been on the same insurance for decades and only recently started receiving bills they can't afford, or listening to the front desk person explain that now medicare no longer covers them for a routine thing.
Ideally, we could have both great research _and_ great general care in this country. I just don't know if I will ever see that day.
I think the largest issue with health care right now is that the US is artificially shrinking the supply of Doctors. This is due to:
1. Size of medical school classes not increasing with population
2. US has an artificially small amount of residency slots.
These are largely due to AMA lobbying afaik and bad bills. But if we allowed every qualified medical student to enroll, and gave a residency slot to every graduate. In a decade we would have really shrunk the gap.
Does that matter though? My impression is that most people don't see doctors anymore. Every urgent care visit I've had in the past few years has been with a physicians assistant or nurse. Same for our pediatrician, I can't remember the last time we saw her instead of one of the nurses.
I actually have a routine visit with a specialist at one of the top hospital systems in the country in 2 days, and I see in the portal I'm seeing a "CRNP, MSN", not a doctor.
This affect is because of the doctor shortage though.
I am in the process of trying to find a primary care provider, and I cant find anyone accepting new patients.
Bigger places you basically see the doctor for 2 minutes when you actually need one. I went to a ortho surgeon and they had a dozen patients “seeing them” at the same time. As he just went between rooms and nurses prepped everything.
I went down a Reddit rabbit hole, a sub called /r/noctor. Basically people, mostly doctors, complaining about the prevalence of nurse practitioners, PAs practicing independently/outside of their scope, etc. The general consensus I see there is that the only people benefiting from this are private equity firms trying to squeeze more profit since they bill the same based on whether you see a doctor or an NP. This in turn has an affect where it doesn’t make sense financially to go through so much school and take on so much debt.
The primary utility of most medical professionals is to act as a gatekeeper to distinguish me from a drug-seeker. They are glorified security guards around medication. Fortunately, I always get what I want.
As an internist (not in the US), I would like to put in my two cents to say this is just wrong.
The primary utility of most medical professionals is to diagnose and treat a condition correctly. In the ER and elsewhere, the correct diagnosis is indeed often "drug seeking behaviour". And this is also a major aspect of medicine that many relatively healthy people interface with and remember. They are in pain for whatever reason, they desire to be relieved of said pain, and that desire puts them into contact with the skepticism and hesitancy around opiods that physicians have built up out of unfortunate necessity. It's often a hurtful and protracted experience, and so they remember it and form opinions like yours.
But this area of contact with medicine is a tiny, very visible tip of a much larger iceberg. Your description of "security guard around medication" is not strictly wrong for my field, seeing as internal medicine is largely about administering the right drug at the right time, but the 99% of the drugs we guard are not desirable at all for any drug-seeker. They are potent, full of side effects, are sometimes potentially deadly. But they do work. And you do not see any of this until you get properly sick, which to most people does not happen very often often (at least until they approach 70). And when it does happen, most people tend to focus on the one little side of the ice berg they come into contact with. But it is there, and it is about much more than distinguishing you from a drug seeker.
No professional has ever taken kindly to being told their primary function. The notion of greater grandeur infects everyone from janitor to president. I'm not foolish enough to tell doctors these things. If I did, I doubt I'd get what I want.
There are limits, naturally. I don't really expect to fit the percutaneous pins into my hand myself, even if I had third hand capable of equal dexterity. But if I have to sing a song you can be sure the song is sung. It's no different from selling B2B SaaS. You just need to make the sale.
I'm sure that's at least somewhat correct, but if I'd offer a similar reply, I could say that amateurs rarely takes kindly to being told that they do not understand what they are talking about. Dunning Kruger is endemic, and especially prevalent in populations making reductive comments about a group of professionals they maintain an adverserial relationship with.
My point was not about the emotional experience of being presented with a certain viewpoint of the function of physicians. My point was simply that if you look at the details of what physicians actually do, the stated viewpoint is wrong.
Of course, "primary function" is a somewhat subjective concept that you could define however you'd like, so it is more or less unfalsifiable as a standpoint.
Haha that is just as true. I suppose I should say “the primary function to me of doctors who are not family members is”. They are a vending machine with a code and fortunately I know the code.
Others need to be told to “advocate for themselves”. I simply get what I want and it always works.
What exactly is the problem with giving drugs to someone who might be a drug seeker? Is it worth letting someone sit in pain on the chance you might allow an addict to get high?
Harm reduction by just giving drugs to addicts in an organized fashion is honestly a strategy that might work fine on a societal level, and I'm not against it (although I am unsure about the details of implementations). However when your society does not practice it, and the ER/family med practioner becomes the one point of contact for potentially cheap drugs, you run into some practical problems over time. Essentially you can't have an open "drug seekers in line B" policy due to legal issues, so drug seekers will have to lie about being in pain and figure out a convincing lie.
Let us say they try to simulate an acute ruptured appendicitis. If they do this convincingly, they will get an acute CT with contrast. In my hospital system these machines and interpretation of resulting images is expensive and resource constrained, especially during evening and night time, meaning that the prioritisation of one patient will generally mean that another, let us say a patient in the process of having a very real stroke, might get delayed if traffic is high.
This is beyond the fact that roughly 30-120 minutes of the physicians time in the ER will be wasted in examining the patient, ordering blood work, the imagery, writing notes, and so on, which means that another patients time, who is often literally waiting in line for your time, is being wasted. Furthermore this kind of clientele have an unfortunate tendency to become unpleasant when you tell them that you can't find any reason for their pain or giving opioids, which is an extremely unpleasant and frankly often traumatic experience for green eyed doctors that enlisted in this career with the goal of aiding the sick. You can only get threatened, spat upon or assaulted so many times and maintain your professional enthusiasm. Many quit for this reason. And for the ones that don't, the experience of being forced to take on the role of distinguish between drug seekers and non drug seekers will generally turn you into a more unpleasant human being.
In summary, mostly due to unfortunate societal circumstances, you really, really, really do not want to encourage drug seekers to try their luck. It is an expensive waste of everyone's time, in circumstances where both money and time is tight.
Conversely, you really cannot predict in advance which ones of your opioid-naive patients will become addicts because the opioids that you gave them, which effectively means that you've fucked their life forever. Opioids are really, really dangerous. Sometimes people are obviously in pain and you open the tap quickly. But there's a name for the historical consequence of playing fast and loose with pain relief, it's called the opioid epidemic.
the largest issue in American health care is private equity and middle men raising the cost of everything.
edit if doctor scarcity were the issue then doctors would have a lot more leverage in salary negotiations than they do, which is to say they don't have much. because the hiring practices are limited by what they can bill, which they have no power over.
Private Equity is the effect not the cause. We need them to create efficiency because of the shenanigans that the AMA guild did in limiting doctor supply. Just allow people to take an exam to get credentialed, we'd have foreign doctors flown in by the hundreds of thousands and care would be as cheap as it is in India.
private equity doesn't create efficiencies. The real world is not some MicroEcon 101 class.
> “As our investigation revealed, these financial entities are putting their own profits over patients, leading to health and safety violations, chronic understaffing, and hospital closures. Take private equity firm Leonard Green and hospital operator Prospect Medical Holdings: documents we obtained show they spent board meetings discussing profit maximization tactics—cost cutting, increasing patient volume, and managing labor expenses—with little to no discussion of patient outcomes or quality of care at their hospitals. And while Prospect Medical Holdings paid out $645 million in dividends and preferred stock redemption to its investors—$424 million of which went to Leonard Green shareholders—it took out hundreds of millions in loans that it eventually defaulted on. Private equity investors have pocketed millions while driving hospitals into the ground and then selling them off, leaving towns and communities to pick up the pieces.”
Private Equity does not create efficiency and we do not need them. What they do is to take debt to buy healthy companies, transfer debt onto them and then kill them.
None of that is efficiency in any reasonable sense.
Ugh I wish this braindead populist 'private equity boogieman' meme that's taken ahold of reddit-types would die.
No, private equity is not the reason healthcare costs in the US are out of control, you can even ask chatgpt.
PE is a 3rd tier mild symptom in certain niche health markets that sits downstream of all the structural root issues created due to the twisted public/private incentive misalignment nightmare of US healthcare.
People would have an opportunity to change their stance if you explain why they should hold a different one with evidence and persuasion. Berating them and then saying they are wrong without explaining why is not going to change anyone's mind.
What may be necessary is for other countries to be better. These treatments / studies don't just affect USAmericans but everyone everywhere, and if there's enough signals of "this treatment saves kids abroad but we can't afford them in the US because of policy", MAYBE said policy will change. Maybe. Not likely because the corporations have control over the government, and the US government system is stuck in laws drafted up in the 1700s.
Does that really happen "any time you go to a doctor's office"?
That aside, what if novel therapies like this are linked to the fact that US healthcare is expensive? If you make it cheap -- as in other countries -- there's less incentive for companies to invest and you get less research and fewer breakthroughs. Also fewer doctors, hospital beds, and more rationing.
In an ideal world, everyone would have exactly the right amount of healthcare. But our world isn't ideal, it runs on incentives, and it's not clear to me that all the hand-wringing over US healthcare will lead to positive changes.
> Does that really happen "any time you go to a doctor's office"?
Yes. I recently made a resolution to get established with all the medical professionals I don’t have set up. So a primary care, dermatologist, etc. over the past 2 months I’ve visited and had to go back a couple of times. I’ve literally overheard insurance-related issues in all cases. Whether it was the person in line before me or just overhearing people complaining while I’m in the waiting room.
Just last week I was waiting to get my blood drawn and the woman at the front desk, after continued prodding by an elderly man frustrated with lack of coverage, out loud said “Well, that’s insurance in America for you. Go ahead and call the number on the back of your insurance card because we can’t do anything for you.” Just deeply disheartening stuff to watch a late 80s man not realize after 15 minutes of being tossed between automated insurance phone responses that he simply won’t get the help he needs.
The US healthcare system is not a market system nor did it occur naturally. Do you have any conflicts of interest that could cause you to have an emotional need to misunderstand basic information about it?
The US is a country of cowboys. There is literally nothing that can be considered fair. The only thing what is left is the kindness of it's people. If that detoriates, well...
It wasn't so long ago that doctors assumed that it would be better for the family if babies like this died quickly - and quietly helped them off. I had a cousin with spina bifida, who only lived because her own mother was a doctor and prevented this outcome. My cousin got to live to adulthood and enjoy life, but still died early because of an infection; likely a consequence of the physical impairments of this condition. It's amazing to see hope for a complete cure.
Incredible to see some promising results in stem cell research. Hopefully a safe and successful application can give a boost to some other areas where stem cells might prove useful (like maybe one day we can regrow damaged heart tissue like this).
The notion of "stem cells" are somewhat of a misnomer as modern biotechnology is showing us. There are an orchestration of probably 1000s of different cell types which can vary in their cell states. We don't have enough knowledge of how to use these various cell types to influence complex self-organization processes like development. But in some cases there are clever fixes without understanding the underlying process.
Not only is it possible, fetal surgery is more or less standard treatment for spina bifida at this point. The news here is about the stem cell patch being applied during the surgery. (I have a child with spina bifida. We tried to get her into this trial, but did not qualify.)
Does the physical repair also help with the mental developmental effects? Children with spinal bifida often develop cognitive abilities much slower than children without it.
The main goal of physical repair of the defect in utero is actually to reduce the incidence of hydrocephalus and hindbrain herniation, which are very common in people with Spina Bifida. The existing fetal surgery reduces the incidence of hydrocephalus from about 80% to about 40%. The improvement in leg and bowel/bladder function is actually a secondary benefit.
My understanding is that the hindbrain herniation (aka Chiari Malformation Type II) is the main cause of cognitive trouble in people with SB. But it's worth noting that it's very far from universal in causing that. Most people with SB are basically normal cognitively assuming they get good early intervention (VP shunt, PT, OT, etc.). Some early cognitive development can be slower as a knock on effect of not being able to move around as much as a baby and toddler, and thus less able to explore the environment, etc.
Source: I'm the parent of a toddler with spina bifida. She's completely on track cognitively and with fine motor skills so far. She's way behind with gross motor skills due to her inability to move her legs very much.
Another sb parent here, my kid is seven now, she’s also on track intellectually. We got the decompression surgery for the Chiari II a few months after she was born, and the VP shunt even earlier than that. Aside from some stammering (which her non SB sister also has, so I suspect it’s hereditary), and weirdness with foods (OT has helped a lot) she’s totally on track intellectually.
Our daughter was a particularly severe case too, and these interventions seem to have helped a lot. For the first four years she’d hold her breath every time she was upset, and need CPR, but we got her breathing again every time, so we don’t think there’s any brain damage. If we’d missed once, maybe I’d be telling a different story now. Thank goodness her head grew!
The CuRe Trial is exploring whether stem cells can add regenerative power to surgery, potentially improving mobility and quality of life.
“This is a major step toward a new kind of fetal therapy, one that doesn’t just repair but potentially helps heal and protect the developing spinal cord,” said Aijun Wang, co inventor of the placental-derived stem cell treatment technology and the study’s co-principal investigator [ . . . ].
They cite this paper which gives the concept: https://www.sciencedirect.com/science/article/pii/S002234681... . The mechanism of injury in spina bifida is that the spinal cord gets exposed and damaged. Current surgery will close the spinal canal to prevent further exposure, but it doesn't do anything to reverse the damage that has already happened. The stem cells integrate into the neural tissue and hopefully help the axons heal.
There are people who do not want to have abortions. Either for religious reasons, because they themselves belong to a specific disability group (e.g. the blind and deaf) or because they tried hard already to get pregnant in the first place.
Especially for the latter, "make a new one" can mean a ticket reaching into the 6 figures, months of egg extractions, implantation attempts and spontaneous auto-abortions.
They should spend the money instead of taking the risk of burdening someone with a disability their whole lives. This treatment is not a sure thing. And yes, I am disabled myself.
What a gross and idiotic take. “Just abort it”; i’m pro choice, but IMO life must be regarded as more sacred than what ‘ole tsss here considers. I can only conclude tsss has never dealt with any real loss in their life.
China is going to be way ahead of us in biological treatments because they are willing to actually remove the red tape and in fact encourage scientists to try these sorts of experimental treatments. Meanwhile, we have a dinosaur FDA, a bureaucratic academia second to only Europeans.
This is amazing to see. Spina Bifida is tough as it can range anywhere from “wheelchair bound and substantial intellectual disability” to “has a hard time with potty training”, and you won’t really know until your child has been born.
My daughter is seven now and was born with spina bifida and it’s been a long journey full of pain, but also joy. The first nine months she had breath holding any time she’d get upset (which for a baby is all the time) so she was simultaneously the healthiest and least healthy baby in the NICU.
She’s wheelchair bound, but intellectually very sharp. Getting her a spinal shunt a few weeks after birth helped alleviate spinal fluid pressure in her brain, although it elevates scenarios of “kid has an headache” to “maybe we need to go to the ER at 3am in the worst snowstorm of the season”, but she’s extremely sociable and a light to everyone that meets her.
I’m glad work is being done that can mitigate this and improve quality of life for these children. She keeps asking me when she’ll get her robot legs and we tell her they have to test it out on adults first to make sure it’s safe! Exciting times for people with physical disabilities.
Thanks for sharing about your daughter. It's good to hear from other parents dealing with it. My daughter with spina bifida is only 18 months. It's early of course, but so far she's right on track cognitively and socially. I expect she'll be in a wheelchair full time, but don't know for sure yet. She's also just the most joyful, loving, social, happy toddler.
I know what you mean about elevating otherwise normal kid illness. She had her first shunt failure in January. It was pretty stressful going from "hmm, she's fussy" to surgery within less than 24 hours. But she was back to her happy self with hours of the surgery too, which was a pretty stark indicator of how much the shunt is doing for her.
One of the nicest things anyone ever did for me was the day after she was born, when I had just started at a new job, an older dev asked if he could talk to me and pulled me into a meeting room. I didn’t know anyone there and was confused. He’d overheard me talking about my daughter just being born, and said “I’m nearly 60, I have spina bifida, and I want you to know it’s going to be alright.” He stressed how important doing a regular catheter routine is, as the most likely thing to kill him in the next 10 years is kidney failure due to bad catheter habits as a kid and young adult. Also, overnight foley catheters with a bag has been a lifesaver, and gave us our sleep back. The doctors often just won’t mention these things, and the quality of care can vary greatly depending on your care team, as I’m sure you’re well aware. At least the doctors seem to have some respect for us as caregivers to a medically complicated child and they often trust our judgment.
Hopefully it’ll make you feel better, but the shunt revisions became far less common for us as her growth slowed down. She had one around a year old, but they put a good amount of tubing in there, and they haven’t had to go do a revision in the past 6 years.
>My daughter is seven now and was born with spina bifida
When did you find out she had the condition?
As the brother of a young, amazing man who we lost due to another genetic ailment (CF), whenever I see stories like this, it makes me so hopeful for families in the future never having to see a loved one deteriorate due to a bad roll of the dice.
Hats off to everyone out there putting in the hours to make the lived experience of these folks much better than they would have otherwise been. If only we had more of you in the world.
Completely agree, this is why we need to detect bad rolls and give people the ability to reroll.
Since this is genetic theraphy, it would be amazing if it corrected the bad roll permanently. Being in-utero, this might be the case here.
Spina Bifida is not primarily a genetic disease. It's caused by a failure of the neural tube in the developing embryo to close fully. No one knows the exact causes, but folic acid deficiency in the mother before and during pregnancy makes it more likely. It also seems to run in families a little, but only weakly, and we haven't identified any specific genetic cause. This treatment is very promising, but it's not a cure, just a (hopefully) even better treatment than the existing in-utero surgery that doesn't include stem cells.
Can you expand on what you mean by that? Otherwise there’s a way to interpret it that is less than lovely.
Conditions like SB affect the entire family.
Long ago, my next door neighbor's daughter had severe SB and was confined to a wheelchair, slow mental and emotion development, etc. Nobody thought she'd live, but in fact got to adulthood. It was basically a full-time job for her (single) mom.
Sadly, the divorce rate is over 50% for parents of spina bifida children. My daughter is almost 7 and my wife and I are happy, we have a good life and I’m fortunate to have a career that lets her stay at home to tend to our daughters multiple monthly doctors appointments, and one where I can largely work from home to help when she needs carrying (which is often!)
That said, our daughter is a miracle, she’s intellectually sharp, and we do everything we can to give her all the experiences any other bright and outgoing child would have. I hold her up so she can play the games she can’t reach at Dave and Busters, even if my arms get tired. We go on hikes with an expensive stroller that’s also a bike made for off road biking because we read Little House and she wanted to know what prairie looked like. We plan on getting an RV to take her to national parks.
Her wheelchair tennis coach recently tried an exoskeleton that allows him to walk at a research lab in New York, she was elated. She asks me when her robot legs are coming. I tell her we don’t know but robots in every house would certainly help that sort of technology move forward. I tell her “they’ve got to test it on adults before kids can get one!”
When she was one, they told us to make plans for the future, to get our affairs in order. Three years later the palliative care worker who had told us our child wouldn’t live past her second birthday came to visit us during a hospital visit and talk to us, so happy to see a case where they’d all been wrong. I’m so happy they were.
You, your wife and your daughter sound like wonderful humans, and I wish you all nothing but the best.
My high school hosted the county's special day class for kids with severe cognitive and physical disabilities, a majority from spina bifida. If this stem cell method can actually repair the spinal cord before birth, the quality of life improvement is absolutely enormous.
Tangentially related, but it is increasingly obvious that there's an ever-growing chasm between these two aspects of medicine in the U.S.:
- What's possible for medical professionals to do for certain conditions, in large part due to the amazing levels of investment into research and implementation.
- How difficult it is for ordinary people to receive care. Primarily due to private insurance companies intentionally making it more difficult to get care.
Like the fact we're giving stem cell therapy to fetuses successfully is amazing, yet any time I go to a doctor's office or bloodwork company I hear an elderly person explain to the front desk person that they've been on the same insurance for decades and only recently started receiving bills they can't afford, or listening to the front desk person explain that now medicare no longer covers them for a routine thing.
Ideally, we could have both great research _and_ great general care in this country. I just don't know if I will ever see that day.
I think the largest issue with health care right now is that the US is artificially shrinking the supply of Doctors. This is due to:
1. Size of medical school classes not increasing with population
2. US has an artificially small amount of residency slots.
These are largely due to AMA lobbying afaik and bad bills. But if we allowed every qualified medical student to enroll, and gave a residency slot to every graduate. In a decade we would have really shrunk the gap.
Does that matter though? My impression is that most people don't see doctors anymore. Every urgent care visit I've had in the past few years has been with a physicians assistant or nurse. Same for our pediatrician, I can't remember the last time we saw her instead of one of the nurses.
I actually have a routine visit with a specialist at one of the top hospital systems in the country in 2 days, and I see in the portal I'm seeing a "CRNP, MSN", not a doctor.
This affect is because of the doctor shortage though.
I am in the process of trying to find a primary care provider, and I cant find anyone accepting new patients.
Bigger places you basically see the doctor for 2 minutes when you actually need one. I went to a ortho surgeon and they had a dozen patients “seeing them” at the same time. As he just went between rooms and nurses prepped everything.
I went down a Reddit rabbit hole, a sub called /r/noctor. Basically people, mostly doctors, complaining about the prevalence of nurse practitioners, PAs practicing independently/outside of their scope, etc. The general consensus I see there is that the only people benefiting from this are private equity firms trying to squeeze more profit since they bill the same based on whether you see a doctor or an NP. This in turn has an affect where it doesn’t make sense financially to go through so much school and take on so much debt.
The primary utility of most medical professionals is to act as a gatekeeper to distinguish me from a drug-seeker. They are glorified security guards around medication. Fortunately, I always get what I want.
As an internist (not in the US), I would like to put in my two cents to say this is just wrong.
The primary utility of most medical professionals is to diagnose and treat a condition correctly. In the ER and elsewhere, the correct diagnosis is indeed often "drug seeking behaviour". And this is also a major aspect of medicine that many relatively healthy people interface with and remember. They are in pain for whatever reason, they desire to be relieved of said pain, and that desire puts them into contact with the skepticism and hesitancy around opiods that physicians have built up out of unfortunate necessity. It's often a hurtful and protracted experience, and so they remember it and form opinions like yours.
But this area of contact with medicine is a tiny, very visible tip of a much larger iceberg. Your description of "security guard around medication" is not strictly wrong for my field, seeing as internal medicine is largely about administering the right drug at the right time, but the 99% of the drugs we guard are not desirable at all for any drug-seeker. They are potent, full of side effects, are sometimes potentially deadly. But they do work. And you do not see any of this until you get properly sick, which to most people does not happen very often often (at least until they approach 70). And when it does happen, most people tend to focus on the one little side of the ice berg they come into contact with. But it is there, and it is about much more than distinguishing you from a drug seeker.
No professional has ever taken kindly to being told their primary function. The notion of greater grandeur infects everyone from janitor to president. I'm not foolish enough to tell doctors these things. If I did, I doubt I'd get what I want.
There are limits, naturally. I don't really expect to fit the percutaneous pins into my hand myself, even if I had third hand capable of equal dexterity. But if I have to sing a song you can be sure the song is sung. It's no different from selling B2B SaaS. You just need to make the sale.
I'm sure that's at least somewhat correct, but if I'd offer a similar reply, I could say that amateurs rarely takes kindly to being told that they do not understand what they are talking about. Dunning Kruger is endemic, and especially prevalent in populations making reductive comments about a group of professionals they maintain an adverserial relationship with.
My point was not about the emotional experience of being presented with a certain viewpoint of the function of physicians. My point was simply that if you look at the details of what physicians actually do, the stated viewpoint is wrong.
Of course, "primary function" is a somewhat subjective concept that you could define however you'd like, so it is more or less unfalsifiable as a standpoint.
Haha that is just as true. I suppose I should say “the primary function to me of doctors who are not family members is”. They are a vending machine with a code and fortunately I know the code.
Others need to be told to “advocate for themselves”. I simply get what I want and it always works.
What exactly is the problem with giving drugs to someone who might be a drug seeker? Is it worth letting someone sit in pain on the chance you might allow an addict to get high?
Harm reduction by just giving drugs to addicts in an organized fashion is honestly a strategy that might work fine on a societal level, and I'm not against it (although I am unsure about the details of implementations). However when your society does not practice it, and the ER/family med practioner becomes the one point of contact for potentially cheap drugs, you run into some practical problems over time. Essentially you can't have an open "drug seekers in line B" policy due to legal issues, so drug seekers will have to lie about being in pain and figure out a convincing lie.
Let us say they try to simulate an acute ruptured appendicitis. If they do this convincingly, they will get an acute CT with contrast. In my hospital system these machines and interpretation of resulting images is expensive and resource constrained, especially during evening and night time, meaning that the prioritisation of one patient will generally mean that another, let us say a patient in the process of having a very real stroke, might get delayed if traffic is high.
This is beyond the fact that roughly 30-120 minutes of the physicians time in the ER will be wasted in examining the patient, ordering blood work, the imagery, writing notes, and so on, which means that another patients time, who is often literally waiting in line for your time, is being wasted. Furthermore this kind of clientele have an unfortunate tendency to become unpleasant when you tell them that you can't find any reason for their pain or giving opioids, which is an extremely unpleasant and frankly often traumatic experience for green eyed doctors that enlisted in this career with the goal of aiding the sick. You can only get threatened, spat upon or assaulted so many times and maintain your professional enthusiasm. Many quit for this reason. And for the ones that don't, the experience of being forced to take on the role of distinguish between drug seekers and non drug seekers will generally turn you into a more unpleasant human being.
In summary, mostly due to unfortunate societal circumstances, you really, really, really do not want to encourage drug seekers to try their luck. It is an expensive waste of everyone's time, in circumstances where both money and time is tight.
Conversely, you really cannot predict in advance which ones of your opioid-naive patients will become addicts because the opioids that you gave them, which effectively means that you've fucked their life forever. Opioids are really, really dangerous. Sometimes people are obviously in pain and you open the tap quickly. But there's a name for the historical consequence of playing fast and loose with pain relief, it's called the opioid epidemic.
the largest issue in American health care is private equity and middle men raising the cost of everything.
edit if doctor scarcity were the issue then doctors would have a lot more leverage in salary negotiations than they do, which is to say they don't have much. because the hiring practices are limited by what they can bill, which they have no power over.
Private Equity is the effect not the cause. We need them to create efficiency because of the shenanigans that the AMA guild did in limiting doctor supply. Just allow people to take an exam to get credentialed, we'd have foreign doctors flown in by the hundreds of thousands and care would be as cheap as it is in India.
private equity doesn't create efficiencies. The real world is not some MicroEcon 101 class.
> “As our investigation revealed, these financial entities are putting their own profits over patients, leading to health and safety violations, chronic understaffing, and hospital closures. Take private equity firm Leonard Green and hospital operator Prospect Medical Holdings: documents we obtained show they spent board meetings discussing profit maximization tactics—cost cutting, increasing patient volume, and managing labor expenses—with little to no discussion of patient outcomes or quality of care at their hospitals. And while Prospect Medical Holdings paid out $645 million in dividends and preferred stock redemption to its investors—$424 million of which went to Leonard Green shareholders—it took out hundreds of millions in loans that it eventually defaulted on. Private equity investors have pocketed millions while driving hospitals into the ground and then selling them off, leaving towns and communities to pick up the pieces.”
https://www.grassley.senate.gov/news/news-releases/private-e...
Private Equity does not create efficiency and we do not need them. What they do is to take debt to buy healthy companies, transfer debt onto them and then kill them.
None of that is efficiency in any reasonable sense.
That doesn’t make sense - private equity has done the same thing in completely orthogonal industries, like manufacturing.
Ugh I wish this braindead populist 'private equity boogieman' meme that's taken ahold of reddit-types would die.
No, private equity is not the reason healthcare costs in the US are out of control, you can even ask chatgpt.
PE is a 3rd tier mild symptom in certain niche health markets that sits downstream of all the structural root issues created due to the twisted public/private incentive misalignment nightmare of US healthcare.
People would have an opportunity to change their stance if you explain why they should hold a different one with evidence and persuasion. Berating them and then saying they are wrong without explaining why is not going to change anyone's mind.
I used to do that when HN was a more rational, thinking-man's place years ago.
It's been poisoned by the hysterical climate of US politics like everything else on the internet, so there are no thinking men left.
It's a lost cause. If I were to explain the situation rationally I would get downvoted for not cheering on the shooting of CEOs.
Upvote communities are all dead and dying. There are no more interesting conversations happening in them anymore.
AMA was lobbying for more residencies for years. And residencies are the bottleneck.
What may be necessary is for other countries to be better. These treatments / studies don't just affect USAmericans but everyone everywhere, and if there's enough signals of "this treatment saves kids abroad but we can't afford them in the US because of policy", MAYBE said policy will change. Maybe. Not likely because the corporations have control over the government, and the US government system is stuck in laws drafted up in the 1700s.
Does that really happen "any time you go to a doctor's office"?
That aside, what if novel therapies like this are linked to the fact that US healthcare is expensive? If you make it cheap -- as in other countries -- there's less incentive for companies to invest and you get less research and fewer breakthroughs. Also fewer doctors, hospital beds, and more rationing.
In an ideal world, everyone would have exactly the right amount of healthcare. But our world isn't ideal, it runs on incentives, and it's not clear to me that all the hand-wringing over US healthcare will lead to positive changes.
> Does that really happen "any time you go to a doctor's office"?
Yes. I recently made a resolution to get established with all the medical professionals I don’t have set up. So a primary care, dermatologist, etc. over the past 2 months I’ve visited and had to go back a couple of times. I’ve literally overheard insurance-related issues in all cases. Whether it was the person in line before me or just overhearing people complaining while I’m in the waiting room.
Just last week I was waiting to get my blood drawn and the woman at the front desk, after continued prodding by an elderly man frustrated with lack of coverage, out loud said “Well, that’s insurance in America for you. Go ahead and call the number on the back of your insurance card because we can’t do anything for you.” Just deeply disheartening stuff to watch a late 80s man not realize after 15 minutes of being tossed between automated insurance phone responses that he simply won’t get the help he needs.
Well I just had an MRI and didn't see one elderly person complaining about bills. Guess that cancels our anecdotes out
This point of view runs directly against mutually agreed upon matters of fact: https://petrieflom.law.harvard.edu/2022/03/15/ama-scope-of-p...
The US healthcare system is not a market system nor did it occur naturally. Do you have any conflicts of interest that could cause you to have an emotional need to misunderstand basic information about it?
> That aside, what if novel therapies like this are linked to the fact that US healthcare is expensive?
you don't have to wonder, people have been writing about this as a major factor of costs for nearly 50 years
The US is a country of cowboys. There is literally nothing that can be considered fair. The only thing what is left is the kindness of it's people. If that detoriates, well...
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It wasn't so long ago that doctors assumed that it would be better for the family if babies like this died quickly - and quietly helped them off. I had a cousin with spina bifida, who only lived because her own mother was a doctor and prevented this outcome. My cousin got to live to adulthood and enjoy life, but still died early because of an infection; likely a consequence of the physical impairments of this condition. It's amazing to see hope for a complete cure.
Incredible to see some promising results in stem cell research. Hopefully a safe and successful application can give a boost to some other areas where stem cells might prove useful (like maybe one day we can regrow damaged heart tissue like this).
The notion of "stem cells" are somewhat of a misnomer as modern biotechnology is showing us. There are an orchestration of probably 1000s of different cell types which can vary in their cell states. We don't have enough knowledge of how to use these various cell types to influence complex self-organization processes like development. But in some cases there are clever fixes without understanding the underlying process.
Best news is the stem cells used are from donated placentas. So no political footballs, just a true blessing to a child.
I did not even know it was possible to operate on a fetus. Its insane how far we have come. Very promising results!
The first episode of the Surgeon's Cut [0] on Netflix shows a doctor:
- operating in utero
- while the mother is awake
- in an outpatient/doctor's office setting
- to implant a balloon in the upper respiratory tract of a fetus with a, I believe, cleft palate so that it's lungs can develop normally.
It really is wild what modern medicine can do these days.
0 - https://www.netflix.com/title/81004466
The Grey’s Anatomy was before that with depicting Prenatal Surgery fellowship.
Not only is it possible, fetal surgery is more or less standard treatment for spina bifida at this point. The news here is about the stem cell patch being applied during the surgery. (I have a child with spina bifida. We tried to get her into this trial, but did not qualify.)
Interesting - they had done surgery before, but not with stem cells. 6 babies operated on, results were very good and they are recruiting for phase 2
Does the physical repair also help with the mental developmental effects? Children with spinal bifida often develop cognitive abilities much slower than children without it.
The main goal of physical repair of the defect in utero is actually to reduce the incidence of hydrocephalus and hindbrain herniation, which are very common in people with Spina Bifida. The existing fetal surgery reduces the incidence of hydrocephalus from about 80% to about 40%. The improvement in leg and bowel/bladder function is actually a secondary benefit.
My understanding is that the hindbrain herniation (aka Chiari Malformation Type II) is the main cause of cognitive trouble in people with SB. But it's worth noting that it's very far from universal in causing that. Most people with SB are basically normal cognitively assuming they get good early intervention (VP shunt, PT, OT, etc.). Some early cognitive development can be slower as a knock on effect of not being able to move around as much as a baby and toddler, and thus less able to explore the environment, etc.
Source: I'm the parent of a toddler with spina bifida. She's completely on track cognitively and with fine motor skills so far. She's way behind with gross motor skills due to her inability to move her legs very much.
Another sb parent here, my kid is seven now, she’s also on track intellectually. We got the decompression surgery for the Chiari II a few months after she was born, and the VP shunt even earlier than that. Aside from some stammering (which her non SB sister also has, so I suspect it’s hereditary), and weirdness with foods (OT has helped a lot) she’s totally on track intellectually.
Our daughter was a particularly severe case too, and these interventions seem to have helped a lot. For the first four years she’d hold her breath every time she was upset, and need CPR, but we got her breathing again every time, so we don’t think there’s any brain damage. If we’d missed once, maybe I’d be telling a different story now. Thank goodness her head grew!
What does the stem cell treatment help with beyond the existing fetal surgery? Since it's in addition to the usual surgical treatment
That doesn't really explain anything biologically. Just vaguely says "potentially helps heal and protect"
They cite this paper which gives the concept: https://www.sciencedirect.com/science/article/pii/S002234681... . The mechanism of injury in spina bifida is that the spinal cord gets exposed and damaged. Current surgery will close the spinal canal to prevent further exposure, but it doesn't do anything to reverse the damage that has already happened. The stem cells integrate into the neural tissue and hopefully help the axons heal.
https://www.thelancet.com/journals/lancet/article/PIIS0140-6...
As a stem cell biologist: my guess is that it doesn't help much
Truly remarkable! Despite the darkness in the world most days, news like this lifts my spirits and gives me hope.
N=6 Phase 1, so this is purely a safety readout. But does the stem cell patch actually prevents hydrocephalus or just delays it.
lets see 35 patients in Phase 1/2a
Spina bifida is usually preventable by folic acid intake (and avoiding some medications).
It pains me to see it is still so prevalent.
It sounds like stem cells come from unrelated people and no rejection, etc?
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There are people who do not want to have abortions. Either for religious reasons, because they themselves belong to a specific disability group (e.g. the blind and deaf) or because they tried hard already to get pregnant in the first place.
Especially for the latter, "make a new one" can mean a ticket reaching into the 6 figures, months of egg extractions, implantation attempts and spontaneous auto-abortions.
They should spend the money instead of taking the risk of burdening someone with a disability their whole lives. This treatment is not a sure thing. And yes, I am disabled myself.
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so edgy
What a gross and idiotic take. “Just abort it”; i’m pro choice, but IMO life must be regarded as more sacred than what ‘ole tsss here considers. I can only conclude tsss has never dealt with any real loss in their life.
China is going to be way ahead of us in biological treatments because they are willing to actually remove the red tape and in fact encourage scientists to try these sorts of experimental treatments. Meanwhile, we have a dinosaur FDA, a bureaucratic academia second to only Europeans.
The good news is that the rest of the world will benefit from China’s treatment philosophy.
What does any of this have to do with China? This study was done in California.
What's the plan in China for when one of these expedited treatments has a terrible side effect?
The FDA's slowness is about maintaining a low level of risk because the reputation cost of a really bad incident is huge.
Well, I'm no ethicist, but I don't think they really care. They'll catalog the results and try again.