Performance-based reimbursement increases administrative burden and moral distress, lowers perceived quality of care

Performance-based reimbursement, illegitimate tasks, moral distress, and quality care in primary care: a mediation model of longitudinal data

American Academy of Family Physicians

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All Quality Metrics Are Wrong; Some Quality Metrics Could Become Useful

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Performance-Based Reimbursement Increases Administrative Burden and  Moral Distress, Lowers Perceived Quality of Care

Background and Goal: Performance-based reimbursement (PBR) is a payment system in which clinics receive compensation based on the quality and outcomes of care they deliver, rather than the volume of services provided. Although designed to improve efficiency and effectiveness, the growth of PBR systems has been linked to increased administrative work for physicians. This study examined how PBR affects doctors' perceived ability to provide quality care at both the individual and organizational levels. 

Study Approach: Researchers conducted a longitudinal study using a three-wave survey of primary care physicians, drawing data from the Longitudinal Occupational Health Survey in Health Care Sweden. The first wave, conducted from March to May 2021, involved a survey sent to a nationally representative sample of physicians (N=6,699), asking respondents to rate the impact of the PBR system on a scale ranging from very negative to very positive. The second wave, conducted from March to May 2022, measured illegitimate tasks (tasks that fall beyond the scope of an employee's primary responsibilities and professional role or tasks not anticipated for a particular position) using the Bern Illegitimate Tasks Scale. Moral distress was assessed using an instrument originally developed for Norwegian physicians and later translated into Swedish. The third wave, conducted from October to December 2023, evaluated perceived quality of care at both the individual and organizational levels using the English National Health Staff Survey.

Main Results: A total of 433 primary care physicians responded to the survey at all three time points. Overall, 70.2% of respondents reported that PBR negatively impacted their work (58.9% negative, 12.3% very negative).

Quality of Individual Care

• PBR was associated with increased illegitimate work tasks and  greater moral distress

• Illegitimate work tasks and moral distress were both associated with lower perceived individual quality of care

Quality of Organizational Care

• PBR was associated with an increase in illegitimate work tasks and lower perceived organizational quality of care

• Moral distress did not have a significant association with perceived organizational quality of care

Why It Matters: The identification of illegitimate tasks and moral distress as factors associated with perceived care quality suggests that reducing tasks which are seen as irrelevant could support physician well-being and health care delivery. 

Performance-Based Reimbursement, Illegitimate Tasks, Moral Distress, and Quality Care in Primary Care: A Mediation Model of Longitudinal Data

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Journal

The Annals of Family Medicine

Pay-for-performance metrics must be more impactful and physician-controlled

All quality metrics are wrong; Some quality metrics could become useful

American Academy of Family Physicians

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Pay-for-Performance Metrics Must Be More Impactful and Physician-Controlled

Background: This editorial builds on a study by Brulin and Teoh, released ahead of the March/April 2025 issue of Annals of Family Medicine, which found that performance-based reimbursement is associated with lower perceived quality of care by increasing illegitimate tasks and moral distress for primary care physicians.

Editorial Stance: Quality metrics and pay-for-performance initiatives are far more expensive than many patients, clinicians, or administrators realize. The authors call for more rigorous review through cluster randomized controlled trials both before and after implementation—and recommend against  implementing metrics with little impact or those that detract from care. They recommend refocusing incentives on targets that are impactful, time-limited, low-cost, and physician-controlled. 

Why It Matters: While no single metric is perfect, some can support better care if applied thoughtfully and tested in real-world settings. All Quality Metrics Are Wrong; Some Quality Metrics Could Become Useful

Michael E. Johansen, MD, MS, et al 

Grant Family Medicine, OhioHealth, Columbus, Ohio

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Journal

The Annals of Family Medicine

Survey finds many Americans greatly overestimate primary care spending

The general public vastly overestimates primary care spending in the united states

American Academy of Family Physicians

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Survey Finds Many Americans Greatly Overestimate Primary Care Spending

Background and Goal: This study, based on an online survey of 1,135 adults demographically representative of the U.S. population, aimed to measure public perceptions of primary care spending.

Key Insights: Respondents believed that 51.8% of overall health care spending goes to primary care—more than 10 times the documented share of 4.7%. Additionally, respondents believed that primary care addresses 58.7% of health care needs, very close to actual primary care utilization as a percentage of all ambulatory physician visits in the United States (50.3%).

Why It Matters: Chronic underinvestment in primary care has resulted in workforce shortages, physician burnout, reduced access, and suboptimal care. Access to high-quality primary care has been associated with better population health and more equitable outcomes. 

The General Public Vastly Overestimates Primary Care Spending in the United States

Melissa Ma, BS, et al

School of Medicine, University of California, San Francisco, San Francisco, California

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Journal

The Annals of Family Medicine

 

Beehive sensors offer hope in saving honeybee colonies

Innovation allows for remote monitoring of beehive health

University of California - Riverside

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A UC Riverside computer science team has developed a sensor-based technology that could revolutionize commercial beekeeping by reducing colony losses and lowering labor costs.

Called the Electronic Bee-Veterinarian, or EBV, the technology uses low-cost heat sensors and forecasting models to predict when hive temperatures may reach dangerous levels. The system provides remote beekeepers with early warnings, allowing them to take preventive action before their colonies collapse during extreme hot or cold weather or when the bees cannot regulate their hive temperature because of disease, pesticide exposure, food shortages, or other stressors.  

“We convert the temperature to a factor that we are calling the health factor, which gives an estimate of how strong the bees are on a scale from zero to one,” said Shamima Hossain, a Ph.D. student in computer science at UCR and lead author of a paper explaining the technology.

This simplified metric — with a score of ‘one' meaning the bees are at full strength — allows beekeepers unfamiliar with the underlying model to assess hive health quickly.

Boris Baer, a UCR professor of entomology, believes the technology could revolutionize beekeeping, which is essential to vast sectors of global agriculture. Honeybees pollinate more than 80 crops and contribute an estimated $29 billion annually to U.S. agriculture. Yet bee populations have declined due to various factors, including habitat loss, pesticide exposure, parasites, and climate change.

“Over the last year, the U.S. lost over 55% of its honeybee colonies,” Baer said, citing data from Project Apis m., which monitors beehive losses throughout the U.S. “We are experiencing a major collapse of bee populations, and that is extremely worrying because about one-third of what we eat depends on bees.”

Beekeepers now rely on their own judgment and manual inspections to detect problems, often leading to delayed interventions. With EBV, they can get real-time insights and predict conditions days in advance, significantly reducing labor costs, said Baer, who collaborated with Hossain and other scientists at UCR’s Bourns College of Engineering.

“People have dreamed of these sensors for a very long time,” Baer said. “What I like here is that this system is fully integrated into the hive setup that beekeepers already use.”

Temperature fluctuations are among the first responses to any kind of threats to a hive’s health. Honeybees maintain a precise internal hive temperature between 33 and 36 degrees Celsius (91.4–96.8°F), a requirement for proper brood development and colony survival, Baer said.

The EBV method is based on thermal diffusion equations and control theory, making its predictions interpretable to both scientists and beekeepers, Hossain said. The model uses temperature data collected from low-cost sensors installed inside the hive, feeding that information into an algorithm that predicts hive conditions several days in advance.

In tests conducted at UCR’s apiary, the EBV method analyzed data from 10 hives during initial development and later expanded to 25 hives. The technology has already proven its effectiveness, detecting conditions that required beekeeper intervention.

“When I looked at the dashboard and saw the health factor dropped below an empirical threshold, I contacted our apiary manager,” Hossain recalled. “When we went to check the hive, we found that there was actually something wrong, and they were able to take action to manage the situation.”
Hyoseung Kim, an associate professor of electrical and computer engineering at UCR, explained that keeping costs low — under $50 per hive — is a high priority.

“There are commercial sensors available, but they are too expensive,” Kim said. “We decided to create a very cheap device using off-the-shelf components so that beekeepers can afford it.”

The research team is already working on the next phase, which is to develop automated hive climate controls that can be installed on hives and respond to EBV’s predictions, adjusting hive temperatures automatically.

“Right now, we can only issue warnings,” Hossain said. “But in the next phase, we are working on designing a system that can automatically heat or cool the hive when needed.”

The title of Hossain’s paper is “Principled Mining, Forecasting and Monitoring of Honeybee Time Series with EBV+” In addition to Hossain, Baer and Kim, the co-authors are Christos Faloutsos, professor of computer science at Carnegie Mellon University, and Vassilis Tsotras, professor of computer science and engineering at UCR.

All the authors are with UCR’s Center for Integrative Bee Research, one of the largest pollinator health research hubs in the nation.

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DOI

10.1145/3719014 

Method of Research

Data/statistical analysis

Subject of Research

Animals

Article Title

Principled Mining, Forecasting and Monitoring of Honeybee Time Series with EBV+

Article Publication Date

24-Feb-2025

Virginia Tech study reveals that honeybee dance ‘styles’ sway food foraging success

Researchers in the Department of Entomology found that the secret to the bees’ success in food gathering is all in the "waggle."

Virginia Tech

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A honeybee doing the waggle dance to entice her sisters to a tasty food source.

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Credit: Photo by Roger Schürch for Virginia Tech.

As far as animals go, honeybees are world-class dancers.

While not as deep and complex as a Super Bowl half-time show, the bees' moves, known as the “waggle" dance, convey very specific food foraging instructions to their nestmates. The direction the dancer moves explains to other bees which way to go, and the duration of the waggle dance, or the “run,” shows how far to go. Once other bees have been convinced to follow the directions, they are “recruited.” After receiving the instructions, these recruits leave the hive to find the food their sisters were so excited about.

Unfortunately, many of these recruited bees do not always successfully find the food they set out in search of. Margaret Couvillon, associate professor in the Department of Entomology in the College of Agriculture and Life Sciences, and her former Ph.D. student Laura McHenry wanted to find out why.

Trying to understand why waggle dances fail

Honeybees have had millions of years to perfect the waggle dance, so it may be surprising to learn that it doesn’t often work. Even though it was first described by scientists over 80 years ago, there is still a lot about the waggle dance that we don’t understand.

Couvillon has learned several interesting patterns related to this form of communication. One such observation was that bees have consistent, unique ways of dancing, meaning each bee has its own “style” that it adds to the communication. Could the success of the waggle dance be related to this uniqueness? Would bees that communicated similarly yield more successful recruits? Or is there some other factor at play? This study reveals the waggle to be a diverse form of communication that helps improve the likelihood that one bee can tell another where food can be found. The findings were recently published in Current Biology.

“Although the waggle dance itself is fascinating, my lab has additionally been intrigued about waggle dance miscommunication, or the hows and whys behind the failure of the dance recruitment,” Couvillon said.

To answer these questions, the Couvillon Lab devised an experiment utilizing clear-walled hives, video cameras, and a method of tagging bees so they could be tracked as individuals when they foraged and danced. Each hive included foragers who had been taught the location of an artificial food source. These trained foragers performed a waggle dance to teach others where this food was, effectively training a new set of recruits. If successful in locating the food, these recruits returned to teach other bees what they learned. Couvillon and her team hypothesized that bees with similar dance styles would more often successfully teach others how to find the food and communication that differed between bees would be less successful.

Whenever a new, tagged bee was observed at the food source, video of the hive was reviewed to determine which dancer had recruited that successful forager. This pattern of data collection allowed the researchers to track the dance the bees used, with each bee learning where the food was located from a slightly different telling. These successful dances were then compiled, and the run of each dance was measured and compared to the earlier dances. The pattern that emerged was not what the researchers expected.

The power of individuality

Based on the data from these dances, Couvillon and McHenry found that similar dance communication did not actually result in the most successful foraging, which was their original hypothesis. Dances that had a longer run, effectively telling the recruits to overshoot the food source, were more successful than dances describing similar, more accurate, distances. This pattern suggested that the “overshooting” instructions may have led to additional opportunities to find the food, once on the way past the food source and again on the way back to the hive. They theorized that the foragers having a second chance to find the food source increased the chance that they find it at all. 

What does this mean for understanding the honeybee waggle dance? One takeaway is the importance of these unique communication styles, where individual dance mannerisms enhance communication success. If every bee communicated the same, the likelihood of foragers reaching the food would decrease as compared to having a diverse set of styles.

This study adds effective dance moves to the list of known benefits of individuality, showing that a diverse set of communication skills helps improve the likelihood that one bee can tell another where food can be found, all through dance.

“We’ve known for a while that behavioral and genetic diversity benefit honeybees, allowing for superior thermoregulation, disease resistance, growth, and foraging,” said Couvillon. “Now we have also seen that diverse communication enhances recruitment success.”

The paper, “Individuality impacts communication success in honey bees,” was published in Current Biology. Couvillon’s research was supported by the National Institute of Food and Agriculture, the Foundation for Food and Agriculture Research, and the Department of Entomology at Virginia Tech. 

Honeybee dancing [VIDEO] | 

A Virginia Tech entomologist marking an individual honeybee so that researchers can match when the bee visits a feeder to the corresponding waggle dance it does for its nestmates.

Credit

Photo by Roger Schürch for Virginia Tech.

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Article Title

Individuality impacts communication success in honey bees

Article Publication Date

24-Feb-2025

 

Melatonin supplementation may help offset DNA damage linked to night shift work

Larger studies of varying doses and longer term effects now warranted, say researchers

BMJ Group

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Melatonin supplementation may help offset the DNA damage associated with night shift work by boosting the body’s ability to repair it, suggest the findings of a small clinical trial published online in the journal Occupational & Environmental Medicine.

Larger studies looking at varying doses and the potential long term effects of melatonin supplementation are now warranted, conclude the researchers.

Normal night-time production of the body clock hormone, melatonin, is suppressed in night shift workers. This compromises the body’s ability to repair oxidative DNA damage, the by-product of normal cellular processes, heightening the risk of certain cancer in these workers, explain the researchers.

They therefore wanted to find out if melatonin supplementation might help offset this damage by enhancing DNA repair in 40 night shift workers.

Half the participants were randomly assigned to a daily 3 mg melatonin pill taken with food and an hour before going to sleep during the day for 4 consecutive weeks. And half were randomly assigned to a 3 mg dummy pill following the same schedule.

All the participants worked a minimum of two consecutive night shifts every week, lasting at least 7 hours a night, for at least 6 months. None had any sleep disorders or long term conditions.

Urine specimens were collected during the second of two subsequent day sleep and night shift periods—once before starting the trial and once near the end of the 4 weeks. 

Participants wore activity trackers to measure how long they slept during the day. Levels of 8-OHdG, which is an indicator of DNA damage repair capacity, were measured in all urine passed during periods of daytime sleep and the subsequent night shift. 

Urinary levels of 8-OH-dG were 80% higher during daytime sleep—indicating better repair— among those taking the melatonin supplement than those taking the dummy pill. But there was no significant difference in urinary 8-OH-dG levels during the subsequent night shift.

This is a small study, and most of the participants worked in healthcare, so the results may not be applicable to other types of night shift worker, acknowledge the researchers. Nor were they able to account for natural light exposure, which affects circulating melatonin levels. 

But they point out: “Increased oxidative DNA damage due to diminished DNA repair capacity is a compelling mechanism that may contribute to the carcinogenicity of night shift work. Our randomised placebo-controlled trial suggested melatonin supplementation may improve oxidative DNA damage repair capacity among night shift workers.” 

And they conclude: “Our findings warrant future larger-scale studies that examine varying doses of melatonin supplements and longer-term impacts of melatonin use. Pending the outcome of such studies, melatonin supplementation may prove to be a viable intervention strategy to reduce the burden of cancer among night shift workers.” 

They add: “Assessing long-term efficacy is critical since those who work night shifts for many years would need to consistently consume melatonin supplements over that time frame to maximise the potential cancer prevention benefits.”

 

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Journal

Occupational and Environmental Medicine

DOI

10.1136/oemed-2024-109824 

Method of Research

Randomized controlled/clinical trial

Subject of Research

People

Article Title

Melatonin supplementation and oxidative DNA damage repair capacity among night shift workers: a randomised placebo-controlled trial

Article Publication Date

24-Feb-2025

We Won't Name a Mountain After Trump, But Maybe a Sink Hole

On a planet that itself is beginning to come apart at the seams, such a president, a man focused on himself above all else, is no small disaster.


A 22-ton Los Angeles Fire Department fire truck protrudes from a sinkhole on September 8, 2009 in the Valley Village neighborhood of Los Angeles, California.
(Photo by David McNew/Getty Images)

Tom Engelhardt
Feb 24, 2025

TomDispatch

Count on one thing: in some almost unimaginable future, no American president (if we even have them anymore) is going to rename a mountain for Donald Trump as he’s recently tried to do with North America’s tallest peak. He wants Alaska’s Mount Denali (to hell with Native American names!) to be called Mount McKinley in honor of President William McKinley, the man who, in the 1890s, launched this country as an imperial power of the first order.

Of course, it’s just possible that someday someone running (or do I mean: walking, hobbling, limping?) this country might rename the Bertha Rogers Borehole, the deepest hole (now plugged and abandoned) in North America, for President Trump. After all, it should be clear enough that, with a helping hand from the world’s richest man, he’s already taking this country down in a remarkable fashion. It seems that we now inhabit an ever more strikingly 3D world and call me D (as in depressed) about it.

Once upon a time, 3D was a form of movie-making in which — I remember this from my youth in the 1950s — something could seemingly fly off the screen and grab you by the throat (or an arrow, spear, or missile could whiz right at you).

Four more years of Donald Trump should worry anyone, whether your fears have to do with the dismantling of this country or the taking down of our world.

Today, 3D (at least to me) has quite a different meaning. The 3Ds of the world of my old age (and believe me they, too, can in some fashion reach right off the screen and grab you by the throat) are The Donald, Dysdopia, and Decline. And yes, I’ve admittedly done a little 3D fiddling of my own with that classic word “dystopia” meant for a deeply negative, apocalyptically horrific future world (think 1984, or do I mean 2025?) — the very opposite, in other words, of utopia. I’ve replaced its “t” with that extra “d” in “honor” (and indeed, that word does have to go in quotation marks) of Donald Trump who is already ushering us into what looks to be the most devastatingly disastrous presidency in this country’s long history.

Denier-in-Chief

In case you don’t think he’s taking us all for one hell of a ride, think again. After all, he and his family started cashing in on his second presidency even before it began. As the New York Timesreported, three days ahead of his inauguration, he announced on his social media account that his family had issued a cryptocurrency called $Trump. And if that stumps (or do I mean $trumps?) you, I’m hardly shocked. Perhaps you won’t be surprised to learn, in fact, that each of its memecoins quickly surged in value from eight cents to $75 before — of course! — dropping off a cliff. It’s now estimated that it made the Trump Organization and its partners an instant $100 million or more, while other crypto-traders lost an estimated $2 billion in the process. And if that doesn’t sum up Donald Trump’s presidency to come, I’ll be surprised.

In fact, I suspect that offered just a hint of the unnervingly dysdopian world we’ve entered. Let’s face it: we couldn’t find ourselves in a more dopily dangerous 3D moment today. After all, Donald Trump and his alter ego Elon Musk, the richest man on earth and growing richer by the hour, possibly even heading for the trillion-dollar mark, seem remarkably intent on stepping off-screen and grabbing us all by the throat, while dismantling the American government as we’ve known it. Their goal is evidently to leave both the courts and Congress, the other two parts of our tripartite form of government, in the dust (the mud?) of history.

After all, Vice President JD Vance has already made it clear that the courts — even the Supreme Court — can have no ultimate power to stop a second Trump administration from running rampant. Or, as he wrote recently in response to the first attempts of various courts to stop Donald Trump and Elon Musk from all-too-literally dismantling significant parts of the government, “Judges aren’t allowed to control the executive branch’s legitimate power.” Do tell! (Of course, as Joe Biden’s presidency ended, the Supreme Court granted Trump substantial immunity from prosecution for more or less anything he had done as president and now he may decide he doesn’t even need them anymore.)

Oh, and despite those three Ds, I actually forgot the fourth and most important one of all: denier. Yes, Donald Trump, the elected president of the United States, is a climate-change denier first class and, once again, this country’s denier-in-chief. In the past, he couldn’t have been blunter on the subject. In the wake of Hurricane Helene’s devastating path across the Southeastern U.S. in 2024, he called climate change “a scam.” He’s also dismissed it as a “hoax” invented by China. Worse yet, he ran successfully for president this time around on the phrase “drill, baby, drill” and the promise of a presidency fossil-fuelized to the hilt. It mattered not at all to him and his crew that the planet was experiencing its hottest months and hottest year ever; that his first month in office, this January, once again broke all heat records; and that climate scientists are predicting far worse to come.

Now back in the White House, President Trump has already taken steps to shut off moves made by the Biden administration to put money into green energy and withdraw from the Paris Climate Agreement (again), while removing mentions of anything related to climate change from government websites. He’s clearly preparing to advance coal, oil, and natural gas development in any way he can. Consider it a deep irony that the executives of the major oil and gas companies, while distinctly in his camp, aren’t eager to over-drill, baby, over-drill, fearing that the price of their products could fall. Of course, to put all of this in even grimmer perspective, in the Biden years this country was already the historically top producer of oil and exporter of natural gas on this planet. In short, President Trump’s goal, it seems, is simply to turn up the heat even further. (Phew, I’m getting hot just writing this!)

In other words, in more or less every way imaginable, as the oldest president ever to enter the Oval Office, his next four years, fossil-fuelized to the hilt, seem all too intent on taking the planet down with him.

President Decline

Think of him as President 3D, or if you prefer 4D, or simply add in the Ds of your choice — disaster, dreaded, dumb, or [fill in the blank here].

Once upon a time, decline (even the decline of great nations) usually proved to be a long, slow process. There were admittedly moments — when the Soviet Union collapsed in 1991, for instance, leaving the U.S. as the “sole superpower” on Planet Earth — when it happened more quickly, but they were rare.

Thanks to Donald Trump, however, it’s possible that the decline of that once-upon-a-time sole superpower could, in this moment, prove uncomfortably closer to the Soviet model than, for instance, to the fading of the British empire. The Big Triple (Quadruple?) D and his buddy, the richest man on Planet Earth, seem remarkably intent on taking us all over a cliff with them.

Admittedly, this country has been on its own trajectory of decline from its status as the planet’s sole superpower for quite a while now. Otherwise, the man once best known for being the host of a TV show, The Apprentice, and for the line “You’re fired!” (as well as for having overseen six companies that went bankrupt — You’re fired!), would never have won in 2016; nor would he be having such an instant blast firing people and closing down or simply shattering government departments the second time around. And again, it would have been inconceivable for Donald Trump to be elected president again if the American imperial world weren’t already declining at home and abroad.

All he’s really doing now is hurrying along the pace, as he (with a helping hand from the most prominent once-illegal immigrant on Earth) tries to wipe out so much, from the U.S. Agency for International Development to the Education Department. And — count on it — this country’s courts aren’t likely to be able to stop him in the end. Why, only the other day, Vice President JD Vance insisted that “if a judge tried to tell a general how to conduct a military operation, that would be illegal,” and obviously the same is true for the president. And in just that spirit, the Trump administration is already beginning to ignore or openly defy court orders on how to deal with parts of the government.

In the end, in his own fashion, Donald Trump may be in the process of closing down this country (at least as we once knew it) and lending a hand to doing the very same thing for Planet Earth (at least as we once knew it). Just what the results of all this will be, we obviously don’t yet know. Count on one thing, though: it ain’t going to be pretty and not just because, with his latest 25% tariffs on aluminum and steel, the costs of products that use either of them (and probably so much else) are going to rise grimly.

No question, though, that decline preceded him into office or, best guess, he never would have been elected in the first (no less second) place. After all, this country was already losing some of its stature globally long before The Donald decided to shut down most aid to the world, while doing his damnedest (with the 13 billionaires he’s appointed to his administration) to ensure that the already wildly wealthy will, in the future, leave the rest of America in a ditch.

And yes, he’s certainly going to be President Decline, Baby, Decline. Don’t, for a second, be fooled by his very open urge, in a strikingly McKinleyesque fashion, “to expand our territory” — to grab, that is, or at least dream about grabbing yet more territory for imperial America, ranging from Greenland and the Panama Canal to that 51st state Canada, and, of course, Gaza. The urge to return to a nineteenth-century version of imperialism, even as he does his best (or worst?) to take this country and this planet down, is striking, to say the least. Especially as, in the wake of the McKinley moment, the American version of imperialism normally involved a far more subtle kind of control over significant parts of this planet, rather than the Trumpian urge to simply grab what you can, bit by bit, island by island, country by country.

Of course, on a planet that itself is beginning to come apart at the seams, such a president, a man focused on himself above all else, is no small disaster. Four more years of Donald Trump should worry anyone, whether your fears have to do with the dismantling of this country or the taking down of our world. In fact, think of Donald Trump’s America as the planetary equivalent of a memecoin. While he and his family may win something significant, don’t count on that for the rest of us, including the 49.7% of American voters in the last election who bought into his scheme.

The Big D — whether you want to think of it as Decline, Dysdopia, Denial, or simply Donald — is now ours for four long, long years. And that couldn’t be sadder.

© 2023 TomDispatch.com


Tom Engelhardtco-founder of the American Empire Project, runs the Type Media Center's TomDispatch.com. His books include: "A Nation Unmade by War" (2018, Dispatch Books), "Shadow Government: Surveillance, Secret Wars, and a Global Security State in a Single-Superpower World" (2014, with an introduction by Glenn Greenwald), "Terminator Planet: The First History of Drone Warfare, 2001-2050"(co-authored with Nick Turse), "The United States of Fear" (2011), "The American Way of War: How Bush's Wars Became Obama's" (2010), and "The End of Victory Culture: a History of the Cold War and Beyond" (2007).
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