Imposter syndrome is common among high achievers in med school

A high percentage of medical students feel like "imposters" during their first year of medical school, which indicates increasing levels of distress.

THEY HAVE YET TO BE INITATED INTO THE GATEKEEPERS LODGE OF THE BROTHERHOOD OF HIPPOCRATES

THOMAS JEFFERSON UNIVERSITY

Research News

 

PHILADELPHIA - Imposter syndrome is a considerable mental health challenge to many throughout higher education. It is often associated with depression, anxiety, low self-esteem and self-sabotage and other traits. Researchers at the Sidney Kimmel Medical College at Thomas Jefferson University wanted to learn to what extent incoming medical students displayed characteristics of imposter syndrome, and found that up to 87% of an incoming class reported a high or very high degree of imposter syndrome.

"Distress and mental health needs are critical issues among medical students," says Susan Rosenthal, MD, lead author of the study published in the journal Family Medicine. "This paper identifies how common imposter syndrome is, and the personality traits most associated with it, which gives us an avenue to address it."

Medical students nationwide report alarming rates of depression, anxiety and burnout. Identifying and intervening to support psychological well-being in these learners is a continuing challenge, especially among first year medical students.

Dr. Rosenthal and her colleagues examined imposter syndrome, which is defined as inappropriate feelings of inadequacy among high achievers, using a validated survey tool called the Clance Imposter Phenomenon (IP) Scale. Of the 257 students who completed the survey, 87% of students who reported high levels of imposter syndrome, were more likely to show an even higher degree of imposter syndrome at the end of their first year. They also found that students' higher IP scores were associated with lower scores for self-compassion, sociability, self-esteem and higher scores on neuroticism/anxiety. Therefore, a high CIP score among entering students may be an indicator of future risk for experiencing psychological distress during medical school.

"Imposter syndrome is a malleable personality construct, and is therefore responsive to intervention," says Dr. Rosenthal, who is also the medical college's associate dean for Student Affairs. "Supportive feedback and collaborative learning, mentoring by faculty, academic support, individual counseling and group discussions with peers are all helpful. For many students, the most powerful first step in addressing and ameliorating imposter syndrome is normalizing this distorted and maladaptive self-perception through individual sessions with faculty and mentored small-group discussions with peers."

It is of interest to note that the students in this study the medical college's Class of 2020 were exposed to the traditional medical school curriculum. The following year, Jefferson introduced an innovative new curriculum, called JeffMD. Dr. Rosenthal and colleagues plan to compare the rates of imposter syndrome in students exposed to the novel curriculum. The new JeffMD curriculum emphasizes collaborative learning with a faculty mentor and a small group of students. The researchers hope, and will test whether this change in the learning environment can ameliorate feelings of imposterism.

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Article reference: Susan Rosenthal, Yvette Schlussel, Mary Bit Yaden, Jennifer DeSantis, Kathryn Trayes, Charles Pohl, Mohammadreza Hojat, "Persistent Impostor Phenomenon Is Associated With Distress in Medical Students," Family Medicine, DOI: 10.22454/FamMed.2021.799997, 2021.

Visa costs higher for people from poor countries

Research team including Goettingen University sheds light on global inequality in travel permit costs

UNIVERSITY OF GÖTTINGEN

Research News

 

IMAGE: MAP OF THE WORLD SHOWING AVERAGE NUMBER OF DAYS THAT SOMEONE HAS TO WORK TO BE ABLE TO AFFORD A TOURIST VISA view more 

CREDIT: GLOBAL VISA COST DATASET

How much do people have to pay for a travel permit to another country? A research team from Göttingen, Paris, Pisa and Florence has investigated the costs around the world. What they found revealed a picture of great inequality. People from poorer countries often pay many times what Europeans would pay. The results have been published in the journal Political Geography.

Dr Emanuel Deutschmann from the Institute of Sociology at the University of Göttingen, together with Professor Ettore Recchi, Dr Lorenzo Gabrielli and Nodira Kholmatova (from Sciences Po Paris, CNR-ISTI Pisa and EUI Florence respectively) compiled a new dataset on visa costs for travel between countries worldwide. The analysis shows that on average people from North Africa and South Asia pay more than three times as much for tourist visas (at just under 60 US dollars), as people from Western Europe (at around 18 US dollars).

The inequality becomes even greater when the differences in wealth between countries are taken into account. While Europeans usually only have to work for a fraction of a day to be able to afford a travel permit, in some African and Asian countries the visa costs are equivalent to several weeks or even months of the average income.

"Our dataset provides information about a dimension of global inequality that has, so far, received little attention," says Deutschmann. "While Article 13 of the Universal Declaration of Human Rights states that every person has the right to move freely and to leave any country, including their own, in reality there are barriers at many different levels which can obstruct global mobility, depending on where you come from. And our data clearly shows that these barriers include visa costs."

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Original publication:
Recchi, E., E. Deutschmann, L. Gabrielli & N. Kholmatova. 2021. The Global Visa Cost Divide: How and Why the Price for Travel Permits Varies Worldwide. Political Geography 86: 1-14.
https://doi.org/10.1016/j.polgeo.2021.102350

What happened to Mars's water? It is still trapped there

New data challenges the long-held theory that all of Mars's water escaped into space

CALIFORNIA INSTITUTE OF TECHNOLOGY

Research News

Billions of years ago, the Red Planet was far more blue; according to evidence still found on the surface, abundant water flowed across Mars and forming pools, lakes, and deep oceans. The question, then, is where did all that water go?

The answer: nowhere. According to new research from Caltech and JPL, a significant portion of Mars's water--between 30 and 99 percent--is trapped within minerals in the planet's crust. The research challenges the current theory that the Red Planet's water escaped into space.

The Caltech/JPL team found that around four billion years ago, Mars was home to enough water to have covered the whole planet in an ocean about 100 to 1,500 meters deep; a volume roughly equivalent to half of Earth's Atlantic Ocean. But, by a billion years later, the planet was as dry as it is today. Previously, scientists seeking to explain what happened to the flowing water on Mars had suggested that it escaped into space, victim of Mars's low gravity. Though some water did indeed leave Mars this way, it now appears that such an escape cannot account for most of the water loss.

"Atmospheric escape doesn't fully explain the data that we have for how much water actually once existed on Mars," says Caltech PhD candidate Eva Scheller (MS '20), lead author of a paper on the research that was published by the journal Science on March 16 and presented the same day at the Lunar and Planetary Science Conference (LPSC). Scheller's co-authors are Bethany Ehlmann, professor of planetary science and associate director for the Keck Institute for Space Studies; Yuk Yung, professor of planetary science and JPL senior research scientist; Caltech graduate student Danica Adams; and Renyu Hu, JPL research scientist. Caltech manages JPL for NASA.

The team studied the quantity of water on Mars over time in all its forms (vapor, liquid, and ice) and the chemical composition of the planet's current atmosphere and crust through the analysis of meteorites as well as using data provided by Mars rovers and orbiters, looking in particular at the ratio of deuterium to hydrogen (D/H).

Water is made up of hydrogen and oxygen: H2O. Not all hydrogen atoms are created equal, however. There are two stable isotopes of hydrogen. The vast majority of hydrogen atoms have just one proton within the atomic nucleus, while a tiny fraction (about 0.02 percent) exist as deuterium, or so-called "heavy" hydrogen, which has a proton and a neutron in the nucleus.

The lighter-weight hydrogen (also known as protium) has an easier time escaping the planet's gravity into space than its heavier counterpart. Because of this, the escape of a planet's water via the upper atmosphere would leave a telltale signature on the ratio of deuterium to hydrogen in the planet's atmosphere: there would be an outsized portion of deuterium left behind.

However, the loss of water solely through the atmosphere cannot explain both the observed deuterium to hydrogen signal in the Martian atmosphere and large amounts of water in the past. Instead, the study proposes that a combination of two mechanisms--the trapping of water in minerals in the planet's crust and the loss of water to the atmosphere--can explain the observed deuterium-to-hydrogen signal within the Martian atmosphere.

When water interacts with rock, chemical weathering forms clays and other hydrous minerals that contain water as part of their mineral structure. This process occurs on Earth as well as on Mars. Because Earth is tectonically active, old crust continually melts into the mantle and forms new crust at plate boundaries, recycling water and other molecules back into the atmosphere through volcanism. Mars, however, is mostly tectonically inactive, and so the "drying" of the surface, once it occurs, is permanent.

"Atmospheric escape clearly had a role in water loss, but findings from the last decade of Mars missions have pointed to the fact that there was this huge reservoir of ancient hydrated minerals whose formation certainly decreased water availability over time," says Ehlmann.

"All of this water was sequestered fairly early on, and then never cycled back out," Scheller says. The research, which relied on data from meteorites, telescopes, satellite observations, and samples analyzed by rovers on Mars, illustrates the importance of having multiple ways of probing the Red Planet, she says.

Ehlmann, Hu, and Yung previously collaborated on research that seeks to understand the habitability of Mars by tracing the history of carbon, since carbon dioxide is the principal constituent of the atmosphere. Next, the team plans to continue to use isotopic and mineral composition data to determine the fate of nitrogen and sulfur-bearing minerals. In addition, Scheller plans to continue examining the processes by which Mars's surface water was lost to the crust using laboratory experiments that simulate Martian weathering processes, as well as through observations of ancient crust by the Perseverance rover. Scheller and Ehlmann will also aid in Mars 2020 operations to collect rock samples for return to Earth that will allow the researchers and their colleagues to test these hypotheses about the drivers of climate change on Mars.

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The paper, titled "Long-term Drying of Mars Caused by Sequestration of Ocean-scale Volumes of Water in the Crust," published in Science on 16 March 2021. This work was supported by a NASA Habitable Worlds award, a NASA Earth and Space Science Fellowship (NESSF) award, and a NASA Future Investigator in NASA Earth and Space Science and Technology (FINESST) award.

Researchers find a better way to measure consciousness

UNIVERSITY OF WISCONSIN-MADISON

Research News

 

MADISON, Wis. -- Millions of people are administered general anesthesia each year in the United States alone, but it's not always easy to tell whether they are actually unconscious.

A small proportion of those patients regain some awareness during medical procedures, but a new study of the brain activity that represents consciousness could prevent that potential trauma. It may also help both people in comas and scientists struggling to define which parts of the brain can claim to be key to the conscious mind.

"What has been shown for 100 years in an unconscious state like sleep are these slow waves of electrical activity in the brain," says Yuri Saalmann, a University of Wisconsin-Madison psychology and neuroscience professor. "But those may not be the right signals to tap into. Under a number of conditions -- with different anesthetic drugs, in people that are suffering from a coma or with brain damage or other clinical situations -- there can be high-frequency activity as well."

UW-Madison researchers recorded electrical activity in about 1,000 neurons surrounding each of 100 sites throughout the brains of a pair of monkeys at the Wisconsin National Primate Research Center during several states of consciousness: under drug-induced anesthesia, light sleep, resting wakefulness, and roused from anesthesia into a waking state through electrical stimulation of a spot deep in the brain (a procedure the researchers described in 2020).

"With data across multiple brain regions and different states of consciousness, we could put together all these signs traditionally associated with consciousness -- including how fast or slow the rhythms of the brain are in different brain areas -- with more computational metrics that describe how complex the signals are and how the signals in different areas interact," says Michelle Redinbaugh, a graduate student in Saalman's lab and co-lead author of the study, published today in the journal Cell Systems.

To sift out the characteristics that best indicate whether the monkeys were conscious or unconscious, the researchers used machine learning. They handed their large pool of data over to a computer, told the computer which state of consciousness had produced each pattern of brain activity, and asked the computer which areas of the brain and patterns of electrical activity corresponded most strongly with consciousness.

The results pointed away from the frontal cortex, the part of the brain typically monitored to safely maintain general anesthesia in human patients and the part most likely to exhibit the slow waves of activity long considered typical of unconsciousness.

"In the clinic now, they may put electrodes on the patient's forehead," says Mohsen Afrasiabi, the other lead author of the study and an assistant scientist in Saalmann's lab. "We propose that the back of the head is a more important place for those electrodes, because we've learned the back of the brain and the deep brain areas are more predictive of state of consciousness than the front."

And while both low- and high-frequency activity can be present in unconscious states, it's complexity that best indicates a waking mind.

"In an anesthetized or unconscious state, those probes in 100 different sites record a relatively small number of activity patterns," says Saalmann, whose work is supported by the National Institutes of Health.

A larger -- or more complex -- range of patterns was associated with the monkey's awake state.

"You need more complexity to convey more information, which is why it's related to consciousness," Redinbaugh says. "If you have less complexity across these important brain areas, they can't convey very much information. You're looking at an unconscious brain."

More accurate measurements of patients undergoing anesthesia is one possible outcome of the new findings, and the researchers are part of a collaboration supported by the National Science Foundation working on applying the knowledge of key brain areas.

"Beyond just detecting the state of consciousness, these ideas could improve therapeutic outcomes from people with consciousness disorders," Saalmann says. "We could use what we've learned to optimize electrical patterns through precise brain stimulation and help people who are, say, in a coma maintain a continuous level of consciousness."

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This research was supported by grants from the National Institutes of Health (R01MH110311 and P51OD011106), the Binational Science Foundation, and the Wisconsin National Primate Research Center.

Feeding cows a few ounces of seaweed daily could sharply reduce their contribution to climate change

Ermias Kebreab, Associate Dean and Professor of Animal Science. Director, World Food Center, University of California, Davis and Breanna Roque, Ph.D. Student in Animal Biology, University of California, Davis

Wed, March 17, 2021


A little seaweed with that? Cowirrie/Flickr, CC BY-SA

Methane is a short-lived but powerful greenhouse gas and the second-largest contributor to climate change after carbon dioxide. And the majority of human-induced methane emissions comes from livestock.

About 70% of agricultural methane comes from enteric fermentation – chemical reactions in the stomachs of cows and other grazing animals as they break down plants. The animals burp out most of this methane and pass the rest as flatulence.

There are roughly 1 billion cattle around the world, so reducing enteric methane is an effective way to reduce overall methane emissions. But most options for doing so, such as changing cows’ diets to more digestible feed or adding more fat, are not cost-effective. A 2015 study suggested that using seaweed as an additive to cattle’s normal feed could reduce methane production, but this research was done in a laboratory, not in live animals.

We study sustainable agriculture, focusing on livestock. In a newly published study, we show that using red seaweed (Asparagopsis) as a feed supplement can reduce both methane emissions and feed costs without affecting meat quality. If these findings can be scaled up and commercialized, they could transform cattle production into a more economically and environmentally sustainable industry.

Plant-digesting machines

Ruminant animals, such as cows, sheep and goats, can digest plant material that is indigestible for humans and animals with simple stomachs, such as pigs and chickens. This unique ability stems from ruminants’ four-compartment stomachs – particularly the rumen compartment, which contains a host of different microbes that ferment feed and break it down into nutrients.

This process also generates byproducts that the cow’s body does not take up, such as carbon dioxide and hydrogen. Methane-producing microbes, called methanogens, use these compounds to form methane, which the cow’s body expels.

We first analyzed this problem in a 2019 study, the first such research that was conducted in cattle rather than in a laboratory. In that work, we showed that supplementing dairy cows’ feed with about 10 ounces of seaweed a day reduced methane emissions by up to 67%. However, the cattle that ate this relatively large quantity of seaweed consumed less feed. This reduced their milk production – a clear drawback for dairy farmers.

Our new study sought to answer several questions that would be important to farmers considering whether to use seaweed supplements in their cattle. We wanted to know whether the seaweed was stable when stored for up to three years; whether microbes that produce methane in cows’ stomachs could adapt to the seaweed, making it ineffective; and whether the type of diet that the cows ate changed the seaweed’s effectiveness in reducing methane emissions. And we used less seaweed than in our 2019 study.

Better growth with less feed

For the study, we added 1.5 to 3 ounces of seaweed per animal daily to 21 beef cows’ food for 21 weeks. As with most new ingredients in cattle diets, it took some time for the animals to get used to the taste of seaweed, but they became accustomed to it within a few weeks.

Steer in barn, University of California, Davis.

As we expected, the steers released a lot more hydrogen – up to 750% more, mostly from their mouths – as their systems produced less methane. Hydrogen has minimal impact on the environment. Seaweed supplements did not affect the animals’ carbon dioxide emissions.

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We also found that seaweed that had been stored in a freezer for three years maintained its effectiveness, and that microbes in the cows’ digestive systems did not adapt to the seaweed in ways that neutralized its effects.

We fed each of the animals three different diets during the experiment. These rations contained varying amounts of dried grasses, such as alfalfa and wheat hay, which are referred to as forage. Cattle may also consume fresh grass, grains, molasses and byproducts such as almond hull and cotton seed.

Methane production in the rumen increases with rising levels of forage in cows’ diet, so we wanted to see whether forage levels also affected how well seaweed reduced overall methane formation. Methane emissions from cattle on high-forage diets decreased by 33% to 52%, depending on how much seaweed they consumed. Emissions from cattle fed low-forage diets fell by 70% to 80%. This difference may reflect lower levels of an enzyme that is involved in producing methane in the guts of cattle-fed low-fiber diets.

One important finding was that the steers in our study converted feed to body weight up to 20% more efficiently than cattle on a conventional diet. This benefit could reduce production costs for farmers, since they would need to buy less feed. For example, we calculate that a producer finishing 1,000 head of beef cattle – that is, feeding them a high-energy diet to grow and add muscle – could reduce feed costs by US$40,320 to $87,320 depending on how much seaweed the cattle consumed.

Map of methane sources by continent.

We don’t know for certain why feeding cattle seaweed supplements helped them convert more of their diet to weight gain. However, previous research has suggested that some rumen microorganisms can use hydrogen that is no longer going into methane production to generate energy-dense nutrients that the cow can then use for added growth.

When a panel of consumers sampled meat from cattle raised in our study, they did not detect any difference in tenderness, juiciness or flavor between meat from cattle that consumed seaweed and others that did not.

Commercializing seaweed as a cattle feed additive would involve many steps. First, scientists would need to develop aquaculture techniques for producing seaweed on a large scale, either in the ocean or in tanks on land. And the U.S. Food and Drug Administration would have to approve using seaweed as a feed supplement for commercial cattle.

Farmers and ranchers could also earn money for reducing their cattle’s emissions. Climate scientists would have to provide guidance on quantifying, monitoring and verifying methane emission reductions from cattle. Such rules could allow cattle farmers to earn credits from carbon offset programs around the world.

This article is republished from The Conversation, a nonprofit news site dedicated to sharing ideas from academic experts. It was written by: Ermias Kebreab, University of California, Davis and Breanna Roque, University of California, Davis.

Read more:

Heat is a serious threat to dairy cows – we’re finding innovative ways to keep them cool


Young California ranchers are finding new ways to raise livestock and improve the land

Ermias Kebreab receives funding from the Foundation for Agricultural Research, Elm Innovations, the David and Lucile Packard Foundation and the Grantham Foundation. He advises feed additive companies such as Blue Ocean Barns and Mootral.

Breanna Roque does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.

The mysterious interstellar object 'Oumuamua was a chunk of planet from another solar system, a new study says


Aylin Woodward
Tue, March 16, 2021, 5:37 PM·5 min read


An artist's impression shows interstellar object `Oumuamua as it passed through the solar system in October 2017. M. Kornmesser/European Southern Obervatory via Reuters

A gigantic interstellar object called 'Oumuamua flew through our solar system in 2017.

The object baffled scientists: Some think it's a comet, others have suggested an alien spaceship.

New research says 'Oumuamua is a piece of a Pluto-like planet from another solar system.

The origin and identity of a massive space object that careened past Earth in 2017 have remained a mystery ever since.

The object, called 'Oumuamua - a Hawaiian name meaning "scout" or "messenger" - traveled on a trajectory that strongly suggested it came from another star system. That made it the first interstellar object ever detected.

But what was it? A few researchers, including Harvard University astronomer Avi Loeb, posited the object was an alien spacecraft. Others suggested it was an asteroid, or perhaps an interstellar comet.

Now, a pair of papers published in an American Geophysical Union journal offers another theory: that 'Oumuamua was shrapnel from a tiny planet in a different solar system.

"We've probably resolved the mystery of what 'Oumuamua is, and we can reasonably identify it as a chunk of an 'exo-Pluto,' a Pluto-like planet in another solar system," Steven Desch, an astrophysicist at Arizona State University and a co-author of the new study, said in a press release.
A planetary fragment made of frozen nitrogen

Desch and his coauthors think that half a billion years ago, a space object struck 'Oumuamua's parent planet. That sent 'Oumuamua careening towards our solar system.

Once it neared the sun, their thinking goes, 'Oumuamua sped up as sunlight vaporized its icy body. Comets follow a similar movement pattern, known as the "rocket effect."

Because 'Oumuamua's makeup is unknown, the researchers calculated what kinds of ice would sublimate (change from solid to gas) at a rate that could account for 'Oumuamua's rocket effect. They concluded that the object is likely made of nitrogen ice, like the surface of Pluto and Neptune's moon Triton.

An enhanced-color view of Pluto, taken by NASA's New Horizons spacecraft. NASA/JHUAPL/SwRI

As it got approached our solar system - and therefore the sun - 'Oumuamua started sloughing off frozen nitrogen layers. The object entered our solar system in 1995, though we didn't realize it at the time, then subsequently lost 95% of its mass and melted away to a sliver, according to the study authors.
It's a comet. It's an asteroid. Nope, it's neither.

An illustration of the space object 'Oumuamua flying through the solar system in late 2017. NASA/ESA/STScI

By the time astronomers became aware of 'Oumuamua's existence in 2017, it was already zipping away from Earth at 196,000 mph. So they had only a few weeks to study the strange, skyscraper-sized object. Several telescopes on the ground and one in space took limited observations as the object flew away, but astronomers were unable to examine it in full. 'Oumuamua is now too far away and too dim to observe further with existing technologies.

The limited nature of the information gathered left room for scientists to offer guesses about what the object might be and where it came from. 'Oumuamua was initially classified as a comet, but it didn't appear to be made of ice, and it didn't emit gases as a comet would.

'Oumuamua's spin, speed, and trajectory couldn't be explained by gravity alone, which suggested it was not an asteroid either. And the object's shape and profile - it's about one-quarter of a mile long but only 114 feet wide - doesn't match that of any comet or asteroid observed before.

According to the authors of the new study, however, 'Oumuamua's frozen-nitrogen composition could explain that shape.

"As the outer layers of nitrogen ice evaporated, the shape of the body would have become progressively more flattened, just like a bar of soap does as the outer layers get rubbed off through use," Alan Jackson, another study co-author, said in the release.
Some astronomers still think it was an alien ship

Unlike most space rocks, 'Oumuamua seemed to be accelerating, rather than slowing down, in telescope observations.

That is in part why Loeb thinks 'Oumuamua was an alien spacecraft. In a book he published in January, titled "Extraterrestrial: The First Sign of Intelligent Life Beyond Earth," Loeb describes 'Oumuamua as a defunct piece of alien technology.

"The object has anomalies that merit some attention - things that do not line up in the ways we expected," he told Insider in December. "Other people say, 'Lets shove those anomalies under the rug of conservatism.' I have a problem with that because when something doesn't line up, you should say it."

An artist's depiction of 'Oumuamua. ESA/Hubble; NASA; ESO; M. Kornmesser

Still, a 2019 study from an international group of astronomers analyzed all the 'Oumuamua data available and concluded that Loeb's theory was unlikely.

"We find no compelling evidence to favor an alien explanation for 'Oumuamua," the astronomers wrote.

Matthew Knight, a University of Maryland astronomer who co-wrote the study, put it this way: "This thing is weird and admittedly hard to explain, but that doesn't exclude other natural phenomena that could explain it."

THIRD WORLD USA

Patient safety at risk, pharmacists say, as they are being pushed to breaking point

Adiel Kaplan and Vicky Nguyen and Mary Godie
Tue, March 16, 2021

From the moment Marilyn Jerominski walks into her pharmacy every morning, her time is in demand. As pharmacy manager of a busy 24-hour Walgreens in Palm Desert, California, she is responsible for the safety and accuracy of the thousands of prescriptions the store dispenses every week.

"There's so much stress," Jerominski said. "You're not only running to the drive-thru but to the front, to the vaccination station to give a vaccination, then to the phone. ... It's almost impossible for any human to keep that momentum day in and out."

It wasn't always that way. When she began working as a pharmacist 13 years ago, it was a very different environment, Jerominski said. There were more staff members and more time to counsel patients about their medications. These days, she is exhausted and often overwhelmed, worried about making a mistake when someone's health is on the line. She is far from alone.

Jerominski is one of an estimated 155,000 pharmacists working at chain drugstores who, over the past decade, have found themselves pushed to do more with less. They're working faster, filling more orders and juggling a wider range of tasks with fewer staff members at a pace that many say is unsustainable and jeopardizes patient safety. Now Covid-19 vaccinations are raising new concerns about what will happen if they aren't given enough additional support for yet another responsibility.

NBC News spoke to 31 retail pharmacists and pharmacy technicians in 15 states. From 12-hour shifts so busy they don't have time to go to the bathroom or eat to crying in their cars every day after work or lying awake at night worrying about mistakes they might have made while rushing, they described an industry of health care professionals at the breaking point.

Image: Shane and Marilyn Jerominski at their home in Indio, 

Calif., on Feb. 19, 2021. (Jenna Schoenefeld / NBC News)

"The expectations they're having and the resources they're giving us just aren't matching up," said a CVS pharmacy technician in New York state. "We're going to have a fatal error somewhere because we're doing too many things at once."

Most pharmacists spoke anonymously out of fear of losing their jobs. Declining profit margins for pharmacies, corporate consolidation and an influx of new pharmacy school graduates in the past decade have led to stagnant or falling wages and fewer employment options, according to pharmacists, experts and recent studies.

The pressure and understaffing issues aren't new, as The New York Times reported last year. But they've worsened during the pandemic, pharmacists said, with new duties like Covid-19 testing, deep cleaning and now vaccinations stretching them even further.

"Pharmacists are being asked to do additional tasks and aren't necessarily receiving the assistance that they need from their employer," said Al Carter, executive director of the National Association of Boards of Pharmacy, a nonprofit that represents state pharmacy regulators. "That's a huge concern for pharmacists' well-being but also, more importantly, for patient safety."

The more overworked they are, the more likely they are to make errors, he said. Pharmacy errors can range from smaller mistakes, like miscounting the number of pills in a bottle, to potentially deadly ones, like missing a dangerous drug interaction. Working conditions and workplace pressures have led to "growing concerns from many state boards of pharmacy" about prescription errors, Carter said.

Walgreens and CVS, the country's largest pharmacy chains, were early government partners in the vaccine rollout. In statements to NBC News, they said that they are grateful for the work their pharmacy staffs have done during the pandemic and that they are hiring thousands of additional staff members to ensure that pharmacies have the support and resources to administer Covid-19 vaccine shots and provide the best care for patients. They and the trade group representing all chain drugstores also said technology improvements have freed pharmacists from many routine tasks in recent years, allowing them to focus on the safety and health of patients — their top priority.

CVS said the majority of stores giving Covid-19 vaccinations will do so through a dedicated team of pharmacists working only on vaccinations. In stores that don't, the company will provide additional staff support and limit the numbers of appointments.

Pharmacies have already begun to vaccinate around the country, but many pharmacists said they're worried about how much additional staffing they'll get to give vaccinations.

Image: Marilyn and Shane Jerominski with their children, from left, Shaela, 7, Shia, 3, Shiloh, 5, and Shalyn, 9, at their home in Indio, Calif., on Feb. 19, 2021. (Jenna Schoenefeld / NBC News)

Jerominski's pharmacy began vaccinating last month. The vaccinations are going well, she said, but other work has been piling up as she struggles to find time to do it all.

"Right now, it's just so crazy," she said during a shift break on her third day vaccinating. "Like, it's 1 o'clock, and I've done 14 Covid vaccines this morning, in between filling prescriptions. ... It's wonderful that we're doing this, and this is our duty. This is what we're supposed to be doing. But we need more help."
'Timed to the minute'

A pharmacist's job is far more than putting pills in bottles. Experts in drugs and medication management, they work everywhere from hospitals to cancer treatment centers and drugstores. They are among the best-educated health care professionals — they earn four-year clinical doctorates, which include rotations and often postgraduate residencies — and make median salaries of $128,000 a year. They are also some of the most trusted and accessible health care professionals in the country, according to the National Association of Chain Drug Stores.

The person who actually hands you your filled prescription at the counter may be a technician, not a pharmacist. Technicians are support staffers who run the cash register; fill, count and bag prescriptions; and unload inventory. They're entry-level employees who typically get on-the-job training or attend certificate programs and are paid a median $16 an hour.

Medication management services for customers can save billions in annual health care expenses, pharmacy groups estimate. Pharmacists said providing that advice is why many got into the business, yet they now have less opportunity to use those skills.

IMAGE: Marilyn Jerominski (Courtesy Marilyn Jerominski)

"I love being a pharmacist. I love being there for my patients," Jerominski said. "We used to be able to have time to actually have in-depth conversations about how the patient is doing."

But what might have once been five- to 10-minute patient consultations now typically happen in under a minute, she said. "It's not 'let us care for the patient.' It's 'how fast can we get the people in and out?'"

Walgreens, like many large pharmacy chains, gives pharmacists a range of metrics to meet and monitors the time they spend on various tasks, from calls to patients to prescriptions filled and vaccinations given per week. The chains, pharmacists said, began to push them more when profit margins started shrinking a little over a decade ago.

"Basically, your day is timed out by the minute — it's like the worst case of micromanaging you can imagine," said an Alabama pharmacist who has worked at Walgreens, CVS and Rite Aid in the past decade.

Walgreens didn't directly respond to questions about quotas and other metrics pharmacists must meet. In a statement, CVS said the metrics it uses to evaluate quality of service aren't unique, saying, "Over the past two years we've actually reduced those metrics by half, providing us with a clearer picture of what's working and where improvements may be needed."

In a statement, a spokesperson for Rite Aid said that the company believes the focus for pharmacists "should be on counseling customers for positive health outcomes" and that it has "created efficiencies and tools to open up pharmacists' time to consult and care for customers."

'The picture was grim'

While margins have tightened everywhere, pharmacists say the working conditions at some of the country's largest chain pharmacies are different from those at many independently owned pharmacies. Jerominski's husband, Shane, whom she met in pharmacy school, spent 10 years working at chain pharmacies and now manages an independent pharmacy. He was part of a class action lawsuit against one past employer, Walgreens, over wages and other issues. The suit was settled in 2014. He said his stress dropped markedly when he switched to working at an independent pharmacy.

"I see the difference. My level of autonomy is vastly different than Marilyn's, and the amount of help that I get is different than Marilyn," Shane said. There's still plenty of stress at his busy pharmacy, he said, but staffing is far better, and he isn't judged on the flurry of metrics he used to be beholden to. "I would never go back, honestly."

Recent surveys have borne out what pharmacists said has happened in their industry. In the 2019 National Pharmacist Workforce Study, which surveys thousands of pharmacists every five years, more than two-thirds of pharmacists said their workloads had risen in the past year. At retail chain pharmacies, 91 percent of pharmacists rated their workloads as "high" or "excessively high," the highest of any pharmacy type.

IMAGE: Shane Jerominski at work in his pharmacy. (NBC News)

Wages for a much greater proportion of pharmacists remained stagnant or fell compared to five years earlier, and the majority of pharmacists felt their job security and ability to find new work had decreased in the previous year. Many pharmacists told NBC News that they worry that leaving current jobs would mean taking pay cuts, if they could find jobs at all.

The job market isn't in pharmacists' favor. There are twice as many pharmacy school graduates a year as there were 18 years ago, according to the American Association of Colleges of Pharmacy, yet the number of pharmacists jobs hasn't grown at the same pace. The Bureau of Labor Statistics predicts that the industry will shrink by 3 percent in the next decade.

A survey of pharmacists by the Vermont Pharmacy Board last fall, months into the pandemic, gave further insight into how working conditions at chain pharmacies compare to those at other pharmacies. Nearly 250 pharmacists from chain, independent and hospital pharmacies responded to the survey (and responded at rates roughly reflecting each category's share of Vermont pharmacists). They gave only retail chain pharmacies an "unfavorable rating" in any of the nine categories the survey examined. In fact, they gave the chains an "unfavorable rating" in every category, from patient safety to shift lengths and staffing.

Four in 5 retail chain pharmacists who responded to the Vermont survey said they worked more than 10 hours each shift; many reported that they arrived early or stayed late or never took meal breaks. Only 1 in 5 of the chain pharmacists said the number of pharmacists on duty was consistently adequate to provide safe patient care, and more than half said they had thought about leaving their jobs because of safety concerns.

Some of the conditions the board heard about "would be found unacceptable in a factory," such as pharmacists' developing kidney problems from skipping restroom breaks, said Gabriel Gilman, general counsel for the Vermont Office of Professional Regulation, which houses the state Pharmacy Board.

"The picture was grim," Gilman said. "We went into it expecting to find things that alarmed us. And we were alarmed at what we found even so."

'More like a fast food industry'

The industry is feeling the squeeze because of systemic financial factors, experts said. Steady profits are far less certain than they once were as pharmacies contend with declining profits for filled prescriptions and higher fees from middlemen who set drug prices nationally. And unlike most health care providers, pharmacists generally don't bill for their services. Instead, pharmacies make the vast majority of their income from dispensing prescriptions. The more prescriptions they dispense, the more money they make.

"Twenty years ago, you could make a decent living off the reimbursement of the drug and you had time to spend with patients," said Scott Knoer, CEO of the American Pharmacists Association. Knoer said that's no longer true and that all retail pharmacies have been struggling.

National chains have bought out regional ones, and independent pharmacies, which are about a third of retail pharmacies, are no longer as profitable as they once were. Independent pharmacy owners' average income fell by nearly half from 2013 to 2019, according to industry analyst Drug Channels Institute.

"The incentive design of pharmacy is: 'We pay you to fill prescriptions. We don't necessarily pay you to make people better,'" said Antonio Ciaccia, a consultant who has worked with the state of Ohio and the American Pharmacists Association on prescription drug pricing transparency and pharmacy payment reform. He said that's a bad model, especially combined with dwindling prescription profits.

"What you have is a race to the bottom, and at the bottom is an underresourced, heavily consolidated pharmacy marketplace that looks more like a fast food industry than a health care industry," he said.

There's no quick, easy fix. In Ohio, the state Medicaid program is trying a new payment model, which Ciaccia worked on, to allow pharmacists to bill insurers for clinical services.

Pharmacy trade groups and others are pushing for a national version of that model, giving pharmacists what's known as "provider status." A bipartisan federal bill to grant pharmacists the status was proposed repeatedly in the past decade, but it has yet to get a hearing.

While financial overhaul of the industry may be the ultimate goal for pharmacist groups, in the meantime, some states are also pushing to improve labor standards.

Image: Marilyn Jerominski holds Shia, 3, at their home in Indio,

 Calif., on Feb. 19, 2021. (Jenna Schoenefeld / NBC News)

In recent years, states like California, Illinois and Virginia have created new rules, from capping shift lengths to mandating safe staffing levels and prohibiting excessive metrics. Vermont is working on new workplace condition rules based on its recent survey results.

About a third of all states now have regulations addressing pharmacy working conditions, according to the National Association of Boards of Pharmacy.

"There are challenges that are still huge concerns for boards of pharmacy ... and I don't see them going away any time soon," said Carter, the head of the association. "Especially with the pandemic, I see them getting worse."

For Marilyn Jerominski, it feels like the industry still has a long way to go. She knew she wanted to be a pharmacist when she was a sophomore in high school, but she said she never dreamed her job would look like it does today.

"You shouldn't wake up every day and feel disappointed in a profession where you go to school for seven-plus years," she said. "But how much more can you do? How much more can you do with less help? How much more can you do without making a mistake?"

Four indices that show how vulnerable India’s democracy is today

REUTERS/ADNAN ABID I Living in a democracy?


By Manavi Kapur

Culture and lifestyle reporter
March 17, 2021

India’s ranking on several global democracy indices has been slipping. But the Indian government is not having it.

Just this month, the country’s status as a democracy has been called into question by two advocacy organisations.

First, Freedom House, an American non-profit advocacy for democratic rights, changed India’s status from “free” to “partially free” on March 3. This status change, according to the report, came “due to a multiyear pattern in which the Hindu nationalist government and its allies have presided over rising violence and discriminatory policies affecting the Muslim population and pursued a crackdown on expressions of dissent by the media, academics, civil society groups, and protesters.”

A week later on March 11, V-Dem, a Swedish rights organisation, demoted India from being a democracy to an “electoral autocracy” in its report titled “Autocratization Turns Viral.”

Indian foreign minister S Jaishankar dismissed these data as nothing but the developed world’s “hypocrisy” while speaking at the India Today Conclave on March 15. Jaishankar may have called these reports “homilies,” but they point to a worrying trend of India’s declining status across key indices.
No freedom, no happiness

This decline has been gradual yet consistent over the past few years. And, given the various civil rights activists who have been arrested over the past two years, India’s rankings are likely going to worsen.

For instance, India has been notoriously worsening on the global press freedom index that is brought out by international non-profit Reporters Without Borders. “Ever since the general elections in the spring of 2019, won overwhelmingly by prime minister Narendra Modi’s Bharatiya Janata Party, pressure on the media to toe the Hindu nationalist government’s line has increased,” the 2020 report noted.



On the comprehensive indices in the World Happiness Report 2020, India slid many points between 2008-12 and 2017-19, an entered the bottom 10 in the list of 149 countries for the first time. “The 10 countries with the largest declines in average life evaluations typically suffered some combination of economic, political, and social stresses,” the 2020 report said.


A function of that happiness is access to food, and according to the Global Hunger Index, an annual peer-reviewed report, India continues to be among the worst in the world. It has, though, been improving its total score on the index since 2000.

On its part, though, the Indian government is now considering setting up with local think tanks to bring out its own freedom indices as a counter to damaging western perspectives. “We may encourage one of the Indian independent think tanks to bring out its own annual world democracy report based on comprehensive parameters as well as an annual global freedom of press index,” said an internal note prepared by India’s foreign ministry and reviewed by Hindustan Times newspaper.

The US wood shortage can be traced to a decades-old beetle infestation in Canada

ANDY CLARK / REUTERSFire-clearance of mountain beetles in British Columbian pine forests

FROM OUR OBSESSION
The climate economy
Every industry can be part of the solution — or part of the ongoing problem.

By Samanth Subramanian

Looking into the Future of Capitalism
March 18, 2021

Lumber is in such short supply in the US that its prices have skyrocketed to an all-time high—so much so that the expense of building the average single-family home has risen by $24,000 since last April to reflect the cost of wood.

The reason, in significant part, is the changing climate—and how it enabled a beetle species to infest forests in the Canadian province of British Columbia years ago.

The steep rise in lumber prices illustrates the uncommon nature of the pandemic economy: a seizing-up of supply, but a constant simmer of demand that is now exploding as countries re-open. In the US, since the spring of 2020, the price of lumber has risen by more than 180%, according to the National Association of Home Builders (NAHB). Futures contracts in lumber now hover around $1,000 per thousand feet of board, nearly four times their April 2020 prices.

On Twitter, Robert Dietz, the chief economist of the NAHB, noted that around 81,000 new homes across the US are awaiting construction in part because of the rising cost of materials like lumber. The NAHB and other housing industry associations have written to the US government, seeking “immediate remedies.”

“I was alive for the last boom like this, but just barely,” says Paul Jannke, a principal at Forest Economic Advisors. “Adjusted for inflation, the last time we saw something like this was in the early 1970s. Since then, in the lifetime of pretty much anyone working in the industry, this hasn’t happened.”
Why there’s a shortage of wood

Lumber has one aspect of its story in common with other sectors of the pandemic economy, particularly manufacturing. Early in 2020, sawmills first ground to a halt, anticipating a crash in demand. Then it turned out that people still wanted wood—to repair or renovate their homes during lockdown, or to build new homes outside cities. Interest rates were, and continue to be, low; it was a good time to finance and construct new houses.

So the sawmills started up again around July. “But it was difficult to ramp up,” Jannke says. “You’re running your mill, someone tests positive, you have to shut down and test and so on. Maybe people have to quarantine, and you lose a portion of your workforce.”

But the shortfall in supply is also part of an older saga, involving Dendroctonus ponderosae: the mountain pine beetle, a quarter-inch insect with a shiny black exoskeleton. The beetle has been in Canadian forests for decades, but they’re usually kept in check by cold winters, said Kevin Mason, managing director of ERA Forest Products Research, a Montreal-based research company.

But in the late 1990s, the beetles started to live longer and reproduce quicker—an outcome, scientists believe, of a warming climate. They swarmed through the pines of British Columbia, attacking more than 44 million acres of forest, an area four times the size of Switzerland. “You could go up in an airplane above British Columbia and see the damage,” Mason said. “I’m a little color-blind, but others could see it better than me. The dead pines had a red tinge to them, so you could fly an hour and just see this red kill.”

Before the infestation, British Columbia used to provide 15-17% of the lumber going into US markets, making up half of Canada’s lumber exports across the border. After the infestation, those numbers dropped, Mason said: “There were points where, for British Columbia, the figure was below 10%, and Canada now is at around 25%.“

The after-effects of the infestation

Many pines killed by the beetle could still be harvested for a period of 5-10 years, and the government of British Columbia offered incentives to the industry to process these dead trees. Mason thinks roughly 800 million cubic meters of dead pine was harvested over a period of 15-odd years, until 2015 or thereabouts. But once that was done, forests had to regrow.”We’re talking about a diminished harvest in British Columbia for decades,” Mason says.

The supply of “fibre”—the lumber industry ‘s term for harvested wood—slowed so much that many sawmills shut down. In fact, Mason thinks that, for a normal year, there are still too many sawmills operating relative to demand. “There’s still another billion board feet of capacity that needs to come out of British Columbia.”

Through most of the last decade, the slowed supply of lumber from British Columbia matched a lethargy in demand in the US. In 2005, the US consumed nearly 65 billion board feet of wood, but after the recession hit, demand hit a trough in 2009: 33 billion board feet. Things recovered very slowly, Jannke said. “In 2019, it was barely back to 50 billion.”

Jannke suspects that, last year, demand for lumber in the US was between 52 and 55 billion board feet, still far below the peak of 2005. In an ordinary year, those needs would have been easily met. But the combination of the pandemic and the shrunken capacity of British Columbian production have muffled supply.

“I think prices will be volatile, but they’ll continue to be high for the next three or four or five years,” Mason says. “You can’t start up new sawmills overnight. And if you go to the equipment makers, there’s a waiting list for some pieces of equipment of two or three years.”

One of the US’s options is to import more lumber, particularly from Europe, which has stock in surplus. Over the past five years, Austria, Germany and the Czech Republic have had to harvest nearly 250 million cubic metres of spruce damaged by another bark beetle infestation, this too brought on by the warming climate. Ironically, if one beetle has depressed wood supplies to the US, another may yet elevate it.

DENIER IN CHIEF

Clerical Sex Abuse in Germany Spiked

Under German Pope Benedict XVI


Barbie Latza Nadeau
Thu, March 18, 2021

Tony Gentile via Reuters

A highly anticipated report on clerical sex abuse and coverups in Germany’s powerful diocese of Cologne released Thursday identifies 202 perpetrators against 314 victims—55 percent of whom were under the age of 14. The report blames “years of chaos, subjectively perceived lack of competence, and misunderstandings” for the rampant abuse.

The 800-page report also points to a sharp rise in abuse between 2004 and 2018, said Björn Gercke, the lawyer who presented the report on Thursday. German Joseph Ratzinger was elected as Pope Benedict XVI in 2005 and resigned in 2013.

Vatican’s Response to 1,000 Children Abused by Priests? ‘No Comment.’


Before that, Ratzinger headed the Congregation for the Doctrine of Faith, which deals firsthand with abuse reports from outlying dioceses. There, he was criticized for downplaying the 2002 Boston Church scandal that led to the Boston Globe investigations central to the film Spotlight. Prior to that, he was the archbishop of Munich, where he signed off on therapy rather than punishment for a proven predatory priest. As pope, he took a harder line, defrocking scores of priests who had been proven abusers, but he remained silent when the choir directed by his brother, who is also a priest, turned out to be a sadistic sex camp for kids.

In 2019, six years after he retired, Ratzinger penned an editorial in which he blamed sexual freedom and the collapse of moral standards—not a church that did not properly protect children—for the problem, writing “in the 20 years from 1960 to 1980, the previously normative standards regarding sexuality collapsed entirely.”

The Cologne report parses the results of a 2018 study by the German Bishops Conference that identified 1,670 clergymen committing sexual violence against 3,677 minors, of whom most were young boys between the years 1946 and 2014, according to German state media Deutsche Welle.

The report accused a number of top church officials, including the Archbishop of Hamburg Stefan Hesse and the late Archbishop of Cologne Joachim Meisner, of breach of duty, but gives a pass to the current archbishop of Cologne, Rainer Maria Woelki, who commissioned the report but who was widely criticized for censoring the release of a preliminary report last year. Speaking ahead of the report release, Georg Baetzing, the president of Germany’s Bishops Conference, called Woelki’s suppression of the first report a “disaster” and said Woelki had “completely failed as a moral authority.” The investigation however did not find he breached his duties.

The German church currently pays victims of clerical sex abuse around €5,000 “in recognition of their suffering” as well as therapy bills.

The report released Thursday is a second report and was published by an independent law firm against Woelki’s recommendation. Following the report, Woelki said the clergy named in the report would be dismissed. “What we have seen shows clearly there was a coverup,” he said. “I am ashamed.”