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Tuition-Free Med School Touches Off Multimillion-Dollar Debate

New York University’s School of Medicine is learning that no good deed goes unpunished.

The highly ranked medical school announced with much fanfare Aug. 16 that it is raising $600 million from private donors to eliminate tuition for all its students — even providing refunds to those currently enrolled. Before the announcement, annual tuition was $55,018.

NYU leaders said the move will help address the increasing problem of student debt among young doctors, which many educators argue pushes students to enter higher-paying specialties instead of primary care, or deters them from becoming doctors in the first place.

“A population as diverse as ours is best served by doctors from all walks of life, we believe, and aspiring physicians and surgeons should not be prevented from pursuing a career in medicine because of the prospect of overwhelming financial debt,” Dr. Robert Grossman, the dean of the medical school and CEO of NYU Langone Health, said in a statement. NYU declined a request to elaborate further on its plans.

The announcement generated headlines and cheers from students. But not everyone thinks that making medical school tuition-free for all students, including those who can afford it, is the best way to approach the complicated issue of student debt.

“As I start rank ordering the various charities I want to give to, the people who can pay for medical school in cash aren’t at the top of my list,” said Craig Garthwaite, a health economist at Northwestern University’s Kellogg School of Management.

“If you had to find some cause to put tons of money behind, this strikes me as an odd one,” said Dr. Aaron Carroll, a pediatrician and researcher at Indiana University.

Still, medical education debt is a big issue in health care. According to the Association of American Medical Colleges, which represents U.S. medical schools and academic health centers, 75 percent of graduating physicians had student loan debt as they launched their careers, with a median tally of $192,000 in 2017. Nearly half owed more than $200,000.

But it is less clear how much of an impact that debt has on students’ choice of medical specialty. The AAMC’s data suggests debt does not play as big a role in specialty selection as some analysts claim.

If debt were a huge factor, one would expect that doctors who owed the most would choose the highest-paying specialties. But that’s not the case.

“Debt doesn’t vary much across the specialties,” said Julie Fresne, AAMC’s director of student financial services and debt management.

Garthwaite agrees. He said surveys in which young doctors claim debt as a reason for choosing a more lucrative specialty should be viewed with suspicion. “No one [who chooses a higher-paying job] says they did it because they want two Teslas,” he said. “They say they have all this debt.”

Carroll questioned how much difference even $200,000 in student debt makes to people who, at the lowest end of the medical spectrum, still stand to make six figures a year. “Doctors in general do just fine,” he said. “The idea we should pity physicians or worry about them strikes me as odd.”

Choice of specialty is also influenced by more than money. Some specialties may bring less demanding lifestyles than primary care or more prestige. Carroll said his surgeon father was not impressed when he opted for pediatrics, calling it a “garbageman” specialty.

There is also an array of government programs that help students afford medical school or forgive their loans, although usually in exchange for agreeing to serve for several years either in the military or in a medically underserved location. The federal National Health Service Corps, for example, provides scholarships and loan repayments to medical professionals who agree to work in mostly rural or inner-city areas with a shortage of medical professionals. And the Department of Education oversees the Public Service Loan Forgiveness program, which cancels outstanding loan balances after 10 years for those who work for nonprofit employers.

Medical schools themselves are addressing the student debt problem. Many — including NYU — have created programs that let students finish medical school in three years rather than four, which reduces the cost by 25 percent. And the Cleveland Clinic, together with Case Western Reserve University, has a tuition-free medical school aimed at training future medical researchers that takes five years but grants graduates who hold both a doctor of medicine title and a special research credential or master’s degree.

This latest move by NYU, however, is part of a continuing race among top-tier medical schools to attract the best students — and possibly improve their national rankings.

In 2014, UCLA announced it would provide merit-based scholarships covering the entire cost of medical education (including not just tuition, like NYU, but also living expenses) to 20 percent of its students. Columbia University announced a similar plan earlier this year, although unlike NYU and UCLA, Columbia’s program is based on students’ financial need.

The programs are funded, in whole or in part, by large donors whose names brand each medical school — entertainment mogul David Geffen at UCLA, former Merck CEO P. Roy Vagelos at Columbia, and Home Depot co-founder Kenneth Langone at NYU.

Economist Garthwaite said it is all well and good if top medical schools want to compete for top students by offering discounts. But if their goal is to encourage more students to enter primary care or to steer more people from lower-income families into medicine, giving free tuition to all “is not the most target-efficient way to reach that goal.”

Kaiser Health News is a nonprofit news service covering health issues. It is an editorially independent program of the Kaiser Family Foundation, which is not affiliated with Kaiser Permanente.

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Hydrogen – Coal of the future (#2)

Why is the idea of a hydrogen economy so popular? What are the steps to getting there?

One of the main motivations is that scientists, engineers, and politicians see the great promise of hydrogen as a clean fuel, no pollution. That’s the nirvana that everyone’s looking for. Politically, it’s very attractive. A lot of areas in the country have real air quality problems. Something has to be done. Hydrogen may be a solution. It’s just going to take a while. There’s a legitimate case for research and development. There could be a dramatic breakthrough in fuel cell operation. There have already been significant reductions in the fuel cell operating costs because material scientists have been able to reduce the amount of platinum used in fuel cell catalysts.

Hydrogen – Coal of The Future (#2)
– Rajneesh Wadhwa

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Hydrogen – Coal of The Future (#1)

If I were a science-fiction writer trying to dream up the perfect fuel, I could hardly do better than hydrogen. High in energy, it produces almost no pollution when burned. It’s also the simplest and most abundant of elements, making up 90 percent of all matter. It’s present in stars and living things, in fossil fuels and, most mesmerizingly of all, in water.

A transition to a hydrogen economy is, at best, decades away. We have a long way to go. Gas is cheap. How can hydrogen compete? If we believe that the corrective policy is to put a tax on gasoline, given the social cost of oil is $50 a barrel, say, you divide that by 42 gallons in a barrel, that’s more than a $1 tax per gallon of gasoline. Which politician would be willing to put a tax of a dollar on gasoline? So that’s the essence of the problem. We’re not paying the true cost of gasoline. The point is that hydrogen and alternative fuels have to compete in that type of market.

Hydrogen – Coal of The Future (#1)
– Rajneesh Wadhwa

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So Much Care It Hurts: Unneeded Scans, Therapy, Surgery Only Add To Patients’ Ills

When Annie Dennison was diagnosed with breast cancer last year, she readily followed advice from her medical team, agreeing to harsh treatments in the hope of curing her disease.

“You’re terrified out of your mind” after a diagnosis of cancer, said Dennison, 55, a retired psychologist from Orange County, Calif.

In addition to lumpectomy surgery, chemotherapy and other medications, Dennison underwent six weeks of daily radiation treatments. She agreed to the lengthy radiation regimen, she said, because she had no idea there was another option.

Medical research published in The New England Journal of Medicine in 2010 — six years before her diagnosis — showed that a condensed, three-week radiation course works just as well as the longer regimen. A year later, the American Society for Radiation Oncology, which writes medical guidelines, endorsed the shorter course.

In 2013, the society went further and specifically told doctors not to begin radiation on women like Dennison — who was over 50, with a small cancer that hadn’t spread — without considering the shorter therapy.

“It’s disturbing to think that I might have been overtreated,” Dennison said. “I would like to make sure that other women and men know this is an option.”

Dennison’s oncologist, Dr. David Khan of El Segundo, Calif., notes that there are good reasons to prescribe a longer course of radiation for some women.

Khan, an assistant clinical professor at UCLA, said he was worried that the shorter course of radiation would increase the risk of side effects, given that Dennison had undergone chemotherapy as part of her breast cancer treatment. The latest radiation guidelines, issued in 2011, don’t include patients who’ve had chemo.

Yet many patients still aren’t told about their choices.When Annie Dennison was diagnosed with breast cancer last year, she readily followed advice from her medical team, agreeing to harsh treatments in the hope of curing her disease.

“You’re terrified out of your mind” after a diagnosis of cancer, said Dennison, 55, a retired psychologist from Orange County, Calif.

In addition to lumpectomy surgery, chemotherapy and other medications, Dennison underwent six weeks of daily radiation treatments. She agreed to the lengthy radiation regimen, she said, because she had no idea there was another option.

Medical research published in The New England Journal of Medicine in 2010 — six years before her diagnosis — showed that a condensed, three-week radiation course works just as well as the longer regimen. A year later, the American Society for Radiation Oncology, which writes medical guidelines, endorsed the shorter course.

In 2013, the society went further and specifically told doctors not to begin radiation on women like Dennison — who was over 50, with a small cancer that hadn’t spread — without considering the shorter therapy.

“It’s disturbing to think that I might have been overtreated,” Dennison said. “I would like to make sure that other women and men know this is an option.”

Dennison’s oncologist, Dr. David Khan of El Segundo, Calif., notes that there are good reasons to prescribe a longer course of radiation for some women.

Khan, an assistant clinical professor at UCLA, said he was worried that the shorter course of radiation would increase the risk of side effects, given that Dennison had undergone chemotherapy as part of her breast cancer treatment. The latest radiation guidelines, issued in 2011, don’t include patients who’ve had chemo.

Yet many patients still aren’t told about their choices.

An exclusive analysis for Kaiser Health News found that only 48 percent of eligible breast cancer patients today get the shorter regimen, in spite of the additional costs and inconvenience of the longer type.

The analysis was completed by eviCore healthcare, a South Carolina-based medical benefit management company, which analyzed records of 4,225 breast cancer patients treated in the first half of 2017. The women were covered by several commercial insurers. All were over age 50 with early-stage disease.

The data “reflect how hard it is to change practice,” said Dr. Justin Bekelman, associate professor of radiation oncology at the University of Pennsylvania Perelman School of Medicine.

A growing number of patients and doctors are concerned about overtreatment, which is rampant across the health care system, argues Dr. Martin Makary, a professor of surgery and health policy at the Johns Hopkins University School of Medicine in Baltimore.

From duplicate blood tests to unnecessary knee replacements, millions of patients are being bombarded with screenings, scans and treatments that offer little or no benefit, Makary said. Doctors estimated that 21 percent of medical care is unnecessary, according to a survey Makary published in September in Plos One.

Unnecessary medical services cost the health care system at least $210 billion a year, according to a 2009 report by the National Academy of Medicine, a prestigious science advisory group.

Those procedures aren’t only expensive. Some clearly harm patients.

Overzealous screening for cancers of the thyroid, prostate, breast and skin, for example, leads many older people to undergo treatments unlikely to extend their lives, but which can cause needless pain and suffering, said Dr. Lisa Schwartz, a professor at the Dartmouth Institute for Health Policy and Clinical Practice.

“It’s just bad care,” said Dr. Rebecca Smith-Bindman, a professor at the University of California-San Francisco, whose research has highlighted the risk of radiation from unnecessary CT scans and other imaging.

Outdated Treatments

All eligible breast cancer patients should be offered a shorter course of radiation, said Dr. Benjamin Smith, an associate professor of radiation oncology at the University of Texas MD Anderson Cancer Center.

Studies show that side effects from the shorter regimen are the same or even milder than traditional therapy, Smith said.

“Any center that offers antiquated, longer courses of radiation can offer these shorter courses,” said Smith, lead author of the radiation oncology society’s 2011 guidelines.

Smith, who is currently updating the expert guidelines, said there’s no evidence that women who’ve had chemo have more side effects if they undergo the condensed radiation course.

“There is no evidence in the literature to suggest that patients who receive chemotherapy will have a better outcome if they receive six weeks of radiation,” Smith said.

Shorter courses save money, too. Bekelman’s 2014 study in JAMA, the journal of the American Medical Association, found that women given the longer regimen faced nearly $2,900 more in medical costs in the year after diagnosis.

The high rate of overtreatment in breast cancer is “shocking and appalling and unacceptable,” said Karuna Jaggar, executive director of Breast Cancer Action, a San Francisco-based advocacy group. “It’s an example of how our profit-driven health system puts financial interests above women’s health and well-being.”

Just getting to the hospital for treatment imposes a burden on many women, especially those in rural areas, Jaggar said. Rural breast cancer patients are more likely than urban women to choose a mastectomy, which removes the entire breast but typically doesn’t require follow-up radiation.

Too Many Tests

Meg Reeves, 60, believes much of her treatment for early breast cancer in 2009 was unnecessary. Looking back, she feels as if she was treated “with a sledgehammer.”

At the time, Reeves lived in a small town in Wisconsin and had to travel 30 miles each way for radiation therapy. After she completed her course of treatment, doctors monitored her for eight years with a battery of annual blood tests and MRIs. The blood tests include screenings for tumor markers, which aim to detect relapses before they cause symptoms.

Yet cancer specialists have repeatedly rejected these kinds of expensive blood tests and advanced imaging since 1997.

For survivors of early breast cancer like Reeves — who had no signs of symptoms of relapse — “these tests aren’t helpful and can be hurtful,” said Dr. Gary Lyman, a breast cancer oncologist and health economist at the Fred Hutchinson Cancer Research Center. Reeves’ primary doctor declined to comment.

In 2012, the American Society for Clinical Oncology, the leading medical group for cancer specialists, explicitly told doctors not to order the tumor marker tests and advanced imaging — such as CT, PET and bone scans — for survivors of early-stage breast cancer.

Yet these tests remain common.

Thirty-seven percent of breast cancer survivors underwent screening for tumor markers between 2007 and 2015, according to a study presented in June at the American Society of Clinical Oncology’s annual meeting and published in the society’s journal online.

Sixteen percent of these survivors underwent advanced imaging. None of these women had symptoms of a recurrence, such as a breast lump, Lyman said.

Beyond wasted time and worry for women, these scans also expose them to unnecessary radiation, a known carcinogen, Lyman said. A National Cancer Institute study estimated that 2 percent of all cancers in the United States could be caused by medical imaging.

Paying The Price

Health care costs per breast cancer patients monitored with advanced imaging averaged nearly $30,000 in the year after treatment ended. That was about $11,600 more than for women who didn’t get such follow-up tests, according to Lyman’s study. Women monitored with biomarkers had nearly $6,000 in additional health costs.

Reeves knows the costs of cancer treatment all too well. Although she had health insurance from her employer, she says she had to sell her house to pay her medical bills. “It was financially devastating,” Reeves said.

“It’s the worst kind of financial toxicity, because you’re incurring costs for something with no benefit,” said Dr. Scott Ramsey, director of the Hutchinson Institute for Cancer Outcomes Research.

Even simple blood tests take a toll, Reeves said.

Repeated needle sticks — including those from unnecessary annual blood tests — have scarred the veins in her left arm, the only one from which nurses can draw blood, she says. Nurses avoid drawing blood on her right side — the side of her breast surgery — because it could injure that arm, increasing the risk of a complication called lymphedema, which causes painful arm swelling.

Reeves worries about the side effects of so many scans.

After treatment ended, her doctor also screened her with yearly MRI scans using a dye called gadolinium. The Food and Drug Administration is investigating the safety of the dye, which leaves metal deposits in organs such as the brain. After suffering so much during cancer treatment, she doesn’t want any more bad news about her health.

Becoming An Advocate

Kathi Kolb, 63, was staring at 35 radiation treatments over seven weeks in 2008 for her early breast cancer. But she was determined to educate herself and find another option.

“I had bills to pay, no trust fund, no partner with a big salary,” said Kolb, a physical therapist from South Kingstown, R.I. “I needed to get back to work as soon as I could.”

Kolb asked her doctor about a 2008 Canadian study, which was later published in the influential New England Journal of Medicine, showing that three weeks of radiation was safe. He agreed to try it.

Even the short course left her with painful skin burns, blisters, swelling, respiratory infections and fatigue. She fears these symptoms would have been twice as bad if she had been subjected to the full seven weeks.

“I saved myself another month of torture and being out of work,” Kolb said. “By the time I started to feel the effects of being zapped [day] after day, I was almost done.”

A growing number of medical and consumer groups are working to educate patients, so they can become their own advocates.

The Choosing Wisely campaign, launched in 2012 by the American Board of Internal Medicine (ABIM) Foundation, aims to raise awareness about overtreatment. The effort, which has been joined by 80 medical societies, has listed 500 practices to avoid. It advises doctors not to provide more radiation for cancer than necessary, and to avoid screening for tumor markers after early breast cancer.

“Patients used to feel like ‘more is better,’” said Daniel Wolfson, executive vice president of the ABIM Foundation. “But sometimes less is more. Changing that mindset is a major victory.”

Yet Wolfson acknowledges that simply highlighting the problem isn’t enough.

Many doctors cling to outdated practices out of habit, said Dr. Bruce Landon, a professor of health care policy at Harvard Medical School.

“We tend in the health care system to be pretty slow in abandoning technology,” Landon said. “People say, ‘I’ve always treated it this way throughout my career. Why should I stop now?’”

Many doctors say they feel pressured to order unnecessary tests out of fear of being sued for doing too little. Others say patients demand the services. In surveys, some doctors blame overtreatment on financial incentives that reward physicians and hospitals for doing more.

Because insurers pay doctors for each radiation session, for example, those who prescribe longer treatments earn more money, said Dr. Peter Bach, director of Memorial Sloan Kettering’s Center for Health Policy and Outcomes in New York.

“Reimbursement drives everything,” said economist Jean Mitchell, a professor at Georgetown University’s McCourt School of Public Policy. “It drives the whole health care system.”

Smith-Bindman, the UC-San Francisco professor, said the causes of overtreatment aren’t so simple. The use of expensive imaging tests also has increased in managed care organizations in which doctors don’t profit from ordering tests, her research shows.

“I don’t think it’s money,” Smith-Bindman said. “I think we have a really poor system in place to make sure people get care that they’re supposed to be getting. The system is broken in a whole lot of places.”

Dennison said she hopes to educate friends and others in the breast cancer community about new treatment options and encourage them to speak up. She said, “Patients need to be able to say ‘I’d like to do it this way because it’s my body.’”

KHN’s coverage related to aging & improving care of older adults is supported by The John A. Hartford Foundation.

Want to contribute to the conversation about overtreatment on Facebook? Click here.

KHN’s coverage of aging and long-term care issues is supported in part by The SCAN Foundation.

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The Scents of Gurugram

For a few years now there has been an expressed need to regulate volatile organic compounds from organic solvents in paints and varnishes by means of legal measures. Many of these toxic solvents continue to be replaced by more environmentally friendly, water-soluble substances. While we may find smaller amounts of compounds such as benzene or toluene, water-soluble substances are much more ubiquitous. These are less reactive, which can have a positive effect on the formation of ground-level ozone with some of these oxygenated components having the ability to form secondary organic aerosols and thus contribute to the formation of particulate matter.

At this point however, while it is not clear how this amount compares to primary urban aerosol sources, there establishes the need for a more comprehensive research aimed at measuring a broad range of compounds at very low quantities to determine the fingerprint of VOC emission sources within a radius of about one kilometer. Since many of the trace gases are odorous, data may be able to reflect the characteristic scent of any city. In this respect Gurugram is quite an extraordinary city. We can find mainly traces of construction solvents & adhesives, food preparation synthetics and solvents that humans associate which define smell of the city. We may be amused to find compounds associated with cosmetics and detergents also in the air. There is already a evidence of silicone oils contained in many cosmetic and cleaning products that leave such a characteristic fingerprint in Gurugram urban air.

The Scents of Gurugram
– Rajneesh Wadhwa

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Bad Air And Inadequate Data Prove An Unhealthy Mix

WASCO, Calif. — Kira Hinslea wanted to play outside, but she knew she couldn’t until her mom checked an air-quality app on her phone.

“Is it OK?” the 6-year-old eagerly asked her mother, Shirley Hinslea, one day late last month.

Hinslea gave Kira the green light, and the child beamed with excitement. “Yes! Yes! Yes!” she yelled, sprinting from the kitchen, across the living room and out to the porch of their mobile home in this small Kern County town.

Kira’s freedom didn’t last long. Within 20 minutes, her throat started to itch and her chest felt heavy, she told her mom. She wearily returned inside and sifted through her backpack for her inhaler.

Kira has had severe asthma since she was 2, and the polluted air in the San Joaquin Valley exacerbates her symptoms.

Valley residents inhale some of the dirtiest air in the nation, and families know to keep masks in their cars and inhalers within reach and to check the air quality on a daily — sometimes hourly — basis.

But Hinslea questions the air-quality readings. The mobile phone apps she uses to search for conditions in her ZIP code often lag hours behind the real-time data. Occasionally, apps and websites show conflicting readings, she said.

Now, local health and environmental groups in the San Joaquin Valley are helping residents like Hinslea get up-to-the-minute air-quality readings by distributing 20 monitors that measure particulate matter.

“We just don’t have all the information we need — not at the neighborhood level,” said Kevin Hamilton, a respiratory therapist and CEO of the Central California Asthma Collaborative, a nonprofit organization based in Fresno. “The regulatory agencies think regionally … not at the neighborhood level.”

Hinslea is enrolled in the collaborative’s asthma management program, and it offered her one of the palm-sized devices. She jumped at the opportunity. The monitors cost about $230 and require a Wi-Fi connection. A map showing all active monitors around the world — along with their data — can be viewed online.

“For [Kira’s] health, I want to have the best, real-time information,” said Hinslea, 47, as a staff member from the collaborative mounted the monitor on the side of the house near her front door.

Efforts by such nonprofits will supplement a new state law that aims to improve air quality — and air-quality monitoring — in communities such as Wasco that are heavily affected by air pollution.

As part of the law, the California Air Resources Board later this month is expected to name 10 polluted communities chosen to get help from the state to clean up their air. They will each have an air-monitoring system composed of several monitors strategically placed in different neighborhoods.

The monitors will track all types of air pollution, including the two most common: ozone, the main ingredient in smog, and particulate matter, which is pollution made up of ash, soot, diesel exhaust and other small particles.

The data from these monitoring systems will help communities identify specific pollution sources, such as sprayed pesticides, emissions from local oil refineries and from port operations. Then the California Air Resources Board and regional air districts will devise a plan to reduce those emissions, said Lindsay Buckley, a spokeswoman for the board. More communities will receive monitoring systems in later years.

Communities slated to receive monitors in the first round include Shafter (near Wasco), south-central Fresno, Boyle Heights, south Sacramento, San Bernardino, El Centro in Imperial County and portside neighborhoods in San Diego County.

The state plans to begin monitoring those communities by next July.

Although Wasco is not among the first communities to receive a tracking system from the state, its residents will likely benefit from the data collected and lessons learned in nearby Shafter, Buckley said.

Wasco, home to about 26,000 people, takes pride in having the ideal climate for growing roses. It is also a big almond producer.

But as more farmers grow almonds, there’s more spraying of pesticides, said Gustavo Aguirre Jr., an organizer with the Central California Environmental Justice Network, which is helping distribute the 20 off-the-shelf air monitors.

Wasco is “surrounded 360 degrees by agricultural production,” he said, and the San Joaquin Valley is also a key player in oil and gas production for California.

“On top of that, we’re also in the middle of Highways 5 and 99,” Aguirre said. “So you have this cumulative effect from all these sources of pollution.”

Wildfire smoke this summer compounded worries over air quality for residents in the region, including Hinslea. “Now you’ve got smoke, and dust and just everyday pollution. … It can get really bad,” she said. “You look outside and think, ‘Is it overcast or is it smog?’”

When her daughter Kira’s asthma flares up, the little girl often coughs and wheezes through the night and misses school the next day, Hinslea said.

Having more timely and reliable information from the small air monitor near her front door will help her decide if her daughter can go to school — and if she does, whether she should stay indoors during recess, she said.

“It wasn’t always like this,” said Hinslea, who was born and raised in Wasco. “When I was little, it seemed crisper and brighter, fresh. It was just different.”

This story was produced by Kaiser Health News, which publishes California Healthline, a service of the California Health Care Foundation.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

Kaiser Health News is a nonprofit news service covering health issues. It is an editorially independent program of the Kaiser Family Foundation, which is not affiliated with Kaiser Permanente.

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ADMISSIONS 2020