Women in Thoracic Surgery,

 The NYT reports on the second annual meeting of Women in Thoracic Surgery, a group for the less than 10 percent of heart and lung surgeons in the United States who are women, one of the smallest percentages of any surgical specialty. 

Female Cardiothoracic Surgeons, Unlocking the Male Fortress
Less than 10 percent of heart and lung surgeons in the United States are women.  By Elisabeth Bumiller 

 "Women make up about 30 percent of surgeons in the United States overall, and a little less than 40 percent of all physicians.

...

"“Cardiothoracic surgery had a reputation, which is fading but probably not gone, as the toughest, meanest and the most macho specialty,” said Dr. [Leslie] Kohman, 76...

...

"The women say the good news today is that some 500 women have been certified as thoracic surgeons in the United States, although there are less than that in active practice — still, enough for them to hold a conference. (The terms “thoracic” and “cardiothoracic” are used interchangeably to refer to doctors who operate on the organs in the chest cavity.) 

#########

My sense, incidentally, is that cardiothoracic surgery is not a growing specialty, as a lot of the work that they used to do is now done by interventional cardiologists, who can access the heart by threading devices through blood vessels. 

When I last studied the thoracic surgery fellowship match, it  was because (unlike the resident match) there were no couples participating in it, so it could serve as a control for  that aspect of the resident match (this was in the paper  Roth, A. E. and Elliott Peranson, "The Redesign of the Matching Market for American Physicians: Some Engineering Aspects of Economic Design," American Economic Review, 89, 4, September, 1999, 748-780.

Today the fellowship match for thoracic surgery is run jointly with vascular surgery.

 

Facing up to face transplants: Pioneering transplants and their pioneering patients

The history of transplantation involves not only pioneering surgeons, but also pioneering patients.  Face transplants are yet another complex case. 

 The Guardian has this (skeptical) story:

Face transplants promised hope. Patients were put through the unthinkableTwenty years after the first face transplant, patients are dying, data is missing, and the experimental procedure’s future hangs in the balance   Fay Bound Alberti 

"On 27 November 2005, Isabelle received the world’s first face transplant at University Hospital, CHU Amiens-Picardie, in northern France. The surgery was part of an emerging field called vascularized composite allotransplantation (VCA), that transplants parts of the body as a unit: skin, muscle, bone and nerves.

...

"The case for face transplants seemingly made, several teams scrambled to perform their nation’s first. The US saw the first partial face transplant (2008), then the first full one (2011); the first African American recipient (2019); the first face and double hand transplant combined (2020); the first to include an eye (2023). There have been about 50 face transplants to date, and each milestone brought new grants, donations and prestige for the doctors and institutions involved.

...

"Add to this picture a set of ethical challenges: face transplants take otherwise healthy people with disfigured faces and turn them into lifetime patients.

...

"In the US, now the world’s leader in face transplants, the Department of Defense has bankrolled most operations, treating them as a frontier for wounded veterans while private insurers refuse to cover the costs.

"With insurance unwilling to pay until the field proves its worth, surgeons have been eager to show results. A 2024 JAMA Surgery study reported five-year graft survival of 85% and 10-year survival of 74%, concluding that these outcomes make face transplantation “an effective reconstructive option for patients with severe facial defects”.

"Yet patients like Dallas tell a different story. The study measures survival, but not other outcomes such as psychological wellbeing, impact on intimacy, social life and family functioning, or even comparisons with reconstruction. 

...

"It’s a double-bind. Without proof of success, face transplants are experimental. And because the procedures are experimental, patients’ long-term needs aren’t covered by grants, leaving patients to carry the burden

...

"Which path will face transplants take? The numbers are already slipping – fewer procedures since the 2010s as outcomes falter and budgets shrink. And unless the field raises its standards, enforces rigorous follow-up, and commits to transparent, systematic data sharing that actually includes patients and their families, there’s no way to demonstrate real success. Without that, face transplants aren’t headed for evolution or stability; they’re headed straight for the dustbin of medical history." 

The abrupt demise of the AMA Journal of Ethics

Medical ethics is full of twists and turns, so it is perhaps fitting that the American Medical Association killed its Journal of Ethics, without explanation, in an abrupt announcement in its November issue that the December issue would be the last issue. 

From the Editor in Chief, AMA Journal of Ethics, Nov 2025
Breaking Bad News, Audiey C. Kao, MD, PhD

"For over a quarter of a century, the AMA Journal of Ethics has striven to publish insightful commentaries, engaging podcasts, and provocative artwork that help medical students, physicians, and all health care professionals reflect on and make sound ethical decisions in service to patients and society. I write to inform you that the AMA Journal of Ethics will cease publishing new content after December 2025. Understandably, this news will be sad and unexpected for the journal’s readers and supporters. I share in this loss.

"Previously published content will be maintained on the journal’s website and remain freely available to all in keeping with our guiding premise that ethics inquiry is a public good. With humility, I am hopeful and confident that this archived journal content will stay evergreen for years to come. "

######

Here's an article in MedpageToday, mourning the demise of the journal in a way that appears to have left authors of forthcoming articles in the lurch:

In Memoriam: The Sudden Demise of the AMA Journal of Ethics
— A great loss for physicians, the profession, and the public
by Matthew Wynia, MD, MPH, and Kayhan Parsi, JD, PhD

"without warning, the American Medical Association (AMA) announced that it would cease publishing AMA JoE after the December 2025 issue. Journals like AMA JoE operate a year or more in advance, so multiple authors and editors of upcoming issues for 2026-2027 were left in the lurch by this unexpected announcement. Students and trainees are now scrambling to find new homes for their articles, some of which have already undergone extensive editorial review."
 

Physicians are now more likely employed than in private practice, and AMA membership has correspondingly declined

 Medpage Today has the story:

Medical Societies Are Facing an Existential Crisis
— It's time to adapt to the employed physician era
by Hemant Kalia MD, MPH, Mark Adams, MD, MBA, and David Jakubowicz, MD 

 

"According to the American Medical Association (AMA), 2020 marked the first time that fewer than half (49.1%) of physicians worked in doctor-owned practices since their tracking began. By 2022, that number had fallen further to 46.7%, down from 60% a decade earlier. Meanwhile, the share of physicians employed by hospitals and health systems has expanded sharply -- from about 29% of physicians in 2012 to more than 40% in 2022. Private equity ownership, virtually absent in previous decades, now accounts for roughly 5% of physician employment. 

...

" this employment transformation has disrupted the very institutions meant to represent physicians. Nationally, AMA membership has plunged from about 75% of U.S. physicians in the 1950s to just 15% today. State and county medical societies mirror this pattern, facing shrinking memberships, aging leadership, and limited engagement among younger doctors.

"Specialty societies have filled much of that vacuum. Groups like the American College of Physicians, the American College of Surgeons, and the American Academy of Family Physicians have seen significant growth over the past few decades. 

John Gurdon (1933-2025)

One hope for a future free of the need for human organ transplants is that it might become possible to re-initiate the process by which embryos originally grow their own kidneys from stem cells, i.e. from cells that are "pluripotent,"  in that they retain the possibility  of growing into any of the organs with which we humans come originally equipped.

Great progress is being made in that direction, although  obviating the need for transplants is still only a distant hope.   I had the good fortune to meet two of the pioneers of those efforts, in Stockholm in 2012, when that year's Nobel Prize in Physiology or Medicine was awarded jointly to Sir John B. Gurdon and Shinya Yamanaka "for the discovery that mature cells can be reprogrammed to become pluripotent"  

John has now died, at the age of 92.  I hope he  derived great satisfaction from the fact that his pioneering work is continuing to lead to steady progress.

 Here's his obituary from the Guardian, which contains an anecdote that I recall he shared in Stockholm. His story should give comfort to students unappreciated by teachers who don't realize that students retain a good deal of pluripotency regarding what kind of adults and scholars they will become.

 Sir John Gurdon obituary. Biologist who won the Nobel prize for discovering that adult cells can be reprogrammed.  byGeorgina Ferry

 " His career narrowly missed being driven off course by a report from his biology teacher, placing him last in his year and dismissing his idea of becoming a scientist as a “sheer waste of time, both on his part, and of those who have to teach him.”

The science and politics (and lawfare) of abortion pills with other uses in reproductive healthcare

Two recent articles shed some light on how the market for reproductive healthcare is evolving.

 Dr. Jessica Chen writes "I dispensed mifepristone every day in the clinic last week, and not once was it for abortion."  Instead it was to help patients who had suffered a miscarriage, and were still carrying a dead fetus.  

The US is expecting legal wrangling over whether mifepristone can be prescribed by telehealth providers, to women in states that forbid abortion.  Some of the arguments may depend on whether it is an "abortion pill," or a drug with multiple uses in reproductive healthcare.

The Clinical Indications for Mifepristone Go Beyond Abortion Jessica Chen, MD, JAMA
Published Online: August 28, 2025  doi: 10.1001/jama.2025.13376

#############

Considering Telehealth Across State Lines in Uncertain Times, by Nicole Huberfeld, JD1; Katharine O. White, MD, MPH2; Rachel Cannon, MD, MSc2, JAMA Published Online: August 11, 2025 doi: 10.1001/jama.2025.12122

"Since the US Supreme Court decided in 2022 that abortion was no longer protected as part of the constitutional right to privacy, state lawmakers have been empowered by the court leaving abortion policy “to the people and their elected representatives.”1 This phrase has fostered deep conflicts between state laws relating to abortion and laws relating to other health care for people of reproductive age, and it has created new risks for physicians who provide care to patients across state lines."

Meat and dairy allergy ( to alpha-gal), ticks and gene-modified pigs

 A previously rare allergy to a sugar molecule called alpha-gal, found in almost all mammals but humans, is now being spread by tick bites.  But alpha-gal is also the sugar that is genetically engineered out of pigs that are being bred for xenotransplants. So there may be a secondary market for pork chops from those pigs... 

‘We can no longer eat burgers or ice cream — all because of a tick bite’
A bug-borne disease has taken over Martha’s Vineyard and is turning people vegan, locals claim.  by Samuel Lovett 

"Sufferers cannot eat any food products that contains alpha-gal, a sugar molecule carried by the lone star tick and which is present in all mammals — except humans and some monkeys. This means cheeses, milk and meats from beef to venison are all off the menu. For some, even white sugar cannot be tolerated because it is processed using animal-bone char.

"Alpha-gal symptoms including hives, stomach cramps, vomiting and breathlessness often start to appear several hours after eating foods containing the molecule, giving the syndrome its nickname “the midnight allergy”.

...

"Although the prevalence of alpha-gal syndrome on Martha’s Vineyard has rocketed in recent years, the island is “definitely not the worst off”, said Roden-Reynolds. Data from the Centers for Disease Control and Prevention indicates that the Midwest has the highest rates per capita, and the agency estimates that about 450,000 people are living with the disease in the US."

 

Resuscitation theater ("slow codes"), and Medical Aid in Dying

 Here's an article pointing out that "slow codes" often constitute resuscitation theater, i.e. they are a way to follow bureaucratic directives requiring attempted resuscitation after cardiac arrest in hospitals, when the physicians don't think that would be in the patient's best interest, i.e. when resuscitation would only prolong dying and suffering.  I think this should be part of the discussion of the kinds of "covert" medical aid in dying that takes place even in jurisdictions that don't legally authorize physicians to help shorten the dying process.

McLennan S, Bak M, Knochel K. Slow Codes are symptomatic of ethically and legally inappropriate CPR policies. Bioethics. 2025 May;39(4):327-336. doi: 10.1111/bioe.13396.

Abstract: Although cardiopulmonary resuscitation (CPR) was initially used very selectively at the discretion of clinicians, the use of CPR rapidly expanded to the point that it was required to be performed on all patients having in‐hospital cardiac arrests, regardless of the underlying condition. This created problems with CPR being clearly inadvisable for many patients. Do Not Resuscitate (DNR) orders emerged as a means of providing a transparent process for making decisions in advance regarding resuscitation, initially by patients and later also by clinicians. Under hospital policies in many countries, however, CPR remains the default position for all patients having cardiac arrest in the hospital if there is no DNR order in place, regardless of whether CPR is medically indicated or in the patient's best interests. “Slow Codes” are the delayed or token efforts to provide CPR when clinicians feel CPR is futile or inappropriate. After giving a historical overview of the development and the changing use of CPR, we argue that more attention needs to be given to the cause of slow codes, namely, policies requiring CPR to be performed as the default action while simultaneously lacking implementing interventions such as advance care planning as a routine policy. This is ethically and legally inappropriate, and hospital policies should be modified to allow clinicians to consider whether CPR is appropriate at the time of arrest. Such a change requires a stronger emphasis on early recognition of patients for whom CPR is not in their best interests and to improve hospital emergency planning.

" Proponents of the ‘slow code’ find that intentionally delaying CPR might, in some cases, be a more compassionate alternative to aggressive and potentially futile interventions.

...

"Cardiopulmonary resuscitation is indicated for the patient who, at the time of cardiopulmonary arrest, is not in the terminal stage of an incurable disease. Resuscitative measures on terminal patients will, at best, return them to the dying state. The physician should concentrate on resuscitating patients who were in good health preceding the arrest, and who are likely to resume a normal existence"

Medical aid in dying: the continuing debate in England

In June, the British Parliament passed a law to permit medical aid in dying, which still needs further action before going into effect.

  The Guardian looks at the harrowing situations facing some proponents of MAID:

‘Bad deaths scar families for ever’: what terminally ill people want you to know about assisted dying

Here's the backstory:

From 20 Jun 2025

MPs vote to accept assisted dying bill

"MPs have voted to accept the assisted dying bill, with 314 votes in favour to 291 against, a majority of 23.

The bill will now go to the House of Lords for further scrutiny".

Organ donation after circulatory death: the NYT recounts some disturbing cases

 The NYT has a disturbing story this morning about organ donation after circulatory death. These are cases in which a decision has been made to remove the patient from a ventilator, in anticipation that they are irreversibly dying.  If death (via cessation of heartbeat and breathing) occurs almost immediately after removal, the patient may still be a viable organ donor, and otherwise not.  Organ procurement organizations (OPOs) are not supposed to be involved until after death has been declared, but apparently in some small hospitals they get involved earlier, and have sometimes pressured physicians to proceed prematurely.

A Push for More Organ Transplants Is Putting Donors at Risk
People across the United States have endured rushed or premature attempts to remove their organs. Some were gasping, crying or showing other signs of life.  By Brian M. Rosenthal and Julie Tate, July 20, 2025

"Across the United States, an intricate system of hospitals, doctors and nonprofit donation coordinators carries out tens of thousands of lifesaving transplants each year. At every step, it relies on carefully calibrated protocols to protect both donors and recipients.
 

"But in recent years, as the system has pushed to increase transplants, a growing number of patients have endured premature or bungled attempts to retrieve their organs. ...  a New York Times examination revealed a pattern of rushed decision-making that has prioritized the need for more organs over the safety of potential donors.

...

"Most donated organs in the United States come from people who are brain-dead — an irreversible state — and are kept on machines only to maintain their organs. Most donated organs in the United States come from people who are brain-dead — an irreversible state — and are kept on machines only to maintain their organs. Circulatory death donation is different. These patients are on life support, often in a coma. Their prognoses are more of a medical judgment call.

"They are alive, with some brain activity, but doctors have determined that they are near death and won’t recover. If relatives agree to donation, doctors withdraw life support and wait for the patient’s heart to stop. This has to happen within an hour or two for the organs to be considered viable. After the person is declared dead, surgeons go in.

"The Times found that some organ procurement organizations — the nonprofits in each state that have federal contracts to coordinate transplants — are aggressively pursuing circulatory death donors and pushing families and doctors toward surgery. Hospitals are responsible for patients up to the moment of death, but some are allowing procurement organizations to influence treatment decisions.

"Fifty-five medical workers in 19 states told The Times they had witnessed at least one disturbing case of donation after circulatory death.

"Workers in several states said they had seen coordinators persuading hospital clinicians to administer morphine, propofol and other drugs to hasten the death of potential donors.

...

"Circulatory death donation used to be largely forbidden. That began to change in the 1990s, when a dying patient asked the University of Pittsburgh Medical Center to remove her life support and donate her organs. The hospital honored her wishes, then spent two years creating guidelines for future cases. Use of the practice gradually spread.

"Procurement organizations attributed the procedure’s recent growth to technological advances. Dozens of employees at the organizations said it was largely because of government pressure.

"Citing the number of Americans waiting for organs, H.H.S. said in 2020 that it would begin grading procurement organizations on how many transplants they arranged. The department has threatened to end its contracts with groups performing below average, starting next year. Many have raised their numbers by pursuing more circulatory death donors."

Aging in bursts

It turns out we don't just fade away...

 New Scientist has the story:

Rapid bursts of ageing are causing a total rethink of how we grow old
Suddenly feeling old? Evidence now suggests that rather than a long, steady decline, we dramatically age around three specific times in our lives. Might it be possible to stay younger for longer? By Graham Lawton

"participants clustered into four groups: the under-34s, those aged 34 to 60, people aged 61 to 78 and the over-78s. Within each group, the protein profiles were very similar, but at the ages of 34, 60 and 78, they suddenly changed, with levels of some proteins rising dramatically while others plummeted. What’s more, some of the proteins that became enriched in the older age groups were already known to be associated with cardiovascular disease and Alzheimer’s"

Informed consent and mortal sin, in the case of Medical Aid in Dying

 Studying morally contested transactions doesn't always suggest paths by which consensus might be reached. It often suggests that conflicting views may be irreconcilable. 

That seems to be the case for the growing legalization of Medical Aid in Dying (MAID, also called medically assisted suicide), about which I've recently blogged several times.  

MAID laws face determined religious opposition.  When Hawaii legalized MAID in 2018, the Catholic Diocese of Honolulu issued some guidance to clergy pointing out that the law's requirements for informed consent seemed to coincide with the requirements for a sin to be a mortal sin.

 Diocese of Honolulu November 5, 2018: Instruction Regarding Sacraments and Funerals In Situations Involving Physician Assisted Suicide for Clergy, Parish Staff and Ministers to the Sick and Homebound
“Everyone is responsible for his life before God who has given it to him. It is God who remains the sovereign Master of life. We are obliged to accept life gratefully and preserve it for his honor and the salvation of our souls. We are stewards, not owners, of the life God has entrusted to us. It is not ours to dispose of” (Catechism of the Catholic Church [CCC], no. 2280)

...

7."For a sin to be a mortal sin, three conditions must be fulfilled:

•  the matter must be grave,
•  the person must have knowledge of the gravity of the matter, and
•  the person must freely choose the matter after sufficient deliberation (see CCC, nos. 1857-1859).

8."The process required by the State of Hawaii for a person seeking medically assisted suicide is meant to guarantee that he or she is fully informed and has made a deliberate consent, thus likely fulfilling the requirements for mortal sin.

9." If a person dies in mortal sin without contrition, such final impenitence results in the “exclusion from Christ's kingdom and the eternal death of hell, for our freedom has the power to make choices for ever, with no turning back” (CCC, no. 1861; see no. 1864)

 

HT: Julio Elias

New York State senate passes medical aid in dying bill

 Yesterday the NY State Senate took the next step in making medical aid in dying legal in NY.  Now the bill goes to the governor...

The NYT has the story:

New York Moves to Allow Terminally Ill People to Die on Their Own Terms
A bill permitting so-called medical aid in dying passed the State Legislature and will now head to Gov. Kathy Hochul for her signature. by Grace Ashford

"Eleven states and the District of Columbia have passed laws permitting so-called medical aid in dying. The practice is also available in several European countries and in Canada, which recently broadened its criteria to extend the option to people with incurable chronic illnesses and disabilities.

The bill in New York is written more narrowly and would apply only to people who have an incurable and irreversible illness, with six months or less to live. Proponents say that distinction is key.

“It isn’t about ending a person’s life, but shortening their death,” said State Senator Brad Hoylman-Sigal, a Manhattan Democrat and one of the sponsors of the bill. It passed on Monday night by a vote of 35 to 27, mostly along partisan lines.

...

"The bill was first introduced a decade ago by Assemblywoman Amy Paulin, a Westchester Democrat who leads the body’s Health Committee, at a time when few states were considering such measures.

...

"The bill has earned the support of a range of powerful interest and advocacy groups, including the New York State Bar Association, the New York State Psychiatric Association, the Medical Society of the State of New York and the New York Civil Liberties Union.

"While it was also backed by some religious groups, including Congregation B’nai Yisrael, a Westchester synagogue, and Catholics Vote Common Good, it was staunchly opposed by the New York State Catholic Conference."

Medical aid in dying bill advances (controversially) in New York State

 A bill to legalize Medical Aid in Dying (MAID) in New York state has passed the Assembly and been referred to the Senate (after which it would go to the Governor for signature).  It's controversial, so I don't have a good sense of whether it will become law.

Here's the text of the bill itself, on the NY State Assembley page: "Medical Aid in Dying Act"

Here's a well written article summarizing the controversy, and ultimately opposing the bill in its present form.

Will New York Soon Make It Too Easy to Die?   By Madeleine Kearns

"In April, New York’s “Medical Aid in Dying Act” passed the state assembly by a vote of 81 to 67. It has until the end of the legislative session—June 12—to face a vote in the Senate. On Thursday, June 5, Senate majority leader Andrea Stewart-Cousins said she believed there were enough votes for the legislation to pass and “it is likely that it will come to the floor.” Perhaps as soon as Monday, June 9.

If the legislation passes, New York would join the 11 other states that have legalized assisted dying in various forms. (It is also legal in the District of Columbia.) For those who have seen difficult deaths or are daunted by the prospect, the kind of death Nancy describes—peaceful and pain-free—is what they are hoping the law will all but guarantee.

But those opposed to assisted suicide—their preferred term—warn that such laws endanger the vulnerable by reshaping social norms so that, for some, the right to die becomes a duty to die. Moreover, New York’s legislation, they argue, is on the “outer edge” of liberalization, eliminating safeguards that exist in other states where medical aid in dying (MAID) is legal."

American doctors moving to Canada

 Many Canadian doctors practice in the U.S., where pay is generally higher and they may have more access to high tech imaging and other medical equipment.  But there's a stream of docs moving in the other direction now.

KFF Health news has the story:

American Doctors Are Moving to Canada To Escape the Trump Administration
By Brett Kelman 

"The Medical Council of Canada said in an email statement that the number of American doctors creating accounts on physiciansapply.ca, which is “typically the first step” to being licensed in Canada, has increased more than 750% over the past seven months compared with the same time period last year — from 71 applicants to 615. Separately, medical licensing organizations in Canada’s most populous provinces reported a rise in Americans either applying for or receiving Canadian licenses, with at least some doctors disclosing they were moving specifically because of Trump.

...

"Doctors Manitoba, which represents physicians in the rural province that struggles with one of Canada’s worst doctor shortages, launched a recruiting campaign after the election to capitalize on Trump and the rise of far-right politics in the U.S.

"The campaign focuses on Florida and North and South Dakota and advertises “zero political interference in physician patient relationship” as a selling point."

Thinking about the ethical, legal and political relationships between IVF and abortion (in JAMA)

Some people support both IVF and abortion (women's right to choose) and some people oppose both (embryos are people), but many oppose abortion but support IVF.  Here's an article that focuses on some ethical distinctions (is the intention to have a child or not), and also on some political ones (IVF patients are on average more affluent than abortion patients).

Watson K. Rethinking the Ethical and Legal Relationship Between IVF and Abortion. JAMA. Published online May 22, 2025. doi:10.1001/jama.2025.6733 

"US voters have elected a president who promised he would make the government or private insurance cover in vitro fertilization (IVF), yet takes credit for reversing Roe v Wade. These positions highlight a question that has lingered since US IVF practice began in 1981: are hospital and governmental policies that support IVF but do not support abortion ethically consistent? And if not, why is this division so common?

"Those who see IVF and abortion as ethically distinct often focus on differences in intention and outcome—having a baby vs avoiding having a baby. Others see them as comparable practices because both destroy embryos. I offer a third perspective, which is that abortion and IVF are comparable practices because both are family-building medical interventions; therefore, support for IVF access ought to lead to support for abortion access.

"Abortion was a federal constitutional right until 2022, and IVF was subject to state regulation like the rest of medicine. Yet constitutional protection did not stop many states from heavily regulating abortion, and IVF rarely faced governmental limits. A stark example of their disparate treatment occurred shortly after Roe v Wade was reversed when the traditionally antiabortion state of Indiana began its statute criminalizing abortion provision by clarifying “This article does not apply to in vitro fertilization” (IN Code §16-34-1-0.5 [2024]).

"Yet like abortion, IVF also involves embryo death. 

...

" differences in patient income, race, age, and education also suggest a stark difference in political power between the constituencies invested in IVF and abortion. Eighty-one percent of fertility patients have household incomes of more than $100 000 and 75% are White6; 72% of abortion patients have incomes less than 200% of the federal poverty line and 59% are Black or Latinx.3 Sixty-four percent of IVF patients are 35 years or older,7 while 70% of abortion patients are in their teens or 20s.3 Fourteen percent of births to women with a college or graduate degree were conceived with the use of assisted reproductive technology, but only 1.5% of births to women with some college or less were conceived with assisted reproductive technology in 2023.8 In contrast, 77% of abortion patients have some college or less.9 (There are no data documenting how many IVF patients deferred their childbearing by having an abortion when they were younger, or how many IVF patients later abort to decrease a multiple pregnancy or avoid unexpected medical problems.)

"Entities involved in providing IVF also have financial interests in preserving the legality of a practice with a median cost of $19 200 per cycle.6 Infertility care generates approximately $8 billion per year in gross revenues in the US.10 High operating margins have drawn private equity investors to many private fertility practices, and IVF is lucrative for hospitals and physicians."

Susan Athey on biggish data and machine learning

 Susan Athey is interviewd in JAMA:

How an Economist’s Application of Machine Learning to Target Nudges Applies to Precision Medicine   by Roy Perlis and Virginia Hunt  JAMA. Published online May 16, 2025. doi:10.1001/jama.2025.4497 

"A recent study by economist Susan Athey, PhD, and her colleagues may shed light on how best to target treatments using machine learning. The investigation, published in the Journal of Econometrics, focused on the effectiveness of text and email reminders, or nudges, sent to students about renewing their federal financial aid. The researchers compared causal targeting, which was based on estimates of which treatments would produce the highest effects, and predictive targeting, which was based on both low and high predicted probability of financial aid renewal.

"In the end, the study found hybrid models of the 2 methods proved most effective. However, the result that may be most surprising to Athey was that targeting students at the highest risk of nonrenewal was actually less effective.

...

"Dr Athey:When I first started working on this, I was like, “Oh, there’s going to be a gold mine. I’m going to go back and reanalyze all of these experiments that have already been run, and we’re going to be doing new scientific discoveries every day.” It didn’t quite work out that way. We had some big successes, but there has been a lot of lack of success.

What are the cases where this doesn’t work? Machine learning is using the data to learn about these treatment effects. You have to do a lot of sample splitting. There’s always a cost to using the data to discover the model. You can do it without sample splitting, but then you have to adjust your P values. There’s no free lunch. If you have a very small dataset, you probably know what the most important factors are. You might be better off prespecifying those and just doing your subgroup analysis. If [there are] hundreds of observations, it’s just unlikely. These techniques are too data hungry to work.

Generally, you need thousands of people in the experiment. Then more than that, the statistical power needed to get treatment effect heterogeneity is large. And even treatment effect heterogeneity is easier—trying to get differential targeting is another thing. Imagine you have 3 drugs. It’s hard enough to say that something works relative to nothing. If you’re trying to say that one drug works better than another drug where both work, that’s hard. Usually you need really large, expensive trials to do that.

Then you add on top of that that I want to say, “This drug is better for these people, and this other drug is better for these other people.” You need 10 times as much data as you would for the basic “is there a treatment effect at all?” Now, of course, sometimes there’s a genetic thing: this drug literally doesn’t work or it has this terrible side effect for some people. That will pop out of the data.

For more subtle effects, you do need larger studies. That’s really been the main impediment. And as an economist, it’s like, why are all these things just barely powered? Why are there so many clinical studies with a t-statistic of 2? Of course, people did the power calculations, and they had some data already when they planned the experiments. If you have more data, maybe you add another treatment arm or something else. You don’t actually overpower an experiment. In my own research, I’ve ended up running my own experiments that are designed to get heterogeneity. I’ve also had a lot of luck when there’s very big administrative datasets, and there’s a really good natural experiment. Then you have lots of data. But former clinical trials are selected to not be good because the researcher themself didn’t overpower their own experiment. That’s why this isn’t so useful.

But nonetheless, that’s not to say it’s not out there. Like in any discovery, if it’s going to save lives and money, it’s worth doing. It’s just that there’s not a whole bunch of low-hanging fruit. There’s no dollars lying on the sidewalk."

There's a gray market for diabetes supplies

 High prices and inadequate medical insurance force some patients to get their diabetes monitoring supplies second hand. Here's a suggestion for some redesign...

Medpage has the story:

The Diabetic Supplies Gray Market Is Ripe for Disruption by Jacob Murphy 

""CA$H 4 SEALED & UNEXPIRED DIABETIC TEST STRIPS -- CALL NOW."

This message, printed in black on a neon yellow poster board, hangs just outside the $1.1 billion Charlotte R. Bloomberg Children's Center at Johns Hopkins Hospital. The sign represents a peculiar offshoot of American healthcare: the diabetic supplies gray market. Here, blood glucose test strips are exchanged within an informal network.

This market operates through handwritten signs and websites like QuickCash4TestStrips.com, often flourishing in areas with high rates of poverty and uninsured patients. How does it work? Insured patients obtain excess test strips at little personal cost through insurance, then sell them to reseller companies. These companies profit by selling the strips below original retail prices, which far exceed manufacturing costs, to uninsured individuals. And, surprisingly, this is all legal.

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"Diabetes costs have steadily risen to thousands of dollars annuallyopens in a new tab or window for individuals. These expenses can be even higher for the 1.5 million diabetic Americans without health insurance, especially if they experience diabetes-related complications. Without proper monitoring, these individuals face life-threatening risks of ketoacidosis, hypoglycemia, and long-term complications including vision loss, kidney failure, and amputations. In the end, they're left with a tough choice: turn to an unregulated "gray" market or potentially face major health complications and financial consequences. 

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"[ academic medical centers] should establish formal redistribution programs that incentivize donations of excess diabetic supplies. These programs would provide safer alternatives to unregulated gray market exchanges, leveraging institutional scale to deliver essential supplies at minimal or no cost to those most in need.

"Incentives to donors could include copay waivers for downstream care, free diabetes check-ups such as eye and foot exams, or connections to food assistance programs. Conditional cash transfers could also serve as effective motivators, particularly for the lowest-income donors. Additionally, centers could help patients transition from test strips to continuous glucose monitors "

Chronic diseases in the U.S.

 The top three chronic diseases--Hypertension, Obesity, and Diabetes--all contribute to the fourth, Kidney Disease.

How Chronic Disease Became the Biggest Scourge in American Health
Americans live shorter and sicker lives than people in other high-income countries   By  Brianna Abbott  | Graphics by  Josh Ulick