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The doctors are not doing well

This story is part of The Aftermath, a Vox series about the health side effects of the Covid-19 pandemic in communities across the United States. This series is supported in part by the NIHCM Foundation.

Last August, Dr. Scott Jolley got home from a busy emergency room at 3 a.m. and looked pale, much older than his 55 years. It was in the middle of the Covid-19 pandemic and he was the only doctor on duty at his hospital in Salt Lake City, Utah. One of his patients went into cardiac arrest after Jolley took off his personal protective equipment to meet his next patient. Jolley, athletic with dusty brown hair, had to frantically get dressed and run back to do a resuscitation. The patient survived, but Jolley was excited.

When Jolley's wife, Jackie, woke up at 6:00 am, she found him hunched over at her kitchen table and unable to sleep. He worried that in his rush he hadn't put his PPE on properly to expose Jackie and her three daughters to the coronavirus. He was also ashamed of what he had muttered to himself as he left the patient room: “I can't take this anymore; that's not good for me. "

Jackie wasn't used to seeing her husband in need. His friends called him "the Patriarch". He was the one everyone else turned to: the guy who talked himself to the intensive care unit to support his daughter after a birth complication, who organized an elaborate fly fishing trip for a friend's child's birthday. In his 28 years as a doctor, Jolley has shown the same attention to detail and compassion to the thousands of patients who came to his emergency room.

But by the time he got into his 50s, the pace and pressures of the job became unbearable. He began to have conflicts with colleagues who at some point organized a meeting to ask Jolley to get his anger under control. In 2018, Jolley began thinking about a way to retire, and asked his managers at Utah Emergency Physicians – a group of doctors who work with hospitals in the Intermountain Healthcare system he worked on – about ways to cut his schedule.

However, with the arrival of the coronavirus pandemic, Jolley had to move faster. He was often on evening shifts – usually the busiest in the emergency room – and was the only doctor on duty because of the pandemic cuts. Having to put on and take off new PPE for every patient, fast enough to keep up with the chaos of a pandemic emergency room, "made every shift and hour much more stressful than ever," said Myles Greenberg, his best friend and former ambulance says.

When Jolley asked his department head for advice on managing pandemic stress, Greenberg recalled Jolley telling him, “She said something like, 'I'll just wait for it to be over.' It was like, grin and bear it. ”an attitude that reflects the“ macho culture of emergency medicine, ”he adds.

Scott and Jackie Jolley hike in Zion National Park in 2018.

Courtesy of the Jolley family

Scott and Jackie Jolley at home in 2019.

Courtesy of the Jolley family

By August, the Utah ambulance had denied Jolley's request for another doctor to assist with his shifts and had not offered him an early retirement plan (since he was under 60 at the time.) He felt he had no choice but one Jackie recalls taking an unpaid sabbatical, and he planned to use the time to explore his options and "get his mental health back on track."

During his time off, a new stressor surfaced: "He was very, very worried about losing his driver's license and certificates," says his wife.

Medicine, ironically, is a profession that penalizes some doctors for seeking psychiatric treatment. Many doctors work under high pressure and are exposed to trauma in the workplace. A worrying number of doctors die from suicide each year. But structural barriers – some of which are enforced by medical associations and hospital systems – often prevent doctors from gaining access to medical care that could save their lives.

One of these barriers is the fear of what can happen to the doctors being treated. In dozens of states, medical associations ask doctors extensive questions about their medical history that would require them to disclose a diagnosis or treatment for a mental illness. Similar questions arise when doctors apply for a hospital card or a reimbursement from the health insurance company. A disclosure could trigger a call to the state committee, a request for medical records, or even a psychiatric examination. In the worst case, doctors can be restricted in their medical work or even lose their license to practice medicine.

Although the Utah state health agency does not require any mental health information, Jolley feared any assistance he received during his sabbatical could jeopardize his career and affect his family's livelihood, Jackie says. He made her a promise that she would keep his fights a secret, even from Greenberg.

In November, Jolley – who had no mental illness before the pandemic – was diagnosed with PTSD. He was given medication to treat depression and anxiety, and to improve his sleep. They seemed to be helping a little, Jackie recalls, but he soon grew tired and excited. That was the first time Jackie had heard him talk about how to end his life.

In the middle of his sabbatical, on February 5, 2021, Jolley attempted suicide. That evening he was admitted to the mental health department of his own hospital, to which he had sent dozens of his emergency room patients over the years. The care he received from colleagues from whom he tried to hide his mental state was a new, immense source of stress and shame, recalls his wife. But he was one of many US health workers whose insurance only covered treatment within the system in which he worked.

In Jolley's room, the lights stayed on and he didn't have a door, so other patients came in and out 24/7, Jackie says. The clothes he was wearing when he arrived were considered risky by the hospital, so Jackie said he had a baggy shirt and trousers left behind by another patient.

He was released from the hospital two days later.

Less than two weeks later, on February 19, he killed himself at home.

Jolley's family and Greenberg are now convinced that the medical profession has failed a doctor who devoted his life to saving other people. They say the stigma and fear of punishment for seeking psychiatric treatment delayed his treatment and then increased stress in his most vulnerable moments. Jolley asked the management of his group of doctors for help at least five times between March and August 2020, according to emails from Vox. Jackie and Greenberg say there have been additional phone calls, conversations, and emails.

"You had a business to run and you wanted to survive the pandemic and didn't realize that Scott was asking for help," says Jackie. "He told me they all thought he was just an angry old doctor."

In an interview, Dr. David Barnes, President of Utah Emergency Physicians, Vox, said the Jolley experience led his group to learn that "people can have trouble without it being obvious or obvious on the surface."

"We know that emergency medicine is a difficult subject and can challenge doctors of all ages," he added. "We need to find ways to support our aging doctors so they can have a satisfactory exit from their careers."

Intermountain Healthcare, the hospital system where Jolley and his colleagues worked, said in a statement, "The loss of a colleague is sad and sincere in any situation, and our thoughts are with family and friends."

The need to support doctors and combat the psychological stress on health workers has never been greater. Vox spoke to more than two dozen colleagues, family members, and friends of doctors who have died or attempted suicide, as well as doctors who have attempted or considered suicide. They said the pandemic exposed an inhumane health system that is sacrificing the mental health of the medical workers who keep it going. They also spoke of a mental health crisis long before the arrival of the coronavirus – one that could worsen after the pandemic.

An "occupational risk"

A warning sign of the disproportionate burden on health workers over the past year and a half surfaced in April 2020 when Lorna Breen, an emergency doctor in New York City, died of suicide. Her family still doesn't know who alerted the press, but Bree's story was made public without her consent. "When it was out there, we decided to join the conversation and tell the world what happened because we believe Lorna's death could have been avoided," her brother-in-law Corey Feist told Vox. "The more we told the story, the more we heard from others around the country and around the world who had similar experiences."

Dr. Lorna Breen (seated) with her siblings in 2012.

Courtesy Corey Feist

Long before Berne's death, suicide was known in medicine as an occupational risk. A recent study, based on five years of CDC data from 27 states, estimates that an average of 119 doctors kill themselves each year in the United States. That number is comparable to the suicide rate in the general population, but probably too low, says Dr. Katherine Gold, lead study author and associate professor at the University of Michigan Medical School. The the number could be 300 to 400 deaths per year – according to an oft-quoted estimate – about twice the suicide rate in the general population.

Increased risk is particularly worrying for doctors, Gold emphasized, because they “have access to health care and the health system and understand mental illness and that (it) is a treatable disorder – and we are still seeing rates as high as (at least) the total population. "

Doctors are also more likely to experience depression than the general population. The problems arise during the stressful years of medical school, and at the beginning of the assistantship – when it was discovered that doctors' DNA ages six times faster than that of their non-doctors – the rate of depression quadruples in the first four months. Across all residency programs, an average of one third of doctors met the diagnostic criteria for major depression. Between 2004 and 2014, suicide was the second leading cause of death after cancer among these newly qualified doctors. According to an analysis, a second peak in the risk of suicide occurs in late middle age.

These phenomena are often referred to as burnout, but that's arguably "a misnomer for what's happening," said Pamela Wible, an Oregon family doctor and mental health activist. "It minimizes the sacrifice and makes them responsible for the situation."

Wible began studying doctors' suicide in 2012 after three of her colleagues died of suicide within 18 months. She has recorded more than 1,600 deaths in the next nine years, and her analysis reveals systemic factors for mental health problems "that are the norm in medical education and practice, and this is a pre-pandemic," she says. The pandemic was like "the icing on the cake," she adds. "What most people suffer from goes well beyond this pandemic."

During their training, many doctors work on shifts that exceed 24 hours, and in some specialties – including emergency medicine, surgery, obstetrics, and intensive care – the strenuous hours and sleep deprivation continue after the assistantship. Several doctors told Vox that they did not have time or suitable places to eat and drink during their shifts.

Many of the problems have become entrenched, according to Wible, because half of US doctors are hired as independent contractors and not protected by many labor laws. Other industries like "the aviation industry, the police force, the fire department" have stricter protections and "value their workers" more, she argues, adding that even her groomer cannot work 8-hour shifts without breaks under Oregon Labor Law.

Doctors and nurses also routinely treat patients in understaffed departments and often cannot deliver the care they want and should because of business decisions in their health systems and gaps in patient access to health insurance. "Our moral compass is being incredibly compromised by the systemic barriers in the US that made it the bottom line rather than what we can do for patients," said Mona Masood, a Philadelphia psychiatrist who served Doctors last year has dealt with in crises.

The structural factors that contribute to doctors 'mental illness and suicide are superimposed on doctors' potentially vulnerable psychology. Medicine attracts people who may be at higher risk for mental health problems, says Masood: powerful perfectionists who put tremendous pressure on themselves to be successful and to help their patients. "To become a doctor, you not only have to be intelligent in the matter, you also have to be the best of all, have all the answers," she explained. "You get applauded and you get so much positive feedback when you sacrifice yourself."

This psychology has led to another paradox: Despite strong evidence of the importance of treating mental health problems, "there is an enormous stigma in medicine about getting help, asking for help, admitting that you've suffered in the first place," says Jessi Gold, a Washington University psychiatrist who specializes in the treatment of health workers. "Emotions, struggles, are imperfections, and medicine is a field of perfection."

“Health workers have not yet processed what they have experienced. We were still in a state where we were constantly taking care of people. ”-DR. Katherine Gold

Untreated depression and burnout among doctors have consistently been associated with a higher risk of malpractice, poor patient safety and, for doctors, a risk of suicide. It is not yet clear how Covid-19 has affected the suicide rate of doctors. Although the rate in the general population declined in the first few months of the pandemic, there are worrying indicators among health workers.

A poll by the Washington Post-Kaiser Family Foundation found that six in ten health workers reported that pandemic stress had harmed their mental health, three in ten had considered quitting the healthcare system, and more than 50 percent said they were burned out. Research on U.S. Emergency Services health workers found that spikes in exhaustion and burnout increased during Covid-19, with up to a fifth being at risk of PTSD. These results reflect studies conducted from China, Canada, Italy and other countries during the pandemic.

In the midst of the pandemic crisis, Masood created the Physician Support Line, a support hotline for doctors and medical students that protects their privacy. She says her service has seen explosive demand: over the past year, they have received more than 2,500 calls from doctors. Wible runs another hotline for doctors affected by suicidality, and says that demand rose so much during the pandemic that it started offering Zoom group calls.

Now that Covid-19 vaccines are rolled out and the stress of the pandemic in the US is easing, many people want to move on. But Masood worries about doctors who may not be able to do it and who feel like they have nowhere to go. For the past year and a half, she says, many of her colleagues have shared a version of the same sentiment: "We felt left to die."

"How do I get back from this?"

Like Scott Jolley's family, the family of Lorna Breen, the New York doctor who committed suicide in April 2020, say she did not have any mental illness. But Breen was a perfectionist who lived and worked in a pressure cooker environment that left her no room to recover after falling ill with the pandemic.

When not running the busy emergency department at New York Presbyterian's Allen Hospital in New York City, she played the cello semi-professionally, trained for marathons, and studied for an MBA. On March 13, the 49-year-old was working on her first coronavirus shift. Five days later, she developed a fever and later tested positive for Covid-19 – and then worked remotely through her illness.

She returned to the hospital on April 5 – a list of nine 12-hour shifts for the month, according to her colleagues. But at a moment when the city's death rate skyrocketed to six times its usual level and the hospital was running out of capacity, the 12-hour shift lasted 18 hours, Feist says.

Dr. Lorna Breen, a New York emergency doctor, committed suicide in April 2020.

Courtesy Corey Feist

More than her own health and recovery, she was concerned about her patients and how failure to care for them would affect her career, says her brother-in-law Corey Feist. "She began to articulate as the week wore on that she was back, that people were realizing she couldn't keep up, and that this was going to be a career limit," he recalls. But she was "exhausted from the very bad illness," he says, and she worked incredibly hard.

On April 9, she was "almost catatonic" and, according to her sister Jennifer Feist, could not get up from her chair. The family reached out to Breen's boss, Angela Mills, chief of emergency medicine at New York-Presbyterian, to check on Breen at her apartment. Mills says she found Breen on a small bench in her doorway, hunched over in a fetal-like position, with a scarf tied around her.

“She was having trouble making eye contact and didn't speak much,” recalls Mills. She says Breen always managed to articulate her concern about whether she would be able to go back to work. “She made a couple of comments, 'I won't be able to get back from this. How am I supposed to face the people? ‘”, Mills tried to calm her down while she waited for another friend of Breen's to arrive.

The Feists arranged for Breen to be driven from New York to their Virginia home. When Breen reached her family, they could hardly recognize them. “Her eyes were cloudy and she looked dazed. Her whole affect was different. She moved slowly, spoke slowly, ”Corey Feist recalls. "She couldn't answer simple questions about whether she was hungry or not, which fast-food restaurant she wanted to stop at." Her family speculates that the coronavirus may have affected Berne's brain function, but they believe that their stress at work and concerns that mental health problems could affect their medical practice contributed to their suicide over the next month.

"She had enough cognition to realize – especially after she was inducted into the University of Virginia Mental Health Department – that there was a stigma attached to receiving mental health care for doctors," says Corey Feist, "that it affected your medical license and may affect your ability to be a doctor.

A "hidden curriculum"

Medical bodies in 37 states and territories are asking a type of question that could compel a doctor to disclose any mental illness or treatment, according to a recent analysis published in JAMA. In the most intrusive of the states, the questions are far-reaching. Wyoming asks, Have you “ever shown signs of behavior, drug, or alcohol problems?” Or, in Idaho, “Have you been diagnosed and / or treated for any mental, physical, or cognitive illness, including a substance use disorder, that affects your ability to use medicine appropriate skill and security to practice? "

Doctors also waive their medical data protection rights, especially when it comes to mental illness, vis-à-vis the bodies that regulate them. According to a 2017 survey published in Mayo Clinic Proceedings, nearly 40 percent of doctors said they are reluctant to seek treatment or seek treatment for a mental illness due to the effects of medical licensing. In another survey of female doctors, half said they believed they had a mental illness but had not sought treatment, partly out of fear of regulatory authorities.

Even if state regulators left out all mental health questions, as 17 states currently do, there are other ways they can study doctors' mental health history, according to Ariel Brown, who co-authored the JAMA analysis. "A board of directors can invite the applicant for an interview to explain anything they're wrong with," says Brown, a founder of the Emotional PPE Project, a nonprofit that connects health workers with free and confidential therapy.

In 33 states, regulators interview doctors about their mental health

Tim Ryan Williams / Vox

Hospital ID cards – the process used by veterinarians who work in hospitals – can be even more intrusive, says Amanda Kingston, a psychiatrist and assistant professor at the University of Missouri who has worked on doctor suicide. A HIPAA waiver that gives an institution access to a doctor's health record has become a common part of hospital ID cards. “A lot of people sign it because it's part of a 40-page package they're trying to get through to get their job started. But even if they are very careful, there is concern, if they don't (sign) there might be a suspicion as to why, ”she says.

For years, a broad coalition of medical groups and health advocates, including the American Medical Association and the American Psychiatric Association, have urged states to stop punishing doctors for seeking help. They argue that regulators should only ask about mental illnesses that are currently affecting a doctor's ability to practice safely or should even eliminate mental health issues altogether. Questions that are too broad, reformers argue, can deter doctors from seeking assistance and could violate the Americans With Disabilities Act.

State policy is slowly changing. The Medical Board of California, for example, previously asked for a full mental health history, but admitted in a statement to Vox that its old policy "may have deterred doctors from getting the treatment they need". The board said that in response to the feedback, it has shifted the focus of mental health research to current impairments only.

But far-reaching questions remain in many corners of the country and the health system. "State Medical Boards are concerned that if they remove the questions and something happens they could be held liable," says Katherine Gold of the University of Michigan. And unlike lawyers, doctors have raised few legal challenges against the practice. She has no data to show that these questions make patients safer, "and we certainly have anecdotal data that prevent doctors from seeking treatment from asking these questions."

Most of the doctors Vox spoke to for this story said they avoided seeking psychiatric treatment, left the state for treatment, or paid out of pocket to get their health insurance billed avoid. Kingston says she has heard from several coworkers in the past few months who are prescribing their own antidepressants or writing prescriptions for coworkers and then paying cash so there are no electronic records or bills. Washington University psychiatrist Jessi Gold said she routinely received requests not to document sessions or to use paper charts that don't appear in electronic medical records.

Even in places more lenient to doctors diagnosed or treated for a mental illness, confusion and fear of regulatory issues are deep enough to drive problems underground. “It is part of the 'hidden curriculum' of medicine that mental health issues are asked for approval and that can affect you,” added Jessi Gold.

Lorna Breen may not have been aware that her state licensing agency is not asking questions that would require mental health disclosure. Even so, she believed her career was in jeopardy when her mental health stalled, her family told Vox. “Lorna said, 'I'm going to lose my driver's license,'” recalls Feist. "'I will never be able to practice medicine again." What is always more tragic about the fact that she was wrong – and she was wrong about many things – this is a deeply ingrained concept for doctors. "

"None of that had anything to do with my job"

When doctors report a psychological problem to their employers – even voluntarily – the consequences can be traumatic and profound.

Justin Bullock, an intern, says UCSF Medical Center asked him shortly after he was admitted to the same hospital for mental health treatment after attempting suicide in March 2020, to undergo a month-long fitness to work assessment. Bullock was transparent about his mental health in the process, including the diagnosis of bipolar disorder he received in medical school. After the assessment, he says, it is "so much less likely that he will ever want help, ever being transparent if I have problems."

Dr. Justin Bullock outside the UCSF Parnassus Medical Center in San Francisco on June 13th.

Preston Gannaway for Vox

Bullock says he had hair, blood, and urine tests for illicit drug use, a personality test, and a psychiatric exam that looked at questions about his childhood trauma, including sexual abuse. “I had the feeling that none of this had anything to do with my job,” he says. "In this evaluation, you never talked about my performance at work or asked questions about it."

Indeed, Bullock had a distinguished clinical and academic career; During his residency, he won numerous honors and awards and received consistently enthusiastic feedback on his performance with patients.

"There are many parts of this process where they rob you of your humanity" – Dr. Justin Bullock

But if he had had serious errors in his file, he could have faced restrictions in practice or even lose his license to practice medicine. Bullock says he recovered from his suicide attempt but not from the investigation. "There are many parts of this process where they steal your humanity," he says.

The UCSF Medical Center did not comment on Bullock's specific case, but wrote in a statement to Vox:

The mental health of our doctors is of tremendous importance as they face the ongoing stresses in education and work that were exacerbated over the past year by the personal and professional challenges of the COVID-19 pandemic. Es ist ein Thema, das UCSF seit Jahren sehr ernst nimmt und für das wir kontinuierlich daran arbeiten, unsere Unterstützung zu verbessern.

USCF nannte das Programm auch, das Bullock „völlig freiwillig“ durchlief, eine Charakterisierung, die Bullock – die kürzlich die Erfahrungen in einer wissenschaftlichen Arbeit detailliert beschrieben – streitet. „Es ist freiwillig“, sagt er, „insofern Sie die UCSF verlassen oder Ihre Lizenz gefährden können, indem Sie Sie der Ärztekammer melden.“

„Es gibt zu viel Verleugnung, zu viel Scham“

Die Bewegung zur Verbesserung der psychiatrischen Versorgung von Ärzten gewinnt dank der Kampagne von Ärzten und trauernden Familien wie den Jolleys und Feists an Fahrt. Jackie Jolley arbeitet mit der University of Utah zusammen, um Ärzten die Möglichkeit zu geben, sich außerhalb ihres eigenen Gesundheitssystems behandeln zu lassen. "Wir wissen, dass es für Ärzte schwierig ist, Hilfe zu bekommen", sagte David Barnes, der Präsident von Utah Emergency Physicians, gegenüber Vox. „Wir suchen nach Lösungen“

Letztes Jahr gründete Breens Familie die Dr. Lorna Breen Heroes’ Foundation, und im Juli 2020 wurde ein Gesetzentwurf mit parteiübergreifender Unterstützung in den Senat eingebracht.

Im März 2021, fast ein Jahr nach Breens Tod, verabschiedete der Senatsausschuss für Gesundheit, Bildung, Arbeit und Renten einstimmig das Gesetz. Sollte das Gesetz vom Kongress verabschiedet werden, würde es sofort Schulungen zur Selbstmord- und Burnout-Prävention für alle Beschäftigten im Gesundheitswesen unterstützen. Es stellt auch Forschungsgelder zur Verfügung, um die Ursachen von Burnout im Beruf zu untersuchen, wobei „Stigmatisierung und Bedenken hinsichtlich der Lizenzierung und Zertifizierung“ als wichtige Faktoren genannt werden, die untersucht werden müssen.

Scott und Jackie Jolley haben gesehen, wie sie am Heiligabend 2019 vor dem Bauernhaus von Scotts Großeltern saßen. Seit dem Verlust ihres Mannes hat Jackie an der Bewegung teilgenommen, um die psychische Gesundheitsversorgung von Ärzten zu verbessern.

Mit freundlicher Genehmigung der Familie Jolley

Wir brauchen bessere Daten nicht nur über die Ursachen des Problems, sondern auch über die genaue Zahl der Ärzte, die durch Suizid sterben. Die Besorgnis über eine erhöhte Selbstmordrate in der Medizin kursiert mindestens seit den 1920er Jahren, aber wir haben immer noch keine endgültigen Zahlen.

"Wenn es ein Problem ist, das wirklich jemanden interessiert, dann sollte es öffentlich zugängliche Nachverfolgungen geben und einige Anstrengungen unternehmen, um es zu stoppen", sagte ein Arzt aus Boston, der zwei Kollegen durch Selbstmord verloren hat und aus Angst vor dem Arbeitsplatz unter der Bedingung der Anonymität sprach Vergeltung, sagte Vox. „In welcher anderen Branche wäre es akzeptabel, dass talentierte und hochkarätige Leute von Gebäuden springen und alle ängstlich daneben stehen, um Kommentare abzugeben?“

Katherine Gold von der University of Michigan schlägt eine Lösung für das Datenproblem vor: Die staatlichen medizinischen Gremien sollten jedes Jahr die Todesfälle ihrer Mitglieder mit den von ihr verwendeten CDC-Daten zu gewaltsamen Todesfällen nach Beruf vergleichen, um sicherzustellen, dass alle Selbstmorde von Ärzten verfolgt und bilanziert werden zum. „Das ist bis heute nicht passiert“, sagt sie.

Mehrere Bundesstaaten, darunter Michigan und Virginia (wo Breen vor ihrem Tod behandelt wurde), haben Gesetze für „sichere Häfen“ eingeführt, die die Krankenakten von Angehörigen der Gesundheitsberufe schützen und es ihnen ermöglichen, sich ohne Angst um Konsequenzen zu kümmern.

Aber „die größte systemische Lösung besteht einfach darin, die Fragen der psychischen Gesundheit zu beseitigen“, sagt Gold und wiederholt damit andere Reformer. Dies müsste nicht nur bei staatlichen Zulassungsanträgen geschehen, sondern überall, wo Ärzte mit ihnen konfrontiert werden, von der Krankenhauszulassung bis hin zu Formularen zur Erstattung von Versicherungsleistungen.

Scott und Jackie Jolley (rechts) beim Schneeschuhwandern mit den Freunden Myles und Carolyn Greenberg im Jahr 2019.

Mit freundlicher Genehmigung der Familie Jolley

Das könnte bei einer ebenso dringenden Aufgabe helfen: das Stigma über psychische Probleme zu beenden, sagt Jolleys Freund Myles Greenberg, der ehemalige Notarzt. „Wie bei jedem anderen medizinischen Problem erkennt man es früh und interveniert früh und hat eine viel bessere Chance auf ein positives Ergebnis“, sagt er. „Es gibt zu viel Verleugnung, zu viel Scham – dieser kulturelle Schwachsinn in der Medizin, der Menschen daran hindert, die Pflege zu bekommen, die sie brauchen.“

„Das Gute, das dabei herauskommen kann, ist, diese Geschichte immer wieder zu erzählen“, fährt er fort. „Nicht nur die Scotts und Lornas, sondern die anderen Leute, die darunter gelitten haben. Die Machthaber müssen anfangen, ihnen durch den Kopf zu gehen, dass dies ein Problem ist.“

Herausgeber: Eliza Barclay, Katherine Harmon Courage, Daniel A. Gross
Visuals-Editor: Kainaz Amaria
Copy editors: Elizabeth Crane, Tanya Pai, Tim Williams
Fact-checker: Becca Laurie
Engagement editor: Kaylah Jackson

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