Another Cause of Doctor Burnout? Being Forced To Give Immigrants Unequal Care

Dialysis patient

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Jake Harper/Side Effects Public Media

One patient’s death changed the course of Dr. Lilia Cervantes’ career. The patient, Cervantes says, was a woman from Mexico with kidney failure who repeatedly visited the emergency room for more than three years. In that time, her heart had stopped more than once, and her ribs were fractured from CPR. The woman finally decided to stop treatment because the stress was too much for her and her two young children. Cervantes says she died soon after.

Kidney failure, or end-stage renal disease, is treatable with routine dialysis every two to three days. Without regular dialysis, which removes toxins from the blood, the condition is life threatening: Patients’ lungs can fill up with fluid, and they’re at risk of cardiac arrest if their potassium level gets too high.

But Cervantes’ patient was undocumented. She didn’t have access to government insurance, so she had to show up at the hospital in a state of emergency to receive dialysis.

Cervantes, an internal medicine specialist and a professor medicine at University of Colorado in Denver, says the woman’s death inspired her to focus more on research. “I decided to transition so I could begin to put the evidence together to change access to care throughout the country,” she says.

Cervantes says emergency-only dialysis is harmful to patients: The risk of death for someone receiving dialysis on an emergency basis is 14 times higher than someone getting standard care, she found in research published in February. Cervantes’ newest study, published Monday in the Annals of Internal Medicine, shows these cyclical emergencies harm health care providers, too. “It’s very, very distressing,” she says. “We not only see the suffering in patients, but also in their families.”

There are an estimated 6,500 undocumented immigrants in the U.S. with end-stage kidney disease. Many of them can’t afford treatment or private insurance, and are barred from Medicare or Medicaid. This means the only way they can get dialysis is in the emergency room.

Cervantes and her colleagues interviewed 50 healthcare providers in Denver and Houston and identified common concerns among them. The researchers found that providing undocumented patients with suboptimal care because of their immigration status contributes to professional burnout and moral distress.

“Clinicians are physically and emotionally exhausted from this type of care,” she says.

Cervantes says the relationships clinicians build with their regular patients conflicts with the treatment they have to provide, which might include denying care to a visibly ill patient, because their condition was not critical enough to warrant emergency treatment.

“You may get to know a patient and their family really well,” she says. Providers may go to a patient’s restaurant, or to family gatherings such as barbacoas or quinceañeras.

“Then the following week, you might be doing CPR on this same patient because they maybe didn’t come in soon enough, or maybe ate something that was too high in potassium,” she says.

Other providers, Cervantes says, report detaching from their patients because of the suffering they witness. “I’ve known people that have transitioned to different parts of the hospital because this is difficult,” she says.

Melissa Anderson, a nephrologist and assistant professor at the Indiana University School of Medicine in Indianapolis who was not involved in Cervantes’ study, says Cervantes research matches her own experience. She says that when she worked at a safety net hospital in Indianapolis, patients would come to the ER when they felt sick. But some hospitals would not provide dialysis until their potassium was dangerously high.

To avoid being turned away when their potassium level was too low, she says, patients in the waiting room would drink orange juice, which contains potassium, putting themselves at risk of cardiac arrest.

“That’s Russian roulette,” Anderson says. “That was hard for all of us to watch.”

Anderson eventually stopped working at that hospital, and like Cervantes, has also worked on research and advocacy efforts to change how undocumented immigrants with kidney failure are treated. “I practically had to take a class in immigration to understand what’s going on,” she says. “Physicians just don’t understand it, and we shouldn’t have to.”

Providers in Cervantes’ study also worried that these avoidable emergencies strain hospital resources — clogging emergency departments when undocumented patients could simply receive dialysis outside the hospital — and about the cost: Emergency-only hemodialysis costs nearly four times as much as standard dialysis, according to a 2007 study from researchers at Baylor College of Medicine.

Those costs are often covered by taxpayers through emergency Medicaid, which pays for emergency treatment for low-income individuals without insurance. In a study published in Clinical Nephrology last year, Anderson and her colleagues found that at one hospital in Indianapolis, the state paid significantly more for emergency-only dialysis than it did for more routine care.

Areeba Jawed, a nephrologist in Detroit who has performed her own survey research into this issue, said many providers don’t understand how much undocumented immigrants actually contribute to society, while receiving few of the societal benefits. “A lot of people don’t know that undocumented immigrants do pay taxes,” she says. “There’s a lot of misinformation.”

“I think there are better options,” says Jawed, who has treated undocumented patients there and in Indianapolis.

To work around this problem, some hospitals simply provide charity care to cover regular dialysis for undocumented patients. But Cervantes argues that a better solution is a policy fix. States are allowed by the federal government to define what qualifies as an emergency.

“Several states, like Arizona, New York and Washington, have modified their emergency Medicaid programs to include standard dialysis for undocumented immigrants,” she says.

Illinois covers routine dialysis and even passed a law allowing undocumented immigrants to receive kidney transplants, she points out.

“Ideally, we could come up with federal language and make this the national treatment strategy for undocumented immigrants,” Cervantes says.

Ultimately, Cervantes says providers don’t want to treat undocumented patients differently. “At the end of the day, clinicians become providers because they want to provide care for all patients,” she says.

This story was produced in partnership with Side Effects Public Media, a news collaborative covering public health.

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Syrian Military Retakes Full Control Of Damascus

A member of the Syrian government forces stands at the entrance of Yarmouk refugee camp on Monday, the day that the military announced it had full control of Damascus and its outskirts.

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Syria’s military announced Monday that it cleared Damascus and its suburbs of the last elements of the Islamic state militant group, ISIS.

According to government reports, the Syrian army had driven ISIS out of the rebel group’s last remaining strongholds in southern Damascus; this marks the first time that President Bashar al-Assad’s government has total control of the capital since the rebellion began in 2011.

Syrian state TV broadcast footage of tanks rolling through a shattered neighborhood once held by rebels, as government troops waved the national flag. Army Gen. Ali Mayhoub announced that military operations in and around the capital had been a success and that the area is “completely secure” after the army captured former ISIS strongholds of Yarmouk refugee camp and the Hajar al-Aswad district south of the capital.

The military left “big numbers of Daesh (ISIS) terrorists dead,” reported the Syrian Arab News Agency.

The Syrian Observatory for Human Rights, a U.K.-based monitoring group downplayed the military victory, saying that it was a “secret agreement” between the government and ISIS that allowed the rebels to depart.

The organization claimed that ISIS fighters and their families boarded “some 32 buses that carried out about 1600 people aboard” and that they were driven toward the Syrian Desert.

Syrian state media denied there was a deal to evacuate fighters, according to the Associated Press, which quoted one military official as saying that a two-day truce had been arranged to evacuate women, children and the elderly on Sunday night from Hajar al-Aswad.

Amy Austin Holmes, a fellow at the Woodrow Wilson Center, told NPR that this was an historic day for Assad’s government. “The regime has been saying for some time now that they want to take back all of Syria. This is just one more step toward accomplishing that goal.”

She added, “Whether it will be able to retake all area currently under Kurdish control, that is a whole other question.”

With support from Russia and Iran, Syrian forces have made sweeping victories in territories controlled by the opposition. The spring saw thousands of rebel fighters surrender and board crammed buses out of eastern Ghouta, a suburb of Damascus, following weeks of bombardment.

In April, the Syrian army took control of at least two villages from the U.S.-backed Syrian Democratic Forces east of the Euphrates River, near the border with Iraq where Kurdish forces had control.

In 2016, government forces enjoyed their biggest victory, capturing neighborhoods in Aleppo that rebels had controlled for years. As Syria’s largest city, Aleppo was considered “the heart of the revolution.”

More than 5.6 million people have fled the war-torn country since the civil war started and 6.6 are internally displaced.

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For Vegas Oddsmakers, Home Team's Fairy Tale Season Becomes A Frightfest

Marc-Andre Fleury, winner of multiple Stanley Cups with the Pittsburgh Penguins, had been cast off to Vegas when a younger player took his spot as starting goalie. Now in goal for the Golden Knights, he’s four wins away from adding his name yet again to the Cup.

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“How good can they be? Spoiler alert: Not Very Good.”

That was one hockey writer’s analysis of the Vegas Golden Knights back in July, not long after the expansion draft in which the brand-new franchise picked its roster from the dregs of other NHL teams. In other words, roughly 10 months before this Not Very Good ™ team (spoiler alert!) made the Stanley Cup final on Sunday.

But we don’t mean to single out one unfortunate prediction here. In the days immediately following the draft, the unfortunate predictions came hot and heavy.

There was this one, which, after the draft, opened with what it called “the obvious”: “We knew the Knights would be bad, but no one believed the Knights would be this bad.” Then this one — headlined “Wow The Golden Knights Are Going To Be Bad” — which predicted “this team isn’t going to have more than a dozen regulation wins.” (They won 51 games in the regular season, by the way, 37 in regulation.)

There were so many, in fact, here are some tweets to save us all a little time.

Remember when we all thought the Golden Knights were going to be better than expected? Yeah, nope.

— Scott Wheeler (@scottcwheeler) June 22, 2017

Wow the Golden Knights are gonna be so, so bad.

— Andrew Berkshire (@AndrewBerkshire) June 22, 2017

Now, there’s no shame in getting the future wrong. Goodness knows your humble reporter would have, if asked for an opinion on the Golden Knights at the time.

The point is just that, with some rare exceptions, virtually no one was bullish on this team coming into the season. And frankly, they would have been a little mad if they were: Before the Golden Knights — or, as their sometimes known, the #GoldenMisfits — the past four expansion teams to join the NHL all finished comfortably seated in the basement of their division.

Made sense, then, that the odds of Vegas winning the Cup at the start of the season hovered around 200-to-1. Jeff Sherman, an oddsmaker at Westgate, noted that at one point his Las Vegas casino had the team’s odds at 500-to-1.

Highest Stanley Cup odds on @GoldenKnights we had was 500/1 during preseason and before game 1 of the regular season … 13 tickets ranging from $10 to $60

— Jeff Sherman (@golfodds) May 20, 2018

Of course, those odds don’t make a whole lot less sense months later, when seen in the harsh light of May — and when, with Vegas four wins away from the Cup, a bettor’s $60 last year stands a decent chance of turning into $30,000 next week. Some bets reportedly stand to pay out at $120,000.

What was once an act of faith (or madness) by an overeager fan could now be a nice car paid in cash. Or, if the bettor happened to be a fan of the Tampa Bay Lightning or the Washington Capitals, both of which still have the chance to beat Vegas for the Cup, that preseason Hail Mary ticket could now seem like a divinely ordained test of loyalty.

Either way, Forbes points out that while casinos stand the chance of staggering losses, perhaps we shouldn’t be weeping too much for their plight.

“Hockey betting has long been at the bottom of the barrel for major sports in Nevada. This year, however, hockey betting is up 35% or so across the board,” Jim Murphy of told the publication. “The Golden Knights have also created a lot more traffic in casinos which not only helps betting revenue in other sports but in other areas of casino operations—slot play, food and beverage.”

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'We Were Expecting That She Will Return Alive': Family Mourns Slain Pakistani Student

Abdul Aziz Sheikh (center), the father of Sabika Sheikh, a victim of a shooting at a Texas high school, shows a picture of his daughter in Karachi on Saturday.

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A Pakistani exchange student was one of the 10 people shot dead in the Santa Fe High School shooting on Friday. She came from a country where militants have attacked schools and killed students, so her death — in a country that once seemed so much safer than Pakistan — shocked many in her home country.

Sabika Sheikh, 17, was in Santa Fe through a State Department exchange program that is meant to foster better understanding of Muslim culture. Her participation in the program reflected Sheikh’s ambitions: she wanted to be a diplomat, says her 60-year-old great-uncle Abdul Jalil Albasit.

She was meant to return to her home city of Karachi next month to celebrate the end of the holy Muslim month of Ramadan with her family.

“Obviously, this is a terrible situation for her entire family,” Albasit tells NPR. “We were expecting her return on the ninth of June. We were expecting that she will return alive.”

Her father Aziz Sheikh says he watched the shooting unfold on CNN as he and his family ate iftar — the evening meal that breaks the day-long fast that Muslims undertake every day during Ramadan. Traditionally, it is a time when families gather.

Sheikh, a businessman in his mid-40s, told the Pakistani news channel Geo that he had contacted the local coordinator of his daughter’s exchange program. “I kept in touch with him for the next two or three hours. I kept calling him and he kept calling me,” he said. “Then, around three in the morning – he confirmed that she’s dead.”

Jai Gillard, a freshman who was in the class where the mass shooting started, looks at a cross for Sabika Sheikh before signing it at a memorial for the victims of the Santa Fe High School shooting on Monday in Santa Fe, Texas.


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Muslim funeral prayers for Sheikh were already held on Sunday. She will be buried in Karachi as soon as her body is repatriated, expected by Wednesday.

Albasit says Sheikh’s parents were aware of school shootings in the U.S., but they never thought it would happen to their daughter.

“We were confident that Sabika will be very much safe there,” Albasait tells NPR.

For decades, ambitious Pakistani parents have worked to send their children to the U.S. and Europe for an education. It is seen as opening up lucrative opportunities in Pakistan and the possibility of citizenship abroad. Plus, the U.S. seemed safe after years of militant attacks in Pakistan.

Pakistani parents have had to contend with deadly risks when sending their children to local schools. Militants have killed thousands of people in Pakistan since 2001. In 2014, Taliban gunmen stormed a school run by the Pakistani army and killed more than 140 people. Two years before that, in 2012, Taliban gunmen boarded a bus and shot Malala Yousafzai, then 15, in the head. They were angry that she was promoting girls’ education. She survived, and in 2014, was awarded the Nobel Peace Prize.

Albasit, Sheikh’s great-uncle, said despite the tragedy of losing a family member, he would still support any of Sabika’s three younger siblings if they wanted to study in the U.S.

“If any children of our family will get any such opportunity, we should allow him or her to proceed,” Albasit said. He said life was ultimately in the hands of God.

In a upscale market in Islamabad, other Pakistanis tried to make sense of the Texas school attack.

“I’ve actually lost somebody in a terrorist attack,” said Akbar Durrani, a 40-year-old employee at the United Nations. “Someone very, very close, so I know how it feels and I know it can easily be someone around you.”

Still, he says, he never imagined a Pakistani student would be a victim of a school shooting in America.

“It seems like it wouldn’t happen to people who go to the U.S.,” Durrani said. “But this time around, it kind of hit home that it could happen to anyone.”

Madiha Kausar-Butt, a 26-year-old homemaker, was strolling through the market with her husband. The attack, she said, taught her that “life is uncertain … Even in America now, you don’t know what’s going to happen next.”

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Stacey And Cardiff Take On The Commencement Speech


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The commencement speech is a proud tradition. Or at least it’s a tradition.

And since no college invited Stacey and Cardiff to give a commencement speech, they’re taking to the podcast to offer their own brand of evidence-based wisdom for new college grads.


Highest Educational Levels Reached by Adults in the U.S. Since 1940

The Education Wage Premium Contributes to Wage Inequality

High income improves evaluation of life but not emotional well-being

Oh no you didn’t!

Why Our Brains Fall for False Expertise, and How to Stop It

Long commutes make you fat, tired, and miserable

Opportunity Costs Surrounding Exercise and Dietary Behaviors

The welcome, belated backlash to the open-plan office

The Open-Office Trap

Music: “Land of Hope and Glory

Find us: Twitter/ Facebook.

Subscribe to our show on Apple Podcasts, PocketCasts and NPR One.

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What Makes A Jazz Standard?

Saxophonist Coleman Hawkins and trumpeter Dizzy Gillespie in concert with the Cannonball Adderley Quintet in November 1960.

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When does a pop song become canon — so influential, so durable, that it can be counted among the classics that make up the Great American Songbook?Christian McBride, bassist, record producer and host of NPR’s Jazz Night In America, joined Audie Cornish on All Things Considered to discuss just how a jazz standard comes to be — as well the role those songs play in a young musician’s development and the criteria for crowning new classics. Hear their conversation at the audio link.

Interview Highlights

On the ground rules for standards

The way a song becomes a standard in the first place is because many people record it. Coleman Hawkins recorded his version of “Body and Soul.” It became a huge jazz hit and it became pretty much the standard for tenor saxophone playing. [But] I think a song has to be covered by a vocalist to become a standard, because people always connect with vocalist. So when people like Frank Sinatra or Ella Fitzgerald or Sarah Vaughan, when a vocalist gives their interpretation of one of these great modern standards, there’s more of a chance of that song becoming a standard.


On interpreting the American Songbook

I think at some point inside of the last half century, there’s been more focus, particularly in the jazz world, on original composition. There was a bridge between the Great American Songbook and modern jazz where you had the bebop era — where people like Charlie Parker and Dizzy Gillespie were covering standards in a very, very clever way. To get around paying royalties to these composers, they would take the harmonic progression of a particular standard and write a new melody on top of it. So you take a song like Charlie Parker’s “Quasimodo” — that was actually “Embraceable You.”

There used to be [an] unspoken law in the jazz world is that you had to know a significant amount of standards. Anytime any of these older jazz legends went out to hear some younger musicians and they would hear them play their music, they would say, “You know, that’s great, but do you know ‘Polka Dots and Moonbeams‘? ‘I’ll Remember April‘? ‘Ill Wind‘?” They would call these old standards, and if you didn’t know them? “Hey kid, get back in the bullpen and practice.” That was the way you earned your right to be a jazz musician.

On the case for a more recent standard

The last great standard, maybe, would have been “Birdland,” which was composed by Joe Zawinul [for the band Weather Report in 1977]. I think I can guarantee that from the time that album was released through the 1980s, every single high school and college band played that song. And then Manhattan Transfer recorded it and it became an even bigger hit than it was when Weather Report recorded it. So yes, that song is definitely a standard.

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Experimental Ebola Vaccinations, Considered 'Paradigm Shift,' Begin In Congo

Doctors Without Borders staff enter an Ebola security zone at the entrance of the Wangata Reference Hospital in Mbandaka, in the Democratic Republic of the Congo.

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Health workers have unsheathed their experimental new weapon against the Ebola virus in the northwest reaches of the Democratic Republic of the Congo. On Monday, the World Health Organization, together with local and international partners, began administering Ebola vaccinations in the region, where at least 49 suspected cases have been reported since early April and at least 26 people are believed to have died.

More than 7,500 doses of the rVSV-ZEBOV — which is still unlicensed — are now available in the country and 8,000 additional doses will be available soon, according to WHO. Health workers in the bustling port city of Mbandaka and the remote village of Bikoro have already begun to receive their vaccines.

First #ebola vaccination done In Mbandaka, DRC Guillaume Ngoie Mwamba , EPI manager leads the way #VaccinesWork

— Seth Berkley (@GaviSeth) May 21, 2018

The effort marks the first widespread use of the vaccine since inaugural tests in 2015, toward the end of the massive outbreak in West Africa. That epidemic killed more than 11,300 people across three countries between March 2014 and June 2016.

But of the thousands of adults who received the vaccine during the trial, not one became infected. Add to that number some 8,000 volunteers tested in Africa, Europe and the U.S., and WHO says “the estimated vaccine efficacy was 100%.” It has yet to be officially licensed, but authorities have obtained special permission to use it in the latest outbreak.

“Use of the VSV-EBOV vaccine marks a paradigm shift in how we fight #Ebola,” Peter Salama, WHO’s deputy director-general for emergency preparedness and response, tweeted on Monday. “This is an important moment that changes the way we’ve seen Ebola for 40 years.”

The areas with red markers represent the major regions where people were confirmed dead of Ebola during the 2014-2016 outbreak in Guinea, Sierra Leone and Liberia. The areas with blue markers represent Bikoro and Mbandaka, the two places in the Democratic Republic of the Congo with confirmed cases of Ebola in the 2018 outbreak.

Still, health workers remain unnerved by the Ebola outbreak’s recent spread to Mbandaka, where four cases have been confirmed. Unlike the site of the first reported cases, Bikoro, which is a small village over 10 hours by car from the nearest airfield, Mbandaka has a population of more than 1 million people perched on the Congo River.

The city’s congestion and connection with other regions potentially makes it a much more dangerous launch pad for a deadly disease spread primarily through direct contact with the blood or other bodily fluids of infected people.

So WHO, the country’s Ministry of Health, Doctors Without Borders and other groups are embarking on what’s called a “ring vaccination.”

“Basically making a ring around a person who has tested positive and then making a second ring — so contacts of contacts,” WHO spokesperson Tarik Jasarevic, who was vaccinated himself as part of the drug’s trial run, explained to NPR’s Don Gonyea on Sunday. “Also, those who will receive vaccination are health workers and the responders. So we consider that for each confirmed case of Ebola, there will be between 100 and 150 people who will be eligible for vaccination.”

Funeral workers will be among those vaccinated, as well.

Karsten Voigt of the International Federation of Red Cross and Red Crescent Societies has been training volunteers specifically on how to handle bodies during burials. Community burial practices in West Africa were one of the prime drivers of the disease’s transmission in the 2014 outbreak.

“A dead body has a very high viral count,” he told NPR’s Scott Simon. “It is very dangerous to touch the body or to move around in the house where this person has died. So the volunteers, Red Cross volunteers, who conduct this work have to be protected. They wear their protective kits, and they have been trained on how to deal with this body.”

Hopes are high that this new weapon will have a powerful impact in the fight against Ebola. But memories of the massive outbreak just years ago — and the lessons that came with them — remain fresh in the minds of residents.

“I tried to greet a friend by shaking hands and he said: ‘No, did you forget that Ebola is here?’ ” a local teacher told the BBC. “They forbid people to greet by using hands, eating animals from the forest, and people are now living with fear.”

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