Port-au-Prince, Haiti
Nearly four months after its reappearance in Haiti, the number of cholera victims has risen to 496 dead, the Ministry of Public Health and Population (MSPP) reported Saturday.

The country has already registered 25,182 suspected cases and 21,407 hospitalized, 73 new, while 312 of the 496 deaths occurred in health institutions and 184 in the communities.

In a bulletin, the health authorities state that the average age of those infected is 19 years, and the positivity rate is 37.25%.

56.60% of the accumulated suspected cases are men, and the remaining are women. The most affected age group is 1 to 4 years old, with 374 confirmed cases out of more than 3,000 suspected cases.

The most affected department is the West, where Port-au-Prince is located and where more than one-third of the population lives, with 1,155 confirmed cases for 16,408 suspected cases.

The World Health Organization (WHO) warned last week that the world is suffering unprecedented cholera outbreaks in countries affected by climate disasters and other crises. As a result, vaccines to prevent this disease have become “extremely scarce.”

The cervix is the lowest part of the uterus and connects the uterus to the vagina. It is covered in tissues made up of cells that grow and change. Sometimes, these can become abnormal. Most cases of cervical cancer are caused by the HPV virus forming cancerous cells in the cervix.

Abnormalities of the cervix can be detected, destroyed and removed before it reaches the cancerous stage. If detected too late, they can spread or grow deeper causing great damage and discomfort. Symptoms of concern include vaginal bleeding between periods, pain during intercourse, pelvic pain and unusual discharge. These symptoms are also common to various ailments of the female reproductive system. Therefore, it is necessary that women over 18 do a yearly Pap smear test with their gynaecologist to ensure any abnormalities are detected.

With this type of cancer affecting such a large population of women, it is crucial that greater access to resources for prevention and early detection are made available to women across the island. Telemedicine platforms, such as MDLink, are one such resource that can aid in limiting the number of women affected by cervical cancer in Jamaica. The following are key ways telemedicine can aid in the fight against cervical cancer:

Early detection

Early detection leads to a decrease in death and disease of cervical cancer. If you believe you are experiencing issues aligned with early signs of cervical cancer or HPV, reaching out to a gynaecologist online may be a useful first step. MDLink can serve as your first step in assessing the symptoms you are experiencing in order to determine if you should be further tested for cervical cancer (through a Pap smear, HPV test or pelvic examination) or if it can be ruled out with another diagnosis. Additionally, your physicians can send over a prescription virtually to help ease your symptoms without you ever having to go in office. Taking advantage of the services MDLink has to offer may save you the time and money for an in-person gynaecologist visit.

Efficient follow-up

After a positive HPV screening or an abnormal Pap smear, you and your doctor can utilise telemedicine to take advantage of out-of-office care and advice. These results do not necessarily suggest that you have cancer and your gynaecologist can discuss with you what the results mean and what your next steps will be. Next steps may include surgery, self-examinations, medication and/or additional screenings. Telemedicine allows you to meet with your doctor via telephone, video call or audio call, all while in your office, home or car — wherever is most comfortable and convenient. It is an advantageous next step, particularly if your follow-up care is not emergent.

Increased access to specialist care

With a shortage of specialists concentrated in urban areas, telemedicine allows those who live in rural areas or outside of busy cities to also gain access to the same level of specialist care with a gynaecologist. Patients are able to know they are getting the best treatment with the most experienced doctors all without the inconvenience of travelling far for assessments and treatment.

Easy access to professional advice relating to vaccines and treatment

The HPV vaccine is one of the main preventative treatments that women aged 18 and older can take to prevent these cell changes and reduce the risk of cervical cancer. Telemedicine can be the starting point in speaking with your doctor about the safety, efficiency and side effects of taking this vaccine.

Ensuring that our women have reliable, convenient and safe access to modern health care is vital to a healthy nation. Cervical cancer affects our mothers, sisters, aunts, friends and family and telemedicine platforms such as MDLink seek to ensure that everyone, regardless of their age or social standing, has access to the highest standard of specialist care. Limiting the cases of cervical cancer will ensure long and healthy lives and telemedicine is just one tool which can be taken advantage of to support our women.

Dr Ché Bowen, a digital health entrepreneur and family physician, is the
CEO & founder of MDLink, a digital health company that provides telemedicine options. Check out the company's website at www.theMDLink.com. You can also contact him at drchebowen@themdlink.com.

Outside the Manhattan shop, he displayed another purchase — a jar containing dried flowers of a cannabis strain called Banana Runtz, which some aficionados say has overtones of "fresh, fruity banana and sour candy".

Inside the store run by the non-profit Housing Works, shelves brimmed with vape cartridges suggesting flavours of pineapple, grapefruit and cereal milk, written in rainbow bubble letter print.

For decades, health advocates have chided the tobacco industry for marketing harmful nicotine products to children, resulting in more cities and states, like New York, outlawing flavoured tobacco products, including e-cigarettes.

Now as cannabis shops proliferate across the country, the same concerns are growing over the packaging and marketing of flavoured cannabis that critics say could entice children to partake of products labelled "mad mango", "loud lemon" and "peach dream".

"We should learn from the nicotine space, and I certainly would advocate that we should place similar concern on cannabis products in terms of their appealability to youth," said Katherine Keyes, a professor of epidemiology at Columbia University who has written extensively about the rise in marijuana use among young people.

"If you go through a cannabis dispensary right now," she said, "it's almost absurd how youth-oriented a lot of the packaging and the products are."

Keyes added that public health policymakers — and researchers like her — are trying to catch up with an industry and marketplace that is rapidly expanding and evolving.

New York, which legalised recreational marijuana in March 2021, forbids marketing and advertising that "is designed in any way to appeal to children or other minors".

But New York's state Office of Cannabis Management (OCM) has yet to officially adopt rules on labelling, packaging and advertising that could ban cartoons and neon colours, as well as prohibit depictions of food, candy, soda, drinks, cookies or cereal on packaging — all of which, the agency suggests, could attract people under 21.

"Consumers need to be aware — parents need to be aware — if they see products that look like other products that are commonly marketed to kids, that's an illicit market product," said Lyla Hunt, OCM's deputy director of public health and campaigns.

Hunt recently saw a cannabis product calling itself "Stony Patch Kids" that she said looked like the popular candy "Sour Patch Kids".

Similar products are being sold by the dozens of illegal pot dispensaries that operate out in the open and that officials worry are selling unsafe products. Once packaging and marketing standards are established, the illicit marketplace will likely not comply, experts say.

State officials hope that products bought at licensed dispensaries will help.

"We can regulate until we're blue in the face. But the truth is, it's a partnership between a compliant industry, strong regulations that are robust in their protections for youth and then with parents, too," Hunt said.

New York Governor Kathy Hochul announced Thursday the upcoming opening of the state's second legal dispensary, which will be located in Manhattan's West Village. The new venture — called "Smacked" — will open as a pop-up next week before opening a permanent location.

Under state law, a minor in possession of marijuana would face a civil penalty of not more than $50. Licensed cannabis retailers who sell to minors face fines and the loss of their licences, but no jail time.

Science has long established the addictive nature of nicotine and the health maladies associated with smoking tobacco, including cancer and emphysema.

Less settled are the health repercussions from vaping, particularly among children whose bodies and internal organs have yet to fully develop.

While smoking tobacco cigarettes has fallen among teens and young adults, the use of e-cigarettes and vapes has risen.

A handful of states — California, Massachusetts, New Jersey, New York, and Rhode Island — have bans on most flavoured tobacco products, including e-cigarettes and vapes. An increasing number of cities, including New York City, also have similar bans.

But those rules need to be broadened to include marijuana, said Linda Richter with the Partnership to End Addiction, who says the issue has yet to be widely addressed.

"There is more scrutiny on the tobacco industry, and very, very little in terms of rules, regulations, scrutiny, limitations when it comes to the cannabis industry," she said.

Because of the relative infancy of the legalised industry, she added, states have yet to coalesce rules on a single national standard. States often look to the federal government to set those standards, but marijuana remains illegal on the federal level.

"That's a real issue where you don't have the weight of the federal government in terms of standards of packaging and marketing," to set parameters to avoid appealing marketing to young people, Richter said.

Anti-smoking groups, including the Campaign for Tobacco-Free Kids, have long railed against the tobacco industry for its marketing, such as using cartoon characters to help market their products. In more recent years, they've campaigned against flavoured nicotine products, including those in vaping form.

But thus far, such groups have not put the marijuana industry in its cross-hairs.

A study released earlier this month documented the steep rise in poisonings among young children, especially toddlers, who accidentally ate marijuana-laced treats.

The uptick in cases coincides with the rise in the number of states allowing the use of marijuana for medicine or recreation. Medical use of cannabis is currently allowed in 37 US states, while 21 states allow recreational use.

"When you're talking about strawberry cheesecake, or mango, or cookies and cream flavours, it's very difficult to argue that those are for older adults," said Dr Pamela Ling, the director for the Centre for Tobacco Control Research and Education at the University of California in San Francisco.

"Folks who consider themselves to be more like cannabis aficionados," she said, "would say that smoking a flavoured cannabis product is like putting ketchup on your steak."

The National Board of Examinations (NBE) has released the curriculum for FNB Hand and Micro Surgery.

I. PROGRAMME GOALS & OBJECTIVES

1. PROGRAMME GOAL

The goal of the Hand Surgery and Microsurgery Fellowship of the Departments of Plastic Surgery and Orthopaedic Surgery and its affiliates is to prepare physicians for a career in Hand surgery either as clinical surgeons or academic surgeons. It is the goal of the program to recruit outstanding men and women who desire to become leaders in their community or academic program

It is the goal of the program to have residents/fellows understands the practice of Hand and Micro surgery and to provide ethical lessons through faculty example and discussion. It is our goal for the resident/fellow to be competent in the knowledge of the practice of Hand surgery, to carry out this practice in a professional and ethical manner, to develop skills for continuing and self-reflective education in the field of hand surgery, and to understand hand surgery in the context of the healthcare system in which they will practice.

The purpose is to help the Fellow develop an understanding of surgical and medical management of musculoskeletal problems of the entire upper extremity. The program provides a mix of basic hand surgery and complex hand surgery conditions.

The goal Hand and Upper Extremity Fellowship is to optimally prepare surgeons- in-training to render contemporary, compassionate and fiscally-responsible care for all pathologies afflicting the hand, wrist, while inspiring the fellow to give back to the specialty through engagement in scientific inquiry and practice as a life-long learner and teacher.

Training emphasizes traumatic and acquired conditions of the hand, wrist, forearm, elbow, arm, and shoulder including peripheral nerve disorders, microsurgical training in collaboration with Plastic Surgery, brachial plexus arthroscopy of the hand, wrist, joint replacement of the hand, wrist, and congenital hand surgery.

2. PROGRAMME OBJECTIVES

The fellowship combines clinical, teaching, and research opportunities for Plastic, Orthopaedic and General surgeons interested in furthering their knowledge of the upper extremity. Training emphasizes traumatic, congenital, and acquired conditions of the hand, wrist, forearm, and elbow.

Objectives include:

i. Development of clinical expertise in the diagnosis and management of disorders involving the upper extremity.

ii. Refinement of clinical skills so new problems can be addressed based on path physiologic and patient-oriented information, allowing an appropriate course of action to be initiated.

iii. Attainment of surgical expertise in traumatic, congenital, and acquired disorders of the upper extremity.

iv. Exposure to research investigations including clinical review and outcomes, and basic science research.

a. These objectives are attained through competency-based educational methods including instruction and formal research experience.

II. TEACHING AND TRAINING ACTIVITIES

The fundamental components of the teaching programme should include:

1. Case presentations & discussion- once a week

2. Seminar - Once a week

3. Journal club - Once a month

4. Faculty lecture teaching- once a week

5. Clinical Audit-Once a Month

6. A poster and have one oral presentation at least once during their training period in a recognized conference.

7. One publication in a national journal and one in an international journal

The rounds should include bedside sessions, file rounds & documentation of case history and examination, progress notes, round discussions, investigations and management plan) Aspects of training would include,

Theoretical: The theoretical knowledge would be imparted to the candidates through discussions, journal clubs, symposia and seminars. The students are exposed to recent advances through discussions in journal clubs.

Symposia: Trainees would be required to present a minimum of 20 topics based on the curriculum in a period of three years to the combined class of teachers and students. A free discussion would be encouraged in these symposia. The topics of the symposia would be given to the trainees with the dates for presentation.

Clinical: The trainee would be attached to a faculty member to be able to pick up methods of history taking, examination, prescription writing and management in rehabilitation practice.

Bedside: The trainee would work up cases, learn management of cases by discussion with faculty of the department.

Journal Clubs: This would be a once a month academic exercise. A list of suggested Journals is given towards the end of this document. The candidate would summarize and discuss the scientific article critically. A faculty member will suggest the article and moderate the discussion, with participation by other faculty members and resident doctors. The contributions made by the article in furtherance of the scientific knowledge and limitations, if any, will be highlighted.

Microsurgery Lab Course: All candidates must undergo one week microsurgery laboratory course either in the institution selected or where it is regularly conducted.

Research: The student would carry out the research project in accordance with NBE guidelines. He/ she would also be given exposure to partake in the research projects going on in the departments to learn their planning, methodology and execution so as to learn various aspects of research

III. SYLLABUS

THEORY

Basic Sciences

• Anatomy of the hand and upper limb

• Embryology of the Hand and Upper Limb

• Physiology of muscle, nerve and bone metabolism

• Principles of infection, microbiology

• Healing of wound, tendon, bone, nerve

• Anatomy and physiology of blood supply to limb including skin

• Imaging (MRI, Ultrasound, Plain radiographs, CT)

• Pathology of rheumatic, degenerative and neoplastic disorders

• Biomechanics of the hand and wrist

• Embryology of the Upper Extremity

• Basic Pathology of the Hand, Wrist, and Forearm: Bone and Joint

• Basic Pathology of the Hand, Wrist, and Forearm: Tendon and Ligament

• Basic Pathology of the Hand, Wrist, and Forearm: Nerve

• Basic Vascular Pathophysiology of the Hand, Wrist, and Forearm Principles of Hand Surgery

• Examination of nerves, tendons, vascular system, joints

• Injured hand - wound care, management of skeletal, vascular, tendon and nerve injuries

• Treatment of fractures and malunions of the hand

• Ligament ruptures and joint instabilities of the hand

• Arthroscopy of the hand and wrist

• Amputations in the hand and upper limb

• Burns of the hand

• Reconstructive surgery of mutilated hand

• Management of upper limb nerve injuries, including brachial plexus injuries

• Management of tetraplegia, stroke, brain injury and cerebral palsy

• Tendon transfers

• Congenital abnormalities of hand and upper limb

• Arthrosis of the hand and wrist

• The arthritic hand in rheumatoid arthritis and other inflammatory arthritides, e.g. LES and scleroderma

• Dupuytren’s contracture

• Overuse syndromes

• Nerve compression syndromes

• Infections of the hand

• Vascular disorders (inc ischaemia,HAVS)

• Tumours of the hand

• Psychiatric manifestations, secondary gainetc.

• Principles of Hand Therapy

• Complex regional pain syndrome

• Skin grafts

• Local, distant and free flaps

• Extravasation injuries

• Enhancing wounds including specialised dressings and vacuum therapy

• Spasticity

Applied sciences

• Anesthesia in Hand and Upper Extremity Surgery

• Radiographic Imaging of the Hand, Wrist, and Forearm

• Principles of Hand Therapy

• Entraarticular Fractures of the Phalanges

• Extraarticular Fractures of the Metacarpals

• Intraarticular Injuries of the Distal and Proximal Interphalangeal Joints

• Intraarticular Injuries of the Metacarpophalangeal and Carpometacarpal Joints

• Fractures and Joint Injuries of the Thumb

• Malunion and Other Posttraumatic Complications in the Hand

• Fractures and Joint Injuries of the Child's Hand

• Extraarticular Distal Radius Fractures

• Intraarticular Distal Radius Fractures

• Acute Injuries of the Distal Ulna

• Malunion of the Distal Radius and Ulna

• Distal Radioulnar Joint Instability

• Triangular Fibrocartilage Complex Injuries and Ulnar Impaction Syndrome

• Fractures of the Carpus: Scaphoid Fractures

• Nonunions of the Carpus

• Wrist Instability

• Ligament Injuries and Instability of the Carpus

• Dissociations of the Radius and Ulna: Surgical Anatomy and Biomechanics

• Principles of wrist Arthroscopy

• Arthroscopic Repair and Stabilizati

• Arthroscopic Debridement, Resections, and Capsular Shrinkage

• Ganglionectomy

• Flexor Tendon Injuries

• Flexor Tendon Grafting

• Early Active Motion after Flexor Tendon Repair

• Early Repair of Extensor Tendon Injuries

• Extensor Tendon Reconstruction after Chronic Injuries

• Rehabilitation after Extensor Tendon Injury and Repair

• Tendon Disorders: de Quervain's Disease, Trigger Finger, and Generalized Tenosynovitis

• Tennis Elbow Entrapment Neuropathies in the Upper Extreimity

• Principles and technique of of Tendon Transfers following nerve injuries

• Brachial Plexus Injury: Acute Diagnosis and Treatment

• Brachial Plexus: Neurotization and Pedicle Muscle Transfer

• Brachial Plexus: Free Composite Tissue Transfers

• Reconstruction of the Spastic Hand

• Burns of the Hand and Upper Extremity

• Frostbite

• Dupuytren's Contracture

• Fingertip and Nailbed Injuries

• Skin Grafts and Tissue Expanders

• Skin and Soft Tissue: Pedicled Flaps

• Free Tissue Transfers for Coverage

• Rheumatoid Arthritis in the Hand and Digits

• Rheumatoid Arthritis of the Wrist

• Crystalline Arthritis and Other Arthritides

• Osteoarthritis of the Hand and Digits: Distal and Proximal Interphalangeal Joints

• Osteoarthritis of the Hand and Digits: Metacarpophalangeal and Carpometacarpal Joints

• Osteoarthritis of the Hand and Digits: Thumb

• Principles of Limited Wrist Arthrodesis

• Scaphotrapeziotrapezoid and Scaphocapitate Fusions

• Four-Corner Fusion

• Radiocarpal and Total Wrist Arthrodesis

• Proximal Row Carpectomy

• Wrist Arthroplasty

• Denervation of the Wrist

• Congenital Disorders: Classification and Diagnosis

• Congenital Disorders: Syndactyly

• Congenital Disorders: Polydactyly

• Congenital Disorders: Hypoplastic Thumb

• Congenital Disorders: Radial and Ulnar Club Hand

• Congenital Disorders: Cleft Hand

• Camptodactyly and Clinodactyly

• Delta Phalanx and Madelung's Deformity

• Macrodactyly, Constriction Band Syndrome, Synostosis

• Replantation

• Vascular Injuries: Acute Occlusive Conditions

• Compartment Syndromes and Ischemic Contracture

• Vascular Disorders: Arteriovenous Malformations

• Raynaud's Syndrome

• Thumb Reconstruction

• Finger Reconstruction and Ray Resection

• Wrist and Mid-Hand Reconstruction

• Tumors: General Principles

• Soft Tissue Tumors of the Hand: Malignant

• Primary Bone Tumors

• Metastatic Lesions

• Hand Infections

• Open-Wound, Injection, and Chemical Injuries

• Practical Guide for Complex Regional Pain Syndrome in the Acute Stage and Late Stage

• Pediatric Brachial Plexus Palsy

• Hand, Wrist, and Forearm Fractures in Children

• Rehabilitation

• Recent advances in hand and microsurgery

PRACTICAL

List of procedures follows a description with the operations to be performed independently by the trainee or, for operations of a higher degree of difficulty, as a participant. Microvascular experience is essential.

Surgical procedures can be listed according to the anatomical structures involved:

Skin and subcutaneous tissue

• Free skin graft

• Pedicled localflaps

• Regional and\or island flaps

• Free flap with microvascular anastomosis

• Treatment of retracting scars of the hand and wrist

• Application of vacuumtherapy

• Dupuytren’ s including PNF, collagenase, limited and radical surgery

• Extravasation

• Infection

Tendons

• Flexor tendon repair

• Flexor tendon graft

• Flexor pulley reconstruction

• Flexor tendon tenolysis

• Trigger finger release

• Extensor tendon repair

• Extensor tendon graft

• Extensor tendon tenolysis

• Tendon sheath synovialectomy

• Tendon reconstruction in rheumatoid arthritis

• Tendon transfers (injury, paralysis, spastic conditions)

• Free muscular flap with microvascular anastomosis

• Flexor sheath infection

Bone and Joints

• Closed reduction and fixation of fractures and dislocations

• Open reduction and fixation of fractures and dislocations

• Corrective osteotomies

• Treatment of non-union

• Bone resections

• Bone grafts and substitutes

• Free bone transfers with microvascular anastomosis

• Finger joint ligament or palmar plate repair\reconstruction

• Wrist ligament repair\reconstruction

• Arthrolysis 11. Digital\wrist arthroplasty (incl. allo-arthroplasty)

• Wrist partial and total fusion, PRC

• Hand Arthrodesis

• Denervation

• Synovectomy

• Arthroscopy

• DRUJ reconstruction

• Fractures in children

Nerves

• Microsurgical repair of nervelesions

• Nerve grafting and neurotisation andconduits

• Neurolysis

• Neuroma

Vascular

• Tumours and malformations

• Ischaemia (inc Kienbock’ s, Raynauld’ s)

• Replantation

• Revascularisation

Other

• Congenital disorders

• Children’ s disorders

• 5. Oncology- biopsy (transcutaneous, open); excision,reconstruction

• Brachial plexus repair\reconstruction

• Neuromas

• Nerve tumours

• Treatment of nerve compressionsyndromes

Blood vessels

• Microsurgical arterial anastomosis

• Microsurgical venous anastomosis

• Vein graft

• Adventitiectomy

List of procedures should also include operations for the treatment of complex trauma of the hand, special diseases, malformations:

Amputations

• Hand level

• Carpal or forearm\upper limb level

Replantation in limbamputations

• Digital or metacarpal level

• Carpal or forearm\upper limb level

• Lower limb

Treatment of thermal burn, chemical injury, electrical trauma

Mangled hand treatment

Fasciotomy

• Acute

• Chronic

Infections of the Hand

• Treatment of wound infection incl. tendonsheath

• Treatment of paronychial or pulpinfection

• Treatment of osteomyelitis or septic arthritis

• Necrotising fasciitis

Tumours

• Resection of skin and soft tissue tumour

• Resection of bonetumour

• Resection of tumour-likelesion

Contracture

• Dupuytren’ s

• Volkmann’ s

• Stiffness

• Burns

Treatment of congenital malformations of the hand

RESEARCH

The Hand Surgeon should undertake some research during his/her training, At the very least, a thorough understanding of the basics of research is essential

• Formulating a hypothesis

• Designing an appropriate methodology to test that hypothesis

• Using appropriate statistics to report the research

• Deducing appropriate conclusions form the data

• Understanding the limitations of a study

• Epidemiological principles

Biostatistics, Research Methodology and Clinical Epidemiology Ethics Medico legal aspects relevant to the discipline

Health Policy issues as may be applicable to the discipline

In addition, the Hand Fellow will attend one national Hand Surgery meeting and is encouraged to become a member of the National body of Hand Surgery.

Skills

Intellectual Skills

Education: A Hand Surgeon must be able to critically assess a research article or podium presentation, to understand the strengths and weaknesses of the material and to apply it to his own practice.

Continuing Medical Education: Education is a life-long process; the Hand Surgeon should take personal responsibility to use all resources to improve and update his knowledge and practice.

Personal Skills

Team working: Hand Surgeons work with theatre teams, therapists, nurses, junior doctors and many others who are involved in the care of patients. The Hand Surgeon will often be the leader of the team and should develop the necessary qualities of leadership.

Delegation: Many problems in Hand Surgery can be shared with others. The Hand Surgeon should develop skills of delegation so that patient care can be safely delegated to the appropriate practitioner to help provide an efficient, safe and cost- effective service.

Time Management and Stress Management: Surgery is stressful. It requires long hours with many competing demands on time and skill. Some decisions are uncertain; some procedures are very complex with potentially serious complications and uncertain outcome. The Hand Surgeon must learn to manage time and cope with stress.

Referral: The Hand Surgeon must appreciate the responsibility of asking for advice or referring to another practitioner when a case is beyond his expertise or comfort.

Other Skills

Consent: Informed consent is important in developingt he confidence of a patient by engaging them in the choice of treatmen and avoiding medico-legal issues with unexpected outcomes.

Documentation: Clear contemporaneous documentation is important for many reasons: to allow proper handover, for example post-operative instructions; to record the basis of clinical decisions; for medico-legal protection; to collect data for research and audit.

Service Management: A Hand Surgeon must be able to prioritise and also develop the skills to manage their service with the skills, resources and personnel available

IV. COMPETENCIES

1. Patient Care

a) Demonstrate appropriate evaluation and treatment of patients with hand surgery problems in the emergency room and as part of the inpatient consultation service, including application of physical examination tests specific to the diagnosis.

b) Be able to examine the injured hand with a high level of sophistication and detail to determine any bony or ligamentous injury, flexor or extensor tendon injury, nerve injury, arterial injury, and infections of the upper extremity.

c) Be able to perform a detailed clinical examination of the forearm and wrist.

d) Be able to order appropriate diagnostic tests and imaging studies to assist with diagnosis and accurate assessment of the level/severity of the injury.

e) Be able to initiate and interpret a logical course of investigations for patients complaining of chronic wrist pain, including bone scan, arthrogram, CT scan and MRI scan of the wrist.

f) Be able to interpret x-rays of fractures of the wrist and hand to determine the need for closed reduction or admission for open reduction and internal fixation.

g) In consultation with the appropriate hand surgery attending, provide treatment for the patient as appropriate for level of training as a hand surgery fellow.

h) Be able to treat both simple and complex infections of the hand, wrist and forearm (e.g. flexor tenosynovitis, large or complex abscess, deep space infections of the hand, complicated cellulitis requiring inpatient therapy, necrotizing fasciitis, etc.).

i) Be able to reduce and apply appropriate cast immobilization for displaced or angulated fractures of the metacarpals, phalanges and distal radius.

j) Be able to repair nail bed injuries or apply split thickness or full thickness skin grafts for fingertip injuries.

k) Be able to perform steroid injections of the A1 pulley of the flexor tendon sheath for trigger fingers, first dorsal extensor compartment for deQuervain's tenosynovitis, lateral/medial epicondyle for epicondylitis, and carpal tunnel for carpal tunnel syndrome.

l) Demonstrate a thorough understanding of the operative anatomy and be able to perform at least the following procedures:

• Open reduction and internal fixation of metacarpal and phalangeal fractures using K- wires, interosseous wires, interfragmentary and/or lag screws, and screws and plates.

• Repair/reconstruction of ligament injuries in the hand (e.g. repair of thumb MP joint ulnar collateral ligament rupture).

• Carpal tunnel release, radial tunnel release, cubital tunnel release, and radial tunnel release.

• Open reduction and internal fixation of scaphoid fractures.

• Russe bone graft, distal radius bone graft, iliac crest bone graft, and vascularized bone graft for scaphoid nonunions.

• Release of Dupuytren's contracture, including needle aponeurotomy.

• Arthrodesis of interphalangeal joints.

• Understand the operative approach to the digits (Bruner approach).

• Dorsal and volar approaches to the wrist joint, including open reduction/internal fixation vs. closed reduction/percutaneous K-wire fixation of distal radius fractures.

• Treatment of ulnar shaft fractures.

• Wrist arthroscopy.

• Limited intercarpal fusions (e.g. STT fusion, four-corner fusion).

• Proximal row carpectomy.

• Complete wrist fusion.

• Syndactyly release and treatment of other common congenital hand differences.

• Lateral/medial epicondylectomy for epicondylitis.

• Tendon transfers.

• Radius and ulna shortening osteotomies.

• Distal ulna resection procedures (e.g. Darrach procedure, Feldon wafer procedure, Bower's hemiresection).

• Trapezium excisional arthroplasty for metacarpal-trapezial arthritis

• Extensor tendon repairs.

• Flexor tendon repairs, including "no man's land" repairs for zone II flexor tendon injuries.

• Tenolysis, secondary tendon reconstruction, flexor tendon sheath pulley reconstruction

• Extensor and flexor tendon grafting.

• Joint arthroplasties of the MP and PIP joints.

• Neurolysis.

• Excision of upper extremity tumors.

• Excision of common hand masses (giant cell tumor, ganglion cysts, mucous cysts, volar retinacular cysts, neuromas, schwannomas, etc.)

2. Be able to apply an external fixator for reduction of distal radius fractures.

3. Demonstrate microsurgical skills under the operating microscope and be able to perform microsurgical procedures such as arterial anastomoses, group fascicular nerve repair, nerve grafting and free tissue transfers.

4. Medical Knowledge

a) Develop an advanced understanding of the anatomy of the forearm, wrist and hand, including the bones, ligaments, tendons, nerves and arteries.

b) Demonstrate a thorough understanding of the treatment of fractures of the hand and wrist, fingertip injuries, tendon injuries, nerve injuries.

c) Demonstrate ability to diagnose and treat nerve compression syndromes, including carpal tunnel syndrome, cubital tunnel syndrome and radial tunnel syndrome.

d) Understand the indications and contraindications for replantation in the upper extremity.

e) Be able to perform reconstructive hand surgery, including treatment for congenital hand anomalies, tendon transfers and Dupuytren's contracture.

f) Focused reading of other appropriate textbooks and journals of hand surgery, Incorporate online sources of information available on the internet to augment the knowledge base and to facilitate acquiring specific information for specific questions or problems that arise.

g) Demonstrate a detailed understanding of the use of splints for fracture immobilization and tendon rehabilitation.

h) Prepare and present at least three 45-minute presentations on three different hand surgery topics at the weekly hand service conference during the rotation (over a twelve-month period).

i) Prepare and present a monthly report for the hand surgery Morbidity and Mortality conference, including a detailed presentation of "Cases of the Month".

j) Attend and participate at the weekly hand service conference during the rotation.

k) Attend the orthopaedic residents' journal club that focuses on hand surgery, hosted 2-3 times per year by Drs. Azari, Meals and Benhaim.

l) Attend and participate at the biannual lecture series on hand surgery (24 lectures total), presented at the weekly orthopaedic surgery basic science course on Wednesday mornings.

m) Attend the monthly hand surgery journal club, hosted by Dr. Meals at his home.

5. Practice-Based Learning and Improvement

a) Frequently use, in a focused fashion, the available printed textbooks, online textbooks, and Medline sources for application to specific patients. The goal is to demonstrate the ability to locate and interpret scientific studies and known medical knowledge into an appropriate knowledge base that will be of direct benefit to patients.

b) Frequently present and discuss patients with the attending hand surgeons after initial evaluation and review of available diagnostic tests to confirm the appropriate treatment plan. The hand fellow will be expected to formulate a plan of treatment, which will then be reviewed in detail and either confirmed or altered as necessary to achieve optimal patient outcome.

c) Use appropriate sources (e.g. textbook, selected articles from the literature, etc.) to obtain more detailed information about a specific patient or diagnosis, based on his/her experiences on the hand surgery service and any specific questions that arise as part of that experience/exposure.

d) Play an active role in the teaching of senior orthopaedic surgery residents, junior plastic surgery residents, junior orthopaedic residents, sports medicine fellows, senior medical students (sub-interns) and junior medical students on the service.

e) Demonstrate expertise in use of available information technology and hospital information systems to manage patient data (e.g. lab tests, imaging tests, etc.) and access online information that will be of direct benefit to his/her own education.

f) Integrate feedback from faculty to ensure that the hand fellow is able to analyze his/her own practice experience, with the goal of improving future patient care. Feedback is provided systematically at the weekly hand service conference, which includes a morbidity and mortality format to identify areas of potential improvement for all members of the hand surgery service.

g) Undergo formal evaluation at least twice per year, including review of progress and suggestions for improvement).

6. Interpersonal and Communication Skills

a) Demonstrate ability to communicate effectively with all members of the hand service, including medical students, junior residents, senior residents, sports medicine fellows, and hand surgery attending staff.

b) Demonstrate ability to communicate effectively and work well with all members of the hospital staff, including nurses, nursing assistants, radiology staff, social workers, discharge planners, physical therapists, hand therapists, operating room/surgery center staff, inpatient/outpatient support staff, etc.

c) Demonstrate the ability to interact effectively, professionally, and empathetically with patients and family members.

d) Demonstrate the ability to provide appropriate and detailed information to patients and family members, when appropriate.

e) Demonstrate the ability to develop an appropriate relationship with a patient that fosters communication, respect, and ethics of the highest degree.

f) Demonstrate the ability to recognize important cultural and generational differences that may affect patient care, and to apply appropriate changes in approach to these patients that respect these important differences (e.g. amputation of a digit in Asian cultures has important cultural implications that need to be addressed).

g) Demonstrate effective listening and communication skills with patients, which may include both verbal and non-verbal skills.

h) Demonstrate ability to understand and respond appropriately to patient inquiries.

7. Professionalism

a) Demonstrate a strict adherence to medical/ethical principles.

b) Demonstrate a keen sensitivity to the differences and challenges that a diverse patient population may present.

c) Treat all patients with respect, empathy, and with compassionate care. All patient inquiries and requests will be considered seriously, professionally, and in a timely manner.

d) Recognize the important social, economic, emotional, and work-related implications that a hand problem or injury may represent for the patient.

e) Provide patients with excellent care in all aspects.

f) Maintain patient confidentiality, including strict adherence to HIPPA guidelines.

g) Obtain informed consent from patients in accordance with established guidelines that ensure full patient comprehension after a detailed discussion of all pertinent issues relating to patient care/surgery. This includes the opportunity for the patient to ask and have answered questions relating to any proposed procedures.

h) Demonstrate the ability to accommodate and adapt to differences in patients' culture, age, gender and disabilities.

8. Systems-Based Practice

a) Develop an awareness of how the care that they provide to patients can affect other caregivers and in general.

b) Demonstrate an ability to effectively utilize hospital resources in a way that directly benefits patient care.

c) Develop a more in-depth understanding of the different types of medical practice available in the context of hand surgery..

d) Develop a more detailed understanding of the differences in different payor types, such as worker's compensation, managed care, HMO, PPO, Medicare, MediCal, and student health insurance plans.

e) Develop a mature understanding of the necessity to provide efficient and cost- effective health care in the context of appropriate use of limited medical resources, yet without sacrificing quality of care.

f) Act as a patient advocate and assist patients in obtaining the necessary care, including coordination of post-discharge care if necessary (e.g. home health care, postoperative hand therapy, placement into appropriate rehabilitation facility, etc.).

V. LOG BOOK

A candidate shall maintain a log book of operations (assisted / performed) during the training period, certified by the concerned post graduate teacher / Head of the department / senior consultant.

This log book shall be made available to the board of examiners for their perusal at the time of the final examination.

The log book should show evidence that the before mentioned subjects were covered (with dates and the name of teacher(s) The candidate will maintain the record of all academic activities undertaken by him/her in log book .

1. Personal profile of the candidate

2. Educational qualification/Professional data

3. Record of case histories

4. Procedures learnt

5. Record of case Demonstration/Presentations

6. Every candidate, at the time of practical examination, will be required to produce performance record (log book) containing details of the work done by him/her during the entire period of training as per requirements of the log book. It should be duly certified by the supervisor as work done by the candidate and countersigned by the administrative Head of the Institution.

7. In the absence of production of log book, the result will not be declared.

VI. RECOMMENDED TEXT BOOKS AND JOURNALS

TEXT BOOKS

• Green's Operative Hand Surgery: 2-Volume Set, 6e 6th Edition by Scott W. Wolfe MD (Author), William C. Pederson MD (Author), Robert N. Hotchkiss MD (Author), Scott H. Kozin MD (Author)

• Lister’s The Hand :Diagnosis and Indications

• ASSH Manual of Hand Surgery By Warren C. Hammert, Martin I. Boyer, David J. Bozentka, Ryan Patrick Calfee

• Microsurgery Practice Manual by Robert.D.Acland and Raja S Sabapathy

• Operative Microsurgery by J.Brian Boyd and Neil F Jones

• Principles of Hand Surgery and Therapy Thomas E. Trumble, Ghazi M. Rayan, Mark E. Baratz

JOURNALS

• Journal of Hand Surgery, European Volume

• Journal of Hand Surgery (American)

• Journal of Hand Surgery (Asia Pacific)

• Hand Clinics

• Journal of Bone and Joint Surgery (American and British volumes)

• Techniques in Hand and Upper Extremity Surgery

• Plastic and Reconstructive Surgery

• Journal of Plastic Reconstructive and Aesthetic Surgery

• Indian Journal of Plastic Surgery

• Indian Journal of Orthopaedics

• Internet sources Pubmed Medscape Web of Science

On Wednesday, the St Mary Health Centre and St Ann's Bay Regional Hospital each received a fully equipped ambulance, while Port Maria Hospital was provided with a panel van. The ambulances are 2022 models while the van is a 2023 vehicle.

"These vehicles will enhance the hospitals' capabilities to move supplies needed for… operation, reducing the cost associated with mileage and transportation of goods and protecting these goods while in transit," said NERHA Regional Director Fabia Lamm.

She was speaking at the official handover ceremony held at NERHA'S office at Ocean Village Plaza in Ocho Rios.

The vehicles, valued at $33.47 million in total, will be used to cover St Ann, St Mary and Portland.

"St Ann's Bay Regional Hospital will get one ambulance, increasing its fleet from five to six and overall number of vehicles from seven to eight. St Mary Health Department will get one ambulance to strengthen its response to emergency and, based on their gravity of illness, to transfer patients from the health centre in the parish to hospitals. This will increase its total from one to two and their cumulative from eight to nine. The panel van will be given to Port Maria Hospital to increase their vehicles from three to four as their three vehicles are ambulances," Lamm said.

She added that while there is still a gap between what is available and the ideal number of ambulances needed in the region, NERHA is immensely grateful for the gifts.

"I want to express our appreciation to the procurement and finance teams for their continued commitment in ensuring the vehicles are serviced, repaired and road worthy," said Lamm.

"After today the current gap of ambulances will be five; and this is if all things remain equal. In the primary area, which is health centres and clinics, we will have a gap of two; and in secondary, which is our hospital, the gap will be three," she added.

NERHA board chairman, Laura Heron, said her team is actively working to procure additional vehicles for the region along with other major upgrades to the health-care system.

"We have a number of major projects ongoing to provide primary care service which is a part of the primary health-care reform. I'm very encouraged by that because I know it will help to alleviate some of the stress we undergo on a day-to-day basis at our secondary facilities. We will continue to work tirelessly to achieve our vision for health 2030," Heron promised.

Ambulance driver at Port Maria Hospital Kesna Bailey beamed with joy as he sat around the steering wheel of the new panel van that was handed over to the hospital.

"This will benefit staff as well as the hospitals in a number of ways. For the most part, we have been using the utility vehicles from the health department, so now we have our own. So, the transporting of blood and samples from one hospital to another will be easier," he told the Jamaica Observer.

Lamm, meanwhile, has urged health-care professionals to handle the vehicles with care.

"It is important to note that as of the 31st of December 2022, 85 per cent [of our vehicles] are in service and that would be 48 of the 57. We implore our drivers and health-care team to protect these assets to ensure that we can serve our patients," she added.

Member of Parliament for St Ann North Eastern Marsha Smith, who was also in attendance at the function, commended NERHA's dedication to fulfilling its role.

"NERHA has been quietly but resolutely putting all the plans in place to ensure that the north-eastern region of the country is improved. These service vehicles, in the long term, will ensure that we have a better resourced health system that is able to manage the things that come its way and this will create the conditions needed for a better society," said Smith.

Portrait of Dr. Etienne unveiled to join gallery of former PAHO Directors

Cristina Mitchell

20 Jan 2023

The purpose of this petition is to eliminate illegal littering & dumping in Grenada

View the full post Petition for the Implementation of the Abatement of Litter Act 2015 on NOW Grenada.

DrNB Clinical
Immunology and Rheumatology or Doctorate of National Board in Clinical
Immunology and Rheumatology also known as DrNB in Clinical Immunology and
Rheumatology is a super specialty level course for doctors in India that is
done by them after completion of their postgraduate medical degree course. The duration of this super
specialty course is 3 years, and it focuses on the diagnosis and treatment of autoimmune diseases and rheumatological disorders.

The course
is a full-time course pursued at various accredited institutes/hospitals across
the country. Some of the top accredited institutes/hospitals offering this
course include Army Hospital- Delhi, ESIC
Medical College Hospital and Super Specialty Hospital-
Telangana, Indraprastha
Apollo Hospital- Delhi, and more.

Admission to this course is done through the NEET-SS Entrance exam
conducted by the National Board of Examinations, followed by counseling based
on the scores of the exam that is conducted by DGHS/MCC/State Authorities.

The fee
for pursuing DrNB (Clinical Immunology and Rheumatology) varies from accredited
institutes/hospital to hospital and may range from Rs. 1,25,000 to Rs. 3,00,000
per year.

After completion of their respective course, doctors can either join the
job market or can pursue certificate courses and Fellowship programmes recognized by
NMC and NBE. Candidates can take reputed jobs at positions as Senior residents,
Consultants, etc. with an approximate salary range of Rs. 5,00,000 - 45,00,000 per
year.

DNB is equivalent to
MD/MS/DM/MCh degrees awarded respectively in medical and surgical super
specialities. The list of recognized qualifications awarded
by the Board in various broad and super specialties as approved by the
Government of India are included in the first schedule of the Indian Medical
Council Act, 1956.

The Diplomate of National Board in
broad-specialty qualifications and super specialty qualifications when
granted in a medical institution with the attached hospital or in a hospital with
the strength of five hundred or more beds, by the National Board of
Examinations, shall be equivalent in all respects to the corresponding
postgraduate qualification and the super-speciality qualification granted under
the Act, but in all other cases, senior residency in a medical college for an
additional period of one year shall be required for such qualification to be
equivalent for the purposes of teaching also.

What is DrNB in Clinical Immunology and Rheumatology?

Doctorate of National Board in Clinical
Immunology and Rheumatology, also known as DrNB (Clinical Immunology and
Rheumatology) or DrNB in (Clinical Immunology and Rheumatology) is a three-year
super specialty programme that candidates can pursue after completing a
postgraduate degree.

Clinical Immunology and Rheumatology is the
branch of medical science dealing with the diagnosis and treatment of autoimmune diseases and rheumatological disorders.

The National
Board of Examinations (NBE) has released a curriculum for DrNB in Clinical Immunology
and Rheumatology.

The curriculum
governs the education and
training of DrNB in Clinical Immunology and Rheumatology.

The postgraduate students must gain ample of knowledge and
experience in the diagnosis, treatment of patients with acute, serious, and
life-threatening medical and surgical diseases.

PG education intends to create specialists who can
contribute to high-quality health care and advances in science through research
and training.

The required training done by a postgraduate specialist in
the field of Clinical Immunology and
Rheumatology would help the specialist to recognize the health needs of the
community. The student should be competent to handle medical problems
effectively and should be aware of the recent advances in their speciality.

The candidate is also expected to know the principles of
research methodology and modes of the consulting library. The candidate should
regularly attend conferences, workshops and CMEs to upgrade her/ his knowledge.

Course
Highlights

Here are some of the course highlights of DrNB in Clinical Immunology and
Rheumatology

Name of Course

DrNB in Clinical Immunology and Rheumatology

Level

Doctorate

Duration of Course

Three years

Course Mode

Full Time

Minimum Academic Requirement

Candidates must have a postgraduate medical Degree in MD/DNB (General Medicine) or MD/DNB (Paediatrics) obtained from any college/university recognized by the MCI (Now NMC)/NBE, this feeder qualification mentioned here is as of 2022. For any further changes to the prerequisite requirement please refer to the NBE website.

Admission Process /
Entrance Process / Entrance Modalities

Entrance Exam (NEET-SS)

INI CET for various AIIMS, PGIMER Chandigarh, JIPMER Puducherry, NIMHANS Bengaluru

Counseling by DGHS/MCC/State Authorities

Course Fees

Rs. 1,25,000 to Rs. 3,00,000 per year

Average Salary

Rs. 5,00,000 - 45,00,000 per year

Eligibility Criteria

The eligibility criteria for DrNB in Clinical Immunology and
Rheumatology are defined as the set of rules or minimum prerequisites that
aspirants must meet in order to be eligible for admission, which include: 

Name of the super specialty course

Course Type

Prior Eligibility Requirement

Clinical Immunology and Rheumatology

DrNB

MD/DNB (General Medicine) or MD/DNB (Paediatrics) 

Note:

·
The feeder qualification for DrNB in Clinical Immunology and Rheumatology is defined by the NBE
and is subject to changes by the NBE.

·
The feeder qualification mentioned here
is as of 2022.

·
For any changes, please refer to the
NBE website.

• The prior entry qualifications shall be strictly
  in accordance with Post Graduate Medical Education Regulations, 2000 and its
  amendments notified by the NMC and any clarification issued from NMC in this
  regard.
• The candidate must have obtained permanent
  registration of any State Medical Council to be eligible for admission.
• The medical college's recognition cut-off dates
  for the Postgraduate Degree courses shall be as prescribed by the Medical
  Council of India (now NMC).

Admission Process

The admission process contains a few steps to
be followed in order by the candidates for admission to DrNB in Clinical Immunology and Rheumatology. Candidates can view
the complete admission process for DrNB
in Clinical Immunology and Rheumatology mentioned below:

• The NEET-SS or
  National Eligibility Entrance Test for Super specialty courses is a
  national-level master's level examination conducted by the NBE for admission to
  DM/MCh/DrNB Courses.
• Qualifying Criteria-Candidates placed at the
  50th percentile or above shall be declared as qualified in the NEET-SS in their
  respective specialty.
• The following Medical institutions are not
  covered under centralized admissions for DM/MCh courses through NEET-SS:

1.
AIIMS, New Delhi and other AIIMS

2.
PGIMER, Chandigarh

3.
JIPMER, Puducherry

4.
NIMHANS, Bengaluru

• Candidates from all eligible feeder specialty
  subjects shall be required to appear in the question paper of the respective group if they are willing to opt for a superspecialty course in any of the super-specialty courses covered in that group.
• A candidate can opt for appearing in the
  question papers of as many groups for which his/her Postgraduate specialty
  qualification is an eligible feeder qualification.
• By appearing in the question paper of a group
  and on qualifying for the examination, a candidate shall be eligible to exercise
  his/her choices in the counseling only for those superspecialty subjects
  covered in said group for which his/ her broad specialty is an eligible feeder
  qualification.

Fees Structure

The fee structure for DrNB in Clinical Immunology and Rheumatology varies from accredited institute/hospital to
hospital. The fee is generally less for Government Institutes and more for
private institutes. The average fee structure for DrNB in Clinical Immunology and
Rheumatology is around Rs. 1,25,000
to Rs. 3,00,000 per year.

Colleges offering DrNB in Clinical Immunology and Rheumatology

There are various accredited institutes/hospitals across India that
offer courses for pursuing DrNB in Clinical Immunology and Rheumatology.

As per the National Board of Examinations website, the following accredited
institutes/hospitals are offering DrNB (Clinical Immunology and Rheumatology) courses for the academic year 2022-23.

Hospital/Institute

Specialty

No. of Accredited
Seat(s)
(Broad/Super/Fellowship)

Army Hospital (R and R)
Delhi Cantt, New Delhi
Delhi-110010

Clinical Immunology and Rheumatology

2

ESIC Medical College Hospital and
Super Specialty Hospital
Sanath Nagar, Hyderabad
Telangana-500038

Clinical Immunology and Rheumatology

2

Indraprastha Apollo Hospital
Delhi-Mathura Road, Sarita Vihar, New Delhi
Delhi-110076

Clinical Immunology and Rheumatology

2

Kerala Institute of Medical Sciences
P B No.1, Anayara P O, Trivandrum
Kerala-695029

Clinical Immunology and Rheumatology

1

Krishna Institute of Medical Sciences
1-8-31/1, Minister Road, Secunderabad
Telangana-500003

Clinical Immunology and Rheumatology

2

Manipal Hospital
No. 98, Rustum Bagh, Old Airport Road, Bangalore
Karnataka-560017

Clinical Immunology and Rheumatology

1

Max Super Specialty Hospital
1,2, Press Enclave Road, Saket,
Delhi-110017

Clinical Immunology and Rheumatology

1

Medanta The Medicity
Sector-38, Gurgaon
Haryana-122001

Clinical Immunology and Rheumatology

2

Narayana Hrudayalaya Hospital
(NH-Narayana Health City, Bangalore) #258/A, Bommasandra
Industrial Area, Anekal Taluk, Bangalore
Karnataka-560099

Clinical Immunology and Rheumatology

1

P.D. Hinduja National Hospital and
Medical Research Centre
Veer Savarkar Marg, Mahim, Mumbai
Maharashtra-400016

Clinical Immunology and Rheumatology

1

SCB Medical College and Hospital
Mangalabag, Cuttack, Odisha Orissa
Orissa-753010

Clinical Immunology and Rheumatology

2

Sir Ganga Ram Hospital
Rajinder Nagar, New Delhi
Delhi-110060

Clinical Immunology and Rheumatology

2

Sree Sudheendra Medical Mission
Chittoor Road, Cochin
Kerala-682018

Clinical Immunology and Rheumatology

2

St. Johns Medical College Hospital
Sarjapur Road, Koramanagala Bangalore
Karnataka-560034

Clinical Immunology and Rheumatology

2

Syllabus

A DrNB
in Clinical Immunology and Rheumatology is a three years
specialization course that provides training in the stream of Clinical Immunology and Rheumatology.

The course
content for DrNB in Clinical Immunology and Rheumatology is given in
the NBE Curriculum released by the National Board of Examinations, which can be
assessed through the link mentioned below:

DrNB Clinical Immunology and Rheumatology In India: Check Out NBE Released Curriculum

1. Structure and function of bone, Joints, and connective tissue:

2. Biology of the normal joint and articular structures:

i. Hands

ii. Wrists

iii. Elbows

iv. Shoulders

v. Neck

vi. Low Back

vii. Spines

viii. Hip joint and Pelvic Girdle

ix. Knees

x. Ankles-feet

xi. Synovium, Cartilage, Bone and Chondrocytes

3. Normal and Pathological synovial tissue and cartilage

4. Connective tissue:

i. Collagen-collagenases

ii. Proteoglycans-mediators derived from polyunsaturated fatty acids

iii. Prostaglandins

iv. Thromboxane's

v. Leukotrienes

vi. Mediators of acute and chronic inflammation

vii. Vascular endothelium

viii. Interleukins

ix. Free radicals

x. Nitric oxide

xi. Apoptosis.

5. Formation and resorption of Bone- Bone as a tissue and an organ.

6. Muscle: Anatomy - contractile proteins - ultrastructure of the muscle fibre –neuro muscular junction-physiology of motor unit-excitation-contraction

7. Coupling - biochemistry of contraction- Muscle energy metabolism — pharmacology of the motor unit.

8. Nerve: Neuropathies of special interest in Rheumatology – laboratory investations –pain bath ways.

9. Synovial physiology

10. Collagen in normal and diseased connective tissue

11. Articular cartilage, Chondrocyte structure and function

12. Basics of immunology

13. Pharmacology of drugs in rheumatology practice

14. Broad issues in the approach to Rheumatic Disease:

i. Principles of Epidemiology in Rheumatic Disease

ii. Economic Burden of Rheumatic Diseases

iii. Clinical Trial Design and Analysis

iv. Assessment of Health Outcomes

v. Design of clinical trials in rheumatology

vi. Comorbidities of rheumatic disease

vii. Social aspects(work)

viii. Registries

ix. Outcomes of pediatric rheumatic disease

x. Basics of genetics

xi. Immunology

xii. Environment

xiii. Epigenetics

xiv. Genetics of rheumatoid arthritis

xv. Genetics of spondyloarthropathies

xvi. Genetics of connective tissue diseases (rheumatoid arthritis, SLE, Scleroderma, Sjogren's syndrome, Inflammatory muscle diseases, mixed connective tissue disease)

xvii. Genetics of juvenile rheumatic diseases

xviii. Genetics of osteoarthritis

xix. Genetics of Gout and other crystal arthritis

xx. Genetics of chronic musculoskeletal pain

xxi. Biologic Markers

xxii. Occupational and Recreational Musculoskeletal Disorders

xxiii. Cardio vascular Risk in Rheumatic Disease

xxiv. Cancer Risk in Rheumatic Diseases

15. Rheumatic diseases of childhood:

i. Etiology and Pathogenesis of Juvenile Idiopathic Arthritis

ii. Treatment of Juvenile Idiopathic Arthritis

iii. Pediatric Systemic Lupus Erythematosus, Dermatomyositis, Scleroderma and Vasculitis

16. Medical Orthopaedics and Rehabilitation:

i. Sports Medicine

ii. Entrapment neuropathies

iii. Physiotherapy

iv. Occupational therapy

v. Health outcome assessment

vi. Rehabilitation of patients with rheumatic diseases

17. Other areas in which knowledge is to be acquired:

i. Biostatistics, Research Methodology and Clinical Epidemiology

ii. Ethics

iii. Medico legal aspects relevant to the discipline

iv. Health Policy issues as may be applicable to the discipline

A. Rheumatological Diseases

1. Regional pain syndromes:

i. Spinal pain

ii. Intervertebral disc disorders

iii. Spinal canal or foraminal stenosis & related syndromes

iv. Limb pain syndromes (e.g. rotator cuff disease, epicondylitis & other soft tissue conditions, nonspecific

v. Limb pain, plantar fasciitis, bursitis, algodystrophyetc)

vi. Chest wall pain syndromes

a. Fibromyalgia and related somatoform disorders

b. Benign jointly per mobility

c. specific to childhood – e.g. nocturnal limb pain, Osgood-Schlatter's, Perthe'setc

2. Osteoarthritis and related conditions:

i. Osteoarthritis

ii. DISH

iii. Neuropathic arthritis

iv. Crystal associated arthropathy–urate, CPPD, basic calcium phosphate, oxalate

3. Spondylarthropathy

i. Ankylosing spondylitis

ii. Enteropathicarthropathies

iii. Psoriatic arthritis

iv. Reactive arthritis

v. Whipple's disease

4. Autoimmune rheumatic disease

i. Rheumatoid arthritis

ii. Systemic lupus erythematosus and related overlap syndromes

iii. Systemic sclerosis, Sjogrens syndrome

iv. Inflammatory muscle disease

v. Vasculitides, antiphospholipid syndrome, Behcet's disease

5. Metabolic, endocrine and other disorders

i. Osteoporosis

ii. Rickets and osteomalacia

iii. Bone & joint dysplasia's

iv. Renal bone disease

v. Endocrine disorders affecting bone, joint or muscle (e.g. thyroid, pituitary, parathyroid)

vi. Metabolic disorders affecting joints (e.g. alkaptonuria, haemochromatosis etc.)

vii. Heritable collagen disorders

viii. Haemoglobinopathies

ix. Hemophilia and other disorders of hemostasis

x. Regional disorders– Paget's disease, HPOA, osteonecrosis, Perthe's disease

xi. Osteochondritisdissecans, transient regional osteoporosis

6. Neoplastic disease

i. Primary and secondary neoplastic conditions of connective tissue

ii. Pigmented villonodular synovitis

iii. Paraneoplastic musculoskeletal syndromes

7. Infection and arthritis:

i. Septic bone and joint lesions

ii. Lyme disease

iii. Mycobacterial, fungal & parasitic arthropathies

iv. Viral arthritis

v. AIDS

vi. Post-infectious rheumatologically conditions (e.g. rheumatic fever, postmeningococcal arthritis)

8. Miscellaneous:

i. i. Sarcoidosis, Eosinophilic fasciitis, Familial Mediterranean Fever, Relapsing polychondritis

ii. Hypogammaglobulinaemia& arthritis, Amyloidosis, Sweets syndrome (neutrophilic dermatoses)

iii. Primary immunodeficiency

iv. Auto-inflammatory syndromes

v. IgG4-relateddisease

Career Options

After completing a DrNB in Clinical Immunology and
Rheumatology, candidates will get employment opportunities in Government as
well as in the Private sector.

In the Government sector,
candidates have various options to choose from which include Registrar, Senior
Resident, Demonstrator, Tutor etc.

While in the Private sector the
options include Resident Doctor, Consultant, Visiting Consultant (Clinical
Immunology and Rheumatology), Junior Consultant, Senior Consultant (Clinical
Immunology and Rheumatology), etc.

Courses After DrNB
in Clinical Immunology and Rheumatology
Course

DrNB in Clinical Immunology and Rheumatology is a
specialization course that can be pursued after finishing a Postgraduate
medical course. After pursuing specialisation in DrNB in Clinical Immunology and Rheumatology, a candidate could
also pursue certificate courses and Fellowship programmes recognised by NMC and
NBE, where DrNB in Clinical Immunology
and Rheumatology is a feeder qualification.

Frequently Asked Questions (FAQs) – DrNB
in Clinical Immunology and Rheumatology
Course

Question: What is the full form of DrNB?

Answer: The full form of DrNB is a Doctorate of National
Board.

Question: What is a DrNB in Clinical Immunology and Rheumatology?

Answer: DrNB Clinical
Immunology and Rheumatology or Doctorate of National Board in Clinical
Immunology and Rheumatology also known as DrNB in Clinical Immunology and
Rheumatology is a super specialty level
course for doctors in India that is done by them after completion of their
postgraduate medical degree course.

Question: What is the duration of a DrNB in Clinical
Immunology and Rheumatology?

Answer: DrNB in Clinical Immunology and Rheumatology is a super specialty programme of three years.

Question: What is the eligibility of a DrNB in Clinical Immunology and Rheumatology?

Answer: Candidates must have a postgraduate medical Degree in MD/DNB (General Medicine) or MD/DNB (Paediatrics) obtained from any college/university recognized by the MCI (Now NMC)/NBE, this feeder qualification mentioned here is as of 2022. For any further changes to the prerequisite requirement please refer to the NBE website.

Question:
What is the scope of a DrNB in Clinical
Immunology and Rheumatology?

Answer:
DrNB in Clinical Immunology and
Rheumatology offers candidates various employment opportunities and career
prospects.

Question:
What is the average salary for a DrNB in
Clinical Immunology and Rheumatology candidate?

Answer:
The DrNB in candidate's average salary is between Rs. 5,00,000 - 45,00,000 per year depending on the experience.

Question: Can you teach after completing DrNB Course?

Answer: Yes, the candidate can teach in a medical
college/hospital after completing DrNB course.

Question: Is immunologist and rheumatologist the same?

Answer: Immunologists and rheumatologists are both
internal medicine doctors. While immunologists treat conditions that affect
your immune system, rheumatologists specialize in the musculoskeletal system.

The Host

Julie Rovner
KHN

@jrovner

Read Julie's stories.

Julie Rovner is chief Washington correspondent and host of KHN’s weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.

While repealing the Affordable Care Act seems to have fallen off congressional Republicans’ to-do list for 2023, plans to cut Medicare and Medicaid are back. The GOP wants Democrats to agree to cut spending on both programs in exchange for a vote to prevent the government from defaulting on its debts.

Meanwhile, the nation’s health care workers — from nurses to doctors to pharmacists — are feeling the strain of caring not just for the rising number of insured patients seeking care, but also more seriously ill patients who are difficult and sometimes even violent.

This week’s panelists are Julie Rovner of KHN, Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico, Tami Luhby of CNN, and Victoria Knight of Axios.

Panelists

Joanne Kenen
Johns Hopkins Bloomberg School of Public Health and Politico

@JoanneKenen

Read Joanne's stories

Tami Luhby
CNN

@luhby

Read Tami's stories

Victoria Knight
Axios

@victoriaregisk

Read Victoria's stories

Among the takeaways from this week’s episode:

• Conservative House Republicans are hoping to capitalize on their new legislative clout to slash government spending, as the fight over raising the debt ceiling offers a preview of possible debates this year over costly federal entitlement programs like Medicare.
• House Speaker Kevin McCarthy said Republicans will protect Medicare and Social Security, but the elevation of conservative firebrands — like the new chair of the powerful House Ways and Means Committee — raises questions about what “protecting” those programs means to Republicans.
• Record numbers of Americans enrolled for insurance coverage this year under the Affordable Care Act. Years after congressional Republicans last attempted to repeal it, the once highly controversial program also known as Obamacare appears to be following the trajectory of other established federal entitlement programs: evolving, growing, and becoming less controversial over time.
• Recent reports show that while Americans had less trouble paying for health care last year, many still delayed care due to costs. The findings highlight that being insured is not enough to keep care affordable for many Americans.
• Health care workers are growing louder in their calls for better staffing, with a nursing strike in New York City and recent reports about pharmacist burnout providing some of the latest arguments for how widespread staffing issues may be harming patient care. There is bipartisan agreement in Congress for addressing the nursing shortage, but what they would do is another question.

Plus, for extra credit, the panelists recommend their favorite health policy stories of the week that they think you should read, too:

Julie Rovner: Roll Call’s “NIH Missing Top Leadership at Start of a Divided Congress,” by Ariel Cohen

Tami Luhby: CNN’s “ER on the Field: An Inside Look at How NFL Medical Teams Prepare for a Game Day Emergency,” by Nadia Kounang and Amanda Sealy

Joanne Kenen: The Atlantic’s “Don’t Fear the Handshake,” by Katherine J. Wu

Victoria Knight: The Washington Post’s “‘The Last of Us’ Zombie Fungus Is Real, and It’s Found in Health Supplements,” by Mike Hume

Also mentioned in this week’s podcast:

The New York Times’ “As France Moves to Delay Retirement, Older Workers Are in a Quandary,” by Liz Alderman

Stat’s “Congressional Medicare Advisers Warn of Higher Drug Prices, Despite New Price Negotiation,” by John Wilkerson

Click to Expand

Episode 280 Transcript

KHN’s ‘What the Health?’Episode Title: As US Bumps Against Debt Ceiling, Medicare Becomes a Bargaining ChipEpisode Number: 280Published: Dec. 19, 2023

Tamar Haspel: A lot of us want to eat better for the planet, but we’re not always sure how to do it. I’m Tamar Haspel.

Michael Grunwald: And I’m Michael Grunwald. And this is “Climavores,” a show about eating on a changing planet.

Haspel: We’re here to answer all kinds of questions. Questions like: Is fake meat really a good alternative to beef? Does local food actually matter?

Grunwald: You can follow us or subscribe on Stitcher, Apple Podcasts, Spotify, or wherever you listen.

Julie Rovner: Hello! Welcome back to KHN’s “What the Health?” I’m Julie Rovner, chief Washington correspondent at Kaiser Health News. And I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, Jan. 19, at 10 a.m. As always, news happens fast, and things might have changed by the time you hear this. So here we go. Today we are joined via video conference by Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico.

Joanne Kenen: Good morning, everybody.

Rovner: Tami Luhby of CNN.

Tami Luhby: Good morning.

Rovner: And Victoria Knight of Axios.

Victoria Knight: Good morning.

Rovner: So Congress is in recess this week, but there is still plenty of news, so we’ll get right to it. The new Congress is taking a breather for the MLK holiday, having worked very hard the first two weeks of the session. But there’s still plenty going on on Capitol Hill. Late last week, House Republicans leaked to The Washington Post a plan to pay only some of the nation’s bills if the standoff over raising the debt ceiling later this year results in the U.S. actually defaulting. Republicans say they won’t agree to raise the debt ceiling, something that’s been done every couple of years for decades, unless Democrats agree to deep spending cuts, including for entitlement programs like Social Security, Medicare, and Medicaid — why we are talking about this. Democrats say that a default, even a partial one, could trigger not just a crisis in U.S. financial markets, but possibly a worldwide recession. It’s worth remembering that the last time the U.S. neared a default but didn’t actually get there, in 2011, the U.S. still got its credit rating downgraded. So who blinks in this standoff? And, Tami, what happens if nobody does?

Luhby: That’s going to be a major problem for a lot of people. I mean, the U.S. economy, potentially the global economy, global financial markets, but also practical things like Social Security recipients getting their payments and federal employees in the military getting paid, and Treasury bond holders getting their interest payments. So it would be a giant mess. [Treasury Secretary Janet] Yellen last week in her letter to [House Speaker Kevin] McCarthy, signaling that we were going to hit the debt ceiling, likely today, urged Congress to act quickly. But instead, of course, what just happened was they dug their heels in on either side. So, you know, we have the Republicans saying that we can’t keep spending like we are. We don’t have just an unlimited credit card. We have to change our behavior to save the country in the future. And the White House and Senate Democrats saying this is not a negotiable subject. You know, we’ve been here before. We haven’t actually crossed the line before. So we’ll see what happens. But one of the differences is, this year, that McCarthy has a very narrow margin in the House. Any one of his members — this is among the negotiations that he did not want to agree to but had to after 15 rounds of voting for his job — any member can make a motion to vacate the speaker’s chair. And if that happens, then we don’t have to worry about the debt ceiling because we have to worry more about who’s going to be leading the House, because we can’t deal with the debt ceiling until we actually have someone leading the House. So this is going to be even more complicated than in the past.

Rovner: Just to be clear, even if we hit the debt ceiling today, that doesn’t mean we’re going to default, right? I mean, that’s not coming for several months.

Luhby: Right. So Social Security, seniors and people with disabilities, and the military and federal employees don’t have to yet worry about their payments. They’re going to be paid. The Treasury secretary and Treasury Department will take what’s called “extraordinary measures.” They’re mainly just behind-the-scenes accounting maneuvers. They won’t actually hurt anybody. Yellen had said that she expects these extraordinary measures in cash to last at least until early June, although she did warn that the forecast has considerable uncertainty, as does everything around the debt ceiling.

Rovner: So, Victoria, obviously, the sides are shaping up. Is this going to be the big major health fight this year?

Knight: I think it’s going to be one of the big topics that we’re definitely talking about this year in Congress. I think it’s going to be a dramatic year, as we’ve already seen in these first two weeks. My colleagues at Axios, we talked to some Republicans last week, asking them about: Do you actually think they will make cuts to entitlement programs, to Medicare, Medicaid? Is that realistic? It’s kind of a mixed bag. Some are like, yeah, we should look at this, and some are like, we don’t really want to touch it. I think they know it’s really a touchy subject. There are a lot of Medicare beneficiaries that don’t want the age increase. You know, there’s some talk of increasing the age to 67 rather than 65. They know that is a touchy subject. Last week in a press conference, McCarthy said, “We’re Republicans; we’ll protect Medicare and Social Security,” so they know people are talking about this. They know people are looking at it. So I think in a divided government, obviously, the Senate is in Democratic control. I think it seems pretty unlikely, but I think they’re going to talk about it. And we have a new Ways and Means chairman, Jason Smith from Missouri. He’s kind of a firebrand. He’s talked about wanting to do reform on the U.S. spending. So I think it’s something they’re going to be talking about. But I don’t know if that much will actually happen. So we’ll see. I have been talking to Republicans on what else they want to work on this year in Congress. I think a big thing will be PBM [pharmacy benefit managers] reform. It’s a big topic that’s actually bipartisan. So I think that’s something that we’ll see. These are the middlemen in regards to between pharmacies and insurers. And they’re negotiating drug prices. And we know there are going to be hearings on that. I think health care costs. There’s some talk about fentanyl, scheduling. But I think in regards to big health care reform, there probably isn’t going to be a lot, because we are in a divided government now.

Kenen: Just one thing about how people talk about protecting Medicare and Social Security, it doesn’t mean they don’t want to make changes to it. We’ve been through this before. Entitlement reform was the driving force for Republicans for quite a few years under … when Paul Ryan was both, I guess it was budget chair before he was speaker. I mean, that was the thing, right? And he wanted to make very dramatic changes to Medicare, but he called it protecting Medicare. So there’s no one like Ryan with a policy really driving what it should look like. I mean, he had a plan, yet the plan never got through anywhere. It died, but it was an animating force for many years. It went away for a minute in the face of the last 10 years that were about the Affordable Care Act. So I don’t think they’re clear on what they want to do. But we do know some conservative Republicans want to make some kind of changes to Medicare. TBD.

Rovner: And Tami, we know the debt ceiling isn’t the only place where House Republicans are setting themselves up for deep cuts that they might not be able to make while still giving themselves the ability to cut taxes. They finessed some of this in their rules package, didn’t they?

Luhby: Yes, they did. And they made it very clear that they, in the rules, they made it harder to raise taxes. They increased it to a supermajority, 3/5 of the House. They made it easier to cut spending in the debt ceiling and elsewhere. And, you know, the debt ceiling isn’t our only issue that we have coming up. It’s going to be right around the same time, generally, maybe, as the fiscal 2024 budget, which will necessitate discussion on spending cuts and may result in spending cuts and changes possibly to some of our favorite health programs. So we will see. But also just getting back to what we were talking about with Medicare. Remember, the trustees estimate that the trust fund is going to run out of money by 2028. So we’ll see in a couple of months what the latest forecast is. But, you know, something needs to be done relatively soon. I mean … the years keep inching out slowly. So we keep being able to put this off. But at some point …

Rovner: Yeah, we keep getting to this sort of brinksmanship, but nobody, as Joanne points out, ever really has a plan because it would be unpopular. Speaking of which, while cutting entitlement programs here is still just a talking point, we have kind of a real-life cautionary tale out of France, where the retirement age may be raised from 62 to 64, which is still younger than the 67, the U.S. retirement age is marching toward. It seems that an unintended consequence of what’s going on in France is that employers don’t want to hire older workers. So now they can’t get retirement and they can’t find a job. And currently, only half of the French population is still employed by age 62, which is way lower than other members of the European Union. France is looking at protests and strikes over this. Could the same thing happen here, if we might get to that point? It’s been a while since we’ve seen the silver-haired set out on the street with picket signs.

Knight: I think it would be pretty contentious, I think, if they decide to actually raise the age. It’ll be interesting to see [if] there are actual protests, but I think people will be very upset, for sure, especially people reaching retirement age having counted on this. So …

Kenen: They probably wouldn’t do it like … if you’re 62, you wouldn’t [go] to 67. When they’ve talked about these kinds of changes in the past, they’ve talked about phasing it in over a number of years or starting it in the …

Rovner: Right, affecting people in the future.

Kenen: Right.

Rovner: But I’m thinking not just raising the retirement age. I’m thinking of making actual big changes to Medicare or even Medicaid.

Kenen: Well, there’s two things since the last debate about this. Well, first of all, Social Security was raised and it didn’t cause … it was raised slowly, a couple of months at a time over, what, a 20-year period. Is that right? Am I remembering that right, Julie?

Rovner: Yeah, my retirement age is 66 and eight months.

Kenen: Right. So … it used to be 65. And they’ve been going, like, 65 and one month, 65 and two months. It’s crept up. And that was done on a bipartisan basis, which, of course, not a whole lot is looking very bipartisan right now. But I mean, that’s the other pathway we could get. We could get a commission. We could move toward some kind of changes after … last time there was a commission that failed, but the Social Security commission did work. The last Medicare commission did not. The two sides are so intractable and so far apart on debt right now that there’s probably going to have to be some kind of saving grace down the road for somebody. So it could be yet another commission. And also in 2011, 2012, which was the last time there was the big debate over Medicare age, was pre-ACA [Affordable Care Act] implementation. And, you know, if you’re 65 and you’re not working, if they do change the Medicare in the out years, it’s complicated what it would do to the risk pools and premiums and all that. But you do have an option. I mean, the Affordable Care Act would … right now you only get it to Medicare. That would have to be changed. So it’s not totally the same … I’m not advocating for this. I’m just saying it is a slightly different world of options and the chessboard’s a little different.

Rovner: Well, clearly, we are not there yet, although we may be there in the next couple of months. Finally, on the new Congress front. Last week, we talked about some of the new committee chairs in the House and Senate. This week, House Republicans are filling out some of those critical subcommittee chairs. Rep. Andy Harris, a Republican from Maryland who’s also an anesthesiologist who bragged about prescribing ivermectin for covid, will chair the Appropriations subcommittee responsible for the FDA’s budget [the Agriculture, Rural Development, Food and Drug Administration subcommittee]. Things could get kind of interesting there, right?

Knight: Yeah. And there is talk that he wanted to chair the Labor [Health and Human Services, Education] subcommittee, which would have been really interesting. He’s not.

Rovner: Which would’ve been the rest of HHS. We should point out that in the world of appropriations, FDA is with Agriculture for reasons I once tried to figure out, but they go back to the late 1940s. But the rest of HHS is the Labor HHS Appropriations subcommittee, which he won’t chair.

Knight: Right, he is not. Rep. Robert Aderholt is chairing Labor HHS. But this is, as we were talking about, they’re going to have to fund the government. Republicans are talking about wanting to pass 12 appropriations bills. If they actually want to try to do that, they’re going to have to do a lot of negotiations on what goes into the Labor HHS bill, what goes into the AG bill with FDA, with these chairs over the subcommittees, they’re going to want certain things in there. They’re going to maybe want oversight of these agencies, especially in regards to what’s happening with covid, what’s going on with the abortion pills. So I think it’ll be really interesting to see what happens. It seems unlikely they’re actually going to be able to pass 12 appropriations bills, but it’s just another thing to watch.

Rovner: I would point out that every single Congress, Republican and Democrat, comes in saying, we’re going to go back to regular order. We’re going to pass the appropriations bills separately, which is what we were supposed to do. I believe the last time that they passed separately, and that wasn’t even all of them, was the year 2000; it was the last year of President [Bill], it might have been. It was definitely right around then. When I started covering Congress, they always did it all separately, but no more.

Luhby: And they want to pass the debt ceiling vote separately.

Rovner: Right, exactly. Not that much going on this year. All right. Well, last week we talked about health insurance coverage. Now it is official. Obamacare enrollment has never been higher and there are still several weeks to go to sign up in some states, even though enrollment through the federal marketplace ended for the year on Sunday. Tami, have we finally gotten to the point that this program is too big to fail or is it always going to hang by a political thread?

Luhby: Well, I think the fact that we’re all not reporting on the weekly or biweekly enrollment numbers, saying “It’s popular, people are still signing up!” or under the Trump years, “Fewer people are signing up and it’s lost interest.” I think that in and of itself is very indicative of the fact that it is becoming part of our health care system. And I mean, I guess one day I’m not going to write the story that says enrollment opens on Nov. 1, then another one that says it’s ending on Jan. 15.

Rovner: I think we’ll always do that because we’re still doing it with Medicare.

Luhby: Well, but I’m not. So … it’s possible, although now with Medicare Advantage, I think it is actually worth a story. So that’s a separate issue.

Rovner: Yes, that is a separate issue.

Luhby: But yeah, no, I mean, you know, I think it’s here to stay. We’ll see what [District Judge Reed] O’Connor does in Texas with the preventive treatment, but …

Rovner: Yes, there will always be another lawsuit.

Luhby: There will be chips around the edges.

Kenen: I mean, this court has done … we all thought that litigation was over, like we thought, OK, it’s done. They’ve … upheld it, you know, however many times, move on. But this Supreme Court has done some pretty dramatic rulings and not just Roe [v. Wade], on many public health measures, about gun control and the environment and vaccine mandates. And, of course, you know, obviously, Roe. Do I think that there’s going to be another huge existential threat to the ACA arising out of this preventive care thing? No, but we didn’t think a lot of the things that the Supreme Court would do. There’s a real ideological shift in how they approach these issues. So politically, no, we’re not going to see more repeal votes. In the wings could there be more legal issues to bite us? I don’t think it’s likely, but I wouldn’t say never.

Rovner: In other words, just because congressional Republicans aren’t still harping on this, it doesn’t mean that nobody is.

Kenen: Right. But it’s also, I mean, I agree with Tami … I wrote a similar story a year ago on the 10th anniversary: It’s here. They spent a lot of political capital trying to repeal it and they could not. People do rely on it and more … Biden has made improvements to it. It’s like every other American entitlement: It evolves over time. It gets bigger over time. And it gets less controversial over time.

Rovner: Well, we still have problems with health care costs. And this week we have two sort of contradictory studies about health care costs. One from the Centers for Disease Control and Prevention found a three-percentage-point decline in the number of Americans who had trouble paying medical bills in 2021 compared to the pre-pandemic year of 2019. That’s likely a result of extra pandemic payments and more people with health insurance. But in 2022, according to a survey by Gallup, the 38% of patients reported they delayed care because of cost. That was the biggest increase ever since Gallup has been keeping track over the past two decades, up 12 percentage points from 2020 and 2021. This has me scratching my head a little bit. Is it maybe because even though more people have insurance, which we saw from the previous year. Also more have high-deductible health plans. So perhaps they don’t want to go out and spend money or they don’t have the money to spend initially on their health care. Anybody got another theory? Victoria, I see you sort of nodding.

Knight: I mean, that’s kind of my theory is, like, I think they just have high-deductible plans, so they’re still having to pay a lot out-of-pocket. And I know my brother had to get an ACA plan because he is interning for an electrician and — so he doesn’t have insurance on his own, and I know that, like, it’s still pretty high and he just has to pay a lot out-of-pocket. He’s had medical debt before. So even though more people have health insurance, it’s still a huge issue, it doesn’t make that go away.

Rovner: And speaking of high medical prices, we are going to talk about prescription drugs because you can’t really talk about high prices without talking about drugs. Stat News reports this week that some of the members of the Medicare Payment Advisory Committee, or MedPAC, are warning that even with the changes to Medicare that are designed to save money on drugs for both the government and patients — those are ones taking effect this year — we should still expect very high prices on new drugs. Partly that’s due to the new Medicare cap on drug costs for patients. If insurers have to cover even the most expensive drugs, aside from those few whose price will be negotiated, then patients will be more likely to use them and they can set the price higher. Are we ever going to be able to get a handle on what the public says consistently is its biggest health spending headache? Victoria, you kind of previewed this with the talk about doing something about the middlemen, the PBMs.

Knight: Yeah, I think it’s really difficult. I mean, the drug pricing provisions, they only target 20 of the highest-cost drugs. I can’t remember exactly how they determine it, but it’s only 20 drugs and it’s implemented over years. So it’s still leaving out a lot of drugs. We still have years to go before it’s actually going into effect. And I think drugmakers are going to try to find ways around it, raising the prices of other drugs, you’re talking about. And even though they’re hurt by the IRA [Inflation Reduction Act], they’re not completely down and out. So I don’t know what the answer is to rein in drug prices. I think maybe PBM reform, as I said, definitely a bipartisan issue. This Congress … I think will actually have maybe some movement and we’ll see if actually legislation can be passed. But I know they want to talk about it. So, I mean, that could help a little bit. But I think drugmakers are still a huge reason for a lot of these costs. And so it won’t completely go away even if PBMs have some reforms.

Rovner: And certainly the American public sees drug costs as one of the biggest issues just because so many Americans use prescription drugs. So they see every dollar.

Knight: Yes.

Rovner: So the good news is that more people are getting access to medical care. The bad news is that the workforce to take care of them is burned out, angry, and simply not large enough for the task at hand. The people who’ve been most outspoken about that are the nation’s nurses, who’ve given the majority of the care during the pandemic and taken the majority of patient anger and frustration and sometimes even violence. We’re seeing quite a few nurses’ strikes lately, and they’re mostly not striking for higher wages, but for more help. Tami, you talked to some nurses on the picket line in New York last week. What did they tell you?

Luhby: Yeah, I had a fun assignment last week. Since I live in the Bronx, I spent two days with the striking nurses at the Montefiore Medical Center, and there were 7,000 nurses at Mount Sinai Hospital in Manhattan and Montefiore in the Bronx that went on strike for three days. It was a party atmosphere there much of the time, but they did have serious concerns that they wanted to relay and get their word out. There was a lot of media coverage as well. Their main issue was staffing shortages. I mean, the nurses told me about terrible working conditions, particularly in the ER. Some of them had to put babies on towels on the floor of the pediatric ER or tell sick adults that they have to stand because there aren’t even chairs available in the adult ER, much less beds or cots. And every day, they feared for their licenses. One said that she would go to sleep right when she got home because she didn’t want to think about the day because she was concerned she might not want to go back the next day. And she said, heartbreakingly, that she was tired of apologizing to families and patients, that she was stretched too thin to deliver better care, that she was giving patients their medicines late because she had seven other patients she had to give medicine to and probably handle an emergency. So the nurses at Montefiore, interestingly, they’re demanding staffing. But one thing they kept repeating to me, you know, the leaders, was that they wanted enforcement ability of the staffing. They didn’t just want paper staffing ratios, and they wanted to be more involved in recruitment. While the hospitals — interestingly, this is not necessarily over in New York as it probably won’t be elsewhere. These hospitals reached a tentative agreement with the unions, but there’s another battle brewing. The nurses’ contract for the public hospital system expires on March 2, and the union is already warning that will demand better pay and staffing.

Rovner: Yeah. Well, it’s not just the nurses, though. Doctors are burnt out by angry and sometimes ungrateful patients. Doctors in training, too. And I saw one story this week about how pharmacists, who are being asked to do more and more with no more help — a similar story — are getting fried from dealing with short-tempered and sometimes abusive patients. Is there any solution to this, other than people trying to behave better? Is Congress looking at ways to buttress the health care workforce? This is a big problem. You know, they talked about, when they were passing the Affordable Care Act, that if you’re going to give all these people more insurance, you’re going to need more health care professionals to take care of them.

Knight: Yeah.

Rovner: Yet we haven’t seemed to do that.

Knight: Yeah, I know. It’s something that is being talked about. My colleague Peter [Sullivan] at Axios talked to both Sen. [Bernie] Sanders and Sen. [Bill] Cassidy about things they might want to work on on the HELP [Health, Education, Labor & Pensions] Committee. And I know that the nursing workforce shortage is one thing they do actually agree on. So it’s definitely possible. I do think the medical provider workforce shortage is maybe a bipartisan area in this Congress that they could work on. But I mean, they’ve been talking about it forever. And will they actually do something? I’m not sure. So we’ll see. But I know nursing …

Rovner: Yeah, the spirit of bipartisanship does not seem to be alive and well, at least yet, in this Congress.

Knight: Yeah, well, between the House and the Senate. Yeah, well, we’ll see.

Kenen: But the nursing shortage is, I mean, been documented and talked about for many, many years now and hasn’t changed. The doctor shortage is more controversial because there’s some debate about whether it’s numbers of doctors or what specialties they go into. I mean, and, also, do they go to rich neighborhoods or poor neighborhoods? I mean, if you’re in a wealthy suburb, there’s plenty of dermatologists. Right? But in rural areas, certain urban areas … So it’s not just in quantity. It’s also an allocation both by geography and specialty. Some of that Congress could theoretically deal with. I mean, the graduate medical education residency payment … they’ve been talking about reforming that since before half of the people listening to this were born. There’s been no resolution on a path forward. So some of these are things that Congress can nudge or fix with funding. Some of it is just things that have to happen within the medical community, some cultural shift. Also student debt. I mean, one reason people start out saying they’re going to go into primary care and end up being orthopedic surgeons is their debt. So it’s complicated. Some of it is Congress. Not all of it is Congress. But Congress has been talking about this for a very, very, very, very, very long time.

Rovner: I will point out — and Joanne was with me when this happened — when Congress passed the Balanced Budget Act in 1997, they cut the number of residencies that Medicare would pay for with the promise — and I believe this is in the report, if not in the legislation — that they would create an all-payer program to help pay for graduate medical education by the next year, 1998. Well, now it’s 2023, and they never did that.

Kenen: They meant the next century.

Rovner: We’re a fifth — almost a quarter of the way — through the next century, and they still haven’t done it.

Kenen: And if you were on the front lines of covid, the doctors and the nurses, I mean, at the beginning they had no tools. So many people died. They didn’t know how to treat it. There were so many patients, you know, in New York and other places early on. I mean, it was these nurses that were holding iPads so that people could say goodbye to their loved ones. I don’t think any of us can really understand what it was like to be in that situation, not for 10 minutes, but for weeks and over and over …

Rovner: And months and years, in some cases.

Kenen: Right. But I mean, the really bad … it’s years. But these crunches, the really traumatic experiences, I mean, we’ve also talked in the past about the suicide rate among health care providers. It’s been not just physically exhausting, it’s become emotionally unimaginable for those of us who haven’t been in those ICU or ERs.

Rovner: Well, it’s clear that the pandemic experiences have created a mental health crisis for a lot of people. Clearly, people on the front lines of health care, but also lots of other people. This week, finally, a little bit of good news for at least one population. Starting this week, any U.S. military veteran in a mental health crisis can get free emergency care, not just at any VA [Department of Veterans Affairs] facility, but at any private facility as well. They don’t even have to be in the VA health system because many former members of the military are not actually eligible for VA health care. This is for all veterans. It’s actually the result of a law passed in 2020 and signed by then-President [Donald] Trump. How much of difference could this change, at least, make? I mean, veterans in suicidal crises are also, unfortunately, fairly common, aren’t they?

Kenen: Yeah, but I mean, we have a provider shortage, so giving them greater access to a system that doesn’t have enough providers, I mean, will it help? I would assume so. Is it going to fix everything? I would assume not. You know, we don’t have enough providers, period. And there are complicated reasons for that. And that’s also … they’re not all doctors. They’re, you know, psychologists and social workers, etc. But that’s a huge problem for veterans and every human being on Earth right now. I mean, everybody was traumatized. There’s degrees of how much trauma people had, but nobody was untraumatized by the last three years. And the ongoing stresses. You can be well-adjusted traumatized. You could be in-crisis traumatized. But we’re all on that spectrum of having been traumatized.

Knight: Yeah.

Rovner: Well, lots more work to do. OK. That’s the news for this week. Now it is time for our extra-credit segment, where we each recommend a story we read this week we think you should read, too. Don’t worry if you miss it; we will post the links on the podcast page at khn.org and in our show notes on your phone or other mobile device. Victoria, why don’t you go first this week?

Knight: The story that I’m recommending is called “‘The Last of Us’ Zombie Fungus Is Real, and It’s Found in Health Supplements.” It’s in The Washington Post by Mike Hume. “The Last of Us” is a new HBO show everyone’s kind of talking about. And, basically, people become zombies from this fungus. Turns out that fungus is real in real life. It’s spread by insects that basically infect people and then kind of take over their minds and then shoot little spores out. And in the show, they do that as well, except they don’t spread by spores. They spread by bites. But it’s used in health supplements for different things like strength, stamina, immune boost. So it’s kind of just a fun little dive into a real-life fungus.

Rovner: To be clear, it doesn’t turn people into zombies.

Knight: Yes. To be clear, it does not turn people into zombies. If you eat it, that will not happen to you. But it is based on a real-life fungus that does infect insects and make them zombies.

Rovner: Yes. [laughter] It’s definitely creepy. Tami.

Luhby: My story is by my fantastic CNN colleagues this week. It’s called “ER on the Field: An Inside Look at How NFL Medical Teams Prepare for a Game Day Emergency.” It’s by my colleagues Nadia Kounang, Amanda Sealy, and Sanjay Gupta. Listen, I don’t know anything about football, but I happened to be watching TV with my husband when we flipped to the channel with the Bills-Bengals game earlier this month, and we saw the ambulance on the field. So like so many others, I was closely following the story of Damar Hamlin’s progress. What we heard on the news was that the team and the medical experts repeatedly said that it was the care on the field that saved Hamlin’s life. So Nadia, Amanda, and Sanjay provide a rare behind-the-scenes look at how hospital-quality treatment can be given on the field when needed. I learned that — from the story and the video — that there are about 30 medical personnel at every game. All teams have emergency action plans. They run drills an hour before kickoff. The medical staff from both teams review the plan and confirm the details. They station certified athletic trainers to serve as spotters who are positioned around the stadium to catch any injuries. And then they communicate with the medical team on the sidelines. But then — and this is what even my husband, who is a major football fan, didn’t know this — there’s the all-important red hat, which signifies the person who is the emergency physician or the airway physician, who stands along the 30-yard line and takes over if he or she has to come out onto the field. And that doctor said, apparently, they have all the resources available in an emergency room and can essentially do surgery on the field to intubate a player. So I thought it was a fascinating story and video even for non-football fans like me, and I highly recommend them.

Rovner: I thought it was very cool. I read it when Tami recommended it. Although my only question is what happens when there’s a team, one whose color is red and there are lots of people wearing red hats on the sidelines?

Luhby: That’s a good point.

Rovner: I assume they still can find the doctor. OK, Joanne.

Kenen: There was a piece in The Atlantic by Katherine J. Wu called “Covid Couldn’t Kill the Handshake.” It had a separate headline, depending on how you Googled it, saying “Don’t Fear the Handshake.” So, basically, we stopped shaking hands. We had fist bumps and, you know, bows and all sorts of other stuff. And the handshake is pretty much back. And yes, your hands are dirty, unless you’re constantly washing them, your hands are dirty. But they are not quite as dirty as we might think. We’re not quite as dangerous as we may think. So, you know, if you can’t get out of shaking someone’s hand, you probably won’t die.

Rovner: Good. Good to know. All right. My extra credit this week is a story I wish I had written. It’s from Roll Call, and it’s called “NIH Missing Top Leadership at Start of a Divided Congress,” by Ariel Cohen. And it’s not just about not having a replacement for Dr. Tony Fauci, who just retired as the longtime head of the National Institute for Allergy and Infectious Diseases last month, but about having no nominated replacement for Frances Collins, who stepped down as NIH [National Institutes of Health] director more than a year ago. In a year when pressure on domestic spending is likely to be severe, as we’ve been discussing, and when science in general and NIH in particular are going to be under a microscope in the Republican-led House, it doesn’t help to have no one ready to catch the incoming spears. On the other hand, Collins’ replacement at NIH will have to be vetted by the Senate HELP Committee with a new chairman, Bernie Sanders, and a new ranking member, Bill Cassidy. I am old enough to remember when appointing a new NIH director and getting it through the Senate was a really controversial thing. I imagine we are back to exactly that today.

OK. That’s our show for this week. As always, if you enjoyed the podcast, you could subscribe wherever you get your podcasts. We’d appreciate it if you left us a review; that helps other people find us, too. Special thanks, as always, to our ever-patient producer, Francis Ying, and to our KHN webteam, who have given the podcast a spiffy new page. As always, you can email us your comments or questions. We’re at whatthehealth — all one word — @kff.org. Or you can tweet me. I’m still at Twitter, for now, where I’m @jrovner. Tami?

Luhby: I’m @Luhby — L-U-H-B-Y

Rovner: Victoria.

Knight: @victoriaregisk

Rovner: Joanne.

Kenen: @JoanneKenen

Rovner: We will be back in your feed next week. Until then, be healthy.

Credits

Francis Ying
Audio producer

Emmarie Huetteman
Editor

To hear all our podcasts, click here.

And subscribe to KHN’s What the Health? on Spotify, Apple Podcasts, Stitcher, Pocket Casts, or wherever you listen to podcasts.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

USE OUR CONTENT

This story can be republished for free (details).