Frye, an emergency room nurse with 25 years of experience, felt that ignoring inequality’s role in health and sickness was an affront to the compassionate soul of the nursing profession.��

“It felt like a step��against��everything I believe in,” Frye said. “And I didn’t feel like I belonged there anymore.”��

Now Frye has found a new place to belong. She is part of a surge of American nurses and other health care workers moving to Canada��—��specifically,��British Columbia��—��to escape the policies of President Donald Trump. Frye settled in Nanaimo on Vancouver Island, where the local hospital has hired 20 American nurses in less than a year.��

“There are so many like-minded people out there,” said Justin Miller, another American nurse who started at Nanaimo Regional General Hospital this month. “You��aren’t��trapped. You��don’t��have to stay. Health care workers are welcomed with open arms around the world.”��

More than 1,000 U.S.-trained nurses have been approved to work in British Columbia since April, when the province streamlined its licensing process for Americans, then launched an advertising campaign to take advantage of the “chaos and uncertainty happening in the U.S.” Nursing associations in Ontario and Alberta said they too have seen increased interest from American nurses in the past year.��

“Some of them were living in fear of the administration, and they shared a sense of relief when crossing the border,” said Angela Wignall, CEO of Nurses and Nurse Practitioners of British Columbia. “As a Canadian,��it’s��heartbreaking. And��also��a joy to welcome them.”��

The Trump administration, for its part,��doesn’t��seem concerned. When asked to comment, the White House dismissed accounts of nurses moving to Canada as “anecdotes of individuals with severe cases of Trump derangement syndrome.”��

This aligns with��an article��we reported last year that found��American doctors were also relocating north��to get away from the Trump administration. According to the Medical Council of Canada, more than 1,200 American doctors created accounts on����in 2025��—��typically the first step to getting licensed in Canada��—��compared��with��only about 300 in 2024.

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The Millers resettled on Vancouver Island, their scenic refuge accessible only by ferry or plane. Justin went to work in the emergency room at Nanaimo Regional General Hospital, where he became one of at least 20 U.S.-trained nurses hired since April.

Fear of Trump, some of the nurses said, was why they left.

“There are so many like-minded people out there,” said Justin, who now works elbow to elbow with Americans in Canada. “You aren’t trapped. You don’t have to stay. Health care workers are welcomed with open arms around the world.”

The Millers are part of a new surge of American nurses, doctors, and other health care workers moving to Canada, and specifically British Columbia, where more than 1,000 U.S.-trained nurses have been approved to work since April. As the Trump administration enacts increasingly authoritarian policies and decimates funding for , insurance, and medical research, many nurses have felt the draw of Canada’s progressive politics, friendly reputation, and universal health care system.

Additionally, some nurses were incensed last year when the Trump administration said it would reclassify nursing as a , which would impose strict federal limits on the loans nursing students could receive.

Canada is poised to capitalize. Two of its most populous provinces, Ontario and British Columbia, have streamlined the licensing process for American nurses since Trump returned to the White House. British Columbia also launched a last year to recruit nurses from California, Oregon, and Washington state.

“With the chaos and uncertainty happening in the U.S., we are seizing the opportunity to attract the talent we need,” Josie Osborne, the province’s health minister, said in a statement announcing the campaign.

Fears Realized

Amy Miller, a nurse practitioner, said she and her husband were determined to move their children out of the country because they felt Trump’s second term would inevitably spiral into violence.

First, the Millers got nursing licenses in New Zealand, but when the job search took too long, they pivoted to Canada.

Justin was offered a job within weeks.

Amy found one within three months.

So they moved. And just a few days later, the Millers watched with horror from afar as their fears came true.

As federal immigration forces clashed with protesters in Minneapolis on Jan. 24, federal agents fatally shot an ICU nurse, Alex Pretti, as he filmed a confrontation and appeared to be trying to shield a woman who was knocked down. Video of the killing showed border agents pinning Pretti to the ground before seizing his concealed, licensed handgun and opening fire on him.

The Trump administration quickly called Pretti a “domestic terrorist” who intended to kill federal agents.��That allegation was disputed by eyewitness videos that circulated on social media and spurred widespread outrage, including from nurses and nursing organizations, some of whom invoked the profession’s duty to care for the vulnerable.

“I don’t want to say it was expected, but that’s why we are here,” Amy Miller said. “Even our oldest kid, she was like: ‘It’s OK, Mom, because we are not there anymore. We are safe here.’ So she recognizes that, and she’s not even in middle school yet.”

Both the U.S. and Canada have a severe need for nurses. The U.S. is projected to be short about 270,000 registered nurses, plus at least 120,000 licensed practical nurses, by 2028, according to from the Health Resources and Services Administration. In Canada, nursing job vacancies tripled from 2018 to 2023, when they reached nearly 42,000, according to from the Montreal Economic Institute, a Canadian think tank.

When asked to comment, the White House noted that shows the number of nurses licensed in the U.S. increased in 2025. It dismissed accounts of nurses moving to Canada as “anecdotes of individuals with severe cases of Trump derangement syndrome.”

“The American health care workforce is the finest in the world, and it continues to expand under President Trump,” White House spokesperson Kush Desai said. “Employment opportunities in the American health care system remain robust, with career advancement and pay that far exceed that of other developed nations.”

‘A Sense of Relief’

It is unknown precisely how many American nurses have moved north since Trump returned to office, because some Canadian provinces do not track or release such statistics.

British Columbia, which has done the most to recruit Americans, approved the licensing applications of 1,028 U.S.-trained nurses from when the province’s streamlined application process took effect in April 2025 through January, according to the British Columbia College of Nurses and Midwives. In all of 2023, only 112 applicants from the U.S. were approved, the agency said. In 2024, it was 127.

Increased interest from American nurses was also confirmed by nursing associations in Ontario and Alberta, as well as by the nationwide Canadian Nurses Association.

Angela Wignall, CEO of Nurses and Nurse Practitioners of British Columbia, said American nurses used to move north because they had fallen in love with Canada (or a Canadian). But more recently, she said, she had met nurses who feared the White House would spur violence and vigilantism, particularly against families that included same-sex couples.

“Some of them were living in fear of the administration, and they shared a sense of relief when crossing the border,” Wignall said. “As a Canadian, it’s heartbreaking. And also a joy to welcome them.”

Vancouver Island, which has a population of about 860,000, has gained 64 U.S.-trained nurses since April, including those at Nanaimo Regional, said Andrew Leyne, a spokesperson for the island’s health agency.

One of the nurses was Susan Fleishman, a Canadian who moved to the U.S. as a child, then worked for 23 years in American emergency rooms before leaving the country in November.

Fleishman said hateful rhetoric from Trump has fueled an angry division that has permeated and soured American life.

“It wasn’t an easy move — that’s for sure. But I think it’s definitely worth it,” she said, happily back in Canada. “I find there is a lot more kindness here. And I think that will keep me here.”

Brandy Frye, who also worked for decades in American ERs, said she moved to Vancouver Island last year after waiting to see whether Mark Carney would become Canada’s prime minister. Carney’s rise was widely viewed as a rejection of Trumpism.

Meanwhile, Frye said, the California hospital where she worked had been stripping words associated with diversity and equity out of its paperwork to appease the Trump administration. She couldn’t stand it.

“It felt like a step against everything I believe in,” Frye said. “And I didn’t feel like I belonged there anymore.”

Like many of the American nurses who have moved to Vancouver Island, Frye was first wooed to the area by a that was meant to attract tourist dollars but ended up doing much more.

About a year ago, Tod Maffin, a and former CBC Radio host, invited Americans to the port city of Nanaimo for a weekend event designed to offset the impact of Trump’s tariffs on the local economy.

Maffin said about the April event.

“A lot of them were health care workers looking for an escape route,” Maffin said. “They were there to help support our economy but also to look into Canada.”

Maffin saw an opportunity. He repurposed the event website into a recruiting tool and launched a Discord chatroom to help Americans relocate.

Maffin said he believes the campaign helped about 35 health care workers move to Vancouver Island. Volunteers in have since duplicated his website in an effort to attract their own American nurses and doctors.

“There are communities across Canada where the emergency room closes at night because one nurse is out. That’s how thin staffing is,” Maffin said.

“One new nurse in a small town, or in a midsized city like Nanaimo,” he said, “makes a difference.”

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Republicans remain divided over how to address the impending expiration of more generous Affordable Care Act plan tax credits, which will send premiums spiraling for millions of Americans starting in January if no further action is taken. The Trump administration floated a proposal over the weekend that included a two-year extension of the credits as well as some restrictions pushed by Republicans, but the plan was met with strong pushback on Capitol Hill and its unveiling was delayed.��

Meanwhile, the Department of Education has declared that a long list of health careers are not “professions,” meaning that students pursuing those tracks — including as nurses, physical therapists, and physician assistants — will no longer be eligible for federal student loans large enough to cover their tuition.��

This week’s panelists are Julie Rovner of �������ýҕ�l Health News, Sarah Karlin-Smith of the Pink Sheet, Alice Miranda Ollstein of Politico, and Sandhya Raman of CQ Roll Call.

Panelists

Among the takeaways from this week’s episode:

• The news of Trump’s health care plan landed as Sen. Bill Cassidy of Louisiana was working on a separate GOP proposal to direct money into health savings accounts. Congressional Republicans suggested they were left out of Trump’s planning and, among other things, opposed his proposed extension of limited ACA premium tax credits.
• Health and Human Services Secretary Robert F. Kennedy Jr. has confirmed that he ordered the change to the Centers for Disease Control and Prevention website to assert the false claim that vaccines may cause autism. That development puts Republicans in a tough spot — particularly Cassidy, a physician who voted for Kennedy’s confirmation after saying he’d secured an agreement that Kennedy would not make changes to the CDC’s vaccine policy.
• Three states have revived the lawsuit challenging the approval of mifepristone, adding to the case the FDA’s recent approval of another generic version. The Supreme Court threw out the first case, ruling then that the plaintiffs — who were doctors — lacked standing to prove harm. Yet the revived case may very well end up at the Supreme Court again.

Also this week, Rovner interviews Joanne Kenen and Joshua Sharfstein of the Johns Hopkins Bloomberg School of Public Health about their new book, .

Plus, for “extra credit,” the panelists suggest health policy stories they read this week that they think you should read, too:��

Julie Rovner: The New Yorker’s “,” by Tatiana Schlossberg.����

Alice Miranda Ollstein: CNBC’s “,” by Jonathan Vanian.����

Sarah Karlin-Smith: The Guardian’s “,” by Sirin Kale and Lucy Osborne.����

Sandhya Raman: �������ýҕ�l Health News’ “Kids and Teens Go Full Throttle for E-Bikes as Federal Oversight Stalls,” by Kate Ruder.����

Also mentioned in this week’s podcast:

• The Center for Law and Social Policy’s “.”��
• The New York Times’ “,” by Sheryl Gay Stolberg.
• The Atlantic’s “,” by Katherine J. Wu.
• ��NPR’s “,” by Yuki Noguchi.
• ��Campaign for Accountability’s “.”

[Editor’s note:��This transcript was generated using both transcription software and a human’s light touch. It has been edited for style and clarity.]��

Julie Rovner:��Hello from �������ýҕ�l Health News and WAMU Public Radio in Washington, D.C., and welcome to��What the Health?��I’m��Julie Rovner, chief Washington correspondent for �������ýҕ�l Health News, and��I’m��joined by some of the best and smartest health reporters in Washington.��We’re��taping��early��this��Thanksgiving��week on��Tuesday, Nov.��25,��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 Alice Miranda��Ollstein��of Politico.��

Alice Miranda��Ollstein:��Hello.��

Rovner:��Sandhya Raman of CQ Roll Call.��

Sandhya��Raman:��Good morning.��

Rovner:��And��Sarah Karlin-Smith, the Pink Sheet.��

Karlin-Smith:��Hi,��everybody.��

Rovner:��Later in this episode,��we’ll have my interview with��What the Health?��panelist Joanne Kenen and Dr. Joshua Sharfstein,��both of the Johns Hopkins��Bloomberg School of Public Health, about their new book called��Information Sick: How Journalism’s Decline and Misinformation’s Rise��Are Harming Our Health and What We Can Do��About It.��

But first, this��week’��news. So,��for about 24 hours there,��it looked like we might have an actual health��care plan from President Donald Trump, but,��alas, it was not to be. What we all heard about on Sunday felt like a plan with a lot of pieces that could��actually be��palatable to a lot of Democrats. A two-year extension of the��covid-era enhanced tax credits with an income cap higher than the 400% that subsidies are about to revert to, and��minimum��premiums for those paying zero now. And,��not surprisingly, or maybe surprisingly, Republicans on Capitol Hill, particularly those in the House who had been adamant about no extension of the premium subsidies, freaked out,��to use a technical term. And now the announcement of the Trump plan has been��“delayed.”��But there is a deadline this time, Jan.��1, when the enhanced tax credits expire��— and,��before that, the second week of December, when the Senate is supposed to vote on a subsidy extension. That was the deal��that got��the government reopened. So where are the Republicans at this point?��

Ollstein:��It’s��a total mess. Very few people have confidence that this will get done at all or in time to make a difference��for��the cost of people’s health��care that has already gone up. So,��House Republicans��were, one, upset just process-wise. They��didn’t��like finding out that Trump was going to release a plan from news reports and social media. They felt left out of the loop.��

Rovner:��On a Sunday?��

Ollstein:��Congress has been left out of the loop on a lot of things in this administration, and this is yet another one. But they were also opposed to the substance of what was leaked. The few details they have, we still haven’t seen what this actual plan is, but they didn’t like that it was a two-year extension, even with these limitations that conservatives had wanted in terms of cutting off people of higher incomes from getting subsidies and requiring everyone to pay a minimum premium, which research shows��will��lead to a lot of people losing their insurance. And so even with those limitations, there were a lot of people upset. Meanwhile, on the Democratic side, yes,��you had some people being cautiously optimistic about this plan, but then you had other Democratic ranking members in the House on the relevant health committees put out a statement saying,��Anything��short of a clean extension, without these conservative limitations, anything short of that was unacceptable. And��so��you really have both sides digging in, and I��don’t��really see how this gets solved.��

Rovner��[laughing]:��Sandhya, what are you hearing?��

Raman:��I was going to say that in addition to the House being blindsided,��I think it��puts the Senate in an awkward position. Senate Republicans, they have been gearing up on an HSA��[health savings account]��proposal as��kind of their��alternative to extending the premium subsidies. And Sen.��Bill��Cassidy��[R-La.]��has said that he wants to do a hearing the week they come back from Thanksgiving to follow up on the��[Senate] Finance��[Committee]��hearing, and this kind of pushes them in a totally different direction after just a few days ago, Trump himself had said,��We don’t want to pay the insurance companies, we want the money to go to the consumers directly, kind of in line with one of the HSA proposals going around.��So��it caused a lot of confusion, and��I think it��just really further underscores��…��I��don’t��think a lot of people are confident this comes together.��

Dec.��15 is when open enrollment ends, and I think that even if you look at some of the bipartisan stuff that has been floated before��—��even last week we had another one come out that was a little similar to the stuff being floated on Sunday that would extend open enrollment more to give them a little bit more time. But one thing that we kept hearing yesterday was��just��even the changes that were being floated yesterday, why they��weren’t��being supported by people that do want an extension is��there’s��such��a short time��crunch to implement these changes in��basically a��month.��

Rovner:��And now Republicans are talking about doing a whole new health bill,��maybe using��budget reconciliation so they��won’t��need Democratic votes. And I guess��I’m��the one��that’s��going to have to remind them that the ACA��[Affordable Care Act]��didn’t��pass under reconciliation because there were a whole lot of things in it that they��couldn’t��put in a budget reconciliation bill. They used budget reconciliation to��basically cut��a deal between the House and the Senate after the Senate lost its 60th vote.��But the original ACA passed with 60 votes.��So��if the Republicans think��they’re��going to do something��really big��next year with just Republican votes,��they’re��going to find out��fairly quickly��that a lot of that is not going to be allowed.��

Ollstein:��Just in time, as our Twitter friend says.��

Rovner:��Somebody pointed out that��it’s��been 10 years since Trump said he would have a health plan sometime in the next two weeks. Although as I��say, this��time��two weeks is really going to be important. I feel like poor Sen.��Cassidy, who we will talk about later with RFK��[Robert F. Kennedy Jr.], also kind of got cut off at the knees by the president because he was all over the Sunday shows talking about his plan to give the money to consumers, which is what President Trump had been endorsing until he wasn’t.��So��we have no idea where the administration is at this point, right?��

Ollstein:��And I will say, something that in part led to the postponement and backlash and chaos this week is that folks on Capitol Hill, Republicans��and��Democrats, have no idea what the White House is going to do about this abortion issue that has been roiling��—��this whole debate where conservatives are saying that it’s a red line, they have to basically ban all plans on the individual market from covering abortion. Right now,��it’s��up to states:��Half��ban��them, half��don’t. Some��require��them,��some allow them but��don’t��require them. And conservatives are demanding that there be��sort of a��blanket ban on that coverage, that any federal funding going to these plans, even if they pay for abortion with other money, they consider that a subsidization. And this has been��a real sticking��point. Democrats say they��won’t��accept any expansion of abortion restrictions in Obamacare;��Republicans say they��won’t��accept anything without the��additional��restrictions, and we still��don’t��know where the White House is going to come down on this.��

Rovner:��Because, as I like to��say��every week, health��care is��really hard. All right. In big news that’s��kind of lost��already, Reuters is reporting that the White House has��terminated��DOGE, the Department of Government Efficiency, eight months early. In practice, DOGE has been dormant for many months, even before the departure of Elon Musk back to his day jobs at Tesla and SpaceX. But DOGE has left behind a lot of cuts. The nonprofit Center for Law and Social Policy has a��tracker of all the funding and personnel changes��made by the administration down to the program level, including at HHS��[the Department of Health and Human Services]. I will����in the show notes.��

But if you want a more personal look, you should go read my��extra��credit this week, which we can all talk about now.��It’s��an achingly����by Tatiana Schlossberg, daughter of Caroline Kennedy and granddaughter of JFK��[President John F. Kennedy]. Tatiana, an environmental journalist and mother of two young children,��is dying of a rare and��difficult-to-treat��form of leukemia. Among other things, she was undergoing rounds of��ultimately unsuccessful��treatment while watching huge cuts to health��care research being made��at��the direction of her cousin RFK Jr., all the while realizing how those cuts will��likely threaten��the survival of patients like her. I heard a lot about this story over the weekend, and I wonder if it might have some impact reaching the public about what the HHS cuts are likely to mean going forward in a way that just the numbers being repeated��haven’t.��

Karlin-Smith:��I think,��I mean,��it’s such a human connection story, and when she talks about not probably being able to live to see her kids grow up and the kind of research NIH��[the National Institutes of Health]��was funding that maybe would’ve given her a little bit of hope with a clinical trial that��was working. One thing I thought about a lot reading this is she talks about how she’s,��I guess,��34 or 35, she felt like she��was young and healthy, she was��very active, ate right. And one of RFK’s��way��of thinking,��I guess,��in the way of orchestrating his health goals is this idea that if you eat right and you exercise and you take certain personal responsibilities, you can avoid illness. And there are lots of kinds of illnesses that,��unfortunately,��you can do the best you��possibly can��on an individual personal level and you are not unfortunately exempt from getting, and��cancers are��one of them. And it’s not to say that there cannot be any role for those other things that can maybe help keep you healthy and prevent certain diseases, but it’s interesting to think about her realization around what can happen to you even if you’re trying your best to live a healthy lifestyle, and the juxtaposition of an administration that is, and their policies also, forgetting that this is not just based on what you eat and how often you exercise and so forth.��

Rovner:��To quote President Trump, who was talking about something else entirely,��“Things happen.”��It goes back to the ACA discussion.��People who are young and healthy and think they don’t need health insurance because nothing bad is going to happen to them, and a certain number of people��…��bad things are going to happen no matter how exemplary healthily they live their lives.��That’s��why we have health insurance. Well, meanwhile,��over at HHS,��Secretary Kennedy over the weekend����that he��was��personally responsible for the website changes at the Centers for Disease Control and Prevention that now say scientists��“have not ruled out the possibility that infant vaccines cause autism.”��Just a reminder, this was a change that Kennedy had promised��HELP��[Health, Education, Labor & Pensions] Committee chair and gastroenterologist Bill��Cassidy��he��would not make in exchange for Cassidy’s vote to confirm him in the Senate. Yet Cassidy still demurred when asked on��the Sunday��shows if he regrets being the deciding vote to make Kennedy the secretary.��I’m��wondering if Cassidy is the new Susan Collins, the main moderate, who continually said during Trump’s first term that she was��very, very concerned��about many of the president’s policies, but still declined to vote against most of them. Has Cassidy��kind of replaced��her in that role?��

Ollstein:��I think Cassidy��is really in a situation of his own. I��don’t��think��he’s��the new��anything. I think��he’s��the first Cassidy, and��maybe in��the future��we’ll��be referring to other��Cassidys. But I think given his medical background,��and not just any medical background, like given his background specializing in hepatitis, which is one of the vaccines that people are most anxious will become unavailable or restricted in the future, and given his direct role in extracting promises in order to confirm RFK and now having those promises pretty blatantly stepped on and there not really being much repercussions. Also,��him being up for reelection next year. I think��it’s��quite unique,��all of��those dynamics, as much as we see parallels with some other members.��

Rovner:��Yeah,��it’s��true.��I’ll��say Collins is��a moderate��because she comes from a moderate state.��Cassidy’s��from Louisiana, which is not a moderate��state,��it’s��a very red state.��So��he does find himself in these extremely uncomfortable positions. Well,��it’s��not just vaccines and not just the CDC��that’s��turning against settled science. Over at the National Institutes of Health,����at��The Atlantic, leaders have a new pandemic preparedness plan that suggests that rather than study pathogens and develop and stockpile vaccines, the country would be better off eating better and exercising. This kind of goes back to what you were just saying, Sarah.��I’m��not sure to where to start with this, other than I guess��it’s��better to be healthy than not. But as��we’ve��pointed out, even healthy people are susceptible to germs.��

Karlin-Smith:��Right. And��so��one thing her piece raises is that Kennedy,��in particular,��has��sort of dismissed germ theory, which does not quite believe in the way that most scientists and people do of these roles, of these infectious organisms in disease. And while Katherine’s piece,��I think very nicely,��talks about there is some element of somebody who is not able to feed themselves enough of the right quantities of food may do worse with an infectious disease, but at the end of the day it’s about your immune system being exposed to these viruses and having some knowledge of how to fight them off.��And so younger people, like in the 1918 flu,��actually,��in��some cases would say we’re dying at higher rates even than older people.��Obviously again, the pre-vaccine era, this is why so many children under the age of��5��died young. It��wasn’t��that these were all children born with particularly unhealthy lifestyles or something about them that made them more��likely,��it was just that their body needed to somehow learn to experience this antigen.��

Rovner:��We call them childhood diseases for a reason, right?��

Karlin-Smith:��Right.��And I think Katherine Wu does a really good job of talking about the multifold strategies you need to be able to be prepared to fight a pandemic.��And being so close to��covid��still,��knowing that bird flu and different strains of bird flu are circulating, it does seem a bit concerning that people may be changing the forms of preparation that��we’re��preparing for rather than building up.��

Rovner:��Well,��meanwhile over at the FDA, the sharp knives��remain out��among the top deputies to Commissioner Marty Makary. The latest missive comes from newly appointed drug regulator Richard��Pazdur, who unlike many of his fellow center��directors��is��actually a��veteran of the agency. But��Pazdur��has��reportedly warned��that some of the new FDA efforts to speed the approval of drugs, including deals that trade faster reviews for lowered prices, could be illegal and dangerous to the public health. Sarah, what is going on over there?��

Karlin-Smith:��Yeah, so��it’s��been an untraditional year at FDA in terms of how this commissioner��operates, but Makary’s��what’s��called this Commissioner National Priority Voucher program has rolled out in more detail over the past couple��weeks.��It’s��designed to give companies a two-month review, which most FDA reviews tend to be in the��six-[month]��to one-year��time��frame.��So��two months��is��superfast. And the criteria for qualifying to try and get that is��really vague, and it essentially at the end of the day results��to��the commissioner in their close��circle kind��of picking who they want.��That’s��raised a lot of questions because��it’s��just not clear. They have��sort of a��fair and��established��process. Makary has also suggested that if you give commitments to keep the price of the product low, or deal with Trump on his��most-favored-nation��pricing deal,��we’ll��give you this.��

And��FDA��does not deal with drug pricing. It has no levers or authority to, if a company says,��“Of course Marty, we’ll price this product at a fair price if you give us a two-month review.”��They have no levers to enforce that, to��determine��what a fair price is, and it also raises ethical questions of��Should FDA?��And potentially again, legal questions,��Does FDA have the authority to prioritize an application because a company makes these commitments over another application where a company��doesn’t?��And is that fair?��Particularly,��you��have to��think about normally��FDA is��prioritizing things based on how devastating��the disease is or how quickly it kills things or are there other treatments?��And��so��some of the criteria Makary is using,��I think,��is striking people as a bit more political in that sense.��

Rovner:��Yeah. Well, moving on to a segment called��“Honey I Shrunk the Health��Care Workforce,”��you��might’ve��heard that the Trump administration is busy dissolving the Department of Education and transferring its responsibilities to other agencies. On its way out of existence,��however, the department has��determined��that��a long list��of health��care careers��don’t��qualify as professions, including nursing, social work, physical therapy, public health,��and physician assistants. This is not just��semantic,��it means that people studying for these graduate degrees��won’t��be able to get federal student loans for anywhere near what tuition costs. And this comes at a time when the U.S.��badly needs��more, not fewer,��of these health professionals for an aging and increasingly less healthy population. In fact, this feels like a way to make health��care more, not��less,��expensive, since many of these professionals can do work otherwise done by higher-paid medical doctors. Am I missing something here?��

Raman:��I think��you’re��exactly right, especially as over the last few years��we’ve��seen��in Congress them really ramping up,��looking at ways to expand the pipeline of workers. You��can’t��create a��health��worker overnight. The more advanced the degree, the longer��it’s��going to take. And I mean, I think it’ll take a little while to see some of the effects of this if it stays in effect, because there’s going to be people that maybe won’t even consider some of these fields rather than if they’re midway through or about to enter one,��if they know that it’s not going to be something that their family or themselves can afford. At the same time,��as��we’re��going to have the population aging and��we’re��going to need��more and more��of these��folks, so��I think��it’s��a two-pronged thing that��we’ll��see over time.��

Rovner:��Yeah. And I know in my workforce studies, I’ve seen a lot of people who wanted to be doctors who ended up going to nursing school or physician assistant school because it was so much cheaper and it took less time, so it was sort of an easier career path. But this is throwing up another roadblock. It just seems like,��why are they doing this?��I guess nobody has yet said��… I��have to��tell you, I’ve gotten dozens of emails from organizations representing a lot of these career professionals saying, “What are they doing here?”��It seems puzzling.��

Karlin-Smith:��Some of these professions, like public health workers,��don’t��end up making the most money once you come out.��So��people talk about how��well��doctors,��med school,��is��really expensive��and they don’t make��enough …��but eventually you recover from that process. And in some of these professions,��like public health, it really might not just make it totally unviable for people to go into the field because they don’t have that guarantee they’re going to be able to get a salary that will ensure they can repay their loans afterwards.��

Rovner:��Yes. Well and speaking of doctors, Yuki Noguchi over at NPR has a����about how the administration’s crackdown on immigration is giving international medical school graduates pause about wanting to come practice in the U.S. This is also a big deal because immigrant physicians are not only a big part of the physician workforce in general in the U.S., but in areas with the biggest doctor shortage they often make up as much as half of the doctors in practice. Since this administration is all about affordability, the combination of these two policies seems likely to create a giant shortage, yes?��

Ollstein:��Yeah.��We’re��cutting off our domestic pipeline and��we’re��cutting off our international pipeline, and this is coming��…��there are already shortages. There��was��so much burnout and people retiring early and people quitting during and after the pandemic, and this��couldn’t��come at a worse time,��really. And��there’s��more punches than the one-two punch. People are also concerned about the high-skilled worker visa fees going up and that making it harder to bring in international medical workers for hospitals that are already struggling to pay an extra fee of tens of thousands of dollars is not really��viable��right now.��So yeah,��there’s��a lot of concern.��

Rovner:��And��it’s��certainly not going to bring down medical prices, which I guess is��maybe what��I mean. I know that in the case of the cap on medical school tuition, the hope is to bring down tuition, is to force tuition down by not making the loans big enough. But��it’s��one thing to say that having unlimited loans is inflationary and allows tuition to go up;��it’s��another thing to say that cutting off the loans is going to make tuition go down.��

Raman:��Yeah, I mean��it’s��a complicated process when you also have,��I mean,��for a variety of degrees, the��international students are often paying full price,��and that subsidizes the cost of some other folks going.��So��there are many pieces of this puzzle, so��it’ll��be interesting to see what happens next.��

Rovner:��We will continue to watch this space.��OK,��we’re��going to take a quick break. We will be right back.��

So��turning to��the��“everything that is old is new again,”��now we have the return of the public charge rule, which Trump tried to rewrite during his first term to make it harder for immigrants to qualify for permanent residency, only to have it reversed by the Biden administration. Alice, remind��us��what this is and what Trump 2.0 is trying to do��that’s��different from what Trump 1.0 did.��

Ollstein:��Right.��So��this has gone back and forth, and��it’s��not a straight,��clear-cut revival of the policy under the first Trump administration. I think in part��that’s��because that one was struck down in court, and so��this trends��of the new. So,��basically,��after the comment period and when things get finalized, this is��giving,��instead of directing all immigration officers to deny permanent residency applications to people who have used Medicaid and have used these social safety-net programs, it’s basically just leaving it up to the individual officer. And there’s language about considering the totality of circumstances, and so there’s a lot of concern in the immigration advocacy community that this will lead to discrimination and decisions made based on basically vibes of if someone seems like they might become a burden on society later, and so I expect there will be lawsuits for sure.��

There is already a lot of concern, even though this��hasn’t��gone into effect yet, about having a chilling effect on immigrants who are perfectly eligible and can legally qualify for these programs not using them, avoiding health��care, avoiding preventive care, avoiding testing and treatment for infectious diseases. And there were several studies about the impact of this policy in the first Trump administration that showed that it really took a toll on public health. And we live in a society��if you pass a policy that��impacts��one part of the��population,��it’s��going to��impact��other parts of the population. And��so��this is predicted to make things harder for citizens as well, both the cost of care and the spread of infectious diseases.��

Rovner:��All right. Well,��finally this week,��moving��on to reproductive health. Remember that lawsuit in Texas that was filed by a group of anti-abortion doctors that wanted to reverse the FDA’s approval of the abortion pill��mifepristone? Well, the doctors are no longer part of the lawsuit because the Supreme Court said they��didn’t��have��standing��to sue, and the case is no longer in Texas, but it is still around. And now the three states that are pursuing it, Missouri, Kansas, and Idaho,��are adding to their suit the FDA’s recent approval of a second generic of the original abortion pill. Alice, how is this case still going? And now what happened?��

Ollstein:��It’s��very much still going.��It’s��just been bouncing around, and now��it’s��being considered by a whole different court in a whole different��state��and��they’re��going to start the process all over again. And I��wouldn’t��be surprised if it made it all the way back to the Supreme Court, even though��it’s��already been there with different plaintiffs. So there was a lot of outrage in the anti-abortion community about the recent approval of another generic of��mifepristone, even though the way that works is if it’s chemically identical to the versions that have been already approved, it kind of automatically goes through and it doesn’t really have anything to do with the other things they’re challenging.��It’s��just something else that��they’re��upset about.��

Rovner:��So��they’re��adding it to it. Well,��we will watch that lawsuit too. And last, we don’t talk enough about AI��[artificial intelligence]��in health��care, but a study caught my eye this week from the nonprofit Campaign for Accountability that found a number of chatbots, when asked about medication abortion, gave instructions to call a hotline that urged those with unplanned pregnancies to try��“abortion pill reversal,”��which is not a thing, although it is pushed by many anti-abortion activists. This��appears to be��a case where the flood of misinformation so outnumbers the��real information��that the chatbot thinks that��the misinformation��is the right answer. Quantity over��quality, if��you will. This feels like��kind of a��major flaw in using AI, not just for abortion questions, but for health information in general,��given how much health misinformation is out there.��

Raman:��I think��we’ve��seen this in other types of health��care,��where��they’ve��tried to roll out some of these chatbots to help with different things,��especially like��mental health, and��it’s��backfired for��different reasons��because of��it might promote something that it��shouldn’t��for that group.��I think there��was one at one point where it was offering dieting tips to someone with an eating disorder, just things that��maybe might��be applicable��to someone else but not to that specific group.��So��there are��definitely things��that need to be hammered out in this.��

Rovner:��Yeah, I feel like we’re having sort of a real-time clinical trial of how AI works with the��general public��in health��care, and I don’t know who is really keeping track of what it is doing.����

OK. That is this week’s news. Now we will play my interview with Joanne Kenen and Joshua Sharfstein about their new book, and then��we’ll��come back and do our extra credits.��

I am pleased to welcome to the podcast Joanne Kenen and Dr. Joshua Sharfstein, two of the three authors of the new��book Information Sick: How Journalism’s Decline and Misinformation’s Rise are Harming Our Health��— And What��We Can��Do About It. Our regular listeners all know Joanne,��she’s��the former health editor at Politico who now teaches at the Johns Hopkins Bloomberg School of Public��Health and writes for Politico Magazine. Joshua Sharfstein, who��I’ve��known��almost as��long as��I’ve��known Joanne, is��distinguished��professor of��the practice��at Johns Hopkins Bloomberg School of Public Health.��He’s��a physician��who’s��worked on Capitol Hill and at��the��Food and Drug��Administration, and��also served as the city of Baltimore’s��public health��commissioner and the State of Maryland’s��secretary of��health and��mental��hygiene. Joanne and Josh, thank you so much for joining us.��

Joanne��Kenen:��Thanks for having us.��

Joshua��Sharfstein:��Great to be here.��

Rovner:��So first, explain the title. What does��“information��sick”��mean?��

Sharfstein:��Well,��“information sick”��is a diagnosis. It’s a��diagnosis��both of��individuals who are confused by information about health that they’re getting, and as a result can’t make good decisions for themselves and their families. And��it’s��also a diagnosis for our society, that there’s so much bad information on health out there, there’s��so little��good information��that as a country,��we’re��at risk of making some bad decisions on health policy.��

Rovner:��So��I have��kind��of a��mea��culpa. We have spent a lot of hours on this podcast talking about how public health officials should be doing a better job communicating��to��the public, combating mis-��and disinformation, but without really addressing the other side, the decline of journalism.��Joanne, how much of the problem is how information is communicated to the public by health officials, and how much��is��the changing ways that people are��actually communicating��with each other?��

Kenen:��That’s��what our book,��where they explore it,��is this nexus. There’s been lots written about the decline of journalism, there’s been lots written about failures of public health communication, some of which may be��overstated actually, and��some of��it’s��clearly��mistakes have been made. But the connection is something that we really explored starting in the class we taught a couple of years��ago, and��then putting together the book. People do not get information in the ways that we��grew��up getting information. Local news has really been eviscerated in large parts of the country. There’s county after county that does not have any local news, or that has something very meager. And that was trusted,��it’s��still trusted where it exists, that was a way people got health information. National news is polarized, with some outstanding exceptions.��There’s��just not a lot of policy news that people get. And people instead, particularly younger people, are getting��…��instead of their��doctor,��they’ve��got their TikTok. And��there’s��a lot of wrong stuff. And��it’s��not only vaccines,��it’s��pretty much everything.��

Rovner:��So how much of the problem within the information ecosystem is information��that’s��just wrong��because��it’s��being distributed by non-experts, and how much is from actual bad actors, those with either��a potential��monetary gain from spreading bad information or those purposely trying to sow discord?��

Sharfstein:��Well, one of the challenges is that there isn’t really good information because social media companies,��in particular,��have��not been very forthcoming about what is on their site.��It’s��very clear��that there are bad actors, as you say, including nations that are deliberately putting out information to confuse Americans, and including people who are really trying to make a quick dollar selling things that��really��shouldn’t��be on the market. But��there’s��also a big gray area because sometimes information gets seeded, but people are passing it on,��believing it to be true. And so it’s not all one or all the other, but the quantity of information that’s out there that is not reliable is staggering��—��so much so that this idea of a public health communication is, to some experts in the field, almost laughable because it will get washed away by the tidal wave of misleading information and make it very hard for people to know what to believe.��

Kenen:��There’s��a communication media element in this,��too. Because if you’re a reporter working for a little tiny newspaper that used to have maybe five or six reporters, and someone could have developed some expertise in health, you know, when��you can,��if you’re on a national beat doing it full-time, but you can develop some confidence in knowing what you’re talking about. If��you’re��now one of two reporters and��you’re��covering eight beats and health is one of them, and you��don’t��have an editor who can mentor you on health either,��there’s��a lot of bad reporting. And��it’s��what we call false equivalence a lot. If you��don’t��know if this source is an expert, and that source is a charlatan,��or vice versa, you tend to put them��both as��equals.��So��they’re��in the newspaper story or on the local news where you have somebody saying,��“Vaccines are safe,”��and somebody else saying,��“They’re toxic, damaging, barbaric things that are going to kill us all.”��So��you’re��getting something from a news outlet that you should be able to trust, but because of the shrinkage and lack of resources and lack of money and lack of��expertise, you end up inadvertently feeding the misinformation monster.��

Rovner:��So��yeah, some of it is deliberate,��and some of it is��kind of accidental��because of the decline of journalism. So,��luckily,��your book��doesn’t��just lay out the��problem,��you also offer up some potential solutions. Joanne, can you summarize how journalism can do a better job of curing information sickness? And then,��Josh, can you talk about how the health community can do its part?��

Kenen:��Well, I think that in journalism, if��you’re��a young reporter starting out and you��don’t��have the resources to do your job, there are some tools and resources.��There’s��more and more��training opportunities in health, medicine, climate, other areas.��So��you��can��get some free training online, and I would urge anyone��who’s��starting out on this beat��…��and not just on the beat. I mean if��you’re��a business reporter or a politics reporter or a general assignment reporter,��you’re��a health reporter,��you’re��going to end up doing this.��So��there are��a number of��programs through philanthropies and universities, as well as journalism organizations, to bolster local news and bolster health reporting.��So��anyone who falls into that category who is listening,��do��it. You��won’t��come out with an MPH��[master’s��of public health], but��you’ll��come out with��knowledge and confidence��and competence.��

Congress had been talking��for,��I��don’t��know, 15 years or so about tax breaks and other things to prop up journalism.��It’s��not going to pass now if it��hasn’t��passed in the last 15 years, I��don’t��see that happening in the current environment. The consolidation that��we’re��seeing in the media and TV stations is��probably going��to make it worse, not better.��So��if we tell our students,��“There is a lot of free stuff out there. You can be informed without spending three hours and hundreds a day trying to read everything.”��Our podcast is free, KFF is free, �������ýҕ�l Health News is free. There are things you can do to get quality information and quality journalists.��

Rovner:��And Josh,��what’s��the role of the public health community in this changing information environment?��

Sharfstein:��There’s��a big role. And I would first echo Joanne’s point that there are new and emerging sources of journalism that are��really important. The nonprofit sector is growing, and there are some large organizations,��like KFF, there are some specific ones,��like The Trace that covers gun violence. There are new outlets for specific communities that are really doing high-quality work,��and we should all be supporting them. And in a sense,��I’ll��start there, because��I think journalism and health and public health��are facing a similar kind of challenge, and we should be supporting each other in addressing it.��

Within the health sector, the first thing is getting the diagnosis right.��That’s��the right thing to do for a patient;��it’s��the right thing to do here.��Information is not just something that is provided by a public health official or communicated by a health��care official.��It’s��actually a��determinant of health.��How people get information, what that information says,��is incredibly important for their health. And we��have to��realize that��that fundamental determinant is in jeopardy right now. And then I would say that there are several things that are��really important. The first is to engage, to��not just say,��“Well,��that’s��just not my job. I’m not going to learn the whole new TikTok thing.”|��People��have to��realize where this information is coming from and do their best themselves and through partnerships to get better information out on these��channels, and��engage with the channels to try to find ways for the algorithms not to take people down a conspiratorial rabbit hole at every opportunity. The second thing, particularly for health��care organizations, is to train clinicians so that��they’re��not just stunned and defenseless when people come in and say,��“I’m��not going to do chemotherapy.��I’m��instead going to do some unproven nutritional treatment instead.”��And help their clinicians��leverage��the great relationships that they have with patients to be able to talk people down from the most severe manifestations of being information sick.��

And the third element that I would highlight is that health��care and public health have an opportunity, and really a responsibility, to win the battle in real life. Like,��the online world is a mess. And a lot of the different techniques that we looked at, like fact-checking and debunking and pre-bunking and all these different ideas,��have��promise, but really have not won the situation.��It’s��a mess online. But in the real world,��it’s��possible to have networks of clinicians and faith leaders and business leaders and political leaders who are standing arm in arm and saying,��“This vaccine really does matter and will keep people in our community safe.”��And for health departments, this is a real opportunity to reconnect with some of those community roots and do��great work��literally in��each other’s presence. In Baltimore here, there was a network of community health workers that played a really��important role��in bolstering vaccine confidence during the pandemic.��It’s��one of the reasons that Baltimore did quite well in terms of��covid��mortality.��So��I think that there’s a big agenda here, and of course it’s an agenda at a very difficult time for both health��care and public health in 2025.��

Kenen:��I think that one thing that we learned about a lot as we researched this, it makes sense when we say it to people, they all nod, but��understanding��why information has power.��There’s��a lot that people researching it��don’t��understand yet, like why once people buy into a myth��it’s��so hard to get it out of their brain. But what does it do? It appeals to our��fears,��it appeals to our��anxieties,��it appeals to our��resentments. Social media does not make you feel calm and serene and��confident,��it makes people agitated and angry. And��it’s��not a coincidence that there was disinformation before the pandemic and there’s disinformation after the pandemic, but the flowering and the sort of exacerbation during the pandemic,��it’s��partly because we were so vulnerable to it.��We were feeling fear and resentment and anxiety, both about health and about��the economic��dislocation during the pandemic, particularly that first year.��So��we were��really vulnerable,��and people who were spreading it, the ones intentionally,��in particular, really��were able to sort of exploit that vulnerability that we had.��There’s��a lot of research.��The role of AI is going to change things for good and bad. I mean,��anything you write about��this about��disinformation is��somewhat out��of date tomorrow. But I think it’s useful for people to understand that what they’re being opposed to that’s so catchy and��grabs��them��is��often��really bad��for them.��

Rovner:��Yeah, well,��bigger societal problem. But thank you for��writing��this book. Joanne Kenen and Joshua Sharfstein,��thanks��for joining us.��

Sharfstein:��Thanks so much.��

Kenen:��Thanks, Julie.��

Rovner:��OK,��we’re��back.��It’s��time for our��extra-credit��segment.��That’s��where we each recognize��a��story we read this��week��we think you should read too.��Don’t��worry if you miss it;��we will put the links in our show notes on your phone or other mobile device. I have already done my��extra��credit this week. Sarah, how about��you go��next?��

Karlin-Smith:��I��took a look��at a piece in��The Guardian called��“,”��and it chronicles a movement started by two women using podcasts and Instagram and social media. And��it’s��not just a��movement,��I would say it was a business for them.��I think The Guardian piece��says they made about $13 million��basically convincing��people to give birth at home with no medical support at all. No midwife, nothing of the sort. And they��oftentimes even seem to discourage��people when they are in medical distress, or their baby is in medical distress,��while birthing��from going to the hospital. It has led to babies being born with various birth defects or disabilities that they would not otherwise have been born with. It has led to deaths of babies and,��possibly,��women.��

And I think one thing that stood out to me is a lot of women the story talks about seem drawn to this movement for a couple of reasons. One is how��high cost��the U.S.��health system is in terms of to get good midwifery care, go to a hospital, see an OB-GYN.��So��some people were drawn to it just because they felt like they��couldn’t��afford it, and this seemed like a good��option. And other people were drawn to it because they had some kind of bad or traumatic experience giving��birth��the first time in the traditional medical system and were sort of ripe to be really taken advantage of and exploited.��

Rovner:��Yeah, it was quite a story. Sandhya, why don’t you��go��next?��

Raman:��So��I picked��“Kids and Teens Go Full Throttle for E-Bikes as Federal Oversight Stalls,”��and��that’s��from Kate Ruder for �������ýҕ�l Health News. And this story looks to��see��are these bikes safe for kids? And that��it’s��a difficult thing��to��kind of spell��out.��There’s��not a ton of federal regulations on e-bikes, and��it’s��a patchwork��on the state and county level. And I learned a lot,��I think,��just because I��didn’t��realize that��there’s��no age for��operating��an e-bike at the federal level, but��it’s��kind of piecemeal��at the state level for other types of motorized vehicles.��So��it looks at some of that and just kind of what the gaps are and some of the regulations that have been pulled back in recent months.��

Rovner:��As somebody who almost got taken out by, like,��an��8-year-old on a motorized vehicle a couple of weeks ago, I very much felt this story. Alice?��

Ollstein:��So��speaking of things that are bad for young people,��. It is about through a lawsuit��… so parents, school districts and state attorneys general have been suing social media companies, primarily Meta, which owns Facebook and Instagram, for negative mental health, emotional health impacts on young people. And through the discovery process in these lawsuits, they uncovered that Meta did research back in 2019 and found that people who stopped using these apps, even for just a week, experienced less depression, anxiety, loneliness, and social comparison. And they buried that finding and did not��disclose��it. And��so��this is coming out in the lawsuit. And they uncovered a quote from a Meta employee who said,��“If they didn’t release the research, they risked looking like tobacco companies,”��who found through their own research about the addictive and damaging properties and did not��disclose��them,��and how that was a bad look later.��So��this is important to keep in mind as we all marinate our brains in it.��

Rovner:��That’s��right. And another lawsuit that we will keep an eye on.����

OK. That is this week’s show. Thanks,��as always,��to our editor,��Emmarie Huetteman, and our producer-engineer,��Francis Ying. A reminder:��What��the��Health?��is��now available on WAMU platforms, the NPR app, and wherever else you get your podcasts. As well as,��of course, kffhealthnews.org. Also,��as always, you can email us your comments or questions.��We’re��at��whatthehealth@kff.org.��Or you can find me still on��X��,��or��on Bluesky��.��Where are you folks hanging these days? Sandhya?��

Raman:��@SandhyaWrites on����and on��.��

Rovner:��Alice?��

Ollstein:����on Bluesky, and����on X.��

Rovner:��Sarah?��

Karlin-Smith:����or��,��on X and Bluesky.��

Rovner:��We’ll��be back in your feed next week. Until then, have a great holiday and be healthy.��

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Bynum, then in his second year of residency training as a family medicine physician, was wrapping up a long shift when he was called into an emergency delivery. To save the baby’s life, he used a vacuum device, which applies suction to assist with rapid delivery.

The baby emerged unharmed. But the mother suffered a severe vaginal tear that required surgical repair by an obstetrician. Soon afterward, Bynum retreated to an empty hospital room, trying to process his feelings about the unexpected complication.

“I didn’t want to see anybody. I didn’t want anybody to find me,” said Bynum, now an at Duke University School of Medicine in North Carolina. “It was a really primitive response.”

The U.S. political environment presents an additional obstacle. Health and Human Services Secretary Robert F. Kennedy Jr. and other top Trump administration health officials have publicly blamed autism, diabetes, attention-deficit/hyperactivity disorder, and other chronic issues in large part on the lifestyle choices of people with the conditions — or their parents. For instance, FDA Commissioner Marty Makary suggested in a Fox News interview that diabetes could be better treated with cooking classes than “.”

Even before the political shift, that attitude was reflected at doctors’ offices as well. A 2023 study found that when treating patients with Type 2 diabetes. About 44% viewed those patients as lacking motivation to make lifestyle changes, while 39% said they tended to be lazy.

“We don’t like feeling shame. We want to avoid it. It’s very uncomfortable,” said , a nurse at the University of Wisconsin-Madison, who has of related studies, published in 2024. And if the source of shame is from the clinician, the patient may ask, “‘Why would I go back?’ In some cases, that patient may generalize that to the whole health care system.”

Indeed, Christa Reed dropped out of regular medical care for two decades, weary of weight-related lectures. “I was told when I was pregnant that my morning sickness was because I was a plus-size, overweight woman,” she said.

Except for a few urgent medical issues, such as an infected cut, Reed avoided health care providers. “Because going into a doctor for an annual visit would be pointless,” said the now 45-year-old Minneapolis-area wedding photographer. “They would only just tell me to lose weight.”

Then, last year, severe jaw pain drove Reed to seek specialty care. A routine blood pressure check showed a sky-high reading, sending her to the emergency room. “They said, ‘We don’t know how you’re walking around normal,’” she recounted.

Since then, Reed has found supportive physicians with expertise in nutrition. Her blood pressure remains under control with medication. She’s also nearly 100 pounds below her heaviest weight, and she hikes, bikes, and lifts weights to build muscle.

, a California psychiatrist, is among a group of physicians trying to bring attention to the detrimental effects of shame and develop strategies to prevent and mitigate it. While this effort is in the early stages, she co-led a session on the spiral of shame at the American Psychiatric Association’s annual meeting in May.

If physicians don’t acknowledge shame in themselves, they can be at risk of depression, , sleeping difficulties, and other ripple effects that erode patient care, she said.

“We often don’t talk about how important the human connection is in medicine,” Woodward said. “But if your doctor is burned out or feeling like they don’t deserve to be your doctor, patients feel that. They can tell.”

In a survey conducted this year, 37% of graduating students at some point in medical school. And nearly 20% described public humiliation, according to the annual survey by the Association of American Medical Colleges.

Medical students and resident physicians are already prone to perfectionism, along with an almost “masochistic” work ethic, as Woodward described it. Then they’re run through a gantlet of exams and years of training, amid constant scrutiny and with patients’ lives on the line.

During training, physicians work in teams and make presentations to teaching faculty about a patient’s medical issues and their recommended treatment approach. “You trip over your words. You miss things. You get things out of order. You go blank,” Bynum said. And then shame creeps in, he said, leading to other debilitating thoughts, such as “‘I’m no good at this. I’m an idiot. Everyone around me would have done this so much better.’”

Yet shame remains “a crack in your armor that you don’t want to show,” said , a family medicine physician at the University of Utah who has taught medical students about the potential for shame as part of a broader ethics and humanities course.

“You’re taking care of a human life,” she said. “Heaven forbid that you act like you’re not capable or you show fear.”

When students are taught about shame, the goal is to help future physicians recognize the emotion in themselves and others, so they don’t perpetuate the cycle, Pippitt said. “If you felt shamed throughout your medical education, it normalizes that as the experience,” she said.

Above all, physicians-in-training can work to reframe their mindset when they receive a poor grade or struggle to master a new skill, said Woodward, the California psychiatrist. Instead of believing that they’ve failed as a physician, they can focus on what they got wrong and ways to improve.

Last year, Bynum started teaching Duke physicians about shame competence, beginning with roughly 20 OB-GYN residents. This year, he launched a larger initiative with , a research and training partnership between Duke University and the University of Exeter in England that he co-founded, to reach about 300 people across Duke’s Department of Family Medicine and Community Health, including faculty and residents.

This sort of training is rare among Duke OB-GYN resident ’s peers in other programs. Dancel, who completed the training, now strives to support students as they learn skills such as how to suture. She hopes they will pay that approach forward in “a chain reaction of being kind to each other.”

More than a decade after Bynum experienced that stressful emergency delivery, he still regrets that shame kept him from checking on the mother as he usually would following delivery. “I was too scared of how she was going to react to me,” he said.

“It was a little devastating,” he said, when a colleague later told him that the mother wished he had stopped by. “She had passed a message along to thank me for saving her baby’s life. If I had just given myself a chance to hear that, that would have really helped in my recovery, to be forgiven.”

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Esto genera una escasez de personal que podría poner en peligro la calidad de la atención a los pacientes.

Según , casi el 60% de los condados de California —que se extienden entre las fronteras con México y Oregon— enfrentan una falta importante de enfermeras.

El gobernador demócrata Gavin Newsom y los legisladores estatales han intentado reforzar el personal sanitario del estado. Lo hacen, en parte, implementando las recomendaciones de la California Future Health Workforce Commission, un panel de 24 miembros integrado por representantes del estado, de los sindicatos, del mundo académico y de la industria.

En los últimos años, el estado ha ampliado de las enfermeras profesionales, permitiéndoles realizar algunas prácticas médicas —como solicitar estudios y recetar medicamentos— sin la supervisión médica tradicional. También ha trabajado para ampliar las plazas académicas de enfermería y los programas de formación.

Aun así, se espera que la escasez de enfermeras registradas en California aumente del 3,7% en 2024 al 16,7% para 2033 —más de 61.000 enfermeras— debido a la falta de reclutamiento, capacitación y retención, según Kathryn Phillips, subdirectora del equipo Improving Access de la California Health Care Foundation, una organización sin fines de lucro dedicada a la investigación y educación en el ámbito de la salud.

Se prevé que aumente la escasez regional de estas profesionales, especialmente en el Valle Central y en la zona rural del norte. “Existen déficits importantes y podrían agravarse”, declaró Phillips.

Los investigadores afirman que la brecha entre la oferta y la demanda de enfermería se ve agravada por la falta de oportunidades de desarrollo profesional y la alta rotación del personal en un sector de alta exigencia.

Las enfermeras y , por el contrario, argumentan que el problema se debe principalmente a una provocada por la mala gestión y las pobres condiciones de trabajo.

Las enfermeras afirman que la suya sigue siendo una vocación noble, pero muchas dicen que se sienten presionadas para desocupar camas rápido y atender más pacientes. Este estrés puede disuadir a las jóvenes de ingresar a la profesión y llevar a las más experimentadas a temprano.

Los representantes del sector presentan estas preocupaciones como argumentos sindicales para aumentar los costos laborales, pero las enfermeras afirman que están perdiendo beneficios, además de trabajar en exceso, lo que debilita su moral y les dificulta brindar incluso atención médica básica en hospitales, clínicas y residencias de adultos mayores de todo el estado.

Lorena Burkett, enfermera del Emanuel Medical Center en Turlock, una ciudad agrícola en el corazón del Valle Central, contó que el año pasado estaba tan sobrecargada que no registró inmediatamente la historia clínica de un paciente psiquiátrico después de administrar la medicación, un paso fundamental para garantizar la dosis adecuada de los medicamentos.

“Me presionaron para que apurara el alta médica y olvidé escanear su medicación opioide; lo pasé por alto”, dijo Burkett, una veterana con 12 años de experiencia, que más tarde actualizó el historial del paciente. “Después de eso dije: no más. Debemos priorizar la atención al paciente, pero estamos bajo mucha exigencia para que los pacientes dejen las camas y así generar ganancias”.

Tenet Healthcare, el sistema hospitalario con fines de lucro con sede en Dallas que es propietario de Emanuel, se negó a responder a la afirmación de Burkett y a las preguntas sobre la dotación de personal. En un comunicado, el vocero de Tenet, Rob Dyer, afirmó que el hospital ofrece “atención de calidad y enfocada en el bienestar del paciente” y desestimó de manera general las preocupaciones de las enfermeras.

“Actualmente estamos negociando el contrato con el sindicato que representa a nuestro personal de enfermería y sospechamos que esto es lo que está detrás de estas afirmaciones falsas”, declaró.

Mejores condiciones para las enfermeras

Hace dos años, los legisladores estatales aprobaron para ayudar a los hospitales con a mantener sus operaciones, lo que puede incluir la retención del personal de enfermería.

Los legisladores también están intentando mejorar las condiciones laborales de las enfermeras de hospital y proteger la atención del paciente de personal en los centros de salud. Algunos también piden que se invierta en una plantilla de enfermería más sólida.

“El personal de enfermería trabaja en hospitales y otros lugares que están muy escasos de personal”, afirmó Michelle Mahon, directora de prácticas de enfermería de National Nurses United, un sindicato que representa a 225.000 enfermeras.

Phillips explicó que las razones varían. En el Área de la Bahía de San Francisco, este personal debe lidiar con la falta de vivienda accesible y el alto costo de la vida y del cuidado infantil. En el Valle Central, la educación, la capacitación y la orientación son insuficientes. Y en el norte rural es difícil atraer suficientes enfermeras para reemplazar a las jubiladas y satisfacer las necesidades de una población que envejece.

Investigadores de la University of California-San Francisco que han estudiado la afirman que, si bien las personas siguen buscando trabajo en esta profesión, han disminuido tanto la matriculación de estudiantes como la de graduados.

La California Board of Registered Nursing informa que había casi 552.000 enfermeras registradas con licencias activas en California al 1 de octubre.

Sin embargo, la California Nurses Association afirma que un número significativamente menor ha estado ejerciendo, señalando que datos de 2024 indicaban que solo 350.850 trabajaban en su profesión.

El mismo problema persiste a nivel nacional, según National Nurses United, que informó que, en mayo de 2024, de enfermeras registradas no trabajaban en el sector.

La vocera de la California Hospital Association, Jan Emerson-Shea, afirmó que los hospitales de todo el estado se enfrentan a “costos que están por las nubes” en mano de obra, productos farmacéuticos, equipos médicos y cumplimiento de las normativas gubernamentales.

Los costos de la atención a los pacientes se han disparado un 30% en los últimos cinco años y siguen aumentando, afirmó. Mientras tanto, el 53% de los hospitales del estado “pierden dinero cada día atendiendo a los pacientes”, añadió.

Y la situación podría empeorar.

Según la ley de impuestos y gastos del Partido Republicano, que el presidente Donald Trump denominó “One Big Beautiful Bill”, el estado estima que aproximadamente de californianos podrían perder su cobertura médica debido, en parte, a importantes recortes a Medicaid y a nuevas normas, como los requisitos laborales que limitan la elegibilidad de los residentes de bajos ingresos y con discapacidades.

California corre el riesgo de perder $30 mil millones en fondos anuales y los hospitales se verán especialmente afectados porque dependen de los reembolsos federales y necesitan un número determinado de pacientes asegurados para mantenerse solventes.

Emerson-Shea afirmó que los hospitales de California podrían perder hasta $128 mil millones en una década�� a consecuencia de esa ley.

“Esta proyección no incluye los probables aumentos en la atención no compensada debido a los requisitos laborales de Medicaid, las pérdidas de cobertura por la eliminación de los subsidios que dispone la Ley de Cuidado de Salud a Bajo Precio, las revisiones más frecuentes de Medi-Cal y las pérdidas de cobertura para quienes tienen un estatus migratorio irregular”, declaró Emerson-Shea.

Si bien algunos hospitales de California pierden dinero en la atención al paciente, los datos financieros muestran que la industria está generando ganancias: en 2024 alcanzó aproximadamente $11,5 mil millones en ingresos netos o beneficios, afirmó Kristof Stremikis, director de Market Analysis and Insight en la California Health Care Foundation.

Stremkins señaló datos estatales preliminares que comparan 365 hospitales. “La industria en su conjunto ha recuperado los niveles de rentabilidad previos a la pandemia”, afirmó.

Sin embargo, reconoció que los recortes a Medicaid reducirán los ingresos de todos los centros de salud.

Los hospitales se verán sobrecargados a medida que aumente el número de pacientes sin seguro médico, quienes a menudo llegan con enfermedades crónicas o traumatismos que pueden encarecer el tratamiento. Esto agravará los desafíos de la atención médica en comunidades con altos índices de pobreza y con una gran población beneficiaria del Medi-Cal, ya que el programa de protección social suele pagar a los hospitales y proveedores menos que los seguros privados o Medicare.

Antes de que se sientan los impactos de los recortes federales a la atención médica, algunos hospitales ya están cerrando debido a dificultades financieras. Otros han limitado el acceso a la atención e incluso cerrado salas de maternidad y de emergencia.

Persiste el agotamiento que causó la pandemia

Las enfermeras de primera línea afirmaron que del personal de salud, ampliamente documentado durante la pandemia de covid-19, todavía se siente hoy y se suma a la creciente demanda hospitalaria, lo que hace que muchos trabajadores se desvinculen del sector. Esta situación está impulsando a algunos hospitales a contratar más enfermeras itinerantes de otros estados.

En el Hazel Hawkins Memorial Hospital, un con problemas financieros en el condado de San Benito, cerca de la Costa Central, la California Nurses Association informó que el hospital emplea a 22 enfermeras temporales, aunque el hospital dijo que son 16.

Las enfermeras locales señalaron que las trabajadoras temporales pueden aliviar la carga de trabajo, pero les preocupa que los hospitales las usen para evitar contratos laborales que requieren mejores salarios y beneficios. Ellas opinan que los hospitales deberían invertir en personal local bien capacitado y familiarizado con la comunidad.

La enfermera de urgencias Ariahnna Sánchez afirmó que los trabajadores de Hazel Hawkins, un centro de acceso crítico con , se ven presionados a dar de alta a los pacientes rápidamente para poder atender a más personas. Según los representantes sindicales, a medida que se acercaba la renegociación de los contratos, los hospitales han recortado drásticamente las prestaciones y no han ofrecido aumentos adecuados para adaptarse al costo de la vida.

Los salarios varían según la región, pero el salario anual promedio de las enfermeras tituladas de California fue de $148,330 en 2024, según la U.S. Bureau of Labor Statistics.

“La moral está muy baja en este momento”, declaró Sánchez. “Estamos intentando dar la batalla, pero constantemente retenemos en urgencias a personas que deberían ser ingresadas debido a que el hospital está al máximo de su capacidad”.

Los datos estatales muestran que el condado de San Benito tiene una de enfermeras y necesita unas 180 más para atender a la población local. Sin embargo, Hazel Hawkins niega que exista esa escasez.

La California Nurses Association sostiene que 40 enfermeras han abandonado el centro desde el año pasado, mientras que el hospital aseguró que reemplazó a 15 de las 21 profesionales que se marcharon.

El portavoz de Hawkins, Marcus Young, dijo que el personal de enfermería está confundiendo la dotación de personal con los protocolos para atender a los pacientes de urgencias cuando no hay suficientes camas.

“No hay escasez significativa de personal de enfermería y las operaciones hospitalarias no se están viendo afectadas en la actualidad”, afirmó Young. “Cumplimos plenamente en todo momento con la proporción de enfermeras por paciente exigida por el estado”, ratificó.

La establece un mínimo de personal en los hospitales, que va desde una enfermera por cada tres pacientes hasta una por cada cinco, según el nivel de atención que requiera cada uno.

Las investigaciones han demostrado que los errores clínicos pueden aumentar en hospitales y otros centros de atención médica cuando el personal de enfermería está estresado y trabaja en exceso.

Desde 2020, el estado ha emitido 32 multas a hospitales de California por incumplir los niveles mínimos de dotación de personal de enfermería, con sanciones económicas que ascienden a un total de $840,000, según el del estado. Ni Hazel Hawkins ni el hospital Emanuel de Turlock recibieron citaciones. El portavoz Mark Smith afirmó que la agencia no podía dar información relacionada con ninguna “investigación potencial, pendiente o en curso” sobre centros de salud que presuntamente incumplen las proporciones estatales de enfermeras.

Burkett, la enfermera de Turlock, afirmó que, aunque puede atender hasta cinco pacientes a la vez, superó esa proporción dos veces el año pasado. En su , Tenet reportó $288 millones en ingresos netos, un aumento con respecto a los $259 millones del mismo período del año anterior.

“Tome esa asignación en contra de mi voluntad”, declaró Burkett, señalando que el sindicato distribuye formularios que protegen a las enfermeras de las consecuencias si cometen errores cuando atienden a más pacientes que los que permite el Estado.

“El formulario dice que estoy aceptando a estos pacientes en contra de mi criterio y estoy protegida porque no estoy de acuerdo con esto, pero el hospital me obliga a hacerlo”, añadió. “Es difícil. Quiero decir que simplemente hay que hacer malabarismos, lo que se pueda, con la esperanza de no perderse nada importante. No es seguro”.

La senadora estatal Caroline Menjivar, demócrata que representa parte de la región de Los Ángeles, puso un para fortalecer la ley estatal de proporción de enfermeras por paciente en el escritorio del gobernador Newsom. En él exige que los hospitales se esfuercen más por encontrar enfermeras disponibles para cumplir con los requisitos de personal.

“Durante años, los hospitales han estado eludiendo la obligación de contar con una dotación mínima de personal de enfermería”, afirmó Menjivar, que fue técnica de emergencias médicas. “Si no proporcionamos más apoyo a nuestras enfermeras, no obtendremos la atención de calidad que se necesita”.

La sobrina de Menjivar, Megan Noguera-DeLeon, está entusiasmada con convertirse en enfermera, a pesar de los desafíos laborales. Estudiante de enfermería que espera graduarse el próximo año de la West Coast University in Southern California comentó que tiene familiares que trabajan como enfermeras y que le han advertido lo difícil que puede ser el trabajo. Le preocupa el agotamiento, pero mantiene su compromiso con su proyecto.

“Creo que cuidar a la gente es algo hermoso”, dijo Noguera-DeLeon. “Sé que este trabajo puede ser muy duro y que muchas enfermeras están sufriendo agotamiento, pero, sinceramente, he visto de primera mano cuánto pueden ayudar las enfermeras a los pacientes, incluso en los días más difíciles, y quiero ayudar a la gente”.

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Democratic Gov. Gavin Newsom and state lawmakers have tried to bolster the state’s health care workforce, in part by implementing recommendations from the California Future Health Workforce Commission, a 24-member panel of state, labor, academic, and industry representatives. The state in recent years has expanded the for nurse practitioners, allowing them to practice medicine — ordering tests and prescribing medication, for instance — without traditional doctor supervision, and has academic nursing slots and training programs.

Still, California’s shortage of registered nurses is expected to grow from 3.7% in 2024 to 16.7% by 2033, or more than 61,000 nurses, due to inadequate recruitment, training, and retention, according to Kathryn Phillips, associate director of the Improving Access team at the California Health Care Foundation, a nonprofit philanthropic organization specializing in health care research and education.

Regional shortages, particularly in the Central Valley and rural North, are expected to swell. “There are major deficits and those could get even worse,” Phillips said.

Researchers say the gap between nursing supply and demand is exacerbated by inadequate career pathways and high turnover in a labor-intensive industry, but nurses and argue the problem is driven primarily by a management-induced and poor working conditions. Nurses say nursing remains a noble calling, but many report feeling pressured to turn over beds and take on more patients, stress that can dissuade young people from entering the field and drive experienced nurses to .

Industry representatives cast those concerns as union talking points to drive up labor costs, but nurses say they are losing benefits while being overworked, hobbling morale and hampering their ability to provide even basic health care in hospitals, clinics, and nursing homes around the state.

Lorena Burkett, a registered nurse at Emanuel Medical Center in Turlock, an agricultural city in the heart of the Central Valley, recounted being so overloaded last year that she didn’t promptly log a medical chart after administering a psychiatric patient’s medication, a critical step for ensuring proper drug doses.

“I was being told get him out, and I forgot to scan his opioid medication; I missed it,” said Burkett, a 12-year veteran, who later updated the patient’s record. “After that I said no more. We have to prioritize patient care, but we are under a lot of pressure to get patients out and turn profits.”

Tenet Healthcare, the Dallas-based for-profit hospital system that owns Emanuel, declined to respond to Burkett’s claim, as well as questions about staffing levels. In a statement, Tenet spokesperson Rob Dyer said that the hospital provides “quality and compassionate care” and broadly disputed nurses’ concerns.

“We are currently in contract negotiations with the union which represents our nurses,” he said, “and suspect that this is what is behind these false claims.”

Improving Conditions for Nurses

Two years ago, state lawmakers approved to help hospitals maintain operations, which can include retaining nurses. Lawmakers are also trying to improve nurses’ work conditions in hospitals and to protect patient care by at health care facilities. Some also call for investing in a more robust nursing workforce.

“Nurses are working in hospitals and other places that are severely understaffed,” said Michelle Mahon, director of nursing practice for National Nurses United, a union that represents 225,000 nurses.

Phillips said the reasons vary. In the San Francisco Bay Area, nurses must contend with a high cost of living, a lack of affordable housing, and expensive child care. In the Central Valley, there’s insufficient education, training, and mentoring. And the rural North has a hard time attracting enough nurses to replace those who are retiring and to meet the needs of an aging population.

University of California-San Francisco researchers who have say although people are still seeking jobs in nursing, student enrollments and graduations have declined.

The California Board of Registered Nursing shows nearly 552,000 active licensed registered nurses in California as of Oct. 1. Yet the California Nurses Association says significantly fewer were practicing, pointing to 2024 data indicating only 350,850 were working in the field. The same problem persists nationally, according to National Nurses United, which reported that, as of May 2024, licensed nurses were not working in the field.

California Hospital Association spokesperson Jan Emerson-Shea said hospitals around the state are facing “skyrocketing costs” for labor, pharmaceuticals, medical equipment, and compliance with government mandates. Patient care costs have soared 30% in the past five years and continue to rise, she said. Meanwhile, 53% of hospitals in the state “lose money every day caring for patients,” she said.

And it could get worse.

Under the GOP tax-and-spending bill that President Donald Trump called the “One Big Beautiful Bill,” the state estimates roughly Californians could lose health coverage due in part to major Medicaid cuts and new rules like work requirements that narrow eligibility for low-income and disabled residents. California is at risk of losing in annual funding, and hospitals will be hit particularly hard because they rely on federal reimbursements and need enough insured patients to remain solvent.

Emerson-Shea said California hospitals stand to lose up to $128 billion over 10 years due to the law.

“This projection does not include the likely increases in uncompensated care due to Medicaid work requirements, coverage losses due to the elimination of the Affordable Care Act subsidies, more frequent Medi-Cal redeterminations, and coverage losses for those with unsatisfactory immigration status,” Emerson-Shea said.

While some California hospitals lose money on patient care, financial data shows the industry is making money, earning about $11.5 billion in net income, or profit, in 2024, said Kristof Stremikis, director of Market Analysis and Insight at the California Health Care Foundation, pointing to preliminary state data comparing 365 hospitals. “The industry as a whole has returned to pre-covid profitability levels,” Stremikis said.

He acknowledged, though, that Medicaid cuts will reduce revenue for all facilities.

Hospitals will be burdened as uninsured patients, who often arrive with prolonged illness or injuries that can make treatment more expensive, increase in number. That will exacerbate health care challenges in high-poverty communities with large Medi-Cal populations, since the safety net program generally pays hospitals and providers less than private insurance or Medicare.

Already, some hospitals are closing due to financial struggles, before the impacts of the federal health care cuts are felt, and others are limiting access to care, including by shuttering maternity wards and emergency rooms. Officials at Glenn Medical Center, about 85 miles north of Sacramento, reported that it would be its ER at the due to staffing shortages.

Pandemic-Era Burnout Persists

Front-line nurses said the well-documented from the covid-19 pandemic, mixed with growing hospital demands, is still being felt today as many part ways with the industry. That is prompting some hospitals to hire more traveling nurses from out of state.

At Hazel Hawkins Memorial Hospital, a public facility in San Benito County near the Central Coast, the California Nurses Association said the hospital is employing 22 traveling nurses, although the hospital put the number at 16. Local nurses said temporary workers can ease workloads, but they worry hospitals are using traveling nurses to avoid labor contracts that require higher pay and benefits. They say hospitals should invest in well-trained, local staff familiar with the community.

ER nurse Ariahnna Sanchez said workers at Hazel Hawkins, a , are pressured to discharge patients quickly so more patients can be seen. As union contracts come up for renegotiation, union officials say, hospitals have slashed benefits and haven’t offered adequate raises to keep up with the cost of living. Salaries vary by region but the average annual wage for California registered nurses was $148,330 in 2024, according to the U.S. Bureau of Labor Statistics.

“The morale is so bad right now,” Sanchez said. “We’re trying to fight the good fight but we’re constantly holding people in the emergency room who should be admitted due to the hospital being at max capacity.”

State data shows San Benito County has an of nurses and needs about 180 more to accommodate the local population. But Hazel Hawkins disputes it has a shortage. The California Nurses Association said 40 nurses have left since last year, whereas the hospital said it has replaced 15 of 21 departing nurses.

Hazel Hawkins spokesperson Marcus Young said nurses are conflating staffing levels with protocols for handling ER patients when there aren’t enough beds. “There is no material shortage of nurses and hospital operations are not being impacted today,” Young said. “We are in full compliance with state-mandated nurse-to-patient ratios at all times.”

staffing minimums at hospitals, ranging from one nurse for every three patients to one nurse for every five patients, depending on the level of care the patients require. Research has shown that clinical errors can increase in hospitals and other health care workplaces when nurses are stressed and overwhelmed. that burnout related to work overload, career satisfaction, and patient satisfaction is a major concern and can lead to mistakes.

The state has issued 32 citations to California hospitals since 2020 for violating these minimum nurse staffing levels, financial penalties totaling $840,000, according to the . Neither Hazel Hawkins nor the Turlock hospital Emanuel had any citations. Spokesperson Mark Smith said the agency could not provide information on any “potential, pending or ongoing investigations” into health care facilities alleged to be in violation of state nursing ratios.

Burkett, the nurse in Turlock, said though she can see up to five patients at a time, she exceeded her ratio twice in the past year. In its , Tenet reported $288 million in net income, up from $259 million over the same period last year.

“I’ve taken that assignment against my will,” Burkett said, noting that the union distributes forms protecting nurses from repercussions if mistakes happen on their watch when they take on more patients than the state allows. “It says I’m taking these patients against my better judgment and I’m protected because I am not agreeing to this, but the hospital is making me do it,” she added. “It’s tough. I mean, you just have to juggle and do what you can and hope you’re not going to miss something important. It’s not safe.”

State Sen. Caroline Menjivar, a Democrat representing part of the Los Angeles region, has to strengthen the state’s nurse-to-patient ratio law by requiring hospitals to work harder to identify available nurses to meet staffing mandates.

“Hospitals for years have been getting a pass on minimum nurse staffing,” said Menjivar, a former emergency medical technician. “If we do not provide more support to our nurses, then we do not get the quality care that is needed.”

Menjivar’s niece Megan Noguera-DeLeon is excited about becoming a nurse, despite workplace challenges. A nursing student who expects to graduate next year from West Coast University in Southern California, she said relatives who work as nurses have warned her how tough the job can be. She’s worried about burning out but remains committed to the mission.

“I think taking care of people is a beautiful thing,” Noguera-DeLeon said. “I know this job can be really hard and a lot of nurses are experiencing burnout, but honestly I’ve seen firsthand how much nurses can help people even on the darkest of days, and I want to help people.”

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There never is.

Dahl Memorial’s three-bed emergency department — a two-hour drive from the closest hospital with more advanced services — instead depends on physician assistants and nurse practitioners.

Physician assistant Carla Dowdy realized the patient needed treatment beyond what the ER could provide, even if it had had a doctor. So, she made a call for a medical plane to fly the patient to treatment at Montana’s most advanced hospital. Dowdy also called out medications and doses needed to stabilize the patient as a paramedic and nurses administered the drugs, inserted IV lines, and measured vital signs.

Emergency medicine researchers and providers believe ERs, especially in rural areas, increasingly operate with few or no physicians amid a nationwide shortage of doctors.

A found that in 2022, at least 7.4% of emergency departments across the U.S. did not have an attending physician on-site 24/7. Like Dahl Memorial, more than 90% were in low-volume or critical access hospitals — a federal designation for small, rural hospitals.

The results come from the 82% of hospitals that responded to a survey sent to all emergency departments in the country, except those operated by the federal government. The study is the first of its kind so there isn’t proof that such staffing arrangements are increasing, said Carlos Camargo, the lead author and a professor of emergency medicine at Harvard Medical School. But Camargo and other experts suspect ERs running without doctors present are becoming more common.

Placing ERs in the hands of nondoctors isn’t without controversy. Some doctors and their professional associations say physicians’ extensive training leads to better care, and that some hospitals are just trying to save money by not employing them.

The , open to all medical students and physicians, and the both support state and federal laws or regulations that would require ERs to staff a doctor around the clock. Indiana, Virginia, and South Carolina recently passed such legislation.

Rural ERs may see fewer patients, but they still treat serious cases, said Alison Haddock, president of ACEP.

“It’s important that folks in those areas have equal access to high-quality emergency care to the greatest extent possible,” Haddock said.

Other health care providers and organizations say advanced-practice providers with the right experience and support are capable of overseeing ERs. And they say mandating that a physician be on-site could drive some rural hospitals to close because they can’t afford or recruit enough — or any — doctors.

“In an environment, especially a rural environment, if you have an experienced PA who knows what they know, and knows the boundaries of their knowledge and when to involve consultants, it works well,” said Paul Amiott, a board member of the Society of Emergency Medicine PAs.

“I’m not practicing independently” despite working 12-hour night shifts without physicians on-site at critical access hospitals in three states, he said.

Amiott said he calls specialists for consultation often and about once a month asks the physician covering the day shift at his hospital to come help him with more challenging cases such as emergency childbirth and complicated trauma. Amiott said this isn’t unique to PAs — ER doctors seek similar consultations and backup.

The proportion of ERs without an attending physician always on-site varies wildly by state. The 2022 survey found that 15 states — including substantially rural ones, such as New Mexico, Nevada, and West Virginia — had no such emergency departments.

But in the Dakotas, more than half of emergency departments were running without 24/7 attending physician staffing. In Montana it was 46%, the third-highest rate.

None of those three states have a program to train physicians as ER specialists. Neither does Wyoming or Idaho.

But Sanford Health, which bills itself as “the largest rural health system in the United States,” is launching an emergency medicine residency in the region. The Sioux Falls, South Dakota-based program is intended to boost the ranks of rural emergency doctors in those states, the residency director said in .

Leon Adelman is an emergency medicine physician in Gillette, Wyoming, which, at around 33,800 residents, is the largest city in the state’s northeast. Working in such a rural area has given him nuanced views on whether states should require 24/7 on-site physician coverage in ERs.

Adelman said he supports such laws only where it’s feasible, like in Virginia. He said the state’s emergency physicians’ organization pushed for the law only after doing research that made it confident that the requirement wouldn’t shutter any rural hospitals.

Camargo said some doctors say that if lawmakers are going to require 24/7 on-site physician coverage in ERs, they need to pay to help hospitals implement it.

Adelman said when instituting staffing requirements isn’t possible, states should create other regulations. For example, he said, lawmakers should make sure hospitals not hiring physicians aren’t refraining just to save money.

He pointed to Vermont, where recommended that several of the state’s hospitals cut physicians from their ERs. The report was part of a mandated process to improve the state’s troubled health care system.

Adelman said states should also require PAs and NPs without on-site physician supervision to have extensive emergency experience and the ability to consult with remote physicians.

Some doctors have pointed to in which a 19-year-old woman died after being misdiagnosed by an NP who was certified in family medicine, not emergency care, and working alone at an Oklahoma ER. Few NPs have emergency certification, .

The Society of Emergency Medicine PAs PAs should have before practicing in rural areas or without on-site doctors.

Haddock said emergency physicians have seen cases of hospitals hiring inexperienced advanced-practice providers. She said ACEP is asking the federal government to require critical access and rural emergency hospitals to have physicians on-site or on call day and night.

Haddock said ACEP wouldn’t want such a requirement to close any hospital and noted that the organization has various efforts to keep rural hospitals staffed and funded.

Dahl Memorial Hospital has strict hiring requirements and robust oversight, said Dowdy, who previously worked for 14 years in high-volume, urban emergency rooms.

She said ER staffers can call physicians when they have questions and that a doctor who lives on the other side of Montana reviews all their patient treatment notes. The ER is working on getting virtual reality glasses that will let remote physicians help by seeing what the providers in Ekalaka see, Dowdy said.

She said patient numbers in the Ekalaka ER vary but average one or two a day, which isn’t enough for staff to maintain their knowledge and skills. To supplement those real-life cases, providers visit simulation labs, do monthly mock scenarios, and review advanced skills, such as using an ultrasound to help guide breathing tubes into patient airways.

Dowdy said Dahl Memorial hasn’t had a physician in at least 30 years, but CEO Darrell Messersmith said he would hire one if a doctor lived in the area. Messersmith said there’s a benefit to having advanced-practice providers with connections to the region and who stay at the hospital for several years. Other rural hospitals, he noted, may have physicians either as permanent staff who leave after a few years or contract workers who fly in for a few weeks at a time.

People eating at Ekalaka’s sole breakfast spot and attending appointments at the hospital’s clinic all told �������ýҕ�l Health News that they’ve been happy with the care they have received from Dowdy and her co-workers.

Ben Bruski had to visit the ER after a cow on his family ranch kicked a gate, smashing it against his hand. And he knows other people who’ve been treated for more serious problems.

“We’ve got to have this facility here because this facility saves a lot of lives,” Bruski said.

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“We are full of people who come from other countries,” Goodness, 92, said about Goodwin House Alexandria’s staff. Without them, the retired Episcopal priest said, “I would be, and my building would be, desolate.”

The long-term health care industry is facing a double whammy from President Donald Trump’s crackdown on immigrants and the GOP’s proposals to reduce Medicaid spending. The industry is highly dependent on foreign workers: More than 800,000 immigrants and naturalized citizens comprise at home care agencies, nursing homes, assisted living facilities, and other long-term care companies.

But in January, former President Joe Biden’s 2021 policy that from Immigration and Customs Enforcement raids. The administration’s broad immigration crackdown threatens to drastically reduce the number of current and future workers for the industry. “People may be here on a green card, and they are afraid ICE is going to show up,” said Katie Smith Sloan, president of LeadingAge, an association of nonprofits that care for older adults.

Existing staffing shortages and quality-of-care problems would be compounded by other policies pushed by Trump and the Republican-led Congress, according to nursing home officials, resident advocates, and academic experts. Federal spending cuts under negotiation may strip nursing homes of some of their largest revenue sources by limiting ways money and making it harder for new nursing home residents to retroactively . Care for 6 in 10 residents , the state-federal health program for poor or disabled Americans.

“We are facing the collision of two policies here that could further erode staffing in nursing homes and present health outcome challenges,” said , an associate professor of internal medicine at the University of Pennsylvania.

The industry hasn’t recovered from covid-19, which long-term care facility residents and workers and led to massive staff attrition and turnover. Nursing homes have struggled to replace licensed nurses, who can find better-paying jobs at hospitals and doctors’ offices, as well as nursing assistants, who can earn more working at big-box stores or fast-food joints. Quality issues that preceded the pandemic have expanded: The percentage of nursing homes that federal health inspectors cited for putting residents in jeopardy of immediate harm or death alarmingly from 17% in 2015 to 28% in 2024.

In addition to seeking to reduce Medicaid spending, congressional Republicans have proposed shelving the biggest nursing home reform in decades: a Biden-era rule mandating minimum staffing levels that of the nation’s nearly 15,000 nursing homes to hire more workers.

The long-term care industry expects demand for direct care workers to burgeon with an influx of aging baby boomers needing professional care. The Census Bureau has projected the number of people 65 and older would grow from 63 million this year to 82 million in 2050.

In an email, Vianca Rodriguez Feliciano, a spokesperson for the Department of Health and Human Services, said the agency “is committed to supporting a strong, stable long-term care workforce” and “continues to work with states and providers to ensure quality care for older adults and individuals with disabilities.” In a separate email, Tricia McLaughlin, a Department of Homeland Security spokesperson, said foreigners wanting to work as caregivers “need to do that by coming here the legal way” but did not address the effect on the long-term care workforce of deportations of classes of authorized immigrants.

Goodwin Living, a faith-based nonprofit, runs three retirement communities in northern Virginia for people who live independently, need a little assistance each day, have memory issues, or require the availability of around-the-clock nurses. It also operates a retirement community in Washington, D.C. Medicare rates Goodwin House Alexandria as one of the in the country. Forty percent of the organization’s 1,450 employees are foreign-born and are either seeking citizenship or are already naturalized, according to Lindsay Hutter, a Goodwin spokesperson.

“As an employer, we see they stay on with us, they have longer tenure, they are more committed to the organization,” said Rob Liebreich, Goodwin’s president and CEO.

Jackline Conteh spent much of her youth shuttling between Sierra Leone, Liberia, and Ghana to avoid wars and tribal conflicts. Her mother was killed by a stray bullet in her home country of Liberia, Conteh said. “She was sitting outside,” Conteh, 56, recalled in an interview.

Conteh was working as a nurse in a hospital in Sierra Leone in 2009 when she learned of a lottery for visas to come to the United States. She won, though she couldn’t afford to bring her husband and two children along at the time. After she got a nursing assistant certification, Goodwin hired her in 2012.

Conteh said taking care of elders is embedded in the culture of African families. When she was 9, she helped feed and dress her grandmother, a job that rotated among her and her sisters. She washed her father when he was dying of prostate cancer. Her husband joined her in the United States in 2017; she cares for him because he has heart failure.

“Nearly every one of us from Africa, we know how to care for older adults,” she said.

Her daughter is now in the United States, while her son is still in Africa. Conteh said she sends money to him, her mother-in-law, and one of her sisters.

In the nursing home where Goodness and 89 other residents live, Conteh helps with daily tasks like dressing and eating, checks residents’ skin for signs of swelling or sores, and tries to help them avoid falling or getting disoriented. Of 102 employees in the building, broken up into eight residential wings called “small houses” and a wing for memory care, at least 72 were born abroad, Hutter said.

Donald Goodness grew up in Rochester, New York, and spent 25 years as rector of The Church of the Ascension in New York City, retiring in 1997. He and his late wife moved to Alexandria to be closer to their daughter, and in 2011 they moved into independent living at the Goodwin House. In 2023 he moved into one of the skilled nursing small houses, where Conteh started caring for him.

“I have a bad leg and I can’t stand on it very much, or I’d fall over,” he said. “She’s in there at 7:30 in the morning, and she helps me bathe.” Goodness said Conteh is exacting about cleanliness and will tell the housekeepers if his room is not kept properly.

Conteh said Goodness was withdrawn when he first arrived. “He don’t want to come out, he want to eat in his room,” she said. “He don’t want to be with the other people in the dining room, so I start making friends with him.”

She showed him a photo of Sierra Leone on her phone and told him of the weather there. He told her about his work at the church and how his wife did laundry for the choir. The breakthrough, she said, came one day when he agreed to lunch with her in the dining room. Long out of his shell, Goodness now sits on the community’s resident council and enjoys distributing the mail to other residents on his floor.

“The people that work in my building become so important to us,” Goodness said.

While Trump’s 2024 election campaign focused on foreigners here without authorization, his administration has broadened to target those legally here, who fled countries beset by wars or natural disasters. This month, the Department of Homeland Security for migrants and refugees from Cuba, Haiti, Nicaragua, and Venezuela who arrived under a Biden-era program.

“I’ve just spent my morning firing good, honest people because the federal government told us that we had to,” Rachel Blumberg, president of the Toby & Leon Cooperman , a Florida retirement community, said in a . “I am so sick of people saying that we are deporting people because they are criminals. Let me tell you, they are not all criminals.”

At Goodwin House, Conteh is fearful for her fellow immigrants. Foreign workers at Goodwin rarely talk about their backgrounds. “They’re scared,” she said. “Nobody trusts anybody.” Her neighbors in her apartment complex fled the U.S. in December and returned to Sierra Leone after Trump won the election, leaving their children with relatives.

“If all these people leave the United States, they go back to Africa or to their various countries, what will become of our residents?” Conteh asked. “What will become of our old people that we’re taking care of?”

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Forget a lunch break; she often eats a sandwich or some nuts as she heads to her next patient visit.

On a gloomy Friday in January, Johnson, a nurse practitioner who treats older adults, had a hospice consult with Ellen, a patient in her 90s in declining health. To protect Ellen’s identity, �������ýҕ�l Health News is not using her last name.

“Hello. How are you feeling?” Johnson asked as she entered Ellen’s bedroom and inquired about her pain. The blinds were drawn. Ellen was in a wheelchair, wearing a white sweater, gray sweatpants, and fuzzy socks. A headband was tied around her white hair. As usual, the TV was playing loudly in the background.

“It’s fine, except this cough I’ve had since junior high,” Ellen said.

Ellen had been diagnosed with vascular dementia, peripheral vascular disease, and Type 2 diabetes. Last fall, doctors made the difficult decision to operate on her foot. Before the surgery, Ellen was always colorful, wearing purple, yellow, blue, pink, and chunky necklaces. She enjoyed talking with the half dozen other residents at her adult family home in Washington state. She had a hearty appetite that brought her to the breakfast table early. But lately, her enthusiasm for meals and socializing had waned.

Johnson got down to eye level with Ellen to examine her, assessing her joints and range of motion, checking her blood pressure, and listening to her heart and lungs.

Carefully, Johnson removed the bandage to examine Ellen’s toes. Her lower legs were red but cold to the touch, which indicated her condition wasn’t improving. Ellen’s two younger sisters had power of attorney for her and made it clear that, above all, they wanted her to be comfortable. Now, Johnson thought it was time to have that difficult conversation with them about Ellen’s prognosis, recommending her for hospice.

“Our patient isn’t just the older adult,” Johnson said. “It’s also often the family member or the person helping to manage them.”

Nurse practitioners are having those conversations more and more as their patient base trends older. They are increasingly filling a gap that is expected to widen as the senior population explodes and the number of geriatricians declines. The Health Resources and Services Administration in demand for geriatricians from 2018 to 2030, when the entire baby boom generation will be older than 65. By then, hundreds of geriatricians are expected to retire or leave the specialty, reducing their number to fewer than 7,600, with relatively few young doctors joining the field.

That means many older adults will be relying on other primary care physicians, who already , and nurse practitioners, whose ranks are booming. The number of nurse practitioners specializing in geriatrics has more than tripled since 2010, increasing the availability of care to the current population of seniors, a in JAMA Network Open found.

According to a , of the roughly 431,000 licensed nurse practitioners, 15% are, like Johnson, certified to treat older adults.

Johnson and her husband, Dustin, operate an NP-led private practice in greater Seattle, Washington, a state where she can practice independently. She and her team, which includes five additional nurse practitioners, each try to see about 10 patients a day, visiting each one every five to six weeks. Visits typically last 30 minutes to an hour, depending on the case.

“There are so many housebound older adults, and we’re barely reaching them,” Johnson said. “For those still in their private homes, there’s such a huge need.”

Laura Wagner, a professor of nursing and community health systems at the University of California-San Francisco, stressed that nurse practitioners are not trying to replace doctors; they’re trying to meet patients’ needs, wherever they may be.

“One of the things I’m most proud of is the role of nurse practitioners,” she said. “We step into places where other providers may not, and geriatrics is a prime example of that.”

Practice Limits

Nurse practitioners are registered nurses with advanced training that enables them to diagnose diseases, analyze diagnostic tests, and prescribe medicine. Their growth has bolstered primary care, and, like doctors, they can specialize in particular branches of medicine. Johnson, for example, has advanced training in gerontology.

“If we have a geriatrician shortage, then hiring more nurse practitioners trained in geriatrics is an ideal solution,” Wagner said, “but there are a lot of barriers in place.”

In 27 states and Washington, D.C., nurse practitioners can practice independently. But in the rest of the country, they need to have a collaborative agreement with or be under the supervision of another health care provider to provide care to older adults. Medicare generally reimburses for nurse practitioner services at it pays physicians.

Last year, in , the American Medical Association and its partners lobbied against what they see as “scope creep” in the expanded roles of nurse practitioners and other health workers. The AMA points out that doctors must have more schooling and significantly more clinical experience than nurse practitioners. While the AMA says keep costs lower, a study published in 2020 in found similar patient outcomes and lower costs for nurse practitioner patients. Other studies, including one in the journal Medical Care Research and Review, have found health care models including nurse practitioners had better outcomes for patients with multiple chronic conditions than teams without an NP.

Five states have granted NPs full practice authority since 2021, with Utah the most recent state to , in 2023. In March, however, , which would have increased NP independence, failed. Meanwhile, rallied to tamp down full-scope efforts in Austin.

“I would fully disagree that we’re invading their scope of practice and shouldn’t have full scope of our own,” Johnson said.

She has worked under the supervision of physicians in Pennsylvania and Washington state but started seeing patients at her own practice in 2021. Like many nurse practitioners, she sees her patients in their homes. The first thing she does when she gets a new patient is manage their prescriptions, getting rid of unnecessary medications, especially those with harsh side effects.

She works with the patient and a family member who often has power of attorney. She keeps them informed of subtle changes, such as whether a person was verbal and eating and whether their medical conditions have changed.

While there is some overlap in expertise between geriatricians and nurse practitioners, there are areas where nurses typically excel, said Elizabeth White, an assistant professor of health services, policy, and practice at Brown University.

“We tend to be a little stronger in care coordination, family and patient education, and integrating care and social and medical needs. That’s very much in the nursing domain,” she said.

That care coordination will become even more critical as the U.S. ages. Today, about 18% of the U.S. population is 65 or over. In the next 30 years, the share of seniors is expected to reach 23%, as medical and technological advances enable people to live longer.

Patient and Family

In an office next to Ellen’s bedroom, Johnson called Ellen’s younger sister Margaret Watt to recommend that Ellen enter hospice care. Johnson told her that Ellen had developed pneumonia and her body wasn’t coping.

Watt appreciated that Johnson had kept the family apprised of Ellen’s condition for several years, saying she was a good communicator.

“She was accurate,” Watt said. “What she said would happen, happened.”

A month after the consult, Ellen died peacefully in her sleep.

“I do feel sadness,” Johnson said, “but there’s also a sense of relief that I’ve been with her through her suffering to try to alleviate it, and I’ve helped her meet her and her family’s priorities in that time.”

Jariel Arvin is a reporter with the at the University of California-Berkeley Graduate School of Journalism. He reported this article through a grant from .

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The 14-bed hospital, in Sigourney, doesn’t do surgeries or deliver babies. The small 24-hour emergency room is overseen by two full-time doctors.

CEO Matt Ives wants to hire a third doctor, but he said finding physicians for a rural area has been challenging since the covid-19 pandemic. He said several physicians at his hospital have retired since the start of the pandemic, and others have decided to stop practicing certain types of care, particularly emergency care.

Another rural hospital is down the road, about a 40-minute drive east. Washington County Hospital and Clinics has 22 beds and is experiencing similar staffing struggles. “Over the course of the last few years, we’ve had not only the pandemic, but we’ve had kind of an aging physician workforce that has been retiring,” said Todd Patterson, CEO.

The pandemic was difficult for health workers. Many endured long hours, and the stresses on the nation’s health care system prompted more workers than usual .

“There’s a chunk of workers that were lost and won’t come back,” said , who directs the at the University of California-San Francisco. “For a lot of the clinicians that decided and were able to stick it out and work through the pandemic, they have burned out,” Spetz said.

Five years after the World Health Organization declared covid a global pandemic and the first Trump administration announced a national emergency, the United States faces a crucial shortage of medical providers, for an aging population.

That could have , particularly in states like Iowa with significant rural populations. Experts say the problem has , but the effects of the pandemic accelerated the shortages by pushing many doctors over the edge .

“Some of them made it through covid like ‘Let’s get us through this public health crisis,’ and then they came out of it saying, ‘OK, and now? Now I’m exhausted,’” said Christina Taylor, president of the .

“Iowa is absolutely in the middle of a physician shortage,” Taylor said. “It’s a true crisis for us. We’re actually 44th in the country in terms of .”

A 2022 survey by the Centers for Disease Control and Prevention found a who reported feeling burned out and wanting a new job, compared with 2018. The number of people in health care has , said , an associate professor at the University of Minnesota’s School of Public Health, but the growth has not happened fast enough.

“We have an aging population. We have a lot of needs,” she said.

The projected last year that the U.S. of up to 86,000 physicians by 2036 — if lawmakers don’t invest more money in training doctors.

These shortages could push more people to seek care in ERs when they can’t see a local doctor, said , director of workforce studies at the AAMC.

“We’re already at a point where tens of millions of Americans every year can’t get medical care when they need it,” said Dill (no relation to Janette Dill). “If the shortage is sustained or gets even worse, then that problem gets worse too, and it disproportionately negatively impacts the most vulnerable amongst us.”

Iowa lawmakers made addressing the shortage in the current legislative session. They introduced bills aimed at increasing medical student loan forgiveness and requesting federal help to add residency training slots for medical students in the state.

Last year, Gov. Kim Reynolds that drops the residency requirement for some doctors who trained abroad to get a medical license. Lawmakers in at least eight other states have approved similar changes.

Patterson, of the Washington County hospital, appreciates that Iowa lawmakers are trying to increase the pipeline of doctors into Iowa but said it doesn’t address immediate shortages.

“You have a high school student who’s graduating right now; they’re probably nine to 11 years away from entering the workforce as a practicing physician. So it’s a long-term kind of problem,” he said.

For nurses, workforce experts say, the projected national outlook isn’t as dire as in recent years.

“Nursing education is back up. Nursing employment rates are back up. I think, for that workforce, we’ve largely nationally recovered from all the dislocations that occurred,” said Spetz, of the Institute for Health Policy Studies.

But getting nurses to move to the places that need them, like rural communities, will be difficult, she said.

Some rural hospitals in Iowa say an even bigger challenge right now is finding nurses to hire.

Some of that can be traced to the pandemic, said Sara Bruns, nurse manager at Keokuk County Hospital and Clinics. She recalled that some covid patients in critical condition died when they couldn’t be transferred to larger hospitals with more advanced intensive care unit equipment, because those hospitals didn’t have the staff to take on more patients.

“We had to make the horrible decision of ‘You’re probably not going to make it,’” Bruns recalled, saying many patients were then listed as DNR, for “do not resuscitate.”

“That took a big toll on a lot of nurses,” she said.

Another problem is persuading the area’s young nurses to stay, when they would rather live and work in more urban areas, Bruns said.

Her hospital still relies on contracts with travel nurses to fill some night shifts. That’s something the hospital never had to do before the pandemic, Bruns said. Travel nurses are , adding stress to a small hospital’s budget.

“I think some people just completely got out of nursing,” Bruns said. The pandemic took a special toll “because of the hours that they had to work, the conditions that they had to work.”

Policymakers and health care organizations can’t focus only on recruiting workers, according to Janette Dill at the University of Minnesota. “You also have to retain workers,” she said. “You can’t just recruit new people and then have them be miserable.”

Dill said workers report feeling that patients have been more disrespectful and challenging since the pandemic, and sometimes workers at work. “By ‘unsafe’ I mean physically unsafe. I think that is a very stressful part of the job,” she said.

Research has shown health workers of burnout and poor mental health since the pandemic — though the risks decreased if workers felt supported by their managers.

Gail Grimes, an intensive care nurse in Des Moines, felt more supported by her employer during the worst parts of the pandemic than she does now, she said. Some hospitals offered pay bumps and more to keep nurses on staff.

“We were getting better bonus pay,” Grimes recalled. “We were getting these specialized contracts we could fulfill that were often more worth our time to be able to come in, to miss our families and be there.”

Grimes said she’s seen nurses leave Iowa for neighboring states with better average pay. This creates shortages that she believes affect the care she gives her own patients.

“A nurse taking care of five patients will always be able to provide better care than a nurse taking care of 10 patients,” she said.

She thinks many hospitals have simply accepted staff burnout as a fact, rather than try to prevent it.

“It really is significantly impactful to your mental health when you come home every day and you feel guilty about the things you have not been able to provide to people,” she said.

This article is from a partnership that includes , , and �������ýҕ�l Health News.

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