The age of ideological struggle failed to end with the Cold War.  Francis Fukuyama, who coined the phrase “the end of history”, talks to Anne McElvoy about the rise of identity politics, whether there is any force that can rival it, and which party is playing the identity game better in the American midterms. Listen here.

Some 450 million patient visits to primary care clinics occur in the United States each year. And as the shortage of doctors grows larger each year, primary care teams face increasing pressure both during patient encounters and outside the examining room.

The growing time constraints on primary care clinics — conducting patient consults faster, logging results in EMRs sooner, keeping up with regulatory changes — are worrying patients and physicians alike. 

Stanford Health Policy’s Kathryn M. McDonald and colleagues wanted to better understand the organizational influences of time stressors and the impact they are having on patients.

“Patients get interrupted often when doctors and their care teams are rushed,” said McDonald, MM, PhD, executive director of the Center for Health Policy and Center for Primary Care and Outcomes Research. “They worry about whether their concerns and needs will be addressed adequately. Getting the right diagnosis, treatment and support are all important to patients, so any risk of experiencing suboptimal care due to time stressors is worth understanding better.”

In a study published in the American Public Health Association journal, Medical Care, McDonald and her colleagues wrote that despite concern about the impact time pressure has on the delivery of health care, “scant evidence exists about types of time stress, the organizational factors that shape such stressors in routine care settings, and consequences for patients and practitioners alike.” 

So the researchers analyzed cross-sectional survey data collected from January to August 2016 from primary care teams at 16 randomly selected primary care practices associated with two large Accountable Care Organizations (ACOs) and their patients with cardiovascular disease, diabetes, or both. Through April 2016, they gathered data from 353 physicians and staff members of the clinics.

Then from May to August 2016, the researchers surveyed 1,291 patients by mail and telephone follow-up calls to ask about their concerns.

They determined that the responses translated into two types of stressors related to the lack of time: practice-level time pressure and encounter-level time pressure.

“The stressor condition is similar to the weather—determined by both barometric pressure and temperature — in potentially different way,” they posited.

They found that different organizational factors are associated with each form of time pressure. A patient-centered culture, for example, may include specific patient engagement initiatives, and is associated with reductions in encounter-level time pressure. Similarly, health information systems that provide true support for clinical workflow and good teamwork also corresponded with less encounter-level time pressure. A different organizational influence — leaders that are responsive to the clinic teams — was associated with reductions in practice-level time pressure.

The potential consequences for patients are missed opportunities in patient care and inadequate chronic care support — two very important factors behind successful health care.

“The findings underscore the importance of linking all levels and aspects of physician practice organizations to mitigate  the negative effects of time pressure on patient care” said Stephen Shortell, principal investigator of the Patient Centered Outcomes Research Institute (PCORI) grant that funded the study.  Their other co-author is Hector Rodriguez at the UC Berkeley School of Public Health.

They discovered that one-third of medical team respondents indicated they work in a chaotic practice atmosphere, juggling patient calls, documentation, quality reporting, and many other tasks. The more senior the staff member was, reports of working in a chaotic environment lessened.

Only 31 percent of those respondents said that during patient visits, it was very unlikely for the team to miss all seven specific opportunities related to screening, diagnosis or treatments. 

“Doctors’ offices may increase their chances of preventing adverse effects of time stressors by becoming more patient-centered, coordinating care among team members better and assuring that information technologies make work easier,” McDonald said in an interview about how the results might lead to some solutions. 

“I was struck by the importance of leadership’s responsiveness to their frontline team’s input about changes needed when doctor’s offices are more chaotic,” she said. “Likewise, for clinics that are part of larger groups, like Accountable Care Organizations, the corporate office’s decisions seem to play a role in the perception of time stressors at the practice level.”

The United States is in the grip of an opioid epidemic, which is affecting millions of Americans and claiming thousands of lives. Many trace their opioid dependence back to their doctor’s office, the drugs prescribed for pain after an injury, surgery, or dental procedure. Were these painkillers over prescribed? Did drug manufacturers exaggerate opioids’ effectiveness while deliberately underplaying their danger? Did drug distributors and retailers take necessary steps to ensure that pills weren’t falling in to the wrong hands?  

In this Q&A, Stanford Law Professors Michelle Mello, an expert in health law and core faculty member at Stanford Health Policy, and Nora Freeman Engstrom, an expert in tort law and complex litigation, explain the scope of the opioid problem and discuss the latest cases and legal challenges.

Just how big of a problem is the opioid crisis in the United States? Can you describe the problem’s scope and seriousness? 

Engstrom: The opioid problem is monstrous. Some 2.4 million Americans have an opioid use disorder, and the epidemic has already claimed 300,000 American lives, including 42,000 in 2016 alone. Worse, if the problem isn’t addressed, death tolls will rise: opioids are on track to claim the lives of another half-million Americans within the next decade. That’s like wiping out the entire city of Atlanta. The economic cost is also astronomical. The Council of Economic Advisors has estimated that, in 2015, “the economic cost of the opioid crisis was $504.0 billion, or 2.8 percent of GDP.”

Mello: If there’s one picture that brings home the shocking toll, it’s this one, showing trends in U.S. deaths based on data from the Centers for Disease Control and Prevention.  Nearly all of the “Poisoning” deaths shown here are opioid related. In terms of what’s killing Americans, opioids dwarf car crashes and guns.

Opioid lawsuits are now making news . Some of the actions are criminal, pursued by the states and federal government. Others of those suits are being initiated by cities, counties, and even states. What do those latter suits allege and what damages are the public plaintiffs trying to recover?

Engstrom: In the past four years, roughly 400 cities, counties, and states have initiated lawsuits seeking recovery for their additional public spending traceable to the opioid epidemic. The governmental entities claim they have been injured because defendants—typically, opioid manufacturers, distributors, and big retail pharmacies—have pumped opioids into the hands of their citizens and, in so doing, increased their spending for governmental services. Everything from policing, education, foster care, the provision of health care, even the operation of coroner’s officers, have all been made more expensive because, as compared to a healthy citizenry, an opioid-addicted populace is far less productive and needs much more by way of government help. Facing these spiraling costs, the governmental plaintiffs contend that the opioid defendants—who, they contend, caused and profited from this crisis—should foot the bill.

So, the typical defendants in these cases are opioid manufacturers, distributors, and big retail pharmacies. What is it that the plaintiffs are alleging these defendants did wrong?

Mello: There are some variations state to state, but for manufacturers, plaintiffs are typically claiming that they made false statements to prescribers and others that the drugs were safer and less addictive than alternatives, even when mounting evidence showed otherwise; that they failed to warn physicians and patients about the risks; and that the products were defectively designed—for example, because manufacturers didn’t make the pills tamper-resistant. For distributors and retailers, the claims are that these defendants failed to monitor, detect, investigate, and report suspicious orders of prescription drugs, even though reasonably prudent suppliers would have done so and the federal Controlled Substances Act requires suppliers to maintain effective controls against diversion of controlled substances to illicit markets.

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"Samuel Huntington was not right about everything. Rather, his greatness lay in his ability to conceptualize big ideas in a wide variety of fields," writes Francis Fukuyama in this comparative article. Read here.

The Japan–U.S. alliance is the cornerstone of security, stability, and prosperity in the Asia-Pacific region. As we look at the global challenges we face today, I believe that we must strive to ensure that our special relationship remains strong and vital. One way to accomplish this is by preparing the best and brightest of our young people with the kind of learning opportunities that will deepen mutual understanding. It is my belief that the Reischauer Scholars Program and Stanford e-Japan are admirably working toward this goal by providing the knowledge and expertise our young people will need as future leaders in Japan–U.S. relations. 

Waka Brown and Naomi Funahashi at podium

Attendees represented people from the Stanford community and the U.S.–Japan community in the Bay Area, including Dr. Takeo Hoshi, Director, Japan Program, and Junichiro Hirata, Visiting Scholar, Shorenstein Asia-Pacific Research Center, FSI; and Dr. Kazuhiko Hasegawa, Executive Director, San Francisco Office, Osaka University, Kathleen Kimura, Japan Society of Northern California, and Dr. Yoichi Aizawa, Executive Director, San Francisco Office, Waseda University. Amanda Minami Chao and David Chao were recognized for their many years of support to SPICE.   

Q&A with Rodney C. Ewing, co-director of the Center for International Security and Cooperation, a senior fellow at the Freeman Spogli Institute for International Studies and a Professor in the School of Earth, Energy and Environmental Sciences. Written with Nicole Feldman.

With the Trump-Kim Summit fresh in our minds, Americans are ready to confront nuclear challenges that have been on hold for decades. What many may not realize is that one of the biggest challenges is on the home front. Since the Manhattan Project officially began in 1942, the United States has faced ever-increasing stores of nuclear waste. In Part Three of our series on the consequences of nuclear war, expert Rodney C. Ewing tells us how the U.S.’s failure to implement a permanent solution for nuclear waste storage and disposal is costing Americans billions of dollars a year.

Where does our nuclear waste come from, and what is being done with it?

Broadly speaking, there are two types of nuclear waste.

The first is spent fuel from nuclear reactors used to generate electricity. Those reactors have left us with about 80,000 metric tonnes of used spent fuel, and we don’t have a way forward for the disposal of this waste. It’s stored at more than 75 sites in 35 states around the country, so many of us have some in our state, including California.

The second category is the waste generated by our nuclear weapons complex. That defense waste has accumulated since the earliest days of the Manhattan Project. The highly-radioactive waste from chemical processing is mainly stored in very large metal tanks. They are located at the Savannah River site in South Carolina, the Hanford site in Washington State, at Idaho National Laboratory in Idaho, and Nuclear Fuel Services site at West Valley in New York State.

I think it’s discouraging that we continue to release radioactivity to the environment because after more than 40 years we still have not developed a successful plan for going forward.

What’s wrong with what’s happening now?

This waste is problematic because the volume is large, many hundreds of thousands of cubic meters. The tanks in Hanford and Savannah River are way beyond their design lifetimes, so they’re corroding and some have leaked. The radioactive fluid is being released to the environment. The rates are not high, but I think it’s discouraging that we continue to release radioactivity to the environment because after more than 40 years of effort we still have not developed a successful plan for going forward.

The spent fuel from commercial power plants is much smaller, some 80,000 metric tonnes, but the total amount of radioactivity is roughly 20 to 30 times greater than defense waste. Today, it’s the spent fuel that demands the most attention as an immediate problem, particularly financially.

How much is nuclear waste costing American taxpayers?

The two categories of waste are separated in the budget. At the moment, the budget for the Department of Energy is about $30 billion. Of that budget, about $12 billion is for the nuclear weapons programs. That leaves us $18 billion to use for all things related to energy — nuclear power, fossil fuel, wind, and solar. About $6 billion, one third, is used to deal with the legacy high-level waste from the Manhattan Project. We as taxpayers pay $6 billion every year to address that problem, a huge cost that we will incur for many decades into the future. The projected total cost of clean-up after the Manhattan Project is well over $300 billion. That’s more than the original cost of the weapons programs and the actual total will be even higher. That’s just the defense waste.

What about the waste from nuclear energy? Is that clean-up cost also high?

In short, very. The Nuclear Waste Policy Act of 1982 created a tax on electricity generated by nuclear power plants. This tax would accumulate into the Nuclear Waste Fund for us to build a geologic repository — a mined facility deep within the earth — to safely dispose of the waste. What’s happened to that?

The fund has a balance of more than $40 billion. It’s controlled by Congress on an annual basis, and congressional budget rules make it very difficult to use those funds. It’s not a lockbox where the money goes and waits to be spent. Instead, it’s been applied against our national debt, so even though the fees have been collected, they haven’t been used for their intended purpose.

We pay about half-a-billion dollars a year to the utilities for their simply keeping the fuel because there’s no place for it to go.

The Department of Energy was to take ownership of this fuel on January 1, 1998, but they didn’t because there was no geologic repository. Now the utilities who have the fuel have to continue to deal with it onsite. They have sued the federal government for its failure to take ownership of the fuel, so now we pay about half-a-billion dollars a year to the utilities for their simply keeping the fuel because there’s no place for it to go. The projected cost of this penalty, let’s say, is something on the order of many tens of billions of dollars, depending on how long the spent fuel has to remain at the reactor sites. The cost of doing nothing over time will be equivalent to what we charge the rate payers, $40 billion over time. That doesn’t even include compensation to workers in defense facilities, soldiers exposed during atmospheric testing of nuclear weapons, and so on.

Clearly, the financial cost to taxpayers is high. What about the cost to the environment?

For the spent fuel, the volume — 80,000 metric tons — sounds like a lot, but compared to Gigatonnes of carbon emitted by burning fossil fuels, its volume is not so great. It’s well-contained, but there are some difficulties with how it’s stored. In some cases, the used fuel is kept in pools. Those pools have filled, and they weren’t meant for extended storage. We should be trying to get that fuel into what are called dry casks: obelisks concrete and metal.

Are there other challenges people may not be aware of?

What people don’t realize is that it is actually a serious technical challenge.

It’s very common for people to say there are no technical problems, that it’s just political. They say, “We know how to do it. It’s just a difficult public. Strict regulations. No one will let us solve this problem.”

I think what people don’t realize is that it is actually a serious technical challenge. The half-lives of some of these elements stretch into tens, if not hundreds of thousands of years. We’re asked to design solutions that will last as long as the risk. That’s not something we usually do. The technical and scientific challenge for nuclear waste is, whatever our solution, that we will never see whether we were correct or not. Designing a system where you don’t have feedback is very difficult.

What will happen if we don’t find a solution?

There will not be an immediate catastrophe; I don’t expect anything to explode. There will be environmental contamination, but the biggest problem is financial. We’re spending $6 billion a year trying to deal with the problem, and we’ll continue to spend $4.5 to $5 billion a year without solving the problem. That $5 billion could go to education or research. Imagine if instead of working on waste, we were working on solving our future energy needs.

What’s the best way for us to move forward?

At Stanford, over a two-year period we had a series of meetings to ask just this question: how does the U.S. break out of its gridlock situation and move ahead? We brought in international experts, members of the public, really quite an extraordinary effort, over 75 speakers in five meetings. We have a number of recommendations. We need a new, single purpose nuclear waste management organization. We need a new process for engaging not only the scientific and technical communities, but also the public. We need a new regulatory framework that recognizes the challenges of predicting repository performance over hundreds of thousands of years. Most importantly, we need to realize that dealing with nuclear waste is not only a technical issue, but also requires careful attention to social issues. It is very important to design an approach that engages local communities, states, and tribes. This report, Reset of U.S. Nuclear Waste Management Strategy and Policies, will be released this summer.