Although 33 Democratic presidential candidates will appear on the New Hampshire primary ballot Tuesday, only two reign supreme on the Keene State College campus.
“I hear nothing but Bernie or Warren,” said Madison Shimko, a junior, about the campaigns that have been the most vocal and visible at the college.
“It’s definitely Warren and Sanders,” Shimko’s friend, sophomore Emily Roll, chimed in.
In the week before the N.H. Primary, Shimko and Roll, both still undecided voters at that point, agreed the campaigns of U.S. Sens. Bernie Sanders of Vermont and Elizabeth Warren of Massachusetts have the most energetic presence — and adherents — on campus.
Generation Z, those ages 18 to 23, now represents one in 10 voters nationally, and more than 69,000 eligible voters in the Granite State have reached voting age since 2016, according to data from the University of New Hampshire Carsey School of Public Policy. Of those ages 18 to 24 across the U.S., nearly 60 percent say they’re Democrats, while only a third identify as Republicans, according to analysis from the Pew Research Center in 2019.
In the 2018 state midterm elections, this voting bloc turned out to vote in higher numbers than in past elections, which means the support of young voters could portend well for candidates in Tuesday’s primary.
With clipboards outside the cafeteria and from tables inside Keene State’s student center, organizers for both the Warren and Sanders campaigns have repeatedly tried to lobby students to their candidates, according to Shimko and Roll. The senators have also been among the slew of 2020 contenders who have held events on the college’s campus.
More than two dozen students interviewed in the Young Student Center echoed Shimko and Roll’s conclusion about the perceived front-runners among their peers.
“Bernie is definitely popular among college students, and so is Warren. [Andrew] Yang and [Pete] Buttigieg supporters are fewer and far between, but at least you hear them mentioned, unlike the other candidates,” Tristan Slicer said.
Slicer graduated from Keene State last May but stuck around to work as an organizer for the N.H. Youth Movement, a progressive group advocating for free college and medical care and measures to address climate change.
Davis Bernstein, Keene State student body president and president of the Keene State College Democrats, offered a similar assessment.
“Like most college campuses, I think it seems to be more liberal than not, so there’s definitely a big presence of Bernie and Warren supporters for sure. Pete pulls in support, too, and may be in the top three, and more recently Yang is being talked about,” said Bernstein, a junior, who added he’s staying neutral until after the primary.
Michael Parson, president of the New Hampshire College Democrats and a student at Dartmouth, predicted Sanders, Warren and Buttigieg will be the top three candidates at college campuses throughout the state.
Midday Friday, Bernie Sanders volunteer Alex Harvey, a senior at Keene State, sat in the entrance of the student center at a table littered with Sanders literature and paraphernalia.
“I think he’s the most trustworthy. He’s consistent and has the most integrity. He’s held the same positions for 40 years,” said Harvey, adding Sanders’ focuses on addressing climate change and income inequality are important to him and other Gen Z voters.
Of all the Democrats in the race, Harvey said Sanders, 78, is best positioned to beat President Donald Trump because his supporters are the most passionate and — most importantly — he has the momentum needed to win in the general election.
This month, the N.H. Youth Movement announced it had endorsed Sanders, and Slicer said that as an organizer for the group, he agrees with the choice.
“His campaign is funded by small donors who are looking to make the fundamental change needed in this country,” including government-sponsored universal health-care coverage, free college, and a robust program of government programs to create jobs in green energy, Slicer said.
Over at Franklin Pierce University in Rindge, sophomore Paul Lambert, a member of the school’s Politics FitzU organization — a student group that facilitates events for candidates — said Sanders has the largest weekly student group meeting on campus of any candidate.
“A lot of people I talk to are Sanders supporters and frankly, he’s popular across the board with young people,” Lambert said.
Elizabeth Warren’s campaign is well-organized and energized on campus, said many Keene State students.
“I feel like she fights for the younger generation and the middle class, which are both very important to me,” said Erin McNemar, a senior and intern for the Warren campaign.
A Massachusetts native, McNemar said she has been a fan of Warren, 70, since her arrival in the U.S. Senate in 2013. Warren’s plan for free public college is important to her because McNemar said the expense of higher education is forcing her to finish her degree in three years.
While both visible on campus, McNemar said there’s little contention between the Warren and Sanders camps. Most students on either side “agree to disagree,” she said, and say they’ll bind together behind whoever is the eventual nominee.
Atlas Weil, a volunteer with the Warren campaign and a Keene State senior, said she was a big Sanders supporter in 2016 but decided to go for Warren this cycle after a campaign volunteer approached her on campus.
“I ended up agreeing with a lot of Warren’s political ideas as well as her policies and ways to enact those policies,” said Weil, noting Warren’s plan for free childcare and college, and her platforms to protect LGBTQ rights, drew her in.
“I didn’t have any major political turmoil; it’s just a slight difference between Warren and Sanders, but I really appreciated that on her website and in her speeches, Warren lays out specific plans and talks transparently and openly about how to get them done,” Weil said.
She said she also believes Warren has the most wide-reaching and demographically diverse base of any candidate, which she predicted would enable the Bay Stater to win in the general election.
Seeking more youth
After Sanders and Warren, many at Keene State — along with Parson at Dartmouth — said Buttigieg comes in a close third in terms of visibility and support from students.
“I’m currently more of a Buttigieg person because I think we need someone more middling,” Nora Marcinuk, a Keene State sophomore, said, of the former mayor of South Bend, Ind. “I think we need to take baby steps to get things done. People are very extremist right now, but if they go to the opposite left or right end, we’re not going to make change. We need to start with something we can agree on.”
Marcinuk said she first saw commercials for Buttigieg, 38, several months ago and researched his platform.
“He still stands for climate change and equal rights, but he’s not screaming it as much as the others, which is why I think more conservative viewpoints will support him,” Marcinuk said.
“The only negative thing I’ve heard is he’s too young, which I don’t think is much of a downside.”
Also in the student center Friday was Aliza Cilley, 24, a University of New Hampshire graduate who now lives in Keene and works in the Keene State admissions office.
For the past year, Cilley has volunteered for the Buttigieg campaign.
“It’s a generational thing for me. I love Bernie and Liz, but I think we need to get someone younger. I also think it would be great to have a president who’s gay,” Cilley said.
She said she was drawn to Buttigieg for his plans to make college and medical care more affordable, but not fully government-funded as proposed by Sanders and Warren.
“I’m not for free college. I don’t think it’s realistic, and I don’t think the funding would work,” Cilley said.
Mentions of the other candidates, including the leader in the national polls, former Vice President Joe Biden, were conspicuously absent on the Keene campus.
But some said tech entrepreneur and philanthropist Andrew Yang was gaining traction among students, and posters with Yang’s slogan, “Not left, not right, forward,” were scattered throughout the student center, along with ones for Warren and Sanders.
“In our country, there’s a huge partisan divide and I think he could heal that,” Keene State senior and Yang campaign volunteer Bryce Bodie told a reporter at the candidate’s town hall at The Colonial Theatre Wednesday night.
Student energy is an important marker of which candidates will come out on top Tuesday. The ultimate outcome, however, will remain opaque until the results are in, said Dan Bristol, press secretary for NextGen New Hampshire, an organization focused on climate issues and young voter registration that was founded by billionaire Democratic candidate Tom Steyer.
“It’s really anyone’s game when it comes to young people,” Bristol said. “It’s easy to say that one candidate has more support than another, but I think that also depends on who’s the loudest, and there’s quiet supporters of every candidate out there as well.”
Dr. Keith Corl was working in a Las Vegas emergency room when a patient arrived with chest pain. The patient, wearing his street clothes, had a two-minute exam in the triage area with a doctor, who ordered an X-ray and several other tests. But later, in the treatment area, when Corl met the man and lifted his shirt, it was clear the patient had shingles. Corl didn’t need any tests to diagnose the viral infection that causes a rash and searing pain.
All those tests? They turned out to be unnecessary and left the patient with more than $1,000 in extra charges.
The excessive testing, Corl said, stemmed from a model of emergency care that forces doctors to practice “fast and loose medicine.” Patients get a battery of tests before a doctor even has time to hear their story or give them a proper exam.
“We’re just shotgunning,” Corl said.
The shingles case is one of hundreds of examples that have led to his exasperation and burnout with emergency medicine. What’s driving the burnout, he argued, is something deeper — a sense of “moral injury.”
Corl, a 42-year-old assistant professor of medicine at Brown University, is among a growing number of physicians, nurses, social workers and other clinicians who are using the phrase “moral injury” to describe their inner struggles at work.
The term comes from war: It was first used to explain why military veterans were not responding to standard treatment for post-traumatic stress disorder. Moral injury, as defined by researchers from veterans hospitals, refers to the emotional, physical and spiritual harm people feel after “perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations.”
Drs. Wendy Dean and Simon Talbot, a psychiatrist and a surgeon, were the first to apply the term to health care. Both wrestled with symptoms of burnout themselves. They concluded that “moral injury” better described the root cause of their anguish: They knew how best to care for their patients but were blocked from doing so by systemic barriers related to the business side of health care.
That idea resonates with clinicians across the country: Since they penned an op-ed in Stat in 2018, Dean and Talbot have been flooded with emails, comments, calls and invitations to speak on the topic.
Burnout has long been identified as a major problem facing medicine: 4 in 10 physicians report feelings of burnout, according to a 2019 Medscape report. And the physician suicide rate is more than double that of the general population.
Dean said she and Talbot have given two dozen talks on moral injury. “The response from each place has been consistent and surprising: ‘This is the language we’ve been looking for for the last 20 years.’ ”
Dean said that response has come from clinicians across disciplines, who wrestle with what they consider barriers to quality care: insurance preauthorization, trouble making patient referrals, endless clicking on electronic health records.
Those barriers can be particularly intense in emergency medicine.
Corl said he has been especially frustrated by a model of emergency medicine called “provider-in-triage.” It aims to improve efficiency but, he said, prioritizes speed at the cost of quality care. In this system, a patient who shows up to an ER is seen by a doctor in a triage area for a rapid exam lasting less than two minutes. In theory, a doctor in triage can more quickly identify patients’ ailments and get a head start on solving them. The patient is usually wearing street clothes and sitting in a chair.
Deep systemic problems
These brief encounters may be good for business: They reduce the “door to doc” time —how long it takes to see a doctor —that hospitals sometimes boast about on billboards and websites. They enable hospitals to charge a facility fee much earlier, the minute a patient sees a doctor. And they reduce the number of people who leave the ER without “being seen,” which is another quality measure.
But “the real priority is speed and money and not our patients’ care,” Corl said. “That makes it tough for doctors who know they could be doing better for their patients.”
Dean said people often frame burnout as a personal failing. Doctors get the message: “If you did more yoga, if you ate more salmon salad, if you went for a longer run, it would help.” But, she argued, burnout is a symptom of deeper systemic problems beyond clinicians’ control.
Emergency physician Dr. Angela Jarman sees similar challenges in California, including ER overcrowding and bureaucratic hurdles to discharging patients. As a result, she said, she must treat patients in the hallways, with noise, bright lights and a lack of privacy —a recipe for hospital-acquired delirium.
“Hallway medicine is such a (big) part of emergency medicine these days,” said Jarman, 35, an assistant professor of emergency medicine at the University of California, Davis. Patients are “literally stuck in the hallway. Everyone’s walking by. I know it must be embarrassing and dehumanizing.”
For example, when an older patient breaks an arm and cannot be released to their own care at home, they may stay in the ER for days as they await evaluation from a physical therapist and approval to transfer to rehab or a nursing home, she said. Meanwhile, the patient gets bumped into a bed in the hallway to make room for new patients who keep streaming in the door.
Being responsible for discharging patients who are stuck in the hallway is “so frustrating,” Jarman said. “That’s not what I’m good at. That’s not what I’m trained to do.”
Jarman said many emergency physicians she knows work part time to curtail burnout.
“I love emergency medicine, but a lot of what we do these days is not emergency medicine,” she said. “I definitely don’t think I’ll make it 30 years.”
Also at UC Davis, Dr. Nick Sawyer, an assistant professor of emergency medicine, has been working with medical students to analyze systemic problems. Among those they’ve identified: patients stuck in the ER for up to 1,000 hours while awaiting transfer to a psychiatric facility; patients who are not initially suicidal, but become suicidal while awaiting mental health care; patients who rely on the ER for primary care.
Sawyer, 38, said he has suffered moral injury from treating patients like this one: A Latina had a large kidney stone and a “huge amount of pain” but could not get surgery because the stone was not infected and therefore her case wasn’t deemed an “emergency” by her insurance plan.
Good for business; bad for patients
“The health system is not set up to help patients. It’s set up to make money,” he said.
The best way to approach this problem, he said, is to help future generations of doctors understand “how decisions made at the systems level impact how we care about patients” —so they can “stand up for what’s right.”
Whether these experiences amount to moral injury is open for discussion.
Cynda Rushton, a nurse and professor of clinical ethics at Johns Hopkins University, who has studied the related notion of “moral distress” for 25 years, said there isn’t a base of research, as there is for moral distress, to measure moral injury among clinicians.
But “what both of these terms signify,” Rushton said, “is a sense of suffering that clinicians are experiencing in their roles now, in ways that they haven’t in the past.”
Dean grew interested in moral injury from personal experience: After a decade of treating patients as a psychiatrist, she stopped because of financial pressures. She said she wanted to treat her patients in longer visits, offering both psychotherapy and medication management, but that became more difficult. Insurers would rather pay her for only a 15-minute session to manage medications and let a lower-paid therapist handle the therapy.
Dean and Talbot created a nonprofit advocacy group called Moral Injury of Healthcare, which promotes public awareness and aims to bring clinicians together to discuss the topic.
Corl said he was so fed up with the provider-in-triage model of emergency medicine that he moved his ER clinical work to smaller, community hospitals that don’t use that method.
He said many people frame burnout as a character weakness, sending doctors messages like, “Gee, Keith, you’ve just got to try harder and soldier on.” But Corl said the term “moral injury” correctly identifies that the problem lies with the system.
“The system is flawed,” he said. “It’s grinding us. It’s grinding good docs and providers out of existence.”