It wasn't what we thought
A mother came in with her child for a routine and common complaint. While my MA was rooming them, she saw bruises around the mother's neck and the mother was lifting up her collar to cover the bruises. So my MA came to me with her concern. I don't actually deal with this kind of overt thing much. We have these handouts that we can give patients with domestic violence resources...except no, we actually didn't. So I had to run to the nurses (shout out to the nurses on this sub; I'm so glad we have nurses) who helped me find some resources and we scraped something together. Then I looked up scripting of how to open the conversation without shutting everything down. So after the visit, I asked to speak to her alone for a moment, took her into another exam room and told her that my MA had noticed bruising around her neck when she came in and she seemed to be covering it up and I just wanted to check in and see if everything was OK at home...when the mom cut me off with a roar of laughter. "OMG, I'm so embarrassed! They're hickeys! I was covering them up because I was embarrassed!" And she then pulled down her collar to reveal two very large suction purpura. I could literally *FEEL* my SBP drop by 15 mmHg right then and there. "OK, whew! Uh...that is absolutely permitted and even encouraged. Sorry if I made you uncomfortable." Hey, at least someone is getting some! -PGY-21
The Chen 2023 Paper Raises Serious Concerns About Pediatric Gender Medicine Outcomes
When I started my Child and Adolescent Psychiatry training in the 2010s, the diagnosis and treatment of gender dysphoria were rapidly becoming controversial in the field. Doctors and nurses who had spent decades on inpatient adolescent units, usually seeing one gender dysphoric child every 4-5 years, now saw multiple transgender-identifying kids in every inpatient cohort. It was a rare patient list that did not include at least one teenager with pronouns not matching their sex. Viewpoints about this differed, with every student, resident, fellow, and attending having their own perspective. All of us wanted what was best for patients, and these discussions were always productive and collegial. While I am not naive about how heated this topic can be online, I have only ever had good experiences discussing it with my colleagues. Some of my attendings thought that this was merely a social fad, similar to Multiple Personality Disorder or other trendy diagnoses, like the rise in Tourette's and other tic disorders seen during the early pandemic and widely attributed to social media. Others, including myself early on, thought we were merely seeing psychological education doing what it is supposed to do: patients who would, in earlier decades, not realize they were transgender until middle age were now gaining better psychological insight during their teen years. This was due to a combination of increased tolerance and awareness of transgender people and was a positive good that shouldn't necessarily raise any red flags or undue skepticism. During my outpatient fellowship year, I began to suspect a combination of both theories could be true, similar to ADHD or autism, where increasing rates of diagnosis likely reflected some combination of better cultural awareness (good) and confirmation bias leading to dubious diagnoses (bad). Confirmation bias is always a problem in psychiatric diagnosis, because almost all psychiatric diagnoses describe symptoms that exist along a spectrum, so almost anyone could meet the DSM5TR criteria for any condition, so long as you ignored the severity of the symptom, and people are often not good at judging the severity of their own symptoms, as they do not know what is "normal" in the broader population. I considered myself moderate on these issues. Every field of medicine faces a tradeoff between overtreatment and undertreatment, and I shared the worries of some of my more trans-affirming colleagues that many of these kids were at high risk for suicide if not given the treatment they wanted. Even if you attribute the increase in trans-identification among teens to merely a social fad, it was a social fad with real dangers. If an influencer or spiritual guru on social media was convincing teens that evil spirits could reside in their left ring finger, and they needed to amputate this finger or consider suicide, the ethical argument could be made that providing these finger amputations was a medically appropriate trade of morbidity for mortality. "How many regretted hormonal treatments, breast surgeries, or (in our hypothetical) lost ring fingers are worth one life saved from suicide?" is a reasonable question, even if you are skeptical of the underlying diagnosis. And I was always skeptical of the legitimacy of most teenagers' claims to be transgender, if for no other reason than because gender dysphoria was historically a rare diagnosis, and the symptoms they described could be better explained by other diagnoses. As the old medical proverb says, "when you hear hoofbeats, think horses and not zebras." The DSM5 estimated the prevalence of gender dysphoria in males as a range from 0.005% to 0.014%, and in females as a range of 0.002% to 0.003%, although the newer DSM5TR rightly notes the methodological limitations of such estimates. Regardless, most of the symptoms these teens described could be explained as identity disturbance (as in borderline personality disorder and some trauma responses), social relationship problems (perhaps due to being on the autism spectrum), body image problems (similar to and sometimes comorbid with eating disorders), rigid thinking about gender roles (perhaps due to OCD or autism), unspecified depression and anxiety, or just gender nonconforming behavior that fell within the normal range of human variation. It seems highly implausible that the entire field of psychiatry had overlooked or missed such high rates of gender dysphoria for so long. Some of my colleagues tried to explain this as being due to the stigma of being transgender, but I do not think it is historically accurate to say that psychiatry as a field has been particularly prudish or hesitant to discuss sex and gender. In 1909 Sigmund Freud published a case report about "Little Hans," which postulated that a 5-year-old boy was secretly fixated on horse penis because of the size of the organ. I do not find it plausible that the next century of psychoanalysis somehow underestimated the true rate of gender dysphoria by multiple orders of magnitude because they were squeamish about the topic. In fact, the concept that young girls secretly wanted a penis was so well known that the term "penis envy" entered common English vocabulary! Of course, the psychoanalytic concept of penis envy is not gender dysphoria per se, but it is adjacent enough to demonstrate the implausibility of the notion that generations of psychoanalysts downplayed or ignored the true rate of gender dysphoria due to personal bigotry or cultural taboo. Therefore, for most of my career I have been in the odd position of doubting my gender-affirming colleagues, who would say "trans kids know who they are" and talk about saving lives from suicide, but also believing that they were making the best of a difficult situation. In the absence of any hard outcome data, all we had to argue about was theory and priors. I routinely saw adverse outcomes from these treatments, both people who regretted transitioning and those whose dysphoria and depression kept getting worse the more they altered their bodies, but I had to admit this might be selection bias, as presumably the success cases didn't go on to see other psychiatrists. I could be privately skeptical, but without any hard data there was no public argument to make. The gender affirming clinicians claimed that they could correctly identify which kinds of gender dysphoria required aggressive treatment (from DSMIV-TR to DSM5 the diagnosis was changed to emphasize and require identification with the opposite gender, rather than other kinds of gendered distress and nonconformity), and even when they were wrong they were appropriately trading a risk of long term morbidity for short term mortality. There was nothing to be done except wait for the eventual long term outcomes data. The waiting ended when I read the paper "Psychosocial Functioning in Transgender Youth after 2 Years of Hormones" by Chen et al in the NEJM. This is the second major study of gender affirming hormones (GAH) in modern pediatric populations, after Tordoff 2022, and it concluded "GAH improved appearance congruence and psychosocial functioning." The authors report the outcomes as positive: "appearance congruence, positive affect, and life satisfaction increased, and depression and anxiety symptoms decreased." To a first approximation, this study would seem to support gender affirming care. Some other writers have criticized the unwarranted causal language of the conclusion, as there was no control group and so it would have been more accurate to say "GAH was associated with improvements" rather than "GAH improved," but this is a secondary issue. The problem with Chen 2023 isn't its methodological limitations. The problem is its methodological strength. Properly interpreted, it is a negative study of outcomes for youth gender medicine, and its methodology is reasonably strong for this purpose (most of the limitations tilt in favor of a positive finding, not a negative one). Despite the authors' conclusions, an in-depth look at the data they collected reveals this as a failed trial. The authors gave 315 teenagers cross-sex hormones, with lifelong implications for reproductive and sexual health, and by their own outcome measures there was no evidence of meaningful clinical benefit. 315 subjects, ages 12-20, were observed for 2 years, completing 5 scales (one each for appearance, depression, and anxiety, and then two components of an NIH battery for positive affect and life satisfaction) every 6 months including at baseline. The participants were recruited at 4 academic sites as part of the Trans Youth Care in United States (TYCUS) study. Despite the paper's abstract claiming positive results, with no exceptions mentioned, the paper itself admits that life satisfaction, anxiety and depression scores did not improve in male-to-female cases. The authors suggest this may be due to the physical appearance of transwomen, writing "estrogen mediated phenotypic changes can take between 2 and 5 years to reach their maximum effect," but this is in tension with the data they just presented, showing that the male-to-female cases improved in appearance congruence significantly. The rating scale they used is reported as an average of a Likert scale (1 for strong disagreement, 3 for neutral, and 5 for strong agreement) for statements like "My physical body represents my gender identity" and so a change from 3 (neutral) to 4 (positive) is a large effect. If a change from 3 out of 5 to 4 out of 5 is not enough to change someone's anxiety and depression, this is problematic both because the final point on the scale may not make a difference and because it may not be achievable. Other studies using the Transgender Congruence Scale, such as Ascha 2022 ("Top Surgery and Chest Dysphoria Among Transmasculine and Nonbinary Adolescents and Young Adults") show a score of only 3.72 for female-to-male patients 3 months after chest masculinization. (The authors report sums instead of averages, but it is trivial to convert the 33.50 given in Table 2 because we know TCS-AC has 9 items.) The paper that developed this scale, Kozee 2012, administered it to over 300 transgender adults and only 1 item (the first) had a mean over 3. These numbers raise the possibility that the male-to-female cases in Chen 2023 may already be at their point of maximal improvement on the TCS-AC scale. A 4/5 score for satisfaction with personal appearance may be the best we can hope for in any population. While non-trans people score a 4.89 on this scale (according to Iliadis 2020), that doesn't mean that a similar score is realistically possible for trans people. When a trans person responds to this scale, they are essentially reporting their satisfaction with their appearance, while a non-trans person is answering questions about a construct (gender identity) they probably don't care about, which means you can't make an apples-to-apples comparison of the scores. If this is counter-intuitive to you, consider that a polling question like "Are you satisfied with your knowledge of Japanese?" would result in near-perfect satisfaction scores for those in the general public who have no interest in Japanese (knowledge and desire are matched near zero), but lower scores in students of the Japanese language. Even the best student will probably never reach the 5/5 satisfaction-due-to-apathy of the non-student. I am frustrated by the authors' decision not to be candid about the negative male-to-female results in the abstract, which is all most people (including news reporters) will be able to read. I have seen gender distressed teenagers with their parents in the psychiatric ER, and many of them are high functioning enough to read and be aware of these studies. While some teens want to transition for personal reasons, regardless of the outcomes data, in much the same way that an Orthodox Jew might want to be circumcised regardless of health benefits, others are in distress and are looking for an evidence-based answer. In the spring of 2023, I had a male-to-female teen in my ER for suicidal ideation, and patient and mother both expressed hopefulness about recently started hormonal treatment, citing news coverage of the paper. This teen had complicated concerns about gender identity, but was explicitly starting hormones to treat depression, and it is unclear whether they would have wanted such treatment without news reporting on Chen 2023. Moving on to the general results, the authors quantify mental health outcomes as: "positive affect [had an] annual increase on a 100-point scale [of] 0.80 points...life satisfaction [had an] annual increase on a 100-point scale [of] 2.32 points...We observed decreased scores for depression [with an] annual change on a 63-point scale [of] −1.27 points...and decreased [anxiety scores] annual change on a 100-point scale [of] −1.46 points...over a period of 2 years of GAH treatment." These appear to be small effects, but interpreting quantitative results on mental health scales can be tricky, so I will not say that these results are necessarily too small to be clinically meaningful, but because there is no control group these results are small enough to raise concerns about whether GAH outperforms placebo. It is unfortunate that it is not always straightforward to compare depression treatments due to several scales being in common use, but we can see the power of the placebo effect in other clinical trials on depression. In the original clinical trials for Trintellix, a scale called MADRS was used for depression, which is scored out of 60 points, and most enrolled patients had an average depression score from 31-34. Placebo reduced this score by 10.8 to 14.5 points within 8 weeks (see Table 4, page 21 of FDA label). For Auvelity, another newer antidepressant, the placebo group's depression on the same scale fell from 33.2 to 21.1 after 6 weeks (see Figure 3 of page 21 of FDA label). I won't belabor the point, but anyone familiar with psychiatric research will be aware that placebo effects can be very large, and they occur across multiple diagnoses, including surprising ones like schizophrenia (see Figure 3 of the FDA label for Caplyta). I am genuinely surprised and confused by how minimal this cohort's response to treatment was. Early in my career I thought we were trading the risk of transition regret for great short-term benefit, and I was confused when I noticed how patients given GAH didn't seem to get better. This data confirms my experience is not a fluke. I could go in depth about their anxiety results, which on a hundred-point scale fell by less than 3 points after two years, but this would read nearly identically to the paragraph above. A more formal analysis of this paper might try to estimate the effects of psychotherapy and subtract them away from the reported benefits of GAH, and an even more sophisticated analysis might try to tease apart the benefits of testosterone for gender dysphoria per se from its more general impact on mood, but I think this is unnecessary given the very small effects reported and the placebo concerns documented above. Putting biological girls on testosterone is conceptually similar to giving men anabolic steroids, and I remain genuinely surprised that it wasn't more beneficial for their mood in the short term. Some men on high doses of male steroids are euphoric to the point of mania. But my biggest concerns with this paper are in the protocol. This paper was part of TYCUS, the Trans Youth Care in United States study, and the attached protocol document, containing original (2016) and revised (2021) versions explains that acute suicidality was an exclusion criterion for this study (see section 4.6.4). There were two deaths by suicide in this study, and 11 reports of suicidal ideation, out of 315 participants, and these patients showed no evidence of being suicidal when the study began. This raises the possibility of iatrogenic harm. It would be beneficial to have more data on the suicidality of this cohort, but the next problem is that the authors did not report this data, despite collecting it according to their protocol document. The 5 reported outcome measures in Chen 2023 are only a small fraction of the original data collected. The authors also assessed suicidality, Gender Dysphoria per se (not merely appearance congruence), body esteem and body image (two separate scales), service utilization, resiliency and other measures. This data is missing from the paper. I do not fully understand why the NEJM allowed such a selective reporting of the data, especially regarding the adverse suicide events. A Suicidal Ideation Scale with 8 questions was administered according to both the original and revised protocol. In a political climate where these kinds of treatments are increasingly viewed with hostility and new regulatory burdens, why would authors, who often make media appearances on this topic, hide positive results? It seems far more plausible that they are hiding evidence of harm. Of course, Chen 2023 is not the only paper ever published on gender medicine, but aside from Tordoff 2022 it is nearly the only paper in modern teens to attempt to measure mental health outcomes. The Ascha 2022 paper on chest masculinization surgery I mentioned above uses as its primary outcome a rating scale called the Chest Dysphoria Measure (CDM), a scale that almost any person without breasts would have a low score on (with the possible exception of the rare woman who specifically wants to have prominent and large breasts that others will notice and comment on in non-sexual contexts), even if they experienced no mental health benefits from the breast removal surgery and regretted it. Only the first item ("I like looking at my chest in the mirror") measures personal satisfaction. Other items, such as "Physical intimacy/sexual activity is difficult because of my chest" may be able to detect harm in a patient who strongly regrets the surgery but is worded in such a way as not to detect actual benefit. They should have left it at "Physical intimacy/sexual activity is difficult" because a person without breasts can't experience dysphoria or functional impairment as a result of having breasts, even if their overall functionality and gender dysphoria are unchanged. Gender dysphoria that is focused on breasts may simply move to hips or waist after the breasts are removed. Tordoff 2022 was an observational cohort study of 104 teens, with 7 on some kind of hormonal treatment for gender dysphoria at the beginning of the study and 69 being on such treatment by the end. The authors measured depression on the PHQ-9 scale at 3, 6, and 12 months, and reported "60% lower odds of depression and 73% lower odds of suicidality among youths who had initiated PBs or GAHs compared with youths who had not." This paper is widely cited as evidence for GAH, but the problem is that the treatment group did not actually improve. The authors are making a statistical argument that relies on the "no treatment" group getting worse. This would be bad enough by itself, but the deeper problem is that the apparent worsening of the non-GAH group can be explained by dropout effects. There were 35 teens not on GAH at the end of the study, but only 7 completed the final depression scale. The data in eTable 3 of the supplement is helpful. At the beginning the 7 teens on GAH and the 93 not on GAH have similar scores: 57-59% meeting depression criteria and 43-45% positive for self-harming or suicidal thoughts. There is some evidence of a temporary benefit from GAH at 3 months, when the 43 GAH teens were at 56% and 28% for depression and suicidality respectively, and the 38 non-GAH teens at 76% and 58%. At 6 months the 59 GAH teens and 24 non-GAH teens are both around 56-58% and 42-46% for depression and suicidality. At 12 months there appears to be a stark worsening of the non-GAH group, with 86% meeting both depression and suicidality criteria. However, this is because 6/7 = 86% and there are only 7 subjects reporting data out of the 35 not on GAH from the original 104 subject cohort. The actual depression rate for the GAH group remains stable around 56% throughout the study, and the rate of suicidality actually worsens from Month 3 to Month 12. We cannot assume that the remaining 7 are representative of the entire untreated 35. I suspect teens dropped out of this study because their gender dysphoria improved in its natural course, as many adolescent symptoms, identities and other concerns do. However, even if you disagree with me on this point, the question you have to ask about the Tordoff study is why these 7 teens would go to a gender clinic for a year and not receive GAH. Whatever the reason was, it makes them non-representative of gender dysphoric teens at a gender clinic. The short-term effect of GAH is no longer an unanswered question. Its theoretical basis was strong in the absence of data, but like many strong theories it has failed in the face of data. Now that two studies have failed to report meaningful benefit we can no longer say, as we could as recently as 2021, that the short-term benefits are so strong that they outweigh the potential long-term risks inherent in permanent body modification. Some non-trivial number of patients come to regret these body modifications, and we can no longer claim in good faith that there are enormous short term benefits that outweigh this risk. The gender affirming clinicians had two bites at the apple to find the benefit that they claimed would justify these dramatic interventions, and their failure to find it is much greater than I could have imagined two years ago. I am not unaware of how fraught and politicized this topic has become, but the time has come to admit that we, even the moderates like me, were wrong. When a teenager is distressed by their gender or gendered traits, altering their body with hormones does not help their distress. I suspect, but cannot yet prove, that the gender affirming model is actively harmful, and this is why these gender studies do not have the same methodological problem of large placebo effect size that plagues so much research in psychiatry. When I do in depth chart reviews of suicidal twenty-something trans adults on my inpatient unit, I often see a pattern of a teenager who was uncomfortable with their body, "affirmed" in the belief that they were born in the wrong body (which is an idea that, whether right or wrong, is much harder to cope with than merely accepting that you are a masculine woman, or that you must learn to cope with disliking a specific aspect of your body), and their mental health gets worse and worse the more gender affirming treatments they receive. First, they are uncomfortable being traditionally feminine, then they feel "fake" after a social transition and masculine haircut, then they take testosterone and feel extremely depressed about "being a man with breasts," then they have their breasts removed and feel suicidal about not having a penis. The belief that "there is something wrong with my body" is a cognitive distortion that has been affirmed instead of Socratically questioned with CBT, and the iatrogenic harm can be extreme. If we say we care about trans kids, that must mean caring about them enough to hold their treatments to the same standard of evidence we use for everything else. No one thinks that the way we "care about Alzheimer's patients" is allowing Biogen to have free rein marketing Aduhelm. The entire edifice of modern medical science is premised on the idea that we cannot assume we are helping people merely because we have good intentions and a good theory. If researchers from Harvard and UCSF could follow over 300 affirmed trans teens for 2 years, measure them with dozens of scales, and publish what they did, then the notion that GAH is helpful should be considered dubious until proven otherwise. Proving a negative is always tricky, but if half a dozen elite researchers scour my house looking for a cat and can't find one, then it is reasonable to conclude no cat exists. And it may no longer reasonable to consider the medicalization of vulnerable teenagers due to a theory that this cat might exist despite our best efforts to find it. -An ABPN Board Certified Child and Adolescent Psychiatrist PS - To be clear, I support the civil rights of the trans community, even as I criticize their ideas. I see no more contradiction here than, for example, an atheist supporting religious freedom and being opposed to antisemitism. If an atheist can critique both the teachings and practices of hyper-Orthodox Hasidic Judaism, while being opposed to antisemitism at the same time, I believe that I can criticize the ideas of the trans community ("born in the wrong body") while still supporting their civil rights and opposing transphobia in all forms.
California Court rules against NPs suing to use the title "doctor" in clinical settings
California federal judge today ruled that DNPs in the State of California do not have the right to call themselves doctor in a clinical setting and affirmed California Section 2504 limiting the use of the term doctor in clinical settings. Link for review: https://pacificlegal.org/wp-content/uploads/2023/06/Palmer-v.-Bonta-Opinion-on-Motions-for-Summary-Judgement-9.19.25.pdf -The suit stemmed from a 2023 incident where one of the plaintiffs was finding excess of $20,000 for violating California's laws against misrepresentation with the title "doctor" on her website and social media. -All the plaintiffs noted in their depositions that they did not know what DNP and other such post-nominals until after they had entered the medical field, implying that patients also likely do not know what these terms mean. -The court stated that the use of the title doctor, even when followed by clarification such as "I'm a nurse practitioner" was "inherently misleading." -The court specifically notes that the use of doctor in this context represents more commercial speech, as in the point is to attract and retain patients, and several of the plaintiffs make note of their desire see "income that could have gone to physicians instead going to nurse practitioners." Another plantiff noted his desire to open a cosmetic practice and stated that using the title doctor would "have an impact on his ability to find and attract patients." So very clearly the court identified this there is an economic incentive for misrepresentation. -Case was dismissed in summary judgement with prejudice (meaning cannot be refiled in this court), basically a complete victory for the defendents. All in all a good day for truth and honesty in our field.
Are we tolerating the status quo too much? [Serious}
In today's medical culture, are we undervaluing physicians by tolerating the status quo? The status quo of rising medical school costs, poor mental health, mistreatment in residency, broken technologies, inflated administrative costs, etc?... We limit medical student postgraduate options to internship and residency, yet we graduate NPs and PAs to begin supervised practice with a starting average salary of $105,000.1,2 Meanwhile, medical students graduate unable to practice medicine without an internship (that pays an average starting salary of $56K.)3 I'm not arguing against physician extenders or residency. I'm arguing against the status quo in medicine. To be licensed as a physician in most states, you must complete a year-long internship.4 California is requiring multiple years of post-graduate training.5 Our status quo provides no in-between licensure options for medical students, while we are simultaneously graduating NPs and PAs into supervised practice. In 26 states, NPs can practice autonomously in their field immediately.6 Why are physicians that graduate from a US medical school and cannot match into a residency (for whatever reason) less able to practice medicine than NPs and PAs? Is it just the status quo? Right now, of the medical student graduates who do not go to residency, some become scribes, MAs, and consultants. 7 Very few find research jobs, and even fewer gain a temporary license that allows them to practice at the level of a mid-level under the supervision of a physician like you can in Missouri.8 So what are you, the physician, to do? The Flexner report of 1910 gave us the gold standard of medical training for the time,9 yet we act like no future improvements are needed today.10 If you're like me, you have some changes in mind. I can list several improvements I'd like to see. First, rising school costs are trapping students.11,12 Medical school graduates have, on average, $251,600 in debt these days.13 The debt doesn't disappear, either, for those who cannot match into a residency. Medical schools are increasing tuition annually and federal loans accrue interest from the beginning.14 Why do we allow interest to begin accruing so many years before employment is possible, and why do we pay so little? Medical schools should aim to produce autonomous physicians, but not every graduate can achieve an internship. What are they supposed to do? Physicians should create a "supervision-required" midlevel-style license for medical school graduates that haven't completed an intern year. Otherwise, less painful routes to the top of medicine will continue to gain steam. Administrators need to fill gaps in their hospital systems with providers from somewhere, after all. We have a physician shortage, despite an increasing number of medical schools and residencies.15-(16) In fact, the total number of residencies available has increased at the same rate as medical school enrollment.17 However, in 2019 there were still 44,603 students competing for 35,185 PGY-1 spots.18 You have a huge discrepancy between PCPs and subspecialists, so applicants are unevenly applying to the higher-paying fields. Also, IMGs are applying for US residency positions. Then there is the status quo of mental health crises among trainees and other physicians. Still, physicians and students commit a substantial number of suicides every year.19–23 That's not a fun fact. Perhaps you're like me and have known someone to take their own life. Medical training and practice are toxic because of the high stakes. There are board exams used as gatekeepers to certain competitive specialties. You are often sleep-deprived and stressed. Not to mention, if you are careless then someone dies (no pressure). Also, healthcare costs are skyrocketing due largely to administrative expansion.24 Overall, there are fewer and fewer resources for physicians to utilize.25 It's a tough environment right now. We have to buck the status quo. You can fix the illogical things we are doing in medicine, medical education, and healthcare policy without sacrificing quality. Where to start? Talk to each other. Share your goals, struggles, and challenges. Join together. Drop the poisonous attitudes, the fights, and the competition. Smell the roses. It just takes some common sense, optimism, and compromise. It takes all of us. Physicians need to get more active in politics. Policymakers aren't going to require changes without pressure from a coordinated movement by you, the physicians. For example, we have 1,100+ EHR vendors, in 2020, that cannot communicate data between each other. That is the status quo. However, if forced to do it, I argue EHRs could share data. How? If policymakers mandated some standard changes to the requirements for all EHRs. We would need to mandate the creation of a unique identifier that all healthcare providers use to find common patients, a mapping between coding languages, and a system to distribute stored data storage between systems.26–28 Today, I'm hoping to encourage all of you to remember your leadership roles in the hospital, the community, and beyond to seek progress. Physicians need to acknowledge this responsibility before things worsen. If we can do that, we don't have to worry about anything. The problem is, there are very few physicians with enough of a spine to stand up to the status quo. Perhaps you're discouraged, isolated, and overworked. You're not alone. We are waiting for others to fix medicine, but it's got to be us. It's got to be the physicians. The status quo has got to go. How will you stand up to it? References: Pa-C, S. P. Physician Assistant Salary Comparison Table | 2019 Pay by State | The Physician Assistant Life. The Physician Assistant Life https://www.thepalife.com/salary-2015/ (2019). Nurse Practitioner (NP) Salary Data | All Nursing Schools. All Nursing Schools https://www.allnursingschools.com/nurse-practitioner/salary/. Sign Up. Glassdoor https://www.glassdoor.com/Salaries/pgy1-resident-salary-SRCH_KO0,13.htm. Obtaining a medical license. American Medical Association https://www.ama-assn.org/residents-students/career-planning-resource/obtaining-medical-license. California Physician Professional Licensing Guide - Upwardly Global. Upwardly Global https://www.upwardlyglobal.org/get-hired/california-professional-licensing-guides/california-physician-professional-licensing-guide/. State Practice Environment. American Association of Nurse Practitioners https://www.aanp.org/advocacy/state/state-practice-environment. 10 Things To Do If You Did Not Match Into A Residency Position • Student Doctor Network. Student Doctor Network https://www.studentdoctor.net/2018/03/12/not-match-residency-position/ (2018). Assistant Physician Law. Missouri State Medical Association | Jefferson City, MO | https://www.msma.org/assistant-physician-law.html. Duffy, T. P. The Flexner Report--100 years later. Yale J. Biol. Med. 84, 269–276 (2011). Francis, C. K. Medical ethos and social responsibility in clinical medicine. J. Urban Health 78, 29–45 (2001). Kessler, S. Average Medical School Debt In 2017 - Student Debt Relief. Student Debt Relief | Student Loan Forgiveness https://www.studentdebtrelief.us/news/average-medical-school-debt/ (2018). Greysen, S. R., Chen, C. & Mullan, F. A history of medical student debt: observations and implications for the future of medical education. Acad. Med. 86, 840–845 (2011). Carter, M. Average Student Loan Debt for Medical School for 2020. Credible https://www.credible.com/blog/statistics/average-medical-school-debt/ (2019). Learn about interest and capitalization. Sallie Mae https://www.salliemae.com/student-loans/manage-your-private-student-loan/understand-student-loan-payments/learn-about-interest-and-capitalization/. New Findings Confirm Predictions on Physician Shortage | AAMC. AAMC https://www.aamc.org/news-insights/press-releases/new-findings-confirm-predictions-physician-shortage. U.S. medical school enrollment rises 30% | AAMC. AAMC https://www.aamc.org/news-insights/us-medical-school-enrollment-rises-30. Hayek, S. et al. Ten Year Projections for US Residency Positions: Will There be Enough Positions to Accommodate the Growing Number of U.S. Medical School Graduates? J. Surg. Educ. 75, 546–551 (2018). Main Residency Match Data and Reports - The Match, National Resident Matching Program. The Match, National Resident Matching Program http://www.nrmp.org/main-residency-match-data/. Physician Suicide: Overview, Depression in Physicians, Problems With Treating Physician Depression. https://emedicine.medscape.com/article/806779-overview (2019). 1103 doctor suicides & 13 reasons why | Pamela Wible MD. Pamela Wible MD https://www.idealmedicalcare.org/1103-doctor-suicides-13-reasons-why/ (2018). Farmer, B. When Doctors Struggle With Suicide, Their Profession Often Fails Them. NPR (2018). Kalmoe, M. C., Chapman, M. B., Gold, J. A. & Giedinghagen, A. M. Physician Suicide: A Call to Action. Mo. Med. 116, 211–216 (2019). Is your physician colleague at risk for suicide? Signs to look for. American Medical Association https://www.ama-assn.org/practice-management/physician-health/your-physician-colleague-risk-suicide-signs-look. Abrams, A. The U.S. Spends 2,500 Per Person on Health Care Administrative Costs. Canada Spends 550. Here’s Why. Time (2020). The shift to managing more patients with fewer resources. Healthcare IT News https://www.healthcareitnews.com/sponsored-content/shift-managing-more-patients-less-resources-0 (2016). Stephen H. Hanson, P.-C. EHRs Need to Talk to Each Other. (2016). Knowles, M. Patients likely to suffer when EHR systems can’t talk to each other, researcher says. https://www.beckershospitalreview.com/quality/patients-likely-to-suffer-when-ehr-systems-can-t-talk-to-each-other-researcher-says.html. Inability to share information across systems remains major EHR failure. (2017).
Goodbye
I remember taking handover from a colleague a few years ago as I was starting the night shift. The patient was an elderly man in one of our resuscitation rooms. He’d choked on a piece of bread while sat with his family for dinner, and had a hypoxic cardiac arrest following this. It took some time for paramedics to arrive and get ROSC, but he then had a number of further cardiac arrests en route to the emergency department, where he then had one more. He was maxed out on epinephrine and norepinephrine and still had a blood pressure of 50/20. GCS was a flat 3 on zero sedation, and his oxygenation was also terrible despite being intubated. He was accepted to geriatrics for palliation but ICU did not want to accept him as there was no expectation at all of a meaningful recovery and they wanted to save the bed for someone who'd benefit from the resources ICU provides. So this was the last patient in my handover and the first task of my night. This particular department is a tertiary center that receives trauma. With all of our resuscitation rooms full, we had nowhere to accept the next trauma patient to and nowhere to see the next septic patient to come through the doors. I spent the first few hours of my shift having multiple conversations with the family about their relative's clinical state and tried to explain that the blood pressure was being supported by medication but still too low to allow for adequate oxygenation, urine output, or any chance of neurological recovery. They were aware that our plan was to allow a natural death and that the ventilator and the vasopressors were only prolonging this, but they were desperate to keep everything going as it was for as long as possible. My goal was to try to get them to understand that supporting his physiology was futile and that allowing him to die would be more dignified. During one of these conversations away from the bedside, we were alerted to the fact that his end-tidal CO2 had dropped off. There was no respiratory effort and his blood pressure had become unrecordable. At this point, I said quite firmly that I was turning the ventilator off as it was no longer doing the job that we were using it for. Fast forward a few years. Three months ago, my mother suffered a sizeable stroke that was amenable to clot retrieval, but this was followed by a large subarachnoid hemorrhage and then another shower of clots. She was comatose for a few days and, when I arrived to her bedside (having to fly from the other side of the world, which in itself was a challenge) she was tolerating a nasopharyngeal airway and barely opening her eyes. She got better from this and over the next couple of weeks was breathing fine again. She was looking around, able to move her head and able to move her left upper limb around. She was reaching out for me and stroking my face. She was able to scratch her itches when she needed to and was playing around with the bedside phone. She held my hand when I sat with her. Now let's recap the last 30 years. My mother had many health issues over the course of her life, and had breast cancer shortly after I was born. She didn't deal well with being a single mother undergoing breast cancer treatment and so I spent a lot of time with my aunts. She didn't deal very well with being a single mother after her breast cancer treatment either, and the home situation was often very tense. We grew up dirt poor and on welfare. Social services ended up getting involved when I was 6 and I was on their child protection register. She said bad things to the family that alienated me, was often absent emotionally and sometimes physically, and eventually kicked me out when I turned 16, a few years after I stopped going to school. I haven't really talked to her properly over the second half of my life and haven't spoken to her at all in the last three, but I thought about her every day and always wished that things were better. Now back to present day. Despite reaching this level of consciousness, she is now bedbound and unable to communicate, and this is a woman who previously valued her independence so much that she didn't want to accept any help from her own son despite being burdened with a number of chronic illnesses that limited her mobility and caused her significant pain on a daily basis. Her house is a mess and I had made many offers to help her clean, de-clutter, buy new furniture and a fresh coat of paint. But she always said no, and being asked always angered her. Reading through her diaries, I can see now that she's been miserable for the longest time, even before I was born, feeling like a failure in life because she was so restricted by her health conditions. And yet, knowing this, I still wanted to do everything possible to keep her alive for as long as possible - even though I knew that this wasn't a life she would have ever wanted for herself. Her admission has been horrible, complicated by blood clots in the upper limbs that have caused ischemic changes of the hands and forearms. I've advocated on every occasion for antibiotics, anti-coagulation, consults with surgeons and interventional radiologists, and central venous access to allow these interventions to continue, and I have pushed to continue even when we thought she was close to certain death on fie or six occasions. There was never an expectation, particularly with the extent of brain injury, that she would have a life that was anything like the life she had before, but if she was in a care facility somewhere then I could visit every few months and she'd still be alive. That was enough for me - but not really fair for her. I received a call over the weekend saying that I needed to come in. She'd had multiple episodes of hematochezia which precludes the use of any further anti-coagulation, and a subsequent NSTEMI. Her renal function has suffered and I've not seen her move any of her limbs in the last week; she's probably had another stroke with the anemia. I've not left the ward since then. I've seen the progression from comatose to awake-ish and still tracking objects to crying in pain from the blistering on her hands (the first time I really felt she was back in the room - and the first time I was hopeful she might leave hospital) to now Cheyne-Stoke breathing over the last day and a half. I've cried on her arm so much over the last few days because I regret not having a better relationship with her and I wish so much that I'd given her an opportunity to get to know her son a bit better. On Saturday, I wanted her to receive a blood transfusion after her three episodes of hematochezia. On Sunday, I wanted her to have a second set of blood tests to see if she'd had a type 2 MI. On Monday, the team quite frankly said that the only option now was palliation. But she still had her eyes open and was still looking around, and it still felt wrong. They tried to have a conversation with me about the fact that her kidneys aren't being properly perfused and that she's not expected to make a meaningful neurological recovery, but I still wanted another set of blood tests. On Tuesday, I sat and talked. I told her about all the holidays I wanted to take her on, and that I wanted to fly her to Sydney to see where I've set up home. I told her about all the fridge magnets I'd bought for her on my travels, that I'd been saving up to bring home to her one day. I told her about all the birthday and Christmas presents I'd bought for her but never had an opportunity to give her. I told her that I love her and that I'm proud of her for powering on every single day of her life in spite of obvious pain and disability, and in spite of her less obvious internal struggles. On Wednesday, I finally allowed the first dose of morphine to be given. I was so scared to commit to it because that first dose means that we're committed to this. But the nasogastric feeds continue because I don't want her to become dehydrated, and she's still receiving some of her regular medications because I don't want her last few days to be worsened by a flare of her auto-immune conditions. I'm a doctor. I know better than anyone else in my family what her prognosis has been. I know that this isn't a quality of life that she would have wanted for herself and I've been secretly wishing for the last few months that something would take her away and that it would be swift - because then the decision is taken out of my hands and I don't have to be the one to start her on that final path. But every time she became febrile or tachycardic, I pushed for fluids and antibiotics because I wasn't ready to say goodbye. And I thought back to the family I'd had these same conversations with a few years ago while sat with my mother today. And it all suddenly made sense. His wife was a doctor but she wanted the ventilator, the pressors, the monitoring, the central line, and the ICU admission. She wasn't ready to say goodbye, even when faced with clear evidence that he was never coming back to her. No matter how logical it may seem to you as the healthcare provider and no matter how logical it may seem to me as the relative with a medical degree, saying goodbye is still painfully impossible to do. I've accepted now that she may die today or tomorrow, but I still haven't agreed to withdrawing all treatments because I can't. I wish I could tell that family that I get it now and apologise for only seeing their situation through the eyes of the clinician. Next time I have that conversation with someone, I'll be more patient. I'll be more understanding. I'll walk away if they say no and I'll let them have as much time as they need. I've always known how my mother will go but I've needed three months and it's taken significant complications, a lot of time, and hard evidence in the form of lab results to finally start being able to accept that I need to let her go. Be kind.
RFK Jr. removes all members of CDC panel advising U.S. on vaccines
https://www.cnbc.com/2025/06/09/rfk-jr-cdc-panel-vaccines.html?__source=iosappshare%7Ccom.google.chrome.ios.OpenExtension
Apparently the word “science” is virtue signaling. NYTimes publishes pro-Goop op ed
Who’s Afraid of Gwyneth Paltrow and Goop? In which Elisa Albert and Jennifer Block (a novelist and a woman who “ writes frequently about women’s health”) claim that the anti-Goop backlash is actually anti-woman, that while “cold therapy, energy healing, longevity diets, and therapeutic use of psychedelics . . . may sound esoteric to the uninitiated, . . . none of [them] actually lack sound evidence of benefit.” (Emphasis mine.) Also, “ The word “science” has morphed into a virtue signal.” So yes. The era of being so open minded our brains fall out is well upon us. And all of us otherwise liberal women who vocally educate against pseudoscience are actually unknowingly misogynists! Who knew?
Nursing, PT, PA will no longer be considered "professional" degrees
Article: https://www.newsweek.com/nursing-not-professional-degree-trump-admin-11079650 "The department determined that the following programs were professional: medicine, pharmacy, dentistry, optometry, law, veterinary medicine, osteopathic medicine, podiatry, chiropractic, theology and clinical psychology. This meant that physician assistants, nurse practitioners, physical therapists and audiologist were excluded from the list." Additional Article: https://www.nasfaa.org/news-item/37609/Neg_Reg_Continues_Discussion_of_Program_of_Study_Legacy_Provisions_and_New_Professional_Degree_Definition?utm_source=chatgpt.com Criteria for being considered professional: "1. A professional degree is a degree that: (i) Signifies both completion of the academic requirements for beginning practice in a given profession and a level of professional skill beyond that normally required for a bachelor's degree: (ii) Is generally at the doctoral level, and that requires at least six academic years of postsecondary education coursework for completion, including at least two years of post-baccalaureate level coursework: (iii) Generally requires professional licensure to begin practice; and (iv) Includes a four-digit program CIP code, as assigned by the institution or determined by the Secretary, in the same intermediate group as the fields listed in paragraph (2) (i) of this definition. 2. A professional degree may be awarded in the following fields: (i) Pharmacy (Pharm.D.), Dentistry (D.D.S. or D.M.D.), Veterinary Medicine (D.V.M.), Chiropractic (D.C. or D.C.M.), Law (L.L.B. or J.D.), Medicine (M.D.), Optometry (O.D.), Osteopathic Medicine (D.O.), Podiatry (D.P.M., D.P., or Pod.D.), Theology (M.Div., or M.H.L.), and Clinical Psychology (Psy.D.) (3) A professional student under this definition: (i) May not receive title IV aid as an undergraduate student for the same period of enrollment; and (ii) Must be enrolled in a program leading to a professional degree under paragraph (2) of this definition.” I have mixed feelings on this, because I have a great respect for each of these fields. I think each healthcare team member is vitally important (from the sanitation technician to the physician). My dad is a PT (DPT, OCS), and to think of him as not a professional, given his level of expertise, seems short-sighted. I also hate the idea of people not being able to afford to become a nurse, PA, PT, etc., because their loans are capped at a much lower tier, because they are not "professional" degrees. Overall, I am just not sure if this is a W or L. TL;DR Loans are going to be capped lower for non-"professional" degrees per a new definition created by the Dept of Ed; nursing, PT, PA, and others appear to not qualify as professional per new guidelines to be potentially implemented July 2026.
I am being replaced by an APC
I am a rural FM/OB in the midwest, and I have a group of pretty amazing FM doctors who cover our critical access hospital. We have a fairly busy census for a small town as we serve a large surrounding area. Typically we have 10-17 patients at any one time. We use drips not infrequently, bipap, etc, we have a surgeon all the time, and I think we do a really good job handling what we can and shipping what we can't. We are currently working a hospitalist model where one of is in the hospital each week. It used to be only 1 doctor, and ended up being 36 hour shifts which was exhausting. Then we went to a night float system so there is a day doc and a night doc, which is fabulous. We all really like this, for the most part. Unfortunately that means that 2 docs are out of the clinic in a given week. Our organization is not happy with that because $$$. Their solution? Forcing us to adopt a night time tele-medicine service run by midlevels. So not only will there be no MD/DO physically present on the floor to actually be at the bedside of crashing patients, or to admit patients, it will be an URBAN midlevel on an ipad who is doing our admits and deciding if these patients are appropriate for a RURAL hospital with no specialty backup. Then we will be left with the mess to clean up in the morning. Not to mention what our elderly, conservative patient population is going to think of tele-medicine to begin with. I am completely, 100% against this. So much so that I am questioning continuing to work in the hospital if this goes through. I don't want the liability. This is mostly a rant but if you have any advice...
Would killing a person in the Titanic submarine really help with oxygen supply?
Got into an argument with a fellow physician (full disclaimer, another psychiatrist) about whether it would help to kill another person to preserve more oxygen in the Titanic submarine. On the one hand, there is less respiration. On the other hand, it seems dead tissue would also take up oxygen / generate CO2. Edit: really the question is whether killing a person would improve the physical survivability of the other people. Edit 2: sounds like the consensus is that while respiration takes a lot more oxygen than decomposition, the smell / grossness will lead to a lot more physiological distress (not to mention the moral / psychological distress) for the survivors and would likely negate any oxygen savings from having one less person breathing. Seriously going into a sub sounds like a complete nightmare scenario. I would probably get in a sub like that vs doing residency again, but barely. Edit 3: it’s been brought up that temperatures may be low enough that decomposition / smell may be less of a factor. Others have brought up that physiological distress / panic in a closed oxygen system will likely not deplete oxygen in the same way that an open oxygen system (like ones used by scuba divers) would and this was overstated as a negative against killing someone for the oxygen benefit. However someone also pointed out that ultimately killing one person would only buy a little bit more time (hours) for others as the total amount of oxygen was already so low. You could increase this benefit by everyone else dying and leaving one survivor, though that person would be in a tiny submarine with 4 dead people that they embarked on a “fun” trip with only days ago which sounds like total psychological horror and I would 10/10 prefer death to experiencing that.
What I Think About When I Think About Skin.
He waves at me in a demure way as he directs customers from the common line towards the cashiers. We exchange a glance as I go to pay for my Caesar salad. My office is a few blocks from the grocery store where he is general manager. He is HIV+ and has biologic recalcitrant psoriasis. I started him on light therapy last week and am transitioning him from a TNF inhibitor to an IL-23p inhibitor. His fashionable, hipster clothing belie the 70% body surface area involvement at last visit. I watch him discreetly scratch his back as I walk out into a beautiful fall afternoon. Her thigh is covered in tattoos of skeletal structures of organic chemistry molecules. As I excise the pyogenic granuloma that has been repeatedly bleeding with minor trauma over the past month, I ask her what they are. She tells me they are her favorite drugs: psilocybin, DMT, THC, LSD. She has a spacy, dreamy affect. She asks to see the surgical defect before I close up. I oblige. She contemplates the 8 mm hole in her skin curiously, no hint of revulsion. Satisfied, I suture it closed. We chat about how weed is too strong these days. "Bring back mids!" He is making a scene at the front desk. He insists in heavily accented English on seeing the doctor. My medical assistant pulls me aside and asks me if he can be added on. I look at my 38 patient list, sigh, and tell her sure. He has seen two physicians assistants at different practices for his left thumb nail, which has been come increasingly distorted over the past year. The last one told him he may have cancer; has been struggling to fall asleep ever since. "Very bad thoughts, doctor". I examine the nail and the diagnosis is immediately clear: a digital myxoid cyst. It is quite large, but completely benign. Relief visibly washes over him as I explain the diagnosis. "Mashallah, doctor. May God bless you." We plan for him to see the hand surgeon after he returns from an upcoming trip to Lebanon. I invite him to sit down but he says he'd prefer to stand. He declines a gown. He asks if the female medical assistant can leave the room. She does. His body language is hyper-masculine and vaguely hostile. He explains that his "asshole has been hurting the past few days, probably from wiping too hard". He was in Vegas with the boys a few weeks prior but otherwise nothing out of the ordinary. I ask to examine the area and he reluctantly complies, dropping his gym shorts and boxers while still standing. Shallow perianal erosions. A few intact vesicles: "dewdrops on a rose petal". Genital herpes. I ask if he's had receptive anal intercourse recently and he snaps back, "I ain't no f**got". I do a PCR swab of one of the erosions and send the script for Valacyclovir. I tell him he should inform any sexual partners. His body language softens slightly. "Doc, my wife is pregnant, what do I tell her?" I explain that it poses great risk to his unborn baby and he needs to tell her immediately so she can follow up with her OB about next steps. "Fuck me" he sighs. "I don't envy you, my man. " It is an extraordinarily beautiful early evening in NYC. That brief, sublime moment between stiflingly humid summer and bone chilling winter. The leaves are starting to turn. It's crisp but not cold. Perfectly sunny. I walk past the young families, the hipsters, older, orthodox Jews shuffling towards synagogue. I think back momentarily to the organic chemistry exams, mind-melting 24 hour calls, pointless 2 AM consults: all those little obstacles and challenges that brought me here. Totally worth it.
Follow up on the study showing discrepancies in outcomes for black babies cared for by white and black doctors
Some new reporting came out yesterday regarding a previously widely publicized study that purported lower mortality rates in black babies cared for by black rather than white physicians. Here is the initial reddit post when the study was published: https://www.reddit.com/r/medicine/s/HMNte8DCTy And here is the discussion of a review of the study performed in PNAS: https://www.reddit.com/r/medicine/s/7Wo8Qr6zPf The short summary is that the review showed that the initial statistical analysis failed to control for birth weight of the infants, one of the strongest predictors of infant mortality. White doctors were much more likely to care for low or very low birth weight infants, leading to their higher overall mortality rates. When controlling for this variable the survival rates were not significantly different. Now there's this. A reporter filed a FOIA request for correspondence between authors and reviewers of the article and found that the study did see a survival benefit with racial concordance between physician and patient, however it was only with white infants and physicians. They removed lines in the paper stating that it does not fit the narrative that they sought to publish with the study. https://dailycaller.com/2025/03/31/exclusive-researchers-axed-data-point-undermining-narrative-that-white-doctors-are-biased-against-black-babies/ Pretty wild that they were so open about that in official correspondence. I sincerely hope that they face some sort of institutional consequences for such blatant academic dishonesty.
A $20 over-the-counter drug in Europe requires a prescription and $800 in the U.S.
Original article: A $20 over-the-counter drug in Europe requires a prescription and $800 in the U.S. I never get tired -- or fail to get upset -- about how we in the US are overpaying for everything in healthcare. This is merely just an example of where Pharma really looks for innovation ... not from scientists, but from the C-suite shenanigans. Opening paragraph: A month’s supply of Miebo, Bausch & Lomb’s prescription dry eye drug, costs $800 or more in the U.S. before insurance. But the same drug — sold as EvoTears — has been available over-the-counter (OTC) in Europe since 2015 for about $20. I ordered it online from an overseas pharmacy for $32 including shipping, and it was delivered in a week.
US healthcare costs are beyond comprehension. My eyes are open.
I’m a PA in an orthopedic practice, so obviously there are a lot of x-rays that get ordered by me in the course of a given week. Honestly way more than I feel is necessary/warranted but given medicolegal risks, my attending’s preference, patients demanding, insurance requiring before approving MRI/CTs, need to monitor fx/fusions, etc here we are. I mean I do my very best to be a good steward of medical resources & try to avoid ordering useless tests when able. I didn’t always like it but I’d tell myself “it’s okay not like the patient’s getting billed $100s for it.” Well now my eyes are open. My son needed his adenoids/tonsils out but the ENT wanted a soft tissue neck x-ray prior and then we’d follow-up to talk surgery. We went to an imaging center owned by a local hospital group that many of my patients use for their MRIs. They could see us same day and were in-network. Bang/boom 2 pictures and out in 15mins. Then I got the bill. CPT code 70360 (x-ray soft tissue neck 2 views)…charge $800…insurance adjustment minus $200…patient amount owed $500!!! I’m floored and say there must be a mistake. Call imaging center and verify info/CPT code/insurance plan. They say nope that’s it and submitted correctly. Look up CMS PFS reimbursement for the CPT code…avg $8-40. So I say ok insurance must have coded it wrong or something. There’s no way they’d agree to let them charge me $500. Call insurance company and they say yup all correct on our end “that’s what you owe.” I feel so…idk…disgusted in our system…distraught that I play a role in it…hopeless regarding the future of our healthcare system. Additionally, I’d love to hear from anyone who could help explain these costs. Edit: Just to clarify I’m not necessarily shocked by the $800 billed amount (I mean I am but we know those are hilariously exaggerated numbers that are made up). I’m shocked by the fact I actually have to pay $500 after my insurance’s “negotiated adjustments”. It seems wildly inappropriate. For instance my kid once was in the NICU x4 days and hospital in total x6…billed amount was like $200,000 but I owed $1500 (totally reasonable given the collective Stockholm syndrome we have in the US). My wife’s ED visit + med/surg night x1 + appendectomy…billed amount like $190,000…adjusted amount we owed $2200 (including anesthesia). But a simple outpatient X-ray being $500 after adjustment…
On June 12th, meddit will be going private for 48 hours to protest the Reddit API changes that will effectively kill third party apps.
We did it, reddit! Meddit will be joining the 48 hour blackout being organised in protest of Reddit's API changes and the general contemptuous attitude that the site's administrators have displayed towards their content generators and moderators. Thank you all for your input in the poll and via modmail over the last few days - with particular thanks to those who took the predictably unpopular but sincerely held position to keep the subreddit open. There was a clear preference in votes, comments from established users, and modmails received in favour of joining the blackout, and so we will. You can check out r/ModCoord for the latest updates. This blackout will be from 0400 UTC June 12th until 0400 UTC June 14th, aka from midnight Eastern Standard Time on both days. o7
Finally able to speak to spokesman from UAPD (Physician's Union), here's what I found out
Long post, so buckle up. I posted awhile back about making some surveys so doctors can anonymously voice support for prospective unions at their hospitals. Before I did that, I wanted to speak to the UAPD spokesman myself, so that I can help walk any interested physicians through the process without having to reach out to the UAPD directly until they have something a bit more solid to show for. We talked for quite awhile and he walked me through the process, complications, and what kind of "extracurricular" work would be required to form one (spoiler: not a whole lot on an individual level). It's against sub rules to post surveys here, so I will post those only in other medical subs. Physician's that contacted me & UAPD earlier will be contacted directly by me, and once again to them especially, thanks for taking direct action to end the trend of us getting stepped on. I will list the key findings that I think will be high-yield to actual physicians, who can form actual unions. Ask away with any questions, I'll answer as best I can. And please, do yourself and your profession a favor and have these conversations with colleagues you trust as the Corona mess winds down a bit near you, and then take steps to formally unionize. That's the only way things get better. Do not act on hospital administrators' behalf by refusing to act on your own behalf. Note: I am a dumbass med student, not a lawyer, not a union spokesperson, or anything else like it. I have also paraphrased in some places because the legal stuff is a rabbit hole and a half, though I will clear up nuances in the comments as necessary. Which physicians can unionize? Private practice - cannot unionize; doing so would be racketeering Public employee physicians (e.g. work for university hospital) - generally can, with varying restrictions on details by state law Private hospital employee physicians - essentially always can Laws governing unions are mainly provided by the National Labor Relations Act (NLRA), and various similar state laws. The group of people that are eligible to unionize together form an Appropriate Bargaining Unit (ABU). Very important: to enjoy NLRA protections, you must be a union member. You cannot just hold an impromptu walkout. This is a crime, or at least grounds for board sanctions, since you will have abandoned patients. Unions strike, individual just up and walk out. Who makes makes up an ABU (i.e. who is eligible to join)? Per NLRA, employees that form functionally the same role for the same employer make up the ABU. Keep in mind through-out that these laws were written for factory workers, not doctors, so view all of this through the lens that those same laws will be applied to us. hospital MD/DOs - obviously they're in the doctor's union doctors in the same city, different employer - need a separate union doctors at different hospitals, same employer - could go either way legally, there are factory examples of both; ask yourself if it makes sense for the negotiations to apply to both hospitals' doctors doctors with same employer, different city - likely need separate unions; e.g. cost of living likely differs NP/PAs at same hospital - likely to be eligible RNs, CNAs, PharmDs - likely need a separate union part-time doctors - likely eligible locums doctors - likely eligible MD/DOs in clerical or management roles - uneligible if they're more administrative than clinical those damn neurosurgeons I hate consulting - definitely eligible, suck it up There are laws that allow multi-departmental (e.g. MD/DO + RN) or multi-employer unions, but this more complicated, and often involves mergers of existing separate unions. Why eligibility matters 30% of the labor force (ABU) must sign an "authorization card" to allow the union-to-be to take action to legally force the employer to recognize it. The % of the ABU that has signed auth cards directly determines the strength of union, and how likely UAPD is to prioritize forming your union (note: you do not need 30% before contacting them, see below). If you assume the size of your ABU and the National Labor Relations Board (NLRB) disagrees, that could put you below 30% What UAPD wants ~10 interested doctors that are on-board to contact UAPD, and to discreetly talk to more MD/DO/PA/NPs to get them on-board (that is essentially your biggest time committment) Any information you can glean about the size of your physician/midlevel workforce info about full-time vs. part-time vs. locums is helpful this is why I'm trying to make surveys an "organizational flowchart" outlining management structure from floor managers to CEO; they recommended asking a manager about this one (this is what MBAs get off on doing, so it likely exists) Ain't no NP/PA joining my union In short, too damn bad. Swallow our pride for our own good. Legally speaking, they perform the same role as physicians. You could not convince the NLRB that employed welder's apprentices are not production workers just because they require oversight, so you likely can't convince them that NP/PAs aren't allowed in the club either If you were to choose to not let them in, they would still be in the denominator of the 30% you need (i.e. you're less likely to get enough to unionize) more people = more power. If you refuse to let them in, you're shooting your long-term prospects in the foot for short-term smug satisfaction When you try to legally declare the union, or later on to strike, the hospital will just hire/give raises to the NP/PAs that you kept out of the club. There is nothing saying that their equal vote guarantees equal status/pay. When the union negotiates, the welding apprentices don't get paid like welders. Hierarchies can be worked out in union negotiations once the union exists. Legal Steps to Declare a Union Items in italics are legal requirements, everything else is how UAPD runs things. imagine an estimated 1000-person workforce (scale for your hospital) The 10 interested doctors contact UAPD, hopefully with the materials discussed earlier (if you can get them) They tell each to doctor discreetly recruit 4-5 eligible members. Report back when you have 50. This process repeats, until you have 550 members (55% of ABU- they do this to ensure 30%). UAPD is contact to help manage issues the whole time They set up offices near you and draft legal documents preparing to declare the union Ideally during this time, you've all managed to get 650-700 people (no less than 550) willing to sign authorization cards. Then you do so. UAPD contacts NLRB, at this time the hospital will likely become aware of prospective union, and panic The employer will do anything to invalidate the 30% before the vote. Hire lawyers, run smear campaigns, offer to make concessions if physician's tear up their cards or vote no. They often attempt illegal acts, too: bribery, threats, you name it. Do not back down, do not concede. As a rule, if admin is scared, it's because you're winning. Record (check state laws) all conversation or get it in writing. Threats/bribes should be reported, and are grounds for suits. NLRB orders a vote If 50%+1 of voters are in favor, the union is legally in force. The NLRA now dictates what admins can (not) do. Negotiations begin. Oh God don't stop, I'm almost there It gets better, big boy. They can no longer fire you. They can't change anything up for negotiation that was previously in force: your pay, your hours, your super secret physician's lounge amenities (stripper pole, or so I'm told) They are forced by law to negotiate with you, they can't go elsewhere to hire They can't refuse to negotiate - no "take it or leave it tactics" by law everything is up for negotiation, even the type of soap in the bathrooms What about what we want? Once agreements are made with admin, it must past a 50%+1 union vote to become effective (salaries, hours, patient loads) This means not everything may fit you 100%, but IMO this beats negotiating for yourself, at an informational and tactical disadvantage On the flip side, that means that if UAPD reps are convinced you're getting a good deal but you don't buy it, nothing can be shoved down your throat without passing a vote You cannot be forced to sign a union auth card, nor be forced to join even if it passes vote Dues UAPD is 501(c)3, so they subsist off of dues In right to work states, union members cannot forced to pay dues unless a Collective Bargaining Agreement is voted into effect They are legally required to provide members with documentation of how dues are spent Dues = 0.9% of gross monthly salary ($75/mo ($900/yr) for every $100K of yearly gross salary) This is low, so I'm told, since doctors make more (and thus pay more) vs. other industries. I checked this myself. In other industries, it seems like common dues are 1.2-2.5% Nat'l Nurses United/California Nurses Association requires the equivalent of 2.2 hours of pay per month Take your yearly pay in thousands, and divide it in half. This is your equivalent hourly rate working 40 hr/wk, 50 wk/yr (e.g. $100K/yr = $50/hr) In the RN union case, they ask for 2.2 hrs of pay per month, or 26.4 hrs/yr. Since that standard work year is 2000 hours, that means the nurses union requires 26.4/2000 = 1.32% of gross salary, paid on a monthly basis That's all I have to start. Please lob questions ad lib, there's a lot I didn't cover, and I'll answer whatever I'm capable of. Please have these conversations with colleagues. All of our talk here only matters when we act on it. If anyone is interested and wants more info, or gets some people together and wants a bit of guidance as you prepare to reach out to UAPD, PM me and we can talk privately. UAPD wants to see 10 interested people. If you can manage that, they'll shoulder much of the burden from there. That's all it takes to make it to start to make it real at your hospital. Remember: this may be the one time in our lives/careers and where we have public sympathy, open evidence of administrative overreach and mismanagement, and broad physician consensus that the status quo must change. Do not let it pass quietly by. If you try, and it goes nowhere, you've wasted several hours. If you don't try, and the moment passes, you have the rest of your career to wonder what might have been.
Am I being selfish?
Created a throw away account for this one. I'm a family physician in a large US city where I am one of just two physicians who speak an uncommon African language. As a result, 99% of my patients speak this language and about half are refugees. Both me and the other guy are no longer accepting new patients. I am really grateful that my services are needed, my patients are grateful that they can express themselves to me in their native language, but I'm burnt out by the fee for service model. I have adjusted my practice to fit this model, but I feel like 75% of my brain during the visit is trying to conclude the visit, bill for it, and move on to the next patient before I'm late. When I'm addressing a patient's problems, I feel a mix of reward because I am solving their problem, satisfaction because know nobody else could be giving this level of care, gratitude for their trusting me to address their problem, but there are also threads of frustration and resentment that the visit is dragging on. I feel like the system is built to force me to water down the care just enough to complete the tasks and then get the patient out of there. And this is obviously negatively impacting the visit for me and the patient. No complaints from patients so far, but it sucks to feel that I'm hurrying them out the door. I can't lower the ammount of patients I'm seeing for financial reasons - I earn as much as my peers, but I'm seeing more patients to get there. I live in a modest house, drive a 10 year old car, but have medical school debt. I dream of doing a DPC model or concierge care where I'd have more time, like 30-60 minute visits. But no matter how cheap I make it, it's still more than free for my refugee patients. And I think my feeling is that medical care shouldn't be this thing that is made to be as cheap as possible. We deserve care that is not hurried.... I could easily convert to a DPC practice, I've worked out the mechanics of it, etc, but I can't ignore the fact that it would leave all these patients to be forced to do visits with interpreters (lets face it, it sucks for both physician and patient). Essentially by definition, I'd be excluding patients who need my care the most. And if I do a hybrid model, there is still a big chunk that will be pushed out and I don't even know how I'd make the decision to see one person or the other. Having my fee for service patients leave by attrition is also a bad way to do it in my oppinion. In summary, I feel like I'm being forced to choose between delivering hurried care at an exhausting pace or kicking patients out of my practice who won't be able to get similar care. I'm sure many of you have been in a similar situation and I'd appreciate your thoughts.
Poll: should /r/medicine go dark for 48 hours?
As requested, time for some community input into whether meddit goes dark in response to the upcoming API changes. See https://www.reddit.com/r/ModCoord/comments/1401qw5/incomplete_and_growing_list_of_participating/ for context. Upvote the parent comment below for Yes (sub goes private aka blackout) or No (sub stays open), and reply with a comment explaining your position (to prevent brigading). Yes, I'm blatantly karma farming too. The option with the most unique replies/upvotes will carry. At this time we're not considering anything like an indefinite blackout but feel free to advocate for one if you feel strongly. Edit thanks to u/nomoneysadlife Click here for Yes Click here for No
Hawaii’s largest hospital alerts staff after imaging backlog reaches 8,000 exams
Link. Hawaii’s largest hospital recently alerted staff after its backlog of unread medical images reached 8,000, according to a report published Thursday. Queen’s Medical Center in Honolulu—and others in the Aloha State—are grappling with significant shortages of both radiologists and technologists. The state needed at least 10 more rads as of last year, a number that has likely worsened in 2025, the University of Hawaii’s John A. Burns School of Medicine estimates. Amid these shortages, Queen’s Medical Center radiologists are prioritizing exams for emergency patients and individuals with upcoming appointments or procedures, Hawaii News Now reported April 17. “Like other healthcare organizations in Hawaii and across the United States, we are facing a shortage of radiologists,” Darlena Chadwick, Queen’s Health Systems chief operating officer, told the TV station. “We are seeing high volumes of diagnostic imaging requests, which [tend] to be some of the sickest patients in our community. The care of our patients is our highest priority, and we are working diligently every day to address any delays.” Chadwick said this includes active efforts to recruit additional full-time radiologists, along with bringing aboard telerad temps to work through the queue. Meanwhile on the technologist front, the Healthcare Association of Hawaii estimated in January that there are about 160 open positions. This represents a 39% increase since 2022 and includes 49 ultrasound technologist job openings, a 24% vacancy rate. “Healthcare leaders are increasingly concerned about filling radiologic technologist and ultrasound technologist roles,” the association, which represents over 170 healthcare organizations in Hawaii, said earlier this year. “The demand for these professionals is growing, but because these roles require specialized education, employers struggle to find qualified candidates,” the HAH added, noting there was no sonographer training program in Hawaii at the time of the report. Indeed.com currently lists over 50 open radiology-related jobs in Hawaii including radiologist, tech, PACS administrator and nurse. Queen’s Health System is advertising a salary of $840,000 for a general radiologist who’d work at its North Hawaii Community Hospital in Waimea. (That’s compared to a national average of $520,000, Medscape estimated last week.) The four-hospital system has 11 CT scanners and 7 MRI machines, according to the job listing. Queens wants a rad who’d work a 40-hour week on a hybrid basis with shifts ending at 3:30 p.m. at its 35-bed rural acute care facility. It’s also offering a $20,000 signing bonus, $25,000 for relocation and $4,000 annually toward CME. While providers nationwide are grappling with staffing challenges, Hawaii’s struggles may be more pronounced due to its isolation and high cost of living. As of January, the state had about 4,700 open healthcare positions, the Healthcare Association of Hawaii estimated. When adjusting for various factors, the tally was about 3,835 (or 14% unfilled), down from 3,873 (or 17% unfilled) in 2022.
[Politico] Trump expected to select Robert F. Kennedy Jr. to lead HHS
President-elect Donald Trump is expected to nominate former presidential candidate and anti-vaccine activist Robert F. Kennedy Jr. to lead the Department of Health and Human Services, according to a person with direct knowledge of the selection. The expected pick, which will roil many public health experts, comes after Trump promised to let Kennedy “go wild” with health and food policy in his administration after Kennedy dropped his own presidential bid to endorse the now-president-elect. It’s also a sign of the opening Trump sees after he scored a decisive electoral victory and Republicans won a comfortable majority in the Senate. Trump could still select someone else for the post. The Trump transition couldn’t immediately be reached for comment. “He’s going to help make America healthy again. … He wants to do some things, and we’re going to let him get to it,” Trump said in his victory speech. “Go have a good time, Bobby.” Kennedy, 70, may still face a steep slope to confirmation after his years of touting debunked claims that vaccines cause autism, written a book accusing former National Institutes of Health official Anthony Fauci of conspiring with tech mogul Bill Gates and drugmakers to sell Covid-19 vaccines and said regulatory officials are industry puppets who should be removed. In recent weeks, Kennedy has hit the media circuit to say he isn’t taking vaccines away from anyone. “I’m going to make sure scientific safety studies and efficacy are out there, and people can make individual assessments about whether that product is going to be good for them,” he told MSNBC the day after Trump’s win. He also claimed the Trump administration would recommend against fluoride in drinking water, which is added to prevent cavities. Kennedy has said it’s “almost certainly” causing a loss of IQ in children, as some studies have found. Link