Just to echo what Milan said — everyone be on your best behavior and try to achieve maximum calm and respectfulness in your choices of language and manner of addressing others.
Just dropping in early to remind everyone to play nice in the comments. I know this is a contentious issue but I would like to avoid a repeat of the Florida LGBTQ article’s comments.
I would argue something similar is happening with the DEI industry. The University of Michigan has 163 diversity officials. Now repeat this (though at a lower rate) at every University, every Government office, every major company. Their career incentives ensure they will always find some terrible injustice, some structural edifice that needs to be fixed, some new form of discrimination to fight.
I'm convinced the attention and prevalence of the Transgender issue is driven by a general reduction in overt racism and the acceptance of equal rights for Gay & Lesbians. The activists and DEI careerists will always find a new reason to exist.
It was an interesting approach to frame this within the overall practice of American medicine. It is basically the inverse of how people usually frame it within the overall framework of identity.
Thank you Matt, for clearly laying out what has been bothering me about the whole transition debate. I had a career in international development and then went to medical school in 2001, right in the middle of the Vioxx/EPO/oxy pushes. I was fascinated by the obvious existence of a political economy of medical knowledge that was completely ignored in medical education at the time. I’ve been working in Comparative Effectiveness Research ever since. I believe everyone should be allowed to decide who they are without harassment, but there was something about the aggressive push for early surgery and powerful drug that bothered me. Now I realize I reminds me of the lecturers telling us we would be bad doctors if we didn’t use EPO to push our patients HB up to 15 or hesitates to increase the dose of Oxy at a patient request. Any intervention powerful enough to help has power to harm. Haven’t we learned by now!
Interesting angle and I largely agree with the sentiment that it might be a good thing if US gender-affirming care guidelines were a bit more cautious until more data comes out. However, I'm not sure that the higher "entrepreneurial spirit" of American physicians applies in this case for a pretty simple reason. The majority of teen/young-adult clinics providing gender affirming care are run out academic pediatric institutions (i.e., clinicians within adolescent medicine divisions within Pediatric Departments existing within university medical schools). And while it would be an exaggeration to say that there is no pressure to meet certain billing thresholds, the financial incentives for pediatricians practicing in these contexts are MUCH lower than physicians practicing in private practice (or even surgeons/interventionalists practicing within academic institutions). I'll use myself as an example. I am a pediatrician and clinical researcher at one of the largest children's hospital in the US (albeit in a completely separate field from adolescent medicine). I am paid a salary (side gripe, which is about half of my internist colleagues). I DO have minimum RVU targets that I'm expected to meet each year, which is fairly easy based on normal patient volume. Theoretically, there are potential RVU targets which if I hit, I would receive a relatively modest bonus. HOwever, in our current fee-for-service nightmare, those targets are so high that a pediatrician providing routine "medical" (counseling, med management...meaning nothing procedural) care has little chance of meeting them. This dynamic applies to the vast majority of adolescent physicians providing gender-affirming care . Furthermore, in academic contexts, these physicians receive no payments, additional RVUs, and/or kickbacks for trans youth undergoing reassignment surgeries (the surgeons and anesthesiologists do) - which are the procedures that would generate larger fees.
So what is the main driver in my opinion? Culture and ideology. I worry that many adolescent clinicians and pediatric endocrinologists are now so worried about being labelled as anti-trans (which would be career ending within those specialties) that raising any critiques/concerns of practice habits and trans-related research is not worth the risk. As a result, the clinicians, researchers, and policy advocates at the forefront of this field are operating within a "feedback-free" environment rife with confirmation bias.
Primary care doctor here. Great article. Agree with most of it. Some thoughts:
1) Supplements are a huge problem and one not primarily driven by the general medical community (at least not in my experience). A lot of these are "prescribed" by naturopaths or when people decide to do their own research on-line. Why do people trust facebook for their medical advice? I tell people that just b/c something is "natural" doesn't make it harmless.
2) Agree that the market-driven side of medical practice in the US is a problem causing over-treatment. My husband works at Kaiser where docs are paid a salary. There's no incentive to over-do procedures other than fear of lawsuits and patients' demands (which I do think are true motivators.) It would be interesting if someone did a study looking at rates of cardiac caths, c-sections, elective procedures at Kaiser vs in private practice to see the difference.
3) I think the medical community in the US is doing a of damage with the rapid green-lighting of trans treatment/meds/surgeries for adolescents and children. Good luck with this article -- you're gonna get a lot of hate for it.
Most of my fellow Democratic committee people talk on issues like this of "being on the right side of history." I always thought, "How can you be so sure?"
I think they have a simplistic model of tying everything together (i.e. abolition of slavery, women's right to vote, and Civil Rights) with "gender affirming care" for youth.
This "positive" attitude has led to disasterous results over the last two years with Defund the Police, embracing DEI industrial complex hucksters, and now this.
Time to get out of the "right side of history" and look at issues on merits.
"she saw C-section rates go dramatically up at 4 and 5 p.m. — around the time when doctors tend to want to go home."
This is a little misleading. The doctors go home and are replaced by new doctors coming on shift. It's not that they *need* to wrap things up to leave, it's that they don't want to hand off a patient to someone else if they can finish the work themselves because every hand off leads to worse care. My own daughter was born by C-section at the end of a shift. It was clear she was going to need a C-section to get out because she wasn't moving and was having mild distress. Probably they could have waited another hour or so if the shift change wasn't a factor. Indeed, during the middle of a shift they make non-urgent surgeries wait while urgent surgeries take place. The end of the shift is a time to wrap up the non-urgent surgeries that are still outstanding while the new crew picks up the other work.
Excellent post! I did not see that twist coming, I admit, though in truth it’s not a twist at all. This is the best kind of piece: not merely sharp opinion or suggestions on policy but one which provides a real kind of clarity helping us better understand contemporary phenomena, and -potentially- cool some heads, but perhaps I’m too optimistic…
As a breast cancer survivor who hangs out on Breast Cancer.org's (BCO) message board, I'd say that doctors are often just responding to pushy American consumers who think that they ought to get the best treatment or else they'll switch doctors. The BCO board has American, Canadian, Australian, and British members, and the Americans are the most demanding. They push for second, third, fourth opinions and wonder why they aren't getting the hot, new (and often expensive) treatment. An example: Perjeta, a targeted therapy. Perjeta was approved for early stage HER2+ cancer about eight years ago. Many American patients could get it, but Canadian patients could not. The Canadian patients were resigned to their situation, but the Americans would push their doctors to get it, even when their lumps were smaller than the recommended size (2 cm.)
I'd say the same thing probably happens with the parents of trans kids. They know that gender affirming care is out there, and they think that their kids should have access to the latest and the greatest. If one doctor tries to slow things down and encourages their child to take their time, their parents could always switch providers to the one who will give them what they want. So, doctors give their patients what they -- and their parents -- think they want.
I'm surprised it's apparently not controversial that ADHD medications are overprescribed! I think Americans actually consume drastically *less* health care than we should. There are people in my social circles who avoid seeking out clearly-needed healthcare for financial reasons or individual neuroses. There's stuff we don't have good treatments for, but I suspect there are millions of Americans going through untreated chronic pain. My experience – as a high-SES, college-educated, insured, US citizen, native-English-speaker white gender-conforming cis dude! – is that you have to all but beg doctors to take your pain seriously, and absolutely no one is going to track you down to make sure you get healthcare. If you move to another city and decide it's easier to live with the pain than deal with the healthcare system to start seeing a new doctor, no one will come find you. It's very rare to have anyone in the healthcare system help you work through whatever anxieties you have about medical treatment either.
So it's not obvious to me that "health care is not actually the primary factor in population-level health" – making health care a commodity you consume changes *everything* about how people relate to it. It means refusing to see a doctor becomes, on some level, thrift. It reduces trust in doctors, raises the stakes of every appointment, creates tiered classes of patients. I understand intellectually overtreatment is happening somewhere, but I suspect it's mostly in the last six months of people's lives. It has not been my experience or that of people I know at all. I think undertreatment is part of the same problem as overtreatment – doctors have no incentive to try harder to fix difficult problems, and no incentive to try to relate to the patient, and overtreatment *later* can be caused by undertreatment in the near term – but no one should come away from this article thinking "everyone needs fewer medical tests".
Just to echo what Milan said — everyone be on your best behavior and try to achieve maximum calm and respectfulness in your choices of language and manner of addressing others.
Bravo on including an honest-to-god end of second act twist in an opinion column
Just dropping in early to remind everyone to play nice in the comments. I know this is a contentious issue but I would like to avoid a repeat of the Florida LGBTQ article’s comments.
I would argue something similar is happening with the DEI industry. The University of Michigan has 163 diversity officials. Now repeat this (though at a lower rate) at every University, every Government office, every major company. Their career incentives ensure they will always find some terrible injustice, some structural edifice that needs to be fixed, some new form of discrimination to fight.
I'm convinced the attention and prevalence of the Transgender issue is driven by a general reduction in overt racism and the acceptance of equal rights for Gay & Lesbians. The activists and DEI careerists will always find a new reason to exist.
It was an interesting approach to frame this within the overall practice of American medicine. It is basically the inverse of how people usually frame it within the overall framework of identity.
Good read.
Thank you Matt, for clearly laying out what has been bothering me about the whole transition debate. I had a career in international development and then went to medical school in 2001, right in the middle of the Vioxx/EPO/oxy pushes. I was fascinated by the obvious existence of a political economy of medical knowledge that was completely ignored in medical education at the time. I’ve been working in Comparative Effectiveness Research ever since. I believe everyone should be allowed to decide who they are without harassment, but there was something about the aggressive push for early surgery and powerful drug that bothered me. Now I realize I reminds me of the lecturers telling us we would be bad doctors if we didn’t use EPO to push our patients HB up to 15 or hesitates to increase the dose of Oxy at a patient request. Any intervention powerful enough to help has power to harm. Haven’t we learned by now!
Interesting angle and I largely agree with the sentiment that it might be a good thing if US gender-affirming care guidelines were a bit more cautious until more data comes out. However, I'm not sure that the higher "entrepreneurial spirit" of American physicians applies in this case for a pretty simple reason. The majority of teen/young-adult clinics providing gender affirming care are run out academic pediatric institutions (i.e., clinicians within adolescent medicine divisions within Pediatric Departments existing within university medical schools). And while it would be an exaggeration to say that there is no pressure to meet certain billing thresholds, the financial incentives for pediatricians practicing in these contexts are MUCH lower than physicians practicing in private practice (or even surgeons/interventionalists practicing within academic institutions). I'll use myself as an example. I am a pediatrician and clinical researcher at one of the largest children's hospital in the US (albeit in a completely separate field from adolescent medicine). I am paid a salary (side gripe, which is about half of my internist colleagues). I DO have minimum RVU targets that I'm expected to meet each year, which is fairly easy based on normal patient volume. Theoretically, there are potential RVU targets which if I hit, I would receive a relatively modest bonus. HOwever, in our current fee-for-service nightmare, those targets are so high that a pediatrician providing routine "medical" (counseling, med management...meaning nothing procedural) care has little chance of meeting them. This dynamic applies to the vast majority of adolescent physicians providing gender-affirming care . Furthermore, in academic contexts, these physicians receive no payments, additional RVUs, and/or kickbacks for trans youth undergoing reassignment surgeries (the surgeons and anesthesiologists do) - which are the procedures that would generate larger fees.
So what is the main driver in my opinion? Culture and ideology. I worry that many adolescent clinicians and pediatric endocrinologists are now so worried about being labelled as anti-trans (which would be career ending within those specialties) that raising any critiques/concerns of practice habits and trans-related research is not worth the risk. As a result, the clinicians, researchers, and policy advocates at the forefront of this field are operating within a "feedback-free" environment rife with confirmation bias.
Primary care doctor here. Great article. Agree with most of it. Some thoughts:
1) Supplements are a huge problem and one not primarily driven by the general medical community (at least not in my experience). A lot of these are "prescribed" by naturopaths or when people decide to do their own research on-line. Why do people trust facebook for their medical advice? I tell people that just b/c something is "natural" doesn't make it harmless.
2) Agree that the market-driven side of medical practice in the US is a problem causing over-treatment. My husband works at Kaiser where docs are paid a salary. There's no incentive to over-do procedures other than fear of lawsuits and patients' demands (which I do think are true motivators.) It would be interesting if someone did a study looking at rates of cardiac caths, c-sections, elective procedures at Kaiser vs in private practice to see the difference.
3) I think the medical community in the US is doing a of damage with the rapid green-lighting of trans treatment/meds/surgeries for adolescents and children. Good luck with this article -- you're gonna get a lot of hate for it.
Most of my fellow Democratic committee people talk on issues like this of "being on the right side of history." I always thought, "How can you be so sure?"
I think they have a simplistic model of tying everything together (i.e. abolition of slavery, women's right to vote, and Civil Rights) with "gender affirming care" for youth.
This "positive" attitude has led to disasterous results over the last two years with Defund the Police, embracing DEI industrial complex hucksters, and now this.
Time to get out of the "right side of history" and look at issues on merits.
I actually don't think this will be that controversial of a piece because the argument is laid out too well.
"she saw C-section rates go dramatically up at 4 and 5 p.m. — around the time when doctors tend to want to go home."
This is a little misleading. The doctors go home and are replaced by new doctors coming on shift. It's not that they *need* to wrap things up to leave, it's that they don't want to hand off a patient to someone else if they can finish the work themselves because every hand off leads to worse care. My own daughter was born by C-section at the end of a shift. It was clear she was going to need a C-section to get out because she wasn't moving and was having mild distress. Probably they could have waited another hour or so if the shift change wasn't a factor. Indeed, during the middle of a shift they make non-urgent surgeries wait while urgent surgeries take place. The end of the shift is a time to wrap up the non-urgent surgeries that are still outstanding while the new crew picks up the other work.
Talk about burying the lede; did The Boring Company help you with that?
Excellent post! I did not see that twist coming, I admit, though in truth it’s not a twist at all. This is the best kind of piece: not merely sharp opinion or suggestions on policy but one which provides a real kind of clarity helping us better understand contemporary phenomena, and -potentially- cool some heads, but perhaps I’m too optimistic…
Was it your screenwriter dad who taught you to write a third-act twist that leads to people wanting to kill the screenwriter?
Cause, wow. M. Night got nothing on this.
As a breast cancer survivor who hangs out on Breast Cancer.org's (BCO) message board, I'd say that doctors are often just responding to pushy American consumers who think that they ought to get the best treatment or else they'll switch doctors. The BCO board has American, Canadian, Australian, and British members, and the Americans are the most demanding. They push for second, third, fourth opinions and wonder why they aren't getting the hot, new (and often expensive) treatment. An example: Perjeta, a targeted therapy. Perjeta was approved for early stage HER2+ cancer about eight years ago. Many American patients could get it, but Canadian patients could not. The Canadian patients were resigned to their situation, but the Americans would push their doctors to get it, even when their lumps were smaller than the recommended size (2 cm.)
I'd say the same thing probably happens with the parents of trans kids. They know that gender affirming care is out there, and they think that their kids should have access to the latest and the greatest. If one doctor tries to slow things down and encourages their child to take their time, their parents could always switch providers to the one who will give them what they want. So, doctors give their patients what they -- and their parents -- think they want.
I'm surprised it's apparently not controversial that ADHD medications are overprescribed! I think Americans actually consume drastically *less* health care than we should. There are people in my social circles who avoid seeking out clearly-needed healthcare for financial reasons or individual neuroses. There's stuff we don't have good treatments for, but I suspect there are millions of Americans going through untreated chronic pain. My experience – as a high-SES, college-educated, insured, US citizen, native-English-speaker white gender-conforming cis dude! – is that you have to all but beg doctors to take your pain seriously, and absolutely no one is going to track you down to make sure you get healthcare. If you move to another city and decide it's easier to live with the pain than deal with the healthcare system to start seeing a new doctor, no one will come find you. It's very rare to have anyone in the healthcare system help you work through whatever anxieties you have about medical treatment either.
So it's not obvious to me that "health care is not actually the primary factor in population-level health" – making health care a commodity you consume changes *everything* about how people relate to it. It means refusing to see a doctor becomes, on some level, thrift. It reduces trust in doctors, raises the stakes of every appointment, creates tiered classes of patients. I understand intellectually overtreatment is happening somewhere, but I suspect it's mostly in the last six months of people's lives. It has not been my experience or that of people I know at all. I think undertreatment is part of the same problem as overtreatment – doctors have no incentive to try harder to fix difficult problems, and no incentive to try to relate to the patient, and overtreatment *later* can be caused by undertreatment in the near term – but no one should come away from this article thinking "everyone needs fewer medical tests".