Healthcare in the News

[CAdamsPAC]

1 hour ago, jmj11 said:

I accept your argument. Medicaid is not ideal, only better than nothing. I think we could do better as a society. My European friends love their national care.

" My European friends love their national care." I am a believer in you get what you pay for. I read numerous articles on the impending collapse of the UK National Health Service, Canadians traveling to the US for surgical care. While there are no perfect health care systems, I don't think Americans are prepared to have politicians/administrators determining the level or degree of care they might receive. 

1 hour ago, sas5814 said:

trans·pho·bi·a

 

NOUN

1. dislike of or prejudice against transgender or transsexual people:

    

    

   You can disagree with her premise. You can think she is wrong headed or even just stupid if you choose. Nothing in what she said indicated hatred, dislike or prejudice. Her words indicated just the opposite. It just angers you that she doesn't share your truth so you attack with a hot button weaponized word. It doesn't fortify your argument.

    

   Make you arguments thoughtfully. Deconstruct hers. Have an actual discussion instead of a shouting match across a picket line. Nobody's mind was ever changed by anger and name calling.

Personally, I am past tolerating or accepting  the use of perjoratives as rebuttals to a stated position.

[sas5814]

Interestingly as I have gotten older I have become less rigid in my thinking rather than more so. I have found this thread, with a couple of exceptions, thought provoking and I have gone back and read all the posts several times....and I may read them again.

"Truth" is a pretty tricky word. There is very little absolute truth in the world. My wife, who is way smarter than me, once told me "truth is personal." In this discussion several people have expressed different perspectives that, to each of them, are true or their truth. If a man believes he is a woman (or should be) it is their truth. If a person believes we are what we are born that is their truth. It goes on from there.

The magic sauce is to keep an open mind and disagree respectfully if you must actively disagree. Discussion, dialogue, mutual respect. Nobody says we all have to agree on everything. If I hated everyone who disagreed with me my life would be pretty empty. If everyone who disagreed with me felt the need to attack me my days would be full of conflict. My wife, whom I adore more than anyone else on the planet and have been happily married to for more than 20 years, disagree about religion...and that's a biggie. But we either have respectful discourse or just agree to disagree. So far her only impetus to hit me with a shovel came from other (legit) causes.

I don't know what the answer is in gender identity and I think anyone who claims to know the truth is taking a hubris bath. I'm just listening and trying to keep an open mind.

[CAdamsPAC]

2 minutes ago, sas5814 said:

Interestingly as I have gotten older I have become less rigid in my thinking rather than more so. I have found this thread, with a couple of exceptions, thought provoking and I have gone back and read all the posts several times....and I may read them again.

"Truth" is a pretty tricky word. There is very little absolute truth in the world. My wife, who is way smarter than me, once told me "truth is personal." In this discussion several people have expressed different perspectives that, to each of them, are true or their truth. If a man believes he is a woman (or should be) it is their truth. If a person believes we are what we are born that is their truth. It goes on from there.

The magic sauce is to keep an open mind and disagree respectfully if you must actively disagree. Discussion, dialogue, mutual respect. Nobody says we all have to agree on everything. If I hated everyone who disagreed with me my life would be pretty empty. If everyone who disagreed with me felt the need to attack me my days would be full of conflict. My wife, whom I adore more than anyone else on the planet and have been happily married to for more than 20 years, disagree about religion...and that's a biggie. But we either have respectful discourse or just agree to disagree. So far her only impetus to hit me with a shovel came from other (legit) causes.

I don't know what the answer is in gender identity and I think anyone who claims to know the truth is taking a hubris bath. I'm just listening and trying to keep an open mind.

Exactly. disagreement, differing point of views somehow are now hatefulness, racism, xenophobia or whatever  the" pejorative de jour" is in so many peoples views!!

[rev ronin]

2 hours ago, Emdecc said:

Boosting this! The distinction between sex (objective, biological) and gender (a personal identifier, subjective to the individual) is clear and generally agreed upon. It is quite easy to refer to someone by their preferred pronouns while still accounting for their biological sex in your treatment plan.

No, actually, while the different usage of sex and gender can be easily understood, the notion that a gender identity, rather than biological sex, should determine how people are addressed is a religious, or ideological if you prefer, perspective not generally agreed upon. To plenty of people, probably including a number of your peers here on this forum, the act of linguistically misgendering someone would to be call a biological male 'she' or a biological female 'he'. That may sound horrible in certain circles that have bought into the difference between sex and gender identity as real and meaningful, but many people have not.

So if a medical professional does not believe in the (again, ideological or religious and devoid of objective findings) narrative of gender identity, on what basis would it be ethical for them to call a patient by pronouns discordant from the patient's biologic sex?

[ANESMCR]

2 hours ago, rev ronin said:

Sorry, but WPATH guidelines are based on a "very low certainty" level of evidence at best. If I'm interested in caring for individuals with gender dysphoria, why on earth would I want to consult guidelines based on low quality evidence? My concern is doubled when we're talking about children, doubled again when we're talking about irrevocable hormonal or surgical interventions.

(https://www.tandfonline.com/doi/full/10.1080/0092623X.2022.2046221)

(and I treat individuals with gender dysphoria on a regular, currently weekly, basis, and have been doing so for years. Many of them have eating disorders.)

I don’t know anything about WPATH guidelines, but when did we stop using guidelines with low quality or very low quality evidence? 

[Emdecc]

4 hours ago, rev ronin said:

So if a medical professional does not believe in the (again, ideological or religious and devoid of objective findings) narrative of gender identity, on what basis would it be ethical for them to call a patient by pronouns discordant from the patient's biologic sex?

Thanks for elaborating. I think we will have to agree to disagree here. Fundamentally you believe that it is not within a patient's own autonomy to decide how they would like to be identified, but rather your own. If my biological sex is female but my name is Charlie, I doubt you would object to calling me by my name, even though it is a traditionally male name. So why would it raise such concerns to call me traditionally male pronouns in place of my name? Both names and pronouns are social constructs introduced by an individual to another person. I think it is quite straightforward to refer to them how they introduce themselves, or if you cannot bring yourself to use their pronouns, simply call them by their name. Linguistically, every pronoun in a sentence can be replaced by a person's name. Regardless of our dissenting opinions in important discussions such as this, the exam room is not the place to impose our own opinions. It is important to build trust with a patient to ensure that they are comfortable sharing all pertinant information without fear of judgement - this is how we provide the best quality of care. 

Edited October 20, 2022 by Emdecc
spelling

[iconic]

It is quite unfortunate that it is scripture instead of guidelines that guides medical professionals. I often forget about the prejudice and biases my colleagues unfortunately impose on patients in many parts of the country 

[rev ronin]

10 minutes ago, Emdecc said:

Thanks for elaborating. I think we will have to agree to disagree here. Fundamentally you believe that it is not within a patient's own autonomy to decide how they would like to be identified, but rather your own. If my biological sex is female but my name is Charlie, I doubt you would object to calling me by my name, even though it is a traditionally male name. So why would it raise such concerns to call me traditionally male pronouns in place of my name? Both names and pronouns are social constructs introduced by an individual to another person. I think it is quite straightforward to refer to them how they introduce themselves, or if you cannot bring yourself to use their pronouns, simply call them by their name. Linguistically, every pronoun in a sentence can be replaced by a person's name. Regardless of our dissenting opinions in important discussions such as this, the exam room is not the place to impose our own opinions. It is important to build trust with a patient to ensure that they are comfortable sharing all pertinant information without fear of judgement - this is how we provide the best quality of care. 

So, I'm asking questions, rather than disputing anything.  Hopefully everything I've said has been quite obvious, so there's no "agree to disagree" needed: you can help me understand what's going on, or not, your choice.

So, in the spirit of asking questions, let's try two about the centrality of self-identification:
- Is Rachel Levine a woman?
- Is Rachel Dolezal Black?

In point of specific practice, I never use third person pronouns in an exam room anyways, because it's never indicated when speaking between two people unless referencing a third party.  All the medical professionals I know who refuse to use a gendered third person preferred pronoun at odds with that patient's biological sex to refer to a transgender-identified patient do use the patient's preferred first name. I have heard of, but never personally witnessed, medical office staff intentionally using the biologically accurate pronouns to refer to a patient who did not want to be addressed in such a manner, but that's not what I think anyone would consider professional behavior.

[rev ronin]

4 hours ago, ANESMCR said:

I don’t know anything about WPATH guidelines, but when did we stop using guidelines with low quality or very low quality evidence? 

How much damage could be done if they're wrong, compared to previous reasonable and customary care?

[rev ronin]

4 minutes ago, iconic said:

It is quite unfortunate that it is scripture instead of guidelines that guides medical professionals. I often forget about the prejudice and biases my colleagues unfortunately impose on patients in many parts of the country 

I wholeheartedly agree, but in entirely the opposite direction: It is quite unfortunate that it is ideology, instead of biology, which guides many medical professionals. I sometimes wish I could forget about the prejudice and biases my colleagues unfortunately impose on patients in many parts of the country.

[CAAdmission]

Here are a couple questions I struggle with:

-If someone's sex does not correspond with their mental gender, is that a pathologic state, or just... diversity? Normal variation?

-For the vast majority of my professional career, if someone's sex and mentally conceived gender did not match, it was treated as psychological pathology. Then one day the DSM threw a switch and poof, now it is treated solely as physical pathology. Any attempt to even suggest psychological treatment is somehow viewed as hateful. Why is that?

Edited October 20, 2022 by CAAdmission

[Emdecc]

52 minutes ago, rev ronin said:

 Hopefully everything I've said has been quite obvious, so there's no "agree to disagree" needed: you can help me understand what's going on, or not, your choice.

I appreciate your contributions, but I wouldn't call them "obvious." And this discussion alone surely shows that there is a lot of gray area to agree or disagree on. That's the backbone of a respectful debate! So let's keep it respectful

And I am no expert in the psychology of gender identity, so I only want to contribute my opinion on the topic of respecting how others ask to be addressed. When serving diverse communities, we respect differences in other social constructs (religion, politics, culture, etc.) without imposing our own beliefs, so I am only suggesting we extend the same courtesy regarding gender. 

[rev ronin]

23 minutes ago, Emdecc said:

I appreciate your contributions, but I wouldn't call them "obvious." And this discussion alone surely shows that there is a lot of gray area to agree or disagree on. That's the backbone of a respectful debate! So let's keep it respectful

By all means, do highlight what I've said that you don't think to be obvious, so I can clarify any uncertainty.

When it comes to disagreements, there are matters of opinion (Chocolate or vanilla ice cream?) with no objective "right" answer; there, there is plenty of room to differ.

There are other disagreements over matters that do have objective answers. Two plus two will always equal four, whether anyone else likes it or not. There is no room for disagreement here: if a PA doesn't think 2+2 = 4, I definitely do not want him or her prescribing medication, and so will do my best to correct the mistaken belief because it could impact patient safety.

While I appreciate the call to respectful debate, that only applies to the former.

More important are the debates that one can phrase in a PICO format: should you push amiodarone vs. lidocaine in an out of hospital cardiac arrest to reduce mortality? There is a right answer, but it may be conditional or nuanced and so the debate isn't really like discussing either of the first two examples, but an entirely different sort of "prove it" debate, where the stakes are patient care. Moreover, we've found any number of cases where the entire question was formulated wrong. Bottom line? The patient's outcome is the ultimate proof of an answer's correctness in such cases.

[kettle]

16 hours ago, jmj11 said:

I accept your argument. Medicaid is not ideal, only better than nothing. I think we could do better as a society. My European friends love their national care.

My Canadian friends despise their healthcare. Waiting 3 years for a knee replacement. Another example, friends kid recently fell off the tractor. Closest hospital closed as there's no providers there. Next closest ER 2 hrs. They went to the clinic, doc put in order for Xray, that clinic doesn't have an xray tech, so they had to drive to a different clinic a half hour away for films. Buckle fracture. No one could splint it or cast it as the second clinic didn't have a provider just film's. The initial clinic doc is only there Monday and Thurs so they had to wait 3 days for a cast or drive two hours. They couldn't afford the drive with fuel at 1.91$ a liter.

Our system may not be perfect but it could be worse...

Edited October 20, 2022 by kettle

[iconic]

9 hours ago, rev ronin said:

By all means, do highlight what I've said that you don't think to be obvious, so I can clarify any uncertainty.

When it comes to disagreements, there are matters of opinion (Chocolate or vanilla ice cream?) with no objective "right" answer; there, there is plenty of room to differ.

There are other disagreements over matters that do have objective answers. Two plus two will always equal four, whether anyone else likes it or not. There is no room for disagreement here: if a PA doesn't think 2+2 = 4, I definitely do not want him or her prescribing medication, and so will do my best to correct the mistaken belief because it could impact patient safety.

While I appreciate the call to respectful debate, that only applies to the former.

More important are the debates that one can phrase in a PICO format: should you push amiodarone vs. lidocaine in an out of hospital cardiac arrest to reduce mortality? There is a right answer, but it may be conditional or nuanced and so the debate isn't really like discussing either of the first two examples, but an entirely different sort of "prove it" debate, where the stakes are patient care. Moreover, we've found any number of cases where the entire question was formulated wrong. Bottom line? The patient's outcome is the ultimate proof of an answer's correctness in such cases.

You sound close minded as well as ignoring evidence and guidelines from all major medical association on the treatment of transgender individuals. Also your understanding of middle school genetics is less than impressive. Gender is not limited to the sex chromosomes and there are in fact brain differences between transgender men vs cisgender women; transgender women and cisgender men. But go on with your simplistic understanding of gender 

Edited October 20, 2022 by iconic

[CAAdmission]

58 minutes ago, iconic said:

You sound close minded as well as ignoring evidence and guidelines from all major medical association

Ok @iconic, since you feel strongly about this, I'll ask you directly. 

What is the difference (if any) between an XY person that identifies as a woman and has their genitals removed and a healthy, able-bodied person that identifies as handicapped and wants a leg removed?

[rev ronin]

5 hours ago, iconic said:

You sound close minded as well as ignoring evidence and guidelines from all major medical association on the treatment of transgender individuals. Also your understanding of middle school genetics is less than impressive. Gender is not limited to the sex chromosomes and there are in fact brain differences between transgender men vs cisgender women; transgender women and cisgender men. But go on with your simplistic understanding of gender 

So, you open with an appeal to authority.  Let me ask: how is WPATH constituted? Is it not a voluntary association of medical professionals with an interest in a topic? Are all such groups equal? Would you honor a position paper from AAPLOG, a similarly-constituted association, that notes that there is a link between abortion and breast cancer?

If you think I've been using middle-school genetics, then you're neither reading my posts thoroughly nor extending the courtesy of treating me like a fellow medical professional who, per ARC-PA standards, has to have had genetic instruction at the graduate level.  Allow me to quote myself from earlier in the thread: "Now, using that chromosomal reality, a human being is constructed, with parental genetic material, gestational influences, and postpartum influences."  My apologies if that seems to be simplified by not noting epigenetic factors among parental influences, or some other tidbit you think I should have covered; I wasn't speaking specifically to your assertion when I posted that, I just bring it up now as a rebuttal to your statement.

As far as evidence of brain differences go, please tell me more. (side note: for those of you reading this, this is a rhetorical device, not an indication that I don't already know the answer) Was this a meta-analysis, a single-center trial, or somewhere in between?  How many patients total were involved in all these studies, how were they selected, and was the level of statistical certainty asserted?

If you want to say "follow the evidence" be prepared to put forth the evidence you suggest as normative and defend its scientific rigor. Again, as Levine et al noted in their abstract, "Beliefs about gender-affirmative care need to be separated from the established facts. "

[ventana]

13 hours ago, kettle said:

My Canadian friends despise their healthcare. Waiting 3 years for a knee replacement. Another example, friends kid recently fell off the tractor. Closest hospital closed as there's no providers there. Next closest ER 2 hrs. They went to the clinic, doc put in order for Xray, that clinic doesn't have an xray tech, so they had to drive to a different clinic a half hour away for films. Buckle fracture. No one could splint it or cast it as the second clinic didn't have a provider just film's. The initial clinic doc is only there Monday and Thurs so they had to wait 3 days for a cast or drive two hours. They couldn't afford the drive with fuel at 1.91$ a liter.

Our system may not be perfect but it could be worse...

It is worse

kids. Adults and everyone rations or never gets care 

 

just research our world WHO rankings and you realize how horrible we are. 
 

speed of care delivery and ease of accessing care are not surrogate for quality care. 
 

There is always tons of stories about Canadians and there system. Do the research and they all fall apart as untrue.  
 

for 5 years I ran a walk in about 4 hrs from Canada. Saw a lot of Canadian citizens with urgent care complaints. Never, not even once was someone happy to access care in the USA.  Almost universally they would ask to be patched up well enough to get back to Canada and there they would get the care they needed. 
 

you do realize the insurance company will spend one dollar short of total bankruptcy trying to convince the American public that the Canadian system is broken and should be feared

 

but that is an alternative fact.
 

peace out.  

[kettle]

10 hours ago, ventana said:

It is worse

I guess we'll have to agree to disagree. I'll definitely agree on the fact that health insurance companies here do whatever they can to not pay but personally I like my health insurance and I've had to use it for long term illnesses.

I work on occasion at a hospital where I can see Canada from the main entrance. 

For life threatening stuff I too would like it all paid for and fixed right away but for chronic illness and multiple appointments I like our system here. By no means is it perfect and I wholeheartedly respect your opinion and do understand it.

[sas5814]

On 10/19/2022 at 4:25 PM, ANESMCR said:

I don’t know anything about WPATH guidelines, but when did we stop using guidelines with low quality or very low quality evidence? 

I think we, as intelligent people, should decide if low value data is for us to use.  To me that means there is a lot more research needed. A wise old doc once told me...never be the first or last to do anything. I believe in that.

[rev ronin]

1 hour ago, sas5814 said:

A wise old doc once told me...never be the first or last to do anything. I believe in that.

My academic coordinator in PA school told us all that half of what we were being taught would eventually prove to be wrong, and it was up to us to figure out which half and correct it. I know that saying wasn't original with her, but the caution seems especially apt in application to politically or ideologically charged medicine.

[sas5814]

22 minutes ago, rev ronin said:

My academic coordinator in PA school told us all that half of what we were being taught would eventually prove to be wrong, and it was up to us to figure out which half and correct it. I know that saying wasn't original with her, but the caution seems especially apt in application to politically or ideologically charged medicine.

One of the docs I work with said he believes in 10 years or so we will be looking retrospectively at gender reassignment the same way we currently view the pain management we did 10-20 years ago. We will have much better science and more of it and find we screwed up a lot of things because we were acting on feelings and not science. Seems likely.

[CAdamsPAC]

17 minutes ago, sas5814 said:

One of the docs I work with said he believes in 10 years or so we will be looking retrospectively at gender reassignment the same way we currently view the pain management we did 10-20 years ago. We will have much better science and more of it and find we screwed up a lot of things because we were acting on feelings and not science. Seems likely.

Feelings or emotions based activity IMHO equates to the line , the road to hell is paved with good intentions.

[ANESMCR]

3 hours ago, sas5814 said:

I think we, as intelligent people, should decide if low value data is for us to use.  To me that means there is a lot more research needed. A wise old doc once told me...never be the first or last to do anything. I believe in that.

Respectfully, that’s nonsense, to both of you. Review your clinical guidelines. We use low and very low evidence all of the time. Have you ever ordered fecal immunochemistry? How about a cologuard? Should we not screen 45 year olds for colon cancer? Just minor examples of very low evidence. 

[sas5814]

4 minutes ago, ANESMCR said:

Have you ever ordered fecal immunochemistry? How about a cologuard?

1) Only because its mandated and 2) not without trying to talk the patient out of it. If it is the only choice I have then I'll order it.

Blindly following low value data is lazy. It took 25 years of poking our fingers into butts to feel prostates annually (low value data) before it was determined to not have changed prostate cancer morbidity or mortality at all and it fell out of popularity. I quit years earlier.

Like I said...we are (or should be) thinking clinicians and not robots.