We can choose to keep fighting from our ideological trenches—or we can collectively climb out of them. The path forward lies in recognising shared aims, refining our language, and renewing our commitment to listening across differences.
We must get rid of the “quality metrics” that punish the providers that do have nuanced discussions with patients and therefore may have less than the required % of mammogram or CT lung screen or Prevnar takers. When providers are judged by and paid more for getting people to do screening/ preventative things, it is not encouraging these discussions.
Thank you for writing and publishing this. Over-generalized “quality” and “prevention” metrics have distorted the idea of spectrum that you propose as well as patient partnership and autonomy. We need more open conversation and to climb out of the trench as you say.
Dr Davies -- Excellent insights! You are correct that ethics underlies much of the debate on screening and overdiagnosis, but miss the gorilla in the room. Those promoting screening, testing, and so forth invariably have a financial interest in their agenda. Sceptics have no such contamination, and are much more likely to be intellectually honest.
The burden of proof always lies on the opinion leaders and 'early adopters'. We must maintain the highest degree of scepticism of anything they author.
Brilliant framing on this whole issue. The spectrum approach catches something that binary debates always miss, especially when folks are coming from genuinely differnt lived experiences with diagnosis. I've seen colleagues get stuck inthe 'screening wars' language and it just shuts down any real conversation. What grabbed me most is the point about precise language replacing loaded terms, that's the kind of shift that could actualy let people find common ground without losing their core concerns.
I am wondering if this conference covered gender medicine, where even the facts regarding outcomes are not understood by some who provide the interventions (judging from what they write in their articles). Many in blue states who want to protect the vulnerable young people involved appear to believe that the only problem with these interventions is limited availability, not that they are not shown to help, that significant lifelong harm is being reported, and that it's not even clear why these interventions were offered outside of experimental protocols.
Many providers do not know that the natural history is unknown, long term outcomes with interventions are unknown, and significant and devastating harm is being reported but not investigated. Not even quantified (how many did well/poorly after the honeymoon period, for instance?).
Many don't know that there is no understanding by anyone of what a gender dysphoria diagnosis implies--that is it unknown whether it will even persist a year later (for very young children, absent medical/social reinforcement of identification outside of their sex, it has remitted, for the majority, by mature adulthood in past studies). There is no understanding for whom medical intervention will likely be beneficial, or, again, even how many have been harmed, have regretted, etc.
The HHS report on pediatric gender dysphoria includes a comprehensive peer reviewed umbrella review of systematic reviews on intervention, but it's labeled as "Trump" and literally politicized, and ignored by many.
Much of this is being covered very well in the BMJ, but not in the US, I've not found an accurate article on the Cass Review or the HHS report in NEJM, JAMA had one viewpoint which described the Cass Review (Gorin et al, 2025 and response to an LTE).
Let me further try to bring some of my colleagues up to speed:
“Prioritise listening, curiosity, and humility” was listed by Davies as a strategy to move beyond polarization. This approach is badly needed in this area of medicine in the US.
The utter lack of curiosity on the part of most medical organizations in the US regarding the systematic reviews that led the UK, Sweden, Finland, Denmark & others to reverse their previous positions on gender medicine, is concerning.
I agree, inexplicably, the Cass Review and the HHS report have not been given fair consideration. Kids are more important than our political biases…we need to get over ourselves already.
Also concerning, is the lack of a good faith effort to find and debate the best evidence on this topic:
AAP members have been asking for a systematic review of evidence and review of the AAP gender medicine guidelines since 2019. They finally indicated they would undertake the review in 2023, but nothing has been published.
WPATH suppressed publication of some of the systematic reviews they commissioned from Johns Hopkins.
WPATH “Standards of Care 8” lists recommendations which lack a grading system to indicate the quality of evidence used to create their guidelines.
2025: McMaster University (a well respected center of evidenced based medicine) has published 3 of 5 commissioned systematic reviews. The results revealed that only low certainty evidence exists regarding the benefits of the gender affirming care interventions addressed in their systematic reviews.
Their researchers and the University have been harassed by individuals who are unhappy with the findings, which has threatened the publication of the final two reviews.
Because of outside pressure to avoid open debate of this issue, we have failed to engage in thoughtful self regulation within our profession. Our patients (especially pediatric patients) deserve better.
I feel that unfortunately medical discussion centered on the collaborative goal of investigating the best outcome for a patient has become much more difficult.
The medical environment has been clouded by questions of intention. "In the past" questionable intention might be that few and far between individual who's primary goal was self-promotion.
Today with the corporatization of medicine and shortened times for thorough diagnosis I feel that a lot of practitioners are lost. I truely believe that in the majority of cases the intention of the individual practitioner is still pure- the best outcome for the patient; and the practitioner would welcome open discussion to ensure that they're making the best decision which would decrease a lot of mental anxiety when making a difficult and critical plan of action.
Unfortunately, the medical environment today has understandably made many suspicious of intention which has created a less collaborative environment, despite the very best intentions of the majority of practitioners.
I really like this framework. Thank you. How would a doctor move forward if he has been labeled, criticized, ostracized, or threatened with license revocation for speaking his mind during COVID? Can we move forward without making amends with our colleagues?
Thank you May I also suggest that we move past lip service to patient centeredness and fully embrace the complexity of patient choice in these matters? And may we acknowledge that the data we use for assessment of the benefits of risk and harm for the various detection methodologies that we use and treatment methodologies are done in oftentimes quite narrow patient populations which prevent us from making any clear determinations about their utility in our patient populations or more importantly in our individual patients.
It seems to me that the answer to the dilemma is to assess the screening method scientifically, understand the pros and cons, explain them to the patient and let the patient decide. That becomes problematic when the government is in control of medical care, or at least for whom and for what it is paid. Another reason to get the government out of medical care to the greatest extent possible.
You’re describing informed consent and free patient choice which practically no longer exists in healthcare. A lot of doctors claim they give informed consent but it’s not true informed consent where they’re prepared to not coerce the patient into a decision either way.
Here's my thought. As it stands the patient makes the decision regarding screening procedures based on factors like perceived discomfort, inconvenience, etc, but not on price. Payment is often the main factor for the medical community, e.g. the screening PSA controversy. Doctors don't frame it that way, but getting the screening paid for by the third parties is the crux of the argument. The government says that screening tests should be gratis and they should decide which to "cover". I think it should be just the opposite. Patients are paying the bill either way and they should be the ones taking the cost into account. If they did, I suggest that there would be a lot less doctor infighting.
Yep. If the patients paid directly instead of through third parties we would soon know which screening tests were of value based among other considerations on the true prices of the procedures.
We must get rid of the “quality metrics” that punish the providers that do have nuanced discussions with patients and therefore may have less than the required % of mammogram or CT lung screen or Prevnar takers. When providers are judged by and paid more for getting people to do screening/ preventative things, it is not encouraging these discussions.
Thank you for writing and publishing this. Over-generalized “quality” and “prevention” metrics have distorted the idea of spectrum that you propose as well as patient partnership and autonomy. We need more open conversation and to climb out of the trench as you say.
There needs to be some agreement on the "problems" on medicine before any real progress can be made on fixing them.
Some of us see overutilization as a major cost driver with no real impact on "health".
What must be made clear to medicine is that it's too expensive for is to support. Period, full stop.
Doctor, heal thyself.
Dr Davies -- Excellent insights! You are correct that ethics underlies much of the debate on screening and overdiagnosis, but miss the gorilla in the room. Those promoting screening, testing, and so forth invariably have a financial interest in their agenda. Sceptics have no such contamination, and are much more likely to be intellectually honest.
The burden of proof always lies on the opinion leaders and 'early adopters'. We must maintain the highest degree of scepticism of anything they author.
I find a combo of Dr. JMM’s framing, and some Thomas Sowell concepts, to be helpful here.
Patients can be maximizers or minimizers.
Physicians can have constrained or unconstrained approaches to how they practice.
I agree with the author, that there may not be a universally right answer, for all comers in all scenarios.
Ultimately, what is falsely called "healthcare" today is simply a profit making Medical Industrial Complex, where the primary means to profit are:
-overdiagnosis, the more chronic the better
-aging is an illness to be fixed
-lack of patient choice
-obsession with medicating geriatrics for decades
Let's get government entirely out of medicine:
-end all mandates
-end all subsidies
-end all exemptions from liability
-end public involvement, completely
Brilliant framing on this whole issue. The spectrum approach catches something that binary debates always miss, especially when folks are coming from genuinely differnt lived experiences with diagnosis. I've seen colleagues get stuck inthe 'screening wars' language and it just shuts down any real conversation. What grabbed me most is the point about precise language replacing loaded terms, that's the kind of shift that could actualy let people find common ground without losing their core concerns.
I am wondering if this conference covered gender medicine, where even the facts regarding outcomes are not understood by some who provide the interventions (judging from what they write in their articles). Many in blue states who want to protect the vulnerable young people involved appear to believe that the only problem with these interventions is limited availability, not that they are not shown to help, that significant lifelong harm is being reported, and that it's not even clear why these interventions were offered outside of experimental protocols.
Many providers do not know that the natural history is unknown, long term outcomes with interventions are unknown, and significant and devastating harm is being reported but not investigated. Not even quantified (how many did well/poorly after the honeymoon period, for instance?).
Many don't know that there is no understanding by anyone of what a gender dysphoria diagnosis implies--that is it unknown whether it will even persist a year later (for very young children, absent medical/social reinforcement of identification outside of their sex, it has remitted, for the majority, by mature adulthood in past studies). There is no understanding for whom medical intervention will likely be beneficial, or, again, even how many have been harmed, have regretted, etc.
The HHS report on pediatric gender dysphoria includes a comprehensive peer reviewed umbrella review of systematic reviews on intervention, but it's labeled as "Trump" and literally politicized, and ignored by many.
Much of this is being covered very well in the BMJ, but not in the US, I've not found an accurate article on the Cass Review or the HHS report in NEJM, JAMA had one viewpoint which described the Cass Review (Gorin et al, 2025 and response to an LTE).
You make many excellent points.
Let me further try to bring some of my colleagues up to speed:
“Prioritise listening, curiosity, and humility” was listed by Davies as a strategy to move beyond polarization. This approach is badly needed in this area of medicine in the US.
The utter lack of curiosity on the part of most medical organizations in the US regarding the systematic reviews that led the UK, Sweden, Finland, Denmark & others to reverse their previous positions on gender medicine, is concerning.
I agree, inexplicably, the Cass Review and the HHS report have not been given fair consideration. Kids are more important than our political biases…we need to get over ourselves already.
Also concerning, is the lack of a good faith effort to find and debate the best evidence on this topic:
AAP members have been asking for a systematic review of evidence and review of the AAP gender medicine guidelines since 2019. They finally indicated they would undertake the review in 2023, but nothing has been published.
WPATH suppressed publication of some of the systematic reviews they commissioned from Johns Hopkins.
WPATH “Standards of Care 8” lists recommendations which lack a grading system to indicate the quality of evidence used to create their guidelines.
2025: McMaster University (a well respected center of evidenced based medicine) has published 3 of 5 commissioned systematic reviews. The results revealed that only low certainty evidence exists regarding the benefits of the gender affirming care interventions addressed in their systematic reviews.
Their researchers and the University have been harassed by individuals who are unhappy with the findings, which has threatened the publication of the final two reviews.
Because of outside pressure to avoid open debate of this issue, we have failed to engage in thoughtful self regulation within our profession. Our patients (especially pediatric patients) deserve better.
I feel that unfortunately medical discussion centered on the collaborative goal of investigating the best outcome for a patient has become much more difficult.
The medical environment has been clouded by questions of intention. "In the past" questionable intention might be that few and far between individual who's primary goal was self-promotion.
Today with the corporatization of medicine and shortened times for thorough diagnosis I feel that a lot of practitioners are lost. I truely believe that in the majority of cases the intention of the individual practitioner is still pure- the best outcome for the patient; and the practitioner would welcome open discussion to ensure that they're making the best decision which would decrease a lot of mental anxiety when making a difficult and critical plan of action.
Unfortunately, the medical environment today has understandably made many suspicious of intention which has created a less collaborative environment, despite the very best intentions of the majority of practitioners.
The principles outlined here are a wonderful framework that should be applied across the political spectrum as well. Brava!!
Thank you for this essay. I agree completely. Also, I am very envious that Dr. Cifu was able to attend the Overdiagnosis conference!
I really like this framework. Thank you. How would a doctor move forward if he has been labeled, criticized, ostracized, or threatened with license revocation for speaking his mind during COVID? Can we move forward without making amends with our colleagues?
You may want to make amends for the WAY you spoke your mind, but please don't make amends for being right.
Thank you May I also suggest that we move past lip service to patient centeredness and fully embrace the complexity of patient choice in these matters? And may we acknowledge that the data we use for assessment of the benefits of risk and harm for the various detection methodologies that we use and treatment methodologies are done in oftentimes quite narrow patient populations which prevent us from making any clear determinations about their utility in our patient populations or more importantly in our individual patients.
It seems to me that the answer to the dilemma is to assess the screening method scientifically, understand the pros and cons, explain them to the patient and let the patient decide. That becomes problematic when the government is in control of medical care, or at least for whom and for what it is paid. Another reason to get the government out of medical care to the greatest extent possible.
You’re describing informed consent and free patient choice which practically no longer exists in healthcare. A lot of doctors claim they give informed consent but it’s not true informed consent where they’re prepared to not coerce the patient into a decision either way.
"Free" care converts into do whatever the doctor orders at checkout time unless there's unusual discomfort or inconvenience involved.
And you think the medical industry won't use the same tools? Who sits on the government committees do you think?
Here's my thought. As it stands the patient makes the decision regarding screening procedures based on factors like perceived discomfort, inconvenience, etc, but not on price. Payment is often the main factor for the medical community, e.g. the screening PSA controversy. Doctors don't frame it that way, but getting the screening paid for by the third parties is the crux of the argument. The government says that screening tests should be gratis and they should decide which to "cover". I think it should be just the opposite. Patients are paying the bill either way and they should be the ones taking the cost into account. If they did, I suggest that there would be a lot less doctor infighting.
Absolutely. Make the patient pay for it would also drop the price-like a rock. Those pushing it wouldn’t have all that free money to play with.
Yep. If the patients paid directly instead of through third parties we would soon know which screening tests were of value based among other considerations on the true prices of the procedures.
And you think the medical industry won't use the same tools? Who sits on the government committees do you think?
Love this. Bravo!
Excellent!
Drive on...