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.
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).
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.
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.
I am sure the author is familiar with A Better Way out of the UK with Dr. Tess Lawrie (I think I have that correct )They are a group who I think are aligned with the author's thinking. Maybe here in the USA we are too big for such a group to catch on in a larger sense. This author has a refreshing view!
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).
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?
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.
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.
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...
Excellent article! I would add limiting use of the verb “to be” as a way out of binary thinking.
This was taught to me in a systemic racism workshop. Doing racist actions has a spectrum that being a racist does not.
Yes!! As physicians if we approach these discussions with humility and curiosity we can achieve great things!
Thank you for the continued and much needed conversations.
I am sure the author is familiar with A Better Way out of the UK with Dr. Tess Lawrie (I think I have that correct )They are a group who I think are aligned with the author's thinking. Maybe here in the USA we are too big for such a group to catch on in a larger sense. This author has a refreshing view!