MS4 from wake forest in HOT water!!!

[FootballAndSkiing]

I suspect the patient will be making their public statement in the form of a civil legal filing as well as for damages via a formal HIPAA complaint.

You know the attorneys must be lining up to do this pro bono if for no other reason than the free air time on Fox.

I think there is a pretty descent chance the patient doesn't care, or doesn't want the media attention.

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[operaman]

I think there is a pretty descent chance the patient doesn't care, or doesn't want the media attention.

Maybe. But then again he did make fun of someone’s pronoun pin when they were about to stick him with a needle, so who knows.

It’s definitely an easy payday as wake would almost certainly want to settle it quietly. Wouldn’t be surprised if risk management had already reached out to the patient to pre-empt a filing. I could probably deal with a couple tv interviews for a six figure payday. Got a lot of student loans to pay off over here.

 

[FootballAndSkiing]

It’s definitely an easy payday as wake would almost certainly want to settle it quietly. Wouldn’t be surprised if risk management had already reached out to the patient to pre-empt a filing. I could probably deal with a couple tv interviews for a six figure payday.

Is it a 6 figure pay day? Not a lawyer, but doesn't there have to be actual damage or pain and suffering to have a case? There really wasn't any physical damage, its more of an ethical concern.

 

[operaman]

Is it a 6 figure pay day? Not a lawyer, but doesn't there have to be actual damage or pain and suffering to have a case? There really wasn't any physical damage, its more of an ethical concern.

Yeah not sure but it seems like a small price to avoid the bad press and expense of litigation. And there’s huge potential for punitive damages here, especially given Wake’s response and leaked emails.

The only reason I could see them not suing would be if the med student completely fabricated the whole thing. It’s certainly common for students and trainees to overstate their role in care when talking to others. Twitter is full of residents talking about their practice like they aren’t just doing what their attending tells them. There’s a good chance this girl was just standing around blending into the paint like most students while the nurse did the work and didn’t even make an attempt herself. That’s probably what the documentation reflects - that the nurse herself did both attempts. She likely overstated her role in her tweet to sound more important or something.

Still a reasonable HIPAA case though even if the student fabricated parts of it. Memory is fuzzy but I think there are potential damages to be had under the federal law as well, plus fines assessed against the hospital.

 

[FootballAndSkiing]

Yeah not sure but it seems like a small price to avoid the bad press and expense of litigation. And there’s huge potential for punitive damages here, especially given Wake’s response and leaked emails.

The only reason I could see them not suing would be if the med student completely fabricated the whole thing. It’s certainly common for students and trainees to overstate their role in care when talking to others. Twitter is full of residents talking about their practice like they aren’t just doing what their attending tells them. There’s a good chance this girl was just standing around blending into the paint like most students while the nurse did the work and didn’t even make an attempt herself. That’s probably what the documentation reflects - that the nurse herself did both attempts. She likely overstated her role in her tweet to sound more important or something.

Still a reasonable HIPAA case though even if the student fabricated parts of it. Memory is fuzzy but I think there are potential damages to be had under the federal law as well, plus fines assessed against the hospital.

This is not a HIPAA violation

 

[operaman]

This is not a HIPAA violation

It absolutely could be. If the patient was able to be identified it doesn’t matter how careful she was, this would be a violation. Just sharing details of the encounter may be enough to violate it. This is a big reason why schools are so anal about social media posting, because it’s much easier to run afoul of the law than many realize. It’s not just obvious info that gets you in trouble.

 

[VA Hopeful Dr]

It absolutely could be. If the patient was able to be identified it doesn’t matter how careful she was, this would be a violation. Just sharing details of the encounter may be enough to violate it. This is a big reason why schools are so anal about social media posting, because it’s much easier to run afoul of the law than many realize. It’s not just obvious info that gets you in trouble.

Nothing in that tweet contained protected information.

 

[operaman]

Nothing in that tweet contained protected information.

Except details of an interaction that may be enough to identify the patient. My understanding is that if enough detail is shared to where the patient can be identified, it could be a violation.

The extreme example has always been something like “my patient with Tay-Sachs came in today and…” where it may be obvious who it is. This isn’t quite as obvious, but it seems was still enough to be identified.

 

[VA Hopeful Dr]

Except details of an interaction that may be enough to identify the patient. My understanding is that if enough detail is shared to where the patient can be identified, it could be a violation.

The extreme example has always been something like “my patient with Tay-Sachs came in today and…” where it may be obvious who it is. This isn’t quite as obvious, but it seems was still enough to be identified.

I don't think it's enough for a layperson to identify. Wake could do it because they knew where she was and could look up everyone who was there for blood draws that day.

Plus, being there isn't considered private. It's why you can call the hospital and ask if so and so is currently admitted. They'll tell you that but nothing else.

 

[Redpancreas]

This is not a HIPAA violation

Gender was identified from my recollection and more features can be inferred.

 

[FootballAndSkiing]

Gender was identified from my recollection and more features can be inferred.

Conservative male in North Carolina doesn't really narrow it down too much

 

[Redpancreas]

Conservative male in North Carolina doesn't really narrow it down too much

Agreed, it doesn't narrow it down.

Googled PHI:
the demographic information, medical histories, test and laboratory results, mental health conditions, insurance information and other data that a healthcare professional collects to identify an individual and determine appropriate.

I don't know the technicalities. Would be good if @VA Hopeful Dr or someone could educate us from a legal perspective.

 

[FootballAndSkiing]

But that info isn't in the tweet

 

[DrStephenStrange]

NC medical school backs student who suggested she harmed patient for mocking pronoun pin

Wake Forest University Medical School is standing by student Kychelle Del Rosario, who suggested she intentionally harmed one of her patients over comments made about her pronoun pin.

www.foxnews.com

 

[VA Hopeful Dr]

NC medical school backs student who suggested she harmed patient for mocking pronoun pin

Wake Forest University Medical School is standing by student Kychelle Del Rosario, who suggested she intentionally harmed one of her patients over comments made about her pronoun pin.

www.foxnews.com

Meh, Wake hasn't made a decision yet. That's not the same as backing the student. My assumption is they are working through their established disciplinary procedures which takes time.

 

[GoSpursGo]

NC medical school backs student who suggested she harmed patient for mocking pronoun pin

Wake Forest University Medical School is standing by student Kychelle Del Rosario, who suggested she intentionally harmed one of her patients over comments made about her pronoun pin.

www.foxnews.com

That headline is factually inaccurate. Unless there is any new information beyond the statement from last week, I don’t see any evidence that they are “standing by” her. Could simply be continuing their investigation.

It seems like a manufactured headline to keep the story going and increase pressure on the school to take their preferred action, which is to expel the student. Which, as discussed at length, could be appropriate… but this headline is just misleading, at absolute most generous interpretation. This is not news.

 

[Lawpy]

That headline is factually inaccurate. Unless there is any new information beyond the statement from last week, I don’t see any evidence that they are “standing by” her. Could simply be continuing their investigation.

It seems like a manufactured headline to keep the story going and increase pressure on the school to take their preferred action, which is to expel the student. Which, as discussed at length, could be appropriate… but this headline is just misleading, at absolute most generous interpretation. This is not news.

the article also says:

The university publicly responded to the incident in a statement on Wednesday, saying Del Rosario's tweet was not an accurate recounting of the incident.

"Our documentation verifies that after the student physician was unsuccessful in obtaining the blood draw, the student appropriately deferred a second attempt to one of our certified professionals. The student did not attempt to draw blood again," the school wrote.

 

[Lost in Translation]

“So she intentionally missed on her attempt before turning the needle over to a more experienced practitioner.” is the vibe I’m getting. Whether that’s true or not will never be known to anyone beyond the student.

 

[FootballAndSkiing]

the article also says:

The university publicly responded to the incident in a statement on Wednesday, saying Del Rosario's tweet was not an accurate recounting of the incident.

"Our documentation verifies that after the student physician was unsuccessful in obtaining the blood draw, the student appropriately deferred a second attempt to one of our certified professionals. The student did not attempt to draw blood again," the school wrote.

It does seem like that lines of with her tweet though. She said "I missed his vein so he had to get stuck twice" Its passive voice, she never said she did it twice. Still its her actions that lead to the patient getting stuck twice.

 

[FootballAndSkiing]

That headline is factually inaccurate. Unless there is any new information beyond the statement from last week, I don’t see any evidence that they are “standing by” her. Could simply be continuing their investigation.

It seems like a manufactured headline to keep the story going and increase pressure on the school to take their preferred action, which is to expel the student. Which, as discussed at length, could be appropriate… but this headline is just misleading, at absolute most generous interpretation. This is not news.

I think from Fox's standpoint the fact that she hasn't been expelled yet is the school backing her. The school was hoping it would just go away and thats what was happening. I see nothing wrong writing another article to keep the story alive, seems like its fair game.

 

[GoSpursGo]

the article also says:

The university publicly responded to the incident in a statement on Wednesday, saying Del Rosario's tweet was not an accurate recounting of the incident.

"Our documentation verifies that after the student physician was unsuccessful in obtaining the blood draw, the student appropriately deferred a second attempt to one of our certified professionals. The student did not attempt to draw blood again," the school wrote.

But that was reported last Wednesday.

I think from Fox's standpoint the fact that she hasn't been expelled yet is the school backing her. The school was hoping it would just go away and thats what was happening. I see nothing wrong writing another article to keep the story alive, seems like its fair game.

But it’s not news. It’s lobbying for a desired outcome. Regardless of what you think should happen, this kind of behavior (from both sides) is bad journalism.

 

[FootballAndSkiing]

But it’s not news. It’s lobbying for a desired outcome. Regardless of what you think should happen, this kind of behavior (from both sides) is bad journalism.

Yeah but everyone is doing it. The rules for the MSM have changed. No news organization is only publishing news.

 

[futureapppsy2]

This is the type of nuance that gender advocates miss and patients suffer.

I don't think this is a fair statement. As someone who is fairly involved in--and has published in--LGBTQ+ healthcare, any decent clinician recognizes nuance in gender identity, and the WPATH guidelines, which are the standard for medical transition care, recommend a period of time on HRT and living socially as one's "preferred" gender before undergoing surgery. Recommendations of social transition before hormones in adults gets much trickier, as an adult who looks unambiguously like their birth gender while living as another gender is often at risk for significant violence and discrimination. Also, non-binary and gender-fluid identities throw some additional wrenches into how we traditionally think about transition. If a non-binary person has significant chest dysphoria, for example, is it ethical to make them live as a male or take T as a condition of surgery if they don't actually identify as male and T may cause additional gender dysphoria? I wouldn't be surprised if a lot of detransitions, especially among adults. involve people who come to realize that they actually have a non-binary gender identity, don't pass and can't tolerate the social discrimination involved in being a "clocked" trans person, and/or something like wanting to have bio children. With children, there is the issue of potential confusion between gender identity and sexual orientation, but as we study this more, we're getting a better handle on differences between gender non-conformity, especially in sexual minority children, and true gender dysphoria. The narrative of using people who detransition as "proof" that trans people are not real or are simply the result of mental illness is harmful and ignores the effects of minority stress on mental health, which is an evidence-based construct.

 

[Lawpy]

But that was reported last Wednesday.

Oh i must’ve have missed that. Idk then. The headline is completely misleading now

 

[sloop]

I don't think this is a fair statement. As someone who is fairly involved in--and has published in--LGBTQ+ healthcare, any decent clinician recognizes nuance in gender identity, and the WPATH guidelines, which are the standard for medical transition care, recommend a period of time on HRT and living socially as one's "preferred" gender before undergoing surgery. Recommendations of social transition before hormones in adults gets much trickier, as an adult who looks unambiguously like their birth gender while living as another gender is often at risk for significant violence and discrimination. Also, non-binary and gender-fluid identities through some additional wrenches into how we traditionally think about transition. If a non-binary person has significant chest dysphoria, for example, is it ethical to make them live as a male or take T as a condition of surgery if they don't actually identify as male and T may cause additional gender dysphoria? I wouldn't be surprised if a lot of detransitions, especially among adults. involve people who come to realize that they actually have a non-binary gender identity, don't pass and can't tolerate the social discrimination involved in being a "clocked" trans person, and/or something like wanting to have bio children. With children, there is the issue of potential confusion between gender identity and sexual orientation, but as we study this more, we're getting a better handle on differences between gender non-conformity, especially in sexual minority children, and true gender dysphoria. The narrative of using people who detransition as "proof" that trans people are not real or are simply the result of mental illness is harmful and ignores the effects of minority stress on mental health, which is an evidence-based construct.

Except a lot of gender advocates do miss this. There is a difference between being a gender-affirming provider and being a gender advocate.

Unfortunately, there is an extreme position that holds that gender transition is entirely a personal choice and that providers acting as gatekeepers to medical and surgical interventions is inappropriate. In my city, there is a particular clinic that is notorious for basically taking a person’s stated gender identity as itself an indication for hormones and/or a surgery letter.

As I have alluded to, I have no interest in withholding gender-affirming care from the people it will help. At the same time, these interventions carry real risks of harm and they’re not appropriate for everyone who asks for them.

I think it’s definitely possible to practice good medicine in these areas even if you have strong political views regarding trans people. That being said, I also think that those with strong views are more likely than those without to let their politics influence their clinical decision making. Someone who goes into this work because they feel strongly about “supporting trans people” or something similar is going to be less likely to push back on someone requesting interventions for inappropriate reasons. It’s not at all obvious that people with strong positive countertransference towards gay and trans people are going to provide better care to those populations. It seems equally if not more probable that they will provide worse care. I think this is something that people need to be aware of if they start seeing this population.

Similarly, although this may be an unpopular thing to bring up given how charged the issue is, I’m sure that there’s a similar issue with some of the OB/GYNs working for places like planned parenthood. I’m sure they’re all well intentioned and most of them are probably great doctors for most of their patients. At the same time, I’m sure there are people in those positions who feel very strongly about abortion rights. That’s fine but if they don’t check their countertranference, sooner or later their counseling is going to wind up pushing some ambivalent pregnant woman towards an abortion she will be worse off because of.

 

[FootballAndSkiing]

 

[GoSpursGo]

Surprise surprise.

 

[Browns99]

Surprise surprise.

Are you still carrying on about who reports the news, my gosh, give it a break. Regardless of who reported it, or who continues to report it, the student either deliberately stuck a patient twice on purpose and should be barred from medicine, or, she did not do it on purpose, but took pleasure in the fact that it occurred, all because someone had opposing beliefs. Behavior like what she exhibited is totally unprofessional and we surely don't want doctors who feel or act that way.

Again, I'm really curious why you are so hung up on Tucker Carlson? Sure, does the media spin things to the right or left, depending on their political philosophy, of course they do.

While debate on SDN should always be encouraged, it nonetheless should be focused on the issue at hand, like what this medical student did. There has been no question as to the validity of her post, so why don't we focus on that and leave the reporting out of it, even if one feels they are misinterpreting/misrepresenting the post.

 

[GoSpursGo]

Are you still carrying on about who reports the news, my gosh, give it a break. Regardless of who reported it, or who continues to report it, the student either deliberately stuck a patient twice on purpose and should be barred from medicine, or, she did not do it on purpose, but took pleasure in the fact that it occurred, all because someone had opposing beliefs. Behavior like what she exhibited is totally unprofessional and we surely don't want doctors who feel or act that way.

Again, I'm really curious why you are so hung up on Tucker Carlson? Sure, does the media spin things to the right or left, depending on their political philosophy, of course they do.

While debate on SDN should always be encouraged, it nonetheless should be focused on the issue at hand, like what this medical student did. There has been no question as to the validity of her post, so why don't we focus on that and leave the reporting out of it, even if one feels they are misinterpreting/misrepresenting the post.

You’ve made your position clear, as have i. But seriously, when someone posts a new article when nothing new has happened I’m not allowed to respond because you think I’m “hung up on the wrong thing?”

 

[futureapppsy2]

Except a lot of gender advocates do miss this. There is a difference between being a gender-affirming provider and being a gender advocate.

Unfortunately, there is an extreme position that holds that gender transition is entirely a personal choice and that providers acting as gatekeepers to medical and surgical interventions is inappropriate. In my city, there is a particular clinic that is notorious for basically taking a person’s stated gender identity as itself an indication for hormones and/or a surgery letter.

As I have alluded to, I have no interest in withholding gender-affirming care from the people it will help. At the same time, these interventions carry real risks of harm and they’re not appropriate for everyone who asks for them.

I think it’s definitely possible to practice good medicine in these areas even if you have strong political views regarding trans people. That being said, I also think that those with strong views are more likely than those without to let their politics influence their clinical decision making. Someone who goes into this work because they feel strongly about “supporting trans people” or something similar is going to be less likely to push back on someone requesting interventions for inappropriate reasons. It’s not at all obvious that people with strong positive countertransference towards gay and trans people are going to provide better care to those populations. It seems equally if not more probable that they will provide worse care. I think this is something that people need to be aware of if they start seeing this population.

Similarly, although this may be an unpopular thing to bring up given how charged the issue is, I’m sure that there’s a similar issue with some of the OB/GYNs working for places like planned parenthood. I’m sure they’re all well intentioned and most of them are probably great doctors for most of their patients. At the same time, I’m sure there are people in those positions who feel very strongly about abortion rights. That’s fine but if they don’t check their countertranference, sooner or later their counseling is going to wind up pushing some ambivalent pregnant woman towards an abortion she will be worse off because of.

I definitely agree countertransference can be an issue with trans treatment, but I think that can be true in both directions. Someone who holds essentialist beliefs about transgender identity—for example, that someone has to demonstrate extreme gender non-conformity as soon as they can talk to be “truly” trans—can just as easily see denying care to trans and non-binary folks as protecting them when it actually causes harm.

I think the issue of co-occurring mental illness and trans-ness is complex. On one hand, I do think there are some cases where people can express mental illness through gender dysphoria/GNC behavior (think BPD or histrionic PD), and cases where adolescents may question their gender identity for a bit but be cisgender. On the other hand, a) we see higher rates of mental illness in LGBTQ+ folks due to minority stress (and we see those rates drop significantly with affirmation, demonstrating a degree of causality) and b) someone can be both mentally ill and legitimately trans. Of course, those cases may require more careful decision-making (e.g., do they only express gender dysphoria when in an acute manic or depressive episode), but having a mental illness and being “actually” trans aren’t mutually exclusive, just like having a mental illness and a legitimate physical illness aren’t mutually exclusive. I worry about a small minority of people seeking or getting inappropriate gender affirming care inappropriately being used to deny care to patients who would benefit greatly from it.

 

[sloop]

I definitely agree countertransference can be an issue with trans treatment, but I think that can be true in both directions. Someone who holds essentialist beliefs about transgender identity—for example, that someone has to demonstrate extreme gender non-conformity as soon as they can talk to be “truly” trans—can just as easily see denying care to trans and non-binary folks as protecting them when it actually causes harm.

I think the issue of co-occurring mental illness and trans-ness is complex. On one hand, I do think there are some cases where people can express mental illness through gender dysphoria/GNC behavior (think BPD or histrionic PD), and cases where adolescents may question their gender identity for a bit but be cisgender. On the other hand, a) we see higher rates of mental illness in LGBTQ+ folks due to minority stress (and we see those rates drop significantly with affirmation, demonstrating a degree of causality) and b) someone can be both mentally ill and legitimately trans. Of course, those cases may require more careful decision-making (e.g., do they only express gender dysphoria when in an acute manic or depressive episode), but having a mental illness and being “actually” trans aren’t mutually exclusive, just like having a mental illness and a legitimate physical illness aren’t mutually exclusive. I worry about a small minority of people seeking or getting inappropriate gender affirming care inappropriately being used to deny care to patients who would benefit greatly from it.

A couple points:

One of your broader points seems to be that providers with negative countertransference towards gay and trans people can cause harm. This is obviously true, but I would also contend that it is a good deal less relevant in the context of providing gender-affirming treatments. The reality is that physicians tend to gravitate to treating populations that they fundamentally like. My experience has been that the people who are doing evaluations for gender dysphoria tend not to be people with simplistic or negative views about gender. They tend to be people who are pretty open about the nature of gender. That is why I brought up the fact that positive countertransference can be a problem—because those are the people who are primarily treating trans people.

I will stay away from the discussion of non-binary gender identity for now, because that is a very complicated issue. All I will say is that I think there are people with legitimate dysphoria due to non-binary gender identity but, in practice, assessing it is very complicated. My experience has been that most of the people identifying as non-binary do not present with a classic gender dysphoria picture and do not have the history that usually accompanies gender dysphoria. Not every trans person with gender dysphoria has a history of cross-gender play behaviors and intensifying body dysphoria as they approach and go through puberty, either, but this seems significantly less common with people identifying as non-binary. My general experience has been that these individuals often develop a sense of their identity later, have less clear ideas about exactly what phenotypic changes would resolve their distress, and have higher rates of comorbid mental illness. In many cases, there's not really a clear answer regarding how to best help these patients. These decisions are made even more difficult by the fact that the idea of non-binary gender identity is relatively recent. Yes, you can say that non-binary people have existed historically, but clinical and research attention to the issue is relatively recent. There really is a paucity of good information about this population and their prognosis with various interventions. By comparison, we have a lot more solid data for binary trans patients.

You make the point that someone can have mental illness and gender dysphoria. I don't disagree with this. I explicitly mentioned this as a possibility in my initial post. If you're making some sort of political point by raising concern that those seeking inappropriate interventions shouldn't be used to deny care (on a systemic or governmental level) to people with legitimate dysphoria, I don't really disagree with this either. I will say, though, that as an individual provider it is your responsibility to figure out who would likely benefit from medical interventions and who would not. Inherent to evaluating someone for any condition that might indicate a certain intervention is some sort of gate-keeping function. Being a good doctor inherently means being willing to deny people inappropriate treatments. That is an essential part of medicine. The fact that most patients seek treatments for appropriate reasons shouldn't really factor into the way you approach patients. The reason is that this is a population-level statement about motives, rather than an individual statement about the patient you are actually seeing. As a general rule, most people asking for antipsychotics are probably asking for it for appropriate reasons. That doesn't mean that you shouldn't be trying to figure out if they're just trying to get high on Seroquel or sell it on the streets. I also think that it is generally good clinical practice to always look for the thing that you don't expect. If someone seems totally believable to you, you should force yourself to at least consider the possibility that they're malingering. If someone seems classically borderline, you should at least consider the possibility that what you're observing is actually an affective illness, etc. Same thing here. As a physician, you're supposed to be looking out for the minority cases rather than just doing a cursory assessment and playing the odds.

 

[futureapppsy2]

A couple points:

One of your broader points seems to be that providers with negative countertransference towards gay and trans people can cause harm. This is obviously true, but I would also contend that it is a good deal less relevant in the context of providing gender-affirming treatments. The reality is that physicians tend to gravitate to treating populations that they fundamentally like. My experience has been that the people who are doing evaluations for gender dysphoria tend not to be people with simplistic or negative views about gender. They tend to be people who are pretty open about the nature of gender. That is why I brought up the fact that positive countertransference can be a problem—because those are the people who are primarily treating trans people.

I will stay away from the discussion of non-binary gender identity for now, because that is a very complicated issue. All I will say is that I think there are people with legitimate dysphoria due to non-binary gender identity but, in practice, assessing it is very complicated. My experience has been that most of the people identifying as non-binary do not present with a classic gender dysphoria picture and do not have the history that usually accompanies gender dysphoria. Not every trans person with gender dysphoria has a history of cross-gender play behaviors and intensifying body dysphoria as they approach and go through puberty, either, but this seems significantly less common with people identifying as non-binary. My general experience has been that these individuals often develop a sense of their identity later, have less clear ideas about exactly what phenotypic changes would resolve their distress, and have higher rates of comorbid mental illness. In many cases, there's not really a clear answer regarding how to best help these patients. These decisions are made even more difficult by the fact that the idea of non-binary gender identity is relatively recent. Yes, you can say that non-binary people have existed historically, but clinical and research attention to the issue is relatively recent. There really is a paucity of good information about this population and their prognosis with various interventions. By comparison, we have a lot more solid data for binary trans patients.

You make the point that someone can have mental illness and gender dysphoria. I don't disagree with this. I explicitly mentioned this as a possibility in my initial post. If you're making some sort of political point by raising concern that those seeking inappropriate interventions shouldn't be used to deny care (on a systemic or governmental level) to people with legitimate dysphoria, I don't really disagree with this either. I will say, though, that as an individual provider it is your responsibility to figure out who would likely benefit from medical interventions and who would not. Inherent to evaluating someone for any condition that might indicate a certain intervention is some sort of gate-keeping function. Being a good doctor inherently means being willing to deny people inappropriate treatments. That is an essential part of medicine. The fact that most patients seek treatments for appropriate reasons shouldn't really factor into the way you approach patients. The reason is that this is a population-level statement about motives, rather than an individual statement about the patient you are actually seeing. As a general rule, most people asking for antipsychotics are probably asking for it for appropriate reasons. That doesn't mean that you shouldn't be trying to figure out if they're just trying to get high on Seroquel or sell it on the streets. I also think that it is generally good clinical practice to always look for the thing that you don't expect. If someone seems totally believable to you, you should force yourself to at least consider the possibility that they're malingering. If someone seems classically borderline, you should at least consider the possibility that what you're observing is actually an affective illness, etc. Same thing here. As a physician, you're supposed to be looking out for the minority cases rather than just doing a cursory assessment and playing the odds.

I don't think we disagree on the point about good assessment of transgender care and needing to do a thorough assessment on all patents seeking this care. I guess my point is that, in gender-affirming care, people often claim "neutrality" for being less affirming or more welded to a "true trans" narrative, and I think it's dangerous to make the assumption that being more conservative is inherently more neutral. Certainly, we shouldn't just prescribe treatment to everyone without doing a good clinical assessment, but we also shouldn't ignore, say, emerging science that suggests that trans and non-binary identities may be more prevalent than previously thought and that treating people with gender-affirming care can have really positive clinical and social outcomes.

I do think we disagree on non-binary identities--there's strong evidence that non-binary identities have always existed, but the social language just wasn't always there to represent them, so people ended up taking it on the chin and addressing it in other ways (e.g., gender non-conformity, transition because the other gender felt closer to their identity, not transitioning and dealing with the dysphoria because their birth gender was closer to their identity, etc). It's kind of like saying that high-functioning ASD didn't exist until we start diagnosing it as Asperger's Syndrome.

 

[sloop]

I don't think we disagree on the point about good assessment of transgender care and needing to do a thorough assessment on all patents seeking this care. I guess my point is that, in gender-affirming care, people often claim "neutrality" for being less affirming or more welded to a "true trans" narrative, and I think it's dangerous to make the assumption that being more conservative is inherently more neutral. Certainly, we shouldn't just prescribe treatment to everyone without doing a good clinical assessment, but we also shouldn't ignore, say, emerging science that suggests that trans and non-binary identities may be more prevalent than previously thought and that treating people with gender-affirming care can have really positive clinical and social outcomes.

I do think we disagree on non-binary identities--there's strong evidence that non-binary identities have always existed, but the social language just wasn't always there to represent them, so people ended up taking it on the chin and addressing it in other ways (e.g., gender non-conformity, transition because the other gender felt closer to their identity, not transitioning and dealing with the dysphoria because their birth gender was closer to their identity, etc). It's kind of like saying that high-functioning ASD didn't exist until we start diagnosing it as Asperger's Syndrome.

I'm not saying that neutrality requires any particular framework for understanding gender identity. I'm saying that treating this population because you have preexisting positive feelings or affinities for the population is not neutral. That is countertransference. I'm not saying people with those feelings can't provide good care in this area. I'm simply saying that they need to recognize that countertransference and be aware of the ways it can negatively impact the care they provide if they lose sight of it. This is one of the fundamental reasons I suggest that people always look for what they don't see in clinical practice, as I mentioned previously.

I also never said that non-binary identities don't exist or that they never existed. I actually said exactly the opposite: "Yes, you can say that non-binary people have existed historically, but clinical and research attention to the issue is relatively recent." The fact is that the research on how binary transgender people fare with interventions when you parse them into a variety of relevant subpopulations with various characteristics is much more robust than for non-binary people. Non-binary people may well have always existed, but I don't understand how you think that the answer to that question is particularly helpful for evaluating and treating patients. The questions relevant to the care of these patients involve things like: their prognosis with and without various treatments, the specific characteristics that portend good or poor response to different treatments, the rates of regret after certain procedures and the characteristics that predict that outcome, the course of gender dysphoria in non-binary patients and how it may differ from binary patients, whether non-binary gender dysphoria actually encapsulates a number of distinct syndromes with different clinical courses, etc. Some of these questions haven't even been adequately answered for binary transgender people, but many of them have been to one degree or another. In comparison, the evidence-base regarding non-binary patients is much smaller and less robust. We really don't know that much about this population, so the idea that there is a clearly correct way to go about treating them seems specious to me. A lot of the common recommendations include things like being non-judgmental, curious about their experiences, understanding of their difficulties, etc. That is all well and good, but those recommendations are very non-specific, could be applied to virtually any population, and are mostly speculative recommendations based on qualitative statements made by patients rather than particularly evidence-based. Again, I'm not saying that we shouldn't do those things. I'm just saying that, if that's as concrete as the guidance gets, we clearly don't have a great idea of how to best treat these people.

 

[Dr Meow]

Looks like cancel culture to me.
I didn't read the twitter post in its actuality until now.

The post can be interpreted any number of ways.
is this what is come down to? Ruining people's lives over an ambiguous post?

Of course, this is still unprofessional. But you can't apply "guilty until proven innocent" rules to social media
There's also the possibility that none of this happened at all and egotistical people can embellish imaginary stories to an overworked and burnt out ego. WHO KNOWS?!?!

Basically, the rule is: Social media has evolved into any excuse to apply cancel culture based on words that are taken literally without need for physical evidence and that the very act of being in the spotlight is guilt in and of itself.

 

[Acapedia]

I don't know, reading her tweet, it doesn't say she did this on purpose. Although, her language is a little suspicious. That said I have missed so many veins and had to try again..... Maybe she didn't mean it in the way it sounded. I hope so anyway!

 

[VA Hopeful Dr]

I don't know, reading her tweet, it doesn't say she did this on purpose. Although, her language is a little suspicious. That said I have missed so many veins and had to try again..... Maybe she didn't mean it in the way it sounded. I hope so anyway!

I'll quote myself from earlier in the thread:

And even if we give the most generous interpretation possible which is that she genuinely just missed the vein the first time (which certainly can happen), that tweet makes it pretty clear that she's at best not sorry that it happened and at worst pleased that the patient had to get stuck twice.

If she doesn't get expelled for this she should thank whoever made that decision on bended knee.

 

[Billiam95]

Looks like cancel culture to me.
I didn't read the twitter post in its actuality until now.

The post can be interpreted any number of ways.
is this what is come down to? Ruining people's lives over an ambiguous post?

Of course, this is still unprofessional. But you can't apply "guilty until proven innocent" rules to social media
There's also the possibility that none of this happened at all and egotistical people can embellish imaginary stories to an overworked and burnt out ego. WHO KNOWS?!?!

Basically, the rule is: Social media has evolved into any excuse to apply cancel culture based on words that are taken literally without need for physical evidence and that the very act of being in the spotlight is guilt in and of itself.

If a cis, white male medical student implied he missed a vein on purpose because the patient wore a pronoun pin, the student have been expelled yesterday - and rightfully so. Code of conduct standards should be applied equally, regardless of political affiliation.

 

[Dr Meow]

If a cis, white male medical student implied he missed a vein on purpose because the patient wore a pronoun pin, the student have been expelled yesterday - and rightfully so. Code of conduct standards should be applied equally, regardless of political affiliation.

Politics shouldn't be mixed in.
This is purely a matter of claim vs. evidence. Implications aren't evidence. Though from her post, even the implication is barely there. Really looking at interpreting clouds here and the clouds look like an elephant to me, maybe it's a lion.

 

[Browns99]

Politics shouldn't be mixed in.
This is purely a matter of claim vs. evidence. Implications aren't evidence. Though from her post, even the implication is barely there. Really looking at interpreting clouds here and the clouds look like an elephant to me, maybe it's a lion.

Regardless of whether she purposefully did it or not, her post at a minimum, suggests she was all too happy that it happened all because the patient had a different belief than she does. It was unprofessional discussing a patient on SM to begin with, and one has to wonder if she is predisposed to acting out again in the future when she comes across a patient that does not share her beliefs and trust me, she will.

 

[Dr Meow]

Regardless of whether she purposefully did it or not, her post at a minimum, suggests she was all too happy that happened all because the patient had a different belief than she does. It was unprofessional discussing a patient on SM to begin with, and one has to wonder if she is predisposed to acting out again in the future when she comes across a patient that does not share her beliefs and trust me, she will.

Unprofessional yes. Though she didn't give enough info to violate HIPPA.

Predisposed?
Should you or the public be making diagnoses based on an ambiguous isolated social media incident? Is this really an informed judgement? Why should "trust" in your words be taken as evidence?

People are applying slippery slope fallacies willy nilly.

 

[Billiam95]

Unprofessional yes. Though she didn't give enough info to violate HIPPA.

Predisposed?
Should you or the public be making diagnoses based on an ambiguous isolated social media incident? Is this really an informed judgement? Why should "trust" in your words be taken as evidence?

People are applying slippery slope fallacies willy nilly.

The argument that most are making here don't involve HIPPA violations - she obviously did not, imo.

Instead, the primary question is, 'does implying that she intentionally double stick a patient (or, at best, take pleasure in a patient having to be double stuck) on social media due to differing political beliefs constitute a severe enough professional transgression to warrant expulsion?'

 

[Goro]

If a cis, white male medical student implied he thought it was karma that the patient got stuck a second time because the patient wore a pronoun pin, the student have been expelled yesterday.

1) FTF
2) Reread VA Hopeful's last post.
3) Sadly, I would predict the above would happen

 

[Redpancreas]

If a cis, white male medical student implied he missed a vein on purpose because the patient wore a pronoun pin, the student have been expelled yesterday - and rightfully so. Code of conduct standards should be applied equally, regardless of political affiliation.

This is not an equivalent comparison.

If any medical student said a patient with a pronoun pin deserves to get poked twice they should receive a harsher penalty than Kychelle because they are:

1.) Doing what Kychelle did.
AND
2.) Demonstrating malcontent towards those who support transgender people.

Last time I checked, discrimination on basis of sex or gender was wrong as is broadcasting or promoting that. There’s no reason to make the demographics of the perpetrator the central issue.

 

[Billiam95]

This is not an equivalent comparison.

If any medical student said a patient with a pronoun pin deserves to get poked twice they should receive a harsher penalty than Kychelle because they are:

1.) Doing what Kychelle did.
AND
2.) Demonstrating malcontent towards those who support transgender people.

Last time I checked, discrimination on basis of sex or gender was wrong as is broadcasting or promoting that. There’s no reason to make the demographics of the perpetrator the central issue.

Rules for thee but not for me

 

[FootballAndSkiing]

How is "demonstrating malcontent towards those who support transgender people" different than demonstrating malcontent towards those who don't support transgender people?

 

[RangerBob]

This is not an equivalent comparison.

If any medical student said a patient with a pronoun pin deserves to get poked twice they should receive a harsher penalty than Kychelle because they are:

1.) Doing what Kychelle did.
AND
2.) Demonstrating malcontent towards those who support transgender people.

Last time I checked, discrimination on basis of sex or gender was wrong as is broadcasting or promoting that. There’s no reason to make the demographics of the perpetrator the central issue.

Transgender patients deserve the extra protection (just as racial/religious minorities who have also traditionally been marginalized do), but I don’t think a person’s support for transgender rights earn them any additional protection compared to those who don’t support those rights.

We’re all allowed to have beliefs. But we can’t infringe on others essential rights based on our beliefs.

 

[GoSpursGo]

How is "demonstrating malcontent towards those who support transgender people" different than demonstrating malcontent towards those who don't support transgender people?

This seems like a good time to remind everyone that SDN specifically supports diversity, including in gender and sexual orientation, in our Terms of Service.

Not that I think this counterfactual proves or disproves that the student deserves or doesn't deserve any specific punishment, and there is plenty of room to "support" transgender people without ascribing to the most liberal interpretation. But outright supporting discrimination against transgender people would not be OK.

So let's tread lightly with this counterfactual, folks.

 

[FootballAndSkiing]

This seems like a good time to remind everyone that SDN specifically supports diversity, including in gender and sexual orientation, in our Terms of Service.

How was my post the comment that made you issue the reminder? The point I was trying to make is that its not OK to demonstrate malcontent to anyone, whether you agree with their politics or not.

 

[sloop]

This seems like a good time to remind everyone that SDN specifically supports diversity, including in gender and sexual orientation, in our Terms of Service.

Not that I think this counterfactual proves or disproves that the student deserves or doesn't deserve any specific punishment, and there is plenty of room to "support" transgender people without ascribing to the most liberal interpretation. But outright supporting discrimination against transgender people would not be OK.

So let's tread lightly with this counterfactual, folks.

I have to say that I’m pretty confused by this invocation of the Terms of Service. Do you mean to imply that someone saying that it is wrong to revel in the pain of a patient whether that patient is trans or transphobic is somehow being unsupportive of diversity?

 

[GoSpursGo]

How was my post the comment that made you issue the reminder? The point I was trying to make is that its not OK to demonstrate malcontent to anyone, whether you agree with their politics or not.

Just explicitly—if someone signals that they don’t support trans people, that shouldn’t be tolerated. Doesn’t mean I want them to get stabbed by a needle, or harmed in any way, and of course I would not recommend speaking out in a clinical setting in response to a patient who reveals that bias.

But supporting trans people and not supporting trans people should not be seen as equally valid positions. So while I think it’s clear what you meant, I do think we should be careful in where the discussion goes.