STAT’s "First Opinion" platform serves as a vital forum for insightful, illuminating, and provocative discourse within the life sciences. It is a space where biotechnology insiders, healthcare professionals, researchers, and other experts share their perspectives on a wide array of critical issues shaping the future of health and medicine. To foster robust and good-faith dialogue, STAT thoughtfully publishes selected Letters to the Editor in response to these essays, offering a platform for diverse viewpoints and further analysis.
The following compilation presents a curated selection of these exchanges, highlighting key debates and expert opinions on pressing healthcare challenges, from the primary care paradox and the complexities of gender-affirming care to the classification of obesity, the screening of young athletes, and the critical role of physicians in medical emergencies.
The Primary Care Crisis: A Paradox of Underinvestment and Undervalued Expertise
A foundational essay, "The primary care crisis paradox," authored by Christopher P. Childers and Thomas C. Tsai, ignited a significant response, underscoring the intricate relationship between primary care and specialty services. The authors argued that the nation’s healthcare challenges cannot be resolved by viewing primary care and specialty care as mutually exclusive choices, asserting that patients require both for comprehensive well-being. They highlighted the necessity of a trusted primary care physician for ongoing management of chronic conditions like diabetes, while acknowledging the indispensable role of specialists for addressing acute complications. Similarly, pediatricians are crucial for monitoring child development and identifying the need for specialized interventions.
The response, penned by Sarah Nosal, M.D., president of the American Academy of Family Physicians; Jan Carney, M.D., M.P.H., president of the American College of Physicians; and Andrew Racine, M.D., Ph.D., president of the American Academy of Pediatrics, echoed this sentiment. They emphasized the shared concern among family physicians, pediatricians, and internal medicine physicians regarding outdated Medicare physician payment policies and budget neutrality rules. These policies, they contended, have a ripple effect, influencing reimbursement rates from other payers, including Medicaid, which is the primary source of health coverage for children in the United States. The signatories stressed that building a healthcare system that values primary care while ensuring timely access to specialized services is not a zero-sum game.
The evidence supporting the efficacy of primary care is substantial. Adults with a usual source of primary care are significantly more likely to receive recommended preventive services for chronic diseases, with rates reaching 95.5% compared to 67.6% for those without such a connection. Children with a consistent primary care clinician are also more likely to receive vital preventive care, including immunizations and behavioral health screenings, enabling early detection of potential issues. Furthermore, robust data links having a usual source of primary care to a reduction in emergency department visits and hospitalizations – an 11% decrease for adults and a 50% reduction for children. These visits are also associated with substantially lower healthcare costs, approximately 54% lower for adults with chronic diseases and nearly 40% lower for children. Additional research indicates that each primary care visit is linked to roughly $700 in lower healthcare costs, and continuity of care can reduce overall spending by up to 10%.
These statistics translate into tangible benefits for patients, including those with a family history of cancer requiring regular screenings, parents ensuring their children receive timely vaccinations, and families avoiding the stress and financial burden of preventable emergency room visits due to established relationships with primary care physicians. Despite the United States spending more on healthcare than other developed nations, outcomes often fall short. This reality, the authors argued, necessitates an honest, data-driven conversation about the factors contributing to healthier lives, extending beyond physician payment to encompass nutrition, physical activity, housing, behavioral health, and parental support – all social determinants of health that profoundly influence well-being long before a patient seeks medical attention.
While primary care is not the sole solution to America’s health challenges, it represents one of the most impactful investments for early illness detection and cost reduction. Concurrently, patients with complex conditions such as cancer, kidney disease, and severe heart disease must have unimpeded access to specialized care. The authors concluded that a collaborative approach, moving beyond policies and narratives that create artificial divisions between specialties, is essential. Comprehensive payment reform that strengthens primary care, prioritizes patients, and addresses upstream health determinants is crucial.
Jeffrey Millstein of Penn Medicine offered a nuanced counterpoint, suggesting that the original essay misrepresented the rationale for increased primary care investment. While acknowledging the importance of the data presented, Millstein argued that the focus on primary care as the "sole lever that moves population health" overlooks other critical factors. He emphasized that the true value of primary care lies not just in population health metrics, but in addressing fragmented care, poor time-sensitive access, and overwhelming workloads that diminish clinical efficacy and sustainability for primary care physicians (PCPs). MedPac data, he noted, indicates that Medicare patients generally have favorable access to PCPs, with most able to see their doctor within two weeks for wellness exams and routine follow-ups. However, this timeframe is often insufficient for acute illnesses, leading patients to costly urgent care centers and overcrowded emergency rooms, thereby disrupting continuity of care. The pressure to see more patients in less time, coupled with administrative burdens, erodes PCPs’ capacity for thoughtful patient evaluation and care, resulting in an increase in non-essential referrals to already strained specialists. Millstein advocated for payment reform as a means of fairly compensating cognitive work, thereby revitalizing primary care, expanding the workforce, and enhancing continuity, which in turn would improve specialty access for those genuinely in need. He concluded that primary and specialty care are interdependent, and patients require both.
Debating Gender-Affirming Care: Evidence, Ethics, and Advocacy
Kavitha Ranganathan’s essay, "Banning gender-affirming care doesn’t protect children – it makes it harder to help them," spurred a direct response from the Society for Evidence-Based Gender Medicine (SEGM). William Malone, representing SEGM, refuted the characterization of his organization as an "anti-trans group." He clarified that SEGM is a nonprofit dedicated to advancing evidence-based medical care for children, adolescents, and young adults with gender dysphoria. Their work, he stated, involves evaluating scientific literature, conducting systematic reviews, assessing clinical practice guidelines, and promoting higher-quality research in a field where significant questions remain unanswered. SEGM collaborates with international researchers and clinicians who, despite differing views on clinical practice, share a commitment to improving the evidence base for patient care.
Malone asserted that SEGM rejects the notion of being "anti-trans," emphasizing their belief in the dignity, compassion, and respect due to all individuals. Their focus, he explained, is on the scientific evidence underlying medical interventions and the rigorous evaluation of that evidence, rather than engaging in broader political or ideological debates. SEGM advocates for compassionate care for young people experiencing gender dysphoria, informed by the best available evidence, with transparent discussion of both benefits and risks. They argue that where uncertainty exists, the appropriate response is to strengthen the evidence through ethical research, not to suppress scientific debate. The conflation of scientific inquiry with political advocacy, Malone contended, is a mischaracterization. Medicine, he stressed, advances through continuous testing of assumptions, critical appraisal of research, and open debate about the strength and limitations of evidence. These principles, foundational to evidence-based medicine, should be applied consistently across all fields, including pediatric gender medicine. SEGM’s ultimate goal, Malone concluded, aligns with that of many clinicians and researchers: to improve the quality of research and clinical care for young people with gender dysphoria. This requires open scientific inquiry, respectful dialogue, and a commitment to following the evidence. Mischaracterizing scientific inquiry as prejudice, he warned, undermines this effort and hinders constructive dialogue, ultimately failing both patients and the advancement of evidence-based care.
A brief, supportive response from Karen Kinsell, M.D., lauded Ranganathan’s article as "great, well-written, informative, and persuasive," expressing hope that it would "help move the needle" and emphasizing that their practice is for patients, not the government.
The Disease Classification of Obesity: Commercial Interests and Clinical Realities
Max Moser’s essay, "Who benefits from classifying obesity as a disease?", ignited a debate about the implications of this classification, particularly in light of advancements in pharmacotherapy. Sera Ramadan, an independent obesity doctor, countered the author’s premise, emphasizing the necessity of a comprehensive approach that includes pharmacological intervention for patient success. She described "food noise" as a well-documented dopamine reward circuit, akin to addiction, and stated that without GLP-1s, many patients struggle with consistency in their weight loss plans. For obesity, a condition leading to serious comorbidities like diabetes and heart disease, patients should be empowered to utilize all available tools to prevent and reverse the disease.
Ramadan directly addressed the author’s question about who benefits, asserting that commercial incentives do not distort the disease framing. She pointed to the American Medical Association’s declaration of obesity as a disease in 2013, years before the prominence of GLP-1s, and the World Health Organization’s classification of it as a chronic disease in 1997, demonstrating that the disease framing predates the commercial windfall by decades. This timeline, she argued, refutes the notion that commercial interests are the primary drivers. Ramadan also refuted the false dichotomy between disease framing and behavioral or environmental approaches, noting that major clinical guidelines frame pharmacotherapy as an adjunct, not a replacement, for lifestyle and environmental interventions. She criticized the assertion that disease framing diverts resources, stating that there is no evidence of clinicians or guidelines abandoning these approaches. In her practice, Ramadan advocates for access to all possible tools, viewing healthcare as a personalized approach. For many patients, GLP-1s are an integral part of a holistic regimen that includes environmental and lifestyle changes.
Ramadan further argued that disease classification influences insurance coverage. Classifying obesity as a disease not only makes clinical sense but also facilitates insurance coverage for medications. From a health equity standpoint, she supports disease framing and the subsequent commercial incentives that improve health outcomes and save lives.
Wayne Ho, representing The Obesity Society, the American Diabetes Association, and USC Keck School of Medicine, echoed some of Ramadan’s points while offering his own clinical perspective. Ho stated his views were formed not in boardrooms but in exam rooms, caring for patients whose lives were shaped by obesity long before effective medications existed. This clinical experience, he explained, led him to become an obesity medicine specialist and advocate for comprehensive care. He cited Medicare’s coverage for bariatric surgery in 2006, which implicitly assumed obesity to be a disease with significant complication risks, as further evidence against commercial motivation driving the designation.
Ho agreed with the author that obesity’s disease classification has clinical, political, risk, and self-conception implications. However, he refuted the perceived emphasis on pharmacologic therapy as the sole treatment, reiterating that it is one component of comprehensive obesity care, alongside nutrition, physical activity, and bariatric surgery. Concerns about the risk implications of GLP-1 medications were also addressed. Ho likened obesity to other chronic diseases like hypertension, diabetes, and heart failure, where symptom recurrence after stopping medication is expected. He argued that concerns about counterfeit products and off-label cosmetic use do not invalidate the appropriate, evidence-based prescribing of GLP-1 medications for obesity, drawing a parallel to prescription opioids for acute pain.
Regarding the self-perception argument, Ho found it unconvincing, noting that patients often believe they can maintain weight loss without medication after achieving it. However, due to the chronic nature of obesity, biological processes resume upon treatment cessation, leading to weight regain. Ho concluded that obesity’s disease framing is not the cause but part of the solution, alongside improved access to effective medication and lifestyle counseling. He pointed to market analyses predicting GLP-1s’ significant impact on the cardiovascular and metabolic disorders market, suggesting that if such opportunities extend beyond obesity and diabetes, the disease classification of other conditions might also be questioned.
Florida’s EKG Mandate for Athletes: A Debate on Prevention and Cost
Katherine Hofmann’s essay, "Florida is the first state to require EKGs for high school athletes. This is a mistake," presented a critical perspective on the state’s new law mandating electrocardiograms (EKGs) for high school athletes. Martha Lopez-Anderson of Parent Heart Watch responded, asserting that while no single screening tool is perfect, relying solely on medical history and physical evaluation leaves too many young people with undetected heart conditions. She highlighted that sudden cardiac arrest (SCA) is the leading medical cause of death in young athletes, and most associated heart conditions are silent, often lacking symptoms or family history, and passing annual sports physicals without raising suspicion. An EKG, Lopez-Anderson argued, complements medical history and physical evaluations by identifying abnormalities that would otherwise go undetected.
Lopez-Anderson cited statistics indicating that approximately 23,000 children under 18 experience out-of-hospital cardiac arrest annually, and 75% of fatalities in sports among NCAA athletes are cardiovascular-related. She acknowledged concerns about false positives, unnecessary testing, and cost but argued these must be weighed against current realities. The International Criteria for ECG Interpretation in Athletes has reportedly reduced false-positive rates to approximately 3% when interpreted by proficient physicians. While Black athletes may have a higher false-positive rate, they also face a significantly higher risk of sudden cardiac death, with Black NCAA basketball players exhibiting a 21-fold higher rate than the average high school athlete. The law, she noted, requires affordability and physician proficiency in these international criteria.
Lopez-Anderson questioned whether continuing with a standard of care that misses the majority of serious heart conditions in young athletes is acceptable when a safe, inexpensive, noninvasive test can identify many of them before tragedy strikes. She detailed the collaborative process leading to Florida’s Second Chance Act, named in honor of Chance Gainer, as a thoughtful effort to identify hidden heart conditions. Lopez-Anderson contended that suggestions of inequity overlook the populations most affected, citing higher rates of SCA among Black youth, lower likelihood of bystander CPR and AED intervention, and consequently, lower survival rates. These disparities, she noted, were among the reasons the Congressional Black Caucus supported the law. She concluded that every child identified before a catastrophe underscores that statistics represent real people, and thoughtful debate should be grounded in current evidence and the shared goal of protecting young athletes.
The Unsung Heroes of the Skies: Physicians on Call
Sriman Swarup’s essay, "Is there a doctor on board? Yes, and airlines depend on it," shed light on the critical role physicians play during in-flight medical emergencies. The responses highlighted both the willingness of physicians to assist and the inconsistencies in airline protocols and appreciation. Peter David Miller shared his experiences responding to in-flight medical calls, noting a lack of gratitude from airline staff. He recounted instances where the emergency medical kit was refused due to anticipated paperwork and where his medical license, presented on his iPhone, was met with skepticism. Despite averting a diversion over Brazil and offering his services, he has never been thanked or offered even frequent flyer miles, leading him to offer his assistance "reluctantly."
Irv Loh, M.D., of Ventura Heart Institute, supported Swarup’s observations, confirming that he and other healthcare professionals have occasionally stepped in to assist during in-flight medical situations, and their help has "always been appreciated." Loh suggested that some structure to the process would enhance the current system and welcomed any recommendations from Swarup.
Alzheimer’s Diagnosis: The Specialist’s Blind Spot and the Limitations of Current Tools
Elizabeth Bevins’ essay, "I’m an Alzheimer’s specialist. I still missed it in my own father," explored the personal and systemic challenges in diagnosing Alzheimer’s disease. Adrian Owen of the University of Western Ontario offered a perspective that extended Bevins’ argument further back, to the limitations of the diagnostic tools themselves. Owen agreed with Bevins that the system often waits for unmistakable decline, but he argued that the instruments used were built to find the disease at precisely the stage where intervention is already difficult.
Owen explained his work with patients diagnosed as vegetative, where the assumption of a lack of awareness proved incorrect for a significant minority whose brains generated signals not detectable by existing methods. These signals were often intermittent, fluctuating, and difficult to capture with current technology. He drew a parallel to early Alzheimer’s disease and mild cognitive impairment, which also manifest inconsistently as occasional lapses, changes in attention or reasoning that are difficult to pinpoint, an increased reliance on routines, or a spouse’s vague but persistent sense that something has changed. Bevins’ father, Owen noted, passed a screening test not designed to detect these subtle early signs but rather to identify dementia once impairment was obvious and stable.
This inconsistency, Owen argued, also limits the utility of blood-based biomarkers. While identifying amyloid years before symptoms appear indicates a pathological process, it does not reveal whether that process has begun to affect the individual – the very question Bevins’ mother raised. Owen concluded that if the cognitive assessment accompanying blood tests cannot differentiate early impairment from an ordinary bad day, advancements in detection will not translate into a better understanding or tracking of how and when these early changes become significant. He emphasized that the field has long mistaken the limits of its tests for the nature of the disease. To achieve earlier intervention, Owen stressed the need to measure cognition as sensitively as the biology demands.
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