They once tried to prove that DNPs (Doctorate of Nurse Practitioner) was just as good as an MD or DO education. They did this by taking the top DNP grads from the best programs and gave them a dumbed down version of the easiest part of the medical license exam, and only 40% passed it.

For context, to get a medical license, a physician has to have passed Steps 1-3 of the USMLE (US Medical License Exam) or Levels 1-3 of COMLEX (Comprehensive Osteopathic Medical Licensing Exam) to be eligible to apply for a medical license. Step/Level 2 is usually considered the hardest one of the three, and Step/Level 3 is the longest exam (2 full days), but generally considered to be the easiest. This DNP exam took the easiest 20% of questions from Step 3 and made a half-length version of the exam…and 60% of the DNPs still failed it.

The NP/DNP education is almost entirely algorithm-based and doesn’t meaningfully get into the anatomy, physiology, pathophysiology, and pharmacology that the first 2 years of medical school are devoted to. I have seen NPs miss life-threatening diagnoses because they were rare diseases that don’t come up outside of those first 2 years of drinking from a firehose of textbooks in medical school. Their education just isn’t long enough or in-depth enough to actually be equivalent to an MD or DO degree.

Also, MDs and DOs have almost 4000 hours of supervised medical practice where a physician is checking their work and directly observing or guiding their clinical experience before finishing medical school. Residency is, at minimum, another 8000 to 10000 hours of supervised practice in the specialties that only require 3 years of residency (it ranges from 3 to 9 years based on specialty).

NPs don’t have any standardized requirements for supervised practice to get their licenses and most programs only require 1000 hours or less of shadowing where they are just observing a licensed NP practice and not actually doing anything hands-on themselves… And they try to argue that this education is sufficient for them to be equal to physicians. There are some NPs who are amazing providers, but they’re usually the ones that were bedside nurses for 10+ years before going back to school for their NP license. The newer NPs that are going straight through from their BSN without any actual experience are the really dangerous ones.

TO BE CLEAR: I love the nurses I work with and I value their work and their input immensely. I was an EMT/ER tech before med school and it’s really sad when nurses are so confused when I help them clean up patients or reposition or whatever as a med student because most physicians and medical students don’t stop to help the nurses clean up poop. You can always tell which physicians have never had to clean up poop before, and I try very hard not to be like them.

Actually, the problem is the number of residencies. Once you graduate from medical school, you MUST complete an accredited residency program to be able to practice independently. The number of residency programs is controlled by Congress because residencies are funded through Medicare, and the last substantial increase in the number of residencies was when they added 1000 more in the Covid Omnibus bill.

It’s actually a growing crisis because more medical schools are opening and existing ones are increasing their class sizes, but the number of residencies isn’t keeping pace. This means that more and more people are going to be medical graduates with no way of obtaining a medical license without a residency and therefore no way to pay off their student loans. There’s a couple stories every year about medical graduates that couldn’t get into residency or couldn’t complete residency that end up dying by suicide, but it gets pretty effectively swept under the rug.

So we should ban every cleaning product, gasoline, diesel, basically every other fluid that goes into a car, potting soil, fertilizers, every item that can be used as a weapon, every actual weapon, and water because those can all be used to harm oneself?

Your argument here boils down to “either everything needs to be completely freely accessible to everyone with no restrictions or every substance on the planet needs to be confiscated and controlled because people could use something to harm themselves”…and I’m only exaggerating your position by a smidge.

Do you also think the FDA should stop having standards for food and drugs? After all, if people want cheaper weight loss supplements, they’re way cheaper to manufacture if they’re contaminated with lead and toxic substitutes for the advertised herbal ingredients.

Bleach and ammonia are cleaning chemicals that were never intended for human consumption, not OTC medications. Nicotine should be banned entirely, and ethanol needs to be heavily reined in, but again, they are not OTC medications.

Besides acetaminophen (Tylenol) which I have already addressed as being problematic in its packaging and advertising, which other OTC medications are you talking about?

Here’s a list of medications that are available OTC (and not behind the pharmacy counter) that I think should be more restricted in terms of packaging, quantity limits, or accessibility (i.e. put them behind the counter with the Sudafed so they’re available without a prescription, but there’s a strict limit on how much you can buy.)

• Acetaminophen/Tylenol
• Diphenhydramine/Benadryl (and the “PM” version of other medications)
• NyQuil/DayQuil/Robitussin (and other cocktail medications that contain more than 2 active ingredients)
• Oxymetazoline/Afrin
• Aspirin
• Excedrin
• Ibuprofen/Naproxen/Motrin/Aleve

Among many, many others.

There’s also a huge list of vitamins and supplements that shouldn’t be as freely available in such high doses, and others that shouldn’t be allowed at all because of safety risks. Not to mention the fact that a bunch of energy drinks out there contain enough caffeine in a single can to cross the threshold of caffeine toxicity if consumed in under an hour. (Celsius is a good example)

I think that uneducated or gullible people deserve full bodily autonomy, even if that means bad results from their choices.

There is a difference between safety regulation and paternalism that I think you are failing to parse. As a society, we share a collective responsibility to build safeguards and fail-safes into the structures of our environment for the protection of those among us that need help. Unfettered freedom and rugged individualism with “full bodily autonomy” is a recipe for disaster.

many countries have OTC HRT and do not have significantly higher morbidity or mortality rates

And many of those countries have wildly different healthcare systems and health culture. The American population is so utterly bombarded with misinformation (including from our own government and regulatory bodies now) that I don’t see phenomena or results from other countries as fully applicable to Americans. There are tons of studies about vastly different outcomes of treatments or interventions in other countries (especially Scandinavian countries) that I do not apply to my clinical practice because a lot of those results are heavily confounded by factors that the study doesn’t account for like cultural diet, healthcare access, amelioration of poverty, and genetics that would skew the results into uselessness in America. So, I’d love to get a list of these countries you’re talking about because if they’re civilized countries with accessible healthcare, it’s not even an apples to oranges comparison; more like apples to chunks of concrete.

Elsewhere in this thread I talked about a couple patients I have actually treated. One was a woman in her 60’s that got mystery doses of estrogen from implanted pellets that now has to take blood thinners for the rest of her life because she got a DVT and pulmonary embolism because of the excessive estrogen. She’s also at much higher risk for uterine and breast cancer too. Another was a man in his 50’s that had to get coronary stents and start a pile of medications to try to mitigate his heart and liver damage from taking the doses of testosterone recommended by body building influencers. I actually care about HIPAA, so I won’t be giving you any more specific information about these cases.

It really isn’t the trans folks I’m worried about when it comes to HRT, but if it’s freely available to trans folks, that means it’s also freely available to cis folks that are more likely to do it wrong and suffer severe consequences.

I am concerned for the population at large, and unfortunately, safety regulations have to account for the lowest common denominator unless you think that uneducated or gullible people deserve to suffer. Prescriptions are a way to make sure that people are getting the medications they need in the appropriate doses for the correct indications. There’s enough trouble with people hurting themselves with the medications that are already OTC. I don’t think more OTCs (HRT or otherwise) are a particularly good fix for the disaster that is American healthcare.

I think you are severely underestimating how much education is actually required to fully understand how medications work and how they can interact with each other. The internet is full of quack grifters like the “Hims” and “Hers” sites that will give people unregulated compounded semaglutide (that doesn’t undergo actual health inspections) to people that are likely to be seriously harmed by it because they don’t do their due diligence of actually screening for comorbid conditions that could lead to serious health consequences.

I just got home from a shift at the hospital where two medical students, two resident physicians, and an attending physician couldn’t find the information on how to adjust dosing for a couple of medications to prevent dangerous interactions so we had to go ask the pharmacist. She responded with more questions about the patient’s clinical condition so that she could give us appropriate recommendations. If we had gotten that medication combination wrong, our patient could have easily ended up with a pulmonary embolism or a stroke.

Point being: even physicians have to phone a friend to figure out medication safety sometimes and I do not think it’s reasonable to put the responsibility of medication safety on patients who don’t have over a decade of study and training to know what the risks are.

On the other hand, when I’ve worked in emergency departments I’ve seen patients that have been severely harmed by medications that they got on their own. A perfect example was the man that thought he had a rare parasite from a continent he had never been to because Chat GPT told him so and it also told him that the treatment for that parasite is Ivermectin. He went and got the horse paste version from Tractor Supply and turned up in our emergency department with fulminant liver failure because he didn’t know how to do the dose conversion correctly (and didn’t know the safe human dosing anyways).

Your model of “total bodily autonomy” with every medication being OTC would drastically worsen the Darwinian hell caused by medical misinformation. I don’t want to see my patients harmed by dangerous medications even if I wasn’t the one that prescribed it.

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I also said that many OTC medications need to be more strictly regulated. The American capitalistic approach to marketing drugs is obscene and needs to be heavily reigned in. HRT is not a special category of medication because every substance that has a desired effect also has side effects that need to be considered. Acetaminophen (aka paracetamol or Tylenol) in other countries is regulated similar to how pseudoephedrine (Sudafed) is regulated as in needing to get it from the pharmacist in limited quantities in individual blister packs. It is absurd how poorly controlled dangerous medications are in this country, but it’s unlikely that will ever change because of the attitudes of American individualism and pharma lobbying groups.

Does my ethical autonomy count for nothing? Am I really obligated under your worldview to harm my patients by acquiescing to their demands carte blanche?

Even as a medical student, I have had patients die in my care from things I couldn’t do anything about. I had no way to save them because the medicine to fix the problem simply does not exist. As an ER tech, I have had multiple times where the physician running the code called the time of death while I was the one doing compressions on the patient. Most of those were children. I am already haunted by the patients I have lost through no malpractice, negligence, incompetence, or malice of my own. I refuse to intentionally add to my nightmares by doing something that I truly believe would harm my patient, even if it is what they are asking for.

To be clear: I am not saying this about HRT specifically because, most of the time, HRT is safe when dosed appropriately.

That being said, if I think a medication is going to be dangerous, harmful, or lethal to a patient and I prescribe it anyways, I am legally and morally liable for any harm that comes to them from that medication. I have had conversations with patients about weight loss drugs that they really want, but that would be extremely dangerous based on other comorbid conditions like heart problems or pancreas issues. If a patient asks me for something that I think is unsafe, I engage them in a discussion about why they want that medication, the risks and benefits of it, and possible alternatives that could be safer. If a patient is dead-set on getting a medication that is very likely to harm them, I’m not going to write that prescription because if the worst happened, their blood is on my hands.

It is very uncommon that physicians refuse to prescribe something that a patient is asking for specifically. The much more common situation ends up being that the physician can write the prescription, but insurance won’t pay for it. There are obviously some physicians out there that refuse to prescribe things like birth control based on their personal beliefs, but they are obligated to refer that patient to a provider that will give them the prescription.

It isn’t the cis kids I worry about. It’s the menopausal woman in the emergency department with a DVT and PE from the estrogen she got online on the advice of her chiropractor. It’s the man in his 50’s that thought testosterone would fix his lost libido and fatigue that now has to get coronary artery stents because he got his dosing recommendations from body building influencers.

It’s the real patients I have seen and treated that concern me when these hormones aren’t even that freely available. It’s not a hypothetical for me, it’s real people that have suffered real harm even if they didn’t die from it.

HRT is extremely safe when dosed appropriately. As I said in another comment, I’m less worried about trans folks getting the HRT wrong than cis people taking a bunch of extra hormones because some influencer convinced them that more estrogen or more testosterone will fix all their health problems. Making something OTC makes it available to everyone, not just the people that need it. Trans people need HRT, cis people very rarely do.

As a soon-to-be physician that has sought training in trans healthcare, I do not see my role as gatekeeper, but the role of educator includes teaching about and monitoring for the risks and complications that can come from HRT. Estrogen and Testosterone are both powerful and potentially dangerous hormones and I do not want to see my trans patients dying from strokes or heart attacks that could have been prevented with more careful dosing of their HRT.

In countries besides America, Tylenol comes in blister packs of maybe 20 total pills per package in a lower dose than the American variation. The drug and marketing regulations here are not a good example and I think a lot of medications that are currently OTC need to be much more closely regulated or have things like the inconvenient packaging and MUCH better warnings on them for patient safety.

That being said, poorly managed (or un-managed) HRT has more potential for significant harm than most OTC medications. There are many complications that can come from exogenous hormone treatment for both trans and cis patients, and the risks need to be adequately assessed and managed. Estrogen significantly increases the risk of blood clots and strokes, and Testosterone drastically increases the risk of heart attack and organ failure if not dosed appropriately.

In no way do I intend to restrict trans healthcare, but most medications on the market in America need to be much more closely regulated than they are now because of the risks of harms that can vastly outweigh the benefits, especially when not dosed or monitored accurately.

I am very glad that you were able to get your own care and didn’t have any bad outcomes. On the other hand, I’ve had cis-female patients go to naturopaths or chiropractors to get estrogen and/or testosterone pellets for peri-menopause symptoms and they had no idea what the risks were. In the emergency department, I’ve had cis-female patients on estrogen replacement therapy that was not well managed show up with DVTs. Cis-male patients on supraphysiologic testosterone are at risk for several different kinds of organ failure along with a drastically increased risk of heart attacks.

I don’t think that trans patients are terribly likely to harm themselves with DIY HRT, but having hormones available OTC is going to lead to a lot of cis people getting sick or getting killed by taking extra hormones to try to fix their problems because scammers and quacks have convinced them that hormones will magically fix all of their problems.

I’m going to push back on OTC HRT because of the health risks. Supraphysiologic estrogen and testosterone can both have lethal side effects, so correct dosing and monitoring for health complications are essential components of trans healthcare.

The ACE mods have single-handedly kept Arma 3 alive for over a decade. They add so much complexity to the game with so many options for customization by both mission makers and players. It’s amazing to me how much difference the ACE modset makes to the game.

In high end circuses, the clowns are the most experienced acrobats and performers. There’s a decent chance the clowns are the coaches for the new performers doing the fancy stuff. It takes a ton of practice and experience to do acrobatics and gymnastics “badly” without getting horribly injured.