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Join Meredithe McNamara, a pediatrician and adolescent medicine specialist, in discussing the challenges adolescent medicine physicians face due to the current political climate. We explore the impact of unfilled pediatrics residency spots and the importance of their expertise in caring for youth. Join us to learn about the struggles, sacrifices, and steps needed to support this essential field of medicine.

Meredithe McNamara is a pediatrician and adolescent medicine specialist.

She discusses the KevinMD article, “The current political climate is leaving youth and their physicians behind.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Get CME for this episode by clicking on the CME link in the show notes. Today we welcome Meredithe McNamara. She’s a pediatrician and adolescent medicine specialist. Her KevinMD article that she co-wrote is titled “The current political climate is leaving youth and their physicians behind.” Meredithe, welcome to the show.

Meredithe McNamara: Thanks so much for having me, Kevin.

Kevin Pho: So we’ll get into the article in a little bit. First off, briefly share your story and journey to where you are today.

Meredithe McNamara: Wow, briefly. So I’m the oldest of eight. I come from a huge family. I’ve always been around kids, and as I got older, they got older, and I found myself just loving being around teenagers. I kind of underwent a massive shift in my career plans in residency and decided that I only wanted to care for teens, despite having thought that I was going to be a baby doctor. Really, it was my clinical experiences on the South Side of Chicago, dealing with marginalized and vulnerable youth, that struck a chord with me.

So I have done advocacy and research work in gun violence prevention and in improving safety climates in schools. But within the past year or so, since I took my position at Yale, the political climate around transgender youth has become something like nothing we’ve ever seen before. I have become very concerned that trans youth are kind of like canaries in a coal mine, and that they signal an entry point for a cascade of dangerous interference into standard health care. So I co-founded an initiative with a law professor and friend, Anne Alstott, and that initiative is called the Integrity Project. So now I think that my career is going to be about infusing health policy with scientific integrity standards, and we can talk more about what that means. But that is probably the most galvanizing realization I’ve had in all of my training, all of my postgraduate training.

Kevin Pho: So let’s get into your article, “The current political climate is leaving youth and their physicians behind.” But before you do, just give us some context. Give us a little bit of background. What is adolescent medicine? Tell us a little bit about the specialty.

Meredithe McNamara: So I want all your listeners to know that adolescent medicine is the greatest field, first and foremost. I endorse it highly. There are no hard-and-fast definitions of adolescence, either. So teens need all different types of things. They need concrete areas of clinical care, like sexual and reproductive health. They need mental health services. They need substance use counseling. They have growth and development issues. But what they also really need is a developmentally focused, youth-friendly approach to all aspects of their care.

One of the things that I love about adolescent medicine is that it’s not a physician-driven field. We train alongside nutritionists, social workers, nurse practitioners, and physician assistants in fellowship programs, because youth get care in a variety of ways and in a variety of settings, and it’s our job to make that care better.

The final thing I’ll just say about this is that the other thing I think adolescent medicine physicians and their colleagues do is advocate for our patients. Because we love our patients wholeheartedly, we make really good advocates for them. And youth are pathologized, scapegoated, and thrown under the bus when it comes to social policies, so it’s our job to speak up for their needs.

Kevin Pho: All right, let’s talk about your KevinMD article, “The current political climate is leaving youth and their physicians behind.” How did your article come together?

Meredithe McNamara: Well, Dr. Waters is my co-author, and he is an assistant program director of the fellowship program at Children’s National in D.C. He and I met at a conference, and we had a very serious discussion about the climate that our patients are facing. We noted that Match Day numbers in pediatrics were among the lowest that they’d been in years, and anything that stems the flow of pediatricians in this country hurts kids, and it ripples into pediatric subspecialties. We don’t want to be junior faculty inheriting a field and finding ourselves in several years far less resourced than we already are. So we decided to write about the things that we’re seeing on the ground, the harassment and vilification that our colleagues are facing in states where legal intrusion is threatening standard health care for youth. And we wanted to tie it into an expression of advocacy for your readers about just how worthy our patients are of protecting.

Kevin Pho: So you mentioned that you wanted to share stories about what you’re seeing on the ground. Tell us some of those stories.

Meredithe McNamara: Well, within the past year, bans on gender-affirming care for trans youth have ripped through state legislatures in this country. And what that has done, and those bans, by the way, are not really based on anything scientifically provable or real, and in many cases are based on outright bad information about standard health care for trans youth, what those bans have done is give cover to and excuse the harassment of physicians who provide this care.

Now, I don’t want anyone to think that I am here to talk exclusively about how physicians are harassed. I want people to know that if physicians, pediatricians, are getting harassing emails, bomb threats to their hospitals, and threatening and harassing protests at their clinics, if that’s going on, then the experience of our patients these days has to be so much worse. So we wanted to call attention to that, because we’re living in an unprecedented time where physician experts in all fields are facing a really concerning level of distrust and hate from certain loud minorities. And I’m just worried about what that means for years to come.

Kevin Pho: So you’re at a teaching institution, and I’m sure that you have contact with medical students. Are these political issues, the harassment and the threats, at the forefront of these medical students’ minds as they’re choosing a specialty?

Meredithe McNamara: I would say that they’re much more at the forefront of their minds than they are for the people who teach them. And you know, that’s also a nice parallel to why I just love my field so much. It’s often the younger people, the more junior people, who have insights that deserve to be paid attention to.

Now, I’ve seen two things. I’ve seen the political climate be galvanizing and inspiring; it makes people want to step up and join the fight. And then I’ve also seen people think, “You know, I don’t want a life where I’m a political target. I’d rather pursue something that I don’t think anyone’s going to object to.” However, I don’t think there’s a limit to where this political interference will go if it’s allowed to fly, in gender-affirming care, in reproductive health, and in HIV prevention. I really can’t imagine that there’s a point at which biased political actors back off, and I think that the students I work with know that.

Kevin Pho: Now, you mentioned that at the latest Match, the pediatric numbers were down. Give us a sense of the context of some of those numbers. How dire is the situation?

Meredithe McNamara: I don’t think it’s imminently dire. I think anytime you see a trend in the early phases, you’ve got to call it out, analyze it, and talk about it. There are parts of the country where it is hard to get access to pediatric care. Notably, a hospital in Idaho had to shut down its labor and delivery services because they couldn’t get pediatricians to staff deliveries and they couldn’t get OB/GYNs to care for expecting moms. That’s the sort of thing that we’re seeing in certain places in the country. But we’ve got to talk about it, and we have to look at why that’s going on, rather than fall into crisis mode and be managing situations that harm people on a large scale. So I’m not worried about today; I’m worried about tomorrow’s tomorrow.

Kevin Pho: So as it relates to your field of adolescent medicine, assuming this trend of fewer pediatricians, how’s that going to affect adolescent medicine?

Meredithe McNamara: Well, all pediatric subspecialties are experiencing workforce shortages. In adolescent medicine in particular, there are something like 25 states where there is less than one provider per 100,000 pediatric patients. Now, with all the things that I listed off that we do, you can imagine that there are adolescents everywhere who need that type of care. So adolescent medicine physicians are charged not only with providing that care but also with building capacity in general pediatric workforces to provide it as well. And I’m worried that as legal interference expands throughout the country, if it goes unchallenged, those gaps in care will widen.

The final problem, which perhaps deserves the most attention, is the geographic gaps in care. If you look at bans on gender-affirming care, they’re often in places where there are very few or no adolescent medicine physicians. And if we start to see an exodus of this relatively small field among the pediatric subspecialties to states where care is preserved, then it’s going to create a massive discrepancy in safe and receptive clinical climates for youth. I don’t want to see two categories of states in this country. I don’t want to see a reality where your state is your social determinant of health. So that’s why Dr. Waters and I felt compelled to write this and to kind of sound the alarm.

Kevin Pho: We’re talking to Meredithe McNamara. She’s a pediatrician and adolescent medicine specialist. Her KevinMD article that she co-wrote is titled “The current political climate is leaving youth and their physicians behind.” Meredithe, let’s talk about a path forward. So clearly you drew attention to this in your KevinMD piece and on this podcast. What are the things that physicians can do to help stem the tide?

Meredithe McNamara: All physicians have to understand the health needs of some of the most marginalized patients we all care for. I don’t care what your specialty is; you do take care of transgender people, and knowing the basics goes a long way in destigmatizing their health needs and their identities, and in making the world safer for them. So first and foremost, I would say learn a little bit about gender-affirming care and transgender people. Make your clinics safe spaces. The knowledge gaps that even medical students have when it comes to transgender people are really concerning, and we are doing work to fill those gaps, but we need to do it quickly. Transgender people are being targeted on a political scale that we have never seen before in this country. Families are literally picking up and leaving their homes in states that they’ve lived in their whole lives so that their kids can get health care somewhere safe. American refugees on American soil: I’ve never heard of that before.

So awareness in the medical community and advocacy are also huge. I mean, physicians are natural advocates, because we see the minutiae. We see what’s going on on the ground, and we know what needs to be better.

And the final thing I would say is that we all need to steel ourselves for the reality of the climates that we advocate in. This is not in my piece, but I testified at a congressional hearing a couple of weeks ago about an amendment to the CHGME Reauthorization Act, which provides reauthorized funding for pediatrics residents. Unfortunately, a Republican congressman amended the bill to defund programs that care for trans youth. And while that seems crazy, and you’d think there’s no way that millions of dollars to fund peds residents would suddenly be taken from children’s hospitals, we shouldn’t even have to think about that reality to begin with. My testimony against that bill has led to harassment in basically every way you can imagine.

And I’m not a victim. I am frustrated by it. It is certainly disheartening, but I have no right to be surprised by it. We live in an era where a loud minority of people are angry at physicians and have a lot of fear. I would just encourage your listeners who are looking to engage in advocacy to know that that’s going on, to not be surprised, and to develop networks of mutual support. It’s my colleagues in red states who do this care every day, the people who I know and respect, who kind of get me through these tough moments. And I do genuinely believe that what’s right and good for our patients will prevail in the end.

Kevin Pho: What are some things that physicians can do to prepare themselves for that?

Meredithe McNamara: Talk to each other about it. I mean, I think we’ve just got to build networks of mutual support. It’s not personal; it’s more just an indicator of the climate that we live in. It’s the post-COVID world. And there are very practical things that you can do as well. There’s a really great nonprofit, actually, that protects faculty free speech, which I can send you some information on, and you can link it in your notes. Academics have been dealing with this for a long time in various areas, and the fact that physicians deal with it too now just means that we need to learn from our peers in other fields.

Kevin Pho: And my final question, Meredithe: Tell us some of your take-home messages that you want to leave with the KevinMD audience.

Meredithe McNamara: I want everyone to be hopeful. I think that there is a spectrum of how we all view reality. You know, there’s tragic optimism, there’s toxic positivity, and then there’s abject despair. I would like us to follow along the tragic optimism point of view, because we have to be honest about what’s hard, but we have to be optimistic that things will be OK if we do something about it.

Kevin Pho: Meredithe, thank you so much for sharing your time and insight, and thanks again for coming on the show.