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Thursday, June 18, 2026

The Bill of Rights Museum

 by Sean Ring

Lysander Spooner said it plainly in 1867: the Constitution has no authority over anyone who never consented to it.

At the time, people thought he was being provocative. A century and a half later, the evidence is on his side.

The document that was supposed to limit government power has become the very thing it was designed to prevent — a rubber stamp for whatever the political class decides to do. The Bill of Rights is still printed. It’s just not particularly enforced. And the gap between what the Constitution says and what Washington actually does has grown so wide that at some point you have to ask Spooner’s question: Was the document ever really in charge?

Let’s go through the evidence.

The First Amendment: Free Speech, With Exceptions

The text is unambiguous. “Congress shall make no law abridging the freedom of speech.” Not “limited law.” Not “reasonable law.” No law.

What we have instead is the Espionage Act of 1917, which has been used to prosecute journalists and whistleblowers. Section 230 pressure campaigns where the federal government leans on private platforms to remove content it dislikes — and calls it “misinformation.” The Treasury Department’s OFAC sanctions list makes it illegal to publish certain information about designated entities. Campus speech codes are blessed by federal funding conditions.

None of this is directly banned. It never is. The modern state has learned that you don’t need to repeal the First Amendment. All they have to do is build a suppression infrastructure around it and call it something else.

In No Treason, Spooner argued the Constitution’s protections were only as good as the willingness to enforce them. When the enforcers are the violators, the document is rendered useless.

The Fourth Amendment: The Right to Privacy, Mostly Gone

The Fourth Amendment reads, “The right of the people to be secure in their persons, houses, papers, and effects, against unreasonable searches and seizures, shall not be violated.”

Then came the insidious third-party doctrine. In 1979, Smith v. Maryland held that information you share with a third party — a phone company, a bank, an internet provider — carries no Fourth Amendment protection. You “voluntarily” handed it over. The government can have it without a warrant.

In 1979, that meant phone records. In 2025, it means your location data, financial transactions, search history, and your messages. All of it sits with third parties. And since it does, with the right paperwork, all of it is accessible without the warrant the Fourth Amendment explicitly requires.

Exposed by Edward Snowden in 2013, the NSA’s bulk collection program collected the phone records of virtually every American. The FISA court approved it. The legal theory was that because the data sat with telecoms, there was no Fourth Amendment issue.

The Founders wrote the Fourth Amendment because the British used “general warrants” to conduct fishing expeditions through colonists’ papers. The NSA program was a general warrant for every American, running continuously, indefinitely. The Constitution said this was the one thing the government could never do. The government did it anyway, got a secret court to bless it, and kept it classified for a decade.

Spooner’s framework handles this cleanly. He argued that unjust law is no law at all — that legislation which violates prior natural rights has no moral claim to obedience. The FISA court didn’t make the surveillance constitutional. It made it legal. Those are different things.

The Fifth Amendment: Takings and the Death of “Public Use”

“Nor shall private property be taken for public use, without just compensation.”

Two qualifiers. Public use. Just compensation. The Founders were specific because they knew what governments do with vague language.

For most of American history, “public use” meant roads, bridges, and military installations—things the public actually used.

Then came Kelo v. City of New London in 2005. The Supreme Court held that the government could seize private homes and transfer them to a private developer because the development might generate tax revenue. The public benefit was theoretical. The seizure was real. Susette Kelo’s house — the one she’d painted pink in defiance — was bulldozed. The development was never built.

The Fifth Amendment said “public use.” The Court said “public benefit.” One word changed, and the constitutional protection for private property effectively disappeared. Any government that wants your land badly enough can now find a developer, project some tax revenue, and take it.

Spooner saw this coming. His argument about legal monopolies — that government routinely transfers wealth from private citizens to politically connected interests under cover of law — is precisely what Kelo institutionalized.

The Sixth Amendment: The Right to Trial, Quietly Abolished

The Sixth Amendment reads, “In all criminal prosecutions, the accused shall enjoy the right to a speedy and public trial, by an impartial jury.”

In all prosecutions. Not most. All.

Today, roughly 97% of federal convictions are obtained through plea bargains. There is no trial. No jury. No public proceeding. A prosecutor presents a defendant with a choice: plead guilty to a lesser charge, or face trial on the full indictment — which, given mandatory minimum sentencing, could mean decades in prison. Most people take the deal.

Most Americans have been priced out of the constitutional right to trial. Built up through legislation from the 1980s onward, the mandatory minimum sentencing system turned the right to trial into a trap. You can exercise it and risk catastrophic punishment. Or you can waive it and go home sooner.

Spooner identified this in An Essay on the Trial by Jury. He argued that the jury was the citizen’s last check on prosecutorial and legislative overreach. Remove the jury, and the state can enforce any law it likes without ever facing a citizen veto.

The Tenth Amendment: The One That Doesn’t Even Pretend Anymore

The Tenth Amendment reads, “The powers not delegated to the United States by the Constitution, nor prohibited by it to the States, are reserved to the States respectively, or to the people.”

This was supposed to be the hard limit. The federal government has specific, enumerated powers. Everything else belongs to the states or the people. That’s not a suggestion. That’s the structure of the document.

The Commerce Clause killed it. Starting in the New Deal era, the Court ruled that Congress could regulate virtually any economic activity because that activity could, in theory, affect interstate commerce. In Wickard v. Filburn (1942), a farmer growing wheat on his own land for his own consumption was found to be affecting interstate commerce because his self-sufficiency reduced his purchases from the market. It doesn’t get more ludicrous than that.

The Tenth Amendment was reduced to a bunch of clauses with no teeth. Today, the federal government regulates education, healthcare, housing, agriculture, local policing, and school bathroom policies. These powers aren’t enumerated but are justified through Commerce Clause reasoning. The Founders didn’t intend this.

Spooner’s response to this would be the same as his response to everything: show me where the people consented. Not their representatives. Not their grandparents. Them.

The Through Line

Spooner’s great insight was that the document cannot enforce itself.

Every protection has been hollowed out the same way: redefine the terms, construct a legal doctrine that technically complies with the text while gutting the substance, and find a court to bless it.

Free speech applies “except in these categories,” like hate speech (whatever that is).

Unreasonable searches become reasonable when a third party holds the data.

Public use means public benefit.

The right to trial means the right to a trial you’d be insane to actually exercise.

The document is still there. It gets cited constantly — usually by the side trying to expand government power — to explain why the expansion is, in fact, constitutional. The Constitution has become a tool for justifying what the state wants to do, not a limit on it.

Which is exactly what Spooner said would happen.

He argued in No Treason that a constitution which the government interprets, enforces, and adjudicates cannot limit the government. The fox doesn’t guard the henhouse by constitutional design. The people who benefit from power decide what the limits on power mean.

Though anarchocapitalists have adopted Lysander Spooner, he wasn’t arguing for anarchic calm (or chaos, for that matter). He merely wanted an open conversation. If the Constitution doesn’t actually bind the people who wield power, let’s stop pretending it does. Start asking what real limits on power would look like and who would actually enforce them.

Wrap Up

The Fifth Amendment was supposed to protect property. It doesn’t. The dollar is legal tender by federal law. Its value is managed by an institution (the Fed) the Constitution doesn’t mention, and the Founders didn’t authorize. The Fed exists in the same constitutional gray zone as everything else. It’s technically sanctioned by Commerce Clause logic, practically beyond any limit the document anticipated.

Lysander Spooner’s solution was this: First, stop treating the Constitution as a living guarantee. Then, start treating it as a historical document that tells you what the government promised and failed to deliver. Finally, act accordingly.

The Bill of Rights is worth reading. It tells you what they took from you.

https://dailyreckoning.com/the-bill-of-rights-museum/

Big Pharma Taps UK Playbook to Pressure European Capitals on Drug Prices

 Global pharmaceutical companies, facing pushback from European capitals on drug pricing, are turning to a playbook that brought them recent success in Britain: threats of pulling investment and expansion plans to pressure policymakers.

The latest target has been Germany, which is ⁠debating legislation to tighten spending on medicines. The industry notched a win in Britain when the government agreed to increase spending on medicines as part of a broader deal to avoid Washington-imposed tariffs.

Pfizer wrote last week to the German chancellor that its Germany investments were at risk over the drug-pricing ⁠policy, while AstraZeneca warned that it may not launch new medicines in Germany if the changes go ahead.

Earlier in June, Eli Lilly announced it would halve a planned 2.3 billion euros ($2.7 billion) investment and even Germany-based Boehringer Ingelheim said ⁠it was scrapping expansion plans worth 900 million euros. Both cited the proposed legislation.

"The ‌industry is delighted with how the UK government folded in the face of their pressure," said Diarmaid MacDonald of Just Treatment, a UK-based patient group. "They would love to see others replicate that capitulation."

Germany's health ministry said this week that nothing had been decided yet and declined to comment further on any parliamentary deliberations.

Critics say Britain yielded to industry pressure. The UK government said the April agreement with Washington secures tariff-free access to the U.S. while creating a more innovation-friendly environment for drugmakers to provide high-skill jobs.

Now the pressure on Germany is starting to hit home.

On Monday, a government source told Reuters it would scrap some of the plan ‌the industry opposed, ditching a variable discount mechanism for a fixed one to address concerns the uncertainty would hit investment.

While the move would reduce uncertainty, industry sources said ​that does not address ‌broader concerns about Germany's pricing environment. The proposed law faces parliamentary debates over the coming months ‌and could be changed.

The industry sources said the UK agreement was viewed positively by drugmakers not only due to changes to the system for valuing and paying for new drugs, but also because it involved commitments on innovation and patient access.

Healthcare analyst Diederik ⁠Stadig of ING Bank said drugmakers were being more reactive in Germany versus a more premeditated strategy for Britain, though he ‌agreed the two cases were similar.

"The German government made a ⁠proposal, 'we want to reform pricing'. And the industry said, 'OK, that's all well and good, ​but that affects our return on investment'," he said.

Tariffs, U.S. pricing policy, the rise of ‌China and the lucrative nature of the U.S. market all make Europe less appealing currently, Stadig said. "The industry is making Europe acutely aware of this".

The proposed legislation in Germany to cap rapidly growing costs in the statutory health insurance system has thrust the country into the centre of a broader tussle between drugmakers and European governments that began several months ago.

In France, the national health ​authority in April accused drugmakers of using "coercive pressure" to influence clinical assessments, including threats to withdraw medicines from the market.

HollandBio, the Netherlands' biotech lobby, ‌said ‌companies were becoming more cautious about reimbursement filings and that the country risked slipping further down drug-launch priority lists.

That tension has been sharpened by the impact on Europe of U.S. President Donald Trump's most-favored-nation pricing push, ‌which aims to tie prescription medicine prices in the lucrative ​U.S. market to lower prices elsewhere, including in Europe.

Major drugmakers have struck deals with the White House to lower drug costs in exchange for tariff exemptions, adding to pressure for increasing prices elsewhere.

Some critics saw Germany's partial retreat as a troubling sign of the industry's leverage, but noted that European nations also had sway given the bloc remained an important market despite being less lucrative ⁠than the United States.

"America is not the only market in the world," said Sally Gainsbury, analyst at healthcare think tank Nuffield Trust, while adding that the ‌UK-U.S. pricing agreement was nonetheless a warning for Europe.

"The depressing reality is that the 'UK playbook' here means health systems will spend more, but will get less health benefit for their populations," she said.

https://www.medscape.com/s/viewarticle/analysis-big-pharma-taps-uk-playbook-pressure-european-2026a1000kde

Readiness Is Not a Prerequisite for Lifestyle Change

 A common question I hear from policymakers and payers in response to examples of successful lifestyle intervention outcomes is, “That’s terrific, but doesn’t this only really work for patients already motivated and ready to change?”

It’s a fair question. Most of us have observed that patients who arrive at appointments inspired and engaged to improve their health tend to achieve better outcomes, regardless of the treatment plan. When lifestyle counseling occurs, it's generally delivered to patients who appear receptive and bypassed for those who do not portray themselves as “ready.”

What I came to understand after creating lifestyle medicine programs is that motivation and engagement are not static traits that we should merely screen for at the beginning of a patient encounter. They represent a mindset that clinicians can actively build by educating, empowering, and supporting individuals through the full activation arc: meeting people at their current stage of readiness, then using evidence-based tools like motivational interviewing, coaching, and longitudinal relationships to propel them.

Reframing Patient Readiness

The transtheoretical model has long recognized that patients move fluidly between precontemplation, contemplation, preparation, action, and maintenance, often more than once. The Eat for Life Trial study, an intervention to increase fruit and vegetable intake conducted through Black churches, determined that fruit and vegetable intake of participants initially classified as precontemplators was similar to that of participants who were in a more advanced stage of readiness. Additionally, precontemplators’ change in psychosocial outcomes was as large as or larger than that of those in the preparation stage.

Large trials including the Diabetes Prevention Program (DPP) and Look AHEAD ( Action for Health in Diabetes) found that improvements that occurred during the intervention — such as changes in confidence, dietary patterns, and self-regulation — were among the most consistent predictors of outcomes. Therefore, strategies that rely solely on screening for motivation could limit access to care for the patients most likely to benefit. Techniques such as motivational interviewing and autonomous support have been shown to engage patients across the motivational spectrum. 

In Practice

A patient who isn't ready today may be ready next month, given the right encounter. In practice, the line between support and pressure is usually crossed the moment a clinician starts supplying answers the patient didn't ask for. 

The most reliable safeguard I've found is to ask permission before offering information: "Would it be alright if I shared a couple of things that have helped other patients in your situation?" A patient who says yes has invited the conversation; a patient who hesitates has told me something useful about where they are. Either way, their autonomy stays intact.

The next habit that keeps me on the supportive side of that line is offering a menu rather than a mandate. Instead of saying, "You need to cut out sugar," I might say, "Some people start by changing breakfast, some by walking after dinner, some by cooking one extra meal at home a week — does any of those feel doable for you?" The patient chooses the entry point, which means the plan is already theirs before they leave the room.

This work may be most visible in group settings, such as shared medical appointments (SMAs) or group medical visits (GMVs). In lifestyle medicine group sessions that I have been a part of, we deliberately enrolled patients who varied greatly on the spectrum of readiness, not just those who appeared already motivated to make confident changes. During group visits, patients who struggle to engage within the confines of a one-on-one encounter in an exam room may connect with peers dealing with similar conditions and daily struggles, and they are inspired by stories from others who may be a few steps ahead of them in making successful behavior changes. Patients also experience the support of an interdisciplinary team that treats behavior change as a shared process and not a test of willpower. 

Up Access, Get Measurable Clinical Outcomes 

In intensive lifestyle medicine, patient adherence is engineered, not incidental. Sustained behavior change tracks closely with how a program is built and delivered: clinician-supervised sessions, care delivered by a coordinated interdisciplinary team, frequent in-person touchpoints, and individualized action plans anchored in measurable, time-bound goals. Across the published trial literature, the variable most tightly correlated with clinical improvement is not who the patient was at baseline but how consistently they engaged with the intervention itself. In other words, adherence is the active ingredient and intensive lifestyle medicine protocols are deliberately designed around resource-rich scaffolding that makes that adherence achievable.

Engagement can translate into outcomes that are measurable and clinically meaningful. Intensive lifestyle medicine programs have well-established outcomes, including measurable improvements in ejection fraction in patients with heart failure. These are cardiac remodeling endpoints, not soft measures, and not the kind of result most clinicians ever expect to see from a behavioral intervention.

Every patient deserves the opportunity to know the full range of options available to them, and patients cannot choose a treatment they have never been offered. What may appear to be a lack of readiness for lifestyle change could be a signal that another approach or setting is needed. 

Padmaja Patel, MD is President; Board of Directors, American College of Lifestyle Medicine, Midland, Texas Served as a director, officer, partner, employee, advisor, consultant, or trustee for: ACLM 

https://www.medscape.com/viewarticle/why-readiness-not-prerequisite-lifestyle-change-2026a1000jx2

New Immune Therapy Boosts Disease Control in Prostate Cancer

 Adding an experimental immunotherapy to radiation treatment may extend disease-free survival in men with localized intermediate- or high-risk prostate cancer, according to a phase 3 trial.

The treatment, which has been fast-tracked by the FDA, has two steps: Intraprostatic injection of a replication-defective adenovirus carrying the herpes simplex virus thymidine kinase (HSV-tk) gene, followed by a course of valacyclovir. The viral enzyme then converts valacyclovir to a toxic metabolite that kills dividing cells, releasing tumor antigens that trigger an immune response.

If approved, this would be the first new therapy for men with localized prostate cancer in over 20 years, researchers led by Paul P. Tak, MD, PhD, of Candel Therapeutics in Needham, Massachusetts, wrote in The Lancet Oncology.

However, outside experts urged caution, citing concerns about the trial’s design and saying it’s too soon to judge whether the findings will translate into an overall survival benefit.

“One must walk a fine line between optimism and realism, especially when a biotech company is involved and trying to get and appease investors,” said Otis W. Brawley, MD, of Johns Hopkins University School of Medicine in Baltimore.

Around 30% of men with localized prostate cancer treated with curative-intent radiotherapy have disease recurrence, underscoring a need to improve local disease control.

In a phase 2 study, the experimental immunotherapy — called aglatimagene besadenovec or CAN-2409 — seemed to have synergistic effects in combination with radiotherapy. Among men with low- to high-risk prostate cancer, the combination produced a pathologic complete response rate topping 90%.

The new phase 3 trial included men planning to undergo definitive external beam radiation (EBRT) for intermediate-risk (85%) or high-risk (15%) prostate cancer. Of the former, more than 60% had unfavorable intermediate-risk disease.

Patients at 51 medical centers received either standard EBRT (78 Gy in two Gy fractions) or hypofractionated EBRT (60 Gy in three Gy fractions or 70 Gy in 2.5 Gy fractions). Short-course androgen-deprivation therapy (ADT) was optional.

The study team randomly assigned 496 men to receive aglatimagene plus valacyclovir and 249 men to receive placebo plus valacyclovir. Patients were given three ultrasound-guided injections of aglatimagene or placebo, at least 2 weeks apart; after each, they took oral valacyclovir for 14 days.

The primary endpoint was disease-free survival, defined as time from randomization to local failure, regional failure, distant metastases, or death from any cause.

After a median follow-up of 50 months, disease-free survival events had occurred in 31% of placebo patients vs 23% of those receiving aglatimagene. Median disease-free survival in the placebo arm was 86.1 months and not reached in the treatment arm (hazard ratio, 0.70; P = .016).

Any impact on overall survival remains to be seen. At the 50-month mark, death rates were similar in the trial arms, at 7% with aglatimagene and 6% with placebo. There were only two prostate cancer-related deaths, one in each group.

Treatment-related adverse events were more common with aglatimagene (74%) than with placebo (53%) and were most often flu-like symptoms. Serious treatment-related adverse events occurred in 2% of patients in both arms, including four cases of acute kidney injury in each group.

While the trial met its primary endpoint, the significance of that is questionable, according to Oliver Sartor, MD, who directs the Transformational Prostate Cancer Research Center at East Jefferson General Hospital in Metairie, Louisiana.

One issue he highlighted: ADT was optional in the trial, but it’s typically recommended for patients with high-risk or unfavorable intermediate-risk disease. Overall, 58% of trial participants with intermediate-risk disease received no ADT.

And subgroup analyses showed that only patients who did not receive ADT saw a significant reduction in disease-free survival events with aglatimagene.

“Where ADT was given,” Sartor said, “there was no clear benefit of the experimental treatment.”

He also raised concerns that the primary endpoint was “ too heterogenous for straightforward interpretation,” vs alternative endpoints such as metastasis-free survival, prostate cancer-specific survival, or overall survival.

Brawley had similar reservations about the endpoint of disease-free survival. He acknowledged the value of using shorter-term outcomes rather than waiting years for mortality data. But Brawley said, there have been “many instances” where a treatment looks promising based on surrogate endpoints, only to disappoint when long-term survival data become available.

Candel Therapeutics said it plans to submit a Biologics License Application for aglatimagene to the FDA in the fourth quarter of 2026.

The study was designed, conducted, and funded by Candel Therapeutics. Brawley disclosed serving on the board of several healthcare companies, none of which has a product involving prostate cancer treatment, and he consults for Grail on cancer screening issues. Sartor disclosed serving as a consultant to or received research funding from Bayer, Sanofi, AstraZeneca, and various other companies.

https://www.medscape.com/viewarticle/new-immune-therapy-boosts-disease-control-prostate-cancer-2026a1000kmn

'Warning: Your doctor may be angry'

 Time constraints, staffing shortages, high patient volume, excessive paperwork, public misinformation, disillusionment with the system, scheduling protocols, administrative snags, insurance restrictions, lack of autonomy…

The list of stressors and frustrations in healthcare today goes on. Anger is a widespread reaction.

A survey of more than 55,000 healthcare workers revealed that 40% of respondents felt angry either some of the time, most of the time, or all the time. Those feelings have real consequences when more than half of the respondents reported that being angry sometimes or often prevented them from thinking in a clear-headed way.

Jacob Royle Hopping, MD, says he doesn’t recognize the surgeon he was a decade ago. His angry outbursts among colleagues in operating and meeting rooms escalated to the point that a senior partner stepped in, telling Hopping to “stop it.”

“What was missed that day, and multiple times before, was an opportunity to see a surgeon in distress,” Hopping wrote of his experience in a recently published essay.

Personally, Hopping was struggling to adjust to a new job in a new city while managing his wife’s increasing medical issues. Professionally, he was frustrated by administrative problems getting in the way of caring for his patients, such as colleagues rescheduling nonemergent surgeries.

“I’m swearing…in a department meeting because we can’t operate a hospital this way, and all that does is make me look like the bad guy,” Hopping acknowledged. He knew his response was inappropriate and wasn’t going to solve anything, but he struggled to get control of his emotions.

The fact that society often regards physicians as “godlike” and impervious to emotional struggles further complicates the issue. Healthcare professionals can find themselves living in a paradox: higher expectations for interpersonal behavior in an environment that remains structurally enraging. The water in the pot boils harder and harder.

Examining the Emotion

Anger is not a pathology, said Patrick Hudson, MD, a retired board-certified plastic surgeon turned psychotherapist and physician coach dubbed “The Anger Doctor.” Anger is information.

photo of Patrick Hudson MD
Patrick Hudson, MD

Hudson provides anger management training and coaching exclusively for physicians, working with them to understand the root causes of their anger and how to manage it effectively. “Anger is pointing at something,” Hudson said. “The key is to figure out what it’s pointing to and learn to manage the emotion.”

A fellow of the National Anger Management Association, Hudson recalled being invited to speak at the organization’s international convention. He was surprised to discover that the crowd of “very caring human beings” didn’t have much sympathy or empathy for physicians. “They were used to criminals committing angry acts,” he said, “but physicians had money and time and resources, so they thought they didn’t need help like others did.”

Hudson knew otherwise. “I came away from those experiences even more convinced that I need to change things from inside the system,” he said. Identifying feelings and interrogating what is behind them is something many physicians aren’t comfortable sitting with, he added. He knew he would be met with reluctance, particularly by physicians required to get help for anger management who saw therapy as punitive.

To help his clients understand what triggers anger, Hudson speaks their shared language: science. He begins by explaining that angry outbursts occur during an “amygdala hijack.” The amygdala reacts quickly and intensely to perceived threats, whereas the prefrontal cortex lags behind.

The goal is to pause and create a space between stimulus and response. “We want the doctor to be aware of what’s going on in the amygdala when it hijacks us,” Hudson explained. The triggered response, while intensely felt, is not reasoned or logical, and pausing allows a moment for the brain to respond more appropriately.

“That space is how we choose how we want to live our lives,” Hudson said. “Physicians, and surgeons especially, love to be in control, and when they learn they can choose how they respond to a stimulus, they are empowered.”

The Quieter Emotion Fueling the Louder Emotion

“When doctors get angry, it’s generally about what they have to do to get the resources they need,” said Anne Krancus, MSN, RN, at a critical access hospital in Eastern Washington. Issues ranging from scheduling protocols to insurance restrictions and lack of autonomy prevent many doctors from practicing medicine in the way they believe is best for the patient.

Hudson agrees that there can be an emotion behind anger that’s particularly difficult for physicians to recognize — grief. “They aren’t practicing the kind of medicine that they thought they’d be practicing,” he said. “Their meaning and purpose are being taken away from them. They are being directed by organizations.”

The COVID pandemic vastly amplified many of these systemic issues. The spread of misinformation in general, and anti-vaccination rhetoric in particular, pushed healthcare professionals who were already scared, overworked, and grieving the extensive loss of life to the edge.

“I was angry at everything,” Kathryn Ivey, a critical care nurse, wrote in a 2022 op-ed. “Angry at the systemic failures of the government to act, angry at the individuals who treated COVID as a joke, and angry at the disinformation that ushered in more death.”

Ivey described the constant fury and demoralization that she and her colleagues felt during the pandemic as they lost unvaccinated patients to the disease and were accused of “getting paid to make COVID look worse than it is” or even of killing patients intentionally.

“Everyone has a breaking point,” she wrote. “Many healthcare workers have been driven close to ours, not just because of COVID itself but because of all the ugly things that humanity — particularly in the US — has revealed about itself in our response to COVID.”

Though we have since emerged from the intensity of the pandemic, many healthcare workers still feel, as Ivey described, that they are “shouting into an abyss.”

When the Heat Helps

Brinda Sarathy, MD, a family medicine resident at the University of Colorado in Denver, said that anger has been a persistent emotion for her since beginning residency in ways she didn’t used to experience. “It’s new for me, for sure,” she said.

photo of Brinda Sarathy MD
Brinda Sarathy, MD

But Sarathy argues that anger can be a valuable emotion when it comes to growth — emotionally, systemically, or sometimes both. In an essay, she recalled a particularly challenging shift where “every interaction felt frustrating, and every task felt burdensome.” As her rage grew, so did her fiery reactions until an attending pulled her aside and gently offered some well-meaning advice: “You don’t have to get angry about things that won’t change.”

Even this angered Sarathy, but by the end of the shift, she found herself reflecting on her emotions and realized two things. One, being angry meant that she wasn’t burned out; she had a clear sense of right and wrong and a desire to make positive changes. Two, while she was picking some of the wrong battles — commonplace electronic medical record malfunctions or schedule conflicts — there were others that were still worth fighting.

“These ranged from inadequate medication reconciliations to a missed diagnostic workup to personal microaggressions,” Sarathy wrote. “This category of frustrations highlights systemic gaps, workflow inefficiencies, and unsafe practices — all things that should not be tolerated.”

Today, Sarathy says that when she gets angry, she takes a step back and asks what she can do about it. Sometimes the answer is nothing. “I’ve experienced a lot of radical acceptance recently of just the way things are, and you’ve got to work with the tools you have,” she said.

Other times, stepping back from her anger, particularly in patient situations, allows her to determine where she can put her advocacy. “Like talking to a social worker or talking to a patient’s loved ones about their situation or just trying to get collateral on advocating for patients in the hospital who probably aren’t safe to go back home,” Sarathy explained. “That has been a more productive way of managing my anger. It’s not necessarily a fix but an outlet.”

A Generational Shift

For a long time, medical training tolerated, if not encouraged, a certain archetype: the brilliant but volatile surgeon, the exacting attending, or the physician whose temper was excused as the price of excellence.

Krancus recounts an experience she had early in her nursing career while orienting in the operating room with an ob/gyn she hadn’t worked with before. The patient’s blood pressures were “getting pretty soft” during a planned C-section, and in a fit of rage, the physician ripped the drape off the patient and threw it at Krancus in frustration.

“You never throw things, ever, in a surgical suite,” she said. “The crazy thing was, the other people in the room weren’t even stunned by it.”

The lack of response was telling. Not because the incident was acceptable but because it reflected how deeply embedded these reactions were in certain environments.

“I’ve gotten really upset in the operating room,” admitted Bobby Yanagawa, MD, PhD, a cardiothoracic surgeon in Toronto. “But in heart surgery, it’s a game of millimeters. Things can change within seconds.” While he said it happens infrequently, Yanagawa admitted those moments put a tremendous amount of stress on the surgeon and the surgical team.

Anger, in this context, is often about stakes. “When the temperature goes up, it’s not because someone is a tyrant,” said Yanagawa, “but because they really care about the patient, and we want to deliver the patient safely to their family.”

Yanagawa became a heart surgeon in 2015 alongside broader cultural movements such as #MeToo, #TimesUp, and Black Lives Matter, which he said reshaped expectations inside the operating room. As a result, there’s less overt hostility, fewer outright tirades, and ultimately a more respectful work environment.

As part of his ongoing research at the University of Toronto, Yanagawa conducted a recent survey (submitted for publication at the time of this article) of medical students in surgical rotations at the university. The survey asked about the prevalence of harassment, discrimination, and intimidation. He said the results show a “huge improvement” compared with the survey results from 20 years ago.

Krancus sees it from the nursing side. “New nurses don’t put up with a lot,” she said. “They expect respect right off the bat, whereas I thought I had to earn it.”

A Way Forward

The danger, many physicians say, isn’t the presence of anger but what it can become. “When you hold onto anger as a predominant emotion, it eventually turns into cynicism, thinking this is just the way things are and you can’t do anything about it,” said Sarathy. “It’s a sense of learned helplessness that’s masked by people who are quite burnt out in medicine, and I feel like that is not productive.”

But as Hudson pointed out, there is power in recognition. A path forward involves not erasing or denying anger but reframing it as information that can be managed.

The goal is not to create physicians devoid of emotion. It is to support their capacity to feel deeply, respond thoughtfully, and sustain their patients and themselves in a system that often demands more than it gives.

https://www.medscape.com/viewarticle/what-physician-anger-telling-us-and-why-we-should-listen-2026a1000kks

GLP-1s Tied to Higher Risk for Dizziness, Fainting for Some

 Hypotension-related events increased after initiation of GLP-1s in patients taking multiple antihypertensive medications, researchers found. Patients aged 65 years or older and those with type 2 diabetes were most at risk.

“Hypotension is the most dreaded potential side effect of treating hypertension and actually far more dangerous,” study co-author Micah Eimer, MD, Northwestern University Feinberg School of Medicine in Glenview, Illinois, said in a statement. “People die from that. You can hit your head, or you can crash your car or break your hip. So it’s a very bad outcome when it happens.”

When he became aware that some of his patients on GLP-1s were complaining of lightheadedness, dizziness, and fainting, Eimer decided to investigate. His team’s study was presented at ENDO 2026: The Endocrine Society Annual Meeting.

‘Potential to Do Harm’

The researchers retrospectively analyzed the electronic health records of 42,262 patients taking at least two antihypertensive medication classes and evaluated these patients for hypotensive events in the 6, 12, and 24 months following GLP-1 initiation.

Hypotensive events were defined as a combined endpoint of a new diagnosis of hypotension, syncope or near syncope, dizziness, falls, documented systolic blood pressure ≤ 90 mm Hg, or antihypotensive drug prescription.

At 6 months, hypotensive events increased from 8.7% to 10.2%. At 12 months, the rate rose from 13.6% to 14.3%. At 24 months, the difference was 17.7%-18.1%.

Adults aged 65 years or older accounted for 53% of hypotensive events despite representing only 37% of the study population. Patients with type 2 diabetes made up 75% of those experiencing hypotensive episodes, but only 63% of the overall cohort.

In a subset analysis of 40 randomly selected patients, the researchers found that approximately 25% had their antihypertensive medications reduced in dose or number during the study period.

Secondary analyses showed that weight loss alone did not explain the increased risk.

“The predominant reason [for the hypotensive events] is likely due to weight loss, which is known to lower blood pressure,” Eimer told Medscape Medical News. “Even 5% weight loss will result in significant blood pressure lowering.”

“But other mechanisms that might be at play include potentiation of certain blood pressure medications by the GLP-1s, dehydration caused by GLP-1s, direct blood pressure-lowering effects by relaxing blood vessels, decreasing sympathetic nerve activity, and promoting sodium excretion in the urine,” he said.

Meanwhile, he added, “I’m just saying, let’s watch out for hypotensive events in select patients because I think there’s the potential to do harm. I am particularly worried about the risk to patients who obtain GLP-1s without direct and ongoing clinical supervision.”

‘A Prompt for Vigilance’

Sara Ghoneim, MD, an inflammatory bowel disease specialist at Massachusetts General Hospital in Boston, and a spokesperson for the American Gastroenterological Association, commented on the study for Medscape Medical News.

“The findings are biologically plausible and consistent with clinical experience,” she said. “GLP-1 receptor agonists lower blood pressure through several converging mechanisms, including weight loss, natriuresis, improved endothelial function, and possibly direct vascular effects. When you add a steadily falling blood pressure to a fixed regimen of two or more antihypertensives, the arithmetic predicts exactly what this study found — a drift toward hypotension as therapy continues.”

“Many of us have seen patients on semaglutide or tirzepatide who become lightheaded, orthostatic, or frankly hypotensive months into treatment, often prompting us to peel back their antihypertensive agents.”

However, Ghoneim flagged several study limitations. As a retrospective observational study, it establishes association, not causation, and is vulnerable to confounding and ascertainment bias, she said. “Patients on a new drug are seen and measured more often, which can inflate the apparent detection of dizziness, falls, or low readings.”

The composite endpoint is broad, she noted. “It lumps a coded hypotension diagnosis together with nonspecific symptoms like dizziness and falls, so the headline incidence is sensitive to how those soft outcomes are counted.”

Furthermore, “the absolute effect sizes are modest and the 24-month difference lost significance [and] the medication-change subanalysis was based on only 40 randomly selected patients, which is too small to anchor a 25% figure firmly.”

Nevertheless, she said, this is something clinicians should be alerted to, “though as a prompt for vigilance rather than alarm. When you start a GLP-1 in a patient already on multiple antihypertensives, anticipate that their blood pressure may fall, monitor more closely in the first months, counsel about orthostatic symptoms and fall risk — especially in older adults and those with type 2 diabetes — and be ready to de-prescribe antihypertensives proactively rather than waiting for syncope.”

“That’s already good practice,” she said. “This study reinforces why it matters.”

Eimer declared serving on the advisory board of Eli Lilly. Ghoneim declared having no conflicts of interest.

https://www.medscape.com/viewarticle/glp-1s-tied-higher-risk-dizziness-fainting-some-2026a1000kjq