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When to Use Telemedicine vs. Urgent Care: How I Spot the Sick One

On August 23, 2026September 2, 2026 By Dr. Scott RennieIn Healthcare System & TechnologyLeave a comment

A paper in the American Economic Review this month compared nurse practitioners and physicians across 1.1 million emergency department visits. Physicians came out ahead on average. NPs came out ahead in 38 percent of random head-to-head matchups, and thirty-day mortality showed no significant difference (1)(2). I wrote separately about what that study does and does not say.

This piece is about the setting I actually work in. Every visit I do is a video visit, and virtual urgent care has quietly become one of the largest places in American medicine where the question of who is on the other end of the call gets settled by economics rather than by clinical reasoning. The emergency department findings do not carry over to it cleanly, and the reasons they do not are worth their own article.

What changed about who answers

The staffing model in this corner of medicine changed fast, and most patients never noticed. Direct-to-consumer telemedicine launched staffed largely by physicians and runs now largely on nurse practitioners and physician assistants. The reason was never clinical. An NP costs less per hour and is easier to hire at scale, and when the product is a cheap video visit available at two in the morning, that arithmetic decides the roster. About 13 percent of emergency visits nationwide are now handled by NPs (2). In virtual urgent care the share is far higher, and those platforms are built for volume and speed.

The training gap is worth stating precisely, and I would rather use nursing education’s own accrediting standards than anybody’s talking points. The National Task Force standards that govern NP programs set a minimum of 750 direct patient care clinical hours for a population-focused track (4). No residency is required after that. A physician arrives at the same video visit having done clerkships and then residency, which the AMA puts somewhere between 10,000 and 16,000 hours (3). And about 87 percent of the 461,000 licensed NPs in this country trained in programs focused on primary care (5), which is preparation for the undifferentiated but mostly well patient rather than for the sick one.

Now let me argue against my own instinct, because the data do not go where a physician would expect. If thinner training meant missing sick patients, NPs in the Chan and Chen cohort should have under-admitted the dangerous presentations. They did the reverse. For sepsis, stroke, and heart failure they were substantially more likely to admit (2). The signature of that whole paper is a lower threshold to spend a resource when the picture is murky, which is caution rather than blindness, and it predicts over-referral out of telemedicine rather than under-referral.

Here is why I do not think that settles the question. The emergency department is a rigged environment for this comparison, rigged in a way that flatters everyone working inside it. The patient is physically present. A triage nurse has already taken vitals and assigned an acuity level. Somebody has laid eyes on them before the clinician decides anything, which means most of the signal that says this one is sick arrives free. Take that away, which is precisely what a video visit does, and the task becomes generating suspicion from a history and a small rectangle of video. Chan and Chen did not measure that task, and as far as I can tell nobody has.

Drop that mechanism into a video visit and the two available levers are prescribe empirically or send the patient somewhere with hands, which are exactly the two the study found NPs pulling more often. In telemedicine that shows up as more empiric courses and more requests to be seen in person today.

There is already independent evidence pointing the same direction. Ray and colleagues looked at children treated for acute respiratory infections and found antibiotics prescribed at 52 percent of direct-to-consumer telemedicine visits, against 42 percent at urgent care and 31 percent at a primary care office. Guideline-concordant management ran 59 percent in telemedicine versus 78 percent with the child’s own doctor (6). That was a finding about the modality, not about who was staffing it. Stack a modality that pushes toward empiric treatment on top of a staffing model that also pushes that way, and you have compounded the same bias twice.

The part nobody audits

Every telemedicine urgent care company writes its own clinical practice guidelines. Sinusitis follows this pathway, dysuria follows that one, and here is the list of complaints that must be routed to an in-person evaluation no matter how well the patient looks on camera. The documents are usually sensible. The problem lives downstream of the document.

They are not always followed, and at these volumes nobody is checking most of the time. Chart review is a sampling exercise and the sample is thin. A clinician who has drifted off the pathway, who has learned that the fastest route through a shift is a prescription and a click to the next patient, can drift a long while before anything notices. That is not a nurse practitioner problem. I have watched physicians do the same thing under the same incentives. It does interact badly with a workforce carrying fewer residency-trained reps for the case the guideline did not anticipate, and those are the visits that hurt people.

If I ran one of these companies, the number I would want on the dashboard is one I have never seen a platform publish. What fraction of visits departed from the pathway, broken out by clinician, with the bad outcomes tracked forward past the end of the encounter. Visit volume gets measured continuously. Guideline adherence gets measured occasionally. What happened to the patient afterward gets measured close to never.

Spotting the sick one is the whole job

Strip a virtual urgent care shift down to its clinical core and it is one decision repeated all day. Not what is the diagnosis. Does this person need to be somewhere with hands, equipment and a laboratory, and do they need to be there now.

Nearly everything else is forgiving. Choose the wrong antibiotic for a sinusitis and the patient is annoyed and books a second visit. Miss the atypical presentation of an acute coronary syndrome, or a subarachnoid bleed, or an ectopic pregnancy, or the child whose respiratory rate nobody counted because nobody asked, and that visit becomes the first line of a malpractice complaint or worse.

The instruments available for that decision are thinner than patients realize. No vitals unless the patient owns a cuff and a pulse oximeter and knows how to use them. Nothing to palpate. No chance to watch someone walk across a room, which is one of the most informative things I ever did in person. What remains is the history, and a history taken properly is the entire safety margin. The questions that carry weight cost time a productivity dashboard works against.

Now add the payment model, which pulls the wrong way all shift. Most virtual urgent care pays by the visit, or by the hour with a visit target attached. Nobody gets paid extra for the encounter where you spent eleven minutes on a history, decided something was off, and sent the patient to an emergency department without writing a prescription. On the dashboard that was your least productive visit of the day. It may have been the only one that mattered.

That visit scores badly a second time after you log off, because the patient rates you and at many platforms the rating feeds into your pay. Satisfaction scores capture real things, whether you listened and whether somebody felt taken seriously at eleven at night, and they are worth measuring. The trouble is timing. Satisfaction can be measured the second a visit ends. Whether the decision was correct often cannot be measured for weeks. The fast signal gets attached to the paycheck and the slow one does not, which is a design problem rather than anybody being a villain.

That pull is documented, and the study documenting it looked at physicians rather than nurse practitioners, which is rather the point. Across 8,437 direct-to-consumer telemedicine visits for respiratory infections handled by 85 physicians, 66 percent ended with an antibiotic. Patients who received one gave five stars 90.9 percent of the time, against 72.5 percent for those who left with no prescription (7). Individual physicians prescribed antibiotics anywhere from 19 to 90 percent of the time, and the heavier prescribers scored better. None of this is a telemedicine invention. Fenton and colleagues reported more than a decade ago that the most satisfied patients in a national cohort carried higher expenditures and higher mortality (8), an association rather than a mechanism and argued over ever since.

Nobody should stop asking patients what they thought. But a rating collected sixty seconds after the video ends cannot see whether the person who needed to be sent somewhere actually got sent. Until that number sits beside the satisfaction number, the clinician who declines the antibiotic and recommends the emergency department absorbs a cost nothing credits back.

A specific failure mode grows out of that, and it has nothing to do with anybody’s credential. You see forty upper respiratory infections across a shift. Thirty-nine are exactly what they appear to be. Your threshold quietly resets, because it has been rewarded for resetting all day, and the fortieth looks like the other thirty-nine right up until you ask the question that separates them. Volume does this to everyone. I have felt it happen to me.

This is where inpatient training earns its keep, and the claim is easy to overstate so let me be precise. I am not saying patients should see only physicians. I am saying the particular skill at issue, sorting the person who needs closer evaluation from the person who can be managed at home, gets built by having been responsible for patients who were admitted and then deteriorated overnight. Residency is years of exactly that, with somebody senior checking your reasoning. It is not the only route to that skill. It is the most reliable one we have.

Referral also assumes a mechanism exists, which is something you learn fast working inside one of these services. A good deal of virtual urgent care cannot order anything at all. Not a basic metabolic panel, not a chest film, not a cardiology consult. Payers frequently will not honor an order originating from a telemedicine encounter, reserving that authority for a primary care physician or an in-person urgent care, and platforms understandably do not build plumbing for something insurers will not pay for. Some services do have that capability. Several large national ones do not, and a patient cannot tell which sort they have reached before the visit begins.

Which narrows the toolkit further than most patients imagine. If I cannot send someone for a troponin, the disposition decision stops being one tool among several and becomes the only one. Every bit of uncertainty has to collapse into a single sentence. This can wait. Go be seen today. Go now.

That may loosen. Curbside specialist consults built into the encounter, where a cardiologist or a dermatologist can be pulled onto the call while the patient is still sitting there, are beginning to appear and would change this arithmetic considerably. They are not part of everyday practice yet. Plan around what exists today.

One more piece gets ignored. Referring is not the same as protecting. When a telehealth visit generates a recommended test or referral, patients complete it less often than when the same recommendation comes from an in-person visit. Across 4,133 orders, completion inside the expected window ran 58 percent for in-person against 43 percent for telehealth (9). That study looked at elective primary care work rather than emergency escalation, so do not stretch it. The direction still matters. Telling somebody to go to the emergency department is a recommendation, not a handoff, and a real fraction will not go.

Which brings me to the one staffing opinion I will state without hedging. Virtual urgent care is a poor first job. A nurse practitioner or physician assistant fresh out of school should not be making disposition decisions alone, on camera, without vitals, at production speed. Neither pathway requires a residency, so nobody has yet watched them be wrong somewhere it got caught and corrected. Spend a few years somewhere with a hallway and a colleague in it.

So when patients ask whether it matters that they drew a nurse practitioner instead of a physician, this is my honest answer. On the ordinary complaint, which is most of them, it does not matter much, and the 38 percent figure is why I say that with a straight face. On the visit where something is quietly wrong and nobody has said so out loud yet, training and repetitions matter more, and the average NP has fewer of both. That is not about anybody being careless. It is what 750 hours buys against several thousand, and any NP a decade into acute care has closed most of that distance.

For patients

You can ask who you are seeing and what their background is, and no reasonable clinician will take offense. Do not treat the letters after the name as the whole answer, because a randomly chosen NP outperforms a randomly chosen physician 38 times out of 100 (1). How long they have been doing acute care is the more useful question.

Two practical things. If you call with chest pain, a severe headache, abdominal pain, or a child who is breathing fast, expect to be sent somewhere with hands and equipment, and understand that this is the visit working rather than failing. And if you are told to be seen in person today, go. On many platforms that instruction is the entire product of the encounter, and it only helps if you act on it.

For clinicians

If you build or run these services, the actionable finding from the emergency department data is the complexity gradient rather than the average effect. Route sore throats and rash checks broadly. Route diagnostic ambiguity and high-acuity complaints to whoever has the most reps with them, and make that assignment on individual performance data rather than on license class. That is a solvable engineering problem and almost nobody is solving it.

If you work in them, two suggestions. Keep a private count of how many visits in a shift you closed without writing a prescription, because that number tells you something a satisfaction score cannot. And treat your last hour differently from your first, since threshold drift is worst when you are tired and the pattern has looked the same all day.

The Bottom Line

Virtual urgent care asks one question of a clinician, over and over, all day. Does this person need to be somewhere with hands, equipment and a laboratory, and do they need to be there now. Nearly everything else about the visit is forgiving.

The pressures working against that question are structural rather than personal. Payment by volume. Ratings collected sixty seconds after the video ends. Guidelines nobody has the capacity to audit at scale. And on many platforms no ability to order a test or generate a referral at all. None of that is a nurse practitioner problem and none of it is anybody being a villain. It is what happens when the fast measurements get attached to the paycheck and the slow ones never get taken.

If I were staffing one of these services, I would not put anyone into this work as a first job. And if I were the patient, I would care far less about the credential on the screen than about how many years the person behind it has spent deciding who was sick.

Sources

Chan DC Jr, Chen Y. The Productivity of Professions: Evidence from the Emergency Department. American Economic Review, August 2026. https://www.aeaweb.org/articles?id=10.1257/aer.20241007
Berkeley Research. New study upends traditional thinking about doctors versus nurse practitioners. August 22, 2026. https://vcresearch.berkeley.edu/news/new-study-upends-traditional-thinking-about-doctors-versus-nurse-practitioners
American Medical Association. Nurse practitioners’ care linked to 11% longer stays in the ED. https://www.ama-assn.org/practice-management/scope-practice/nurse-practitioners-care-linked-11-longer-stays-ed
National Task Force on Quality Nurse Practitioner Education. Standards for Quality Nurse Practitioner Education, 6th edition, 2022. https://www.aacnnursing.org/Portals/0/PDFs/CCNE/NTFS-NP-Final.pdf
American Association of Nurse Practitioners. Nurse Practitioners in Primary Care (2025 NP count). https://www.aanp.org/advocacy/advocacy-resource/position-statements/nurse-practitioners-in-primary-care
Ray KN, Shi Z, Gidengil CA, Poon SJ, Uscher-Pines L, Mehrotra A. Antibiotic Prescribing During Pediatric Direct-to-Consumer Telemedicine Visits. Pediatrics. 2019;143(5):e20182491. PMID 30962253. https://pubmed.ncbi.nlm.nih.gov/30962253/
Martinez KA, Rood M, Jhangiani N, Kou L, Boissy A, Rothberg MB. Association Between Antibiotic Prescribing for Respiratory Tract Infections and Patient Satisfaction in Direct-to-Consumer Telemedicine. JAMA Internal Medicine. 2018;178(11):1558-1560. PMID 30285050. https://pubmed.ncbi.nlm.nih.gov/30285050/
Fenton JJ, Jerant AF, Bertakis KD, Franks P. The Cost of Satisfaction: A National Study of Patient Satisfaction, Health Care Utilization, Expenditures, and Mortality. Archives of Internal Medicine. 2012;172(5):405-411. PMID 22331982. https://pubmed.ncbi.nlm.nih.gov/22331982/
Zhong A, et al. Completion of Recommended Tests and Referrals in Telehealth vs In-Person Visits. JAMA Network Open, November 2023. PMID 37966837. https://pubmed.ncbi.nlm.nih.gov/37966837/

Large red EMERGENCY sign on the exterior of a hospital emergency department

Nurse Practitioners vs. Doctors in the ER: What the Research Actually Shows

On August 23, 2026August 30, 2026 By Dr. Scott RennieIn Healthcare System & TechnologyLeave a comment

A paper landed in the American Economic Review this month that is going to get quoted badly by almost everyone who quotes it. Physician groups will pull three numbers out of it. Nursing organizations will pull a different three. Both sets are in there, which is exactly why the paper is worth an hour of your attention instead of a headline.

David Chan and Yiqun Chen looked at 1.1 million emergency department visits across 44 Veterans Health Administration sites, involving 156 nurse practitioners and 1,348 physicians (1)(2). What makes it different from the usual scope-of-practice study is the design. VA provider schedules are set months in advance. Patients show up when they show up. That mismatch means the question of whether you got an NP or a physician on a given night was close to a coin flip rather than a reflection of how sick you looked, and it lets the authors claim causation instead of the correlation that plagues most of this literature.

What the numbers say

Patients seen by NPs had emergency stays 11 percent longer and cost about 7 percent more, roughly 66 dollars per visit (1)(3). Thirty-day preventable hospitalizations ran 20 percent higher. The AMA ran the arithmetic forward and estimated that routing a quarter of VA emergency patients to NPs adds about 129 million dollars a year net, after accounting for the salary difference between the two groups (3).

Thirty-day mortality showed no statistically significant difference (2).

Hold onto both of those. People are going to publish articles this fall that mention one and not the other.

The number everyone is going to skip

Here is the finding I think actually matters, and it is the one I expect to see least in the press coverage. It needs a slow walk, because it is the part that gets garbled every time.

Everything in the section above compares two averages. Add up all 156 NPs and take the mean. Do the same for the 1,348 physicians. Compare the two. Physicians win that comparison, and I am not waving that away.

Now throw the other profession out and look at physicians alone. We are not all the same. Some of us order a great deal of testing and some order very little. Look at length of stay instead, or at thirty-day bouncebacks, and the same wide scatter turns up. The NP group has an equally wide scatter inside it.

What Chan and Chen found is that the spread inside each profession is larger than the distance between the two averages. The gap between a low-resource physician and a high-resource physician is wider than the gap between the typical physician and the typical NP.

Put those two facts together and the distributions overlap most of the way. The strongest NPs sit well inside the physician range. The physicians at the expensive end sit well inside the NP range.

So the authors ran the obvious test. Pull one NP at random. Pull one physician at random. Compare what each of them actually did, and repeat that many times over. The NP is the better performer in 38 out of every 100 draws (1)(2).

That is not a rounding error, and the number is worth calibrating against the two ends it could have landed on. If the professions were genuinely separate tiers, with the weakest physician still ahead of the strongest NP, you would expect something near zero. If they were interchangeable you would expect 50. Thirty-eight sits far closer to interchangeable than to separate.

Two things it does not say. It does not say NPs are 38 percent as good. It does not say that 38 percent of NPs outperform physicians across the board. It describes random one-to-one matchups and nothing wider than that.

And physicians still take 62 of those 100 draws. The average difference did not evaporate. Both of those are true at the same time, and holding both at once is the whole trick with this paper.

The gap also moved around depending on what walked in the door. For the least complicated cases, the extra cost attached to NP care fell by roughly 80 percent compared with the average case (2). It narrowed further as NPs accumulated years, and narrowed again as they accumulated reps with a specific condition. Chan framed the takeaway as a question of “which patients they should see” rather than whether NPs should practice at all, and I think that is the honest reading of his own data.

The mechanism looks like uncertainty, not carelessness. NPs ordered more diagnostic testing and more specialist consults. For sepsis, stroke, and heart failure they were substantially more likely to admit. They wrote fewer opioid prescriptions and more antibiotic prescriptions (2). Read that list as a set and a pattern shows up: when the picture was ambiguous, the threshold to spend a resource dropped. Anyone who has been six months out of residency recognizes that behavior in themselves, because we all did it, and the thing that fixed it was not a different diploma but two thousand more patients.

An aside, because the word keeps getting misused. “Productivity” here is an economics term. It means outputs relative to inputs consumed, not effort expended and not how hard someone works. Nothing in this paper says NPs work less hard. It says a given clinical result cost more to produce.

Where I think it is weakest

One health system. One care setting. One hundred fifty-six NPs, against a national workforce of more than 461,000 licensed NPs (4)(5). The AANP’s objection that you cannot generalize from that sample to every emergency department in the country is fair, and I would make the same objection if the finding had gone the other way.

The VA population is also not America. Older, more male, more comorbidity, and enrolled in an integrated system with a shared record. The VA also grants full practice authority, which means these NPs were working without the collaborative arrangement most of my colleagues in private systems actually have. What the paper cannot see is the physician who glanced at a chart, said one sentence in passing, and quietly changed a plan. That interaction leaves no data trail and it happens constantly.

None of that makes the effect estimates wrong. It makes them local. An 11 percent length-of-stay difference in a VA emergency department is a measurement of that department, and treating it as a national verdict on a profession is a category error.

What this means for a virtual urgent care visit

Most of my work is telemedicine, so this is the setting I thought about first. Virtual urgent care now runs largely on nurse practitioners and physician assistants, and the mechanism Chan and Chen identified does not carry over to a video call cleanly. I cannot order a CBC in the middle of an encounter. I cannot walk anyone down the hall for imaging. When uncertainty rises the levers available are prescribe empirically or send the patient somewhere with hands, which happen to be the same two the study found NPs pulling more often (2).

There turned out to be more to say about that than belongs inside a piece about an economics paper. What the payment and rating structures do to the decision. Why recognizing the sick patient matters more in this setting than almost any other. What happens when the platform cannot order a test at all. I put all of it in its own article: Spotting the Sick One: The Only Decision That Really Matters in Virtual Urgent Care.

Virtual weight management is a different problem, and a more forgiving one.

Weight management is a different animal, and I think the gap mostly closes

Obesity medicine breaks almost every condition that produced the ED result. There is no undifferentiated chest pain arriving at 2 a.m. The diagnosis is usually made before the visit starts. Care is longitudinal, protocol-heavy, and forgiving of a decision revisited in four weeks. The study’s own results predict a smaller gap here, because it found the difference shrinking by about 80 percent on the least complex cases and shrinking again with condition-specific experience (2). An NP who has titrated a thousand patients through semaglutide dose escalation has more relevant pattern recognition than a physician who has titrated forty.

That said, the complexity in this field is real. It just shows up in different places than people expect. Sorting expected GLP-1 nausea from something needing imaging. Recognizing that a patient on 30 units of basal insulin and a sulfonylurea will need those doses coming down as the weight comes off, before the hypoglycemia arrives rather than after. Pancreatitis history. Family history of medullary thyroid carcinoma. Restrictive eating patterns that look like excellent adherence on a video call and are not. Secondary causes, and the long list of psychiatric medications that drive weight gain and never get revisited.

So the risk in virtual weight management is not the credential on the screen. It is the eight-minute refill visit, whoever is running it. A physician doing rushed protocol care and an NP doing thorough protocol care are not close, and I would put my patients with the second one.

The tell is what got asked. Did anyone go back through the medication list once the weight started coming off, or was the box checked and the refill sent? Did anyone ask what the patient is actually eating on the days the nausea is bad, which is the question that separates a tolerable side effect from six weeks of accidental starvation. Nothing on that list has a degree attached to it. It has time attached to it, and time is a scheduling decision made by somebody in an office who has never met the patient.

For patients

You are allowed to ask who you are seeing and what their background is, and no reasonable clinician will be offended. What you should not do is treat the letters after the name as the whole answer. This study says a randomly chosen NP outperforms a randomly chosen physician 38 times out of 100. Experience with your specific problem is the more useful question. If you are starting a GLP-1, ask how many patients they have managed on it. If you are calling a virtual urgent care with chest pain or a severe headache, understand that any competent clinician in that setting is going to send you somewhere with a CT scanner, and that is the correct answer rather than a failure of the visit.

For clinicians

Two things I would take into practice from this paper. First, the within-profession spread being wider than the between-profession spread should change how we think about quality improvement. We spend enormous political energy on scope-of-practice fights and almost none on identifying and coaching the outliers inside our own group, and the data says the second one has more room in it.

Second, the actionable finding for anyone designing care is the complexity gradient rather than the average effect. Straightforward cases should route broadly. Diagnostic ambiguity and high-acuity complaints should route to whoever has the most reps with them, assigned on individual performance data rather than on license class. That is a solvable engineering problem and almost nobody is solving it.

The Bottom Line

This is a serious paper with a genuinely strong design, and its central finding is not the one being headlined. Physicians came out ahead on average in a VA emergency department. NPs came out ahead in 38 percent of head-to-head matchups, the difference nearly disappeared on straightforward cases, and thirty-day mortality was a wash. The spread inside each profession was wider than the gap between them, which is the part worth carrying around.

For virtual weight management I expect the gap to be small, and I care far more about how much time the visit gets and how deep the protocol runs than about which degree is on the screen.

Match the case to the clinician. That is the finding.

Sources

Chan DC Jr, Chen Y. The Productivity of Professions: Evidence from the Emergency Department. American Economic Review, August 2026. https://www.aeaweb.org/articles?id=10.1257/aer.20241007
Berkeley Research. New study upends traditional thinking about doctors versus nurse practitioners. August 22, 2026. https://vcresearch.berkeley.edu/news/new-study-upends-traditional-thinking-about-doctors-versus-nurse-practitioners
American Medical Association. Nurse practitioners’ care linked to 11% longer stays in the ED. https://www.ama-assn.org/practice-management/scope-practice/nurse-practitioners-care-linked-11-longer-stays-ed
Clinician.com. Organizations Take Issue with Data Regarding Nurse Practitioner Care in the ED. https://www.clinician.com/articles/organizations-take-issue-with-data-regarding-nurse-practitioner-care-in-the-ed
American Association of Nurse Practitioners. Nurse Practitioners in Primary Care (2025 NP count). https://www.aanp.org/advocacy/advocacy-resource/position-statements/nurse-practitioners-in-primary-care
Chan DC Jr, Chen Y. The Productivity of Professions: Evidence from the Emergency Department. NBER Working Paper No. 30608, issued October 2022, revised August 2026. https://www.nber.org/papers/w30608

A flat black rectangle lying on cream linen surrounded by sprigs of dried sage, lit by soft window light.

FDA Removes Black Box Warning From Menopause Hormone Therapy

On August 14, 2026August 30, 2026 By Dr. Scott RennieIn Menopause & Women's HealthLeave a comment

Since the headlines ran, some version of the same question has been opening my video visits. “So it’s safe now, right? I saw it on the news.”

The women asking are usually a few years past their last period, sleeping badly, foggy at work, and frustrated. Somewhere along the way they were told hormones would give them breast cancer, and that was the end of the conversation. Something did change this summer. What changed is not what most people think.

The FDA did not run a new trial. No fresh outcome data landed on anyone’s desk. What happened is better described as a labeling correction: a regulatory acknowledgment that a warning written for one population had been applied, for more than twenty years, to a completely different one. That distinction is the whole story. It tells you how much permission this gives us, and it tells you exactly where the permission stops.

What Actually Happened

On November 10, 2025, HHS and the FDA announced they were initiating removal of the boxed warning from menopausal hormone therapy products containing estrogen. The specific language coming out covered cardiovascular disease, breast cancer, and probable dementia. (1) The move followed a public expert panel the agency convened in July 2025 and a comment period after that.

Then came the slower part, the part that got almost no coverage. Removing a boxed warning is not a press release. It is a product-by-product labeling supplement for every manufacturer. In February 2026, the FDA approved the first batch: labeling changes for six products spanning all four categories of menopausal hormone therapy, including systemic combination therapy, systemic estrogen alone, systemic progestogen for women with a uterus, and topical vaginal estrogen. (2) Twenty-nine companies had submitted proposed changes by that point. (2) More have been approved since.

The new labels also add something that wasn’t there before: age-specific framing, pointing toward initiation within ten years of menopause onset or before age 60 for systemic therapy. (2)

So the headline “HRT is safe now” is doing a lot of work it can’t support. The accurate version is that a warning which never fit a healthy 52-year-old with hot flashes has finally been taken off her prescription.

Why That Warning Was There In The First Place

You cannot understand the correction without understanding the error.

In July 2002, the Women’s Health Initiative stopped its estrogen plus progestin arm early. That trial had randomized 16,608 postmenopausal women with an intact uterus to conjugated equine estrogens plus medroxyprogesterone acetate or placebo. (3) The data safety monitoring board pulled the plug at 5.2 years because the global index crossed a predetermined boundary.

The relative risks made every front page in the country. Invasive breast cancer, hazard ratio 1.26. Coronary heart disease, 1.29. Stroke, 1.41. Pulmonary embolism, 2.13. (3)

What ran in far smaller type, if it ran at all, were the absolute numbers. Per 10,000 women per year of treatment: seven more coronary events, eight more strokes, eight more pulmonary emboli, eight more invasive breast cancers. Also five fewer hip fractures and six fewer colorectal cancers. (3) These are small absolute differences. “A twenty-six percent increase in breast cancer” and “eight additional cases per ten thousand women per year” describe the same finding, and only one of them ended a generation of treatment.

The estrogen-alone arm, which enrolled 10,739 women who had already had a hysterectomy, was stopped separately in 2004. That arm never showed an increase in breast cancer at all. If anything it trended the other direction. (4) The boxed warning went on both.

The dementia language came from WHIMS, the memory substudy. WHIMS enrolled women aged 65 to 79. (5) That is worth reading twice. A finding generated exclusively in women 65 and older became a printed warning handed to women in their early fifties for the next two decades.

The Trial Didn’t Study The Women Who Got The Warning

Mean age at enrollment in WHI was 63.3 years. (3)

Think about who that is. The average American woman reaches menopause around 51. A 63-year-old enrolling in the mid-1990s was, on average, more than a decade out from her final period. Many were two decades out. Most were not symptomatic, which was by design, because WHI was built as a chronic disease prevention trial and not a symptom trial. Participants were also carrying the cardiovascular risk you would expect at that age, including a substantial proportion with hypertension, obesity, and subclinical atherosclerosis nobody had imaged.

Put estrogen into an artery that already has established, possibly unstable plaque and you are not doing the same thing you do when you put estrogen into a 52-year-old’s relatively clean vasculature. That is the biological core of what became known as the timing hypothesis: estrogen appears to be protective, or at least neutral, in healthy endothelium, and potentially destabilizing in diseased endothelium.

The evidence for it isn’t a hunch.

The ELITE trial randomized 643 postmenopausal women to oral estradiol or placebo, stratified by how far out from menopause they were. In women less than six years postmenopause, estradiol significantly slowed carotid intima-media thickness progression. In women ten or more years out, it did nothing. (6) Same drug, same trial, opposite vascular story depending on when you started it.

The Danish Osteoporosis Prevention Study randomized about 1,000 recently postmenopausal women to hormone therapy or no treatment and followed them for ten years. The treated group had a lower composite rate of death, heart failure hospitalization, and myocardial infarction, with no increase in cancer, stroke, or venous thromboembolism. (7) It was open-label, which limits it, and it wasn’t powered as a cardiovascular outcomes trial. But it points the same direction.

And WHI’s own investigators, when they went back and stratified by age, found the pattern sitting in their own data. Women who started in their fifties looked different from women who started in their seventies. (8) The 18-year follow-up of both WHI arms, published in 2017, found no increase in all-cause mortality, cardiovascular mortality, or cancer mortality in either treatment group. (9)

None of this is new. ELITE published in 2016. The mortality follow-up published in 2017. The FDA’s 2025 action was a review of literature that already existed, which is exactly why calling it a labeling correction is fair. The evidence got there long before the label did.

Now The Part Nobody Is Covering: What This Does Not Do

Here is where I want to slow down, because the celebratory version of this story is going to get people hurt.

The endometrial cancer warning did not go away

The FDA explicitly did not seek removal of the boxed warning regarding endometrial cancer for systemic estrogen-alone products. (1) Unopposed systemic estrogen in a woman with a uterus causes endometrial hyperplasia and carcinoma, and the PEPI trial put hard numbers on how fast. Over three years on unopposed conjugated estrogen, 22.7 percent of women developed complex hyperplasia and 11.8 percent developed atypical hyperplasia. Every arm that included a progestogen held hyperplasia under 1 percent. (14) That risk is dose and duration dependent, it is real, and it is almost entirely preventable. Nothing in this label change touched it.

The word doing all the work in that paragraph is systemic, and it is worth slowing down on, because this is the single most muddled point in the entire subject.

Low-dose vaginal estrogen does not need a progestogen. Not for the cream, not for the ring, not for the tablet. A systematic review of 20 randomized trials covering nearly 3,000 women found endometrial cancer in 0.03 percent and hyperplasia in 0.4 percent, which is background noise, and the WHI Observational Study found no association either. (15) The Menopause Society does not recommend adding a progestogen to low-dose vaginal estrogen therapy. Neither do I. If you have a patient on Estring or a small twice-weekly dab of vaginal estradiol cream for dryness and recurrent UTIs, she does not need progesterone, and putting her on it adds side effects for no endometrial benefit.

Here is the part that trips people up. The dividing line is not oral versus topical. It is systemic versus local. A patch, a pump gel, a spray, and a compounded body cream are all systemic estrogen, and they all raise endometrial risk the same way a pill does. Transdermal delivery changes the clot risk, which I will get to in a minute. It does nothing for the endometrium. If she has a uterus and the estrogen is reaching her bloodstream at systemic levels, she needs a progestogen at an adequate dose for as long as she is on it, no matter what the delivery device looks like.

I bring it up because the compounded and direct-to-consumer market blurs exactly that line, and “cream” gets used to mean two completely different products. I have picked up patients well into a compounded systemic estradiol cream, rubbed on the inner arm at a real systemic dose, with no progestogen prescribed and nobody having mentioned that they needed one.

Removing a warning does not remove a risk

Venous thromboembolism with oral estrogen is the cleanest example. The large UK nested case-control analysis of more than 80,000 VTE cases found oral hormone therapy carried an adjusted odds ratio of 1.58 overall, with oral conjugated equine estrogen plus medroxyprogesterone acetate at 2.10. Transdermal preparations showed no increased risk. Head to head, oral was associated with roughly 70 percent higher VTE risk than transdermal. (10)

That finding should change your prescription pad, not your enthusiasm. The route matters here, and this is the one place it does. First-pass hepatic metabolism drives the procoagulant shift, and transdermal estradiol bypasses it. For a woman with obesity, a prior clot, a thrombophilia, migraine with aura, or a family history that makes you uneasy, transdermal isn’t a preference. It’s the answer.

Breast cancer risk was overstated, not erased

The 2019 Lancet collaborative reanalysis of the worldwide epidemiological evidence put it in numbers a patient can actually hold onto. For a woman of average weight starting at age 50 and using therapy for five years, the excess breast cancer incidence through age 69 is roughly one additional case per 50 users of estrogen plus daily progestogen, and about one per 200 users of estrogen alone. (11) Small. Not zero. And dose and duration dependent, which means the conversation at year eight is a different conversation than the one at year two.

For context I give patients, because context is what they are usually missing: that magnitude sits in the same neighborhood as two alcoholic drinks a day, or carrying significant excess weight after menopause. Nobody puts a black box on either of those.

This is still not a primary prevention drug

The approved indications didn’t change. Systemic hormone therapy is indicated for moderate to severe vasomotor symptoms, for moderate to severe genitourinary symptoms of menopause, for prevention of postmenopausal osteoporosis in appropriate candidates, and for hypoestrogenism from hypogonadism or primary ovarian insufficiency. That’s the list.

The USPSTF continues to recommend against menopausal hormone therapy for the primary prevention of chronic conditions, a grade D recommendation. (12) You do not start a 58-year-old on estradiol to prevent her heart attack. If the timing hypothesis eventually earns a prevention indication, it will do so through a trial designed to answer that question, and that trial has not been run.

A boxed warning coming off is not new evidence coming in

There were no new randomized trials behind the November 2025 action. The FDA reviewed what already existed and concluded the label misrepresented it. That is a real and overdue fix. It is not a discovery, and anyone selling it to you as one is probably selling you something else too.

If You’re A Patient: You Can Reopen This

If you were told no in 2009, or 2015, or honestly even in 2023, the answer you got was shaped by a warning that has since been withdrawn. You are allowed to ask again.

A few things worth knowing before that appointment.

The window matters. The risk-benefit math is most favorable for women who are generally healthy, under 60, and within about ten years of their final menstrual period. The further out from that window you are, the more carefully the decision has to be individualized, and for some women the answer will still be no.

Vaginal estrogen is a separate conversation entirely. Low-dose vaginal estrogen for genitourinary symptoms, meaning dryness, painful sex, recurrent urinary tract infections, urgency, has minimal systemic absorption. The Menopause Society specifically welcomed the boxed warning removal for these products, describing them as safe and effective for a condition that affects most menopausal women. (13) If vaginal symptoms are your issue, the systemic risk conversation largely doesn’t apply to you, and you almost certainly do not need to take progesterone alongside it.

There are still real contraindications. A history of breast cancer, an estrogen-dependent tumor, prior stroke or heart attack, active or prior venous thromboembolism, a known thrombophilia, significant liver disease, or unexplained vaginal bleeding that hasn’t been worked up. If any of those apply to you, the answer may genuinely be no, and there are non-hormonal options worth discussing, including the newer neurokinin receptor antagonists for hot flashes.

And bring specifics, even to a twenty minute video visit. How many nights a week you wake up. Whether you have stopped exercising. Whether sex hurts. Whether you are thinking about leaving a job you used to like. A recent blood pressure reading, when your last mammogram was, and what your mother’s and sister’s history looks like. Symptom burden is half the equation, and “I’m having some hot flashes” badly undersells what is usually going on.

If You’re A Colleague: How I’m Counseling Now

I practice entirely by telemedicine, so everything below happens over video, usually in one visit and a follow-up. Here is how I run it in 2026.

I start by asking what she was told before, and by whom. Roughly half of my perimenopausal and postmenopausal patients are carrying a specific prior refusal, and if I don’t surface it, it sits there and quietly undermines everything I say next.

Then I frame the decision around three questions instead of one. Is she in the window? What is her baseline cardiovascular and thrombotic risk? And what is her symptom burden, honestly measured? A woman at 52 with severe vasomotor symptoms and no risk factors is a different patient than a woman at 64 with controlled hypertension and mild night sweats. The label change does not collapse that difference.

The remote setting changes the logistics of that second question, not the standard. Before I start systemic therapy I want a blood pressure I trust, which usually means a home cuff and a few readings rather than one number she remembers from a year ago. I want her mammogram status current, her personal and family history of clot and breast cancer taken carefully rather than checkbox-style, and any abnormal bleeding evaluated in person before we go anywhere near estrogen. None of that requires me to be in the room. All of it requires me to actually ask.

Route selection is where I have gotten more opinionated. Transdermal estradiol is my default for anyone with obesity, hypertriglyceridemia, migraine with aura, gallbladder disease, or any thrombotic history, personal or family. (10) The oral versus transdermal difference in VTE risk is one of the few places in this entire discussion where we can meaningfully reduce absolute harm by changing one line on the prescription.

Progestogen goes with every uterus on systemic estrogen, and only with systemic estrogen. Micronized progesterone is my preference for the metabolic profile and possibly the breast profile, though I will say plainly that the comparative data across progestogens is observational and not as strong as some of the marketing suggests. If she is on vaginal estrogen alone, she does not get a progestogen from me.

I still ask about duration out loud, every year. Not because there is a hard stop at five years, because there isn’t one, and the old “lowest dose for the shortest duration” language has aged badly. But breast cancer risk is duration dependent (11), and the woman who has been on therapy for nine years should be making that choice consciously rather than by inertia.

And I document the shared decision making. Symptom burden, risk factors reviewed, route and rationale, progestogen plan, alternatives discussed. That note protected me before the label change and it protects me now.

One more thing, and it matters more in this setting than any other. The current news cycle is producing a wave of patients who want hormones for reasons that are not on the label. Longevity. Body composition. Cognitive performance. Telemedicine is where most of that demand is landing, and a lot of it is landing on platforms that will ship estradiol after a four-question intake form and never once ask about the uterus. I would much rather have the honest conversation about what the evidence does and does not support than have someone go around me to get a worse version of the same drug.

The Bottom Line

A warning that should never have been applied to a healthy 52-year-old with hot flashes has been removed. That is a genuine correction, and the women who were denied treatment for twenty years deserved it a long time ago.

What did not happen is a change in the underlying biology. Oral estrogen still raises clot risk. Unopposed systemic estrogen still endangers the endometrium, whatever it is delivered in. Breast cancer risk is still small, still real, still duration dependent. Hormone therapy still isn’t a preventive medication.

The label was wrong. The nuance was always right. We just get to have the conversation now without a black box sitting in the middle of the table.

Do Ozempic and Zepbound Cause Muscle Loss?

On August 8, 2026August 30, 2026 By Dr. Scott RennieIn Weight Loss & Metabolic HealthLeave a comment

Every few months a new worry about GLP-1 therapy moves through the news cycle. Lately the one I’m fielding most on video visits is muscle. Patients read a headline about “Ozempic muscle” or see a segment warning that these drugs are quietly turning people frail, and they show up to their visit asking whether the weight they’re losing is actually fat, or whether they’re hollowing out their strength along with it. Most just phrase it in terms of what they saw online: GLP or Ozempic muscle loss. Truth is, most of my patients aren’t that worried about it at first. They’re focused on getting the fat off. But some have seen the scare ads on Facebook and other social media railing against GLP-1 medications in general, touting muscle loss as the reason to avoid them. It’s a fair question, and it deserves a real answer.

What the data actually shows

Here’s the uncomfortable part first: the concern isn’t manufactured. Across GLP-1 and dual-agonist trials, roughly 25 to 40 percent of total weight lost is lean mass rather than fat mass, and that share climbs with higher doses and greater total weight loss. In patients losing more than 15 percent of body weight on high-dose therapy, average lean mass decline runs in the range of 10 to 15 percent. That’s not trivial, and it’s higher than what we’d want to see if the sole measuring stick were “weight coming off.”

Lean mass loss and clinically meaningful muscle loss aren’t the same thing, though, and this is where I think the public conversation gets sloppy. Lean mass includes water, organ tissue, and connective tissue alongside contractile muscle. Some degree of lean mass loss happens with any significant weight reduction, including bariatric surgery and aggressive caloric restriction without any medication at all. The relevant clinical question is whether strength and function held up, and whether frailty risk moved. On that narrower and more important question, the current evidence is reassuring for most patients: there’s no consistent signal that GLP-1-induced weight loss causes outright sarcopenia or functional decline in the general obesity population studied so far.

Where the concern sharpens is in specific subgroups: adults over 65, patients with baseline sarcopenia or frailty, and anyone starting from a lower muscle reserve. That’s the population where I’m paying closer attention now, more than the healthy 40-year-old with obesity and good baseline strength.

What’s changing in how we prescribe

A few practical shifts have made their way into how I approach this with patients this year. When muscle preservation is a priority, I start low and titrate slower. This isn’t new advice for tolerability, but it applies here too: aggressive, fast weight loss appears to pull proportionally more from lean mass than a slower trajectory toward the same endpoint.

Protein intake is no longer an aside I mention on the way out the door. Current guidance points to 1.2 to 1.6 g/kg of body weight per day for patients on GLP-1 therapy, meaningfully higher than general population recommendations, and given how much these medications suppress appetite, hitting that number takes real intention. I’ve started asking patients to walk me through a typical day’s protein intake rather than assuming they’re getting enough just because they’re eating less overall.

Resistance training is now part of the treatment plan itself, prescribed with the same specificity as the medication. Two or more sessions a week of resistance work is the most consistent lever we have for preserving lean mass during GLP-1-driven weight loss. For patients who’ve never lifted weights, even bodyweight or band-based resistance work at home is a reasonable starting point, and it’s worth a specific referral to physical therapy or a trainer rather than a general nudge.

And I’m tracking more than the scale. For patients on higher doses, losing significant weight, or starting from a place of reduced muscle reserve, I’m now discussing body composition tracking, whether that’s a DEXA scan, bioelectrical impedance, or simply following functional measures like grip strength and chair-stand time, rather than relying on weight alone to judge how treatment is going. I’ll say plainly: I don’t yet fully trust the consumer-grade body composition numbers patients bring me on their phones. Grip strength and chair-stand time are the measures I put the most weight on. Over video I’m relying on what a patient can demonstrate on camera and tell me, rather than testing it myself, which is a real limitation of doing this work remotely.

Muscle is not the only tissue worth watching on these drugs. Nerve complaints turn up too, from skin that hurts to the touch through to the more serious neuropathies, and the risk of both rises with dose and with how fast the weight comes off. I cover that separately in GLP-1 skin and nerve pain.

What’s coming that may change this conversation further

Drug development is moving on this too, well past prescribing technique. At the American Diabetes Association’s 85th Scientific Sessions this year, early data from the BELIEVE study looked at bimagrumab, an antibody that blocks activin receptor signaling, paired with semaglutide, specifically to see whether it could preserve lean mass during GLP-1 weight loss without blunting fat loss. Separately, researchers at Stanford published mouse data in June showing that a muscle-repair-targeted compound improved muscle regeneration and strength recovery alongside GLP-1 treatment, again without compromising fat loss. Neither approach is available for patients today, but they reflect where the field is heading: toward combination approaches that decouple fat loss from lean mass loss more deliberately.

Where the newer agents in the pipeline land on this question is also worth watching. Retatrutide, the triple GIP/GLP-1/glucagon agonist from Lilly, posted strong topline results across its TRIUMPH program this year, with weight loss in the 20 to 28 percent range depending on the trial population, and a BLA submission is planned for early 2027. Amgen’s MariTide, a monthly injectable combining a GLP-1 agonist with an amylin antibody, showed roughly 20 percent weight loss in Phase 2 with a safety profile consistent with the existing GLP-1 class. Body composition data from both programs will matter as much as the topline weight-loss numbers once they mature.

The bottom line

Muscle loss with GLP-1 therapy is real, but it’s manageable, not a reason to avoid treatment or panic mid-course. Older adults and anyone with baseline frailty need the closest attention, and so does anyone pursuing rapid, high-percentage weight loss on a higher dose. I order a DEXA when I actually need an answer to how much of that weight is fat, and it’s an easier call in a patient who might also have osteoporosis, since the same scan answers both questions. Insurance makes this harder than it should be, and plenty of patients who already know they’re overweight don’t want to pay out of pocket just to confirm it. Protein intake and resistance training aren’t optional add-ons anymore. They’re as much a part of the standard prescription as the injection itself.

Wegovy 7.2 mg: Who Should Consider the Higher Dose?

On July 31, 2026August 30, 2026 By Dr. Scott RennieIn Weight Loss & Metabolic HealthLeave a comment

Wegovy just got a new top rung on the ladder. In March of this year, the FDA approved a higher, 7.2 mg dose of semaglutide, marketed as Wegovy HD, for adults with obesity or overweight. This is a new ceiling on a drug we already know well. Same drug. Higher rung. I think it’s worth walking through what the data actually shows before deciding who in your practice, or mine, is a good candidate for it.

The approval leaned on two trials, STEP UP and STEP UP T2D, both 72-week phase 3 studies. In STEP UP, which enrolled adults with obesity but without type 2 diabetes, patients on 7.2 mg lost an average of 20.7% of body weight, compared with 15.6% on the standard 2.4 mg dose and 3.9% on placebo, a meaningful jump and not a marginal one. Almost a third of patients on the higher dose, 31.2%, lost a quarter or more of their starting body weight. In the companion trial, STEP UP T2D, which looked at patients with obesity and type 2 diabetes, the numbers were lower but still substantial: 14.1% average weight loss, with about a fifth of patients losing 20% or more. That gap between the diabetes and non-diabetes cohorts isn’t surprising. We see it consistently with GLP-1 therapy, and it’s a good reminder to set expectations differently for patients with T2D up front.

Here’s the part that matters most for how I’ll actually use this in practice: Wegovy HD isn’t a starting dose. The label requires that a patient have already tolerated 2.4 mg for at least four weeks before stepping up, and the escalation is meant for patients where additional weight loss is clinically indicated, meaning the 2.4 mg dose hasn’t gotten them where they need to be. So the ideal candidate is someone who’s already on semaglutide, tolerating it reasonably well, but has plateaued short of their goal or still has a lot of excess weight to lose relative to their comorbidities. Think of a patient who’s been on 2.4 mg for six months, lost maybe 10-12% of body weight, tolerates the GI side effects fine, but still has a BMI well into obesity range with sleep apnea or hypertension that hasn’t fully responded. That’s the kind of case where I’d bring up 7.2 mg. It’s not for someone just starting therapy, and it’s not for someone who’s struggling with nausea or GI symptoms at the lower dose. If they can’t tolerate 2.4 mg, going higher solves nothing.

Which brings up the safety side, because the tradeoff here is real.

Overall tolerability at the higher dose was described as similar to what’s been seen with 2.4 mg, with GI effects like nausea, vomiting, constipation, and abdominal pain remaining the most common complaints. But two numbers stood out to me. Dysesthesia, essentially altered or abnormal skin sensation, occurred in 22% of patients on 7.2 mg versus 6% on 2.4 mg and 0.3% on placebo. That’s not a side effect I’d been counting on discussing much with patients on standard-dose semaglutide, and it’s one I’ll need to specifically ask about at follow-up visits once patients move up. I’ve seen the same pattern in my own patients, the ones who dose escalate quickly on standard Wegovy dosing, well before anyone gets near 7.2 mg. The trial data and my own visit notes agree on that one. Dose reductions due to adverse events were also more common at the higher dose, 18.5% versus 12.4% on 2.4 mg, and discontinuation due to side effects ran around 5.4%. The higher dose isn’t a free upgrade. You’re trading tolerability for more weight loss, and that’s a conversation to have explicitly with the patient rather than assume they’d automatically want the escalation.

One safety finding from STEP UP deserves more attention than it got. Dysesthesia, meaning abnormal skin sensation, was reported by 22.9 percent of patients on 7.2 mg against 6.0 percent on 2.4 mg and 0.5 percent on placebo. I go through what that means and how to counsel for it in my article on GLP-1 skin and nerve pain.

From a practical standpoint, Wegovy HD is expected to be available through pharmacies and telehealth channels starting in April, delivered in a single-dose pen. I don’t think this changes how I approach a new patient starting on semaglutide at all, the same titration principles from 2.4 mg still apply. What it does is give me another option for the subset of patients who’ve done well but not well enough, and who’ve shown they can handle the medication without major GI intolerance. That’s a narrower group than “everyone on Wegovy,” and I’d resist the urge, mine or a patient’s, to jump to the higher dose just because it’s now available. The data supports it for the right patient. It doesn’t support treating it as the new default starting point.

Foundayo vs. the Wegovy Pill: Comparing the Two New Weight Loss Pills

On July 31, 2026August 30, 2026 By Dr. Scott RennieIn Weight Loss & Metabolic HealthLeave a comment

For years, if you asked me “is there a pill version of these weight-loss drugs?”, the honest answer was no, not really. That changed twice in the past eight months. If you haven’t been following the news closely, the options today look very different than they did just a year ago.

A quick note on names first, since patients ask me this a lot. The Lilly drug some people have heard called “Fonday-o” is actually called orforglipron. Its brand name is official now, not a guess. The FDA approved it on April 1, 2026, under the brand name Foundayo. Before that, on December 22, 2025, the FDA approved a 25 mg oral semaglutide tablet under the Wegovy name. GLP-1 medicines help control appetite and blood sugar, and this was the first pill version of one approved for long-term weight management. Both pills are real, both are approved, and both can be prescribed today.

Why the two pills work so differently in your body

Semaglutide is a peptide, which is a small chain of amino acids, the building blocks of proteins. Your stomach is very good at breaking down peptides, which is exactly why semaglutide originally had to be given as a shot instead of a pill.

Novo Nordisk’s solution was to add an ingredient called SNAC that helps the drug get absorbed before your stomach destroys it. According to a review in the medical journal Clinical Diabetes, SNAC does three things at once. It changes the local acidity around the tablet as it dissolves, it briefly protects the drug from a stomach enzyme called pepsin that would otherwise break it down, and it helps the drug pass through the stomach lining into your bloodstream. This absorption happens in the stomach itself, not the intestines, which is unusual for a pill. The drug essentially enters your body right where the tablet is sitting against your stomach wall.

That clever trick comes with a catch. You have to take oral semaglutide on an empty stomach with no more than about four ounces of plain water, and you can’t eat or drink anything else, including coffee or other medications like thyroid pills, for at least 30 minutes afterward. Taking it too close to breakfast or your other pills can reduce how much of the drug actually gets into your system. This isn’t a small detail. It can be the difference between the medicine working well and not working at all.

Orforglipron works completely differently. It’s what’s called a small molecule, meaning it’s a simple, stable chemical rather than a fragile peptide chain. It belongs to the same family of drugs as semaglutide. GLP-1 receptor agonists mimic a natural gut hormone that reduces appetite, and because orforglipron has no peptide to protect, it doesn’t need any special absorption booster and doesn’t come with a strict timing routine. Lilly describes it as the only GLP-1 weight-loss pill you can take at any time of day, with or without food or water. In real life, that means someone who works night shifts, or who already takes six other pills each morning, doesn’t need a complicated schedule to make it work.

What the study results actually show

Here’s where I want you to slow down before drawing conclusions, because it’s easy to misread these numbers.

In a 64-week study called OASIS 4, which tested the drug in 307 adults with obesity or being overweight who did not have diabetes, oral semaglutide 25 mg led to about 17% average weight loss in people who stayed on the medicine the whole time, compared with about 3% for those taking a placebo (an inactive pill used for comparison). When you count everyone in the study, including people who stopped early, the numbers were about 14% versus 2%. Seventy-six percent of people lost at least 5% of their body weight, compared with 31% on placebo.

In a separate study called ATTAIN-1, published in the New England Journal of Medicine, orforglipron was tested at three different doses (low, medium, and high) over 72 weeks. Average weight loss was 7.8%, 9.3%, and 12.4% at those doses, compared with 2.1% on placebo. At the highest dose tested in the trial, 36% of people lost 15% or more of their body weight, and 18.4% lost 20% or more, compared with 5.9% and 2.8% on placebo.

If you compare those numbers side by side, it looks like semaglutide wins, and I don’t think that comparison holds up. These are two separate studies, different patients, different lengths of time, different ways of measuring results, and nobody has run them head-to-head in the same people at the same time. What I can say confidently is that both pills produce weight loss that’s meaningful and far beyond anything we had in pill form before 2025.

One more detail worth knowing, because it can be confusing if you read news coverage of the studies. The doses of Foundayo that actually got approved are 0.8, 2.5, 5.5, 9, 14.5, and 17.2 mg, and your doctor increases your dose gradually, about every 30 days. Those numbers are different from the 6, 12, and 36 mg doses mentioned in the New England Journal of Medicine study. That’s because the trial used a different capsule formula than the one that ended up on the market. The 17.2 mg tablet you can actually get prescribed is equivalent to the 36 mg dose used in the trial. So if you notice your maximum dose sounds much smaller than what you saw in the news, that’s why.

Side effects

Both drugs work in a similar way in the body, and both come with similar side effects: nausea, vomiting, diarrhea, and constipation.

The ATTAIN-1 study reported specific numbers for orforglipron. Nausea occurred in 28.9% to 35.9% of people across the different doses, compared with 10.4% on placebo. Constipation occurred in 21.7% to 29.8%, versus 9.3% on placebo. Vomiting occurred in 13.0% to 24.0%, versus 3.5% on placebo. The number of people who stopped taking the drug because of side effects went up with higher doses, from 5.3% at the lowest dose to 10.3% at the highest, compared with 2.7% on placebo. Most side effects were mild to moderate.

Novo Nordisk reported that oral semaglutide’s side effects looked similar to what we already know from the injectable version of semaglutide, including the same warnings about pancreas inflammation, gallbladder problems, and allergic reactions. If you’ve taken injectable semaglutide before, this side effect pattern will likely feel familiar.

How I think about choosing between them

If you’re already doing well on injectable semaglutide and want to get away from needles, the oral tablet is the more natural next step. It’s the same active medicine, has a familiar side effect pattern, and carries the same approved benefit for heart health in people with existing heart disease.

If your biggest obstacle is fitting a medicine into a busy or unpredictable schedule, orforglipron tends to be more forgiving. That 30-minute waiting period for oral semaglutide sounds minor when we talk it through on a video visit, but in real life it trips people up. I’ve seen patients struggle with oral semaglutide not because it didn’t work, but because busy weekday mornings made it hard to follow the timing rules.

Cost is the third thing to consider, and it’s changing quickly. Novo Nordisk launched the 1.5 mg starting dose at $149 per month, with savings programs available. Lilly is offering self-pay pricing through its LillyDirect program, with commercially insured patients paying as little as $25 per month, and some Medicare Part D patients paying $50 starting as soon as July 1, 2026. These programs get updated often, so it’s worth checking the current terms before assuming a specific price applies to you. I haven’t run into a prior-authorization fight or a stocking problem with Foundayo yet. Most of what I prescribe goes through LillyDirect, cash pay, because it’s one of the cheaper options on the table. Patients who have insurance coverage tend to ask for injectable Wegovy or Zepbound instead.

We finally have two pill options, and each one tends to fail for a different reason, whether that’s the timing rules or something else. Figuring out which failure point matters most for your life is really the key to choosing the right one.

What Is Hantavirus? What You Need to Know Right Now

On May 8, 2026August 30, 2026 By Dr. Scott RennieIn Infectious Disease1 Comment

If you’ve been following the news lately, you’ve probably seen hantavirus come up more than once. First it was the tragic death of Betsy Arakawa, the wife of actor Gene Hackman, in Santa Fe in February 2025. Then, just days ago, a cruise ship in the Atlantic became the center of an international health response involving the WHO, multiple governments, and passengers scattered across more than a dozen countries. So let’s talk about what hantavirus actually is, where the risk really comes from, and why one particular strain of this virus is changing how we think about transmission.

The Basics: A Rodent-Borne Illness

Hantavirus isn’t new. In the United States, it first grabbed serious attention in 1993 when healthy young adults in the Four Corners region of the American Southwest started dying of a mysterious respiratory illness. The culprit turned out to be a newly identified pathogen called Sin Nombre virus, spread by the deer mouse. That outbreak gave us a new diagnosis, hantavirus pulmonary syndrome, or HPS, and it launched decades of surveillance that continues today. According to the CDC, from 1993 through the end of 2023, the United States recorded 890 total cases. (1)

In the U.S. strain, the virus spreads from rodents to humans, not from person to person. People get infected when they breathe in aerosolized particles from the urine, feces, or saliva of infected animals. You don’t have to be bitten. You don’t have to handle a dead mouse. You can be sweeping out a shed or a cabin that sat empty all winter, and if infected rodents were living in there, you’re at risk the moment those dried particles become airborne. That’s how Betsy Arakawa most likely got sick. She was found deceased at her Santa Fe home in late February 2025, and the New Mexico Office of the Medical Investigator confirmed she died of hantavirus pulmonary syndrome. (2) Her husband, Gene Hackman, tested negative for the virus and died of heart disease. (2)

That case was a painful reminder. Hantavirus doesn’t make headlines often, but it doesn’t disappear either. New Mexico, Colorado, Arizona, and the broader Southwest are endemic areas. We see cases here. Our patients are at risk.

What the Disease Actually Looks Like

The illness comes in stages. The early phase looks frustratingly like the flu: fever, muscle aches, headache, fatigue, sometimes nausea, vomiting, and diarrhea. (3) That prodromal period can last several days. Then comes the part that kills people. The lungs fill with fluid. Patients develop acute respiratory distress syndrome. Blood pressure drops. The heart begins to fail. According to the WHO, the case fatality rate for hantavirus in the Americas reaches up to 50%. (4) The CDC and other sources put HPS mortality in the 30 to 40 percent range, depending on the strain. (5)

There’s no specific antiviral treatment that works for HPS. Ribavirin, a drug that works for some other viral hemorrhagic fevers, was tested and didn’t show benefit. (6) What we have is supportive care: ICU management, mechanical ventilation when respiratory failure sets in, careful fluid management to avoid making pulmonary edema worse. The CDC is clear that if you suspect HPS, get the patient to the ICU immediately, before you even have lab confirmation. (6) Without early aggressive care, most deaths occur within 24 to 48 hours of the cardiopulmonary phase onset. (6)

This is a disease where the clock moves fast once it turns.

Andes Virus: A Different Transmission Pattern

Here’s where things get more complicated. Most hantaviruses, including Sin Nombre, the strain we deal with in the U.S., don’t spread person to person. A patient with HPS from Sin Nombre is, for practical purposes, a dead end for transmission. Standard precautions are appropriate. That’s reassuring.

The Andes virus is different.

Andes virus is found in South America, primarily Argentina and Chile, and it’s carried mainly by the pygmy rice rat. (7) It’s the only hantavirus known to be capable of human-to-human transmission. (8) That capacity was first documented in a 1996 outbreak in southern Argentina, where 18 cases occurred in and around the towns of El Bolson, Bariloche, and Esquel. Notably, five of the patients were physicians, three of whom had directly cared for infected patients. (9) Two additional people who had contact with the patients but hadn’t visited the affected area also got sick, which strongly suggested person-to-person spread. That outbreak was significant. It forced a rethinking of how we approach Andes virus cases in clinical settings.

The transmission appears to happen through close, sustained contact with an infected person, likely through respiratory secretions. It isn’t casual. It’s not the kind of spread you get from being in the same room briefly. But it happens, and it happens enough that the WHO has classified hantaviruses as emerging priority pathogens with high potential to spark international public health emergencies. (10)

The Cruise Ship: A Real-Time Case Study

What’s unfolding right now on the MV Hondius, a Dutch-flagged expedition cruise ship, is the most visible illustration of Andes virus transmission risk in years.

The ship departed Ushuaia, Argentina on April 1, 2026, carrying 147 passengers and crew from 23 countries. The leading theory, according to Argentine health officials, is that a Dutch passenger couple contracted the Andes virus during a bird-watching trip in Ushuaia before boarding. Investigators believe the couple may have been exposed at a landfill during that outing, where infected rodents were present. (11) They had been traveling through Argentina, Chile, and Uruguay for months prior, passing through areas where Andes virus is endemic. (11)

Two people got sick. What makes this case significant is what happened next. By the time the WHO was notified on May 2, 2026, there were already multiple cases on board. As of today, May 8, 2026, there are nine suspected cases, six confirmed, and three deaths. (12) Patients are hospitalized in South Africa, Germany, the Netherlands, Switzerland, and Saint Helena. (12) The WHO has acknowledged that some cases among close contacts, including cabin-sharing passengers, may represent person-to-person transmission. (13) That distinction is critical. The initial infections almost certainly happened on land in South America. But the chain didn’t stop there.

A WHO epidemiologist noted at a briefing that “we do believe that there may be some human-to-human transmission happening among really close contacts, the husband and wife, people who’ve shared cabins.” (14) This is how Andes virus behaves when it gets into a confined space with sustained close contact. It doesn’t spread like a respiratory virus through casual exposure. But it can move.

The infected passengers came from multiple countries, disembarked at multiple ports before the outbreak was understood, and are now dispersed globally. Health authorities in the U.S. are monitoring former passengers in at least five states. (15) No Americans have shown symptoms as of this writing. The WHO’s assessment is that the global public health risk remains low, and WHO Director-General Tedros has stated that a large epidemic similar to COVID-19 is not anticipated. (15) That assessment reflects what we know about Andes virus: its person-to-person transmission is real but limited, and typically tied to close, prolonged contact rather than broad community spread.

The Argentina Context: Cases Are Rising

This is happening against a backdrop of a significant increase in hantavirus cases in South America. Argentina has recorded 101 confirmed hantavirus cases since June 2025, roughly double the 57 cases recorded in the same period the year before. (16) The mortality rate in Argentina’s current season has been approaching one-third of confirmed cases. (17) Chile has confirmed 39 cases through May 2026, already approaching its full-year 2025 total, with a fatality rate around 33%. (18)

Researchers and health officials point to climate change as a contributing factor. Warming temperatures and shifting rainfall patterns are expanding the habitat of infected rodents, allowing them to move into areas that weren’t previously endemic. (17) More rodents in more places means more exposure risk for more people.

This isn’t a fluke uptick. It’s a trend that warrants attention.

What This Means for Clinicians and Patients

In my practice here in Colorado, I haven’t had a hantavirus case this season. None yet. For patients in the American Southwest generally, the risk remains what it has been: don’t disturb rodent habitats without protection. If you’re cleaning out a garage, barn, cabin, or shed that may have had rodent activity, wet the area down with a disinfectant before sweeping. Don’t dry-sweep. Use gloves and, ideally, an N95 mask. Ventilate the space well before working in it. Those measures aren’t complicated, but they genuinely matter. (19)

For clinicians, the Andes virus situation is a reminder: take travel history seriously. Ask about travel. Every time. A patient presenting with a febrile illness and early respiratory symptoms who recently traveled to Argentina, Chile, or Uruguay deserves a careful look, and the incubation period for hantavirus is one to six weeks after exposure (3), so someone who bird-watched in Ushuaia in early April might not get sick until May. If a patient’s rapid flu test is negative, their COVID test is negative, and they look like they’re heading toward respiratory compromise, hantavirus should be in your differential.

If you’re dealing with a confirmed or suspected Andes virus case, talk to your infection control team. The evidence for person-to-person transmission isn’t theoretical. The 1996 Argentine outbreak included healthcare workers. The WHO and CDC guidance is clear that for Andes virus, standard precautions aren’t sufficient. Enhanced droplet and contact precautions are appropriate. (8)

There’s no vaccine. There’s no proven antiviral. Early ICU admission genuinely changes outcomes. A study using convalescent plasma from HPS survivors showed a reduction in mortality from 32% to 14% in one analysis. (20) That approach isn’t widely available, but it’s worth knowing exists.

The Bottom Line

Hantavirus isn’t new, but the Andes outbreak is a reminder that a rare disease still deserves a place in the differential.

For our patients here in Colorado, the message is straightforward: rodent exposure is the primary risk, and it’s avoidable with the right precautions. For those traveling to South America, know that the Andes virus is endemic there and that the current season has been severe. For clinicians seeing febrile illness with respiratory symptoms, keep a broad differential and ask about travel.

This week, if you’re clearing out a shed, barn, or cabin that sat closed over the winter, wet it down before you touch it. Wear a mask. Don’t dry-sweep.

Measles Is Back: What Urgent Care and Telemedicine Clinicians Need to Watch For

On February 27, 2026August 30, 2026 By Dr. Scott RennieIn Infectious DiseaseLeave a comment

Measles is back in our daily practice in a way many of us have never seen in our careers. In just the first weeks of 2026, the United States has already recorded more than 900 confirmed measles cases, with most linked to active outbreaks rather than isolated travel related infections. Those numbers are not abstract. They reflect real patients who often first appear with what looks like an ordinary viral upper respiratory infection.

In Virginia, where some of my colleagues practice, the health department has already confirmed 10 measles cases this year, the majority in young children in the Northern region. Public exposure sites in that region now include grocery stores, urgent care centers, emergency departments, churches, and big box retailers, with symptom watch dates stretching into early March. That list reads like a map of daily life, which is exactly the point. Measles is circulating in the same spaces our patients and our own families move through every day.

Clinically, we know this pattern. Early measles often looks like influenza or another common respiratory virus, with fever, cough, coryza, and conjunctivitis. The rash, when it appears, typically starts on the face or hairline and then spreads down the body over several days. The catch is timing. Patients are contagious for about four days before the rash and about four days after it appears, which means they have already spent several days at work, school, religious services, or stores while shedding virus. On a virtual visit, we are often meeting them right in the middle of that window.

On a 24/7 virtual care platform, measles usually does not present with a red flag label in the chief complaint. Instead, it shows up as “fever and cough,” “pink eye,” or “rash on face” typed into a symptom field at 10 p.m. A typical encounter might start with a parent worried about a toddler who has had three days of high fever, a worsening dry cough, a streaming nose, and eyes that are red and watery. The parent may have tried acetaminophen and fluids at home and is now concerned because the child just looks wiped out. At that point there may be no rash, or the parent might mention a few faint spots on the forehead that they are not sure about.

The current outbreaks highlight just how contagious measles is. The virus lives in the nose and throat and is released into the air when an infected person breathes, coughs, or sneezes. It can remain viable in the air or on surfaces for up to two hours after the person leaves. This is why unannounced walk ins to clinics or emergency departments are so risky and why strict infection control and coordination with public health are not optional. One infectious patient who sits in a crowded waiting room can trigger a long chain of secondary cases.

From an epidemiologic standpoint, the current U.S. numbers are sobering. As of mid to late February 2026, national case counts have passed 900 and are now over 1,100, with infections documented in more than two dozen states. A large share of these cases are tied to ongoing outbreaks that began in 2025 and spilled into this year. The vast majority of patients are unvaccinated or have unknown vaccination status, often children and adolescents. Hospitalization rates vary by age, but recent CDC data show that even in 2024, several percent of cases required inpatient care, with higher risk among young children and adults. Measles can lead to pneumonia, encephalitis, and death, even in high resource settings.

On the Virginia Department of Health dashboard, six of the ten cases reported in 2026 have occurred in children under five years old, a group that cannot always be fully immunized yet and that we worry about the most. That number is the one I keep coming back to. Exposure notifications list locations like a grocery store in Lorton, multiple retail sites and restaurants in Manassas, a church, and an office building in Alexandria, each with specific time windows and follow up symptom watch dates 21 days out. It is easy to imagine the scenarios. A preschooler with early measles sitting in a shopping cart. A young adult with mild symptoms walking into an urgent care center after work. These are ordinary moments that turn into public health events.

For virtual care clinicians, the practical question is what to do when that next “simple viral illness” consult pops up in the queue. First, we cannot afford to ignore vaccination status. Every patient with upper respiratory symptoms, especially in outbreak regions, should be asked directly about MMR doses and prior measles infection. This includes adults who vaguely recall “getting shots as a kid” but are not sure which ones. Second, we need to look closely at risk factors: unvaccinated or incompletely vaccinated patients, infants who are too young for full immunization, immunocompromised individuals, pregnant patients, and anyone with recent travel to areas with known outbreaks or exposure to crowded settings.

When clinical suspicion is high, escalation needs to happen quickly and in a structured way. Patients should be referred for immediate in person evaluation and diagnostic testing in a setting that is prepared to implement airborne precautions. Instead of showing up unannounced at a clinic or emergency department, patients should call ahead, so infection prevention teams can arrange safe arrival and isolation. Coordination with local health departments is key. I haven’t hit real friction getting a family to follow that plan, since I haven’t had a suspected measles case reach that point yet. What I do run into, often, is patients, mostly kids, who are unvaccinated because a parent made that choice on purpose and says so plainly when I ask. On the Virginia site, there is even a specific survey link for people who may have been exposed, which triggers public health follow up. Similar mechanisms exist in other states and are often underused.

Virtual clinicians also have a clear boundary here. On the Teladoc platform, for example, management of suspected or confirmed measles is explicitly prohibited, and all such cases must be referred to in-person care. That restriction exists because measles care and infection control require physical assessment, access to testing, immunoglobulin and vaccine for post-exposure prophylaxis, and the ability to initiate supportive treatment for complications, none of which can be delivered over video.

Vaccination remains the core prevention strategy. Two doses of MMR vaccine provide about 97 percent protection against measles. Breakthrough infections can occur, but they are uncommon, and most cases in the current outbreaks are in people who are unvaccinated or not fully vaccinated. The Virginia data show that over 90 percent of the state’s population, and roughly 95 percent of kindergarteners, are vaccinated against measles, yet small pockets of under vaccination have still allowed the virus to spread. In every virtual encounter, we have a chance to answer questions, correct misinformation, and nudge patients toward getting up to date on their shots.

I haven’t personally managed a confirmed measles case over telemedicine. But here’s the kind of scenario clinicians in virtual care should be watching for, a hypothetical built from the pattern these outbreaks produce, not a real patient of mine: A college student logs on late at night with a fever, sore throat, and mild cough after returning from a service trip where they worked in crowded community settings. They mention that their university recently sent out an email about a measles exposure but they “think” they had all their vaccines as a child. As the clinician, you dig a little deeper, learn there is no documentation of a second MMR dose, and find that the student has started to notice a faint rash near the hairline. In that moment, treating this as a routine viral upper respiratory infection would be a miss. Instead, you walk the student through the concern for measles, arrange urgent in person evaluation, instruct them to call ahead before arrival, and notify your internal public health liaison to coordinate with the local health department. That single decision can prevent dozens of secondary cases in a dormitory and on campus.

The current surge of measles cases is a reminder that this disease remains an ongoing threat, one that follows gaps in vaccination and public health infrastructure. For those of us working in virtual care, our role is to keep it on the differential, ask the extra questions, recognize the pattern a day or two earlier, and move swiftly when suspicion is high. The work can feel routine until it is not. Two years ago I wasn’t asking about immunization status at every visit. I do now, at any health-related visit, and especially with kids. I’ve also changed how I handle a rash over video, because video alone is generally not as good quality as a high-resolution photo. Getting a usable photo takes some coaching. The patient needs to stand back far enough, get the angle right, and hold the phone steady so it isn’t blurry. I like a distance shot to see the whole pattern and a macro shot up close if the patient can manage it.

Centers for Disease Control and Prevention. Measles Cases and Outbreaks. Updated February 26, 2026. Available at: https://www.cdc.gov/measles/data-research/index.html. Accessed February 27, 2026.

Centers for Disease Control and Prevention. Measles Vaccination. Updated December 29, 2025. Available at: https://www.cdc.gov/measles/vaccines/index.html. Accessed February 27, 2026.

Centers for Disease Control and Prevention. Measles, Mumps, and Rubella (MMR) Vaccination: Information for Healthcare Professionals. Updated January 25, 2026. Available at: https://www.cdc.gov/vaccines/hcp/by-disease/mmr.html. Accessed February 27, 2026.

Virginia Department of Health. Measles. 2026. Available at: https://www.vdh.virginia.gov/measles/. Accessed February 27, 2026.

Virginia Department of Health, Office of Emergency Preparedness. VDH OEP Weekly Situation Update. Published February 19, 2026. Available at: https://www.vdh.virginia.gov/emergency-preparedness/2026/02/20/vdh-oep-weekly-situation-update-137/. Accessed February 27, 2026.

Virginia Department of Health. Virginia Health Officials Investigating Two Confirmed Measles Cases in Northern Virginia. News release, February 18, 2026. Available at: https://www.vdh.virginia.gov/news/public-relations-contacts/2026-regional-news-releases/virginia-health-officials-investigating-two-confirmed-measles-cases-in-northern-virginia/. Accessed February 27, 2026.

Robinson A. VDH: Measles outbreak not likely in Northern Virginia despite uptick in cases. ALXnow. Published February 22, 2026. Available at: https://www.alxnow.com/2026/02/23/vdh-measles-outbreak-not-likely-in-n-va-despite-uptick-in-cases/. Accessed February 27, 2026.

WSBT / Sinclair Broadcast Group. Measles cases surpass 1,100 so far in 2026 as outbreaks continue to spread. Published February 26, 2026. Available at: https://wsbt.com/news/nation-world/us-measles-cases-surpass-1100-so-far-in-2026-health-experts-warn-centers-for-disease-control-and-prevention. Accessed February 27, 2026.

Direct Primary Care: Access Problems in Today’s Clinics

On January 3, 2026August 30, 2026 By Dr. Scott RennieIn Healthcare System & TechnologyLeave a comment

When I talk to patients about how they access care, I hear a lot of frustration with the way primary care is delivered today. People describe having to wait weeks for a routine appointment at a clinic owned by a large corporation. They tell me they freeze up when they see a copay, even for simple follow-ups. And they often end up sitting in urgent care lines for something that should have been sorted out by a doctor who knows their story.

That experience is not unique. Many traditional primary care clinics are now owned or managed by big health systems and private equity firms. Those organizations run medicine like a business, with incentives tied to volume and billing rather than the patient’s whole-person health. That often means large patient panels and shorter visits. It also means that, with limited appointment slots and competing demands, a visit may not come soon enough when someone needs timely care.

Direct primary care (DPC) grew out of that dissatisfaction. In the simplest terms, DPC is a model where patients pay their doctor a flat membership fee, usually monthly, for direct access to routine and preventive primary care without billing insurance for every visit. You don’t see a copay or deductible for that visit the same way you do in the traditional system. What you pay upfront buys you ongoing access to your clinician for check-ups, chronic disease management, urgent but non-emergency care, and preventive services. It’s a direct contract between you and your doctor, not a third party like an insurer in the middle.

One of the most striking differences between DPC and a corporate primary care clinic is access. In a typical insurance-based practice, panels can be very large. Physicians might have multiple thousands of patients, which contributes to long waits for appointments and brief encounters when you finally get in. In contrast, many DPC practices purposefully keep panel sizes smaller, sometimes by orders of magnitude, so patients can get same-day or next-day visits and more time with the physician.

That difference matters to patients trying to manage chronic illness or catch problems early. I’ve had patients tell me they opted for DPC after a night of struggling with a new symptom and knowing that at an urgent care clinic they would only get episodic treatment. They want someone who sees the full picture of their health year after year, not someone who treats symptoms in isolation.

That contrast between DPC and urgent care is important. Urgent care excels when a child’s flu symptoms spike at 3 a.m. or when someone twists an ankle. It’s great for acute, episodic problems, and you don’t need an appointment. But those clinics are not set up to build a longitudinal understanding of you as a person: your past medical history, your family health history, your social context, your chronic disease patterns. Urgent care providers are trained to stabilize and treat the immediate issue. They rarely have time or the patient record in front of them to integrate your whole story into a care plan.

Direct primary care, on the other hand, puts continuity and relationship first. If you see your doctor regularly, they come to know your lab values alongside your life stressors, your diet, your work, and how your family affects your health trajectory. They can tailor plans accordingly, and they are available when you need guidance early on, often avoiding a need for more costly or fragmented care later.

Here is a hypothetical, not an actual patient encounter: a persistent cough that won’t clear up. In urgent care, a patient might get evaluated and sent home with instructions to rest or a prescription for symptomatic relief. In a DPC clinic, the doctor can say “let’s see you today,” review the full chart, adjust chronic meds if needed, and schedule a follow-up next week. That continuity can make the difference.

DPC is not perfect for everyone. Membership costs money, and that cost has to be weighed against sporadic traditional visits, though many patients find that predictable pricing encourages them to seek care early instead of waiting for a problem to become urgent. It doesn’t replace insurance. Hospitalizations, specialized care, and emergency services still need coverage of their own; DPC handles primary care, not surgeries or specialist procedures. Geographic access is a real constraint too. Not every area has a DPC practice within reach, and for some patients that alone rules it out.

Advocates of DPC argue that the financial predictability and relationship-based care improve satisfaction. Members appreciate straightforward pricing without surprise bills. Physicians appreciate less paperwork and more clinical time with patients.

The model works best for primary care needs alone. It doesn’t cover everything, and patients should pair a DPC membership with adequate insurance for catastrophic events.

Where I think the DPC pitch oversells itself: it markets convenience as though it solves a shortage problem. A membership fee doesn’t create more primary care doctors in a region that doesn’t have any. It only helps if a DPC practice already exists within reach.

I ran a concierge practice in 2010 and 2011, before anyone was calling it direct primary care. Patients felt less rushed and more heard, and that part was real. They call or message with early symptoms and get help quickly. That often prevents minor issues from becoming major ones. It’s a different rhythm of care, one that reflects the old-fashioned doctor-patient relationship many of us went into medicine to preserve. If a patient values that kind of access and ongoing partnership, and understands the limits of what DPC covers, it can be a powerful option that keeps them healthier and more engaged with their care.

I hear it almost every day now. “I think I just need a Z-Pak.”

On January 2, 2026August 30, 2026 By Dr. Scott RennieIn Infectious DiseaseLeave a comment

Sometimes it’s phrased as a question. Sometimes it isn’t. In telemedicine especially, many patients request azithromycin by name within the first minute of the visit. The symptoms are familiar. Runny nose. Congestion. Post-nasal drip. Scratchy throat. Maybe a cough that started yesterday. No fever. No shortness of breath. No focal findings anyone could reasonably point to as bacterial.

But they’re convinced the Z-Pak will help them get better faster. They’ve taken it before. It worked last time. Or at least they felt better a few days later and connected the dots.

This didn’t happen by accident.

Azithromycin earned its place in outpatient medicine because it was easier to tolerate than older antibiotics like erythromycin, had fewer drug interactions than clarithromycin, and came packaged in a way that felt efficient. Six pills. Five days. Done. The Z-Pak became a symbol of modern medicine that didn’t slow you down.

Over time, it also became the antibiotic people expected.

In telemedicine, that expectation is even stronger. There’s no exam table. No stethoscope. No labs. No chest X-ray down the hall. The visit is brief by design. When a patient feels sick and wants something tangible, the Z-Pak becomes the path of least resistance. Prescribing it can shorten the encounter. It avoids a long explanation. It reduces the risk of a bad review. It keeps patient satisfaction scores high. It keeps supervisors and clinic managers happy. Everyone moves on to the next visit.

I understand why this happens. I’ve seen it from the inside.

But convenience doesn’t make a treatment safe or appropriate.

Azithromycin does not treat viral infections. It does not help the common cold. It does not clear post-nasal drip. It does not shorten the course of uncomplicated upper respiratory infections. When patients feel better after taking it, they almost always would have improved anyway.

What it does do is expose people to real risk.

Azithromycin can prolong the QT interval. That matters. QT prolongation can predispose patients to dangerous heart rhythms, including torsades de pointes and sudden cardiac death. This risk is higher in people with underlying heart disease, electrolyte abnormalities, or those taking other QT-prolonging medications, but it is not zero in otherwise healthy adults. Large observational studies have shown an increased risk of cardiovascular death during azithromycin treatment compared with other antibiotics or no antibiotics at all.

That risk is invisible to patients. They don’t feel their QT interval getting longer. They just know they want something to help them feel better.

Antibiotics also carry more familiar side effects. Nausea. Diarrhea. Abdominal cramping. Yeast infections. Rashes. Allergic reactions. These are not rare, and they are not trivial when the medication wasn’t needed in the first place.

Then there’s resistance. Every unnecessary antibiotic course applies selective pressure. Azithromycin resistance is already a growing problem in common respiratory pathogens. When we reach for it reflexively, we make it less useful for the patients who actually need it.

The harder part of these visits is the explaining.

It takes longer to walk someone through why their symptoms are viral. Why time, fluids, nasal saline, antihistamines, or intranasal steroids actually help. Why rest matters. Why antibiotics won’t fix inflammation or mucus production. Why feeling miserable does not automatically mean something dangerous is happening.

It’s much faster to send a prescription.

But faster is not better medicine.

I get patients asking for Z-Paks every day that I work in telemedicine. It’s so common that it happens at least once a day, if not three or four times a day. One example sticks with me. A patient requested a Z-Pak for congestion and sinus pressure that had been present for two days. No fever. No facial pain. No worsening course. When I explained why antibiotics wouldn’t help, they were frustrated at first. We talked through what sinus infections actually look like and when antibiotics are appropriate. We discussed symptom control instead. Two days later, they messaged to say they felt better and were glad they didn’t take an antibiotic they didn’t need.

That outcome required time. It required education. It required saying no.

Not every visit goes that smoothly. Some patients remain disappointed. Some leave poor reviews. That pressure is real, especially in high-volume telemedicine environments.

But prescribing antibiotics to keep the peace comes at a cost. It shifts risk onto the patient. It shifts harm into the future. And it reinforces the idea that medicine should always offer a pill, even when the best treatment is patience and support.

Azithromycin became dominant because it was easy. That same ease is why we need to be more careful with it now.

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