KHN  — 

Pregnant and scared, Natasha Valle went to a Tennova Healthcare hospital in Clarksville, Tennessee, in January 2021 because she was bleeding. She didn’t know much about miscarriage, but this seemed like one.

In the emergency room, she was examined then sent home, she said. She went back when her cramping became excruciating. Then home again. It ultimately took three trips to the ER on three consecutive days, generating three separate bills, before she saw a doctor who looked at her bloodwork and confirmed her fears.

“At the time I wasn’t thinking, ‘Oh, I need to see a doctor,’” Valle recalled. “But when you think about it, it’s like, ‘Well — dang — why didn’t I see a doctor?’” It’s unclear whether the repeat visits were due to delays in seeing a physician, but the experience worried her. And she’s still paying the bills.

The hospital declined to discuss Valle’s care, citing patient privacy. But 17 months before her three-day ordeal, Tennova had outsourced its emergency rooms to American Physician Partners, a medical staffing company owned by private equity investors. APP employs fewer doctors in its ERs as one of its cost-saving initiatives to increase earnings, according to a confidential company document obtained by KHN and NPR.

This staffing strategy has permeated hospitals, and particularly emergency rooms, that seek to reduce their top expense: physician labor. While diagnosing and treating patients was once their domain, doctors are increasingly being replaced by nurse practitioners and physician assistants, collectively known as “midlevel practitioners,” who can perform many of the same duties and generate much of the same revenue for less than half of the pay.

“APP has numerous cost saving initiatives underway as part of the Company’s continual focus on cost optimization,” the document says, including a “shift of staffing” between doctors and midlevel practitioners.

In a statement to KHN, American Physician Partners said this strategy is a way to ensure all ERs remain fully staffed, calling it a “blended model” that allows doctors, nurse practitioners and physician assistants “to provide care to their fullest potential.”

Critics of this strategy say the quest to save money results in treatment meted out by someone with far less training than a physician, leaving patients vulnerable to misdiagnoses, higher medical bills, and inadequate care. And these fears are bolstered by evidence that suggests dropping doctors from ERs may not be good for patients.

A working paper, published in October by the National Bureau of Economic Research, analyzed roughly 1.1 million visits to 44 ERs throughout the Veterans Health Administration, where nurse practitioners can treat patients without oversight from doctors.

Researchers found that treatment by a nurse practitioner resulted on average in a 7% increase in cost of care and an 11% increase in length of stay, extending patients’ time in the ER by minutes for minor visits and hours for longer ones. These gaps widened among patients with more severe diagnoses, the study said, but could be somewhat mitigated by nurse practitioners with more experience.

The study also found that ER patients treated by a nurse practitioner were 20% more likely to be readmitted to the hospital for a preventable reason within 30 days, although the overall risk of readmission remained very small.

Yiqun Chen, who is an assistant professor of economics at the University of Illinois-Chicago and co-authored the study, said these findings are not an indictment of nurse practitioners in the ER. Instead, she said, she hopes the study will guide how to best deploy nurse practitioners: in treatment of simpler patients or circumstances when no doctor is available.

“It’s not just a simple question of if we can substitute physicians with nurse practitioners or not,” Chen said. “It depends on how we use them. If we just use them as independent providers, especially … for relatively complicated patients, it doesn’t seem to be a very good use.”

Chen’s research echoes smaller studies, like one from The Harvey L. Neiman Health Policy Institute that found nonphysician practitioners in ERs were associated with a 5.3% increase in imaging, which could unnecessarily increase bills for patients. Separately, a study at the Hattiesburg Clinic in Mississippi found that midlevel practitioners in primary care — not in the emergency department — increased the out-of-pocket costs to patients while also leading to worse performance on nine of 10 quality-of-care metrics, including cancer screenings and vaccination rates.

But definitive evidence remains elusive that replacing ER doctors with nonphysicians has a negative impact on patients, said Dr. Cameron Gettel, an assistant professor of emergency medicine at Yale. Private equity investment and the use of midlevel practitioners rose in lockstep in the ER, Gettel said, and in the absence of game-changing research, the pattern will likely continue.

“Worse patient outcomes haven’t really been shown across the board,” he said. “And I think until that is shown, then they will continue to play an increasing role.”

Private equity companies pool money from wealthy investors to buy their way into various industries, often slashing spending and seeking to flip businesses in three to seven years. While this business model is a proven moneymaker on Wall Street, it raises concerns in health care, where critics worry the pressure to turn big profits will influence life-or-death decisions that were once left solely to medical professionals.

Nearly $1 trillion in private equity funds have gone into almost 8,000 health care transactions over the past decade, according to industry tracker PitchBook, including buying into medical staffing companies that many hospitals hire to manage their emergency departments.

Two firms dominate the ER staffing industry: TeamHealth, bought by private equity firm Blackstone in 2016, and Envision Healthcare, bought by KKR in 2018. Trying to undercut these staffing giants is American Physician Partners, a rapidly expanding company that runs ERs in at least 17 states and is 50% owned by private equity firm BBH Capital Partners.

These staffing companies have been among the most aggressive in replacing doctors to cut costs, said Dr. Robert McNamara, a founder of the American Academy of Emergency Medicine and chair of emergency medicine at Temple University.

“It’s a relatively simple equation,” McNamara said. “Their No. 1 expense is the board-certified emergency physician. So they are going to want to keep that expense as low as possible.”

Not everyone sees the trend of private equity in ER staffing in a negative light. Jennifer Orozco, president of the American Academy of Physician Associates, which represents physician assistants, said even if the change — to use more nonphysician providers — is driven by the staffing firms’ desire to make more money, patients are still well served by a team approach that includes nurse practitioners and physician assistants.

“Though I see that shift, it’s not about profits at the end of the day,” Orozco said. “It’s about the patient.”

The “shift” is nearly invisible to patients because hospitals rarely promote branding from their ER staffing firms and there is little public documentation of private equity investments.

Dr. Arthur Smolensky, a Tennessee emergency medicine specialist attempting to measure private equity’s intrusion into ERs, said his review of hospital job postings and employment contracts in 14 major metropolitan areas found that 43% of ER patients were seen in ERs staffed by companies with nonphysician owners, nearly all of whom are private equity investors.

Smolensky hopes to publish his full study, expanding to 55 metro areas, later this year. But this research will merely quantify what many doctors already know: The ER has changed. Demoralized by an increased focus on profit, and wary of a looming surplus of emergency medicine residents because there are fewer jobs to fill, many experienced doctors are leaving the ER on their own, he said.

“Most of us didn’t go into medicine to supervise an army of people that are not as well trained as we are,” Smolensky said. “We want to take care of patients.”

Joshua Allen, a nurse practitioner at a small Kentucky hospital, snaked a rubber hose through a rack of pork ribs to practice inserting a chest tube to fix a collapsed lung.

It was 2020, and American Physician Partners was restructuring the ER where Allen worked, reducing shifts from two doctors to one. Once Allen had placed 10 tubes under a doctor’s supervision, he would be allowed to do it on his own.

“I guess we’re the first guinea pigs for our ER,” he said. “If we do have a major trauma and multiple victims come in, there’s only one doctor there. … We need to be prepared.”

Allen is one of many midlevel practitioners finding work in emergency departments. Nurse practitioners and physician assistants are among the fastest-growing occupations in the nation, according to the U.S. Bureau of Labor Statistics.

Generally, they have master’s degrees and receive several years of specialized schooling but have significantly less training than doctors. Many are permitted to diagnose patients and prescribe medication with little or no supervision from a doctor, although limitations vary by state.

The Neiman Institute found that the share of ER visits in which a midlevel practitioner was the main clinician increased by more than 172% between 2005 and 2020. Another study, in the Journal of Emergency Medicine, reported that if trends continue there may be equal numbers of midlevel practitioners and doctors in ERs by 2030.

There is little mystery as to why. Federal data shows emergency medicine doctors are paid about $310,000 a year on average, while nurse practitioners and physician assistants earn less than $120,000. Generally, hospitals can bill for care by a midlevel practitioner at 85% the rate of a doctor while paying them less than half as much.

Private equity can make millions in the gap.

For example, Envision once encouraged ERs to employ “the least expensive resource” and treat up to 35% of patients with midlevel practitioners, according to a 2017 PowerPoint presentation. The presentation drew scorn on social media and disappeared from Envision’s website.

Envision declined a request for a phone interview. In a written statement to KHN, spokesperson Aliese Polk said the company does not direct its physician leaders on how to care for patients and called the presentation a “concept guide” that does not represent current views.

American Physician Partners touted roughly the same staffing strategy in 2021 in response to the No Surprises Act, which threatened the company’s profits by outlawing surprise medical bills. In its confidential pitch to lenders, the company estimated it could cut almost $6 million by shifting more staffing from physicians to midlevel practitioners.

On average, around 4,500 drugs and medical devices are pulled from shelves across the United States each year.¹ This alarming statistic underscores the importance of controlling and mitigating risk in healthcare-related products. latest updates to regulatory guidances and standards are encouraging life sciences companies to step up their risk management efforts by infusing risk-based thinking into their entire quality ecosystem. For example:

• ISO 13485:2016 – The current version of ISO 13485 has a significant focus on integrating active risk assessment and mitigation in quality processes, which includes documenting requirements and maintaining risk management records throughout the product’s life cycle.²
• ISO 14971:2019 – The 2019 updates to ISO 14971 regarding risk management with medical devices include risks related to biocompatibility, data and systems security, electricity, moving parts, radiation, and usability. It applies to risk with intended use, reasonably foreseeable misuse, identifiable characteristics related to safety, and identification of hazards and hazardous situations throughout the product’s life cycle.³
• European Union Medical Device Regulation (MDR)/In-vitro Diagnostics Regulation (IVDR) – The updated regulations for medical devices are slated to go into effect in May 2021, while the regulations for in vitro devices are slated to go into effect in May 2022. Compliance requirements include establishing and documenting a risk management plan for each device. The requirements for postmarket risk management will be more granular and stringent. Once the product is on the market, manufacturers will be accountable for continuing to gather and examine data throughout the device’s life cycle.⁴
• Medical Device Safety Action Plan – The FDA’s Center for Devices and Radiological Health (CDRH) is pursuing initiatives to protect patients and promote public health while continuing to drive innovation to address unmet medical needs. A key component of the agency’s efforts is its Total Product Life Cycle (TPLC) approach to device safety.⁵

Healthcare providers need to have the necessary medical devices available to perform procedures. Unless a device is fully compliant with the regulations, it cannot be used where it is needed. With more robust global regulatory requirements being enforced, companies will need to revisit their core quality system processes—particularly risk management.

Overall, employing risk-based thinking throughout the organization is important, but how do companies put risk policies and procedures into practice? Most often, risk management is viewed as a requirement to meet regulatory compliance. The guidances and standards leave the “how” up to the companies. Some of the most common methods for assessing risk include a risk matrix, a risk register, and a failure mode and effects analysis (FMEA). But what is really needed is a practicable and effective risk management system within the organization.

Risk management needs to be a continuous, iterative process. It involves employing a systematic, data-driven approach to monitoring trends and identifying and mitigating risks before they result in costly delays, rework, or product recalls. Individual events such as out of specifications (OOS) and other deviations are easy to silo and overlook as part of a larger risk. For instance, there could be a new risk that may have been missed or an unforeseen hazard that now needs to be monitored. That said, risk management is not a quality-only responsibility—it needs to be integrated into all areas of the company.

Much of the impetus for making risk management an all-hands endeavor is attributed to advancing technology and more-sophisticated medical devices. Software-based medical devices are a prime example. More disparate entities (internal and external) are involved in the design and development of the components of these devices. All too often, defects or functionality discrepancies go undiscovered until later in the production process or postmarket. Risk management needs to start earlier and be performed in greater detail and at every stage of the product’s life cycle. Staff involved in product design, development, manufacturing, supply chain, etc. must participate in risk control and mitigation.

Setting up an effective risk management system involves effectively aligning people, processes, and technology. This all starts with building a risk management plan that includes clearly defined, documented policies, such as a policy for risk acceptability. Best practices include establishing organization-wide collaboration, clarifying priorities, and empowering people in all areas to make decisions, including stopping production if necessary. This way all employees understand the purpose of the procedures as well as the overall goals of the risk management system.

To successfully implement this type of all-inclusive system means all stakeholders need the ability to access and share data in real time in order to more effectively track and trend risk data. The need for this level of interaction, speed, and efficiency renders paper-based or spreadsheet data collection and analysis impracticable.

With platform-based technology, every business unit can have an appreciable impact on the company’s overall risk management efforts. Integrating business unit-specific systems across the organization dissolves siloes, harmonizes disparate operations, and fosters real-time, company-wide communication. This augments the company’s capacity for gathering quality data and making more confident decisions based on predictive insights.

Using technology to proactively monitor and control risk reduces regulatory interaction, which makes sense on a compliance and business level. In return, the organization experiences shorter product development cycles and faster regulatory clearance, reducing the overall cost of compliance. Regulators have greater assurance of the company’s ability to identify and mitigate risks and develop safe and effective products. Essentially, the organization's risk management system becomes a catalyst for business success. 

1. "FDA Recalls,” Drugwatch, https://www.drugwatch.com/fda/recalls/.
2. “Reducing the Risks of Medical Devices: International Guidance Just Updated,” Clare Naden, Dec. 18, 2019, https://www.iso.org/news/ref2465.html.
3. “ISO 14971:20198 Medical Devices – Application of Risk Management to Medical Devices,” https://www.iso.org/standard/72704.html.
4. “The European Union Medical Device Regulation of 2017,” https://eumdr.com/.
5. “Medical Device Safety Action Plan: Protecting Patients, Promoting Public Health,” Center for Devices and Radiological Health, Jan. 5, 2021, https://www.fda.gov/about-fda/cdrh-reports/medical-device-safety-action-plan-protecting-patients-promoting-public-health

© Provided by CNET Natalia Gdovskaia/Getty Images

Many of us don't go to the doctor until there's something wrong. The phrase "if it ain't broke, don't fix it" comes to mind. Unfortunately, that thinking doesn't cut it when it comes to your heart health. 

Heart disease is the leading cause of death in the US, yet around 80% of cardiac events are avoidable through early detection and prevention plans. 

Heart disease screenings give you a snapshot of your health. Knowing your numbers for key factors can help you monitor your wellness and adjust your lifestyle. Let's talk about heart disease, why you need to get screened and when you should do it. 

What is heart disease?

Heart disease is a general term used to describe several conditions that affect the heart, including but not limited to arrhythmias, valve disease and congenital heart defects. The most common heart disease is coronary artery disease, which impairs the blood vessels, hinders blood flow to the heart and can increase your risk of a heart attack. 

Heart disease frequently goes undiagnosed until symptoms of a heart attack or heart failure present themselves. Regular heart disease screenings are essential to help you get ahead of many health scares. 

What causes heart disease? 

Heart disease can happen at any age. In the case of congenital heart disease, it can happen at birth. Other times, it develops throughout our lives, like coronary artery disease, slowly progressing as plaque builds up. The cause of heart disease will vary depending on the type of condition. Let's focus on coronary heart disease since it's the most common type people experience. 

The causes of coronary heart disease are genetics, high blood pressure, high cholesterol and smoking. Essentially, your heart has to work harder because things are standing in the way, putting more strain on the organ than necessary. Your heart can only function for so long under excessive stress. 

The CDC says that almost half of Americans have at least one risk factor for heart disease. That's why you should get screenings regularly. Now let's dig into when you should.

Hint: it's before symptoms like shortness of breath, chest pressure or weakness present themselves. 

© Provided by CNET Su Arslanoglu/Getty Images

When should you get screened for heart disease?

The American Heart Association recommends that routine screenings should start at age 20. That sounds early, but heart disease can affect younger people, too. By starting regular screenings at 20, your doctor can establish a baseline for your body and monitor changes as you age. At this stage, even if you are not considered at high risk (see below), it's important to monitor blood pressure, cholesterol, blood glucose and lifestyle factors through family history, physical exams and blood tests. Routine screenings for those at lower risk should be as follows:

• Blood pressure: If your blood pressure is below 120/80 mm Hg, testing should be done at least every two years, or more often if your blood pressure is higher. 
• Cholesterol: Patients with normal cholesterol levels should have a fasting lipoprotein profile through a blood test at least every four to six years. 
• Blood glucose: This should be done at minimum every three years starting at age 45.
• Lifestyle factors: With each doctor's visit, factors like physical activity, diet and smoking will be discussed. 

High-risk factors require more frequent monitoring 

Regular screenings for all patients should begin at age 20 and proceed in intervals. However, if you're at high risk for cardiovascular disease, you're likely to be screened more frequently. Risk factors include high blood pressure, cholesterol or glucose results, a family history of heart disease, being overweight and certain lifestyle factors, including diet, smoking and activity level.

Generally, if you have two or more risk factors, additional cardiovascular testing becomes necessary, especially if you are experiencing symptoms associated with heart disease, such as an irregular heartbeat. 

Additional tests can include: 

• Electrocardiogram: To measure your heart's rhythm and electrical activity, you may need an EKG. It's a painless, noninvasive method of monitoring heart function. All it takes is a few sticky electrodes on your chest. Risk factors that warrant an EKG are chest pain, heart palpitations or irregular beating. Your doctor may require you to wear a portable EKG called a Holter monitor for a few days to get a fuller picture. 
• Echocardiogram: There are times when your doctor may want to look at the structure of your heart. An echocardiogram involves an ultrasound machine to assess how your heart pumps. 
• Stress tests: Cardiac stress tests are basically EKGs with exercise. Your doctor will attach the electrodes to your chest, and you will either walk, run or pedal while your doctor monitors your heart's response. Nuclear stress tests include radioactive dye and imaging machines while resting and exercising. 
• Cardiac computed tomography for calcium scoring: To determine how much plaque has built in your arteries, your doctor may use a CT.
• Coronary artery angiogram: Either with a CT scan or catheter threaded through your groin or arm, an angiogram measures blood flow and the size of your arteries.

Practical tips to prevent heart disease 

Heart disease is serious, but it's also largely preventable and treatable, especially with regular screenings. You have more control over your heart health than you think. Try adding these daily habits to your life to lower your risk of heart disease. 

Too long; didn't read?

Don't just take a "good enough" approach to your health. The heart is one of the body's most vital organs, and sometimes it's hard to know when it's sick. That's why heart health screenings start so early. High blood pressure and high cholesterol are some of the most common conditions, and unfortunately, they significantly increase your risk of developing heart disease. 

Regular screenings and checkups are among the best tools to determine your health and help you make changes that can lower your chances of developing heart disease. You don't have to wait to check up on yourself. If you have a history of heart concerns, try using at-home health monitors between doctor's visits.  

The MarketWatch News Department was not involved in the creation of this content.

Feb 09, 2023 (The Expresswire) -- Medical Grade Honey Market 2023: | 112 Pages Report Worldwide Industry Trends, Size, Development, Opportunity, and Forecast 2023-2027," gives an intensive examination of the market Segments such as Types [UMF 5+, UMF 10+, UMF 15+, UMF 20+, Others, ] and Application [Ulcers, Surgical Wounds, Traumatic Wounds, ], Additionally, it covers important aspects of industry like market size, share, trends, and key drivers with SWOT and PESTLE analysis. Medical Grade Honey Market research incorporates research methodologies with futuristic and historic performance, key financial statements, CAGR status and revenue estimations in terms of value and volume.

The MarketWatch News Department was not involved in the creation of this content.

A Martensville father is alive today thanks to the work of paramedics, but also thanks to the quick thinking of his 16-year-old son.

Thursday in Martensville, paramedics and community leaders gathered to celebrate the work of a teen whose basic CPR training saved a life.

Jarren Cusson was awoken by his mother on Jan. 14 to find his father, Steven, unresponsive on the ground.

“I knew I had to do something,” said Cusson. “I saw him there on the ground, and I just figured, doing nothing is the worst thing I could do. And even the wrong thing is better than nothing. It turns out, (CPR) was the correct thing to do.”

Paramedics arrived shortly after and, using a defibrillator, got Steven conscious and breathing on his own again.

But they say it was the quick actions of Jarren that were cause for recognition on Thursday..

Jarren Cusson was presented with the Chief’s Life Saving Award for his role in saving his dad Steven's life. (John Flatters/CTV News)

“CPR is everything.” Said Troy Davies, Media Relations with Medavie Health Services West. “So when we talk about cardiac arrest situations and when we’re responding to calls, every minute, you basically lose a 10 per cent chance of survival."

By performing CPR on his father immediately and helping save his father’s life, Jarren was presented with the Chief’s Life Saving Award.

Steven Cusson says he’s young, fit, and healthy. But he says this experience was a sobering reminder of the importance of basic first aid.

“I just can’t stress enough the importance of CPR or first aid,” Steven Cusson said. “I’ve taken CPR in the past. I thought it was a waste of time. But as I’ve learned now, it’s very important.”

While Jarren was already certified, he’s taking a refresher course in a few weeks.

“I’m actually hosting a CPR clinic at my shop here for family and friends in a couple of weeks, because it’s that important to me.”

While Jarren, a member of the Air Cadet program, wants to be a fighter pilot when he grows up, he says he’d be happy to work as a paramedic if that doesn’t turn out.

Emily Dickt, a mom of two from Indiana, said she was "hit hard" after learning that a mother in Massachusetts had been charged with killing her three kids.

"It really got me thinking about my own mental health and things that I had struggled with since having kids," Dickt told ABC News. "From what I've seen, it scared a lot of us [mothers].'"

The Massachusetts mom, Lindsay Clancy, appeared in court last week via Zoom from her hospital bed to face charges that she strangled her three young children to death. In addition to two counts of murder, Clancy is also charged with three counts of strangulation and three counts of assault and battery with a dangerous weapon, court documents show.

On the day of the incident, Jan. 24, police received a 911 call just after 6 p.m. ET from a man who said his wife had attempted suicide by jumping out of a window at their house.

First responders subsequently found three young children, a 5-year-old girl, a 3-year-old boy and a 7-month-old boy, inside the home "unconscious with obvious signs of severe trauma," Plymouth County District Attorney Timothy Cruz said last month.

Clancy has pleaded not guilty to the charges. In court on Feb. 7, a judge ordered her to remain hospitalized until medically cleared to move to a rehabilitation facility.

Clancy is scheduled to appear in court next on May 2, for a probable cause hearing.

Dickt, whose daughters are ages 4 and 2, said that while all the details of Clancy's case are not publicly known, she felt compelled to share a video on TikTok about Clancy to let other moms know they are not alone if they are struggling postpartum.

Dickt's video said, in part, "We live in a society that is so quick to judge. When in reality it could be any of us."

"When I shared that post, it like came flooding in with just so many other people sharing their stories and what they struggled with," she told ABC News. "People just feel alone, like they're the only ones that are dealing with it, and that's a scary feeling."

Dickt was not alone in taking to social media to talk about Clancy's case and share her own mental health struggles as a mom.

"I am lucky to be alive today thanks to daily medication but its an uphill battle every day," another mom, Bex Spencer, shared on TikTok. "My heart is broken for this family."

Erica Moreno, a mom of two, shared on TikTok that reading about Clancy brought her back to the time she was six months postpartum and struggling with postpartum depression, anxiety and rage.

"Scared. Out of my mind. Thinking my daughter would be better if I weren't there," she wrote, later adding, "I somehow survived."

Putting a spotlight on different types of postpartum struggles

In Clancy's first court appearance on Feb. 7, prosecutors alleged that she planned the killings, saying she showed no signs of "distress or trouble" earlier in the day and that she searched the time it would take to drive to and from a restaurant in an adjacent town and called the restaurant to place a pick-up order before asking her husband, Patrick, to drive to get the meal.

Assistant District Attorney Jennifer Sprague said Clancy, a 32-year-old nurse, was evaluated by a psychiatrist in late December and was told she, "did not have postpartum depression and she had no symptoms of postpartum depression." Sprague said Clancy wrote in her journal about having suicidal thoughts and, in one instance, thoughts of harming her children prior to checking herself into a mental health facility on Jan. 1, according to ABC affiliate WCVB-TV.

"She did not write or voice those thoughts after a stay at the hospital," Sprague said of Clancy, whom she said was discharged from the facility on Jan. 5.

Clancy's defense attorney, Kevin Reddington, argued that the killings "were not planned by any means" and were a product of mental illness.

Reddington also said in court that Clancy had been heavily medicated as she suffered from postpartum depression “as well as a possibility of postpartum psychosis that is pretty much ignored," according to WCVB-TV.

Prosecutors said Clancy called her husband from her hospital bed and told him she killed their children "because she heard a voice and had 'a moment of psychosis,'" though he told prosecutors his wife had never mentioned hearing voices.

The public spotlight on Clancy's case has highlighted an important distinction between postpartum psychosis and the more common postpartum depression.

Postpartum depression -- a depression that occurs after having a baby -- affects as many as 1 in 8 women who give birth, according to the Centers for Disease Control and Prevention.

Postpartum psychosis is rare and causes delusions or hallucinations that can prompt suicidal or homicidal action, according to the Cleveland Clinic.

Among the court documents submitted by Clancy's lawyer so far are nearly 40 letters from friends and co-workers that describe Clancy as a caring and loving mom and nurse.

One former coworker of Clancy's said in her letter that she had suffered from postpartum depression herself, writing, "I could of [sic] been Lindsay. Any one of us could have been."

Another letter was signed by over 80 moms who identified themselves as the "mothers of Foxboro, Mansfield, North Attleboro, MA."

"Lindsay will have to live with the aftermath of her postpartum depression and that is a sentence that we would not wish on any grieving mother. None of us can even begin to imagine what she is feeling, nor do we want to," they wrote in the letter. "As mothers, we know Lindsay was not in a healthy space to carry out the acts she is accused of and we will stand by her in her darkest hour as we wish any other mother would do for us if we found ourselves struggling too."

Alicia Murray, a licensed mental health therapist in Syracuse, New York, said she has no connection to Clancy or the case but felt compelled to speak about it on TikTok after hearing from her patients, many of whom are mothers.

"In the first week or so after [Clancy's story] hit the news, women were coming to therapy saying, 'It could have been me,'" Murray told ABC News. "I think women that have gone through their own postpartum experiences and have felt that like, intense, out-of-body, like really intense emotions and experiences, they sit down with me, and they're like, 'I get it. It totally could have been me.'"

Murray said that as both a mom and a mental health practitioner, she also chose to speak out in hopes of erasing the stigma that exists around postpartum struggles.

She noted that on her TikTok post, while many moms shared their own stories, other comments sought to negatively portray the mental health struggles of mothers.

"It breaks my heart that other moms are reading those comments," Murray said. "It's very uncomfortable to hear women talk about thoughts of hurting their baby and thoughts of something happening to their baby, and I get it, when we're uncomfortable sometimes we act with anger or shame or try to deflect the conversation, but that's not OK to do."

She continued, "The moms who are sharing their stories, I think, are so incredible, and people should listen, because they've been through it firsthand."

'There's a ton of stigma and misunderstanding'

Katayune Kaeni, a licensed psychologist board chair of Postpartum Support International, told ABC News the organization, a support network for postpartum moms, has seen a "big jump" in inquiries amid Clancy's case.

"What ends up happening is that a lot of people who are dealing with postpartum depression get so worried that what has happened to Lindsay is going to happen to them because people don't have adequate information to understand what is going on," Kaeni told ABC News. "And so rightly so, it's really upsetting and anxiety-provoking for people."

Kaeni, who has no affiliation with Clancy or her case, said in addition to offering a helpline and support groups for new moms so they know they are not alone, much of the work Postpartum Support International does focuses on educating people about mental health, both during and after pregnancy.

"There's a ton of stigma and misunderstanding around all perinatal mental issues," she said. "When people don't understand what it is, it's much easier to make assumptions about the person who's suffering, and that's what happens oftentimes."

Postpartum psychosis "is a true medical emergency," Dr. Jennifer Ashton, ABC News chief medical correspondent and a board-certified OBGYN, said earlier this month. "This is mental illness," she added.

Ashton noted that in her 22-year career as a practicing OB-GYN, she has not personally encountered a case of postpartum psychosis, which she said appears "more acutely" than postpartum depression, meaning symptoms can progress quickly and are more severe.

"It can present with signs and symptoms like confusion, hallucinations, delusions, paranoia, obsessive thoughts and then of course, tragically, attempts to harm one's self or baby," Ashton said, referring to postpartum psychosis. "This is a completely different entity than postpartum depression."

Symptoms of postpartum depression include withdrawing from loved ones, crying more than usual, feeling worried or overly anxious, feeling anger, doubting your ability to take care of your baby and thinking about harming yourself or your baby, according to the CDC. The symptoms may last for weeks or months after giving birth, and are more intense and longer lasting than the "baby blues" that women may experience after giving birth.

Treatment options for postpartum depression will differ based on severity and type of symptoms and may include medication options, psychotherapy or support groups. In 2019, a drug, called Zulresson, was approved by the U.S. Food and Drug Administration as the first-ever medication made specifically for women suffering from postpartum depression.

Ashton noted that it is important to seek professional medical help in any case of a woman experiencing mental health struggles after giving birth. If a person is experiencing postpartum psychosis, he or she should seek help at an emergency room.

"Absolutely, intervention is warranted for either," Ashton said of both postpartum psychosis and postpartum depression. "Medication can be lifesaving."

Postpartum Support International’s free and confidential helpline is available via call and text at 1-800-944-4PPD (4773). If you or someone you know is struggling with thoughts of suicide, call or text 988 or chat 988lifeline.org. Free, confidential help is available 24 hours a day, 7 days a week. You are not on your own.

ABC News' Angelica Grullon, Vera Drymon and Will McDuffie contributed to this report.

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Born between 1997 and 2012, Generation Z grew up wired to the internet. They've spent their days Googling, YouTubing, and elevating selfies to an art form. Their early and constant exposure to screens made connectivity a way of life and provided them with a new lens through which to see themselves—along with infinite ways to enhance the view.

Gen Z's coming of age also coincided with the rise of modern cosmetic treatments and the mainstreaming of plastic surgery, making these digital natives bona fide aesthetics natives. "They've been brought up in an era where it's very much the norm to get plastic surgery," says Dr. Richard Reish, a board-certified New York City plastic surgeon specializing in rhinoplasty, which is the most frequently performed surgical procedure among teens and 20-somethings. 

The normalization of plastic surgery has fostered an uncanny level of comfort with procedures, ushering Gen Z into exam rooms at an unusually early age. "They're really going forth unafraid into the world of medical aesthetics," says Dr. Lara Devgan, a board-certified plastic surgeon in New York City. "Whereas Millennials were curious and research-oriented and Gen X and older were more reticent and cautious, the Gen Z patients in my practice are forward-thinking and open—to experimentation, invasiveness, risk, and downtime."

The Gen Z Aesthetic

Dr. Devgan notes that the Gen Z aesthetic is somewhat hard to characterize because their tastes are distinctly variable. "They're more fluid in their thinking—less rigid about what is feminine and what is masculine, what is beautiful and what is not." She views their "niche and individualistic" preferences as a sort of reaction to the looks popularized by previous generations. "Gen Z has truly leaned away from 'Instagram face' and anything cookie-cutter," says Dr. Devgan. In rejecting past trends and classical archetypes, she adds, "they're able to try on uniqueness as expression, and that lends itself to more bespoke types of outcomes."

Dr. Camille Howard-Verovic (a.k.a. @dermbeautydoc), a board-certified dermatologist in New York City, also paints the Gen Z patient as unconventional. "They intuitively challenge the idea of ideals," she says, particularly those related to textbook notions of symmetry and proportion. When choosing Botox or fillers, they usually make small adjustments that align with their identity, not some arbitrary beauty standard. 

These traits and attitudes seem to transcend geography. According to Dr. Karan Lal, a double board-certified pediatric and cosmetic dermatologist, the Gen Z patients who visit his Scottsdale, Arizona clinic predominantly "want to look like themselves"—not clones of friends or famous faces. They're clear about their goals, and their vibe is refreshingly nuanced. If they feel their lips are a little thin, they'll try injectables, he says, but they'll emphasize contours and eversion over volume alone.

For Gen Z, "tweakments" are a form of self-care, and "they're applauded instead of stigmatized," says board-certified Seattle dermatologist Dr. Joyce Park (@teawithmd to her nearly 500K TikTok followers). "Getting Botox, which is a go-to procedure for Gen Z, is considered part of their regular skin-care maintenance rather than a way to treat wrinkles."

Frozen foreheads are a hard pass. And "anti-aging" is not in their vocab. But "they have definitely bought into the concept of prejuvenation," reports Dr. Kavita Mariwalla, a board-certified dermatologist in West Islip, New York. This includes getting baby doses of neuromodulators to stave off burgeoning expression lines. "They want to own this part of their life in terms of how they age and what they can do to best modulate it, whether it's topicals, supplements, or procedures," Dr. Mariwalla notes. 

Complexion concerns are a top priority for this age group, adds Dr. Lal, noting that the vast majority come in wanting to minimize pores and acne scars with chemical peels, non-ablative lasers, and microneedling. To bolster results, he says, "they all use sunscreen and topical retinoids at home."

Similarly obsessed with skin texture, Dr. Howard-Verovic's youngest patients are big into lasers and radiofrequency (RF) microneedling devices, like the Morpheus8 and Secret RF, which promise to smooth skin. This zest for procedures spans ethnicities in a way she's never seen before. (Gen Z is known to be the most racially diverse generation in U.S. history.) "When I was younger, aesthetic treatments weren't something we talked about in the house at all," she says. "But this generation, across ethnicities, they're all more informed."

Misinformation and Skewed Perceptions

However, failing to consider the source is often commonplace when investigating procedures nowadays. "There is a lot of misinformation on TikTok, which is where the majority of Gen Z gets their information," points out Dr. Catherine Chang, a board-certified plastic surgeon in Beverly Hills, California. 

Ironically, adds Dr. Mariwalla, Gen Z patients will fall for myths touted by non-experts on social media, yet they'll question a medical diagnosis from their board-certified dermatologist. Perhaps empowered by a steady intake of skincare content, they tend to resist "the traditional doctor-patient relationship—meaning: we know, we tell you, and you do what we say," explains Dr. Howard-Verovic. Instead, they want a provider who is more of a collaborator or sounding board than a sole authority.

Other physicians also noted glitches in the typical Gen Z research process. For example, in Dr. Reish's experience, many nose job-seeking Gen Zers are easily duped by fake before-and-after photos. "They'll find a surgeon on TikTok or Instagram who filters all of their results," he says. "Or, they'll be drawn in by a 3D simulation [a photoshopped image of their nose] rather than real results—which is extremely dangerous in rhinoplasty." Dr. Reish attributes the rise in teenage revision surgeries primarily to inadequate research. 

Dr. Dara Liotta is a board-certified facial plastic surgeon who performs nose jobs almost exclusively. In her New York City practice, she's seeing a "huge increase in younger patients requesting rhinoplasty"—many of whom have unrealistic nose goals, fueled by a heavily filtered digital diet. "I think Gen Z patients feel like nobody else has to filter or Facetune their pictures as much as they do," she says. Despite their digital savvy, "they somehow don't understand that 98% of what they're consuming visually is not reality, [which has caused] this crazy increase in expectations of what you should look like when you wake up in the morning."

According to a 2021 survey, 62% of U.S.-based Gen Zs routinely use filters. The nagging urge to filter images when they'd rather be natural only sharpens their focus on bothersome features. "Every time they take a selfie and feel like they have to filter it, it's turning up the dial on the desire for surgery," says Dr. Liotta. "And the drive for surgery to make you look filtered—an unattainable goal—is high and super-emotional." 

She says prospective patients occasionally bring inspiration images of extremely filtered or stylized noses—currently, the scooped, upturned nose is trending. "It's visually impressive, which plays well to this generation," Dr. Liotta notes. "It exaggerates the way light hits you in a photo." IRL, though, the overdone nose is pinched and unnatural-looking and can age the face over time. But for many Gen Z patients, she says, "they almost care more about what they look like in a picture than in person."

In the dermatology realm, too, there's sometimes "a skewing that happens due to TikTok and Instagram filters, where people still want to look like their selfie version," Dr. Mariwalla says. She warns of a "potential for dysmorphia" in this group, related (in part) to their reliance on tech. "They use their iPhones as mirrors, not realizing the distortion the camera creates, especially in the midface and nose," she says. "Mirrors [offer] a truer depiction."

How to Approach Cosmetic Procedures

Based on our doctors' generalizations—and, to be fair, they are just that—Gen Z is enthusiastic, confident, and transparent about all things aesthetics. They're tuned in to treatment options, and their skincare literacy is off-the-charts. They're also a study in contradictions. They can be informed but not properly educated. They can value authenticity but not always exemplify it. They may be torn between embracing an unvarnished individuality and maintaining the airbrushed status quo. But who's to say they can't be both candid and curated?

Like every generation, Gen Z is a product of the times. And beauty has never been more complex—from the untold ways we can modify our looks to what it all means for our identity and esteem. To elucidate the journey for cosmetic newcomers, we've rounded up expert advice for skirting the most common pitfalls and getting the results you want.

Do Your Research

First things first, don't use social media to find your doctor. On these platforms, where "anyone can be a self-proclaimed beauty expert, it can be difficult to assess who is actually qualified to do your procedure," says Dr. Park. 

Instead, ask friends for referrals or use reputable organizations like the American Academy of Dermatology, The Aesthetic Society, or the American Academy of Facial Plastic and Reconstructive Surgery to locate a licensed derm or surgeon. This handy website, run by the American Board of Medical Specialties (ABMS), also makes it easy to confirm any U.S. doctor's board certification status. Depending on the procedure you're getting, you'll want a physician who's board-certified in dermatology, plastic surgery, otolaryngology (head and neck surgery), or ophthalmology (for eye-area concerns).

When meeting with doctors, Dr. Park suggests asking where they completed their training, how they diagnose and manage cosmetic complications, and what kind of experience they have treating different skin colors and types.

In most cases, adds Dr. Lal, "medical spas are not the way to go if you're trying to get the best benefit from your hard-earned money."

Seek Specialists

If you're seeing a dermatologist for injectables, lasers, and the like, be sure they're a cosmetic derm (not strictly a medical derm) who frequently performs your treatment of choice. It helps if they have a varied armamentarium of tools—an extensive selection of devices and injectables—so they can truly tailor your treatment. 

The field of plastic surgery is a bit more involved. There are general plastic surgeons who are qualified to do cosmetic and reconstructive procedures across the entire body, from head to toe; facial plastic surgeons (or otolaryngologists/ENTs) trained exclusively in facial plastic and reconstructive surgery; and oculoplastic surgeons who operate on the eyelids and brow.

Many aesthetic surgeons specialize beyond these parameters. Plastic surgeons will often choose to treat only the breasts and body. Within that group, some carve out subspecialties, becoming known for their tummy tucks or breast work. Likewise, facial plastic surgeons commonly have niche practices built around rhinoplasty or deep-plane facelifts.

As you can imagine, specialized surgeons tend to shine at their signature procedure. By immersing themselves in the anatomy of a particular area and honing their craft, day in and day out, they develop the know-how to produce reliably great results—and to correct less-than-stellar outcomes, which is an even more exacting skill.

Most of the teens who call on Dr. Reish for revisions originally got their noses done by surgeons who were not rhinoplasty specialists—usually because their parents were driving the research, he says. "What often happens with younger patients is that Mom had a breast lift in the past, so she sends her kid to that surgeon, even though they don't do noses all that often—and then the patient gets a terrible result and ends up needing a revision," he explains.

Be Critical of Before and Afters

Social media is awash in deceptive B&As, with unscrupulous providers enhancing their afters with filters, editing apps, and lighting and camera tricks. Equally misleading are posts comparing bare-faced before photos to fully made-up afters. Same for on-the-table pics taken in the operating room, immediately post-op, absent any swelling or healing: "Those are meaningless," Dr. Reish says. "If you're looking at a surgeon's page and that's all you see—that's a major red flag."

He recommends reviewing B&As on surgeons' websites, not their social accounts exclusively. "Most doctors don't mess with websites," he says. "If they're going to alter photos, it's going to be on Instagram or TikTok. But you should be able to go on a surgeon's site and see hundreds of real, unedited, non-photoshopped B&As." 

Look for multiple views of standardized images (not selfies) with consistent lighting, focal length, patient positioning, and facial expressions. After photos should show long-term results that are months to years out from surgery.

Consider a Consultation

"Gen Z should embrace that consultation moment, where you just talk with your doctor about what you're thinking, without any pressure to get work done that day," says Dr. Howard-Verovic. Part of ensuring a great experience, she adds, is discussing not only the benefits of treatment but the risks as well.

Don't Chase Trends 

You've heard it before, but it bears repeating: Your body is not a trend. The tilt of your eyelids, the contour of your buccal sulcus, or the size of your butt shouldn't be subject to the whims of fashion. "If you're going to have a cosmetic procedure, do it because you like the look of the desired result—not because it's 'in' right now," Dr. Park says. Even then, be sure the intended effect will suit you and live in harmony with your other features.

Think Better, Not Perfect 

To paraphrase elementary school teachers everywhere: There's no such thing as perfect. And in aesthetics, "the pursuit of perfection can cause a very slow decay of self-confidence," cautions Dr. Howard-Verovic. 

While your doctor should strive to deliver the best possible result, "as a patient, you want to be thinking of your outcome as an improvement over a baseline," says Dr. Devgan. "If you think of it as a shortfall from perfection, you'll never be happy; you'll never find fulfillment." 

This advice becomes especially poignant with age as time transforms the topography of the face, creating shadows, nasolabial folds, and hollows under the eyes. "These are natural anatomic features," Dr. Devgan points out. Without them, we hardly look human—yet it can be tempting to try to erase them. "We need to make peace with signs of normal aging," she says. 

Go Slow

When refining your appearance via syringe or scalpel, "you want to slowly achieve your endpoint in a way that allows you to have a safe and predictable outcome," Dr. Devgan explains. There's value in doing less and making smaller moves. When in doubt, she adds, "it's never the wrong answer to sleep on it."

Respect Surgery

"With Gen Z, there seems to be this feeling like injections and surgery are no big deal," Dr. Liotta tells us. "It's nice to have procedures not be stigmatized, but I'm constantly struggling to convey that surgery is serious, even though you can encapsulate it in a 45-second TikTok." 

It's crucial to consider the risks of an operation and the nitty-gritty of the recovery period. Above all, realize that plastic-surgery regret is real. While "reversal" has become a beauty buzzword of late, the truth is, "you can't get a million revisions and change into whatever you want," Dr. Liotta says.

The best way to avoid the spiral of a bad outcome is to be sensible and specific about your goals from the outset, she adds, and to think carefully about how your aesthetic ambitions might evolve.  

Up Next:This Is What Gen Z Wants From Beauty Brands in 2022

Members of the Medical History Society of Nova Scotia presented an exhibit on "How to Mend a Broken heart" at the Museum of Natural History in Halifax with the goal to educate people on the technological advancement of pacemakers and defibrillators.

Margaret Casey, a member of the society said since graduating from medical school in 1986, a lot has changed.

“They were just starting to use pacemakers and implant them,” Casey said,

Back then, pacemakers and defibrillators were a new technology.

With every new advancement, Casey said the medical scope broadened.

“It enhances the lives of people who have heart problems that would impair their quality of life and there’s no question that it’s made a huge difference,” she said.

Casey along with other members of the Medical History Society of Nova Scotia are educating people about its history.

The cardiac pacemaker was first invented in the 50’s, since then it has changed significantly.

“It’s gone from extremely large – so large you imagine it being implanted in the body, down to the size of a toonie,” said Dr. Allen Marble, chairman of the Medical History Society of Nova Scotia.

Pacemakers help control the heartbeat and requires a surgical procedure.

The society has collected a number of pacemakers throughout the years.

Unlike technology in the past, pacemakers can last up to 10 to 15 years before they need to be replaced.

“Before it would only last two or four years before needing to be replaced and you can imagine how difficult it must be to do surgery every two to three years,” said Dr. Marble.

An Innovation that people around the world continue to rely on to live.

© Provided by Rough Draft Atlanta

As rates of anxiety, depression, substance abuse, and suicidal thinking rise, the existing gaps in access to care widen in Georgia.

The Peach State has long been at or near the bottom of states ranked for access to insurance, access to treatment, quality, and cost of insurance, access to special education, and workforce availability.

Mental Health America recently ranked the state 48th in access to mental health care.

That’s largely because Georgia has not expanded Medicaid, which would provide preventative care and treatment for people with behavioral health issues, Georgia Budget and Policy Institute expert Danny Kanso said.

“Certainly, if we just look at the numbers, it is plainly obvious that fully expanding Medicaid would be the most fiscally responsible direction and the best way to cover the most people at the lowest cost,” Kanso said,

In the absence of such a policy change, five organizations including CHRIS 180 are using grants from the Substance Abuse and Mental Health Services Administration to fill the gaps.

The Atlanta-based nonprofit focuses on trauma-informed behavioral and mental health for youth. But, as soon as CHRIS 180 is certified as a Community Behavioral Health Clinic, it can expand its services, Chief Clinical Officer Anne Cornell said.

SAMSA in 2014 designed a Certified Community Behavioral Health Clinic model to Strengthen equitable access to comprehensive behavioral health care, including crisis services that are available 24 hours a day, and seven days a week.

The model combines federally qualified health centers that primarily serve physical or medical needs with behavioral health services, which Cornell said were underrepresented in federally qualified health centers.

Substance abuse programs and mental health services, in particular those helping veterans, are at the top of CHRIS 180’s list for how to best use the $4 million grant over the next four years.

“So the hope is in being able to provide a comprehensive service, and have a service array that you can really meet people’s and manage their needs, give them a support service, skill building, whatever the issue is, before it becomes a major crisis,” Cornell said.

Identifying vulnerable folks and connecting them to local services offers a more holistic approach, she said, including a wraparound process for a family.

A struggling middle school student may find a counselor who recognizes that the parents are also fighting depression while balancing responsibilities at work and home.

These community-based services are tough to quantify because people don’t get to crisis level.

“I mean, that’s, I think, a lofty goal, but you have to break people out of that crisis,” Cornell said. “And our goal, hopefully, is to try to be as preventative as possible.”

Cornell said CHRIS 180 will also expand its support of national and state-level services like the 988 behavioral health crisis system.

Anyone can request care for mental health or substance use disorder from a CCBHC, regardless of their ability to pay, place of residence or age, including developmentally appropriate care for children and youth.

This story comes to Rough Draft Atlanta through a reporting partnership with GPB News, a non-profit newsroom covering the state of Georgia.

The post Atlanta nonprofit to use $4M to fill behavioral health care gaps in access to local services appeared first on Rough Draft Atlanta.

The MarketWatch News Department was not involved in the creation of this content.

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