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With little FDA oversight, melatonin supplements vary widely in … – STAT

With little FDA oversight, melatonin supplements vary widely in ... - STAT

WASHINGTON Consumers turning to melatonin gummies to get some help falling asleep might be getting a lot more help than they bargained for, according to a new study published Tuesday in the Journal of the American Medical Association.

Researchers tested the melatonin concentration in more than two dozen gummy dietary supplements that recently launched and that were available at mainstream retailers like Amazon and Walmart. Nearly all of the products had more than 10% more melatonin than advertised. One product was even three times more powerful than the label suggested.

The study underscores the Food and Drug Administrations lax regulation of melatonin supplements, and natural products more generally. The agency does not review supplements before they hit the market like it does for prescription drugs.

The study is the perfect example of why the FDA needs to do a better job overseeing dietary supplements, according to Stephen Ostroff, a former FDA official who served as both acting commissioner and deputy commissioner of the agencys food program.

Ostroff was reluctant to criticize the FDA for the current situation, and instead argued that the agency needs more money and legal authority to police the growing supplement market.

The new studys lead author, Pieter Cohen, an associate professor of medicine at Harvard Medical School, was less forgiving. While he acknowledged the FDAs current legal authority to regulate supplements is weak, he argued the agency shares some of the blame for not enforcing its existing supplement rules.

We have an inactive FDA, he said. The industry knows that if they put whatever they want to in these melatonin products theres going to be no consequences.

In a statement, the FDA promised to review the findings of the paper, and said it takes product quality concerns, including under- or over-potent products, seriously. However, the agency underscored that it does not have the authority to approve dietary supplements before they are marketed, and firms have the primary responsibility to make sure their products are not adulterated or misbranded before they are distributed.

Large amounts of the substance have also been shown to have adverse effects in children, prompting an exponential increase in poison control calls in recent years, adding to the researchers alarm.

However, one dietary supplement lobbying group argued that variability in strength of the gummies studied is to be expected, and is often purposefully done by manufacturers to ensure they do not degrade overtime and thereby run afoul of the FDAs rules. Dietary supplements are required to demonstrate they contain 100% of the listed ingredient until their expiration date, and thus manufacturers will put an overage in to start to be sure that six months from now that when that consumer buys the product, theyre still getting 100% of whats on the label, according to Steve Mister, the CEO of the Council for Responsible Nutrition.

The new study is not the first to find quality issues with melatonin supplements. A 2017 study found that the strength of melatonin supplements sold in Canada was also unreliable. That study also found several products containing undeclared amounts of the drug serotonin, which the newly published study did not find.

Mister conceded that he did share concerns about two of the products studied one which included no melatonin and another that included more than 300% of the advertised amount. He maintained, however, that there is absolutely nothing in this study that should alarm consumers.

However, the report is likely to prompt debate about the potential risks associated with the increasingly popular sleep aid.

A 2022 study found that melatonin use among U.S. adults more than quintupled from 1999 and 2018, and the number of adults taking high doses more than tripled from 2005 to to 2018.

Theres scant information available about the highest melatonin dose consumers can safely take. One of the only recommendations comes from Health Canada, which recommends no more than 10 milligrams per day.

Two of the products studied would provide users more than that daily maximum in just one recommended serving, according to the study.

This is something that we should be concerned about, said Jocelyn Cheng, a senior director at the drugmaker Eisai and a spokesperson for the American Academy of Sleep Medicine. In general [melatonin] is construed as being safe, but in high quantities we just dont have enough data to say with certainty that it would be safe.

Theres also increasing evidence that melatonin supplements are landing children in the hospital.

A report published last June found that pediatric melatonin-related calls to poison control centers spiked by 530% from 8,337 in 2012 to 52,563 in 2021, and that 4,097 children were hospitalized as a result.

Cohen argued in an interview that the extra-high potency of the products may help explain the recent spike in poison control calls.

Having something that [contains] 50% more melatonin could be the difference between whether [a child needs] to go to the emergency room or you just rest it off at home, he said.

The dietary supplement lobby, however, argued that the new studys focus on children raises a false alarm, because manufacturers typically warn that their products are not meant for children, and most calls to the poison control center were the result of accidental ingestion.

Its a misleading comparison to look at scenarios where kids, for example, got their hands on an entire bottle of adult gummies and became ill after eating multiple servings, versus having slightly more of an ingredient in a single serving that, if taken as directed, would pose no harm, Mister said.

The JAMA study did not name each product individually, but STATs review of the database used to identify the products did reveal that many products included a disclaimer they were not meant for kids. It did appear, however, that certain products bearing that disclaimer also appeared marketed to parents.

One product, for example, included a warning on the back of the bottle indicating it was not meant for people under 18, but the Amazon listing for the product also included a photo advertisement of a mother kissing a young boy good night.

Sarah Ash Combs, an emergency medicine physician at Childrens National Hospital, said the study raises the question of why melatonin and other supplements are sold as gummies in the first place.

What worries me about things being put into gummy form is if you get a hold of that and youre a little kid, youre going to chow down on it, Combs said. It continues to be problematic to me that we put dietary supplements [that are] unregulated by the FDA, such as melatonin in a form that is attractive to kids.

Combs added that she was surprised by the variability in strength of products, and it should be a signal to parents considering using melatonin to help their kids sleep that they should try other remedies like limiting screen time and maintaining a bedtime routine before reaching for melatonin. She added that if a parent still thinks their child needs melatonin that they should talk to their doctor first.

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Burns, how bad is the patient? About Wallace’s Rule of Nine – Emergency Live International

Burns, how bad is the patient? About Wallace's Rule of Nine - Emergency Live International

Dealing with an emergency scenario involving the possibility of severe burns results in a certain speed of assessment.

It is therefore important for the rescuer to be equipped with some basic knowledge that will enable him/her to correctly frame the burn victim.

Measuring the initial surface area of the burn is important for estimating fluid resuscitation requirements since patients with severe burns will experience massive fluid loss due to the removal of the skin barrier.

This tool is only used for second- and third-degree burns (also referred to as partial-thickness and full-thickness burns) and assists the provider in the rapid assessment to determine severity and fluid requirements.

The Rule of Nine has proven to be the algorithm most frequently recited by physicians and nurses to estimate burn surface area in numerous studies.[1][2][3]

The Rule of Nines estimation of burnt body surface area is based on assigning percentages to different areas of the body.

The entire head is estimated at 9% (4.5% for front and back).

The entire torso is estimated at 36% and can be further divided into 18% for the front and 18% for the back.

The front part of the trunk can be further subdivided into thorax (9%) and abdomen (9%).

The upper extremities total 18% and then 9% for each upper extremity. Each upper extremity can be further subdivided into anterior (4.5%) and posterior (4.5%).

The lower limbs are estimated at 36%, 18% for each lower limb.

Again this can be further subdivided into 9% for the anterior aspect and 9% for the posterior aspect.

The groin is estimated at 1%.[4][5]

The Rule of Nine functions as a tool for assessing the second- and third-degree total body surface area (TBSA) in burn patients.

Once the TBSA is determined and the patient is stabilised, fluid resuscitation can often begin with the use of a formula.

The Parkland formula is often used.

It is calculated as 4 ml intravenous (IV) fluid per kilogram of ideal body weight per TBSA percentage (expressed as a decimal) over 24 hours.

Due to reports of excessive resuscitation, other formulas have been proposed such as the modified Brooke formula, which reduces IV fluid to 2 ml instead of 4 ml.

After establishing the total volume of resuscitation with intravenous fluids for the first 24 hours, the first half of the volume is administered in the first 8 hours and the other half is administered in the next 16 hours (this is converted to an hourly rate by dividing half of the total volume of 8 and 16).

The 24-hour volume time starts at the time of the burn.

If the patient presents 2 hours after the burn and fluid resuscitation has not been started, the first half of the volume should be administered in 6 hours with the remaining half of the fluids being administered as per protocol.

Fluid resuscitation is very important in the initial management of second- and third-degree burns comprising more than 20 per cent of TBSA as complications of renal failure, myoglobinuria, haemoglobinuria and multi-organ failure may occur if not treated aggressively early.

Mortality has been shown to be higher in patients with TBSA burns greater than 20% who do not receive appropriate fluid resuscitation immediately after injury.[6][7][8]

The Rule of Nine can best be used in patients weighing more than 10 kilograms and less than 80 kilograms if defined by BMI as less than obese.

For infants and obese patients, special attention should be paid to the following:

Patients defined as obese by BMI have disproportionately large trunks compared to their non-obese counterparts.

Obese patients have closer to 50% TBSA of the trunk, 15% TBSA for each leg, 7% TBSA for each arm and 6% TBSA for the head.

Android-shaped patients, defined as a preferential distribution of trunk and upper body adipose tissue (abdomen, chest, shoulders and neck), have a trunk that is closer to 53% TBSA.

Patients with gynoid shape, defined as preferential distribution of adipose tissue in the lower body (lower abdomen, pelvis and thighs), have a trunk that is closer to 48% TBSA.

As the degree of obesity increases, the degree of underestimation of TBSA involvement of the trunk and legs increases when adhering to the Rule of Nine.

Infants have proportionally larger heads that alter the surface contribution of other major body segments.

A Rule of Eight is best for infants weighing less than 10 kg.

This rule imposes approximately 32% TBSA for the patients trunk, 20% TBSA for the head, 16% TBSA for each leg and 8% TBSA for each arm.

Despite the efficiency of the Rule of Nine and its penetration into surgical and emergency medicine specialities, studies show that at 25% TBSA, 30% TBSA and 35% TBSA, the percentage of TBSA is overestimated by 20% compared to computer-based applications.

An overestimation of the TBSA burned can lead to excessive resuscitation with intravenous fluids, giving the possibility of volume overload and pulmonary oedema with increased cardiac demand.

Patients with pre-existing comorbidities are at risk of acute cardiac and respiratory decompensation and should be monitored in the intensive care unit (ICU) during the aggressive phase of fluid resuscitation, preferably in a burn centre.[9][10]

Studies have found that after examining the fully undressed patient, the percentage of TBSA can be determined by the Rule of Nine within minutes.

Several studies found in a review of the literature stated that the patients palm, excluding the fingers, accounted for approximately 0.5 per cent TBSA and that verification was detected with computer-based applications.

The inclusion of the fingers in the palm accounted for approximately 0.8% TBSA.

The use of the palm, which is the basis on which the Rule of Nine was established, is considered more appropriate for smaller second- and third-degree burns.

It has been noted that the more training a specialist has, the lower the overestimation, especially on minor burns.

Due to the inherent nature of error in human burn assessment even in rule setting, computer-based applications available for smartphones are produced to minimise over- and underestimation of TBSA rates.

The applications use standardised sizes of small, medium and obese male and female models.

Applications are also moving towards measurements of newborns.

These computer applications are experiencing variability in the reporting of TBSA rates of up to 60 per cent overestimation of the burned surface up to 70 per cent underestimation.

Intravenous fluid resuscitation guided by the Rule of Nine is only valid for patients with a TBSA percentage above 20% and these patients should be transported to the nearest trauma centre.

With the exception of special areas, such as the face, genitals and hands, which must be seen by a specialist, transfer to major trauma centres is only necessary for more than 20% TBSA burns.

The American Burn Association (ABA) has also defined criteria for which patients should be transferred to a burn centre.

Once fluid resuscitation has begun, it is important to identify whether appropriate perfusion, hydration and renal function are present.

Resuscitation derived from the Rule of Nine and intravenous fluid formula (Parkland, Brooke modified, among others) should be carefully monitored and adjusted as these initial values are guidelines.

The management of severe burns is a fluid process that requires constant monitoring and adjustments.

Lack of attention to detail can lead to increased morbidity and mortality as these patients are critically ill.

The Rule of Nine, also known as Wallaces Rule of Nine, is a tool used by healthcare professionals to assess the total body surface area (TBSA) involved in burn patients.

The measurement of the initial burn surface area by the healthcare team is important for estimating fluid resuscitation requirements because patients with severe burns have massive fluid losses due to the removal of the skin barrier.

The activity updates healthcare teams on the use of the Rule of Nine in burn victims that will produce better outcomes for patients. [Level V].

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Class of 2023 President’s Engagement and Innovation Prize Winners – University of Pennsylvania

Class of 2023 President's Engagement and Innovation Prize Winners - University of Pennsylvania

Class of 2023 Presidents Engagement and Innovation Prize Winners

On April 21, Penn President Liz Magill announced the recipients of the 2023 Presidents Engagement and Innovation Prizes. Awarded annually, the prizes empower Penn students to design and undertake post-graduation projects that make a positive, lasting difference in the world. Each prize-winning project will receive $100,000, as well as a $50,000 living stipend per team member. The prizes are the largest of their kind in higher education. All prize recipients collaborate with a Penn faculty mentor.

Two seniors and one December 2022 graduate were named recipients of the 2023 Presidents Engagement Prize. They are Seungwon (Lucy) Lee for Communities for Childbirth, and Kenneth Pham and Catherine Chang for Act First. Gabriella Daltoso, Sophie Ishiwari, Gabriela Cano, Caroline Amanda Magro, and Tifara Eliana Boyce have received the Presidents Innovation Prize for their project, Sonura.

This years Presidents Engagement and Innovation Prize recipients are fueled by a desire to make a differencein their community, across the country, and around the world, said PresidentMagill. Communities for Childbirth, Act First, and Sonura embody an inspiring blend of passion and purpose. They are addressing consequential challenges with compelling solutions, and their dedication and smarts areexemplary. I congratulate them and wish them success as they launch and grow their ventures.

The 2023 prize recipientsselected from an applicant pool of 76will spend the next year implementing the following projects:

Seungwon (Lucy) Lee for Communities for Childbirth:Ms. Lee, a neuroscience major in the College of Arts and Sciences, is CEO and co-founder of Communities for Childbirth, an international organization that empowers maternal and child health in Jinja, Uganda. With the support of the Presidents Engagement Prize, Ms. Lee will create a community-based referral system that provides efficient transportation to health facilities and patient-hospital communication during obstetric emergencies. Ms. Lee is mentored by Lisa D. Levine, the Michael T. Mennuti Associate Professor in Reproductive Health in the Perelman School of Medicine.

Kenneth Pham and Catherine Chang for Act First:Mr. Pham, a chemistry major in the College of Arts and Sciences, and Ms. Chang, a December 2022 CAS graduate, willexpand on an idea started through Penns Medical Emergency Response Team (MERT) to provide critical first-aid training to high school students in Philadelphia, including opioid reversal, CPR, and bleeding prevention. Mr. Pham is a former MERT administrative director and Ms. Chang is a former MERT general board member. They are mentored by Joshua Glick, an assistant professor of emergency medicine in the Perelman School of Medicine.

Gabriella Daltoso, Sophie Ishiwari, Gabriela Cano, Caroline Amanda Magro, and Tifara Eliana Boyce for Sonura:Ms. Daltoso, Ms. Ishiwari, Ms. Cano, Ms. Magro, and Ms. Boyce are bioengineering majors in the School of Engineering and Applied Science. Their startup, Sonura, is developing a beanie that promotes the cognitive and socioemotional development of newborns in the NICU by protecting them from the auditory hazards of their environments while fostering parental connection. The Sonura beanie is composed of a frequency-dependent filter and a mobile application. The Sonura team is mentored by Brian Halak, a lecturer in the engineering entrepreneurship program.

We are very proud of the wide-ranging curiosity and passionate commitment to improving the world that characterize our great Penn students said Interim Provost Beth A. Winkelstein. These three exciting projects provide creative, innovative solutions that will shape the future of areas from cognitive development of newborns to childbirth in Africa to first-aid training here in Philadelphia. We are deeply grateful to the committees that worked tirelessly to review this years exceptional applicants, as well as to the Center for Undergraduate Research and Fellowships and the outstanding faculty advisors who worked closely with these students to develop their visionary ideas.

The prizes are supported by Trustee Emerita Judith Bollinger and William G. Bollinger, in honor of Ed Resovsky; Trustee Emerita Lee Spelman Doty and George E. Doty, Jr.; Trustee Emeritus James S. Riepe and Gail Petty Riepe; Trustee David Ertel and Beth Seidenberg Ertel; Trustee Ramanan Raghavendran; Wallis Annenberg and the Annenberg Foundation; and an anonymous donor.

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ADHD in Medical Learners and Physicians | AMEP – Dove Medical Press

ADHD in Medical Learners and Physicians | AMEP - Dove Medical Press

Plain Language Summary

Attention Deficit Hyperactivity Disorder (ADHD) is a condition characterized by functionally impairing levels of poor focus and/or hyperactive-impulsive behavior. While initially thought of as a childhood disorder, studies have shown that in 60% of cases, symptoms persist into adulthood. It affects 3% to 5% of adults. This perspective piece aims to highlight the occurrence of ADHD in medical learners (ie, medical students and residents) and practicing physicians. It reviews what has been published about the prevalence of ADHD in these groups, why the rates in residents and practicing physicians may be higher than what has been reported in the scientific literature, the consequences of untreated ADHD in these groups, and a potentially helpful, innovative educational tool to help medical learners and physicians with ADHD with an important aspect of their training and practice the reading of scientific articles. Dr. Ims team concludes that although it has received less attention in the scientific literature than depression, anxiety, and burnout in medical learners and physicians, ADHD has numerous and significant consequences for these individuals that can have a negative effect on medical training, practice, and ultimately patient care. This makes it imperative to support medical learners and physicians with ADHD via evidence-based treatments, program-based accommodations, and innovative educational tools.

The multiple challenges, physical and emotional, associated with pursuing a career in the medical profession are well-documented.1,2 Recent studies have documented significant rates of depression, anxiety, psychological distress, and burnout among medical students,35 with some research noting higher rates of these conditions among medical students (58% depression, 27.233.8% anxiety, 49.6% burnout) compared to age-matched population samples.68 Significant rates of depression, anxiety, and burnout have also been reported among medical residents (7% to 47% depression,915 18% to 56% anxiety,918 and 37% to 85% burnout)9,1114,19 and practicing physicians (22% to 40% depression,6,9 44% anxiety,9 and 37% to 73% burnout).6,9

While increasing attention has been appropriately paid to these concerning levels of depression, anxiety, and burnout in medical students, residents, and practicing physicians, comparatively little attention has been devoted to the occurrence of symptoms of attention deficit hyperactivity disorder (ADHD) in medical learners and physicians. ADHD is a neurodevelopmental disorder characterized by a persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development.20 Symptoms of ADHD can include not seeming to listen when spoken to, easy distractibility, forgetfulness, making careless mistakes in work or school, procrastination, difficulty sustaining attention, difficulty completing tasks, excessive fidgetiness or restlessness, impulsivity, becoming easily bored or impatient, and blurting out answers or interrupting others.20 Although originally conceptualized as a childhood disorder, research has shown that ADHD persists in up to 60% of adults who experienced symptoms as children.21 Evidence from genetic, neuroimaging, and neurological studies reveals difficulty in executive functioning in ADHD associated with lack of availability of dopamine and norepinephrine in the prefrontal cortex.2225

The purpose of this perspective piece is to highlight the occurrence of ADHD in medical learners and physicians, including its reported prevalence in these groups, why reported rates may reflect underestimates, consequences of untreated symptoms, accommodation-based interventions to date, and a potentially helpful innovative educational tool to assist with a vital aspect of their medical training and practice.

While several studies have reported on the prevalence of ADHD in medical students,2632 some of these studies focused primarily on the non-medical use of prescription stimulants rather than on ADHD per se,3032 and the published literature on ADHD in medical residents and practicing physicians is scant. For example, for medical students, disability-related registry data from the Association of American Medical Colleges (AAMC) suggest an ADHD prevalence of 0.9% to 1.4%,4,26 while other studies, mostly employing self-report methodology, have reported prevalence rates of 3.5%,27 4.5%,28 5.5%,30 9%,31 12.7%,32 and 24.4%.29 For medical residents, rates of ADHD are largely unknown; one survey of emergency medicine residency program directors33 noted that 3 of 4644 (0.06% of) residents were known by program directors to have ADHD. Another study, also a cross-sectional survey of emergency medicine residency program directors,34 noted that 4 of 104 programs reported having one or more residents with known disability due to ADHD. For practicing physicians, data from the 2019 AAMC National Sample Survey of Physicians indicate a prevalence of ADHD of 0.32%.35

At first glance, the lower reported rates of ADHD in medical learners (particularly residents) and practicing physicians compared to published rates of depression, anxiety, and burnout in these groups and compared to ADHD prevalence estimates of 3% to 5% in the general adult population36,37 - may seem intuitive, since having ADHD would ostensibly constitute a significant barrier to successfully completing the rigorous level of focused study, clinical rotations, scholarly activities, and other tasks necessary to complete medical training. In essence, then, it could be argued that medical residents and practicing physicians represent a sample that is pre-selected not to have ADHD.

However, five factors warrant consideration before presuming that rates of ADHD among medical residents and practicing physicians are sufficiently negligible to obviate concern about this diagnosis in these groups. First, it is possible that a significant number of medical residents and practicing physicians with a confirmed diagnosis of ADHD do not report having this diagnosis out of fear of being stigmatized or scrutinized by colleagues or supervisors, or because of concern about legal or licensing ramifications.38,39 Second, many medical residents and practicing physicians, despite long experiencing symptoms of ADHD, may not seek formal evaluation and treatment for these symptoms, either because of lack of recognition by themselves, family members, or friends that these symptoms represent ADHD (eg, symptoms are exclusively attributed to personality traits or are dismissed because the individual was accepted into medical school) or an internal belief that as a future or current medical provider, having a neurodevelopmental disorder warranting treatment is unacceptable.3941 Third, even when medical residents and practicing physicians do seek evaluation and treatment for ADHD, they may face resistance by mental health providers to diagnosing and treating the condition due to cognitive and affective biases on the part of psychiatrists about prescribing medications like stimulants.42,43 Fourth, as with many mental health conditions, significant inter- and intra-individual variability affects assessment of severity and functional impairment of ADHD symptoms,44 and many medical residents and practicing physicians, prior to medical training, may have compensated for ADHD symptoms by relying on strong intellectual ability, the flexibility of teachers/professors, the support of significant others, and selected areas of study or activities that either provide a level of structure protective against academic, athletic, or social floundering, or are sufficiently void of tight deadlines and/or the need to regularly prioritize or multi-task that goals are achieved successfully despite the presence of inattentive symptoms.38,40 These compensatory mechanisms then become challenged when the volume and complexity of material to be learned and applied increase dramatically during medical training.38,44,45 Finally, although varying across studies, reported prevalence rates of ADHD in medical students27,28,3032 are comparable to rates in the general adult population, making a precipitous drop (on the order of 1015 times less) in such rates among residents and practicing physicians difficult to reconcile.

The consequences of experiencing untreated ADHD symptoms, while not extensively studied for medical learners and providers, are likely numerous and significant for these groups, if we extrapolate from general studies in adults with ADHD.21,37,46 These conceivably include difficulty engaging in effective and efficient study, poor academic performance,47 tardiness for or absence from clinical duties (due to forgetfulness or disorganization),43 poor sleep (due to inefficient completion of coursework, poor time management, and baseline sleep difficulties associated with having ADHD),44 relationship difficulties (due to inattentive or impulsive symptoms causing conflicts or less dedicated free time),21 secondary anxiety,21 secondary depression,21 and increased substance use as a means to manage poor focus, sleep deprivation, or stress.21 Moreover, one study found that medical students with ADHD (among other cognitive/learning disabilities), compared with matched cohort controls, had lower United States Medical Licensing Examination (USMLE) Step 2 scores, were less likely to graduate on time, and were less likely to match into a residency program on their first attempt.48 Ultimately, untreated ADHD symptoms in medical learners and providers have the potential to adversely impact patient care, if knowledge and skills critical to serving as a competent physician are not mastered (for students and residents), if careless mistakes are made in the process of performing procedures, interpreting test results, or prescribing medications (in the case of residents and practicing providers), or if associated depression, anxiety, substance abuse, or burnout hinder sufficient motivation, concentration, energy, and persistence to provide medical care.

Research suggests that even when adults are properly diagnosed and treated for ADHD, over time about half of them discontinue treatment (specifically stimulant medications, the first-line treatment for ADHD), with the most common reason being lack of perceived effectiveness.49,50 This underscores the need to not only increase awareness of the possibility that symptoms of ADHD may adversely impact the lives of some medical learners and providers, but to develop effective, durable interventions to support these individuals during and after their medical training.

Accommodation-based interventions for medical students and residents with ADHD, guided by interpretations of the Americans with Disabilities Act (ADA) of 1990 and subsequent Americans with Disabilities Amendments Act (ADAAA) of 2008, have been reported or suggested in the literature to include task management strategies (such as detailed instruction and templates for guiding task completion), environmental modifications (such as quiet, distraction-free environments for testing, learning, charting, or phone calls), and self-management strategies (such as frequent reorientation to tasks, pacing of workflow, use of timers and alarms to help with time management, and scheduling explicit time each day to organize tasks using tools like checklists and filing systems).21,51 Other accommodation-based strategies have included direct daily feedback to residents regarding time management, task prioritization, and areas for improvement, review of daily task lists by residents, guidance by the resident to staff members as to when and how to provide instruction and non-urgent teaching, assistance by faculty for residents to develop a comprehensive reading plan, time allowance by faculty for residents personal health-care appointments, and coordination between residents care providers, program supervisors, and residents regarding helpful accommodations and any changes in these over time.52

While these accommodations have likely provided significant benefit to medical students and residents struggling with ADHD, little to no mention is made in the literature about one particular task area that is a crucial part of medical training and practice, and likely an area of challenge for learners and physicians with ADHD: the reading of scientific articles.

Scientific article reading and application of information contained therein has long been part of training and practice in many disciplines, including medicine. At the medical student level, it may receive less emphasis compared to textbooks, course packs, and pocket reference guides, but the practice may gain more salience during clinical rotations, when attending physicians either ask medical students about their knowledge of the literature in a given area or provide brief teaching points during rounds that reference recently published studies. At the resident level, scientific article reading becomes more important, as two of the general competencies that residents are expected to demonstrate based on the Accreditation Council for Graduate Medical Education (ACGME) guidelines,53 medical knowledge and practice-based learning and improvement, require that residents appraise and evaluate scientific evidence and demonstrate knowledge about established and evolving biomedical, clinical, and cognatesciences and the application of this knowledge to patient care, respectively.21 These skills can practically come into play when residents staff cases with attending physicians, during which time there is discussion about evidence-based approaches to patient care and any recent changes in the relevant evidence base. For practicing physicians, scientific article reading is often required to meet continuing medical education (CME), self-assessment, and cognitive component requirements for board re-certification as dictated by the American Board of Medical Specialties.54 It is also an integral part of conducting research, which, for physicians in academic settings, is either a requirement of employment (for tenure track faculty) or a partial requirement for promotion (for clinical or instructional track faculty).

While the specific content of scientific articles varies based on medical specialty, subspecialty, journal featuring the article, writing style of the author(s), and other factors, these articles generally have several features in common that may pose challenges for medical learners and physicians with ADHD. First, scientific articles are often lengthy, typically spanning several pages. It is well-documented that individuals with ADHD struggle with sustained attention, particularly with subject matter that is experienced as more mundane and not personally stimulating (eg, a resident or faculty member needing to read an article that is outside their area of subspecialty interest).20 Second, scientific articles are typically written in the third person style, which avoids use of I or you pronouns, providing less immediate engagement for readers in general and becoming problematic for individuals with ADHD, who are more inclined to become easily bored due to under-release of dopamine and norepinephrine in the prefrontal cortex.2225 Third, scientific articles frequently contain jargon or concepts that are not immediately comprehensible to readers who are unfamiliar with the particular subject matter of those articles. Neuropsychological studies have shown that adults with ADHD exhibit poorer performance on tasks higher in complexity or time requirements, as would characterize the reading of scientific articles containing jargon or concepts needing clarification via looking up of such terminology;55 moreover, recent studies have suggested impaired reading comprehension abilities in ADHD, with particular difficulty picking out main ideas from material that is read.56 Fourth, scientific articles are presented, with rare exceptions, in small-font text format with minimal illustrations. Neuropsychological studies have revealed that adults with ADHD struggle with tasks requiring use of verbal memory (responsible for encoding much of information presented in written form), focused attention, sustained attention, and abstract verbal problem solving with working memory.57 As a result, it has been recommended that individuals with ADHD have information presented to them in multimodal (eg, visual and auditory) forms and in a well-structured and highly interesting way in order to engage interest, avoid waning of attention, and enhance encoding and consolidating of memory processes.58 Most of these methods of information presentation are not provided by scientific articles.

Given the likely aforementioned numerous challenges associated with reading scientific articles for medical learners and physicians with ADHD, and the already heavy demands on time, concentration, energy, and sleep for medical learners and providers in general (making timely, consistent, and thorough reading of scientific articles challenging), we propose the development of an innovative educational tool for presenting relevant information from scientific articles. This consists of a 5-minute recorded video summary in which an engaging speaker presents the relevant information from a scientific article using a brief PowerPoint (Microsoft Corporation, Redmond, Washington, United States)59 presentation shared using videoconferencing (eg, Zoom [Zoom Video Communications, Incorporated, San Jose, California, United States])60 technology. Use of a limited number of slides, underlining, bolding, and graphics when possible are employed to highlight the salient aspects of the visually presented information, and regular eye contact, engaged facial expression, variable vocal tone, and insertion of periodic commentaries similarly are used to de-monotonize verbally expressed material. Information is thus presented in both written and oral form, providing visual and auditory engagement of the learner, while keeping the session brief to prevent waning of attention over time. The recording would be captured in a video file that can be easily accessed from the learners desktop computer, laptop computer, smartphone, or other electronic device, and can be listened to (without being viewed) while exercising, driving, or engaging in other activities for convenience. The recording can be paused, stopped, re-wound, and re-played at the learners convenience (eg, to clarify content that may have been missed the first time, or to review particularly complex material), in line with the benefit of repeating presentation of instructions or other information to individuals with ADHD to address forgetfulness, distractibility, or difficulty following through. The video summary, while brief, would allow presentation of information on study limitations, discussion points, and other material that would not typically be captured in article abstracts.

One might question how the 5-minute video summary (5MVS) differs from the use of video abstracts offered by some scientific journals. Key differences include: (1) Video abstracts provide a video summary of the background, methods, results, and conclusions of the article being presented a visual form of the article abstract, as the title implies. The 5MVS, however, includes not only these elements of the article, but discussion of the strengths and limitations of the article via commentaries designed to enhance reader engagement. The longer duration of the 5MVS (five minutes) compared to video abstracts (typically one to three minutes) facilitates this inclusion of additional information. (2) Video abstracts are typically presented by the author(s) of the featured article, to provide an overview of the research from the standpoint of the authors, who presumably are in the best position to describe the context, motivation, and intent behind the study. The 5MVS, on the other hand, is presented by a physician who is not one of the articles authors, providing potentially greater objectivity in disseminating the articles findings, particularly with use of commentaries on the strengths and limitations of the article, as noted above. (3) While both video abstracts and the 5MVS can be viewed by any medical learner or physician, the 5MVS is specifically designed to help medical learners or physicians with ADHD through intentional use of visual enhancements (such as text bolding, underlining, italicizing, coloring, and use of easy-to-follow pictures and schematics), engaged facial affect, variation in vocal pitch/tone, and insertion of periodic commentaries, with the goal of capturing and maintaining attention through multiple modes of information presentation. (4) Video abstracts are customarily offered by the scientific journals featuring the articles on which the video abstracts are based, as a means of enhancing reader interest in the articles featured, whereas the 5MVS would be made available independent of an articles particular journal affiliation, with the goal of providing readers with ADHD an avenue to process and retain the important content of scientific articles more effectively and efficiently.

The effectiveness of the 5MVS tool could be assessed via real-time and cumulative approaches. Real-time approaches could entail including a limited number (eg, three) of multiple choice questions at the end of the 5MVS designed to assess understanding, retention, and application of the material presented, with responses by each individual viewer (including percent correctly answered) tracked and recorded in a central database, akin to how retention of material from maintenance of certification articles is assessed and tracked by the American Board of Medical Specialties.54 Cumulative approaches could involve, for example, assigning a group of residents with ADHD six articles to read in four weeks; half of the residents would have access to 5MVSs of these articles, and half would not (all residents would have access to the full-length articles, which could feature topics relevant to the medical field but unlikely to have been previously read by the residents). The two resident groups could be matched on demographic, specialty, ADHD severity, comorbid psychiatric and learning conditions, and other variables. At the end of the six weeks, the residents would take a multiple-choice quiz designed to assess understanding, retention, and application of material from the six articles. Those who had access to the 5MVSs could then be compared to those who did not in terms of quiz scores.

One might question the utility of the 5MVS in terms of helping medical learners and physicians to critically appraise scientific literature, rather than merely read it. Two points are noteworthy here: (1) The 5MVS includes commentaries by the presenter regarding the strengths and limitations of the article, to both increase engagement of the viewer as well as encourage the viewer to critically evaluate the articles findings; and (2) The 5MVS is not intended to replace other approaches aimed at encouraging medical learners and physicians to critically assess scientific literature, including the use of journal clubs, workshops, clinical and methodological critiques, listserv discussions, and other approaches.61,62 That stated, to the extent that some of these approaches utilize articles or other formats that may lend themselves to video summarization (eg, workshops, clinical and methodological critiques), the 5MVS could prove valuable in helping medical learners and physicians with ADHD improve their development of critical appraisal skills.

Residency training programs and medical institutions could provide training of interested providers (perhaps residents and faculty with a passion for teaching) in the construction and implementation of the 5MVSs, incorporating the aforementioned elements to optimize the educational experience for all learners, including those with ADHD. One potential barrier to this would be time constraints on the part of busy residents and faculty physicians. This might be addressed by providing a certain percentage of protected time for residents and/or faculty members to devote to the creation of this tool for learners. Another potential barrier could be technology constraints, although most academic institutions currently have the capability of employing videoconferencing technology, and current costs associated with acquiring such technology do not appear prohibitive for most organizations.63 It would also be important to achieve an acceptable balance between making a presentation stimulating and engaging (through use of visual techniques, tone of voice, insertion of commentaries, and other methods as above) and maintaining objectivity in how scientific information is presented, so as not to inadvertently introduce bias in presentation of the material.

While receiving less published attention than depression, anxiety, and burnout, untreated ADHD in medical learners and physicians has numerous and significant consequences that can adversely impact training, practice, and ultimately patient care. Standard, first-line treatments for ADHD (ie, stimulant medications) provide benefit, but nearly half of adults with ADHD discontinue treatment over time due to lack of perceived effectiveness, and accommodation-based interventions, while helpful and important, do not specifically address a crucial facet of medical training and practice the reading of scientific articles. We propose an innovative educational tool for helping medical learners and physicians with ADHD acquire relevant information from scientific articles, taking into account constraints imposed by the disorder and learning approaches that are more likely to be effective in light of these challenges. Future research should examine both the perceived effectiveness of this tool among medical learners and providers with ADHD who have used it and objective data (using validated measures of information comprehension, retention, and conceptual application) comparing the effectiveness of this tool with standard approaches to the reading of scientific articles. As noted by Duong and Vogel (2022),39 a growing community of physicians is challenging the notion that neurodivergence (defined as having a neurodevelopmental condition such as ADHD that may produce challenges functioning in a neurotypical society but may also offer strengths) is incompatible with a medical career, particularly if individuals with these conditions are properly supported via evidence-based treatments, program-based accommodations, and innovative educational tools.

The authors report no conflicts of interest in this work.

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Anatomy

The Anatomy of Panic, by Michael W. Clune – Harper’s Magazine

I had my first panic attack when I was fifteen, in the middle of January, while I was sitting in geometry class. Winter in Illinois, flesh comes off the boneswhat did we need geometry for? We could look at the naked angles of the trees, the circles in the sky at night. At noon we could look at our own faces. All the basic shapes were there, in bone. Bright winter sun turns kids skinless. Skins them. But there we were in geometry class. The teacher also taught physics. He was grotesquely tall. Thin. Hed demonstrate the angles with his bones.

This was Catholic school. The blackboard was useless. A gray swamp dense with half-drowned numbers. Mr.Streeling would bend a leg in midair: 90 degrees, cleaner than a protractor. Hed stand and tilt his impossibly flat torso: 45 degrees. He could lift his pant leg, unbundle new levels of bone like a spider: 15 degrees, 55, 100.

I was sitting under the fluorescence when it happened. The first time, technically. Though I could tell it was the first time only in retrospect, looking back from the third time. My right hand on my desk, my left hand fiddling with a pencil in the air.

Mr.Streelings voice booms: Open the textbook, page 96. The textbook lies next to my hand on the desk. Next to the textbook is a large blue rubber eraser. Hand, textbook, eraser. Desktop bright in the fake light.

My hand, I realize slowly, its a... thing.

My hand is a thing. Hand, textbook, eraser. Three things.

Oh.

Thats when I forgot how to breathe. Ty saw it happen. He was sitting across the room. But he saw me, and he gave me a look like what the hell. Watching me trying to remember how to breathe. It wasnt going well. I was sucking in too much air, or I wasnt breathing enough out. The rhythm was all wrong.

Darkness at the edge of vision...

Two seconds blotted out. When I came back my lungs had picked up the tune. The old in-and-out, the tune you hear all the time. If it ever stops, try to remember it. You cant. Breathe in, breathe out, breathe in, breathe out. It never stops. But if it does, its hard to remember how it goes. Ask dead people. Ask me. I gave Ty a weak smile, like Id been joking, my face probably red or maybe white or even a little blue. Ty turned slowly back to his textbook, shaking his head like I was crazy.

The second time it happened was in a movie theater. My dad had taken me to see The Godfather Part III. It was a Tuesday night. Late January. The theater was basically deserted. Kind of depressing, this father-son outing on a school night. Kind of cool too. Like we didnt give a fuck about school nights.

I think the show started around 10pm. Everything was fine. The film was pretty good. Until halfway through, when the Al Pacino character says he has diabetes. As he said that word, diabetes, I could feel gas rising in my blood. The gas started to rise maybe a minute before diabetes. Like I knew he was going to say it. Like I prophesized it.

This time what I forgot was how to move blood through my body. My blood stopped. When your blood stops, the gas rises. Thats my experience. Gas rising in the blood. Dad snored beside me. I woke him up, said we have to go. He looked at me. Okay.

As soon as we got up my blood started to move again. I was still in shock or something. Walking like I was about to fall over. When we got to the car I lay back in the passenger seat and pressed my forehead to the cold glass and Dad asked me if I was okay and I said yes, which he knew was a lie, but there was nothing else I could say.

I couldnt tell him that my blood had stopped. I couldnt tell him about the gas in my blood. Those were inside symptoms, not outside symptoms. I knew on some intuitive level that my blood stopping at the word diabetes wasnt a symptom Dad could work with. Thered be questions. Plus my blood actually stopped about a minute before the word. Hard to explain.

In fact there was nothing that could be said between myself and Dad about what had happened to me in the theater. So it was the same as nothing happening. That was the second time.

The third time was two weeks later. A Sunday night in February. I climbed into my narrow bed in my narrow room at Dads place. I was reading Ivanhoe. The old Signet Classic paperback. There was a painting of a joust on the cover. A lot of red in the painting, I remember that. But not from bleeding knights like youd expect. The knights were whole. The red was in the atmosphere. I sat up in my bed with my pillow propped against the wall and opened the book and started to read. It was probably 10:15 or so. I usually read for a little while before falling asleep.

At a certain point early in the first chapter I became aware that I was having or was about to have a heart attack. As long as I kept reading I didnt have to think about this too much. When youre reading, the words of the book borrow the voice in your head. Words need a voice. The voice they use when you read is your voice. Its the voice your thoughts talk in. So if you give the voice to the book, your thoughts have no voice. They have to wait for paragraphs to end. They have to hold their breath until the chapter breaks.

So the lords and ladies went to the joust, and the Saxon guy threw meat to his dog in his hall, and the other Saxon guy ran away, and the Jewish guy spoke to his daughter, and I was having a heart attack, and the Knight Templar looked down from atop his war horse. He had an evil look in his eye.

I read at a medium pace. Too fast and the voice in your head cant keep up with the words. Thats what your thoughts are waiting for. They catch the voice and flood your head with news of the catastrophe unfolding in your body.

But if you read too slow then its not just the chapter breaks you have to watch out for. Now youve got holes and gaps between the words. Maybe in some situations thats a good thing. You can savor the words. The words come swaddled with silence, like expensive truffles, each one separate, while cheap chocolates are packed next to one another with their sides touching.

In a reading situation like mine you want the words packed together with their sides touching. Because silence isnt delicate truffle-swaddling in that situation. Its heart-attack holes. Its not even silence. Every second the book isnt talking your thoughts are talking, urgently, telling you about this heart attack youre either having or about to have.

So I read at a medium pace. A constant, medium pace. I developed a technique where Id read over the chapter breaks, and run the paragraphs together. I didnt pause. Sometimes Id feel myself speeding upthe voice in my head began slipping on words. But I didnt lose it. I slowed down. Not too much. I kept the pace medium.

By chapter three I had it down cold. I was a genius at reading Ivanhoe by chapter three. I doubt its ever been read so well. It had a voice all to itself, with no interruptions, and no breaks, for the entire length of the book. How often has that happened in the history of Ivanhoe? The whole time I was reading I never even found out whether I was actually having the heart attack or just about to have it. Thats how good an Ivanhoe reader I got to be. The very next thought would have told me. But the next thought never came.

I suspended the heart attack in Ivanhoe. Like when you shake a solution of oil and vinegar. As long as you shake it, the oil and vinegar are suspended in one another. When you stop, they separate. So long as I read Ivanhoe my heart attack stayed suspended in the story.

I didnt stop reading. I didnt go to the bathroom. I didnt change my position. I didnt look at the clock. We went through the hours like that. Me, the Saxon lord, the Jewish guy, the heart attack, and the Knight Templar. We moved through 11pm like that. In suspension. Midnight. 1am. 2am. 3am. And then the legendary, unseen hour. 4am.

I heard Dad get up. The end of the story was very close now. Richard Coeur-de-Lion has come home. The news of his return spreads. Dad moves behind the thin wall that separates my room from his. Ivanhoe, Rowena. The sound of the shower. Rebecca! Rebecca... Dad goes down the stairs and I can hear the clink of silverware. The sound of the fridge opening.

Ivanhoe distinguished himself in the service of Richard, and was graced with farther marks of the royal favour. He might have risen still higher but for the premature death of the heroic Coeur-de-Lion, before the Castle of Chaluz, near Limoges.

At 4:35 am Ivanhoe ended. I put down the book. I put on my pants and pulled on my sweater. Then I walked downstairs and told Dad that I was having a heart attack.

At the emergency room they told me what I was actually having was a panic attack.

A panic attack? I repeated.

The bright fluorescence of the hospital room shone on red and black medical devices. Shone on my hands, which were crossed on my lap. They looked more like things than ever.

Dad welcomed the news.

A panic attack, he said. Nothing to worry about, thank God.

The emergency room doctor nodded.

People often think theyre having a heart attack when they first have a panic attack.

Actually it was the third time, I realized. It took three tries for it to learn how to mimic recognizable symptoms, to make itself public.

What am I panicking about? I asked.

They didnt find it easy to answer that question. To tell the truth they didnt find it a very compelling question. In the emergency room they deal with organ failure, stab wounds. Things of that nature. Philosophical questions about quasi-diseases give way to the urgency of actual vivid outside-the-body blood, in large amounts. Pulseless wrists, severed legs. Prestigious, respectable conditions with absolutely unfakeable symptoms.

Probably nothing, Dad ventured after a few seconds, looking hesitantly at the doctor.

Could be anything, said the doctor. If it happens again, breathe into a paper bag.

What?

A paper bag, he repeated.

He explained, as best as I could understand him, that what happens when you have a panic attack is you hyperventilate. You breathe more and more quickly. So you have more oxygen than carbon dioxide, and your blood vessels constrict, which causes you to feel lightheaded. You get tingling in the extremities, and other symptoms which can easily mimic an ignorant persons impression of what a heart attack is like.

He looked at me compassionately.

But if you breathe into a paper bag, that will restore the carbon dioxide.

So a paper bag cures panic attacks? Dad asked.

The doctor paused. His beeper started to go off.

Yes, he said. Please excuse me.

On the way back from the hospital, Dad stopped at the grocery store to buy some paper bags. He gave me two to stuff into my backpack. Then he dropped me off at school.

Wait, he yelled from the car as I was walking away.

I hurried back. He thrust something at me through the open window.

Better take one more bag, he said. In case one of them gets wet.

My mouths dry, I said.

What, he said.

Its not wet, I said. Theres no way the bag can get wet.

What, he said.

Okay, I said, taking the bag.

Have a good day, he said, rolling up the window and driving off.

The regular entrance, where the bus dropped us off, was locked. So I had to go in through the main entrance. Id never used it before. Plainly it was designed for adults. The door swung open into a corridor with what looked like a real marble floor. Expensive-looking dark-green tiles on the walls.

I crept through silently. The right side of the wall had about a hundred framed black-and-white photographs hung on it. Priests. All smiling. Facing the camera with the confidence of men who know they wont have faces for long. Now theyd all stepped out of their faces. Thats what black-and-white photographs mean.

The faces hung there like rows of empty sneakers in a shop window. The priests had stepped out. Into the air, I thought. Breathing out, never breathing in. Maybe thats what its like when you step out of your face at the end. Like the opposite of a panic attack. You breathe out more than you breathe in. Then youre out. Free.

I fingered my paper bag. What had the doctor said? A paper bag is a device for breathing out more than you breathe in? Was that it? I wondered if other people used them. I stared at the wall of priests. Huffing their own carbon dioxide in a paper bag right before the shutter clicked. Maybe thats how they practiced for not having a face any more.

I was sweating in my winter coat.

Pull yourself together, I thought. I hurried down the corridor.

When I was about ten feet from the end, the door swung open. A nun Id never seen before stepped through, glaring.

What are you doing here?

I blinked guiltily. Sweating in my coat, still holding the empty paper bag Dad had given me. I hadnt had a shower that morning. Greasy hair plastered my forehead.

Get to class, she said.

She held the door open, pointing. I stuffed the bag in my pocket and shuffled forward. When I got close she stopped me. Put her long white hand on my shoulder.

Whats in your pocket?

I gulped.

Nothing, I said.

Show me.

I dug the bags out.

Just some paper bags, I said.

She squinted down through her spectacles.

Thats trash, she observed. What are you carrying trash around in your pockets for? Throw it out.

She pointed. For a second I didnt realize what she was pointing at. It looked like a model of a space ship. That opening on top... A garbage can! I clutched my bags tighter.

I cant throw them out, I said. The doctor gave them to me. I mean he prescribed them. The nun opened her mouth. She stared at me incredulously. Then she closed her mouth.

Youre planning to steal something, she said at last.

No! I said.

Those bags wont be empty when you leave, she said. Because youre going to steal something to put in them.

No way, I said.

Im right, arent I?

No.

What are you going to steal?

I didnt know how to respond.

Three items, mused the nun. Three items smaller than a paper lunch bag...

They arent lunch bags, I insisted. Theyre medical bags.

She ignored this.

When you leave today, she said, stepping aside, still holding the door open, come this way. I want to see you before you try to leave.

She made a brushing motion with her free hand, moving me along.

I walked through the door.

Actually, she snapped at the last second, dont come this way when you leave. Dont come through here again.

The door swung shut. I looked down at the bags, clutched in my sweating hand.

They were wet. They were soaking wet.

I went into the first bathroom I saw and tried to dry out one of the bags under a hand dryer.

Dry, I thought. Dry, you bastard.

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The Anatomy of Panic, by Michael W. Clune - Harper's Magazine

Anatomy

Grey’s Anatomy Round Table: Did Maggie’s Farewell Exceed Expectations? – TV Fanatic

Maggie Pierce has left Grey Sloan.

With a supersized installment starting with Grey's Anatomy Season 19 Episode 14, we got an extensive farewell for Maggie by the end of Grey's Anatomy Season 19 Episode 15 that didn't disappoint. We also saw the possible end of Kaimelia, Jo facing a crisis, Bailey inching toward danger, and so much more.

Join former TV Fanatic and diehard Swiftie Meaghan Frey, Grey's Fanatic and actor Joshua Johnson, and Jasmine Blu as they discuss it all.

Did the series execute Maggie's sendoff well? What was your favorite part about it? What do you think they could've done better?

Joshua: The series executed the sendoff well in terms of final episodes. Everything leading up to it was maddening, though, and that may have lessened the impact of Maggie leaving. For almost the whole season, Maggie felt unrelatable and unlikeable, so going into this episode, I had some trouble caring about the fact that it was her last.

However, in this episode, Maggie was everything that I'd always liked about her: open-minded, optimistic, relatable, a good teacher, a cardio god, etc. It was refreshing but also annoying that the writers dragged her through the mud to get here.

My favorite parts about her send-off were her scenes with Catherine, Simone, and Richard. It's always nice to see Catherine's softer side, and seeing her treat Maggie like a daughter is even nicer.

Watching Maggie work with Simone was great, especially because it wasn't even a cardio case, but also, it was just nice to see Maggie be a good teacher and to someone who would appreciate her.

And, of course, the scene where Richard gave Maggie the business card holding bench was especially effective. I teared up a bit in the moment, mostly for Richard's sake (and then I got annoyed that we didn't get anything like that between Richard and Meredith).

The final scene in the elevator was killer, and I was wholly unprepared for it until just a couple of seconds before it happened. Ever the crybaby, I burst into spontaneous tears.

Meaghan: Given how rocky the end of Maggie's journey on Grey's Anatomy has been, I'm satisfied with the sendoff we got. I'm glad that she and Winston were able to come to a place of understanding and recognize that they do love each other.

Unfortunately, a relationship that once burned so brightly faded out quickly; unfortunately, life sometimes gets in the way.

I'm also happy we got a few great Richard and Maggie scenes before she left. Richard and Maggie's relationship has felt absent at times recently, but watching Richard give Maggie the miniature bench had it feeling a little dusty in my living room.

Jasmine: I was not pleased with how things were playing out for Maggie leading up to her departure, but they pulled it off well in the end with this double episode, and I appreciated that. I loved her final moment with Webber and that elevator scene. The elevator scene with her mothers was fantastic.

Were you surprised that Maggie and Winston fell into bed together? What did you think about him asking Maggie to stay and her asking him to come with her? Did they make the right choice?

Joshua: ABSOLUTELY, they made the right choice. I was a little surprised that they fell into bed together, but it was definitely necessary for them to eventually decouple. It was clear that both of them wanted to make the relationship work, but there was just no way for it to happen.

Meaghan: There is no question that these two love each other, but sometimes love isn't enough. Of course, they will try to cling to that last bit of hope for reconciliation. It's only natural. But Maggie couldn't stay, and Winston couldn't leave without one of them having to give up something extremely important to them.

Maggie would have resented Winston if she had given up such a huge opportunity for him; Winston would've always felt like the second best in Maggie's life if he had gone with her. I'm glad each of them made the decision they did because they both deserve to be happy.

Jasmine: I didn't expect the hookup because they've loathed each other so much before that. But they both made the right choice.

Maggie deserved the chance to leave and spread her wings, and I was proud of Winston for sticking his ground and not following after Maggie like a puppy. He made a home at GSM and deserved the chance to do his own thing too.

What are your thoughts on Maggie's journey processing if she was like Ellis or not after what Winston said?

Joshua: I've been the most vocal about Maggie becoming like Ellis, and this episode changed my perspective of Ellis entirely by reframing the kind of person that Ellis was.

Ellis wasn't cold and harsh for the sake of being cold and harsh; she was driven and dedicated to her career to the point where she expected that same drive from everyone else. She demanded excellence from herself. Maggie is absolutely all of those things and always has been.

However, Maggie wasn't raised by Ellis; she was raised by Diane, where she learned all of the things Ellis wasn't: warm, effusive, and compassionate. One of the reasons I think this episode was as effective as it was, is because the writers could balance the two.

Meaghan: This was a great moment of character growth for Maggie, but it felt like one that should've begun sooner rather than them shoehorning it into her final episode.

We started to get some of it when she had her Ellis fever dream, but it was like they completely forgot about it until last night. It's extremely important that Catherine pointed out that there was more to Ellis than just her negative qualities.

Ellis Grey has gotten a pretty bad rap over the years, but she was still a pioneer for women in the medical field; that shouldn't be forgotten.

Jasmine: I agree with you 100%, Meaghan. I liked the emphasis on Ellis being more than just a terrible mother or wife. She had so many layers to her, and that was perfectly okay. Having some aspects of Ellis in there is not always a bad thing.

I also found it interesting because being like Ellis didn't mean Maggie had to be precisely like her bit by bit or in the same ways. There wasn't anything wrong with Maggie being ambitious or genuinely loving saving and helping people.

But the criticisms were about how she handles other people in her relationships, and I thought that was valid without accusing her of being this cold, unfeeling person.

There was a narrow view of what it meant when people said she was like Ellis. It was a storyline they could've explored much better rather than throwing it in like this at the end.

How do you feel about Kai's decision to move to London and they and Amelia ending things? Should Kai have said something sooner, or have they always been clear about their stance? Did Amelia make everything about herself?

Joshua: I'm not worried for Amelia, but my heart is breaking for her. Kai should have said something sooner, but I also understand them wanting to talk about it with Amelia in person.

What I find the most interesting about this plot point is that Amelia and Kai seemingly had yet to discuss what their relationship would be in the long term, especially considering Kai's opinion on children.

Amelia made the moment about herself, but I understand that. Addison was put in danger and then left, Meredith left, Maggie left...all of the people closest to Amelia are leaving her, and in a moment when she finally felt safe and content, Kai pulled the rug out from under her.

Given Amelia's past, and all of her defense mechanisms, it made total sense for Amelia to think of herself first. I did appreciate how Kai gently called Amelia out rather than rage at her.

Meaghan: I have such mixed feelings about this storyline. First, what was the point of having Amelia and Kai get back together if Kai was going to leave? I'm tired of Amelia getting the shit end of the stick in the Grey's Anatomy universe. But I digress.

I understand where Kai is coming from to an extent, but at the same time, I don't. If Kai were to move to Seattle to do research, that wouldn't automatically mean they have to be involved in Scout's life. It would just mean they don't have to take a plane to spend time together.

But, If London is their dream, they shouldn't have to give that up. The least they could've done is talk to Amelia about it before deciding so they could figure out, together, what that move would mean for their relationship: do they break up? If they stay together, how do they see each other?

Amelia can't just take a plane to London regularly between her job and Scout, so would Kai be flying to Seattle? It just ended up feeling like Kai didn't care about their relationship.

Jasmine: They really love to make Amelia suffer, don't they?

I was never invested enough in Kaimelia to have strong feelings, mainly because I felt the kid issue and Kai's devotion to their work would always be an issue.

Kai said precisely who they were from the beginning, and they tend to stick to their convictions, and I just never saw how Kaimelia could sustain a relationship by separating parts of their life like this.

My issue was that Kai didn't give Amelia a head's up when things were happening or discussed anything. They also had all of these romantic moments and rolled around in bed together and all of this BEFORE they broke the news to Amelia which didn't sit right with me either.

And they seemed like they just shut their emotions off like a switch the second Amelia got annoyed about all of this, which made me question how invested they were in Amelia this whole time since she fell hard and fast as usual.

But Amelia definitely made everything about her the whole time, which sucked.

I like Amelia, but sometimes I tire of her coming with this huge disclaimer of how someone has to handle her or what they need to know to make sense of Amelia. It's something other people don't get.

She made everything about her at that moment, and it was also feeling as if she's been holding out hope that things would change for Kai, that they would reach a point where they would put Amelia first or maybe change their mind about kids, and that's wrong, too.

How concerned are you about Bailey's well-being? Do you think she's finally taking the situation seriously?

Joshua: I thought Bailey was slightly cavalier at the beginning of the episode, but I also understood her brushing it off. It wasn't a problem until it became a problem.

It took seeing that her family was in danger, with the picture of Tuck sent to her phone, to take it seriously. Before that, there was almost a badge of honor that Bailey was wearing--if Addison can go through what she goes through on the road, then Bailey should be able to deal with some unknown phone calls.

Once it became more than just about her, though, it became real. Finally, she's taking it seriously, and I hope she gives that phone number to the police.

Meaghan: I have to hope that they won't let anything too horrible happen to Bailey, but it also seems like they are headed in that direction, so I'm terrified at the same time. Once they started involving her family, it really began to sink in for Bailey how dangerous this situation is.

Jasmine: I'm concerned about Bailey. They touch on this in Grey's Anatomy and Station 19, which makes me feel like something terrible will happen, and I won't be able to deal. I'm glad she's gotten out of her denial and is taking this as seriously as Ben has been the whole time.

Link's attempt to tell Jo his feelings got thwarted, and now Luna is hearing impaired. React!

Joshua: This is the most Grey's thing, to get us to the point where finally a character is ready to act only to have a tragedy set them back. This will only give Jo a chance to see how dedicated Link is not just to her but to Luna as well. My biggest takeaway from this plot was, "Can Jo really never get a break?"

Like, come on, Grey's, let a girl be happy for once!

Meaghan: Poor Link. That was about to be such a beautiful moment. Also, poor Luna! That little girl has already had to go through so much in her young life. It's so unfair.

This situation with Luna will inevitably bring Jo and Link closer. Right now, she is pushing him away due to the shock of it all, but he is her person; she will need him now more than ever.

Jasmine: Link is back to giving me all that romantic male lead energy -- what he fully delivered before that whole invasion of the body snatchers Link they gave us randomly last season, and I'm just so happy about that. He's got that rizz, and we need somebody to deliver on that. He was crushed, and I hated that for him, but their time will come.

I'm genuinely looking forward to this storyline with Luna's hearing impairment. It could be very interesting, and I know how complicated and emotional that is...

I watched my mom have to process that with my brother. And I think we'll see the family unit Jolink has formed become even tighter because Link will be there for Luna as much as Jo.

Do you think people were being harsh and unfair to Levi? Has he found his specialty with Peds?

Joshua: They were absolutely being unfair! Schmidt listed them off himself:

Also, he's only a fourth-year resident! Meredith didn't even claim a specialty until halfway through her fifth year!

I think peds is a great specialty for him because Schmidt was often overlooked, and people who were overlooked knew how to look out for others. Peds needs that kind of doctor.

Meaghan: Levi's career has been an absolute shit show up until now, so I will need everyone to back off. After seeing Levi with his patients this week, I could absolutely see him going into Peds. With losing Hayes, we completely lost the specialty, which is unfortunate because the Peds cases were always some of the best.

Jasmine: I was so put off by how everyone was treating him! Like, he lowkey was getting the Millennial treatment with Boomers and Gen Z ragging him over stuff he had no control over without ever considering the situation he was in.

Like, the residency program got shut down. He legitimately went through burnout because of the pandemic; THE FREAKING PANDEMIC, HELLO?!

Nothing about Levi's residency has been status quo because of things outside his control, so it was maddening that they acted like he was some slacker with no guidance.

Nevertheless, I'm here for him going into Peds to break up the monotony of General Surgery, and I can't think of any other specialty that suits him. Also, we need a Peds doc.

What was your favorite intern storyline?

Joshua: Interestingly, I enjoyed Simone and Jules' interactions the most this week, especially culminating in Jules helping Simone with her measurements.

Something this group of interns does consistently well is show up for each other. They may snip and gripe at each other, but ultimately they support and care for each other in a way that the original five didn't.

Meaghan: I loved Jules finding her passion for cardio and reinforcing for Winston that he was making the right decision by staying. It felt like the perfect storyline to bridge the gap between the old and the new.

I'm also really loving the messiness of Simone's marriage storyline. This is the kind of drama that I love from Grey's Anatomy. More of this and less of Teddy/Owen or Maggie/Winston type drama, please, writers.

Jasmine: I was amused by Lucas carting Pru around for semi-shallow reasons. They looked so precious, and I swear they almost look related.

Simone's messiness delights me. I love Jules emerging as one of the best of the interns. And I'm incredibly worried about Mika.

What was your favorite moment, storyline, etc., from the episode?

Joshua: I liked when Maggie and Winston removed the cardiac tumor and waited for the heart to adjust. It was a nice callback to Season 12. Another great callback to classic Grey's was the bar mitzvah ceremony; I wish we'd gotten to know Grayson and his grandfather a little more, just for the emotional impact. I'm a sucker for crying during the show.

Meaghan: Maggie's final scene standing in the elevator with both of her mothers -- the two women who have made her who she is -- was such a powerful and emotional moment.

Where was that kind of moment in Meredith's goodbye episode? Sorry, I'm still just so salty over Ellen Pompeo getting the short end of the stick with that goodbye.

Jasmine: Yes, Meaghan. Everything you said.

I loved that final shot of her in the elevator with her mothers. And it's so wild that she got this meaningful sendoff compared to Meredith's, which felt like they threw something together on the back of a Post-it.

As a Maggie fan, I'm happy that she got something good. She deserved it; Kelly McCreary deserved it.

Is there anything else you'd like to add or discuss?

Meaghan: Last week, Jasmine asked whether or not we thought Amelia would relapse, and I was a hard no; now I'm not so sure. Maggie leaving is one thing, but Kai leaving her at the exact same time? This will bring up many issues and push her in a dark direction.

Jasmine: I am worried about Amelia after this Kai blow. I'm also worried about Catherine because it feels like we're headed somewhere dark. And I'm concerned that Mika is stretching herself too thin, and no one is taking that seriously.

Over to you, Grey's Fanatics.

Do you agree with us? Do you disagree? Sound off below.

Grey's Anatomy airs Thursdays at 9/8c on ABC.

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Jasmine Blu is a senior staff writer for TV Fanatic. She is an insomniac who spends late nights and early mornings binge-watching way too many shows and binge-drinking way too much tea. Her eclectic taste makes her an unpredictable viewer with an appreciation for complex characters, diverse representation, dynamic duos, compelling stories, and guilty pleasures. You'll definitely find her obsessively live-tweeting, waxing poetic, and chatting up fellow Fanatics and readers. Follow her on Twitter.

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Grey's Anatomy Round Table: Did Maggie's Farewell Exceed Expectations? - TV Fanatic

Anatomy

The anatomy of sugar prices: Will the taste sour this summer? – Economic Times

Summer is here, and so is our craving for fizzy drinks and ice creams. But with sugar prices likely to go up, we could be shelling out more to stay cool this summer. The international market has witnessed a recent surge in sugar prices. One of the key factors is the likelihood that India wouldnt allow additional exports. And India's expected pause is mainly due to a fall in the production of sugarcane due to untimely rains and moves towards fulfilling its carbon-reduction commitments i.e. the ethanol-blending programme.

With the likelihood of extreme heat waves this summer, demand for sugar will go up, especially when supply is limited due to a fall in production.

The factors that affect sugar prices

About 70% of the sugar in India is manufactured using sugarcane, according to Indian Sugar Mills Association (ISMA). Being a water-guzzling crop, sugarcane poses a serious threat. On an average, 1kg of sugar requires about 1,5002,000 kg of water, according to a NITI Aayog estimates. Pressure on water due to sugarcane cultivation in states such as Maharashtra has become a serious concern. Heatwaves, untimely rains and depleting water level directly affect the sugarcane production leading to disruption in demand and supply cycle.

As per a NITI Aayog report, 35% of sugar is used in household consumption and 65% goes for industrial uses, including beverages and food manufacturing. So, any fluctuation in prices will hit the kitchens as well as contribute to the rise in prices of various FMCG goods.

Various research agencies have forecasted a fall in sugar production this season. According to the Industry body National Federation of Co-operative Sugar Factories (NFCSF), India's year-on-year sugar production is expected to fall by 10% in 2022-23. It has pegged sugar production at 325 lakh tonne against 359.25 lakh tonne in the previous year.

Maharashtra, which accounts for more than one-third of India's sugar production, witnessed a fall to 104.2 lakh tonne from 118.8 lakh tonne, with output in Karnataka also declining to 55.2 lakh tonne from 57.2 lakh tonne. In the state, the picture appears grim as it could churn out nearly 16% less sugar than previously estimated as mills are closing early due to limited availability of sugar cane, said a Reuters report. In 2021-22, Maharashtra sugar mills were operational until mid-June, but this year, out of 210 sugar mills that started operations, 155 mills had stopped crushing as of March 26, the report said.

Domestic price rise

The domestic market for sugar has seen a recent increase in prices, especially in Uttar Pradesh, reported Centrum Institutional Research. It expected a further rise in sugar prices. "We anticipate further increases (in prices) in the coming months as demand for sugar is expected to surge during the summer season," Centrum said in a recent research note.

The industry is also expecting a price rise in the coming months. "Soft drinks and ice cream manufacturers' are expected to consume more sugar this year as we are expecting a severe summer," said Prakash Naiknavare, Managing Director, NFCSF, in a release.

India's carbon commitments

India normally produces a surplus of sugar. According to government data, in a normal sugar season, the production of sugar is around 320-360 lakh metric tonne (LMT) whereas domestic consumption stands at around 260 LMT which used to result in a huge carry-over stock of sugar with mills.

In order to solve this surplus problem, India is encouraging sugar mills to divert excess sugarcane to ethanol. India has a fixed target of 20% blending of fuel-grade ethanol with petrol by 2025. In sugar seasons 2018-19, 2019-20, 2020- 21& 2021-22 about 3.37, 9.26, 22 & 36 LMT of sugar respectively have been diverted to ethanol, said the official data. In the current sugar season 2022-23, about 45-50 LMT of excess sugar is targeted to be diverted to ethanol.

By 2025, it is targeted to divert 60 LMT of excess sugar to ethanol, which would solve the problem of high inventories of sugar, and improve the liquidity of mills, thereby helping in the timely payment of cane dues of farmers.

As per the official data, in the past three ethanol supply years, the revenue of about Rs. 48,573 crore has been realized by sugar mills from the sale of ethanol to oil marketing companies.

As part of its carbon-reduction commitments, India has launched the ethanol-blended-petrol (EBP) programme to mix this biofuel with petrol to reduce the consumption of fossil fuel. Earlier, the government announced the achievement of E10 target, that is, the petrol used in the country had to have 10% ethanol in it. The country saved as much as Rs 53,894 crore in forex from 10 per cent blending besides it benefiting the farmers.

India is likely to take a call on the additional exports of sugar and this is what will tell whether there will be any upswing in the prices in the upcoming summer season.

Pause on additional exports

India, the world's second-largest sugar-producing country after Brazil, is unlikely to permit additional sugar exports this year. The food ministry has allowed 6 million tonnes (60 LMT) of sugar exports for the current 2022-23 marketing year (October-September). Out of which, about 4 million tonnes (40 LMT) have been exported so far, as per the trade report. India exported a record 11 million tonnes (110 LMT) of sugar in the previous year. Now, the sugar industry is expecting the government to allow additional exports of around 2 million tonnes (20 LMT) in a second tranche.

It is after 2004-05 that global prices soared over domestic rates. Maharashtra mill operators and experts told TOI that the sugar prices in the global market had touched Rs 45 per kg, while it is selling at Rs 34-36 per kg in the domestic markets. But no sugar mill in the country has any export quota left. Several mill operators told TOI that they were unable to cash in on the rising prices of sugar in international markets as they have exhausted the first quota. They said they were assured of a fresh export quota but it has not materialised yet. They feel that fresh exports are allowed, they will be in a better position to pay off the loans.

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The anatomy of sugar prices: Will the taste sour this summer? - Economic Times

Anatomy

Grey’s Anatomy: 15 Heaviest Topics the Series Tackled – MovieWeb

On the surface, it is easy to categorize Grey's Anatomy with other medical drama television series. It focuses on the professional and personal lives of doctors, and expected scandals take place given that a lot of attractive people work under the same roof. All of that is standard within this genre. What Grey's Anatomy does differently than other hospital dramas is that it does not shy away from heavy topics. Rather than skirting around harsh truths and difficult conversations that real people deal with every single day, this series welcomes the conflict and plot points.

19 seasons ago, when Shonda Rhimes first started creating the show, she knew she wanted to address certain issues such as Alzheimer's disease and alcoholism. What she may not have known nearly 20 years ago is that her creation would become a focal point for heavy topics. Fans are able to watch and rewatch the series and not only identify with characters, but they also sympathize and relate to major and minor events. Here are 15 of the heaviest topics that Grey's Anatomy was not afraid to address and tackle.

The show starts off strong with Meredith Grey hiding the fact that her award-winning mother is in a nursing home due to having early-onset Alzheimer's. Meredith is not only burdened with trying to live up to her mother's expectations, but she is torn with keeping her whereabouts a secret.

Grey's Anatomy further dives into this topic as others learn about Ellis Grey's condition. Derek even begins a clinical trial with Ellis in mind in an attempt to cure the disease. During the trial, the Chief of Surgery's wife is discovered to be in the early stages of having Alzheimer's as well. While disease and illness are the obvious focus points in a medical drama, making the main characters personally deal with someone who has a lifelong disease or illness gives light to how difficult it is for loved ones to handle their own reality.

Addiction comes in a variety of forms in Grey's Anatomy. Richard is the first character to address his own sobriety, but he eventually relapses and begins drinking again after some difficult events. While Richard has a reliable support system to help him through his addiction, Meredith's own father is shown to struggle with alcoholism after the passing of his second wife. Meredith's half-sister seems to be the only one taking care of him, and the struggle is brutally apparent.

Later on in the series, Meredith's sister-in-law, Amelia, comes to stay in Seattle. At first, she tries to hide her past drug addiction due to her colleagues not respecting or trust her. However, as the series goes on, Amelia's former addiction becomes a main subject as she tries to help a struggling teen mom overcome her own addiction.

Though Grey's Anatomy is eventually dominated by a powerful women-led cast, the sexism that goes on in the medical field is brought to attention. From Alex calling Meredith a nurse in the pilot episode to Derek's death being at the hands of a doctor who did not trust the opinions of a woman resident, sexism is not a topic dealt with lightly in this series.

When Bailey goes to a hospital (not Grey Sloan Memorial Hospital) with the belief that she is experiencing a heart attack, she is met with different male doctors who disregard her concerns. They run tests, but everything comes out normal. Being the strong-willed woman that she is, Bailey lectures that the symptoms men experience are different when having a heart attack. After hours of pain, it turns out Bailey was correct in her self-diagnosis.

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While there are several GSW patients throughout the series, Rhimes chose to draw attention to gun violence in a very direct way. Gary Clark, a hurt and angry widower, chose to take action after his wife passed. Instead of naturally grieving, he chose to exact revenge on Derek Shepherd for "killing his wife."

His plan was methodical, but the execution between entering the front doors of the hospital and committing suicide left a lot of casualties on his hands. The bloodshed and emotions run high in this two-part event, and the PTSD that lingers for several of the main characters gives a good reflection about how people process trauma.

Cristina (Sandra Oh) is an interesting character from the start. She loves medicine more than anything, she's blunt, and she does not possess a warm and nurturing demeanor. Needless to say, when she got pregnant in the first season, an abortion did not seem out of the blue. In an interview with HuffPost, Rhimes openly talked about how she wanted abortion to play a role in her series. Being that she was still new to the entertainment industry, she chose to write in an ectopic pregnancy for Cristina rather than go through with the initial abortion.

Years later, when Cristina gets pregnant again with Owen's baby, she does go through with an abortion. Rhimes felt it was important to highlight women's rights to their own bodies, and her portrayal of how other characters take Cristina's decision is spot-on. There is acceptance, doubt, and feelings of betrayal. Hard conversations are had, and lingering resentment later unfolds.

By the second episode of Grey's Anatomy Season 1, immigration was already a topic. Izzie Stevens was trying to help a patient, Ms. Lu, in the pit despite the language barrier between the two. After many attempts, Ms. Lu leads her outside to help her daughter. The daughter is able to explain that she will not go into the hospital because she is illegally in American, and she is afraid of being sent away.

Though Izzie tries to reassure her and her mother that nothing bad would not happen, she finds it better to treat the girl outside the hospital. Later in the series, a new intern, Sam Bello, appears at Grey Sloan Memorial Hospital. After a traffic violation, an ICE agent appears at the hospital to arrest and send her back to El Salvador. Believing that Bello is better than her minor mistake, Meredith manages to help Bello escape deportation and move to Switzerland.

Relationships of all kinds differing races, religions, cultures, sexual orientation, etc. exist in Grey's Anatomy, but the experience of discovering one's changed sexual orientation and later telling others about it is remarkably done in the show. Callie Torres, an iconic queer TV character, was the first character to realize she was not as straight as she once thought.

When she came out, she faced some initial backlash from her parents, her friends were very accepting, and her future wife called her a "baby." Later in the series, Callie helps Erica Hahn discover herself as a lesbian. Coming out is not always an easy thing to do especially when considering the possibility that people will cut ties over the matter. However, this show tackles the differing responses characters have after announcing their sexual orientation.

Racial profiling is not hard to depict in a series, but creating those hard conversations when conflicting viewpoints are involved is rather intricate. In Grey's Anatomy Season 14, a young African American boy shows up in the ER with police right behind him. Believing he was breaking into a house, an officer shot the boy. When his family later showed up and said he was climbing through the window of their own house, tension immediately rose. Jackson Avery is rightfully livid, and he goes as far to lecture the police officers on needing better training.

This subject is later brought up in Season 17, when characters are dealing with the effects of Black Lives Matter demonstration. Several conversations are had between main characters about how they have been wrongfully treated and accused of things simply due to the color of their skin.

Jo Wilson grew to be a very strong character, so when she revealed that she had come from a horrible marriage with an abusive partner, Grey's Anatomy fans were shocked. Her harsh past was enough to toughen her up for what goes on in the world, but adding in that her husband beat her regularly was a tough pill to swallow.

When her husband (they never officially divorced) showed up to her hospital to file for divorce with the plan of marrying his newest fianc, Jo was hesitant to sign the papers. She knew that he had not changed, and he would beat his new wife just like he did to her in the past. No detail is left to the imagination with this topic. Jo talks about black eyes, broken bones, and the threats he made to keep her in her place.

Physical illness is a given in a medical drama, but Grey's Anatomy takes the topic of "illness" much further as several characters directly and indirectly deal with mental illness. To start off the series, Alex Karev opens up about what it was like to grow up with a mom who suffered from schizophrenia. He talks about having to step up as the only adult in the house and how it took a toll on his life. Years after Alex becomes an established doctor, he learns that his mother is back on her medication and is learning to successfully live with the illness.

Andrew Deluca and Miranda Bailey, on the other hand, directly suffer from their own mental disorders. Deluca's manic episodes and outbursts lead to a bipolar diagnosis just like his father, and Bailey's obsessive-compulsive disorder presented itself after she unknowingly infected patients with staph. Both characters had support systems by their sides, but the stress and issues that came with the mental illnesses was very much present.

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Though Bailey touches on the topic when she has a heart attack, the conversation explodes into action with Jackson questioning his role as an African American man in a privileged situation. Following the events of George Floyd's death and the Black Lives Matter demonstrations, Jackson finds himself questioning the quality of care people of color receive in hospitals. He has watched a number of Black and Hispanic men and women die from COVID-19 complications, and he cannot help but think there is more he can do to solve the problem than working the in a treatment tent.

With hope that he will be able to equalize quality care for all patients, he packs up and goes to Boston to head the Catherine Fox Foundation. Jackson's character addresses one of the most underrated problems in the real medical field, and his actions got people thinking about how opportunities and care are far from equal for people of color.

Jo opened up to a couple different people about being abandoned at a fire station as a newborn. When she started dated Alex, she was very honest with him about having abandonment issues. Given that she had been through so much, fans were rooting for her to finally find stability and settle down with a guy who loved her for being herself. That dream came true for a short period of time until Alex abandoned her through a letter.

Alex may have done right by his kids, but fans were enraged with how he simply left Jo without proper closure. It is easy to create a rags-to-riches story with a character who was abandoned at a young age, but to have that character go through the raw emotions of being left as an adult is difficult.

When real events become the talk of the country, a good writer knows just how to incorporate such topics into their work. For several months, people all across America were marching and protesting against police brutality, racial profiling, and social injustice experienced by African Americans. During that time, the writers of Grey's Anatomy were taking notes. The Black Lives Matter movement was incorporated into the show by having main characters march on the streets as well as patients coming in from being injured during peaceful demonstrations.

Richard Webber and Cormac Hayes both talk about what an honor it is to take part in the streets with others protesting for change. While conversations are had among characters with differing viewpoints, the show creates a safe place for opinions to be heard and addressed.

Rhimes was not afraid to address this heavy topic right off the bat. In the second episode of Grey's Anatomy Season 1, an unconscious woman arrives to the hospital with her attacker's penis in tow. Several conversations are had about the attack, and the looks of concern, anger, and fear can be felt through the screen.

Nearly 15 years later, Grey's Anatomy aired an episode that furthered the topic. "Silent All These Years" is one of the series' most powerful episodes because it addresses the reality of what a survivor goes through after they are sexually assaulted. From breaking down the steps of the rape kit to lining the hall with women so that the patient does not have to see a man, the details that went into this one episode drew on the raw emotions of fans.

When a global pandemic takes place in the real world, it only makes sense to include it in a modern day medical drama. The doctors at Grey Sloan Memorial Hospital show what it was like to deal with the frustration of medical supply and staff shortages. They set up COVID-19 testing tents outside the hospital and limited the amount of people permitted through the doors.

Several lead characters, Meredith included, contracted the disease, and their storylines addressed what it was like to be isolated from their own families. Rather than love stories and scandal, themes of loneliness, heartache, and death without closure takeover the 17th season of Grey's Anatomy. It was important to the creators that fans saw the realities of the pandemic from a medical perspective.

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