In April this year, Katie Herzog checked into a Boston teaching hospital for what turned out to be a nine-hour-long back surgery.

The 68-year-old consulting firm president left the hospital with a prescription for Dilaudid, an opioid used to treat severe pain, and instructions to take two pills every four hours as needed. Herzog took close to the full dose for about two weeks.

Then, worried about addiction, she began asking questions. “I said, ‘How do I taper off this? I don’t want to stay on this drug forever, you know? What do I do?’ ” Herzog says, recalling conversations with her various providers.

She never got a clear answer.

When none of her providers explained to Herzog how to wean herself off the Dilaudid, she turned to Google. She eventually found a Canadian Medical Association guide to tapering opioids.

“So I started tapering from 28 [milligrams], to 24 to 16,” Herzog says, scrolling through a pocket diary with red cardinals on the cover that she used to keep track.

About a month after surgery, she had a follow-up visit with her surgeon. She had reached the end of her self-imposed tapering path the day before and at the doctor’s, she recalls feeling quite sick.

“I was teary, I had diarrhea, I was vomiting a lot, I had muscle pains, headache, I had a low-grade fever,” Herzog says.

The surgeon thought she had a virus and told her to see her internist. Her internist came to the same conclusion.

She went home and suffered through five days of what she came to realize was acute withdrawal, and two more weeks of fatigue, nausea and diarrhea.

“I had every single symptom in the book,” Herzog says. “And there was no recognition by these really professional, senior, seasoned doctors at Boston’s finest hospitals that I was going through withdrawal.”

Herzog did not name any of the providers who had something to do with her pain management or missed signs of withdrawal. She said she sees this as a system-wide problem. Herzog did share medical records that support her story. After the withdrawal, she did not crave Dilaudid and she manages any lingering pain with Tylenol. She has since returned to her providers, who’ve acknowledged that she was in withdrawal.

Not an isolated incident

Herzog’s story is one doctors are hearing more and more. “We have many clinicians prescribing opioids without any understanding of opioid withdrawal symptoms,” says Dr. Andrew Kolodny, director of Physicians for Responsible Opioid Prescribing and co-director of the Opioid Policy Research Collaborative at Brandeis University’s Heller School. One reason, Kolodny says, is that doctors don’t realize how quickly a patient can become dependent on drugs like Dilaudid.

Sometimes that dependence leads to full-blown addiction. The majority of street drug users say they switched to heroin after prescribed painkillers became too expensive.

Now, a handful of doctors and hospital administrators are asking, if an opioid addiction starts with a prescription after surgery or some other hospital-based care, should the hospital be penalized? As in: Is addiction a medical error along the lines of some hospital-acquired infections?

Writing for the blog and journal Health Affairs, three physician-executives with the Hospital Corporation of America argue for calling it just that.

“It arises during a hospitalization, is a high-cost and high-volume condition, and could reasonably have been prevented through the application of evidence-based guidelines,” write Drs. Michael Schlosser, Ravi Chari and Jonathan Perlin.

The authors admit it would be hard for hospitals to monitor all patients given an opioid prescription in the weeks and months after surgery, but they say hospitals need to try.

“Addressing long-term opioid use as a hospital-acquired condition will draw a clear line between appropriate and inappropriate use, and will empower hospitals to develop evidenced-based standards of care for managing post-operative pain adequately while also helping protect the patient from future harm,” said Schlosser in an emailed response to questions.

Kolodny said it’s an idea worth considering.

“We’re in the midst of a severe opioid epidemic, caused by the over-prescribing of opioids,” Kolodny says. “Putting hospitals on the hook for the consequences of aggressive opioid prescribing makes sense to me.”

Potential addiction vs. pain management awareness

But penalizing hospitals for patients who become addicted to opioids conflicts with payments tied to patient satisfaction surveys. Hospitals that do not adequately address patients’ pain may lose money for low patient satisfaction scores. In response to the opioid epidemic, patient surveys are shifting from questions like, “Did the hospital staff do everything they could to help you with your pain?” to questions that emphasize talking to patients about their pain. But physicians may still prescribe more, rather than fewer, opioids to avoid retribution from dissatisfied patients.

“This is a real concern that patients who may feel that their pain is under-managed may take that out in these patient report cards,” says Dr. Gabriel Brat, a trauma surgeon at Beth Israel Deaconess Medical Center who studies the use of opioids after surgery at Harvard Medical School.

Most patients leave the hospital with more pain meds than they need. Studies show that between 67 and 92 percent of patients have opioid pills left over after common surgical procedures.

One reason that may contribute to over-prescribing is that patients vary a lot. Brat said about 10 percent of patients need intense pain management, while the others, not so much, but it’s difficult to identify that 10 percent.

“Many surgeons are still prescribing opioids for the subset of patients that have higher requirements, as opposed to for the majority of patients who are taking a very small percentage of the pills that they are prescribed,” Brat explains.

There are no firm guidelines for which opioids to prescribe after surgery, at what dose or for how long. The CDC released opioid prescribing guidelines for chronic pain in 2016, but it included only brief references to acute pain.

Some opioid prescribing guidance for surgeons is emerging. A study published in September reviewed surgical records for 215,140 patients. It found that the optimal opioid prescription following general surgery is between four to nine days.

This story is part of a reporting partnership with NPR, WBUR and Kaiser Health News.

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As a lifelong racket-sports fanatic, I’ve dealt with shoulder pain for decades, treating it with bags of frozen peas, physical therapy, cortisone shots and even experimental treatments like platelet-rich plasma. Eventually, however, the soreness prevented me from handling daily-living tasks like pulling a bottle of olive oil off the top shelf of my kitchen or reaching to the back seat of my car to grab my purse. Even low-impact activities such as swimming freestyle hurt a lot. Sleeping also got tougher. After MRI showed two full-thickness rotator-cuff tears, I finally called a surgeon.

My tennis-team pals who had survived the operation gave me valuable advice: sewing Velcro down the front of half a dozen T-shirts to avoid having to put them over my head; borrowing an electric recliner chair in which to sleep for the first six weeks; buying pump bottles of shampoo and conditioner that I could dispense with my left hand; and removing safety caps from medications. To manage the pain after surgery, they also suggested renting an ice machine.

I’ve had bad side effects from anti-inflammatory painkillers and my goal was to take as few opioids as possible, so the ice machine sounded appealing. Two physical therapists recommended models with a mechanical pump that circulates chilled water. They said to be sure to use one that also provides compression, which reduces stiffness, swelling and pain in the joint.

My surgeon, Dr. David Lutton at Washington Circle Orthopaedic Associates in Washington, D.C., agreed that an ice machine was a great idea, saying via email that cool-therapy devices help manage postoperative discomfort “while minimizing the physical and cognitive side effects of pain medications such as narcotics.”

Unfortunately, my doctor’s surgical coordinator told me I’d have to pay to rent one on my own because my insurance wouldn’t cover it. The best price I could find was $250 for a three-week rental of a Game Ready machine from Orthosport, a distributor in Virginia. This price sounded high, but I was relieved that the surgery and physical therapy would be covered, and my fears about excessive post-operative pain outweighed my economic concerns. Despite the pessimistic warnings about coverage, I asked Orthosport to submit the bill to Cigna.

During the first few weeks after surgery, I tried to take opioid painkillers only sparingly, relying mostly on the ice machine. I sometimes left it on throughout the night while I tried to sleep in my sling in a borrowed recliner, and it frequently relieved the discomfort enough that I could sleep for four to five consecutive hours.

After three weeks, I decided that it was worth paying an additional $250 out of pocket to keep the machine for another three weeks. Unlike the type of physical therapy I was used to for sports injuries — the kind that immediately reduces pain — the therapy regimen after rotator-cuff surgery is absolutely excruciating for several weeks, sometimes months.

The ice machine helped me taper my drug use from oxycodone to tramadol, a less powerful painkiller, and now I’m using primarily acetaminophen. More than six weeks after surgery, I’m still relying on the Game Ready machine and dread the day when I’ll have to give it up.

A couple of weeks into my recovery period, Cigna denied my claim. I appealed by explaining that the ice machine was medically necessary because I am unable to take anti-inflammatories, and the unit was providing a safe and effective alternative to opioids, which had given me several adverse side effects when I’d used them in the past. It was also much easier to work without having to hold, strap or tape ice packs on the front, back and side of my shoulder. Cigna denied my appeal and told me that the ice machine was a “personal convenience item” and therefore a noncovered expense.

I was determined to find out why an insurer wouldn’t pay for the ice machine my doctor prescribed when it had covered the oxycodone. This drug and other painkillers have fueled the opioid epidemic, which according to the National Center for Health Statistics killed more than 64,000 people in the U.S. in 2016. I also was curious to find out why insurance companies weren’t convinced about the effectiveness of ice machines, so in between shoulder exercises and tutoring, I switched gears and went into reporter mode.

“Physician or patient anecdotes of good results are the least compelling evidence to payers,” Dana Macher, vice president of reimbursement and market access at Avalere Health, a health care consulting firm, told me in an email. “Bottom line is that it is all about the evidence. The gold standard is multiple randomized controlled clinical trials. Devices rarely have this information due to the fact that they do not (many cannot) invest the sums of money required. Lower-quality data or no published data is likely to result in non-coverage.”

Then I contacted the people at Game Ready, who cited five studies that show benefits for knee- and hip-surgery patients provided by this system compared with passive ice therapy. These benefits include reduced consumption of narcotics; improvement of measurable physical therapy milestones; reduced pain and swelling; increased postoperative function; and improved patient satisfaction with the recovery process. I sent my insurance company links to the abstracts for these studies.

Cigna replied. “Our coverage policies for medications, medical procedures and medical devices are based on an extensive examination of peer-reviewed clinical studies, journal articles and guidelines from professional medical societies,” wrote Dr. Julie Kessel, head of Cigna’s Coverage Policy Unit, via email. “Currently, the clinical evidence for the Game Ready device does not support its coverage, as its benefits over applying ice to the injured area have not yet been established. However, our coverage policies are typically reviewed annually and can be updated based on new clinical evidence.”

Tomasina Barton, senior vice president of marketing at Game Ready, says she doesn’t know whether private insurance companies have seen her company’s clinical studies or use them in relation to their coverage policies.

“Holistically, we would want an insurance company to look at the overall quality and cost of care,” she says. “Hospitals and providers are looking at where the patient does best, and patients are recovering better at home.”

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Insurance didn’t cover the cost of the Game Ready ice machine, but it did cover the cost of opioid painkillers.

Courtesy of Alexander C. Kafka

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Courtesy of Alexander C. Kafka

Insurance coverage for home-care ice machines varies by state and individual policy, according to Barton, but private insurers typically refuse to cover them.

Despite the failure of my appeal to Cigna, several health care professionals told me that appeals are important catalysts for change in the insurance industry even if they don’t produce immediate results.

“The system does rely on people appealing to some degree,” says Dan Mendelson, president of Avalere Health. “Insurance companies will re-review the evidence where there are a lot of appeals, but devices and procedures can be considered experimental for decades, and without peer-reviewed literature, insurance companies won’t cover them.”

Although the use of cryotherapy devices is still considered experimental by many insurance companies, doctors in other specialties besides orthopedics agree that methods to manage pain without opioids should be a top priority.

“The medical community, insurance companies, and patients should all be doing everything in our power to limit our reliance on opioids,” says Dr. Marian Sherman, an anesthesiologist at George Washington University Hospital who has a special interest in opioid-sparing strategies for postoperative pain control. “This means capitalizing on all available pain-reducing modalities. Icing machines have been demonstrated to work, and when used appropriately, the side-effect profile is zero. We can’t say this about a single medication.”

Here’s my conclusion: If insurance companies want to play a part in the solution to the opioid crisis, they are going to need to start thinking outside the traditional boxes. The manufacturers of these cryotherapy devices need to provide insurance companies with more convincing peer-reviewed data of their benefits, including the devices’ role in getting patients out of rehab and back to work sooner, which will cut costs in the long run. Patients need to let their doctors and insurance companies know that they want insurance coverage for safe alternatives to narcotics — even if it means going through the time-consuming appeal process.

“The more information we can get out to the public, the more demand there will be for the ice machines,” Lutton wrote in his email to me. “Ultimately, that’s the only way that the insurance companies will end up paying for them.”

Lauren Kafka is a freelance writer, editor and English tutor and founder of Kafka Consulting in Bethesda, Md. She hopes to be back on the tennis court next summer. She’s on Twitter: @LaurenKafka

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This month diners in Toronto were treated to a four-course meal at a pop-up restaurant called June’s. The menu included Northern Thai leek and potato soup with a hint of curry, a pasta served with smoked arctic char followed by garlic rapini and flank steak. The entire meal was topped off with a boozy tiramisu for dessert.

In addition to a mouthwatering meal, the chefs at June’s also served a message which they wore on their shirts: “Break bread. Smash stigma.”

Worldwide there are more than 30 million people living with HIV/AIDs, including more than a million in the U.S. The two-day event was a fundraiser put on by Casey House, Canada’s only stand-alone hospital for HIV/AIDS treatment. Everyone in the kitchen was HIV-positive.

After running a survey in which 50 percent of Canadians said they wouldn’t eat a meal knowingly prepared by someone with HIV, the hospital decided to put on the project.

Casey House’s CEO Joanne Simons says the point of the project was to get people talking about the stigmas that still surrounds HIV/AIDS. June’s event was a success and Simons says they plan to do another run in Toronto. Simons says they’ve also had interest globally and are “starting to work on a plan to roll this out elsewhere.”

On how the experience was for the HIV-positive staff

There were 14 people who are HIV-positive. They were led by head chef Matt Basile, who is very popular in Toronto — owns a restaurant, has food trucks. And he worked with the chefs to co-create the menu. I think that they felt very empowered to be able to speak up and to be able to offer a meal that was absolutely divine.

On questions diners had about HIV/AIDS

We were receiving many questions about, “Well, can I get HIV through food? What happens if a chef cuts their finger in the kitchen?” I mean the answer is absolutely not. There is no way to contract HIV through the preparation of food and if a chef did cut themselves during the preparation of a meal we would treat it just like we would anybody whether they were HIV-positive or not. You obviously apply first aid, you sanitize the area, you throw out any food that may have had blood on it. And also the virus has a very limited lifespan outside of the body and with the heat and the light within a kitchen environment, the virus would not survive.

On how stigmas about HIV/AIDS have changed

Because the treatment and medication support over the past decade has become a lot more effective, people can live well with this disease and live into very ripe old age. But there’s still a lot of myth and education is required. Unfortunately, for our clients, who are some of the most vulnerable in the community, they experience stigma on a day-to-day basis from their friends, family, coworkers, other health care professionals, so it’s still a very real issue.

Thomas Lu produced the audio version of this story. Wynne Davis adapted it for Web.

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I recently hobbled to the drugstore to pick up painkillers after minor outpatient knee surgery, only to discover that the pharmacist hadn’t yet filled the prescription. My doctor’s order of 90 generic Percocet exceeded the number my insurer would approve, he said. I left a short time later with a bottle containing a smaller number.

When I got home and opened the package to take a pill, I discovered that there were 42 inside.

Talk about using a shotgun to kill a mosquito. I was stiff and sore after the orthopedist fished out a couple of loose pieces of bone and cartilage from my left knee. But on a pain scale of 0 to 10, I was a 4, tops. I probably could have gotten by with a much less potent drug than a painkiller like Percocet, which contains a combination of the opioid oxycodone and the pain reliever acetaminophen, the active ingredient found in over-the-counter Tylenol.

When I went in for my follow-up appointment a week after surgery, I asked my orthopedist about those 90 pills.

“If you had real surgery, like a knee replacement, you wouldn’t think it was so many,” he said. He told me the electronic prescribing system sets the default at 90. So when he types in a prescription for Percocet, that is the quantity the system orders.

Such standard orders can be overridden, but that is an extra step for a busy physician and takes time.

As public health officials grapple with how to slow the growing opioid epidemic — which claims 91 lives each day, according to federal statistics — the over-prescription of narcotics after even minor surgery is coming under new scrutiny.

While patients today are often given opioids to manage postoperative pain, a large supply of pills may open the door to opioid misuse, either by the patients themselves or others in the family or community who can access the leftovers.

Post-surgical prescriptions for 45, 60 or 90 pills are “incredibly common,” says Dr. Chad Brummett, an anesthesiologist and pain physician at the University of Michigan Medical School.

Last year, the Centers for Disease Control and Prevention released a general guideline saying that clinicians who prescribe opioids to treat acute pain should use the lowest effective dose and limit the duration to no longer than seven days.

But more detailed guidance is necessary, clinicians say.

“There really aren’t clear guidelines, especially for surgery and dentistry,” Brummett says. “It’s often based on what their chief resident taught them along the way or an event in their career that made them prescribe a certain amount.”

Or, as in my case, an automated program that makes prescribing more pills simpler than prescribing fewer.

Brummett is co-director of a Michigan program that has released recommendations for post-surgical opioid prescribing for a growing list of procedures.

To determine the extent to which surgery may lead to longer-term opioid use, Brummett and his colleagues examined the insurance claims of more than 36,000 adults who had surgery in 2013 or 2014 for which they received an opioid prescription. None of the patients had prescriptions for opioids during the prior year.

The study, published online in JAMA Surgery in June, found that three to six months after surgery, roughly 6 percent of patients were still using opioids, having filled at least one new prescription for the drug. The figures were similar whether they had major or minor surgery. By comparison, the rate of opioid use for a control group that did not have surgery was just 0.4 percent.

Some insurers and state regulators have stepped in to limit opioid prescriptions. Insurers routinely monitor doctors’ prescribing patterns and limit the quantity of pills or the dosage of opioid prescriptions.

At least two dozen states have passed laws or rules in just the past few years aimed at regulating the use of opioids.

Last year in my state of New York, Gov. Andrew Cuomo signed legislation that reduced the initial opioid prescription limit for acute pain from 30 days to no more than a seven-day supply.

As my experience demonstrated, however, a seven-day limit (those 42 pills in my case) can still result in patients receiving many more pills than they need. (For those who find themselves in a similar situation with excess pills, there is a safe and proper way to dispose of them.)

Still, some worry that all this focus on overprescribing may scare physicians away from prescribing opioids at all, even when appropriate.

“That’s my concern, that people are so afraid of things and taking it to such an extreme that patient care suffers,” says Dr. Edward Michna, an anesthesiologist and pain management physician at Brigham and Women’s Hospital in Boston. Michna is on the board of the American Pain Society, a research and education group for pain management professionals. Michna has been a paid consultant to numerous pharmaceutical companies, some of which manufacture narcotics.

But other doctors say that one of the reasons doctors call in orders for lots of pills is convenience.

“When you land on the front lines, you hear, ‘I like to write for 30 or 60 pills because that way they won’t call in the middle of the night’ ” for a refill, says Dr. Martin Makary, a professor of surgery and health policy at Johns Hopkins School of Medicine.

Makary is spearheading a consortium of Hopkins clinicians and patients that provides specific guidelines for post-surgical opioid use. The program, part of a larger effort to identify areas of overtreatment in health care, also identifies outlier prescribers nationwide to encourage them to change their prescribing habits.

The Hopkins group doesn’t have an opioid recommendation for my surgery. The closest procedure on their website is arthroscopic surgery to partially remove a torn piece of cartilage in the knee called the meniscus. The post-surgical opioid recommendation following that surgery: 12 tablets.

Kaiser Health News is an editorially independent news service that is part of the nonpartisan Henry J. Kaiser Family Foundation. Follow Michelle Andrews on Twitter @mandrews110.

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For years, doctors have asked people about tobacco use and excessive drinking in the hopes that the answers could help lead people to cut down or quit.

But screening alone isn’t usually sufficient to change behavior.

As opioid use hits record highs in the U.S., Christiana Care Health System in Delaware is starting to ask people about opioid use — and then go further.

In November 2016, Christiana Care staff started asking patients during routine visits and in the emergency room questions like these:

“Have you used heroin or prescription pain medications other than what was prescribed in the past week?”

“Do you get sick if you if you cannot use heroin, methadone or prescription pain medications?”

The hospital’s chief of addiction medicine, Dr. Terry Horton, worked to make questions about opioid use standard protocol because emergency room doctors at Christiana Care see about 300 patients a month go through withdrawals. It’s called Project Engage.

“We can actually leverage that withdrawal by identifying it quickly, treating it rapidly and using it to break the vicious cycle they’re in,” he says.

Horton and his team try to break that cycle by immediately giving drugs like Suboxone to ease withdrawal symptoms. Health care workers also pair patients with addiction counselors and get them enrolled in community-based drug treatment program before they’ve even left the hospital.

And so far, Christiana Care has been able to steer two-thirds of patients with opioid addiction into drug treatment, says Horton.

“And of those, a significant portion, more than 60 percent, are actually in treatment a month later in the community,” he says.

There have been other benefits. He says Christiana Care is seeing a reduction in readmission rates and the number of patients leaving the hospital against medical advice.

But screening alone isn’t necessarily a recipe for treatment. Efforts to screen for tobacco use, for example, found that only about a fifth of tobacco users got any actual assistance with quitting. Dr. Richard Saitz, chair and professor of community health sciences at Boston University School of Public Health, says screening generally identifies people who use drugs — legal and illegal — and drink excessively.

“There have been thousands, even hundreds of thousands of people now identified in these programs,” he says. “How many of them go and seek treatment as the result of brief intervention after … identification by screening is very close to zero. It just doesn’t happen.”

The Centers for Disease Control and Prevention and the U.S. Preventative Services Task Force have seen it the same way. Currently, no U.S. government agency recommends screenings for illicit drugs like heroin based on “insufficient evidence” that it will help people reduce drug use. The USPSTF is currently reviewing screening effectiveness for opioids, both prescription and illegal. Even though, Saitz says, screening still may be useful for doctors to have a full picture of their patients.

And Saitz notes Christiana Care’s program goes beyond screening people. The health system is treating opioid addiction as a disease, with medicine and in-house specialists. He says that’s not common in screening programs, nor the American health system in general.

“What we do with alcohol and other drug-use disorder is notice it and maybe, at best, we’ll tell the patient that they ought to find some help somewhere. And often that’s it,” he says.

Saitz and Horton agree, the best way to curb opioid addiction is to connect patients directly with treatment, instead of leaving it up to patients to follow up on referrals, which is typically how it’s done.

They say identifying someone with an opioid addiction and giving them a piece of paper with a phone number to call is prescription for failure.

This story is part of a reporting partnership with NPR and Kaiser Health News. James Morrison is freelance journalist based in North Carolina, you can find him on Twitter at @jcmorrisn.

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On a recent weekday afternoon, Ruby Corado let herself into the drop-in center at the homeless shelter she founded for LGBT youth to make the rounds with new clients.

In the basement of Casa Ruby in Washington, D.C., transgender men and women in their late teens and twenties, mostly brown or black, shared snacks, watched TV, chatted or played games on their phones. Many of them, said Corado, are part of the 31 percent.

That’s 31 percent of transgender Americans who lack regular access to health care. The finding comes from a new poll by NPR, the Robert Wood Johnson Foundation and the Harvard T.H. Chan School of public health.

“I’m not surprised, because 31 percent — it’s a lot,” Corado said quietly. Her own experiences with homelessness, rape, assault have left her all too familiar with the vulnerabilities faced by many transgender people.

Corado pointed to one crucial word in the study that deserves extra emphasis. “What does regular health care mean?” she asked, then answers the question herself: “preventable.”

Preventable problems, including HIV infection and some cancers, kill many people in this community. It’s harder for transgender people to find health care coverage, because it’s harder for them to find jobs. Social stigmas aside, consider the difficulty of getting hired if your gender does not appear to match the one on your legal ID. According to the 2015 U.S. Transgender Study, transgender people face an unemployment rate three times higher than the national average — 15 percent versus 5 percent.

Then, there’s what might happen when seeking medical attention. In the NPR poll, 22 percent of transgender people said they’d avoided doctors or health care for fear of being discriminated against.

“Your trans status is on display and on parade for people to make fun of you,” Corado said, reflecting on insensitive medical professionals who’ve asked her such questions as, “What are you?”

“Right now, it’s very hard for a lot of people to even find a primary care provider who’s willing to work with them,” said Kellan Baker, a doctoral candidate at Johns Hopkins University who studies how health policies affect gay, lesbian, queer and transgender Americans. He said even if you regularly see a physician, a number of insurance companies will not cover care related to gender transition, such as hormones or surgery.

“Which, as you can imagine, is a huge barrier for transgender people in terms of mental health,” he said. “So you’re looking at yourself in the mirror, you’re not able to get health insurance coverage [and] you can’t get health care that you need to make sure that how you look aligns with who you are.”

Surgery on reproductive organs is expensive, so many people leave them alone. That means a trans man with a uterus — or a trans woman with a prostate – might have to endure embarrassing, awkward questions from health care providers when getting regular care, such as an annual physical.

Baker had no trouble providing examples.”What do you mean you need a cervical pap test for a man or a prostate exam for a woman?” he asked. “How do we compute that? You shouldn’t have that part, so we don’t know what to do with you.”

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Yee Won Chong (left) was diagnosed with stage 2 breast cancer, and in a strange coincidence his roommate, Brooks Nelson (right), discovered he had ovarian cancer.

Courtesy of Yee Won Chong

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Courtesy of Yee Won Chong

Those were the kind of questions Yee Won Chong had to face when he was diagnosed with stage 2 breast cancer. He’d undergone what’s known as top surgery, where breast tissue is removed and the chest is reconstructed to a more masculine appearance. However, he later developed cancer in the remaining breast tissue. His doctor didn’t know how to code him into the medical records system.

“I’m her first transgender patient,” Chong explained. But he was lucky. His oncologist, Dr. Tammy De La Melana, committed herself and her office team to the best possible care for Chong. And in a coincidence that Chong described as freaky, his roommate, who is also transmasculine, discovered he had ovarian cancer. They’re working now on a documentary about their experiences, called Trans Dudes with Lady Cancer.

It’s worth noting that Southern Comfort, an earlier documentary about a transgender man with ovarian cancer, won the Grand Jury Prize at the Sundance Film Festival in 2001. Back then, transgender people were even more likely to slip through the cracks of the health care system, but insurance companies and many medical professionals still treat them as though their bodies don’t make any sense.

All that said, there is a place to go for transgender people looking for high-quality and low-cost health care: Planned Parenthood.

Planned Parenthood trains its staff to be sensitive to transgender people. Many of its health centers offer trans people a wide array of services, including primary care, annual exams and STD screenings. Currently, Planned Parenthood offers hormone replacement therapy at health centers in 17 states, and its national headquarters reports an 80 percent increase in centers offering hormones to transgender patients from 2013 to 2015.

At the Virginia League for Planned Parenthood in Richmond, Va., a wide array of services for transgender people are available.

Afton Bradley, the center’s transgender health program manager, ran through some questions he thinks about when providing care to trans patients. “Does our front desk know how to be affirming?” he asked. “Is our electronic health record affirming? Does it ask about pronouns and gender ID in addition to whatever legal sex is on their insurance or ID?”

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Ryan Brazell (left) has his vitals checked by Afton Bradley at the Virginia League for Planned Parenthood in Richmond, Va. Bradley (lower right) makes sure the clinic is sensitive to the needs of trans patients.

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Pat Jarrett for NPR

Bradley said this Planned Parenthood can handle trans-specific problems. What happens when a trans woman injects herself with building-grade silicone to get feminine curves? Or a trans man buys black market testosterone, or injures himself by binding his chest with duct tape?

Ryan Brazell, a trans man who gets his care here, remembered his first visit. “I went out to my car and was like, ‘I felt really weird,’ ” he said. “And it took me a few days to figure out why. It was the first time I had a health care experience I was happy with. And I didn’t know what that felt like until I had that experience at Planned Parenthood.”

That experience is wholly unfamiliar to many clients at the Casa Ruby LGBTQ shelter.”I’ve seen a lot of people die,” said its founder, Ruby Corado. “I’ve been to a lot of hospitals to recognize bodies that were dead from HIV or violence, or shot and stabbed and wounded.”

Dozens of trans people have been violently killed just this year across the country. Another tragic public health issue: almost 20 percent of black transgender women are HIV positive, compared to only three percent in the general population.

“It is very likely, if you are a transgender woman of color, that you will die from HIV,” Corado said, underscoring again the number of deaths suffered by transgender women of color that are potentially preventable. “That you will die from AIDS. That you die stabbed or killed. You’ll die from some kind of cancer, or suicide.”

The U.S. Transgender Survey found that 40 percent of transgender people have attempted suicide in their lifetimes. But that too, is potentially preventable, said Afton Bradley, who manages transgender health services at the Virginia League for Planned Parenthood.

“What we see is a dramatic reduction in those attempts when people have access to affirmative care,” he said. Affirmative care means treating trans people like people, Bradley says, adding that it’s not that hard.

Our ongoing series, “You, Me and Them: Experiencing Discrimination in America” is based in part on a poll by NPR, the Robert Wood Johnson Foundation and the Harvard T.H. Chan School of Public Health. We have previously released results for African-Americans, Latinos, Native Americans and whites so far. In coming weeks, we will release results for Asian-Americans and women.

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Research investigating a popular form of surgery aimed at easing chronic shoulder pain doesn’t fix the problem, a careful, placebo-controlled study suggests.

In the condition known as shoulder impingement, certain movements, such as reaching up to get something off a shelf, for example, or even scratching your own back can be painful and get worse during a night of tossing and turning.

The precise source of pain isn’t clear, says David Beard, a physiotherapist and researcher in evidence-based medicine with the University of Oxford in Oxford, U.K. These aren’t patients who have pain because of a torn rotator cuff or other acute injury. Instead, doctors think the chronic pain may arise from age-related tendon and muscle degeneration, or from a ragged, extra bit of bone — a bone spur — that can rub against a tendon.

In an arthroscopic surgical procedure known as subacromial decompression, surgeons insert an instrument through a small hole in the shoulder to remove some of the bone and soft tissue. The idea, Beard says, is to reduce stress and open up the space — “theoretically relieving the pain.”

The popularity of the procedure has increased dramatically across the United Kingdom, Beard says, and he wondered just how effective it was. So he and colleagues designed a careful test: They tracked the recovery of nearly 300 patients in hospitals in the U.K. who had suffered shoulder pain for at least three months, and who agreed to be randomly assigned to one of three treatment categories.

All the patients filled out questionnaires about pain and function. Then, a third of them got no surgical treatment at all. Another 30 percent got fake, “placebo” surgery — a hole was made in the shoulder but nothing was moved or removed. The final group underwent the actual surgery — a surgical instrument scraped out the area and removed extra bone.

After six months, when patients once again filled out surveys of their pain and function, those who got any surgery — either sham or “real” — responded essentially the same way, Beard says. “There was no difference between the placebo surgery and the surgery which took the bone and tissue away.”

He says his findings, published Monday in the medical journal The Lancet, suggest doctors should rethink when and if to do the procedure at all.

Dr. Richard Baron, president of the American Board of Internal Medicine Foundation agrees. “One of the most important questions any patient should ask anytime they’re thinking about having a surgical procedure is, what happens if I don’t do this? Are there other options? What are the risks?”

The ABIM Foundation, in partnership with Consumer Reports founded the Choosing Wisely campaign, which seeks to advance a national dialogue on avoiding wasteful or unnecessary medical tests, treatments and procedures.

In the case of this surgery, Baron says, useful treatment alternatives include medications such as over-the-counter anti-inflammatory drugs, physical therapy and even liniments that can help by making the skin tingle. “There’s a whole neurological theory about how that helps with pain,” Baron says.

Beard says he and his colleagues don’t mean to completely dismiss surgery for this condition, but they think it should be a last resort. Surgeons, he says, should do more research to see precisely which patients, if any, benefit.

Dr. David S. Jevsevar, chair of the American Academy of Orthopaedic Surgeons’ Council on Research and Quality, agrees that Beard’s study is a good one — he’d just like to see it replicated in a larger group of people, to tease out whether a particular subset of people might be helped by the procedure.

“Most orthopedic surgeons,” he says, “look at conservative treatment before jumping into surgery.”

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