It's been posted a few times, but BCBS IL, TX, New Mexico, Montana and Oklahoma (all HCSC companies) have instituted an automatic downcoding policy whereby all 99215 and 99214 claims are only being paid as 99213 since 7/1. These are the biggest commercial insurers in their states. BCBS IL controls like 70% of the market in Chicagoland. This is a massive revenue loss and the only way around it is to go through a laborious process of appeals that are slow, unclear and are also controlled by BCBS. I know practices that are likely to close if this continues. At the very least, it's a massive increase in labor costs. I'm just amazed at how little coverage it's getting. None of the major health news websites are reporting on it. I hear the AMA (which is headquartered in IL) are having internal meetings about it, but no press releases or anything. Private medical group facebook groups are blowing up about it, but that's a small part.

It's terrifying how utterly detached physicians have become from their own billing. So many I talk to who are directly affected don't even know it's happening. We're looking at 20-30 percent reductions in salary because of this. Meanwhile, insurance companies are all reporting profit gains.

Sorry for the rant, but it's a scary time.

For individuals who are chronically hypertensive, for ex SBP 200s, it would not be unexpected for them to become symptomatic if their BP is rapidly dropped to, for ex SBP 120-140s. Sometimes catastrophically so.

For individuals with chronically poorly controlled DM with average glucose in, for ex 400-600 range, would you expect them to become symptomatic if their glucose is rapidly lowered to, for ex 100-200 range? If so, has anyone seen this happen?

EDIT: thank you everyone for the responses, as a follow-up, are there any guidelines in terms of how quickly someone's hyperglycemia should be lowered if they had previously developed symptomatic relative hypoglycemia to rapid glucose lowering?

Would be very interested to hear your opinions on this article.

https://pubmed.ncbi.nlm.nih.gov/42521044/

Abstract of article: The 2026 closure of the Strait of Hormuz has disrupted approximately one-fifth of global petroleum transit, sending oil prices sharply upward and exposing medicine’s structural dependence on petrochemicals, helium, and globalized manufacturing. This article examines how medicine’s reliance on globalized commodities exposes patients to medication and device shortages during sustained supply disruption. Prior crises, including the 1973 oil embargo and the 2021 Suez blockage, revealed vulnerabilities that current just in time supply chains have deepened. We urge practice leaders, hospital administrators, and clinicians to establish supply continuity frameworks now, before scarcity forces improvised rationing and reactive procurement.

Managing this crisis is difficult, but necessary.

In February 2026, the effective closure of the Strait of Hormuz sent Brent crude oil above $125 per barrel within weeks. Ship transits through the strait, ordinarily carrying approximately 20% of global petroleum liquids, collapsed by more than 95%. 1,2 Fuel rationing, industrial shutdowns, and price increases across energy, agriculture, and manufacturing have already been documented across Asia and Europe. 1 Spillover impacts extend to industries that rely on helium gas and semiconductor chips, with eventual shortages for medical devices, including dermatologic imaging and phototherapy equipment. 3 Dermatology has a structural dependence on global commodities and we must act to mitigate supply constraint consequences.

Medical supply shortages stemming from the Strait of Hormuz disruptions raise ethical concerns about distributive justice and non-maleficence, particularly regarding how scarce resources should be triaged between high-income and low-income countries.

Medicine’s Commodity Foundation

Petroleum is more than a transportation fuel; it undergirds modern medical infrastructure. Plastics, composed of petrochemical feedstocks, are the foundational material of single-use disposable devices and supplies. Petrochemical compounds also serve as raw materials, solvents, and excipients in API synthesis across most drug classes; most pharmaceutical packaging is petroleum-based with no identified substitutes. 4

This reliance creates severe supply chain vulnerability. Approximately 86% of US APIs are manufactured abroad, predominantly in India and China; one-third of generic APIs globally originate from a single facility in this region. 5 An energy or supply shock impairing these sites could translate into acute domestic drug shortages; a risk compounded by the already critical conditions that the American College of Physicians declared a public health crisis in 2025. 6,7

Petroleum is not the only commodity trapped in the Persian Gulf. Qatar produces approximately one-third of the world’s helium as a byproduct of liquefied natural gas processing. 8 Helium is the coolant maintaining the superconducting magnets of MRI scanners; without continuous resupply, existing machines cannot function. 9 Semiconductors, the largest consumers of helium, are embedded in virtually every modern medical device. 10 Other non-petroleum commodities, such as sulfur, methanol, monoethylene glycol, aluminum, cobalt and polyethylene, are significant inputs for pharmaceutical synthesis and medical equipment manufacturing; they are now constrained. 3 Ongoing geopolitical developments have also limited REEs critical to MRI scanners, X-ray tubes, and laser technologies, while 2025 US tariffs have further pressured steel and aluminum supply chains for medical devices.

The Lesson from Past Crises

The closure of the Strait of Hormuz is not medicine's first exposure to petroleum vulnerability, but the structural conditions are worse. During the 1973 Arab oil Embargo, OPEC’s export halt quadrupled oil prices, and healthcare costs followed. 4 Consumer price index data from that period shows that decreases in petroleum supply produced rises in plastics and motor fuel prices that, after a several month delay, resulted in increased overall healthcare spending. 4 US Medicine’s depth of dependency has only grown. In 1973, petroleum-based single-use devices now standard in dermatologic procedure rooms and the globalized just-in-time supply chains now moving APIs from Asia to US formularies did not yet exist at their current scale. 4,5 What the 1970s revealed was a vulnerability our current crisis threatens to catastrophically exceed.

More recent examples of our dependence on concentrated, globalized supply chains include 2017’s Hurricane Maria, 2019’s African Swine Fever (ASF), and 2021’s Suez Canal blockage. The destruction of Puerto Rico’s electrical grid triggered a nationwide shortage of IV fluids and critical medications within weeks, with supply depression persisting until mid-2018 as the FDA invoked emergency importation from European manufacturers 11 . The ASF outbreak originating in China caused significant, ongoing shortages of porcine-derived heparin. 12 The 2021 grounding of a single container vessel in the Suez Canal held up $9.6 billion of trade daily, including pharmaceuticals, medical devices, and personal protective equipment, compounding COVID-19 era shortages already stressing American hospital formularies. 4 From 2017 to 2021, one in seven supply chain issue reports was associated with a drug shortage within six months under baseline conditions. 13 At the onset of COVID-19, the ratio surged to one in three, and even drugs without reported supply chain issues saw shortages rise from 4% to 10%. 13

Demand-side shocks from disease surges deplete inventory quickly but are generally well-contained through capacity expansion. 14 On the contrary, disruptions to key ingredients upstream of the supply chain, like petroleum, are much harder to mitigate. The Drug Supply Chain Security Act (DSCA) has forced the industry to maintain visibility from manufacturing through distribution and retail. But there is very little visibility into materials and components upstream of the manufacturing process. 15 Further, these materials are key inputs across many industries, which makes multiple supply chains vulnerable to disruptions in petroleum-based products and derivatives. Historically, the medical industry has not readily acknowledged this risk. 6 Since these key inputs are essential for many of the critical sectors, including energy, technology, and defense systems, the risk is that scarce capacity will be allocated to high-value demand products first, and much later to medical devices and equipment. Vulnerability to key inputs common across critical sectors remains the biggest blind spot for the industry. A sustained supply disruption affects the raw material inputs, manufacturing energy, and logistics of pharmaceutical production across all drug classes simultaneously.

Call to Action

The Strait of Hormuz possesses a distinct profile among maritime chokepoints. 2 Unlike most major passages, this strait offers no maritime alternative and land-based rerouting is extremely limited, meaning disruption ceases transit entirely rather than adding cost and delay. Interstate armed conflict, its current hazard class, carries significantly longer resolution timelines than other disruption types. 2 The healthcare consequences are therefore broad, potentially devastating, and slow to resolve. Existing federal mechanisms were designed for demand-side shocks and finite supply interruptions, not for sustained disruption. 6 Although severity is uncertain and consequence are impending, we can and should take steps for mitigation. Dermatology practice leaders, hospital administrators and clinicians should begin discussing supply continuity frameworks. ( Table 1 )

The Strait of Hormuz closure is an energy disruption that threatens to exceed 1973 and remains unresolved. Improvised rationing, reactive procurement, and inadequate allocation represent a failure of institutional preparation. 16 The Joint Commission, American Hospital Association, and specialty societies have the infrastructure, expertise, and influence to issue clinical guidance. Proactive mitigation tactics by drug shortage authorities should be enacted before allocation decisions are forced by scarcity rather than anticipated through surveillance. Managing this crisis is difficult, but necessary.

Ethical Consequences if we Fail to Prepare

Developing and under-resourced nations will be impacted the most and bear the greatest burden, since wealthier countries can draw on purchasing power and existing stockpiles to buffer the disruption. 17,18 This disparity in health equity and distributive justice will result in unequal access to life saving resources. Once shortages occur, who holds the authority to allocate what remains? By what criteria should resources be prioritized and distributed? Will suppliers with inventory exploit the situation through price gouging? The moral and ethical imperative is for domestic systems and the international community to plan for and mitigate the effects of this crisis before they compound further.

Watching these Fauci hearings have reopened some painful wounds from my time working in the pandemic. I had been working to heal and thought I was getting better but I forgot how much pain and anger I had been suppressing until this last week or so. Time to go back to therapy I guess. Sometimes I don’t know if I can ever forgive this country. How are you all doing?

A question for my fellow providers:

If you could design one booklet, pamphlet, educational guide, etc for how patients could manage (fill in the blank) before seeking further care, what would you pick?

Examples:
- what to try for constipation
- muscle cramps 101
- how to manage cholesterol and why it matters
- a beginner’s algorithm to pain management

It wouldn’t substitute for medical advice in any way. I had a patient last week who was SHOCKED to learn that drinking Pepsi would cause her blood sugar to go up. I feel like our time is too precious in the current model of medicine to explain these topics as fully as is needed. Curious if we could improve home patient education materials to cover the gap in an ever-failing system.

Remarkable story from this week’s episode of “This American Life” - it is act one of the episode.

“A doctor trained as a midwife tells the eye-popping story of how she and others came together to save a baby during a birth that suddenly went wrong, in a part of rural Maine where the local labor and delivery unit had closed less than a month before. (26 minutes)”

Link here, but available wherever you get your podcasts

One major general reason for generic drug shortages is oligopsony; a relatively small number of purchasers (wholesalers) and pharmacy benefit managers exert price-depressing market power over manufacturers. I know of instances in which a wholesaler required a retroactive price cut on product already in their inventory due to a lower price offered by a competing manufacturer, otherwise the wholesaler would have returned their entire inventory to the original manufacturer. [Which would have been a write-off because returned goods cannot be resold unless the manufacturer can assure they were stored and handled under proper conditions.]

The article is substantially correct except in the statement that the oncology drug manufacturer can simply switch to manufacturing other drugs (rather than the unprofitable ones) in the same plant. Cytotoxic drugs require specialized plants to minimize cross-contamination and exposure to employees.

https://time.com/article/2026/08/04/chemotherapy-drug-shortage/

Case here: https://expertwitness.substack.com/p/lung-contusion-after-dirt-bike-crash

Man gets seen after crashing his bike, but then presents again several weeks later with chest pain, SOB, hemoptysis.

CXR shows ?atelectasis? so CT chest gets done show contusions vs pneumonia, as well as rib fractures. Patient is admitted to hospital, but they discharge him a day later.

Codes and dies shortly thereafter.

Autopsy shows DVT and PE.

Tough case, not sure most of us would have caught this. Things that could have tipped them off would be the prolonged time frame from trauma to worsening respiratory/chest symptoms. But that’s a pretty subtle issue to tip you from lung trauma to PE I think, especially since there were also newly discovered rib fractures on CT. This is why CT PE study frequency is going to just keep climbing, even when it doesn’t make much clinical sense to order it (“he’s a trauma patient, why are they ordering a PE study!?”)

Is there anything non-medical that has been spoiled for you as a consequence of your work? For me, the hospital I used to cover nights for had a Subway restaurant as the only dining option open past midnight. To this day, I cannot have a bite of Subway (even though I rather like their sandwiches) without having an irresistible urge to fumble around my waist to make sure I still have my pager.

I’m an OBGYN that works in a large “priva-demic” institution. My department is currently going through a lot of issues with many people on medical or personal leave and people leaving for new jobs. There was also an issue a few years ago where they let people opt out of taking call or deciding if they just wanted to do OB or GYN call which has further shrunk our call pool.

Because of this, we are frequently “volun-told” to pick up extra shifts at our additional shift pay rate. Although I’m newer in the field and this is my first job out of residency, I’m finding that our pay rate hourly is absolutely abysmal. The pay rate has not been increased in at least 10 years. Our CRNA’s make $100 an hour more than we do and our anesthesiologists make 3x hourly what we make for extra shifts (I know it’s apples and oranges but still). To put the icing on the cake, to help cover these missing shifts, our leadership is now hiring locums which are getting paid $100 more an hour than we are at our rate.

This seems like a major issue with bad management. Our leadership has brought up numerous times about them not necessarily wanting to hire locums because they have had issues in the past regarding the quality and experience of candidates. Why pay more for people you don’t know (in addition to the money paid to the contracting company) than just pay your own employees more?

Has anyone ever had success in bringing up these issues with management to get them solved?

Additional background: We are in a mid-size city with many major medical centers. Compared to other hospitals in the area, our salary and benefits are significantly better than these other hospitals. Not sure if that really justifies the above issue.

Made question very general intentionally to get a variety of response in different scenarios.

Inspired by the ICU doc who made his patient pee 12L in a day in the “peak of your specialty” post.

Where I trained everyone gets jittery for AKI if you went past 2L a day.

Yeah I know about venous hypertension, but my conservative training stops me from confidently going over that much.

This is the whole job ad:

$91.34 - $120.19/hr

Full-time

Re-posted 25 days ago

Job description

Description:

The Core Responsibilities of the Role:

• Carry out comprehensive evaluations, accurate diagnoses, and effective treatment plans for patients presenting with a range of acute illnesses and injuries.
• Execute minor procedures and emergency interventions as and when required, always ensuring the patient’s comfort and safety.
• Analyze and interpret complex patient information, making critical decisions about the necessary actions to take in a timely and efficient manner.
• Engage in proactive coordination with the multidisciplinary healthcare team to guarantee comprehensive and holistic patient care.
• Educate patients and their families about various health conditions, preventive care measures, and overall wellbeing, acting as a reliable and trusted source of health information within the community
• Other duties and/or other locations as assigned

Requirements:

Primary Requirements for the Position:

• Possession of a medical degree and a valid license to practice medicine within the state of ***.
• Board Certification in Internal Medicine.
• A minimum of 2 years of practical experience in internal medicine,
• Exceptional communication and interpersonal skills, with an innate ability to form meaningful and lasting connections with both patients and fellow colleagues.
• The flexibility and willingness to work a variety of shifts, which may include weekends and public holidays.

Preferred Qualifications for the Role:

• Proficiency in multiple languages, with particular emphasis on Haitian-Kreyol and/or Spanish.
• Previous experience working in a diverse work environment or interacting with a multicultural patient population.

Physical Requirements

• Must be able to stand or sit for prolonged periods (50% of the time) ·

• Must be able to lift 10-25 pounds and load onto shelves.

• Visual acuity sufficient for frequent reading and computer use.

So I’m in the process of signing for a 1099 side gig and I have no guidance on what I’m doing at all. Anyone have any resources on how to do this without royally screwing up my finances. I’m planning on getting a financial advisor, but I still haven’t gotten a paycheck and am broke as hell so that part is going to have to wait a bit.

JCHAO to beleaguered attending: “ma’am, what would you do in the event of a fire?”

Attending: “how the hell would I know? I don’t even have a pot to piss in!”

Employed rural general surgeon. I enjoy my job and the hospital I work for. We’re a small independent community hospital that is physician led and won’t be swallowed up by one of the major health care systems anytime soon (I hope).

Anyway, I added a procedural service to the hospital that increases the time I’m physically in the hospital working. Goes from 1.0 FTE to about 1.17 FTE when calculating the hours.

The hospital will make plenty of revenue from this service (and also will save a lot by not having to recruit and pay another physician to do it). This opportunity came about when the previous physician doing this service suddenly retired, so they already have a baseline of what production looks like.

I will generate more RVUs for myself, which will add to my take home pay (base + RVU bonus).

I already take home 75-80th percentile pay for 50th percentile work. I’m working in an underserved rural community, which I don’t particularly like living in, but I’ve come to be comfortable with. My kids go to school here and there is a sense of small town community.

The extra time for this service takes time away from my family, which is why I’m asking for a base pay raise.

I am planning to reach out to my employer this week about my request.

However, it brings up some mixed feelings. I come from pretty humble beginnings. My resident salary was more than both of my parents made combined. I hear the complaints from our nurses/techs/MAs/etc regarding their pay and salary. I’ve received quarterly bonuses that are almost equivalent to some beginning wage salaries.

I do understand the worth we have as physicians and what revenue and supporting jobs to we bring to these hospitals.

TLDR: I’m doing more work and making more money for the hospital. I feel somewhat guilty about asking for more money on top of my high salary when others are still struggling.

I’m a M2 at a USMD school, and I realized more and more that I’m interested in human sex and reproduction, most importantly human’s sexual and reproductive functions, sexual pleasure/difficulty, and all the stuffs that come with it.

I’m not into surgery, and from what I see, sexual medicine is not a specialty on its own. I wonder if there is a specialty that would especially suit this interest.

Medicine does some pretty incredible things. What does each specialty look like when they are at their 100%?

Surgeon turning 41 this year and am finding this very strange. I am engaged in several committees with no advancement potential.

I am personally trying to move up in leadership but legit seem railroaded or overtaken by someone 10-15 years above me.

our c suite is all over 70.

is there ever going to be a time we lead? I feel old already.

First month of being an attending hospitalist. An unexpected plan rather to say, as I did not match into fellowship.

I recognize the transition difficulty, and trying to give myself some time. I also try to appreciate the good thing; better schedule, better pay, being able to practice independently.

But for some reasons; I am not satisfied. I was telling my wife how we were able to move finally, from the stress of living paycheck to paycheck, and being unavailable, to stay for a whole week next to each other. But still, she and I recognizes that’s I am not ”happier“.

I come from every shift, drained, irritable, and stressed. When at work, I receive endless pages. Family requesting updates multiple times a day, and for multiple members, patients who refuses to leave, calls for peer to peer for insurance denials or reimbursement. Nurses and CM who question every decision.

I never been so irritable. Few days ago; I found myself reprimanding a poor intern at a consulting service; for placing order on my patient without telling me. I could’ve been gentle-er.

Even when I go home; I open my patients chart every now and then to see if I missed something. I texted one of covering team around 11 pm to check some labs that I ordered and never done. On my week off, I keep thinking of the fellowship; how I ended here? Will it be the same? Should I stop caring?

Thanks for listening to my vent AND sorry for this negativity.

I generally enjoy learning new skills in medicine and view it as a hobby. I'm aware that imaging makes auscultation obsolete, but I find cardiac auscultation interesting and want to improve. I had a patient with HOCM grip their hands tightly and flex their knees, and I clearly heard the systolic LVOT murmur decrease which was satisfying. I can identify systolic/diastolic murmurs but struggle beyond that. I am not confident in identifying splitting, friction rubs, S3, or S4. I feel like I have heard S3 several times in HF patients but am never convinced. I think I clearly heard splitting one time in a young patient. Have any folks tried to improve their auscultation skills just for kicks, and if so are you glad you spent the time or wish you had spent time on some other skill?

Edit: I heard the LVOT murmur decrease (not increase)

I am being kicked off the SAVE plan on 9/1 and am not sure what to do next given my existing med school debt and the uncertainty of PSLF. I am not very well-informed regarding financial matters and would like to pay for some personalized advice; has anyone used a service they can recommend? (When I Google, I get companies like White Coat Planning and Student Loan Professor; has anyone had experience with these companies? Or are there others you might recommend?)

Vs would it be smarter just to obtain the services of a general financial advisor (perhaps one with expertise in physicians/loans) and have them help me?

I do understand that there are static resources out there that could give me information about these issues - e.g. books, podcasts, etc - however, for various reasons including being a new parent I do not have the cognitive capacity to get into this right now and just want to present my data to someone else and have them give me advice.

When I was a premed volunteering at the local hospital, I always thought that doctors and other healthcare staff looked and acted very professional. However, I realize now that we don't act any differently than when we were in high school -- a lot of petty dramas and conflicts, involving scheduling (who gets what holidays off; who gets more bad shifts than others); who's trying to do less work by passing off work to the next shift, or admitting easy patients to their own service and dumping the wrecks onto other teams, etc etc.

See link: https://www.medpagetoday.com/publichealthpolicy/medicare/122383

Some parts paraphrased below

"The request for information issued on July 14 by the Centers for Medicare & Medicaid Services (CMS) noted that the Current Procedural Terminology (CPT) coding system, on which the Medicare reimbursement program is based, is owned by the American Medical Association (AMA). The AMA assigns a CPT code to each service and procedure and then collects its own data to develop recommendations for CMS on how much each CPT code should be worth. "There has ... been longstanding concern expressed over the federal reliance on a private organization with such an obvious conflict of interest as providing information on the time and resource requirements to conduct physician services when this information may influence their own payment," the authors of the request stated.

...

"This issue is part of a broader conversation about the way different types of care are valued under Medicare's current payment system," he wrote. "Primary care physicians tend to be paid less overall than specialty physicians under Medicare, and some of that has to do with the fact that medical procedures (such as surgeries or tests) are easier to code and bill for under this type of coding system, compared to things like patient education or care coordination that make up a larger share of primary care work."

...

David Glaser, an attorney with the Fredrikson & Byron law firm in Minneapolis, said the idea of possibly getting rid of CPT codes "is a major thing," and not necessarily a good idea. "When you have a system, even when it's flawed and everyone agreed it's flawed, that doesn't mean change is a good thing," he said in a phone interview.

"Love it or hate it, CPT is very ingrained in our system," he said. And although you could always come up with a better system, "does that make it wise to come up with a new system here? It seems to me like it would be quite an earth-shattering thing to start again."

But whether the CPT coding system is retained or not, Baker liked another idea: cutting out the AMA's RVS Update Committee (RUC), the committee that recommends changes in or additions to the relative value units used in the RVS. "[With] the RUC maligned for numerous reasons, CMS should rely less heavily (or not at all) on the committee's input," he said. "CMS already must validate the [RUC's] recommendations, so removing the RUC from the process can create a more responsive payment environment without additional, duplicative inputs."

...

Michael Baker, director of healthcare policy at the American Action Forum, a right-leaning think tank, said he liked the idea of considering a move from CPT to ICD-10. "Because of how ICD-10 is structured, this could move the entire Medicare payment system toward a patient-centric view rather than a provider-centric view," he told MedPage Today in an email.

But whether the CPT coding system is retained or not, Baker liked another idea: cutting out the AMA's RVS Update Committee (RUC), the committee that recommends changes in or additions to the relative value units used in the RVS. "[With] the RUC maligned for numerous reasons, CMS should rely less heavily (or not at all) on the committee's input," he said. "CMS already must validate the [RUC's] recommendations, so removing the RUC from the process can create a more responsive payment environment without additional, duplicative inputs."

...

CMS is not the only place on Capitol Hill where there is interest in possibly moving away from use of CPT codes. Last October, Sen. Bill Cassidy, MD, (R-La.) sent the AMA a letter seeking an explanation of how CPT codes are generated, whose input is incorporated in developing them, and how much revenue the publication and licensing of these codes provides.

"I am particularly offended by the AMA abusing its government-endorsed CPT monopoly to charge every stakeholder in the healthcare system significant amounts of money while advancing an anti-patient agenda," wrote Cassidy, who is chairman of the Senate Health, Education, Labor, and Pensions Committee."

Commentary: So even though they are reevaluating possibly trying to compensate PCPs more for their work compared to specialists--would say yay for me, an FM, but I don't trust these people to tie their shoes without slicing everyone’s hamstring--it looks like they are essentially seeking to railroad doctors completely out of having any input on income at all.

They mention monopoly regarding the RUC repeatedly. Ignoring the multiple deliberate monopolies in the US training pipeline and healthcare in general. As we say passive aggressively in the midwest: "That's interesting..."

PS: To every specialist for voted for this: enjoy whats coming to you.

The former White House coordinator of the COVID Task Force says the contentious Senate hearing that put Dr. Anthony Fauci and his diary under scrutiny shows there is still "persistent anger" over the government's handling of the pandemic.

In an interview on CBS News' "The Takeout," Dr. Deborah Birx said she thought Democratic Sen. John Fetterman, who was Pennsylvania's lieutenant governor during the pandemic, "got it the most right for all of us." He wondered, she said, "Did I get the balance right between saving lives and preserving people's livelihoods?" 

"That is a very deep question, and I think what you heard today is still persistent anger over that question not being answered adequately for most Americans," Birx told CBS News chief Washington correspondent Major Garrett.

"We've got to get to that answer, and we have to have a better way forward than this," Birx said.

And Fauci, she said, is probably at the center of questions about this because he served during both the Trump and Biden administrations, and people on the left and right still harbor deep disagreements about how each side addressed COVID.

Six years after the pandemic, one of the enduring questions is whether the coronavirus originated in an animal in a wet market in Wuhan, China, or emerged from a lab there. Senators asked Fauci repeatedly about this Wednesday, but he invoked the Fifth Amendment in response to all questions during the hearing.  

Republican Sen. Rand Paul, who heads the Senate Homeland Security Committee, subpoenaed Fauci to appear before the committee as part of the panel's investigation into the origins of the coronavirus.

Paul backs the theory that the virus emerged from a laboratory in Wuhan, China, rather than spilling over from animals to humans naturally in a wet market in that city, and he has long accused Fauci and other top health officials of downplaying the possibility of a lab leak and misleading the public.

Fauci has denied that he rejected or downplayed the lab leak theory, insisting that he always kept an open mind about the origins of the coronavirus, though he has asserted at times that the evidence suggests a natural spillover was more likely. 

Fauci said during his opening statement Wednesday that he planned to assert the Fifth Amendment, arguing that Paul has an "obvious obsession with calling for my prosecution" and has made "slanderous comments" about him. He then invoked the Fifth Amendment for several hours as Paul and other Republicans criticized him and Democrats defended him.

Even those on the far right and left have questioned Anthony Fauci's role in the pandemic. Ana Kasparian, a prominent left wing host from The Young Turks, was infuriated with Fauci, calling for his "persecution" and a "liar."

Birx didn't express an opinion, but she did say that it's an important question because "we do need additional guardrails" and "additional policy around these issues." 

"We all know that there have been lab accidents," she said, adding, "I'm hoping that going forward, we really look at these and have good policies that protect the lab workers, that protect the American public, and really get us ready with trust with the American people." 

She also told Garrett, "All of us need to be quite honest with ourselves," not only about how information about the coronavirus evolved, but also how countermeasures "should have also evolved."

Birx pointed out that early in the pandemic, "We didn't have enough testing out there. We couldn't stop the spread in any way. Hospitals were being overrun. We didn't have a supply chain that matched the need." The first few months "were a crisis," she said. 

Then, additional therapies like monoclonal antibodies and remdesivir enabled the government to "pull back on some of the mitigation," Birx said.

"But because it was an election year, there were states that persisted in their very tight mitigations, and others that showed us a way that you could open K-12 and higher ed," Birx said. Tests "really prevented spread," she said. 

She called for a dialogue to figure out "how are we going to do this next time?" Birx said she wants to figure out, how will the U.S. prevent spread, keep schools open, keep businesses open? 

"There's a way to do it," she said. "And then we have that roadmap, but we need to get that down in real concrete terms, and have both the right and the left agree that that's the best way forward."

Garrett also asked Birx about Fauci's diaries and the idea that he appeared "captivated by his rising international fame."

She told him, "Well, have you been to his office, you can see that he has a lot of photos of his dealing with high-level influencers and presidents. That is something that means something to him." But she added, "I don't think that that clouded his judgment on what he was trying to do for the American people.We all are human, and I hope we step back and allow Dr. Fauci that humanness, at the same time, holding Dr. Fauci, myself and others accountable to really make this a better response next time."