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You probably know that you have a thyroid gland. Perhaps you or someone you know has had thyroid tests or a thyroid disorder such as hypothyroidism.

But did you know you also have a parathyroid gland? It’s true — in fact, most people have four of them, even though one would suffice.

Where are the parathyroid glands?

From the name, you might assume the role of the parathyroid glands is related to that of the thyroid gland. Well, you’d be wrong. The name comes solely from their location: they sit just behind the thyroid gland: two on the right side, two on the left.

The parathyroid glands are small (the size of peas), and can weigh less than a thousandth of an ounce each. Although it’s normal to have four parathyroid glands, about 13% of people have fewer and 5% have more. And some people have parathyroid glands in other locations, such as alongside the esophagus or in the chest. This variation rarely matters, unless surgery is necessary to remove one or more of them.

What do the parathyroid glands do?

Logically enough, parathyroid glands make parathyroid hormone (PTH). And what does PTH do? It has several functions, including:

• Regulating calcium: Calcium is a mineral with many essential roles throughout the body, such as maintaining bone strength, allowing nerves and muscles to function normally, and making sure blood clots as it should. Higher levels of PTH lead to higher calcium levels in the blood through actions on the kidneys and bones.
• Regulating phosphorus: Among other roles, this mineral is a key component of our DNA, bones, and teeth. Phosphorus activates essential enzymes throughout the body, including enzymes necessary for cell reproduction and survival. It also helps with nerve and muscle function.
• Regulating vitamin D: This vitamin is actually a hormone that helps maintain normal levels of calcium throughout the body, by controlling how much gets absorbed from food in the intestinal tract and how much is lost by the kidneys in your urine. Remember PTH? Well, PTH regulates production of the enzyme that converts inactive vitamin D to an active form that helps your gut absorb calcium and reduces the loss of calcium in urine.

PTH released by the parathyroid glands helps keep each of these nutrients in balance. For example, if your blood calcium level falls, your parathyroid glands make more PTH. Higher amounts of PTH prompt bones to release stored calcium into the bloodstream, and also signal the kidneys to pull back on the amount of calcium lost through urine.

What if your blood calcium level rises? Then the parathyroid glands make less PTH, which helps to correct the blood calcium level.

Which diseases involve the parathyroid glands?

The most common are:

• Hyperparathyroidism: This is a condition in which the parathyroid glands make more than the normal amount of PTH. This can be due to a benign or cancerous tumor on a single gland, or due to multiple glands becoming overactive. Or it may be due to some other trigger, such as a low level of calcium in the blood, inadequate vitamin D levels, or kidney failure. When there’s too much PTH, blood calcium levels can become dangerously high and phosphorus levels fall. Surgery may be recommended to remove the overactive gland or glands.
• Hypoparathyroidism: This rare condition is diagnosed when less than the normal amount of PTH is produced. The most common causes are prior neck surgery or radiation, autoimmune disease, or low magnesium levels.
• Parathyroid cancer: Risk factors for parathyroid cancer include certain genetic diseases and prior radiation to the neck.

Why do we rarely hear about the parathyroid glands?

The reason is that most of the time they do their job without fuss or fanfare. Although disorders of the parathyroid glands are not rare, they are just uncommon enough that most people will never hear about them. I think of the parathyroid glands as one of many parts of our bodies that play a huge role in our health, but go unappreciated because they are so good at what they do.

Many other quiet heroes, including the thymus gland, serve as testaments to the remarkable design and function of the human body. Then again, I can think of a few body parts that could be considered expendable.

The bottom line

I hope it’s comforting to know that your amazing parathyroid glands are keeping tabs on your calcium levels and helping your bones, nerves, muscles, and other organs to function normally.

Ounce for ounce, the parathyroid glands may be the most important glands you’d never heard of. Until now.

About the Author

Robert H. Shmerling, MD, Senior Faculty Editor, Harvard Health Publishing; Editorial Advisory Board Member, Harvard Health Publishing

Dr. Robert H. Shmerling is the former clinical chief of the division of rheumatology at Beth Israel Deaconess Medical Center (BIDMC), and is a current member of the corresponding faculty in medicine at Harvard Medical School. … See Full Bio View all posts by Robert H. Shmerling, MD

Colon cancer is the second-deadliest form of cancer after lung cancer. If recent messages about colon cancer screening have left you a little confused, that's understandable. In August, the American College of Physicians (ACP) released updated guidance for colon cancer screening that differs from other major organizations, including recommendations from the American Cancer Society (ACS) and the US Preventive Services Task force (USPSTF).

So, what do you need to know?

How does the advice differ?

First, please note that this advice applies only to people at average risk without a family history of colon cancer. If you have family history, or if other health issues put you at higher-than-average risk for colorectal cancer, talk to your doctor about the best course of action for you.

The main point of disagreement relates to the age at which people should start getting screened. The new ACP guidance says 50, while the other two organizations recommend 45. That earlier age is endorsed by the U.S. Multisociety Task Force on Colorectal Cancer. It's also endorsed by many physicians, including Harvard Medical School professor Dr. Andrew T. Chan, a gastroenterologist and director of epidemiology at Massachusetts General Hospital Cancer Center, who helps explain key facts below.

Why do experts suggest starting screening earlier?

"We're facing an unexplained and alarming increase in the incidence of colon cancer in people younger than 50," says Dr. Chan.

Overall, deaths from colon cancer dropped by 2% per year from 2011 to 2020. But that's not the case among people younger than 50. In that age group, deaths from colon cancer rose between 0.5% and 3% during the same time period, according to statistics published in 2023.

The rising rates of colon cancer in younger people are occurring in all racial and ethnic groups, with the steepest rises seen among Alaskan Natives and Native Americans. Overall, Blacks and African Americans are more likely to get and die from colon cancer than whites, and early-onset cases are higher in Black individuals than whites.

Efforts to encourage colon cancer screening began in the mid-1990s. Today, about 60% of adults over 50 follow the advice to receive a colonoscopy (described below) on a regular basis. This track record, while not perfect, likely explains the decline in deaths from colon cancer in older adults.

"I think that promoting earlier screening will help stem the rise in early-onset cases, at least for those in their 40s. We've also seen that earlier colonoscopies may be associated with lowering incidence of colon cancer even later in life, "says Dr. Chan.

What are the different screening tests for colon cancer?

The two most widely used screening tests are a standard colonoscopy and various stool-based tests.

Colonoscopy. For this test, a gastroenterologist or surgeon snakes a long, flexible tube with a camera on the end through your rectum and beyond to inspect the entire length of your colon. Considered the gold-standard test, this procedure can detect precancerous polyps called adenomas, and allow for their removal.

The test requires taking laxatives and drinking lots of fluids beforehand to clean all the fecal material (stool) out of your colon. Serious complications, which include perforation or bleeding, are rare, occurring in about three in 1,000 procedures. If no polyps are found, a repeat colonoscopy isn't recommended for another 10 years. If you have polyps, or your risk or symptoms change, this interval will be shorter.

Stool tests. The more worrisome colon polyps (adenomas) often shed tiny amounts of blood and abnormal DNA into the stool. This can be detected from samples you collect yourself at home.

• Two tests, the fecal occult blood test (FOBT) and fecal immunochemical test (FIT), check for blood. They require small stool samples that you put on a card or in a tube that's then mailed to a lab. These tests should be done every year.
• A third option, the FIT-DNA test, checks for both blood and abnormal DNA; it's usually repeated every three years.

Additionally, the guidelines from the American College of Physicians suggest another option: flexible sigmoidoscopy, which inspects only the lower part of the colon, once every 10 years, combined with a fecal FIT testing every two years. However, doctors in the United States rarely order sigmoidoscopy today.

If flexible sigmoidoscopy or any of these stool tests show evidence of a problem, a colonoscopy is needed to check for adenomas or cancer.

Why might stool-based screening make sense for younger adults?

Colonoscopy isn't necessarily the best initial screening test for everyone, says Dr. Chan. That's especially true for younger people, mainly because it's time-consuming and inconvenient.

"Maybe you just can't find time in your schedule or are worried about having a colonoscopy," he says. If that's the case, a stool-based test — which is noninvasive and takes very little time — is an appropriate option.

"The worst option is not doing anything, because early detection and treatment can prevent deaths," he says.

About the Author

Julie Corliss, Executive Editor, Harvard Heart Letter

Julie Corliss is the executive editor of the Harvard Heart Letter. Before working at Harvard, she was a medical writer and editor at HealthNews, a consumer newsletter affiliated with The New England Journal of Medicine. She … See Full Bio View all posts by Julie Corliss

About the Reviewer

Howard E. LeWine, MD, Chief Medical Editor, Harvard Health Publishing

Dr. Howard LeWine is a practicing internist at Brigham and Women’s Hospital in Boston, Chief Medical Editor at Harvard Health Publishing, and editor in chief of Harvard Men’s Health Watch. See Full Bio View all posts by Howard E. LeWine, MD

When preschoolers are melting down or teens are slamming doors, parents face two difficult tasks: keeping themselves composed and supporting their kids’ ability to self-soothe while building skills to handle future challenges.

These abilities are at the heart of co-regulation, a parenting tool that requires patience and practice. But what exactly is involved, and how does it help support children and teens wrestling with big emotions?

What is co-regulation?

“Co-regulation is a supportive, interactive, and dynamic process,” says Lauren Marchette, a child, adolescent, and family psychologist and a lecturer in psychiatry at Harvard Medical School.

Through warm and responsive interactions, caregivers help young people learn better ways to regulate their emotions during the inevitable upsets and challenges of life. “At its heart, co-regulation is connecting with a child who’s in distress and being able to evaluate what that child needs in the moment to help calm themselves.”

But before a parent or trusted adult can help a child, they need to understand — and possibly expand — their own emotional skills and limitations. Emotions are often contagious, whether a person is upset or sharing a sense of calm.

“The tricky part of co-regulation is that adults have to recognize how they’re feeling and be able to regulate their own emotions in difficult moments so they can help children to gain these same skills,” Marchette says. “But this will be so important for kids to develop healthy relationships over time, and affects how people do in school, work, and life in general.”

How does building emotional skills help children and teens?

As children grow up, they learn different skills — how to build a block tower, play a sport, or solve a math equation. They also learn emotional skills: how to recognize and handle feelings of anger or anxiety, for example.

Known as self-regulation, such emotional skills are truly the basis of wellness in life, Marchette says. By consistently practicing co-regulation, parents and other trusted adults foster self-regulation skills in kids.

The list of self-regulation skills is wide-ranging, involving

• emotional awareness and literacy, including the ability to identify emotions
• emotional regulation skills such as self-soothing
• perspective-taking, or the ability to "walk in another’s shoes”
• social skills such as taking turns and practicing patience
• paying attention and remaining focused when needed
• problem-solving
• thinking flexibly
• time management skills
• goal-setting.

What are the potential benefits of co-regulation?

Co-regulation enables kids to eventually learn to

• handle stress
• resist immediate gratification
• avoid hasty, ill-informed decisions
• make and stick to plans
• solve problems
• adapt to challenges
• take healthy risks.

Some research suggests that having better self-regulation skills is linked to more positive outcomes in life, such as higher income and lower rates of substance use and violence.

Who might especially benefit from co-regulation?

Everyone wins when kids are better able to navigate frustrations and manage their reactions to their thoughts and feelings. Parents, teachers, coaches, guidance counselors, mentors, and other adults who interact closely with children also stand to benefit.

As for kids themselves, it’s hard to think of any whose lives won’t be improved by adults who have invested themselves in practicing co-regulation, Marchette says.

But practicing co-regulation skills with certain children and adolescents — including those whose families are experiencing economic hardship, substance abuse, divorce, or other distressing situations — can be especially important.

Is there evidence that co-regulation works?

“While co-regulation is built upon a solid theoretical framework, not many studies have delved into its effectiveness — at least across all age groups,” Marchette says. “Research that does focuses mainly on infants and preschoolers.”

“Much less is known about how co-regulation interventions work for older youth,” she says. “The research is trying to catch up to what we know from years of clinical experience.”

How can a parent coach a child through co-regulation?

Co-regulation doesn’t stand alone as a skill. It relies on fostering a warm, responsive relationship with children, providing structure, and setting limits. “Children benefit from consistent, predictable routines with clear expectations and consequences,” Marchette says.

When a child begins experiencing big emotions, a co-regulation response will look different depending on the child and circumstances. But the steps to take are similar.

“First, the parent needs to pause and self-regulate their own emotions, such as by taking a deep breath,” Marchette explains. “The next steps are validating the child’s feelings, observing the child’s response, and then deciding how to respond next, including verbally and nonverbally, such as with a touch.”

Marchette offers an example based on her own practice: 12-year-old “Eric” is tackling a writing assignment in his bedroom when his mother suddenly hears loud noises. She walks to his door and finds him throwing a stapler, notebook, and container of pens off his desk. “What’s wrong with me?” he yells. “I suck at writing and I hate school!” Then Eric puts his head down on his desk.

The sixth grader’s mom knows he needs help calming down, so she pauses and takes a deep breath. Then she walks over and whispers his name, placing her hand on his shoulder. After more silence, Eric gradually starts sitting up in his chair. “I can tell how frustrated you are with this assignment,” she says to him, validating his feelings. “It must be a really challenging one.”

Eric’s mother knows he needs a break after he mutters, “I can’t do it.” She suggests a getting a glass of ice-cold water, and Eric glumly follows her to the kitchen. After the break, they can re-evaluate if Eric is ready to return to his homework or needs further coping strategies — like a walk outside or a round of jumping jacks — to get his frustration out.

What resources can help parents practice co-regulation?

The Administration for Children and Families offers a free Co-Regulation in Action video series. And some therapists — especially those who specialize in behavioral parent training or cognitive behavioral therapy — can help parents who feel their skills need a boost.

It’s worth noting that it can be hard to have sufficient resources — emotional, financial, and other supports — to practice co-regulation consistently. Those who wish to try should give themselves some grace as they learn the process. “Even parents who are thinking their own self-regulation skills aren’t where they want them to be should realize this is a muscle they can strengthen,” Marchette says. “It’s important to have that growth mindset.”

About the Author

Maureen Salamon, Executive Editor, Harvard Women's Health Watch

Maureen Salamon is executive editor of Harvard Women’s Health Watch. She began her career as a newspaper reporter and later covered health and medicine for a wide variety of websites, magazines, and hospitals. Her work has … See Full Bio View all posts by Maureen Salamon

About the Reviewer

Howard E. LeWine, MD, Chief Medical Editor, Harvard Health Publishing

Dr. Howard LeWine is a practicing internist at Brigham and Women’s Hospital in Boston, Chief Medical Editor at Harvard Health Publishing, and editor in chief of Harvard Men’s Health Watch. See Full Bio View all posts by Howard E. LeWine, MD

Each year, more than 4.5 million dog bites occur in the United States. Despite what you might assume, most of these incidents don’t happen when an unfamiliar dog attacks someone in a park or another outdoor location. Instead, most dog bites are inflicted by a pet dog in a home.

Here’s advice for avoiding these upsetting and potentially serious injuries — and the steps you should take if you sustain a dog bite.

Why do dog bites happen?

Some dog bites happen by accident when people wrestle or play tug-of-war with their dog. But most of the time, dogs bite people as a reaction to feeling stressed, threatened, scared, or startled, according to the American Veterinary Medical Association (AVMA). More than half of dog bites occur in children, and they’re far more likely to be seriously injured than adults.

“People don’t always heed the behavioral signals that a dog is uncomfortable,” says Dr. Christopher Baugh, associate professor of emergency medicine at Harvard Medical School. For example, some dogs are highly territorial and will bark, growl, snap, and lunge if outsiders enter their space — whether that’s an apartment, yard, or crate. Or dogs may exhibit resource guarding, which shows up as anxious, aggressive behavior around food, toys, or beds.

“These situations can be high-risk, and children in particular have less awareness of that risk,” says Dr. Baugh, who has children and two mixed-breed rescue dogs, Harley and Roxi.

What can you do to prevent dog bites?

Any dog — even a sweet, cuddly dog — can bite if provoked, according to the AVMA. Never leave young children alone with a dog without adult supervision. And teach children to never disturb a dog while it’s eating, sleeping, or caring for puppies.

In a study of 321 facial dog bites treated at Harvard-affiliated Massachusetts General Hospital over a 20-year period, 88% of the bites were from known dogs. Most were in adults and occurred after playing with the dog, feeding the dog, and placing their face close to the dog. However, the hand (usually a person’s dominant hand) is probably the most common location for a dog bite in an adult, says Dr. Baugh.

Other tips from the CDC to prevent dog bites include the following:

• Always ask a dog’s owner if it’s okay to pet their dog, even if the dog appears friendly.
• Make sure the dog sees and sniffs you before reaching out to pet it.
• Don’t pet a dog that seems to be hiding, scared, sick, or angry.

What if an unfamiliar dog approaches you? Remain calm and still, avoiding eye contact with the dog. Stand with the side of your body facing the dog and say “no” or “go home” in firm, deep voice. Wait for the dog to retreat or move yourself slowly away.

What should you do if you’re bitten by a dog?

Clean the wound with mild soap and running water, then cover it with a clean bandage or cloth. Some online resources recommend applying an antibiotic ointment or cream. But these products are recommended only for people with clear evidence of an infection, such as redness, pus, pain, swelling, or warmth, according to the American Academy of Dermatology.

If the injury is serious — with a bite on the face, heavy bleeding, or a possible broken bone — go to the emergency room. That’s also a good idea if you’re bitten by an unknown or stray dog, in the rare event that you might need medicines to prevent rabies (rabies post-exposure prophylaxis).

“Often, people are shocked after being bit and will understandably focus all their attention on their wound,” says Dr. Baugh. The dog’s owner may check in to see if you’re okay, but then walk away. But you should get the person’s contact information and make sure the dog is vaccinated against rabies, he says.

Keep in mind that:

• Emergency rooms are often crowded with long waits, so an urgent care clinic is a good option if the injury doesn’t require immediate attention.
• Some wounds require stitches, ideally within 12 to 24 hours.
• The doctor may prescribe antibiotics to prevent possible infections, especially if you have health problems such as a weakened immune system or diabetes.
• You may also need a tetanus booster if you haven’t had one in the past 10 years. If your vaccine history isn’t available or you can’t remember, you’ll get a tetanus booster just in case.

What if a dog bite is less serious?

Let’s say you have a less serious bite from a family dog known to have a current rabies vaccine. Bites that don’t require stitches can be cleaned with mild soap and running water, then evaluated by your regular health care provider. They may tell you to simply monitor the wound for signs of infection.

“Doctors are trying to be more thoughtful about prescribing antibiotics and limit their use in low-risk situations, because overuse contributes to antibiotic resistance and exposes people to potential side effects without any benefit,” says Dr. Baugh.

About the Author

Julie Corliss, Executive Editor, Harvard Heart Letter

Julie Corliss is the executive editor of the Harvard Heart Letter. Before working at Harvard, she was a medical writer and editor at HealthNews, a consumer newsletter affiliated with The New England Journal of Medicine. She … See Full Bio View all posts by Julie Corliss

About the Reviewer

Howard E. LeWine, MD, Chief Medical Editor, Harvard Health Publishing

Dr. Howard LeWine is a practicing internist at Brigham and Women’s Hospital in Boston, Chief Medical Editor at Harvard Health Publishing, and editor in chief of Harvard Men’s Health Watch. See Full Bio View all posts by Howard E. LeWine, MD

When you first learned the facts about pregnancy — from a parent, perhaps, or a friend — you probably didn’t learn that up to one in three ends in a miscarriage.

What causes miscarriage? How is it treated? And why is appropriate health care for miscarriage under scrutiny — and in some parts of the US, getting harder to find?

What is miscarriage?

Many people who come to us for care are excited and hopeful about building their families. It’s devastating when a hoped-for pregnancy ends early.

Miscarriage is a catch-all term for a pregnancy loss before 20 weeks, counting from the first day of the last menstrual period. Miscarriage happens in as many as one in three pregnancies, although the risk gradually decreases as pregnancy progresses. By 20 weeks, it occurs in fewer than one in 100 pregnancies.

What causes miscarriage?

Usually, there is no obvious or single cause for miscarriage. Some factors raise risk, such as:

• Pregnancy at older ages. Chromosome abnormalities are a common cause of pregnancy loss. As people age, this risk rises.
• Autoimmune disorders. While many pregnant people with autoimmune disorders like lupus or Sjogren’s syndrome have successful pregnancies, their risk for pregnancy loss is higher.
• Certain illnesses. Diabetes or thyroid disease, if poorly controlled, can raise risk.
• Certain conditions in the uterus. Uterine fibroids, polyps, or malformations may contribute to miscarriage.
• Previous miscarriages. Having a miscarriage slightly increases risk for miscarriage in the next pregnancy. For instance, if a pregnant person’s risk of miscarriage is one in 10, it may increase to 1.5 in 10 after their first miscarriage, and four in 10 after having three miscarriages.
• Certain medicines. A developing pregnancy may be harmed by certain medicines. It’s safest to plan pregnancy and receive pre-pregnancy counseling if you have a chronic illness or condition.

How is miscarriage diagnosed?

Before ultrasounds in early pregnancy became widely available, many miscarriages were diagnosed based on symptoms like bleeding and cramping. Now, people may be diagnosed with a miscarriage or early pregnancy loss on a routine ultrasound before they notice any symptoms.

How is miscarriage treated?

Being able to choose the next step in treatment may help emotionally. When there are no complications and the miscarriage occurs during the first trimester (up to 13 weeks of pregnancy), the options are:

Take no action. Passing blood and pregnancy tissue often occurs at home naturally, without need for medications or a procedure. Within a week, 25% to 50% will pass pregnancy tissue; more than 80% of those who experience bleeding as a sign of miscarriage will pass the pregnancy tissue within two weeks.

What to know: This can be a safe option for some people, but not all. For example, heavy bleeding would not be safe for a person who has anemia (lower than normal red blood cell counts).

Take medication. The most effective option uses two medicines: mifepristone is taken first, followed by misoprostol. Using only misoprostol is a less effective option. The two-step combination is 90% successful in helping the body pass pregnancy tissue; taking misoprostol alone is 70% to 80% successful in doing so.

What to know: Bleeding and cramping typically start a few hours after taking misoprostol. If bleeding does not start, or there is pregnancy tissue still left in the uterus, a surgical procedure may be necessary: this happens in about one in 10 people using both medicines and one in four people who use only misoprostol.

Use a procedure. During dilation and curettage (D&C), the cervix is dilated (widened) so that instruments can be inserted into the uterus to remove the pregnancy tissue. This procedure is nearly 99% successful.

What to know: If someone is having life-threatening bleeding or has signs of infection, this is the safest option. This procedure is typically done in an operating room or surgery center. In some instances, it is offered in a doctor’s office.

If you have a miscarriage during the second trimester of pregnancy (after 13 weeks), discuss the safest and best plan with your doctor. Generally, second trimester miscarriages will require a procedure and cannot be managed at home.

Red flags: When to ask for help during a miscarriage

During the first 13 weeks of pregnancy: Contact your health care provider or go to the emergency department immediately if you experience

• heavy bleeding combined with dizziness, lightheadedness, or feeling faint
• fever above 100.4° F
• severe abdominal pain not relieved by over-the-counter pain medicine, such as acetaminophen (Tylenol) or ibuprofen (Motrin, Advil). Please note: ibuprofen is not recommended during pregnancy, but is safe to take if a miscarriage has been diagnosed.

After 13 weeks of pregnancy: Contact your health care provider or go to the emergency department immediately if you experience

• any symptoms listed above
• leakage of fluid (possibly your water may have broken)
• severe abdominal or back pain (similar to contractions).

How is care for miscarriages changing?

Unfortunately, political interference has had significant impact on safe, effective miscarriage care:

• Some states have banned a procedure used to treat second trimester miscarriage. Called dilation and evacuation (D&E), this removes pregnancy tissue through the cervix without making any incisions. A D&E can be lifesaving in instances when heavy bleeding or infection is complicating a miscarriage.
• Federal and state lawsuits, or laws banning or seeking to ban mifepristone for abortion care, directly limit access to a safe, effective drug approved for miscarriage care. This could affect miscarriage care nationwide.
• Many laws and lawsuits that interfere with miscarriage care offer an exception to save the life of a pregnant patient. However, miscarriage complications may develop unexpectedly and worsen quickly, making it hard to ensure that people will receive prompt care in life-threatening situations.
• States that ban or restrict abortion are less likely to have doctors trained to perform a full range of miscarriage care procedures. What’s more, clinicians in training, such as resident physicians and medical students, may never learn how to perform a potentially lifesaving procedure.

Ultimately, legislation or court rulings that ban or restrict abortion care will decrease the ability of doctors and nurses to provide the highest quality miscarriage care. We can help by asking our lawmakers not to pass laws that prevent people from being able to get reproductive health care, such as restricting medications and procedures for abortion and miscarriage care.

About the Authors

Sara Neill, MD, MPH, Contributor

Dr. Sara Neill is a physician-researcher in the department of obstetrics & gynecology at Beth Israel Deaconess Medical Center and Harvard Medical School. She completed a fellowship in complex family planning at Brigham and Women's Hospital, and … See Full Bio View all posts by Sara Neill, MD, MPH

Scott Shainker, DO, MS, Contributor

Scott Shainker, D.O, M.S., is a maternal-fetal medicine specialist in the Department of Obstetrics and Gynecology at Beth Israel Deaconess Medical Center (BIDMC). He is also a member of the faculty in the Department of Obstetrics, … See Full Bio View all posts by Scott Shainker, DO, MS

Last year, headlines describing a study about artificial intelligence (AI) were eye-catching, to say the least:

• ChatGPT Rated as Better Than Real Doctors for Empathy, Advice
• The AI will see you now: ChatGPT provides higher quality answers and is more empathetic than a real doctor, study finds
• Is AI Better Than A Doctor? ChatGPT Outperforms Physicians In Compassion And Quality Of Advice

At first glance, the idea that a chatbot using AI might be able to generate good answers to patient questions isn’t surprising. After all, ChatGPT boasts that it passed a final exam for a Wharton MBA, wrote a book in a few hours, and composed original music.

But showing more empathy than your doctor? Ouch. Before assigning final honors on quality and empathy to either side, let’s take a second look.

What tasks is AI taking on in health care?

Already, a rapidly growing list of medical applications of AI includes drafting doctor’s notes, suggesting diagnoses, helping to read x-rays and MRI scans, and monitoring real-time health data such as heart rate or oxygen level.

But the idea that AI-generated answers might be more empathetic than actual physicians struck me as amazing — and sad. How could even the most advanced machine outperform a physician in demonstrating this important and particularly human virtue?

Can AI deliver good answers to patient questions?

It’s an intriguing question.

Imagine you’ve called your doctor’s office with a question about one of your medications. Later in the day, a clinician on your health team calls you back to discuss it.

Now, imagine a different scenario: you ask your question by email or text, and within minutes receive an answer generated by a computer using AI. How would the medical answers in these two situations compare in terms of quality? And how might they compare in terms of empathy?

To answer these questions, researchers collected 195 questions and answers from anonymous users of an online social media site that were posed to doctors who volunteer to answer. The questions were later submitted to ChatGPT and the chatbot’s answers were collected.

A panel of three physicians or nurses then rated both sets of answers for quality and empathy. Panelists were asked “which answer was better?” on a five-point scale. The rating options for quality were: very poor, poor, acceptable, good, or very good. The rating options for empathy were: not empathetic, slightly empathetic, moderately empathetic, empathetic, and very empathetic.

What did the study find?

The results weren’t even close. For nearly 80% of answers, ChatGPT was considered better than the physicians.

• Good or very good quality answers: ChatGPT received these ratings for 78% of responses, while physicians only did so on 22% of responses.
• Empathetic or very empathetic answers: ChatGPT scored 45% and physicians 4.6%.

Notably, the length of the answers was much shorter for physicians (average of 52 words) than for ChatGPT (average of 211 words).

Like I said, not even close. So, were all those breathless headlines appropriate after all?

Not so fast: Important limitations of this AI research

The study wasn’t designed to answer two key questions:

• Do AI responses offer accurate medical information and improve patient health while avoiding confusion or harm?
• Will patients accept the idea that questions they pose to their doctor might be answered by a bot?

And it had some serious limitations:

• Evaluating and comparing answers: The evaluators applied untested, subjective criteria for quality and empathy. Importantly, they did not assess actual accuracy of the answers. Nor were answers assessed for fabrication, a problem that has been noted with ChatGPT.
• The difference in length of answers: More detailed answers might seem to reflect patience or concern. So, higher ratings for empathy might be related more to the number of words than true empathy.
• Incomplete blinding: To minimize bias, the evaluators weren’t supposed to know whether an answer came from a physician or ChatGPT. This is a common research technique called “blinding.” But AI-generated communication does not always sound exactly like a human, and the AI answers were significantly longer. So, it’s likely that for at least some answers, the evaluators were not blinded.

The bottom line

Could physicians learn something about expressions of empathy from AI-generated answers? Possibly. Might AI work well as a collaborative tool, generating responses that a physician reviews and revises? Actually, some medical systems already use AI in this way.

But it seems premature to rely on AI answers to patient questions without solid proof of their accuracy and actual supervision by healthcare professionals. This study wasn’t designed to provide either.

And by the way, ChatGPT agrees: I asked it if it could answer medical questions better than a doctor. Its answer was no.

We’ll need more research to know when it’s time to set the AI genie free to answer patients’ questions. We may not be there yet — but we’re getting closer.

Want more information about the research? Read responses composed by doctors and a chatbot, such as answers to a concern about consequences after swallowing a toothpick.

About the Author

Robert H. Shmerling, MD, Senior Faculty Editor, Harvard Health Publishing; Editorial Advisory Board Member, Harvard Health Publishing

Dr. Robert H. Shmerling is the former clinical chief of the division of rheumatology at Beth Israel Deaconess Medical Center (BIDMC), and is a current member of the corresponding faculty in medicine at Harvard Medical School. … See Full Bio View all posts by Robert H. Shmerling, MD

What is a drought?

A drought is a prolonged dry period without rain. In the last few decades, droughts are occurring more frequently worldwide.

With climate change, rising temperatures are making many regions dry within the US and beyond. Here’s how to recognize potential harms if drought has a grip where you live, and actions you can take to stay healthy.

How do droughts affect our world?

The downstream effects of droughts on the planet and our health are complex. One example is water shortages, which can harm crops, livestock, and aquatic life. This compromises food supplies, drives up prices, and worsens food insecurity and malnutrition. Trees, which offer shade during hot weather and help counter climate change, may die during severe droughts. Droughts are making some parts of the world uninhabitable, leading to climate migration.

How can droughts harm health?

There are many ways, big and small, through which dryer conditions harm health.

Droughts play a role in diseases

During droughts, lower water flow leads to stagnation. This can

• increase the concentration of health-harming water pollutants in streams, rivers, and reservoirs
• contribute to harmful algal blooms that can cause skin or gastrointestinal problems
• offer breeding grounds for mosquitoes that carry diseases.

And as water levels drop, the water also becomes warmer. This can foster the growth of pathogens (like some viruses, protozoa, and bacteria). If your drinking water is from a private well, this may be a particular concern for you.

Also, farmers may be more likely to use recycled water for irrigation during droughts. This may lead to more infectious agents like E. coli or Salmonella harbored on crops.

Droughts contribute to poor air quality

The dry conditions during droughts lend themselves to wildfires. That’s an immediate threat to local communities, but also can send harmful wildfire smoke to more distant regions, depending on wind patterns.

Droughts can also lead to dust storms that carry and transport microorganisms, allergens like pollen, and other polluting particulate matter. This can increase the risk of infections, like Valley fever, and worsen respiratory illnesses, such as asthma, chronic obstructive pulmonary disease (COPD), and other lung conditions.

One more challenge is reduced availability of the renewable hydropower energy. Dry periods often coincide with high temperatures. The increased energy demand may require utilities to shift to using more-polluting fossil fuel sources, which further increases the greenhouse gas emissions that cause climate change.

We can all take steps to keep the air we breathe healthier — whether or not drought is contributing to worse air quality where we live.

What can we do to lessen the impact of droughts?

Around the planet, groundwater is stored in natural spaces called aquifers. As overused groundwater aquifers dry up due to drought combined with demands from people and agriculture, more countries face water scarcity. There is growing interest in solutions like treating wastewater for reuse and in desalination of ocean water, though these alternatives come with their own challenges.

To address the drought problem, the US has created the National Integrated Drought Information System (NIDIS) to coordinate research, drought monitoring, and a drought early warning system.

What actions can you take to stay healthy during a drought?

• Stay hydrated. But also stay informed on the quality of your drinking water, especially if you rely on well water. You can contact local water authorities for information on public water quality.
• Check for local advisories on harmful algal blooms before going in the water to swim or allowing pets to swim.
• Follow your local air quality on AirNow.gov, which offers daily information on local air quality. The site also tracks wildfires, and offers guidance on when to minimize your time outdoors and downloadable guides to protect yourself when air quality is unhealthy.
• Be careful about recreational water activities like boating and diving during droughts when the water level may be down.
• Follow Smokey Bear’s advice on how to prevent wildfires.
• If your community is experiencing a drought and water shortage, the Environmental Protection Agency (EPA) provides some tips on home water conservation. But even during water shortages, it is important to not skip hand hygiene and washing fruits and vegetables. And if you are using a rain barrel to conserve water, using a fine mesh screen can help keep away mosquitoes (which only need a teaspoon of water to lay their eggs).

About the Author

Wynne Armand, MD, Contributor

Dr. Wynne Armand is a physician at Massachusetts General Hospital (MGH), where she provides primary care; an assistant professor in medicine at Harvard Medical School; and associate director of the MGH Center for the Environment and … See Full Bio View all posts by Wynne Armand, MD

Birth control pills have been safely used in the US (and sold only by prescription) for more than half a century. In 2023 the FDA approved Opill, the first daily contraceptive pill intended for sale over the counter with no prescription needed. This offers many more people access to a new nonprescription option for preventing pregnancy.

Opill is available online and soon to be stocked on drugstore shelves. Here’s what anyone interested — adults, parents, and teens — should know.

What is in Opill and how does it work?

Opill is a progestin-only form of birth control. That means it uses a single hormone called progestin (or norgestrel) to prevent pregnancy. It works by

• affecting ovulation so that the ovaries do not release an egg every month
• thickening cervical mucus, which blocks sperm from reaching an egg
• changing the uterine lining in ways that keep a fertilized egg from implanting.

How effective is Opill at preventing pregnancy?

It depends on how consistent you are about taking Opill:

• Perfect use means taking the pill every single day at the same time. With perfect use, Opill is 98% effective. That means that if 100 people take the medication perfectly, two or fewer people would become pregnant. Taking a pill perfectly can be difficult, though.
• Typical use averages how well a method works to prevent pregnancy when real people use it in real life. It considers that people sometimes use the pill inconsistently, like forgetting a dose or not taking it at the same time every day. With typical use, Opill is 91% effective. This means that if 100 people use Opill, but don’t take it perfectly, at least nine could become pregnant in a year.

It’s also important to know that some medications make Opill less effective at preventing pregnancy. These include medicines used to treat migraines and seizures. Even though this birth control pill will be available over the counter, you should ask your health care provider if any medicines you take could make it less effective.

How do you take Opill?

• Take it once a day at the same time each day until you finish the entire pack.
• Sticking to a consistent time of day, every day, is crucial. Timing matters with progestin-only pills like Opill because this medication works by raising progestin levels. However, progestin only stays elevated for 24 hours after you take each pill. After that, the progestin level will return to normal.
• After you complete a 28-day pack, you should immediately start a new pack of pills the next day.

What happens if you forget to take a dose at the specific time or miss a dose?

• If you take the pill more than three hours late it will not be as effective at preventing pregnancy.
• Take the missed pill as soon you remember.
• You will need to use a backup birth control method such as condoms every time you have sex for the next 48 hours.

Is Opill safe for teenagers?

Opill is generally safe for most people who could get pregnant, including teenagers. There’s no evidence to suggest that safety or side effects are different in teenagers compared with adults.

Research done by the manufacturer has established the safety of Opill in people as young as 15 years old. It will be available without an age restriction.

When teens use birth control, what is the best choice for them?

There isn’t a one-size-fits-all birth control method for all teenagers. The best method is the one a teen personally prefers and is committed to using consistently.

For teens who struggle with taking medication at the same time every day –– or anyone else who does –– Opill may not be the right choice. Fortunately, there are many options for preventing pregnancy, catering to individual preferences and goals.

Learn more about different contraception methods at the Center for Young Women’s Health website.

What side effects are common with Opill?

Progestin-only pills are usually associated with mild side effects. The most common side effects are:

• unexpected vaginal bleeding or spotting
• acne
• headache
• gastrointestinal symptoms such as nausea, abdominal pain, and bloating
• change in appetite.

Opill does not cause problems with getting pregnant in the future, or cause cancer. Unlike birth control pills that combine the hormones estrogen and progestin, Opill will not increase the risk of a developing a blood clot.

Will Opill cause any mood changes?

Research looking at possible effects of progestin-only pills on mood is limited, so this is unclear. We do know that most people who take hormonal birth control methods do not experience negative mood changes.

Fortunately, there are many different types of effective birth control. If one method causes you unwanted side effects, talk to your health care provider. Together, you can figure out if another type of birth control may work better for you.

Can it be used as emergency birth control?

No, it should not be used as emergency birth control.

What should you know about STIs?

This type of birth control does not protect you from sexually transmitted infections (STIs) such as syphilis, gonorrhea, or chlamydia.

You can reduce the chance of getting STIs by correctly using condoms each time you have sex. There are different types of condoms: one made for penises and one made for vaginas.

Vaccines help protect against some STIs such as hepatitis B and human papillomavirus (HPV). A medicine called PrEP can help prevent HIV. Ask your medical team for more information about the right choices for you.

About the Authors

Candice Mazon, MD, Contributor

Dr. Candice Mazon is a second year adolescent medicine fellow at Boston Children's Hospital. She's a board certified pediatrician and received her training at MedStar Georgetown University Hospital. She earned her MD degree from Drexel University … See Full Bio View all posts by Candice Mazon, MD

Amy Desrochers DiVasta, MD, MMSc, Contributor

Amy Desrochers DiVasta MD, MMSc, is chief of the division of adolescent medicine at Boston Children’s Hospital. She is the co-director of the adolescent long-acting reversible contraception program, and co-director of the reproductive endocrinology and PCOS … See Full Bio View all posts by Amy Desrochers DiVasta, MD, MMSc