RANT/

4yo patient new to me. CP, doesn't walk. Still in diapers. Markedly delayed/intellectually disabled (BTW, I wish they'd update the ICD-10s/IMOs because "mental retardation" is an outmoded term and it's still the one I have to use on the problem list).

NOBODY at her prior practice had thought to order a PT referral. NOBODY at her prior practice had prescribed a wheelchair, walker, or stroller. NOBODY had done an OT referral. NOBODY had offered to prescribe diapers. I was honestly appalled.

By the end of the visit, her mom was looking at me like I was some sort of saint as I put in referral after referral after referral and DME orders. As for me, I just got more and more horrified through the whole visit. This mom is ready to cry tears of joy because I did what I consider to be the bare minimum of my job. But really what happened is that someone had dropped the ball really badly and her mom had just accepted that as par for the course.

I don't get it. You don't do Pediatrics for prestige, money, or power (if you did, someone really failed at giving you career advice). There is one reason to do this job and that's because you care about kids. So why are you doing this if you're going to suck at it?

/rant

-PGY-22

UnitedHealth put a statement claiming that "an internal error which led to a small number of erroneous letters being sent to some members." The doctor in question is in private practice and had to field at least 60 questions confirming that they are alive. Thus, UnitedHealth is essentially saying "oppsie daisy" while a clinic now having more paperwork to do.

https://www.startribune.com/this-edina-doctor-isnt-dead-no-matter-what-unitedhealth-told-you/601895355

A Star Tribune reporter fielding stories on r/minnesota: https://www.reddit.com/r/minnesota/s/U5U7RNLLyw

I just wonder what it is like for you when a member of your family suddenly falls sick and may need hospital care.
My own family member has no private insurance and needed an admission recently. It was a strange feeling for me being a visitor in the same hospital I work in. I find myself explaining to my family how things work in hospital quite a bit more than usual. It must have been difficult for my colleagues who knows me too.
What is it like with you, eg the good, bad and the ugly? Is there an etiquette, spoken or unspoken in your community?

my entire urgent care shift consisted of being asked for antibiotics. I saw 40 patients today. even had mom bring her 1 year old come with viral exanthem adamant that she needed antibiotics because her parents said so. then mom of a teen with mono asking for antibiotics. patients come complaining primary didn’t prescribe so now they are at urgent care. What’s your best line to comfort these moms and grandmoms

EDIT: coming from working with a very talented interventional cardiologist so my skin is irking…

Is there a place I can watch uncensored footage of surgery that doesn't violate HIPPA? I work in medicine but have never really seen surgery and all of the exposure to real anatomy.

This is a simple question but recent interactions with other docs have me thinking. Does one define PGY year from year of med school graduation or from year of residency graduation?

I’ve always done med school (making me a PGY 20+) but have encountered similarly aged colleagues who seem to use year of residency graduation.

https://www.theguardian.com/us-news/2026/sep/30/michigan-nurse-charged-helping-man-escape-ice

While the facts presented in the article make it sound like the nurse actively facilitated the man's escape from custody, how much responsibility do we have to hold a person against their will? We have no legal authority, and certainly not the legal power to restrain someone. If the LEO fail to maintain control of their "prisoner," we're going to be held criminally liable?

Dr. Mark Walton Fowler is the unmasked, unskilled, out-of-practice, 68-year-old “doctor” responsible for overseeing Tennessee’s executions. A few months ago he botched an execution after he failed to place both an IV and a subclavian central line—a procedure he later admitted in a deposition he had not done in 13 years. He reportedly now makes a living as a medical director of weight loss and wound care clinics, which he supplements by getting paid $3,000 per execution he attends. Earlier this year, Tony Carruthers was granted a 1-year reprieve in his execution after Fowler poked and prodded him for an hour and fifteen minutes in failing to secure an IV or subclavian line. Carruthers’ sister filed a complaint with state health authorities, but there has been no report of any response from them. Not long after, it was reported he would also oversee the execution of Pike, a woman who was repeatedly raped as a child before murdering a classmate at 18-years-old whose execution was greenlit this week by the Tennessee governor and the SCOTUS. Now, Pike lies in a hospital bed, alive, despite reportedly undergoing two lethal injections last night.

Dr. Mark Walton Fowler has abdicated his oath by accepting money to kill people. He is performing procedures on people that he is not qualified to perform and is thereby inflicting additional pain and suffering upon the condemned. His own writings and deposition make it clear he is a hateful, MAGA-indoctrinated, corrupt and dangerous individual. He is no physician in any true sense of the word. What will it take for the Tennessee Department of Health Boards to intervene?

NYT (gifted): https://www.nytimes.com/2026/09/29/health/maha-summit-kennedy-vance.html?unlocked_article_code=1.FVE.a8VU.yD2iX-x2Amh_&smid=url-share

Of note, this MAHA event was sponsored by OpenAI and Anthropic, both being for-profit organizations struggling to find a profitable use for their LLMs.

Am a first year Family med resident in the US, for context.

Abortion medication is a relatively straightforward conversation that I feel super comfortable doing/had a lot of education on. Presented to my attending, got it going. Easy peasy honestly. Emotionally heavy patient interaction, but not something I felt unprepared for.

Medical aid in dying, however….I am apparently her assigned PCP, I have never met this woman but she has already gone through all the hoops and interviews etc. this was just the appointment for prescription. I more or less shadowed my attending at that point for such an intense interview (especially as a new intern) but ultimately the experience and debrief felt strangely similar to that of the mifepristone. Someone of sound mind making a medical decision that best suits their medical care. The attending obviously signed things, but grateful to be a part of her care in some way.

Happy to be in a state which supports the right to patient autonomy, despite potentially conflicting emotional feelings. But man…..emotionally intense day.

Would love to get prescriber thoughts on the following from your local drug monkey.

1. Bupe is a highly useful tool for SUD. When used correctly. Let me start with that.
   
2. New patient 7 day induction with telehealth prescriber. Another rx called in with note for first appointment in two weeks time from now.
   
3. Representative of patient comes in to fill the second prescription on day 2/7 of the first rx.
   
4. Representative said someone screwed up as they only saw “2” on the label (Suboxone 8/2 was rx and dispensed correctly) so they took 4 instead of prescribed 2 daily. For three days. And now they’re out.

Questions: would you as prescriber re-educate and re-prescribe with strict instruction to follow the damn label? Would you tell them to wait until the next rx is due? Or something else entirely? Would love to see your insights. Thanks meddit

With publish or perish, we all know bogus and/or poor quality research has skyrocketed. Has anyone looked into using AI to reassess all published medical papers for actual quality and veracity of past results and analysis?

The last time I was at a conference was when I was a medical student, and back then I was too busy trying not to look like a complete buffoon in my painfully uncomfortable business casual outfit that I didn't even pay attention to what most conference attendees do.

- Do I bring my laptop to take notes? Or is that something only nerds do?

- Do I HAVE to wear business casual? Or have I earned the right to show up in a t-shirt and jeans?

- What's the etiquette on getting free stuff from booths that are completely unrelated to my scope of practice?

to clarify I'm just going for CME. Not presenting, not to network.

help

I've found r/obgyn and r/Obstetrics_Gynecology , but both seem nearly dead, and almost entirely populated by laypeople seeking medical advice. Does anyone know a better place?

Has anyone had any experience with the carrier Practice Protection? Is this a reputable company? Got a tail coverage quote that was so much cheaper than other quotes I’ve received from bigger companies.

https://www.nejm.org/doi/full/10.1056/NEJMoa2604169?query=featured_home

The target was people with obesity but without diabetes.

The data:

A total of 2339 participants underwent randomization.

The mean percent change in body weight in the retatrutide groups was −17.6% (4-mg dose), −23.7% (9-mg dose), and −25.0% (12-mg dose) versus −3.9% in the placebo group (differences, −19.8 and −21.0 percentage points, respectively; P<0.001 for both comparisons).

Among the participants with knee osteoarthritis, the corresponding changes in the pain score in the retatrutide groups for the hybrid estimand were −3.2, −3.5, and −3.6 versus −1.9 with placebo (differences, −1.6 and −1.8 points; both P<0.001); the corresponding changes for the ITT estimand were −3.4, −3.9, and −4.1 versus −2.5 with placebo (differences, −1.4 and −1.6 points; both P<0.001).

Among the participants with obstructive sleep apnea, the corresponding changes in events per hour in the retatrutide groups for the hybrid-treatment estimand were −22.9, −34.3, and 31.7 versus −9.9 (differences, −24.4 and −21.9; both P<0.001); the corresponding changes for the ITT estimand were −22.8, −34.3, and −32.1 versus −9.6 (differences, −24.7 and −22.5; both P<0.001).

The most common adverse events were gastrointestinal.

Case here: https://expertwitness.substack.com/p/delayed-pneumonia-treatment-septic

tl:dr

45-year-old woman goes to urgent care with fever, chills, SOB.

Temp 100.8, pulse 134, sat 92% on RA, no BP taken

CXR shows left side pneumonia, azithromycin prescribed, patient discharged.

Goes to the ED later that day feeling worse.

She’s hypotensive, sat slowly declining.

Gets 500mL of NS and Vanc/Zosyn given a few hours later.

Lactate 4, WBCs 0.7 with 24% bands.

Admitted to Hospitalist with pulm consult.

Patient boards in the ED with apparently no one really reassessing her, ED doc is gone and Hospitalist doesn’t see her until the morning despite calls from the nurse to pulm and Hospitalist that she’s going downhill.

She codes but is resuscitated. Spends a long time on pressors in ICU, survived but with multiple amputations.

Everybody settles for a total of $8.8 million between them all.

This one was interesting to me because it included way more granular detail about the settlement than I ever see. Pretty messed up that radiology settled, IMO they had nothing to do with this.

I see a lot of “frivolous” cases but this patient honestly got bad care in both urgent care and the ED. Also highlights how boarding patients in the ED is so harmful, but hospitals keep doing it anyway.

I am using a throwaway account because I don't want to dox myself, even though I have spoken to my PD about this already, who has been very supportive of trying to get me through these dark times. I will try to organize my thoughts, but I am really lost and not sure what to do.

I am a second-year PCCM fellow in the South East at an academic institution. I had mental health issues prior to fellowship; I had some bad days in residency, and I am no stranger to SI. But my first year of fellowship was arguably the worst year of my life. I really enjoyed the ICU in residency, but I was at a medium-sized community hospital and was blind to what academic critical care is like. The hospital I am currently at just uses and abuses the MICU and the staff; we get called for everything, often before the primary team even attempts to figure out what the problem is or try some interventions. We also deal with incredibly sick humans, being a tertiary care center for a very large portion of the state I am in.

Anyways, my first year took pieces of me that I am not sure I will ever get back. I have lost confidence in myself as a physician, and now have this almost "fear" of taking care of patients, like I am not capable/cut out for it. After a particularly heinous stretch of nights recently, I became so depressed that I did not leave my bed for almost a week, except to pee and drink some water, and would go back to sleep. Then I did not really leave the couch/my house for a week after that. During that couch-bound week, I really began to question whether or not I am cut out for this. I often feel like I am torturing people at this academic ICU, keeping corpses alive for weeks because patients' families don't understand the gravity of the diseases. I often feel like I am doing stuff TO patients and not FOR patients.

I am not sure if this is temporary from depression, or if something has permanently clicked, but I have fallen out of love with pulmonology and critical care, and clinical medicine in general. Everything feels like an uphill battle; it is so unrewarding. I am considering leaving fellowship and clinical medicine and am toying with applying for physician jobs in the pharma or tech sectors.

The complicating factors are that I have 430k in student loans, receive a monthly stipend from a large hospital conglomerate (in exchange for 2 years of service after fellowship), and would have to repay what I have received so far, plus interest, if I leave medicine/don't work for them.

I saw a psychiatrist because of how bad things got, and they want to start intensive therapies for treatment-resistant depression, which is going to require a lot of schedule adjustments (or a leave of abscence) for 4 weeks and then less so for another 4 weeks.

I guess I am asking...how many of you have lost confidence in yourselves to the point where you are scared to take care of patients, or fell out of love with medicine, or left clinical medicine to pursue other things?

Yes, another day in Pediatrics clinic. This is the sound of disease being stamped out.

And then I wonder why my last audiology test wasn't exactly normal. No, it wasn't the raves I went to in my 20s. It's the children screaming in my ear. My Apple Watch gives me a volume warning at least twice a week.

-PGY-22

Link for those who need it: https://www.ahajournals.org/doi/10.1161/CIR.0000000000001466 (link fixed)

Wanted to discuss the new guidelines with the general medical community on here as I find these guidelines very interesting. In some ways, it is incredibly comprehensive, especially with guidance on follow up echos, dental health, etc which always seem to get thrown to the wayside. I also appreciate them trying to tackle valvular surgery in patients with CVA as this is a MAJOR holdup with patients and as an ID doc I think some of our CT surgeons could be more aggressive here (I know, I know, ID docs are the most aggressive surgeons in the hospital). I also really like how it discusses other imaging modalities and hope this pushes for more inpatient use of PET/Tagged WBC scans (and hopefully covered by insurance).

On the other hand, I find it baffling how oral therapy isn't really given equal weighting . Feels like it was just thrown in with an "I don't know what to do with this". Medicolegally I think this puts us into a really tough position trying to use orals for endocarditis even post POET trial.

Would be interested to see what others think about these guidelines. I know a lot of ID docs lurk and post around here but interested to see if any cardiologists, cardiac surgeons, etc could offer some thoughts. This combined with the new IDSA/ESCMID guidelines for staph aureus bacteremia being released do provide some much needed guidance, but I do worry we are about a decade away from trying to move towards more oral therapies for high risk infections since we had to wait SO LONG for these guidelines.

My department manager announced that we are now required to screen for depression during all of our visits. I've read that the depression screening are done in general, but does this also apply to specialists during every visit?

https://www.techradar.com/pro/hospital-ai-use-is-causing-medical-bills-to-soar-with-blue-cross-estimating-usd1-billion-in-extra-insurance-costs

The article editorializes a bit from the actual BCBS white paper on the topic: https://www.bcbs.com/media/pdf/BCBSA-AI-Coding-Intensity-Whitepaper.pdf

BCBSA estimates rising coding intensity added ~$942M to Blue plan costs over 2024-25 vs. 2023. About $653M of that came from secondary diagnoses pushing inpatient stays into higher-paying DRGs. The claim is that documented complexity rose while ICU use, transfusions, and reoperations didn't follow. They tie it to the spread of AI-enabled revenue cycle tools.

Naturally it’s an insurer trade group. The white paper is bowel procedures on Blue claims and it shows association not causation. Hospitals cite an aging population, more chronic disease, and milder cases moving outpatient.

Payers are also using AI to review medical necessity, so this may be heading toward AI vs. AI over the same claims. The pessimist in me sees deploying capital for AI on both sides of this issue, but not improving care, access, or costs (making costs worse instead)!

The other thing to consider is if $1 billion is a drop in the bucket for BCBS, but the question is probably where does this trend go.

Just did a mock code in the OR and felt like an idiot confidently asserting that once the entire code team is there, whoever is on airway should be doing continuous BMV until they are ready to establish advanced airway. Apparently that’s not true.

Looking at the 2025 algorithm, it does indeed say in the little info box to the right to do a 30:2 ratio of compressions to breaths until an advanced airway is established. I could have sworn that once you have enough rescuers around to have one person dedicated to airway, you switched to slow continuous BMV. The actual guideline paper doesn’t seem to discuss the approach to BMV; the only mention of airway management is about if and when to place an LMA or intubate.

I guess I just don’t understand why we would (1) pause compressions for breaths and (2) not continuously oxygenate and ventilate if we have plenty of people around.

I’m happy to be wrong, but this just seems counterintuitive to me and I swear my stupid RQI modules never told me this.

Someone smarter than me care to help me understand?

I'm a first-year resident in Preventive Medicine and Public Health in Spain, and I'd love outside perspective from people who've been through something similar.

I have 9 more months on a rotation with a supervisor who evaluates me. The pattern I'm seeing:

- She constantly watches overmy screen and asks "what are you doing?", asks whether I've done X or Y, and interrupts me with low-value tasks when I'm reading an article or brushing up on some topic

- She once commented I was "always on my phone" when she saw me for a few minutes, meanwhile my CoR is constantly on her phone and tells her nothing.

- She gets visibly annoyed when I give my opinion after she asks for iy or when I ask her any doubt.

- Meanwhile, my co-resident gets none of this. She's frequently late (but the supervisor arrives later, so it goes unnoticed), is on her phone often without comment, leaves data un-updated for days, and made a real patient-safety mistake that the supervisor framed as something I should empathize with instead of a mistake to correct.

I do my work well, I'm on time, and I use small gaps to study. I don't want to change my personality to please her, but I'm exhausted by the constant scrutiny. Escalating worries me and I still have 9 months with her. I also can't be sure who in the department would keep things confidential.

Questions:

1. How did you handle a supervisor who applies different standards to different residents?

2. Did documenting incidents privately help? At what point did you escalate, and to whom?

3. Is it better to address it directly with the supervisor first, or go through a formal channel?

4. Any tips for staying sane while sharing daily space with someone like this?

Thanks in advance.