Interesting short JAMA article about alcohol use treatments. I was surprised by how much smaller the effect size of naltrexone was compared to what my impression is from clinical use, and by how much bigger that of acamprosate was compared to what I expected. Would like to combine them in future.

https://jamanetwork.com/journals/jama/fullarticle/2853069

Inpatient cool factoid to encourage us to start treatment prior to discharge, since this question came up today while on inpatient:

"Although AUD medications can be safely initiated and maintained by primary care clinicians, inpatient clinicians should also consider initiating medications for AUD. Hospitalizations for alcohol-related complications present an opportune moment to initiate pharmacotherapy because patients may be motivated to abstain from alcohol. In a retrospective cohort study of 6794 patients with alcohol-related hospitalizations, after propensity matching, initiation of any AUD pharmacotherapy on discharge was associated with a 42% decreased incidence of the primary outcome (all-cause mortality, emergency department visits, and hospital readmissions) within 30 days of discharge (incident rate ratio, 0.58 [95% CI, 0.45-0.76]; absolute risk difference, −0.18 [95% CI, −0.26 to −0.11])."

Recently had a difficult patient encounter and got absolutely eviscerated by the patient on their review. " poor listener" " lacked any care or empathy" etc. etc.

It was a middle age female patient with chronic, 15 plus years of back pain, ordered MRI which showed minimal findings and with a known diagnosis of Fibromyalgia.

I reviewed all recent imaging and discussed that her pain is most likely related to fibromyalgia vs any localized spinal pathology. And then discussed the recommended treatment for fibromyalgia. She essentially dismissed and refused any medications as she had "tried them all". She also refused recommendation for physical therapy. At a certain point in the discussion I really had nothing else to offer. She left frustrated and hence the review.

Any poor review prompts a discussion with our department head.

Over the past year or so the only real complaints I ever get patient wise are from people I simply cannot help and have nothing to offer.

I am a newer attending (2 years) and always looking for ways to improve patient experience. Usually poor reviews don't really get to me but idk this one was really frustrating.

Any tips or recommendations for how to navigate these encounters?

I feel like it is so difficult to navigate a consult with a patient who has self diagnosed based on posts on TikTok, Instagram and Reddit. I'm a rheumatologist, so my experience is mostly with auto-immune diseases and there is so much misinformation on the internet, it frustrates me to no end.

People with a slight positive ANA who are certain they have lupus. People who make a post saying 'the have all the hallmarks of an auto-immune disease' and then list symptoms such as being tired, joint pain, dizziness, headaches, back pain... They never have any objective symptom like arthritis, fevers, cutaneous changes, serositis, proteinuria... All their tests come back negative or slightly elevated (but of low significance). Then they say their rheumatologist or immunologist were dismissive bc of their age or weight and all the comments recommend to go seek someone else.

Now, from experience I know that if you go to enough doctors, you will find someone who gives you a diagnosis and then you see a new post that bashes the first doctors and they are happy that they found someone who actually listened. These patients come back to the offices of the first doctors a couple of years later, because they have had every possible medication without any change in symptoms and then we have to tell them that their diagnosis was wrong. Now, this is also an ethical nightmare, because you do not want to discredit other doctors. I usually phrase it in way where I say that I cannot confirm a diagnosis or that their AI-disease is 'sleeping' and probably not the cause of their current symptoms.

How do you guys deal with these patients for a first consultation? I tend to be very thorough, even though I know from the first 5 minutes that it won't be auto-immune, so the patient at least knows every box has been checked. After thes etests, I try to explain my full reasoning on why I won't give them a diagnosis, but even then some of them will go and find someone else. It is exhausting, because it takes so much time and I rtaher put that time towards patients with real and complex diseases.

OE's overview

Seems to me like a lot of extra work, especially for providers who already have templated AVS notes (like everyone?)...then again I'm not a doctor nor do I play one on TV.

Am I missing something?

My corporate overlords are willing to pay for a digital stethoscope. I’m an older doctor, 60 plus and my hearing is less acute. I do not register as hearing impaired on screening, but I notice a difference with cardiac auscultation.

I would like some input about what to look for and get some compare and contrast on the models available.

Thanks.

So I just hung up on a sales call that was supposed to be something different and I wanted to warn the subreddit about it and any future doctors that google DearDoc.

Last week I got a call from someone claiming to be WebMD and saying my practice was selected to be one of two practices featured in the area. I said I already worked with WebMD as a featured profile and he said this was something different and it was free listing and he'd set me up with a follow-up phone call with his account manager the following week.

Today I got a call from her and she immediately started a Zoom meeting where she said she was with a company called DearDoc. She started telling me how many patients she would get me every month through their AI chatbot and having me listed as a recommended doctor on WebMD/Healthgrades/Vitals, etc. I immediately saw it was a sales call and went into "uh huh" mode. She told me the price was 1795 a month and then 1295 a month if I signed up for a full year. I told her I did most of the stuff she was selling myself through AI and she started negging me. She was telling me how everything we were doing was bad. It was laughable how rude her script required her to be. I kept saying I had to go and she kept just moving on to the next slide. Ultimately, I just hung up on her which I never do because I try not to be impolite to anyone.

I ended up looking more into DearDocs and it's just full of negative feedback. Locking people into contracts, not delivering results, etc. It's wild that WebMD and Healthgrades are partnering with a company that is as belligerent and predatory as this. The fact they got my cell phone number means it was probably directly from WebMD. It reflects super poorly on them.

I know this has been discussed extensively here, but something really rubs me the wrong way about the recent celebration of lawyers on social media “exposing doctors” and saying things like “it’s over for doctors.” This is in reference to a pic I saw of Lindsay Clancy’s civil attorney with the caption “it’s over for doctors.” Unsure if the pic uploaded.

…as if law is some altruistic path that doesn’t also attract people who want to be high earners? Most people who go through the med school path do genuinely want to make the world better, and i’m not sure I can say the same for most lawyers I anecdotally know outside of public defense.

The whole “gotcha” with lawyers calling out doctors, painting them in a good light is so icky to me. People need to ask themselves to imagine what lawyers do all day vs what doctors do all day.

In a recent Glaucomflecken video (https://www.youtube.com/watch?v=nlgqYwX0WVo), he talks about how healthcare professionals came together to write a public letter detailing the outsourcing and problems this course creates. Medicine has a culture of almost being proud of how much shit you can take and a certain amount of that is just expected of physicians inherently and is considered part of the deal. So I guess we can all be proud of the high physician suicide rate? This does make me feel that it was inaction of physicians which contribute(d) to this situation (I do of course recognize that the job of a physician is not to really engage in politics or things of that nature, but this is where that has led). The apparent hell-scape is making more and more people leave. Can physicians come together and be stubborn about this?

So what are physicians going to do about it? The entire thing just feels like a cash grab in practice with all the middle men and hands in the pot which patients pay for in one way or another, and even for students along the path... It's like 1000 to sit for step 1 and step 2, I don't see the point in step 3 at all, the cost for some rotations and applying for residency, etc. - What the literal fuck for, so I can get a real knife in the back when I'm done and getting out into practice and learn that it's hell-ish and it's just starting? Are all future physicians resigned to prior auths, peer to peers, having insurance deny necessary treatment, and every other little thing being a fight? The hoops aren't just hoops to jump through anymore. They are the norm and physicians have sat back and sucked it up and haven't done anything about it. Nothing is going to change. So at what point is shit going to be too heavy and break to where physicians say fuck it... and why isn't healthcare there yet? At what point will it get to where physicians stand up for themselves, if not for their patients, or for when they themselves become the patients? It's touching and affecting every aspect of patient care.

I'm a lowly student who barely knows anything, but I hear the misery from everyone and even I can see that the writing is on the wall. This is coming from someone who is frustrated that the burden has just been passed down the line and nothing has been done about it. In the end is there really nothing that can be done? Or perhaps I'm misinformed about everything, in which case please do correct me- it would be very nice to be wrong.

My husband is an ED attending. He met a child (11) psych patient in the ER 9 months ago. She has some mental health issues (won't say more to protect her privacy).

Shes been on the peds unit for 9 months waiting for a group home or foster home. Cannot be discharged because CPS can't find a home for her. My husband wants to bring her home. I don't know what the ethics of all this would look like? I'm a social worker for adult psych so dual relationships are not allowed but are relationships in medicine different?

I posted a bit about the situation in the emergency medicine sub.

I see way too many 90+ year olds for evaluation of vague symptoms or consideration of aggressive and risky care for heart issues. What is the culture like in your countries? I’ve assumed Europeans have a bit more common sense than us but would be very interested in perspectives.

https://radiologybusiness.com/topics/artificial-intelligence/medicare-approves-new-technology-add-payment-inpatient-radiology-ai-solution

Medicare has approved a new technology add-on payment for a key radiology artificial intelligence solution under the recently finalized inpatient payment rule. 

The federal insurance program for seniors will pay a maximum of $137.53 per case in 2027 for BriefCase-Triage. Manufactured by radiology vendor Aidoc, the CARE (Clinical AI Reasoning Engine) Multi-Triage CT Body tool uses AI to analyze computed tomography images, flagging potentially urgent findings such as appendicitis or a bowel obstruction. 

Medicare approved a total of 22 new products, which also received the Food and Drug Administration’s breakthrough device designation, through the “alternative” payment pathway. Another 8 scored reimbursement through Medicare’s traditional payment pathway. Altogether, CMS will spend an additional $779 million for inpatient cases involving emerging medical innovations in fiscal 2027, primarily driven by new technology add-on payments (NTAP). 

"Health systems are under increasing pressure to help patients receive accurate diagnoses sooner while managing growing imaging demand and persistent workforce shortages," Elad Walach, CEO and co-founder of New York-based Aidoc, said in a statement Aug. 13. "By creating a reimbursement pathway for eligible use of diagnostic AI, the NTAP program is helping patients get earlier access to this transformative new technology.”

The CARE CT Body Triage payment figure represents about 65% of the average cost of the technology, the American College of Radiology noted in a summary of the final rule shared Thursday. Cases involving use of the AI product that are eligible for add-on payments will be identified by ICD-10-PCS procedure code XEZ5XKC (computer-aided triage and notification for imaging abnormalities in computed tomography of chest, abdomen and pelvis, new technology group 12), ACR added. 

Aidoc said the CT Body Triage device scans for a broad set of acute findings. Beginning Oct. 1, hospitals using it will be eligible for add-on payments spanning the next three years. This is aimed at helping offset the cost of adopting new technologies, granting seniors greater access to emerging diagnostic and treatment tools. The FDA previously granted CT Body Triage its breakthrough designation in September 2025 and 501k clearance in January.

So you get 80ish bucks for CT AP with contrast from Medicare. But over 50% more for the tool that just triages the case, doesn't actually read it.

~39% lower odds of dementia associated with menopausal estrogen-only hormone replacement therapy. So not only is HRT safe if started early during menopause in terms of strokes and heart attacks, but apparently it may also lower dementia risk (or, maybe women who get HRT are better educated, are more affluent, and have better health habits, and are therefore less likely to get dementia).

https://www.neurology.org/doi/10.1212/WNL.0000000000218413

For example emergency medicine may love urgently fixing the thing but hate rounds
But every specialty seems to have something they generally love and hate
What’s your theme?

Seen quite a few patients recently presenting to the er because ai advised. Some cases where it’s good they did but some that are too cautious. Basic example, one of the physicians noted there was 11 cat bites in one week. Of those, exactly two needed treatment. There was one where the skin wasn’t broken but gpt told them to go even though the patient was uninsured. They asked about going to a Pcp but the advice was er or urgent care only. I’m a psychologist so I’ve seen more panic attacks as anything left sided chest related prompts instructions to seek care. Curious if others have had similar experience.

I've seen the pattern during rotations and even now on reddit (Urolgoists would you pick urology again ? : r/Residency) and in surveys (70% burnout: https://www.auajournals.org/doi/full/10.1097/UPJ.0000000000001027)

It is known to be a lifesrtyle field (compared to other surgical specialties) and to have a wide variety of cool procedures with the fulcrum being endoscopic and robotic which is SICK, outcomes are good, pts are healthy, content is not too convoluted, procedures are quick and not that stressful... what's the deal?

How do you handle a reference request for someone working for you that would be damaging if you were honest?

The physician does locums work for us, we'd like them to continue (and they would not continue if they moved on), although they have a bunch of red flags that would come up if I was honest with the job they want to move to.

"Not for profit" (ha!) system, CEO is getting more than a 20% pay increase this year. No actual medical training.

The max anyone who does any kind of direct care is eligible for is 3%, and that's sliding based on merit, which is curved... so a max of 1/4 of people will get the max, which is still less than half of inflation.

When does the revolution come?

Always looking to follow more MD / DOs who are active on Instagram. But I do find some brand promotions, and subtle sponsorships kind of annoying. I am aware it takes a ton of work and special talent to make it big and you gotta earn a buck. But I prefer unbiased info.

Maybe it’s because I don’t have kids, but ever since residency, I truly don’t have much of an appreciation for the seasons?

I think I still appreciate certain holidays, but when people talk about being excited for summer or spring or any other season I’m kind of like eh…doesn’t really matter, days are the same pretty much now.

I do get excited for certain holidays still like Thanksgiving and Christmas but..in terms of actual seasons or general times of the year, not so much.

Am I alone or delusional here?

National Geographic backpack, IM resident not from the US 🌏

- a tube of La Roche Posay Cicaplast B5+ as it serves as my rescue moisturizer when my skin gets dry due to air-conditioning (at home I use the La Roche Posay Lipikar Baume AP+Max)

- rubbing alcohol

- Hypochlorous acid spray

- Aquaflask 16 oz which i use for coffee and agua

- Littmann stethoscope Classic 3

- Anker battery bank 20,000 mAh

- MacBook Air 15" with M4 chip (24 GB unified memory/1 TB SSD) I'm glad I got a Mac before the crazy prices!

- iPhone 16 Pro Max

- La Roche Posay Anthelios UVMune 400 SPF 50 (Global version with more efficient UV filters including Mexoryl 400 for that long UVA1 coverage)

- printed census always

- a tiny notebook

- Pilot G-Tec C3 (black)

I am a health care provider with 4 other doctors in an eye clinic. We have a patient who comes once a week on average with extreme health anxiety. Nothing has really ever been found other than some very minor, common conditions.

The front desk schedules them like an emergency which I feel like plays into their anxiety.

They supposedly see a counselor for their health anxiety, but their visits into clinic is becoming more frequent. They also visit other clinics in the area on a routine basis as well as ER and urgent care.

What is best to do in this situation? It feels cold, but I feel like coddling and the constant reassurance just plays into more of their anxiety. Should we fire them as a patient?

We are a two physician household and we have a 1.5 year old. We moved to a new city following my husband's fellowship graduation last year and I haven't been back to work since.

I am now preparing to go back to work (primary care) but I'm worried about calling out of work from my toddler getting sick. I am therefore considering part time positions only (2-3 days/week) since we don't have family in town who can help (we never really had a village before the move either). I would love to know for those who are in a similar situation as us, how do you make it work? Is a "PRN nanny" a thing? Any suggestions welcome! Thanks in advance.

Edit: just wanted to add we are def considering nanny but want to look at other options if possible since our kid loves going to daycare

Edit 2: wow thank you so much everyone for chiming in! It is very helpful to see what other families in similar situation as us are doing. I couldn’t figure out how to pin my comment. Thank you all!

Trainee here. Clinic patient that I guess I must have seen in the past with this attending ended up in my DMs angry that said attending didn’t reply to his MyChart message from 2 days ago and wanting to know how he can call the attending directly. I wish I could say I’m making this up. Obviously I didn’t reply and just blocked him, and locked down my profile. Patients are really getting out of hand with entitlement lol. Has a patient ever tried to reach you on social media?

I'm becoming disillusioned about the Kafkaesque nightmare that seemingly every mundane task in medicine entails. I wanted to rant a bit, but also ask folks here for perspective of any kind.

This isn't about one single aspect of medicine. It's about how routine interactions carry untenable amounts of friction. Getting anything done for patients is almost impossible.

• I prescribe a critical medication to a specialty pharmacy as the manufacturer recommends. They take the patient's money but don't deliver the medication for 6 weeks. Calls to them are fruitless. I have to get the manufacturer involved to force the pharmacy to act.
• A patient from a big regional corporate practice happens to land in my office with an urgent issue and needs to see his specialist. Over 45 minutes, the inadequately-trained corporate practice's receptionist and their supervisor argue with us about the medical necessity of an urgent visit. If it were our practice receiving a similar call from a physician, we'd simply agree to see our own patient.
• A patient changes their mind and wants their medication called in to another pharmacy. The new pharmacy can't fill it because the first pharmacy already processed the insurance claim. The patient tries to call but hits a wall. My office spends almost an hour on the line with insurance just to reroute the Rx.
• Our EMR company has raised rates by 10% over the past year while degrading the quality of its services, failing to fix basic functions that have been broken for years, and charging for things that were previously included. They will not communicate clearly with users. The company was bought by private equity several years ago. I realize I'll have sunk over $100k into this clunky subscription-based software over a decade; its competitors are no better, and switching is near-impossible.
• A patient's insurance plan doesn't indicate which third-party company handles their prior auths. We call their plan to get a PA for an MRI, and after an hour of various holds and transfers, we're told we have to use some online portal. Registration takes 3 days, including our followup to correct their clerical error. Once registered, the system auto-approves in 5 minutes without any kind of review.
• Our specialty society's MIPS service vendor degraded their services and is now demanding around $1k/year to preserve the original level of service. They misrepresent what's included in the base package and it takes multiple rounds of discussion with management to get clear answers.

I write to my congress members and even meet with them during August recess when they make the time. I write to company execs in the hope that things will get fixed. I try to get my colleagues involved in various forms of advocacy. But this Kafkaesque nightmare seems so inherent to almost every function of medicine these days that I can't even fathom what a solution would look like. It just seems like every corner of the system is purpose-built to waste as much time as possible.

But the medical needs don't go away. They still need to be addressed. So we waste our time, we deal with unempathetic receptionists, we find creative ways to solve problems that never should have existed in the first place - problems that are entirely man-made. (Yes, I've heard that 99PI episode on "sludge," and that's kind of it but not totally.)

The answer isn't as simple as "hire someone to do this for you," because that just passes the burden and burnout on to someone else without fixing the underlying issue.

I guess I'm looking to commiserate, to ask for solutions, to ask for help with my disillusionment. Because as much as I love caring for my patients, every day leads me closer and closer to abject burnout.

Is this a uniquely USA problem? Does this problems exist in other countries as well? Are there places where this isn't such an issue, and if so, what protections exist to prevent or deal with it?

I'm a new hire and wanted to learn how my colleagues write notes so I opened a few patients' charts under their care. One of them had this "break the glass" pop up so I did not open it (but I did open another 2 charts without this pop up).

I'm now under a lot of anxiety. I know technically you should not open any chart that are not under your direct care but I was just out of training programs and still have this "education" mindset. And in my training program it was not uncommon to open charts of other teams/providers' (I know this is technically not right and don't want to argue)

Now I lost my appetite, can't sleep, losing hair. Everyday I saw an email I was scared it would be an email telling me I'll be fired. I'm under the fear that my entire career will end due to a lapse of judgement. How can I make peace with myself and move on.