Questions about medicine as a career, about which specialty to go into, or from practicing physicians wondering about changing specialty or location of practice are welcome here.

Posts of this sort that are posted outside of the weekly careers thread will continue to be removed.

As a Canadian I find the US healthcare system baffling. Since the shooting of the UnitedHealthcare CEO, I’ve read multiple articles written from the perspective of health insurance workers that seem to assume that given they work in the same system as doctors and nurses, they should be treated with the same respect. I find this puzzling since I had this image in my mind of health insurance as populated by accountants crunching the numbers rather than folks who heal the sick. My question is do doctors and nurses in the US view health insurance workers as colleagues?

The news items I refer to are:

This article in The New York Times (Gift link) from today:

I was struck in particular by this paragraph:

In a message sent to employees on Wednesday evening, Mr. Witty, the United executive, stressed the positive impact the company has on people’s lives and getting the care they need. “Never forget: What you do matters. It really, really matters. There is no higher calling than helping people. Nothing more vital to the human condition than health care. And while these days have been dark, our patients, members, customers are sending us light.”

And this from WBUR:
https://www.wbur.org/hereandnow/2024/12/05/health-care-threats

Got my first cases in office today. Mom of five kids. Three have flu A today. Cousin who lives a few houses down has Flu B. Symptoms developed this morning. Mom now has symptoms.

So that’s a round of oseltamivirs. I sent mom’s PCP a message asking for a mercy dose of baloxavir for her.

And if anyone needs me, I’ll be hiding under a rock until May.

As a side note, I saw my first case of RSV in a baby who had been given nirsevimab and the baby had…a little cold. Remarkable.

-PGY-20

Just posting this as a follow up to the thread from last week. Somebody get u/choxmaxr a cookie.

https://www.cidrap.umn.edu/malaria/initial-samples-dr-congo-unexplained-outbreak-positive-malaria

Tedros Adhanom Ghebreyesus, PhD, said that, of 12 samples, 10 were positive for malaria. He added that more samples will be collected and tested to determine the exact cause or causes.

Abdi Mahamud, MD, interim director of alert and response coordination for the WHO, said malaria is endemic in the area and the rainy season has come with an increase in respiratory diseases within expected levels. For example, he said Kinshasa is seeing a rise in flu and COVID activity.

Hi all

There's obviously a lot of reactions to the United CEO murder. I'd like to focus all energies on this topic in this megathread, as we are now getting multiple posts a day, often regarding the same topic, posted within minutes of each other.

Please use your judgement when posting. For example, wishing the CEO was tortured is inappropriate. Making a joke about his death not covered by his policy is not something I'd say, but it won't be moderated.

It would be awesome if this event leads to systemic changes in the insurance industry. I am skeptical of this but I hope with nearly every fiber of my body that I am wrong. It would be great if we could focus this thread on the changes we want to see. Remember, half of your colleagues are happy with the system as is, it is our duty to convince them that change is needed. I know that "Medicare for All" is a common proposal, but one must remember insurance stuck their ugly heads in Medicare too with Medicare Advantage plans. So how can we build something better? OK, this is veering into commentary so I'll stop now.

Also, for the record, I was the moderator that removed the original thread that agitated some medditors and made us famous at the daily beast. I did so not because I love United, but because I do not see meddit as a breaking news service. It was as simple as that. Other mods disagreed with my decision which is why we left subsequent threads up. It is important to note that while we look forward to having hot topic discussions, we will sometimes have to close threads because they become impossible to moderate. Usually we don't publicly discuss mod actions, but I thought it was appropriate in this case.

Thank you for your understanding.

An older gentleman on a low, fixed income told me his wife would make him grilled cheese 4-6x a day, and sometimes she would make him eat frozen strawberries. They had been doing this for at least a year since they had both been struggling with mobility issues.

There have been a lot of posts recently complaining about insurance denials. I recently had an exchange where I pointed out that insurance companies likely have very different systems in place for commercial insurance vs Medicare Advantage insurance and it got me wondering. Do you notice more denials/delays in approvals with Medicare or Commercial insurance? Or is it about the same.

I realize that this is going to be hard to answer because you are likely making more requests with your Medicare Advantage patients since they are more likely to need services. Thought I would put the question out there none the less.

Hey!

So one of our attendings (pediatrics, Central-Eastern Europe region) is really unapologetic about his appearance. Gold watch, really nice clothes etc. He's super nice, also does his job very well, so generally patients seem to like him.

But I was wondering how these status symbols translate outside of our profession (to patients)? Is there any science on it?

The question comes because colleagues seem to disapprove this, saying it's projecting the wrong message. But I could also imagine that some patients see it as a confirmation of a doctor's professionalism and aptitude.

I've read somewhere on pubmed that for example white coats are associated with higher patient satisfaction in the ED. Is there some science on the category of gold watches?

Apologies if this isn’t the sub for this. I’m a non-clinician that puts together scientific plans that are “IND enabling.”. So I’m OK on evaluating PK, for instance.

I feel kind of out of my depth when it comes to being slick on interpreting RCTs, particularly within CV. I was wondering if anyone can give their experiences on how they wrangled this area. I imagine the learning curve might be harder without seeing patients’ outcomes firsthand.

I recently pulled up the 2009 advisory committee to look at the meeting minutes for rivoraxaban as I try to evaluate what bullshit to look for as I look at new RCTs prior to approvals (but also the post-hoc crap that they do in phase IV).

How do you get a sense of what’s BS when you don’t have direct contact with pts on a daily basis?

I have been lurking on various subreddits and x.. seems like general public do not feel we earning too much.. I was thinking about what we can do, obviously, medical societies, lobbying efforts.

But what about a dot phrase at the end of the notes explaining how pt is charged is not reflective to what physicians is getting paid? Somewhat explains their astronomical bill is not reflective to what actually is going on?

Hello all! I recently accepted a position as a procurement clinical coordinator. This is not a field I’ve had significant exposure to, and while it sounds like the orientation and training program is decently robust, I’d love to get ahead a bit in the several weeks before I start.

The role is multifaceted and largely logistical, interfacing with the donor’s clinical team as well as the hospitals that will be receiving organs, as well as a healthy amount of either directly managing care for the donor patient or advising their clinical team as to needed interventions/goals/testing.

I’m hoping some of you may have guidance to finding quality resources and education for the medical management of these donor patients to help me kick-start and gain confidence as I transition to this new role, any help is appreciated!

Stick with me, y'all. I promise this is a real question and not as stupid as it sounds. If there are any cardiovascular physiology experts floating around here, it's your input I'm looking for. I'm helping update a board review textbook, which requires reading a bunch of practice questions, eliminating old ones, and writing new ones. One of the questions was:

Systolic blood pressure is highest in which of the following blood vessels?

A) Ascending aorta

B) Descending aorta

C) Femoral artery

D) Dorsalis pedis artery

E) Pulmonary artery

The correct answer is apparently the dorsalis pedis. Now look, I may be a product of the Texas public education system, but I'm pretty sure fluid flows from areas of higher pressure to areas of lower pressure. If the pressure is higher in the dorsalis pedis than the aorta, why is it not flowing backwards?

I asked OpenEvidence this question and it explained it as follows:

Systolic blood pressure is higher in the dorsalis pedis artery than in the ascending aorta. This phenomenon is due to the amplification of the pressure wave as it travels distally from the heart. As the pressure wave moves through the arterial system, it encounters various points of reflection and changes in vessel compliance, leading to an increase in systolic pressure in peripheral arteries compared to central arteries. This is well-documented in the literature, including studies that show higher systolic pressures in the ankle arteries compared to the arm. The American Heart Association explains that the amplification of the systolic blood pressure waveform occurs as it travels distally, resulting in higher systolic blood pressure in the lower extremities, such as the dorsalis pedis artery, compared to central locations like the ascending aorta.

I (sorta) get the physics of that explanation, and have personally witnessed this phenomenon in patients with IABPs that read lower values than their radial art lines, but I'm still stumped on why blood moves forward when the distal pressure exceeds the proximal pressure.

My best guess is that the arterial tree contains more than one pressure wave moving through it at any given time and that although the *peak* aortic pressure might be lower than the *peak* radial pressure, those two peaks are not happening simultaneously. The wave needs time to propagate down the arterial tree, so at the moment of aortic peak pressure, the radial pressure is lower, and it's a few fractions of a second later that the radial pressure peak occurs and exceeds aortic pressure. At which time, there probably *is* some amount of retrograde flow, which is how, for instance, the coronaries fill during diastole.

I guess mostly I'm just looking for others' thoughts on this and some confirmation that I'm not a complete moron. Thanks in advance!

If fact, most a gleefully celebrating his death. Why did we let these psychopaths destroy our profession and what can we do to take it back?

Case here: https://expertwitness.substack.com/p/lumpectomy-misses-cancer

tl;dr

51-year-old woman has screening mammogram, right breast mass seen.

Biopsy, clip left behind for localization, path confirms cancer.

Sees surgeon, elects for lumpectomy.

Here’s where things get a little hazy… apparently a radiologist in the OR helped localize the lesion for the surgeon.

Surgeon removed some tissue, sends to radiology to confirm clip and cancer is in the tissue.

Radiologist calls to OR and says “yep, got it”

Tissue goes to pathology a few days later and the pathologist is like…. no cancer and no clip.

Patient told there was a mistake and they missed the cancer/clip.

Understandably she loses confidence and goes to a different health system to have it actually removed.

Then she hires an attorney and they just sue the surgeon. Not the radiologist.

We’ve likely all seen them, plenty of variations too. From EKG tracings, to medical symbols like the rod of Asclepius, to a variety of medication structures. So how cringe do think they are in general from 1-10? And what’s the cringiest medical tattoo you’ve seen?

Edit: this isn't hate towards people with medical tattoos, I have one myself and don't regret it at all. Just curious about how everyone feels about them in general and come on... you know you've seen at least one that made you go "really..?"

Article: https://www.wsj.com/health/healthcare/medicare-health-insurance-diagnosis-payments-b4d99a5d

Pretty damning findings. Obviously this is quite topical with the recent UHC and BCBS news. I haven't personally seen this in my charts, but I'm in academic medicine dealing mainly with acute issues. Curious to see if others in the community are familiar with this phenomenon/abuse by insurers.

I make the call schedule for the group. I do three months at a time. 5 docs total. I had sent out a text around Halloween asking if anyone had any weekends they really needed off (i.e., this past quarter, I wanted a specific weekend off for a local wedding but I didn't take PTO for it) because I wanted to work on the schedule.

Only 1 person (out of the other 4) got back with me. Our manager had also given me the PTO (which ended up being just me & this other doc who actually texted me). I make up a call schedule, which was published today.

I just got off the phone with another doc - she was asking to trade weekends because she's currently assigned to be on call on her kid's birthday. THIS IS WHY I ASKED FOR STUFF LIKE THIS BEFORE I EVEN START WORKING ON THE SCHEDULE!!!!!

Had my first Flu+ for the season today. Flu B. I’m in NC. Anyone else started seeing it yet?

This may be specific to my patient population, but what do you all do with patients who demand you use their professional title during patient care?(Think Pastor Jane Smith during clinical care.) I have one upcoming that I think she does largely as power move because she talks down to the staff and mid levels. Typically I have no problem using preferred names, but this is a title conferred by an institution and not a degree, and wouldn’t really be appropriate to use outside of its professional context.

My German book about eczema comes with a curious paragraph, talking about the atopic personality: "Each of us can tell a story about a very unpleasant meeting with a mother (or a father) of an eczema child - especially when being a teacher and member of the Green Party, she or he knows everything better than a doctor and nurse and is maximally demanding- all in all a very subjective and wrong prejudice." Eyerich, Kilian, and Johannes Ring. Atopic Dermatitis-Eczema: Clinics, Pathophysiology and Therapy. Springer

https://x.com/dylanmatt/status/1864788376391385542?s=46&t=4Pkwm3-GxBHfeEhw3kOxyg

A good quote that follows this post: “The fact that physicians have to defend themselves during this obvious lobbyist funded psyop means we've already lost. When we can't even remain still in the face of obvious lies, it reveals the fact that we have ZERO leverage or power.”

Yes, I understand Twitter is a right-wing echo chamber. That doesn’t mean these sentiments don’t exist out there in the general populace to a significant degree.

My hospital has a policy regarding management of patients readmitted for treatment of vaso-occlusive pain crises in sickle cell disease, which is that if a patient has been admitted and received IV narcotics within the last 5 weeks, they shall not be given IV narcotics during any subsequent admission.

Case Vignette: 45 year old male comes in for treatment of a vaso-occlusive pain episode brought on by colder weather. He has a history of HbSS disease and has had multiple similar hospitalizations. Acute chest in his history but no concerns now. Hgb and bili are at baseline.

On review of his chart, he takes 40 mg of oxycodone q4h as needed for pain (insurance will not authorize a long-acting narcotic like OxyContin). He was admitted last month for a similar episode and was placed on a morphine PCA in addition to his oral medications and was discharged after 5 days in the hospital. Has been following up with hematology and doing well.

Today, because of his recent admission, I am not allowed (per hospital policy) to order any IV narcotics for this patient. I can give him oral medications in excess of his home doses and am not otherwise limited in my management.

This current case is hypothetical but the policy and cases like it are very real. Is this crazy? I feel like this policy is structured to discriminate against patients with HgbSS — “Don’t come here too frequently”. I recognize the complex nature of the disease and concern for comorbid opioid use disorders, but as a blanket policy I feel it is discriminatory and wrong. Not to mention a slap in the face of standard care for patients like this.

Setting is a large community hospital.

What do you think, meddit?

TL;DR Hospital policy prohibits giving IV narcotics to patients who have been admitted and received IV pain medication for any reason in the past 5 weeks. Is this discriminatory/wrong? Or have you seen something similar in your area?

I am an international medical student who is considering doing residency in the United States, particularly IM and then Heme/Onc. How common is insurance denial in Heme/Onc, IM and other specialties? Does it affect or impact your practice often? Would you rather practice medicine somewhere you didn't have to deal with this?

I'm really fascinated by the field and i'm seriously considering a residency in it, but i also like general medicine and the way it all connects to itself like a closed circuit (IM for example). Now of course, what happens in the nervous system can have a huge impact on other organs, but i'm wondering if neurosurgeons in general need (and retain) that "internal med" knowledge in their day to day work in some capacity or is there something similiar to a running joke about orthopedics being scared of diabetes patients and EKGs :) Thanks in advance.

In light of this week’s events, what are the community’s thoughts for solutions to our current for-profit employer-linked insurance model?

I’ve thought and thought about this and the only things I can come up with consistently:

1. A system where patients pay more for less and less and doctors/hospitals do more for less and less while a black box middleman takes billions of profits for ??? Is unsustainable.
2. We are our own worst enemies and spend far too much time pitting specialty against specialty than uniting against a common cause.
3. The medical world is terrible at PR. When an insurance company denies something, the spin is always that it is either greedy doctors not accepting fair (or no) payment or lazy doctors not willing to (spend hours of uncompensated) time doing forms.

How do we move forward? What are things that we can all agree upon?

https://apple.news/Apeg1zBKnT7y74J-v6_w8XQ

“Americans have many justified grievances with insurance companies, which often refuse to cover necessary care. But this particular fight was not actually about putting the interests of patients against those of rapacious corporations. Anthem's policy would not have increased costs for their enrollees. Rather, it would have reduced payments for some of the most overpaid physicians in America. And when millionaire doctors beat back cost controls — as they have here — patients pay the price through higher premiums. Anthem's policy would have cost anesthesiologists, not their enrollees Anesthesia services are billed partially on the basis of how long a procedure takes. This creates an incentive for anesthesiologists to err on the side of exaggerating how long their services were required during an operation. And there is evidence that some anesthesiologists may engage in overbilling by overstating the length of a procedure, or the degree of risk a patient faces in undergoing anesthesia.”

“But the avarice and inefficiencies of private insurers are not the sole — or even primary — reasons why vital medical services are often unaffordable and inaccessible in the United States. The bigger issue is that America’s health care providers — hospitals, physicians, and drug companies — charge much higher rates than their peers in other wealthy nations. “

This reporter with no understanding of what goes on in the system and probably got paid by fucking BCBS to shit post this to our incredibly ill informed nation.

PCP is a low-grossing specialty that is overworked. Dermatology attracts lifestyle physicians who are overpaid and have months-long waitlists. Why not provide a pathway for PCPs to gain derm competencies/billing capabilities to reduce the oversaturation of derm applicants and increase earning potential/attractiveness of PCP positions?

edit: not a dermatologist, never been to a dermatology residency, just medical student looking at the system i’m becoming a part of

Please come share your stories…. Overall started this subreddit after 15 years of dealing with Corporate Medicine… got tired of them gaslighting me, not listening to our needs, and then hiring a bunch of middle management who couldn’t manage a hemorrhoid, telling me how to take care of sepsis…. It has become demoralizing to a certain extent. Please come share your stories… especially if you are from Ohio… but all are welcome. r/Physician_Unions

Edit -- this is a duplicate of https://www.reddit.com/r/medicine/comments/1h8sf6i/eat_what_you_kill_when_rvubased_compensation_goes/

-- sorry.

A remarkable story about potential medical mismanagement (and more) in Helena MT:

"Hailed as a savior upon his arrival in Helena, Dr. [] became a favorite of patients and his hospital’s highest earner. As the myth surrounding the high-profile oncologist grew, so did the trail of patient harm and suspicious deaths.

https://www.propublica.org/article/thomas-weiner-montana-st-peters-hospital-oncology

https://montanafreepress.org/2024/12/07/a-propublica-investigation-of-helena-montana-oncologist-tom-weiner/

ProPublica’s journalism is, as always, illuminative and chilling. The article isn’t just about the pitfalls of RVU-based compensation - it’s also a cautionary tale of what happens when we isolate practitioners from the systems of peer accountability that are supposed to keep them coloring within the lines.

https://www.propublica.org/article/thomas-weiner-montana-st-peters-hospital-oncology