Give the nature of our sub, I think it's expected I elaborate further.

I'd like this to turn into an interesting conversation given recent events around CEO assassinations.

It's not a deep thought. But I'm Just saying that if we had some other payment system, for example, based on your average patient population health in relation to that geographic location, then it seems more likely that you would weigh your time against the time of treating somebody who very obviously doesn't have a life threatening condition.

Hi All,

Happy to be here for another AMA as the year winds down. The Gout Education Society and I attended ACR Convergence last month in Washington D.C. and I figured this would be a great time to check in with the community here in r/medicine to help answer any questions you have about gout. As a fellow physician, I enjoy these conversations as they can have a direct impact on the quality of care that patients receive across the world.   

I’m more than happy to answer any questions you may have about the disease, its diagnosis, treatment strategies, or considerations to keep in mind when faced with comorbidities.

If you haven't participated in any of my previous AMAs, here’s a little more about me. I am Larry Edwards, a rheumatologist and specialist in internal medicine at the University of Florida in Gainesville. I am also the chairman and CEO of the Gout Education Society, a nonprofit organization dedicated to educating the public and healthcare community about gout. I founded the Society in 2005, along with the late Dr. H. Ralph Schumacher, Jr. The Society offers educational and unbiased gout resources, so both patients and doctors can access the right tools to both manage and treat gout. We also offer a medical professional locator for patients to find gout specialists nearby.

I’ll answer questions from 2:30 – 4:30 p.m. ET on Thursday, December 19 in the thread below. So, AMA!

Find out more about me
Visit GoutEducation.org to access our resources for medical professionals and patients alike.

Has anyone successfully used a patient questionnaire that imports into Cerner Powerchart? I've used them with Epic before, but didn't know if it's possible with Cerner. Looking for symptoms, prior meds, etc.

Thanks in advance!

https://www.wral.com/news/investigates/raleigh-doctor-sexual-assault-allegations-license-revoked-september-2022/

https://www.nbcnews.com/health/health-care/doctor-fired-er-warns-effect-profit-firms-us-health-care-rcna19975

I've had so many issues with pharmacies for months now. I'll send in a 90 day refill, then two days later have an electronic request for a 90 day refill from them. The biggest issue is the lying. I'll send in a prescription, then pharmacies don't tell patients it's ready or tell the patient that I never sent it in. I'll then call the pharmacy and they'll acknowledge that they did get it, but don't have the medicine in stock (usually stimulants or whatnot). This has happened many times and it's frustrating. Just tell the patient the truth. Don't tell them that we didn't send it in or that you've tried reaching us when you haven't.

EDIT: Let me be clear, I know that pharmacies are understaffed and are massively overworked. The issue is telling patients that we didn't send it in when we did. This is a recurring problem that then makes more work for everyone as I have to then call the pharmacy, make them confirm it's there and then reach out to the patient to confirm it.

This is the fourth instalment of The Nurse Will See You Now, a series documenting how the increasing reliance on nurse practitioners is imperilling US patients.

Published in Bloomberg https://www.bloomberg.com/news/features/2024-12-16/nursing-students-find-own-clinical-training-as-schools-leave-them-without-help

Hi all— just need to take the temperature of the waters out there this Christmas. Today one of the senior docs in my department approached me to collect a monetary donation to be divided amongst our staff as a holiday "bonus gift" for our MAs and nurses. I reached for my wallet to pull out a couple of twenties and then promptly Clark Griswolded them back into my pocket when she informed me that she needed $400 per provider. I was shocked by this amount— this is more than we're spending on our kids for Christmas for crying out loud. She told me that doctors in surgical subspecialties that she knows were giving $500 per doc and that it'd be nice if the nurses and MAs could "buy snowblowers and things if they wanted."

For reference we are a midwestern outpatient primary care practice employed by a health system and I am nobody's boss here. Just a humble PGY15 PCP trying to get my work done. And no, the PAs and NP in the department were NOT asked to contribute.

So AITGH (am I the grinch here)? This just seems like a lot of dough.

Zyprexa is olanzapine and ziprasidone is Geodon.

It kills me every time.

I am a proceduralist. In 2019, I have treated a patient with an intervention for a very high risk cardiovascular condition. Unfortunately patient expired during the procedure (which is not uncommon but the complication itself uncommon).

I was sued for it and retained national expert in my field who stated that my technique and practice were completely within the standard of care. The plantiff’s side’s expert is not even an specialist in my field. The case was settled far below the average amount in NY because i just wanted to be done with it.

I have left NY and have not practiced there for years. I have been practicing in another state with zero issue or significant complications. I have performed the same procedure and saved lives.

I was completely in shock and saddness when I found a letter from the office of professional medical conduit with NY department of health asking for the following

An interview with the office or to decline it. I was told I may have legal representation and pay for my own recorder.

The issue under investigation was this specific patient I got sued for, whether the care and technique was appropriate or not.

Have anyone gone through this? What’s the best approach? Have the interview? Decline the interview?

This is an absolute gut punch over an unfortunate incident. I was devastated that I couldn’t save that patient’s life. I was devastated that I got sued for it, and now five years later I am told I am being investigated by a state I don’t even practice in anymore?

This might seem like a stupid question but I'm genuinely wondering given the wide range of progress notes I've seen. Let's say there's an inpatient who occasionally requires IV electrolyte replacement due to GI losses because of chemo and they also have bad pain, on senna/PEG.

I've been altering my progress notes daily to indicate the amount of IV electrolytes given. However, I've seen some notes where they just say "Electrolyte replacement as needed" or if under their pain management "Patient on bowel regimen" without indicating the specific medications.

So that being said, how specific do progress notes need to be when mentioning medications, replacements, etc.

I'm looking for some book recommendations about coping as a physician and resilience. I'm early in my career and split time between two specialties. I'm finding it increasingly difficult to compartmentalize due to stress of reflecting on if I've made the right decisions and potential outcomes. I do fear that if (when) I have a bad outcome that I won't be able to recover from my own judgement.

Books I've read prior to this season of life: This is Going to Hurt, Do No Harm, When Breath Becomes Air, Being Mortal

ETA: Thanks for all the thoughtful replies, they are appreciated. Wanted to add that I read non-medical/just for pleasure books daily. Typically I would read one medical book per year (fiction or non-fiction) to kind of renew my interest in medicine. I feel like the crux of my problem is poor work-life balance and I'm working through this with multiple avenues, but I still find myself getting stuck in my head when I'm trying to enjoy my off time. Just trying to find different coping skills from others that have been doing this longer.

Soapnote.org unexpectedly shut down last week. I liked this resource for shared soap note templates. I regret not saving them into my own dot phrases. Alas, any recommendations for alternatives?

Rph here, spoke to a dr office yesterday and the person I spoke to had never heard of a PBM. FYI, PBMs are one of the biggest problems in healthcare, yet few people seem to know what they are. Here is a video explanation by the one and only Dr glaucomaflecken. Also there is legislation in the works to try to get pbms to divest from their pharmacy business.

https://youtu.be/_khH6pZnHCM?si=n8wIf62T9UUzjtAq

https://www.reuters.com/business/healthcare-pharmaceuticals/health-insurer-stocks-fall-wsj-says-lawmakers-set-break-up-pharmacy-benefit-2024-12-11/

https://www.nytimes.com/2024/12/17/business/pharmacy-benefit-managers-opioids.html

Hello, I was wondering if anyone here had successfully gone through the New Jersey medical license requirements. I'm a locums provider looking to start working in NJ.

On the licensing requirements, it is asking for every place I've worked with/been affiliated with in 5 years to fill out paperwork and stamp it, get malpractice paper work from every place (I have different malpractice thru each site) and then contact every single state I have a license thru and have them fill out paperwork they need to send thru to New Jersey. And then I heard the turn around after that is over 5 months.

For me, this is a lot of people I need to get paperwork from, and I'm worried people won't do it. I'm worried I won't even find out who submits the paperwork/what else needs to be done.

I'm wondering if anyone else has gone thru this process. I have a license from multiple other states, no one's required me to do any of this...

https://www.indianagazette.com/business/lifestat-ambulance-has-gone-out-of-business/article_aaf3f9d8-b731-11ef-9ff3-c301ee7b76b1.html

Once again another non-profit EMS services closes due to reimbursements fat under the cost of providing the service.

Medicare pays 80% of what they say costs. Payment by Medicare advantage plans is often even worse. And there is no consideration, for what opperation cost's actually are.

Three surrounding EMS properties have Matt come up with a plan, even though all three of them face the same financial difficulties, with no plan by the municipal government who has the legal obligation in Pennsylvania to ensure EMS coverage to meet and address the issue.

This agency operated for 40 years.

I need 2 hours of professional boundaries/physician misconduct. Anyone got a link to a free resource?

He was caught using UF Health wifi to access CSA material. He was sentenced last week and will be required to register as a sex offender when released. https://www.gnvinfo.com/former-uf-health-anesthesiologist-sentenced-to-ten-years-in-prison-for-possessing-child-sexual-abuse-material/

I feel like Trump would agree to just about anything no matter how crazy it sounds. Why not organize and petition their administration to get rid of board certification, eliminate board organizations and leave requirements up to states for CME. PAs and NPs don't have to do endure the same rigorous process and these organizations are absolute parasites sponging up millions. I do recognize there would be risks to specialties including radiology if we're playing it fast and loose. What are everyone's thoughts?

I’ll start - in nursing school first semester my teacher literally watched every single student wash their hands at a sink singing the alphabet song - the entire song “🎶A, B, C, D….next time won’t you sing with me 🎶 “. Obviously we all know how important handwashing is, but this was actually graded 😆.

https://www.nytimes.com/2024/12/13/health/aaron-siri-rfk-jr-vaccines.html

How successful is he going to be doing this and for other vacccines? Can FDA just tell him to pound sand?

So.. Congress has delegated its authority to insurance and pharma companies and they get their kickbacks.. considering the nature of Healthcare, that is essentially giving these "industries" claims of ownership on Americans' lives.

They are the ones who profit from sickness, and they are the ones invested in keeping this system in place..

Physicians are ultimately labor.. most people don't think of us as such including oureselves because of the nature of the work.. but it is labor that we've spent decades honing.. only to get bossed around by accountants and MBAs who don't care about our patients or us and would squeeze us out of the process if they could legally do it without shouldering the culpability.

They know that well.. for all these people seemingly surprised that there's a media push to smear doctors and say they are the cause of the problem not these middle men.. these are paid propagandists..

This is the scope of the problem we are facing now.. you spend 20 of your most productive years on the straight and narrow, working hard through classes as a teenager and onto your 20s and 30s, you save lives and in return, well you see how the system is set up.

We are going to need a solid, unified vision and the ability to form unions and a framework for strikes.

"The people that are driving up healthcare costs in this country are, frankly, not the insurance companies, they're the providers. It's the hospitals, the doctors..."
This quote starts 30 seconds in, started the clip earlier for context.

That's right all you greedy doctors and providers, you're who the public should be mad at!

Absolutely braindead take from Brooks. The monied elite and media are going to do their best to turn public ire against their healthcare providers. Yet another reminder that medicine needs to find a way to band together and fight against this.

Also, I'm sure Mr. Brooks would love to hear your thoughts, you can contact him here. Be nice!

I keep seeing cefdinir be given from PCPs, urgent care, the ED, or on discharge and it’s mildly infuriating to me. What’s more, when I’m trying to call in a 2nd/3rd gen cephalosporin for one of my PCN-adverse patients, the only thing most pharmacies seem to keep in stock is cefdinir.

From an incredibly early point in my training, I was firmly dissuaded from ever ordering or prescribing cefdinir for anything other than a bloodstream infection because it has a terrible Vd—especially in adults (bad PK/PD in general from what I understand)—and thus does not penetrate the tissues well at all. What’s more, for infants with AOM, it can actually bind to the iron in their formula preventing the absorption of an already questionable antibiotic.

Price, marketing, and/or general lack of awareness are the only things I can think of for this trend, but cefpodoxime—which to me seems better in almost every way—is barely more expensive and Ceftin (RIP) was on par.

While I do feel strongly about this medication, I am 100% open to the idea that I’m missing something or just flat out wrong in my understanding of pharmacokinetics so if anyone can shed some light on this for me I would definitely appreciate it.

Edit: to clarify, I am definitely not arguing that cefdinir should ever be used for a BSI (again I hate it), I was more saying that whatever amount does get absorbed into your body, it’s staying in the bloodstream bc of its terrible Vd

Edit 2: https://shmpublications.onlinelibrary.wiley.com/doi/abs/10.1002/jhm.13415

I apologize for the strained wording. I tried to Google this but I couldn't figure out the right search terms.

In the US, generally health insurance will not pay for medications prescribed for non-FDA-approved/"off-label" uses, and/or for compounded medications. It is completely legal to prescribe off-label medications, they just might not be covered for non-approved diagnoses.

In ophthalmology, we treat a LOT of esoteric diseases and have to rely a LOT on compounded medications. Insurance often won't cover these medications for these uses, despite an abundance of peer-reviewed research supporting their usage. It would be nearly impossible to get FDA approval for these indications due to the cost-prohibitive nature of FDA trials.

Examples of non-covered medications and/or off-label uses that I routinely encounter:

• Cyclosporine eye drops (Restasis, Cequa) for non-dry eye ocular surface inflammation, such as Thygeson's SPK (price varies)

• Difluprednate eye drops (such as Durezol) for intraocular inflammation unrelated to surgery (about $60 for a 1-2 week supply cash price, depending on usage)

• Autologous serum tears for any reason, including severe dry eye ($700 for a sterile compounded 6-month supply)

• Compounded n-acetylcysteine eye drops for filamentary keratitis ($200 for a 1-month supply)

• Compounded fortified antibiotic eye drops for infectious keratitis (about $200 for a 2-week supply, on average in my experience)

Sometimes, this lack of coverage and commercial availability can be sight-threatening (for example, if a patient can't afford to pay $200 for compounded fortified vanc/tobra for a corneal ulcer, which can absolutely cause permanent blindness if untreated).

I'm curious what happens in other countries. Do healthcare systems in other countries cover medications for indications that have not been officially approved by the relevant government agency? Do they cover compounded medications?

This process has been endlessly frustrating to me in the US, since it restricts access to critical medications and forces patients to pay high out-of-pocket costs. I'm curious if it's different elsewhere, particularly in countries that have universal healthcare.

I am reaching out as a surgeon currently involved in an EMTALA-related case, and I am seeking guidance from those with experience in similar situations.

Many months ago, I was contacted by a stand-alone emergency department (ED) regarding a patient with a flare of hidradenitis suppurativa. The ED physician recommended transfer to a hospital where I was take call for wide debridement. I communicated that my understanding of acute flares are initially managed medically. Based on the clinical details provided, I suggested a medical management regimen—including topical antibiotics, anti-inflammatory medications, and possibly biologics—should be attempted first. I also communicated that surgical debridement is typically reserved for cases where medical management has been exhausted. At the time I was contacted, none of this was done.

During the conversation, I disclosed the limitations at my facility, including the lack of plastic surgery coverage, and stated that, in my judgment, the patient would benefit from being managed elsewhere for optimal care. However, I clarified that if no alternative placement could be found, I would accept the patient and provide care. At no point do I recall refusing to take on the patient.

This matter has now been escalated to the Department of Health. My leadership, including my boss and CMO, has informed me that a meeting will be held to address this case. I was informed that no fault maybe discovered, the hospital maybe fine and I also maybe fined. Since this was a stand alone ED, I do not have access to their EMR. Our transfer center does have the conversation recorded. However, I have not been provided with documentation, recordings, or any additional information about the complaint, which I find concerning.

I am seeking advice on the following:

1. What to expect during this process?
2. How best to prepare for the meeting?
3. Should I consult with a healthcare attorney in advance?

I understand EMTALA violations can carry significant consequences, including fines, and I want to ensure I handle this matter appropriately. Unfortunately, I lack mentorship or direct support in navigating this situation and would greatly appreciate any insights or recommendations from this community.

https://www.nytimes.com/2024/12/13/us/texas-new-york-abortion-pills-lawsuit.html

My response (as a proud New Yorker and lover of all women): fuck you. Seriously. You cannot stop this because ironically the US government, via USPS, is the largest drug dealer in America, thanks to the 4th amendment, without a search warrant, the government can't open your postal mail. And that's how the dark web flourishes. So instead go after a doctor in another state with a state law that doesn't apply to somebody who doesn't live in that state? Yeah, sounds like something the Texas AG would attempt. I heard this was a possibility but I really didn't think it would happen. How stupid was I. God, I am pissed off reading this.

This question comes from a now deleted question that was posed on r/residency : https://www.reddit.com/r/Residency/comments/1hd2ah2/is_it_normal_that_a_fellow_performed_a/

OP asked whether it was normal for a fellow to do the entire colonoscopy with no attending supervision in the room.

A lot of users said it was normal.

This is news to me. It's my understanding that endoscopy does NOT fall under the surgical supervision rules of just needing to be present for "key portions" and that the attending must be present for the entire procedure from insertion to removal, though obviously do not have to be physically holding the scope.

I haven't found direct guidance from CMS but there are several training programs with published policies online that follow this rule:

UWSOM GI Fellowship: https://uwsom-web01.s.uw.edu/wp-content/uploads/2019/05/Gastroenterology-Supervision-Policy.pdf

Northwell Health Teaching Hospital and BIling policy: https://www.northwell.edu/sites/northwell.edu/files/2024-04/800.21-physicians-at-teaching-hospitals-supervision-and-billing-policy-24.pdf

Columbia PATH regulations: https://www.compliance.cuimc.columbia.edu/compliance-standards/physicians-teaching-hospitals-path-regulations

Does anyone else know differently?

EDIT For clarification:

I agree that a basic bronch is near zero risk and that in the middle of the night, in an emergent situation, a fellow or resident thats competent should just do it, but im more asking about the policy aspects and whether thats institutionally set or there are national guidelines. As far as I'm aware, you cant bill for a endoscopy you are not present and supervising directly for the entirety of the procedure (unlike surgery)

If no physician in the facility will prescribe the medication requested by the patient, the facility must then grant temporary privileges to a physician who will.

there is no inhouse prescriber willing to prescribe the off-label drug, then the patient's outpatient Ohio-licensed physician prescriber, after a prompt consultation with the patient's hospital care team and a review of all of the patient's drugs, shall be allowed to immediately begin applying for temporary privileges, based on criteria within the hospital medical staff bylaws used to determine the issuance of temporary privileges to treat that patient only

And the state medical board can't do anything about it

A health-related licensing board, department of health, state board of pharmacy, or other state board or agency responsible for the licensure or regulation of health care professionals shall neither infringe on medical free speech nor threaten to pursue, or pursue, an administrative or disciplinary action against a prescriber, pharmacist, or other licensed health care professional or hospital or inpatient facility for publicly or privately expressing an opinion about off-label prescribing that does not align with the opinions of the board or agency, a board of health of a city or general health district, the department of health, or other health authority.

Patient is a 27 year old male with significant health anxiety, no past medical history, whose mother was diagnosed with renal cell cancer last week. He said that a mass in her kidney had been growing undetected for what is likely the past 10 years. He is now requesting a full body MRI.

It feels a little wasteful to order an MRI Brain, Chest, Abdomen, Pelvis in a healthy asymptomatic 27 year old male. I'm wondering if you guys have any good advice on how to approach this discussion.

Edit: They told me they called their insurance company this morning and were told an MRI would be covered. They also told me their mom had a kidney ultrasound a few years ago and found nothing, but their oncologist said it could have been growing for 10 years.

Edit 2: Many of you are preaching to me what the correct thing is - I know the MRI won't be covered without medical indication, I know the US is more appropriate. But it seems like you're all answering the easy question of "What is the correct medicine to practice here" and not the harder question of "How do you approach this patient without alienating them?"