Just that - patient is very very ill, treatment is not working and outside of ICU, the ceiling of care is reached. You, the attending, call the family in and … baring immediate EOL care - find that the patient does belatedly recover stabilise.

How do you re-manage expectations and deal with the confusion amongst staff who have to now provide active medical care to someone whom, hours ago, they were expecting to pass?

If i cannot find it on lib g en or on anna’s archives

Wife has an opening in the primary care clinic she manages and was considering applying. We would have no problems working together so thats not my issue but I am concerned that I have been away from o/p medicine for 8 years. Has anyone made this transition and felt successful with said transition? Are there any crash courses in primary care medicine out there i could attend prior to starting? Books you would read? My biggest concern is not having done a Pap since residency and there really is not a mechanism to "practice" this procedure. Thanks alot

As a new attending, while I grind to adjust to my new practice I hear constantly from more experienced physicians from all different specialties at work and on here, our very own r/medicine, that the road we are on is not sustainable. Here are some of the various reasons with some (unsolicited?) commentary added in:

1. In 20 yrs, Medicare pay has gone down 22% while cost of practice increased by 47%

2. Admin and private equity continue to increase their parasitic effect on funding and distribution of payment. Somehow the answer is to always see more patients and hire more admin, yet the financial situation is always dire.

3. Insurance companies increasingly control larger market shares and dictate medical care through coverage decisions and lobbying... or they simply buy up or open their own hospital systems.

4. Hospitals likewise increase their market share to compete with insurance, yet constantly claim to be running in the red. Options for patients to seek care and physicians to seek employment are increasingly limited.

5. Nursing homes are shuttering due to staffing and decreased payments. Even if someone is ready to discharge, they may wallow in the hospital without dispo planning for months--sucking up even more cost.

6. Patients are increasingly complex--every patient encounter in both hospital and clinic settings that was previously a couple issues is now 10 primary issues with 20 previous complex problems. As the saying goes, "Today's clinic triages used to admit to the floor. Today's floor patients use to go to ICU. Today's ICU patients used to be dead."

7. Related to #2-4 and #6, physicians are expected to see the same if not more patient numbers in the same or less time to maintain the same or less RVU compensation related to #1. More time is spent on documentation or coding patient encounters to some criteria not even understood by the coders yet will maybe somehow increase reimbursement slightly without actually improving physician pay or patient outcomes. The end result is burnout and FIRE/early retirements and patients complain their bill is higher for no reason they can perceive.

8. Speaking to a labor economist recently, staffing crises recently were due to COVID rather than actually dealing with the monumental numbers of patients and staff retirements that will be seen when the Silver Wave/Baby Boomers hit. Everything related to population stress above will be amplified.

9. PBMs and national level pharmacy chains continuously buy up and dominate the pharmacy industry while independent pharmacies are, by design, choked out. The result is big box stores that are terrible to deal with, terrible to work at, and patients hate going to.

10. COVID. COVID proved we as a nation are not ready nor willing to face a pandemic. The public showed they weren't willing to protect their neighbor if it meant wearing a mask or getting a vaccine. Both political and medical governing bodies showed they could not respond appropriately. People became SO MUCH nastier and entitled--pseudoscience and opinion became more important than facts and proven medicine. Related to #6, the ever increasing medical complexity of patients seemed to be directly coupled to psychiatric complexity through paranoia, conspiracy theories, uncontrolled personality disorders, and the increasingly common "playful" threats of violence.

There is obviously more than could be written here, but I digress and besides 10 is a nice even number.

My whining aside, what will this lead to? What will the collapse of modern medicine look like? When institutions too big to fail inevitably fail AND take medical care with them, what happens?

Thanks for coming to my TED-Rant

Seems like an unlikely thing to occur, but all the news coverage makes it sound like it happens all the time.

Also, I've heard warnings that you could hurt your eyes using your phone to photograph the eclipse. Huh?

Hi. I hope it´s ok to ask this here. A question came up at work around hypothermia. We all know that when the body gets colder the metabolism slows down, but why does it slow down? Is it biological processes that something happens to or is it physics. We are not getting any wiser and I hope some of you guys here can help.

The Q word. I was having an easy night but still a few more hours to go. Colleague is heading home, and he decides to comment on how easy and quiet my night is going. Literally 10 seconds later I get two consults back to back. Despite the lack of trial data supporting my claim of association [1-4], I still stand by my opinion that I was totally jinxed.

[1] The use of the word "quiet" in the emergency department is not associated with patient volume: A randomized controlled trial

[2] "Shh-don't say the Q-word" or do you?

[3] A quiet place: The impact of the word “quiet” on clinical workload

[4] Q fever-the superstition of avoiding the word "quiet" as a coping mechanism: randomised controlled non-inferiority trial

I've worked (and am further specializing in) elderly care for a few years and am currently doing a 6 month internship in internal medicine. As you can imagine, doing rounds in a long term care facility is a very different experience from a hospital setting.. And after a few discussions with my colleagues, I'm curious how the rest of the (hospital) world does this.

I'm used to sitting with a nurse and then going to the patient afterwards. At my current hospital, they do everything at beside, no matter how many patients are in a room (I have some massive privacy concerns about that), with the argument that it's their info and they should be allowed to hear it all. Opinions about this vary between my colleagues.

So, how do you do your rounds? Curious to hear what your habits - and rules - are!

I'm looking for help/advice on obtaining meds for an organization.

I've just taken a position as medical director for a small non-profit. While it's not a medical organization they do have limited medical services. There is an RN on site. Client meds are kept in the medical room and distributed by the RN as scheduled. In addition we have standing operating procedures for PRN meds and interventions that can be administered by the RNs (inhalers. epi pens, etc). The previous medical director didn't know how to prescribe and obtain these PRNs for the org so he resorted to prescribing it to a staff member for pick up at a local pharmacy.

I'd like to be a little more on the up and up. Can anyone give advice on how I would go about prescribing and obtaining meds for use per SOP for this organization?

So when did hospitals become run by APPs? At my current home hospital the patients are all seen daily by Hospitalist NPs and Specialist NPs. It feels like they have no idea how to do anything but take an HPI. The plans are always extremely basic and I’m left wondering where are all the attendings? I’m only a few years out of residency but I just don’t remember it being like this before. It feels like no one is managing my patients and it makes me want to start rounding on my own patients again.

End rant.

Tried to keep this concise... but basically I am wondering when people generally think it is safe to discharge someone with acute CHF?

Does someone need to be completely not in "acute CHF" anymore before you discharge them? Or can someone who is perhaps only mildly dyspneic with moderate activity, trace edema/JVD, not hypoxic (nyha 2 or less) - can they be discharged with an increased dose of diuresis PO for a few days then follow up with their cardiologist or PCP in a week? I'm not talking about anyone that has brand new or very severe systolic dysfunction.

I just ask because I have this general thought that acute CHF needs to be aggressively diuresed and patients be absolutely not in any sort of acute CHF before discharging them... that discharging someone still having acute CHF symptoms is a huge no-no. But I realized that I am not sure why this is? What is the primary harm with discharging someone still having "mild" acute CHF symptoms? Is the primary risk simply re-admission, or is there real morbidity or mortality associated with it?

Please just bear with me if this question is idiotic. I just find myself wrestling with this issue alot - wondering if someone really needs to stay in-house for another day - particularly if an individual is asking me to leave the hospital - when do i really need to hold someone another day for IV diuresis?

Title Edit: appreciate everyone’s candor and comments

I am NOT trying to open up the entire debate about midlevels … what I am trying to understand is this: what classes in med school are the primary classes that separate you from mid levels? I know the subjects are touched upon in PA school, but is the pathophysiology course more in depth in medical school, is it studying biochemistry, is it pharmacy? I’m also aware that a resident, for example, is being worked to the bone. But I’m talking about medical school. Basically, what about medical school makes a 3rd year student have more relevant medical training/education than a midlevel?

While more relevant to any other doctors lurking here, I have a funny story from work. For context, I'm a doctor from India, who, having passed one heap of British medical exams, and is still recuperating (and losing sleep) from the residency matching process for another, happens to be working at one of the more prestigious hospitals back at home. In India, almost all of our own exams, including from med school, involve actual bona fide sick people, even the more fancy ones.

I turned up, as usual, only to find my ward crammed with dozens of obviously senior doctors and not a patient in sight. And I didn't sign up for any medical conferences, I only attend them if there's a buffet table and booze.

Turns out the MRCP PACES exam, which, as the acronym would suggest, provides membership to the Royal College of Physicians in the UK (basically internists, but sounds cooler), was being conducted there. It involves somewhat more involved cases and more tricky diagnoses than what I had to endure in my own British OSCEs. And which I hope to never have to give myself, since I just want to be a fucking shrink, I don't care to palpate your liver, no, not even if I'm seeing you after a paracetamol overdose. Palpating the fake prosthetic tiddies on a grinning male actor while doing my best to look in the eyes (up there, no, more to the left) the actress who supposedly had a breast lump somewhere in there takes most of the fun out of it.

And nobody had told me. Cue me gingerly creeping to the doctor's room, which kept getting invaded by yet more cute postgrad trainees/residents. I'm not one to complain about that, but I really wanted some goddamn sleep.

Eventually, I spotted a girl feverishly reading MRCP station notes, and I enquired politely about them only to be told she wasn't giving the exam herself.

Huh?

Like, I'm not the most passionate doctor around, but it's pretty rare to study for an exam you're not fucking giving.

Turns out that in lieu of highly trained professional actors fluent in English, as is the case in the UK, at least as far as I can recall my friends telling me, or by googling it myself, they just recruit the medicine residents in India.

Well, it must be fun to be on the other end of the poking and prodding. I recall them chatting about how one poor bastard had to endure some particularly painful tests, and had to do his absolute best to avoid wincing as his abdomen was molested in an effort to find something wrong with his perfectly normal kidneys. Why? Because the test wasn't supposed to be painful, and if he did show his pain, that would be interpreted as an intentional clinical sign by the examinees, who not having access to the script, would then promptly jump to the wrong diagnosis and thus immediately fail the station.

Funnier still were the ophthalmological exams, since a few of the over-qualified patients had visual issues of their own, and the imaginary platonic ideal of the disease they were supposed to embody didn't. One of them found out he had a heart murmur the hard way, which has to suck, but I heard that the examiners did end up agreeing to pass the people who noticed that particular divergence from fiction.

Well, I guess it beats seriously ill patients being subjected to the same, it's a bit awkward when they die on you or have to be shifted to the ICU mid exam, really wreaks havoc on the grading. Well, I've no intention of giving the MRCP, but it was sure funny to just sit there and munch popcorn as the bacon was made, until someone guilt-tripped me into admitting my lack of productive work to my boss and I was reassigned to another ward for the week. Eh, it was good while it lasted. If I do ever give it for the lols, I'll hope the 'patient' takes pity on me or wants respite from my fumbling, and just whispers the diagnosis to me instead. They'd probably know better.

Hi all,

I was wondering if anyone had any idea about the above title; I've been curious to know since much of the literature and resources that I've seen during medical school have well-established that the African-American population is at high risk for certain medical conditions including diabetes, cardiovascular disease, etc., but there is little mention of non-American Africans.

Whereas other conditions such as sickle cell are more so associated with African descent itself (rather than being African-American) given the unique genetic selection due to having some benefit against malaria, there is less so a selection for diabetes / cardiovascular disease. Is the risk of diabetes / cardiovascular disease is unique to that of African-Americans and that they should be viewed as a separate group from the wider population of people of African descent?

Can anyone help or provide any experiences / literature about this? I'm having some difficulty finding any information. I am mostly curious if there is some epigenetic role to the development of these risk factors in the African-American population vs. the wider Non-American Africans.

Or-- Is African-American often used as a blanket term for both populations in literature?

Any insight would be appreciated!

Fight me in the comments.

I never really got a deep grasp of the concepts underlying the items of the criteria. :(

When asked what it does to you patient responds- it makes me drunk and sleepy. Epic stories of inaccuracies - once in chart, its forever.

I'm working with a new practice, and have transitioned from a traditional corporate clinic role to a more flexible role at a family-run private clinic with a somewhat ancient ehr (macpractice). I'm finding that there are areas, particularly telehealth, where I know that I am not billing efficiently. For example, I am typically billing 99441's for lab results for telehealth, even when results of substance are discussed, and/or rx'es prescribed. There must be more effective coding for this, and I appreciate any specific recommendations, as well as resources to broaden understanding of billing and coding resources.

I feel like IR are the nice guys at ours. They are pretty much the dumping ground here and take in all kinds of nonsense at all times. The only time I thought they were not so “nice” is when they called in for sedation on a prone case.

It seems like a no brainer to me.

Does this mean that if you work more, you can earn more money?

Any of you plan to do this? I’ve been Pulm/CC post fellowship for 5 years and I can’t imagine needing my IM certification for anything for the rest of my career. If for some crazy reason I end up going into primary care rather than just doing Pulm clinic, I can always recertify then right? Does your board eligibility ever expire?

200/115?

210/120?

Or is the answer never and to just have the patient follow up with their PCP to address the problem?

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.

https://www.medicaleconomics.com/view/how-plaintiffs-lawyers-pick-their-targets

This is a pretty long and informative Q&A from two malpractice lawyers. Most of their points we probably already know but there are still some interesting points:

• "most of our defendants, particularly the arrogant ones, are men. And the surgeons tend to be the most arrogant of all"
• "we're reluctant to take on elderly plaintiffs: The damages will be less, because their life expectancy is limited and there's not much claim for lost income."
• writing "patient/family is a malpractice attorney" in the chart is a bad idea

Points 1 and 2 are probably why OB is so high risk

What are some common medical myths aka “old wives’ tales” that doctors and other medical providers tend to promote as fact without realizing that they are either blatantly false or without substantial evidence? (I.e. rotating second gen antihistamines to help maintain allergy symptom control). Trying to get a sense for things I may be taking as fact but need to be re-evaluated.

Medical student here, I know we're not supposed to look ourselves up on EMR bc of HIPAA, but has anyone ever done so and received punitive justice? If so, what happened?