Curious to see other input and stories. Had one recently.

Had a 35 yo show up with chronic GI issues. BMI normal. Frequent bouts of severe abd pain, diarrhea, N/V, and skin rash. Skin rash looked like hives, would be over the entire body and very itchy. Would get these episodes every few weeks and rash would coincide with the symptoms. Was getting routine labs, about to send to GI for scopes as was concerned for IBD. Lab tech came and showed me his tube, half oil. TG 1500, LDL 250. Familial hypertriglyceridemia. Skin rash was eruptive xanthomas, seems to coincide whenever he’d drink or eat poorly.

Statin and dietary changes and no further GI symptoms or rash, but TG still needing a lot of work. What’s yours?

Pretty sick and tired of admins patting their back after making more red tape for those actually taking care of patients. Not a good clinician? If they’re poor at managing patients, they’re likely poor at managing staff.

https://www.clasp.com/post/future-nurses-are-betting-on-kalshi-to-pay-for-school

With the new lifetime limits on federal loan borrowing in effect since July 1, nursing students are turning to Kalshi and other prediction markets to try to make money. It is a side effect of the OBBBA, in which the federal government is less trusted to fully fund the education of future healthcare workers like nurses. One in which privatization is more likely than not to exploit.

Although limited to nursing students, I'd not be surprised to see that Physician Assistant students and medical students are also turning to gambling on prediction markets to try making money (only 40% of betting participants in this survey came out ahead).

Personal experience with insurance company today:

Requesting a peer to peer, you have less than 24 hours to call or the request for inpt rehab will be denied.

Call

P2p: this is a recorded line, my ID# xxxx

We are denying the application for rehab because of X reason... continues,

[does not give a chance for me to respond]

...

[I interject]

Me: youre justifying denying the application because of a document from 5 days ago and ignoring all of the other indications for rehab including [Y], [Z], also i have the patients family and medical decision maker here with me as I believe that patients should be involved in their care.

P2p: im sorry dr [a] but it is against our company policy for anyone but you and I to be involved in this conversation, if you cannot abide by these rules then I cannot continue this conversation.

Me: whats your specialty? Whats your name?

P2p: I cannot release that information, you have been given my id #, that will work if this file needs to be referenced.

Me: so youre using outdated information from 5 days ago, to deny an application, you won't let the patient or their family be a part of this conversation, you won't tell me your name or credentials, what about this is fair, and how is this even a peer to peer? I dont know you are who you say you are, you could be someone with no medical education for all I know.

P2p: please address me with the respect I deserve.

Me: please provide your credentials so I can address you with the respect you deserve. This patient has needed [b, c, d] and studies have shown that people at [pts age] with [pts condition] respond very well to rehab and not getting it harms the pt.

P2p: dr [me] if I may, based on the information you have provided we will approve this request.

Me: thanks, bye.

TLDR: insurance are refusing to allow pts to be involved in p2p conversations about pt care, they are refusing to release their information to prove it is a peer, they are using outdated information to deny claims/applications. Just so you all can prepare for your next p2p

In case you arent' already aware, BCBS Texas, Illinois, New Mexico, Oklahama, Montana under the HCSC private company has instituted a policy to automatically downcode all E&M codes. I am sure they and other payers have been doing this elsewhere but this has finally come home to our state. They are the biggest payer by far and our practice future depends on them.

This downcoding is blanket. It is done by AI/claim edit rules. It does not discriminate between providers who upcode or providers who truthfully document and code. It is unethical and could be illegal. Courts will take years to decide.

State medical societies are "monitoring" the situation. /eyeroll.

This has created hundreds of downcoded claims for our practice within a few weeks.

Each requires going into Availity, searching for claim, filing reconsideration with medical notes, awaiting decision, writing letters justifying coding, filing second level appeals etc etc.

To get paid what we should have been paid anyway.

What a ridiculous burden.

What is more after submitting reconsiderations their robot continues to maintain the downcoding stating the following -

According to CMS guidelines: To bill any code, the services furnished must meet the definition of the code. CMS further states, Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed. If an E/M code is reported and the level of service exceeds the maximum level of service allowed, based on diagnostic information, an EMRC flag will be applied, and the E/M code will be recoded to match the level of service allowed.

What the hell happened to Medical Decision Making (MDM) criteria? What is this EMRC flag and how is this legal? Their own published coding policy says they adjudicate claims based on MDM.

So what is this new EMRC flag???

How have you successfully overturned these? And will we have to submit notes and reconsiderations and appeals in perpetuity??

Brainstorming because there has to be a better way!

I’m curious how everyone thinks we should communicate EMR changes and new CI updates to the clinicians actually using the technology?

It feels like death by 1000 emails. I know there are intranet sites and tip sheets that are full of useful information but time is the one piece we don't have. We live in the EMR and rarely do I feel caught up enough to go hunting/sifting for that latest update.

I imagine there are countless useful features that never get adopted for the same reason. For those of you who spend your days caring for patients.... how do you best receive/learn information about meaningful changes? Random pop ups that share the changes live in Epic to time release the info? More frequent but shorter newsletters? In person rounding or info given briefly at meetings with printed tip sheets? I recognize we all learn differently too and there is no one way. Just looking for creative ways to tackle the inevitable.... change.

Thanks!

See link to CNBC-TV18 article reporting that US President Donald Trump claimed in a social media post, that import tariffs on Indian generic drugs would begin on 1 August 2028 starting at 100% and be raised to 200% on 1 August 2029. Trump will not be US President after 20 Jan. 2029. Based on his history of reversing positions, Trump might change this plan tomorrow if not sooner.

https://www.cnbctv18.com/market/sun-pharma-lupin-cipla-biocon-share-price-donald-trump-generic-drugs-tariffs-timeline-impact-19950953.htm

See link to recent article in JAMA Internal Medicine regarding the impact of the immigrant crackdown of the past two years on PCPs whose patients include immigrants.

For expedience I have copied and pasted the "Key Points" section from the article.

Key Points

Question What are the experiences of 38 primary care physicians caring for immigrant patients since January 2025?

Findings In this qualitative study, participants reported moral injury stemming from anti-immigrant policies, which was exacerbated by the adverse effects of the policies on the health of immigrant and US citizen patients, and by health care systems that limited immigrant patient support or remained silent. Moral injury was mitigated by supportive health care system responses and physician advocacy.

Meaning Anti-immigrant policies have adversely affected the well-being of physicians, immigrants, and US citizens; supportive health care system responses and physician advocacy may help mitigate anti-immigrant policy harms and reduce moral injury.

https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2851438

Hospital/insurance credentialing often asks if we provide gender-affrming care.

As an ophthalmologist, I don't specialize in gender-affirming care, but I do provide objective, supportive care to all my patients and consider myself a staunch LGBTQ+ ally.

In this context, does 'gender-affirming care' refer to specific training/specialization? If so, is it correct to answer 'no' despite supporting LGBTQ+ patients?

It feels wrong to write 'no' but I want to be accurate.

From KFF Health News: https://kffhealthnews.org/medicaid/medicaid-work-requirements-medical-frailty-documentation-doctors/

Doctors say they aren’t trained to accurately assess whether someone’s health keeps them from working. Many don’t have time to handle another administrative task that takes them away from patient care. And being involved in whether someone gains access to a public benefit undermines the doctor-patient relationship, several doctor groups and physicians said.

“When you introduce unnecessary, non-evidence-based, confusing, and bureaucratic policies like this into clinical care, it just raises the level of moral distress for providers,” said Christopher Chen, a senior healthcare adviser at the consulting firm Manatt.

I suspect that as a primary care physician with lots of Medicaid patients, this is going to be a huge chunk of my time, starting later this year. This will have significant ripple effects. As I'm seeing patients to fill out their forms to stay on Medicaid, others will be sent to urgent care or the ER instead.

Case here: https://expertwitness.substack.com/p/missed-dvt-despite-ultrasound

Before I jump in to this case, I’ll first say I don’t think it was malpractice. Super sad case, and some learning points for sure, but not malpractice.

It’s gotten a lot of attention in the lay press so I decided to publish what’s been disclosed in the legal records to get as close as possible to the truth. I usually only publish if they include the expert opinion reports, which they didn’t, but there was still a lot of good info and I felt like it justified a post.

College student with history of protein S deficiency (edit for typo: protein C deficiency) and prior DVT comes to the ED with butt pain. Says he thinks he might have a DVT.

Also, has not been taking his anticoagulation.

I’m sure the PA thinks it’s weird (what DVT causes butt pain with no leg pain and no leg swelling), but nonetheless orders the DVT ultrasound.

It’s negative, patient sent home.

Patient codes and dies a few days later. Autopsy shows iliac vein clot and large PE.

Patients family sues and they settle for $3 million.

Not sure I would have caught this and I don’t think it’s malpractice, but here are some good learning points:

1. Iliac vessel pathology sometimes causes referred pain to the butt.
2. DVT ultrasound can’t see iliac vein DVTs. There might be some changes in flow with respiration but most of our techs/rads aren’t looking for that as far as I can tell.
3. Prophylactic anticoagulation is different than therapeutic anticoagulation. I can’t tell you how many doctors sent me messages saying it didn’t matter if the DVT was diagnosed, he should have been taking his blood thinner anyway so there was no change in management. That’s not true. The dosing is different going from prophylactic to therapeutic. You could argue that therapeutic anticoagulation doesn’t prevent all PEs, but the management is definitely different.
4. Easiest way to check the iliac veins is to do a CT venogram pelvis w contrast.

Ultimately I don’t think it’s reasonable to CT scan everyone with butt pain and negative ultrasound (especially if there’s no swelling), but in the appropriate patient, definitely worth considering.

I got zero insight or clarity on this in the legal advice sub Reddit, besides get an employment lawyer, So posting here. If anything just to generate discussion.

Recently enacted House Bill 627 adds to Virginias ban on non competes for low wage employees, and specifically invalidates post-employment non-competes for health care workers. But it is not retroactive, noncompete agreements signed by doctors before July 1, 2026, remain legally valid and enforceable.

In my specific situation I signed my original employment contract in 2011, but it included the following self renewal provision:

(a) This Agreement will become effective August 1, 2011 and will continue until the first anniversary of the Commencement Date, provided, however, the term will be automatically renewed for additional one (1) year periods thereafter, unless terminated by PHYSICIAN'S death, disability (as defined herein) or by either Party as provided herein. Disability shall be defined as any time after PHYSICIAN becomes and remains temporarily or permanently disabled or incapacitated to the extent that he is unable to perform hisprofessional duties for a period of ninety (90) days (or can reasonably be expected to last at least ninety (90) days).

When the contract self renews on August 1, does the non compete remain legal and enforceable? As of yet there is no established precedent testing this, but non completes and self renewal of contracts are common, wondering if anyone is navigating this currently or has been anticipating this laws enactment?

Hi everyone,

Im hoping to find some trans/gender queer doctors or other healthcare professionals that would be open to share if/how being trans has impacted their career, and how that varies across specialities!

Do you find most healthcare professionals to be more open minded and kind, or is it something colleagues pick at? Is it more difficult to be respected? Does it affect the patient-doctor relationship?

I hope this post doesn't break the rules - 1st time poster here.

Thanks in advance!

https://pmc.ncbi.nlm.nih.gov/articles/PMC9244607/

The Guardian

Summary: The twins were both dead in their bedroom. Andrea Shaw, who is also a plantiff on a lawsuit against the American Academy of Pediatrics, is indicted by jury on the basis she suffocated her children rather than the inactivated vaccines they both got, 8 days prior.

The time gap of 8 days between vaccination (DTaP, hepatitis A, influenza) and the simultaneous deaths confidently rules out anaphylaxis (it would at the extreme appear within a day). Additionally, the physicians who reviewed the office documents at the request of The Guardian noted a very common, non-serious and expected reaction in the office. Indeed, a judge agreed with prosecutors that this is not a vaccine injury case, but a double filicide case: "The judge on Tuesday revoked Shaw’s $2m bond, agreeing with the prosecutor’s argument that she posed a threat to her new baby, who was born last month, just days before her arrest."

I am sure the Children's Health Defense and RFK Jr. will come out to say that Shaw is innocent. But they themselves are hiding behind an agenda and take every opportunity to disparage vaccines, even when there is a stronger possibility of homicide.

I read this famous Harvard article that has since been widely reduced to "Harvard says men should ejaculate 21x/m for prostate health." I'm curious why frequent ejaculation in early adulthood would be more protective than frequent ejaculation later in adulthood, if the protective function is to reduce inflammation and stagnation?

https://www.health.harvard.edu/mens-health/ejaculation_frequency_and_prostate_cancer

PCP here and have quite a few patients with RA / other rheumatologic issues taking turmeric successfully controlling symptoms and lowering sed rate / CRP / RF levels that their rheumatologists have weaned down need for methotrexate. Different patients seeing different rheumatologists. But I’ve also seen other physicians talk about liver related injury from turmeric. What is the verdict here? Is there a special formulation of turmeric that’s more effective with fewer potential for side effects?

I know it’s all OTC supplements and the US FDA really has no control on what is commercially available. I just want to know the best way to counsel patients in these situations.

I was chatting with a doctor friend about reporting medication side effects when patients come to them with suspected adverse reactions.

Honestly surprised when he said he rarely reports them to the FDA or drug company, or event within his own institution and that most of the doctors he knows don’t either.

It made me think about the state of post-market drug safety. If healthcare providers aren’t routinely reporting adverse events, and patients often don’t know they can report them themselves, how are we getting an accurate picture of what happens in the real world?

Is this side effect normal? Is the symptom actually caused by the medication? Real-world medication side effects are likely underreported, which means important safety signals can be delayed or missed.

I’m curious about your thoughts. If your patients experienced a medication side effect, do you report it?

Friday mid-morning.

EMS Phone rings: “27 Female. AMS + N/V. +EtOH. 10 min.”

Triage nurses look over. “Ha, what you think doc, Thirsty Thursday happy hour special?” 

“TGIF” I joke

Ambulance backs up to the bay, they unload and roll her in

Eyeball the patient. She looks all too out of place for the ER

She’s young. Pretty. Hair carefully done. Makeup that had obviously taken time, though now a little smeared. She’s wearing a decorative top, fitted jeans. Clearly hadn’t planned her outfit to be hanging out under the fluorescent lights of the ER.

She groans a little as they roll her past towards a vacant room.

One of the medics is new. Young guy, probably not even 20. He does his best to give report.

“27 female…Uh... She was out drinking last night. Threw up everywhere. Friends called when she didn’t come to work, wouldn’t answer her phone. Vitals…umm… heart rate 120-ish, blood pressure a little high at 150. 100% room air. Glucose 115”

“Any history? Anything on scene? Drugs? Meds? Signs of trauma, sexual assault?”

shrugs “Nah dude… she’s just really fucked u---"

Senior medic cuts him off with a glare “We didn’t see anything like that doc. Wellness check, police got no answer but could hear her inside. They got in, saw her like this and called us. Apartment was crystal clean. Just her on the floor, vomiting and from looks of things, in her own urine as well. Her friend called it in, here’s her number.”

Hands me a crumpled piece of paper with a phone number sloppily written in it

‘Sarah’

I address the room to get her moved over to the bed, on the monitor and ask to get some fluids/Zofran going. The basics. Nurses see no previous chart encounters populate when her information is entered. I go through my exam

No obvious trauma.

A bit tachycardic and tachypneic but otherwise stable vitals show up on the monitor

Glucose confirmed normal.

She’s moving all 4 extremities but doesn’t follow commands. She’s just groaning incoherently and occasionally flops from one side of the stretcher to the other.

Pupils equal, 4mm. Sluggish.

She’s got vomit on her but not actively vomiting. Airway okay for now I think to myself. At least we’ve got a little time to figure things out first.  

The nurse for this room looks over “We gonna have to intubate her? She looks pretty off”

“I sure hope not. Let’s see if we can get the vomiting to stop while we figure this out. I’d love to avoid tubing a 20-year-old for tequila.”

---

Step away and call the friend.

“Hey this is Dr. Reflection calling from Middle of Nowhere Podunk ER. Is this Sarah, Katie’s friend?”

“Yes! Oh my god. What’s going on with her?”

“Can you tell us a bit more about what happened?”

“I don’t really know. She was texting me getting ready to go out with this guy she met on a dating app, she doesn’t really date much so she was excited but nervous”

“Does she drink a lot? Do you know this guy, is it possible he gave her something?”

“Katie barely drinks! And the guy, well, I don’t think so. This was their first real date. We met for coffee like a week ago to check him out. Seemed normal, or at least, didn’t seem like a creep… He was kind of a nerd but he clearly really liked her”

She pauses

“Although last night she didn’t really eat before she went out. Was complaining she didn’t feel good. Said she had a headache”

“Any other symptoms? Does Katie get headaches or have any medical issues?”

“No. Not that I know of.” *She laughs, “*She was mostly upset that she was going to have to end the date so early. I think she was bummed. I’m sure the guy was.”

“Did she say anything else?”

 “No, just a bad first date”

Exchange a few more details but Sarah tells me she last heard from Katie in the Uber back and she didn’t seem drunk at the time. She also gives us mom’s contact info. 

---

I go briskly back to the room. Tell the nurses to pack her up and get her to CT. We call the techs en route to get her on the table. CT gives us a little shit for “clearing the table for a drunk girl” but they do so while getting her set up quickly. I stay with them to see the scan results in the reading room.

Non-con images flash up on the screen

The nurse doesn’t react. CT tech’s eyes widen as they look at the screen.

I feel an immediate iciness wash over me as I utter a slow, one syllable word. 

There it was. Like the North Star.

I always recall, during residency, there was a neurosurgery resident a few years ahead of me. Whenever we called her for any type of brain bleed, her first question would always sarcastically be “how big is it, like can you idiots see it?”

I could see this. I couldn’t fucking miss it. 

“Start a CTA right now” I say to the techs who jump out of the room. I turn to the nurse, “Call RT and pharmacy. Get them to her room.  As soon as we get her out of the scan, keep the head of the bed up.”

Nurse looks bewildered, not quite having known what we were looking at. I scroll through the image and point

“That’s blood”

“It doesn’t look that bad, I’ve seen ones the size of a baseball” she says

“They call this the Star of Death” I say with exasperation while dialing the transfer center to talk to neurosurgery. 

---

Return to her room. More vomiting ensues, forcing our airway decision. Intubate. Hypertonic saline. Keppra. BP monitoring. CTA ends up showing the aneurysmal origin. She’d been a time-bomb her whole life and never knew it.

Transfer arranged. Flight is a no-go because of weather and the metro ETA is an uncomfortable number.

Katie’s mom arrived somewhere in that time.

Then Sarah. Then seemingly everyone else in that small town.

About 20-25 people, coworkers, sorority sisters, former roommates and siblings. All piled into a conference room we made use of because the consult room was too small. With mom’s blessing we debriefed the group together

There was a deafening silence…

Followed by quiet sobs and whispers. 

Mom’s complexion turns to pallor; her stare pierces the wall as tears stream down her face

I can hear Sarah say, “I thought it was just a bad date”

---

Katie gets transferred.

In the ensuing days she undergoes drains, decompression, trach/PEG, innumerable medications for seizures, agitation, and blood pressure.

None of it ends up being enough. I followed her chart for a little while until the inevitable became apparent.

Katie’s name sits in my list of patients still, with a little italic word next to it.

Deceased

---

Today, I think of my wife.

I think how we met through a dating app ourselves. Coincidentally, we were 27 years old at the time too. I’m sure I came off as a nerd then. In fact, I’m sure I still am. I wonder if she texted her best friend at the time the same way. Was she nervous and excited like Katie was?

I think back to our first date. I had to drive to the town she was living in just to meet her. I’d never been there, so I had to google dinner/drink spots just to come up with a suggestion. When I made my recommendation, her response was, giggling as she said it “oh, ha-ha no, not that place” before her offering her alternative location that would become our first date.

I think about how she looked. The outfit, the makeup, the hair. How she would have looked so out of place in an ER as well.

I think of all the years between now and then. The story we’ve written for ourselves as we’re currently playing with our first child. Maybe Katie was beginning to write her own story that night. We’ll never know. It was supposed to be their first date, but it ended up being her last.

Is there a particular study (labs/imaging/path) of which you commonly get a dumb satisfaction to seeing the results? Any that you dislike ordering or seeing in your inbox?

For me in Family Medicine (outpatient only), probably:

- Enjoy: Scoliosis survey XR results. I just find it fun to see how close my guess is to the measured Cobb angle. Also look forward to skin biopsy results and interval A1c results.

- Dislike: PSA (Urology access is poor in my region).

- Loathe Entirely: seeing that someone ordered HSV 1/2 antibodies for "STI screening" (whoever ordered it is going to hear from me after)

I'm glad that more women are accessing HRT, but this supply chain issue is a problem that is generating >20 portal messages a day.

This is the info I'm giving patients: 1) Check to see if their pharm has the weekly patch. 2) if not, then check the stock at a pharm that uses a different supplier. From what I can tell, Walmart, Amazon, Optum, Kroger, and King Sooper use one supplier. The other supplier is used by Walgreens, Safeway, CVS, and sometimes City Market.

Oral E2 increases VTE risk while transdermal does not, so I'm not willing to make that switch. I'll do gel or compounded if I have to, but the prior auths and self-pay issues are a nightmare.

Any advice for me or my patients? FWIW, the weekly patches don't stay on well--I have them slap a tegaderm over the top of their patch PRN.

Kalshi - the prediction market - partners with public intelligence AppliedXL to "launch a pilot suite of prediction markets on clinical trial outcomes and FDA regulatory decisions. The markets will create publicly available, accurate probabilities aiming to help solve drug development's information silo problem."

https://news.kalshi.com/p/kalshi-biotech-prediction-markets

https://www.reuters.com/legal/litigation/kalshi-allow-bets-clinical-trials-fda-decisions-2026-07-16/

Some notable examples you can already make a "prediction" (i.e., gamble) on: FDA approval for retatrutide, reclassification of BPC-157, approval of a cure for T1DM before 2033, POLARIS-AD phase III meeting its primary endpoint for Alzheimer's disease, and the timing of approval for camizestrant for breast cancer.

To that end, Kalshi adds some "safeguards" to their usual prediction market rules.

1. People will be ⁠able to bet only on the outcomes of late-stage ​trials as a part of the pilot program. Kalshi and ​AppliedXL will list a contract only after a trial finishes enrolling.
2. Each contract will be based on details of a named public document — the ​registered primary endpoint on ClinicalTrials.gov, the FDA approval letter ​or the voting record of the agency's advisory committee.
3. AppliedXL will define the criteria for reading ‌that ⁠document before the contract opens for trading, not after results arrive.

Commentary

In addition to the usual pitfalls of Kalshi (https://en.wikipedia.org/wiki/Kalshi#Controversies), you also have the ethics of even participating in these "predictions" (i.e., gambling) on clinical trials, as that adds a financial incentive for selective reporting of clinical trials like POLARIS-AD. Prediction markets in 2026 have already seen some widely reported stories on non-medical insider trading including (1) a US serviceman involved in the capture of Madero making said bets on PolyMarket, (2) President Trump's teleprompter operator making suspicious trades on Kalshi, and (3) former representative George Santos making trades on Kalshi on whether he will appear on the guest list for the State of the Union.

how do we think Jimothy, the hospital/insurance executive would feel about Jimothy the raccoon? and how would united healthcare monetize this situation?

Washington Post article calling out the obvious conflicts of interest in a forthcoming meeting of FDA's Pharmacy Compounding Advisory Committee, which is supposed to review the data and decide whether to allow compounding of certain unapproved peptides.

The fact that a significant percentage of the newly appointed members of the committee have a financial interest in these products, is a blatant conflict of interest apparently not seen by HHS Secretary Robert F. Kennedy Jr.

FDA raised conflict of interest concerns ahead of new peptide panel - The Washington Post

Hi there everyone. Just am curious how much of a problem the replication crisis is in medicine and biomedical science is in 2026. I will say despite having worked with public health scientists, most of my background is in a totally different area of science that only occasionally to rarely interacts with medicine and adjacent fields like public health.

I remember books by physicians such as Ben Goldacre (who also has an MPH) talking about the lack of understanding of statistics amongst some physicians and healthcare staff, and I remember John Ioannidis (though he was more shedding light on the replication crisis in science as a whole), but this was all written in the years from 2005 to 2016 and I have heard of registering clinical trials and stuff beforehand as one solution to the problem. Therefore, I'm curious how serious or how bad the problem is in 2026, though I imagine with widespread publicization of the issues facing the research, some improvement has happened (I hope).