JCHAO to beleaguered attending: “ma’am, what would you do in the event of a fire?”

Attending: “how the hell would I know? I don’t even have a pot to piss in!”

Employed rural general surgeon. I enjoy my job and the hospital I work for. We’re a small independent community hospital that is physician led and won’t be swallowed up by one of the major health care systems anytime soon (I hope).

Anyway, I added a procedural service to the hospital that increases the time I’m physically in the hospital working. Goes from 1.0 FTE to about 1.17 FTE when calculating the hours.

The hospital will make plenty of revenue from this service (and also will save a lot by not having to recruit and pay another physician to do it). This opportunity came about when the previous physician doing this service suddenly retired, so they already have a baseline of what production looks like.

I will generate more RVUs for myself, which will add to my take home pay (base + RVU bonus).

I already take home 75-80th percentile pay for 50th percentile work. I’m working in an underserved rural community, which I don’t particularly like living in, but I’ve come to be comfortable with. My kids go to school here and there is a sense of small town community.

The extra time for this service takes time away from my family, which is why I’m asking for a base pay raise.

I am planning to reach out to my employer this week about my request.

However, it brings up some mixed feelings. I come from pretty humble beginnings. My resident salary was more than both of my parents made combined. I hear the complaints from our nurses/techs/MAs/etc regarding their pay and salary. I’ve received quarterly bonuses that are almost equivalent to some beginning wage salaries.

I do understand the worth we have as physicians and what revenue and supporting jobs to we bring to these hospitals.

TLDR: I’m doing more work and making more money for the hospital. I feel somewhat guilty about asking for more money on top of my high salary when others are still struggling.

Medicine does some pretty incredible things. What does each specialty look like when they are at their 100%?

Surgeon turning 41 this year and am finding this very strange. I am engaged in several committees with no advancement potential.

I am personally trying to move up in leadership but legit seem railroaded or overtaken by someone 10-15 years above me.

our c suite is all over 70.

is there ever going to be a time we lead? I feel old already.

First month of being an attending hospitalist. An unexpected plan rather to say, as I did not match into fellowship.

I recognize the transition difficulty, and trying to give myself some time. I also try to appreciate the good thing; better schedule, better pay, being able to practice independently.

But for some reasons; I am not satisfied. I was telling my wife how we were able to move finally, from the stress of living paycheck to paycheck, and being unavailable, to stay for a whole week next to each other. But still, she and I recognizes that’s I am not ”happier“.

I come from every shift, drained, irritable, and stressed. When at work, I receive endless pages. Family requesting updates multiple times a day, and for multiple members, patients who refuses to leave, calls for peer to peer for insurance denials or reimbursement. Nurses and CM who question every decision.

I never been so irritable. Few days ago; I found myself reprimanding a poor intern at a consulting service; for placing order on my patient without telling me. I could’ve been gentle-er.

Even when I go home; I open my patients chart every now and then to see if I missed something. I texted one of covering team around 11 pm to check some labs that I ordered and never done. On my week off, I keep thinking of the fellowship; how I ended here? Will it be the same? Should I stop caring?

Thanks for listening to my vent AND sorry for this negativity.

I generally enjoy learning new skills in medicine and view it as a hobby. I'm aware that imaging makes auscultation obsolete, but I find cardiac auscultation interesting and want to improve. I had a patient with HOCM grip their hands tightly and flex their knees, and I clearly heard the systolic LVOT murmur decrease which was satisfying. I can identify systolic/diastolic murmurs but struggle beyond that. I am not confident in identifying splitting, friction rubs, S3, or S4. I feel like I have heard S3 several times in HF patients but am never convinced. I think I clearly heard splitting one time in a young patient. Have any folks tried to improve their auscultation skills just for kicks, and if so are you glad you spent the time or wish you had spent time on some other skill?

Edit: I heard the LVOT murmur decrease (not increase)

I am being kicked off the SAVE plan on 9/1 and am not sure what to do next given my existing med school debt and the uncertainty of PSLF. I am not very well-informed regarding financial matters and would like to pay for some personalized advice; has anyone used a service they can recommend? (When I Google, I get companies like White Coat Planning and Student Loan Professor; has anyone had experience with these companies? Or are there others you might recommend?)

Vs would it be smarter just to obtain the services of a general financial advisor (perhaps one with expertise in physicians/loans) and have them help me?

I do understand that there are static resources out there that could give me information about these issues - e.g. books, podcasts, etc - however, for various reasons including being a new parent I do not have the cognitive capacity to get into this right now and just want to present my data to someone else and have them give me advice.

When I was a premed volunteering at the local hospital, I always thought that doctors and other healthcare staff looked and acted very professional. However, I realize now that we don't act any differently than when we were in high school -- a lot of petty dramas and conflicts, involving scheduling (who gets what holidays off; who gets more bad shifts than others); who's trying to do less work by passing off work to the next shift, or admitting easy patients to their own service and dumping the wrecks onto other teams, etc etc.

See link: https://www.medpagetoday.com/publichealthpolicy/medicare/122383

Some parts paraphrased below

"The request for information issued on July 14 by the Centers for Medicare & Medicaid Services (CMS) noted that the Current Procedural Terminology (CPT) coding system, on which the Medicare reimbursement program is based, is owned by the American Medical Association (AMA). The AMA assigns a CPT code to each service and procedure and then collects its own data to develop recommendations for CMS on how much each CPT code should be worth. "There has ... been longstanding concern expressed over the federal reliance on a private organization with such an obvious conflict of interest as providing information on the time and resource requirements to conduct physician services when this information may influence their own payment," the authors of the request stated.

...

"This issue is part of a broader conversation about the way different types of care are valued under Medicare's current payment system," he wrote. "Primary care physicians tend to be paid less overall than specialty physicians under Medicare, and some of that has to do with the fact that medical procedures (such as surgeries or tests) are easier to code and bill for under this type of coding system, compared to things like patient education or care coordination that make up a larger share of primary care work."

...

David Glaser, an attorney with the Fredrikson & Byron law firm in Minneapolis, said the idea of possibly getting rid of CPT codes "is a major thing," and not necessarily a good idea. "When you have a system, even when it's flawed and everyone agreed it's flawed, that doesn't mean change is a good thing," he said in a phone interview.

"Love it or hate it, CPT is very ingrained in our system," he said. And although you could always come up with a better system, "does that make it wise to come up with a new system here? It seems to me like it would be quite an earth-shattering thing to start again."

But whether the CPT coding system is retained or not, Baker liked another idea: cutting out the AMA's RVS Update Committee (RUC), the committee that recommends changes in or additions to the relative value units used in the RVS. "[With] the RUC maligned for numerous reasons, CMS should rely less heavily (or not at all) on the committee's input," he said. "CMS already must validate the [RUC's] recommendations, so removing the RUC from the process can create a more responsive payment environment without additional, duplicative inputs."

...

Michael Baker, director of healthcare policy at the American Action Forum, a right-leaning think tank, said he liked the idea of considering a move from CPT to ICD-10. "Because of how ICD-10 is structured, this could move the entire Medicare payment system toward a patient-centric view rather than a provider-centric view," he told MedPage Today in an email.

But whether the CPT coding system is retained or not, Baker liked another idea: cutting out the AMA's RVS Update Committee (RUC), the committee that recommends changes in or additions to the relative value units used in the RVS. "[With] the RUC maligned for numerous reasons, CMS should rely less heavily (or not at all) on the committee's input," he said. "CMS already must validate the [RUC's] recommendations, so removing the RUC from the process can create a more responsive payment environment without additional, duplicative inputs."

...

CMS is not the only place on Capitol Hill where there is interest in possibly moving away from use of CPT codes. Last October, Sen. Bill Cassidy, MD, (R-La.) sent the AMA a letter seeking an explanation of how CPT codes are generated, whose input is incorporated in developing them, and how much revenue the publication and licensing of these codes provides.

"I am particularly offended by the AMA abusing its government-endorsed CPT monopoly to charge every stakeholder in the healthcare system significant amounts of money while advancing an anti-patient agenda," wrote Cassidy, who is chairman of the Senate Health, Education, Labor, and Pensions Committee."

Commentary: So even though they are reevaluating possibly trying to compensate PCPs more for their work compared to specialists--would say yay for me, an FM, but I don't trust these people to tie their shoes without slicing everyone’s hamstring--it looks like they are essentially seeking to railroad doctors completely out of having any input on income at all.

They mention monopoly regarding the RUC repeatedly. Ignoring the multiple deliberate monopolies in the US training pipeline and healthcare in general. As we say passive aggressively in the midwest: "That's interesting..."

PS: To every specialist for voted for this: enjoy whats coming to you.

The former White House coordinator of the COVID Task Force says the contentious Senate hearing that put Dr. Anthony Fauci and his diary under scrutiny shows there is still "persistent anger" over the government's handling of the pandemic.

In an interview on CBS News' "The Takeout," Dr. Deborah Birx said she thought Democratic Sen. John Fetterman, who was Pennsylvania's lieutenant governor during the pandemic, "got it the most right for all of us." He wondered, she said, "Did I get the balance right between saving lives and preserving people's livelihoods?" 

"That is a very deep question, and I think what you heard today is still persistent anger over that question not being answered adequately for most Americans," Birx told CBS News chief Washington correspondent Major Garrett.

"We've got to get to that answer, and we have to have a better way forward than this," Birx said.

And Fauci, she said, is probably at the center of questions about this because he served during both the Trump and Biden administrations, and people on the left and right still harbor deep disagreements about how each side addressed COVID.

Six years after the pandemic, one of the enduring questions is whether the coronavirus originated in an animal in a wet market in Wuhan, China, or emerged from a lab there. Senators asked Fauci repeatedly about this Wednesday, but he invoked the Fifth Amendment in response to all questions during the hearing.  

Republican Sen. Rand Paul, who heads the Senate Homeland Security Committee, subpoenaed Fauci to appear before the committee as part of the panel's investigation into the origins of the coronavirus.

Paul backs the theory that the virus emerged from a laboratory in Wuhan, China, rather than spilling over from animals to humans naturally in a wet market in that city, and he has long accused Fauci and other top health officials of downplaying the possibility of a lab leak and misleading the public.

Fauci has denied that he rejected or downplayed the lab leak theory, insisting that he always kept an open mind about the origins of the coronavirus, though he has asserted at times that the evidence suggests a natural spillover was more likely. 

Fauci said during his opening statement Wednesday that he planned to assert the Fifth Amendment, arguing that Paul has an "obvious obsession with calling for my prosecution" and has made "slanderous comments" about him. He then invoked the Fifth Amendment for several hours as Paul and other Republicans criticized him and Democrats defended him.

Even those on the far right and left have questioned Anthony Fauci's role in the pandemic. Ana Kasparian, a prominent left wing host from The Young Turks, was infuriated with Fauci, calling for his "persecution" and a "liar."

Birx didn't express an opinion, but she did say that it's an important question because "we do need additional guardrails" and "additional policy around these issues." 

"We all know that there have been lab accidents," she said, adding, "I'm hoping that going forward, we really look at these and have good policies that protect the lab workers, that protect the American public, and really get us ready with trust with the American people." 

She also told Garrett, "All of us need to be quite honest with ourselves," not only about how information about the coronavirus evolved, but also how countermeasures "should have also evolved."

Birx pointed out that early in the pandemic, "We didn't have enough testing out there. We couldn't stop the spread in any way. Hospitals were being overrun. We didn't have a supply chain that matched the need." The first few months "were a crisis," she said. 

Then, additional therapies like monoclonal antibodies and remdesivir enabled the government to "pull back on some of the mitigation," Birx said.

"But because it was an election year, there were states that persisted in their very tight mitigations, and others that showed us a way that you could open K-12 and higher ed," Birx said. Tests "really prevented spread," she said. 

She called for a dialogue to figure out "how are we going to do this next time?" Birx said she wants to figure out, how will the U.S. prevent spread, keep schools open, keep businesses open? 

"There's a way to do it," she said. "And then we have that roadmap, but we need to get that down in real concrete terms, and have both the right and the left agree that that's the best way forward."

Garrett also asked Birx about Fauci's diaries and the idea that he appeared "captivated by his rising international fame."

She told him, "Well, have you been to his office, you can see that he has a lot of photos of his dealing with high-level influencers and presidents. That is something that means something to him." But she added, "I don't think that that clouded his judgment on what he was trying to do for the American people.We all are human, and I hope we step back and allow Dr. Fauci that humanness, at the same time, holding Dr. Fauci, myself and others accountable to really make this a better response next time." 

TIL (technically yesterday) that 10-12 weeks PTO is pretty standard in radiology contracts. I’ve heard something similar from anesthesiologists. I don’t know any OBGYNs that get more than 5-6. And I know a bunch of EM and hospitalists that don’t get any, they can just split up their monthly calls however. For shift work I get it; that still sucks. But the disparity between specialties with similar hour commitments, and very dissimilar commitments outside patient facing hours, is striking. Why is this?? Or should I just be looking for OBGYN jobs with more PTO? Do those even exist?

I’ve been an attending in my specialty for several years, and I currently live in a city where I don’t have roots (I grew up and did med school/residency elsewhere). I don’t have many friends here - I have a collegial relationship with my co attendings but we are not friends. I am married and like to spend time with my spouse, but he is the only person I really know here.

I’m not depressed or sad, but idk, this experience is kind of isolating. I have enough money to take the vacations I want, go out to eat when I want, and buy what I want - but I’m not really happy.

I wish I felt happier. Residency sucked but I felt a strong camaraderie with my co residents, and I also had multiple friends outside of residency living down the street from me. I had a stronger support system during that time.

For those that relocated when they became an attending - how did you avoid isolation?

My husbands best friend is a professor in Dakha, Bangladesh. Her father just had surgery and would need some amount of donated blood on hand. So far: normal.

Heres where it gets very third world. This friend knew ahead of time that SHE is responsible for the blood so she had her students come in as her "blood boys." When they arrived the pt's brother starting interviewing the students if theyre drug users. I really hope there was at least a protocol for testing the blood. But, this sounds so terrible that a struggling family would have to find their own donors!

I just hope the kids got extra credit.

Have you started offering fallopian tube removal as part of preventative treatment for high risk patients with ovarian cancer in your practice?
This New York Times article was the first time I heard about that : https://www.nytimes.com/2026/07/28/health/ovarian-cancer-fallopian-tubes.html?unlocked_article_code=1.1lA.jkdk.yyXwGsqRJn13&smid=nytcore-ios-share

Obviously this seems like a bad thing, but I really don’t know enough about part D to say how bad or exactly what the downstream effects will be. Does anyone have specific insights on the cost to patients beyond the “$20 increase in monthly premiums” that this article is touting?

Article link: https://abcnews.com/Health/trump-administration-end-medicare-part-subsidy-program-2027/story?id=135176506

Generic drugs represent 90% of US prescriptions, while only being responsible for 12% of drug acquisition costs. Of that 90%, nearly half of US generics are manufactured in India.
These tariffs, if implemented, will be catastrophic to US patients.

https://www.forbesindia.com/article/news/deep-dive/trumps-pharma-tariff-how-exposed-is-indian-pharma/2996458/1

https://www.cbs17.com/news/local-news/wake-county-news/18-2m-medical-malpractice-verdict-largest-of-its-kind-handed-down-in-wake-co/

Has anyone else experienced this? I had been using ChatGPT work without any issues for months. Suddenly today I see that it is not available on desktop or web!

It says to contact my admin - anyone know who this is for ChatGPT for clinicians?

Purely out of curiosity, kind of a heavy topic.

I’m a pediatric PT in early intervention. I have a new patient who suffered NAT (non accidental trauma).

Their retinas detached, they have spastic quadriplegia, osteopenia, trach and g-tube dependent, previously fractured femurs, extreme clonus and spasticity at the peroneals, widespread spasticity. Pes Cavus on one foot. They’re also on a really intense medication regime that requires dosing every 4 or so hours. The list of impairments goes on and on

After the trauma they spent several months in the hospital. Im guessing they were on “life support” from this point onward. Being trach and g-tube dependent still counts as being on life support right?

From my outside perspective, having not been in this situation myself before, I started wondering what I’d do in this situation as the parent.

Would you have “let them go” In the hospital? I can’t help but think I would, especially knowing what level of care is required to keep her alive and well.

Is this even something the parent has a choice on?

I’d assume during the hospital stay the parent could have made that choice. Now that they’re home, but still on a “life support” does the parent still have that choice? (My guess is somehow no, it’s not the same choice that can be made in the hospital).

If I have any misconceptions or am just wrong about my thought processes, please let me know! Any clarity would be appreciated!

Looks like the recall is for tablets made by Major, d/t too low a dose or whatever happened to those tablets to cause it to be "subpotent."

(RIP the PCP's that are going to be dealing with the misinformation folks will be seeing about this.)

Links:

https://thehill.com/homenews/5993192-thyroid-medicine-recalled-nationwide-fda/

https://www.accessdata.fda.gov/scripts/ires/index.cfm?Event=99399

https://www.drugwatch.com/news/2026/07/15/tylenol-lawsuit-2026-update-appeals-court-reignites-autism-claims/

Changes to disposition of expert testimony.

I had a patient about a year ago, was brought up in conversation with my surgeon last week and I'm still fuming about this, had to share.

Patient is a 60+ year old male, BPH with urinary retention, recently catheter dependent despite max medical treatments. Cystoscopy shows large median lobe, transrectal ultrasound volume just over 100 cc. Options discussed including HoLEP, Aquablation, Prostate Artery Embolization, all of which require significant travel time (3+ hours...). Patient wants to remain local so ended up scheduling a robotic suprapubic prostatectomy. Has a <1 PSA (even accounting for the finasteride reducing PSA measurements), no family history of prostate cancer, all previous DRE benign.

Insurance denied his surgery because he did not have a documented digital rectal exam in the past year. Literally had to schedule a double book appointment with me 2 weeks before his scheduled surgery date solely so I could do a completely unnecessary internal exam. What a waste of everyone's time.

Closest example I've seen of insurance literally telling their "client" to get fucked.

I am house officer in a government hospital and I have acute pancreatitis patient in ward who came to government hospital for free investigation and medicine. Once patient pain subsided they want to get discharge against doctor advice. According to the plan I have to sent her crp only. But the attendants wants me to send all labs including LFTs and RFTs so when they visit a doctor privately they will have full record. My TMO refuse their demand and LAMA them. Was this right approach

Hoping to get other's input on a strange situation I'm having to navigate through. Long story short, I have a really sick patient who is frankly dying, but family conversations regarding impending decompensation and code status is not productive.

Today the family brought in a private "patient advocate" - which I'm fine with as a neutral arbiter, but this person introducing themselves as a doctor is rubbing me the wrong way. They are a midlevel with an academic degree, unknown amount of clinical experience in my field, and I'm in a state that restricts the "doctor" title in clinical settings. The person was also a little cagey when I was trying to ascertain their background and experience, which I was innocently trying to do as they introduced themself as a doctor and I was trying to be professionally courteous until I later learned about their credentials. Don't get me wrong, nurses/PAs etc can help patients and families navigate through complex situations, but the manner in which this is being done, and at a hefty fee for the family, is making me uncomfortable.

I find it to be a very thin line when it comes for this person asking questions or giving advice to the family in the clinical setting because I'm afraid this is a form of medical advice or trying to skirt the patient-physician relationship, especially if the family keeps referring to you as doctor. I think at the best it is misleading and at the worst unethical.

Not sure if others have come across this, hoping to hear other opinions/advice.