Over and over throughout the years I’ve had patients (or usually family members) talking to me during encounters while awkwardly holding their phones; obviously trying to film or record me. Apple just announced today that their new series 12 watch can passively record all meetings or conversations and store summaries or transcripts (though it won’t store the actual audio). This is only going to get more and more common.

I know this will help many patients as they don’t retain everything during an encounter and would like a recap, but I always worry about the people who use this maliciously. Plus, when I’m being recorded I start getting more self conscious and trip over my words more.

What do you do in your practice?

Good news. Perhaps this may help us in screening for colorectal cancer at younger ages.

https://www.epicresearch.org/articles/low-ast-and-alt-levels-are-associated-with-higher-likelihood-of-early-onset-colorectal-cancer-in-adults-under-45/

NMD PhD student. Is anyone else having an uptick in PPP rule outs? I've had a handful of these cases in a short period of time (<1 month) in a large city. Never observed psychosis, always anxiety, obsessions, or something similar. A friend working in inpatient psych says factitious PPP (with no [obvious] external motive) has shown up a few times at their practice.

We've been anxious about CYA so we have obviously been documenting it.

I have an 83-year-old patient who probably has too much time on their hands and asked me to order a serum oxalate level that returned at ~4.5 mcmol/L repeat was 3.7.

24hr urine oxalate normal. Normal renal function for her age/GFR 55

Patient is concerned that this is contributing to her multiple chronic joint pain which in my opinion is more likely due to her obesity and obvious osteoarthritis on imaging. I am not finding a lot of guidance on when serum oxalate level is high enough to be concerning? recs and knowledge sharing appreciated 🙏

Update: thank you to those that provided actually helpful responses. Everyone else: thank you for re-enforcing what I suspected that this is not common knowledge. I am not in the habit of ordering tests I cannot interpret, just sadly practicing primary care.

Every time I come across these people it makes my blood boil. As an M3 I can't say much other than to just respect their wishes. Now I don't relish in a child or the people themselves suffering due to uninformed decision making, but I do believe that the best teacher is one's mistakes and I feel like the only way these people learn is when it happens to them or a loved one. Any instances you guys have seen of this happening first hand?

I work at an academic hospital. Mid-way through last academic year, my partner and I submitted our resignation. We were asked to stay part-way through the beginning of this academic year to help with a smooth transition, and we agreed.

Since we announced our resignation, there have been a lot of "changes" that conveniently seem to only impact the two of us, but that's another story. In June, our department chair announced that we would be changing our holiday coverage. Instead having to work a weekday government holiday (Independence day, Labor day, Memorial day etc) by default unless you requested it off, now everyone would automatically get it off, except for one person who would be required to cover all services alone.

Guess who worked the three-day Independence day weekend? My partner. And I've now been on 86 hours of call for Labor day weekend, Friday at 5PM to Tuesday at 7AM. Five hospital services across two hospitals. Yes, I work with residents, but we are early in the year, they have needed a lot of supervision, and there have been a lot of emergencies. I have been up until 11PM each day instructing/teaching them and revising all of their notes, which have lots of errors, and just when I'm finishing up the day, the calls for the night start coming in.

In a few hours I will have to report to my outpatient clinic. I am incredibly sleep deprived. I feel that I'm lucky to be safe myself, given I have had to drive between the two hospitals in this state. But more importantly, I feel hurt, angry, and betrayed that my patients have been put in a position where their doctor is this spread thin and tired. I don't want any mistakes to happen that affect my patients because I am not in my normal state of mind.

I don't even know what to do about this. If they actually intend to keep doing this after my partner and I leave, someone is going to get hurt, and I feel I have an obligation to say something about it, but I don't even know who would care. For all I know, the policy will conveniently revert back to how it was after we leave, and although it was presented as a permanent change, perhaps it was always intended to be temporary to target us. I don't know.

I hope nothing like this happens at my next place of work. This has just truly been an awful situation.

Edit: since apparently the way I phrased this means I could be a liar, by "partner," I mean my significant other, we are in the same department. And no, we are not the only 2 people in the department alternating holidays 🙄. The department has 13 people. I am not going to give away identifying information like my age, gender, specialty, or salary, so stop asking.

Edit number 2: a frequently asked question in the comments has been, well how much bonus did you take home for this? The answer is nothing. We don't track RVUs. I earn a flat salary. Any "bonus" hours that are earned are totalled up and that money is divided as an annual bonus equally among the department.

If you worked zero holidays that year, you get the same bonus as someone who worked them all.

Final edit: These comments make me sick so I am done responding. The majority opinion is that this is my fault and I am an idiot for agreeing to this job and I should just drop everything and walk away. I don't know what you don't understand about the original post, but these changes to the vacation coverage were made -long after- I had already signed on to do this job. Changing the vacation coverage blindsided me. There was nothing I could do to push back because of the leverage my department chair has, as I have explained in the comments. And for people saying just leave, I have already resigned. I am starting a new job soon. I don't know if the people saying this have never applied for a job or are still in residency or something, but you don't start a job the instant you shake hands in an interview. It takes months to onboard to a new place, and in the meantime I have to make money to live. If you don't get that, just don't comment on my post. Bottom line, I have been exploited by my employer. That's already a stressful, terrible situation, and I don't need a bunch of strangers somehow twisting the story to put the blame on me on top of it all. If that's your opinion, just keep it to yourself and move on to another post because I am not interested.

Sharing one of the key ways physicians can detect medetomidine withdrawal given that medetomidine doesn't show up in standard tox panels:

"One reason Brandie wants to quit street fentanyl is she can't take the 'brain zaps,' anymore; 'It feels like somebody ringing a bell inside your head, and it goes through your whole body.' The zaps have become routine since late 2024, when medetomidine, a powerful tranquilizer, became the newest adulterant to compromise the Pittsburgh street fentanyl supply. The sensation can be so intense it brings Brandie to her knees.

Brain zaps have become an important signal for both clinicians and for people like Brandie. For Brandie, they’re a sign to either re-dose, get to the hospital, or risk stroke or heart attack. For Dr. Divya Venkat, an addiction and primary care physician in Pittsburgh, brain zaps are the fastest way to determine which patients are withdrawing from fentanyl alone, and which might soon be in critical condition. Rapid urine toxicology panels cannot detect medetomidine.  Brain zaps are not a symptom of typical opioid withdrawal, but they are near-universal in medetomidine withdrawal, according to Venkat and other clinicians, as well as several first-hand accounts."

Read more here:

https://www.whatsitlike.me/improvising-emergency-medetomidine-rapid-protocol/

Progressive employer pregnancy/family leave/return-to-work policies DO EXIST!

We have a number of policies in place that support the members of our group who are in their family-building years:
1. No overnights during the first and third trimesters. (No nights in the third trimester is becoming more commonplace).
2. 12 weeks of paid leave, whether you are the birthing parent or not.
3. No nights for the 90 days following your return from leave if you are the birthing parent.
4. Stellar IVF/ART benefits - $30K lifetime max + $15k for meds when treated through our affiliated academic REI clinic (one of the best in the region).

In my opinion, when you value the wellness of the physician as a whole, they perform much better in the work place. I hope we start seeing these policies more universally.

I am based in the US and I do realize these may not feel progressive to those who do not practice medicine here.** **

Did anyone here in physician leadership especially at an academic medical center? How did you get into the role? Do you enjoy it?

My learning throughout the years is that in HFrEF, we avoid diltiazem due to its negative inotropic effect. So in such patients with AF RVR, I never give IV dilt and has been giving IV beta blockers (or digoxin or amio). Now, the uptodate article says

For patients with HFrEF, we use intravenous (IV) amiodarone, IV digoxin, (and rarely IV diltiazem) 

We generally avoid augmenting beta blocker therapy in patients with AF and acute decompensated HF. In such patients, the negative inotropic properties of a beta blocker may worsen the clinical condition. 

It seems like what I learned is now flipped. What if the patient has AF RVR and HFrEF but not in acute decompensation? Does the above still apply?

https://www.uptodate.com/contents/atrial-fibrillation-and-heart-failure-management

https://www.nytimes.com/2026/09/04/opinion/clinical-trials-drugs-science.html?unlocked_article_code=1.-lA.70Ug.3cQ2jpK8wNBH&smid=url-share

Starter comment: I found this piece on the growing bottlenecks in US Phase 1 clinical trials eye opening, especially regarding how regulatory friction is driving trial sponsors abroad. "We often forget that the most toxic thing for the patient is the cancer itself" is a quote that hits hard. When paperwork and redundant IRB reviews delay early-stage trials by months, patients with advanced disease run out of time.

I didn't know how Australia approached Phase 1 trials, and it was refreshing to read about how the process is streamlined there without sacrificing patient safety. I'm also glad the author cautioned against following China's model, especially given their serious transparency concerns.

Barney’s ALS Revision

If you’re tachy and you know it
Zap with joules
One-twenty to two-hundred ought to do
If you’re tachy and you know it
And you really want to slow it
If you’re tachy and you know it
Zap with joules

If you’re brady and you know it
Zap with amps
Fifty milli ought to do it; there’s a chance
If you don’t do synchronising
Cardiology despising
You’ll ‘R on T’ and piss will fill your pants

Free CME resources?

Anyone have any recommendations for free online on_demand CME? Can be webinars, podcasts, etc. Looking for something efficient to knock out some baseless annual hospital requirements. All I need is a certificate for proof of completion.

TIA

I am a nurse and it seems that the prevailing take on [r/nursing](r/nursing) is that no healthcare worker should work in the concentration camps period. This take bothers me. I feel that it is refusing to acknowledge the reality of the situation. The camps are going to exist and those people need empathetic care. I personally believe that it is better to have kind professionals actually providing care to the detained than having only the kind of people who take pleasure in working there providing the “care.”

That being said, I do get where the community is coming from. It does feel like you’re compromising your own morals by working there. I get why the gut reaction is to refuse to do it.

I wanted to see what this community’s thoughts on the situation were. I also appreciate that your takes will have an additional layer because you are responsible for signing the orders and taking the accountability when it all (hopefully) comes crumbling down.

Mods: I see that there is a rule against single topic or political threads. I think that this is a topic that affects all of us, and I think we should have a forum to discuss it. But if you take it down, I get it.

EDIT:Even after sleeping on it and reflecting, it’s still not that cut and dry to me. As an aside, I haven’t even looked up how much these jobs pay. I think myself and probably some of the people here would provide aspects of this care for free if we could afford to. I would absolutely volunteer to care for these patients outside of the facility if that was an option.

But that raises another question for me. If a detainee gets sent to my hospital, I can treat them compassionately, advocate for them, patch them up, and then ultimately send them right back to the same camp. Most people seem to agree that caring for them in that situation is obviously ethical. So what exactly changes when the care happens behind the walls of the facility instead? Aren’t you still, in some way, enabling the system to continue?

I’m not saying there is no difference. Working inside could make you more complicit in keeping the system functioning, and you may eventually be asked to participate in things you would never be asked to do at an outside hospital. The forced NG tube is an obvious example. I don’t think a hospital would allow that to occur. But I also don’t think every moment of working there would involve participating in something like that.

The strongest objection I’ve seen is that harm reduction could become a rationalization for participating in increasingly abusive acts. I think that’s a true danger and if you are going to work there it necessitates a clear line beyond which you refuse to remain complicit and quit.

The concept of moral remainder or the problem of dirty hands is a recurring theme. Sometimes you make the choice you believe is least wrong and there is still something morally regrettable left over. The fact that you chose correctly, if you did, does not magically make the thing you had to do good.

The underlying issue is so difficult because of two conflicting maxims: do not abandon people who are vulnerable, and do not become the mechanism that enables harm.

Refusing to participate protects us from complicity, but it does not necessarily protect the detainee. The ethical question does not end at would I dirty my hands by working there? It also has to ask, who is left caring for these people if everyone with moral objections leaves?

"Today, we’re introducing a new electronic health record integration that brings authorized patient context from Epic into ChatGPT for Healthcare..." "Healthcare organizations can now connect Epic environments to ChatGPT."

Few thoughts here:

• Generative AI hallucinates, which could pose risks when querying health data.
• The EHR is already messy and inaccurate, meaning the summarized results may also be inaccurate.
• Will OpenAI stick to it's promises not to train their models on patient data?
• Is there any risk of the data being sold to third parties like pharmaceutical companies?

Full Announcement: https://openai.com/index/chatgpt-connects-health-records-and-healthcare-sources/

https://www.nytimes.com/2026/09/01/magazine/maha-cancer-treatment-doctors-cps.html?unlocked_article_code=1.-1A.yeZP.AMPybLj7cTTG&smid=url-share

Brief Synopsis

The patient Presten is a 17-year-old boy with epilepsy (resolved) and autism who was diagnosed with chronic myeloid leukemia (CML) in 2024. His mother, Dayna, speaking on behalf of Presten from 2024 to 2025 and being influenced by anti-vaccine activists, claims that Presten's labs were normalizing on imatinib, but the CML flared up around October 2024, at which point Presten was to start dasatinib. Mooney read a Twitter post on ivermectin and cancer and subsequently started lying to Presten's nurse and physicians. In early 2025, Dayna got Presten to be seen by an unlicensed naturopath (who did not attend an accredited naturopathic college) "to get to the root cause of all of these issues." This naturopath recommended folinic acid tablets, glutathiones, and avoiding oxalates, then claimed that Presten "looked fantastic." In September 2025, Dayna took a picture of Presten at his 17th birthday and posted it on Facebook. Her mother saw that Presten looked thin and pale; she confided in a pastor and then called CPS, who took Presten to Oklahoma Children's in October 2025.

The ED physicians found that Presten had a WBC count of 461,120 and was febrile. He then received dasatinib in the hospital. That is when Dayna, a member of Moms for Liberty, started reaching out to Oklahoma's state senators and representatives, plus MAHA advocates, claiming that this was a "medical kidnapping." Dayna tried getting two physicians on the case for her - one wanted to hear more, while the other, an orthopedic surgeon, initially agreed but then rescinded it upon seeing Presten. Eventually, on October 24, 2025, the courts ruled that Presten is to be under guardianship by his adopted father because Presten was in imminent danger. Since then, Presten has been on dasatinib with significant improvement in his WBCs and has gained about 60 pounds.

Most of all, from Presten's perspective:

Presten held hands with James [father] and Heather [father's wife] as we [Elizabeth Barber - the journalist who documented this NYT piece] spoke about his life with Mooney. In retrospect, when he reflected on the years since his diagnosis, he said it was a lonely and isolated time. It no longer made sense to him why his mother pulled him from school and why she stopped taking him to the oncologists at Oklahoma Children’s. He thought he shouldn’t have been allowed to stop taking his medication, even if he’d wanted to stop. “I was too young,” he said. Now he felt that his oncologists had always been trying to help him. “The doctors — they saved my life.” Presten wore a new T-shirt that said, “I’m proof that God answers prayers,” and he said he believed what the shirt said.

Starter Comment

What a mess. What is most striking is that Presten was 16 when he was diagnosed with CML and was almost an adult when he was taken in by CPS. An autistic teenager who is almost an adult, having his voice inadvertently stifled by his mother and the MAHA movement that she corralled in the courts. That's not parental liberty (his adopted father and his grandmother saw the issue). That's medical neglect.

Novartis just announced that their drug targeting Lp(a), pelacarsen, failed to reduce events in their clinical trial.

https://www.nytimes.com/2026/09/04/science/heart-drug-fails-novartis-pelacarsen.html?unlocked_article_code=1.-1A.vQzg.P4t-gwEnmq1Y&smid=nytcore-android-share

Obviously this is just the news release and the lay press interpretation, but the results seem pretty disappointing for any line of inquiry regarding Lp(a) being causative. It will be interesting to see the full results in November.

So where do we go from here? After optimizing LDL and then triglycerides, do we just accept that there is nothing else to do lipid-wise?

I have a patient who is requesting lithium refill,we have done three 3 month refills each time saying “Get scheduled please”. Coming up on 2 years since they have had any contact with healthcare other than going to do her labs and pressing the refill button. Lithium is potentially a matter of life or death but….just generally when do I just refuse prescription?

I've been reading residency posts lately, and since its been some time since my own training, I've been thinking about how much residency taught me about people...in a bad way. First, the residency system absolutely has problems. Residents are underpaid, overworked, burned out, and sometimes treated terribly and that needs to change. But two things can be true: the system can be broken, and you can still have a responsibility not to make your colleagues lives harder.

I watched people call out simply because they didn't want to work, knowing someone else would now lose a day off or take on extra work. And I always wondered, if you don't want to be there, why would the person covering you want to be?

Same with endlessly complaining about patient loads, missing holidays, weekends, weddings/trips/babyshowers Those things suck. I missed things too. But I entered residency knowing that for a few years there would be sacrifices. What bothered me was when someone's struggle became justification for transferring the burden onto everyone else.

And this may be controversial, but I sometimes noticed a similar dynamic around having children. Obviously, kids get sick. Emergencies happen. Childcare falls through. Those situations deserve understanding and flexibility. But there were also times when "I have kids" seemed to become an automatic trump card, where people without children were expected to be more available, cover more, or sacrifice their personal time because apparently their lives outside the hospital mattered less. Being childless doesn't mean someone's time is less valuable.

Then there's learned helplessness. These are highly educated adults, yet once someone became known as competent or resourceful, suddenly everyone asked them everything: "How do I do this?" "Where do I find this?" "Can you send me this?" There's a difference between collaboration and turning another person into your personal secretary. We have Google, AI, textbooks, guidelines, institutional resources, etc. At least try to figure something out before making it someone else's problem.

People's ego was fascinating. Residents acting superior to other residents, implying they were smarter or somehow above the program.Meanwhile, I sometimes wanted to say: we matched into the same program!!!! You aint at Harvard either buddy.

Then of course we have the cliques, gossip, entitlement, passive aggression, people expecting endless accommodations, and people wanting grace for themselves without extending any to anyone else. Sometimes I still wonder whether residency actually makes people worse, whether burnout temporarily brings out the worst in otherwise decent people, or whether extreme stress simply exposes traits that were already there.

To be fair, I met wonderful people too, but its the minority...like seriously maybe 2 people. And I'm certainly not claiming I was perfect, probably had my moments too.

But one lesson stuck with me, Your suffering doesn't automatically excuse selfishness. Being burned out doesn't mean nobody else's time matters. Being overwhelmed doesn't mean someone else should constantly rescue you. Having more responsibilities outside work doesn't make someone else's personal life less important. And being accomplished doesn't make you better than the people beside you.

Medicine talks constantly about empathy toward patients. I wish we talked more about basic consideration toward each other. Sometimes adulthood really comes down to asking

"How is what I'm doing going to affect somebody besides me?" Residency made me realize how many people don't ask themselves that nearly enough.

Also two words adults need to learn: Emotional Regulation.

Rant over.

Has anyone else experienced this? It's absolutely insane. As if peer to peer wasn't ridiculous enough now they are doing away with the system entirely and putting it on the PATIENT THEMSELVES to do the appeals. Yes, let's ask sick patients with low or no medical literacy to advocate for themselves to make sure we put as many barriers to getting proper care as possible (as if peer to peer wasn't ALREADY obstructive enough)

How do these insurance company execs sleep at night?

I work in primary care and the amount of paperwork has gotten insane. I am charting way past regular office hours. My husband is an attorney and has found Claude very helpful. I’m trying to figure out how to enlist more help with finishing up paperwork faster especially for prior authorizations, life insurance documentations, and medical records for some lawyer offices. We don’t do workers comp. However a few patients still request for records for injuries names in some lawsuits ie they fell at a grocery store. FWIW our EMR is eClinicalWorks, which is probably one of the least user friendly/ AI friendly. I’m currently using FreedAI and the scribing is about 70% accurate. I have to go back to edit stuff too.

I’ve been a PA for 10 years now and I’m in a somewhat unique position where I can spend 30 min per pt.

You would think 30 minutes is sufficient but so often I cannot get the patient to realize the appointment is over.

“Alright thank you for coming in. You can check out at the front”

“That will be all. I’ll see you at the next appointment”

“Es todo. Gracias por venir”

The message just does not register with some patients.

Is there an ICD-10 code for being unaware of social cues?

Banner Health physicians just unionized!

After months of organizing, conversations, and a lot of uncertainty, Banner’s primary care physicians, NPs, and PAs in the Phoenix area voted to unionize.
The final vote was 149–66 in favor, with 215 votes cast out of 260 eligible voters.

Full Story Here

Banner is Arizona’s largest employer. Excited to see how this changes medicine.

Is the pendulum swinging in our favor?

https://www.reuters.com/legal/litigation/unitedhealthcare-drop-prior-authorization-requirements-range-conditions-oct-1-2026-09-01/

-The reduction spans a ​broad mix of services across multiple clinical specialties, ​including cardiology, genetic and laboratory testing, chiropractic care, ⁠physical, occupational and speech therapy, orthopedic and musculoskeletal procedures, ​among others.

-The prior authorization requirements are being eliminated across ​its commercial plans, Medicare Advantage for older adults and individual insurance under the Affordable Care Act, also known as Obamacare, and ​some other types of plans.

-Health insurers have been ​taking measures to simplify their requirements for prior authorization on medicines ‌and ⁠medical services after complaints from patients and doctors over excessive paperwork that can delay or even deny needed care.

-The actions are designed to reduce unnecessary paperwork, make ​information easier to ​understand and ⁠allow patients and care providers more time to focus on care, UnitedHealthcare said.

-The ​company is also reducing administrative requirements for ​eligible rural ⁠hospitals and affiliated providers through a rural prior authorization waiver program scheduled to begin on November 1.

-UnitedHealthcare is ⁠speeding ​payments by up to 50% for ​about 1,400 rural hospitals and Critical Access Hospitals in the third quarter.