The nursing staff on my unit are highly demoralized and distressed. Part of it is the patient population (a mix of very sick-and-frequently-dying patients and part simple-medicine-but-very-high-psychosocial-needs-with-related-difficult-behaviors) with equally heavy families, part of it is a unsupportive-to-the-point-of-acrimonious management, and part of it is no one talks about how this environment and patient care is affecting us other than at a surface level of "this unit is hard."

I don't really know how to describe what's happening to everyone, or what terms to use. I don't know how we can get help and feel better beyond everyone quitting.

Do you guys have any suggestions? Has this happened to you? Beyond individual therapy, meds, and/or leaving your work, what helped? What didn't help?

How are you and your colleagues doing at work?

https://www.whatsitlike.me/cocaine-deaths-are-up-in-many-states-despite-trumps-claims/

Cocaine involved deaths in 13 states, more than deaths involving any other illicit substance.

Fentanyl involved deaths fell below pre pandemic rates for the first time in late 2025.

Methadone involved deaths ticked up very slightly in 2025 but have remained consistently low.

Who else was in the room besides the doctor and the husband? This is absurd. He couldn’t get the biopsy from the hip and switched it up without consent? Punctured the pericardium. What? He’s 85!!!
https://news.sky.com/story/dr-isyaka-mamman-85-who-lied-about-age-admits-killing-mother-in-botched-procedure-12645685

I recently had a patient with MG and had Iodine Contrast listed as an “allergy” with the only reason being Myasthenia Gravis. I’m a nurse and never heard of this contraindication before. I looked into it and the research seems to be very contradictory.

Is this something you allow your patients to have or do you consider it a contraindication?

Does modern contrast actually cause a symptom to flare or lead to a crisis?

Several months ago I saw a new patient who was referred (peds surgical specialty) for a benign cyst. At the wrapping up stage of the encounter patient’s mother inquired about another mass patient had that was rapidly growing and had been previously diagnosed as a lipoma. On my exam, this mass was absolutely not consistent with lipoma. I advised them we could remove this mass but would like MRI for further eval preop. Not long after seeing me they end up visiting ED at another hospital for a complaint (trying to be vague here) that ultimately was due to mass effect of this tumor. Had excisional biopsy of the mass at said outside hospital and turned out it was an aggressive sarcoma, stage IV at diagnosis. Patients mother told me they’d seen several doctors at primary care and urgent care for this and advised no further workup was needed/given the runaround in a sense.

The patient ended up coming back to see me now for a complication from chemo/radiation. This poor mother. She said she wanted to sue the other hospital, xyz. I obviously don’t know the whole story, just her account, but from my perspective I don’t blame her.

There are several patients I can think of in addition to this patient that in my opinion got subpar care prior to seeing me. Sometimes no harm comes from it, sometimes there is harm. Sometimes patients are angry and tell me outright about pursuing litigation, or even ask my thoughts.

In every case I focus on empathizing with the patient, tell them my thoughts on what possibly happened (framing as a simple miss that could happen to anyone) or how I may have approached the diagnosis/plan, and if they bring up litigation, tell them I can’t speak on that as I don’t have all the info and am not a malpractice attorney. I never place blame on previous providers.

But in some cases it’s tough as I do feel patients were failed. I always leave these encounters feeling a bit unsettled and wondering if my response may have been lacking. Any good approaches or phrases you use in these cases? Any of you actually told a patient outright the standard of care wasn’t met in your opinion?

Is this just Reddit slop or has there really been an uptick in this? Feels like every day I run into a post on some rando subreddit where someone is ranting how a doctor won’t listen to them and they’re sure they have one of those two diagnoses and if the doctor just did an evaluation and gave them some meds they’d be all set.

https://www.nytimes.com/2026/10/19/well/andrea-shaw-death-penalty-toddler-deaths-vaccines.html?unlocked_article_code=1.KFE.qbVw.CvbFZmXrOJ3C&smid=url-share

In essence, a rural county prosecutor of Idaho (Payette County) is pursuing the death penalty for Andrea Shaw. She is the mother of two twin toddlers whom she claimed died from the routine DTaP and HAV vaccines in May 2025, and she was on the Children's Health Defense podcast about their deaths. She also sued the American Academy of Pediatrics, claiming they defrauded families in collusion with Big Pharma. However, in June 2026, she was indicted for murdering her toddlers via smothering.

Now, the Children's Health Defense is doubling down on the vaccine case, and the trial date is set for January 2027. The courts shall reveal the evidence in this case. That the prosecutor is going for the death penalty suggests that there is some damning evidence.

I presided over the death of a child today. While I feel some need to process that event, I am hesitant to do so through the written word because I worry it will actualize the trauma into something substantive and present in my memory rather than allow me to do as I would usually do and relegate it into the murky tapestry of past scars that skulk around in the shadows of my subconscious.

There's not much to it actually. She killed herself for some reason that will never be known, not that I would ever get that answer anyway. She died the same death we all ultimately face regardless of circumstance, so in that respect it's no different than any other death I have attended to, or may soon attend. We did all the things that are meant to be done, and did them as well as we could. But still, there sometimes persists this illusion of some other potential outcome or meaning or choice that might've been acted upon or seen to bring about something more palatable than what actually was. But, that's not the way it is. Not at all.

One of the firefighters was a little shaken after it was over. My partner was too. But, for me, I am, as always, left thinking not about the circumstance itself but why I am not bothered by it in that same way. Why do I go through this circuitous self-analysis where I beat myself up for being unfeeling about the thing and instead only care about my reaction to it. Or, more correctly, the lack thereof. I don't know. I wish I could say that I stopped trying to answer this question long ago and that I've just accepted that this is my process, but that's not the case. I'm not sure why I think it's relevant. But, I do, and this is what I'll hammer on for a couple days until I deem myself sufficiently self-admonished, or maybe I'll just move on.

So I'll write this and post it here. In time, some new tragedy will likely replace this one and I'll go through this same process again, and that's okay. Maybe some good work will happen in the interim that I can point to and insist that this is what it's all about. I'm not all that somber on any given day, after all. It's just time to pay the piper.

Regardless, I'll leave this passage here to memorialize the time I thought enough to write something down for posterity despite my better instincts to push it away to deal with some other day. Whether it will work, I don't know, but I'm gonna give it a shot. Thanks.

I just got finished telling off a whole group of medical providers (PA, MD, RN) for vanco dosing. 58yo F on HD comes to the ER for a fever. ER orders vanco 2g loading dose for sepsis, with bcx drawn prior to admin. Unnecessary to go straight for vanco, but okay fine. MRSA nasal neg. Bcx biofire comes back as staph, no mec detected. Patient gets admitted for bcx+ with permacath. Admitting doc orders vanco 2g q12h overriding warnings for 1) daily dose >3g requires ID consult daily dose is <3g. 2) dose is >100% of the recommended dose based on renal function ER said she needed vanco. 3) vanco requires monitoring levels, please order level no level needed and then nurse arguing she needed the dose now... 6hrs after the loading dose. Then the PA telling me the dose seems fine, she needs to get her antibiotics. Then the admitting doc telling me the ER says she needs it. At which point I got pissy and told them off and refused to verify or dispense the vanco. Recommended ancef post HD. Called ID doctor, explained all of the above... he demanded names so he could also tell them off, and proceeded to order ancef post HD and demand the permacath be removed after it was cultured.

I get vanco is part of the sepsis order set... but... why continue it with no evidence its needed? And why insist on a ridiculous dose that is clearly not appropriate for an established HD patient? And why is admitting doc just doing whatever the ER says? And if these people all somehow missed it and ignored the warnings, why couldn't they just follow my instructions? Or call ID themselves if they were not understanding? Or even Google it if they dont believe me...?

And why on earth does everyone else get sepsis bundle in the ER when they dont have a fever, dont have elevated wbcs, have vitals wnl, and presented for arm pain with no visible signs of infection. Please make it make sense...

Hello, dietitian here hoping to get some nephrology insight about starting sodium bicarbonate for patients. I work with the CKD population. I often see patients with a serum bicarbonate around 20, many times with borderline high or elevated potassium as well, who aren’t taking an alkali agent like sodium bicarbonate. A lot of these patients are very concerned about high potassium foods, of course, so I always try to consider other possible causes for hyperkalemia to avoid excessive dietary restriction. And in many case these patients would benefit from eating more fruits & veggies to help reduce their dietary acid load.

My question is, at what point do you generally prescribe an alkali medication and what would be reasons for not prescribing it if someone’s bicarb is consistently around 20? Is it concern about the additional sodium? Does the medication just make the numbers look nicer w/o actually doing much to slow CKD progression? Thank you in advance for helping me understand this better!

Well, this is fascinating.

A new study suggests that even under general anesthesia, the brain may still process spoken words, despite patients having no conscious awareness or memory of what's being said.

Makes you wonder how much is actually getting through when someone is supposedly out cold.

Source: https://www.scientificamerican.com/article/the-brain-processes-overheard-words-under-anesthesia-but-it-may-not-remember-them/

IM here. In my head, flumazenil exists primarily as a board exam trap. Possibly bc I've never seen it used. Possibly because I vividly recall a coresident giving Narcan on night float leading to the patient’s EKG developing v v unwelcome ST changes. Entirely different drug, and we are pro Narcan around here, but my brain tagged has absolutely tagged flumazenil under "REVERSAL: MAYBE JUST DON'T POKE THE BEAR."

And my recollection of benzo overdoses is basically “support the airway and chill.”

Has anyone actually used flumazenil outside peri-procedural sedation? Practically, how do you use it for peri procedural stuff? I am here for darkly funny anecdotes as well as pearls.

Hello friends, i'm IM PCP. I'm a few years out of residency.

I feel like the AUA guidelines leave a lot to be desired. Research (10.1056/NEJMoa2406050) is showing how useful mp-MRI of prostate is for risk stratifying and being more selective in prostate biopsies. It feels like this is something primary care should be doing more of - being selective and only referring certain patients for prostate biopsy - not all PSA elevations. I think this disagrees with the guidelines that advocate all 4+ should go to urology - is this really correct with how useful MRI is now?

PSA also varies by age. I don't like how vague the guidelines are but I am assuming that's because of limited evidence:

Most studies identifying age-varying thresholds specify threshold values of 2.5 ng/mL for people in their 40s, 3.5 ng/mL for people in their 50s, 4.5 ng/mL for people in their 60s, and 6.5 ng/mL for people in their 70s.

I met a urologist who recommended doing a one time test at ages 40 and 45 and ensuring PSA <2.5, too. Against guidelines which recommend only those that are at higher risk. He argued that MRI makes the risk of unnecessary biopsies and treatment marginal compared to the very serious consequences of treatment of clinically significant prostate cancer. He advocated for use of PSA density which is definitely supported by guidelines.

Let me summarize my questions:

How do you, Dr Urologist or Dr Primary Care, think about PSA? Do all PSAs 4+ go to urology? Is primary care in a spot to do active surveillance with MRI?

I don't mind being pointed to medical literature. Thanks very much.

Are there any up to date books on basically diagnostics for rheum conditions? With all the new myositis testing coming out I feel a bit old and want to brush up but don’t want to slog through journal articles to find

Only been using for about 6 months without any accidental damage, and the build quality seems poor. My original set had eartips that were too loose to stay on, and I had to buy my own replacements from them that somehow fit better, and now the connector is breaking off but there’s a wire that’s intact so it works for now since I’ve taped it together, which has incidentally solved the issue with it not screwing in tightly enough.
Do I have a lemon or are the Eko stethoscopes generally poorly made?

Used Littman for 10 years and never had issues with them breaking. I love the noise filtering and sound amplification features and don’t pay for the AI, but wouldn’t buy another one when this breaks.
Any other competitors with digital stethoscopes anyone likes?

What would happen if an IO was placed too far away from the correct site into the spongy bone, and rather into a part of the bone that placed the needle into the yellow marrow? For example, if you used the proximal tibia but placed it several inches distal instead. Would you just get slower flow rates and slower entry of IO medications into the bloodstream?

Amusing discussion on the LawyerTalk subreddit about whether our degrees are terminal, academic, "full" doctorates, or only equivalent to a master's degree from people that are ostensibly a bunch of lawyers that appear unable to agree on what constitutes an "attorney". Fun nonsense to read while I'm stuck in an airport.

Personally, I think it's equivalent to a International Baccalaureate diploma, but I never did learn how to read.

https://www.statnews.com/2026/10/15/health-data-privacy-medical-record-opt-out-barriers-investigated/

The notary requirement is absurd. It’s more than a front desk problem when the people who are supposed to know better won’t follow their own policy.

Health systems treat opt outs as a nuisance to manage instead of something patients are actually entitled to, and they'll keep doing that as long as there's no real penalty.

Hi!

I am an MS4/soon-to-be resident with goal of having a career in PCCM. My first career was as a respiratory therapist, which has a very special place in my heart as my start in medicine, especially having worked as an RRT through COVID.

I have worked with several pulmonologists who were also RRTs previously. Some proudly kept their RRT as part of their signature and/or openly shared it with RTs they worked with, others have given me the advice to keep it to myself as I may be treated negatively by some RTs if they know my background. When I was accepted to medical school, I had some coworkers who were hateful towards me afterwards, but the majority of my coworkers were very supportive and excited to see one of their own become a physician and advocate for RTs as part of the team to my MD classmates.

My question is what advice do you have regarding me sharing my RRT-ACCS credential as a physician? Can I keep it as part of my signature because I am proud of that background, or will that perceived negatively?

Thank you in advance!

Without exaggeration, this is a harder feat for me to accomplish than almost anything I do as a pediatric pulmonologist. Complicated ventilator management, management of the myriad of CF concerns, interstitial lung diseases, complex structural airway disorders are all easier than this.

I'll be accepting awards all day.

Has anyone come up with any creative strategies to prevent the foreign body frequent flyers from coming back?

Mine are almost always men from the jail/prison who shove a piece of plasticware up the urethra to get a free ride to the hospital and a change of scenery.

I have a guy right now who came back within 12 hours of discharge. FML.

I’m not sure how well this is going to go over but figured I’d post it. Throw away alt account. And to add this has not been my experience with community medicine rotations that I had during residency, although we would get some wild transfers from the boonies.

Fresh out of training, first attending job. Trained at a large academic center that has every kind of transplant and sent absolutely nothing out. Great specialists. Everyone was up to date, including the in system PCPs. Midlevels were involved a lot but the care still seemed great.

First job is in an academic affiliated community health system as a IM trained PCP. Great access to specialists and resources. Partners are great and seem to be up to date on the standard of care. That’s not the issue. The issue is that there are tons of mid levels managing care independently and even the attending care is just wild. generally when I’m precharting im like actually saying what the fuck are we doing out loud to myself. The care difference between what I was seeing in residency and here is just stark and frankly concerning.

I’m really not trying to shit on community medicine but like at the same time there have been a dozen instances where I have considered messaging the provider in question. I’ve only been here for a few weeks.

For example: cards NP dropping someone’s diuretics completely even though their BNP is increased from the hospitalization they are following them up for, new EF drop with WMA on the echo that nobody addressed during hospitalization or at the cards follow up in a patient with known CAD. They were concerned that he had pneumonia, didn’t order any imaging and just punted to “pcp follow up” even though they acknowledged the pneumonia in their notes. Attending physicians not checking LFTs on a patient with HH for years, doing thrombectomy for minor dvts, etc.

I know not my monkey, not my circus. I’m really not trying to seem like I know everything. I ask my partners for advice several times a day. Just the whiplash between the level of care has been stark and I’m looking for some advice on how to navigate it a bit better or if I should just do my best and let what other people do happen.

This was said by my patient, a semi-retired health professional, at a routine followup visit. I have a policy of not debating with cult members and crazy people, but I did voice my support for Dr. Fauci. On with the visit, come back in 6 months. Later, I was thinking, I could have said, "Listen, this is where you and I part ways." It somehow feels right, but even cult members deserve healthcare. On the other hand, does it have to come from me? I sort of feel that I'm enabling a truly harmful point of view, but I know I can't talk him out of it. (see Carl Sagan re bamboozle) What do you good people think?

​Public health discourse frequently frames spatial access, such as food deserts and food swamps, as a core driver of the obesity epidemic and metabolic disease.

However, as causal inference methodologies, health economics, and longitudinal epidemiology have advanced, the empirical consensus has shifted sharply away from spatial infrastructure interventions.

When controlling for individual-level socioeconomic status, income, education, genetic predisposition, and total energy expenditure, spatial proximity to healthy or unhealthy food outlets demonstrates a near-zero causal effect on individual BMI, total caloric intake, or glycemic control.

​A comprehensive review of causal studies by Groom et al. in Social Science and Medicine found that once strict causal inference tools are applied, changes to local food environments produce no generalizable impact on adult obesity rates.

You can review this study at https://doi.org/10.1016/j.socscimed.2022.114879.

​so, landmark national tracking study by Allcott et al. in The Quarterly Journal of Economics demonstrated that spatial availability accounts for less than ten percent of the nutritional gap between high and low income households. Over 90percnt of dietary choices were dictated by income, education, and entrenched individual demand preferences.

You can access the paper at https://doi.org/10.1093/qje/qjz015.

​Prospective longitudinal tracking of communities following government funded supermarket additions in designated food deserts yielded similar conclusions. Cummins et al. in Health Affairs (https://doi.org/10.1377/hlthaff.2013.1206) and Elbel et al. in Health Affairs (https://doi.org/10.1377/hlthaff.2015.0667) revealed no measurable reductions in BMI, daily caloric consumption, or sugar intake compared to control communities.

Multi-decade longitudinal tracking by Boone-Heinonen et al. in Archives of Internal Medicine (https://doi.org/10.1001/archinternmed.2011.283)

also confirmed no consistent association between spatial exposure to fast food or grocery outlets and diet quality or weight status over a fifteen to twenty year span.

​While building local infrastructure provides urban convenience and community satisfaction, treating physical proximity as a primary clinical or public health intervention for obesity and metabolic disease is largely unsupported by prospective causal data.

Look, given that individual purchasing power, educational background, and behavioral preferences dominate dietary choices, should structural health interventions pivot away from spatial zoning and retail subsidies, and instead move toward direct financial support, nutritional literacy, and targeted metabolic clinical care?