r/medicine

Today I had a patient, who I have not seen for over a year, send me a MyChart message out of the blue. She has been uninsured for about a year, which is why she has not been able to come in for any appointments. She is not currently taking any meds (because, you know, no insurance). She has two special needs kids who have had to ration care because of expense.

She was able to get a job with Walmart, but her benefits don’t kick in for 90 days. So she can’t come in because, despite having a job, doesn’t get insurance until her other benefits kick in. The kicker to all this though, is she wasn’t even messaging me about her meds. She was wondering if I could write her a note so that she could have a chair or a stool available to her while she is checking customers out. She had spinal fusion surgery 4 years ago and can barely stand for any amount of time. So, instead of just letting her have a seat, Walmart required her to ask her doctor for approval, despite not providing any insurance to see said doctor.

And yes, I did write her the letter.

From a physician standpoint, I've been thinking about how much of our industry is protected and economically resistant. Which specialties do you believe are AI-proof and/or recession-proof? Are there specialties that are truly both AI-proof and recession-proof, or is every specialty ultimately at risk?

My thoughts are that acute care specialties (ie trauma surgery, general surgery, EM) are the safest bet. You can't automate hands-on crisis management, and the work isn't elective--patients don't get to choose when they need a surgeon or an ER just because the economy sucks.

Hi, I just got scolded from senior EP staff as an Intern (finished 6 years of medical school, have been working as MD for 10 months, currently in Emergency rotate)

on indecisiveness and not managing patients

I don't know whether this is from lack of sleep, burn out, or something else (Depression, Stress, Imposter syndrome, and Other things)

But I am HATING myself for being like this and I don't know what to do or how to fix it. Appreciate all the advices.

How do you all go about sorting through these types of invitations? Some are for journals I know/read or are on a topic I have no business reviewing/editing, but I frequently get invites from journals that are unfamiliar to me, and the journal seems legit or the topic is of interest.

Impact factor? Identity/reputation of the editorial board? Just do whatever you have time for and have the appropriate knowledge for? I don’t have capacity to do everything I’m sent, but I also don’t want to just pick things at random…

I am a very proficient proceduralist in my 2 procedures - LPs and bone marrow biopsies. I am well known by OR staff to be skilled and efficient, and colleagues will call me if they are struggling. I typically go straight in, feel the pop, and get the fluid. A med student once gasped watching me do an LP. I perform these procedures across the lifespan - neonate to adult.

BUT… like 2-3 times a year, out of probably close to a hundred procedures, I struggle with an LP. It’s now been enough times that I can identify the commonality - typically mid-to-late adolescent young women.

I am NOT someone who is good with spatial reasoning. When I struggle, I troubleshoot systematically:

- patient positioned well - shoulder, hips, knees stacked, as tucked as possible (we do them all left lat decub)

- needle length appropriate

- angle of entry appropriate (toward head)

- triple check landmarks

- ask anesthesia to watch to make sure I’m not missing something - never have they ever been able to identify some obvious failure of my technique or positioning

The issue I (literally) run into is that I am able to advance the needle so far and then hit bone. I am always able to get it eventually, mostly because I am comfortable just adjusting and trying a different spot/angle, and I am told that my “struggle” is still half the time of most people’s “success”, but it’s really frustrating and affects my confidence, which affects my success.

It’s not every adolescent female I struggle with, and I have done back to back LPs on the same adolescent female patient and struggled once and then got it the first try on the next one.

Anyone with better understanding of skeletal development and anatomy of an LP able to clearly see and explain what might be going awry in these cases and how I could troubleshoot preemptively or just more effectively?

H. R. 7961 - H-Bs for Physicians and healthcare workforce act

Pretty interesting bill that was introduced last month to exempt medical professionals on H1-b from paying 100K fee that was introduced in late 2025. Which creating hurdles for rural hospital and primary care facilities in underserved areas from recruiting specialists especially non profits.

I think it’s worth a discussion on this might help mitigate upcoming shortages by allowing underserved areas to get the help they need. Maybe see if other peoples have already noticed any impacts who live or work in such areas

You can check if your rep is a cosponsor on the congress website

Mullens CL, Sinamo JK, Hallway A, Sheetz KH, Ehlers AP, Telem DA. Contemporary Outcomes of Cholecystectomy. JAMA Surg. 2026;161(4):398–405. doi:10.1001/jamasurg.2025.6865

>Morbidity from cholecystectomy ranges from 10% to 20%,1,2 yet recent research efforts have disproportionately focused on rare but high-stakes complications such as bile duct injury, which occurs in approximately 0.3% of patients.3,4 In recent decades, there has been increased attention on reducing overall morbidity from this common procedure.

I thought it was nice to see that we can continue to make one of the most common procedures safer, especially in the elderly population. The cholecystectomy is often seen as "no big deal" by patients and many doctors, but the seasoned general surgeon knows otherwise! I've heard a few accurate sayings, such as "There are no friends in the right upper quadrant" or "It's a nickel-and-dime operation with a million dollar complication."

A bile duct injury is the biggest concern, but hematomas, abscesses, retained bile duct stones, duodenal/colon injuries, hernias, and more are all possible.

One of the possible reasons for a decrease in injury is the rise of cholecystostomy tubes. I see that as a double-edged sword. Some of the worst cholecystectomies I've ever done were after a cholecystostomy tube. Acute inflammation is like cleaning up wet cement. Chronic inflammation is like cleaning up hardened concrete. The acute inflammation is often bloody, but the dissection planes reveal themselves with some blunt dissection and suction. Chronic inflammation has to be cut sharply or cauterized, and you might not realize you're in trouble until too late. The last time I referred a patient for a cholecystostomy tube was when the cardiologist flat out told me the patient couldn't have general anesthesia. Not a tough choice there, but almost everyone else I will try to take for the definitive procedure.

Indocyanine green (ICG) has also been a great help. Being able to flip on a fluorescent mode and see where the common bile duct is hiding is like having x-ray vision. I've been using it since ~2019 or 2020, and I'd never want to go back.

The American healthcare system and the political landscape are making me regret dedicating my entire adult life to medicine. I guess the point of this post is to vent, and to ask if anyone has advice on how to keep going.

Every single day has some new hurdle or attack. For every kid and family who are grateful for something I have done, there are 3 other things happening that burn me out a little more.

The head of HHS is fighting against vaccines and more and more parents are believing in this nonsense. They are voluntarily putting their children at risk because of a horrifically effective combination of misinformation, grifters, and scientific illiteracy. I have had to send infants to the ER in respiratory failure from whooping cough. Their parents could have prevented it, but they never see it that way. Parents are telling me "the less vaccines the better."

The head of Medicare and Medicaid said pediatricians are "groomers" for wanting to talk to adolescents without their parents in the room. Tell that to the teenage boy who was comfortable telling me (but not his mom) that he tried to hang himself the night before. That teenager is alive and well because I was able to get him help. Tell that to the teenage girl who came in for her well check and was on the verge of tears but could not tell me why. After bypassing the physical exam so she would not have to get undressed, and spending time talking to her and letting her get comfortable, she talked to me in private and revealed that her stepdad was molesting her. She is safe now. I could not have done those things without getting the parents out of the room.

Nearly half of all children in the US are on Medicaid or a related program. More than half of my patients are. Medicaid reimbursement rates are not adequate, and efforts to increase rates always fail. Many offices are flat out refusing to see patients with Medicaid because it costs too much.

Insurance companies are getting bolder with their denials and prior authorization requests. Child with clearly diagnosed autism? I have to write a letter of medical necessity to get them covered for ABA. Patient with a seizure disorder and motor delay who needs leg braces? Sorry, the detailed note you wrote about their condition is not good enough. You need to go to their well check 6 months ago and amend it using this very specific phrasing to get insurance to pay (it is riddled with typos). Patient with concern for a brain mass and the CT is not enough for a clear diagnosis, and the radiologist and nearest neurosurgery service both recommend an MRI? Sorry, cannot approve that without a peer-to-peer, but the "peer" is a podiatrist who has never treated children.

My state is run by conservatives who are clueless about medical care of any kind, but especially related to children. They spout that they want to protect children. But they don't want to fund good schools, a functional CPS service, social workers, contraception, SNAP, WIC, etc. They vote to restrict doctors from being able to practice evidence-based care. As far as they are concerned, their children are their property, with no rights of their own. The political, legal, and economic environment are so toxic that specialists and PCPs are fleeing the state. There is not a single pediatric psychiatrist within 80 miles of my clinic. I have taken extra trainings to try and cover gaps like this, but I can only do some much. No primary care offices are taking new Medicaid patients in our town.

My practice got bought by private equity. They have also snapped up every single independent practice within an hour of me. They push me to see more patients every day, while continually firing our front office staff and medical assistants so that we don't have support. They offer "benefits" including healthcare plans with deductibles that are more than 2 weeks of my pre-tax salary. They push us to bill excessively (but technically not illegally).

My student loans are in the 6 figures despite getting scholarships for both medical school and undergrad. I had to declare bankruptcy after residency because of debt I went into with costs of medical education that don't get covered by student loans (residency applications, travel, lodging, cross-country moves) and the cost of living limit placed on federal student loans, despite the location of my medical school undergoing a huge cost of living spike. I managed my money well, did not spend excessively, lived in the cheapest apartment I could find, and it still was not enough. But god forbid I ask for a cost-of-living adjustment raise. They are happy paying me 20% of the collections I bring in.

To sum up - every day feels like being asked to do more, with less, while being denigrated and villainized by the government, the media, and the public. All while children are being ignored at best, or actively maliciously harmed at worse.

Sorry if this is rambling. I just needed to get it off my chest.

https://www.acponline.org/acp-newsroom/new-guidance-from-acp-says-all-average-risk-females-aged-50-74-should-undergo-biennial-mammography

https://www.acpjournals.org/doi/10.7326/ANNALS-25-05116

In summary, biennial screening mammography for women aged 50-74 and shared-decision for those aged 40-49.

For stopping breast cancer screening, discuss with women aged 75 and older, and those with a limited life expectancy.

For women with dense breast, consider supplemental DBT - MRI and ultrasound not recommended because of unclear risk/benefit profile.

___

This one oughta be interesting, especially from USPTSF, gynecology, oncology, and radiology who currently advise starting screening at age 40. ACP, in their generalist viewpoint, probably weighed the harms of overdiagnosis and overtreatment higher, particularly for interventions on breast cancer that would never become meaningful in a woman's lifetime.

Peds here, getting frustrated with the amount of no-shows regarding anxiety and depression. I typically have them follow-up 2-3 weeks after initiation of therapy to ensure the medication is working well, no SI, side effects are manageable, etc., and I always ask them to follow-up in the interim with any issues/concerns prior to that appointment.

Lately, I have been getting an increasing number of kiddos (parents, really) no-showing their follow-ups, calling to say they are doing fine, and asking for a refill. How do you guys handle this scenario in your practices? If you do refill the medication, how many times and for how long would you do it without an appointment? Maybe I'm on the more rigid end of this than my colleagues, but refilling psych medications without regular, appropriate follow-up intervals, especially in the pediatric population, makes me uneasy. However, I also hate to think I have a patient that is actually doing well on medication and won't get it as a result of a parental mistake. What's the solution, docs of reddit?

I’m starting to think my patient panel is statistically…special.

Every single patient who gets their gallbladder out is told it was “the worst gallbladder the surgeon has ever seen.”

Not just bad... The worst. Ever.

Same clinic. Different surgeons. Somehow I’ve curated a collection of once-in-a-career gallbladders.

Should I start buying lottery tickets?

General question, but we hear headlines about RFK, CDC. I'm not really seeing much in regards to Oz and how any of his changes are or could impact our day to day. Anybody have any insight on things he's doing or plans to do?

A former colleague used to write “opine” as in “will ask cardiology to opine on this.” Another once casually slipped “sharted” (no quotes) into the note as if it were standard medical terminology. Personally I rather enjoy some stream of thought writing, like when things are “while perhaps unlikely, certainly not clinically insignificant.”

Of course, I usually just want notes to get to the point, but, I know some of you out there must’ve missed your calling as a writer or just found a hilarious or impressive way to capture what we’re all actually thinking. Would love to hear some things you never miss the opportunity to write or have gotten a kick out of reading in the chart.

I feel like in medicine, we are often in a silo with minimal meaningful feedback about what really matters. If your organization were to evaluate you on your performance outside of billing and production, what would you want them to measure to determine if you or one of your colleagues is doing a good job or bad job?

Clearly patient satisfaction shouldn’t be a main driver (or should it)?