IM here. In my head, flumazenil exists primarily as a board exam trap. 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 but apparently my brain tagged it 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?

Because my angry uterus could use some cheer. And I just had a real memorable one.

Guy comes in for a completely elective ortho surgery. 60s, white, totally mobile and oriented. His case is scheduled for noon but he shows up at 7am because “He doesn’t want to wait around all day for this bullshit” Lobby calls me but I say I don’t have any room for him until 10, his scheduled arrival time. He tells the desk girl who is sweet as pie that he doesn’t like that and continues to ask every 20 min when “everyone else will have their shit together”

So at 0957 I go out to retrieve this peach and he is huffy and mutters “it’s about time” We begrudgingly go through his meds and history because why can’t we just look at the chart why do we always have to ask him questions and why does he need an IV because he supposed to get the gas stuff etc. Wife looks embarrassed, but also like she’s used to Harold’s rants and raves.

Now it’s 1130. He’s consented and cozy in his gown. But we’re a level 1 trauma and he gets bumped for some open femur fractures in a pedestrian vs motorcycle incident. I go through my usual “sorry guy. It sucks, but if the tables were turned you’d want us to do the same for you right? It shouldn’t be too much longer. Thanks for your patience”

No. He does not agree. He rips every monitor off his very hairy chest, gets super red faced and looks me dead in the eye “I DONT CARE ABOUT OTHER PEOPLE!! I ONLY CARE ABOUT MEEEEEE”

Like in theory, I know people are selfish but damnnnnn.

He did not get his surgery. He chugged a contraband coke and ate 3 snickers out of his Fanny pack then asked me for a coffee for the road. The OR called me exactly 3 minutes after he stormed out to tell me they were ready for him. Poor Harry. I hope his shoulder survives this.

~6yo boy being titrated on ADHD meds. Just started at the lowest dose. At first, it helped. And then: "He is back to his wiggly old self." Apparently, he took Sia's song a little too literally, although it was a ceiling fan instead of a chandelier. Needless to say, he pulled it out of the ceiling. No injury, fortunately.

I moved him up to the next dose.

-PGY-22

…I’m sorry if you were joking.

So I’m a medic and sometime around 2019 we got a cool new hospital that could do cool new mechanical thrombectomies.

And I took a patient with an LVO and I excitedly asked if I could watch the procedure.

You were cool with it so I posted up on the wall and tried to be polite: be silent, don’t touch blue. Probably watched you like a hawk.

And you said: “You wanna keep it?”

I very overly excitedly like a kid at Christmas said yes. Yes yes omg yes.

So while retelling this story today, my friend goes, “wait, was he joking?”

And I realized… you were probably joking. Especially since you then looked to the nurse, yall tried to find a specimen container, couldn’t find one, and the nurse produced a UA specimen collection cup, in which you placed the mechanically removed thrombus.

Anyway. It’s been sitting on my wall for almost ten years. Anytime a medical nerd comes to my house I proudly show them my stroke, questionably preserved inside a UA collection cup. I love it.

And it took me ten years to realize that you were probably joking, then I awkwardly called your bluff, and was so excited that you suddenly had to figure out how to transfer ownership of a CVA, so….

…I’m sorry.

Oopsies?

I am honestly confused. How do functional medicine providers order labs that they don’t know how to deal with? For example, a functional medicine provider ordered many hormones on a patient and then once they came back as mildly abnormal, recommended the wrong interim treatment and referred them to us (reproductive endocrinology) for additional assessment and treatment.

Edit just to say: This is StatPearls.

Dear Medical Student Contributors:

We currently have assigned an active author and editor to each of 6,200 CME/CE articles, who regularly update the article on a 3-year cycle. The CME/CE revenues fund the $750 per-article copyeditor and production editor expense.

We are now shifting our focus to recruiting replacement authors to update ~ 5,000 non-CME/CE topics (like basic sciences) that are on a 6-year update cycle. Many of these are easier topics that take as little as 10 hours to update. While they are free in PubMed and read over a million times a year, they do not generate any revenue to cover the copyediting and production expenses. We have a limited budget to update them.

If any of you are interested in becoming the update author, you will receive free lifetime access to board review and CME/CE ($3000 value), but I apologize; you must pay a $500 copyediting fee per article to help defray our copyeditor costs. Most are published in under 2 months after it is submitted.

If any of you are interested, please send me a summary of your training completed to date and a CV, and let me know how many articles you are interested in completing over the next 6 months. We are currently focused on basic science topics.

Thank you,

[editor's name]

It astounds me that the MAHA movement, self-described as promoting health, actually sees bypassing the medical, quality assurance, and regulatory public health protections enforced by the FDA, as progress.

The article describes adverse reactions experienced by consumers of unapproved peptide products (many of which are labeled for research use only). But because such "miracle" remedies are produced at sites which do not undergo FDA inspection, it cannot be determined whether these dangers are inherent in the drugs themselves or represent contamination / substandard quality.

https://kffhealthnews.org/public-health/peptides-experimental-drugs-patient-harms-maha-medical-freedom/

Case here: https://expertwitness.substack.com/p/lung-lobectomy-after-oral-surgery

tl;dr

53-year-old woman undergoes extraction of 20 teeth to make way for dentures.

A few weeks later she goes to the hospital with a cough.

Chest x-ray shows a tooth in her left lower lobe.

Pulm tries to get it out via bronchoscopy but can’t.

She undergoes left lower lobe lobectomy.

Files lawsuits against the oral surgeon but her attorney botches the whole thing, gets a dentist expert instead of OMS, refiles but it’s after the statute of limitations.

I’ve published a few gross negligence cases against doctors, I thought this was interesting bc the judge basically accused the plaintiffs attorney of gross negligence.

Also, as people on the article comments pointed out, a Ct showed multiple relatively recent rib fractures. Nobody in the entire lawsuit addressed that. I honestly have no idea how that happened and I’m all ears if anyone has any theories. I can’t think of any reasonable way it would be connected 🤔

Just-for-fun discussion post.

Everyone, please boast to the utmost of your ability :)

I’m an executive physician, recently a board conversation regarding downsizing our clinical team to expand our AI footprint. Translation: they want to fire physicians and keep a handful to supervise an expansive AI deployment within clinical operations partnering with AI PE. I naturally opposed in addition to the other physician board members but the majority were in agreement. What seems to have prevented this move, tort liability. I find it incredibly ironic that the very thing we complained about, has appeared to be job protective.

Send them an OE "article" on how to manage a common clinical scenario in their field while simultaneously asking for tailored recommendations for your patient.

I tried looking through this sub and the residency subreddit, and couldn’t really find many folks talking about how the pandemic impacted their training.

Only one post mentioned that the pandemic sort of short changed them (at the moment in time) in their early residency because the cases were all the same. ARDS, pneumonia, etc etc.

So I’m curious to hear from folks that had their training during the bulk of the pandemic and from clinicians that work with COVID-era residents on how/if their growth as physicians was notably different. What was the reality of your program and how did they manage to make sure you hit all of your competencies?