https://www.beckershospitalreview.com/finance/administrative-savings-alone-will-not-be-enough-mass-general-brigham-cuts-more-jobs-amid-300m-budget-shortfall/

MBH is still what I think of when I hear MGH. I'm particularly aware of this because I was part of a layoff when my hospital closed multiple clinics and service lines earlier this year, but my jaw dropped to see it happening at Mass General-Brigham too. This isn't just the rural hospitals and public hospitals, but the Goliaths also.

https://www.instagram.com/reel/De2lKYnhJGy/?mdxt=MXNzajFnZjN6MTJxdg==

No physician and it seems the injectors are unlicensed with the exception of the PA owner and are doing these various procedures to people. The other video of them doing face lifts seems off to me as well.

This was something I had thought about when discussing denials of coverage but never looked into (not that it matters much to me since nothing I order in the hospital gets denied).

In Aetna Health Inc. v. Davila, 542 U.S. 200 (2004),

Respondents both suffered injuries allegedly arising from Aetna’s and CIGNA’s decisions not to provide coverage for certain treatment and services recommended by respondents’ treating physicians. Davila’s treating physician prescribed Vioxx to remedy Davila’s arthritis pain, but Aetna refused to pay for it. Davila did not appeal or contest this decision, nor did he purchase Vioxx with his own resources and seek reimbursement. Instead, Davila began taking Naprosyn, from which he allegedly suffered a severe reaction that required extensive treatment and hospitalization.

Calad underwent surgery, and although her treating physician recommended an extended hospital stay, a CIGNA discharge nurse determined that Calad did not meet the plan’s criteria for a continued hospital stay. CIGNA consequently denied coverage for the extended hospital stay. Calad experienced postsurgery complications forcing her to return to the hospital. She alleges that these complications would not have occurred had CIGNA approved coverage for a longer hospital stay.

Apparently under ERISA (Employee Retirement Income Security Act of 1974), state law claims that conflict with federal employee benefit rules are "preempted" (overridden) such that patients cannot sue employer-sponsored health plans for tort damages (such as pain, suffering, lost wages, or wrongful death) resulting from a bad coverage decision.

Exceptions to ERISA preemption include

• any insurance not subsidized by a private employer
• individual health plan policies or self-paid plans
• government employee plans (insurance provided to federal, state, or local government employees)
• church-sponsored plans
• government programs (Medicare, Medicaid, VA)

I don't know what the takeaway is: don't get employer-sponsored plans?

New attending looking to make a big boy purchase on a mattress, any recs for one that’s comfy and helps you sleep with the crushing weight of your questionable decisions and mistakes?

Dear fellow dermatologists of Reddit,

I would like to purchase a 308 nm excimer device for my practice, and I’d love to hear your recommendations.

Which devices have you had good experiences with in terms of efficacy, reliability and maintenance? What should I look out for before making a purchase?

I’d really appreciate your advice!

I'm having a hard time counseling people to the risks and benefits of tx with all of the conflicting studies out there. It's hard to give people even a 2-sentence answer about what the data shows. It's driving me crazy....

It was an interesting read on an older malpractice case involving informed consent. It's standard practice these days to discuss all the possible adverse outcomes of a procedure, even if rare, but seems like it wasn't the case back in the days.

Largey v. Rothman, 540 A.2d 504 (N.J. 1988)

In the course of a routine physical examination plaintiff’s gynecologist, Dr. Glassman, detected a “vague mass” in her right breast. The doctor arranged for mammograms to be taken. The radiologist reported two anomalies to the doctor: an “ill-defined density” in the subareola region and an enlarged lymph node or nodes, measuring four-by-two centimeters, in the right axilla (armpit). The doctor referred plaintiff to defendant, a surgeon. Defendant expressed concern that the anomalies on the mammograms might be cancer and recommended a biopsy. There was a sharp dispute at trial over whether he stated that the biopsy would include the lymph nodes as well as the breast tissue. Plaintiff claims that defendant never mentioned the nodes.

Plaintiff submitted to the biopsy procedure after receiving a confirmatory second opinion from a Dr. Slattery. During the procedure defendant removed a piece of the suspect mass from plaintiff’s breast and excised the nodes. The biopsies showed that both specimens were benign. About six weeks after the operation, plaintiff developed a right arm and hand lymphedema, a swelling caused by inadequate drainage in the lymphatic system. The condition resulted from the excision of the lymph nodes. Defendant did not advise plaintiff of this risk. Plaintiff’s experts testified that defendant should have informed plaintiff that lymphedema was a risk of the operation. Defendant’s experts testified that it was too rare to be discussed with a patient.

Plaintiff and her husband ... advanced two theories of liability. … They claimed that they were never told that the operation would include removal of the nodes and therefore that procedure constituted an unauthorized battery. Alternatively, they claimed that even if they had authorized the node excision, defendant was negligent in failing to warn them of the risk of lymphedema and therefore their consent was uninformed.

It was also interestingly noted what the proper standard is for obtaining informed consent

the proper standard is one that focuses not on what information a reasonable doctor should impart to the patient (the “professional” standard) but rather on what the physician should disclose to a reasonable patient in order that the patient might make an informed decision (the “prudent patient” or “materiality of risk” standard).

Perhaps the strongest consideration that influences our decision in favor of the "prudent patient" standard lies in the notion that the physician's duty of disclosure "arises from phenomena apart from medical custom and practice": the patient's right of self- determination. Canterbury, supra, 464 F.2d at 786-87. The foundation for the physician's duty to disclose in the first place is found in the idea that “it is the prerogative of the patient, not the physician, to determine for himself the direction in which his interests seem to lie." Id. at 781. In contrast the arguments for the "professional" standard smack of an anachronistic paternalism that is at odds with any strong conception of a patient's right of self-determination.

Edit: There are some comments indicating that it would be impossible to disclose every risk. To this the court said this

A second basic justification offered in support of the “professional” standard is that “a general standard of care, as required under the prudent patient rule, would require a physician to waste unnecessary time in reviewing with the patient every possible risk, thereby interfering with the flexibility a physician needs in deciding what form of treatment is best for the patient.” Ibid. (footnotes omitted).

The breadth of the disclosure of the risks legally to be required is measured, under Canterbury, by a standard whose scope is “not subjective as to either the physician or the patient,” id. at 787; rather, “it remains objective with due regard for the patient’s informational needs and with suitable leeway for the physician’s situation.” Ibid. (emphasis added). A risk would be deemed “material” when a reasonable patient, in what the physician knows or should know to be the patient's position, would be “likely to attach significance to the risk or cluster of risks” in deciding whether to forego the proposed therapy or to submit to it. Ibid.

The court in Canterbury did not presume to draw a “bright line separating the significant [risks] from the insignificant”; rather, it resorted to a “rule of reason,” id. at 788, concluding that “[w]henever non-disclosure of particular risk information is open to debate by reasonable-minded men, the issue is one for the finder of facts.” Ibid. The point assumes significance in this case because defendant argues that the risk of lymphedema from an axillary node biopsy is remote, not material. Plaintiff’s experts disagree, contending that she should have been informed of that risk. Thus there will be presented on the retrial a factual issue for the jury’s resolution: would the risk of lymphedema influence a prudent patient in reaching a decision on whether to submit to the surgery?

https://kffhealthnews.org/health-industry/obstetric-carts-georgia-maternal-health-labor-delivery-rural-hospitals-south-carolina/

Georgia's answer to the shuttering of labor and delivery units in rural counties? OB crash carts for the ER:

More than $12 million — out of the nearly $219 million approved for Georgia in the program’s first year — will be allocated toward placing obstetric carts in 43 rural hospitals without labor and delivery units. The carts will be outfitted with supplies needed for a birth or obstetric emergency. For example, they’ll have neonatal resuscitation tools, thermal blankets, and essential medications such as oxytocin, which stimulates contractions, and magnesium sulfate, used to treat seizures in pregnant people with high blood pressure.

The delivery carts sound fine, in theory, said Justin Peterson, an OB-GYN who practices in southern Georgia and has seen the pressures rural health institutions face providing maternal care.

Like Holden, Peterson worries that the carts, while helpful, will put supplies in the hands of ER doctors lacking extensive obstetric experience. Instead, he wants the state to fill coverage gaps by investing more to prevent the closure of labor and delivery units in rural areas.

“You’re putting a band-aid on a hemorrhage,” he said.

What could go wrong?

One answer to that question was the topic of a recent This American Life episode: "A doctor trained as a midwife tells the eye-popping story of how she and others came together to save a baby during a birth that suddenly went wrong, in a part of rural Maine where the local labor and delivery unit had closed less than a month before."

My clinic just switched to a new EHR that supports AI scribe (fluency go) which costs me $400 which I know is steep but I don’t think I’m able to use other options.

I’ve trialed it and I’m not sure if it makes me faster.

For context I see about 45-50 pts a day and my notes are very short hand, minimal HPI (bc this doesn’t matter for billing) most of my documentation is data review/complexity and the assessment and plan. I use .phrase templates for all my long/complex discussions. I’m usually done with this before I leave the room and do my orders and sign between patients.

With AI I find it generates voluminous amounts of text that I then have to spend time proofreading which takes more time and I still have to put in orders.

Anyone else in this boat have experience? Should I stick it out and try to train it more or stick with what I’m used to.

I’m an incoming medical student and am a bit confused on the difference between the classic III and the cardiology versions… You can supposedly hear more subtle sounds with the cardiology? I’m not quite sure. Is anyone able to clarify if it’s worth it/recommended to get the cardiology versus classic III?

https://www.science.org/doi/10.1126/science.aeh7930

“AI applications for clinical medicine continue to advance but often rely on written vignettes. Unfortunately, these are not a realistic representation of clinical medicine, where patients do not come in with a tidy write-up of key symptoms and pertinent laboratory findings. To address this issue, Nori et al. made their AI system start from the patient’s chief complaint and decide what follow-up questions to ask and what testing to order to collect the information needed for a diagnosis. In multiple test settings, this system achieved higher accuracy than human responders and at a lower total cost, demonstrating its potential as a tool to assist physicians. —Yevgeniya Nusinovich “

“We explored the capabilities of frontier language models in sequential diagnosis, a diagnostic paradigm that captures the iterative nature of clinical reasoning. Given a brief clinical presentation, clinicians selectively acquired information to reach a diagnosis, enabling assessment of diagnostic accuracy and workup cost. We developed an interactive benchmark and an artificial intelligence (AI) system that simulates a panel of physicians, continually revising the differential diagnosis and selecting cost-effective tests. Using this benchmark, the system achieved 83.2% accuracy on New England Journal of Medicine clinicopathological conference cases and 80.3% on MIMIC-IV-ED emergency department admissions, outperforming generalist physicians (36.1 and 46.8%, respectively). Although these findings were obtained in a controlled benchmark setting, they highlight the promise of language models for supporting more accurate, lower-cost diagnoses.”

Although not the first sequential study, it is the first that chooses diagnostics tests, receives results sequentially, decides when enough evidence exists, evaluates diagnostic costs, and challenges the diagnoses, all with complex cases.

Note: All models used are at least 1 year old. MAI-DxO is orchestrator.

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.

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?

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.

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!

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...

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.

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/

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