Case here: https://expertwitness.substack.com/p/choking-death-in-nursing-home

tl;dr

Elderly man in nursing home with dementia for many years.

He’s had some issues with swallowing, SLP changed his diet. Then later seemed to improve and his diet got advanced again after being tested with a PB&J sandwich as well as an egg salad sandwich.

Shortly thereafter he’s eating a pulled pork sandwich in his room when he starts coughing and gasping. CRNA calls nurse, who calls supervisor. He quickly worsens, they try to suction him with a Yankauer, try the Heimlich, try a finger sweep, but he codes.

EMS is called, transports him to ED where code continues. They ram a bougie through pieces of pulled port sandwich and get him intubated, but he dies.

Family sues, alleging that the SLP was negligent in not testing him with a meat sandwich (as opposed to PB&J and egg salad).

They also claim that the choking was mismanaged, that it was negligent to use a Yankauer to suction him bc it pushed the food down farther.

On one hand I can understand not wanting your loved one to asphyxiate, seems like a rough way to go. On the other hand, I think most people get so much enjoyment out of eating food that it seems cruel to ban elderly patients from eating what they want bc they might choke. And how was this guy still a full code???

Never thought I’d see a lawsuit related to PB&J 😩

I'm aware that there are many bad physicians out there, but I'm curious what makes patients who are reasonably health-literate feel like their physician was bad even when they are receiving good care -- or whatever the most tactful way is to say, I'm not talking about people who come in with medically unreasonable requests who are less than open-minded.

Essentially -- what are some reasons patients feel they weren't listened to, or that doctors didn't take their symptoms seriously and missed a diagnosis, etc, that are not related to poor medical practice?

edit: seems like a good amount of this might be from the fact that not all diagnoses are easy to make right away. Ie, patients with rarer conditions might not immediately be diagnosed, not due to incompetence but because it was just less likely and it's not reasonable to test everyone with symptoms. Even if it's on the differential

edit 2: another thing I just read -- "none of the doctors I saw could figure it out" could be because every doctor will start with more common possibilities (or maybe insurance requires it before other tests), so if you're getting 10 different opinions you're not really getting the chance to be fully evaluated?

My wife (peds) just got a job offer that has, what seems to me, to be a wild non compete. For some context, we have been looking pretty hard for the past almost year to get her a job in a specific area. We are geographically limited due to my job and family in a HCOL area. To start the pay is bad but that is expected for peds in big metro areas/desirable places to live. No sign on bonus. No tail coverage. Then it comes to the wild part which is the non compete: “if Provider is
involved directly or indirectly as a provider or in any other capacity in any other medical practice or
business which is similar to or competitive with X’s business within a 15 mile radius,
within twenty-four (24) months following termination of this Agreement, Provider
shall pay to X an amount equal to the negative difference in X’s net profit lost from
provider leaving for the ninety (90) day period following termination of this Agreement times the
number of quarters left in the twenty-four (24) month period, calculated from the date of the
breach. “

This seems absolutely predatory to me. This is a small private practice. It sucks because the job market here is bad for her specialty but if they don’t remove this we have to walk right? True non competes are illegal in our state but there is technically a loop hole with financial damages for competing. Like I don’t think this would ever hold up with how brutal it is where we are as there have been a lot of recent changes to healthcare specific non compete agreements. We are getting a contract attorney involved as well.

This is in CO. There are some decent large health systems (that do not have these non compete clauses) in the area but they have not been hiring for a while.

Primary care physician here. Recently discovered that one of my patients is being billed for Chronic Care Management by their urologist. She says some woman calls her a few times a month but she doesn’t know what it’s about. She said that she did raise one medical concern but the woman referred her to her PCP.

Then I found out that another patient, on a visit to her podiatrist, was told about a program they were offering that would “cost you nothing”. They sat her in front of a tablet and she had a 5 minute conversation with a nurse practitioner who was—somewhere. Then they billed her for Advanced Primary Care Management (APCM).

Both Medicare beneficiaries, both elderly.

Not only do these situations seem sketchy at best and maybe fraudulent, they prevent me, who I think is a more appropriate provider of these services, from charging for them. I’m doing the work and they are getting paid! In both these cases the practice is part of large, multi-state group.

Has anyone else run across this?

Please go here and make your feelings known on this topic. https://www.regulations.gov/document/HHS-OS-2026-0332-0001

RFK jr wants to eliminate vaccines. He is not just a “vaccine skeptic”. Most of us know that he uses frilly words like “ shared decision making” but what he actually means is making it more difficult for parents to get their children vaccinated by putting up barriers and creating doubt about their safety and efficacy. The less people that vaccinate, the less likely the manufacturers will make them. We WILL see outbreaks of a scale no one can imagine if this is allowed to happen. Take 5 minutes to make your thoughts known. It may or may but make a difference but at least we will have done something. Thank you in advance!

This applies more so with patient asking for opiates for chronic pain (frequent flyer for recurrent abdominal pain usually). I usually can get past the first hurdle:

Patient: i want dilaudid

Me no, your condition does not warrant opiates and in fact can get worse with opiates. You can try XYZ instead

A few hrs later nursing will call me saying pt tried XYZ and still in 10/10 pain and asking for dilaudid. Sometimes patients will even say "I'm allergic or have a bad reaction to XYZ so I can't take the other meds." They sometimes make the RN put those non-opiates in the allergy list just so it wont even be offered.

What do I do when this happens? Pain is subjective so it's not like I have an objective measure if they're indeed at 10/10. I've heard that some pts can have 10/10 pain even if they aren't actively writhing or grimacing. At this point I usually just cave and give something although I'm pretty sure I'm just getting played.

tips?

For those of you who are intensivists and/or billing critical care, I am just confirming that it is fraud to bill for more than the time of your shift (eg, 12 hours in my case).

Because I’m being asked by my admin to bill a high number of minutes across the board for each ICU patient, which equals more than 12 hours. I briefly read the CMS guidelines for critical care billing online but I’m trying to find actual policy outlined saying that it is fraudulent so I can start a paper trail in case I leave this job early. Admin is trying to argue that an audit is unlikely 🙄🙄

Suffice to say, I am not risking my license for this but I need ammunition in case they continue to push back. Thanks in advance.

https://www.thecut.com/article/fell-for-husbands-doctor-his-fault-mine-boundaries.html

A 90-day supply of 20mg esomeprazole magnesium OTC, even the brand name Nexium, is around $50. I just picked-up a #90 Rx and the package says “Retail price: $659.99”, and it’s for a generic. Insurance paid for it, but that price is beyond ridiculous. I’m pretty sure I understand how pharmaceutical manufacturers make heavy investments in R&D to bring a medicine to market, and via the patent system they are rewarded with exclusive/monopoly privileges for a period of time. I even understand how the maker of Nexium took the active ingredient in Prilosec and called it Nexium, and ended-up with another bunch of years of exclusivity to make high profits. But it came off patent in 2014, and pretty much everywhere sells esomeprazole now for over 10 times less than the “Retail Price” my pharmacy label says. So what explains this, (other than trite comments like “welcome to American medicine”)?

Is there a way to export/transfer my Cerner autotexts and then upload/import them at my upcoming new job in Epic? Or do I have to just copy and paste / re-create everything manually?

Link to the 80-page pdf is here: Ascension Saint Thomas Hospital 2567 reviewed 8262026 R | DocumentCloud
Snippets from the report:
"The hospital failed to ensure identifying factors for checking of potential errors was added into the Pharmacy medication system" by not ensuring the National Drug Code (NDC) and Manufacturer of selected medication vials were entered into the system; hospital failed to ensure patient safety by allowing Pharmacy Technicians to override and manually enter data into the pharmacy system without oversight by a Pharmacist on duty; hospital failed to ensure patient safety by not ensuring all individuals involved in the adverse event was put on immediate administrative leave pending investigation; hospital failed to ensure patient safety by not implementing immediate corrective actions to lessen risk of medication errors required for patient safety. Hospital failed to ensure high-alert medications were appropriately labeled and stored consistent with standards of practice to ensure patient safety and lessen the risk of potential medication errors."

"This failure permitted pharmacy technicians the ability to override the barcode scanning process and manually enter vial information without pharmacist verification which allowed omission of critical vial identifying information, including the National Drug Code...and Manufacturer name, and circumvent multiple opportunities to detect an incorrect medication before it was prepared, verified, dispensed, and administered intrathecally to 4 of 7 surgical patients (Patient#1, #2, #3, and #4).

The chronology of how this error happened in the pharmacy begins at the end of page 15. It's all on video and camera surveillance. "Pharmacy Tech went to the bins for an additional vial and went to the wrong bin. And then compounded the error: "When the Potassium Phosphate would not scan, Pharmacy Technician #1 returned to the medication storage area and placed the initially selected Mepivacaine 2% vial into the bin containing the Potassium Phosphate vials and retrieved another vial of Potassium Phosphate from the back of the bin." Pharmacy Tech #2 was place on performance probation on 8/13.

There is much, much more at the link. Four people "looked" at these vials, clicked on a computer screen, and sent those syringes on their way.

https://www.psychiatrictimes.com/view/psychiatry-on-trial-are-psychiatrists-responsible-for-their-patients-criminal-behavior

"Patients can receive excellent psychiatric care and still have devastating outcomes. Imagine an oncologist providing the best possible treatment to a patient with stage IV cancer. If the patient ultimately dies, would that alone demonstrate that the oncologist provided poor care? Of course not. The outcome is heavily influenced by the severity and biology of the disease, not simply by the quality of medical care. Psychiatry is no different in this regard. Despite the best care, occasionally there are bad outcomes and deaths-suicides and homicides both

The question should not be, "Given what happened, what should the psychiatrist have known?" The question should be, "Given what was reasonably knowable at the time, what would a reasonable psychiatrist have done?" That distinction is essential. Otherwise, psychiatry risks being judged not by the quality of the care provided, but by whether the patient ultimately had a good outcome. And if we begin to judge psychiatric care by the crimes our patients commit rather than by the care we provide, psychiatry itself may end up on trial"

Had a new patient appointment yesterday.

Full history work up, evaluation/discussion on two separate chronic conditions, medication management, risks benefits discussion, general counseling and cheering them up.

At checkout she is shocked at why the visit was $160 and kicks up a fuss. Sad to say she isn't the first one to do this.

Before everyone says the following

1. Times are tough
2. Patients don't understand insurance plans particularly what a deductible is

I understand. But do you recall a time when it was not tough to make ends meet for the public? What should the value of our training be? How do I explain to someone $80 of that $160 isn't even going into my pocket but to keep the lights on.

How do I explain to someone if it wasn't the remaining $80 I wouldn't even give up ten years of my life and be in medicine?

Where does this entitlement come from? just so disllusioned...

EDIT: It is nice to see this generate a meaningful discourse. For the folks telling me that I am entitled to not understand the plight of my patient, here is some food for thought.

1. I have a private practice of a single practitioner. Me. I have been in healthcare for over 20 years and know the ins and outs of how healthcare dollars are funded and flow through the system. I am also acutely aware that my inflation adjusted reimbursement has effectively fallen by 33% in those last 20 years while every other metric (including physicians payment if they are employed in a hospital) has gone up. So when the patient complains about cost of living increases and affordability, they better hear me out as well. Those steep increases that sting them? Well they sting me too - my overhead has increased by 50% while my reimbursement has dropped 33%. I have mouths to feed as well including my own family and my staff and their families. Perhaps I should blow up this chart and display it in the lobby.
2. I understand high deductible plans. My patients mostly understand high deductible plans. Some patients like hers don't or choose not too. It is a question of financial literacy. In this post-capitalistic apocalyptic healthcare hellscape, where most Americans get insurance through their employer's it is patient's to understand what they are signing up for and paying and up to the employer's HR (and by association, to some degree, by the employees) to make their voice heard to the plan's and say - we just won't accept these year over year increases in premiums for higher and higher deductible plans. If enough Fortune 500 corporations make a noise, plans will listen. Now you may say well most large corporations are self-insured so its their own money - how can they lower their premium? The answer is demanding more from the insurer who has several levers they are not incentivized to pull until enough pressure is applied. Now if a Boeing or a Toyota or a Bank of America with its huge book of business tells UHC or Cigna or Aetna we need to revisit your ASO fees, network guarantees, pharmacy rebates, PBM pricing, stop-loss terms, performance guarantees, care-management fees, and provider-network economics, or we walk - trust me they will listen.
3. Why does Reddit always love to jump straight to the "minimum wage earner's" scenario anytime affordability is discussed. My practice is next to a golf course/country club in a HCOL area where median household income is 3x that of national median. I just checked. The top 5 most common occupations per BLS data are engineers, management, computer specialists, HR and marketing professionals. Literally none of my patients are farmers lol. There isnt a farm 50 miles radius near me. This particular patient was a director of marketing at a large company. I do not take marketplace plans. They are largely HMO based in my state and I am a specialist and do not have the bandwidth to deal with missing HMO referral auth from PCPs and refuse to play the insurance companies' tag game if referrals are invalid. This patient was NOT the quintessential Reddit archetype of struggling Amazon worker trying to make ends meet.

Look - I get it. The system sucks. But take your anger out at those who deserve it. That would require understanding the unfair system in which we live. Step 1 would be knowing what a deductible is. Step 2 would be writing letters and electing those who want to transform healthcare funding and delivery.

I’m a young attending and I’ve already worked in different environments and states. Income has fluctuated depending on responsibilities or duration of contracts. I was curious if anyone was familiar of what happens when you go from making a higher income, to let’s say working part time and making less or moving to locums - does your coverage change for long term disability, like are you supposed to update your income to the insurance company or how does that work? I’ve asked a few colleagues and nobody knew so was curious if anyone else here might know. Appreciate your input. Thanks

Hi all,

I got frustrated with the non-stop medical junk-mail my wife gets (conferences, jobs, insurance, misc trash) so I started looking into how to get her information removed. Since they make it intentionally difficult to opt-out I put instructions in this spreadsheet to share with our friends:

https://docs.google.com/spreadsheets/d/1EVX8zxRN5IVs6IsU4oujmPPWZpOrKe-woRulUK0ZGGo/edit?usp=sharing

If you only do 1 thing, file to remove your information with AMA to since it's their “Physician Master File” is the main source material the data brokers buy and repackage for sale. Some you can click the link for, others require you to email their privacy department and the AMA requires you to mail a form (wtf).

disclaimer - not sure if the links will work if you aren't in California, most of it was available to be removed because of Californias privacy act. Probably same for Europe but not sure you y'all have this issue.

Hope we all get less junk mail. Good luck!

I’m staring my neuro block and genuinely haven’t been able to elicit a reflex in any person except the knee jerk a few times, I have been using a babinski hammer so far and I’m starting to consider buying a new one.
What hammer is easiest to use for a dummy such as myself?

I spent almost an hour yesterday getting a prior authorization pushed through for a medication the patient has been stable on for two years, and not one minute of that was reimbursed or counted as anything. It isn't utilization review at this point, it's just free labor they've offloaded onto us because we're the ones who cave first when a patient is waiting. Every denied authorization means another portal login, another peer to peer with someone who isn't even in my specialty, another few days a patient goes without something that should be routine. I didn't go through residency to spend my afternoons re-justifying a drug I already documented three times in the chart. How is everyone else absorbing this without burning out?

Calorie restriction enhances longevity, and it reduced activated C3a from a subset of adipose tissue macrophages in humans. Depleting adipose tissue C3 in mice enhanced their lifespans. Since GLP1RAs reduce caloric intake and reduce adipose tissue, would they enhance human lifespan and healthspan (I.e., longevity) in part by reducing adipose tissue macrophage C3 activation-mediated inflammaging?

https://www.nature.com/articles/s43587-026-01107-0

P.s. please steal this idea, and let me know what you find out! If interested, message me (I think admin may consider me capped for projects currently). I know an endo guy seeking apps for some less competitive niche pilot funding opportunities that would fit well with this.

To flesh out a study idea in response to comment feedback below: Does tirzepatide plus low-intensity strength training for 7 minutes, 3 days per week, possibly with augmentation by a myostatin inhibitor and tesamorelin, for 12 weeks promote longevity in overweight but otherwise healthy middle-aged adults by reducing inflammaging via adipose tissue macrophage C3 inhibition, and by reducing insulin resistance via adipose tissue mTORC1/IRS1 pathway inhibition, while preserving lean muscle mass?

If you get good results from that, you could use it as preliminary data to apply for and win a larger, R01-level grant for a more ambitious RCT, maybe including a relatively short-term composite longevity outcome measure like 5-year rate of non-accidental mortality, incident aging-related disorders (e.g., type II diabetes, CAD, OA, OSA, cancers, MCI, dementia, etc.), and other longevity-related endpoints like MACE.

What does your system have in place to reduce 30-day hospital readmission?

Obligatory fuck RFK Jr and Bill Cassidy for voting him in.

Anti-vaxxers like RFK Jr will never argue in good faith, however we must stop giving them ammunition in how we communicate. The Pennsylvania Department of Health really messed up communicating about these two recent measles deaths. More details here: https://www.cidrap.umn.edu/measles/newborn-one-2-measles-associated-deaths-pennsylvania

We all love nuance, that is why we are in medicine. We know that most deaths are not one simple cause, but often a cascading series of events. The public is not going to understand this. When we say things like "measles associated death" or a death with a positive measles test, some in the lay public are going to ask what that means, and then every anti-vaxxer is going to say "see, they didn't die of measles, they died of something else but just had a positive measles test!" Just like they did with COVID.

If after reviewing all the evidence, we think measles was the ultimate cause of death, we just need to state that plainly. "This person died from measles." If we are not sure yet, we need to wait!

Rant over.

https://meps.ahrq.gov/data_files/publications/st540/stat540.shtml

The most commonly treated condition among the top 5 percent of spenders in 2019 was hypertension (46.2 percent), followed by osteoarthritis/other non-traumatic joint disorders (44.5 percent) and nervous system disorders (38.7 percent). In the overall population, the percentages of persons who received treatment for these conditions were only 18.6, 15.5, and 11.9, respectively. Other commonly treated conditions for persons in the top 5 percent of spenders include mental disorders; hyperlipidemia; heart disease; chronic obstructive pulmonary disease (COPD), asthma, and other respiratory conditions; and diabetes mellitus. Note that while these conditions are the most common among high spenders, they are not necessarily the most expensive conditions to treat. Rather, the top spending group is more likely to include persons with multiple chronic conditions or expensive treatments (e.g., surgeries, hospitalizations) related to these conditions.

My husband is still in residency and is currently in his most difficult year to date (in terms of hours spent at the hospital). I’m still a young attending and while my hours are better than in residency it’s still not amazing. I’m left to being the default parent to our son who is not even 2 yet. While my husband is a great dad and tries to do as much as he can when he is home, it’s still a lot managing my own work, being the primary caregiver for our son (and two dogs) and managing our house.

Any tips or tricks from people in similar scenarios?

Source:

https://www.fda.gov/news-events/press-announcements/fda-approves-first-class-targeted-therapy-metastatic-pancreatic-cancer

It's been known pancreatic cancers harbor RAS mutations. There are KRAS inhibitors approved for NSCLC.

Rasonque is the 1st for panc.

Rasonque improved median overall survival to 13.2 months compared to 6.7 months for standard chemotherapy.

It also got approved via the Commissioner's Priority National Review Voucher (CNPV). Does this program still exist post-Makary?

Also, here is the NEJM publication on data.

https://www.nejm.org/doi/full/10.1056/NEJMoa2605555

Im reading an article on uptodate on "Heart failure: Self management". One passage reads:

--

For instance, while 71 percent of low-literacy patients in one study could read "Take two tablets by mouth twice daily," only 35 percent could correctly describe how many pills to take each day [15].

--

https://pubmed.ncbi.nlm.nih.gov/17135578/

Im kinda shocked by this finding. I mean, is that an issue of health literacy or simply basic math? That seems like a major hurdle if one would have to teach patients basic math and not just health literacy.

Any experience with this?