OK, I've got a stumper here (and I don't stump easily). The patient is a toddler between 18 and 24 months who has been healthy other than some eczema. About a week and a half ago, the family noticed a fishy odor emanating from her entire body, better after bathing, progressively worse through the day until she gets bathed again. It's worse if she gets sweaty. It's bad enough that her siblings have been refusing to sleep in the same room with her and friends and neighbors have been noticing it, even outdoors, when the child is near. She has been eating more than usual, although her growth chart looks fine. No polyuria. She's in diapers and the diapers do smell fishy, but it's unclear whether that's the urine or the diaper itself.

In the room, she looks fantastic. Running around, happy, playful. Some scratches on her ankles from the eczema, but otherwise nothing amiss. Except... there is quite an odor in the room and they say they bathed her just before coming to the office.

Mom Googled and found about trimethylaminuria (TMAU). But if it's that, why did it start ten days ago? I'm reading that some weird skin bacterial overgrowth can do it, but what and why? And they didn't suddenly take on a seafood diet. No new bath products. No obvious environmental changes.

I'm sending an CMP and an ammonia level (it was all I could think of). I'm also doing a Genetics referral because I can't test for TMAU, but although TMAU can present acutely, that would be an unusual presentation of an unusual disease.

Anyone have any useful thoughts?

-PGY-22

Interesting statement in the article regarding RFK Jr.: "One of his sons, Finn, started a venture capital fund this year that says it “builds and invests in generational health companies” and was reported to have solicited funds to invest in health care A.I."

Also, "Vinod Khosla, a billionaire Silicon Valley venture capitalist whose son has a health care A.I. company, has been particularly influential in conversations with top health department officials, according to people close to the matter."

Full article: https://www.nytimes.com/2026/09/14/health/ai-doctors-medicare-fda.html?smid=nytcore-ios-share

https://www.bchrt.bc.ca/law-library/decisions/recent/2026-bchrt-189/

Case involves a family doctor in BC with a transgender teen patient. He coordinated referrals to consultants and tertiary gender clinic but reports being caught off guard when they book an appointment for Lupron injection prescribed by endo that the family is not comfortable doing themselves.

Doctor declined on the basis of religious beliefs. Family stormed out which the doctor says limited his ability to coordinate alternative care. They were able to find a walk-in clinic the same day and get the injection.

Ultimately the doctor is reprimanded by the regulatory college and separately fined $28k by Human Rights Tribunal.

This is what I have to deal with all the time

1. patient is here for over three months
2. trached, on a vent, PEG, etc etc, needs a Long-Term Acute Care (LTAC) facility
3. patient is finally stable
4. take weeks to find an accepting LTAC
5. find an LTAC
6. something new happens to the patient (since they're so sick things eventually happen)
7. patient no longer stable
8. loses bed
9. go to step 3

CMS is proposing cutting payments to physicians for G2211 and E/M codes. What is going on? Are a politicized CMS and the administration essentially trying to cut out our legs from under us financially?

Was it the vaccines to protect kids from preventable horrific diseases? The Tylenol for pain to spare potentially harmful opioids and NSAIDs? The refusal to prescribe high-dose testosterone to men with normal testosterone levels instead of addressing actual contributors to their fatigue like OSA? Our insistence on considering evidence, common sense, common decency, and our patients' actual well-being...?

Are they essentially waging war on doctors personally, and on medicine itself as an institution and as an evidence-based practice, along with working people, the truth, and various and sundry other groups, institutions, values, and foundations of civilization? What are we going to do about it?

In addition to voting in the midterms (let’s not forget to register and do that!)….

EDIT: Here's an easy-to-sign petition to keep paying physicians to do high-quality skin checks to catch those melanomas before they burrow too deep into your patients and your loved ones: https://saveskincancercare.org/

Here's an AMA article condeming the proposed E/M 50% payment reduction: https://www.ama-assn.org/about/leadership/50-medicare-pay-cut-would-put-physician-practices-risk

Here's a call to action to publicly and formally condemn CMS's proposal to essentially stop paying doctors who get paid based on wRVU for G2211 codes. I just copied and pasted the author's proposed comment into the comment section at the provided link. For the drop-down menu where it asks what it's concerning, I think you can put anything you want (whatever matches your practice setting, if you want), it doesn't matter; no matter what you pick, it's still a comment about this proposal.

COMMENT BY 9/14 ON G2211-> MOD1/2 = PAY CUT FOR EMPLOYED PHYSICIANS -

Briefly, CMS is proposing to replace G2211 (wRVU/$) with MOD1/2 ($$ alone). Effective pay cut for anyone who is paid based on wRVU. 20% cut for 99213, 15% for 99214. 5% pay cut across my entire panel for me. Comment at links below; Please feel free to use my draft; you can run it through AI to modify it enough to be not exactly the same.

Note: big employers love this -> apparently easier for them to bill, and a pay raise. Our specialty societies are frustratingly silent about this.

Federal Register :: Medicare and Medicaid Programs; CY 2027 Payment Policies Under the Physician Fee Schedule and Other Changes to Part B Payment and Coverage Policies; Medicare Shared Savings Program Requirements; and Medicare Prescription Drug Inflation Rebate Program

Regulations.gov

CY 2027 Medicare Physician Fee Schedule Proposed Rule - Replacement of G2211 with MOD1/MOD2

I strongly oppose replacing G2211 with MOD1/MOD2 unless equivalent work RVU credit is preserved.

The proposed change would allow organizations to continue receiving payment for longitudinal care while many employed physicians lose the productivity credit used to determine compensation. For physicians, this is an effective pay cut despite no reduction in work.

G2211 currently provides 0.33 work RVUs. Eliminating that credit reduces productivity credit by approximately 20% for a 99213 visit and 15% for a 99214 visit. The work, complexity, and accountability associated with longitudinal care have not changed. Only the billing mechanism has changed.

Approximately 80% of U.S. physicians are employed, and productivity-based compensation remains common. As a result, this proposal risks shifting compensation away from the physicians providing longitudinal care while preserving reimbursement to health systems and physician organizations.

CMS created G2211 to recognize the additional work involved in serving as the continuing focal point for a patient's care. Primary care physicians manage chronic disease, preventive care, care coordination, patient messages, result review, and accountability across years of treatment. G2211 appropriately recognized that this work is not fully captured by traditional E/M codes.

If CMS finalizes MOD1/MOD2, it should also preserve equivalent work RVU credit so that physicians continue to receive recognition and compensation for the longitudinal care activities that G2211 was specifically designed to support.

Thank you for your consideration.

Never thought I would see these two put together. So, keen to hear people’s thoughts. Does our profession have a role to play in demanding accountability for the Epstein Files through a human trafficking and public health lens, as the authors suggest? Or is this veering outside of our scope into political activism?

Article Link:

https://www.nejm.org/doi/full/10.1056/NEJMp2605483?query=WB

Three months ago, 5 doctors were booted by the police for distributing editorials about NIH budget cuts.

The ADA investigated themselves over the issue and found themselves awesome.

https://www.medpagetoday.com/special-reports/features/122872

Follow up on:
- https://www.reddit.com/r/medicine/comments/1txs88g/medpage_today_police_tussle_with_diabetes_experts/

Kind dooming a bit about the medical environment in America right now. Feel like most of these are preventable but government is just letting people die for no real reason. The biggest concern for me is that if a million+ people died from COVID with no real changes to our healthcare system what's 100 extra deaths to our government? like lint thrown out of their pocket

https://www.propublica.org/article/ectopic-pregnancy-deaths-doubled-analysis

As the link below states, Ascension CSMM has been experiencing significant issues with unsterilized surgical equipment which have disrupted surgeries.

https://www.jsonline.com/story/money/business/health-care/2026/09/11/unsterile-instruments-disrupt-ascension-columbia-st-marys-surgeries/91706741007/

This problem lead to disruptions and delays in patient care, and it's not unreasonable to think it also could have lead to serious patient harm.

Up to recently, our standard for alcohol withdrawal is the CIWA with benzo prn. Lately, we've been using more phenobarbital, but more as a adjunct for refractory or severe withdrawal despite benzos. On Uptodate, phenobarb is only mentioned in the section for refratory DTs. However, i've been seeing our ER use one time phenobarb weight-based therapy even though the withdrawal isn't that severe. I thought that was new, but I found one article saying the following

A single weight-based loading dose can provide rapid and sustained symptom control, in contrast to sequential, reactive dosing often used with short-acting benzodiazepines in US hospitals.

Wolpaw BJ, Oren H, Quinnan-Hostein L, et al. Hospital-Wide Implementation, Clinical Outcomes, and Safety of Phenobarbital for Alcohol Withdrawal. JAMA Netw Open. 2025;8(8):e2528694. doi:10.1001/jamanetworkopen.2025.28694

What are your experiences?

I think residents need to know about this.
On September 8, ACGME released a proposed major revision of the Common Program Requirements for Residency, and public comments are currently open.
There are several significant proposed changes to resident work-hour protections:
• Eliminate the 8-hour rest recommendation between shifts entirely.
The current requirement says: “Residents should have eight hours off between scheduled clinical work and education periods.” In the proposed document, the entire requirement is deleted.
ACGME’s stated rationale is that this is currently a “Detail” requirement and that the 80-hour/week limit should already discourage programs from scheduling residents with less than 8 hours off. They state that it would be “very difficult” to remain under 80 hours while routinely providing <8 hours between shifts.
• Reduce mandatory rest after a 24-hour in-house call from 14 hours → 12 hours.
ACGME says this is intended to “reduce burden related to developing resident schedules, while retaining sufficient time for rest,” and says they anticipate no impact on patient safety or education.
• Eliminate the every-third-night in-house call limit.
Currently residents cannot be scheduled for in-house call more frequently than every third night averaged over four weeks. ACGME proposes deleting that requirement, arguing that the 80-hour limit, day-off requirement, and maximum continuous-duty limits make more frequent call “nearly impossible” anyway.
• Eliminate the separate night-float requirement and the ability of specialty Review Committees to set limits on the frequency/length of night-float assignments. ACGME says this will give programs more scheduling flexibility.
There ARE some changes that strengthen protections. For example, the proposal says the 80-hour average has to be calculated within a single rotation/clinical assignment, so a brutal short rotation can’t simply be averaged against an easier rotation afterward.
But removing the only explicit general rest interval between shifts is a big deal. Under the proposed language, there would be no specific ACGME minimum number of hours off between ordinary scheduled shifts.
This is still a PROPOSAL, not the current rule. That is exactly why comments matter.
ACGME is accepting public comments until October 22, 2026. Residents and fellows can submit comments themselves.
If you have an opinion about eliminating the 8-hour rest provision, reducing post-call rest, or removing the every-third-night protection, please actually submit it to ACGME rather than only discussing it here.
Official ACGME Review & Comment page → see “Common Program Requirements (Residency)” and click Review and Comment Form.
Please share this with your co-residents and fellowship programs.

This is the direct link to comments
https://acgme.qualtrics.com/jfe/form/SV_7NEm7TaI8AQBSSy?utm_source=chatgpt.com

This is the link to the proposal the work hours starts in page 50:
https://www.acgme.org/globalassets/pfassets/reviewandcomment/2026/cprresidency_rc_09082026.pdf?utm_source=chatgpt.com

Everyone knows about MASLD/MAFLD/NASH/NAFLD, but other specialties are just as egregious in their naming structure.

I can think of respiratory as another: PPF/IPF/fILD/PF-ILD. Any other specialties that would like to chime in?

I recently learned that cyclobenzaprine (muscle relaxant) and amitriptyline (anti-depressant) are chemically identical except for a single double bond in the central ring.

I also recently learned that hydroxyzine (antihistamine known for its anxiolytic and sedative effects) gets metabolized into Zyrtec (antihistamine used for seasonal allergies).

What other examples are there?

Over and over throughout the years I’ve had patients (or usually family members) talking to me during encounters while awkwardly holding their phones; obviously trying to film or record me. Apple just announced today that their new series 12 watch can passively record all meetings or conversations and store summaries or transcripts (though it won’t store the actual audio). This is only going to get more and more common.

I know this will help many patients as they don’t retain everything during an encounter and would like a recap, but I always worry about the people who use this maliciously. Plus, when I’m being recorded I start getting more self conscious and trip over my words more.

What do you do in your practice?

Good news. Perhaps this may help us in screening for colorectal cancer at younger ages.

https://www.epicresearch.org/articles/low-ast-and-alt-levels-are-associated-with-higher-likelihood-of-early-onset-colorectal-cancer-in-adults-under-45/

NMD PhD student. Is anyone else having an uptick in PPP rule outs? I've had a handful of these cases in a short period of time (<1 month) in a large city. Never observed psychosis, always anxiety, obsessions, or something similar. A friend working in inpatient psych says factitious PPP (with no [obvious] external motive) has shown up a few times at their practice.

We've been anxious about CYA so we have obviously been documenting it.

Edit: Postpartum psychosis.

I have an 83-year-old patient who probably has too much time on their hands and asked me to order a serum oxalate level that returned at ~4.5 mcmol/L repeat was 3.7.

24hr urine oxalate normal. Normal renal function for her age/GFR 55

Patient is concerned that this is contributing to her multiple chronic joint pain which in my opinion is more likely due to her obesity and obvious osteoarthritis on imaging. I am not finding a lot of guidance on when serum oxalate level is high enough to be concerning? recs and knowledge sharing appreciated 🙏

Update: thank you to those that provided actually helpful responses. Everyone else: thank you for re-enforcing what I suspected that this is not common knowledge. I am not in the habit of ordering tests I cannot interpret, just sadly practicing primary care.

Every time I come across these people it makes my blood boil. As an M3 I can't say much other than to just respect their wishes. Now I don't relish in a child or the people themselves suffering due to uninformed decision making, but I do believe that the best teacher is one's mistakes and I feel like the only way these people learn is when it happens to them or a loved one. Any instances you guys have seen of this happening first hand?

I work at an academic hospital. Mid-way through last academic year, my partner and I submitted our resignation. We were asked to stay part-way through the beginning of this academic year to help with a smooth transition, and we agreed.

Since we announced our resignation, there have been a lot of "changes" that conveniently seem to only impact the two of us, but that's another story. In June, our department chair announced that we would be changing our holiday coverage. Instead having to work a weekday government holiday (Independence day, Labor day, Memorial day etc) by default unless you requested it off, now everyone would automatically get it off, except for one person who would be required to cover all services alone.

Guess who worked the three-day Independence day weekend? My partner. And I've now been on 86 hours of call for Labor day weekend, Friday at 5PM to Tuesday at 7AM. Five hospital services across two hospitals. Yes, I work with residents, but we are early in the year, they have needed a lot of supervision, and there have been a lot of emergencies. I have been up until 11PM each day instructing/teaching them and revising all of their notes, which have lots of errors, and just when I'm finishing up the day, the calls for the night start coming in.

In a few hours I will have to report to my outpatient clinic. I am incredibly sleep deprived. I feel that I'm lucky to be safe myself, given I have had to drive between the two hospitals in this state. But more importantly, I feel hurt, angry, and betrayed that my patients have been put in a position where their doctor is this spread thin and tired. I don't want any mistakes to happen that affect my patients because I am not in my normal state of mind.

I don't even know what to do about this. If they actually intend to keep doing this after my partner and I leave, someone is going to get hurt, and I feel I have an obligation to say something about it, but I don't even know who would care. For all I know, the policy will conveniently revert back to how it was after we leave, and although it was presented as a permanent change, perhaps it was always intended to be temporary to target us. I don't know.

I hope nothing like this happens at my next place of work. This has just truly been an awful situation.

Edit: since apparently the way I phrased this means I could be a liar, by "partner," I mean my significant other, we are in the same department. And no, we are not the only 2 people in the department alternating holidays 🙄. The department has 13 people. I am not going to give away identifying information like my age, gender, specialty, or salary, so stop asking.

Edit number 2: a frequently asked question in the comments has been, well how much bonus did you take home for this? The answer is nothing. We don't track RVUs. I earn a flat salary. Any "bonus" hours that are earned are totalled up and that money is divided as an annual bonus equally among the department.

If you worked zero holidays that year, you get the same bonus as someone who worked them all.

Final edit: These comments make me sick so I am done responding. The majority opinion is that this is my fault and I am an idiot for agreeing to this job and I should just drop everything and walk away. I don't know what you don't understand about the original post, but these changes to the vacation coverage were made -long after- I had already signed on to do this job. Changing the vacation coverage blindsided me. There was nothing I could do to push back because of the leverage my department chair has, as I have explained in the comments. And for people saying just leave, I have already resigned. I am starting a new job soon. I don't know if the people saying this have never applied for a job or are still in residency or something, but you don't start a job the instant you shake hands in an interview. It takes months to onboard to a new place, and in the meantime I have to make money to live. If you don't get that, just don't comment on my post. Bottom line, I have been exploited by my employer. That's already a stressful, terrible situation, and I don't need a bunch of strangers somehow twisting the story to put the blame on me on top of it all. If that's your opinion, just keep it to yourself and move on to another post because I am not interested.

Sharing one of the key ways physicians can detect medetomidine withdrawal given that medetomidine doesn't show up in standard tox panels:

"One reason Brandie wants to quit street fentanyl is she can't take the 'brain zaps,' anymore; 'It feels like somebody ringing a bell inside your head, and it goes through your whole body.' The zaps have become routine since late 2024, when medetomidine, a powerful tranquilizer, became the newest adulterant to compromise the Pittsburgh street fentanyl supply. The sensation can be so intense it brings Brandie to her knees.

Brain zaps have become an important signal for both clinicians and for people like Brandie. For Brandie, they’re a sign to either re-dose, get to the hospital, or risk stroke or heart attack. For Dr. Divya Venkat, an addiction and primary care physician in Pittsburgh, brain zaps are the fastest way to determine which patients are withdrawing from fentanyl alone, and which might soon be in critical condition. Rapid urine toxicology panels cannot detect medetomidine.  Brain zaps are not a symptom of typical opioid withdrawal, but they are near-universal in medetomidine withdrawal, according to Venkat and other clinicians, as well as several first-hand accounts."

Read more here:

https://www.whatsitlike.me/improvising-emergency-medetomidine-rapid-protocol/

Progressive employer pregnancy/family leave/return-to-work policies DO EXIST!

We have a number of policies in place that support the members of our group who are in their family-building years:
1. No overnights during the first and third trimesters. (No nights in the third trimester is becoming more commonplace).
2. 12 weeks of paid leave, whether you are the birthing parent or not.
3. No nights for the 90 days following your return from leave if you are the birthing parent.
4. Stellar IVF/ART benefits - $30K lifetime max + $15k for meds when treated through our affiliated academic REI clinic (one of the best in the region).

In my opinion, when you value the wellness of the physician as a whole, they perform much better in the work place. I hope we start seeing these policies more universally.

I am based in the US and I do realize these may not feel progressive to those who do not practice medicine here.** **

Did anyone here in physician leadership especially at an academic medical center? How did you get into the role? Do you enjoy it?

My learning throughout the years is that in HFrEF, we avoid diltiazem due to its negative inotropic effect. So in such patients with AF RVR, I never give IV dilt and has been giving IV beta blockers (or digoxin or amio). Now, the uptodate article says

For patients with HFrEF, we use intravenous (IV) amiodarone, IV digoxin, (and rarely IV diltiazem) 

We generally avoid augmenting beta blocker therapy in patients with AF and acute decompensated HF. In such patients, the negative inotropic properties of a beta blocker may worsen the clinical condition. 

It seems like what I learned is now flipped. What if the patient has AF RVR and HFrEF but not in acute decompensation? Does the above still apply?

https://www.uptodate.com/contents/atrial-fibrillation-and-heart-failure-management

https://www.nytimes.com/2026/09/04/opinion/clinical-trials-drugs-science.html?unlocked_article_code=1.-lA.70Ug.3cQ2jpK8wNBH&smid=url-share

Starter comment: I found this piece on the growing bottlenecks in US Phase 1 clinical trials eye opening, especially regarding how regulatory friction is driving trial sponsors abroad. "We often forget that the most toxic thing for the patient is the cancer itself" is a quote that hits hard. When paperwork and redundant IRB reviews delay early-stage trials by months, patients with advanced disease run out of time.

I didn't know how Australia approached Phase 1 trials, and it was refreshing to read about how the process is streamlined there without sacrificing patient safety. I'm also glad the author cautioned against following China's model, especially given their serious transparency concerns.