u/chiddler

Fortunately I don't have to decide because she sees GYN who orders the US. They asked me today to but I refused and asked them to get order from GYN.

I had some teeth cleaning done once and dentist explained to me a similar concept in their practice. Deep cleaning was recommended to a patient, they declined so dentist just did basic cleaning. Patient had bad outcome. Dentist got sued because they offered the wrong treatment which led to bad outcome.

Granted this isn't treatment, it's a diagnostic screening test. But in my mind it's similar. If I order the wrong test and something is missed, I imagine I would be held liable for ordering the wrong test even though the patient knowingly declines. Am I right to refuse offering any testing or am I being too extra about this?

Thanks!!

My dad is very experienced he recommended only grafting in milder weather. But a lot of internet shows grafting in summertime with success.

As we creep closer to summer I wanted to ask others for their experience. Can grafting be successful in hotter weather? What are measures that you take to improve your chance of success that is different than cool weather grafting? Is it better to just wait for late winter or spring?

Things I am grafting include cherimoya and yangmei and some other subtropicals.

Thanks!!

I tried grafting for the first time earlier this year. I had a multi grafted stone fruit. I didn't really like the varieties except for the apricot. So I removed some of the apricot and I grafted it onto the tree, removing mostly everything else. I kept some major branches in case I failed.

Some of the grafts failed. They're just little stumps. Can I try again this year would it work? Or do I need to try again after next season? I was thinking doing it the same time of summer pruning.

It was a woman in her 60s with the usual metabolic problems - DM, HTN, HLD. She had CKD3 when I first met her like 4 years ago. She always came with her husband, and he always spoke with authority for her. I usually try to ignore the person who overspeaks, but she looked at him whenever I asked her a question, and again when I discussed results and medications. Fine, I guess I’ll direct things to him.

"Hey her kidneys and diabetes suck. She's had some heart stuff. Please take these meds, go see some specialists, go get these tests done."

She does some tests. She takes some meds. She skips several appointments. She never sees a single specialist. Eventually it becomes routine. Like I am annoyed I even have to see her because it feels pointless. Socially, they are very low income, on and off homeless.

Her diabetes progressed. CKD4. Her memory started deteriorating. “Can you please see a neurologist?” She actually did - friggin once. That was the only specialist she ever saw. MRI was normal and LP was recommended.

Now that her memory is impaired, I decided to file a report with APS. Nothing really happens. I privately tell my MAs that unless a miracle happens, her husband is straight up going to kill her due to neglect. I document every visit like I am standing in front of a judge and I make it a point to give copies of specialist auths to the husband every single visit. I demand to see her every month. I (foolishly) spend time teaching how to use and titrate insulin since her CKD is so bad she can't use any other agents anymore. I try to guilt him into seeing ANY specialist. Nope. I am the only doctor they will see I don't know why.

I considered firing her as a patient because I couldn’t take the emotional weight of watching this unfold. Eventually, I did the bare minimum - PRN visits, repeating that I couldn’t help her without specialty care. I stopped investing extra time. I couldn’t handle the rollercoaster.

Maybe 6 months later, hospitalization, palliative care, tunneled cath. I see her again. Turns out her memory was shit due to uremia because after dialysis she's sharper. Not as sharp, but sharper. Nothing changes.

And then! Her daughter is with her! After four years!

“Please just tell me what’s happening at home. Why hasn’t she seen specialists? Followed insulin instructions?”

“Our dad never took her. Didn’t tell anyone. Didn’t give her insulin correctly. He said the doctor doesn’t know what he’s doing and to let him handle the insulin”

The catharsis in that moment was overwhelming. I felt validated. Heard. She was being abused. It wasn’t my fault. There wasn’t anything more I could have done. I paused, suddenly emotional.

The daughter got defensive: “I swear we didn’t know! We would have done something.”

But that moment wasn’t about her anymore. It was for me. An end of a saga.

I’m seeing her again in two weeks. I’m hoping the fifth time I’ve explained how basaglar works will be the last.

I applied and have an interview to a local university. I was really surprised because as a DO and graduate of a not prestigious residency I didn't really think I would be considered.

But it's happening. I don't really know if it's for me I just wanted a position where I can teach again. The pay seemed nice and it seems like a 4 day work week (details to be determined).

All my interviews since graduating residency (I've had like 5?) have been digital or phone. This is the first in-person interview I will have since applying to residency 8ish years ago.

I'm a man. Should I be wearing suit and tie or is business casual acceptable? I'd normally err on the side of caution but my suit doesn't fit me well so I'd have to consider purchasing a new one. For a position I don't even know if I want.

Thanks for advice!!