Recently had a difficult patient encounter and got absolutely eviscerated by the patient on their review. " poor listener" " lacked any care or empathy" etc. etc.

It was a middle age female patient with chronic, 15 plus years of back pain, ordered MRI which showed minimal findings and with a known diagnosis of Fibromyalgia.

I reviewed all recent imaging and discussed that her pain is most likely related to fibromyalgia vs any localized spinal pathology. And then discussed the recommended treatment for fibromyalgia. She essentially dismissed and refused any medications as she had "tried them all". She also refused recommendation for physical therapy. At a certain point in the discussion I really had nothing else to offer. She left frustrated and hence the review.

Any poor review prompts a discussion with our department head.

Over the past year or so the only real complaints I ever get patient wise are from people I simply cannot help and have nothing to offer.

I am a newer attending (2 years) and always looking for ways to improve patient experience. Usually poor reviews don't really get to me but idk this one was really frustrating.

Any tips or recommendations for how to navigate these encounters?

I feel like it is so difficult to navigate a consult with a patient who has self diagnosed based on posts on TikTok, Instagram and Reddit. I'm a rheumatologist, so my experience is mostly with auto-immune diseases and there is so much misinformation on the internet, it frustrates me to no end.

People with a slight positive ANA who are certain they have lupus. People who make a post saying 'the have all the hallmarks of an auto-immune disease' and then list symptoms such as being tired, joint pain, dizziness, headaches, back pain... They never have any objective symptom like arthritis, fevers, cutaneous changes, serositis, proteinuria... All their tests come back negative or slightly elevated (but of low significance). Then they say their rheumatologist or immunologist were dismissive bc of their age or weight and all the comments recommend to go seek someone else.

Now, from experience I know that if you go to enough doctors, you will find someone who gives you a diagnosis and then you see a new post that bashes the first doctors and they are happy that they found someone who actually listened. These patients come back to the offices of the first doctors a couple of years later, because they have had every possible medication without any change in symptoms and then we have to tell them that their diagnosis was wrong. Now, this is also an ethical nightmare, because you do not want to discredit other doctors. I usually phrase it in way where I say that I cannot confirm a diagnosis or that their AI-disease is 'sleeping' and probably not the cause of their current symptoms.

How do you guys deal with these patients for a first consultation? I tend to be very thorough, even though I know from the first 5 minutes that it won't be auto-immune, so the patient at least knows every box has been checked. After thes etests, I try to explain my full reasoning on why I won't give them a diagnosis, but even then some of them will go and find someone else. It is exhausting, because it takes so much time and I rtaher put that time towards patients with real and complex diseases.

My corporate overlords are willing to pay for a digital stethoscope. I’m an older doctor, 60 plus and my hearing is less acute. I do not register as hearing impaired on screening, but I notice a difference with cardiac auscultation.

I would like some input about what to look for and get some compare and contrast on the models available.

Thanks.

My husband is an ED attending. He met a child (11) psych patient in the ER 9 months ago. She has some mental health issues (won't say more to protect her privacy).

Shes been on the peds unit for 9 months waiting for a group home or foster home. Cannot be discharged because CPS can't find a home for her. My husband wants to bring her home. I don't know what the ethics of all this would look like? I'm a social worker for adult psych so dual relationships are not allowed but are relationships in medicine different?

I posted a bit about the situation in the emergency medicine sub.

I know this has been discussed extensively here, but something really rubs me the wrong way about the recent celebration of lawyers on social media “exposing doctors” and saying things like “it’s over for doctors.” This is in reference to a pic I saw of Lindsay Clancy’s civil attorney with the caption “it’s over for doctors.” Unsure if the pic uploaded.

…as if law is some altruistic path that doesn’t also attract people who want to be high earners? Most people who go through the med school path do genuinely want to make the world better, and i’m not sure I can say the same for most lawyers I anecdotally know outside of public defense.

The whole “gotcha” with lawyers calling out doctors, painting them in a good light is so icky to me. People need to ask themselves to imagine what lawyers do all day vs what doctors do all day.

So I just hung up on a sales call that was supposed to be something different and I wanted to warn the subreddit about it and any future doctors that google DearDoc.

Last week I got a call from someone claiming to be WebMD and saying my practice was selected to be one of two practices featured in the area. I said I already worked with WebMD as a featured profile and he said this was something different and it was free listing and he'd set me up with a follow-up phone call with his account manager the following week.

Today I got a call from her and she immediately started a Zoom meeting where she said she was with a company called DearDoc. She started telling me how many patients she would get me every month through their AI chatbot and having me listed as a recommended doctor on WebMD/Healthgrades/Vitals, etc. I immediately saw it was a sales call and went into "uh huh" mode. She told me the price was 1795 a month and then 1295 a month if I signed up for a full year. I told her I did most of the stuff she was selling myself through AI and she started negging me. She was telling me how everything we were doing was bad. It was laughable how rude her script required her to be. I kept saying I had to go and she kept just moving on to the next slide. Ultimately, I just hung up on her which I never do because I try not to be impolite to anyone.

I ended up looking more into DearDocs and it's just full of negative feedback. Locking people into contracts, not delivering results, etc. It's wild that WebMD and Healthgrades are partnering with a company that is as belligerent and predatory as this. The fact they got my cell phone number means it was probably directly from WebMD. It reflects super poorly on them.

I was just thinking: The root word for hysteria is the Greek word hyster/hystero, which refers to the uterus or womb. I got kinda pissed off about that. Like, really? What I'm getting from that association is that the word hysteria basically means womb insanity.

Was hysteria an actual provable phenomenon, or was it just misogyny? Also asking because I remember a comedianne doing a 1950s housewife bit and saying something along the lines of "The doctors say it's hysteria, but I say it's Tuesday!" I have a gut feeling it was just sexist doctors writing off women struggling with mental health as "Women be talking, am I right, fellas?"

I see way too many 90+ year olds for evaluation of vague symptoms or consideration of aggressive and risky care for heart issues. What is the culture like in your countries? I’ve assumed Europeans have a bit more common sense than us but would be very interested in perspectives.

For example emergency medicine may love urgently fixing the thing but hate rounds
But every specialty seems to have something they generally love and hate
What’s your theme?

How do you handle a reference request for someone working for you that would be damaging if you were honest?

The physician does locums work for us, we'd like them to continue (and they would not continue if they moved on), although they have a bunch of red flags that would come up if I was honest with the job they want to move to.

TL;DR: Yes, comment on the 2027 CMS proposed rule. The immediate dollars matter. But even if physicians win every argument in this year's comment period, we have not fixed Medicare physician payment.

The deeper problem is statutory. Congress has created a physician payment system that does not reliably keep pace with the cost of running a medical practice and that can impose additional conversion-factor reductions through budget neutrality. Congress then periodically gives us temporary relief, the relief expires, and we mobilize again.

For once, there are bipartisan bills already in Congress that address major pieces of the structural problem.

That is where I think physicians — private practice AND employed — need to focus.

First: this is not just about the proposed 2027 cut

CMS is currently taking comments on the 2027 Physician Fee Schedule through September 14, 2026. We should absolutely comment where CMS has regulatory discretion. The proposed rule matters. (Centers for Medicare & Medicaid Services)

But we need to understand what a successful comment campaign can and cannot accomplish.

The fundamental Medicare physician update mechanism is established by federal statute. CMS administers that law. CMS can change many details of the fee schedule, but it cannot simply decide on its own that physicians will receive a permanent annual inflation adjustment if Congress has not put one into the statute.

This is why we keep seeing some variation of the same cycle:

Payment falls behind practice costs → physicians protest → Congress gives temporary relief → temporary relief expires → another cut appears → physicians protest again.

Even if CMS substantially improves the 2027 final rule, if the underlying statute remains unchanged, we are setting ourselves up for another version of the same fight.

So:

Comment on 2027. But don't confuse winning 2027 with fixing Medicare physician payment.

What would actually constitute a long-term fix?

At minimum, I think there are two structural problems that have to be addressed.

1. Physician payments need a permanent inflation adjustment

If staff wages, supplies, rent, insurance, technology and other practice expenses rise every year, physician reimbursement cannot sustainably remain essentially disconnected from those costs.

The relevant inflation measure already exists: the Medicare Economic Index, or MEI, which measures changes in the costs of providing physician services.

We should not have to return to Congress every year asking for another temporary percentage increase.

2. Budget neutrality needs major reform

Under the Physician Fee Schedule, sufficiently large increases in projected spending resulting from changes in relative values or services generally have to be offset elsewhere.

That means CMS can increase reimbursement for certain services while reducing the conversion factor to maintain budget neutrality.

Physicians end up fighting each other over shares of a constrained pool.

Budget neutrality does not necessarily need to disappear completely, but its current mechanics can create large and sometimes inaccurate reductions and need substantial reform.

The important part: Congress already has bills addressing this

This is why I don't think the message should simply be "write Congress and tell them Medicare reimbursement is too low."

They know.

There are actual bills physicians can ask them to move and improve.

H.R. 9693 — Patients First Act of 2026

This is probably the most important comprehensive bill currently on the table.

It was introduced July 15 by a large bipartisan group, led by physician members of Congress including John Joyce, MD, Greg Murphy, MD, and Kim Schrier, MD. It has been referred to both the House Energy & Commerce Committee and Ways & Means Committee. As of August 17, it has not yet cleared those committees or received a House floor vote. (GovInfo)

Read H.R. 9693 — official GovInfo text

This bill is significant because it addresses both inflation-linked updates and important Medicare payment-system reforms.

But there is a major gap.

For most physicians, its permanent update would generally be based on:

MEI minus 1 percentage point, with additional floors and ceilings.

In other words, it finally links physician reimbursement to practice-cost inflation — but it still deliberately allows physician reimbursement to trail that inflation over time. (GovInfo)

That is much better than what we have now.

But if our goal is to stop another 20 or 30 years of inflation-adjusted reimbursement erosion, partial inflation protection does not completely solve the problem.

H.R. 6160 — Strengthening Medicare for Patients and Providers Act

This bill contains the cleaner inflation solution.

It was introduced by Raul Ruiz, MD (D-CA), Gus Bilirakis (R-FL), Jimmy Panetta (D-CA), Ami Bera, MD (D-CA), and Kim Schrier, MD (D-WA).

It simply provides that the annual physician conversion-factor update should equal 100% of the estimated increase in MEI. (GovInfo)

Read H.R. 6160 — official GovInfo text

That is much closer to what physicians should ultimately want:

If the cost of providing physician services rises with MEI, physician reimbursement rises with MEI.

The problem is momentum. H.R. 6160 was introduced in November 2025 and referred to Energy & Commerce and Ways & Means, but it has not advanced nearly as far legislatively. (GovInfo)

H.R. 8163 / S. 5180 — Provider Reimbursement Stability Act

These bills attack the other major problem: budget neutrality.

Among other things, the legislation would:

• raise the extraordinarily low budget-neutrality threshold;
• index that threshold going forward;
• require corrections for certain CMS utilization estimates when actual experience proves materially different;
• require periodic updates to direct practice-expense inputs such as clinical staff wages, supplies and equipment;
• limit large year-to-year conversion-factor changes attributable to budget neutrality. (GovInfo)

There is actually meaningful bipartisan momentum here.

H.R. 8163 was approved by the House Ways & Means Committee in May. The official Congressional Record confirms that it was ordered reported as amended. (GovInfo)

Its bipartisan Senate companion, S. 5180, was introduced July 30 by John Boozman (R-AR), Peter Welch (D-VT), Roger Marshall, MD (R-KS), Angus King (I-ME), Thom Tillis (R-NC), and Jeanne Shaheen (D-NH), and has been referred to the Senate Finance Committee. (GovInfo)

Read S. 5180 — official GovInfo text

But this legislation does not itself provide permanent full inflation protection.

So budget-neutrality reform alone is not enough either.

What should physicians actually be asking Congress for?

This is where I think our advocacy needs to become much more precise.

Instead of:

>

Ask for something closer to this:

>

That is an actual legislative objective.

In simplified terms, the destination should look something like:

**H.R. 9693's broader structural reforms

• H.R. 8163/S. 5180's budget-neutrality protections
• H.R. 6160's full-MEI inflation update.**

If Congress enacted that combination, we would have gone a very long way toward fixing the recurring structural problem.

There would still be fights over individual RVUs, specialty redistribution, practice-expense methodology, MIPS, coding policy and other issues.

But those would be very different fights from starting every year with the entire physician fee schedule losing purchasing power.

Private-practice physicians: this obviously affects us

Those of us in private practice see the problem immediately.

Our employees expect raises.

Health insurance increases.

Rent increases.

Medical supplies increase.

Software increases.

Malpractice and other insurance increase.

Almost nobody calls and tells us:

"Because Medicare didn't increase your conversion factor enough this year, we have decided not to raise our prices."

When reimbursement grows slower than expenses, the difference eventually comes out of physician income, staffing, access, investment in the practice, increased volume — or the decision to sell or close.

Private practices cannot absorb that indefinitely.

But employed physicians should not assume this is someone else's problem

I think this deserves much more attention.

If you are employed by a hospital, health system, PE-backed group, academic center or other large organization and your salary looks fine today, do not confuse insulation with immunity.

Your employment contract may shield you from a Medicare cut this year.

Your paycheck does not necessarily fall 2% because the conversion factor falls 2%.

But the professional revenue generated by physicians still matters to the economics of employing physicians.

Employment largely changes who absorbs the reimbursement loss first.

If the gap between physician professional revenue and the cost of employing physicians keeps widening, eventually that pressure has to show up somewhere:

• compensation formulas;
• wRVU conversion rates;
• productivity expectations;
• staffing levels;
• APP ratios;
• support staff;
• appointment length;
• administrative burden;
• bonuses;
• recruitment;
• service-line subsidies;
• or bargaining power when contracts are renewed.

Not necessarily immediately. Not necessarily dollar-for-dollar.

But employment does not repeal the economics.

Hospital systems may have facility revenue and other sources of income that allow them to absorb physician professional losses much longer than an independent practice can. That is precisely why persistent underpayment of independent physician services can accelerate consolidation.

So employed physicians have a stake in fixing this too.

A physician workforce increasingly dependent on a handful of large employers because independent practice is economically nonviable is not a victory for employed physicians. It ultimately reduces physician bargaining power.

So what can an individual physician actually do?

1. Comment on the 2027 CMS proposed rule — but understand the objective

The deadline is September 14, 2026. (Centers for Medicare & Medicaid Services)

CMS 2027 Physician Fee Schedule proposed rule and comment information

Comment on areas where CMS has regulatory discretion.

But don't stop there.

A favorable final rule does not replace statutory reform.

2. Find your House member and contact them

Official House "Find Your Representative" tool

Don't send:

"Please protect doctors from Medicare cuts."

Ask specifically:

Will you support and help advance H.R. 9693?

Will you support strengthening the permanent physician update toward 100% MEI as proposed in H.R. 6160?

Will you support the budget-neutrality reforms contained in H.R. 8163?

And if your representative already supports these bills, don't simply thank them.

Ask:

What are you doing to get them through committee and onto the floor?

Cosponsoring a bill that quietly dies at the end of Congress is not the same as enacting it.

3. Contact both of your senators

Official U.S. Senate contact directory

Ask them to support and move S. 5180 through Senate Finance, while making clear that budget-neutrality reform needs to be paired with a permanent inflation-based physician update.

Again, be specific.

The goal is legislation, not another statement saying everyone agrees physician reimbursement is a problem.

4. If one of your legislators sits on the relevant committees, your voice matters even more

The key committees are:

House Ways & Means
House Energy & Commerce
Senate Finance

Those committees can determine whether these bills ever get close to a floor vote.

A constituent physician contacting a committee member is more useful than another national form letter sent indiscriminately to 535 offices.

5. Ask your specialty society what it is actually prioritizing

Most of us pay dues to multiple organizations.

Ask them:

Where do H.R. 9693, H.R. 6160 and H.R. 8163/S. 5180 rank among your legislative priorities?

How much lobbying effort and PAC activity are being directed toward getting structural Medicare reform enacted?

Are you pushing for full MEI, or are you prepared to accept permanent below-inflation updates?

Which legislators are helping move these bills, and which are preventing movement?

Physicians have limited political capital.

If permanent Medicare payment reform is priority number 37 on a 60-item advocacy agenda, we should not be surprised if Congress treats it the same way.

And we should stop measuring success by temporary patches

If Congress gives physicians another 2% for one year and we call it a historic victory, we reinforce the cycle.

Temporary relief may be necessary.

Take it.

But label it accurately:

a temporary rescue, not reform.

Success should mean that five years from now physicians are not organizing another emergency campaign because another temporary payment increase just expired.

What about paying for this?

This will eventually matter politically.

A permanent full inflation update costs federal money relative to current law.

Rather than pretending otherwise, physicians should participate in the discussion about financing it.

One serious candidate is site-neutral payment reform: reducing situations where Medicare pays substantially more for an outpatient service simply because the facility is hospital-owned rather than an independent physician office.

That discussion will be politically difficult because hospitals have enormous influence.

But at least it presents Congress with something more serious than:

"Please spend more money on us."

It also addresses one of the payment distortions that encourages consolidation in the first place.

The bottom line

I am not arguing that physicians should ignore the 2027 CMS rule.

Fight the immediate fight.

What I am arguing is that after decades of declining real physician reimbursement, we should stop treating each year's conversion factor as though it were a completely new crisis.

It isn't.

The recurring crisis is the result of the underlying payment structure.

And right now Congress actually has bipartisan legislation containing most of the pieces necessary to change that structure.

The question for physicians should therefore change from:

>"How do we stop the 2027 cut?"

to:

>"How do we make sure we don't have to do this again in 2028, 2029, 2030 and every year thereafter?"

Private-practice physicians should care because our practices are absorbing the damage now.

Employed physicians should care because being one layer removed from reimbursement risk does not make that risk disappear — and a world in which independent practice becomes increasingly impossible is ultimately a world in which employed physicians have fewer alternatives and less bargaining power.

The call to action is simple:

Comment to CMS on the 2027 rule before September 14.

Then contact your House member and senators about permanent structural reform.

Support H.R. 9693 — but push its inflation update toward full MEI as proposed in H.R. 6160.

Support the budget-neutrality reforms in H.R. 8163/S. 5180.

Ask your medical societies and PACs to make passage — not another temporary patch — the metric of success.

We have spent decades asking policymakers to undo the next cut.

Maybe it is time to spend our effort changing the law that keeps producing the next cut.

~39% lower odds of dementia associated with menopausal estrogen-only hormone replacement therapy. So not only is HRT safe if started early during menopause in terms of strokes and heart attacks, but apparently it may also lower dementia risk (or, maybe women who get HRT are better educated, are more affluent, and have better health habits, and are therefore less likely to get dementia).

https://www.neurology.org/doi/10.1212/WNL.0000000000218413

Currently in medical school and honestly, I’m finding the lifestyle pretty miserable. I’m trying to figure out whether I’m just going through the “med school phase” or if being a doctor is going to feel the same.

For those in Internal Medicine residency or practicing after residency in the US: what does your typical schedule actually look like? What time do you start/end, how many days a week do you work, and what does your time off look like?

I’ve heard about things like 7-on/7-off for hospitalists, so I’d also like to know what life is realistically like after residency.

Basically: does life get significantly better after med school, or am I signing up for more of the same?

Honest answers appreciated.

Seen quite a few patients recently presenting to the er because ai advised. Some cases where it’s good they did but some that are too cautious. Basic example, one of the physicians noted there was 11 cat bites in one week. Of those, exactly two needed treatment. There was one where the skin wasn’t broken but gpt told them to go even though the patient was uninsured. They asked about going to a Pcp but the advice was er or urgent care only. I’m a psychologist so I’ve seen more panic attacks as anything left sided chest related prompts instructions to seek care. Curious if others have had similar experience.

I've seen the pattern during rotations and even now on reddit (Urolgoists would you pick urology again ? : r/Residency) and in surveys (70% burnout: https://www.auajournals.org/doi/full/10.1097/UPJ.0000000000001027)

It is known to be a lifesrtyle field (compared to other surgical specialties) and to have a wide variety of cool procedures with the fulcrum being endoscopic and robotic which is SICK, outcomes are good, pts are healthy, content is not too convoluted, procedures are quick and not that stressful... what's the deal?

Hey everyone,

I’m looking into the possibility of working remotely as a US-licensed physician while traveling full-time or living abroad (digital nomad lifestyle).

For those of you actually pulling this off—or who know the US telemedicine job market well—what specialties offer the highest flexibility for 100% remote telehealth work?

A few specifics I'm curious about:

Top Specialties: I know Psychiatry (Telepsych) and Teleradiology are classic choices, but how viable are options like Family Medicine, Internal Medicine, Pathology, or Subspecialties (e.g., Sleep Medicine, Allergy/Immunology)?

Legal & Licensing Barriers: How tricky is state licensing, malpractice insurance, and HIPAA compliance when physically practicing from outside the US?

Time Zone Management: Which fields are best for asynchronous work or flexible hours if I’m based in Europe, Asia, or Latin America?

Would love to hear about your setup, schedule flexibility, and any realistic pros/cons. Thanks in advance!

"Not for profit" (ha!) system, CEO is getting more than a 20% pay increase this year. No actual medical training.

The max anyone who does any kind of direct care is eligible for is 3%, and that's sliding based on merit, which is curved... so a max of 1/4 of people will get the max, which is still less than half of inflation.

When does the revolution come?