Ryan Fisher

@twomewtoo @DrDiGiorgio @Chillcatser @MaryBowdenMD This is another example of how patients are misinformed and wrongly accuse doctors of greed due to employer actions. The doctor does not get the money paid for MyChart messages-the employer does.

@DrDiGiorgio @Chillcatser @MaryBowdenMD I don't know how many other offices are starting to do this- but my GI office will charge an office visit for some epic messages now. I think it's a great idea.

Imagine if every passenger on an airplane had a direct line to the pilot. That’s what medicine has become. We have embraced frictionless communication and that not a good thing. With things like Epic Chat, every member of the healthcare team has immediate access to the physician. Now there’s a constant stream of minor questions. It’s discouraged people from thinking critically. “Just ask the doctor,” has replaced any sort of clinical reasoning. When I was a resident, we had an answering service. Anyone who wanted to reach the doctor needed to go through a third party. This provided triage and accountability. If we were getting called in the middle of the night for stool softener orders, there was a record of that. A little friction in communication is a good thing.

@HalCranmer @PaulJRamirez Only catch is they have no doctors working there…

@PaulJRamirez These guys.. natureworksbest.com

Met with a doctor yesterday who had this on her wall. My kind of people..

The Spurs know how to TAKE the lead, they just don't know how to HOLD the lead. And that's really the most important part of the lead: the holding

@drterrysimpson @Tellit007 Unfortunately, some people don’t want to treat the disease before they see the evidence on the CAC scan

@Tellit007 Some want to treat after disease is diagnosed- positive CAC scan. Mine is positive but I wished I’d have treated mine years before I had a positive CAC

Had an interesting exchange today. Someone questioned whether atherosclerosis in low-risk people actually predicts heart attacks. Fair question. Good data on both sides. They challenged the studies. Also fair. They raised the funding gap. No company profits from a keto cardiovascular trial. The NIH has not funded one. Legitimate point. Acknowledged it. Then something interesting happened. One question appeared that none of the above touched. At LDL-C 111 mg/dL in a 40-year-old with no hypertension, no diabetes, no smoking: what does 30 more years of cumulative ApoB exposure predict? Not six years. Thirty. The response: "last chance or else, too busy." Fun times! Classic Ference dodge. Stay awake my friends.

@ketosprinter @DrPlantel What about doctors who are also wellness grifters?

@DrPlantel Doctors are held to a higher standard than wellness grifters, as it should be.

Let’s clear up a common misconception. Doctors are not getting paid every time they prescribe a medication. There is no secret PayPal from Big Pharma. Per prescription kickbacks are illegal. Now, do financial relationships between physicians and industry exist? Yes. But they are generally tied to services rendered or other transfers of value, not prescriptions. Examples include: • Conducting research • Consulting • Speaking or education • Travel related to legitimate professional activities • Meals provided during educational presentations Many of these relationships are publicly reported and searchable through the Open Payments database. That is very different from: “Your doctor prescribed a medication, therefore they got paid.” That is not how this works. And here’s where I think people should apply the same skepticism consistently. If a wellness influencer is selling supplements, detoxes, coaching, testing, memberships, affiliate products, or courses, ask: • How much money do they make from this recommendation? • What happens to their income if you follow their advice? • Are they profiting from keeping you worried about a problem? • Are they selling a solution to a fear they created? • Are they discussing risks, limitations, and uncertainty or only benefits? Because here’s the interesting part: You can look up many physician industry payments in a public database. There is no public website where you can search how much a wellness influencer made from a supplement deal, affiliate link, brand partnership, detox program, or coaching package. Financial incentives deserve scrutiny. All of them. Not just the ones we already disagree with. Skepticism is healthy. Selective skepticism is not.

A non-profit health system can refer a patient to its own MRI, its own lab, its own surgery center, and bill all three. An independent does that once and it's a federal felony. Same referral. Same patient. One of you goes to prison. It's called Stark Law. Read who's exempt. The asymmetry is the whole business model.

@STzorfas And it is so unnecessary! Even if the bloat had to be there to satisfy CMS (which it doesn’t anymore) the electronic chart could easily send only the most important information to other clinics. But the goal was never interoperability, it was control

70 PAGES OF RUBBISH FAXED TO MY OFFICE. A doctor is referring a patient to me for HEADACHE. The EMR is 70 pages long of every frickin diagnosis the patient ever had. Every medicine, surgery, allergy etc. the patient ever had. Medicine is being buried under documentation bloat: 70-page EMRs full of autogenerated narrative, but no clear patient story, no synthesis, and no human clinical reasoning. And this is for a patient with headaches. I know this is a very real frustration for small private practice offices.

In America the left loves to say the free market failed in American healthcare. There's never been a free market in American healthcare. Certificate of Need bans new entrants. Section 6001 bans physician ownership. Nobody can see a price. You outlawed the market, then blamed it for the bodies. Sowell wrote a shelf on this. Start with the prices.

Physicians are not burned out because medicine is hard. Medicine has always been hard. That is not new. We are burned out because the things making it harder have nothing to do with medicine. Fix the system. Keep the physicians.

@mcuban @cremieuxrecueil @makerjak Even then it is a competition for who gets the honor of charging the exorbitant made-up price so that the PBM can show a “discount” on paper and the insurance companies can show they are spending more money on healthcare- padding investors pockets off the 20% they keep

@cremieuxrecueil @makerjak There is no competition, except to be on the PBM formulary.

Drugs are an annoying market. Competition between two branded drugs does basically nothing to prices. But if a generic enters the market, prices plummet. If you're expecting drug prices to fall as a result of competition, think again!

𝐓𝐡𝐞 𝐧𝐞𝐰 𝐗 𝐚𝐥𝐠𝐨𝐫𝐢𝐭𝐡𝐦 𝐫𝐞𝐰𝐚𝐫𝐝𝐬 𝐝𝐰𝐞𝐥𝐥 𝐭𝐢𝐦𝐞. 𝐒𝐨 𝐈 𝐰𝐚𝐧𝐭 𝐲𝐨𝐮 𝐭𝐨 𝐬𝐢𝐭 𝐰𝐢𝐭𝐡 𝐭𝐡𝐢𝐬 𝐨𝐧𝐞. In 2017 the federal government had THREE urban hospitals classified as rural for Medicare purposes. By 2023 it had FOUR HUNDRED and TWENTY FIVE. They included: NewYork-Presbyterian. $9.3B. Rural. Cleveland Clinic. $7B. Rural. AdventHealth Orlando. $6.2B. Rural. UCSF San Francisco. $6.1B. Rural. Cedars-Sinai Los Angeles. $4.3B. Rural. Combined revenue: $33 billion. In the same period: 206 rural hospitals closed. 417 more are currently vulnerable. The program designed to save rural medicine sent $1.3 billion in rural benefits to hospitals with a combined revenue exceeding the GDP of a small country. These "non-profit" health systems is where your rural benefits went.

Me: I am sorry to say this, but your reports show you have liver cirrhosis. 47F: But how? I have never touched a drop of alcohol in my life. It must be a mistake! My husband drinks regularly and his liver is completely fine. I have some version of this conversation in the wards every single week. There is a massive, deeply ingrained myth out there: Cirrhosis = Alcohol. Let's bust it. While alcohol is a notorious liver-killer, it is far from the only cause of irreversible liver scarring. In fact, non-alcoholic causes are quietly becoming a global epidemic. Here is what else destroys the liver 👇

@gymrat_bookworm This Lyme test does NOT confirm Lyme disease. IgG blot: Negative (1/10 bands only P41, which is nonspecific). IgM blot: Positive (2/3 bands), but only meaningful if symptoms started <30 days ago AND the first-tier screening test (EIA) was positive. Otherwise is false positive.

lol so I already had a PCP appointment scheduled, so I rolled in and said, "hey, the health dept just called me and said I have Lyme, but I can't see my labs." And my PCP said, "hold up, imma call my hook up" *ring ring* "Hey, I didn't order labs on this patient, but the health department called her and said she has Lyme, so could you please fax me preliminary RIGHT THIS SECOND?" And they complied no hesitation lol And then she's like, "OMG you're positive on IgM 😭😭😭😭😭 I assumed you were a chronic girlie." And then we call @DrRyanC and put him on speaker and we're like "positive on IgM 😭😭" And he's like, "uhhh, are you going to let me see the labs I ordered?" 😂

@markkaplan20 @drpoppyBHRT @grok what study is he referencing and what are the findings? Are they peer reviewed and hold up to scientific scrutiny?

My doctor put me on a statin after my heart attack at 52. I trusted him. I took the pill. I never asked a question. Then I found this study. 60 clinical trials. 323,950 people. Every cholesterol lowering drug ever made. Statins. PCSK9 inhibitors. Ezetimibe. They measured how much each drug lowered LDL cholesterol. Then they measured whether people lived or died. The line is flat. It did not matter if they lowered LDL by 10% or by 70%. The death rate did not change. In some trials people died more. 323,950 people. Near zero benefit. Published in the Journal of Cardiovascular Pharmacology. 2023. Nobody showed me this chart. Not my cardiologist. Not my pharmacist. Not the drug rep who visited my doctors office every month. I had to find it myself. After the heart attack.

Over half the country is doing the right thing for their children; hopefully more states will join!

@HeddRichard @RestrictedDaily Shh! @QAnon is hiding!

@RestrictedDaily Thought it was Q, but ChatGPT reminded me about Iowa…

Go ahead… start naming all 50 and see where state names start messing with your head. Final Jeopardy strikes again.

@mcuban Most hospitals and clinics are now owned by Private Equity or the Insurance Companies or they lobby for any advantage to be given to them at the expense of independent physicians. Will you financially support the doctors in an organized effort to fight back?

Let’s not change how hospitals and doctors work with the insurance companies. The current system works for doctors and patients. Perfectly. If the insurance companies cared about outcomes and efficiencies they wouldn’t do dumb shit like this. Why won’t hospitals and practices fight back in any way at all ? Not even mean tweets lol

In other news, the sky is blue.

You can't hold hospital privileges without taking call. Call isn't compensated. That's not a calling. That's coercion. Internal medicine physician Corinne Sundar Rao names something physicians have absorbed for decades without ever being able to articulate it cleanly: call is labor. Not a professional obligation. Not a rite of passage. Labor. And it has been either unpaid or minimally compensated for as long as it has existed. The mechanism is worth understanding. To practice what you trained to do, you need hospital privileges. To keep hospital privileges, you take call. There is no opt-out. The work is tethered, undefined, and endless. One day runs into the next. You carry a full patient load after an overnight on call and you are expected to keep going. No other profession works this way. Pilots have mandatory rest periods because fatigue at high stakes is a patient safety issue. The argument applies equally to surgeons making complex decisions after 30 hours without sleep. The hospitalist model is the clearest proof that the old system stopped working. Nobody decided philosophically that hospitalists were a good idea. The system just broke down until it had to adapt. Defined shifts replaced open-ended obligation. The word hospitalist was first coined in a 1996 New England Journal of Medicine article, and the model has been expanding ever since. The laborist model in obstetrics followed the same logic. High-volume hospitals recognized that asking one physician to manage clinic, elective surgeries, GYN, and overnight deliveries was not a sustainable structure. So they separated the labor floor from the rest of the work. Call hasn't made that transition yet across most of medicine. And the cost is becoming visible. Physicians are quietly leaving. Not dramatically. They are going part-time, shifting to direct care or concierge models, or stepping away from clinical medicine entirely. Physician compensation accounts for only 8 to 8.6% of total U.S. healthcare costs. This is not a compensation problem. It is a structural one. Call is not an infinite resource. It is labor. Labor must be compensated, defined, and protected with rest. Corinne Sundar Rao on The Podcast by KevinMD. Listen link in the first comment.

The AHA blocked $140 to $180 billion in site-neutral payments. That’s money that would have lowered costs for patients. They called it “protecting access.” Wall Street calls it margin preservation.