Chris Bray

Social media is supremely confident about health fads, while small but rigorous trials showing powerful effects from simple, affordable, non-pharmacological interventions get ignored by influencers and mainstream medical guidelines alike. True evidence-based medicine has three pillars: (1) a clear-eyed understanding of what has and has not been studied, along with the outcomes and their real-world relevance; (2) patient preferences; and (3) clinician experience. All three matter. All three are being eroded. A fragmented healthcare system that de-emphasizes continuity of care quietly dismantles pillar three. When a physician cannot follow the same patients over time, they lose the ability to learn firsthand what works, what is tolerated, and what is actually affordable for the people in front of them. The result is medicine that is neither truly evidence-based nor truly patient-centered.

@CertaPeptide @OptimalNathan This was a problem, completely agree.

this is the part that drives me crazy. compounding pharmacies had USP 797 sterility requirements, endotoxin limits, pharmacist oversight. the FDA removed the regulated option and people moved to completely unregulated sources. the demand didnt change, the quality floor just disappeared.

From Gray Market to Black Market: The Dangers of Unregulated Peptides We routinely prescribe subcutaneous peptides. Insulin, growth hormone, and the recent explosion of GLP-1 agonists like semaglutide are mainstays of modern medicine, backed by rigorous data and manufacturing oversight. However, it is crucial for clinicians to be aware of a parallel world involving unapproved "bioactive peptides" that patients are increasingly utilizing for optimization, healing, and anti-aging. This trend was historically fueled by compounding pharmacies operating in a regulatory gray area, synthesizing novel molecules outside the traditional approval pathway. A critical shift occurred between 2023 and 2025. The FDA significantly restricted the compounding of most popular peptides, citing insufficient safety data, risks of immunogenicity, and concerns over impurities. This regulatory action did not eliminate demand; it pushed the supply chain underground. Patients are now acquiring these substances from "Research Use Only" websites - effectively a black market with zero quality oversight. The risks are profound. Analysis of falsified peptide drugs acquired from illegal internet pharmacies reveals alarming quality issues. Purity levels can be shockingly low (ranging from 5% to 75%). Contamination with toxic elemental impurities, including arsenic and lead, sometimes exceeding ICH toxicity limits tenfold, has been documented. Clinically, severe adverse outcomes have been reported, including acute compartment syndrome requiring emergent fasciotomy following the injection of these unregulated "peptide cocktails." Three common classes of unapproved peptides to be aware of: 1. BPC-157: A synthetic peptide derived from gastric juice. It is widely marketed for regenerative effects, particularly for musculoskeletal injuries and gut healing. The evidence base remains almost entirely preclinical. 2. Growth Hormone-Releasing Peptides (GHRPs): Including agents like Ipamorelin and CJC-1295. These are utilized for anti-aging claims, muscle growth, and fat loss. They lack long-term human safety data. 3. Thymosin Variants (e.g., Thymosin Beta-4/TB-500): Promoted for immune modulation and tissue repair, though the commercially available fragments often lack specific human clinical validation. As the supply chain moves further underground, the danger of contamination, infection, and dosing inaccuracies increases. It is imperative that we proactively screen patients for the use of these unregulated injectable substances and counsel them on the substantial risks involved. pubmed.ncbi.nlm.nih.gov/40005999/ pubmed.ncbi.nlm.nih.gov/30029448/ pubmed.ncbi.nlm.nih.gov/38461135/

@OptimalNathan I think there is signal here with some of these peptides, the question is how to ensure sufficient funding to allow legitimate high quality studies without the mega profits luring big pharma.

@docbraymd The FDA didn't eliminate demand, they just eliminated your patients' access to tracked, dosed, pharmaceutical-grade BPC-157 and TB-500. Now they're dosing blind from a vial with 40% purity and arsenic. Regulatory win.

Why I Left the Insurance Fee-for-Service Model of Primary Care ...Here is what that looked like from the inside: A patient comes in with knee pain. Before I could properly attend to their knee, I was obligated to address the system’s agenda. Had I counseled them on vaccines this year? Screened them for depression and anxiety? Asked about falls risk and home safety? Assessed their BMI and documented obesity counseling? Confirmed they were on the correct guideline-directed medications for each of their chronic conditions? Each of these boxes — and dozens more — had to be checked, documented, and reportable in a format the insurance company could audit. I want to be clear: many of these are clinically important topics. But performing a scripted review of 250 requirements during a 15-minute visit about an entirely different concern is not good medicine. It is compliance theater. And patients felt it. They could sense when their doctor was working through a list rather than actually listening to them. ... archangelmichaelhealth.com/why-i-left-the…

Medical knowledge gets you the interview. But being easy to work with gets you the job (or residency spot). Programs want to know you are a positive influence on their culture. That proof comes directly from your Letters of Recommendation. A strong letter writer will highlight: 🤝 Teamwork & Reliability: Specific instances where you supported colleagues, stepped up during busy shifts, or ensured safe hand-offs. 📈 Receptiveness to Feedback: How you handle constructive criticism and actively apply it. 🧘‍♂️ Demeanor Under Pressure: Your ability to maintain a calm, professional attitude during high-stress situations. 🗣️ Interpersonal Skills: First-hand anecdotes of you communicating compassionately with patients, families, and multidisciplinary staff.

GitLab's founder was told he has bone cancer. No trials would take him. Doctors signed off. So he went founder mode on his own survival. - Built his own treatments - Used AI to analyze his own tumor data - Open-sourced 25TB of his medical records for any researcher on earth Relapse-free since 2025. The system said he was out of options. He made his own.

@zarabaloc @ACPFLchapter @ACPIMPhysicians Conferences are the best place to learn, connect and become inspired. Best wishes Dr. Baloch. ACP is waiting for your next poster, presentation or committee chairperson role.

Great time at #ACPFlorida in Orlando networking, learning about residency programs and exploring research posters while connecting with medical students and residents from across Florida! #MedTwitter #FuturePhysicians

@AYasinzaiMD @UFHealthCancer @DrMMurphy @DVAraujoMD @AnwaarSaeed3 @SiddiqullahMD_S @IbrahimNassour @GahyunGim Congratulations Abdul. You will be an exceptional internist! 🩺🥼

….wisdom and resources in my professional growth via the @UFHealthCancer. I am also thankful to @docbraymd, @DrMMurphy, @DVAraujoMD, @AnwaarSaeed3, @SiddiqullahMD_S, @IbrahimNassour, @GahyunGim for their feedback, clinical opportunities, & support of my application.

Over the moon to share that I have matched into my top choice, @LSUHS_IM. I could not have reached this milestone without the support of my family & mentors, especially @TGeorgeMD & @PaulCrispenMD, who provided me with opportunities and invested their valuable time… #Match2026

🧵The 2026 ACC/AHA Dyslipidemia Guidelines are officially out! These new updates bring major shifts in risk assessment, novel lipid markers, and cholesterol targets. Open access 🔓 jacc.org/doi/pdf/10.101… Here are the most salient features you need to know.👇

This review shows mechanistic data for intermittent fasting or ketogenic patterns, calorie restriction, high-quality diets (Mediterranean/MIND), and regular exercise to lower neuroinflammation, enhance autophagy, increase BDNF, and reduce amyloid/tau burden, slowing neurodegeneration and cognitive decline. nature.com/articles/s4432…

A single course of antibiotics can disrupt your gut microbiome for up to 8 YEARS, according to this new Nature Medicine study 💊🤯 Avoid antibiotics unless absolutely necessary and consider taking probiotics to counteract these effects.

Doctors Will Brutally Be Replaced By AI. Here’s Why.

The selection of questions and physical exam plus true understanding of the responses (words and nonverbals) is an art.

The history and physical exam is a diagnostic tool that is unparalleled. Most doctors know this, though many take shortcuts due to time constraints. I think more patients should be aware of this as well. Too often, patients want to tell their story and then expect a diagnosis to emerge simply from what they've said.

𝗥𝗔𝗡𝗞 𝗢𝗥𝗗𝗘𝗥 𝗟𝗜𝗦𝗧: 𝗧𝗶𝗽𝘀 & 𝗧𝗿𝗶𝗰𝗸𝘀: ⏳ Match Day is around the corner Your Rank Order List is one of the most important decisions of your career. Get it right. 𝗠𝗮𝘁𝗰𝗵 𝗔𝗹𝗴𝗼𝗿𝗶𝘁𝗵𝗺 𝗪𝗼𝗿𝗸𝘀 𝗶𝗻 𝗬𝗼𝘂𝗿 𝗙𝗮𝘃𝗼𝗿: • Rank programs in the order you truly want, not where you think you will match • The algorithm favors applicants, always • Myth alert: Ranking a program higher because you think you have better chances does NOT increase your odds. Don’t fall for it ❤️ Trust your gut • How you felt on interview day matters more than spreadsheets and rumors. 🔑 Key factors to seriously consider 𝗣𝗿𝗼𝗴𝗿𝗮𝗺 𝗖𝘂𝗹𝘁𝘂𝗿𝗲: ✅ IMG friendliness ✅ Presence of people from similar backgrounds ✅ Respect, teamwork, and professionalism 🚫 Avoid malignant environments, favoritism, scut work, and cut throat competition 𝗟𝗼𝗰𝗮𝘁𝗶𝗼𝗻: • Urban vs rural • Proximity to family and friends • Access to your home country community and religious centers • Cost of living • Weather • Access to an international airport • Direct vs indirect flights within the US and internationally 𝗣𝗿𝗼𝗴𝗿𝗮𝗺 𝗦𝘁𝗮𝗯𝗶𝗹𝗶𝘁𝘆: • Rank programs on probation lower 𝗥𝗲𝘀𝗶𝗱𝗲𝗻𝘁 𝗪𝗲𝗹𝗹𝗯𝗲𝗶𝗻𝗴: • Salary • PTO and sick leave • Wellness culture that actually exists, not just on paper 𝗧𝗿𝗮𝗶𝗻𝗶𝗻𝗴 𝗤𝘂𝗮𝗹𝗶𝘁𝘆: • Clinical exposure • Patient Load and Caps • Electives • Research opportunities, if that matters to you 🎯 If you’re aiming for competitive fellowships • In house fellowship availability • Fellowship match success rate • Protected time for fellowship conferences • A supportive PD who writes personalized letters and actively advocates for you 𝗥𝗲𝘀𝗶𝗱𝗲𝗻𝗰𝘆 𝗟𝗲𝗮𝗱𝗲𝗿𝘀𝗵𝗶𝗽: Residency Program Leadership matters. A lot. • Choose programs where the Program Director and Department Chair are genuinely supportive, visible, and invested in resident success. • An open door culture, easy access to leadership, and residents being heard are signs of a healthy program. ⚠️ 🚩Red flag: Frequent changes in program leadership often signal internal instability, poor morale, or deeper systemic issues 🚫 One golden rule: Do NOT change your rank list based on post interview communication, even if it sounds very encouraging. Rank based on your preference, not reassurance. ⚠️ Common mistakes to avoid • Ranking prestige over happiness • Last minute submission, technical issues are real ✅ Final checklist • Certify your list well before the deadline • Triple check program names and codes • Save a copy for your records • Submit early for peace of mind You’ve worked too hard to second guess yourself now: ✅ Trust the process. ✅ Trust your instincts. You’ve got this. 💪 #ResidencyMatch #ROL #NRMP #RankOrderList #Match2026

Maybe the most important paper so far showing that sports activity helps you live longer, published in @TheLancet. Not all sports are equally effective. See their impact below 👇

@abdulmaleekkoya Yes. It likely does track with other professional careers. It explains why it feels like life is more expensive even when salary dollar amounts go up.

@docbraymd That maybe the same for every occupation. The culprit was ‘inflation’ I suppose.

US physician salary valued in gold. ​In 1970: Gold was artificially cheap (~$36/oz market price). ​In 1971: President Richard Nixon suspended the convertibility of the dollar into gold. This ended the fixed exchange rate.