Posts by Nicholas Myers

Kyle Lee7 said:My apologies, I really didn't mean to call you out like that.

I was just expressing my skepticism regarding any kind of psychotherapy intervention being handled by general practitioners—regardless of the specific type. I actually wasn't aware that "psychotherapeutic counseling" was even a formal term used in that context, but after spending years in actual therapy and years bouncing between various doctors and specialists, my personal take is that you really need a specialist for that. Those various bits of unsolicited advice you often get—like being told "you just need to pull yourself together"—simply don't feel useful to me.

Honestly, I couldn't agree more. 🙂

That’s exactly why I mentioned that anyone seeking "real" psychotherapy shouldn't expect to find it with a primary care physician (especially considering how some sort of "quasi-therapy"* is handled and funded by Medicare in general practice clinics).

*Not the right term, I realize, but I don't know what else to call it since I'm not familiar with the official standards (session length, specific techniques, etc.).

Kyle Lee7 said:If you ask me, there’s no such thing as "psychotherapy in the full sense of the word"—nor is there any such thing as "semi-psychotherapy." You either perform it, or you don't.
Given that becoming a licensed psychotherapist requires years of specialized training and practice, and considering that a standard therapy session lasts 45 minutes while the waiting room at my local clinic is packed with 30 people (my doctor sees anywhere from 60 to 90 patients a day!), I just don't see how any kind of "partial psychotherapy" (like simple talk therapy) could possibly happen in that setting.

I’m sharing this from the perspective of someone who has been in psychotherapy for several years now.

If you look at the billing codes in a standard primary care clinic, Kyle Lee7, you'll see entries for things like "psychotherapeutic counseling" or "superficial psychotherapeutic intervention."

Since I'm no longer working in general practice, I can't give you the exact specifics right now, but these are procedures that don't require advanced training. A standard MD can perform them without being a specialist in family medicine.

So, this "semi-psychotherapy" does exist, and it gets billed—Medicare covers it under certain outpatient procedure codes.

There's no need to question my understanding of psychotherapy. This isn't an official medical seminar, nor is it intended to be a formal academic debate, so precision isn't the priority here.

Thanks.

vividsailor7 said:
Nicholas Myers, regarding the generics issue—this new model for prescribing drugs—what's your view on what Morgan Morgan5 mentioned about people not even knowing the original brand name? It's something I've noted before as well.

I agree with everything said here.
🙂

Morgan Morgan5 said:Here is what happens when someone who actually should be explaining things clearly to patients either doesn't know how—or simply refuses to. I am, of course, talking about Medicare and Prof. Ostojić. Essentially, primary care doctors are going to be forced to prescribe the cheapest option available. But here is the catch: every time a new drug hits the formulary, the prices for everything else tend to drop—which affects most people. We end up with lists containing ten completely identical medications from different manufacturers, or rather, different patent holders. To be specific, there are drugs where both the original manufacturer and another license holder stay on the list. So, it is the exact same medication at the exact same price—just a different name and a different box. For instance, Lipitor has 14 versions on the list, and most of them share that same lowest possible price. When it comes to certain medications, patients don't have even the slightest clue which one is the actual originator. I would love for someone to chime in if they know what the original Diazepam is (like Valium). If you Google it, see if the original brand is even still on the list.
So, for patients, nothing really changes regarding the medications on the basic formulary. As for specialists—the ones pharmaceutical companies fly out to symposia and medical conferences—what will happen is they'll have to coordinate much more closely with the firms that offer the cheaper drugs. However, since there are at least three (if not more) versions of these drugs on the Medicare list, and the choice is left to general practice, it is pretty obvious that general practitioners will be the ones traveling more often.

My concern lies elsewhere: what happens when the formulary includes several different brands for the same drug, but the price points vary significantly?

Take an antibiotic like Zithromax, for instance. Some versions are considerably cheaper than others.

It looks like Zithromax might not be a winning bet here.

rustymason82 said:vividsailor7 or Nicholas Myers, I have a few quick questions

If my pulmonologist schedules annual checkups involving spirometry, plethysmography, and a FeNO test—or even just spirometry—is my primary care physician allowed to refuse to write the referral for those yearly exams?

How is my doctor supposed to accurately monitor my asthma if they don't have access to spirometry, which is the fundamental tool for assessing lung function? Honestly, after he prescribed four different antibiotics in a row for what turned out to be an asthma flare rather than a bacterial infection, can we really trust his stethoscope alone?

Does he actually have the authority to alter the treatment plan my specialist laid out? For instance, could he deny my prescription for Alvesco and instead opt for a cheaper corticosteroid from a different class, especially since I understand there isn't a generic version for Alvesco yet?
Thank you for your help

Under the new Medicare model, based on how they’ve presented it to us, specialists are no longer permitted to list the date for your next follow-up directly on the outpatient chart.

The scheduling and timing of these inspections should be left entirely to the ABA.

No, specialists still have the authority to recommend both diagnostic testing and therapeutic adjustments.

Theoretically, the AMA has the authority to deny someone a referral for a follow-up exam. However, they need to be mindful that doing so shifts the liability onto them if the patient’s condition worsens because the AMA failed to provide proper care.

How exactly is my doctor supposed to gauge my asthma status if there isn't a spirometer available? A spirometry test is the baseline for monitoring this condition. Based on his track record with listening to my lungs via stethoscope, I’m skeptical—he spent enough time prescribing four different antibiotics in a row when what I actually had was asthma, not some random bacterial infection.

That’s an excellent question.

You can't get a real picture of what's actually going on without a spirometer. It’s just guesswork otherwise.

I find it hard to believe that Medicare would turn down a referral for a follow-up exam in a situation like this.

Not quite. He can issue a referral for something like a spirometry test, for instance. If those results look good compared to the last round and the patient’s clinical picture remains stable, he can choose to withhold the referral for a specialist follow-up—effectively taking full responsibility for that call.

Does he actually have the authority to override my pulmonologist's treatment plan? For instance, can he refuse to prescribe the Alvesco that my specialist recommended just to swap it out for a cheaper corticosteroid? I know they belong to different classes, and from what I understand, there isn't a generic version for Alvesco yet.

Based on how Medicare structures its sentences, it’s theoretically possible for the medical board to reject a therapy recommended by a specialist.

The setup goes like this:

The final call on proposed therapies, referrals for further testing, and determining an individual's fitness for work all fall under the authority of the primary care physician.

If... When a primary care physician decides to prescribe a treatment based on a specialist's recommendation, there's a better way to handle it: suggest switching to the most cost-effective generic version with the exact same active ingredients.

My takeaway? Theoretically, it’s possible—but you’re still the one holding the bag.

That’s how I saw it.

I wonder if my colleague will arrive at a similar interpretation.

Olivia Castillo562 said:The swab was taken right when the illness started. I had a sore throat, visible inflammation, and a fever north of 102, which is pretty standard for me.

It’s entirely possible the swab came back a false negative, or perhaps the pharyngitis wasn't caused by strep at all.

So, the initial inflammation flared up on August 12, 2012, and the first CRP test was done on December 18, 2012, during the third bout of throat inflammation. A second CRP was repeated during a period when I was actually feeling healthy.

CRP levels tend to stabilize relatively quickly once treatment begins, which explains why those initial numbers weren't particularly striking. However, that second CRP definitely points toward an ongoing inflammatory process.

Did you have an ESR (sedimentation rate) done?

At this point, I don't understand the reasoning behind the autologous serum test, the computerized telethermography (I have no idea what that even is, other than what Google says), or why I need an ultrasound of the arteries in my arms and legs.

Computerized telethermography is a diagnostic tool that analyzes thermal energy—specifically, the infrared radiation emitted from the surface of the body—and maps it using various color combinations representing heat and cold.

The premise is that in many conditions, skin surface temperature fluctuates (either rising or falling), such as during inflammatory processes or changes in blood flow through specific areas of the body.

This method can be useful for diagnosing inflammatory joint diseases, connective tissue disorders, degenerative joint issues, soft tissue damage, complex pain syndromes, or analyzing circulation in the extremities.

The latter (circulation analysis) is likely why the ultrasound was also ordered.

One more thing: are you dealing with any sinus issues?

vividsailor7 said:Excerpt from the USA Today article: "However, based on this referral, the specialist will not be able to refer the patient for further hospital treatment, order follow-up exams, or issue an opinion regarding the patient's ability to work."
As for the coding issue? Nothing has changed in months, and nothing is going to change. It’s all still going to be logged under PZZ usage just like it always has been.

I realized I misspoke; I was actually referring to tests and evaluations conducted by other specialists.

We’ll still be able to write them—meaning we can recommend specific tests or suggest seeing another specialist. Then the primary care office can issue the referrals and note who made the recommendation. Interestingly, those "Code A" referrals supposedly won't be counted against family practitioners.

My sense is they’ll only track the "C1" referrals, specifically when requesting full specialist evaluations and comprehensive patient management.

That doesn't sit right with me. If Code A isn't being tracked, then doctors will just go back to referring hypertension patients simply to adjust their blood pressure medication doses. 🙂

vividsailor7 said:Let's take this one step at a time.
You got the answer for code A.
Just go on Google, search for the generic version of the medication, and actually read what it says. I’ve put the links right here for you.
I’ve been reading through this latest deep dive on medication management, and frankly, it’s enough to make your blood boil. It’s one thing to deal with the daily grind of managing chronic health issues, but it's an entirely different beast when you realize how much of a minefield the pharmaceutical landscape actually is. Let's be real: navigating the world of prescriptions isn't just about following a doctor's orders anymore. It's a constant battle against side effects, complicated dosing schedules, and the sheer exhaustion of trying to keep everything balanced. You aren't just treating a condition; you're essentially becoming a part-time pharmacist just to stay level. The article touches on some heavy topics regarding how we interact with our meds, and I can't help but feel a sense of frustration. We’re told to trust the system, yet the moment you experience a setback or a nasty reaction, you're left feeling like you're shouting into a void. Whether it's adjusting insulin levels or dealing with the fallout from steroids, there's a massive gap between "clinical guidelines" and the actual, lived reality of someone sitting at their kitchen table trying to figure out why they feel like garbage. It's a mess. A complete, unmitigated mess. We need more transparency and way less hand-waving from the institutions that are supposed to be looking out for us. If you're feeling overwhelmed by the complexity of it all, you aren't alone—you're just paying the price for a broken approach to long-term care.
I’ve been digging through some old archives lately, and I stumbled upon this deep dive regarding how certain medications actually function within our healthcare system. It really gets you thinking about the sheer complexity—and sometimes the frustration—of managing chronic conditions. Let’s be honest: navigating the world of pharmaceuticals feels like walking through a minefield sometimes. You have one day you're feeling fine, and the next, you're staring at a prescription bottle wondering if you're even taking the right thing. Whether it's managing blood sugar levels or dealing with inflammation, the science behind these drugs is intense. Take something like Lantus, for example. Or when you're balancing insulin regimens like Novomix plus Glargine. It isn't just "taking a pill"; it's a constant, calculated dance with your own biology. And don't even get me started on the bureaucracy. Trying to coordinate everything through Medicare can feel like a full-time job in itself. One minute you're checking your coverage, and the next, you're buried in paperwork trying to figure out why a specific brand wasn't approved. It’s easy to get cynical. We see headlines about drug pricing or shifts in medical guidelines, and it feels like the goalposts are constantly moving. But that’s the reality of modern medicine in America. It’s a massive, complicated machine. You have to stay informed, stay skeptical, and—most importantly—stay on top of your own data. You can't just leave your health in the hands of a faceless institution and hope for the best. You have to be your own best advocate.
And there's a whole lot more where that came from.
Look, everything said here carries weight because that’s exactly how the medical establishment operates. They have their way of doing things, and they stick to it. Personally? I don't buy into those kinds of stories for a second.
And just so we’re clear, you can only pay for supplemental coverage yourself. Otherwise, your employer is the one legally required to make those payments on your behalf—unless you're self-employed, obviously. Take a good, hard look at your own pay stub. Ever since the new administration took over, they lowered the healthcare tax rate, yet I haven't seen a single person's take-home pay actually increase because of it. It's ridiculous.
It’s absolutely infuriating how disorganized things are here in America. You can’t even find the same corticosteroids—take Decoritn, Medrol, Cortef, or Dexamethasone, for instance; they are all completely different! It’s just another example of how nothing works the way it should. And don't even get me started on chemotherapy drugs. Almost 95 percent of patients receiving IV treatments have absolutely no clue what they are actually being injected with. Why? Because most of these medications are listed under these vague, unprotected names alongside the manufacturer, rather than being clearly identified. Most medical protocols for common diseases are written so vaguely that it’s impossible to track exactly what is being administered. It's a total mess.
Look, I prescribe corticosteroids on a daily basis, and I deal with oncology patients every single day. So, if you think I don't know what I'm talking about, you're dead wrong—I am intimately familiar with this stuff.
Look, you’ll eventually get that treatment in a major city like Chicago or New York if your specialist actually recommends it—assuming they can get the local medical boards to approve it on your timeline. But let’s be real here: unless you’ve got a massive pile of cash sitting around, don't expect them to just hand it over for free whenever you feel like it. You either follow the recommendation and deal with the bureaucracy, or you prepare to pay out of pocket. Your call.

That isn't quite how it works.
1. I can't just "call in" a patient for a check-up; that decision rests entirely with the Primary Care Physician (PCP).
2. But if they send a patient over with an 'A' code, the PCP is the one issuing the red slip for the required tests. If they send them with a 'C' code (and those are limited), I am under no obligation to issue internal referrals. I haven't issued any of those so far, nor do I plan to, much like most of my colleagues at the Social Security Administration.
3. I also treat patients with other internal medicine issues—diabetes, hypertension, hyperlipidemia alongside GI diagnoses like gastritis—because I'm not strictly tied to just gastrointestinal issues (most people accept this), but rather the whole "internal medicine package." For patients with things like IBD, I usually request follow-ups every 2–3 months; 6 months is the absolute maximum gap I'll allow.
Even though I can't order follow-ups directly anymore, I can still refer them to my colleagues, whether they are specialists or not. And if there is a genuine need, or if I manage to pull some strings with the PCP, we can hospitalize them and then "call them in" three times a year.

The PCP has nothing to do with whether it's IV or oral; Medicare has already decided who covers that.
And the PCP can't even prescribe them if they wanted to, because there are strict limits on diagnosis codes and clinical guidelines.

We can note a three-month follow-up on an outpatient chart for a patient with an I10 diagnosis. There aren't any current restrictions on that.

The AMA can refer that patient for a check-up in three months, and the physician's ID number can be entered under the "specialist code" section on the referral.

Supposedly, Medicare is going to start monitoring how often specific codes appear on those referrals—basically tracking who is ordering what kind of diagnostic testing.

edit: my mistake, not follow-ups, but diagnostic tests. 🙂

vividsailor7 said:

vilenjačica As I was saying:
If you ask me, this is just going to create an even bigger mess... I honestly can't make heads or tails of these new guidelines. It’s a total disaster—nothing makes any sense!Heading out to the outpatient clinic. So, the specialist ordered more testing just because he felt like it... what am I even supposed to do with that now? What kind of referral is he going to write me to make this actually useful? Honestly, I’m starting to think even my own doctor won't have a clue how to handle this mess. Hah!

Honestly, I have no idea why you people think you need to be experts on medical prescriptions. It’s not your job to decipher the fine print!
They’re going to issue you an outpatient referral, and honestly, I don't see what the big deal is. What part of that is unclear?

Jane—look, let’s get one thing straight. Avastin, just like all those other chemos, has absolutely nothing to do with my primary care doctor. These drugs aren't something you just pick up at a local pharmacy on a whim. They are administered in a hospital setting, fully covered by the hospital budget, specialized drug funds, or whatever specific insurance guideline is currently in play. My doctor couldn't prescribe this even if they wanted to! It’s strictly regulated. Because these medications are flagged for hospital administration only, that rule applies whether we're talking about tablets or IV infusions. Period.
What the hell am I going to say? I’ll tell you exactly what I think, and I mean this: if they have a properly signed medical history on file, then I don't give a damn about Medicare's guidelines or their ridiculous penalties. I truly do not care if they get slapped with a fine. I am prescribing medication based on professional medical standards—period. You and Medicare are the only ones treating patients this way anywhere in the world! If you follow those rigid little rules instead of actual medicine, a patient could literally die right in front of you because of it. It has this risk, it has that complication... I don't care. None of that matters to me. YOUR inspectors—you’re the ones who denied the patient their medication in the first place. Why even send it to an inspector if you're just going to block it? I CAN PROVIDE EXAMPLES.
The Cat, I’m sorry you had to deal with that (and I’m sure you weren't the only one), but I completely get why the patient reacted the way they did—not talking about any physical fighting, obviously—but you aren't giving them a drug that is CLEARLY INDICATED BY MEDICAL GUIDELINES. Once that happens, as far as I'm concerned, and 95 percent of SKZZ, the conversation ends right there. We've said our piece; from here on out, the responsibility for that patient lies squarely on your shoulders.

I can't weigh in much more since I'm working in a hospital now myself. 😍

That experience in primary care really helped me grasp how the entire system actually functions.

And yeah, they don't call them inspectors. They just show up at the clinics and comb through the charts. When half your paycheck gets docked because of it, it matters.

If they spot even a few instances of rule violations, the penalties can escalate significantly.

I hate to say it, but you're mistaken. Even we hospital doctors are part of the Medicare system; it's our superior, not just the family practitioners.

It's like saying, "I listen to my department head, but I couldn't care less about the hospital director!"

Every specialist knows the prescribing criteria. No one is asking them to withhold medication, but they are obligated—especially if a primary care doctor sends it back—to explain to the patient that they'll have to pay for it. They shouldn't pretend they've never heard of Medicare guidelines, or worse, lie and claim the patient doesn't have to pay.

That's just plain wrong.

The medication isn't being denied; the patient still gets a prescription, it's just a private pay script.

As for the lack of funding? To be blunt, that falls outside the scope of a family doctor's job.

Angela Wright said:Actually, no. Avastin is a targeted therapy, and while we often think of infusions, there are smart drugs available in capsule form that are currently on hospital formularies; for instance, they’re used alongside chemotherapy for advanced colorectal cancer. Take Temodal, for example—it's a first-line treatment for glioblastoma, administered in combination with radiation during the first cycle and then as a standalone treatment for the next five cycles. That is also on the hospital formulary. We are talking about targeted biological therapies here—extremely expensive medications—even though our legal framework in the US still hasn't clearly defined what actually constitutes an "expensive" drug. Because of that ambiguity, it's completely unclear what criteria will be used to decide if something is considered overpriced or a "budget-friendly" option. It looks like generic manufacturers are going to be hitting the jackpot in America.
And based on how this works, the decision-making process is going to be a mess. An oncologist will propose a specific therapy, Medicare might withhold its blessing, and then you're left asking who is actually footing the bill and how much influence hospital review boards will truly have in the process... or if they'll even matter at all. To receive oncology treatment, a patient doesn't necessarily need to be hospitalized; they can take medications like Temodal at home and just head into the clinic for radiation sessions.

I'm not sure about Avastin in capsule form; I was thinking of this one instead. Avastin. The kind I encounter.

Aside from that, you have Temodal. It’s typically the first line of defense against glioblastoma. Usually, the initial cycle is paired with radiation therapy, followed by five solo cycles. It's also on the preferred drug list.

With this specific medication, general practitioners aren't even in the loop. As far as I understand from the briefings we've received, that rule about doctors being required to prescribe the cheapest option doesn't apply to drugs currently on the hospital formulary.

An oncology patient doesn't necessarily need to be stuck in a hospital bed to receive treatment. It’s possible to manage things from home—taking medications like Temodal, for instance—while simply heading into the clinic for radiation sessions.

Regarding Sutent Tabet, I know for a fact that patients pick up their prescription at the hospital and then just take it once they get home.

There's no connection between the litigation and that medication. Period.

What lies ahead for our hospitals? Honestly, I haven't the slightest clue.

Olivia Castillo562 said:I’ve run AST tests several times now—both when I was feeling under the weather and when I was perfectly healthy.

What kind of illness (inflammation) are we talking about here—something like pharyngitis or just a sore throat?

Dec 10, 2012: 484 IU/ml (sick). Dec 22, 2012: 502 IU/ml (following a full course of antibiotics). Jan 8, 2013: 406 IU/ml (healthy) and 678 IU/ml (sick). Reference range < 200 IU/ml.

AST-O levels typically trend back toward baseline roughly 6 to 12 months after the illness subsides. The peak usually hits about a month into the onset.

Throat swab was done back on December 10, 2012. Results showed physiological flora. I haven't had any nasal or ear swabs done.

I had my CRP tested twice. On December 18, 2012, it was 17.46 mg/l while I was on antibiotics. By January 8, 2013, even though I felt fine, it was 14.28 mg/l. The normal range is under 6 mg/l.

If that throat swab was taken before starting antibiotics, it likely wasn't a strep infection.

When looking at CRP levels, timing is everything. It really comes down to how long ago the illness first showed up—and specifically what kind of illness we're talking about.

Skin tests aren't showing an allergic reaction to any standard inhaled allergens, except for histamine—which shows a 5x5 response—while the autologous serum test came back negative.

A histamine reaction is standard. If there weren't a reaction to histamine, the test itself would be questionable—like testing someone who’s already on antihistamines. This is a textbook finding.

The reasoning behind running an autologous serum test isn't entirely clear if we aren't dealing with chronic urticaria.

Knee pain started about five or six years ago. No swelling in the joints—just this dull ache deep inside. It fluctuates; sometimes it feels like I actually "have" knees, and other times it becomes intensely painful, especially when I'm tackling stairs. Prompted by that discomfort, my doctor ordered a Waller Rose test and checked for LE cells. As for what those LE cells actually signify in my specific situation? I haven't a clue.

The LE cell test isn't really the gold standard it used to be. These days, the ANA test has taken its place. If that comes back negative, the likelihood of systemic lupus is extremely low.

Brandon Lopez6 said:I honestly have no clue, look...

Back in January (after my condition had finally leveled off for a bit), things took a nasty turn for the worse. I stumbled upon some info online about how even primary care doctors are doing some kind of psychotherapy now and prescribing meds for mental health stuff. Personally, I’d much rather just talk things out than pop pills, so that would be perfect. Plus, dealing with a mix of mild agoraphobia and this phobia that keeps me from going anywhere solo, being able to see a doctor right here in my hometown would be a lifesaver.
So, I went to see my doctor and explained what I'd read. He basically told me I should probably head to Washington, D.C., because my issues were "too much" for him to handle. I tried booking an appointment in a nearby city, but when they told me they weren't taking anyone new until late August or September, I just gave up. Sure, it's closer and easier to get to, but I couldn't deal with waiting that long.
Even if my doctor suddenly decided he was down to do counseling sessions with me, I’d be pretty skeptical. If he didn't get it yesterday, why would he suddenly get it today? The only real move is what you guys suggested—switching to a different doctor. But in a small town like this, nobody talks about whether someone is "crazy" (there are only two categories here: crazy or sane), so I have no idea which other doctor to pick or who might actually be more specialized than my current one.
Don't get me wrong, he's a great doctor. He does everything he can to help me out, but when it comes to this side of medicine, he either doesn't understand it or he's too afraid to "play around" with those kinds of things. 🤷

I don't think the new model will change much regarding referrals in your situation; essentially, your primary care physician will likely still be sending you to a psychiatrist.

From what I understand, family practitioners aren't trained to perform psychotherapy—at most, they might handle some surface-level therapeutic interventions. There may be rare cases where a doctor has pursued extra training specifically in psychotherapy, which isn't strictly a field reserved for psychiatrists.

The only gray area is the detail about hospital access. I haven't seen any clear guidelines outlining the specific criteria for which facility a patient can be sent to. So, as for whether you'll be able to receive treatment in Washington, D.C. via a referral, I can't say for sure.

But, as I've mentioned before, under this new model, I doubt anyone is going to force a primary care doctor to stop referring patients to specialists.

Brandon Lopez6 said:So what, we’re just supposed to sit here and take it because—what?—there aren't enough doctors available? 🤷

People could ask the exact same thing about diabetes or high blood pressure. If there are specialists specifically for diabetes or hypertension, why should they be treated by someone who knows less than those experts? They deserve the best specialists in their fields too, right?

In my book, "high blood pressure/diabetes" doesn't really fall into the same bucket as mental illness. Honestly, unless you've been through it (and I don't mean just feeling a little down), it's hard to get how much someone needs constant contact with a psychiatrist. Sure, if the local clinic handles it, problem solved, right? But can I just drop by and hang out for an hour? And what about the folks with blood pressure or sugar issues who are just waiting on a prescription?

Of course not. Instead, there should be some actual vetting involved. We need to distinguish those who truly require psychiatric intervention from those who simply don't. For instance...

So, once LOM starts working, does that just fix everything? Is that the end of the story? Can I just swing by his place and hang out for an hour or so?

Perhaps this conversation serves a dual purpose. It might help some people resolve their issues directly with a primary care physician, potentially bypassing the need for a specialist altogether. Meanwhile, those who truly require psychiatric intervention will likely move up the queue, getting seen sooner because the caseload has been lightened. 🤷

George Allen71 said:So, when we're talking about psychiatrists... and those mandatory checkups... do you guys honestly think they'll scrap them? I mean, there's a massive difference between managing high blood pressure and dealing with mental health issues...

Of course they won't. It’s pretty clear from the paperwork—referrals for follow-up exams are already being planned out.

Brandon Lopez6 said:I’ve gotta say... it just doesn't sit right with me that the government would run any kind of mental health program. I mean, what’s even the point of having psychiatrists then? I could go on and get pretty nasty about it, but I won't. It isn't the doctors' fault—it's the people running the show above them. They’re (thank Bog) perfectly sane, so they couldn't care less about the rest of us. Honestly, their best move would probably be to just lock us all up in some asylum or hospice and call it a day. ☕

And do you really think there are enough psychiatrists to handle everyone struggling with mental health issues?

The same logic applies to patients dealing with diabetes or hypertension. If we have specialists dedicated specifically to diabetes or blood pressure, why should someone with less expertise try to treat them? Surely those patients deserve the top experts in their specific fields.

It brings up the question: what is the role of a family doctor in this setup? Wouldn't it be more efficient for patients to go straight to a specialist? At the end of the day, a specialist is an expert in a specific disease, organ, or system. They know significantly more about their niche than a general practitioner ever could.

Brandon Lopez6 said:Total nonsense. Even the guy at LOM told me himself he had no clue what was going on when I was asking him about the Ad, so now suddenly he’s supposed to be an expert overnight?

Whatever. I’ve still got some credit left, so I might just go private.

You’re well within your rights to switch doctors.

Most antidepressants can be prescribed by a standard family practitioner; no specialized training required.

But if your primary care physician knows nothing about antidepressants, find a new one immediately.

It’s hard to give a definitive answer. Even those of us working in hospitals haven't been briefed on the full scope of the upcoming changes. My sense is that there won't be some rigid, itemized checklist defining exactly which symptoms justify a specialist referral or which ones strictly prohibit it.

Ultimately, the decision will still rest on the primary care physician's clinical judgment.

If they deem a condition mild to moderate, they’ll likely attempt to manage it with whatever medications are currently in their toolkit first. If the treatment fails to yield results or if the progress is insufficient, only then will they refer the patient to a psychiatrist.

As for patients who already have established psychiatric care, psychiatrists will now be much more mindful of appointment intervals, as those visits will be tracked under the new metrics. That said, the GP will retain the authority—just as they always have—to decide whether a follow-up is clinically necessary.

It really depends on the specific diagnosis.

A primary care physician isn't going to call the shots when treating psychosis. That falls squarely within the domain of a psychiatrist.

Think of it this way: a family doctor handles mild to moderate depression. However, once you get into severe cases, treatment-resistant episodes, or depression involving psychotic symptoms, you're looking at a specialist's territory.

We don't expect a GP to act as a full-scale psychotherapist; patients will continue to see their own therapists for that level of care.

But given how mental health issues are surging—some even predict depression will soon be the most prevalent condition out there—it makes sense that not everyone needs a psychiatrist. It should be reserved for those facing moderate to severe struggles.

Olivia Castillo562 said:Hi, this is my first time posting on the health forum, so I hope I'm doing this right.

Age: 28, not pregnant 🙂 non-smoker, using oral contraceptives

Reason for testing: I get sick with strep quite often. Had my tonsils out when I was 16. Since then, infections have been less frequent, but last year I was getting hit hard. First time in August, second time in October—they actually tried to admit me to infectious disease back then, but I refused. Then it happened again in December. In September, I also dealt with severe hives after eating raspberries (twice, even though I’ve never had an allergy before), and this year my arms have broken out multiple times after touching leaves or strawberries. My knees have been aching too, varying in intensity. I felt completely exhausted through November and December. So, I started the workup.

Tests done before seeing the immunologist at Mayo Clinic: I had two separate throat swabs; both times, I tested positive for two out of three days. Thyroid levels look fine, all within range. Negative for Waaler-Rose and latex. CBC values are all within normal limits.

Fibrinogen 4.4 (reference range 1.5 - 4),
last AST-O 678 IU/ml (reference < 200),
last CRP 17.45 mg/l (reference < 6),
protein electrophoresis: elevated alpha 2 at 11.1 (normal 6-10) and beta at 15.5 (normal 8-13).

My primary doctor referred me to immunology at Mayo Clinic, where they recommended: ANA, IEF, anti-thyroglobulin and anti-microsomal antibodies, AST, CT telethermography, autologous serum test, skin prick tests for inhalation allergens, total IgE, C3 and C4, and an ultrasound of the arm and leg arteries.

I’ve completed: the skin prick tests and the autologous serum test; both were negative.

Then the anti-thyroglobulin and anti-microsomal antibodies:



ANA, IEF, total IgE, C3 and C4



I haven't done the rest yet because the wait for the CT telethermography is incredibly long, so I'm in no rush to get the artery ultrasound or the AST done.

I would appreciate some insight on these results, as my doctor is away on vacation for a while and my follow-up with the immunologist isn't until November 6th.

Thanks in advance 🙂

Hello,

As things stand, these results seem fairly disconnected and a bit confusing without a deeper discussion regarding all your symptoms and their exact timeline (for instance, the relationship between joint pain and any potential sore throats).

To start, the elevated AST-O (regardless of the fact that your tonsils were removed) indicates contact with strep in the recent past (relative to when the sample was taken). However, this single value doesn't tell us much; it is vital to monitor the titer dynamics—essentially how that AST-O value changes over time—to determine what is actually happening.

Unfortunately, strep can hide in places other than the tonsils (like the nasopharynx, ears, or skin) and continue causing issues.

The CRP, acting as an indicator of inflammation, is slightly elevated. For interpretation, it is crucial to know if you were experiencing any symptoms at the moment the sample was drawn, as even a common virus could produce a result like this.

While they might seem unrelated, there could be a link between elevated anti-Tg antibodies and hives (though I doubt it applies to your specific case), as well as elevated IgA levels.

Essentially, a positive anti-Tg result means your body is producing antibodies that can target the thyroid and disrupt its function. Since your TSH is within the normal range, medication isn't strictly necessary right now, but you’ll need periodic thyroid hormone monitoring.

Furthermore, a positive anti-Tg finding can sometimes trigger false elevations in IgA levels—largely due to the specific testing methodology used, which is a bit too technical for this forum.

That said, high IgA can also be interpreted as the body reacting to mucosal irritation, such as chronic respiratory infections.

Chronic autoimmune urticaria can indeed be linked to an autoimmune thyroid condition.

I see an autologous serum test was performed, which is useful for diagnosing chronic hives. However, based on what you've described, I'm not convinced we're looking at chronic urticaria. We typically reserve that diagnosis for hives lasting longer than six weeks, whereas it sounds like you experienced two acute episodes.

The LE cell test has largely been phased out in favor of other diagnostic tools for systemic lupus erythematosus, most notably the ANA test.

Your negative ANA result, according to the report, strongly argues against a diagnosis of systemic lupus erythematosus.

A negative rheumatoid factor doesn't completely rule out rheumatoid arthritis, though the symptoms you mentioned don't particularly point in that direction.

Ultimately, it is difficult to provide a definitive commentary on these results without seeing the patient in person and having a full grasp of the clinical picture.

For now, the findings suggest a recent contact with Streptococcus, a predisposition toward mucosal infections (like recurring respiratory issues), and the possibility of an emerging autoimmune thyroid disease—though this shouldn't impact your clinical symptoms or cause any actual distress.

Best regards. 🙂

melloworca6 said:Alright, look, it’s obvious the Secretary and his little inner circle have completely lost the plot. Honestly, if I were a GP, I’d be raising hell right now because they’re about to dump all this liability on our shoulders. We’ll be the ones making the final calls, which just means we’ll be the ones getting sued constantly. And let's not forget that primary care offices employ doctors who haven't even finished their specializations yet—you can't just shove this kind of responsibility onto people like that. It's reckless.

What a circus.

I don't see much shifting for family doctors. It feels like the real impact will hit hospital specialists. Now, their diagnostic recommendations will actually be tracked. Up until now, the system just monitored how many referrals a GP issued.

Specialists will have to think twice before ordering unnecessary tests or follow-ups. Every recommendation they make is going on the record now.

As for chronic conditions—think diabetes, hypertension, asthma, or COPD—primary care has always handled them. The standard was to have at least 80% of those patients managed by a family doctor, with only a small fraction seeing specialists. They've been adjusting blood pressure meds or insulin doses for years, and they'll keep doing it.

That’s exactly what they fought for.

For rare or complex cases, they’ll still write the referrals and leave it to the specialists. I don't expect much change there. But there will be a shift for, say, high blood pressure patients who are used to visiting "their" specialist at the hospital every few months—people who know the specialist better than their own family doctor—just to get a "continue current therapy" note or a minor dosage tweak.

melloworca6 said:Regarding Code A. As far as I know, a consultation is when a group of doctors gathers to discuss a case. At our hospital, this usually happens between 8 and 9 AM before they head down to the wards and clinics. So, if I'm wrong about what that code refers to, fine, my mistake.
My doctor referred me to a consultation, where a panel of doctors discusses my case, suggests therapy, tests, and medication, and then my GP decides how to proceed and what I'll be taking. If I understood this code correctly, the whole system is a total comedy. I honestly wonder how long it will take before we start reading in the news that people have started murdering their GPs—especially if they end up with incompetent doctors like the one I had.☕

For heaven's sake, I know Silapen and Erythromycin are different antibiotic classes. I wasn't comparing them against each other; I was comparing the side effects that both my friend and I experienced from those two drugs.
Since you brought up Sumamed, let me explain my point better. Why do you think there are people for whom Sumamed works perfectly, but the Belupo version doesn't? And vice versa. I'm not going to sit here and study the chemical composition of every pill to see if they are identical, but the physical makeup of a tablet isn't always the same (and when I say "makeup," I mean the inactive ingredients, not the active drug). I have family members who are sensitive to certain fillers used in tablets and have huge issues swallowing any kind of pill. Those people won't have a choice; they'll have to pay out of pocket if the cheapest option makes them sick. These people pay for health insurance, they pay for supplemental insurance—they should have the right to get a medicine that doesn't make them ill or cause massive side effects. People with lactose intolerance know they can get diarrhea from meds containing lactose. I know people who had terrible digestive issues with Euthyrox, but were fine with Letrox, even though they contain the exact same active ingredient. The tablet composition just isn't identical, but go ahead and try explaining that to them. If Euthyrox is the cheaper option, then sorry, folks—either buy the Letrox or take the Euthyrox and deal with the cramps and diarrhea.

Should we talk about the heavy hitters? Things like corticosteroids, antimalarials, or cytostatics—medications where it actually matters which brand you’re taking. Should I mention that people have tried different manufacturers of steroids and found that the side effects weren't the same across the board? Same ingredients, same dosage, yet different results. How do you explain that? 🤷 Maybe it's time to realize the human body isn't some math equation you can just solve. Every organism is its own unique story, and life isn't always black and white; it's mostly gray.

vividsailor7, if we're restricted to only getting treatment in our own backyard, that won't just apply to allergies or minor stuff—it applies to everything. If I want to see the top immunologist in the entire US because my local doctors are basically stumbling around in the dark with no clue what's actually happening to me (I might be exaggerating, but I'm not far off), why should that be blocked? 🤷 And it's not just me. It's anyone else being bounced from ward to ward without a single concrete answer. Look, we have hospitals, we have specialists, but just because half of them don't have a clue doesn't mean we should just shrug and say, "Oh well, we're lucky we don't live somewhere else." Honestly, it's more likely that we're all just unlucky to live in a country where we can't even tell if our healthcare system is supposed to be social or private. This messed-up hybrid we've got here isn't even funny anymore; it's pathetic.

No, melloworca6, that’s not quite right.

A referral with Code A currently refers to a specialist visit. On the updated paperwork, it will be renamed a "consultation review," but the function remains nearly identical—visiting a specialist's clinic for an initial exam or follow-up. The main change is that certain tests previously categorized under Code C will now be bundled under this code.

Nothing fundamental is shifting here.

Don't walk into your appointment expecting a full board of doctors.